THE JOURNAL
OF THE
American Medical Association,
A MEDICAL JOURNAL CONTAINING THE
Official Record of the Proceedings of the Association, and the Papers Read at the Annual
Meeting, in the Several Sections, together with the
MEDICAL LITERATURE OF THE PERIOD.
Edited for the Association under the Direction of the Board of Trustees,
BY
JOHN B. HAMILTON, M. D., LL. D.
VOLUME XXVII.
JULY — DECEMBER,
1896.
36
•
CHICAGO:
AMERICAN MEDICAL ASSOCIATION PRESS.
1306.
" The American Medical Association, though formally accepting and publishing
the reports of the various Standing Committees (and Sections), holds itself wholly
irresponsible for the opinions, theories or criticisms therein contained, except otherwise
decided by special resolution." — Transactions, 1851.
\*>
«• 17
c»j -2.
INDEX TO VOLUME XXVII.
PAGE.
"Ks, gunshot wounds of the 1154
Abortion, essential of Indictment for at-
tempting to procure 879
consent to, no oar to action for damages. 18H
kbont fevers, referring to natural media
1147
~-. extra-dural, from mastoid empy-
emia 571
large pelvie, drainage versus
radical operation in the treatment of . . 301
Academic de Medecine of l'aris 56
Lcoldent Insurance, might be entitled to. . 777
Uvulents from gas or electricity, to report. 1070
lUlotome 1814
655
Aotinoi .mail 226
of the lower jaw 604
treated by iodid of potassium 98
Acute Infectious diseases and general paral-
ysis 1025
Addison's disease cured by extirpation of
-uprarenal capsule 1062
disease, operation and cure of 1348
Africa, practice in 501
Alrol, physiologic action of 506
side, Dr. Mark (1721-1770) 1203
Albany Medical College, Medical Depart-
ment Onion University 634
Albinism 601
Albright, J. D. Catarrhal diseases of the
and throat 906
Albumin, teat for 885
testing 277
Albuminuria in pregnancy and parturition,
and its relations to eclampsia 877
physiologic 269
renipuncture In 1247
Alcohol, cure of carcinoma with injections
of 1206
in therapeutics, some notes on 521
Alcoholic drinks, the abuse of, its relation
to public health, and its prevention. . 474
Alcoholism, ammonia in 925
and opium habit, the strychnia cure of. 379
in children 1070
the French National League against
'\.ieity of 823
Alder, curious superstition concerning the. 1171
in Brothers m-w hospital in Chicago . 828
i.-nv and Pittsburg, l'a.. water supply
277
Allen. T. H. Notes on taka-diastase . ... 874
-'11, H. E. Relations of crime t< > insanity,
and states of mental enfeeblenient . . 646
Allport. Frank. The relatious existing be-
tween ,'culistsand opticians 85
Alternating personalities; their origin and
medico-legal aspects 1082
Alvarenga prize of the College of Physicians
of Philadelphia 925
Amblyopia, central, an early symptom In
tumor of the chiasm 1202
consequent to chronic endometritis. . . 736
Ambulance, the gradual evolution of the . . 1076
American birth rate, the decadent ... . 969
cal Association, an appeal to the
Fellows of the 525
medical college, good showing for. . . .449
Pediatric Society's collective investiga-
tion into the use of antitoxin in the
treatment of diphtheria in private
practice 27
tenacity 282
Analgin In infantile therapeutics 1249
' nastomotic buttons, instrument for re-
moving through the mouth 270
nastomosis, new method of, without open-
ing organs 450
Andrews. Edmund. Do grape seeds cause
appendicitis? 1196
Edmund. In future battles where shall
the held hospitals tie placed? 593
E. R. Chairman's address 1827
nemia, pernicious, changes in the cord in. 1204
Injections of salts of iron in the treat-
ment of 548
pernicious, fifty cases of 709
pernicious, cured with bone marrow . . 924
aesthetics, are deaths from, due to failure
of tiie respiration or circulation? . . . 724
ia pectoris in neurasthenia 1261
pectoris, on the symptoms and treat-
ment of 97
ngio-neiirotic edema 904
iikhs. sprained, new treatment for . . . .1308
nother explanation 164
PAQK.
Anthelmintic, an 498
Anthropology as a positive science 1814
Anthropometric measurements of crimi-
nals, new apparatus for 168
Anti-choleraic inoculations 658
Antlpyrin eruption, a case of 325
effect of. on the kidneys 1158
Antiseptics, fragrant 608
Antitoxin, administration of . .1255
and intubation, some practical pointson
the combined effects of 19
another death from 113
collective investigation (second) Ameri-
can Pediatric Society 828
improvements in 975
treatment as a cure for diphtheria, the
fallacy of 17
an experience with, with instructive
results 20
the use of, in diphtheria and membran-
ous croup 7
in diphtheria in private practice; report
of the American Pediatric Society's
collective investigation into the use
of 27
Antivivisection 170
Antrum disease, treatment of 97
Aphasia of the hand 1256
Apoplexy, peventive medicine in 360
Appendicitis a "dysentery" of the appendix. 1107
do grape seeds cause 1196
etiology of 393
fruit seeds in 557
Helferich on the indications for an oper-
ation in 157
massage in 418
operation for 381, 508
report of cases of 1156
when and how to operate in 1302
Argon in the breath 55
Arkansas Industrial University 624
Army medical administration, problems in. 229
Medical Museum, recent additions to
the ■ • • 926
medical officer, Lord Wolseley on the. . 561
medical officers, newly appointed. . . . 1028
medical school 1027
report of the Surgeon-General of the, for
year ending June 30, 1896 911
surgeons, honors to 1261
Armenian field, retires from the 826
Arons, W. C. Practice in Africa 501
Arsenic in scarlet fever 766
Artificial respiration for infants 877
Ashmead, Albert S. The proposed leprosy
Congress 967
Albert S. Congress of leprologists ... 387
Albert S. Leprosy 219
Albert S. The Church of Rome and the
lepers of Colombia 428
Asiatic ant a surgical adjunct 557
Aspirator needle, grooved, a new 1119
Association of American Medical Colleges. 624
Athletics with music for the insane. . . . .1205
Atkinson, Wm.li. Testimonial to Dr. Davis. 154
Atlanta Medical College 620
Atomizer decision 506
improved 1256
Atresia vagina;, operation for 1023
with retention of the menses 862
Auditory canal, foreign bodies in the .... 1308
Authors, give full names of 1019
Autumnal fevers of the Southern Atlantic
States and their treatment 1319
Ay res, S. C. A case of chtoroma 986
Association News.
Appointments 1MB
Headquarters of the American Medical As-
sociation 109
List of Presidents of the Association .... 18.58
Philadelphia meeting of the Association. . 1251
Philadelphia semicentennial meeting, June
1-4, 1897 1214
Section on Obstetrics and Diseases of Wo-
men 720, 1214
The Rush monument fund .... 876, 1073, 1254
Bacon, C. S. Ovarian tumors complicating
pregnancy 590
Bacterial diarrhea of children 548
Bacteriuria treated by internal drug admin-
istration 1024
Baker, Albert Rufus. Dermoid tumors of
the cornea g4a
Baltimore health statistics for June . . '. . 166
Medical College 630
University School of Medicine 630
Bardwell, Eugene O. State Medicine in
Pennsylvania; and how we may In-
crease its efficiency 4g8
Barker, T. Ridgway. Medical expert testi-
mony 822
Barnes Medical College, St. Louts 682
Barr.G.Walter. How much pharmacy should
be taught in medical colleges?. ... 128
Bartholow, Paul. Homicide in the United
States 1052
Baths for miners , 922
for public school children . ...... 278
cold; their use and abuse 13:10
cold, influence of on the circulation 711
permanent ,' 553
Batman, Win. F. Maternal Impressions '. . 1081
Batten, John M. Therapy of veratruin
viride nog
Bayard. W. The abuse of alcoholic drinks,
Its relation to public health, and its
prevention 474
Bean, J. V. Administration of antitoxin. . 1255
Beard, R. O. The evolution of inedicineand
new methods of medical teaching. 881
Beaumont Hospital Medical College, St.
Louis 632
Bell, W. J. Rachitic chest deformity in
twins; exhibition of casts 1102
W. J. Use of the stomach and rectal
tube in children 981
Belladonna greens, poisoned with .... 277
Bellevue Hospital Medical College, New
York 635
Belt, E. Oliver. Sponge grafting in the orbit
for support of artificial eye 991
Bender laboratory at Albany, N.Y., the new 1171
Benjamin, Dowling. Treatment of diph-
theria 85o
Benson, John A. The value to the medical
student of physiologic study 621
Benzosol, clinical experience with 97
Bequests, some recent 1170
Berens, Conrad. A few remarks on ortiio-
and para- chloro-phenol 728
Beri-beri. . . 548
Bernstein, Edward J. Subconjunctival in-
jections 565
Bertillon method in Brooklyn, the 506
system in New York State, extension of. 226
Beta-naphthol inhibitory of intestinal fer-
mentation J348
Bicarbonate of sodium, excessive doses of 288
Bicycle, a defense of the 501
costume, dress reform for women ren-
dered probable by the 491
dangers of the ] 654
riding among those having unsound
legs 281
the less frequent hazards of the ... 708
Bicycling, dangers of go7
Bile duct, obstruction of the .• ' 106I
system, surgery of the . ) 90
Bills, non-payment of ] U64
Biologic laboratory, a new 110
Birch agaric in cancerous and non-cancerous
gastro-intestinal disturbances. ... 394
Birmingham Medical College 624
Bishop, Louis Faugeres. Petit mal in chil-
dren 935
Seth Scott. A clinical study of 21,000
cases of diseases of the ear, nose and
throat 7oi
Seth Scott. Doctorate address . . . . 1143
Bladder, treatment of chronic inflammation
of the 804
Blech, (iustavus M. Modern methods of
treatment of typhoid fever critically
reviewed, with suggestions for a
rational thcraneiisis 306
Blind, care required of the ' 1 ! 506
Blindness, a case of total; possibly due to
an overdose of quinin 992
Blood and lymph, morphology of the. . . 1863
diluting the. In Infections 113
new ferment in the * 126I
washing in infectious disease, the'p'ro-
ceilure of 154
"Blood-serum therapeutics," an introduc-
tion to the dismission on. . . . 14
Board of health, courts of equity refuse to
restrain 112
u
INDEX.
PAGE.
Boards of health and cemeteries 156
Bolton, Dr. B. Meade 878
B. Meade. Theory of serum therapy:
contribution from the bacteriologic
laboratory of the city of Philadelphia. 26
Bones, implanted 1206
Books, necessity for keeping 1316
Borland, E. B. Prevention of tuberculosis. 252
Boric acid in milk 277
Bracelin, Dr. P. M. The Bracelin remedy
for diphtheria 49
Brain, experimental explorative operations
on the 558
Bread and bakeries, Jersey law as to ... . 888
Breakey, W. F. Syphilis and marriage. . .1231
Breasts, defective, a sign of degeneracy. . .665
Brenz catechuin located in the suprarenal
capsules 825
British Medical Association meeting, notes
on 894
Brooklyn Health report 277
the offensive water supply of 719
Brower, Daniel R. The necessity of reform
in medical expert testimony 686
Daniel K. The teaching of materia med-
ica and therapeutics in Rush Medical
College 123
Daniel R. The welfare of the community
demands that marriage should be reg-
ulated 849
Daniel R. The necessity of granting
privileged communications to the
medical profession of Illinois 1271
Blown, Bedford. The autumnal fevers of
the Southern Atlantic States 1319
Edward J. A prevalent error in refrac-
tion work 1115
George S. A defense of the bicycle ... 501
Geo. V. I. Attention an adjuvant in
therapeusis 128
Bubonic plague, the 922
plague at Hong-Kong in 1894, the .... 107
Budapest exposition 226
Bulkley, L. Duncan. Notes on the newer
remedies used in diseases of the skin. 1125
Burns, potassium nitrate in 1249
treatment of 1012
Burr, Albert H. Gonorrhea in the puerpe-
rium 286
Albert H. Infantile scorbutus 982
Business committee, the 220
Book Notices.
Allbutt. A System of Medicine, by many
Authors 221
Annual Report of the Board of Health and
the City and Port of Philadelphia, 1895. 875
Bartholow. A Practical Treatise on Materia
Medica and Therapeutics 1022
Biennial Report of the Board of Health of
the General Assembly of the State of
Louisiana, 1894-95 . . . . : 1022
Bosworth. A Textbook of Diseases of the
Nose and Throat 1022
Bowditch. An American Text-book of Phy-
siology 1072
Buck. A Vest-pocket Medical Dictionary. . 71»
Burney. Food in Health and Disease . . . 717
Butler. A Text-book of Materia Medica,
Therapeutics and Pharmacology . . . 1117
Clarkson. Textbook of Histology, Descrip-
tive and Practical, for the Use of Stu-
dents 1078
Corwin. Essentials of Physical Diagnosis of
the Thorax 1359
Crookshank A Text-book of Bacteriology. 1312
Culbreth. A Manual of Materia Medica and
Pharmacology 718
Cutler. Medical and Dental Colleges of the
West 876
Davis. A Treatise in Obstetrics for Stu-
dents and Practitioners 1071
Deaver. Treatise on Appendicitis 446
Delaiieid and Prudden. A Handbook of
Pathological Anatomy and Histology. 1168
Dennis. A System of Surgery 445
DeSchweinitz. Diseases of the Eye 1071
DeSchweinitz, Philadelphia Hospital Re-
ports 222
Dorland. A Mannal of Obstetrics 876
Eleventh Annual Report of the Pennsyl-
vania State Board of Health 611
Eleventh Annual Report of the State Board
of Health and Vital Statistics of Peun-
sylvania 556
Ferneaux. 1. Whittaker's Anatomic Model.
2. The Anatomy of the Human Head
and Neck 166
Foster. Reference book of Practical Ther-
apeutics 1811
Foster. A Text book of Physiology 1811
Fourteenth Biennial Report of the State
Board of Health of California .... 1118
Gould. The Student's Medical Dictionary. 166
Gray. Anatomy ^Descriptive and Surgical. 875
Hand book of Subsistence Stores U.S. Army,
1896 1259
Hare. Hare's Practical Diagnosis 71*
Hayden. A Manual of Venereal Diseases . 665
Hudspeth. The Juggernaut of the Moderns. 875
Important Notice Concerning Library Wants
and Supplies 1116
PAGE.
Index-catalogue of the Library of the Surg-
eon General's Oiiice, United States
Army ... 717
Jackson Jackson's Ready Reference Hand-
book of Skiu Diseases 665
Jackson. Skiascopy and its Practical Appli-
cation to the Study of Retraction . . . 1071
Kavlratna. Charaka Samhita 1072
Keil. Keil's Medical, Pharmaceutical and
Dental Register-Dirt ctory 166
Kemp & Co.'s Prescribers' Pharmacopeia. . 875
Keyes. The Tonic Treatment of Syphilis . S76
Ming. The Methodical Examluatiou of the
Eye 718
Lydstou. Over the Hookah 1072
Manual for the Medical Department, U.S.
Army, 1896 1259
Marchand. Peroxid of Hydrogen (Medici-
nal) Glvcozoue, Hydrozoue, and Eye
Balsam 876
Medical Directory of the State of New York. 1859
Meigs. Feediug in Early Infancy 876
Murrell. A Manual of Pharmacology and
Therapeutics 875
Musser. A Practical Treatise on Medical
Diagnosis 1022
Oliver. A System of Diseases of the Eye. . 1073
Park. Treatise on Surgery by American
Authors 610.1117
Postmortem Examinations in Medico legal
and Ordinary Cases 1168
Pringle. A Pictorial Atlas of Skin Diseases
and Syphilitic Affections 718, 1359
Proceedings of the Nebraska State Medical
Society 556
Rockwell. The Medical and Surgical Uses
of Eiectricit 875
Roosevelt. In Sickness and in Health . . . 222
Schaefer. Quain's Elements of Anatomy. . 166
Schaeffer. Anatomical Atlas of Obstetric
Diagnosis and Treatment 1118
See. Le Gonococque 222
Simon. A Manual of Clinical Diagnosis by
Microscopical and Chemical Methods. 664
Stedman. Modern Greek Mastery 1021
Stedman. Twentieth Century Practice, 610, 1359
Stoney. Iractical Poiuts in Nursing for
Nurses in Private Practice 876
Tenth Annual Report of the Ohio State
Board of Health 717
Tenth Annual Report of the State Board of
Health and Vital Statistics of Pennsyl-
vania 1168
The Medical News Visiting List, 1897 .... 1168
The Medical Record Visiting List 1168
The Physician's Visiting List 1169
Thresh. Water and Water Supplies 1073
Transactions of the American Academy of
Railway Surgeons 556
Transactious'of the American Microscopical
Society 611
Transactions of the American Association
of Obstetricians and Gynecologist*. . £22
Transactions of the Colorado State Medi-
cal Society 1311
Transactions of the Fifty-first Annual Meet-
ing of the Ohio State Medical Society. 1118
Transactions of the Illinois State Medical
Society, 1896 875
Transactions of the Medical Societv of the
State of New York 222
Transactions of the New Hampshire Medl
cal Society 1118
Transactions of the Medical Society of the
State of California 664
Transactions of the Medical Society of the
State of Pennsylvania 876
Transactions of the Southern Surgical and
Gynecological Association 108
Transactions of the State Medical Society
of Wisconsin 876
Tronsactions of the Texas State Medical
Association 1118
Treves. A System of Surgery by Various
Authors 874
Tuppy. Deformities; A Treatise on Or'ho-
pedic Surgery, intended for Practition-
ers and Advanced Students 610
Twenty-seventh Annual Report of the State
Board of Health of Pennsylvania . . .1118
Tyson. The Practice of Medicine 1812
Yaughan. Ptomains. Leucomains. Toxins
and Antitoxins, or the Chemical Fac-
tors in the Causation of Disease. . . . 611
Welsh. The J ournal of Experimeutal Medi-
cine 502
Wharton. Wharton's Minor Surgery and
Bandaging 611
Wilson. An American Text-book of Applied
Therapeutics 876
Wise A Text-book for Training Schools for
Nurses 874, 1073
Witthsus. Becker. Medical Jurisprudence,
Forensic Medicine and Toxicology . . 1118
Wood. The Practice of Medicine 1117
Ziegler. A Text-book of Special Pathologic
Anatomy 1072
Cesarean section, improper performance
of 382
Calcified fibroid from cremated corpse. . . 827
Calculus, diagnosis of, by the new photog-
raphy 494
PAGE.
Caldwell, W. S. Ether and chloroform. . .1289
California's mortality report for August . . 773
Calomel in diphtheria 1208
Camphor dressing for the sores left after
furuuculosis 492
in strychnia poisoning 323
Cauadn, high inlaut mortality in 611
Cancer, etiology and pathology of 113
of the pregnant uterus Ill
of the stomach, surgical treatment of. 1808
uterine, palliative treatment of, with
chlorate of sodium 438
Cancers of the rectum, Chaput ou the treat-
meut of 157
Cape of Good Hope, vital statistics of. . . . 504
Carbohydrates, action of alkalies on . . . . 498
Carbuncle, conservative action of 122t;
Carcinoma, alcohol in the treatment of . . . 712
cure of, with injections of alcohol. . . . 1206
of the stomach, Kroenlein's suigical
experience with 288
of the stomach, early diagnosis of, by
means of chemic analysis of the gas-
tric contets . . 70
Cardiac disease in children 121,s
therapeutics 825
Caroid 641
Csrstens, J H. Legislation league 276
Carter, J. M. G. Functional dvspepsia of
children 803
J. M. G. Perihepatitis and pleurisy
resulting from injury 86
J. M. G. Prevention of Infectious dis-
eases 40">
Cascariu as a substitute for cascara sagrada. 268
Casselberry, W. E. Electrolysis for the
reduction of spurs of the nasal septum. 578
Castration and ligatlng the arterla ilinea
interna for h\pertrophied prostate . . 1205
for hypertrophy of the prostate 1261
Cataract, hard, report of 100 cases of extrac-
tion 885
secondary, a knife for 889
Catarrh, gastro intestinal 548
Catarrhal deafness, chronic, simple treat-
ment of 324
diseases of the nose and throat 907
Catgut, cause of suppuration with 288
dry sterilized 888
sterilization, ideal 1219
Cattle tuberculosis, the American blood
test for 320
Celluloid mull bandage, the new 437
Central College of Pnysicians and Surgeons.
Indianapolis 628
Dispensary and Emergency Hospital,
changes at the 927
Cerebral disease following middle ear sup-
puration 574
localization 670
Cerebrospinal meningitis, confirmation by
bacteriologic diagnosis of epidemic. . 722
meningitis, epidemic, etiology and diag-
nosis of 888
Cerium oxalate in the crises of tsbes . . . .1107
Cervix, fibroid of, Porro's Operation for . . S16
Chairs for Maryland salesladies 885
Change of name 1028
Chancres, soft, rapid cure of, by electric
heat 96
Chancrous bubo, iodoform-camphorated
salol in 961
Charcot-Leyden crystals, the 1316
" Charcot's crystals," form of 878
Charitable interests, commission to investi-
gate 1122
Charities, New York State, inspection of.. . 447
Chassaignac, the American suture, the in-
vention of 392
Chattanooga Medical College 640
Chemistry, applied 666
Chiasm, tumor of the. central amblyopia an
early symptom in 1202
Chicago College of Dental Surgery, dedicat-
ory exercises of the 1262
day 878
death rate for July 447
Policlinic and Hospital 627
the Lancet on the health of 710
water must be boiled 278
Chinese women and their feet 167
Chloroform. a c«se of death from,lmproper-
lvso called .170
and ether 1289
narcosis, organic alterations in 1249
Chloroma, a case of 986
Chlorosis, paplllo-retinitis in 1062
treatment of, with ovarian extracts. . . 666
Cholelithiasis, treatment of, with potassium
iodid 54(1
Cholera, a summary of Dr. Waldemar Haff-
kine's work against 1204
and other infectious processes, specific
immunity versus transient protection
In 778
antitoxins, new investigations of ... . 114
in Egypt 50
infantum, treatment of, with subcutan-
eous injections of serum 270
new light on the pathologic processes in. 668
progress in preventive treatment of. . . 392
tract from India 396
Chorea 887
INDEX.
iii
PAGE.
Choroiditis, acute non-syphllitlc iu young
Iran 888
Idiopathic 8M
.sou. J. S. The evidence ol Insanity;
mi outline Tl.s
Chrobak ovarian extract 438
Chroulc tuberculous peritonitis, report of a
of 67
toning, anomalous case of. 168
Cincinnati College of Medicine and Surgery. 637
Circumcision, lufectiou from 960
noi necessary in youug children .... 1176
Claiborne, J. Herbert, (experiments on rab-
bits « Ith • I lew to obtaining a stump
for the accurate ftttiug of glass eyes. . 1091
Clark University, Worcester, Mass 631
Clarke, Augustus P. Degenerative changes
.■.•cur in uterine tiivro myomatous
growths 486
stus I'. Methods of drainage in
aboard municipalities tend,
ini; to the productlou and dissemina-
tion of disease 162
cie, :i new apparatus for fracture of
tile 696
Cleaves, Margaret a.. Frankliniiatlou as a
therapeutic measure in ueurasthenla.1048
palate, new operation for 756
e of Physicians and Sur-
geons, Cleveland. Ohio \ . . . 687
Clevei rreatmeut of the insane . 894
ate and health." discontinuance of. 'J27
Clinic instruction In Infectious diseases In
London 970
liiin; in the modern hospital .... 710
Clinical classes, mixed 973
Club-foot, "molding" treatment of 493
i intoxication 156
substitution of eucain for 1449
ism. chronic, Magnan's sign In ... 706
ulzatlou 1014
Cochran, Jerome. Another explanation . . 164
Cockade aud crests preferred 55
gall for cod liver oil 494
Codein and swabbing the larynx as adjuncts
to O'Dwyer's tube iu membranous
croup . . 270
Coffin carrying 615
Ookenower, James W. Duty of the physic-
ian to the public 489
College of Medicine, Syracuse University,
ise, N.Y 636
of Physicians and .Surgeons, Baltimore. 630
of Physicians and Surgeons, Boston. . . 631
oi I'hvsiclnns and Surgeons, Chicago . . 627
- fracture 326
Colorado climate. Germany officially in vest-
- 277
inebriate law- constitutional 1075
:e board of medical examiners. . . . 223
Colvin. D. Dislocation of hip 609
Commission in lunacy. New York State . . 1216
de luuatico inqulrendo, objectof . . . .1261
..n-atiou must be allowed 615
Compound protozoan aud bacterial infec-
tion 867
Compulsorv rest for working women after
Childbirth 277
arms. Remarks on the manage-
ment of glaucoma 480
Leartus Remarks on the causes of
glaucoma 1037
Constipation: some of its effects and non-
medicinal treatment 247
Consulting surgeuey declined, a 169
lumptlon and typhoid fever 388
among the colored population 922
antistreptococcic serum in the treat-
ment of 542
nonalcoholic treatment of 478
pulmonary, the action of strychnin in . 801
sensational statements regarding. ... 107
Consumptives' home, a contention over the
site of a 1261
Contrast staining 722
Cooper Medical College 626
Copyrighted works, allowable use of . . . .1122
Cornea, dermoid tumors of the 846
Cornick. Boyd. Treatment of phthisis pul-
monalis 609
Corr. A.C. A medical aspect of crime . . . 786
Corsets, plaster, improved method of fasten-
ing 961
Cortex and the labvrinth. connection be-
tweeu the 1123
Cory. A. L. A new instrument for steady-
ing the uterus after curettement . . . 1318
Corvza, abortive treatment of 712
Cottage hospital at Proctor. Vt 780
Coulter. J. Homer. Quinsy: differential
diagnosis and treitment 697
Creosote pills for phthisis 1062
-hill 156
Crime, a medical aspect of 786
Criminal jurisprudence, a plea for reform
in 1085
Crook. J. A. Rational treatment of typhoid
fever 310
Cross of the Iron Crown 110
Crothers, T. D. Expert testimony in dis-
puted cases of inebriety 683
T. D. Introductory address 617
T. D. Medical treatment of inebriety. . 998
PAGE.
Crothers, T. D. Some notes on alcohol In
therapeutics 521
Croup and diphtheria, identity of, olliciallv
recognized in Quebec 278
Crystalline lens, suppression of the l-'i>2
Cuba, medical aid for I860
Cumol as a sterilizing agent 64*
Cuspidor, Improved pocket .... 1457
Cuspidors wanted, illll'loved pocket . ... 56
Cutter. Kphmiin. Preventive medicine in
apoplexy 860
Cysiicotoiny, the new operation .,17
cyst in Bfl
Cystitis, chronic 656
the treatment of. . . 65
Daniel, K. E. A plea for reform In criminal
jurisprudence. 1086
Davis, Prof. N. 8. A testimonial to . . . . 48. lt..|
N.S. Location of the Journal liiil
N. S. What constitutes true clinical ex-
perience iu medical practice aud its
relations to the public health'.'. ... 514
Dartmouth Medical College, Hanover. N. H.
634, 776
Deaf and dumb, provision for Ohio's aged . 722
Deafness, chroulc catarrhal, observations
made during the treatment of 645
hysteric 786, 1348
Dean of the profession 878
Death, evidence of cause of 1816
rates between the sexes, difference in
the 553
Decadent birth rate, the 1070
Deciduomomaliguum 888
Decussation of nerves, the physiology of . . 1188
Deformities, congenital, some unusual . . . 597
Deformity-producing shoes 1122
Degeneracy; its causes and prevention. . . 958
Degenerate jaws and teeth .... 1134. 1199, 1242
DeGrooft, E. E. Treatment of diphtheria . 968
Delaware County (Pa.) league of health
boards 335
Deletl ab variola . . 50
Dental and oral surgerv. Chairman's ad-
dress 1327
inspectors for schools 928.
law, new, for Maryland 926
Dentists can not prescribe whisky for tooth-
ache 114
Denver Medical College 625
Department of health, or bureau: which? . 464
of public health, arguments favoring a. 465
Dermatitis from X ray, 1070
Roentgenl 1014
de Schweiuitz, G. E. Optic nerve atrophy
from toxic agents 988
De Vaux. F. H. Straw charcoal with boric
acid as an antiseptic 771
DeWar, T. A. Serum therapy in tetanus. . 1839
Dewees. Wm. B. Eulogy on Jenner 1128
Diabetes, early symptoms of 764
in early infancy 214
mellltus, the urine in 1385
mellitus, treatmeut of, with rectal injec-
tions of pancreatic glands 157
suggestions on the management of. . . 1280
Diarrhea in infants, acute Infections, treat-
ment of 96
Diagnosis, relationship of, to the future
surgical progress 758
Diaphragmatic hernia 288
Dibrell, J. A., Jr. A new grooved aspirator
needle 1119
J. A. Anew suture needle. Modification
of the Hagedorn 655
Diet is the man 1170
Diphtheria antitoxin, the dangers of . ... 94
a less stringent quarantine for, 774
and croup, age and sex i ncidence of mor-
tality in Michigan from 350
and its organism, the soil in relation to. 431
aud membranous croup, antitoxin in . . 7
and tonsillitis in children, diagnosis
between HI
and tuberculosis, new departures in the
Massachusetts 8tate board of health in. 389
and typhoid fever in Ohio 972
and typhoid in Chicago 663
calomel in 1203
complications aud sequelae of 281
culture work in.forthe Buffalo board of
health 501
Henuing's successful treatmeut of. with
lime water and ice 227
in Illinois M19
in Indiana 1020
In London, vital statistics of 484
local treatmeut of, with sodium hypo-
sulphide 214
orrhotherapy in I
the Bracelin remedy for 49
treatment of 850, 968
serum therapy in 11
Diphtheritic laryngeal stenosis "cured"
with Behriug's serum 381
Diploma mill in Wisconsin, another 444
practicing without 110
Disease. twenty-one years' experience in the
non-alcoholic treatment of 519
Diseases of infants and children, diagnosis
in 881
Disinfection difficulties at Cairo 654
Disinrecting lamp, the Richard Formogen. 616
station ill Paris, description of 1809
Dispensaries, concerning 500
Dlttel's method of elastic ligatures of hem-
orrhoidal nodules . . 557
Dixon, W. A, Observations In cases of epi-
lepsy following injuries to the head. 934
Doctorate address, delivered at the Illinois
Medical College i]48
Doering, E.J. Location of the Journal . . . 105
Dogs, tliyroidectomized, experiments on . . 1260
Dolphin oil in acne 214
Douglas. Richard. Intraligamentous fibro-
myoma complicating pregnancy at full
.. „ te,rm,' ,' ,'. «°6
Douglasitis" 974
Director, a modified 1119
Drainage, methods of, in eastern cities . . . 462
Drake, G. W. Man's brain and spine . 840
Drayton, H. S. A note on the pathomental
effects of degenerative habit . . . . 842
Drinking water for travelers . . . 968
Drewry, Wm. Francis. Feigned insanity;
report of three cases 79s
Drugs, standardized 144
Druggist, unregistered, convicted of being
an 974
Dry heat of high temperature I u chronic joint
affections . . ; 960
Dudley, E. C. Surgical treatment of uterine
flbro-myomata 370
Dufour. Clarence R. Hygiene of the eye 484
Duluth water supply. 107
Duodenum, exploration of, by intubation. ' 93
Dynamic ileus 315
Dyspepsia, functional, of children 803
Ear and eye cases, medico-legal aspect of . 1283
nose and throat, a clinical study of 21,000
cases of diseases of the 701
oto-massage lu suppuration of the. . . . 725
Early aid for Injured employes . ..... .1128
Ears, improving the shape of the 1247
Echinococcusof the liver cured byBacelli's
method • • 75^
Ectopic pregnancy, the present status of— a
surgical disease 192
Ectropion of the upper lid. use of cicatricial
skin flaps in the operation for . ... 648
Eczema, infantile, for 824
permanganate of iron in 824
Education, crusade of ! 1 887
Edema, circumscribed, of gouty origin. . '. 1275
of the eyelids iu Graves' disease .... 41
of the ocular conjunctiva 1092
Edes, Robert T. Points in the diagnosis and
treatment of some common neuroses . 1077
Ehrmann, Fred. J. B, Primary sarcoma of
the tail of the pancreas 1240
Elect the doctors . 567
Electric death, cause of . . . 826
Electro-therapeutics and Electro-diagnosis
simplified 759
Electrolysis for the reduction of spurs of the
nasal septum 57^
medicated , 1352
Elephantiasis case, the Mclntyre ...... 145
Elliott. Arthur R. The urine in diabetes
mellitus 1335
Ellis, H. Bert. A ease of double exophthal-
mos 1035
H.Bert. A case of total blindness . . . 992
Emetic, a powerful .... 894
Empyema, chronic, treatment of. by decorti-
cation of the lung 1159
Enchondrosis 422
Enema, small medicinal, for children. . .1200
English, W. T. Modern respiratorv advan-
tages 528
language, the. 170
physician, the murder of an, in North
Africa 170
Ensiform process. luxation of the 653
Ensworth Medical College and Hospital, St.
Joseph, Mo 632
Enteric fever among children, an epidemic
of 553
Enteroptosis, treatment of, with veast of
beer .'.... 546
Entropion and trichiasis, operative treat-
ment of 380
Enzymes 506
Epilepsy and other convulsive diseases. . . 42
'focal, surgical treatment of 877
intestinal antisepsis, diet and castration
in relation to . . • . 69
observations in cases of, following in-
juries to the head in infancy, child-
hood and early youth , 934
partial, operative treatment of 1023
the status of operative procedure as a
remedial agent for .40
Epileptics, toxicity of gastric juice in. . . '. 776
Epithelioma of the lids, the use of caustics
for ■ 744
Epley, Frank W. Pure water 402
Erb's primary muscular atrophy ! 1140
Erlchsen, John Eric, the late. 11121
Ernst, Harold C. An introduction to the
discussion on "blood-serum thera-
peutics" 14
IV
INDEX.
PAGE.
Erwin, A. J. A knife Jor secondary cataract. 889
Erysipelas and its treatment 67
vasel n in 712
Esophageal sac. or "antrum cardiacum" . . 1075
Esophagus, congenital absence of the. . . . 430
foreign bodies in the 868
Estlander's operation on a child 1107
Ether and chloroform 1289
Ethics, intra-professional 1201
Eucain in tooth-extraction 1206
in urologic practice . . . , 1158
substitution of, for cocain 1249
Eunuchs in China, the demand and supply
of 1075
Everts, O. State suppression of inebriety
and cure of inebriates 517
Eversion of the lower eyelid, operation for. 270
Evidence, exclamations admissible in . . . 1260
Excipient for ophthalmic unguents,an ideal. 57
Exercise, a sleep-producing, preferable to
hypnotics 820
Effophthalmic goitre, incipient symptoms
of : • *"
goitre, section of the cervical sympa-
thetic in 546, 1248
Exophthalmus, double, a case of 1035
Expert medical testimony 822
testimony, Russian jury discounts ... 723
Experts charged with not telling the truth. 1818
right of , to extra pay 116
Eye and ear cases, medico-legal aspect of . 1283
glasses, improved, for school children
and artisans J*
hygiene of the . . ■ ■ ■ • • • ■ 484
Eyes, examination of, in the public schpols
of Baltimore 11T7
Editorial.
A century's advance in pediatry 1164
A slander on the medical profession .... 820
Air-embolism in connection with twin preg-
nancy 1J5S
Ambulance ship, the. ............ 1352
American Public Health Association ... 819
An imperfect list ... 108
Annual report of the Banitary commission-
er with the Government of India. . 215
Another donation to the Newberry library . 872
Aphasia of the hand 1162
August beat, the 4%
Bacillus of paresis, the 551
Bicycling, pro and con 884
Book enterprise • 1306
British Medical Association, the 387
Celebration of the introduction of anes-
thetics 768
Cellar, the, in its hygienic aspect. . . . . . 99
Chanees in the pupillary reactions of the
insane 120*
Climate and health 271
Color vision . . . . . . . 917
Commitment of the insane in the State of
New York -108
Congenital hypertrophy of the pylorus and
stomach wall 1207
Consanguineous marriages 273
Contagiousness of tuberculosis 1015
Cook county (Illinois) hospital, the ... 966
Daily medical inspection of schools .... 1805
Dangers of cocain 1018
Death of Falstaff, the 1252
Degeneracy theories of the 17th century . . .1016
Diagnosis of twin pregnancy . 1253
Diploma mills • 1068
Disfigurements of smallpox, the .716
Early American pharmacopeias and their
authors I3*9
Eating of ices, the 159
Educational number 608
Empiricism vs. working hypotheses in ther-
apeutics • • ...... . . 919
Examination of school children's eyes, the 6o7
Excellent work of the American Academy
of Medicine 497
Getting rich " by degrees" in Italy 966
Hematozoa in the lower animals 216
Hematozoa of malarial fevers 100
Imported custom, an 1307
Insanity and divorce 331
Intestinal perforation complicating ty-
phoid fever 1306
Janus **^
Kleptomania and "shopping" . 1066
Labor movement and medicine, the .... 660
Language of medical terminology and med-
ical congresses • • • 713
Lay distrust and enmity of the medical
profession - - - 212
Least attractive duty of the surgeon, the . . 828
Legislative prevention of suicide 1018
Library wants and supplies 1114
Litholapaxy and a new lithotrite 1161
Local action of the X rays 1254
Location of the Journal 381
Lowering death rate, the 607
Malpractice case of extraordinary and un-
usual character 441
Mania for proper names, the 821
Medical charity and abuse in England and
elsewhere 439
"Medical defense" ■ • • • «9
Medical departments of the army and navy 1017
PAGE.
Medical examiners and medical teaching . 657
Medical journal, the, and the " reading no-
tice" 47
Medical satirist of medicine, a 872
Milwaukee-Chicago diploma mill, the . . .1354
Mirror speech 1807
Murder of the innocents, the 767
Neuron, the 161
New medico-legal question, a 495
New nurse, the 274
No full dress uniform 442
Nomenclature of diseases, the 327
Obstetric side of hysteropexy, the 1353
Panicky sanitation 43
Parasite and host 10&5
Paresis and pseudo-paresis 162
Passing of the holy-stone 1110
Philadelphia meeting of the American Med-
ical Association 1251
Physical training in the army 160
Physiologic treatment of neurasthenia . . . 963
Poisons of alcoholic drinks, the 272
Poliencephalomyelitis 1109
Prognosis of exophthalmic goitre 1208
Prognosis of mania and melancholia .... 871
Proposed legislation in regard to expert
testimony 770
Public health department, the 45
Regrettable oversight, a. . . .' 886
Roentgen rays in diagnosis 386
Rush monument, the 1254
Sanitary and insanitary plumbing 272
Second State hospital for the insane of
Maryland, the 716
Secret cures of inebriety in Bellevue hospi-
tal, New York 218
Serum diagnosis of typhoid fever 1114
Should government encourage medicine or
quackery? 329
Sir Henry Halford and the reviewers. ... 102
Slowness with which important medical
discoveries are generally put to practi-
cal use 1210
Smoke nuisance, the; a fable 871
Social status of the British medical profes-
sion 920
Strengthen the Association 551
Tablet medication 964
Teaching of materia medica and therapeu-
tics 658
The American Public Health Association
and American bacteriologists 1015
'• The great unready" vaccination commis-
sion ... 163
The hoodooed Texan 1)63
The Journal itself 215
The microbe as a factor in evolution .... 714
The " new nurse " again 606
The physician's wife 1110
The poisoning of a people 1063
The quadrennial election 1019
The question of physical examination ... 44
The U.S. medical profession and the Mon-
treal meeting of the British Medical
Association in 1897 549
Thvroid therapeutics 498
Treatment of insanity eighteen centuries
ago 8C9
Vital and psychic complications in castra-
tion tor prostatic hypertrophy 659
Washington and his physician's bill .... 872
Water Supplies 217
Water supplv of Denver and Chicago. . . . 964
Wicked house fly, the 383
Fallopian tube tabloids 228
False testimony and suggestion 879
Fee, will the consultant get his 166
Felkin, Dr. K. W 1218
Female physician, right to have examina-
tion made by 776
Fenn. CM. If she had only been Battey-
ized 164
Fevers, an epidemic of 873
protracted simple continued 114
Fibroma of the uterus, efficacy of thyroid
treatmentfor 380
Fibromyomacomplicatingpregnancyatfull
term 906
Field hospitals, where shall they be placed
In future battles? 593
Filmogen in dermato-therapeutics 1248
Filter, a home-made, for domestic purposes. 1258
Filters and sterilizing processes for drink-
ing water, inefficiency of 447
for army use 168
Fischer, Louis. Some practical points on
the combined effects of antitoxin and
intubation 19
Fiske, George F. Sarcoma of the choroid . 845
James Porter. Spinal injuries in infants. 902
Flat foot.celluloid soles for 825
Flood, Everett. Intestinal antisepsis, diet
and castration in relation to epilepsy. 69
Florida quarantine, the navy to assist in . . 836
Food laws in Pennsylvania 167
tuberculosis, infection from 527
Forbes, W. 8. Litholapaxy 1145
Forceps, use of, in France and Germany . . 655
Formal added to milk, detection of. .... 006
in urinary therapeutics 270
PAGE.
Formaldehyde, vapor of, disinfection of in-
fected apartments by. . . 1357
Formalin as an official disinfectant 447
gelatin as an antiseptic 646
in dental practice 825
in ophthalmic practice 157
vapor of, disinfection of books by. . . .1023
Formic aldehyde as a disinfectant 766
Fort Wayne College of Medicine 628
Fortune telling, does not believe in 505
Foster, Burnslde. "God and the doctor we
alike adore" 1213
Burnslde. An explanation 1308
Eugene. The statistic evidences of the
value of vaccination to the human race,
past, present and future, 671, 750, 808,
857, 908, 956. 999
Fracture, ununited; use of bone ferule. . . 604
Fractured shaft - of bone in children ; simple,
complicated and compound, treatment
of . . . ' 929
Fraenkel. Prof. E. 1260
Fraenkel's method of narcosis and after-
treatment of laparotomies. . . . .1206
FreemaD. Leonard. Treatment of chronic
Inflammation of the bladder, with re-
port of two cases of congenital diver-
ticula 804
French hospitals 280
medical schools, foreign graduates in. . 450
national popular alliance, the 544
Frigor therapeutics, first trials of 548
Galloway, D. H. Experience of an Ameri-
can physician in Mexico 705, 1235
Gallstones, rare case of 973
Garbage collection, new regulations in New
York city concerning 389
question at Baltimore, the 1120
removal of, controlled by board of
health 1258
Garber, J.B. Alcohol or no alcohol in the
treatment of typhoid fever 584
J.B. Railroad rates 277
Gargle, the decadence of the 158
Garrison, Harriet E. Evolution of girls . . 1081
Gastric ulcer, with perforation 1864
Gastroenterostomy 1247
Gastro-intestinal tract, the frequent depend-
ence of insomnia, mental depression
and other neurasthenic symptoms
upon disease of the 62
Gastrostomy by a circular valve method . .1142
General practitioner, apotheosis of the . . .1362
Geneva convention, the South African Re-
public and the 973
Genital organs, female, organ extract thera-
peutics of 436
German hospital, Chicago, staff of the . . . 336
Germs, anent 896
Gersuny's sign for differentiating stercoral
tumors 1062
Gilchrist, T. C. Observations on urticaria . 1222
Gilpin, Henry B. Standardized drugs ... 144
Girls, evolution of 11132
Glandularinterdependence 966
Glass eyes, experiments on rabbits with a
view to obtaining a stump for the ac-
curate fitting of 1091
to drill holes in 826
Glasses, the common use of 1279
Glaucoma, cause and prevention of 988
remarks on the causes of 1037
remarks on the management of 480
simple, and optic nerve atrophy, differ-
ential diagnosis between 989
some questions relating to 1040
Glycerin, intra-cervical injection of 962
God and the Doctors we alike adore 1256
Goelet, Augustin H. Improved trachelor-
rhaphy H74
Augustin H. Surgical treatment of retro-
deviations of the uterus 249
Goitre, evolution of the modern surgical
treatment of 89
from administration of thyroid extract . 1013
thyroid medication in ggi
treatment of, with thymus preparations. 1159
Gonorrhea, formalin In 35
in the puerperlum 236
latent 55
thermotherapeutics of 603
use of argon in 546
Gonorrheal conjunctivitis; its treatment. . 641
Good tenements that pay 1301
Gottheil Wm. S. A fatal case of multiple
subcutaneous gummata 1228
Gould, Geo. M. ** Parasite and host". . . .1115
Geo. M. Important notice concerning
library wants and supplies 1116
Gout, the "livery" phase of; the case of
Sir Walter Scott 1011
treatment of, with piperazin 656
Gradle. Henry. A handy form of hot snare
for tonsillotomy ..... 708
Graef, Chatles & Co. Drinking waters for
travelers 968
Graham, David W. The mutual relations of
the medical profession and the public. 509
Grant, U. Gifford. Relation of the medical
profession to the public 1325
Granular lids 1278
INDEX.
page.
Grav's Anatomy, new edition of 606
Greater New York City health department . 619
Greene. K. M. Treatment of typhoid lever . 809
Drinker. Julius. Reply to the oontroversy
over tin- Harvey Medical College of
Chicago Mil
Gross Medical College 626
Gunshot wound of the chest 81
wound of tlio stomach 109
wounds of the lungs, treatmentof. . . . 158
liutta -pcrchagause for postpartum hemor-
rhage 1107
Gynecology, operative, live questions In . . 1299
principles ami progressof 862
the lust method 01 teaching 618
Hack's truss improved hv Wolfcrmaun. . . 114
Hall. .1. \V. Apply the Baconian method . . 106
Wlnfleld S. Medical education in Amer-
[g past, present and future . , . 1266
Hamilton. John B. Health departments of
s and their organization . . 160
Ham! sity, Minneapolis, Minn. . 682
Hand injuries, treatment of 647
Harlan. Herbert. Examination of eyes in
the public schools of Baltimore . . ..1177
Henry, Removal of the lens in myopia. H88
Harnden, R. Sayre. Typhoid fever 276
Harvard Medical Alumni Association ... 66
Harvey medical college 126b
Med!. of Chicago, reply to the
controversy over the 1—11
Hatch. Henry. Chorea NIT
Havelburg, m Leprosy 219
Hayseed sprouted in the ear Ill
Head-swaying in children 214
llg craft defended . . • ' 1024
Heal thooards as disturbers of the peace . . 466
codes U I o sowers 888
departments Of large cities and their or-
ation 460
in Ohio, to protect 1070
in Michigan, August, 1896 611
of Buffalo. N. V '_"->:t
of New York Mate in June 836
physician, liability of city for acts of . . 18.V,
report for city of Chicago 1356
report of New York State for August,
lM.fi 878
Heart disease, gymnastics in 436
some common affections of the, and
their treatment 57
Hermatoeatharsis. study of 169
Hematuria, persistent renal 650
Hemiplegia following typhoid fever 1246
HemogloDinometer, a new 277
Heinol bromld 764
Hemoptysis, treatment of 712. 1248
Hemorrhage, excessive, after enucleation of
ill 1098
into the ponsand opium poisoning . . . 865
- of the bones with shoe nails. . . 826
Heredity as a social burden 843
H'-rnia.fiit as a factor in the production of. 666
linal.uew method for radical cure of. 1348
i ion for from a medico-legal stand-
point 979
Hernias, gangrenous 825
in women, special 978
two methods of treating 1347
Herpes zoster i:s.s
zoster, treatment of 1278
Herrick. S. S. A department of health, ora
bureau: which 464
ns, F. W. Aphasia of the hand . . . .1256
W. W. Edema of the ocular conjunctiva. 1092
Higher preliminary education 110
Hinde. Alfred. A case of suppurating mas-
toiditis cured by chiseling 427
Alfred. A new middle ear mastoid and
lachrymal syringe 445
Hip. dislocation of 609
joint, congenital luxation of the 1018
Hippocrates the founder of an enduring
ethical system 560
Hirsch vs. Nordau 1170
Hobby, C. M. The coordinations of the ocu-
lar muscles 1179
Holmes. Dr. O. W. Standard biography of. 395
Bayard. Surgery of the kidney . . .582, 650
Bayard. The seminary method in teach-
ing surgery 817
H. H 253
Homatropin, the value of, in the diagnosis
of ametropia 1095
" Homeopathy and venesection 1861
Homestead rights retained 1170
Homicide in the United States 1052
Horner, Frederick. An appeal to the Fel-
- of the American Medical Associ-
ation 525
Horse-meat consumption in Paris 773
Hosmer, A. J. E. Werthelm's new method
of restoring retrodeviations of the
uterus through the vagina 595
Hospital College of Medicine, Louisville . . 629
corps U. S. army, drill regulations for. . 282
interne, the life of the 1026
Hotz, F. C. A prevalent error in refraction
work 1218
F. C. The use of cicatricial skin flaps in
the operation for ectropion of the
upper lid 648
PAGE.
Howard University, medical department. . 826
How,., Luoien, Chairman's address . ... 568
Huff, Oliver N 226
Hughes, C. H. The psyeho-ncuralfaetor in
surgery 956
Humerus, resection of the, and wiring. ... 548
Hunter's time, the "unsurgeon-llke horrors
of" Ill
Hutchins, M. B. Kxcislon and skin graft-
ing for tubercular disease of the skin . 1228
Hydatic cyst, sudden death after puncture
of a 892
cysts of the lungs, pneuniotomy in the
treatment of 1802
Hydrocele, radical cure of 712
Hydrocephalus, puncture in 228
Hydrophobia 1308
preventive treatment of 614
Hydrostatic exploration of the body, new . 156
Hydrotherapy, the curative serum of . . . . 484
Hygiene pays 106
versus drugs 844
Hygienic decalogue, a quaint 552
Hygienists. criminality of 665
Hyperthermia, death of children from . . . 978
Hypnotic anesthesia 1027
anesthesia, ease of 1247
Hypothetic questions, can answer 616
Hysterectomy as an accompaniment to bilat-
eral removal of the appendages .... 294
combined vagino-abdominal 1025
Hvsterla, etiology of 398
Ice, death from eating 167
Ichthyol in tuberculosis, success of 608
successful treatment of ozena with.. . . 608
Illinois Medical College commencement . . 665
State Board of Health 167, 1122
State Board of Health and medical edu-
cation 1010
vaccine establishment 1121
Immigrants, treasury regulations regarding 828
Implied contract, a question of 778
Impotence in law 1074
Indian sacrifice, the 978
treatment of smallpox 1S60
Indiana, new health laws desired in ... . 228
State Board of Health, regulations of the 1810
Inebriates, the "curatel" treatment of, In
Austria 491
Inebriety, expert testimony in disputed
cases of 688
medical treatment of 998
State suppression of, and cure of ine-
briates 517
Infants, spinal injuries in 902
Infection hv pets 557
Infectious disease hospitals of Berlin .... 824
diseases, etiology of 1347
diseases, intercurrence of 1011
diseases, piea of ignorance as to 1808
diseases, prevention of 405
Ingals, E. Fletcher. Abscess of the lung,
with report of cases 897
E.Fletcher. Orrhortherapy in diphtheria 1
E. Fletcher. Portable compressed air
apparatus and nasal saw 785
Ingraham, Charles W. Control of tubercu-
losis from a strictly medico-legal stand-
point 693
Inguinal hernia, a new operation for the
radical cure of 210
hernia of children, indications for rad-
ical cure of 227
Injections, subconjunctival 565
Ink for writing on glass 722
Insane, amendment of South Carolina law
as to commitment of 667
asylum appointment 887
asylum nurses, training school for . . . 826
athletics with music for the 1205
can commit, to asylum 776
Illinois' new hospital for the 615
indigent, New Jersey law as to, amended 722
treatment of the 894
Insanity and tuberculosis, the increase of,
in the Southern negro since 1860 . . . .1186
cures of, after many years 1262
feigned; report of three cases 798
in court 680
in Mexico, non-expert evidence of . . 1074
must give notice of trial for 615
post-influenza 431
prophylaxis of 1815
relations of crime to, and states of men-
tal enfeeblement 646
the evidence of 748
the proof of 394
Insolation, treatment of, at the Pennsylva-
nia Hospital 507
Inspectors of mercantile establishments in
New York 611
Instruments, how to sterilize, without dan-
ger of rust." 547
Insurance lost by use of intoxicants .... 1260
International bacteriologic "concours" ... 65
congress of medicine, twelfth 969
scientific language 776
Intestinal surgery, remarkable operation in 558
fermentation, with constipation 548
surgery, a new appliance in 156
"In the crowd," a study of the popular mind 1216
PAGE.
Intoxicants and sunstroke in Australia. . . 226
Intoxication and insanity 691
evidence required to prove 505
from seopalamin 1814
Intra-abdominal disease, deceptive dissimi-
larity of signs and symptoms of . . . . 812
injuries, diagnosis and indications for
treatment of, without external evi-
dence of violence 211
Intravenous injections of water and strong
salt solutions 269
Intrusive drug drummer abroad, the . . ..1158
Intubation and antitoxin, some practical
points on the combined effects of. . .. 19
Iowa boards of health, power of, to employ
physicians 1257
College of Physicians and Surgeons. . . 629
Ireland's unapproached record Tor legiti-
macy 106
Iron, absorpton of, by the organism 666
Island sanitarium, an 874
Jackson, Edward. The value of homatropin
in the diagnosis of ametropia 1095
Jagielski, Victor. Therapeutic action of the
Turkish bath 418
Jefferson Medical College, Philadelphia . . 689
Jenkins, J. F. Our Journal 165
J. F. Should the State provide hospitals
for the tuberculous poor 470
Jenner. a Scottish sanitarian's view of the
English disregard for 406
Edward, the memorials on 812
Edward, eulogy on 1128
Jenner's poesy 116
John A. Creignton Medical School, Omaha,
Neb 634
Johns Hopkins University, Medical Depart-
ment, Baltimore 680
Johnson, Joseph Taber. Chairman's ad-
dress 178
Joints, progress in surgery of the 1260
affections, chronic, dry heat of high
temperature in the treatment of . . . 711
Journal, our 47
location of the 105
he likes our, but money is scarce .... 969
Justice, C. R. Typhoid fever treatment . . 275
Kahlenberg, Louis. On the toxic action of
dissolved salts and their electrolytic
dissociation 138
Kane, Evan O'Neill. A new apparatus for
fracture of the clavicle 506
Kansas City Medical College 683
Keller, Lester. The bicycle 660
Kellogg, Geo. M. New Mexico as a health
resort 582
Geo. M. The physiology of decussation
of nerves 1188
Dr. J. H 55
J. H. Twenty-one years' experience in
the non-alcoholic treatment of disease 519
Kentucky institute for the education of the
blind 452
School of Medicine 887, 629
State board of health bills, payment of .1020
Keokuk Medical College 629
Keratitis dendritica 328
Kidney, movable 818
surgery of the 532, 650
surgery of the. recent experience of. . . 1178
tuberculosis of the 582
tuberculous, transverse resection of . . 877
Kidneys, contribution to the physiology and
therapeutics of the 1025
effect of antipyrin on the 1158
influence of the vagus on the 1361
pathologic study of the 666
Kiernan, Jas. G. Resigned his editorship. . NS
Kime, R. R. Puerperal infection; its path-
ology,prevention and treatment. . . 284
Klebs, Edwin. Repudiates an attempt to
place him in a false light 444
Prof. Edwin. A letter from 499
Edwin. Medical education 781
Edwin. On healing and immunizing
substances of tubercle cultures 176
Klebs-Loffler bacillus, virulence of 280
Knapp, Dr. Herman, heroism of the daugh-
ter of HI
Kneass, Samuel S. The antitoxin of tetanus 134
Knee-joint affections, diagnosis of 661
Koch missions 1260
Kola preparations 1261
Kollock, Charles W. Obscure cases of optic
nerve atrophy of cerebral origin ... 988
Krauss, Wm. C. Dangers of bicycling, with
report of a case of acute dilatation of
the heart 807
Kyle, D. Braden. Nasal hydrorrhea .... 697
Lachrymal apparatus, a few paragraphs on
affections of the 1029
disease 129S
Lackersteen, M. H. Glandular inter-depen-
dence • • 966
Lactophenln 546
Laidlaw, G. The Mclntyre elephantiasis
case 146
VI
INDEX.
PAGE.
Lancaster, K. A. Cure for whooping cough 22c
Langerhans case, sequel of the 115
Laiinelongue's new treatment of inguinal
hernia 270
laparotomies, Friinkel's method of narcosis
and after-treatment of 1206
Laparotomy, causes of death after 1013
intestinal obstruction after 28(*
pain after 656
Lai-kins, E. L. The use of antitoxin in the
treatment of diphtheria and membra-
nous croup 7
Larned, E. R. A modified director 1119
Laryngoscope, the 2X0
Larynx, intubation of the 428
Laughter as a symptom of disease 558
Laura Memorial Woman's Medical College,
Cincinnati 687
Lautenbach, Louis J. Gonorrheal conjunc-
tivitis; its treatment 641
Louis J. Otomassage in suppuration of
the ear; its value for the relief of deaf-
ness and the treatment of the sup-
puration 725
Lederman, M. D. Cerebral disease follow-
ing middle ear suppuration 574
Lee, Elmer, How to cure rheumatism . . . 202
Elmer. Prevention of smallpox .... 816
Elmer. Syphilis successfully treated by
hydriatics 1224
Elmer. The fallacy of antitoxin treat-
ment as a cure for diphtheria 17
Legislation league 276
Leonard Medical School, Raleigh, N. C . . . 886
Lepers, detention hospital for, at Honolulu 923
flocking to Bogota 1896
isolation of, in Russia 773
of Colombia. Church of Rome and the. . 42s
Leprologists, Congress of 887
Leprosy 21f
congress, the proposed 967
danger of, from Russian emigrants.. . . 388
serum treatment of 50
Levin. Asley. Maasage in appendicitis . . . 418
Lewaschew method of substituting the effu-
sion in pleurisy with equal amount of
salt solution 214
Lewis, Denslow. The beat method of teach-
ing gynecology 618
Liability for harshness in examination . . . 777
Of counties In emergency eases 1123
Liehty, Daniel. Congenital absence of the
esophagus 480
Lids, granular 1276
Life insurance examiner's decalogue . . . . 827
insurance, the medicine of, is yet in its
infancy 710
Lindsley, C. A. It was pernicious fever 444
Linen, how to change, into silk for surgical
purposes U1(
Lipoma in upper end of the semitendinosus
muscle 1242
Li's bullet loetcd by the Roentgen ray . . . 168
Lithium preparations 826
Litholapaxy 1145
Liver, abnormal mobility of the 490
hydatie cysts of the 766
rupture of the liver 1002
the extent of the glycogenic function
of the ' ■ ' 1317
Location of the Journal 221
Locomotor ataxia, trunk anesthesia in . . . 759
Loeli, Hanau W. The electro-cautery snare
as an excising agent in diseases of the
nose and throat 730
Ldlllcr's solution 492
Lofton, Lucius. Luxation of the ensiform
process 658
London Pathological Society, jubilee of the. 1216
population of, in 1896 60
Long Island College Hospital, Brooklyn,
N. Y 635
Loomis mountain sanitarium, the 1215
Loretin . 823
vs. iodoform • • • 948
Louisville Clinical Society 1217
Love, Dr. I. N.. retirement of, from Marion-
Sims College, St. Louis 393
I. N. Water 848
Louis F. Retinal detachment and
edema occurring in chronic Bright's
disease 742
Lumbar puncture of the subarachnoid space 888
Lunatic, not proper proceeding for release
Of 1170
duty of committee of 1363
Lung, abscess of the 897
Lupus vulgaris, in the wife and daughterof
a tuberculous subject 1220
vulgaris, treatment of, by means of elec-
trolysis 1198
Lutaud's treatment of obesity in women . . 1250
Luxation of the tendons, new operation for 925
Lymph, blood and morphology of the .... 1362
Macdonald, Willis G. The present status
of ectopic pregnancy— a surgical dis-
ease 192
Macewen, Professor, entertainment to . . . 826
Maclean, Donald. An open letter to the
members and friends of the medical
profession ( regular) In Michigan . . . 310
PAGE.
Maclean, Donald. The Michigan medical
legislation league 832
Donald. The Michigan State legislation
league ' 443
Macroquilla 1107
Madden, John. Herman W. Mudgett alias
H. 11. Holmes 500
Malacin in rheumatism 1013
Malaria 117,205,264, 318
in children, treatment of 1108
marching from 1076
the parasite of, the flagellate form of
the 1217
Malarial parasitic infection diffused by air-
currentsas well as by water 212
splenic troubles. treatment of ,with oleate
of rue and cyclamen 604
Male genital organs, tuberculosis of the, 182, 257
Malpractice ease, expert evidence as to cause
in 668
Mammary tumors, treatment of 1159
Manlev, Thomas H. Treatment of fractured
shafts of bona in children 929
Man's brain and spine 840
Maragliano's sera-therapeutics of tuber-
culosis 1105
Marcy, Henry O. Intestinal obstruction
'after laparotomy 289
Henry O. Operation for the cure of
hernia viewed from a medico-legal
standpoint 979
Marinesco's pilgrimage . . 614
Marlon-Sims College of Medicine, St. Louis. 633
Marriage should lie regulated, the welfare
of the community demands that . . . 849
Marshall. John S. A new trocar and canula
with safety guard 1256
Mason, R. Osgood. Alternating personal-
ities; their origin and medico-legal
aspects 1082
Massachusetts bakery law, boards of health
to enforce 1071
pharmacy law codified 1074
Massage In appendicitis , 418
increasing uses of 270
in treatment of post-operative intestinal
obstruction .... 213
Masseurs, trained, for the French army . . 280
Mastoid, primary Inflammation and abscess
of the 572
Mastoiditis, suppurating, a case of, cured by
chiseling 127
Matches, substitute for yellow phosphorus
in the manufacture of 56
Materia medicaand therapeutics, the teach-
ing of. in Rush medical college . . . .•128
Maternal Impressions 1031
Mauser rifle in the Cuban revolution. . . . 288
May give opinion as to nearness of shoi. . . 1815
May. Louis F. Hydrophobia 1308
Mays. Thos.J. The action of strychnin ill
pulmonary consumption in relation to
the necrotic origin of this disease. . . 801
McCassy.J. H. Lachrymal disease 1298
McClanahan, W. S. Tvphoid secondary in-
fection 220
MeClintock. Charles T. The outlook in
scrum-therapy 4
MeCurdy, Stewart L. Resection of humerus
and wiring: easeof wiring clavicle for
ununited fracture 548
McDaniel, E. D. The prevention of war and
tile promotion of peace in relation to
State medicine 458
McDonald. Dr. Carlos F 614
McGill alumni at New York 1215
Mclntire. Charles. Health boards as dis-
turbers of the peace 156
McLanthlin. H. W. Report of a case of
chronic tuberculous peritonitis . ... 67
Meany. William B. A few paragraphs on
affectionsof the lachrymal apparatus. 1029
Measles and diphtheria in Sioux City. . . . 873
excessive mortality by 554
in London, havoc by 889
prevention of . 553
treatment of 655
Medical appropriations by the fifty-second
congress 56
charities, bequests to 973
college appointments 110
College of Alabama 624
College of Georgia 627
College of Indiana 629
College of Ohio. Cincinnati 637
College of South Carolina, Charleston . 639
colleges of the United States, the. ... 624
council of Pennsylvania 58
Department Columbian University. . . 626
Department Georgetown University . . 626
Department Syracuse University .... 880
Department Tulane University of Louis-
iana 630
Department University of Tennessee,
Nashville 640
diplomas in Michigan 719
education 781 822
education in America; its past, present
and future 1265
education in the United States; a brief
history 1098
examinations, preliminary in Pennsyl-
vania 447
PAGK.
Medical examiner, construction of repre-
sentations to \ 1123
examiners appointed 160
expenses, to recover 721
expert testimony !»21
expert testimony and proposed relative
legislation, remarks upon 677
expert testimony, the necessity of reform
in . j, 686
grievances
hardships in Russia, alleged 560
inspector for schools
journal enterprise in Paris
journal in Havana, cessation of a . . .
longevity SCO
London S3
Paris 1S7, 711
practiceact of Illinois '.'72
practice and its relations to the public
health, what constitutes true clinical
experience in 511
profession and the public, the mutual
relations of the 509
profession, lay distrust of the 1069
profession, relation of the, to the public 132.",
profession under the Roman Empire ISM
tuition free 986
Vienna and Heidelberg, 1066
Medicine man of the Congo, the. . ... 827
the evolution of, and new methods of
medical teaching 88]
the influence of the Jews on lion
Medicines, absorption of, by the vagina. . . 974
Medico-chirurgical College, Philadelphia. . 680
Medico-legal case affecting a young German
practitioner 282
Medico-literary noles 77»
Mediums, culpability of. in suggested
crimes 1815
Megaloscope, the 739
Membranous bronchitis, chronic 961
Memphis Hospital Medical College. 640
Menstrual nervous troubles, treatment of,
with injestion of ovarian tissue. ... 57
Mental automatism 58
fatigue and exercise 1311
Mencantile marine medical service of Great
Britain. . 1810
Merck's American Medico-Surgical Bulletin. -
a sneer from 391
Methylene green for staining nerve termi-
nals in the muscles 87s
Metropolitan throat hospital, New York . . 57
Mettler.L. Harrison. Anglo-neurotic eden
L. Harrison. Insanity in court 680
L. Harrison. Medical London. Notes
from my sketch book S3
L. Harrison. Medical Paris. Notes from
my sketch 1 k. 487, 711
L. Harrison. Medical Vienna and Hei-
delberg 1056
L.Harrison. Paracelsus 920
Mexico, experience of an American phy-
sician in 705,123.".
Mexican exchanges, our 280
Miami Medical College, Cincinnati 687
Michigan College of Medicine and Surgerv.
Detroit rsrg
health ill, July, 1896
medical legislation league, the
State legislation league. Letter No. 3. . 143
State Board of Health 989
Michigan's progress, attempt to copy. . ,
M ie robes, pathogenic. 11011 -excretion of, with
the perspiration 156
Middle ear suppuration, mastoid and Intra-
cranial complications of 113
Midwives in Chicago, regulation of SSI
Milk cows, examination of 3S8
infection, acute 324
low temperature Pasteurization of . 381, 1106
sterilized, the distribution of, in New-
York and Brooklyn 823
Milkmen, when licensing of, not authorized. 978
Million dollar prize, a 16S
Ministry of health, the 1259
Minnesota coroner's fees 430
" Mirror," the, reflects 1302
Missouri, higher education in 719
Medical College, St. Louis 633
rule as to burden of proof of insanity . . 168
Mitchell, Hubbard Wlnslow. A new treat-
ment of phthisis 362
Money paid for partnership not recoverable. 1315
Monocular fixation, the field of.and its rela-
tion to heterophoria . . 1130
Monongahela valley, the 335
Montgomery. E. E. Puerperal fever; its pro-
phylaxis and treatment 231
Liston H. Argumentsfavorlng a depart-
ment of public health 465
W. T. Electrolysis in the treatment of
detached retina 702
Monster, composite, report of a case of . . .1238
Moore. James E. Diagnosis of knee-joint
affections 661
Morbus Basedowi a neurosis 325
Morphin antidote to eyanid of potassium. . 916
identification of, in toxicologic cases. . 213
Morris, Robert T. Lay distrust of the medi-
cal profession ...'.. 1069
Mortality by casualty from an insurance
standpoint 278
«
INDEX.
vn
r LQB.
Mortality, midsummer, ;• t Philadelphia.. . 507
low rate of 11211
report of Connecticut for August ■ ■ • "<::
Motor oculi and ciliary ganglion, relations
between the . . 1360
Mudgett, HermairW., alias II. II. Holmes . . ■"><»)
Mullius. George Lane. Was Goldsmith a
physician? 838
Multiple subcutaneous gumniata— fatal ease
or. . ia»8
Muu>. g. B. Tetanus treated with antitctanic
scrum l'-IU
. the hones shaped by the pres-
sure of the 170
Muscular current, the effeol of stretching on
the negative varlatlonsof the. . 1817
Mvlts. Robert Cunningham. Surgery of the
nasal vestibule with reference to oer-
tain forms of stenosis and facial dis
Bgurement 686
a, removal of the lens in
Naboosis, improved method of 136
Narcotism, the psychology of 796
Nasal accessory cavities, uiseases of the, . 1294
oavity, malignant dlseaseof the showing
tin- value Of earl; 644
hydrorrhea 69?
speculum, a new self-retaining 66]
the
Naval hospital. New York 1816
Navy, animal report of the Surgeon-General
" of the 977
Nelson, CD. Albumin testing 877
Nephrorrhaphy, the limits of mi
Nephrectomy, with clamp forceps instead
mires 269
Nephr larlatina, treatment of. . .1018
venesection in . . . . l].\s
Nervous diseases, functional, etiology mid
prophj laxis of ■•....
Neurasthenia, angina pectoris in 186]
Franklinization as a therapeutic meas-
ur,' In ,, 1048
the nature of • • ■ 11
treatment of 1166
Neuritis from compression of the ulnar
nerve by the bicycle 157
cured by local compression wis
Neuroses, common, points in the diagnosis
and treatment of 1077
Newman. Henry 1'. Stenosis of the cervix
'actor in uterine disease 187
Newton, Richard C. Medical education . . 822
Richard C. ntir journal .- is
paper rallies 42
New .Mexico as a health resort 582
New Orleans University, Medical Depart-
ment 630
New York County medical association . . 228
Greater, no shade for .">]
Polyclinic Medical school ami Hospital. 635
Post-Graduate Me,!,, -a! School. . . .226, 685
quarantine, improvements at the . . . . 77:;
ilth of 106
; ra I'niversity, Medical Department.
Buffalo. N. Y 686
dycerin, dosage of 1159
. Charles P. Drainage versus radical
operation in the treatment of large
pelvic abscesses 303
Noise, a society for the prevention of , . . 77::
of city, can not regulate by Injunction . 1857
Normalphysi indaTdsin Mexico . . 973
North Carolina Medical College. Davidson,
N.C 637
western I niversity Medical School,
Chicago 627
University Woman's Medical School,
Chicago 628
\ •-< and throat, the electro-cautery snare
excising agent in diseases of the. 730
and throat, uncommon accidents fol-
lowing operations on the 699
Not liable for removal of injured cm). love. . Ill
Noyes, Guy L. Test for albumin 335
Nurses as non-experts 559
trained, in California 925
Necholog v .
Auawalt, James VY 618
Anderson, George Botibright 878
Anderson, S. T 449
Anderson, William t . . . 62
Arey. Clarence O 449
Barkley, Joseph 225
Baumaun, Eugen 1259
Baxter. John Springs 1021
Beebe, Richard 1021
Benedict. William C 608
Benkendorff, Edward 772
Benson. J. L 661
Bernacki, Charles 772. 1215
Betton, George W 1120
Beverly, P. H 772
Blouse, J. A 613
Bottomley. S. H 279
Brennan. Daniel H 449
Bricker. William R 721
BrowD. Walter P . 1021
Bucnaoan, Alexander 991
PAGE.
Caldwell, William C 825
Callander, Jobs 11
Campbell, William K 556
Cardcu, P. 8 ... MB
Chaffee, c. C 449
Chalklcy. Charles H ^■il
Chancellor, James Edgar 721
Chapin. llci.ry c ii«9
Cheney, Oscar 11 mio
Chontc. George C. Sbattuck 108
Cochran, Jerome 118
1 liouia< Ferris 62
Corwlyou, Lawrence c 391
Curtwell, Simon M 149
Davis, Henry Gasaet ... IBiU
Dawson, John Lawrence 772
Day. Labury M titii
Decker, Dayton E 449
Meson's. Aruiand BIS
Dunlap, .lames 1-19
Dunn, K. L 226
Eaton, William 878
Ellsworth, l'iuckney Webster 1.(10
Knchsen. John Eric BSE
Fnrrington. Edward B 721
Kitield. William Craueh Bond 721
Fisher, Walter 52
Flood, Charles S 1860
Foster. Thomas A I860
Kurraan. Guido i860
him.-, Therou Z 279
Grant lies J. A. S 608
Griswold, Elisha 878
Grlswold. Samuel '22t;
Haekett. Colin J 1860
Hance, F. W 721
Hanoi. Professor . 1259
Hard rich. Herman 1020
Henderson, George R 608
Henot, J. 1, 449
Hertzog, Dr 1818
Hildreth, Charles Lolin Ml
IIodgen.Harrv A 1169
Hollemhack. Henry H Wi9
Holsten, George D 555
Holt, William Morris BSD
Hope, James S 1115
Hough, Thomas L 108
Humphry. Sir George Murray 923
Hun, Thomas 52
Hunt. H. H 772
Hurlhut. Vincent Lombard 279
Hoard. Louis Octave 52
Johnson. Horatio H 449
Job uson. Sir George 1(15
Kellam, Frec.C. A 449
Kelly. William M 721
Kenny, Arthur G 109
v. Kerchensteiuer, J 878
Key, Luciuda 656
Killough, Thomas 555
K ittredge, Charles M 1119
Knoll. L. 1" 1199
Lagneau. G BBS
Lahgan, John T 11(19
Lewin, Georg R chard 1260
Livezey, Abraham 661
Mackey, Argylc 555
Matlack, William H 449
McAdam, Alexander H 721
McCarthy, Martin C 503
McClurg, John Russell Wi9
McGivern, John H 449
McKuight. Lewis 503
McLaury, William M 721
McLellan.A.C 1021
Milne. Charles 825
Mitchell. Henry Hooper 825
Monell, Joseph Augustus 503
Moritz. Schiff 1078
Morrison. Edward T 449
Morton. William Joseph 449
Mosher, D.J 721
Murdoch. James Bissett 1073
.Nell.E. M
555
Nicaise.E 613
Norris.JohnH 449
Northrop. James 449
Oldendorff. Adolph 225
Orr, Thomas S 1313
d'Sullivan, George B 1020
Pajot, Professor 555
Parker, William C 508
Pelton, D. R 1169
Perkins. William H. . . 772
Pettns, James Thomas 279
Pierce, Andrew J , 508
Piper, William A 279
Prendergast, Paul P 279
Pusey. Henry K 613
Kaymond, M. H 1021
Roberts, Algernon Sidney 508
Richardson, Sir Benjamin W 1215
Rochard, Jules 826
Rosenthal, Jacob 655
Ross, W. H 449
Rothacker, William A 449
Royal. Woodman W 508
Ryan, George W 165
Ruedinger, W 825
Rutherford, A. J 226
Sabine. Gustavus A 1214
SwJfcvJire; J. C 773
PACK.
Salzer, Henry 62
Sanford, Leonard J L8M
Seblesslnger, W 225
seot i. Joseph T 108
Selbert, John 878
Selman, J. L 108
Sexton, Samuel 225
Shaw, A. B 923
Sinhh. Curran C 449
Smith, Ellsworth F 555
Smith, Normand 503
Speir. Kobert Fleet 503
Sioltz, P.
53
Styer, ''harles 165
Taylor. William Remseu 1216
Temple. Frank M 52
Thomas. Joseph C 1169
Thomas, M. 8 225
Thompson. Levi Il'i9
Toner. Joseph Meredith 890
Tyier, Gustavus B 1260
V'lalle. Dr " 1318
Villa. Luiga 225
Walker. R. C 1021
Weinholtz, Charles H 449
Wellington, W. W 1169
Whalcv.B.H 1021
Wiley. T. B 109
Wilkes, William Henderson 721
Wilton, J. T 1215
Wintermnte, J. S 1120
Wood.E.W 1H20
Woolley, Charles N 1860
Wooteri, William Turner 775
Worthington. J. C 565
Young, Matt 661
Obstetric forceps, new 1358
Obturator, hernia, a point in differenti-
ating 493
Ocular muscles, the coordinations of the . . 1179
Oculists and aurists, unqualified, the British
law as to 1363
and opticians, the relations existing
between 35
Ohio hoards of health to regulate plumbing. 1167
charitable societies can Sell real estate. 722
institutions to be inspected 723
lawas topuhiicbuildingsextended . . . 718
Medical I'niversity. Columbus 638
Ohio's new electrocution law 723
Ohmann-Dumesnil, A. H. Treatment of
herpes zoster 1273
Oligemia as a cause of death in pneumonia. 1248
Omaha Medical College. Medical Depart-
ment University of Omaha 634
"Omnibus physicians" 1023
Ontario hoards of health must act for them-
selves 718
Ophthalmia neonatorum in South Carolina. 335
neonatorum, painless treatment of . . . 924
neonatorum, prevention of 824
Oppenbetmer drink cure in Bellevue Hos-
pital and Gen. O'Beirne's letter.. . . 3S4
Optic atrophy 57
nerve atrophy from toxic agents 988
nerve atrophy in general disease, the
occurrence of 892
nerve atrophy of cerebral origin, ob-
scure cases of 988
nerve atrophy of obscure spinal origin . 948
nerve atrophy, treatment of IJ81
Orchotomy, mania following; successful
treatment with testiculin 1024
unilateral ' 552
Oregon insane asylums, one location for . . 1314
opium law constitutional 282
Orphol 94
Orrhotherapy in diphtheria 1
Ortho- anripa'a-chloro-phenol 728
Otitis media, acute, modern pathology and
treatment of 1281
Otorrhea, chronic. permanently cured with
trichloroacetic acid 437
Ovarian 'pockets" 1260
therapeutics 1260
tumors complicating pregnancy 590
Overlock. S. Burden. A testimonial to Prof.
N.H. Davis 48
Overstudy in the young, evil results of . . . 404
Ovary, mixed tumors of the 813
Oxycvanid of mercury; ophthalmia neona-
torum 437
Oxygen, the use of, after ether in surgical
operations 777
Oxygenized chloroform Ill
0zena,8ucces8ful treatment of, with ichthyol 603
treatment of, with the antidiphtheral
serum 765
Ozone in tuberculosis 1166
Pain, woman's inferior sensitiveness to. . . 777
Pan-American Medical Congress,104,666,S29, 1817
Papain, indicitlons for use of 646
Paquin, Paul. Tubercle antitoxin or anti-
tuberculin 125
Paul. Sero-therapy in tuberculosis. . . 365
Paracelsus 920
Paralysis: delayed after the use of the
antldiphtheritic serum 488
general, a study of Dhe blood in 118
Vlll
INDEX.
,__, . PAGE.
laralysis, Infantile, arthrodesis in 1007
infantile, cerebro-surgical relations in . 1006
infantile, clinical aspects of 960
infantile, contagious and infectious dis-
ease, etiology of 958
infantile, craniectomy in 1008
infantile, forensic aspect of 1004
infantile, eye symptoms In. ..."•• . 960
infantile, mental aspects of , 1004
infantile, obstetric aspect of 959
infantile spinal, orthopedics in 1009
infantile, surgical and orthopedic aspect
.of 1006
infantile, syphilitic aspect of 959
of the soft palate 1804
transient bulbar, caused by malaria. . . 96
Paracelsus, the monument of 878
Parasite, a new 557
and host" 1115
of malaria, the flagellate form of the . . 1217
Parasitic cutaneous diseases in Russia, two
„ new 57
Parenchymatous goitre treated with hypo-
dermic injections of Durante's solu-
tion of iodoiodid 56
Paris exposition of 1900, medical service at
_ , the 392
Park, J. Walter. Medico-legal aspect of eye
and ear cases • • • . . 1283
Parker, W. Thornton. Evil results of over-
study in the young 404
Parks, W. B. Circumcision not necessarv
in young children 1176
Parturition, chloroform and ether in . ... 878
Passengers, sick, duty to 396
Pasteur, a characteristic anecdote of ... . 506
homage to 665
monument committee of the U. S. ... 461
Pasteurism— the new religion 226
Patch. Edgar L. Pharmaceutic notes. . . . 304
Patent and copyright laws, the eminently
scientific nature of our 434
medicine announeements.the indecency
of---,- 398
medicine scandal at Bellevue Hospital.. 282
Pathogenic bacteria in suspected waters,
differentiation of 386
Pathomental effects of degenerative habit, a
note on 842
Pattee, Asa Flanders. Clinical notes upon
spasmodic torticollis; with special ref-
erence to treatment 59
Pedicle ligature, a new figure of-8 707
Peeples, D. F. Unilateral orchotomy. . . . 552
Pellotiu, a cactus alkaloid • • . . 226
anew hypnotic 494
Pelvic disease, the prevention of 1269
diseases and their principal causes.. . 811
inflammations, acute, prevention of sup-
puration in 667
Inflammation, most potent causes of . . 812
suppurations, American methods of
treating 878
Pennsylvania Hospital annual report . . . 780
State quarantine board 878
Peppermint king, the 728
Percussion of the vertebral column, diag-
nostic value of 765
Pericarditis, chronic, simulating cirrhosis
of the liver 1012
Pericardotomy 156
Perihepatitis and pleurisy resulting from
,, . injury 86
1 entonitis accompanying typhoid fever,
snrgical intervention in 1249
acute diffuse, surgical treatment of - . . 167
acute, produced by pneumococcus . . . 490
Peri-uterine phlegmon or pelvic cellulitis,
non-surgical treatment of 1014
septic diseases, treatment of 814
Personal injury case, examination and evi-
dence in 1075
1 ertussis as a neurosis 901
treatment of * 493
Pessaries, on the misuse of 924
Peterson, Reuben. Hysterectomy as an ac-
companiment to bilateral removal of
the appendages 294
Reuben. The prevention of pelvic dis-
ease 1269
Petit mal in children 936
Petroleum from linseed oil 723
Pettyjohn, E. S. Constipation; some of its
effects, and its non-medicinal treat-
ment 247
E. S. Erb's primary muscular atrophy. 1140
Phugocytosis in malaria 155
Pharmaceutic notes 804
Pharmacologic investigations by the Ameri-
can Medical Association and the Amer-
ican Pharmaceutical Association ... 141
Pharmacy, how much should be taught in
medical colleges? -128
the practice of, as a liberal profession . 74
Pharyngitis, chronic 492
local applications in 488
I'helps, E. J. Civil service commission . . 502
Phenic acid, traumatic tetanus cured by . . 1247
Philadelphia municipal home for consump-
tives proposed 879
Polyclinic and College for Graduates in
Medicine 689
Phlyctenular keratitis, treatment of ... . 655
PAGE.
Phonendoscope the 615
Phosphorus necrosis 826
workers in i elation to life insurance . 829
Photograph evidence 974
Phthisis, a new treatment of 362
pulmonalis, treatment of 609
reported rapid recovery from under the
Maragliano serum 548
the open air treatment of 95
the significance of the Diazo reaction in. 925
Physician, duty of the, to the public .... 459
the, and the criminal 788
Physicians as pauperizing agents 407
can testify as to stains 615
cards 660
commended under unusual circum-
stances 670
for Indians, authority to employ .... 112
in Cuba, scarcity of 1360
registration of, in Massachusetts 1361
who can not recover for services .... 170
Physiologic study, the value to the medical
student of 621
Pica or dirt-eating among children 211
Pierce, Norval H. Modern pathology and
treatment of acute otitis media . . . .1284
Pistol shot wound of abdomen 1146
Place, O. G. Non-alcoholic treatment of
consumption . . 478
Placenta previa 1012
Pliny's botanic gardens and some later at-
tempts 1815
Plenge's method of hardening with formal-
dehyde and making frozen sections for
rapid diagnosis 57
Pleural ectopic gestation 226
Pleurisy, Lewaschew method of substituting
salt solution for the effusion in . ... 437
Pleuritic effusions and their treatment. . . 756
Plumbing, bad, in New York 61
Pneumatophor, the 1814
Pneumonia, acute, treatment of, with Injec-
tions of artificial serum 168
oligemia as a cause of death in 1248
treatment of .1248
treatment of, with Inhalations of it m vl
nitrite 1018
Poison in black hair dyes 50
in normal urine, traces of 723
'* Poisoning of a people, the" 1S60
Policemen trained in care of sick and
wounded 969
Polyarthritis deformans, progressive, mod-
ern treatment of 711
Population, another shrinkage in " esti-
mated" 50
Porokeratosis 1025
Portable compressed air apparatus and
nasal saw 735
Portman, Adeline E. Idiopathic choroiditis. 891
Postmortem examinations in South Caro-
lina, fees for 392
Post-Graduate Medical School and Hospital,
Chicago.. . . • ■ • 628. 665
Potas8inm,iodid of, actinomycosis treated by 98
Powell, Theophilus O. Increase of insani-
ty and tuberculosis in the Southern
Negro since 1860 1185
Practice, to prevent illegal, in New York
city S88
Practitioner, general, narrowing field of the 710
Pregnancy, early diaguosis: Hegar's sign. 493
following salpingo-oophorectomy. . . . 388
ruptured tubal, symptoms, diagnosis
and time for operation in 196
Pregnant uterus, tolerance of the 156
Premises that menace public health. . . .1356
Preparations, solid, for internal use 601
Prescription writing and pharmacy as prac-
ticed in our large hospitals' and dis-
pensaries 142
Price, Joseph. Symptoms.diagnosis and time
for operation in ruptured tubal preg-
nancy 196
Prisoners, mutilation of 776
Private patient, no appeal from commit-
ment of 115
Privileged communications, the necessity
of granting 1271
Professional complaints 717
Prolapsus ani ' • ■ 4&s
ani, new treatment of 1205
uteri, treatment of 1302
Promotion 972
Prostate, enlarged, dangers of the opera-
tive treatment in 961
hypertrophied. castration and ligating
the arteria iliaea interna for 1205
hypertrophy of, treated by castration. . 493
Prostatic hypertrophy 433
Prostitute, the female criminal and the. . . 718
Providence sewerage system 969
Pruritis ani 438
Pseudo-erysipelas after the instillation of
1-120 grain of atropin 57
-parasitic Infestation, a rare form of . . 115
Psittacosis 1166
Psycho-neural factor in surgery, the .... 955
Public institutions, advice to inmates of. . .335
Puerperal eclampsia, intravenous injec-
tions of saline solutions in 1107
eclampsia, some suggestions on the pro-
phylaxis and management of 242
PAGE.
Puerperal eclampsia, veratrum viride in . . 604
fever; its prophylaxis and treatment . . 281
infection ; its pathology, prevention and
treatment 234
Pulsford, Henry A. A case of syphilis In a
young girl 1196
Punton, John. Etiology and prophylaxis of
functional nervous diseases 948
Pupil, action of the, and relation to disease. 228
Purdy, Charles W. Managementof diabetes. 1280
Pus tubes, how to remove, without rupture. 190
Pyelophlebitis; operation; death 319
Pylorus, catheterization of the, through the
mouth 493
Pyoktanin, a clinical note on the use of. . 1042
Quarantine, British, the abolition of. . . . 823
local, decision relative to 277
orders, annual 106
station for Northern New Jersey .... 77:;
Quadriceps extensor, rupture of 112
Quinsy; differential diagnosis and treat-
ment 997
Rachitic chest deformity in twins 1102
Rachitis and humidity, connection between. 665
Radcliffe, S. J. Pertussis as a neurosis . . .901
Rags, importation of 1166
Randall, B. Alex. Differential diagnosis be-
tween simple glaucoma and optic nerve
atrophy 989
B. Alex. Extra-dural abscess from mas-
toidempyemta 571
Ransom, J. B. Medical expert testimony. . 93]
J. B. The physician and the criminal . 78.N
Randolph, Robert L. The anatomic changes
in two cases of retinal detachment . . 7.17
Rape In Virginia 280
Ravogli. A. Treatment of lupus vulgaris by
means of electrolysis 1193
Roy, Dunbar. Primary inflammation and
abscess of the mastoid 572
Rear tenements, crusade on 338
Rectum, conditions which may simulate
organic obstruction of the 759
Red cross, report of the 1096
Reed, Boardman. The frequent dependence
of insomnia, mental depression and
other neurasthenic symptoms upon
disease of the gastrointestinal tract . 62
Charles A. L 668
Refraction, some interesting points pertain-
ing to 1097
work, a prevalent error in 1115, 1313
Regents control 777
Reik, H. O. Etiologic factors, other than
myopia in the production of retinal
detachment T88
Reilly, F.W. Not antitoxin 164
Renal surgery 1205
Rrnipuncture in treatment of albuminuria. 1247
Respiration, importance of the chemistry of
the, in diagnosis and therapeutics . . 1317
Respirator, new, for factory workers . . . . 501
Respiratory advantages, modern 528
Restrictions upon evidence of attending
physician 1074
" Resultant tones," study of, and their
acoustic phenomena 1361
Retina, detached, electrolysis in the treat-
ment of 70S
treatment of detachment of tin Tin
Retinal detachment and edema occurring
in chronic Bright's disease 742
detachment, etiologic factors, other
than myopia, in the production of. 788
detachment, the anatomic changes in
two cases of 787
Retrovacclnation, successful 823
Reynolds, Arthur Rowley. Degeneracy; its
causes and prevention 953
Dudley S. Granular lids 1276
Rheumatic iritis 870
Rheumatism, articular, the micrococcus of. 158
how to cure 202
the whale, for cure of 1*8
Rhinoplasty, new method of 1803
Ricketts, B. Merrill. Enchondrosls 439
Ridlon, John. Some unusual congenital
deformities 597
Robinson, Byron. Controversy over Harvey
Medical College 1165
Roe, John O. Stricture of the upper portion
of the trachea successfully treated by
divulsion through the larynx 727
Rochester death report 447
Roentgen photographs of vesical and renal
calculi 08
ray, increased intensity of the lltO
ray, new application of the fluorescent
screen 981
ray visible to insects 168
rays in the witness box 168
rays, location of foreign bodies in the
eye with 961
rav. sensibility of the eye to the 1360
Root, Eliza H. Report of a case of compo-
site monster 1238
Rosenthal, Edwin. Serum-therapy in diph-
theria "
INDEX.
IX
PAGE.
Boy, Dunbar. Optic nerve atrophy of ob-
soure spinal origin ■ 943
Rubella 95
Rubl>er foot, a new 1287
. . 11. 11. Joint pharmacologic in\ i
on by the American Medical Asso-
on ami the American Pharmaceu-
tssociatton Ill
Bosh Medical College, Chicago 628
Medical College, annual dinner 153
i. an echo from 167
Russian superstition, an ancient 776
doctors, customs of 11'-"
larln solutions, hypodermic alimenta-
tion with , . 60S
"Sadism." or sexual perversion with violent
tendency, a oase of 763
Safe drinking water for travelers 663
in lien of fees 1257
Salicvilc medication through the skin, expe-
rience with 869
Salol ill progressive pernicious anemia . . .1107
-. suppurative, pathology and
lent of - 76n
dissolved, the toxic action of, and
their electrolytic dissociation 138
of copper, the use of. in the manufacture
of canned vegetables 50
Lamination in England S88
■lambing for Toledo, Ohio 336
prisons for Paris, Improved 447
regulations In Brazil 1287
rules for mothers 447
roles for schools in Indiana 775
triumph, a; swill-feeding enjoined at
Philadelphia. .' 1120
■ma. cure of, in Algeria by native doc-
tors 450
of the choroid 846
primary, of the tail of the pancreas . ..1240
Sattler, Robert. Excessive hemorrhage after
enucleation of eyeball 1093
ne Interesting points per-
'taining to refraction 1097
s, best treatment of 1347
Scarlet fever, a mild epidemic of, at Louis-
ville 491
fever, arsenic In 766
fever in Brazil, epidemic of ...'... . 1120
Schachner, August. Transfusion, infusion
andanto-transfusion; their compara-
tive merits and indications 587
Schmitt. F. A. 'The poisoning of a people". 1255
eld, A. E. Pistol shot wound of abdo-
men 1146
■ Is, public, high pressure process of
teaching in our 1034
the daily medical inspection of, in a
great city 923
c neuralgia, mechanical treatment of. 765
ledlcine and pharmacy in China,
progress of 762
amin. therapeutic value of 112
utus, infantile 982
v. infantile 214
,-, J.T. Intoxication and insanity . . 691
-. prevention and cure of 386
i, a medical man's experience at .... 395
Senn. K. J. t.astrostomy by a circular valve
method 1142
E. J. Pathology of synovitis hyperplas-
tica granulosa of the shoulder joint. . 541
N. Ideal catgut sterilization 1219
N. Tuberculosis of the male genital
organs 182, 257
- of the newborn 835
Serocysts. injections of carbolic acid in . . . 283
Serum, artificial 1348
antidiphtherial, results from, at Edin-
burgh 381
artificial, for washing out the serous
cavities 1012
artificial, subcutaneous injections of, In
anemia and septicemia 281
diagnosis of typhoid fever 1107
from convalescents, treatment with. . . 325
Serum-therapy 914, 989,1019
in diphtheria 11
in disease 472
in tetanus 1339
the outlook in 4
of typhoid fever 1107
theory of; contribution from the bacter-
iologic laboratory of the city of Phila-
delphia 26
tragedy at Berlin; official report of . . . 94
treatment of cancer, further experi-
ments with 655
treatment of diphtheria in Cracow . . . 56
treatment for sheep rot 168
treatment of Oriental plague, success of. 603
_-e farms, dangers from 106
ne Medical College, University of the
South, Sewanee, Tenn 640
pc, Norville Wallace. Electric trau-
mata; their peculiarities and treat-
ment 995
-tid, Thomas H. Observations made
during the treatment of chronic catar-
rhal deafness 645
PAGE.
shuw. W. E. A plea for conservative treat-
ment of carbuncle IU|
Shepard, Charles H. Chairman's address.. 286
Charles H. Public Turkish baths needed 117
Charles H. Teaching temperance in pub-
lic schools 623
Shinumek, F. A new flgure-of-8 pedicle lig-
ature 707
Short, O, J. Treatment of optic nerve
atrophy 1184
W. H. High pressure process of teach-
ing in our public schools considered
from a medical standpoint 1034
Shorter, J. H. Malignant disease of the
nasal cavity, showing the value of
early diagnosis 64-1
Sliurly, E. L. Reply to Dr. Maclean's "Open
letter t«i the members and friends of
the medical profession (regular) in
Michigan" 276, 387
Sick passengers, carriers of 1216
Silico-fluoria of mercury 665
Simonton, A. C. Location of the Journal . . 221
Silver as an antiseptic 1160
craze, the 892
Skiagraphy 118
of the Emperor 269
Skin and cancer hospital, the New York . . 506
diseases of the, notes on some of the
newer remedies used on 1125
effect of the X ray on the 777
tubercular disease of the, excision and
skin grafting for 1228
skinner, G. C. Dermatitis from X ray . . .1070
Skins, dangers of handling 823
Slack, Henry R. Prescription writing and
pharmacy as practiced in our large
hospitals and dispensaries 142
Slagle, C. C. Diagnosis in diseases of in-
fants and children 831
Smallpox and yellow fever in Cuba 106
at Marseilles 828
In Cuba OB
Indian treatment of 1360
in Texas 51
New Orleans free from 447
prevention of 346
Smith, Frank Trester. The use of caustics
for epithelioma of the lids 744
Sodium chlorid, keratolytie effect of ... . 1248
hyposulphite antidote for malonic
nitrite 487
Soft palace, paralysis of the 180-1
Solidified casein casts and improved band-
ages 667
Somatose increases the lacteal secretions
and improve? the blood 487
Sore eves, epidemic of 388
Souchon, Edmond The methodic descrip-
tion of a surgical disease 80, 148
South America, international privileges to
physicians iu 1260
South Carolina boards of health, vacancies
in 391
Southern Medical College Association ... 624
Spanish language, the, and the P.-A. medi-
cal cougress 771
Spasmodic torticollis, clinical notes upon,
with special reference to treatment . . 69
Specialist, no duty to provide 169
Speculative evidence 449
Specimens, new method of preserving, with
the original coloring 604
Sphacelotoxin,the active principle of ergot. 1074
Spinal injuries in infants 902
Spine, straightening the, by wiring the
spinous processes together 766
"Spitting'' in Indiana 278
Sponge grafting in the orbit for support of
artificial eye 95, 991
Stanley, the explorer, the health of 1215
Stanton, Dr. 8. C 972
Staples, Franklin. Concerning medical ed-
ucation in the United Slates; a brief
history 1098
8tarkey, Horace M. The business committee 220
Starling Medical College, Columbus, Ohio . (I3S
State Medicine in Pennsylvania and how we
may increase its efficiency 468
State medicine, the prevention of war and
the promotion of peace in relation to. 453
State University of Iowa, Medical Depart-
ment 629
Statkiewicz, W. The Polish physicians of
Chicago 610
Stenosis of the cervix as a factor in uterine
disease, a note on 187
Sternberg, Surgeon-Qeneral. Annual Re-
port 911
Stewart, Douglas H. Physicians as pauper-
izing agents 407
F. E. The eminently scientific nature
of our patent and copyright laws. The
Klebs antiphthislu case 424
F. E. The practice of pharmacy as a lib-
eral profession 74
Stickler. Joseph Wm. An experience with
antitojin with instructive results. . . 20
Stigmata hereditary, the etiology of 1020
Stirling, Alex. W. On bony growths invad-
ing the tonsil 734
Alex. W. On certain subjective visual
sensations 1181
PAGE.
Stirling, Alex. W. Some questions relating
to glaucoma 1040
Stoakley, Wm. S. About fevers 1147
Stomach and Intestines, experimental ex-
tirpation of the 646
and rectal tube, use of the, in children.. 981
effect of warmth on the secretions of the 156
fistula, new method of making a 1107
the normal, investigation of ihe HC1 se-
cretion and motility of 228
treatmentof Inflammatory disease of the 756
Stone, I. 8. How to remove pus tubes with-
out rupture 190
Storer, Horatio R. The memorials of Ed-
ward Jenner 312
Stover, G. H. Treatment of gunshot wounds
of the lungs 153
St. Louis College of Physicians and Surgeons 688
tornado, aftermath of the 51
Straw charcoal with boric acid as an anti-
septic 771
J. R. Anew self retaining nasal specu-
11 lu 111 661
Strangulated hernia i . ! 824
street noises injurious to health 106
Stricture, urethral, the silk ligature (n . . . 88
Strueh, Carl. Serum-therapy 1019
Strychnin, the action of, in pulmonary con-
sumption, in relation to the neurotic
origin of this disease 801
Sublimate spray as a disinfectant, cause of
inefticacy of 924
Suburethral calculi in the female 824
Sudduth, W. Xavler. The psychology of
narcotism 796
Sugar, influence of, on the energy of the
muscles 666
Suicide, valid warranty against 1122
Suicides, July 51
Suider, A. Waiter. Remarks upon medical
expert testimony and proposed rela-
tive legislation 677
Summer Rest Society, New York 1260
Sunstroke, treatment of 825
Superintendent's power to employ physi-
cian and nurse 112
Suppurations of the ear, significance of . . .1249
Suprapubic puncture, the technique of. . . 382
Surgeon-extraordinary to Queen Victoria. .1360
Surgery, a half century of 1157
gauze as drainage in abdominal and
pelvic 199
liquid salol in 392
of the stomach and intestines 89
plastic 655
renal 1205
the history of, lu tableaux 1074
the seminary method in teaching 317
Surgical disease, the methodic description
of a 80, 148
instruments and appliances out of place 156
shock, observations on 324
Sutherland, J. Lue. Gunshot wound of the
chest 87
Suture of intestines, circular, new method
of 1303
needle, a new 555
Synovitis hyperplastica granulosa of the
shoulder joint 541
Syphilis and marriage 1231
further success with serum treatmentof 547
hospital contagion of 1014
in a younggirl.acase of 1196
injections of gray oil in the treatment of 880
reinfection of 666
successfully treated by hydriatics. . . . 1224
treatment of. with mercuric iodid hemol 008
Syphilitic, wet nurse for a child of a cured. 1356
infection, unusual case of 557
Syringe, a new middle ear, mastoid and
lachrymal 445
Syringes, sterilization of 269
Society News.
Alabama, Georgia and Tennessee meeting.. 446
Allegheny County Medical Society 58
American Academy of Railwav Surgeons,
446, 771
Association of Obstetricians and Gyne-
cologists 556, 811, 802
Dermatoiogical Society 166, 505
Electro-Therapeutic Association. . . 446, 662
LaryneolOKical, Rhinological and Oto-
logical Society 972, 1170
Microscopical Society 5g
Neurological Association 40
Public Health Association, 109,891,753,
816, 864
Anderson County Medical Society 1259
Annual Congress of the Surgeons of Ger-
many 89
Association of American Medical Colleges 1214
of Assistant Physicians of Hospitals for
the Insane , . 1119
of Erie Railway Surgeons 771
of Surgeons or the Louisville, New Al-
bany and Chicago Railway Svstem . . 53
Autopsieal Society of Paris 771
British Medical Association 375,431
Orthopedic Society 92
Canadian Medical Association 391, 771
Central Medical Society of New York. ... 771
INDEX.
PAGE.
Central Texas Medical Association 280
Chautauqua County (N.Y.) Medical Society. 280
Chicago Academy of Medicine 958, 1U04, 1294. 1818
Ophthalmologlcal and Otological Soci-
ety 1009. 1152
Pathological Society 1250,1297,1844
Cleveland Medical Society 110
College of Physicians of Philadelphia, Sec-
tion on Ophthalmology 772
Colorado State Medical Society 53
Congress of Dermatology 109
of Germau Naturalists and Physicians.. 972
of International Medicine in Germany. 280
Douglas County (Wis.) Medical Society. . . 613
Easteru Iowa District Medical Association. 106
International Congress of Criminal Anthro-
pology 761
Congress of Charities, Second 924
Congress of Gyuecology and Obstetrics,
700, 865
Periodical Congress of Gynecology and
Obstetrics 109
Iowa and Illinois Central District Medical
Association 225
Lehigh Valley Medical Association 446
Lexington and Favette Couuty (Ky.) Medi-
cal Society 280
Maryland State Medical Society 53
Medical and Chirurgical Faculty of Mary-
laud 1149
Society of the County of Clinton. N.Y. . 280
Society of the District of Columbia. . . 1021
Minnesota State. Medical Society 53
Mississippi Valley Medical Association 53,
337, 505, 613, 756
Mitchell District Medical Society 91
National Association of Nurses 7a0
Sanitary Association 972
New Jersey State Medical Society 88
New York State Medical Association . . 165, 662
North Central Illinois Medical Association. 1170
Missouri Medical Association 53
Northern Tri State Medical Association . . 53
Northwestern Ohio Medical Society . .1169, 1358
Ohio Dental Society 1259
Ohio State Medical Society 53
Oneida County IN. Y.) Medical Society. . . 280
Pan-American Medical Congress 605
Transportation arrangements 556
Pennsylvania and Maryland Union Medical
Association 556
Reading (Ha.) Medical Association 613
Rui-sian National Medical Congress 109
Scott County (Iowa) Medical Society . . . . 166
second Pan American Medical Congress . . 1021
Sheboygan County (Wis.) Medical Society.. 556
Southern Surgical and Gvuecological Asso
ciation 1102,1153
State Board of Medical Examiners of New
Jersev 165
Tri-State Medical Society of Alabama, Geor-
gia and Tennessee 771
Twelfth International Medical Congress.
972, 1170.1358
Upper Peninsula (Mich.) Medical Associa-
tion 887
Utah State Medical Society 720
Virginia State Medical Society 720
Watertown (N. Y. i Medical Society 662
Wayne County (N. Y.) Medical -society. . . 225
County (Ohio) Medical Society 720
West Virginia State Medical Society .... 166
Western Ophtbalniological, Otological. Lar-
yugological and Rhinologieal Society. 135S
Surgical and Gynecological Association. 1119
Winnipiseogee Academy of Mediciue. . . . 225
Wvomiug County (N.Y.) Medical Society. . 280
Tabes, treatment of gastric crises in. . . . 157
Tanlet medication 1164
Taka-diastase. notes on 374
Talbot, Eugene S. Degenerate jaws and
teeth 1134, 1199, 1242
EugeneS. H.H.Holmes 253
Talipes, treatment of 1302
Tannigen in diarrhea 325
Tannosal 1348
Temperance, teaching, in public schools . . 523
Tendons, experimental suturing of 507
Tenements, rear, in New York city, deci-
sion relative to 278
Tennessee medical college 640
Tertiary syphilis in a child of five 1014
syphilis, statistics of 12 5
Tetanus antitoxin in Brooklyn 922
some unrecorded symptoms of 668
serum therapy in 1339
treated with autitetanic serum 1294
treatment of, with carbolic injections . 493
the antitoxiu of . 134
Therapeusis, attention an adjuvant in. . . . 128
Therapeutics of exercises 169
substantial professional advance in . . 827
suggestive, the practical uses of 131
used in . .1363
Therapy of antitoxin serum, nuclein solu-
tion and thyroid extracts 89
Thermic fever, hvpodermoclysis in treat-
mentof 1108
Thermodynamics of the muscles, study of.. Ill
Thermometer, the dumb 978
Things experts can testify to . . 1217
PAGE.
Thomas, John D. Cold baths, their use aud
abuse 1880
J. D, The silk ligature in urethral
stricture 88
Thomason, Henry D. Foreign bodies in the
auditory c«"ual 1338
H. D. Some suggestions on the prophy-
laxis and management of puerperal
eclampsia 242
Thorner, Max. Uncommon accidents fol-
lowing operations on nose and throat 699
Thrombus of the labium 281
Thymus, congenital abscess of 1346
preparations, treatment uf goitre with. 1156
Thyroid therapeutics in stunted growths. . 1802
Thyroidectomy, experimental 507
Thyroids in catalepsy 450
Tic douloureux 381
Tinnitus aurium, vascular and muscular.
differential diagnosis of 96
Tobacco, a rare effect of 66
and cholera 719
Toledo medical college, Toledo, Ohio. . . . 138
Tongue, cancer of the 1151
what is indicated by the 604
Toner. Dr., tribute to 928
Tonsil, bony growths invading the 734
Tonsils, affections of the. parenchymatous
injections of carbolic acid in . . . . 1249
Tonsillotomy, a handy form of hot snare
for 708
by cautery 700
Tooth extraction, eucain in 1206
Toxins of erysipelas, employment of the,
upon malignant tumors 760
Trachea and larynx, fractures of the . . . .1062
stricture of the upper portion of the,
successfully treated by divulsiou
through the larynx, . . . * 727
Trachelorrhaphy, improved 1174
Tiaining school for nurses wanted in Rio
de Janeiro 280
Transfusion, infusion and anto-transfusiou ;
their comparative merits and indica-
tions 587
Transportation of the wounded, improve-
ment in 728
Traumata, electric; their peculiarities and
treatment 995
Traumatic tetanus cured by phenic acid . . 1247
Trional, the hypnotic potency of 765
Trocar and cauuia with safety guard, a new. 1256
True, Rodney H. On the toxic action of
dissolved salts and their electrolytic
dissociation 188
Truss, antiqu.'ty of the 110
Tryon. Surgeon General, annual report. . . 977
Tubercle autitoxiu or auti-tuberculln. . . . 125
cultures, on healing aud immunizing
substances of 176
Tubercular meningitis ending in recovery . 924
Tuberculin, restriction of use of 1070
Tuberculosis, contagiousness of, in hos-
pitals, report of committee on 612
control of, iroma strictly medicolegal
standpoint 693
do flies spread 167
experimental, attenuated by the Roent-
gen ray 281
In animals 1257
free sanitation for 1096
hydro therapeutics of 1158
infection from food 681
latent and disguised 169
local cutaneous, cure of, by Bier's con-
gesting method 1062
Maragliano serum in 712
ot the bladder, surgical treatment of . . 962
of the foot and wrist, extensive resec-
tions for 57
of the lungs in its incipiency 881
of the male genital organs 182,257
of the spinal cord 1014
ozone In 1158
prevention of 252
serotherapy in 30o
success of ichthyol in 603
the toxin of 227
treatment of, with baths of rarefied air. 656
Tuberculous at hotels, on the management
of the 107, 655
children, new French sanitarium for, at
Saint Trojan 874
diseases, public health aspects of . . . . 4:il
pneumothorax, operative treatment of.. 1302
poor, should the State provide hospitals
for the 470
Tubo-ovarian cysts, with interesting cases. 813
Tufts College Medical sclfool. Boston. ... 631
Tuley, Henry E. Sep-is of the newborn. . 835
Tumors, malignant or viral 547
malignant, treated with toxins of erysip-
elas and bacillus prodiginsus . . .'557, 106t
two, on the bead of an infant 547
Turkish bath in mental disorders 411
baths needed, public 417
bath, therapeutic action of the 418
Tuttle. Albert H. Fibroid tumors of the
uterus: when and how to operate. . . 246
Twin extrauterine pregnancy; one fully
developed fetus of 15 years' retention. 778
Typhoid fever, alcohol or no alcohol in the
treatment of 584
PAGE.
Typhoid fever at Albany, N. Y 773
fever caused by ice cream 719
fever, etiology of 1120
fever, elimiuative treatment of 486
fever in Chicago 970
fever in North Carolina, wide dissem-
ination of 448
fever in Plymouth, Pa 106
fever in the Navy 77.:
fever, modern methods of treatment of,
criticully reviewed 806
fever, new method of diagnosing, with
serum from patient M
fever, preventive inoculation of 1257
fever, rational treatment of 310
fever, serum diagnosis of 962. 1167
fever, surgical intervention in peritoni-
tis accompanying 1249
fever treatment 48,27
in Columbus, Ohio s;;;
in Kankakee, (111.) insane asylum. . . . 71s
in Marion Couuty, W. Va Hi:)
secondary infection 220
scrum, the agglutinating substance in . 973
Typographical Union hospital 927
Tyson, James. Give full names of authors .1019
Ulcer, gastric, with perforation UM
Ulceracorneie, treatment of
Ulcers, hot compress for 156
varicose, Bekarewitsch treatment of . . L86
Ulrlch, C.F. Hygiene versus drugs . . . . 844
Umbilical hernia In infants, treatment of . . 1248
Unfortunate appointment, an 507
Unguents for insect bites 1107
University College of Medicine, Rich-
mond, Va 640,826
Medical College, Kansas City, Mo. . .
of Buffalo, Medical Department 886
of California, Medical Department. .
of Colorado, Medical Department . .
of Maryland, Baltimore ';::i
of Michigan. Ann Arbor 6 83
of Minnesota, Minneapolis 683
of Oregon, Medical Department ....
of Pennsylvania. Medical Department. . 688
of the City of New York, Medical De-
partment
of the Stateof Missouri, College of Med-
icine, Columbia, Mo 634
of Tomsk. Western Siberia 1318
of Vermont 188, 641
of Virginia. Medical Department . . . . 640
Universities, creation of , in France 668
Urethral stricture, the silk ligature in . . . 88
Urinals, oil in 888
Uriue. changes in, from medicine 761
relation of the, to disease 545
the, in diabetes mellitus
Urobilin and indiean in the urine 270
formation of 971
Urticaria, observations on 1222
U. S. Army, changes in. 98, 116. 230, 284, 340,
396, 452. 508. 562. 616,670, 724.780. 881
978, 1028. 1076, 1124, 1172, 1218, 1264. . . .1818
army, breaking up one of the hospital
corps companies
Marine hospital service, changes in. 98,
230, 886,608, 616
Marine-hospital service, circular letter, 896
Marine-hospital service, remarks rela-
tive to 471
Navy, changes in. 98, 116, 1711,280,284,889,
452, 508, 562, 611), 724, 780, 978, 1076, 1124,
1218, 1318 1886
Utah State board of medical examiners . . 186
Uterine contractions, spasmodic, during
labor, remedy for 1217
flbro-myomatous growths, degenerative
changes that occur in 236
flbro-myomata, surgical treatment of . 370
hemorrhages, efficacy of stypticin in
arresting 547
surgery, galvano-cautery in 709
Uterus, a new instrument for steadying
the, after ctirettemeut 1818
fibroid tumors of the, when and how to
operate 246
lactation atrophy of the . 214
retrodeviations 'of the. E. Wertheim's
new method of restoring through the
vagina SOB
retrodeviations of the, surgical treat-
ment of 249
rupture of; an unusual case 227
spontaneous rupture of 815
the causes of retroversion and retro-
flexion of the 158
Vaccinia remittens 1348
Vaccinate the children 223
Vaccination, antiquated methods in . . . .1309
in London neglected 774
the statistic evidences of the value of,
to the human race, past, present and
luture 671, 750, 808,857, 90s. 868, 999
Vaccine lyroph. bacteriologic contamina-
tion and the preservation of IStt
Vagina, effects of complete h\>terectomy
on the 209
primary sarcoma of the, in early life . .1198
INDEX.
XI
PAGK.
Vaginal hysterectomy 655
hysterectomy, new process of 1303
injections, hot water ~<V<
is abdominal section for small 111-
:md |>iis m the pelvis 898
Vagus, luflaenoe of the, on the kidneys. 1361
- of the leg 110
aau, George Tolly. A new operation
for the radical cure of Inguinal hernia -.Mil
Osorge Tally. Serum therapy in dis
MH 479
Vegetable meat, a ■ . 557
eotiou. homeopathy and 1361
in nephritis 1158
Veratruui viride in puerperal eclampsia.. . 604
vlriiie, therapy of 1108
al puncture. multiple 824
tumor 227
Veterlnsrj Medicine in Virginia, regulation
ot practice of 827
Vienna meoleal association 506
Viper's venom, action of porcelain filters
on 226
Virchow's birthday 776
in health law, changes in 561
itlous, certain subjective . . .1181
Vitreous hemorrhage, treatment of, by
■odium lodid 498
Vivisection, ■ UNhop upholds 498
Vomit, inn*! not go out on car steps to .ISM
Volvulus, cause and treatment of 380
w v, ; s Kit. Dr.l'arl. disclaims eonnection with
the Milwaukee University 552
Walker. Edwin. The abuse of water in sui-
l«ry 708
11. 0. Keeeut experience of surgery of
the kidney 1178
War. new weapons in, and their effect on
military surgery 91
Ward. Milo B. Gauze as drainage in ab-
d mlnal and pelvic surgery 199
Milo B. The Pan-American Medical
Congress 104
page. ;
Ware, Lyman. Report of 100 oases of ex-
motion of hard cataract 885 i
Warts, new treatment of .S24
Was Goldsmith a physician 333 i
Washington State Medical Examining Board i«8 i
University, St. Louis 888
Water • • • 818
famine among the East Loudon poor . . 560
pure US
supply of East London 1019
in surgery, the abuse of 703
tanks of city buildings, dangerous ... 504
the old-time enemies of 863
Waxham, F. E. Five hundred cases of in-
tubation of the larynx 423
Weaver, W. H. Antistrcptoooeous serum in
the treatment of consumption 542
GtO, H. Bacteriologic contamination
and preservation of vaccine lymph . . 1840
Qao. 11. Lipoma In upper end of semi-
tendlnosus muscle 1242
Weber, W. C. Early diagnosis of carcinoma
of the stomach by means of chemie
analysis of the gastric contents 70
Western insane asylum, the 1264
Pennsylvania Medical College, Pitts-
burg 639
Reserve University, Medical Department
Cleveland, Ohio 688
West Virginia, practice of medicine in . . . 661
Whooping cough, a cure for 2211
cough, result! of treatment with ich-
thyol 546
cough, sulphur baths in 924
Whiting. Ellsworth D. Malaria. 117, 205, 264, 318
Wilbur. Cressy L. Age and sex incidence of
mortality in Michigan from diphtheria
and croup 850
Willamette University of Oregon Medical
Department, Salem. Ore 638
Wilmarth, A. W. Heredity as a social bur-
den 341
Winfield, James M. Lupus vulgaris in the
wife and daughter of a tuberculous
subject 1220
PAGE.
Winslow, Charles E. Tuberculosis infection
from food 527
L.Forbes. The Turkish bath in mental
disorders 411
"Wisconsin Eclectic Medical College of Mil-
waukee " 607, 13-VI
College of Physicians and Surgeons,
Milwaukee 641
State Hoard of Health 106
Wolff, Bernard. Acutecircumscril.cd edema
of gouty origin 1275
Woman's Medical College, Baltimore .... 631
Medical College of Pennsylvania . ... 639
Medical College of the New York Infir-
mary 636
Women in medicine Ill
Wood, Casey A. A new beinoglobinoineter. 277
Casey A. The field of monocular fixation
and its relation to heterophoria . . . .1130
Casey A. Treatment of detachment of
the retina 740
Woods, Hiram. Acute non-syphilitic choroi-
ditis in young children 889
Hiram, Jr. Examination of eyes in the
public schools of Baltimore 1177
Woolen, G. V. Chairman's address 565
Wounds, healing of, among the negroes of
Africa 723
Wurdeinann, H. V. Hysteric deafness . . . 736
H. V. The occurrence of optic nerve
atrophy in general disease 892
Wyman, Walter. Remarks relative to the
1'. S. Marine-hospital service 471
Yale University, Department of Medicine.. 626
Yale's oldest medical graduate 337
Yellow fever, treatment of 961
Yemans. 11. W. Treatment of typhoid fever. 49
Young, H. B. A clinical note on the use of
pyoktsnln 1042
H. B. Crusade of education 387
Zygomatic arch, reductioti and fixation of
fracture of the 602
CONTRIBUTORS TO VOLUME XXVII.
John B. Hamilton, M.D., LL.D., Chicago, III., Editor.
EDITORIAL CONTRIBUTORS.
H. M. Bannister.
Paul Bartholow.
T. D. Crothers.
Aug. A. Eshner.
A. L. Gihon, U.S.N.
John B. Hamilton.
F. C. Hotz.
Ludvig Hektoen.
James G. Kiernan.
Henry M. Lyman.
Harold N. Moyer.
Fred. D. Owsley.
Frank W. Reilly.
J. E. Rhodes.
J. L. Rosenberger, Esq.
Charles Smart, U.S.A.
R. M. Wyckoff.
John Shrady, and others.
W. B. Atkinson.
E. B. Smith.
STAFF CORRESPONDENTS.
G. I. Cullen. E. Cushing. J. B. Eagleson. R. A. Hamilton.
H. E. Tuley.
W. Whitney. R. M. Wyckoff.
H. L. E. Johnson.
Wm. Whitford.
CONTRIBUTORS OF ORIGINAL ARTICLES.
Andrews, Edmund, Chicago, 111.
Andrews, R. R., Cambridge, Mass.
Albright. J. D., Akron, Pa.
Allen, T. H., New York, N. V.
Allison, H. E., Fishkill Landing, N. Y.
Allport, Frank, Minneapolis, Minn.
Ashmead, Albert S., New York, N. Y.
Atkinson, Wm. B., Philadelphia, Pa.
Ayres, S. C, Cincinnati, Ohio.
Bacon, C. S., Chicago, 111.
Baker, Albert Rufus, Cleveland, Ohio.
Bard well, Eugene O., Emporium, Pa.
Barker, T. Ridgway, Philadelphia, Pa.
Barr, G. Walter, Quincy, 111.
Bartholow, Paul, Philadelphia, Pa.
Batman, William F., Lebanon, Ind.
Batten, John M., Pittsburg, Pa.
Baum, William L., Chicago, 111.
Bayard, W., St. Johns, New Brunswick.
Bean, J. V., Fairfield, Iowa.
Beard, R. O., Minneapolis, Minn.
Bell, W. Jay, Atlanta, Ga.
Belt, E. Oliver, Washington, D. C.
Benjamin, Dowling, Camden, N. J.
Benson, John A., Chicago, 111.
Berens, Conrad, Philadelphia, Pa.
Bernstein, Edward J., Baltimore, Md.
Bishop, Seth Scott, Chicago, 111.
Bishop, Louis Faugeres, New York, N. Y.
Blech, Gustavus M., Detroit, Mich.
Bolton, B. Meade, Philadelphia, Pa.
Borland, E. B., Pitteburg, Pa.
Bracelin, P. M., Chicago, 111.
Breakey, W. F., Ann Arbor, Mich.
Brower, Daniel R., Chicago, 111.
Brown, Bedford, Alexandria, Va.
Brown, Edward J., Minneapolis, Minn.
Brown, George S., Birmingham, Ala.
Brown, G. V. I., Duluth, Minn.
Brown, Luther, Rockford, 111.
Bulkley, L. Duncan, New York, N. Y.
Burr, Albert H., Chicago, 111.
Caldwell, W. S., Freeport, 111.
Carstens, J. H., Detroit, Mich.
Carter, J. M. G., Waukegan, 111.
Casselberry, W. E., Chicago, 111.
Christison, J. S., Chicago, 111.
Church, N. H., Chicago, 111.
Claiborne, J. Herbert, New York, N. Y.
Clarke, Augustus P., Cambridge, Mass.
Cleaves, Margaret A., New York, N. Y.
Clevenger, S. V., Chicago, 111.
Cochran, Jerome, Montgomery, Ala.
Cokenower, James W., Des Moines, Iowa.
Colvin, D., Clyde, N. Y.
Connor, Leartus, Detroit, Mich.
Corey, A. L., Chicago, 111.
Cornick, Boyd, Knickerbocker, Texas.
Corr, A. C, Carlinville, 111. 9
Coulter, J. Homer, Chicago, 111.
Crook, J. A., Jackson, Tenn.
Crothers, T. D., Hartford, Conn.
Cutter, Ephraim, New York, N. Y.
Daniel, F. E., Austin, Texas.
Davis, N. S., Chicago, 111.
De Schweinitz, G. E., Philadelphia, Pa.
De Vaux. F. H., Valley City, N. D.
Dewees, William B., Salina, Kan.
Dewar, T. A., Detroit, Mich.
Dibrell, J. A., Jr., Little Rock, Ark.
Dixon, W. A., Ripley, Ohio.
Doering, E. J., Chicago, 111.
Doty, Maurice F., Chicago, 111.
Douglas, Richard, Nashville, Tenn.
Drake, G. W., Chattanooga, Tenn.
Drayton, H. S., New York, N. Y.
Drewry, William Francis, Petersburg, Va.
Dudley, E. C, Chicago, 111.
Dufour, Clarence R., Washington, D. C.
Edes, Robert T., Jamaica Plains, N. Y.
Ehrmann, Fred. J. E., Chicago, 111.
Ellis, H. Bert, Los Angeles, Cal.
Elliott, A. R, Chicago, 111.
English, W. S., Pittsburg, Pa.
Epley, Frank W., New Richmond, Ind.
Ernst, Harold C, Boston, Mass.
Erwin, A. J., Mansfield, Ohio.
Everts, O., College Hill, Ohio.
Fenn, C. M., San Diego, Cal.
Fernandez-Ybarra, A. M., New York, N.Y.
Fischer, Louis, New York, N. Y.
Fiske, James Porter, New York, N. Y.
Fiske, George F., Chicago, 111.
Flood, Everett, Baldwinsville, Mass.
Foster, Eugene, Augusta, Ga.
Foster, Burnside, St. Paul, Minn.
Forbes, W. S., Philadelphia, Pa.
Freeman, Leonard, Denver, Colo.
Galloway, D. H., Chicago, 111.
Garber, G. B., Dunkirk, Ind.
Garrison, Harriet E., Dixon, 111.
Gifford, U. Grant, Avondale, Pa.
Gilchrist, T. C, Baltimore, Md.
Gilpin, Henry B., Baltimore, Md.
Goelet, Augustin H., New York, N. Y.
Gottheil, William S., New York, N. Y.
Gould, George M., Philadelphia, Pa.
Gradle, Henry, Chicago, 111.
Graham, David, Chicago, 111.
Greene, F. M., Lexington, Ky.
Grinker, Julius, Chicago, 111.
CONTRIBUTORS.
Hall, J. N., Denver, Colo.
Hall, Winfleld S., Chicago, 111.
Harlan, Herbert, Baltimore, Md.
Harnden, R. Sayre, Waverly, N. H.
Hatch, Henry, Quincy, 111.
Heath, F. C, Indianapolis, Ind.
Henry, Frederick P., Philadelphia, Pa.
Herrick, S. S., San Francisco, Cal.
Higgins, F. W., Cortland, N. Y.
Hinde, Alfred, Chicago, 111.
Hobby, C. M., Iowa City, Iowa.
Holmes, Bayard, Chicago, 111.
Horner, Frederick, Marshall, Va.
Hosmer, A. J., Ashland, Wis.
Hotz, F. C, Chicago, 111.
Howard, William Lee, Baltimore, Md.
Howe, Lucien, Buffalo, N. Y.
Hughes, C. H., St. Louis, Mo.
Hutchins, M. B., Atlanta, Ga.
Ingals, E. Fletcher, Chicago, 111.
Ingraham, Chas. W., Bingham ton, N. Y.
Jackson, Edward, Philadelphia, Pa.
Jagielski, Victor, London, Eng.
Jenkins, J. F., Tecumseh, Mich.
Johnson, Joseph Taber, Washington,
D. C.
Justice, C. R., Poland, Ohio.
Kahlenberg, Louis, Madison, Wis.
Kane, Evan O'Neill, Kane, Pa.
Keller, Lester, Ironton, Ohio.
Kellogg, George M., Chicago, 111.
Kellogg, J. H., Battle Creek, Mich.
Kime, R. R., Atlanta, Ga.
Klebs, Edwin, Chicago, 111.
Kneass, Samuel S., Philadelphia, Pa.
Kollock, Charles W., Charleston, S. C.
Krauss, William C, Buffalo, N. Y.
Kyle, D. Braden, Philadelphia, Pa.
Lackersteen, M. H., Chicago, 111.
Laidlaw, G., Chicago, 111.
Lancaster, R. A., Gainsville, Fla.
Larkins, E. L., Terre Haute, Ind.
Lautenbacb, Louis J., Philadelphia, Pa.
Lederman, M. D., New York, N. Y.
Lee, Elmer, Chicago, 111.
Lewis, Denslow, Chicago, 111.
Lichty, Daniel, Rockford, 111.
Lindsley, C. A., New Haven, Conn.
Loeb, Hanau W., St. Louis, Mo.
Lofton. Lucien, Atlanta, Ga.
Love, I. N., St. Louis, Mo.
Love, Louis F.. Philadelphia, Pa.
Macdonald, Willis G., Albany, N. Y.
Maclean, Donald, Detroit, Mich.
Madden, John, Milwaukee, Wis.
Manley, Thomas H., New York, N. Y.
Marcy, Henry O., Boston, Mass.
Mason, R. Osgood, New York, N. Y.
May, Louis F., Chicago, 111.
Mays, Thomas J., Philadelphia, Pa.
McClanahan, W. S., Woodhull, 111.
McCaesy, J. H., Dayton, Ohio.
McClintock, Charles T. , Ann Arbor, Mich.
McCurdy, Stewart L., Pittsburg, Pa.
McDaniel, E. D., Mobile, Ala.
Mclntire. Charles, Easton, Pa.
McLauthlin, H. W., Denver, Colo.
McNutt, W. F., San Francisco, Cal.
Meany, William B., St. Louis, Mo.
Mettler, L. Harrison, Chicago, 111.
Mitchell, Hubbard W., New York, N. Y.
Montgomery, E. E., Philadelphia, Pa.
Montgomery, Liston H., Chicago, 111.
Montgomery, W. T., Chicago, 111.
Moore, James E., Minneapolis, Minn.
Morris, Robert T., New York, N. Y.
Muir, Joseph, New York, N. Y.
Mullins, George Lane, Sydney, Australia.
Muns, G. E., Montgomery City, Mo.
Myles, Robert Cunningham, New York,
N. Y.
Mylrea, W. H., Madison, Wis.
Nelson, C. D., Greeley, Colo.
Newman, Henry P., Chicago, 111.
Newton, Richard C, Montclair, N. J.
Noble, Charles P., Philadelphia, Pa.
Ohmann Dumesnil, A. H., St. Louis, Mo.
Overlook, S. Burden, Pomfret, Conn.
Paquin, Paul, St. Louis, Mo.
Park, J. Walter, Harrisburg, Pa.
Parker, W. Thornton, Groveland, Mass.
Parks, W. B., Atlanta, Ga.
Patch. Edgar L., Boston, Mass.
Pattee, Asa Flanders, Boston, Mass.
Peeples, D. F., Navasota, Texas.
Peterson, Reuben, Grand Rapids, Mich.
Pettyjohn, Elmore S., Alma, Mich.
Phelps, E. J. , Chicago, 111.
Pierce, Norval H., Chicago, 111.
Place, O. G., Boulder, Colo.
Plummer, G. R., Key West, Fla.
Portman, Adeline, Washington, D. C.
Powell, Theophilus O., Milledgeville, Ga.
Price, Joseph, Philadelphia, Pa.
Pulsford, Henry A., South Orange, N. J.
Punton, John, Kansas City, Mo.
Purdy, Charles W., Chicago, 111.
Putnam, B. H., Northeast, Pa.
Radcliffe, S. J., Washington, D. C.
Randall, B. Alex., Philadelphia, Pa.
Randolph, Robert L., Baltimore. Md.
Ransom, J. B., Dannemora, N. Y.
Ravogli, M., Cincinnati, Ohio.
Reed, Boardman, Atlantic City, N. J.
Reik, H. O., Baltimore, Md.
Reilly, F. W., Chicago, 111.
Reynolds, Arthur R., Chicago, 111.
Reynolds, Dudley S., Chicago, 111.
Ricketts, B. Merrill, Cincinnati, Ohio.
Ridlon, John, Chicago, 111.
Robinson, Byron, Chicago, 111.
Roe, John O., Rochester, N. Y.
Root, Eliza H., Chicago, 111.
Rosenthal, Edwin, Philadelphia, Pa.
Roy, Dunbar, Atlanta, Ga.
Rusby, H. H., New York, N. Y.
Sattler, Robert, Cincinnati, Ohio.
Savage, G. C, Nashville, Tenn.
Saxlehner, Andreas, New York, N. Y.
Schachner, August, Louisville, Ky.
Schmitt, F. A., La Grange, Texas.
Scofield, A. E.. Tilden, Neb.
Searcy, J. T., Tuscaloosa, Ala.
Senn, E. J., Chicago, 111.
Senn, N., Chicago, 111.
Sharpe, Norvelle W, St. Louis, Mo.
Shastid, Thomas H., Galesburg, 111.
Shaw, W. E., Cincinnati, Ohio.
Shepard, Charles H., Brooklyn, N. Y.
Shimonek, F., Milwaukee, Wis.
Short, O. J., Hot Springs, Ark.
Short, W. H., La Grange, Ind.
Shorter, J. H., Macon, Ga.
Shurly, E. L., Detroit, Mich.
Simonton, A. C, San Jose, Cal.
Skinner, G. C, Cedar Rapids, Iowa.
Slagle, C. G., Minneapolis, Minn.
Slack, Henry R., La Grange, Ga.
Smith, Frank Lester, Chattanooga, Tenn.
Souchon, Edmond, New Orleans, La.
Spiich, O. B., Chicago, III.
Staples, Franklin, Winona, Minn.
Starkey, Horace M., Chicago, 111.
Statkiewicz, W., Chicago, 111.
Stewart, Douglas H., New York, N. Y.
Stewart, F. E., Detroit, Mich.
Stickler, Joseph W., Orange, N. J.
Stirling, Alex. W., Atlanta, Ga.
Stoakley, Wm. S., Millboro Springs, Va.
Stone, I. S., Washington, D. C.
Storer, Horatio R. , Newport, R. I.
Stover, G. H., Eaton, Colo.
Strueh, Carl, Chicago, 111.
Sudduth, W. Xavier, Chicago, 111.
Suiter, A. Walter, Herkimer, N. Y.
Sutherland, J. Lue, Grand Island, Neb.
Talbot, E. S., Chicago, 111.
Thomas, J. D., Pittsburg, Pa.
Thomas, John D., Washington, D. C.
Thomason, H. D., Albion, Mich.
Thorner, Max, Cincinnati, Ohio.
True, Rodney H., Madison, Wis.
Tuley, Henry E., Louisville, Ky.
Tuttle, Albert H., Cambridge, Mass.
Tyson, James, Philadelphia, Pa.
Ulrich, C. F., Wheeling, W. Va.
Vaughan, Geo. Tully, Philadelphia, Pa.
Wagner, Carl, Chicago, 111.
Walker, Edwin, Evansville, Ind.
Walker, H. O., Detroit, Mich.
Ward, Milo B., Topeka, Kan.
Ware, Lyman, Chicago, 111.
Waxham, F. E., Denver, Colo.
Weaver, George H., Chicago, 111.
Weber, W. C, Cleveland, Ohio.
Whiting, Ellsworth D., Aurora, 111.
Wilbur, Cressy L., Lansing, Mich.
Wilmarth, A. W., Norristown, Pa.
Winfleld, James Macfarlane, Brooklyn,
N. Y.
Winslow, Charles E., Los Angeles, Cal.
Winslow, L. Forbes, London, Eng.
Wolff. Bernard, Atlanta, Ga.
Wood, Casey A., Chicago, 111.
Woods, Hiram, Jr., Baltimore, Md.
Woolen, G. V., Indianapolis, Ind.
Wiirdemann, H. V., Milwaukee, Wis.
Wyman, Walter, Washington, D. C.
Yemans, H. W., San Francisco, Cal.
Young, H. B., Burlington, Iowa.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL, JULY 4, 1896.
No. 1.
ORIGINAL ARTICLES.
ORRHOTHERAPY IN DIPHTHERIA.'
Kiiul before the Illinois State Meilicul Society, May, 1MW1.
1!Y K. FLETCHER INGALS, A.M., M.D.
CHICAGO.
As a result of the work of Pasteur and the numer-
ous investigations which have followed in the same
line, it is now generally believed by bacteriologists
that many diseases, especially those which seldom
affect individuals more than once, are self-limited by
the formation within the blood of a product capable
of destroying the toxic material that excites the dis-
cus.. hence called antitoxin. In such diseases if life
be prolonged until a sufficient quantity of the anti-
toxin has been developed the toxic agent is destroyed
and recovery follows if no serious complications have
arisen.
In diseases that can be communicated from man to
animals and vice versa, such for example as rabies,
anthrax and diphtheria, advantage has been taken of
this fact by inoculating animals with the attenuated
toxic principle in small but steadily increasing
quantities until an antitoxin is developed in the blood
in sufficient quantity to render the animal immune to
the further pernicious effects of the contagium.
Behring enunciated the law that blood serum
which had in this manner been rendered immune
might be transferred to another individual with the
effect of rendering the latter also immune, no matter
how suscepticle he might be to the disease. Further
investigations by Kitasato, Aronson, Roux and
Behring have determined what animals have blood
serum that produces the least ill effects when intro-
duced into the human system, and how to render a
small quantity of blood capable of producing immun-
ity in a second individual. They have also discovered
methods of preserving the serum and of measuring
its strength and purity.
Diphtheritic poison has been introduced into ani-
mals, preferably into the horse, until immunity to its
further effects has been obtained. The animal has
then been bled, the blood allowed to separate and the
serum preserved under the name of antitoxin.
Until recently the serum prepared by Aronson,
Behring and the New York Health Department was
of strength known as from 60 to 150 antitoxin units
to the cubic centimeter, the different preparations
being numbered 1, 2 and 3. Stronger preparations
are now made; No. 4 representing 200 antitoxin units;
No. 5, 300 units, and No. 6, 400 units to the cubic
centimeter. These are obtained, not by concentration
of weaker solutions, but directly from the animal that
has been inoculated. The stronger preparations are
considered quite as safe and are preferable on account
of their smaller bulk which obviates to a considerable
degree the pain caused by the large injections.
i Bee correspondence, page 49.
One thousand antitoxin units is considered the ordi-
nary curative dose, but in severe cases or those not treat-
ed until the third day, 1,500 to 2,000 units are often
employed, and sometimes these are repeated until
altogether from 4,000 to 6,000 units are administered
in a single case. The dose considered necessary for
immunizing a healthy individual is about one-fourth
the curative dose. The serum is administered by
hypodermic injections, preferably in some part of the
body where there is an abundance of loose cellular
tissue, as at the lower angle of the scapula, in the
gluteal region, and upon the abdominal or chest walls.
Dr. Chantemesse (New York Medical Record, 1896)
reports that he has had quite as good results when
administering the antitoxin per rectum as by hypo-
dermic injections.
It is generally believed that the earlier the injection
is made the better the result; still the classification
of cases by days to determine the prognosis and the
size of the dose is at fault for there is much difference
in individuals in the rapidity with which absorption
of toxins takes place and in their resisting power to
the poison; therefore, in some, injections made the
fourth or fifth day might be quite as advantageous as
those in others made on the first day, though the
earlier the remedy is used the better the result that
would commonly be expected. The rapidity of the
accession, the general condition and the age of the
patient are of more importance in determining the
use of the serum, its dose, and the prognosis to be
given than is the number of days since the onset of
the disease.
Very little interest was manifested in the antitoxin
treatment of diphtheria until 1894, after Roux had
presented the subject to the International Congress of
Hygiene at Buda-Pesth with the report of. five hun-
dred cases treated by this method. Since then many
physicians and the health departments of cities and of
national governments have employed the serum exten-
sively in the treatment of this disease. Although no
crucial experiments have been made to determine the
value of diphtheria antitoxin yet the statistics obtained
from many sources seem to prove that it is capable of
greatly diminishing the mortality of this disease. In
studying the literature of this subject I find the
majority of reports have been from many physicians
who have recorded only one or two cases. From a
perusal of these one can not help suspecting that in
many instances only the favorable cases have been
recorded. The statistics of hospitals are probably
more complete and accurate, but the statistics of
Health Boards although more extensive are likely to
be very inaccurate for many reasons.
In Dr. Foster's report, No. 7, of the accompanying
various hospital reports and published records which
I have obtained (see Table I), it was noted that all
of the cases treated on the first day recovered; of
those treated on the second day 9.3 per cent, died; of
ORRHOTHERAPY IN DIPHTHERIA.
[July 4,
\,
those treated on the third day 20 per cent, died; of
those treated on the fourth day 33 per cent. died.
The following points were noted in the report from
the London Hospitals (No. 12): First, that there
was a great reduction in mortality in cases treated on
the first and second days by antitoxin, second a low-
ering in mortality in all ages to a point below that of
any preceding year, and third a lowering of the mor-
tality of laryngeal cases over the preceding year.
In a personal letter (report No. 13) received from Dr.
Wm. M.Welch of Philadelphia regarding the statistics
from the Municipal Hospital of that city, I find that
the use of antitoxin was mainly limited to cases con-
sidered favorable that were admitted in the early
stage of the disease, that is, somewhere from the first
to the fourth day. In cases that were far advanced,
many of which were in a hopeless condition or showed
great malignancy when they were admitted to the
hospital, the antitoxin was not employed and a large
number of the cases which received the antitoxin in
the early stages were not severe. Of 302 cases receiv-
ing antitoxin 51 or 16.8 per cent, were intubation
reports so obtained were open to the sk^P1™011 of "*°*
having been accompanied by the unfav«ra repoits
which should have been published at thtf. sn-m® U™f
The observations Nos. 10 and 11 are from the Kl)i,r(ls
of Health of large cities and are very unreliable for
the reason that many physicians do not report cases
of diphtheria at all until they fear the patient is going
to die, whereas physicians who obtain antitoxin from
the Board of Health would necessarily report nearly
all cases where it is to be employed. It is therefore not
at all improbable that the percentage of mortality as
given for cases in which antitoxin was not used is tw< i or
three times larger than it should be. There are other
reasons, well known to the profession, why statistics
obtaine'd from this source are peculiarly unreliable.
In observations Nos. 4, 5, 6 and 9 the mortality
among patients treated by antitoxin is compered
with that of patients not treated by antitoxin in
previous years, and as has already been stated the
mortality varies so greatly in different years, whatever
the treatment, that very little information can be
derived from such statistics. Observation No. 12 is
Table I.
No.
Place of observation.
Treated by Antitoxin.
Not treated by Antitoxin.
Date of
Observation.
Number
of
cases.
Per cent.
of
Mortality.
Date of
Observa-
tion.
Number
of
Cases.
Per cent,
of
Mortality
References.
1
Cf.8
2
8
4
5
Kaiserin Frledrieh Hospital .
Trousseau Hospital
Wlllard Parker Hospital. . . .
Hospital for Children, Paris .
Trousseau Pavilion
Germany — Hospitals and Private Practice.reported
by Dr. Enlenberg
Collected from journals by Dr. Foster of Wash
Ington
Berlin observations by Professor Behring
Russia— Dr. Zabalatinl
1894
1804 to Apr. 18H
181*4
1894 and 1896
To Febru'ry 1895
1896
1895
New York — Dr. Louis Fisher
New York Board of Health
Chicago Board of Health
Hospitals of London, Joint Report
Municipal Hospital, Philadelphia, reported by Dr.j
Wm. II. Welch '
1S95
1895
lS'.lo
is'.,.",
308
280
164
10,240
2,740
5,800
109
200
225
138
Laryngeal
eases, Hil
I'rnle-sor Von Ranke
Mr. Lennox Browne, Northwestern Fever Hospital,
London
18.2
14.7
27.
24.23 '
under2yrs.
21.
2 to 10, 8.8
overlOyrs.
4.7
18.5
9.8
12.8
15.
15.
6.12
42.
28.14
18.
27.
1894
1890 to 1894
1894
Previous
to
1894
Same
period.
1895
Previous
records.
1894
1895
Previous
8 years.
4,445
4,479
Laryngeal
eaSeS. Ilili
47.
51.11
60.7
15.
8.8
47.86
14.
48.
25.99
27.
New York Med.
Record, 1KB.
Journal Axes.
Mkd. Ass'n.
I'll I la. Medieal
News, I1".,:,.
Journal Ameb.
Med. Ass'n.
New Yol'U Med.
Record, tetfi.
Health Report.
British Medical
Jour.. Apr., 1896
Journal Amkr.
Med. Ass'n and
private letter,
.lour. Laryngol-
ogy, Apr., 1896.
cases; of the 404 cases which did not receive antitoxin
71 or 17.57 per cent, were intubation cases. Of the
51 intubation cases which received antitoxin 27 or
52.94 per cent, died, while of the 71 cases in which it
was not received 40 or 56.33 per cent. died. The differ-
ence, therefore, in favor of antitoxin in intubation
cases amounted to only 3.39 per cent, notwithstand-
ing the greater malignancy of the disease in some of
these. In this series of cases the antitoxin was given
to those in which it is claimed to be most beneficial,
and was not given to the worst cases. Had the anti-
toxin been given in alternate cases of this group half
of the more serious cases that died without the serum
would probably have died with it, or at least they
would not have been counted against other methods
and this series would therefore have shown a record
for antitoxin considerably more unfavorable than it
does now.
An analysis of these reports shows that Nos. 1, 2,
3, 4, 5, 6, 7, 9 and 14 are very favorable to the use of
antitoxin, but the cases reported in No. 7 were made
up from journals and as already stated many of the
favorable to the antitoxin treatment on its face but i*
will be observed that the cases treated by antitoxin
were in 1895 and those not treated were in 1894.
Behring's statistics, Observation No. 8, show that in
Berlin diphtheria was very much less fatal in 1895
than in the previous years even when antitoxin was
not employed, the ratio apparently being about 14 to
40 or 50. If a similar ratio were maintained in Lon-
don for the two years of observation, No. 12 instead
of being favorable to the antitoxin treatment is de-
cidedly unfavorable; the same remark would apply to
some of the other observations, where the comparison
has been between different years. No. 15 can hardly
be considered favorable.
As an immunizing agent it is -claimed that one-
fourth the curative dose is efficient and that the
larger the dose given the longer the immunity, but
that repeated small doses are even more effectual.
The immunity is said to last from one week to thirty
days. Out of ten thousand cases thus treated at
Berlin only one contracted diphtheria. As reported
in the' Annual of the Universal Medical Sciences for
1896.]
ORRHOTHERAPY IN DIPHTHERIA.
1892 Granoher of Paris stated that in a diphtheritic
wanl in Paris among 1,741 patients admitted there
wore 153 children that did not have diphtheria at the
time, yet not one of these contracted (he disease.
This was before the days of antitoxin, and when it is
remembered that the children were surrounded in the
BUne ward by diphtheria these facts detract much
from the credit given diphtheritic antitoxin as a pro-
phylactic agent.
Several cases have been reported in which this
treatment seems to have proven deleterious to the
patient and some fatalities have already occurred. In
the Journal of the American Medical Association
April I. 1896, a fatal case is recorded in which a healthy
child died within five minutes after the injection
hail been given to protect it from contagion. Another
ease with serious symptoms in which a prophylactic
dose had been given is reported in the same Journal
April IS. and still another fatal case has just been
reported from Berlin in which Dr. Langerhans lost
his little child shortly after an immunizing injection.
Nevertherless considering the large number of injec-
tions which have been given and the few reports of
deleterious effects it must be admitted that there is
but slight danger in using the remedy as a pro-
phylactic.
There is some reason to believe that injurious
effects follow its use in remedial doses in many
instances but as has been claimed by those who favor
the remedy, it is possible that the deleterious effects
are often observed from the fact that serious cases
that would otherwise have died before the develop-
ment of sequelae are saved and that naturally in these
cases the unfavorable after-effects of the disease
would be more numerous. As stated by Mr. Lennox
Browne in his book on "Diphtheria and its Associates,"
1895, the power of the serum to do good and per
contra its capacity for inflicting injury is in propor-
tion to the duration of the disease, in other words, to
the degree of toxemia. He claims that a greater
number of children have been found liable to attacks
of cyanosis, necessitating a demand for the freer use
of nervines and stimulants, also that complete recov-
ery is found to be delayed and that unexpected fatal
results at a late period are more frequent. In the
joint report of the hospitals of London already quoted
3,040 cases treated in 1894 without antitoxin are com-
pared with 2,182 cases treated in 1895 with antitoxin.
These show the following complications:
Table II.
Treated in 1894.
Without Antitoxin.
Treated in 1895.
With antitoxin.
Number
of Cases.
Per
cent.
Number
of Cases.
Per
cent.
603
8"
24.0
1.2
13.0
.8
1.6
.9
1,081
45
507
18
80
81
40.9
2.0
408
23.0
Pneumonia,
Pneumonia,
Belapse of d
iphtheria. . . .
11
50
28
.8
8.6
1.4
The above figures show a larger percentage of com-
plications af ier the antitoxin treatment. The experi-
ence in these hospitals showed that by far the most
frequent complication was a rash, usually urticarial,
sometimes erythematous or having the appearance of
scarlatina. A rash was observed in 45.9 per cent, of
all cases. This was accompanied by fever in many
cases, amounting to 29.6 per cent, of the patients
presenting a rash. In some instances the rash per-
sisted for many days, but usually it had run its course
by the end of the third or fourth day. There were a
a few instances of effusion into the joints and abscesses
were found at the site of injection in 2.3 per cent, of
the cases.
In an abstract from the discussion at the meeting
of the British Medical Association 1895, reported in
the Journal of Laryngology, April, 1896, Dr. (xoodale
gave the following statistics, based on his observation :
Of 105 cases of diphtheria treated with antitoxin, 29
per cent, died; of 136 cases not so treated, 33 per cent,
died; albumin was found in the urine of 53.3 percent,
of the cases treated by antitoxin, but only in 49.2 per
cent, of the cases not so treated. Nephritis was not
noted in any of the cases; paralysis followed diph-
theria in 17 per cent, of the cases treated by antitoxin,
and in only 14.7 of the cases treated by other methods.
Prof. Von Ranke of Munich gave statistics of 163
cases treated by antitoxin in which there was not a
single case of laryngeal stenosis. Dr. A. Baginsky
of Berlin gave statistics of 525 cases treated by anti-
toxin in which there had been no laryngeal .stenosis.
Dr. C. V. Kahlden (Journal of the American Med-
ical Association, Oct. 19, 1895) reports that in
numerous experiments on guinea pigs and rabbits
that have been injected with very large doses of anti-
toxin for the body weight of the animal he was unable
to find any evidence of nephritis in the animals that
were killed after one or more injections.
The consensus of opinion of observers as to the
symptoms manifested after curative doses of the anti-
toxin is that the temperature may be either reduced
or rendered higher, though it appears that in the
majority of cases it is rendered somewhat lower in the
next twelve to twenty-four hours; the pulse is
strengthened and the general condition appears to be
improved in the same time; extension of the diph-
theritic membrane to other parts is checked and the
membrane commonly begins to loosen within twenty-
four hours. The remedy, however, does not prevent
suppuration of the cervical glands, does not prevent
paralysis and does not favorably modify paralysis
when it has once appeared.
Laboratory experiments have undoubtedly proven
that antitoxin, when injected into guinea pigs that
have been inoculated with large quantities of diph-
theria toxin, saves their lives, and also that immunizing
doses in these animals are not followed by bad results,
but prevent contagion for a certain period.
The reports of clinical investigations taken as a
whole are considerably in favor of the antitoxin treat-
ment. There is still, however, much skepticism as to
the efficacy of the remedy, based upon the fact that
no crucial experiments have been reported. It is well
known that the mortality in diphtheria varies from 10
to 75 per cent, in various epidemics or in different
portions of the same epidemic, therefore accurate
information can not possibly be obtained by comparing
the death rate of any year with that of any preceding
year, or even by comparing the death rate of one
month with that of preceding or succeeding months.
Until, in the large hospitals alternate cases are treated
by antitoxin alone and by other methods we will have
no certain information upon the subject. The report
from the Municipal Hospital of Philadelphia ap-
proaches nearer a crucial test than any other that I
have been able to find. It unfortunately shows a
higher death rate with antitoxin than without it; even
THE OUTLOOK IN SERUM THERAPY.
[July 4,
though the antitoxin was given mostly to those cases
which were considered to be especially favorable for its
action and in extreme conditions it wTas withheld. Until
more definite information is obtained conservative
physicians may well be excused for declining to experi-
ment upon their patients with this remedy. However,
the wide belief that it does much good and the com-
paratively certain knowledge that it does but little
harm suggests that our duty to our patients demands
that when diphtheria exists we should administer the
antitoxin if it is desired, but that at the same time
we should use such other remedies as have been
proven of most value in combating this disease; but
we should hesitate to recommend it as a prophylactic
agent.
Antitoxin certainly has not been proven a specific
for diphtheria. In estimating its value it should not
be forgotten that the bacteriologic diagnosis of this
disease is not perfect; that in a large percentage of
cases having diphtheritic membrane the Klebs-Loffler
bacillus is not found and also that in a large percentage
of perfectly healthy mouths a bacillus morphologically
the same is present.
' We believe that experimentation in the treatment of
diphtheria by serum is in the right direction and we
hope that the enthusiastic friends of orrhotherapy may
be largely vindicated, yet we can not search far into the
history of medicine to find that very many of the
remedies now employed have in the beginning been
lauded excessively, and that not a few of those that
were formerly supposed to be extremely efficacious
have been found to be practically worthless.
36 Washington Street.
THE OUTLOOK IN SERUM THERAPY.
Read before the Michigan State Medical Socifctv, at Mt. Clemens,
June 5, 18%.
BY CHARLES T. McCLINTOCK, Ph.D., M.D.
ANN ARBOR, MICH.
A year ago, in a paper read before this Section, I
stated that an average of the reports from serum
treatment in diphtheria showed a reduction of 50 per
cent, in mortality. I repeat this statement to-day
with all confidence. Then we had reports from a few
thousand cases, to-day from hundreds of thousands.
With the profession at large there is no longer any
question as to the value of this treatment. Here and
there some belated traveler may be heard crying that
we are on the wrong road, that trouble and disap-
pointment alone await us. The observer whose oppo-
sition has attracted the widest attention in the past
year is possibly Dr. Lenox Brown of London. Dr.
Brown is a very able man, an authority on many sub-
jects. He attacks the statistics, makes much of the
harmful effects of the serum, and enters a general
denial against all the claims of good. The best
answer to Dr. Lenox Brown's objections is not a
review of all the facts and figures, but the recently
issued report of the Medical Superintendents of the
Metropolitan Asylum's Board of London. This
report covers some six thousand cases of diphtheria
treated in these hospitals; in round numbers, 8,000
without and 3,000 with the serum treatment. Their
conclusion is, that not less than 250 lives were saved
in 1895 by the antitoxin that would have been lost
under the old methods of treatment.
There have been some improvements in the produc-
tion of serum that are worthy of note. A year ago,
in a vial of 10 c.c. we thought we had a very good
serum, if it contained 1,000 units. Now we have one
containing 5,000 units, and I think it altogether prob-
able that by the end of the year we can have a serum
of such strength that a 10 c.c. bottle will hold 10,000
units. This is an important advance. To inject 10
c.c. of anything into a child is a heroic procedure.
But the injection of 1 or 2 c.c. is quite another matter.
Two c.c. of this stronger serum is a full curative dose
for an average case; 7 minims is an immunizing dose.
There are certain unpleasant complications, urticarias,
rheumatic pains, etc., that not uncommonly follow
serum injections. In general these are proportional to
the amount of serum used. We expect to note a very
great diminution in the annoying sequela? from these
stronger serums. Allow me to call your attention to
a mistake which I believe many practitioners are mak-
ing. They argue in this way. "Ten cubic centime-
ters can be injected without harm. Now if I can get
a serum that contains from two to five times the anti-
toxic power of that I have been using, I will inject
the same amount and will get control of the disease in
proportion to the strength of the antitoxin." This, I
believe, is mistaken reasoning. It is very well estab-
lished that this serum is not directly antitoxic, /. e.,
the serum that you give does not of itself destroy the
poison. It in some way nourishes or stimulates the
cells of the body, and they in turn destroy the toxin.
It does not follow, either in theory or in practice, that
you will get this needed stimulus better from 5,000
than from 1,000 units. In fact, in so far as 1 can
judge, from a somewhat careful examination of many
reports, Behring's original recommendation, 250 units
for immunizing, 500 to (500 for mild cases, 1,000 for
average, and 1,500 for severe cases, repeated as neces-
sary, still give the best results. On theoretic grounds,
I believe that even smaller doses repeated more
frequently would give better results. Remember
the toxin is not produced all at once, but continu-
ously through the course of the disease, so long as the
germs are growing.
The marvelous results obtained in diphtheria very
naturally led to enthusiastic work in all microbic dis-
eases. At first it seemed that the same methods could
be applied and like results obtained in all of the com-
municable diseases. And yet, after an enormous
amount of work done by careful and skillful investi-
gators, the results obtained are very disappointing.
Typhoid and cholera, tuberculosis and smallpox are
still unconquered. Why is it that a method applica-
ble to diphtheria will not give as good resnlts when
applied to tuberculosis or typhoid? They have similar
causes; the germs in these diseases as well as in diph-
theria or tetanus can be isolated, pure cultures grown,
toxins produced. The chief reason for the failure, I
believe, is in this. In an ordinary case of diphtheria
there are relatively few germs, confined to a very lim-
ited surface. But these germs produce a large amount
of a very virulent poison, so much that every tissue
of the body may feel its harmful effect. In tetanus
this condition is even more pronounced. The germs
are confined to the neighborhood of the wound and
are so few in number that the skilled bacteriologist
must make repeated examinations, or cultures, to find
them at all. And yet these few germs will in the
average case produce sufficient poison to cause
death. How does this compare with tuberculosis, for
example? One estimate has it that in the last stages
of this disease as many as four billions of the germs
1896.]
THE OUTLOOK IN SERUM THERAPY.
are expectorated in a day. This, I take it, without
claiming any exactness for the figures, is a far greater
number of germs than is produced in the entire
(•diuso of a case of diphtheria or tetanus. Yet in
pure, unmixed, non-septic tuberculosis, the amount
of toxin produced, measured by the temperature curve
■ad general symptoms, is small. To illustrate: Here
is a tetanus toxin grown in bouillon from an old and
iimably weakened germ, with no attempts to
increase its virulence. Of this one five-hundredth
e.c. is fatal to guinea pigs. Here is the toxin from
the tubercle germ, grown as carefully as can he. This
has been concentrated to one-tenth of the original
hulk, ami yet it requires from '2 to 5 c.o. to kill a
guinea pig. At the lowest estimate the tetanus toxin
is 10,000 times as strong as that obtained from the
tnlnrcle germ. Conversely, it is probably a safe esti-
mate to say that in the average fatal cases of these
two diseases, there are a million times as many tuber-
cle germs produced as in the case of tetanus. I
believe 1 am justified in saying that in tetanus it is
the toxin that kills, while in tuberculosis it is the
germs. The old name consumption is correct, the
disease is a literal eating up of the tissues by the
germs. Bearing these things in mind, the success of
the method in the one case, and its failure in the other
can K' understood. To cure tetanus we need an anti-
toxin, while for the cure of tuberculosis we must
have a germicide. The antitoxins of tetanus and
diphtheria are not germicidal. Such an agent is not
needed: free the tissues from the harmful effects of
the poisons and they will easily take care of the
few germs present. But not so in tuberculosis.
Neutralize or destroy all the toxin and you still have
left in an advanced case, untold millions of germs,
feeding on and literally eating up the tissues in which
they are located. I would not say that the toxins in
tuberculosis are of no importance, but in an uncom-
plicated case I think the toxin is relatively unim-
portant. In the work of the past year these theoretic
conclusions have received some experimental proof.
Pfeiffer and his assistants in the Berlin laboratory
have shown that the blood serum of an animal or man
immune to cholera, can help an animal infected with
cholera germs, but it does so, not by destroying a
toxin, but by killing the germs themselves. Further.
that the direct germ-destroying power of this immu-
nized serum is small. But that when injected into
the infected animal it so stimulates, or assists the cells,
that they or their soluble products can in turn destroy
enormous numbers of germs. Pfeiffer illustrates this
in the following manner: A drop of the immunized
serum is placed in a test tube with a portion of a
bouillon culture of the cholera germ. This is left at
the body temperature. Exactly similar amounts of
serum and culture are injected into the abdominal
cavity of a susceptible animal. In another, control
animal, an equal quantity of the germ culture is
injected without the serum. After a given time the
containers, the test tube and the abdominal cav-
ity (jf the animals, are examined, both microscopically
and by the plate method. It is found that a few
germs have been killed by the drop of serum in the
test tube, while in the animal receiving the mixture
tlie most or all of the germs have been destroyed. In
the control animal the germs have increased in
number.
Note the exact similarity here, both in theory and
in results, to that advocated by Dr. Vaughan and my-
self several years ago in explaining the action of the
nucleins in the body. Results corresponding in gen-
eral to the above have been obtained with typhoid.
Results which go far to show that in these diseases
at least curative effects are produced by germ-destroy-
ing rather than by antitoxic agents.
A BRIEF SURVEY OF THE VARIOUS SERUMS.
Erysipelas Scrum for Malignant Tumors. — There
have been a few, apparently well authenticated, cases
where an intercurrent attack of erysipelas has mark-
edly benefited, and in a few instances cured malignant
neoplasms. Following this indication, several expe-
rimenters have inoculated the site of these tumors
with the germs of erysipelas, but this procedure
proved entirely too dangerous. Whatever the effect
on the tumor the patient often died.
Coley then attempted the treatment of these tumors
with the toxins of erysipelas. He claimed very
favorable results, but in other hands the treatment,
although still occasionally used, has not given satis-
faction.
Emmerich and Scholl, the former a well-known
bacteriologist, conceived the idea of preparing a serum
that would antagonize the growth of these tumors.
They injected sheep with carefully prepared virulent
cultures of the erysipelas germs. These injections
were continued for some time. The serum from the
sheep was then used for injection into the neoplasms.
In theory, they were not attempting to produce an
antitoxin, in the sense that we understand that word.
Their theory is practically the same that Klebs
advances for his antiphthisin. A germ produces both
toxic and antitoxic bodies. Although there has been
no experimental proof of any such condition, the
possibility of its truth seems to have impressed many
of the German investigators. Klebs claims that he
can take tuberculin and by chemic methods remove
the poisonous substances and retain the curative
ones. Emmerich and Scholl used the animal body
for this purpose. It was to be a separating filter, the
poisonous substances eliminated and the anti-poisons
or toxins stored in the blood of the injected animal. By
repeated injections, a large amount of these curative
bodies could be stored in the blood and this in turn
used for the treatment of disease in man. These
authors believed that they had found a specific cancer
(heilserum), and notwithstanding the failure of the
remedy in the hands of Bruns, Czerny, Petersen,
Reinebroth and others, they persist in asserting that
the serum does cure, and in this they are supported
by a few clinicians. Bruns thinks it probable that
in case there is amelioration, it is not due to any
specific action, but results from the fever induced,
causing fatty degeneration, and cites numerous
instances of neoplasms degenerating in other fevers,
as in typhoid, meningitis, etc.
Other experimenters have injected extracts or sus-
pensions of tumors into animals, and then used their
serum for injections. There is little promise in this
work. For the present, judgment must be suspended.
Meanwhile, despite the enormous amount of work
done in the past three years attempting to find the
cause of these growths, it remains that for the cancer-
ous diseases there is no cure and no palliation save
narcotic sleep to the end.
Cholera. — Ferran, a pupil of Pasteur, in 1884 showed
that guinea pigs could be made immune to cholera by
the injection of gradually increasing doses of bouillon
6
THE OUTLOOK OF SERUM THERAPY.
[July 4,
containing cholera germs. He did not follow up this
work in a scientific manner but immediately began
injecting men. Large numbers submitted to his
inoculations. In Spain 25,000 were injected in one
year. He even advocated that wells should be infected
with the germs, so that those drinking the water
should be gradually immunized to the disease. He
did not use pure cultures but grew them from feces
of cholera patients. This was shortly after Pasteur's
notable discoveries on vaccines. Ferran saw that the
serum of men who had recovered from cholera had
immunizing properties and he used this in treating
other individuals. He had discovered the underly-
ing principles in our present methods of serum-
therapy. He made the fatal mistake of keeping his
methods secret. Ferran's methods were dangerous,
his results uncertain and his professional attitude
deplorable.
Haffkine. another of Pasteur's pupils, in India, has
continued this work of vaccinating against cholera,
injecting 40,000 men last year.
Lazarus was the first to demonstrate that the serum
of men who had recently recovered from this disease,
would confer an immunity on guinea pigs, against
the intra-peritoneal injection of cholera germs. Since
that time many investigators have busied themselves
with the problem of immunity and cure in this dis-
easy. There is at present a wordy discussion in prog-
ress as to whom belongs the priority for some of the
principal discoveries. Pfeiffer of the Koch school in
Berlin claims to have discovered a new ground for
immunity. He finds it easy to immunize animals so
that their serum can be used to protect other animals
against the disease. But the interesting and import-
ant part of this work is the light thrown on the
nature of these anti-bodies contained in the immu-
nized serum. Pfeiffer finds that these anti-bodies
have a specific action. For example, when a mixed
culture containing the cholera germ along with
various other species is subjected to this serum, the
cholera germs alone are destroyed. Even when the
mixture consists df morphologically related germs,
the vibrios, the germs of cholera alone are attacked.
He believes that in this we will have an entirely
reliable proof of the presence of this germ that can
be applied in diagnosis.
This serum can in the test tube destroy a certain
number of germs and a far greater number in the
body. By heating the serum to 60 degrees its ability
to destroy germs in the test tube is taken away; but
when injected into the body it still exerts its immu-
nizing power and destroys the germs. His explana-
tion for these facts is, that there is a sort of specific en-
zyme having two stages, an inactive and an active one.
He compares these with glycogen and glucose. The
serum does not contain the active substance, but a
precursor of it. When this serum is injected into an
animal the enzyme-like body becomes active, capable
of destroying large number of germs. He finds that
this immunized serum has no antitoxic action but is
strong^ germicidal. As to the chemic position of
this body his results are negative. He thinks that
he proves that it is not an albumin, as it resists peptic
and pancreatic digestion; that it is not a nuclein, that
it is not a peptone, albumose or salt, for when freed as
far as possible from these substances, it still exerts its
specific action.
Here we have a direct experimental proof of arti-
ficial immunity due to a germicidal action, not to an
antitoxin, and we are probably justified in concluding
that in natural immunity the same principle is true.
The body protects itself by an ability to destroy the
introduced germs. Pfeiffer does not think that the
serum treatment will be of much value in well devel-
oped cases of cholera. We are getting nearer and
nearer to an understanding of how the body defends
itself from the attacks of disease germs. And when
once we understand this, the hope is justified that we
can lend assistance when there is need.
Antistreptococcic Serum. — Puerperal fever, erysip-
elas and certain of the septicemias are due to strepto-
cocci. This class of germs often attacks the weakened
tissues and modify and complicate such diseases as
scarlet fever, measles, diphtheria, tuberculosis and
broncho-pneumonia.
As soon as it became certain that serum treatment
as practiced in diphtheria and tetanus was successful,
a number of observers turned their attention to the
diseases caused or complicated by the streptococci.
It was easy to see that a serum that would success-
fully check the attacks of these germs would have a
wide range of usefulness, far greater, indeed, than
that for diphtheria.
To obtain an antitoxic serum was the problem. But
there were difficulties in the way. At the outset, here
are several varieties, possibly species of the germs.
Suppose we obtain a serum antitoxic to the germ
found in erysipelas. Will it have any effect on the
germ found in puerperal fever? I may say that it has
been shown that the serum of an animal made
immune by the injection of the germs or toxin obtained
from any one of these diseases, is antitoxic to the
whole group of streptococci. So far as we know, one
serum can be used against this whole class of diseases
and complications. Another difficulty : The strepto-
cocci did not take kindly to our artificial nutrient
media. We would isolate the germs from a case of
erysipelas, for example. In the first culture we would
have a moderate growth; in the next it would be
feeble, and after a short time it would die out
altogether. Even in our most recent cultures neither
the germs nor their toxins were very virulent. For
example, it required something like 15 c.c. of a
bouillon culture of the germs to kill a half-grown
rabbit. After a careful study of the question Mar-
morek was able to increase the virulence of the cul-
tures in an almost incredible manner. He claims to
have finally obtained cultures, by growing in a mix-
ture of human blood serum and beef bouillon and
alternately passing through animals, so virulent that
one one-hundredth billion of a c.c. was fatal to rabbits.
With these, cultures he immunized his animals.
This serum has been extensively used in the hos-
pitals of Paris in treating the streptococcus diseases.
Puerperal fever has, fortunately, become so infre-
quent that it will require some time before sufficient
experiments can be made to show the value of the
serum. The most striking results obtained with the
serum are reported for scarlet fever. While we are
wholly ignorant of the organism causing scarlet fever,
we are quite sure that many of the complications of
the disease, the throat, ear, kidney and heart lesions
are, in part at least, due to streptococci. The Paris
clinicians report very favorable results from the treat-
ment. Baginsky in Berlin reports on the treat-
ment of fifty-seven cases with the serum supplied by
Marmorek and Roux. He says that, owing to the
small supply of the serum, he was not able to give in
1896.]
ANTITOXIN IN DIPHTHERIA.
most of his cases the dose recommended by Mnrmorek.
The doalh rate was 14.6 per cent., while the average
death rate from 1890 to 1S95 in this hospital was 24.9
percent. He believes that but little importance is
to be attached to these figures, owing to the great
variation in the mortality in this disease, and con-
cludes, that he is unable to draw any conclusion from
his experiments, except that the disease was no worse
for the treatment and that he intends to .continue its
trial.
In measles, as in scarlet fever, we believe that the
complications are for the most part due to strepto-
coccus infection, and the serum should be equally
efficaoious here.
It stems to me, although I have seen no suggestions
for such application, that the greatest field for use-
fulness for an anti-streptococcus serum would be in
tuberculosis. For some years the belief has been
growing that pure, uncomplicated, non-septic tuber-
culosis is relatively a mild, curable and often self-
limited disease. It is the complications that kill in
tuberculosis. Most of us will agree that when there
is any benefit from the administration of creosote and
its allies, it is due to the action on the septic processes
and not on the disease itself. And not a few hold
that the chief, though not the whole benefit of moun-
tain climates, is the aseptic atmosphere. Most of you
are probably familiar with the work published by
Prudden last year, where he conclusively showed that
for rabbits, at least, cavity formation in tuberculosis
was almost entirely due to secondary streptococcus
infection. Now, if with this serum we can hold in
check the septic processes we will have half conquered
the disease. Although the work with this serum is
still in the experimental stage, the outlook is very
promising.
Anti-tubercle Serum. — Maragliano, Boinet, Picq,
Babes. Maffuoci, Paquin and others have reported
work in this line. Most of them claim good clinical
results. But tuberculous patients under any treat-
ment, and without any, often improve and occasionally
yet well. So that, whether with justice or not, the
claims of these investigators have met with but little
approval. In experimental animals the best results
I have seen reported are a prolongation of life in
guinea pigs from an average, for untreated animals of
some fifty days, to ninety in the treated ones. No
treatment yet devised, be it serum or anything else,
can save a guinea pig when inoculated with tubercu-
losis. And while our experimental animals are far
more susceptible to the inoculated disease than man,
the profession at large will be slow to trust any
remedy that can not give demonstrable results in
animal experiments.
A id i- pneumonic Serum. — The work of the Klem-
perer brothers on the immunization of rabbits against
pneumonia has been followed up by Emmerich and
Fowitzky, Redner, and Foa and Carbone. It has been
possible to immunize a rabbit so that it would with-
stand more than three hundred thousand times the
fatal dose of the germs for an untreated animal. With
serum taken from such highly immunized animals it
is possible to save inoculated rabbits if the serum is
given five hours or earlier after the infection. In
rabbits pneumonia is often fatal in twenty-four hours.
The duration of the immunity produced in rabbits is
long. After three months they resist fatal doses of
the germs. So far as I know, the successful immuni-
zation of larger animals capable of producing serum
in quantities sufficient for the treatment of the disease
in man has not yet been reported.
Anti-rabic Sertoli. — Following the general lines of
procedure in this field, the Italian bacteriologists
have produced a serum for the treatment of hydro-
phobia. Their experimental work seems to be con-
vincing. They claim many advantages for this serum
over the Pasteur method of vaccines. The claims
are that results are more certain and the dangers of
treatment lessened, and of even more importance, the
serum keeps well and can be used anywhere by any
practitioner.
Anti-venom. — Drs. Calamette of Paris and Fraser
of Edinburgh seem to have succeeded in producing a
very satisfactory serum for antagonizing snake poison.
That animals could be immunized to these poisons
was shown years ago by Dr. Sewell in Michigan Uni-
versity. It seems that the serum produced from the
venom of any one of the serpents is antagonistic to
the poison of the whole group.
Typhoid. — In general the statements I have made
in regard to cholera are true for typhoid. Animals
have been immunized and a protective action can be
demonstrated, but clinically the results are not con-
vincing. Here, as in cholera, a germicidal instead of
antitoxic action is shown. But where in cholera there
is a specific action against one germ, it seems that in
typhoid the serum antagonizes all related germs, as
the coli group. This is as we find it in the strepto-
cocci.
Si/philis. — It is well known that one attack of this
disease confers an almost perfect immunity against
subsequent infection. Attempts have been made to
borrow this resisting power. The serum of persons
who have recovered from the disease has been injected
into those who have been recently infected. Again
syphilitic nodules have been macerated and this
material injected into animals and their serum in
turn used for the treatment of the disease. Good
results are claimed from the serum of animals that
have been treated for some time with mercury and
iodids.
Smallpox. — Practically the same experiments have
been tried with smallpox, the serum of immune indi-
viduals being used. Again, the serum from vaccine
heifers that have become refractory to the inoculation
has been used in treatment. Thus far the results of
this treatment in these two diseases have not been
noteworthy.
Possibly the best thing I have to report in the line
of serum-therapy is the continued growth of the
belief that disease can be conquered; that knowing
the cause and the methods of many disease processes,
we can and will find preventative or curative measures.
THE USE OF ANTITOXIN IN THE TREAT-
MENT OF DIPHTHERIA AND MEM-
BRANOUS CROUP.
WITH A COLLECTIVE REPORT OF ONE HUNDRED AND
THIRTt-TWO CASES.
Read before the Indiana State Medical Society, May 29, 1896.
BY E. L. LARKINS, M.D.
TEBBK HAUTK, IND.
During the year 1894, there were reported to the
Board of Health at Terre Haute, Ind., 233 cases diag-
nosed as diphtheria. Of this number 102 were males
and 131 females. There were 39 deaths recorded as
8
ANTITOXIN IN DIPHTHERIA.
[July 4,
clue to the disease. During the same period, 19 cases
were reported to the Secretary of the County Board of
Health, in the county outside of the city, of which
number 9 were males and 10 females, with 6 deaths,
making a total number of cases reported for the county
252, and the total number of deaths 45.
During the year 1895, there were reported for the
city 182 cases, of which number 79 were males and
103 females, with 23 deaths. For the same period in
the county outside of the city, 11 cases of which 7 were
males and 4 females, with 6 deaths, making the total
number for the county of 193 cases and 29 deaths.
From Sept. 1, 1894 to April 1, 1895, there were
reported 197 cases, of which 92 were males and 105
females. Of this number, 20 were fatal — 9 males and
11 females.
From Sept. 1, 1896, to April 1, 1896, there were
reported 150 cases, of which 62 were males and 88
females. In this period there were 21 deaths — 12
males and 9 females.
Prior to Sept. 1, 1895, antitoxin had not been used
except in a few cases. Since that time, it has been
used by a majority of physicians in Terre Haute, and
with a view of ascertaining as nearly as possible, the
exact number of cases treated with it, with results,
etc., I sent out a chart and find the total number to
be 132, with 18 deaths, or 13.6 per cent., a summary
of which is as follows:
SHOWING THE USE OF ANTITOXIN IN DIPHTHERIA AND
MEMBRANOUS CROUP.
Number of cases reported, 132. Males, 61 ; females, 71.
Times used : 98 cases, one time ; 25 cases, two times ; 3 cases,
three times ; 4 cases, four times ; 2 cases, six times.
Day of disease used : 21 cases, first day ; 41 cases, second
day ; 24 cases, third day ; 22 cases, fourth day : 8 cases, fifth
day ; 4 cases, sixth day ; 10 cases, seventh day ; 1 case, eighth
day ; 1 case, thirteenth day.
Age of each : 1 case 2 months, 1 case 5 months, 1 case 8
months, 1 case 10 months, 1 case 11 months, 7 cases 2 years, 16
cases 3 years, 13 cases 4 years, 18 cases 5 years. 14 cases 6 years, 13
cases 7 years, 16 cases 8 years, 3 cases 9 years, 10 cases 10 years,
3 cases 11 years, 3 cases 12 years, 1 case 14 years, 1 case 15 years,
2 cases 17 years, 1 ca3e 27 years, 1 case 35 years, 1 case 50 years.
Number of cases of membranous croup, 8 ; times used in
each case, from one to six ; result, six recoveries and two
deaths.
Number of immunizing injections given, twenty ; result, im-
munity in all. In nearly every case no effort was made at
isolation. No unfavorable symptoms reported.
Original location of disease and extension to other parts :
Fauces in almost all cases, and tonsils principally ; extension
to larynx, 29 cases, 5 deaths ; intubation 7 times, 3 deaths ;
extension to nares, 18 cases, 8 deaths ; tracheotomy not
reported.
Disease extended after injection in only one case, and in that
the physician said he was not certain how long the child had
been sick before he was called.
Death did not occur in any case where injection was used
within the first forty-eight hours of the disease.
Did not notice any unfavorable effect of the injection.
Number of deaths, 18 ; within the first 24 hours in 14 cases,
in 2 days in 2 cases, in 2 and 8 weeks in 2 cases.
Days of disease : 1 case 3 days, 4 cases 4 days, 6 cases 5 days,
3 cases 7 days, 1 case 8 days, 1 case 9 days.
Number of cases followed by sequelae, 9 ; otorrhea in 1, naso-
pharyngeal paralysis in 6, aphonia and paralysis of right side
of face and neck in 1, and paralysis of all voluntary muscles
except of the head in 1. Recovery in all.
Thus we have the following table for the years:
No. of Cases, No. of Deaths. Mortality
Per cent.
1894 252
1895 193
Sept. 1, 1894 to April 1, 1895 . 197
Sept. 1, 1895 to April 1, 1896 . 150
Number treated with antitoxin from Sept. 1, 1895
45
17.8
29
15
20
10.1
21
14
to April 1, 1896 — males 61, females 71; total 132,
number of deaths 18, mortality, 13.6 per cent.
In the majority of cases only one injection was
given to each patient, but in several it was repeated
two or three times, and in two laryngeal cases six
injections were administered, the cases being desperate
and one eventually recovering.
It would appear from recent experience and a study
of the literature upon the subject, that some of the
deaths herein reported might possibly have been
avoided had the remedy been vigorously pushed to
its full therapeutic effect. It is the opinion of all
observers that the earlier in an attack of diphtheria
antitoxin is used, the better the results and conse-
quently the greater the chances of recovery, and in
an analysis of this collection of cases the statement is
abundantly verified. In the 132 cases only one death
is reported where the remedy was used within the
first forty-eight hours of the disease, and in this case,
there is doubt about the length of time the child had
been sick before the physician was called. One phy-
sician reports a series of fifteen and another ten cases
without a death, three of the latter being laryngeal,
and with nearly all, the remedy was used on the first
day, in four or five on the second day and in- only
three on the third day. In one case it is reported
used on the thirteenth day, but upon inquiry the
physician states the child had tonsillar diphtheria,
from which it apparently recovered, but it subse-
quently extended to the larynx, for which latter in-
volvement antitoxin was used with favorable results.
According to the reports read, the death rate, in-
creases panpassu with the length of time the disease
had run before the remedy was used. In the 17 of
the above 132 cases in which I used antitoxin, the
result was favorable, except in two of the three cases
where it was administered on the fourth day of the
disease. These two proved fatal on the fifth day in
twelve and eighteen hours after the injection, from
sepsis consequent upon extension of the disease to the
nares and laryngeal obstruction from extension to
the larynx. I advised the use of antitoxin when I
first saw the children on the second day of the dis-
ease, but the parents objected. I am still of the
opinion that the children would have recovered had
the antitoxin been used when I first saw them. On
the fourth day of the disease when it became appar-
ent that the children were sinking, request was made
to have the antitoxin administered, but it was then
my opinion, concurred in by the consulting physician
that nothing would avail, as the little sufferers were
beyond hope of recovery. In this collection of cases,
the ages ranged from two months to seventeen years,
but the great majority were from three to eight years
of age.
Membranous croup is here classed separately from
diphtheria, on account of the uncertain relation of
the two diseases. There were eight cases of croup
reported with two deaths, neither tracheotomy nor
intubation being performed in any of them. These
were reported as idiopathic or true croup — croup
commencing in the larynx, in contradistinction to sec-
ondary croup, or diphtneritic laryngitis, due to exten-
sion of the diphtheritic process from the fauces. Of
the latter class, twenty cases are given, with five
deaths. In two of these the nasal and post-nasal
cavities were extensively involved also, and it is diffi-
cult to determine which contributed most to a fatal
termination — sepsis or laryngeal obstruction. In the
L896.]
ANTITOXIN IN DIPHTHERIA.
'.»
above twenty cases, intubation was performed seven
times, with three deaths. No case of tracheotomy
was reported.
In eighteen cases, the disease extended to the nares,
eight of which died. The time of death in reference
to the injection, was within the succeeding twenty-
four hours in all but four. Two of these are given
as the second day and two in two and eight weeks
respectively. The last two cases were evidently due
to some secondary effect of the disease.
The time of death in reference to the day of dis-
( except in the last two cases above mentioned)
is given from the fourth to the eighth day. This
taken in connection with the time in which death
occurred after using the injection, clearly shows that
the remedy was not used until after systemic infec-
tion had taken place, or laryngeal obstruction had so
prostrated the system that the therapeutic effort of
the antitoxin could not be obtained. Then, too, the
remedy may not have been used as vigorously as it
should have been.
There were reported twenty cases in which immu-
nizing injections were given with no development of
the disease and no unfavorable symptoms were
observed to follow. In only two of the 132 cases is
the disease reixjrted to have spread after the injection
was used. In one case of diphtheria, the nervous
symptoms in a choreic patient, aged 12, appeared ag-
gravated during the next 24 hours and then improved.
In this series, six had post-diphtheritic paralysis; one
had otorrhea. In one ease the paralysis effected the
lower limbs and in another case the whole voluntary
muscular system, except the head. Aphonia and par-
alysis of the muscles of the right side of head and
neck in one. All recovered.
I will only give the history of a few illustrative
oast
( >n the morning of Nov. 8, 1895, 1 who called to see
Frank M.. age 7 years, and found him recovering from
a severe convulsion. The history obtained, was that
of some error of diet on the previous day and he had
had a light chill a few hours before the spasm. As
convulsions were easily provoked in the child there
seemed to be no special reason for alarm, but his gen-
eral condition lead me to suspect some grave disease.
Pulse was 110, feeble; temperature 101 degrees, and
be had vomited once during the morning. The throat
was not examined on account of his general nervous
condition.
I prescribed calomel, quinin and bromids, hot
mustard foot-bath and hot cloths to the head and
over the stomach. In about an hour and a half, I
was hurriedly sent for, as the child had another con-
vulsion. I increased the bromids and ordered a gen-
eral hot pack in blankets. He soon recovered from
the spasm and had no more during his sickness. I
advised isolation, as I thought it might be diphtheria.
Calomel J gr. every hour; quinin 2^ grs. every three
hours and bromids as necessary, were given during
the afternoon and night, followed by castor oil the
next morning.
November 9, 9 a.m., temperature 100.5, pulse 112,
complains of nausea and weakness. Examination of
the throat shows the whole fauces deeply congested,
tonsils swollen and a gray deposit on each about the
size of a split pea. Diagnosis of diphtheria was
made. Quinin was continued, mercury bichlorid one-
sixteenth gr. in elix. pepsin and bismuth every two
hours and teaspoonful of whisky every two hours,
were given. Local applications of Loeffler's solution
were made every four hours, and spray of peroxid of
hydrogen 50 per cent, with saturated solution potas-
sium chlorid every two hours; i p.m., the membrane
has covered both tonsils and the uvula, and the child
has had nasal hemorrhage.
November 10, 9 a.m., temperature 100, pulse 115.
Throat emits a very fetid odor and there is a thin
acrid nasal discharge. The whole fauces is com-
pletely covered by a thick leathery grayish-white
membrane. The membrane is visible in the anterior
nares and the child has a coarse croupy cough. I
explained to the parents the serious and probably
fatal condition and advised that antitoxin be imme-
diately given. The mother dissented. The child's
condition continued to grow worse and by the morn-
ing of 11th laryngeal obstruction was added to the
faucial and nasal involvement. A more serious con-
dition could not be depicted. They now consented
to the use of antitoxin and I gave the child a full
dose of the Behring No. 2. Now I would give the
No. 8, and repeat in six or eight hours, in such a case.
The laryngeal obstruction continued to grow worse
during the day. In about six hours after giving the
injection the child seemed much worse, but rallied
some toward evening. About 8:30 p.m. I was sent for
hurriedly, as the child was thought to be dying. A
severe attack of dyspnea came on and the mother laid
him on the lounge, thinking he was dead. When I
arrived, he had rallied and was breathing better and
improvement was continuous and rapid. I consid-
ered the sudden increase of dyspnea the night before,
to be due to loosening of large portions of membrane
thus producing complete obstruction of the larynx.
I now omitted the mercury and gave small and fre-
quently repeated doses of tincture chlorid of iron.
During the whole sickness effort was made to keep
the nose and throat clear of septic matter, by the use
of syringe and spray. The appetite was irregular and
proper feeding was attended with difficulty. Aphonia
remained several weeks after recovery.
I have given at length the history of this case in
order to show by comparison the probable effect of
antitoxin. About two weeks after my last visit to
this patient, I was called to see two other children in
the same family, one aged 5 years, and one 11 months.
The course of the disease was exactly the same,
with the exception of the initial convulsion. I
advised the immediate use of antitoxin, but the
mother strenuously objected. -I could not then con-
ceive, that with such practical demonstration of the
efficacy of the remedy in the other child, why objec-
tion should be made to its use in these two.
The children continued to grow rapidly worse until
the afternoon of the fourth day of the disease, and all
hope of recovery was abandoned, when request was
made to have the antitoxin administered. My opinion,
concurred in by the consulting physician, was that
nothing would do any good, as the children were
dying. Behring No. 2 was given, but both died in
twelve and eighteen hours respectively.
It may be said that if antitoxin saved the first, it
should have saved the other two. The inference is
not justified, as the latter were profoundly septic, in
addition to having laryngeal obstruction. The argu-
ment in this is, not that it saved one, but if used not
later than the second day it would probably have
saved all of them. Subsequent experience in the use
of the remedy confirms my belief in this statement.
10
ANTITOXIN IN DIPHTHERIA.
[July 4,
I will relate one other case of diphtheria, in a girl
aged 8 years, who had enlarged tonsils and almost
complete nasal obstruction from adenoid growths in
the post-nasal cavities. The initial chill, followed by
vomiting, occurred in the evening, and I was called
the next morning. I found a typical case of diphthe-
ria, the membrane covering the tonsils and extending
up the edges of the palate. The characteristic acrid
nasal discharge was present, showing extension to that
cavity. The breath had a very fetid odor and her gen-
eral condition showed profound infection. A full dose
of Behring No 8 was immediately given, and a No. 2
given the next morning. We could do little with
sprays and washes and no effort was made at local
application. She immedintely began to improve and
the recovery was uneventful. I attribute her recovery
entirely to the antitoxin.
A marked feature in this case was the very great
reduction in size of the tonsils after recovery. An
older brother of this girl had diphtheria in November,
1895, to whom two injections of Behring No. 2
were given, and his general health has been better
since than ever before. Previous to this sickness, he
was subject to frequent attacks of sick-headache, but
now seems entirely free from them.
The effect, apparently, of antitoxin in the case of a
delicate, nervous girl, 5 years of age, to whom two
injections of Behring No. 2 were given, and in whom
choreic movements had been frequently noticed and
nystagmus was almost constantly present when the
child was excited, was that since recovery both have
disappeared, and she appears perfectly well.
Diarrhea did not follow the use of antitoxin in my
cases, but constipation was of such frequent occur-
rence that I suspect some causative relation.
In the treatment of membranous croup with anti-
toxin, I have only one case to relate. I was called in
November, 1895, to see a girl aged 5 years. I informed
the mother of the serious illness of the child, prescribed
the usual remedies and advised that antitoxin be used.
Consent was given. Next morning I injected a full
dose of Behring No 3. By this time the disease was fully
developed. In twelve hours another dose of Behring
No. 2 was given. Next morning the chrld was better.
There was considerable dyspnea for two days, but the
child recovered without further treatment, except
some simple remedies.
In all the cases, except two, in which I used anti-
toxin, I called another physician to see the case, that
it might not be said I used it where no diphtheria
existed.
Reliance was placed in all cases upon the clinical
picture of the disease for diagnosis. This is partly
in accord with the recommendations of the boards of
health of New York, St. Louis, Chicago and other
cities, as they advise the use of antitoxin in suspicious
cases, and especially in those where the physician is
satisfied diphtheria exists, and not wait for a bacterio-
logic examination, as that can be made later. It is in
the early use of antitoxin that its specific effect can
be obtained.
The Klebs-Loffler bacillus develops upon the false
membrane, and in most instances accompanies the
local manifestations of the disease. The streptococ-
cus, said to be the most virulent of the supposed
pathogenic microorganisms, develops beneath the
membrane, is a late product of diseased action, and is
found in cases termed mixed infection. They are
found (as the Klebs-Loffler bacillus) in the throats
of healthy persons, and even in the substance of the
tonsils.
As to medical treatment of these cases, it has been
claimed that it in no wise interfered with the use of
antitoxin. I believe that large doses of bichlorid of
mercury, in some degree at least, counteracts the effect
of the antitoxin. Lately, I have confined myself to
the use of small and frequently repeated doses of
tincture chlorid of iron, and the moderate use of
quinin and whisky. The free use of warm salt water
or listerin properly diluted, for the purpose of keep-
ing the parts clean, appears to answer every purpose.
This paper deals principally with an analysis of the
reported cases.
Antitoxin in the treatment of diphtheria being of
comparatively recent introduction, personal experi-
ence of the general practitioner must necessarily be
limited in its use, and in many instances no oppor-
tunity has been afforded to observe its effects. It is
from the experience of others that we must learn, and
through collective investigation knowledge may be
acquired by comparison.
The 132 cases herein given were reported by twenty-
five physicians. The report is confined to Vigo County
and principally to the city of Terre Haute. It will
be observed that more deaths occurred in 1895 than
in 1894, presumably on account of the greater sever-
ity of the disease. The report represents only the
rate per cent, of deaths to the number reported and
not to the actual number of cases, as physicians there
seldom report more than one case in a family.
No subject could be of more profound interest to
the physician, than that of the cure of diphtheria.
In using the word cure, I refer to its literal meaning
and practical application. No discovery since the
days of Jenner, when he listened to the story of the
milkmaid, and placed the practical banishment of that
dreadful scourge, smallpox, within the power of all
civilized nations, has been of such great value to
mankind.
In antitoxin, I believe we have a true specific for
diphtheria. In theory, and probably in fact, it is
based upon the principle of vaccination, viz, to ren-
der the human body immune to a virulent disease by
introducing artificially into the system, a protective
product developed through modification of its specific
agent in foreign media. After successful vaccina-
tion, a person may have varioloid, and thereafter, as
a rule, be immune to the contagion of smallpox. The
immunity conferred by the antidiphtheritic serum in
the healthy subject appears to be practically evanes-
cent, but what subsequent effect in this line, a cura-
tive dose of antitoxin has upon the human body suf-
fering from a fully developed diphtheria case, has not
been observed. So far as I am aware, a second attack
of diphtheria has not been recorded as occurring in a
patient cured of the first attack by antitoxin. It is
well known that one attack of diphtheria confers
immunity for a time, and it may be that the introduc-
tion of antitoxin into the system in the developed
stage of the disease, may so fortify the protective
elements that the body will not again become suscep-
tible to the contagion.
The length of time in which antitoxin has been
used is not sufficient for extended observation in this
direction, but a second attack would be worthy of
record.
The exact manner in which antitoxin cures diph-
theria, is not definitely settled. According to the law
L&96.]
SERUM THERAPY IN DIPHTHERIA.
11
of Behring, material is developed in the blood which
neutralizes the effects of the specific poison of the
disease, and routers immunity to those in whom the
serum of such blood is artificially introduced. The
studies of Pfeitfer have, however, led him to the con-
clusion that substances are formed which destroy the
infectious material and therefore eradicate the cause
of the disease. It may be that cell action is so stim-
ulated and the metabolic processes so changed that
effectual resistance is offered, through the medium of
tlie blood serum, to the further invasion by the infec-
tious material. This is probable, as experimenters
have found that the supposed pathogenic microorgan-
isms may be cultivated in the blood serum of animals
immunized for the disease which they produce. More-
over, antitoxins are held in solution in the blood, but
do not pass through the coats of the vessels.
SERUM THERAPY IN DIPHTHERIA.
Read in the Section on Materia Medica, Pharmacy and Therapeu-
tic-at the Forty-seventh Annual Meeting of the American
Medical Association, held at Atlanta, Ga., May 5-8, 1896.
BY EDWIN ROSENTHAL, M.D.
PHILADELPHIA, PA.
Since the introduction of the diphtheria antitoxin
as a specific remedy in diphtheria, I have used it in
127 cases of diphtheria with a record of five deaths.
As the character of my cases were in many
instances of the most dangerous variety, and in nine-
teen instances necessitated the operation of intuba-
tion. I may not be misjudged if I ascribe to the spe-
cific action of antitoxin the results obtained.
To briefly summarize my work they are: Tonsillar
(>7: pharyngeal and tonsillar 14; nasal, pharyngeal
and tonsillar 1 ; pharyngeal 1 ; laryngeal 12; tonsillar and
laryngeal 18; pharyngeal, tonsillar and laryngeal 8;
nasal, pharyngeal, tonsillar and laryngeal 4; pharyn-
geal and laryngeal 2; total 127; number of deaths 5.
The ages were: Under 1 year 4 cases; between 1
and •") years 55 cases; between Sand 10 years 30 cases;
between 10 and 20 years 13 cases; between 20 and 40
years 25 cases. Nearly 50 per cent, occurred below
the age of 5 years and about 25 per cent, between
the ages of 5 and 10 years.
1. The deaths occurred below the age of 8 years and
were as follows: Age 1 year, 7 months; variety,
laryngeal and tonsillar; operation, intubation; time
of injection, about seventy-two hours after injection;
time of death, forty-nine hours after injection and
intubation; cause of death, sepsis.
2. Age, 2 years, 2 months; variety, laryngeal, ton
sils, nasal, pharynx; operation, intubation; time of
injection, about the fifth day; time of death, thirty-
three hours after injection and intubation; cause of
death, sepsis and nephritis.
'■). Age, 1 year; variety, tonsils, nose, pharynx, lym-
phatics; time of injection about the fifth day; time
of death, three days after injection; cause of death
heart failure — a septic case.
4. Age, 8 years; variety, tonsils, nose, pharynx
and larynx; time of injection, about the fifth day;
time of death, nine days after injection; cause of
death, heart failure.
5. Age, 1 year 1 month; variety, tonsils, nose,
pharynx and larynx; time of injection, fourth day;
time of -death, five days after injection; cause of
death, heart failure.
They were as regards sex, 51 males, 76 females.
The time in which injections were made : first day,
21 cases; second day, 52 cases; third day, 34 cases
with one death; fourth day, 8 cases with one death;
fifth day <> cases with three deaths; sixth day, 3 cases;
seventh day, 1 case; eleventh day, 1 case; seventeenth
day, 1 case.
Many cases were immunized, using for that pur-
pose antitoxin from several laboratories. In those
cases immunized no visual traces of the disease were
Been, although the bacteriologic examination fre-
quently revealed the Lorfler bacilli. In one case
treated for diphtheria of the faucial variety (case 87)
a re- infection took place on exposure six months after-
ward (case 123) the disease manifesting itself in the
same way. This proves, that while antitoxin has
curative and immunizing virtue, it does not confer
lasting or permanent immunity; but the suscepti-
bility to infection remains as in any other form of
treatment.
The complications noted: Broncho-pneumonia five
cases, only seen by me in the laryngeal variety. Neph-
ritis one case. Albumin was found frequently both
before and after injection, antitoxin not increasing
the amount. Sepsis four cases. Eruptions noted in
about fifteen cases, and was also noticed in several
cases that received an immunizing dose.
Sequelae : Undoubted paralysis of the lower extrem-
ities in a female suffering from diphtheria of the
laryngeal variety with membranes on the tonsils, com-
plicated broncho-pneumonia, intubated, the tube
being worn twelve days, and who received 1,000 units
of Behring's antitoxin. The age of this child was 1
year 10 months; the injection was made on the third
day, and there was perfect recovery months after-
ward. Heart failure in two cases, after disappear-
ance of the membranes ; in one case three days after
the visits ceased. Ozena was noticed in one case.
Method of using the diphtheria antitoxic serum :
Antitoxin should be chosen of undoubted reliability.
I am pursuaded that my results are mainly due, not
only to my method, but to the purity and efficacy of the
antitoxin used The technique pursued in the one
case is that pursued in all.
Antitoxin is graded as regards strength into what is
termed by its originators antitoxic normals or immu-
nity units, which is an amount of antitoxic serum
required to save a 500 gramme guinea pig from a
minimum fatal dose of the diphtheritic toxin. The
number of immunity units per c.cm. gives a stand-
ard strength of the serum; for instance: one one-
hundredth c.cm. will protect a 500 gramme guinea
pig, therefore 1 c.cm. of antitoxic serum, which pro-
tects 50,000 grammes of guinea pig, contains 100
immunity units, and would protect an individual
weighing one hundred times as much as a guinea pig
(about one hundred and twenty pounds, if the suscep-
tibility were the same. The serum, of which 1 c.cm.
equals 100 immunity units, is that with which most
of my work was done. Serum of greater strength
wTas used. Knowing the strength of the serum makes
me have no regard for the quantity used, as I grade
my dosage in immunity units and so apply it.
The technique. The antitoxin serum is used as a
curative or immunizing agent by subcutaneous injec-
tion into the tissues of the body. For the purpose of
making these injections any hypodermic syringe may
be used if of sufficient capacity, as the Pravaes
syringe, the Koch bulb syringe; I prefer a special anti-
toxin syringe, made for this purpose, having a capacity
12
SERUM THERAPY IN DIPHTHERIA.
[July 4,
of 10 c.cm,, and which can be measured accurately
by a screw, so that the quantity used can be admin-
istered in one injection. This syringe is supplied in
metal case, with vulcanized rubber packing, thus per-
mitting complete sterilization of both syringe and
case. I have discarded asbestos packings since they
become soft and pulpy.
The parts chosen by myself are in the back between
the scapulae on either side of the vertebral column.
Other parts of the body, as the loins, groins or sides
of the chest have been selected.
The parts are thoroughly cleansed by means of alco-
hol soaked upon sublimate cotton or gauze, and after
injection are hermetically sealed with iodoform
collodion.
The syringe is cleansed by means of very hot water
and the whole operation rendered as aseptic as possi-
ble. I have yet to record an abscess, or even any
inflammatory reaction following at the seat of injec-
tion, all of which I ascribe to the rigid cleanliness
enforced, in the use of my needles as well as in the
parts acted upon.
The dosage. The amount of antitoxin used de-
pends upon the time of making the injection, the
age and body weight of the individual, and the grav-
ity of the disease, also whether for the purpose of
immunization or cure.
Experience has taught me that the method arrived
at by the originators of the antitoxin as to the quan-
tity of serum necessary to antagonize the toxins of
diphtheria was the correct one ; I therefore follow the
original method and grade my dose into immunity
units.
As an immunizing dose I give an injection of 100
units to perfectly healthy individuals exposed to the
contagion — their body weight averaging 120 pounds,
basing the dose on these being of equal suscepti-
bility to the guinea pig. This dosage is now the
general rule. If there be constant exposure I increase
this dosage to 200 units. By constant exposure I
mean where the individual to be protected lives in
the same room or house, as the tenement system of
any large city. In extraordinary instances, as a
woman in the last days of pregnancy, about to be con-
fined, I inject a full dose, 600 units, as an immuniz-
ing dose. Of such cases I have seen two instances
with the most satisfactory results; the accouchement
taking place in one instance in the very room occu-
pied by the still affected child, and no symptoms
being manifest.
As a curative dose. If the case be seen early,
within twenty-four to forty-eight hours, and is of the
faucial variety, where the infection has not reached
the lymphatics, I administer at once 600 units. If
the case be seen on the third day, or if at the very
beginning the infection is such that leads one to
believe in the necessity of prompt heroic treatment,
as in the laryngeal cases or where the lymphatics are
involved, or where the bacteriologic examinations
show mixed infections (streptococcus, staphylococcus,
etc.), I immediately inject 1,000 units. I then await
results. If in six . to twelve hours no change takes
place or the symptoms are aggravated, I again inject
1,000 or 1,500 units of the serum, and so on in increas-
ing quantities until there be an amelioration of the
symptoms shown by a decline in the pulse rate and
temperature and an improvement in the general con-
dition.
The quantity of antitoxin can be increased to
enormous dosage; being harmless, no danger can be
apprehended. I have used as high as 13,000 units in
one case. Others have used 200 c.cm. — 20,000 units,
with complete recovery.
Clinical manifestation of the diphtheria antitoxin
serum.
1. The effects on the pulse and circulation. In
faucial diphtheria, within a very short period, about
eight hours in the most favorable cases, the pulse rate
declines and remains down and the circulation assumes
the normal. This, however, may not be permanent,
and if the rate increases again it is an indication for
the administration of more antitoxin. Especially is
this an indication in those cases where the toxemia is
so marked that the temperature is only slightly above
the normal or is subnormal. In laryngeal cases,
however, the pulse rate remains high in the majority
of cases, and this is seen especially in those cases
intubated. The indication then is not so much for
the antitoxin as for judicious collateral medication.
2. Effects on the temperature. In the most favor-
able cases, by which I mean the pure and simple
diphtheria, there is a rapid decline from any elevation
of temperature to the normal, and this decline is per-
manent. Where, however, there may be a recurrence
of the fever and no manifestation of any intercurrent
complication as pneumonia, and the like, it is an indi-
cation for an additional administration of the anti-
toxin, even if the occurrence should take place in one,
two or three days after the injection. An elevation of
the temperature later than four days indicates a bron-
cho-pneumonia or some other disease and should be
treated accordingly. In laryngeal cases is this espe-
cially marked, and in those cases intubated it has
been seen by myself even after the tube was withdrawn.
3. Action on the diphtheritic membrane. The
action of the antitoxin is visible to the naked eye by
the effects on the diphtheritic membrane.
It limits the extension within twenty-four hours
and promotes the separation in forty-eight to seventy-
two hours.
As an indication for the sufficient use of the serum
I have noticed a distinct red line surrounding the
membrane, making a line of demarkation between the
healthy and diseased mucous membrane. Over this
line I have never seen the membrane spread, and
when it has formed my experience has taught me to
expect a very favorable prognosis in that especial case.
The membranes separate differently; in some cases
it comes away in one piece, leaving a healthy mucous
membrane beneath. In other cases, especially those
in which there is mixed infection the membranes
soften and become pultaceous, and seem to dissolve
or melt away.
4. Effects in laryngeal diphtheria. When used
early enough it prevents the spread of the membranes,
thereby averting asphyxia, and avoids the operation
of intubation or tracheotomy. The membranes dis-
appear in the same manner as in the faucial variety,
stenosis being invariably relieved on the third day.
Where the laryngeal diphtheria is complicated with
membranes on the tonsils, pharynx or nose, these dis-
appear at the same time as the stenosis.
Intubated cases. Of the forty-four cases of laryn-
geal diphtheria, sixteen cases necessitated the opera-
tion of intubation, three of which were within the
twenty-four hours after injection; the others were
intubated before or at the time of the injection.
The average reduction in the time the tube was
18%.]
SERUM THERAPY IN DIPHTHERIA.
13
worn was sixty-nine hours. Previous to the serum
period the average time was IS5.25; since this period
the average time was L16.25 hours. This reduction
noticed and soon recorded by Huebner ( Klinische
Studien, etc.), Von Ranke, Johan Bokni, O'Dwyer
and others.
Inasmuch as the indication for tracheotomy was
the Length of time the tube was worn, with the con-
current symptoms, decubitus, etc., the time being
placed above 120 hours. No urgent symptoms were
manifested even in the long cases to necessitate trache-
otomy. For that reason antitoxin has proven itself
of the utmost value and is one of the conspicuous
evidences of its effects.
Antitoxin has reduced the mortality in cases of
intubation. In my cases so treated the reduction
has been from a mortality of 62 percent, before the
serum period, to L0.5 percent with antitoxin. Nor do
1 stand alone in this experience. Bokai (Stephanie,
Kinder hospital, Buda-Pesth) reports in his hospital
work an increase of 17 per cent, in his cures. The
reduction in the time the tube was worn in those cases
of recovery was eighteen hours, the average being
sixty-one hours serum period, against seventy-nine
hours before the serum period.
Jos. O'Dwyer of New York, whose work on this
especial method of treatment is so well known to you
all. has very kindly sent me a short report of his cases,
a transcription of which I give here:
"My results up to the present time in 500 cases, in
a series of hundreds: First hundred — largely experi-
mental seventeen recoveries; second hundred, twen-
tv-seven recoveries: third hundred, thirty recoveries;
fourth hundred, twenty-six recoveries; fifth hundred,
thirty-nine recoveries.
" The marked increase in the last series was due to
the antitoxin, in thirty cases, of which there were
twenty recoveries. In the seventy preceding cases in
which no antitoxin was used, there were only nineteen
recoveries, which was about the same percentage as
in all the other series."
< I'Dwyer's statistics substantiate my own: from a
mortality ranging from S3 to 70 per cent, before the
serum period his reduction has been to 30 per cent.
T'ne average time the tube was worn, serum period,
was 80 hours; before this period the time was 147
hours. So the reduction in time in O'Dwyer's cases
was i>7 hours.
Tta action on the duration of the disease. Anti-
toxin limits the duration of the disease to four or five
days and shortens the period, which may reach to
weeks.
When administered early in simple diphtheria all
visual traces of the disease disappear on the third day.
In mixed contagion the diphtheria infection is
antagonized and the complications treated without
regard to the existence of diphtheria.
In the laryngeal variety the stenosis disappears
the third day in those cases not requiring operative
interference. In cases intubated, the tube can be
withdrawn with a certainty and exactness on the
fourth or fifth day, such a rule being unknown before
the serum period.
The general condition of the patient in the major-
ity of cases improves at once, and by its early use,
even before depression was manifested; thereby pre-
venting complications and sequela?, the termination
of which, even with the antitoxin treatment can not
be averted.
.Is a prevention of the meddlesome and dangerous
method of constant local and systemic treatment in
vogue. As antitoxin acts specifically and the gene-
ral condition of the patients improve so quickly, no
necessity arises for the constant and persistent methods
of applying local applications formerly pursued.
It is true that the membranes of the throat are
the foci for the invasion of the system by the diph-
theria toxin; it is equally true that the injection of
the antitoxin antagonizes and prevents further infec-
tion. If this be so, and thousands of cases have
clinically demonstrated it, the persistent endeavors to
remove the membrane by hourly or half-hourly appli-
cations are not only superfluous but dangerous, as
not only tending to keep the patient awake and in
dread, but by weakening the recuperative powers
open a way for complications and a dangerous or
perhaps fatal sequelae (paralysis, heart failure and
the like).
For this reason when treating a patient with anti-
toxin, local applications may be made once in four to
six hours, and simply for the purpose of cleanliness,
or for the specific purpose of ridding the throat of
the bacteria, thus preventing the danger of contagion
to others.
Poisonous drugs, as corrosive sublimate and the
like, are unnecessary, or if administered as indica-
tions might require (as ulcerations resulting from
the diphtheria, etc., in long cases) may be given at
longer intervals.
Nourishment and stimulants are required, but for
shorter periods than before, two or three days, and dis-
pensed with when no longer indicated.
While antitoxin is a specific for diphtheria, it is
not a " cure all," and complications must receive
thorough attention as if diphtheria no longer existed.
If the circulation be weak and the case urgent, stim-
ulants, strychnin, digitalis, camphor or ammonia
may be indicated. Again if a complication, as pneu-
monia or nephritis, exists this should be treated with-
out any regard to the diphtheria or intubation, by the
wet packs or any method most favored by the opera-
tor. But the constant applications to the throat and
syringing of the nose at too frequent intervals is to
be deplored as tending to a fatal result.
On the presence of bacilli in the throat. Antitoxin
does not destroy the Klebs-Loffler bacilli in the
throat. They persist as long after convalescence as
under any other form of treatment.
It is therefore well to make frequent cultures before
permitting the patient to mingle with others, thereby
spreading the contagion.
I am at present studying what remedies are most
useful in destroying these bacilli, and I have the
hearty cooperation of Dr. B. Meade Bolton, the direc-
tor of the bacteriologic laboratory in Philadelphia,
who examines these cultures for me.
I have used calomel combined with salol; corrosive
sublimate, Loffler's solutions and a solution of nascent
chlorin with tincture of the chlorid of iron, which I
have used for a long period. The Loffler solutions
and the chlorin iron mixture have given me the best
results.
The formulas of the Loffler solutions are as follows:
No. 1.
Menthol 10 grms.
Toluol, q. 8 36 c.c.
Alcohol absol 60 c.c.
Liq. ferri sesquichlor 4 c.c.
14
BLOOD-SERUM THERAPEUTICS
[July 4,
No. 2.
Menthol .10 grms.
Toluol, q. 8 36 c.c.
Creolin 2 c.c.
Alcohol absol 65 c.c.
They are used by applying locally to the throat or
nose by a mop or spray. Loffler's No. 1 is a painful
application and is very much objected to for that
reason, and can not be frequently used. The No. 2
is less painful and is applicable to a wider range of
use.
The chlorin-iron mixture is administered in tea-
spoonful doses to a child 5 years of age once in two
or three hours, during the day time only.
The formula is:
Potassii chloridi
Ac. hydrochloric, C. P aa 1 00
Tinct. ferric chlor 5 00
Syr. simplicis or glycerini 12000
The bacilli disappeared under either of these medi-
caments in two weeks.
Gruaiacol has been used by Dr. Martin W. Barr
and Dr. Solomon Solis Cohen as a local application.
The application is as painful as Loffler's, though Dr.
Cohen has obviated this somewhat by the addition of
menthol. Their results have been good, though sys-
tematic bacteriologic examinations have not demon-
strated any superiority over my methods.
As an immunizing agent. That antitoxin produces
immunity against an attack of diphtheria has been
abundantly verified by a vast number of observers
both in hospital experience and in private practice.
The quarantine system in vogue in Philadelphia
has given me frequent opportunities to verify the
assertion of Behring, Roux and others. This immun-
ity is not lasting. Biggs of New York places it (from
careful observation) at thirty days, Behring places it
from six to eight weeks. I have seen no case immun-
ized show clinical traces of the disease, though fre-
quently Loffler's bacilli were found in the throat;
where such cases existed, they were carefully watched
and cultures made from time to time (once in three
days). No other treatment except the immunizing
dose was used, and cultures made and examined by
Dr. B. Meade Bolton or Dr. H. D. Pease evinced the
the presence of the bacilli even to three weeks, though
no visual traces were ever seen.
Antitoxin does not confer permanent or lasting
immunity from diphtheria even to those who suffered
from an attack of diphtheria and were treated with a
curative quantity of the serum. For the suscepti-
bility to a reinfection on exposure still remains with
the patient, and therefore it should always be proper
to immunize the patient whenever exposed.
The influence of antitoxin on the mortality records.
There is no city in the world whose records have been
carefully kept that has not shown a marked reduction
in the death rates by the antitoxin treatment. I
might except Philadelphia, which seems to be behind-
hand in the method of presenting her records as com-
pared with other cities.
There is no hospital in the world where antitoxin
has been used that has not shown a reduction in the
death rate. Again I must note exception to this by
the records of the Philadelphia Municipal Hospital,
where it appears only hopeless or the most serious
cases are sent, for this hospital holds the most unique
position of recording an increased mortality from this
method of treatment.
There is hardly an exception to be noted in the
statistics of private practitioners, which also show a
reduction in the death rate.
Still, despite these positive proofs of the utility of
the serum treatment; there seems to be a passive
antagonism by some to this form of treatment. I can
only explain it in the words of Dr. Charles L. Dana,
New York ( Diphtheritic Palsies and the Use of Anti-
toxin, Medical Record, April 11, 1896), from whose
excellent monograph I quote: "While the treatment
of diphtheria by antitoxin is a method that has been
approved in all parts of the world and is upheld by a
volume of statistics whose brute force is almost ever-
whelming, yet there is still some degree of skepticism
about its real value. Most of the skepticism is the
result of profound and banal ignorance, coupled, per-
haps, with some hysterical obsession in the lines of
zoophilism and antivivisection. There are, however,
some conservative physicians whose character and
attainments we respect, who still hold a position of
reserve, if not of disbelief, as to the value of the
method, and they advance some very ingenious expla-
nations of the way in which the statistics that so
apparently favor antitoxin are gotten up."
These statistics are supposed to contain in a major-
ity of instances cases whose recognition is simply bac-
teriologic and where the clinical diagnosis is secondary.
Even if this be so, and I for my part have not counted
as cases treated those immunized in whom the specific
bacilli were found. I think the statistics are super-
ior to the former for this reason : Given a case of
diphtheria as formerly treated prognosis was out of
the question; a mild case might suddenly become a
serious one. A laryngeal case may become tracheal.
With antitoxin the disease is aborted and the serious
lesions now so commonly noted by different observers
as broncho-pneumonia, multiple neuritis, post-diph-
theritic palsies, etc., were not noted before because
the patients perished long before these complications
were noted. Therefore, given a case as now treated
with antitoxin, if the serum is used early enough and
in a judicions manner, mortality records should be
simply to prove exceptions to the rule, and the death
rate noted show a lack of careful observance of the
earliest symptoms of diphtheria.
AN INTRODUCTION TO THE DISCUS-
SION UPON "BLOOD-SERUM THERA-
PEUTICS."1
Read in the Section on Materia Medica, I'harmacy and Therapeutics at
the Forty-seventh Annual Meeting of the American Medical
Association at Atlanta. Georgia, May 6 8, 1896.
BY HAROLD C. ERNST, A.M., M.D.
PROFESSOR OF BACTERIOLOGY IN HARVARD UNIVERSITY.
Probably the most radical change in the ideas of
the causation of disease that has ever occurred has
taken place during the last thirty years, its final out-
come being the subject of the discussion before this
meeting to-day. The steps leading up to the position
at present occupied have been taken only after many
wanderings and painful experiences, but as a result
we seem to have reached a rational standpoint from
which further progress may be made. The basis of
blood-serum therapeutics is the idea of immunity, and
the procedure is the result of the investigations made
to determine how immunity occurs. It had been
known for a long time that after attacks of certain
l In the preparation of this paper I have received much assistance
from the little work of Lac halme," Blood-Serum Therapeutics, Paris,
1S8«."
18%.]
BLOOD-SERUM THERAPEUTICS.
15
diseases, there was a period during which a second
attack ct' this same disease did not occur. This was,
iind is. known as acquired immunity to the disease in
question. Certain races of animals are known to be
immune to certain diseases, and this is a natural
immunity, for which there must be some explanation
if only it could be found. This explanation would
give a basis for work directed toward the solving of
the problem of how this immunity could be produced
intentionally, and if this could only be done, we
should have made a long step toward the actual and
proper treatment of disease.
The securing of artificial immunity has been
attempted in several ways; the best known and long-
est employed is that of vaccination. This method
consists in the employment of the virus of a milder
disease of tlie same type, thus, after the attack of the
milder disease, ami lx>eause of it, securing an immu-
nity against the malignant form of disease. Since
the introduction of bacteriologic methods, other
means have been sought to attain the same end. The
protective inoculations against rabies illustrate the
use of the actual virus of the disease in an attenuated
form, but of gradually increasing strength, to produce
an immunity against the full strength of the same
virus. Another method makes use of the living cul-
tures of the bacteria producing the disease, as in the
protective inoculations against anthrax, and still
another of the products of the growth of the bacteria
in the test tube, as in the employment of tuberculin.
The theory of the action of these various methods is
not the same, but their results, so far as they have
been explained at all, have been supposed to rest upon
some changes produced in the tissue cells or those of
the blood, and it is to explain these results that much
of the recent work has been carried on.
As to priority in the suggestion of the method
under discussion, the position of the British Medical
Journal seems to be a reasonable one: "The question
of who was the originator of the serum treatment is
one of interest. It is always difficult to speak with
certainty on a point of priority of this kind, for new
ideas seldom spring from one man, but we believe
that the method had its origin from the observation
made in 1887 by Von Fodor, that blood, when drawn
from the body, had a distinct bactericidal action.
NuttaJl and others then pointed out that although
this bactericidal action might be connected with the
corpuscles of the blood, it was not confined to them,
as the serum of freshly coagulated blood was found
to contain some proteid substance which undoubtedly
exerted a powerful bactericidal effect. In July, 1889,
Babes and Lepp recorded a number of experiments in
which they had found that the blood of dogs which
had been vaccinated against rabies exerted a distinctly
protective action when injected into susceptible ani-
mals either previous to or along with the virus pro-
cured from a rabid animal. Ferran appears to have
been the next observer to accentuate this point. He
was followed by Bouchard in France, whilst Behring
and Kitasato in Germany, and then Roux in Paris,
and others in rapid succession pointed out that there
was in the serum of the blood of animals vaccinated
against diphtheria and tetanus a distinct prophylactic
ami curative agent which, however, it was difficult to
separate from the serum. In 1891 patients were
treated in Berlin by the serum prepared by Behring,"
and the endeavors1 in this direction are more numer-
ous and widespread to-day than in any other line of
medical activity.
So far as the bactericidal properties of an immune
body are concerned, all experiments tended to show
that they lay especially in the blood, and the main
portion of modern endeavor is in the study of the
properties of this portion of the body.
The results put it beyond question that the serum
of certain animals is so much opposed to some bac-
teria as not only to hinder their development but
actually to destroy them. But this is very far from
establishing a general rule as regards immunity, for
the refractory condition of an animal and the bacteri-
cidal property of its blood are not by any means
always, or even most often, present in proportional
degree. As for example the bactericidal property of
the rabbit's serum, an animal extremely receptive to
anthrax, and the absence of bactericidal properties in
a dog's blood, who is especially refractory himself to
anthrax. So that while the bactericidal property of the
serum is a very important matter, it can not be con-
sidered as being a factor in the production of immu-
nity. Its existence, however, has served to show that
the serum is not an inert material and has been the
basis of other important investigations upon the
properties of this tissue.
The attenuating power is one to which much atten-
tion has been paid by Bouchard, Roger and others,
and is probably only a part of its preventive power.
This latter factor seems to have been neglected by
these observers, and it would seem that the mixtures
of serum and bacteria "they injected were harmless,
not because the bacteria were attenuated but because
the serum preserved the tissues from the pathogenic
action of the bacteria which accompanied it. From
the latest work on this question it appears that the
bacteria increase their virulence in the blood of
refractory animals, whether in the living body or in
the test tube, and that this increase of virulence is
the result of a new adaptation, or of a selection among
the most resistant bacteria. So that even the exist-
ence of an attenuating power of the serum seems to
be doubtful at present.
The possibility of the antitoxic action of the serum
first suggested itself to Behring as an explanation of
the constantly observed fact of the persistence and
development of bacteria at the point of inoculation in
refractory animals. The immunity in such cases
could not be due to any effect upon the vitality of the
bacteria, and the only explanation remaining was that
of a neutralizing or destructive action upon their
toxic products, this action being carried out by the
blood-serum, in preference to the other tissues of the
body. Taking up the study of diphtheria and
tetanus, two diseases in which the results appeared
to be especially due to the action of the products of
the bacteria and not of the bacteria themselves, Behr-
ing and Kitasato showed that a mixture of the toxins
of these bacteria with a small amount of the serum of
immune animals could be injected without any results
in animals extremely susceptible to the toxin alone.
The results were found to be the same whether the
mixture was made in the living animal after injection
or in the test tube before injection; and also that the
injection of the serum in another part of the body,
and a little before or a little after that of the toxin
could protect the animal from many times the fatal
dose of the toxin so far that no effect would be pro-
duced by the latter. These observations were of the
utmost importance and were asserted to destroy any
ground for belief in the theory of phagocytosis. They
16
BLOOD-SERUM THERAPEUTICS.
[July 4,
were and are believed by many to represent a direct
chemical action of the antitoxin upon the toxin,
which it either destroys entirely or turns into an
harmless product. This antitoxic property is some-
thing wholly distinct from a bactericidal power, and
is much less easily destroyed, for it resists a tempera-
ture of 65 degrees C, the addition of small percent-
ages of antiseptics, and dilution of the serum with
water. The antitoxic property has been ascribed to a
definite substance contained in the serum, and this
substance has been compared to a globulin or a
diastase, without as yet ever having been separated,
although many efforts to that end have been made.
Whatever it may be, its power is enormous, as is shown
by the experimental results obtained with serum con-
taining it.
The idea of Behring and Kitasato, of the destruction
of the toxin by the serum containing the antitoxin,
although simple and easy of comprehension, does not
appear to be applicable as a general theory, the more
particularly if the observations of Metschnikoff and
his followers be correct and taken into account.
Metschnikoff has shown in his researches upon the
blood of rabbits immunized against hog cholera, that
their serum exercised a manifestly curative and pre-
ventive effect in fresh animals and without of itself
possessing any attenuating or antitoxic property. In
other words, that the effect was not merely due to a
direct action upon the toxin or bacteria, but that a
most important factor was the vitality of the tissues
themselves in which the action took place. So that
according to Metschnikoff, the action of the serum is
especially a stimulation of the tissue resistance, exer-
cised more particularly upon the phagocytes, making
them better able to carry out their defensive action.
The globucidal power of the serum is another factor
that has to be reckoned with. It is closely allied to
the bactericidal, and has been studied more especially
by Buchner and Daremberg. It is shown upon intro-
ducing blood corpuscles of one animal into the serum
of another. In such an experiment, the corpuscles
are very rapidly disintegrated, and disappear in a very
few moments.
This phenomenon occurs in the circulating blood or
in the test tube, and Buchner especially has attempted
to identify it with the bactericidal property of the
blood-serum. They do in fact have characteristics in
common, for they are both destroyed at a temperature
of about 55 degrees C, upon exposure to light, or
upon a modification of the saline constituents of the
serum, but the existence of a special albuminoid sub-
stance, an alexin, as supposed by Buchner, is not by
any means an accepted fact. The coagulating power
of the serum is shown by its introduction by intra-
venous injection in another species of animal. Coag-
ulation very quickly follows because of the precipita-
tion of fibrin, but Richet and Hericourt demonstrated
that this was to be avoided by making the injection
in the cellular tissue, not directly into the blood ves-
sels, so that the injected serum could only enter the
blood current after passing through the lymphatics',
and it has been recently shown by Hayem that this
coagulating power is destroyed by raising to a tem-
perature of 55 degrees C, while Mairot and Bosc
found that only 52 degrees C. was necessary to accom-
plish the same purpose. The same authors have
demonstrated the toxic properties of serum injected
into animals of another species, as manifested by
muscular pains, febrile disturbances, respiratory affec-
tions and even fatal convulsions. These properties
are somewhat more resistant to heat than those already
spoken of and are supposed to be due to certain albu-
minoid materials. They are extremely variable in
different animals and in the same animal toward
different species, and they also vary very much in
accordance with the condition of health of the animal
from which the serum comes. The existence of such
properties as these in the serum is of the utmost
importance, and that they may exist is unquestion-
able. At the same time it must be remembered that
their effects are only markedly present in intravenous
injection and that a wholly different picture is pre-
sented as the result of introduction into the sub-
cutaneous cellular tissue. In this situation these
toxic effects are so slight as to be inappreciable and
may therefore be practically disregarded.
These powers of the serum are apparently closely
allied to the physiological characteristics like tin-
"glycolitic" of Lepine and others, and the "pepto-
saccharizing" of Lepine and Barral.
This paper being merely introductory, the foregoing
portion has been devoted to a brief and incomplete
summary of the present knowledge of the properties
of the serum in general, so far as they are concerned
with the present subject.
The production of the antitoxic power has been
attempted in the effort to secure immunity or the cure
of many diseases, and these efforts are carried out in
the same general way. The steps include the produc-
tion of a toxin immunity first and then an antitoxin
immunity. The differences between the two condi-
tions are, that the former is slow in coming, is danger-
ous during the process, but is lasting and complete
when obtained. It is, however, wholly inapplicable
to general use. The second is very easy to obtain, is
very rapidly reached, is not dangerous, but is not
lasting, and sometimes, owing to the uncertainty as to
how far it is necessary to go, is not complete. The
process of obtaining the first is by the injection into
the selected animals of gradually increasing doses of
the toxin, either filtered free of the bacteria, or else
with them still present, these injections being kept up
until they have reached such a point that the animal
is not affected by a dose of the toxin or culture suffi-
ciently large to be fatal to untreated controls. This
animal has then reached the condition of toxin immu-
nity, and this immunity is a very lasting one. The
condition is due to the presence of the antitoxic prin-
ciple in the blood-serum. This antitoxic property
may be used to secure an antitoxic immunity in other
animals, and these not necessarily of the same species,
provided the serum containing it be injected sub-
cutaneously.
These are the simple bases of the method, the
details are of the most varying and, as yet, indefinite
character. The remarkable thing is, not that we know
so little in regard to these details, but that so much
has been accomplished in the time over which the
investigations have extended.
A simple list of the diseases in which it has been
sought to apply these principles for the production of .
the antitoxin is a long one, without any attempt being
made to give an account of the methods pursued in
each. Such a list — and incomplete perhaps — would
include the investigations of Richet and Hericourt
upon their staphylococcus pyosepticus, and the work
upon anthrax, hog cholera, avian septicemia and
symptomatic anthrax. Babies, typhoid fever, pneu-
1896.]
ANTITOXIN TREATMENT AS A CURE FOR DIPHTHERIA.
17
noma ami tuberculosis have also been studied, with-
out great success so far as is generally known. In
diphtheria certainly, probably in cholera, and possi-
bly in tetanus arc to be found the main results that
justify us in hoping for further advances in this direc-
tion so far as the application to man is concerned.
Very possibly, too, results that may be immediately
forthcoming will show that we are much nearer to a
solution of the problem of the streptococcus antitoxin
than at present seems to me to be the case.
THE FALLACY OF ANTITOXIN TREAT-
MENT AS A CUBE FOR
DIPHTHERIA.
Rend in the Section on Diseases of Children, at the Forty-seventh
AiimiHl Meeting of the American Medical Association,
at Atlanta, tia„ May 5-S, 1896.
BY ELMER LEE, A.M., M.D., Ph.B.
President American Academy of Medicine; Chairman section on
Btate Medicine American Medical Association. Chicago.
Early in my medical career, and at the time that
Pasteur declared he hail discovered a certain remedy
for hydrophobia, it seemed a pity to me that the pro-
found effort could not have been directed to the cure
of diphtheria. Hydrophobia is such a rare disease,
occurring not oftener than one to the million per
annum, whereas diphtheria is universally prevalent,
is the reason why regret was felt at the time of his
publication. What it was hoped he might have done,
is alleged to have been done by other investigators.
Pasteur claimed in 1884, that a product made from
the culture of the brain of an animal which had been
inoculated with the disease of hydrophobia, was able,
when injected beneath the skin of the human being,
to cure rabies. This prophetic utterance emanated
from a man who seemed to me, during this period of
medical adolescence, to be utterly irrefutable. The
scientific position which was accorded him, made his
declaration appear to the world at that time, and to
me with almost the same awe inspiring force, as if it
had been an inspiration which had directed his mind
and his hand. Hundreds and thousands of human
beings have turned their faces toward the Pasteur
Laboratory since 1884, supposing that they were mor-
tally wounded by the teeth and the virus of mad dogs.
There have been many who have presented themselves
at his gate who were bitten, but not by a mad dog;
hundreds of others who were bitten through the pro-
tecting folds of the clothing; many, indeed, who were
simply licked by the tongue of a dog, not bitten at
all. Still others have submitted to the inoculation
through curiosity, having had no injury whatsoever.
So great is the influence of the modern press that a
scientific proposition, while still in the germinative
state, is heralded throughout the civilized world, and
is quickly transformed into a perfected science by
writers of the press. There were a few who were able
to doubt the truth of the allegation as to the curative
influence of the Pasteur lymph. Long before cool
and scientific inquiry could be made by physicians
away from this center of discovery, the die had been
cast that hydrophobia was curable by Pasteur lymph.
At this present moment there are unmistakable proofs
that error in judgment and in practice is the largest
element in the hydrophobia cure. During the first
few years of the experimental inoculations for rabies,
many deaths occurred among the patients; so many,
in fact, that Pasteur himself became alarmed at his
own work. During a later period the death rate from
hydrophobia, as stated at the Pasteur institute, became
less. The lowered death rate was proclaimed to be
the result of the natural improvement in the process,
and at the time, was accepted by nearly all. In the
last few years of the hydrophobia cure the death
rate has been materially lessened and is attributed to
still further advancement in the understanding of the
treatment. Right here is where the point, which is
to be drawn from the foregoing statements, appears.
Whatever may be the view of persons who have
not personally investigated the treatment of hydro-
phobia by Pasteur lymph, the real explanation of the
reduced mortality since the declaration of the treat-
ment in 1884, is directly due to the dilution of the
curative lymph. In so far as the reduction of the
virility of the laboratory product is concerned, just so
far has there been advancement in the progress; per-
haps, if the lymph was indefinitely attenuated, the
mortality would be still less. This recital is intro-
duced to show the error which may exist in one of the
greatest therapeutic faiths close to the end of the
nineteenth century.
Bacteriologic investigators, in Berlin and Paris,
sent word to the United States recently, that diphthe-
ria is curable by a specific medicine. This specific
cure is produced as follows: A culture of the germs
of diphtheria is injected, day after day, in increasing
doses for a long time, into a horse, until it is able to
withstand the poison of 250 cubic centimeters of the
diphtheria virus, whereas one-tenth of a cubic centi-
meter of the same virus would be fatal to a guinea
pig. After a certain period has elapsed a quantity of
blood is drawn from the jugular vein of the horse,
and the serum, after being further treated in the lab-
oratory, is ready to be injected beneath the skin as a
cure for diphtheria.
Ever since the discovery by Tyndall that the atmos-
phere, as well as the soil and the water, is inhabited by
life in invisible form, there has been a prolific series
of theories concerning germ organisms. It is gener-
ally accepted that a constant state of antagonism
exists between minute organic life, and it is supposed
that preservation as well as destruction of life,
is attributable to these germs which are warring with
each other. First came the discovery of germ life in
nature, followed in due time by the declaration that
all diseases are due to the influence of pathogenic
germs. The next step consisted of a conception that
pathogenic germs must be antagonized by other germs
in the preservation of life and the treatment of dis-
ease. The next step in the process is that pathogenic
germs, or their ptomaines, are able to be counteracted
in their influence upon the life of the human body,
by either the same germ or its own ptomaine. It is
believed that during the period of inoculation of a
horse with the diphtheria culture, a process is going
on which is generating a fluid in the animal, that is
antagonistic to the disease which it is assumed is
caused by the original germ, namely, diphtheria.
Let us now consider diphtheria from a clinical
standpoint. There are two varieties of diphtheria
which exist to-day, but, one of which did not exist
yesterday. One is true clinical diphtheria, the gross
symptoms of which are entirely sufficient for prac-
tical diagnosis. The other form is the diphtheria of
the bacteriologic laboratory. One is diagnosticated
by the clinician, while the other is discovered by the
bacteriologist. These two varieties are made neces-
sary by reason of the claims of bacteriology, by which
18
ANTITOXIN TREATMENT AS A CURE FOR DIPHTHERIA.
[July 4,
discoveries practical medicine has been both aided
and retarded. Aided, by helping to a clearer under-
standing of the pathogenic and bacteriologic changes
during the process of disease, and hindered, for
the time being, by throwing a cloud across the path-
way of natural and practical therapeutics.
Diphtheria is a systemic disease with both general
and local manifestations. The local manifestations
are located principally in the throat and larynx. By
some observers the local symptomatology is considered
paramount. It is taught by bacteriology that local
microbes develop toxins upon the mucous mem-
brane of the throat, and from this source the entire
system is infected, whereas the true explanation
regards the pathologic changes in the throat as but
local exhibitions of general systemic poisoning. The
laboratory declaration that a Klebs-Loffler bacillus
found in the secretions of the throat establishes
prima facie evidence that a disease is diphtheria, need
not confuse our judgment and interfere with the con-
clusion previously stated in the foregoing sentence.
It is undoubtedly true, that suitable nourishment
for the growth of germs is found in the throats of
children whose general system is impaired with diph-
theritic sepsis. The so-called specific germ is found
upon the tonsil both in health as well as in disease.
Is it, therefore, a reliable means of determining the
diagnosis of diphtheria?
Is the explanation of the false membrane which
forms upon the throat, thus interfering with respira-
tion, to be found by bacteriologic inquiry ? When the
system is impaired, and a determination of the weak-
ened vital forces results in an inflammation of the
fauces, there is thrown out upon the mucous . mem-
brane a thick, tenacious, glairy fluid, which dries and
thickens into a membrane. The inflammatory state
of the mucous membrane keeps adding fresh serous
discharges, thus augmenting the deposit and ulti-
mately filling the free space of the throat. In this
serum the colonies of a variety of germs find normal
food for nourishment and growth. Owing to the
occlusion of the breathing space, insufficient air
enters the lungs and further embarrassment of the
health of the child quickly ensues. Examinations of
the blood show an altered relationship among the
component parts. Capillary circulation is diminished
and congestions arise, both in the structures of the
throat and neck, and in other tissues which are
adjacent. The physical economy of the vital organs
is imperiled and their functions are imperfectly per-
formed. Retention of morbid matter rapidly accu-
mulates throughout the entire system, especially in
the capillary and lymphatic vessels. Great efforts are
made by the resisting vitality to unload its burden
and repair the damage.
At this time of the pathologic processes there are two
therapeutic measures which are imperatively demand-
ed: first, the supply of new force to the tissues by fresh
nutrition; and secondly, aid to the impaired efforts of
the organism to remove the morbid and retained mat-
ters. Nature is doing all that it can to carry the effete
material produced by the disease, out of the system
through the excretory organs. At this moment what
is accomplished by forcing into the circulation a
substance which has no natural relationship to the
structure of a single element composing the entire
body? The system is laboring and panting for life,
under the oppression of toxins which it is trying to
eliminate. At the very crisis of the greatest strain
upon vital resources, a serum which does not belong in
the human economy, is strangely added to the fearful
load, which is in some cases the last straw that
breaks the camel's back. Its use is therefore unphysi-
ologic and absolutely contraindicated. The bacteriol-
ogist affirms to the contrary, observe which is the
better able to judge, practical clinicians or the ultra-
scientist in the laboratory?
The claims that are seductively held out that
cases treated early by antitoxin would recover have
utterly failed. The claim subsequently that cases
treated by antitoxin recover more quickly than those
not so treated has utterly failed to be true. The claim
that the death rate would be lessened has proved to
be a disappointment. The claim that antitoxin was
harmless has been proven to the contrary by many
fatal terminations. Judging from the facts con-
cerning the use of antitoxin in practice, does there
stand on record to-day one single valid reason,
from a clinical standpoint, to encourage the hope of
better results in the future than have been attained in
the past by other methods of treatment? It is not
the purpose to impute insincerity, or lack of intelli-
gent industry, on the part of the profession, concerned
in experimenting with antitoxin, but the promises of
better results through its use have unfortunately
failed to be substantiated.
The human system, when laboring under morbid
influences, needs rather those elements which can
add strength and vigor to the vital resistance. By
what law or principle in physiology can augmented
vital resistance be maintained by the introduction of
antitoxin into the system ? Has the explanation of the
action of antitoxin been satisfactorily given by those
who are its sponsors? It is to be conceded that there
are cases of diphtheria which, when treated by anti-
toxin, have seemingly progressed favorably, while there
are other cases which have quickly terminated fatally.
The influence of the antitoxin virus is directly depend-
ent upon the condition of the patient at the time of its
introduction. If the powers are well maintained, as
during the first few days of the disease, naturally the
system is stronger and its efforts more effective toward
elimination, both of the antitoxin introduced and of
the autogenerated toxin. Here is the explanation of
the advantage claimed by the early use of antitoxin.
It follows, when the system is further impaired its
phagocytic action is also impaired, and the chances
for recovery by reason of the further introduction of
extraneous matter are lessened. What physiologic
problem could be more simple? The point is this,
that the blood does not need to be further polluted
in order to expel the autogenerated products which it
already contains. Can any one explain the reaction
which takes place in the human living organism when
antitoxin is added? There is a reaction, but that the
reaction is a curative influence is open to discussion.
A small amount of morbid matter adjacent to
living cell structures is dissolved away by the leuco-
cytes and forced out of the body through the escapes
provided by nature. This takes place regularly
when the cell is aided by forces which contribute to
its vigor. If the vitality is diminished by extensive
morbid processes, extraneous matter added to the sys-
only further weakens the reconstructive agencies
which are at work. The theory that sepsis of any
kind, already in the system, is able to be neutralized
by the addition of manufactured toxins from without,
though freely taught, is utterly inconsistent and
1896.]
ANTITOXIN AND INTUBATION.
19
unreasonable. Can the chemic reactions of the labora-
tory be Buccessfuly repeated in the lalx>ratory of the
human body?
Has horse scrum, plus disease, any natural place in the
human blood? And the red corpuscles are dissolved
by its presence. No material success has ever been
achieved by the transfusion of healthy animal blood
into the human body for the cure of disease. Trans-
fusion of salt water accomplishes all that is claimed
for the process. Now then, how much the less is
likely to be accomplished when an infected animal
serum is injected for the cure of diphtheria?
The blood has lost some of its component elemen-
tary conditions. It is thereby altered in character, and
when acting through inflamed mucous membranes
morbid symptoms are produced, such as are seen in
diphtheria. The fluid which patrols the entire body
should be strengthened rather than further decom-
posed and disorganized by the addition of extraneous
and poisonous matter.
The records of the cases treated in the Willard
Parker Hospital of New York City prove that anti-
toxin is dangerous and even fatal. The statistics of
that hospital establish that the further use of anti-
toxin is unjustifiable. Extreme interest and effort to
know the truth has guided the staff of the Willard
Parker Hospital. Dr. Joseph E. Winters of New
York has sought difigently to establish the value of
antitoxin, but the clinical experiences have forced him
unwillingly to condemn its use. Is it safe to ne-
glect the warning of such an experienced clinician
and medical teacher? Professor Lennox Browne of
London, patiently and earnestly sought for clin-
ical reasons to further the interests of antitoxin. His
conclusions are emphatic and pronounced against it.
Dr. Weeks of Philadelphia also deprecates the use
of antitoxin, basing the conclusions upon an extensive
experience in the Municipal Hospital of that city.
Health department statistics of New York are cited
in Chicago to the advantage of antitoxin, and Chicago
statistics are published in the interest of antitoxin in
New York. Health department methods of collect-
ing information must be taken with allowance for
accuracy. Previous to leaving Chicago a culture was
made of the tongue of the office boy and the tube left
at the city health office. The answer received stated
that the case was one of true diphtheria. In fact, the
boy was not ill at all. Provisions were immediately
made by the department to fumigate and otherwise
annoy the family at the boy's home. Is it not easy
to be seen that the enthusiasm and overzealous inter-
est < >f the medical corps in the employ of cities may
bring to the notice of the health departments cases
similar to the one cited? Such reports go on the
records and contribute toward the statistics which are
sent broadcast. The statistics very quickly become
confused and their power for usefulness is absolutely
tt&. Unquestionably large numbers of cases which
have been reported to be diphtheria and cured by an
injection of antitoxin have been of the bacteriologic
class.
It was recently stated to me, upon good authority,
that the sales were falling off rapidly and an early
termination of the demand for antitoxin was not for
off; also that offers to purchase antitoxin upon most
advantageous figures had been declined because of the
fear of pecuniary loss. Thus the straws point the way
the wind blows.
103 State Street.
SOME PKACTICAL POINTS ON THE COM-
BINED EFECTS OF ANTITOXIN AND
INTUBATION,
WITH SPECIAL REFERENCE TO INFANT FEEDING IN
MALIGNANT DIPHTHERIA.
Read in tin' Section on Diseases of Children at the Forty-seventh
Annua] Meeting of the Amerloan Medical Association at
Atlanta, <la.. May 5-8, 1H»H.
BY LOUIS FISCHER, M.D.
Associate Professor Diseases of Children, New York School of Clinical
Medicine; Physician to the Messiah Home for Children: Attending
Physician Children's Department, German PoUkllnlk and to
tiic West side German Dispensary.
Certain factors appeal to us in a severe case of
laryngeal diphtheria. The main point to be consid-
ered, however, is to afford instantaneous mechanical
relief and prevent asphyxia. This, to my mind, is of
more importance than the consideration of what the
real therapeutics shall be.
If therefore, a child has recovered from the exhaus-
tion following this mechanical relief by intubation,
then it is necessary to commence with the real thera-
peutic management of the case.
If a history of diphtheria exists, and we are posi-
tive of the diagnosis, then we should without delay
inject our case with either 5 c.cm. of antitoxin of the
strength of 500 normal units, and if no relief is afforded
in twenty-four hours, then we repeat the injection of
the same dose of antitoxin. The choice as to the
location of the injection depends on the practitioner.
My own preference has been, that seen by me in
Berlin with Professor Baginsky, in the interscapular
space. It is not the purpose of this paper to detail
the technique of intubation, for every one of us, no
doubt, knows when and how to place a tube.
The same might be said for the injections of anti-
toxin. They have become so universally used that
the technique is very well understood. It is an im-
portant point to lay stress on what I consider of vital
importance, especially so, when we hear of sudden
deaths occurring within a minute or two after an in-
jection of antitoxin has been given. Any one famil-
iar with the danger of injecting air into a vein will at
once recognize the great importance of selecting that
part of the body which is least likely to have large
veins, and where we would be least apt to puncture
them. A thrombus forming in a vein can easily pro-
duce death, and we all know that were the barrel of
the syringe filled with plain water or milk or with any
other ingredient, that death would occur just as quickly
if air is injected into a vein, as it does or has done
when antitoxin is injected.
We then have reached the two main indications
demanded by science of to-day in the treatment of an
obstinate case of laryngeal diphtheria: 1. We have
satisfied nature's demand for the relief of the stenosis
by intubation, and probably avoided asphyxia. 2.
We have aimed, by injecting the antitoxin, at the
destruction of septic elements or toxins introduced in
the system through the agency of the Klebs- Loftier
bacilli. The most important part of the treatment of
a severe laryngeal diphtheria consists in the after
treatment. I insist in every case of laryngeal diph-
theria, with a tube in the throat, on feeding per rec-
tum. By this means we can guard against that most
dangerous complication, namely, Schluck-pneumonie.
This latter is caused by the suction or flowing into
the trachea, bronchi and capillaries of liquids,
intended for swallowing, and causing pneumonia.
20
AN EXPERIENCE WITH ANTITOXIN.
[July 4,
That such a pneumonia is not only a very difficult
matter to handle, as a complication, should not be lost
sight of, for more than one-half of all fatal cases die
of this complication. I therefore advise giving a
cleansing enema of soap and water, usually a pint in
all, and throw it into the rectum and colon to wash
away accumulated feces, and follow this cleansing
enema by nutrient enema of peptonized milk, pepton-
ized yolk of egg, peptonized beef juice, and sometimes
small quantities of brandy if stimulation is called for.
The interval of three hours is usually called for owing
to the risk of exciting too active peristaltic move-
ments and having the nutrition emptied out of the
bowel.
It is well to bear in mind that the rectum absorbs
and does not digest, and therefore that only liquid
nourishment' should be thrown in. No solid food
should be pushed into the rectum. Small quantities
will be better borne than large ones; all farinaceous
food, like barley, rice and farina, soup made from beef,
veal or chicken can be thrown into the rectum in
quantities of one to two ounces.
I have frequently tried to resort to forced feeding
by pushing a catheter through the nares into the
esophagus and pouring small quantities of liquid food
directly into the stomach, but this is such a highly
objectionable plan in private practice that I have
almost completely abandoned it. You will agree with
me that while some parents will think it cruel to push
a Nelaton catheter through the nose of their beloved
infant for feeding purposes, they will not object in
any way to using the rectum and colon for this
purpose.
A point to remember in connection with dyspnea
which sometimes occurs in an intubated child, is that
relief is frequently afforded by giving inhalations of
oxygen so that as a matter of routine, I invariably ad-
vise a cylinder of oxygen to be kept handy, in a malig-
nant case of diphtheria with stenosis and threatened
asphyxia.
The wonderful results achieved by me in the treat-
ment of this dreadful disease are due to the rapidity
with which I tried to overcome urgent symptoms.
Thus I never leave a high temperature, of 105 degrees,
without at once giving an antipyretic bath, immers-
ing the child in a temperature of 90 and gradually
cooling to 70, the duration of the bath to be in all
about five minutes. This is to be continued every three
hours until the temperature remains at 102. I do not
use antipyretics during the course of treatment of
diphtheria. One of the greatest mistakes encountered
by physicians is that after an injection of antitoxin
has been given, they discontinue all further medi-
cation. They do not properly nourish their patients
and merely look for miraculous disappearance of the
pseudo-membrane and all further symptoms after this
one injection, and thus it is that the great many fail-
ures in the treatment of diphtheria with antitoxin are
not due to the impotency of this most valuable thera-
peutic agent, but rather to the careless after-treatment,
and sometimes the exhaustion of the patient, from
lack of proper nourishment.
I insist on a thorough nasal irrigation of warm salt
water solution at least twice a day, in every case of
diphtheria without nasal complication, merely as a
hygienic measure.
Sustain the Heart. — This can best be done with
nourishment, and the less drugs used, excepting those
urgently called for, as for example strychnin in minute
doses, the better. A wise plan is to give most chil-
dren as little alcohol as possible. It is a good plan to
give all medication hypodermically, so, for example,
a minute dose of strychnin can be used if required, or
alcohol can be injected. A cool, clear temperature of
65 to 70 degrees will add much to the comfort of our
patient. If the glands of the neck are very much
swollen, then an ice collar will do a great deal toward
relieving the swelling. Spartein is sometimes called
for, but unusual care must be exercised owing to the
irritability of the stomach. Pseudo-membrane should
be carefully noted in regard to its size, and every
diminution looked upon as favorable progress. Fetor
ex ore is a usual symptom of necrotic tissue, be it in
the form of a pseudo-membrane or otherwise, and is
usually found during the course of laryngeal diph-
theria. A gradual fall of the temperature, not by
crisis, but by lysis, should be looked forward to as a
favorable symptom; so also the diminution of the size
of the glands of the neck.
Such symptoms as high-colored urine with small
traces of albumin, possibly a cast, were now and then
found during the ordinary course of a malignant case
of diphtheria, long before antitoxin was discovered.
It is therefore not surprising to find it now.
I look upon the disappearance of a high color and
a freer secretion of urine, and a disappearance of the
albumin as favorable symptoms indicating convales-
scence. The respiration in some of my cases reached
as high as one hundred per minute. A diminution in
the number of respirations and at the same time
decrease in the rapidity of the pulse, with the fall o*
temperature by lysis, are all favorable symptoms.
Diaphoresis, when commencing after a few days of
treatment of a malignant case of diphtheria, I look
upon as very favorable symptom, being nature's effort
of eliminating toxic elements through the sweat
glands.
I have purposely refrained from tiring you with the
description of clinical histories of single cases of
diphtheria, and furthermore, do not care to give you
statistics which can be made to suit the whims of any
author, but can assure you that I recognize to-day in
diphtheria, not the old foe of former times, but am
willing to give a better prognosis to-day, with proper
antitoxin treatment, aided by so called supporting
treatment, which consists in concentrating nutrition
when the body most needs it, than by any old fangled
method of treatment known.
AN EXPERIENCE WITH ANTITOXIN WITH
INSTRUCTIVE RESULTS.
Read in tbe Section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association,
held at Atlanta, Ga.. May 5-8, 1896.
BY JOSEPH WM. STICKLER, M.S., M.D.
OEANGE, N.J.
I will quote but two cases, types of others, to call
attention to points which seem to me to be of import-
ance in connection with the administration of anti-
toxin.
Case 1. — Some time ago I was asked •by Dr. Simmons of
Orange, N. J., to see a boy about 7 years of age, who was suf-
fering from some form of laryngeal stenosis. At the time he
requested me to consult with him he could not discover by the
ordinary method of examining the throat (with tongue de-
pressor) any membrane. When I arrived at the house the child
was sitting upon his mother's lap, presenting the appearance of
a child in the advanced stage of so-called membranous croup,
I S'.tC. I
AN EXPERIENCE WITH ANTITOXIN.
21
)'.<■.. laryngeal diphtheria. The breathing was however fairly
easy, at times losing its marked stridulous character. When
the respirations wire not markedly quickened and labored the
skin was normal in appearance and the lips ruddy in color.
Tlir pulse was full, strong and regular. Mind clear, urine
normal, and body well nourished. An examination with the
laryngoscope revealed the presence of quite a large amount of
membrane within the larynx. This discovery when coupled
with the previous history of the case led me to give a very
unfavorable prognosis. 1 told the Doctor I would be ready to
perform tracheotomy any moment he might desire it, fully
•t ing to be sent for before the following morning. During
the interim 1 advised the use of antitoxin. Three days passed
In fore 1 heard of the boy's condition. Imagine my surprise
when Dr. Simmons told me that the patient began to improve
almost immediately after theuseof the serum and madeacom-
plete recovery in one week. The points presented by this case
are : I. The laryngeal stenosis had been gradually increasing
up to the time I saw the patient. 2. The stenosis was due to
the presence of membrane which was demonstrable by the use
of the laryngoscope. 3. The vital powers of the child had not
been markedly depressed by the toxins of the Loffler bacilli,
and it is to this latter point I wish to direct special thought.
( 'tis, :. Dr. Thomas S. Fitch of Orange, >i. J., asked me to
see ■ little girl 5 years of age who had diphtheria. The disease
had developed three days prior to my first consultation. When
1 was admitted to the sick room the child was breathing at the
rate of thirty to thirty -five times per minute, and the respira-
tions were very labored in character. The pulse was weak and
averaged 100. The pupils were somewhat dilated, and the
child was very irritable. The skin was mottled and of an ashy
hue. The lips were red but somewhat shriveled. The hands
trembled and the gait was unsteady. When left alone she
would sleep, turning occasionally from one side of the bed to
the other. The urine was diminished in quantity and was
slightly albuminous. The body was fairly well nourished, but
only small quantities of fluid nourishment could be given at
comparatively long intervals. The entire pharynx, tonsils, soft
palate and a portion of the hard palate presented to view a
dense membrane broken only at a few points. The nostrils
also contained membrane. Bacteriologic examination showed
the presence of myriads of the Klebs-Loffler bacilli. Dr. Pitch |
felt inclined to use antitoxin. My opinion was that because of
the tremendous depression of the vital forces the child must
die. It seemed best therefore to support the heart's action, if
possible, till nature could rally her spent powers, and to accom-
plish this result we decided to use active heart stimulants and
such nutriment as the patient could and would take. In ad-
dition to this line of treatment we thought we would try anti
toxin, giving 10 c. c. at twelve-hour intervals. The patient got
steadily worse until about twenty-four hours later, when she
died. The point presented by this case, which seems to me to
be of great moment, is this, the folly of using antitoxin when
the whole animal economy has been struck such a tremendous
blow by the poison of the diphtheria bacilli.
Judging from these and other cases, I believe that
when the heart's action is fairly good, when the sys-
tem at large has not been seriously impaired in its
tone, when the urine shows little or no albumin and
indicates no organic nephritic trouble, as in the first
case quoted, I care not how much membrane there
may be present, antitoxin when judiciously used is
likely to benefit the patient. When, on the other
hand, conditions obtain such as are mentioned in
Case 2, I believe antitoxin to be contraindicated.
DISCUSSION ON PAPERS «F DRS. ELMER LEE, JOS. M. STICKLER
AND LOUIS FISCHER.
Prof. Edwin Klebs, Citronelle, Ala. — First permit me to
speak on the papers read before us. Dr. Elmer Lee stands on
the old standpoint of the pathology of diphtheria, which is not
tenable. We must, it seems, accept the bacilli as the only
cause of diphtheria. That is necessary not only from a bacte-
riologic or a laboratory view, but of a clinical view also. You
know that in diphtheria we first see an affection of the throat,
a slight angina, and later a general affection ; that is the con-
sequence of the action of the diphtheria bacillus in the throat.
The few cases in which we have no local affection are not con-
trary to this opinion. The local affection may occur in parts we
can not see in the larynx or be a very slight one. But we need
not dwell on this point longer. Now the second point he has
brought forth, the observation of the diphtheria bacillus in
the throat of some healthy people. That part is often dis-
cussed. But it seems to me quite clear that the right explan-
ation of it is not given by Dr. Lee.
We see so often in grave diphtheritic epidemics, that the
children become sick in a grave manner immediately after
having caught cold. In this manner I have lost a child. He
was out in a heavy snow storm in Zurich, and upon returning
had diphtheria. How was this to be explained? Surely the
child had the diphtheria organisms present before, and under the
influences of the cold there was made some change in the
mucous membranes, probably an obstruction of the circulation
that we can see microscopically in fresh cases, so that the
tissues become better adapted for the growing of the diph-
theria bacilli. And then, if the gentleman does not accept
that the diphtheria bacillus is the cause of diphtheria, we
would have two different diseases in the same body and we
must ask, What is that other disease not differing from the
diphtheria bacillus? Now, the other preferred opinions are
very difficult to speak upon. He has said the antitoxin can
be dangerous. I asked him and he said, yes, he had person-
ally seen such cases. But we will return to that point later.
Dr. Stickler hits brought forward two cases, one doing excel-
lently, in such manner as, if I have understood it right, one
can not think otherwise than that there has been a very ben-
eficent influence of the antitoxin. In the second he had no
effects. But, have we any one treatment that will be efficient
in all cases? That is not possible. But 1 think Dr. Stickler
has given us a very important paper. Clear observations are
often more valuable than greater statistics.
Now as to the last paper. I have not understood much of
it, but I believe the gentleman had good results with the anti-
toxin. I can not enter into details and return to a more gen-
eral discussion. From some we hear that the antitoxin serum
is inefficacious and may be sometimes dangerous ; from others
we hear that it seems totally reliable. Now, we must have fair
play in this matter. It is enough to now state that numerous
observers had good results in a great number of cases. That
in farther progressed cases there is noted inefficiency, can not be
a ground for rejecting the treatment ; a graver objection is the
possibility of sudden death after the injection of the antitoxin.
The first point we must regard in this question is the exper-
imental foundation of the whole question. It seems to me
there can be no doubt that an anti-poisonous or antitoxic effect
of these substances is fairly demonstrated. If Behring and
others inject great quantities of it at the same time as poison-
ous matter from diphtheria cultures, into the abdominal cavity
of guinea pigs, and the animal will not die while control ani-
mals die in a very short time, we can not say otherwise than
that there is a benefiting antitoxic influence. The same
observations have been made by all good observers. If we find
such a degree of security in animal experiments we can not say
there is nothing in it and it is not probable that the same sub-
stance is of no use in man, when it is effective in guinea pigs.
But there is another point to discuss. Behring and others
have said the antitoxin has alone a healing influence,
but it has also a preventive influence. That is another ques-
tion. We must ask, Can we immunize with the antitoxic
serum in a certain quantity susceptible animals? Some phy-
sicians have asserted that they have had good preventive
results by injecting as small a dose as one cubic centimeter of
serum into children. But, gentlemen, that must be a mistake.
They may have injected the serum and the children have not
become diphtheritic, but that does not prove that the injec-
tion prevented the diphtheria. It is very difficult to speak of
such a preventive action without proof of infection. But we
have other and better ground to say it can not be that there
22
DISCUSSION.
[July 4,
is given by the injection of so small doses immunity to any
animal or human being. The serum has proven a good nour-
ishment substance in which it is possible to cultivate the diph-
theria bacillus. Now, can the same substance, in such small
quantity, immunize an animal if the diphtheria bacillus can
grow upon it? We will remember how great quantities of the
strongest diphtheria cultures are necessary for immunizing
animals. These must be continued for a long time and the
immunity lasts for only a short time. And so I think the
antitoxin has not an immunizing power ; or, at any rate, such
power has not been demonstrated. I must say I have not been
able to read the latest German papers, but I think conclusive
experiments have not been made. Whether the assertion of
R. Pfeiffer that his cholera serum effects degeneration of
the cholera vibrio is acceptable or not we can leave undecided.
I think statistics are always a little uncertain. When a new
remedy is used, many mild cases are healed in a short time.
In Berlin there are two hospitals. The patients in the St.
Urban Hospital were treated with the serum whereas in the
Bethanien-Hospital the patients were not treated with the
antitoxin. The death rate was reduced in the first from 50 to
20 per cent., in the second from 50 to 30 per cent. But in the
first the cases were nearly doubled in number, so that more
lighter or fresher cases were treated by antitoxin.
Now I come to a point that seems to me to be of the highest
importance, the danger of antitoxin. I wish that point would
be illustrated in a more extensive manner by publishing all
cases in which the injection was shortly followed by death.
We have such cases, but a part of them seems to be on account
of the disease. But if in one case alone the patient has been
killed by antitoxin, we have a great interest to find out the
true cause of the death. Such a case is that of Professor
Langerhans in Berlin. After a girl in the house became diph-
theritic, he thought he would, if possible, prevent the spread-
ing of the disease to his own children, but after the injection
the first child died immediately. So it is possible that death
may occur after the most cautious injection of antitoxin, a fact
that gives a high responsibility to every physician using this
remedy. We must search, therefore, to find out, what may
have been the cause of such fatal accident.
In this case it is reported that the body of the dead child
was quite normal, well nourished. There was no introduction
of air into the blood. The danger of introducing air is, by the
way, not so great as often accepted. One can inject some centi-
meters of air in the blood vessels of a rabbit without any
bad effect, as the air is resorted in a very short time. It will
be better to inject the fluid in children into the muscles far
distant from the lungs, in the dorsal or gluteal region. Then
it is convenient to push the needle alone in first and see if
bleeding follows or not. If not, one may inject without fear,
but always slowly, under no high pressure. If these precau-
tions are followed, I think that no danger can be feared from
the injection.
If all these precautions were taken in the Langerhans case,
I can not tell, but it is clear that, if the death occurred by the
injection into a vein, the antitoxin used must have been in a
high degree poisonous.
I do not know, if the consequences of such injections in the
blood of animals are studied, or if kymographic designs for
measuring the blood pressure and action of the heart before
and after the injection of antitoxin are made, certainly they
should have been, if they were not.
I think it is not probable that the antitoxic serum itself con-
tains such a formidable heart poison, as very great quantities
of it injected into the peritoneal cavity of animals proves
harmless. Much more probable it seems to me. that in this
and other similar cases observed in Brooklyn, N. Y., an acci-
dental pollution of the antitoxin has combined with intrave-
nous injection to produce the fatal effect.
The sure disinfection of serum is a very difficult matter.
Twice I have found microbes in tubercle-serum. On the other
side, the best antiseptics, as mercury-bichlorid, phenol and
kresol make coagulations in the serum. Therefore, one must
search for other disinfectants that will not coagulate albu-
minous matters. I note that chinosol is proclaimed as such
by Emmerich ; its antiseptic action is forty times stronger than
carbolic acid and does not coagulate albumin. I have proved
it a very good disinfectant for external and internal use, and
I would recommend it for the disinfection of serum. Certainly
we must demand from the manufacturers of antitoxic serum,
that they must prepare the serum in an absolutely pure man-
ner, excluding totally the possibility of accidental pollution.
It is not a good manner to dispense it in colored bottles. It
can be protected against the light by dark coverings.
I am sure that all these precautions can be executed and
will be executed, in this land, in which I have seen as good
bacteriologic work as anywhere in Europe. I remember with
pleasure that in many of our cities are instituted health offices
for the preparing of the anti-diphtheritic serum (New York,
Pittsburg), in which in every case of diphtheria the presence
of the diphtheria-bacillus is controlled by bacteriologic exam-
ination and the serum is given gratuitously to the profession.
In Berlin the magistrate has declined to do the same. I hope
that the demands of science will always find here a ready
reception.
Dr. W. E. Casselberry, Chicago — Having had considerable
experience with antitoxin, especially in laryngeal diphtheria,
I feel I may at least recite my experience. Previous to the
introduction of antitoxin, the results in laryngeal diphtheria
and membranous croup were very unsatisfactory. The pub-
lished results, on the average, only saved about 25 per cent, of
all cases that had come to the operating stage. The antitoxin
has reversed my statistics, or at any rate my statistics have
been reversed, to the saving of about 75 per cent, of cases. I
attribute this to the antitoxin, in the first place, because the
two epidemics were parallel, and secondly, because of the course
of the clinical symptoms. The antitoxin in my hands has,
both in laryngeal and pharyngeal diphtheria, within twenty-four
hours after its administration, had the result of reducing the
intumescence of the parts. I have not observed it caused a
rapid falling off of the membrane, but the swelling and intumes-
cence, which is responsible largely for the laryngeal obstruc-
tion, within twenty-four hours subsided. The other clinical
symptoms also ameliorated under the influence of the remedy.
The broncho-pneumonia does not so frequently supervene.
The antitoxin appears to limit the disease and prevent its
further extension. The tube having been introduced into the
larynx, we have to dread much less the extension of the disease
in the form of broncho-pneumonia and membranous bronchitis
into the respiratory passages not within the reach of the tube.
And I feel here the antitoxin has been a very decided help. I
do not regard the antitoxin as an innoxious remedy. It has
not been my custom to recommend it as a prophylactic meas-
ure. I endeavor to make the diagnosis as soon as possible.
The microscopic tests I consider of value, but I do not rely
wholly upon them. I think the experience of the clinician is
of equal value with the bacteriologic examination, and if
with that we can And the Loffler bacillus, I think the diagno-
sis may be made with certainty. But I like to have the clini-
cal experience and the bacteriologic examination both to
indicate diphtheria before the serum is used. I think we can
conceive that the individual in health might be more affected
by the antitoxin than are those affected with diphtheria. In-
as-much as cases have been reported of death following the use
of the serum as a prophylactic measure, I think it is better to
wait until a diagnosis of diphtheria is made.
Dr. J. A. Larrabee, Louisville, Ky. — In the discussion it
seems the papers went back far enough to discuss the germs
L8Q6.]
DISCUSSION.
23
themselves. There is no such thing as germ theory at the
■■want time; it is germ fact. Soto make progress we must
not go back and stir up the germ theory.
1 1 is said of all microorganisms, they are omnipresent, but
it is only during the arousing and calling into activity of these
■gnu we have disease. And all those things which put the
germs into activity, are causes of disease.
It is surprising we should contemplate immunizing against a
disease which does not immunize against itself. The compari-
son of antitoxin with Jennerian vaccination has fascinated the
laity. In one we have a very complete protection continuing
for life, ordinarily. This is a molecular change, which remains.
1 1 is not and may not be expected the antitoxin, when it fills our
greatest expectation, will secure immunity. So, I have not in
a single instance attempted immunization in practice. The
theory has not appeared tenable to me. I have arrived at this
point, there can be no question about toxins and antitoxins.
There is no question, even in diphtheria, but that antitoxins,
if properly prepared and if they are the real antitoxins, are
potent to arrest the disease in its progress. I have seen four
children die who I believe would not have died if they had not
Mad antitoxin. I have seen twelve cases of laryngeal stenosis
gat well, that would have died without the antitoxin.
It is an accepted law, that remedies are capable of doing
harm in the abscence of disease. It is untenable to suppose
■officiant air was injected to produce death. When the jugu-
lars are injected with sufficient air, death may supervene. It
is probable a curdling ferment has been introduced, which
upon the teturn of the circulation, in two or three minutes,
has produced a thrombus. But I believe the antitoxin does
produce an immediate effect on the kidneys. In one poor little
fellow, apparently doing well, death occurred within twenty-
four hours with complete anuria. Anuria is almost pathogno-
monic in diphtheria, but this was not the time for it to appear
in the case 1 have mentioned.
Another important point is with reference to pure serum.
All who have used antitoxin much have observed the diphtheria
rashes. These indicate the heterogenous products formed. I
have found the greatest care necessary in color inspection of
these bottles before using, and I stopped one just in time,
perhaps, to prevent an accident. The fluid was turbid and
milky.
We know these cases without intubation died and with
intubation we formerly relieved only 25 per cent, of cases.
Since the introduction of antitoxin, I have had less fear of
laryngeal stenosis, and four cases have gotten well without
intubation. I do not believe we can get such good results
from anything else. I do not think we should abandon the
other treatment. We should take all due pains to remove
septic material from the throat. Since I have done this in
scarlet fever, I have had less ear trouble and other complica-
tions. I believe most of the cases of sepsis have an origin in
the throat and not outside of it, and many cases usually sup-
posed to die from diphtheria really die from sepsis. I hoped
somebody would bring out the value of the knee-jerk in diph-
theria. It is considered by some of my friends in the Windy
City as diagnostic of diphtheria.
Now in regard to this treatment, it does not inhibit or pro-
hibit the old well known fortification of the blood. What-
ever may be introduced in the form of animal toxins, the
invasion of the blood is the principal danger. So I shall not
give up the old-fashioned muriated tincture of iron, given
internally and applied externally.
Dr. W. B. Parks, Atlanta — The city of Atlanta has just sent
in its first order for antitoxin. The only cases we have had
here have been cases of follicular tonsillitis, and hence we have
not secured the antitoxin sooner.
Dr. Rosenthal, New York — As to the changes in the blood,
due to the injections of the antitoxin, the latest paper was
published April 25, by a gentleman from New York, and was a
report made to Professor Biggs, of New York. He had three
series of cases : one of pure diphtheria ; another, in which the
antitoxin was used, and the third, in which the results were
given before and after the antitoxin. After the introduction
of the antitoxin there was no change in the red blood corpus-
cles or in the leucocytes. As a curative dose in diphtheria, I
have used as high as 13,000 antitoxin units ; others have used
20,000 units of the antitoxin, and these patients are walking
the streets to-day, well. I have never seen any bad complica-
tions following the injections. I give the injections between
the scapulas. I prepare the back by washing with corrosive
sublimate. I have in my room a chart, which my student and
an assistant have made, in which they have taken hourly the
temperature and respiration of the patient, and made chemic
and microscopic examinations of the urine nearly hourly, and
they have found no increase of albumin in the cases with albu-
min before the injection was made. They only found an in-
crease of the urates and heightening of the specific gravity, no
sugar and only a little albumin.
Regarding prophylaxis. The antitoxin does not immunize.
Diphtheria is diphtheria, whether you useonec.c. orlOOOc.c. If
you treat the diphtheria with a curative dose of antitoxin and
expose the patient a month afterward to diphtheria, he will
surely get diphtheria. I have in my room the record of the
case of a little fellow who was exposed. He was left quite sick,
locked up in a house with another case of diphtheria. In this
case it had no permanent effect.
I use the Loftier solution, or the guiacol, or — and it is as good
as anything — the tincture of the chlorid of iron.
The post-diphtheritic palsies. We hear more of these than
formerly because the patients died, before they had th°se pal-
sies. We have multiple neuritis, ozena, inflammation of the
middle ear, which would have been seen before the use of the
diphtheritic antitoxin had the cases lived. But now the toxins
have been neutralized by the antitoxins and we have a clearer
field to work in. If antitoxin has any virtues it antagonizes
the Klebs-Loffler bacillusand nothing else. If we find a mixed
infection, then is the time to give the iron.
Another point is the reduction of the time the tube is needed
in laryngeal stenosis since the use of antitoxin. In my own
cases I have found the reduction has been sixty-nine hours. I
could take the tube out on the third or fourth day. Often
there is no indication for intubation or tracheotomy.
All my cases have been substantiated by microscopic exam-
ination. If we did not have the evidence of diphtheria, we
would believe we had been treating follicular affections or
something else for diphtheria. We probably all have bacilli in
the throat, but when you have set up a chemic or mechanic
action in the throat, the disease immediately comes forth and
there you have diphtheria which you wonder you did not see
before. It is the same thing in pneumonia and other conta-
gions. I have no doubt you could find the pneumococci or the
bacilli of diphtheria in my throat. Perfectly healthy gentle-
men and phthisical patients have had the secretions examined
in the laboratories, and the returns have been made that they
were very vi-ulent cases of diphtheria.
I do not not stand alone in the matter of intubation. I have
here a letter from a doctor who in his last thirty cases has
saved twenty. The method we pursue now in Philadelphia, is
this : If we have a case with the clinical manifestations of
diphtheria, we make the injection first and make the bacterio-
logic examination afterward.
As to the quotations by Dr. Lee. Dr. Lennox Browne's book
is out and has had sufficient criticism. Dr. Winters, I under-
stand, has been entirely crushed and has come out in favor of
the antitoxin. Professor Welch has quoted every authority,
French, German, Austrian and Russian, who has had any-
thing to do with the antitoxin, in all, 10,000 cases and now
24
DISCUSSION.
[July 4,
favors antitoxin. Some people have a sort of fever in
the antivivisection line, but, he says, it is to the glory and
honor of the bacteriologists the antitoxin has come forth. The
statistics of Dr. Welch of the Johns Hopkins Hospital are
unique. He told me he had to go to other treatment, but with
the other treatment his mortality rate has increased from 29 to
•33 per cent. Kitasato of Japan, Metschnikoff, Kasmann, Was-
sermann, Ehrlich and others have given statistics showing a
decrease in the death rate. Statistics often lie, but there is
certainly great similarity between them ; and if they are all
liars, I am very glad to be counted among such a class.
Dr. Ross, Kokomo, Ind.— Unfortunately in the little city
where I live we have had a good deal of diphtheria. The phy-
sicians have in almost every case injected antitoxin early. My
partner and myself have probably treated forty-five or fifty
cases and have in every case injected the antitoxin. We have
sometimes used the Behring preparation and sometimes the
preparation made in New York. We have tried to use the
utmost antiseptic and aseptic care. We have not had as much
irritation about the point of injection as I have seen from a
mosquito bite. We have only once seen an erythema, which
was slight and disappeared in a few hours. We have not had
any trouble from shock or other adverse symptoms. We have
never failed to see, within thirty-six hours, the temperature
become normal and the membrane begin to disappear. We
have not lost a case of diphtheria. No regular physician in
our city, of the 200 or more cases treated, has lost a case of
diphtheria during this epidemic. Perhaps a dozen cases have
died but they were cases treated by irregulars, who refused to
use the antitoxin. We have accepted what has been promul-
gated by the investigators and teachers ; we have tried to use
suitable precautions, and we have had good results. I shall
certainly go on, not at all deterred by the frequency of the
word "poison" in the paper by Dr. Elmer Lee, of Chicago. I
have not seen nor heard of a case of disease of the kidneys fol-
lowing the injection of antitoxin. Heretofore, in cases treated
by the old method, frequently after a patient was discharged
and I supposed the disease and my treatment were ended, I
have been called back to see the little patient with pulseless
wrist and pale countenance, and witness its death in a short
time. Such a thing has not occurred in the cases we have
treated with the antitoxin.
I was called to see a case of laryngeal diphtheria. The case
called for intubation or tracheotomy. The condition of the
patient was such I thought neither procedure promised much.
We tried intubation without success. We prayed to be per-
mitted to use the antitoxin. The child was apparently almost
in the agonies of death. After assuring the mother of the
necessity, we were permitted to use the antitoxin. In the
evening we made the injection. The next morning, instead of
finding the child dead, we found it sitting up in bed, playing,
and breathing as if nothing had happened to it.
Dr. Gray — We have had, during the past year, an epidemic
of diphtheria. I have seen from fifty to seventy cases treated
with the antitoxin, and have given it personally in twenty-
eight cases, of which only one died. In the fatal case death
occurred one hour after the administration of the antitoxin.
In that case I gave it only at the earnest solicitation of the
family, knowing at the time it would be useless.
I found a child 2}{ years old suffering from diphtheria. The
little patient had been sick about three days and was cyanotic.
In the same bed during those three days another child, of 4 or
5 years, had been sleeping. I administered 2,000 units of the
antitoxin and in eight hours gave 1,500 units. In a week the
child was well. I had cultures made from the throat of the
child that slept with him and also from the father and mother,
in which the KlebsLoffler bacillus was found, but they did
not develop diphtheria.
At first the doctors were afraid of it and gave small doses. I
have found with the large dose at first we have much better
results. I give all my injections into the interscapular region,
first washing the back of the child with alcohol. I use an
aseptic needle, first soaking it in a weak carbolic acid solution
and then washing it with alcohol. I have never had a rash nor
the slightest indication of abscess. In the case of a child 4
years of age, sick three days, the larynx, nasal passages and
pharynx were involved. The child was cyanotic, with a weak,
thready pulse of 140, temperature 103% degrees, albumin in
the urine, and apparently near death. I injected 1,500 units.
In eight hours afterward there seemed to be some improve-
ment and I repeated the antitoxin, and again in the course of
twenty four hours, and the child recovered with a subsequent
mild nephritis. I have given small doses of brandy to support
the heart. Sometimes I have stuck to the iron. Of the
twenty-eight cases, I do not think one (except the one that
died) did not recover within a week or ten days so it could be
on the street.
Dr. Thomason, Albion, Mich. — I can only give some deduc-
tions from my own clinical experience. A year ago, in Wash-
ington this same subject was discussed. The antitoxin treat-
ment was then in its infancy. Those of us who defended the
antitoxin at that meeting had considerable opposition to meet.
The fate of the Koch tuberculin was talked about, and they
were all afraid of antitoxin. When the papers were read giv-
ing favorable results in a number of cases, and I gave my lim-
ited experience of some twenty cases in the same epidemic, in
the first few of which (treated before we were able to obtain
the antitoxin) there was a mortality of 50 per cent, and in the
others, with the antitoxin, 100 per cent, recovered, many
thought I was prevaricating. But now we feel antitoxin is
very nearly a specific in the treatment of diphtheria. A few
cases are reported of death as the result of antitoxin, but it is
questionable whether death in those cases was due to antitoxin.
But even if it has killed a few, it has saved many. The same
applies to cocain. Cocain killed a patient just as he was leav-
ing my office, but for that reason I shall not discard cocain. I
take the same aseptic precautions I would take in an abdom-
inal section. I make the injection into the deep muscular tis-
sues of the subscapular region. Prior to the introduction of
antitoxin, I operated in twenty cases, every one of which was
fatal. Since the introduction of antitoxin I have had four
cases and all recovered.
I know I am not in harmony with some of the gentlemen, in
regard to it being an immunizing agent. I have used it as an
immunizing agent and, rationally or irrationally, I have had
justifiable results. In one family of six children, five children
had diphtheria and one did not. I gave an immunizing dose
to that child and it escaped ; and I also gave the parents
injections and they escaped. In a family of five children
in which three had the disease, I gave immunizing doses to the
remaining two and they escaped. I have never had any bad
results but an erythema.
The deaths in diphtheria, after the use of antitoxin, I believe
to be due to secondary causes. I never neglect the general
treatment. The antitoxin arrests the primary trouble, that is
all ; consequently I stick to the old chlorid of iron treatment
as tenaciously as ever.
Dr. J. A. Larrabee, Louisville, Ky. — I would like to ask
one question of Dr. Thomason. The Doctor speaks of results
in immunizing. How is it known these cases would have had
diphtheria if he had not immunized them?
Dr. Thomason — I do not know. It may be rational or irra-
tional, but I have used the antitoxin with the results I have
given.
Dr. W. J. Bell, Atlanta — In 1894 we had an epidemic in an
institution with which I was connected. There I had an occa-
sion to use the antitoxin. The conclusion reached there, by
Dr. Parks and Dr. Peck, was conclusive, that antitoxin had an
1896.]
DISCUSSION.
25
antitoxic effect. The statistics bear out that conclusion.
Daring my term there I held to the iron treatment, as was
insisted upon by our Resident, and it was certainly indicated.
I noticed these eases bear iron to an enormous degree of toler-
anre. 1 gave ;it first a small dose, increasing to forty drops in
children IS months to 'i years old. The cases did well. In a
great number of those cases 1 was satisfied I had not only a
local effect from the iron but also a good general effect on the
system. It seems to me our best result would be obtained
if we could use the antitoxin and so saturate the system of
those exposed we could render them temporarily immune. I
do not think there are any who claim the immunity is perma-
nent, but there is a temporary immunization. Therefore, in
those cases where the Klebs Loftier bacilli are found in the
throat, the antitoxin should be used, in smaller doses than for
;i regular case, but at regular intervals, immunizing the gen-
eral system. During the first part of the epidemic we had our
work done in New York, but afterward we established a labo-
ratory and did the examining for the institution. There were
some five hundred children in the institution. We had a regu-
lar quarantine and an intermediate quarantine, and we went
over the cases as well as possible. We had spots of infection
in a number of places through the wards and so could not
locate the point of infection. We selected forty cases, where
the Klebs Lotller bacilli were found, and used the usual treat-
ment. Out of this number only two cases developed, which
seems conclusive evidence that we obtained an immunizing
effect from the antitoxin.
Dr. H. E. Garrison, Dixon, 111. — In our town we have not
found the Klebs-Lotfler bacilli, but the antitoxin has been used
with wonderful results. We had an examination made by the
State Hoard of Health, of Illinois, and they found the staphy-
lococci only. One or two cases died without the antitoxin and
five or six with the antitoxin. There is a population of about
8,000, of which number not less than 1,000 have had a sore
throat.
Dr. Baker, Erie, Pa. — I think the cases of infectious dis-
may be divided into three classes : 1, cases which are
mild and will recover at any rate ; 2, cases that may or may
not recover ; 3, cases that will die. To simply say a case is
diphtheria, the antitoxin is given and the case recovered,
^ives no information whatever. But if you treat a series of
cases such as I would include in the third section, and get
good results, the statistics are of some value. I saw 150
cases, out of which three or four to me meant some-
thing. One boy I remember especially was very sick. We
had him early and administered the antitoxin thoroughly, but
he died. I do not think, from the observations there, I saw the
antitoxin do anything that has not been duplicated without it.
In private practice my experience covers some fifteen cases.
The theory is seductive. The line of treatment is on a trunk
line and it is exceedingly probable it will be worked out in time.
Whether that time has arrived is doubtful. I think the ques-
tion of immunization is answered absolutely by the fact the
disease does not immunize itself.
Dr. Hodgkis, Connecticut — I had the opportunity of wit-
nessing a number of cases of diphtheria, and being a little dis-
trustful of the results of antitoxin, 1 allowed one case I con-
sidered mild and would get well if left to time, to go on for a
period of eighteen days, with a great deal of diphtheritic mem-
brane covering the uvula, soft palate, tonsils and pharyngeal
walls, and at the end of that time there was no disappearance
of the membrane under the old treatment. Paralysis having
resulted, I considered the case going on to the worst and it
was a proper time to use the antitoxin. I had previously used
it in other cases. After using 10 c.c, on the following day the
membrane had disappeared from the uvula and the soft palate.
On the next day we used 5 c.c. and on the following day all the
membrane had disappeared. This is an illustration showing
positively the disappearance of the membrane after the use of
the antitoxin.
Dr. D. C. Wilson, Ironton, Ohio— We had a severe epidemic
in our town during the past winter. The first few cases I lost.
I immediately ordered antitoxin and lost no cases in the some
sixty cases treated after that. One child contracted the dis-
ease. Inside of eight hours another of the same family con-
tracted diphtheria, and I injected the ten other children and
none of them contracted the disease. But the father con-
tracted the disease. In his case I did not use the antitoxin at
first and he grew worse until I thought it unjustifiable to wait
longer and injected it, with recovery. I was called to a case of
laryngeal diphtheria. The child was cyanotic. The consult-
ing physician refused to use antitoxin but I insisted. The
next morning the child seemed somewhat better. Later I
injected the child again, and the child was soon up and about
the house. I have had no bad results. I had in one case an
erythema follow. I use the injection in the side. I first thor-
oughly antisepticize the chest, brush off the skin with alcohol,
and use the carbolic solution. I have not sealed up the wounds
at all.
Dr. Knipe, Norristown, Pa. — [ merely would like the con-
sensus of opinion about this. One man claims antitoxin could
not immunize simply because the disease does not immunize
itself. Theoretically, my own impression is that ordinarily
diphtheria does immunize against another attack. Dr. Garri-
son has reported a number of cases of diphtheria in which the
bacillus was not found. These may have been only cases of
tonsillitis. But I believe true diphtheria does immunize as
much as smallpox. I believe the statistics from the German
army show a good mark of vaccination is a greater security
than having had smallpox itself.
Dr. Edwin Klebs, Citronelle, Ala. — Permit me to make a
few remarks on this question of immunizing. We have very
different qualities of immunity in the different forms of infec-
tious disease. We can not compare, in this point, diphtheria
and smallpox. We would be very glad if we had such a high
degree of immunity in diphtheria as in smallpox. But some
gentlemen have thought they have immunized. Some mem-
bers of a family have diphtheria and in the other members of
the family they found the bacilli, and they injected them with
the serum and they did not get diphtheria. In Zurich, for
weeks after diphtheria in a family we found in the children
who did not have diphtheria the diphtheria bacilli, but they
did not have diphtheria although they were not injected. We
have two sides to this question of infection ; the germ on one
side and the body on the other. We must consider, first, suffi-
cient infectionability of the germ ; and second, sufficient sus-
ceptibility of the body. We know an infectious germ can be
in the nose of a healthy child and not cause diphtheria.
Dr. Elmer Lee, Chicago — There is not much more to be
said. The position taken in the paper read by me, in correct.
It is admitted, in that paper, that diphtheria is treated by the
use of antitoxin, seemingly with favorable results. If you
undertake to say to me or to the world, that that treatment is
based upon scientific knowledge, it is my contention that it is
an incorrect statement. If you base it upon empiricism, there
is nothing more to be said. It is contrary to physiologic law.
Physiologic law is the law of our nature and being. That an
impurity will secure purity, is not the lesson we learn by watch-
ing the bubbling water as it comes out of the side of the hill,
that is made muddy by the foot-print of the cattle. The
stream will clear itself if we will only let it alone.
There is one weak point in my paper. I know my weak
points better than the audience. The weak point is, while
criticising antitoxin, no substitute has been offered to you.
The old treatment, as it is called, is not satisfactory.
Here is a letter, that happens to come in, fortunately, to save
the day because of the ferocious attack by the gentleman from
26
THEORY OF SERUM THERAPY.
[July 4,
Philadelphia. This letter is from Dr. Joseph Winters, Profes-
sor of Diseases of Children and head of the staff of the Wil-
lard Parker Hospital, New York. The communication is of
recent date and is as follows : "... It seems to me that
one of the main features of this discussion, is the increase of
the number of cases of reported diphtheria, as a result of the
present method of diagnosis." That method of diagnosis is
the one referred to in my paper as the bacteriologic, as distin-
guished from the clinical diagnosis. Dr. Winters says, further :
"I spent three and a half months in the hospitals of Europe,
last summer, making a constant study of the results of the
antitoxin treatment, and am convinced that there is, abso-
lutely, no value in it." It don't make any difference, gentlemen,
Dr. Winters is an experienced man. He is fifty years old, and
his judgment is not puerile and it is not to be neglected.
Now, the object of bringing out the paper before you to-day
was not to antagonize the profession nor to indulge in any
aspersions. It was to call your attention to just exactly what
is true. In so much as you have spoken your views, in so
much you have delighted me and accomplished that which was
intended and expected by the paper. It is not my purpose
nor in my power to answer the objections to the paper nor to
go into the clinical part of the disease.
In conclusion, it is my purpose to present to you, at the next
annual meeting, a substitute for antitoxin, a complete method
by which all cases in my practice have recovered quickly and
surely, and pleasantly and scientifically.
Dr. W. A. Dixon, Ripley, Ohio— I wish to say I admire Dr.
Lee for his bold paper yesterday. But if a man has a convic-
tion and is bold enough to state it, he ought to be commended
for it. And I expect he is about half right.
The Chairman— He certainly put himself in a very trying
position. .
Dr. Dixon — I have never yet had an opportunity to test
antitoxin, because we have had no true diphtheria. But every
man has his fad and if you start him in the right place he is a
"crank," and I have my "cranky" ideas about diphtheria.
I believe diphtheria is not primarily a disease of the human
family at all, but a disease of animals, obtained from birds,
cats, rabbits, rats, etc. I have had occasion to dissect the pet
animal of a child seized with true diphtheria. The child was
isolated in the country and had no opportunity whatever to be
infected from other children. Unless we can devise some the-
ory to explain an autoinfection or the presence of the bacilli
in a healthy place in the country, we must look for the conta-
gion in something else. The most noted case I can refer to is
the case of a child 3 years old. Not being able to discover how
it might have taken diphtheria, and believing as I have stated,
I asked if the child had a pet. The mother replied, "O yes,
it has a pet cat that it carries in its arms continually and often
takes to bed with it." I asked for the cat, and on examination
I found it had enlarged glands and discharged at the nose. I
took it home, dissected it, examined the membrane microscop-
ically and found it had true diphtheria. Therefore I believed
the child obtained its diphtheria from the cat. I have had
occasion to report several cases of like kind. In one case the
canary bird was sick prior to the child ; in one or two cases
turkeys were sick prior to the child, etc. I read a paper on
this subject at Milwaukee, in the Section of Diseases of Chil-
dren, but I suppose it must have been a very poor one, for it
did not draw out any comments and I have not heard anything
from it since. But I am just as firm a believer as ever that the
contagion of diphtheria is often derived from an animal or bird.
Hence we might have some reason, on that theory, to believe
in the virtue of antitoxin, just as we have reason to believe in
the value of vaccine as a remedy to prevent smallpox. Those
who have read extensively upon the subject of diphtheria,
know the first epidemic in this country was brought by the
importation of birds, particularly turkeys.
THEORY OF SERUM THERAPY; CONTRI-
BUTION FROM THE BACTERIOLOGIC
LABORATORY OF THE CITY
OF PHILADELPHIA.
Read In the Section on Materia Medica, Pharmacy and Therapeu-
tics at the Forty-seventh Annual Meeting of the American
Medical Association, at Atlanta, Ga., May 5-8, 1896.
BY B. MEADE BOLTON, M.D.
CHIKF OF DIVISION, PHILADELPHIA, PA.
Some of the theories which have been advanced to
explain immunity from infectious diseases have a
bearing upon the production of antitoxin; others
leave this out of consideration. It is evident that no
theory can stand if it offers no explanation of the rea-
son why it is possible to use the blood serum of inoc-
ulated animals to protect and cure other animals and
human beings. It will be my purpose in this paper
to put the various theories, that have been advanced,
to this test. Some of the theories merely attempt to
explain why the bacteria do not grow in the body of
non-susceptible animals and leave out of account the
neutralization of the disease producing products, and
for this reason fail to be universally applicable.
1. The exhaustion theory of Pasteur claims that the
bacteria are unable to grow in the body of an animal
that has suffered from an attack of the microorganism
in question, because all of the necessary food has been
exhausted by the first attack. There are other rea-
sons for discarding this theory, but it is evident that
it offers no explanation of the production of substan-
ces in the blood which can be used in treating other
animals. Even if it should explain the reason why
recovery protects the animal itself from subsequent
invasion it offers no explanation why the serum of
this animal will counteract the poisonous properties
of the bacteria in another animal.
2. The accumulation theory of Chauveau comes
somewhat nearer an explanation, though not as it was
originally conceived. According to the original con-
ception the waste products of the growth of the bacteria
in the body simply accumulate till the tissues become
so saturated with the effete material that the bacteria
are unable to grow. The bacteria, in other words, are
poisoned by their own excreta. In order to make this
theory fit the facts it would have to be extended so as
to mean that not only the bacteria are unable to grow
on account of the accumulation of effete products but
also that these products neutralize the poisonous
products of the bacteria. This enlargement of the
theory is practically what has been done in the
following:
3. The theory of special organs, Brieger, Kitasato
and Wassermann, claims that there are probably two
substances in every culture of bacteria, viz., a disease
producing substance and a substance tending to
counteract this. It is supposed that the disease pro-
ducing substance is destroyed by certain organs of
the body, notably the thymus gland, and that the
other substance, the antidote, is liberated,
4. The accommodation theory claims that the tis-
sues of the body gradually become accustomed to the
bacteria and their products just as men become
habituated to large doses of arsenic, opium or other
poisons. But this explanation is not satisfactory
because in the production of immunity there is always
a crisis observable. The animal undergoing inocula-
tion often more or less suddenly shows a great power
of resistance. The process is not gradual enough for
it to be accounted for by this theory.
is%. ]
REPORT OF ANTITOXIN.
27
."). Pfeiffer's theory of special enzymes claims that
in animals gradually inoculated with the products of
the cultures of bacteria two substances are developed:
A substance capable of being converted into the
germicide, b. The germicide itself. The former is
converted into the latter by special ferments residing
in the animal tissues. The former is called the
immunity substance in contradistinction to the latter
which is called the germicide. It is contended at
least tor typhoid fever and cholera that blood serum
taken from animals inoculated for a long time with
cultures of the bacteria of these diseases contains a
certain amount of both these substances, and if an
ordinary susceptible animal is inoculated with cul-
tures or typhoid fever or cholera and is given a dose
of the protective serum at the same time that the ger-
micide acts at once, and that the immunity substance
becomes oonverted into the germicide, thus furnish-
ing an additional supply. Animals that have been
gradually inoculated with the products of typhoid
or cholera cultures are supposed to have the immunity
substance stored up in their tissues and that this is
converted into the germicide when the animal is inocu-
lated with virulent cultures. The action is specific, i, c,
animals immunized from cholera have the immunity
substance of cholera, and the same with typhoid
lever.
(>. Under the cellular theory are embraced: a. The
phagocyte theory of Metschnikoff. b. The starva-
tion theory of Grawitz. c. The theory of the alex-
ins of Hankin.
a. The phagocyte theory has been more actively
advocated and more vigorously assailed than perhaps
any other theory. According to this theory, the
white corpuscles of the blood destroy the bacteria.
The corpuscles concerned are believed to be the polynu-
clear leucoey tes and the large mononuclear ; the lym-
phocytes are not supposed to be concerned. The leu-
cocytes are supposed to actually devour the bacteria at
once, or to produce degeneration of the bacteria first
and devour them afterward. In the latter case the
leucocytes are supposed to break up and liberate a
substance which causes the bacteria to degenerate
and then fresh leucocytes appear to devour the degen-
erated bacteria. The breaking up of the leucocytes
he calls phagolysis.
b. According to Grawitz's starvation theory the leu-
cocytes deprive the bacteria of nutrition.
c. Hankin 's theory, which is advocated by Buch-
ner and others, claims that the neutrophilic leucocytes
break up and liberate a substance that destroys the
bacteria. Hankin's original statement was that the
eosinophilic leucocytes break up and liberate alexins,
but he has retracted this statement and his present
view is more in accord with Metschnikoff's theory of
phagolysis.
7. The humoral theory of Behring claims that
there is developed a substance in the humors of the
body that neutralizes the poisonous products of the
bacteria. It is believed that this substance is gener-
ated by the fixed cells of tissues rather than by the
leucocytes.
Opinion among bacteriologists is now practically
divided between the humoral and the phagocyte
theory. Both have been ably supported and both
have been vigorously attacked. It is possible that in
the production of immunity many of the explanations
advanced may play a part. It may be that no one of
them is sufficient to explain all the phenomena.
REPORT OF THE AMERICAN PEDIATRIC
SOCIETY'S COLLECTIVE INVESTIGA-
TION INTO THE U.SE OF ANTITOXIN
IN THE TREATMENT OF DIPH-
THERIA IN PRIVATE
PRACTICE.
REPORTED AT THE EIGHTH ANNUAL MEETING HELD AT
MONTREAL, CANADA, MAY 26, 1896.
This subject was chosen by the officers of the
Society for its eighth annual meeting, with the belief
that a large amount of valuable experience, not other-
wise available, might in this way be reached and col-
lated. It was also believed that a more trustworthy
estimate of the value of the serum treatment of diph-
theria might thus be obtained than by statistics taken
from hospital practice. There are very few hospitals
in America that receive diphtheria patients, and the
conditions under which patients are admitted to hos-
Xntals, and the surroundings while there, are so differ-
ent from those of private practice, that the measure of
success in hospital cases can not be taken as an index
of the results which have been obtained upon this
side of the Atlantic with the new treatment.
In order, therefore, to obtain an expression of
opinion from American physicians as to the serum
treatment, after what had been, with most of them,
their first year's experience, a circular letter was pre-
pared and issued by the Committee early in April.
This was distributed through the members of the
Society as widely as could be done during the time
allowed. An attempt was made to reach as many
physicians as possible who had had experience with
the remedy.
The first surprise of the Committee was in learning
how very widely the serum treatment had been
employed, especially in the Eastern and mid- Western
States. With more time, the number of cases col-
lected might easily have been doubled and perhaps
trebled ; but enough reports have come in to enable
one to see what opinion was held on the 1st of May,
1896, by American physicians who have used this
remedy.
The circular letter asked for information upon the
following points : Age ; previous condition ; dura-
ration of disease when the first injection was made;
the number of injections ; the extent of the mem-
brane— tonsils, nose, pharynx and larynx ; whether
or not the diagnosis was confirmed by culture ; corn-
plications or sequelae, viz., pneumonia, nephritis,
sepsis, paralysis ; the result ; and remarks, including
other treatment employed, the preparation of anti-
toxin used, and general impression drawn from the
case.
Reports were returned from 615 different physicians,
with 3,628 cases. Of these, 244 cases have been
excluded from our statistical tables. These were cases
in which the disease was said to have been confined
to the tonsils and the diagnosis not confirmed by cult-
ure, and therefore open to question. A few cases
were reported in such doubtful terms as to leave the
diagnosis uncertain. The figures herewith given are
therefore made up from cases in which the diagnosis
was confirmed by culture (embracing about two-thirds
of the whole number) and others giving pretty clear
' evidence of diphtheria, either in the fact that they
! had been contracted from other undoubted cases, or
' where the membrane had invaded other parts besides
28
REPORT ON ANTITOXIN.
[July 4,
the tonsils, such as the palate, pharynx, nose, or larynx.
It is possible that among the latter we have admitted
some streptococcus cases, but the number of such is
certainly very small.
There are left then of these cases, 3,384 for analysis.
These have been observed in the practice of 613
physicians, from 114 cities and towns, in fifteen differ-
ent States, the District of Columbia and the Domin-
ion of Canada.
In the general opinion of the reporters, the type of
dipthheria during the past year has not differed materi-
ally from that seen in previous years, so that it has
been average diphtheria which has been treated. If
there is any difference in the severity of the cases
included in these reports from those of average diph-
theria, it is that they embrace a rather larger riropor-
tion of very bad cases than are usually brought together
in statistics. The cases according to the extent of
the membrane, are grouped as follows: In 593 the
tonsils alone were involved. In 1,397 the tonsils and
pharynx, the tonsils and nose, the pharynx and nose,
Only two reports embracing a series of over 100
cases have been received, ihost of the observers hav-
ing sent in from five to twenty cases, although there
are many reports of single cases, particularly of single
fatal ones.
In addition to this material which has come in
response to the circular, there have been placed at
the disposal of the Committee by the courtesy of Dr.
H. M. Biggs, 942 cases treated in their homes in the
tenements of New York. Of these, 856 were injected
by the corps of inspectors of the New York Health
Board, upon the request of the attending physician,
and eighty-six others were treated by physicians
receiving free antitoxin from the Health Board. In
the first group the diagnosis of diphtheria was con-
firmed by culture in every case, and in all of the latter
except twenty-six; in these the diagnosis rested upon
extensive membranous deposits or laryngeal invasion.
The cases of the New York Health Board were of a
more than ordinarily severe type, 485 or more than
50 per cent, of these being reported as being in bad
TABLE I.— DAY OF INJECTION AND RESULT.
Injected on
Injected on
Injected on
Injected on
Injected on
Day
OF Injec-
1st Day.
2d Day.
8d Day.
4th Day.
5th Day.
TION
Unknown.
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The Committee's
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7«4
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4.9
1,065 89; 8.8
620 79
12.7
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77
22.9
390
152
38.9
215
Bl 7.0
8,884
450
18.0
New York Health
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IM
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58
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4.9
1,616 120
7.4
1,508! 184
8.8
758: 147
20.7
690
244
35.8
282
19 8.2
5,794
713
12.3
TABLE III
.—AGE AND RESULT OF TREATMENT
0 to 2 Years.
2 TO 5 YEARS. 5 TO
10 Years.
10 TO
15 Years.
16 TO
20 Years.
20 Years
Over.
AND
i
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Deaths.
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21.7
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1,276 17.".
466 83
13.7 : 883
17.8 178
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Mortality excluding moribund cases. .
43
192
59
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9
3.8
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3.2
4
2.1
or all three were affected. In 1,256 cases the larynx
was affected either alone or with the tonsils, pharynx
and nose, one or all. In many instances the state- ;
ment is made by the reporters, that the serum was |
resorted to only when the condition of the patient
had become alarmingly worse under ordinary methods
of treatment. This is shown by the unusually large
number of cases in which injections were made late
in the disease. Again, many physicians being as yet
in some dread of the unfavorable effects of the serum
have hesitated to use it in mild cases, and have given
it only in those which from the onset gave evidence
of being of a severe type. The expense of the serum
has unquestionably deterred many from employing it
in mild cases. These facts, it is believed, will more
than outweigh the bias of any antitoxin enthusiasts
by including many mild cases which would have
recovered under any treatment. It will, however, be
remembered that tonsillar cases not confirmed by cult-
ure have not been included.
condition at the time of injection; to mild cases the
inspectors were not often called. Further, an unusu-
ally large number of them (38 per cent.) were injected
on or after the fourth day of the disease. In 182 of
these cases only the tonsils were affected; in 466 the
tonsils with the pharynx or nose, the pharynx and
nose, or all three; in 294 the larynx was invaded
with or without disease of the tonsils, nose, or pharynx.
Through the courtesy of Dr. Biggs, the Committee
is able to include also a partial report upon 1,468
cases from Chicago, treated in their homes in that
city by a corps of inspectors of the Health Depart-
ment. It was the custom in Chicago to send an
inspector to every tenement- house case reported, and
to administer the serum unless it was refused by the
parents. These cases were therefore treated much
earlier, and the results were correspondingly better
than were obtained in New York, although the serum
used was the same in both cities, viz., that-of the
New York Health Board.
L896 :
REPORT ON ANTITOXIN.
29
THi: RESULT AS INFLUENCED BY THE TIME OF INJECTION.
In Table I, are given the results obtained in these
three different groups of cases, classified according to
the daj "ii which they received the first injection of
serum antitoxin.
The grand total gives 5,79-1 cases with 713 deaths,
or a mortality of L2.3 per cent., including every ease
returned; but the reports show that 218 cases were
moribund at the time of injection, or died within
twenty-tour hours of the tirst injection. Should these
!>(- excluded there would remain 5,576 cases (in which
the serum may be said to have had a chance) with a
mortality of 8.8 per cent.
Of the 4,120 cases injected during the first three
days, there were 303 deaths — a mortality of 7.3 per
cent., including every case returned. If from these
we deduct the cases which were moribund at the time
of injection, or which died within twenty-four hours,
we have 4.013 cases, with a mortality of 4.8 percent.
Behring's original claim, that if cases were injected
on the first or second day the mortality would not be
5 per cent., is more than substantiated by these fig-
ures. The good results obtained in third-day injec-
tions were a great surprise to your Committee. But
after three days have passed the mortality rises rapidly,
and does not differ materially from ordinary diphtheria
statistics. Our figures emphasize the statement so
often made, that relatively little benefit is seen from
antitoxin after three days; however, it must be said
that striking improvement has in some cases been
seen even when the serum has been injected as late
as the fifth or sixth day. The duration of the disease,
therefore, is no contraindication to its use.
THE INFLUENCE OF BACTERIOLOGIC DIAGNOSIS UPON
THE STATISTICS.
This is shown in Table II.
Table [I.— Diagnosis Confirmed by Bacteriologic Examination.
Committee's Reports.. '2.453 oases; 802 deaths; mortality, 12.3 per cent.
H. T. Board of Heal th . . 816 " 160 " " 16.9
Chicago Board of H'lth. 1,468 " W " " 6.4
11.4
8.7
Totals 4,837 " 556 "
(Excluding 145 cases which were moribund or
Which died iii twenty-four hours) "
Diagnosis from Clinical Evidence Only.
931 cases; 148 deaths; mortality, 15.7 per cent.
2« " 9 " 34 6 "
Committee's RejMirts
X.Y. Board of Health
Totals 957 " 157 " " 16.3
i Excluding '■! eases either moribund or dying In
twenty-four hours) " 9.6 "
In the cases in which the diagnosis was not con-
firmed by a bacteriologic examination the mortality
is thus 5 per cent, higher than in the bacteriologic
cases. This difference is to be explained by two facts:
first, as already stated, that we have excluded from
our reports all tonsillar cases (and hence most of
them very mild ones) not confirmed by bacteriologic
examinations; and secondly, by the fact that this
group of cases comprises those treated in the country
where physicians have hesitated to use antitoxin
unless the type of the disease was a grave one, and
where also a large proportion of the injections were
made later than in the cities. However, should we
leave out the moribund cases, the mortality is but
9.fi per cent., which differs but slightly from the cases
confirmed by bacteriologic diagnosis.
In our subsequent statistics we shall consider
together all the cases bacteriologically confirmed and
otherwise, as the statistics are not materially altered
by this grouping.
THE RESULTS AS MODIFIED BY THE AGE OF THE
PATIENTS.
Unfortunately the ages have not been furnished in
the report of the Chicago cases, and we have therefore
only the cases reported to the Committee, and those
from the New York Board of Health for analysis. In
Table III, are shown the mortality of the different
ayes grouped separately.
The highest mortality is seen as in all reports to be
in the cases under two years, but including all those
returned, even those that were moribund when
injected, the death rate was but 23.3 per cent. (21.7
per cent, of the Committee's cases), while if we
exclude cases moribund when injected or dying
within the first twenty-four hours, it falls to 19.2 per
cent.
After the second year there is noticed a steady
decline in mortality up to adult life. In many of the
reports previously published, the statement has been
made that no striking improvement in results was
observed in adult cases treated by the serum. Our
figures strongly contradict this opinion. Of 359 cases
over 15 years old which were returned, there were
but thirteen deaths. That the reader may judge
for himself how far antitoxin is to be held responsi-
ble for the result a brief summary of these thirteen
cases is appended:
Case 1. — Fifteen years old ; injected on the fourth day ;
membrane covering tonsils and pharynx ; profoundly septic,
sinking rapidly when injected ; died in two hours. "My only
death in seventeen cases." (Jones, Gloucester, Mass. )
Case 2. — Forty-four years old ; injected on the fourth day ;
membrane on the tonsils and pharynx ; in bad condition ; died
three hours after injection. The tonsils had been previously
incised, the early diagnosis having been quinsy.
Case 3. — Thirty-one years old ; injected on the sixth day ;
membrane on the tonsils, nose, pharynx, and larynx ; intuba-
tion ; sepsis ; in bad condition ; lived eight hours after
injection.
Case 4. — Thirty-five years old; injected on the fifth day;
membrane on the pharynx and nose(?) ; in bad condition ; sep-
tic ; died in twelve hours.
Case 5.- Sixty years old; in bad condition; had serious
mitral regurgitation ; injected on the fourth day ; membrane
covering tonsils, pharynx, and larynx ; died from heart failure
on following day.
Case fj.^Sixty years old ; "kidney trouble for years"; in-
jected on the third day ; very extensive membrane, covering
tonsils, pharynx, and nose ; profound sepsis ; in bad condition ;
dies suddenly on the day after injection.
Case 7. — Seventeen years old ; in bad condition : convales-
cing from measles ; enormous adenopathy ; profound sepsis :
exceedingly high temperature ; membrane covering tonsils and
nose ; injected at the end of forty-eight hours ; three injections,
temporary improvement after each one ; duration of life not
given.
Case 8. — Fifteen years old ; in bad condition ; injected on the
ninth day ; membrane covering tonsils, nose pharynx, and
larynx ; no operation ; enormous infiltration of the tissues of
the neck ; nephritis ; sepsis ; lived four days and died of sepsis.
Case 9. — Twenty years old ; injected on the third day ; mem-
brane upon the tonsils, nose, pharynx and larynx; "a stub-
born patient who got up before he was allowed, and died sud-
denly after it."
Case 10. — Twenty-five years old ; injected on the fifth day ;
membrane covering both tonsils, entire pharynx, and com-
pletely occluding nose ; nephritis and sepsis ; throat cleared off
entirely ; died suddenly on the fourteenth day from cardiac
paralysis.
Case 11. — Nineteen years old: injected on the fifth day;
membrane upon the tonsils and pharynx ; profound sepsis ;
duration of life unknown.
Case 12. — Twenty-two years old ; injected on the fourth day ;
membrane upon the tonsils and gums ; sepsis ; died on the
sixth day.
Case 13. — The well-known Brooklyn case, reported in 1895.
Girl, 16 years old, who died suddenly ten minutes after
injection.
30
REPORT ON ANTITOXIN.
[July 4,
Such are the adult cases which antitoxin failed to
cure. Four of them were moribund at the time of
injection, no one of them living over twelve hours.
Two, both 60 years old, were already crippled by pre-
vious organic disease, one of the heart and the other
of the kidneys. In the measles case there was
undoubted evidence of streptococcus septicemia.
Only two of the cases were injected as early as the
third day; three of them on the fifth day, and one on
the ninth day. Omitting the four moribund cases the
the mortality of 355 adult cases treated with the
serum is 2.5 per cent.
PARALYSIS.
Reliable data upon this point and those hereafter
to be mentioned are to be had only from the 3,384
reports returned to the committee. Of these paralytic
sequelae appeared in 328 cases, 9.7 per cent. Of the
2,934 cases which recovered, paralysis was present in
276, or 9.4 per cent. Of the 450 cases which died,
paralysis was noted in fifty-two, or 11.4 per cent.
The variety of the paralysis and the date of injec-
tion is shown in the following table:
TABLE IV.— VARIETY
OF PARALYSIS
INJECTION.
AND THE DAY OF
RECOVERY CASES.
DAY OK INJECTION.
Paralysis mentioned (variety not specified). IDS
Throat only (aphonia, nasal voice or regur-
gitation) HI 1«
Extremities M ;1
Ocular 11
General (multiple neuritis) 4
bterno-mastoid . . . • 3,
FATAL CASES.
Paralysis mentioned (variety not specified). It
l Cardiac, late after throat clear (in four of
them throat also) 32
Throat only H
General late ■*
Muscles of respiration 1
Totals
B0
82 ill
I
25 11
2 . .
I I
18 23
18 21
:i 1
2 1
2 .
78 43 19 •'.'.'
Observations of some of the individual cases are
interesting, particularly those of cardiac paralysis. It
is twice stated that the child had gotten up and
walked out of the house, where it was found dead.
Twice death occurred after sitting up suddenly ; once,
on jumping from one bed into another. One patient
of 20 years, got up contrary to orders and died soon
afterward. Another patient was apparently well until
he indulged in a large quantity of cake and candy,
soon after which cardiac symptoms developed and he
died shortly. One case was that of a woman, 60
years old, who had serious organic cardiac disease.
It is difficult from these statistics to state what
protective power the serum may have over the nerve
cells and fibers. Apparently this is not great unless
the injections are made early in the disease, and even
then in severe cases the amount of damage done to
these tissues in twenty-four hours may be very great,
even irreparable. Time is not the only element in
estimating the effect of the diphtheria toxins.
Great discrepancy exists in the statements made
regarding the frequency of paralytic sequelae after
diphtheria. In a series of 1,000 cases reported by
Lennox Browne, paralytic sequelae were present in
14 per cent. In 2,448 cases by Sanne\ paralysis was
I Cases of heart failure occurring at the height of the disease have
not heen included here; although they are mentioned among the cases
of cardiac paralysis in the table of fatal cases.
noted in 11 per cent. In the series of cases here
reported, the difference is slightly in favor of the
antitoxin treatment, but paralysis is certainly frequent
enough to show how extremely susceptible the nervous
elements are to the diphtheria toxins. One thing is quite
striking from a study of these cases, and that is the
proportion that have died from late cardiac paralysis,
That many of them would undoubtedly have suc-
cumbed, earlier in the disease from suffocation (laryn-
geal cases) or diphtheritic toxemia, had the serum not
been employed, is beyond the question. Although
the serum is able to rescue even many such desperate
cases it can not overcome the effects of the toxins
upon the cells which have occurred before it was
injected.
SEPSIS.
Sepsis is stated to have been present in 362 of the
3,384 cases, or 10.7 per cent. It was present in 145,
or 33 per cent, of the fatal cases. Some explanation
is necessary for a correct appreciation of these figures.
The majority of the reporters, it is plain from their
remarks, have not distinguished between diphtheritic
toxemia and streptococcus sepsis. The former is cer-
tainly meant in the great majority of the cases. There
is a very small proportion in which there is evidence
of streptococcus sepsis. The six cases complicating
measles and the five complicating scarlet fever, how-
ever, should possibly be included among this list.
NEPHRITIS.
The statements on this point are quite unsatisfac-
tory. The reports state that nephritis was present 350
times, or in 10 per cent, of the cases. On the one
hand it must be stated that the diagnosis of nephritis
rests in many cases simply upon the presence of albu-
min in the urine; but, on the other hand, it is true
that in a large number of the cases, more than half,
no examination of the urine is recorded as having
been made, so that it is impossible to state with any-
thing like approximate accuracy, the frequency of
nephritis in these cases. Of the 450 fatal cases, the
presence of nephritis is mentioned without qualifica-
tion or explanation in thirty-nine cases, these being
usually put down also as septic, dying in the acute
stage of the disease. There are fifteen fatal cases,
however, in which the renal disease was stated as the
cause of death. In no less than nine the nephritis
occurred late in the disease, usually during the second
or third week. In these fifteen cases the evidence of
severe nephritis was conclusive, such symptoms being
present as dropsy, suppression of urine, with coma or
convulsions.
BRONCHO-PNEU MONIA.
Broncho-pneumonia is stated to have been present
in 193 of the 3,384 cases, or 5.9 per cent., a remarkably
small proportion when compared with hospital statis-
tics. Among the patients that recovered broncho-
pneumonia was noted 114 times, or in 3.8 per cent.;
among the fatal cases seventy-nine times, or in 17.5
per cent., but in only about one-half of these was the
pneumonia the cause of death. Of these, thirty-seven
were laryngeal cases operated upon late, ten were sep-
tic cases and the the pulmonary disease was coinci-
dent with the height of the diphtheritic process. In
seven pneumonia was independent of both the above
conditions, occurring late in the disease in all but two.
LARYNGEAL CASES.
Of the 3,384 cases reported to the committee, the
[«W.]
REPORT ON ANTITOXIN.
31
larynx is stated to have lieen involved in 1.25(5 cases,
or 37.5 per cent. This proportion is somewhat higher
than is usual, and is partly explained by the fact that
several physicians have sent in the reports only of
their laryngeal cases. These laryngeal oases occurred
in the practice of 379 physicians.
In 681, or a Little more than one-half the number,
DO operation was done, and in this group there were
128 daths. In forty-eight of them laryngeal obstruc-
tion was responsible for the fatal issue, operation
being refused by the parents or no reason for its
being neglected having been given. In the eighty
remaining fatal eases the patients died of other com-
» plications, and not from the laryngeal disease.
In the ■">•>:; eases, or 1(5.9 per cent, of the whole
number, there was clinical evidence that the larynx
was involved and yet recovery took place without
operation. In many of these cases the symptoms of
stenosis were severe, and yet disappeared after injec-
tion without intubation. No one feature of the cases of
diphtheria treated by antitoxin has excited more sur-
prise among the physicians who have reported them
than the prompt arrest, by the timely administration
of the serum, of membrane which was rapidly spread-
ing downward below the larynx. Such expressions
abound in the reports as "wonderful,'' "marvelous,"
"prepared to do intubation, but at my next visit the
patient was so much better it was unnecessary," "in
all my experience with diphtheria have never seen
anything like it before," "no unprejudiced mind
could see such effects and not be convinced of the
value of the serum," etc.
In establishing the value of the serum, nothing
has been so convincing as the ability of antitoxin,
properly administered, to check the rapid spreading
of membrane downward in the respiratory tract, as is
attested by the observations of more than three hun-
dred and fifty physicians who have sent in reports.
Turning now to the operative cases we find the
me remarkable effects of the antitoxin noticeable.
Operations were done in 565 cases, or in 1(5.7 per
cent, of the entire number reported. Intubation was
performed 533 times with 138 deaths, or* a mortality
of 25.9 per cent. In the above are included nine
cases in which a secondary tracheotomy was done,
with seven deaths. In thirty-two tracheotomy only
was done with twelve deaths, a mortality of 37.4 per
cent. Of the 565 operative cases, sixty-six were
either moribund at the time of operation, or died
within twenty-four hours after injection. Should
these be deducted, there remain 499 cases operated
upon by intubation or tracheotomy, with 84 deaths, a
mortality of 16.9 per cent.
Of the 2,819 cases not operated upon, there were
312 deaths, a mortality of 11.3 per cent. Deducting
the moribund cases, or those dying within twenty-
four hours after injection, the total mortality of all
non-operative cases was 9.12 per cent.
Let us compare the results of intubation in cases in
which the serum was used, with those obtained with
this operation before the serum was introduced. Of
5,546 intubation cases in the practice of 242 physi-
cians, collected by McNaughton and Maddren (1892)
the mortality was 69.5 per cent. Since that time
statistics have improved materially by the general
use (in and about New York, at least) of calomel
fumigations. With this addition, the best results
published (those of Browne) showed in 279 cases a
mortality of 51.6 per cent.
Let us put beside the cases of McNaughton and
Maddren the 533 intubations with antitoxin, with
25.9 per cent, mortality. With Browne's personal
cases let us compare those of the fourteen observers
who have reported to the committee ten or more in-
tubation operations in cases injected with serum.
These comprise 280 cases with sixty-five deaths, a
mortality of 23.2 per cent. In both comparisons the
mortality without the serum is more than twice as
great as in the cases in which serum was used.
The reports of some individual observers concern-
ing intubation with the serum are interesting:
Neff, New York, twenty-seven operations, with
twenty-seven recoveries.
Rosenthal, Philadelphia, eighteen operations, with
sixteen recoveries.
Booker, Baltimore, seventeen operations, with
seventeen recoveries, including one aged ten months,
and one seven and one-half months.
Seward, New York, eight operations, with eight
recoveries.
McNaughton, Brooklyn, " In my last seventy-two
operations without serum, mortality 66.6 per cent.;
in my first seventy-two operations with serum, mor-
tality 33.3 per cent. "
O'Dywer, New York, " In my last 100 intubations,
first seventy, without serum, mortality 73 per cent.;
last thirty, with serum, mortality 33.3 per cent. "
But even these figures do not adequately express
the benefit of antitoxin in laryngeal cases. Wit-
ness the fact that over one-half the laryngeal cases
did not require the operation at all. Formerly 10
per cent, of recoveries was the record for laryngeal
cases not operated upon. Surely, if it does nothing
else the serum saves at least double the number of
cases of laryngeal diphtheria that has been saved by
any other method of treatment.
The great preponderance of intubation over trache-
otomy operations shows how much more highly the
profession in this country esteems the former operation.
A STUDY OF THE FATAL CASES.
Of the 450 fatal cases in the committee's report, 229,
or one-half, received their first injection of the serum
on or after the fourth day of the disease, and 152, or
over one-third of these, on or after the fifth day.
There were fifty-eight cases in which it was stated
that the child was moribund at the time of injection,
the serum being administered without the slightest
expectation of benefit, but at the earnest solicitation
of the parents.
There remain 350 cases in which the cause of death
could be pretty accurately determined by the reports.
These died from the following causes, the most im-
portant cause being placed first.
Sepsis (including diphtheritic toxemia) was the
cause of death in 105 cases, of which sixteen had
nephritis, four were intubated or tracheotomized, two
were laryngeal cases not operated upon, four had
paralysis, one had pneumonia, and in one the fatal
sepsis was attributed to a traumatic condition of the
left knee.
Cardiac paralijsis was the cause of death in fifty-
three cases. Under this head are included cases of
sudden heart failure occurring at the height of the
disease (twenty-one in number) as well as those more
commonly designated as heart paralysis, where death
occurred suddeidy after the throat cleared off. Of
the latter there were thirty-two examples; four of
these had paralysis, nineteen were septic, eight had
32
REPORT ON ANTITOXIN.
[July 4,
nephirtis, five were intubated, and one tracheotomized.
Broncho-pneumonia was put down as the cause of
death in fifty-four cases. In thirty-seven of these it
followed laryngeal diphtheria ; of these twenty-two were
intubated, and four tracheotomized; two had nephritis;
nine were septic. Broncho-pneumonia and sepsis
was the cause of death in ten cases, of which three
had nephritis and one general paralysis. Broncho-
pneumonia caused death in seven cases, apart from
sepsis or laryngeal diphtheria; of these only one had
nephritis; one died from heart failure; and in five,
pneumonia came on late in the disease.
Laryngeal diphtheria without operation caused
death in forty-eight cases. In some of these the
operation was refused by the parents, in others it was
neglected by the physician, the patients dying of
asphyxia; three of these cases had nephritis, four
were septic, two had pneumonia, and one had sepsis
and nephritis.
Diphtheritic tracheitis or bronchitis caused death
in eleven cases; all of these were intubated, and in
two there was evidence of the existence of membrane
in the bronchi before operation. There were thirty-
three other cases in which death followed laryngeal
diphtheria without the supervention of pneumonia.
It is highly probable that in some of these death was
due to membranous tracheitis or bronchitis. All of
them were operated upon; ten were septic, two had
paralysis, and one had nephritis.
Sudden obstruction of the intubation tube was the
cause of death in three other laryngeal cases.
The tube was coughed up in three cases, fatal
asphyxia occurring before the physician could be
summoned.
Died on the table during tracheotomy, one case.
Nephritis was the cause of death in fifteen cases;
seven of these were septic, and three had been
intubated.
General parah/sis was the cause of death in five
cases; in all probably the pneumogastric was involved.
Paralysis of the respiratory muscles produced
death in one case, one of laryngeal diphtheria, which
was intubated, was complicated by broncho-pneu-
monia."
Measles associated with diphtheria produced
death in six cases; five of these were laryngeal and
were intubated, in two there was pneumonia, and in
two sepsis. Diphtheria developed during the height
of measles, or immediately followed it.
Scarlet fever with diphtheria was the cause of death
in six cases; in three of these there was broncho-
pneumonia, nephritis and sepsis; in two scarlet fever
preceded diphtheria, and in one of these there was
sepsis with gangrene of the tonsils. In the sixth case
the patient died of scarlet fever, which developed dur-
ing convalescence from the diphtheria.
Gangrene of the cervical glands or cellular tissue
of the neck was the cause of death in two cases asso-
ciated with profound general sepsis.
Endocarditis caused death in one case, nineteen
days after the diphtheria.
Diphtheritic inflammation of the tracheal wound
with sepsis caused death in one case.
General tuberculosis, five weeks after diphtheria,
was assigned as the cause of death in one case.
Exhaustion was the cause of death in three cases,
one a protracted case; another complicated by pneu-
monia and sepsis; one by nephritis.
Convulsions was the cause of death in three cases
apart from disease of the kidneys. In one, the well-
known Brooklyn case, the girl died ten minutes after
the injection, in another, twenty-four hours after
injection, in the third the particulars were not given.
Meningitis was assigned as the cause of death in
one case.
THE KIND OF ANTITOXIN USED.
They are given in the order of frequency with
which they have been used: 1, the serum prepared
by the New York Board of Health; 2, Behring's;
3, Gribiers;2 4, Mulford's; 5, Aronson's; 6, Roux's.
In addition a large number of cases are reported as
having been treated by the serum prepared by the
Health Boards of different cities — Brooklyn, Newark,
Rochester, Pittsburg, etc. The largest number of
cases have been treated by the serum prepared by the
New York Health Board, a very large number by
Behring's serum, all others being relatively in small
numbers.
Dosage and number of injections. In the great
majority of cases but one injection is reported. In
very severe ones two and three have been given. The
largest amount is in a case by Wiener (Chicago) who
gave eighteen injections of Behring's serum to a
laryngeal case in a child thirteen years old. Another
instance of ten injections is reported with no unf avi ar-
able symptoms.
As a rule the dosage has been smaller in antitoxin
units than is now considered advisable, particularly
in many of the laryngeal cases and others injected
later than the second day.
CASES INJECTED REASONABLY EARLY (DURING THE FIRST
THREE DAYS) IN WHICH ANTITOXIN IS SAID TO
HAVE PRODUCED NO EFFECT, THE DIS-
EASE ENDING FATALLY.
These cases are twenty in number. Brief reports
are introduced that the reader may judge to what
degree they may be regarded as a test of the serum
treatment. In our statistical tables all of them have
been included among the fatal cases.
In Cases 1 and 2, the cultures were reported negative. Case I,
by Gallagher, New York : Child eighteen months old ; septic :
although no eruption was present, the reporter was " inclined
on reflection to regard this case as one of scarlatinal sore
throat."
Case 2, by Potter, Buffalo : Male, fourteen months old ; two
cultures made, but no Loftier bacilli found ; membrane in the
nose and pharynx. Injected on the third day one dose of
Behring's serum No. 1. No improvement; death from sepsis.
"Probably pseudo-diphtheria" (I. H. P.).
In Cases 3 to 9, no cultures were made.
Cose 3, by Tefft, New Rochelle : Seven years old ; injected
after eighteen hours' illness ; two injections of Behring's No.
2 serum ; membrane on the tonsils, pharynx and nose ; no
effect observed from injections, patient dying on the third day.
Case 4, by Tefft : Male, four years old ; membrane on the
tonsils and pharynx ; injected after thirty-six hours' illness with
Behring's No. 2 ; died on the third day ; no noticeable effect
from the injection.
Case 5, by Tefft : Six years old ; membrane on the tonsils,
nose and pharynx ; septic ; injected after thirty-six hours' ill-
ness; three injections of Behring's No. 2. "Saw no effect
from the injections, the disease going steadily on to a fatal
termination."
Cased, by Cameron, Montreal : Two and a half years old ;
fifty hours ill ; membrane on the tonsils, nose and pharynx :
septic ; no improvement noticed, and child died twenty hours
after injection.
Case 7, by Baker, Newtonville, Mass. : Three years old ;
laryngeal diphtheria: injected, on the third day 10 c.c. Roux's
2 It is worthy of note that in the tests made by the State Board of
Health of Massachusetts, published under date of April 6. 1S96, this
serum was found far below the standard as labeled upon the bottle;
thus, a package marked to contain 2,500 units, by test was found to con-
taiu less than 700. All the other varieties of serum tested were found
essentially up to the standard.
1896. ]
REPORT ON ANTITOXIN.
33
■Brum ; cyanosis : intubation : temperature 103 degrees 1<\, and
continued high until death in eighteen hours after operation :
Injections had no effect
(.'us, S, by Anderson, New York : Three years old ; injected
after three hours' illness: membrane on the tonsils, noSc and
pharynx : one injection New York Health Hoard antitoxin.
•• A ease of malignant diphtheria, full duration twenty-four
hours.''
( Suae '', by MeLain, Washington : Four years old ; twelve
hours sick: membrane on the pharynx and the larynx; two
Injections : no operation : first injection early in the morning,
the other early in the afternoon: died the same day; no
change in the condition : antitoxin had no apparent effect.
In eases 10 to 13 diphtheria complicated measles, all reported
by \V. T. Alexander. New York. Disease confined to the
larynx in all: in three the stenosis developed during measles,
and in one while the patient was convalescing from measles;
diagnosis confirmed by culture in every case, and in all intuba-
tion performed. Antitoxin seemed to have no effect, the cases
going on to a fatal termination ; all received their injec-
tions within twenty four hours after the laryngeal symptoms
appeared.
In three eases 14 to 16— the type of the disease was malig-
nant from the outset.
('(i<c 14, by Lloyd, Philadelphia: Fifteen months old;
injected after thirty six hours' illness; diagnosis confirmed by
culture ; membrane covered the tonsils, pharynx, nose and
larynx; intubation: sepsis; death on the fifth day. Although
antitoxin was used as promptly as possible no perceptible effect
noticed. One injection, Behring's No. 3, was given.
( bM 16, by Wert, Mount Vernon, N. Y. : Eighteen months
old : injected on the third day ; diagnosis confirmed by cul-
ture: membrane on the tonsils and pharynx. "Very intense
type of the disease." Antitoxin could not be procured before
the third day: Gibier's serum used. "Died suddenly in
apparent convulsions about ten hours after injection; urine
not examined : very little passed."
( Sum IS, by Ingraham : Six years old ; membrane covered
the tonsils, pharynx, and larynx ; diagnosis confirmed by cul-
ture: pneumonia present; condition very bad ; injected after
two and a half days' illness; three injections of Behring's
serum : no benefit noticed.
; ,". by Johnson, Buffalo : Three years old ; twelve hours
ill: case septic from the start; membrane on the tonsils,
pharynx, and larynx ; diagnosis confirmed by culture. "Anti-
toxin apparently had very little effect."
i tasi 18, by Baker, Newtonville, Mass. : Two and a half years
old : twenty hours ill : disease confined to larynx ; diagnosis
confirmed by culture ; one injection of Gibier's serum ; intuba-
tion. "Was doing well a few minutes before death when child
got up in its crib, changed color and died almost immediately."
Death attributed to "sudden heart failure ; found no obstruc-
tion of the tube."
' use 19, by Story, Washington : Five years old ; in fair con-
dition ; thirty-six hours ill : diagnosis confirmed by culture ;
membrane on the tonsils, pharynx, and larynx ; one injection
of United States Marine Hospital antitoxin ; injection pro-
duced no effect.
(ASKS IS WHICH UNFAVORABLE SYMPTOMS WERE, MIGHT
HAVE BEEN, OR WERE BELIEVED TO HAVE BEEN,
DUE TO ANTITOXIN INJECTIONS.
Only three cases reported to the committee could
by any possibility be placed in this category. All of
the details furnished by the reporters are reproduced :
Case 1, by Kortright, Brooklyn : Sudden death in convul-
sions ten minutes after injection. This case is the already
well-known Valentine case, occurring in Brooklyn in the spring
of 1895. The principal points were as follows : A girl sixteen
years old ; in good condition ; tonsillar diphtheria ; diagnosis
confirmed by culture : injected on the first day with 10 c.c.
Behring's serum ; died in convulsions ten minutes later.
Case 2, by Kerley, New York : Fairly healthy boy, two and
one-half years old ; membrane on tonsils, pharynx and in nose.
Diagnosis confirmed by culture : injected on the morning of
the fourth day with 10 c.c. (1,000 units) New York Health
Board serum; temperature at time of injection 100.4 degrees
F. ; no sepsis, and child apparently not very sick ; urine free
from albumin. Distinctly worse after injection ; in ten hours
temperature rose to 103 degrees F. ; urine albuminous ; throat
cleared.off rapidly, but marked prostration and great anemia,
with irregular fluctuating temperature continued and death
from exhaustion with heart failure four days after the use of
the serum.
Case 3, by Eynon, New York : Male, three and one-half
years old ; diagnosis confirmed by culture ; two days ill ; mem-
brane on tonsils and in nose ; two injections New York Health
Board serum. "A rapid nephritis developed after the second
injection, causing coma, convulsions and death twenty hours
after the second injection." In response to an inquiry for
further particulars the following was received : "The case
sinned a mild one, but the injection was given one afternoon
and repeated the following afternoon, about 1,500 units in all.
The urine up to that time had not been examined. About
fourteen or sixteen hours after the second injection unfavor-
able symptoms began to develop pointing to infection of the
kidneys. The urine was found to be loaded with albumin.
My impression at the time was that the antitoxin either pro-
duced, hastened or intensified nephritis, thereby causing the
fatal termination."
In regard to the three fatal cases just cited, Case 1
is wholly unexplained. In Case 2 the query arises,
did this sudden change hinge upon the injection of
the serum or was it one of those unexplained abrupt
changes for the worse in a case apparently progress-
ing favorably, so often observed in diphtheria? As
regards Case 3, it will be seen from the letter that the
evidence is not at all conclusive. All details available
are given and the reader may draw his own conclusions.
CLINICAL COMMENTS.
The following are selected from hundreds which
have been received and may be taken fairly to repre-
sent the sentiments of the physicians who have sent
in reports:
Dr. Douglas H. Stewart, New York, sends reports
of four cases, all desperate ones, and all " presumably
fatal under any other form of treatment." Very
extensive membrane in all; larynx involved in
three; in one neglected case in a child 3 years old,
injected upon the fifth day, the membrane covered the
tonsils, nose, pharynx and larynx. Broncho-pneu-
monia, nephritis and sepsis all present. Temperature
107 degrees F. at the time of the first injection.
Prostration so great that he dared not attempt intu-
bation. Believes that this case would certainly have
been fatal in a few hours without antitoxin. Perfect
recovery.
In another case 3 years old, membrane first discov-
ered in the left ear, next morning seen upon the
tonsils, and spread in a few hours over the pharynx
into the larynx and trachea. Intubation necessary in
a few hours; had never seen membrane spread so
rapidly as in this child. Urine albuminous ; mem-
brane subsequently expelled from larynx and trachea
in large casts with profuse bloody expectoration.
Complete recovery on the ninth day. The physician
describes this as "the very worst case of diphtheria that
has ever come under my notice." Five thousand four
hundred antitoxin units were given in four injections.
He remarks: " My experiences in the past have been
so very unfortunate that the advocates of antiseptics
or therapeusis were a constant surprise to me. It has
been my fate to have the most desperate cases
unloaded upon my shoulders. I had been forced into
the belief that the profession was absolutely power-
less in the presence of true diphtheria; have lost case
after case with tube in the larynx and calomel fumi-
gations at work. Previous to antitoxin my only hope
had become centered in nature and stimulants. In
two years have not lost a single case, and surely I may
be pardoned if I suffer from diphtheria-phobia in
a sub-acute form, and use antitoxin sometimes
unnecessarily."
Dr. L. L. Danforth, New York, states that during
his twenty-two years of practice in New York he has
34
REPORT ON ANTITOXIN.
[July 4,
seen many fatal cases of diphtheria, had used all kinds
of remedies, mainly those of the homeopathic school,
and while he had as much confidence in the latter as
in anything else, he had seen so many deaths during
the year past that he " hailed with delight the advent
of antitoxin and determined to use it." Reports five
cases, all of a severe type. " The result in every case
has been marvelous. I would not dare to treat a case
now without antitoxin."
Dr. H. W. Berg, New York, reporting fourteen cases,
says: "I have not yet ceased to be surprised at the
recovery of some of these cases, which, in the light of
my former experience with diphtheria treated without
antitoxin, seemed to be irretrievably lost."
Dr. George McNaugh ton, Brooklyn, reports seventy-
two laryngeal cases, with twenty-four deaths: sixty-
seven of these were intubated, with twenty -one deaths.
He states that he has kept no records of cases other
than laryngeal ones, as these seemed the best test of
the serum treatment. He believes that if the serum
is used early, very many cases will not need opera-
tion for the relief of stenosis. " I would urge the use
of antitoxin in all cases of croup in any patient who
has an exudation upon the pharynx; would not wait
for bacteriologic confirmation of diagnosis, for in so
doing valuable time is lost." Has noticed that the
tube is coughed up more frequently in injected cases,
and believe this due to the fact that the swelling of
the tissues subsides at an early date.
Dr. D. C. Moriarta, Saratoga, reporting four cases,
says that the' first was a malignant one and "I only
used the remedy because I am Health Officer and was
urged to do so, as the type of the disease was that from
which I have seen recovery but once in eleven years."
Boy 5 years old, four days ill when injected; great
prostration, rapid breathing, and he was " practically
gone." Nares filled and tonsils and pharynx covered;
severe nasal hemorrhage; cervical glands greatly
swollen; heart's action very frequent and feeble; child
unable to lie down. Behring's serum twenty c.c.
injected; in six hours evidently more comfortable; in
eighteen hours decidedly improved; in twenty-four
hours sitting up and feeling much better; in forty-
eight hours all urgent symptoms gone and membrane
loosening. Subsequently had nephritis which lasted
six weeks, and multiple neuritis which persisted for
three months, but ultimately recovered perfectly.
"I send this report because it converted me. No
unbiased person familiar with diphtheria could see
such results as this and not feel there must be good
in it."
Dr. F. M. Crandall, New York, sends report of a
child 7 years old. Membrane on the tonsils and in
larynx, with croup for forty hours when antitoxin was
injected and intubation done. Progress of the disease
had been rapid: semi-stupor and eyes half open; very
feeble, rapid pulse; intense toxemia; general cyanosis.
Both cyanosis and dyspnea persisted after intuba-
tion, showing clearly the presence of membrane below
the tube. Case regarded as "absolutely hopeless."
The first change was seen in the disappearance of
toxemia, with improvement in the pulse, clearness of
the mind, etc.; later a change in the local condition;
large masses of membrane were expelled from the
larynx and trachea, necessitating frequent removals
of the tube. Tube finally removed in a week with
complete recovery.
Dr. Reynolds, Baltimore, mentions a case showing
the danger of relying too implicitly upon the bacte-
riologic diagnosis. Male, 3 years. Culture reported
only staphylococcus and streptococcus, consequently
injection delayed until the fifth day, when membrane
covered tonsils, nose and pharynx. Child died two
days later. A sister subsequently contracted the dis-
ease, received antitoxin on the third day and recov-
ered. The reporter would not wholly rely upon the
culture test for diagnosis.
SUMMARY.
1. The report includes returns from 615 physi-
cians. Of this number more than 600 have pro-
nounced themselves as strongly in favor of the serum
treatment, the great majority being enthusiastic in
its advocacy.
2. The cases included have been drawn from local-
ities widely separated from each other, so that any
peculiarity of local conditions to which might be
ascribed the favorable reports must be excluded.
3. The report includes the record of every case
returned except those in which the evidence of diph-
theria was clearly questionable. It will be noted that
doubtful cases which recovered have been excluded,
while doubtful cases which were fatal have been
included.
4. No new cases of sudden death immediately after
injection have been returned.
5. The number of cases injected reasonably early
in which the serum appeared not to influence the
progress of the disease was but nineteen, these being
made up of nine cases of somewhat doubtful diagno-
sis; four cases of diphtheria complicating measles,
and three malignant cases in which the progress was
so rapid that the cases had passed beyond any rea-
sonable prospect of recovery before the serum was
used. In two of these the serum was of uncertain
strength and of doubtful value.
6. The number of cases in which the patients
appeared to have been made worse by serum were
three, and among these there is only one new case in
which the result may fairly be attributed to the
injection.
7. The general mortality in the 5,794 cases reported
was 12.3 per cent.; excluding the cases moribund at
the time of injection or dying within twenty-four
hours, it was 8.8 per cent.
8. The most striking improvement was seen in the
cases injected during the first three days. Of 4,120
such cases the mortality was 7.3 per cent.; excluding
cases moribund at the time of the injection or dying
within twenty-four hours, it was 4.8 per cent.
9. The mortality of 1,448 cases injected on or after
the fourth day was 27 per cent.
10. The most convincing argument, and to the
minds of the Committee an absolutely unanswerable
one, in favor of serum therapy is found in the results
obtained in the 1,256 laryngeal cases (membranous
croup). In one-half of these recovery took place
without operation, in a large proportion of which the
symptoms of stenosis were severe. Of the 533 cases
in which intubation was performed the mortality was
25.9 per cent., or less than half as great as has ever
been reported by any other method of treatment.
11. The proportion of cases of broncho-pneumonia
— 5.9 per cent. — is very small and in striking con-
trast to results published from hospital sources.
12. As against the two or three instances in- which
the serum is believed to have acted unfavorably upon
the heart, might be cited a large number in which
1896.]
OCULISTS AND OPTICIANS.
35
there was a distinct improvement in the heart's action
after the scrum was injected.
13. There is very little, if any, evidence to show
that nephritis was caused in any case by the injection
of scrum. The number of cases of genuine nephritis
is remarkably small, the deaths from that source num-
bering but fifteen.
1 I. The effect of the serum on the nervous system
is less marked than upon any other part of the body,
paralytic sequela1 being recorded in it. 7 per cent, of
the cases, the reports going to show that the protec-
tion afforded by the serum is not great unless injec-
tions are made very early.
The Committee feels that this has been such a
responsible task that it has thought best to state the
principle which has guided it in making up the
returns. While it has endeavored to present the
favorable results with judicial fairness, it has also
tried to give equal or even greater prominence to
cases unfavorable to antitoxin.
In conclusion the Committee desires in behalf of
the Society to express its thanks to members of the
profession who have cooperated so actively in this
investigation, and to Dr. A. R. Guerard for the prepa-
ration of the statistical tables,
i Signed )
L. Emmett Holt, M.D.,
W. P. Northrup, M.D.,
Joseph O'Dwyer, M.D.,
Samuel S. Adams, M.D..
Committee.
THE ACTION OF THE SOCIETY UPON THE REPORT.
At the close of its presentation, the Society voted
to accept the report of the Committee and after a full
discussion it was decided to embody its conclusions in
the following resolutions:
( 1 i Dosage. For a child over two years old, the
ge of antitoxin should be in all laryngeal cases
with stenosis, and in all other severe cases, 1,500 to
2,000 units for the first injection, to be repeated in
from eighteen to twenty-four hours if there is no
improvement; a third dose after a similar interval if
necessary. For severe cases in children under two
years, and for mild cases over that age the initial dose
should be 1,000 units, to be repeated as above if neces-
sary; a second dose is not usually required. The
dosage should always be estimated in antitoxin units
and not of the amount of serum.
(2) Quality of antitoxin. The most concentrated
strength of an absolutely reliable preparation.
(3) Time of administration. Antitoxin should be
administered as early as possible on a clinical diagno-
sis, not waiting for a bacteriological culture. How-
ever late the first observation is made, an injection
should be given unless the progress of the case is
favorable and satisfactory.
The Committee was appointed to continue its work
for another year and was requested to issue another
circular asking for the further cooperation of the pro-
fession, this circular to be sent out as soon as possible
in order that physicians may record their cases as
they occur through the coining year.
Formalin in Gonorrhea.— Dr. George T. Howland reports five
cases of gonorrhea treated with one half per cent, formalin solu-
tion. By means of Sterns urethral irrigators, one quart of the
warm solution was injected once or twice a day. The discharge
ceased in from twelve to twenty-seven days. Journal of Cuta-
neous and Genito-Urinary Diseases, June, 1896.
THE RELATIONS EXISTING BETWEEN
OCULISTS AND OPTICIANS.
Head before the Trl-Stnte Medical Society, at Chicago, April 8, 1896
BY PRANK ALLPORT, M.D.
I'KOKESHOR OK CLINICAL OPHTHALMOLOGY AND OTOLOGY IN THE MINNE-
SOTA STA*! E VMVKHSITY; PRESIDENT OK THE MINNESOTA STATE
MKPI AL SOCIETY; SKCRt-TAKY OK THE OPHTH A LMOLOGICAL
SECTION OK THE AMERICAN MEDICAL ASSOCIATION, ETC.
MINNEAPOLIS. MINN.
In presenting this paper before your society, I am
impressed with the advisability of an oculist laying
before a body of influential general practitioners one
of the evils of ophthalmology. It is unnecessary to
argue this matter in an ophthalmological society or
section, as we clearly appreciate and understand the
argument. But it is desirable that our common
friend and mother, the general school of medicine and
surgery, should listen to our views, and render us that
aid and cordial cooperation we so earnestly and right-
eously desire, and feel we have a right to expect and
and demand. Many of you, practicing in more gen-
eral lines of work or separating yourselves into other
special fields, do not thoroughly understand and
appreciate the importance and gravity of the situation,
and often, I fear, nay, I am sure, lend your influence
by indifference or positive advice, to the perpetuation
and prosperity of an evil striking at the root of essen-
tial ophthalmological development. I refer to the
alleged correction of errors of refraction by the
numerous varieties of opticians.
In discussing this question, no claim of originality
is made, for the ground has been quite thoroughly
covered by Dr. Pilgrim and others; therefore, what I
have to say must appear largely in the light of repe-
tition; I simply desire to awaken in the minds of
physicians not practicing ophthalmology an interest
in the matter similar to that experienced by them (in
which they expect us to participate), upon witnessing
unqualified and unlicensed men, in the shape of itin-
erants, residents, or druggists, presuming to boldly
practice medicine or surgery. In writing this paper,
I am well aware that to little souls, in and out of the
profession, it may appear as a narrow and selfish com-
plaint, originating from a diminished income, on my
own part and that of my brother oculists. To broad-
minded men, however, an entirely different construc-
tion will be placed upon my words, and my reasoning
will be clear, and understood as an effort to prevent
the practice of medicine by improper persons, and to
protect the public, by improving the status of our pro-
fession. Such reform work has been accomplished
in other branches of our science; it should, and will
be done in this. With regard to such practices dimin-
ishing the incomes of oculists, it is my firm and hon-
est conviction, after years of experience, that this is
not the case. Those who primarily patronize the
optician, would not usually seek an oculist, and do
not except under compulsion, sometimes induced
from sad and unfortunate ocular experiences in an
optical establishment.
Dr. Gould says, "Every pair of lenses worn by
every person in the world has a medical and patho-
logical significance." If this remark is true, and it
undoubtedly is, the adjustment of glasses should only
be confided to men who have not only some knowl-
edge of optics, etc., but who also possess a broad con-
ception of the anatomy, physiology and pathology of
the human body, including the eye. If properly
adjusted glasses are capable of improving the eye and
health, and relieving ocular symptoms and various
36
OCULISTS AND OPTICIANS.
[July 4,
reflex neuroses, improperly adjusted glasses are capable
of producing the same pathologic conditions. The
average oculist can enumerate scores of instances
where this has occurred, by the prescribing of con-
cave for convex glasses, the over-correction of myopia,
the improper setting of cylinders and prisms, etc.;
but such facts are not so well understood by the gen-
eral practitioner, and it is hoped that the honest
assurance by honest oculists that such instances are
of more than frequent occurrence will lead to an
establishment of the truth.
Who is the optician ? He has a plural existence,
the lowest grade of which can be found at the county
fair or the street corner. These men, as a rule, do
r ot pretend to much knowledge, and may content
themselves with selling their wares, and perhaps aid-
ing their patrons with a few lines of printed matter
to select glasses. That they are harmful is certain,
but inasmuch as the customer simply purchases what-
ever glasses he may select, it may be correctly asserted
that the circumstance is similar to the sale of a des-
ignated variety of patent medicine, and until we can
control the sale of the latter, we can not justly demand
the abolishment of the former, although the technical
argument might be raised, that one is patented and
protected by the government and the other is not.
The jeweler or druggist who sells glasses, under
practically the same circumstances, with little or no
protestation of knowledge, and no tendering of advice,
places himself in the same category, an undoubted
evil, but nondescript in character and difficult to con-
trol. The next grade of optician is he who travels
from town to town, announcing himself as Doctor or
Professor So-and-So, carrying with him a formidable
array of poorly understood instruments, and much
seductive literature. He may have "picked up" his
fund of knowledge in some optical establishment, or
"graduated" at some "Refraction" or "Optical School,"
whose existence should be at once condemned. His
methods of doing business are various and astonish-
ing, but will not be here criticised, as such criticisms
are not the aim and object of this paper, which is
written for a broader purpose. Suffice it to say that
the traveling optician usually does a good and profit-
able business, and often forms pleasant acquaintances
with physicians in small towns, who, it must be
regretfully admitted, send them patients who are sup-
posed to need glasses.
Another variety is he who "holds forth" at a depart-
ment store, or in some room or store of his own, or
forms an alliance with a jeweler. He belongs to
a~bout the same class as the traveling optician, except
that he does not travel, and these two classes have
at least one thing in their favor, viz., they do an inde-
pendent business, and ask no favors of the oculist in
the way of prescription work, which can not be said
of the highest grade of optician, viz., he who has a
store and workshop in a large city, does prescription
work for oculists, and all the refraction work he can
do besides. He is the evolution of the original opti-
cian from whom has sprung all the preceding varie-
ties just mentioned, and consequently the "principal
offender" in the present issue. Now permit me to
say on the start, that I have no quarrel with opticians
as a class; I know many of them personally and take
pleasure in testifying to their average honor and
integrity. The better class of opticians realize the
embarrassments and perplexities of the subject keenly,
and would gladly do all in their power toward its rec-
tification; but they are rendered powerless by unprin-
cipled competitors, who are unwilling or unable to see
the difference between an oculist and an optician, and
who either considers that a superficial knowledge of
optics fully equips them to intelligently treat refrac-
tion errors, or who know better, but persist in their
course in spite of their knowledge. It is chiefly such
opticians who come in contact with the oculist, for it
is to such shops that his prescriptions are usually
sent. This places him in the unfortunate and anom-
alous position of directing his business to his princi-
ple, and not always honorable competitor, which fre-
quently leads to a disintegration of confidence between
the oculist and his patient, and an impertinent find
presumptious alteration of a prescription by the opti-
cian from time to time to suit the emergencies of the
case.
Owing to these and many other abuses, a lack of
harmonious relations have necessarily crept in
between the oculist and optician, the former feeling
that an ocular examination and refractive correction
is not a mere mechanical art, but one of the highest
and most exacting branches of medical science, and
to be dealt with by properly educated physicians only,
and the latter, perhaps, feeling that he is as compe-
tent to "fit glasses" as the oculist, and should conse-
quently be allowed to do so unmolested, and that
everybody should strictly "mind his own business."
It is strangely true, however, that the optician feels
aggrieved when the oculist, in view of the fact that
the optician is his active competitor, endeavors to
ignore the latter by dispensing his own glasses. There
is also a higher motive in such a step, viz., a convic-
tion that he who practices medicine without a license
should be discouraged. The optician should remem-
ber, that as long as he even reasonably adhered to his
trade, amicable relations existed between himself and
his best friend and patron, the oculist, and not until
he endeavored to usurp the latter's position, and
inaugurated a series of mutually unfortunate conse-
quences, has the oculist been compelled to resort to
measures that the optician views with mingled feel-
ings of hatred and revenge. He has built his own
house and should be willing to live in it.
The measures of relief adopted by many oculists,
such as purchasing their own glasses, engaging a
private office optician, etc., are not as yet wholly de-
sirable, but no one can doubt the evolution of a plan
satisfactory to both oculist and patient. Let us hope
that the ultimate solution will be the re-establishment
of amicable and mutually profitable relations between
the oculist and optician, and the determination by the
one to adhere to his profession and the other to his
trade, and together exterminate pretenders, who are
neither one thing nor the other.
In order that errors of refraction may be accurately
corrected, it is necessary that the work of both oculist
and optician should be properly performed; both are
dependent upon each other, and should labor together
for their mutual benefit and the good of the public.
The optician possesses a high and honorable calling
and one of which he need not be ashamed. Why
then should he seek to invade the territory of the
practice of medicine? The lame and senseless argu-
ment is sometimes advanced, that the optician ante-
dates the oculist, who has therefore become the
trespasser. The barber might as well claim a right to
practice surgery and dentistry, as history places him
in the pioneer ranks of both these professions. The
18%.]
OCULISTS AND OPTICIANS.
37
truth of tlu> matter is, that correcting errors of refrac-
tion haw developed, by inevitable scientific solution,
from a mere trade to an important branch of medicine
and Burgery, and as such should be performed only
by properly educated men. If the optician wishes to
do such work, he should study medicine and become
a licensed physician, when he will be privileged to
practice his profession in this or any other line he
may select.
1 would not be understood as meaning that a med-
ical diploma is an assurance of knowledge, as the
occupation of a chair in a medical college for fifteen
years, has compelled me to regretfully express an
adverse opinion. I am willing to admit that the most
intelligent resident opticians possesses a better knowl-
edge of optica and errors of refraction than the
average medical man. But two wrongs do not make
a right, and no one unpossessed of a medical license
should perform such work, anil oidy then when
special ophthalmologic training has supplemented a
general medical education. I am happy to say that
ever-increasing salutary medical laws, combined with
efficient postgraduate instruction, have rendered the
special practice of ophthalmology untempting to most
men not thoroughly equipped for its prosecution. The
field would be broadened and deepened, the public
benefited, ami small towns quite generally supplied
witli physicians well qualified to work in this depart-
ment, if only the optician in his various aspects could
lie prevented from attempting to correct errors of
refraction.
The law, as at present interpreted, does not require
that an optician shall possess any knowledge whatever
in order to follow his important and dangerous call-
ing. A druggist is subject to pharmaceutic laws, a
veterinary surgeon to veterinary laws, a dentist to
dental laws, but an optician is subject to no laws
whatever, and may continue adjusting glasses, and
ruining ^eyes at his own option. One would think
that the better class of opticians would take sufficient
pride in their own business, profession, or whatever
they choose to call it, to precipitate some thoughtful
legislation tending toward a purification of their own
ranks. It is hoped that the agitation of this question
will at least accomplish some result, for a proper elim-
inating process will leave broader-minded and better
educated men to deal with, and it is unquestionably
true, that the more intelligent the optician, the more
does he comprehend the position of his calling, and
the more ready is he to exalt its importance, to distin-
guish and admit the difference between an oculist
and an optician, and to govern his actions accordingly.
I am loath to admit that there are many physicians of
more than average ability who, either by word or
deed, sympathize with the optician in this argument,
and do not admit that in attempting to correct errors
of refraction the optician is essaying the practice of
medicine. Such views are born either of indifference
or an ignorant misconception of the facts, and should
be easily overcome by the exercise of reason, intelli-
gence and thought. No special field of our profession
has made greater advances of late years than ophthal-
mology, and the most distinguished of its devotees
unite in declaring errors of refraction and muscular
anomalies its most profound and scientific subject,
and one that has taxed without satisfying many of the
most powerful intellects of the century. These men
declare unhesitatingly that such work can not be sepa-
rated from general ophthalmology, and surely no one
believes that the latter can be alienated from the
practice of medicine.
No. intelligent oculist to-day fails to thoroughly ex-
amine every patient who seeks his advice, even if only
the correction of presbyopia is the object of the visit.
Such an examination includes a general review of the
physical condition of the patient, and an exacting and
systematic investigation of the eye, both intra- and
extra-ocularly, not only as to the refraction and mus-
cular balance, but also as to medial opacities, cataract,
retinal, chloroidal and nerve diseases, and many other
pathologic conditions impossible of detection by the
inexperienced, and yet frequently of the greatest im-
portance to the applicant when once discovered. It
often happens that cases of supposed rapidly advanc-
ing presbyopia vjrove upon careful examination to be
glaucoma, amenable to treatment and possible of
cure. Diminution of vision is sometimes proven by
the ophthalmoscope to be the first evidence of ulbum-
inuria in the retina, which serves as an indication for
successful therapeusis. Headaches, neuralgias, etc.,
are daily discovered to be the reflex evidences of
hypermetropia, astigmatism, muscular insufficiencies,
etc. And so I might proceed in giving instance after
instance explaining why ocular examinations should be
made as frequently as possible and by properly
equipped physicians only, but I refrain, as it appears
almost an insult to intelligent physicians to urge the,
claim after once their attention has been diverted in
this direction.
Without further specification, then, which I am
confident is totally unnecessary, I make the statement
boldly, and without fear of contradiction by those
having sufficient intellect to judge or breadth of char-
acter to concede, that correcting refractive errors is
practicing ophthalmology, which, in its turn, is
practising medicine, and that this should be per-
mitted only by medical graduates, and that where
State medical practice acts exist, the optician is practic-
ing medicine without a license, and should be re-
strained from further prosecuting his calling, so far as
giving advice and prescribing glasses is concerned.
Such work can not be properly performed without a
thorough knowledge of anatomy, physiology, path-
ology, etc., a broad training in ophthalmology and a
general comprehension of the different branches of
the science of medicine and surgery, as taught in first-
class medical colleges and postgraduate institutions.
In presenting this paper I have refrained from cast-
ing slurs upon the optician, and from indulging in any
personalities or instances whatever; they have pressed
in upon my memory, with their aptness and appro-
priateness, so urgently as to render their repression
exceedingly difficult, but I have felt that what was
needed was not a display of acrimonious bitterness,
inspired by personal quarrels and a sense of wrong-
doing and injustice, but a calm, earnest, and unim-
passioned presentation of the point at issue, viz., the
unlicensed practice of the medical profession by my
friend the optician. There is no more reason why an
optician should fit glasses, than that a druggist should
prescribe medicine, and yet you, my brother general
practitioner, would anticipate our aid in expelling
such an evil, and would not expect us to ask you the
reason why. Let us, I beg of you, bespeak your
assistance in sentiment, influence and action.
What is to be done about it? This is a serious
question, and one surrounded with obstacles. Great
movements progress slowly, and we can not anticipate
38
SOCIETY PROCEEDINGS.
[July 4,
a satisfactory settlement at once. We must primarily
awaken a proper comprehension of the subject in the
minds of physicians, and through them compel the
laity to understand, that "fitting glasses" is not a
trifling affair, necessitating only the patient's personal
sensations, and the guidance of an optician to cor-
rectly consummate; but that it is, on the contrary, an
important event, necessitating a thorough examination
and possibly entailing serious consequences, and
should therefore only be performed by a properly
equipped, especially trained, medical practitioner.
Until this is reasonably well accomplished, it will be
futile to attempt more radical measures. Let this
step be well grounded by constant agitation, and a
desirable solution of this perplexing question will be
rendered comparatively easy.
SOCIETY PROCEEDINGS
New Jersey State Medical Society.
Proceedings of the 130th Annual Session held in Asbury
Park, June 23, 1896.
The usual reports, etc., were presented and acted upon. The
committee on the prevention of purulent infection of the eyes
of the new born reported that the Board of Health had issued
a circular to the profession, etc., detailing the plan of Cred6 of
Leipzig, to prevent this. After the umbilical cord has been
divided and the skin cleansed, bathe the eyelids with a cloth
wet with pure water, then touch the everted lids with a glass
rod dipped into a 2 per cent, solution of nitrate of silver. It
was agreed that the State Board of Examiners should be asked
to require of each applicant for a license to have a knowledge
of this method.
The proposed act to prevent cruelty to animals in the District
of Columbia was brought up by Dr. H. Mitchell, the secretary
of the State Board of Health and after some discussion it was
Resolved, That it is the sense of this Society that the bill
entitled a " bill for the further prevention of cruelty to animals
in the District of Columbia" now pending before Congress is a
menace to medical and surgical progress, a bar to proper
scientific investigation and inhumane in that it restricts the
possibility of the acquirement of knowledge that will lessen
human suffering and prolong life : therefore,
Resolved, That the Medical Society of New Jersey respect-
fully requests the members of Congress from this State to use
every proper effort to prevent it from becoming a law.
Resolved, That printed copies of this action be forwarded to
the New Jersey congressmen and to the chairmen of the com-
mittees on the District of Columbia in the Senate and House
of Representatives of the United States.
In the afternoon the Standing Committee gave a very valu-
able resume of the reports of the counties of the epidemics
that had prevailed in their localities, the result of the trial of
new remedies, of improved sanitation, especially of the results
of the employment of antitoxin, mallein and thyroid extract.
There was a great want of uniformity in the results as reported.
Some appeared to have obtained very great benefit, others had
found these remedies useless, while others held them sub judice.
Dr. Philip Marvel of Atlantic City, read a valuable paper
upon
AUTO- INFECTION.
He explained the difference between ptomaines and toxins ;
the one poisonous, the other harmless. The toxins were the
result of decomposition within the body. There is constantly
going on a building up and breaking down ; so long as the two
processes are kept equal, the person is in health. Otherwise,
disease results from the alkaloidal products. The channels by
which the poisons are eliminated are the blood, lymphatics, the
cellular tissue, etc. The putrefaction of foods result in a
toxin formed by the action of the bacteria on the proteids.
This is the principal cause of nearly all diseases. The common-
carriers are the blood and lymphatic systems. When the poison
is in excess of the vital fluids, there is impaired function fol-
lowed by death unless soon relieved. The poisonous substances
are formed by the presence in the body of complex substances
capable of combining with acids through the action of fermen-
tative bacteria producing salts corresponding to organic and
vegetable bases. All animal excretions are poisonous and are
eliminated by the skin, the alimentary canal, the pulmonary
mucous membrane and the skin. Acute auto-infection is very
dangerous and gives rise to symptoms which are alarming,
followed by death in a very short time. He quoted several
cases where death had followed the ingestion of food already
partially decomposed. Also quoted some experiments with
animals where the injection of bile produced death in a short
time. We must have free elimination constantly going on, or
there will be reabsorption. Somewhere in the animal economy
there is an unknown means for transforming toxic into inert
matter or life could not continue. We find also that there is a
different degree of poison for the same toxin in different
individuals and under almost the same circumstances. Excess
of food will often load the system with these toxins and we
also find different types of these troubles. In acute cases we
have a development of gas, tympanites, burning stomach,
eructations, etc. ; with these, headache, depression, fatigue,,
dizziness, vertigo, etc. In graver attacks there are con vulsions,
coma, death. These symptoms must be differentiated from
ordinary impared digestion by the suddenness of the onset,
within six to twenty hours after taking food. When we can
obtain free emesis and relaxed bowels there is more possibility
of relief. In some instances we have extensive skin eruptions
resembling erythema, scarlatina and the like. Sometimes the
absence of vomiting will mask the case. He mentioned cases
where the diagnosis had been measles, etc. He carefully
analyzed several cases which he detailed showing how to prove
the origin. In nearly every case it is the result of food ingested
which had already begun to decompose. Some of the results
of this trouble may be chronic atony of the stomach, dyspepsia,
diarrhea, dysentery, stomach cancer or dilated stomach. 1,
we have disarrangement of the structural tissues ; 2, consequent
interference with the nerve energies ; 3, impairment of cellu-
lar function, inviting abnormal production ; 4, and thus favor-
ing fermentation ; 5, prolonging digestion, thus aiding putre-
faction. Perhaps in the future we may be enabled to observe
these actions by means of skiascopy. He believed that
numbers of cases had been diagnosed typhoid fever and when,
treated by intestinal antisepsis and elimination had been estab-
lished, got well in ten days or two or three weeks, and thus
were quoted as aborted typhoid fever.
Dr. G. H. Balleray gave the details of a number of cases
of fibroids of the uterus obstructing labor, with subsequent
disappearance of the tumor. He detailed the symptoms by
which the presence of some obstruction was determined, the
mode of procedure in delivery, turning, etc. The detail of
cases was unique and interesting and elicited much animated
discussion. It was agreed by those who participated that the
tumors were not ovarian, nor in every case truly fibroids, as
these rarely if ever disappear in this manner.
Dr. Henry Mitchell, the secretary of the State Board of
Health, introduced his aid, Dr. M. Ravenel, who gave a very
able resume of what was proposed to be done by the bacterio-
logic department of the Board. It was mainly devoted to the
investigation of tuberculosis and diphtheria as these would
occupy a central position being most important. The early
diagnosis of diphtheria was of great importance and it was
only by a bacteriologic investigation that the diagnosis could
be made. Then a secondary examination was needed in order
to decide when the patient had ceased to be dangerous to
others. There is no fixed time when these bacteria disappear
L896. j
SOCIETY PROCEEDINGS.
39
from the throat, even mild eases show them six weeks after
the disappearance of the membrane. They often linger in the
nose and so long as a nasal discharge continues, it is suspicious
and investigation should be made. Cholera also is to be looked
after although it is hoped that no such need may arise. The
diagnosis here can be made in eighteen to twenty-two hours
and in no other way. Water being almost invariably the
source of the infection, all water must be examined. It is not
possible to be positive as to typhoid fever bacteria in the pres-
ent state of tin' sci-nee especially in a sample of water, for the
time clasping between the infection and the desire for an
investigation of a Buspected supply is so long, three to six weeks,
that many changes may occur : and then it must be remembered
that the bacillus of typhoid is delicate, non-resistant, and temp-
erature and nutrition are not favorable to it, and the common
water plants are antagonistic to it. Also we have mechanical
precipitation and the disinfection practiced so that there are
too many factors entering into the matter. Again we have the
eonstan't presence of the colon bacillus and perhaps the forma-
tion of ammonia by this bacillus has much to do with this.
1 tissues of animals must occupy the attention as being of great
importance, as in tuberculosis : here tuberculin is an infallible
test. Anthrax does not often occur, but the department is
prepared to make the diagnosis and this very easy. Glanders
can only be diagnosed by the inoculation of animals. Hydro-
phobia is diagnosed by the injection of brain of the suspected
animal rubbed up with sterile water and placed beneath the
dura mater of a rabbit. This is the chief use of this animal to
allay the fears of those bitten and to check the spread of
newspaper hydrophobia. Water examinations are only made
when for public use.
The President, Dr. Wm. Elmer of Trenton, then delivered
the annual address. He dwelt upon the need of personal
hygiene as it must become a matter of intelligent conviction
among all classes. Those who occupy higher positions must
help the lower, the wage earners in this point. The physician
must work in this line regardless of self to spread the gospel
of cleanliness of the person, the house, the surroundings.
Thus to stamp out preventable diseases, which are an insult to
an enlightened community.
The State and local boards may issue orders, but the people
must join to prevent such, as it is a crime greater than many
for which men are punished : the greater the nation, the
greater the regard for a high grade of sanitation. Public
hygiene is now a science, we have a right to demand pure air,
pure water, pure soil. Add to these wholesome food and sur-
roundings. The great misery comes not from numbers but
from our imperfections and want of control of the conditions in
which we live. Sewer waste and filth disease are concomitants
in the crowded community, they are forced upon us. The
great waste of life is among the children : fully one-half die
before they reach the age of 5 years. Cholera infantum is the
usual cause, produced by crowded homes, illy ventilated, with
bad drainage, bad food and equally bad milk. We are glad to
be able to chronicle a great improvement in the last year ; not
only the poor live better, but the training and education of the
young are greatly improved. Munter's "plenty of sleep, milk
and flannel" is old but good common sense. We now have
physicians on the school boards, we have compulsory vaccina-
tion, we have demands for quarantine, and the Health Boards
demand a quarantine of not less than forty days for smallpox,
scarlet fever, measles and diphtheria. In some places the lat-
ter is not regarded safe to release from quarantine until an
examination shows the absence of the bacteria. We must
teach the young the rudiments of isolation and infection and
the laws of living. We demand health of body as well as
trained minds. Ventilation of the sick room air without draft
needs the attention of the physician ; also food well prepared,
wholesome, nutritious, daintily served. Baths and sunlight,
with cheerful demeanor and quiet manner are needed for the
sick and to prevent getting sick. Another great demand is the
filtration of water supplies for the cities. The Cincinnati
process of sedimentation and sand filtration appears the best ;
each bed is independent and there are daily bacteriologic
examinations of each. By those means typhoid fever will be
greatly lessened. He quoted several cities as showing the
value of these methods. The economic value of a life is, say
§780 each, hence a death by typhoid fever is known as destroy-
ing that amount of wealth. He also alluded to consumption,
its communicability, being the most prevalent disease and with
the greatest mortality. It is conveyed by a microscopic para-
site, found in the sputum dust. We must rely upon hygiene,
not drugs, in this disease. There were many other subjects
which demanded our attention, but time would not admit.
Preventive, not curative, medicine is the great question of the
day.
On the second day Dr. Alexander McAllister, of Camden,
read a paper on the
THERAPY OF ANTITOXIN SERUM, NUCLEIN SOLUTION AND
THYROID EXTRACTS.
Most of the paper was devoted to the first subject. He
treated of the discovery of this method and alluded to the work
of Roux, Yersin, Klebs, Koch, LOffler, etc. They prove that
it is not the mere presence of the bacillus that gives rise to the
disease, but the products of it, the ptomaines. Diphtheria is
a toxemia and its toxin acts as a ferment, and when injected
into living tissues, there results a certain albuminoid body, this
isolated, and subjected to alcohol, produces a proto- and dextro-
albumose. Rabbits injected with this exhibited the signs of
diphtheria. It has also been reduced to a white amorphous
powder. Then came the immunizing of animals, next the
injecting the serum of blood rendered immune to certain bac-
teria into animals, thus immunizing them. This is to be
carefully distinguished from the Jenner process for smallpox,
Pasteur's for hydrophobia, which really produce a milder
form of the disease. He described the method of producing
antitoxin. The consensus of medical opinion tends to favor
this treatment of diphtheria. Of course it has met with oppo-
sition. Too sanguine results are expected, a want of under-
standing of the discovery and its limitations, as where it is
used and the patient dies of pneumonia or nephritis, and the
prejudice against a new treatment. Since Jan. i, 1895, he had
treated forty-five cases of diphtheria with antitoxin, all of
which recovered. Too much attention can not be given to the
preservative used in protecting the serum. Carbolic acid is a
toxic and dangerous remedy, highly irritating to the kidneys
and urethral tracts, hence objectionable. Formalin would be
the ideal preservative, except for the fact that it coagulates the
serum after a time. Camphor is uncertain, feeble in power,
and disguises the signs of decomposition, and putrefaction
might be present and t not be recognized. The best germicide
and preservative is tricresol, a very feebly toxic agent, no irri-
tating effect on the kidneys, and only feebly coagulates albu-
min. It is for these reasons that we are apt to have strikingly
different effects of the different kinds of preparations. Since
Jan. 4, 1895, he had treated forty- five cases with the serum;
diagnosis confirmed by culture in all but eight. One died of
laryngeal diphtheria. There were seventeen of laryngeal form,
all recovered. In only five was it necessary to repeat the injec-
tion a second time, and a third time in one. Mulford's serum
was used. Twenty c.c. were used at each injection. He
| believed the serum produced in this country was equal in value
to that made abroad. No local reaction followed ; there was a
rise of temperature in some of one or two degrees, and pulse
somewhat accelerated. In the mild cases improvement was
noticd in ten hours, in others twenty-four to thirty-six hours ;
membrane changes in color and becomes detached. Had a
small abscess in one. Erythema followed in the majority in
eight to ten days after the injection ; in one it persisted two
weeks. Internal treatment was mistura bashami, strychnia,
stimulants, locally hydrozone, boric acid solution, etc. Albu-
min was present in urine of the majority, clearing up as con-
valescence advanced. Post-paralysis occurred in all to a mild
degree. Where paralysis occurs, the results are more favor-
able where the serum has been used. Only three died of the
forty-five ; one of heart paralysis, one complicated with abor-
tion, one of sepsis. Beyond a doubt the mortality is lessened.
It is not a specific, as vaccination for smallpox. It does not
destroy the bacillus, only checks the course of the disease.
The mere presence of the Klebs Loftier bacillus in a case of
sore throat does not constitute it diphtheria : it needs other
symptoms, as fever, etc. Had immunized twenty-one cases,
40
SOCIETY PROCEEDINGS
[July 4,
two had afterward a mild attack of diphtheria. Immunization
takes away the dread of the disease. In intubation the tubes
can be removed sooner than without the serum. Pharyngeal
cases may be doubtful evidence, but the results in laryngeal
cases are conclusive. He quotes 5,794 cases in private practice
with 713 deaths, a percentage of 12.3. Injected during the
first three days 4,120, with 303 deaths. After the fourth day
1,448, mortality 27 per cent. ; 1,256 laryngeal cases, 691 not oper-
ated on, 563 recovered, 80 died from other causes, and 48 from
laryngeal stenosis ; 565 operated on, mortality 25.9 per cent.
Intubation in 533, tracheotomy in 32, mortality 37.4 per cent.
Cases drawn from the practice of 615 physicians : over 600
express themselves strongly in favor of the serum. We regret
that it is impossible to give more at length the details of this
interesting and valuable paper. He gave a valuable bibliogra-
phy, and statistics of American and foreign observers with and
without the serum. There have been upward of a million
injections and but five deaths were attributed to the serum,
and in these no positive conviction can be assigned. With
nuclein and thyroid extracts his experience was limited. The
masters have given us reason to believe in these remedies, and
he believed time would prove them correct. Many able clini-
cians are using nuclein locally and internally. The minimum
dose to begin with is 10 minims, increasing 5 minims daily till
the maximum dose is reached, 30 to 80 minims. In delicate or
nervous patients you may have shock, fainting ; here a stimu-
lant is needed. Sometimes an erysipelatous rash is produced,
usually passing in a few hours. A certain elevation of temper-
ature follows. The leucocytosic effect generally lasts fourteen
hours. It is claimed as serviceable in tonsillitis, indolent
ulcers, incipient phthisis, malaria, diphtheria, etc. The power
of nuclein of supplying building material and arresting disease
germs make it more applicable than the antitoxins. Thyroid
extract is claimed of value in a number of diseases, but
specially in Graves' disease, etc.
In the debate which followed there was shown a great differ-
ence of opinion, one member having 100 intubations which he
had been called to perform. In 20, serum was not used. Here
the percentage of deaths was higher. His belief was in favor
of its use, as 75 per cent, recovered while the others had 38 per
cent, of recovery.
Dr. Barker, of Morristown, regarded it as a double-edged
weapon needing care in its use. In one case that he knew 1,000
units were injected, the temperature and pulse reacted ; vom-
iting was stopped by evening, had a comfortable night, in the
morning appeared to be doing well. Then 1,500 units were
injected, vomiting soon recurred, and death in the evening.
Let well enough alone. Here there was no need of the second
injection.
Dr. Daland, of Philadelphia, was in favor of the remedy.
Many facts must be considered. Formerly many cases were
not called diphtheria which are now decided to be such. It is
unquestionably the reason of the lessened mortality because
of the serum injections. It is difficult to estimate the epidemic
influence. Suffocative cases occur less in the hospitals. It iB
a powerful remedy and needs much care to apply it. He had
good results from the thyroid extract in exophthalmic goitre.
Another member had statistics of 5,030 cases and no acci-
dent, hence we are justified in employing it. Several others
spoke on the subject, and the opinion appeared largely in favor
of the serum and the thyroid extracts.
Dr. C. R. Fisher read a paper on " Antisepsis." With this
we may operate in a farm house with much better hopes of
good results. He did not believe it was necessary before deliv-
ery to employ antiseptics, but the hands and the canal should
be protected by this means at every examination. Puer-
peral fever was not now epidemic as formerly because of anti-
sepis. Antiseptic surgery is now simplified, we no longer spray
the room, etc. ; that was an abuse of it.
Dr. McEwan read a paper on " Chloroform Narcosis." His
conclusions were : 1. Chloroform is a dangerous drug. 2. Its
dangers can be reduced to a minimum by the most scrupulous
attention and conscientious care on the part of the anesthetizer.
3. That the administration of chloroform properly could only be
done by one person having charge of it, and it is not a time to
assist or to indulge in conversation with a bystander, or to
watch an operation in order to familiarize oneself with the
steps of scientific procedure.
The officers for the next year are : President, Dr. T. J.
Smith, Bridgeton ; first vice-president, Dr. D. C. English, New
Brunswick ; second vice-president, Dr. C. R. P. Fisher, Bound
Brook ; third vice-president, Dr. Luther S. Halsey, Williams-
town.
The next meeting will take place in Atlantic City, fourth
Tuesday in June, 1897. It was agreed that the Committee of
Arrangements might arrange for a three days' session.
American Neurological Association.
Annual Meeting held at Philadelphia June 3, 4, 5, 1896.
(Concluded from page 1265.)
Dr. N. E. Brill of New York read a paper on
THE STATUS OF OPERATIVE PROCEDCRE AS A REMEDIAL AGENT
FOR EPILEPSY.
This paper was a protest against promiscuous operation and
surgical treatment in both essential and chronic epilepsy. He
favored the removal of depressed bone where there was evidence
of depression, as in these cases he had seen good results. In
cases due to pathologic conditions, he took the position that
craniotomy with excision of the cerebral cortex was unjustifi-
able, owing to, first, the bad results as far as amelioration is
concerned, attending the operation ; to our inability as yet to
make absolute diagnosis as to the character of the pathologic
lesion which occasioned the epilepsy. He cited cases to show
that where a positive diagnosis has been made previous to the
operation, when the skull was removed, the dura torn back
and the brain excised no evidence of cerebral disease or defect
was found. He argued further that there was an appreciable
risk in the operation even when done with the most careful
attention to technique ; that fatal cerebritis and meningitis
were by no means rare ; that death occurred even on the oper-
ating table from shock ; that we had no right to take even the
slightest risk when the chances of amelioration or cure were
so problematic unless the civilized world and a legal code
endorsed the Spartan doctrine of destroying defective children.
With such a purpose in view the thought of operation might
possibly be justified. Against indiscriminate surgical inter-
ference, he voiced the protest of Lucas, Champonniere and
others. As for the operation of craniectomy in epilepsy, he
could find no justification whatever, especially when viewed in
the light of our ignorance as to the pathology of the disease.
He aovocated conservatism and demanded that the clinician
should hesitate before he ratified surgical measures, as an
ameliorating agent in these cases. He regarded the large
number of reported cases as a striking result of the clinician's
desire to prove his skill in diagnosis by an antimortem opera-
tion and concluded by saying that no operation should be
recommended unless the diagnostician should satisfy his con-
science that the signs of disease were such that there could be
no possible doubt as to the absolute presence of a definite
pathologic condition, the character and nature of which he
had absolutely determined previously.
Dr. A. G. Gerster in discussing the various papers on
epilepsy, spoke on the different methods that have been em-
ployed in operative procedures. He referred to the fact that
the circular saw was considered defective on account of the
slowness of its work and the consequent danger of injuring the
dura mater and stated that he had found a chisel more desir-
able than the trephine. In his opinion, the danger of injuring
the dura mater is nil. He also considered the V-shaped chisels
as too slow and unsatisfactory, as they have a very narrow
groove, and penetration of the thinner lamella? and injury of
the dura mater may occur. He referred to Krause's modifica-
tion of the circular saw and stated that even this did not
entirely obviate the possibility of injury to the dura mater. He
considered the greatest danger in cranial operations to be that
of hemorrhage, and stated that unlike arterial hemorrhages,
which could be easily stopped, it was the continual oozing of
blood that was difficult to control. He considered any appa-
ratus by which the skull could be opened in ten or fifteen
minutes an excellent improvement and he was very glad to see
an instrument invented by a Western man which would permit
of satisfactory and rapid work. This instrument is built on the
principle of the ordinary dental engine ; it is very readily steril-
ized and does not require any expensive apparatus. An inci-
sion is made in the usual way and the extent and size of the
flap having been defined, drill No. 1 is inserted, the object
being to penetrate the entire thickness of the skull, the diame-
ter consequently being a little larger than that of the other
two. After outlining with drill No. 1, drill No. 2, which is
smaller and sharper, is inserted. This is followed by drill No.
3, which is placed in the aperture made by drill No. 1. As
soon as this is finished the flap can be pried up and the section
laid open. The first case in which Dr. Gerster used this instru-
ment, the operation took nineteen minutes, while the last took
less than four minutes.
Dr. M. Allen Starr referred to operative interference in
epilepsy and stated that there had been a recurrence in every
case and none of them had been cured. The first operation
was done in October, 1889, and all the operations were per-
formed on carefully selected cases by one of the most skillful
operators in the country. No case has been operated on where
18%.]
SOCIETY PROCEEDINGS.
41
there has been very long duration between the trauma and the
lit. nor any case of idiopathic epilepsy. With regard to the
(ion of cysts. Dr. Starr mentioned cases that ne had seen
die on the table. He referred to a case operated upon by Dr.
Mel 'osh. who exposed considerable area, laid back the dura and
discovering a clot upon its inner surface, he scraped and thor-
oughly curetted that region. The child had no paralysis and
for ■ time recovered. Concerning abscess of the brain he has
soiii twelve cases of which eleven were operated upon. In each
ui abscess was found either at the operating table or at
autopsy. Of these operations three recovered. There are cases
of brain ;il>sce88 where the temperature is very irregular, vary-
ing between 98 and 106. There are also many cases which
improve without any operation. Concerning the neurologic
side of the question he did not think there was any connection
with aphasia. He referred to an interesting case of aphasia in
which an abscess was found in the temporal lobe. He men-
tioned another ease in which the symptoms pointed to a tumor
in the left hemisphere. The patient had epileptiform convul-
sions with unilateral paralysis. At the operation the tumor
was found in the right hemisphere and there was perfectly good
decussation of the motor fibers. In his opinion the days of
trephining were over and the question now was how to make
the Hap and what instruments to employ. He stated that Dr.
McBurney was doing very rapid work, performing operations
in from fourteen to seventeen minutes with chisels and
rouges, the gouges being but two mm. in width and the chisel
being very sharp and narrow. As to the condition of exoph-
thalmus, he could not understand how this could be caused by
brain tumor except it lay behind the eyes.
l)i;. W. W. Keen mentioned that paralysis frequently
resulted from the injury to the brain caused by the tumor and
the surgical interference. In Dr. Thomas' case there was
nothing but a moderate paresis of the lower face and a moder-
ate aphasia. After the mechanical interference there was no
paralysis, but there was a diminution in the aphasia. He
exhibited a tumor removed in December 1889, from a patient
who is to day living and well. In his opinion it seemed as
though the removal of large tumors was less dangerous than
small ones and if this be true it is doubtless due to the fact
that in searching for tumors, one is apt to inflict an amount of
injury upon the brain which is incompatible with recovery.
During the past ten years the advancement in brain surgery
had been very conspicuous and at the present time we are able
to draw reasonable conclusions as to the result. He has not
reported any of his own cases as he desired sufficient time to
elapse to form an opinion as to the ultimate results. Although
his experience had been moderately large, he is not able to
report a single case cured and by cure he meant that after a
reasonable time had elapsed the patient had had no fits. He
was not willing to accept one year or even two and thought
three should be exacted as the time limit to form an opinion.
Although at the end of three years the patient may be still a
sufferer, yet there will probably be great amelioration. He
considered it worth while in nearly all cases to operate as he I
thought the results ha'1 been sufficiently satisfactory to war-
rant it and he stated that he would rather run the risk of any
operation than go through life with such a frightful disease.
As to idiopathic epilepsy he would not operate, but in Jack-
sonian, he considered operation justifiable judging from a num-
ber of cases recently reported. It is his practice to operate
whether there are brain symptoms or not, but to refuse opera-
tion in cases that have gone on for many years. In his opinion
at least twenty years should elapse before this question can be
settled to the satisfaction of the profession. He did not think
that 50 per cent, of the cases would ever be cured, but that a
sufficient number will be benefited to make it worth while to
run the risk of operation.
Drs. H. M. Thomas of Baltimore and W. W. Keen of Phila-
delphia reported a case of a large tumor removed from the
brain with wide opening of the lateral ventricle. The patient,
a young man of 19, with an excellent family and personal
history and no history of accident, in December 1895, had an
attack of intense headache and vomiting, but without optic
neuritis. The latter symptom followed in the middle of Jan-
uary with blindness later in the right eye, slight vision remain-
ing in the left, slight protrusion of the left eye-ball, pupils
equal and normal, smell, hearing and taste unaffected, paresis
of the lower right face, sensation and the muscles of mastica-
tion unaffected, no muscular weakness in either the arms or
legs, but there was a good deal of muscular restlessness of the
right hand, persisting even during sleep. Reflexes i resent,
mental condition poor. He was dull and apathetic and some-
times slightly wandering mentally. After the early headache
and vomiting, neither of these was a marked feature. There
was slight aphasia. Drs. Osier and Starr saw the patient with
Dr. Thomas and the conclusion reached that it was a tumor in
the left frontal lobe, probably at the base of the second frontal
convolution and subcortical. On May 10, Dr. Keen operated.
The bone was chiseled from the temporal fossa parallel to the
eye-brow and a little above it nearly to the middle line, then
backward nearly to the fissure of Rolando, then downward again
into the temporal fossa. This large flap was reflected and the
dura opened. The tumor presented through a rupture of the
cortex at the base of the second frontal convolution as had been
diagnosticated. After ligating some vessels at its border, the
tumor was easily scooped out by the fingers. The lateral ven-
tricle was then seen to be widely open. To prevent blood fill-
ing the ventricle and passing into the third and possibly the
fourth, the anterior part of the ventricle was packed with a
strip of iodoform gauze. This was removed at the end of the
second day. After the operation 'there was no increase what-
ever in the paralysis. In two weeks the patient had entirely
recovered. The tumor was 7.5 cm. long, 5.5 cm. broad and 4
cm. deep and weighed two and a half ounces. It was a hard
noninfiltrating sarcoma.
"A Case of Cerebral Abscess Situated in the Posterior Part
of the External Capsule (involving the medullary substance of
the first temporal convolution, also the posterior part of the
lenticular nucleus, and extending' into the subthalamic region),
with some Considerations in Regard to the Constitution of the
External Bundle of Fibers in the Cerebro-Peduncle," by Drs.
Charles K. Mills and Win. G. Spiller.
The authors related the details of the case and stated that at
the autopsy an abscess was found in the left hemisphere just
above the level of the callosum. Both tympanic membranes
were normal and microscopic examination of the pus from the
cerebral abscess revealed only the ordinary staphylococcus
pyogenes aureus. In view of the frequency of cerebral abscess
after suppurative processes in the lungs, it may be added that
merely spots of catarrhal pneumonia were found in both lungs.
No degeneration was noticed anywhere in the motor tract.
The fibers from the first temporal gyrus were almost entirely
destroyed as well as those from the upper anterior part of the
second temporal convolution. And as no degeneration had been
found within the latter bundle of the peduncle by the method
of Marchi sixty-eight days after the first attack and twenty-
eight days after the second, it was considered that the case
demonstrated the fact that no fibers from the first temporal
and the upper anterior part of the second temporal gyrus
including a portion of the upper middle of this gyrus enter the
fasiculus of Turck. In another case of hemiplegia in which
death occurred three weeks after the attack the authors were
able to show intense degeneration by the method of Marchi.
Dr. J. Arthur Booth of New York, read a paper on and
presented a case of
EDEMA OF THE EYELIDS IN GRAVES' DISEASE ; THYROIDECTOMY.
After detailing at some length, the circumstances connected
with the patient presented, the author drew the following con-
clusions : 1. Slight decrease of the edema situated in the
extremities is a common occurrence in Graves' disease, but this
symptom limited to the eyelids is very seldom seen. 2. In dis-
tinguishing these various forms of swelling it is necessary to be
guided by the position and the degree. If situated only on the
face and upper limbs, or if unsymmetrical it is entirely of nerv-
ous origin. It may be that it effects the feet, but this will be
slight and temporary. 3. These symptoms are evidently of
vaso-motor origin and are probably due to a paralysis affecting
the constrictor nerves, manifestations of peripheral neuritis.
4. Limited to the eyelids, it may be due to a paresis. If this
be true, however, it is strange that we do not meet with it in
other palsies of the muscles. 5. Thyroidectomy carefully per-
formed and by one cognizant of the occasional complications,
such an operation is not as dangerous as is generally believed.
6. From operative interference in Graves' disease, we may
expect an improvement to some extent.
Dr. M. Allen Starr said that the percentage of death in
operations upon the thyroid gland was high and that he knew
of several cases operated on in New York where every precau-
tion had been taken, but death had resulted from some unex-
plained cause, although the ordinary surgical shock was not
present.
Dr. Philip Coombes Knapp of Boston read a paper on
THE NATURE OF NEURASTHENIA.
The author's study was based on one hundred cases in hospi-
tal and fifty in private practice. The chief symptoms were
nervousness and weakness, the "irritable weakness" which is
considered an essential symptom of neurasthenia. Next in
frequency came headache, indigestion, insomnia and epilepsy.
Depression, backache and other symptoms were much less
common. Neurasthenia was considered to be apalagous to
42
SOCIETY PROCEEDINGS.
[July 4,
chronic fatigue and to be due primarily to exhaustion in the
cells of the brain cortex. Mental depression was not infrequent,
but it was usually secondary to a neurasthenic condition or
the physiologic result of the cause (grief, worry), which had
produced the neurasthenic. Among the morbid fears were
first those pertaining to the physical welfare of the patient
often based upon physical symptoms and having a rational basis,
although resting upon false premises and ignorance of the
significance of these symptoms. In other cases the fears were
of a different character and these cases were not neurasthenia,
but true hypochondria, a mental state akin in some degree to
paranoia. The second class of morbid fears were the so-called
phobias. These fears exist in perfectly healthy people who,
under their influence, may be drawn into considerable anxiety
and distress. In other cases the morbid fears were secondary
to certain unexplained ideas. These fears and unexplained
ideas are not uncommon in mild forms in perfectly healthy per-
sons. In the severe forms they exist as independent psychoses.
These different psychoses may exist independently without
any trace of neurasthenia. It will be found in only a small
percentage of neurasthenic cases which is greater among
private patients. When found in neurasthenia these fears
and unexplained ideas are indicative of the coexistence of
another affection.
Dr. Theo. Diller said in his opinion in all such cases it
was of primary importance to search for neurasthenia as it is
a question whether or not they are the outcome of a neuras-
thenic disease or a degeneration.
Dr. Burt G. Wilder referred to the case of a distinguished
etymologist who was made very uncomfortable by the mere
presence of a cat even if he could not see it and stated that
this fear was greatly intensified if the floor was carpeted.
Dr. Spitzka considered it important to separate the inherent
cases from the acquired.
Dr. Henry S. Upson of Cleveland, read a pager on
NERVE DISTURBANCES FROM INDIGESTION.
Three cases were cited. While conclusions from so few cases
are not warranted, yet the speaker believed that the type of
nerve disturbance found in typhoid is found in intestinal
indigestion without the intervention of this disorder. It may
easily be confounded with mild melancholia or neurasthenia,
which presents many points of similarity. It must be carefully
differentiated from nerve diseases which are amenable to treat-
ment, which treatment should not consist exclusively in the
administration of an antiseptic.
Dr. Langdon — One must not forget that bacteria are of two
kinds, the conservative and the pathogenic and there may be
a third kind, the indifferent. It is well known that we could
not live in our streets except for certain bacteria and it does
not follow that because their presence may have a doubtful
effect in some cases it will do so in all. He had obtained good
results by the administration of mercury given in the form of
calomel, which he claimed is converted into bichlorid of mer-
cury by hydrochloric acid.
Dr. Thomas J. Mays of Philadelphia read a paper on
TOXICOSIS OF THE NERVOUS SYSTEM AS A CAUSE OF PULMONARY
CONSUMPTION.
Dr. Mays said disturbance of the nervous system and espec-
ially of the respiratory nerves induces some form of pulmonary
disease and frequently pulmonary consumption. That diseases
of the pneumogastric nerves leads to these disorders is con-
firmed by the opinions of Chevan, Holland, Copland, Laycock,
Allbutt and Clouston, which are quoted. Besides, clinical
proof and post mortem evidence are adduced from cases found
in medical literature. Alcohol, syphilis, mercury, lead, typhoid
fever, diphtheria, measles, whooping cough, mumps, influenza,
cerebro spinal meningitis, beriberi, rheumatism, etc., intoxicate
the nervous system and become prolific sources of pulmonary
mischief. Of all these poisons alcohol is probably most sure
to bring about pulmonary diseases through the nervous sys-
tem, and a number of cases giving post mortem proof of this
are cited. Syphilis and most of the other poisons mentioned
are treated in the same manner and are shown to have the
same effect ultimately in a great many instances. The chronicity
or the acuteness of the pulmonary disease which is thus de-
pendent on the nervous system, are governed in a large measure,
1, by the virulency of the poison ; 2, by the amount and fre-
quency with which it is introduced ; 3, by the persistency of
its action, and i, by the facility or difficulty with which it is
excreted by the body. They all vary in this respect. Alcohol
is quickly eliminated, but its harmfulness depends on its being
taken frequently and continued for a long time. A single
infection of syphilis permeates the body and the virus remains
for years. Mercury and lead enter the body very gradually,
but are excreted very slowly. The poisons of whooping cough,
influenza and cerebrospinal meningitis, having a selective
affinity for the pulmonary nerves, are liable to be followed by
a more speedy disease of the lungs. This is the case with
those of typhoid fever, diphtheria, measles and mumps. Uric
acid being a normal constituent of the blood, only becomes
harmful when it accumulates persistently in excessive
quantities.
Dr. P. W. Langdon of Cincinnati, presented a paper entitled
EPILEPSY AND OTHER CONVULSIVE DISEASES ; A STUDY IN NEURO-
DYNAMICS.
The anatomic digest accepts the neuron of Waldeyer as the
anatomic and physiologic unit of the nervous system, especial
attention being called to its more complex construction as
elucidated by Max Schultze, Schaefer and Gowers. Physiolog-
ically, attention is directed to the later views that the cell-
processes pr their terminal endings are chiefly concerned in
dynamo-genesis or conversion as opposed to the older doctrine
that the "cell" (neuron-body) was the chief agent of action.
Pathologically, objection was raised to the prevalent view that
"chemical instability" or "explosion" of cell areas are the
main factors in convulsive action. In its place, the view was
advanced that definite defects of structure in the neuron-
processes, chiefly those of the great pyramidal projection
tracts, are responsible for the convulsive phenomena. The
foregoing considerations, anatomic, physiologic and pathologic,
would appear to justify the following propositions as a working
hypothesis: 1. That epilepsy, the choreas and probably most
convulsive disorders are the dynamic expression of an inhibi-
tory insufficiency, not indications of over-production of nerve
energy nor "explosions" due to a "molecular instability" per se ;
2, that the cause of this inhibitory insufficiency is to be sought
for in the end brushes of the collateral processes of various
cortical neurons, the situation varying with the "type" of the
disease, whether sensory, psychic, or motor ; 3, that the
defect consists most probably, in a structural incompleteness
(small capacity, defective insulation, imperfect contact) or a
numerical deficiency, or both, in the collateral processes of the
neurons referred to ; 4, defective collaterals may favor occurr-
ence of convulsions in two days : (a) by impairing connection
with other neurons (inhibitory, storage, etc.); (b) by increased
resistance to "overflow currents," causing temporary over-
charging of motor axis-cylinders. This conception of the
anatomico-dynamic basis of convulsive phenomena I would
call the "collateral theory." On this basis, cases of epilepsy
are classed under three groups, each of which presents import-
ant differences as regards prognosis and treatment. 1. Print-
ary or developmental type, compromising the "idiopathic."
Cases under 20 years of age. In these, the younger the sub-
ject and the better the heredity and environment, the better
the prognosis under intelligent treatment. Ultimate result
depending on the possibility of promoting further and equable
development of collateral communications with inhibitory
mechanisms. 2. The accidental forms. Those due to trauma,
syphilis, lead toxins, etc. The prognosis here varying with
the longer or shorter duration and the possibility of removal of
the cause ; being always favorable so long as permanent struct-
ural changes in collaterals and inhibitory mechanisms have not
occurred. 3. The degenerative type. The rare cases of adult
life and old age (not accidental ) belong in this category. Here
palliation only is to be expected as in degenerative changes
elsewhere. In all forms the rational indications for treatment
are : To lessen the incoming sensory excitation, by diet,
hygiene, occupation, medicines ; and so lessen the intensity of
motor responses which are not provided with suitable overflow
and inhibitory mechanisms.
Dr. Irving C. Rosse read a paper on
NEWSPAPER RABIES.
After referring to the way in which newspapers deal with the
subject of hydrophobia and allied affections, Dr. Rosse stated
that from bibliographic references and experimental research
he felt the following conclusions were warranted : 1, that the
notion of a toxico-rabid bite is an old one being mentioned by
Homer, but not by Hypocrates ; 2, but few physicians have
seen a genuine case of this complex and badly elucidated
affection ; 3, among competent surgeons and neurologists there
is a wide difference of opinion, and even irreconcilable diversity
as to the existence of genuine hydrophobia in man ; 4, there is
also considerable diversity of opinion concerning the exact
value of the Pasteur method ; 5, there is a difference of opinion
as to whether pseudo-hydrophobia ever produced death : 6, in
view of the uncertain knowledge of the disease and aside from
making sensational items of such matters, newspapers are not
to blame for publishing statements inconsistent with biologic
or medical facts, since they merely reflect current opinion, and
holding the mirror up to nature gives us, so to speak, a radio-
graph of what is going on in the minds of medical men.
1896.]
EDITORIAL.
43
THE
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ucntlemeu already members of the Association should send their
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Original communications are only received with the understanding
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INFORMATION WANTED.
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those members of the Association living In large cities, if they would
kindly furnish this office with their street address in those cases where
it is omitted from the wrapper of their Journal, as we have been noti-
fied by the postmasters of the larger cities that second-class mail mat-
ter not having street address, would be placed in the general delivery
to await call.
SATURDAY, JULY 4, 1896.
PANICKY SANITATION.
It has been published as a fact that a law has been
proposed in the British colony of New Zealand pro-
hibiting the admission of all tuberculous individuals
and imposing heavy penalties on ship captains and
steamship companies which furnish them transporta-
tion to the country and permit them to land. If car-
ried out this proposition will be an advance on any
sanitary precautions heretofore attempted and will
doubtless meet with the approval of some of the
more ardent sanitarians. New Zealand is a group
of islands, a rather extensive one to be sure, with only
comparatively limited means of communication with
the rest of the world and it is possible to conceive of
a much more perfect isolation there than is practica-
ble in any continental territory. Whether the New
Zealanders will be able to keep out the ubiquitous
bacillus tuberculosis or do anything more than afford
protection from foreign competition to the home pro-
duced article is a question, and on the grounds of
ordinary humanity, taking this uncertainty into
account there are some objections to the proposed
enactment. Latent tuberculosis certainly can not be
thus excluded, or any other unobtrusive form of the
disease unless some tuberculin or other test is applied
on passengers and others who reach the country by
the ordinary routes of travel, or better through some
consular agency before starting. Only in this way
can the disorder be excluded; the few pronounced
cases will hardly figure among the manifold other
chances of admission of the germs. Then there are to
be taken into account the sources of infection already
existing in the country and the opportunities it may
have of self propagation. Of course the plans must
include the extirpation of these. When all is done
and the islanders have adapted themselves to the new
conditions, supposing these to be possible, is there not
yet a possibility that they may be more than ever vul-
nerable to any accidental introduction of the infection,
by reason of their lack of the possible immunity pro-
duced by familiarity with and habitual resistance to
the microbe. That such an immunity exists in case
of many diseases to some extent is highly possible
from the fact of the quickness with which they
spread in populations hitherto unaccustomed to them.
Such immunity can be easily accounted for by the
law of natural selection alone, to which there is no
reason to believe tuberculosis forms any exception.
If New Zealand, or any other country, has the climatic
and other local conditions favorable to tubercular dis-
ease and if it already exists there as is undoubtedly
the case, the exclusion of pronounced cases by the
severest legal enactments and penalties will be a very
poor method of defense as compared with proper
hygienic local regulations. If on the other hand, its
climate is such as to make it a desirable sanitarium
for consumptives it would be almost a crime against
humanity to exclude them from its benefits, by meas-
ures that can at best be insufficient for preventing the
introduction of the disease and inexcusable in so far
as it already existed in the country.
It is true that it is said that tuberculosis has increased
among the natives of the Riviera and some other regions
resorted to by consumptives, but these localities have
nevertheless not lost their climatic advantages and
tuberculous invalids still find benefit from residence
there. It is not unfair to presume therefore that
the natives have not fully availed themselves of their
hygienic privileges, or that they have not yet acquired
the immunity possessed by residents of less favored
localities. There are few disorders that in a general
way are more amenable to local sanitary and hygienic
measures than is tuberculosis, and there is hardly one
that is more generally distributed or harder to control
by isolation. There are also probably very few other
serious diseases the effective contagion of which is
more dependent upon the susceptibility of the indi-
vidual ; it would be hard to find many or indeed any
adults in this and most other civilized countries who
have not been repeatedly exposed to its germs.
Indeed, if what apparently competent observers state
is true, that 18 per cent, of domestic cattle are infected
with tuberculosis, it might be hard to find a weaned
or bottle-fed infant that had not repeatedly imbibed
the contagion, and yet the race survives, the average
longevity increases and the population question still
troubles the Malthusians.
44
THE QUESTION OF PHYSICAL EXAMINATION.
July 4,
It must not be inferred that it is intended in these
remarks to object to or disparage any reasonable
attempt to protect the public against so great
a scourge as tuberculosis. It is not necessary however
for the State, or the public, to treat the consumptive
as a leper, and such extreme measures as the one
noticed are not only not humane, but can not be said
to be in the true line of progress. They obscure and
rather tend to the neglect of the less obtrusive but
far more efficient local hygiene that is the true
defense against the disease. Such measures can be
justly characterized as panicky legislation, and coward-
ice is not an element that favors success in strife
with disease, and inhumanity which is its common
accessory, is undeserving of it. Tuberculosis does
not increase where it is properly managed, and even
with the prevalent carelessness in regard to disinfec-
tion or destruction of sputa, indiscriminate expecto-
ration, etc., it is no greater a scourge in long settled
communities than it has been in years past. With
the present enlightenment as to its causes and pre-
vention, there is no reason why it should not decrease
with the employment of early rational precautions
against infection.
THE QUESTION OF PHYSICAL EXAMINATION.
At the recent meeting at Philadelphia of the As-
sociation of Military Surgeons of the United States,
during the discussion of the paper prepared and read
by Major Paul R. Brown, Surgeon U. S. Army, on
" Modern Methods of Anthropometric Identification,
so far as the United States Soldier is Concerned," in
which he very earnestly advocated the system based on
anatomic and descriptive data devised by Bertillon,
of whose work he is the translator, Colonel Charles
H. Alden, the Assistant Surgeon-General of the U.S.
Army, and others of that Department, declared their
preference for the method now in vogue in the Army
of recording prominent marks, scars and peculiarities
as proofs of identity, for the reason among others that
the French plan proposed was primarily associated
with the recognition of criminals. Captain Myles
Standish, Mass. V. M., said that the mere fact that
Bertillon's method was employed in connection
with criminals would make it difficult or impossible to
adopt it in this country, and Captain Arthur R.
Jarrett, N. Y. N. G., was also of opinion that in his
State the men would feel it an indignity to be
measured and inspected by the same procedure as was
employed for criminals, which caused Major Havard
of the Army to remark that this objection reminded
him of Martin Luther's reply, when he was reproved
for playing dance music, that he did not see why the
devil should have all the good tunes.
The trend of the discussion illustrated one of the
difficulties experienced in this country in enforcing
any salutary regulation. The sentimental objection
is alleged that the liberty of the individual is en-
croached upon by requirements special to one par-
ticular occupation or to one class of persons, and
resistance is upheld to the point of establishing the
license to do as each one pleases without regard to
the interests of others or to the better control of
public affairs. Only in recent years has the practice
obtained of uniforming railroad employes ; still later
that of requiring letter-carriers to wear a distinctive
dress; and only within the past year has Colonel
Waring been able to clothe the force of the New
York Street Cleaning Department in a prescribed
uniform. The writer recalls the almost rebellious
refusal of the female nurses of the Maryland State
Hospital for the Insane, of which Dr. Rohe was
Superintendent, to wear a uniform dress, and he only
succeeded by inducing the prettiest of the lot to try
on a most becoming and coquettish costume, with
which she was so satisfied that she concluded to keep
it on, all the others quickly following suit.
Municipal administration in this country is hampered
more by this intolerance of restraint, however justi-
fiable, than by any other cause. The same individuals,
who in Great Britain, Germany, France, Italy and
Russia, conform with no apparent reluctance to the
most stringent requirements, are the most defiant of
rules of propriety as soon as they fall within the
limits of this law-contemning country. It is only
necessary to watch the Irish and German drivers of
beer-trucks, grocer- wagons and butcher-carts turning
the corners of public thoroughfares at full speed
without regard for feeble pedestrians, and offensively
unclean Italian and Russian laborers crowding into
public conveyances to realize how the lax adminis-
tration of our cities has transformed the alien serf
into a very unwholesome variety • of American boor.
Within a few weeks, the Board of Health of New York
nerved itself to issue a regulation that " spitting on
the floor of public conveyances is a nuisance, is
frequently the means of communicating disease, and
is hereby forbidden," which was reinforced by an
order of the General Manager of the several street
railway lines that " employes of the company are
required to call the attention of passengers violating
the above order of the Health Department either in
the cars, waiting-rooms, or on the stairways and
station platforms of the company, to the provisions
of the same." The fulmination was printed on cards
which have been hung where they can scarcely be
seen, employes are supremely indifferent to the in-
junction and the spitters continue, their disgusting
practice.
It can not be asserted that indifference and hostility
to sanitary and other municipal regulations are inhe-
rent to the republican form of government, since both
in France and Switzerland, the latter venerable among
republics, the citizens render the same prompt obedi-
1896.]
THE PUBLIC HEALTH DEPARTMENT.
45
euro as the Chinaman, who obeys the law beoause it is
the law, in the same spirit as his child who obeys him
beoause it is his duty to obey. During our civil war,
an American traveling in Europe became acquainted
with a young Swiss merchant who was lamenting that
be had been called upon to perform his military service
in tlie field at a time when his business required his
presence, and who. when asked by the American.
"Why do you not hire a substitute?" as so many
thousands of the citizens of the Great Republic were
doing at that very time, replied, "Hire a substitute!
Why. it is my duty to go" — and he went.
Recurring to the initiatory text, which suggested
this acticle, the alleged objection to the personal indig-
nity and humiliation of a physical examination is
really only a pretext, and intended to conceal the very
physical defects it is the prime object of the examina-
tion to discover. There is no more important duty of
the medical officers of the army, navy and marine-
hospital service than this of physical examination.
Upon its proper performance depends the efficiency
of the personnel of the several services. It secures
the retention of the fittest — of those least predisposed
to disease and most resistant to the morbific influ-
ences of climate and occupation — of the most vigor-
ous and lust able to perform arduous and exacting
labor. The recognition of deserters, convicts and
other undesirable recruits is only incidental and based
upon information obtained originally with another
object. "So far as the indignity and humiliation are
concerned," said Major Valery Havard, U. S. A..
in supporting Major Brown's advocacy of the Ber-
tillon method, "when a man is stripped and his marks
and defects noted he has been subjected to as much
indignity as he can be, and therefore I prefer the
most scientific system based on anatomic data."
Major Philip F. Harvey, of the U. S. Army, goes
even farther, in that he proposes to prevent the
enlistment of undesirable men by a study and inter-
pretation of the marks of degeneracy, indicating moral
defects and criminal tendencies in the individual.
The individual's body is his own most precious pos-
session, but he has no right because of this exclusive
ownership to exact concessions from other bodies that
may be prejudicial to the general welfare. In some
sequestered spot or solitary island, he might go clad
or unclothed, and mutilate, disfigure or destroy it
without let or hindrance, but where other bodies come
within its sphere the inalienable property right has
to be restricted. Examinations conducted in privacy
by competent and experienced professional examiners,
with every regard to decency and delicacy, can be no
more objectionable than the diagnostic explorations
of the attending physician; and the record of the
shape of the nose and other features, the configura-
tion of the body and limbs, and the other points of
the congenital conformation of the individual are as
proper as the noting of a scar on the left cheek, a
wart on the nose, or an eagle and anchor and the let-
ters A. B. in indelible ink on the left breast. It is
gratifying to learn from medical officers of the
National Guard of great States like New York, New
Jersey and Pennsylvania, that they are aiming to
establish the same system of physical examinations
as prevail in the national services, and we trust that
the recent discussion before the Association of Mili-
tary Surgeons may have the effect of making the
practice general in all the States and Territories, and
that the decorous submission to requirements in this
instance may lead to a better disposition to recognize
the value of law and order in other matters, espe-
cially in those concerning the public health. It is not
anticipated that any military surgeon will object to
the most thorough physical inspection, though
hardly to the extent of introducing a rectal speculum
or urethral catheter or requiring the subject to urinate
under observation as has been done in Europe. Sol-
diers and sailors of all men should be trained to
regard their bodies in a manly spirit. Men bathe
together without remark and the familar exposures of
the barracks and bath-deck are neither provocative of
libidinousness nor shamefacedness. The cadets at
the U. S. Naval Academy are annually subjected to
nude inspections, which are made matters of record
and are invaluable elements of their physical history.
Properly conducted physical examinations of the
inmates of girls' schools and colleges would do much
in the way of convincing parents and skeptical
teachers of the progressive deformation of young
women by faulty dress, and now that the injudicious
use of the bicycle is distorting the plastic pelves of
immature females, such examinations will be of incal-
culable benefit. The greater attention paid to the
normal development of the body the better for the
race, and the general adoption of Bertillon's system
of physical inspection and registration by the
National Guard of the United States will be the indi-
rect means of better acquainting the members of that
organization with their bodily selves.
THE PUBLIC HEALTH DEPARTMENT.
We have received the following letter from Dr.
Jerome Cochran, State Health Officer of Alabama,
Chairman of the Committee on a " Department and
Secretary of Public Health" appointed by the Associ-
ation some years since, of which the late Dr. C. G.
Comegys was the first chairman :
Montgomery, Ala., June 29, 1896.
To the Editor: In the Journal of the 27th there is an edi-
torial which has occasioned me no little surprise. It begins on
page 1273 and is entitled "An Explanation Is in Order."
The explanation is very simple. After several years of
unavailing work the Committee on Department of Public
Health presented a report at the Atlanta meeting of the Asso-
ciation proposing a new departure in the effort to obtain
46
THE PUBLIC HEALTH DEPAETMENT.
[July 4,
national public health legislation. This report is to be found
in the Journal for May 16, beginning on page 988. It was
discussed by the Association and unanimously adopted with
all of its recommendations. Among these recommendations is
one authorizing us to invite the cooperation of the conference
of State boards of health.
I accordingly attended the meeting of the conference in
Chicago and laid before it the plan for a national health bureau
which had been approved by the Association and asked the
conference to approve said plan, which it did. I also re-
quested that the conference recommend each State Board of
Health to appoint one member of a committee to act with the
committee of the American Medical Association in securing
for the proposed bill the favorable consideration of Congress.
This also the conference agreed to.
That is the whole story ; and it seems not a little strange
to me that the Journal of the Association should begin in
such hot haste to oppose the plans and orders of the Associa-
tion. The United States mail brings Chicago in easy com-
munication with Montgomery, so that it would have been easy
for the Editor of the Journal to have obtained all the facts
from the chairman of the committee. I will venture to sug-
gest that common justice dictates that you should give this
explanation as prominent a place in the columns of the Jour-
nal as was occupied by the hasty editorial complained of. I
have the honor to remain yours truly,
Jerome Cochran, M.D., Chairman of Com.
We only reiterate a demand for what we believe the
Association wants and what is expressed in the very
name of the committee on a Department and Secretary
of Public Health. The following extracts from the
committee's report (printed in full in the Journal
for May 16, 1896) show that we have made no mis-
take. After reciting the previous failure to obtain a
Board of Health, Dr. Cochran as chairmain on the
Committee on a Department of Public Health, says :
" In the meantime, the Marine-Hospital Service,
which in 1890 had already been invested with some
important health functions, was by the Act of 1893
converted into a National Health Department with
very large and far-reaching powers and abundant
means. It is not called a department of public health,
but is a Department of Public Health in fact.
It seems to us to be a fundamental proposition that
we shall have but one National Department of Public
Health. This being conceded, one of three courses
remain open to us.
1. We may devise and advocate a plan to deprive
the Marine-Hospital Service of its public health
functions, and for the establishment of an entirely
new department; or,
2. We may accept the Marine-Hospital Service just
as it stands as a department sufficient for our present
use; or,
3. We may endeavor to improve the Marine-Hos-
pital Service and make it a more satisfactory National
Health Department than it now is.
It would seem that this last method promises to be
the most fruitful of beneficent results; and the
question then arises as to the modifications that may
be wisely made in the existing law.
Such a scheme as this would probably command
the approval and support of the National Conference
of State Boards of Health, which Conference is quite
as deeply interested in movements of this character
as is the American Medical Association.
As the conclusion of the whole argument, we-
recommend that we be authorized to draw up a new
bill along the lines we have indicated, and that we be
authorized to invite the cooperation of the Conference
of State Boards of Health and of the American Public
Health Association in our endeavor to have the pro-
posed bill enacted into law."
The following was the discussion thereon.
Dr. Hibberd — I move that the report of the com-
mittee be accepted, the plan outlined adopted, the
committee continued and enlarged by the appoint-
ment of a member from each State. Seconded.
Dr. I .N. Love — If I understand the proposition
rightly, it provides for a Department of Public Health
built upon the present foundation of the Marine-
Hospital Service. I am therefore in favor of it. It
is an elaboration, a building up in a stronger and
more definite shape 'of the public health department
and quarantive service which we already have. When
we consider that every other department of life is
represented in our National Conference Board, or
Cabinet, and yet public health is not represented,,
surely the dignity of medicine and the best interests
of the health of the community demand such recog-
nition, and I think the most practical way in which
to accomplish this great and good work is by build-
ing up that which we already have and crystallizing
it in the shape of a more dignified body.
Dr. Summers, of St. Louis — I think, sir, it is time
for this Association to demand of the United States-
of America that it should be represented in its Cabi-
net at Washington. We can learn a great deal from
the old Christian mythology, where Gabriel was the
Secretary of State, Michael the Archangel or Secre-
tary of War, and Raphael the Secretary of Healthy
who flew with his wings close to the earth and shed
healing in his path. Now, I say, the time has come
when this Association in its power and dignity
should rise and demand of the government of the
United States that it create a department of public
health, as has been done in all governments of the
world. This is the solution of the question. Twenty-
five years ago I joined Dr. Cochran in his efforts in
public health matters in Alabama, and it brought out
the fact that it was possible for the State to take hold
of medicine and govern it accordingly.
The report was then adopted.
It is entirely clear that the members thought they
were supporting a measure to create a Department of
Public Health. The proposition was understood to
be as stated by Doctor Love, a Department of Pub-
lic Health built upon the present foundation of the
Marine-Hospital Service.
That is a very different proposition from the one
advocated before the conference. The latter simply
provides for a Division of Public Health in the Mar-
ine-Hospital Bureau, the chief thereof to be appointed
by the Supervising Surgeon General; that is to say
in effect that some subordinate in , a bureau, itself
subordinate to the Treasury Department, has sufficient
power, dignity and authority to represent the impor-
tant interests which ought to be intrusted to him,
with credit to the American Medical Profession.
We do not think the chairman quite understands
the sentiment of the Association on that point.
1896. |
CORRESPONDENCE.
47
Has he submitted any proposition to make the
Marine-Hospital Bureau independent? That would
seem a proper move, as by the words of the chairman,
"It is not called a Department of Public Health, but
is a Department of Public Health in fact." Why
then seek to place the chief of the Public Health
Service two removes further from departmental inde-
pendence? The head of the present bureau is not
now independent; if it be, as Dr. Cochran says, the
real health service, why not make its chief the chief
in fact, instead of merely authorizing him to "appoint"
somebody, or employ a new clerk?
There is rarely time to discuss these questions on
the floor of the Association, especially when the
report is in manuscript, and no one knows what is in
it unless fortunate enough to have a front seat. The
question then finds its appropriate place for discus-
sion in the columns of the Journal, and we sincerely
hope that our esteemed friend, with that courtesy and
tolerance that has always distinguished him, will wel-
come criticism and well-formed opinions from other
members of the Association.
In conclusion we might inquire whether or not
Doctor Hibberd's duly seconded motion to appoint
one additional member of the committee from each
State has been acted upon. That motion was surely
wise, and according to the minutes it was adopted.
THE MEDICAL JOURNAL AND THE "READING
NOTICE."
The manager of a medical journal has his troubles
quite apart from those of securing leader writers.
< >ne of the most annoying and at the same time one
of the most unnecessary, is the unceasing demand
from those who should know better, that the reading
columns of his journal shall frequently present
ai tides descriptive and sometimes eulogistic of some
pill, powder or potion. The article thus presented as
a "reading notice" is usually written by some impe-
cunious or unknown M.D., who, for a consideration or
gratuitously, has furnished our advertiser with this
wedge to force the journal.
The thin edge is inserted when the article is writ-
ten as a scientific one. There is a phase in this mat-
ter that is not quite understood. If Editor Jones or
Editor Smith shall, as many do, decline to publish
the material, then the advertiser may make it a per-
sonal matter and withdraw the advertisement. This
procedure, we are sorry to say, is growing more and
more frequent.
Let us ask advertisers to look this matter squarely
in the face. There are two sides. Editor Jones, we
may say, has given much thought to this subject, and
wishes his esteemed friend C. O, of Selldrugs & Co.,
a large and prosperous business, but he can not com-
ply with the request of the Messrs. Selldrugs & Co.
He tells them in effect that he has only advertising
space for sale in the advertising department. The
scientific department of his journal, he explains, is
not intended for advertisements, and in fact he has
no right to sell any part of it. To do so would be an
open violation of an implied contract with his readers.
The editor, as he warms up to his subject, con-
tinues: "There is still another point of view; we are
carrying your advertisement, my dear friends, and we
thank you very much, but our rates are low, and we
think we are giving you an equivalent, why should
you ask us to insert two advertisements when you pay
only for one? If I send my office boy to your drug
palace and buy a hundred pills, are you obliged to
yield to his demand that having honestly bought the
pills, he must now have a pound of bon-bons and a
box of cigarettes? You would, my dear Merchant
Prince, resent the impudence of the boy. Suppose
now that we go ourselves, or write you a note threat-
ening to withdraw our patronage, even to the extent
of buying our next box of pills from your hated rival.
You would very likely," says Editor Jones, "tell me
that you sold the pills at a low price, and if you fur-
nished anything more it would be a gift. You would
perhaps say aside to your partner that the editor was
coming very close to levying blackmail. I have not
put the case to you," said Editor Jones, "on any sen-
timental grounds, as from the well-known philan-
thropy and public spirit of your long-established
house I might easily do, but I have chosen a simple
commercial standpoint and the case is only overdrawn
in one particular, that is the dealer has all the articles
for sale; in the case of the Medical Journal, the
manager has no right to sell or give away his scientific
space; that part of the journal does not belong to him
for that purpose; it is actually already paid for by the
subscriber."
CORRESPONDENCE.
Our Journal.
Montclair, N. J., June 7, 1896.
To the Editor: — I have just voted to move the publication
office of the Journal to Washington, D. C, and was actuated
by the following reasons :
1. The Journal is the organ of a great national Association
which should know no local prejudice nor be controlled by any
local body of men.
2. Any serial publication must in some measure respond to
the influence of its environment, therefore, in the case of a
periodical whose aims are so broad and whose spirit must be
so catholic as those which the Journal must display, unless it
shall fail of its high mission, its seat of publication should be
the most cosmopolitan possible.
3. Washington is the most cosmopolitan city in this country.
It can have, from the nature of its institutions and govern-
ment, no strong local prejudices.
i. It is, furthermore, the center of scientific thought as well
as the national capital. The fact that it is not a commercial
center fosters the scientific and literary spirit, and makes it a
delightful place of residence as well as an advantageous liter-
ary workshop.
48
CORRESPONDENCE.
[July 4,
5. It has certain advantages for literary work over any other
city in this country, because it contains the Congressional
library, the largest general library in America, and the Sur-
geon-General's library (which has been rendered so avail-
able to all scientific readers by the work of Dr. Billings and his
assistants). Washington contains also various other libraries,
as well as museums and laboratories.
6. These advantages must in the nature of things tend to
increase as time goes on, so that it is quite conceivable that,
even if the publication of the Journal shall be continued at
Chicago for the present, it will be forced to go to Washington
finally. Should this prove to be the case, it is obvious that
the move had better be made now than later on.
7. The unfortunate defection from the ranks of the Ameri-
can Medical Association bids fair to heal in good time. This
promise of better things has been brought about greatly through
the powerful influence of the Journal. If the Journal shall be
moved farther East, a happy outcome of these complications
will come more quickly.
8. The Journal is the only prominent medical publication
in this country which is not issued from the press of some
private publishing firm. Its publishers are, or should be, the
entire medical profession of America. It must, therefore, be
published in the interests of no set or clique ; its opinions must
be quite unbiased by any local interest, any spirit of business
or any private scheme.
9. There can be no question that the nedical profession as
well as the laity need in this country one powerful, well edited
and liberally supported medical journal, which shall be an
acknowledged authority upon scientific medicine, State medi-
cine, hygiene and medical ethics.
10. The high grade of scholarship, the breadth of view and
the business sagacity which have been shown of late in the
management of the Journal, give every promise that it is
bound to become such a publication as has just been described ;
in short, an American medical journal of which Americans
may be justly proud.
11. It will take this high place all the sooner if its seat of
publication, its general surroundings and its support shall be
as favorable as possible.
12. If the present rate of advance in the character of the
Journal shall be maintained the title should become The
American Medical Journal, and in smaller type. The words
The Journal or the American Medical Association should
appear upon the title page.
13. While it is true that the character of a publication is in-
fluenced by its environment it is also true that a publication
exercises an influence upon the thoughts and action of those in
whose midst it may be published, and this influence naturally
increases with the growth and power of the publication ; it
would be well therefore that the Journal should be published
in Washington by reason of the restraining and enlightening
influence its presence may have upon our legislators.
14. Great questions of national health, national hygiene and
physical well-being are now engaging the attention of scientific
men the world over, and as intimated above the Journal of
the American Medical Association should be in a position to
test the alleged discoveries in these lines and to impress what
else may be found valuable not only upon the profession but
upon our public men as well.
15. The advance of the medical profession in America in
learning, dignity, wealth and power has been marvelous during
the past two decades. There is no probability that there can
be in these respects a retrograde movement. The times are
propitious. The future of American medicine is bright with
hope. Let the Journal seize the opportunity to place itself at
the head of the profession and let each and every one of the
members of the Association forgetting all local pride and all
sectional prejudice do all that in us lies to advance no particu-
lar sect nor interest, no especial State, county or city but the
power and good name of American medicine and the prosperity
of its medical association. Let us be broad minded and patri-
otic and sink all sectional feeling in our common love of our
profession and our devotion to the healing art.
Richard C. Newton, M.D.
A Testimonial to Prof. N. S. Davis.
Pomfret, Conn., June 30, 1896.
To the Editor: — D. L.'s letter in the Journal of June 20 in
regard to a memorial to Dr. N. S. Davis reminds me that I
have in my possession a medal struck in 1846, on its face a
medallion and the words "N. S. Davis," and on the reverse
the inscription "American Medical Association," and the
date "1846." This medal was given to me by Mrs. Williams
of this town, whose husband, the late Dr. Lewis Williams, was
a delegate to the 1846 meeting, which 1 think met in Louis-
ville, Ky. S. Burden Overlock, M. D.
Note. — This convention met in New York in 1846.
Treatment of Typhoid Fever.
June 8, 1896.
To the Editor: — I have been much interested in the discus-
sion of the "Woodbridge" treatment of enteric fever, and I
am greatly pleased to see that many realize the necessity for
fulfilling what I have long considered the essential require-
ments in not only this, but most, if not all, intestinal disturb-
ances, viz. : Rid the digestive canal, promptly and thoroughly,
of all offending or decomposing matter, together with the pro-
ducts of decomposition, thus preventing their absorption ;
render the contents of the entire tract aseptic as far as possi-
ble, and lastly this and the first being, to my mind, the prime
consideration— inducing decided alkalinity, as it is in acid media
that most, nearly all, the obnoxious microorganisms thrive best.
The degree of alkalinity should be positive and sufficient, and
as, within reasonable limits, there is no danger of overdoing
the matter, large quantities of alkali, preferably bicarbonate of
sodium, should be given with sufficient frequency to maintain
the condition.
While practicing in San Diego, Cal., I had many cases of
enteric fever to treat, not one of which failed to yield promptly
to the course of treatment here indicated, barring two, which
were moribund as the result of intestinal hemorrhage when I
first saw them.
I had recently on my hands a puny infant to treat, whose
surroundings were in the highest degree unfavorable, suffer-
ing from en tero peritonitis, to which I gave freely sod. bic,
2 drams, and sod. et pot. tart., 1 dram, in milk every two hours.
When I first saw the child it was to all appearances nearly
dead ; thighs flexed upon the abdomen ; too weak to even cry ;
abdomen distended almost to bursting ; temperature 106.5,
pulse too rapid and weak to accurately count. I promptly got
it under the influence of that most reliable and efficient of
all stimulants, nitroglycerin, and then began the administra-
tion of alkalies. It began to respond to treatment at once, free
evacuations of most offensive material soon taking place, fol-
lowed by reduction in temperature and tympanites. Ten days
later the child had practically recovered. In fact I have found
that in all cases of acute intestinal trouble, even when profuse
diarrhea is present, brisk cathartics afford the most prompt
and certain relief. With them moderate doses of anodynes
may be given, but not to the extent of inhibiting catharsis.
While on this subject permit me to invite attention to the
great and decided efficacy of large quantities of alkalies in
chronic digestive disorders. Particularly in those disturb-
ances from which the users of tobacco and alcohol suffer, will
this be found the case. To many such I have frequently given
doses of one to two ounce? of bicarbonate of sodium, fre-
1896. 1
CORRESPONDENCE.
49
quently repeated, not only with great and prompt relief to
the induced trouble, but, in not a few instances, with at least
;i temporary overcoming of the causative trouble as well, As
in nearly every ease of digestive trouble there- is a condition
of hyperacidity of the gastric juice, is not the giving of alka-
lies the rational procedure? In fact is not the "requisite
e of acidity of the gastric juice" one of the numerous
"bugbears" in the path toward "rational therapeutics"?
H. W. Yemans, M.D.
Orrhotherapy In Diphtheria.
To tht Editor: The statistics for my paper on page 1, of
this .Ioikn m.. were collected for me by Dr. Wm. R. Parkes,
who had taken everything that could be found in my own jour-
nals ami in the extensive riles at tha Newberry Library. It
should be kept in mind by the reader that all statistics whether
favorable or unfavorable to the use of antitoxin in diphtheria
have been used and I have attempted to present an impartial
statement. If 1 have failed to give the credit to antitoxin that
many of my readers think is due, it is only because such credit
is not borne out by the statistics and I beg the reader to make
■ careful analysis of the table. It should be specially observed
that in nearly all statistics the comparison of the death rate in
diphtheria has been made for the latter part of 1894 or for 1895
where antitoxin was used, with previous years when antitoxin
was not used. As shown in observation 8 of the table Behring's
statistics for Berlin prove that the death rate for diphtheria in
whether antitoxin was used or not, was very much less
than in previous years, it being only 14 per cent, in 4,479
cases treated in Berlin without antitoxin. If, therefore, sta-
tistics of all the patients treated with antitoxin in the latter
part of 1S94 or in 1895 could have been compared with those
treated w ithout antitoxin in the same period, it would appear
from these statistics that the death rate in the latter would
have been less than in the former.
Yours truly, J. Fetcher Ingals, M.D.
[Received after the article was in press.]
The Bracelln Remedy for Diphtheria.
[After all the talk in the newspapers on the subject, and else-
where, we are sure our readers will gladly know that Dr.
Bracelin is still in the ranks of the profession and repudiates
the term " secret" as applied to his treatment.] —Ed.
Chicago, III., June 29, 1896.
To the Editor: Diphtheria, one of the most common and
the most fatal of all acute infectious diseases from which the
human family suffers, has been the bite noire of the medical
profession.
For years investigators have been studying the disease so as
to learn the cause which produces it, and, if possible, to dis-
cover a remedy which would remove the cause or modify or
neutralize its effects, but without any satisfactory results. At
length, after years of patient study and observation, two Ger-
man scientists discovered that a certain kind of bacteria was
invariably to be found in the diphtheritic deposit. They made
known their discovery and now the Klebs-Loffler bacillus is
looked upon as the specific cause of the disease. Since the
discovery of microbic cause of the disease different antiseptics
known to be destructive to bacteria have been used with vary-
ing degrees of success, but on the whole with unsatisfactory
results.
Medical journals and daily newspapers were filled with
reports of wonderful cures effected by the different methods of
treatment adopted, yet the average death rate has remained
about the same. The last aspirant for professional honors in
the treatment of diphtheria, antitoxin, and most generally
accepted by the profession as a successful remedy, does not
appear to be so useful as it was at first believed it would be.
Clinical tests as rejiorted by some are favorable; as reported
by ethers very unfavorable. According to some reports
the death rate has been lowered, but others again show
that there has been no appreciable lowering of the rate
of mortality. So many authentic records of sudden deaths
following immediately after it had been injected, and appa-
rently caused by the remedy, as also the constitutional
disturbances undoubtedly produced by it have made many of
the profession halt in their advocacy of such a dangerous
remedy, even if it had proved more successful in curing the
disease than it has been, they feeling that it is not safe nor
advisable to use such a dangerous remedy.
In my opinion diphtheria is a self-limited disease of specific
origin. If, after the appearance of the disease, auto-infection
can be prevented the efforts of nature will, unaided, effect a
cure, but if the products of decomposition containing the
specific poison of the disease ( whether we believe this to be the
Klebs-Loffler bacillus or the ptomaines produced by it) are
allowed to enter the circulation the disease increases in viru-
lence, the powers of resistance are weakened and the victim
dies.
Theorectically, a remedy to be successful in the treatment
of diphtheria should be one which would be constitutional as
well as local in effect. It should be destructive to the specific
cause as found in the diphtheritic deposits, prevent decomposi-
tion of the diphtheritic membrane and destroy or prevent for-
mation of the ptomaines which cause auto-infection. But
before treatment has been commenced there may have been a
greater amount of diphtheritic poison in the system than nature
unaided is able to destroy. The remedy must therefore be a
constitutional as well as a local one, so that entering the sys-
tem it may assist nature in her efforts to destroy or neutralize
the poison already there. Such a remedy would be an ideal one
and should, in my opinion, meet the requirements necessary
for the successful treatment of diphtheria.
In January, 189.3, I discovered a remedy which appears to
meet all the requirements of the ideal remedy. I have been
experimenting with, testing clinically and improving on the
original idea, until now I believe it is as near a specific for
diphtheria as it is possible for a remedy to be for any disease.
Since that time I have treated a large number of diphtheria
cases in all stages of the disease and have only lost about one
per cent., and I believe I have verified my theory that, if
chlorin gas, corrected, should prove to be a safe bactericide
for diphtheria, it would also be an effective remedy for all dis-
eases of the respiratory organs of a microbic nature. This
theory has been fully confirmed by the experience of many
physicians beside myself who have used chlorin gas as pre-
pared by me. It is too much to expect that such a small death
rate can always be maintained, but I believe that by the use of
this remedy the death rate will be less than 5 per cent. Not
one who has used it as a prophylactic when exposed to the dis-
ease has been attacked by diphtheria. This is the best evi-
dence of its efficiency as a prophylactic. As it is used by
inhalation, it not only acts upon the diseased tissue locally,
but being a vapor the remedial agent enters the lungs, passes
into the circulation with the oxygen and materially aids
nature in destroying the systemic poison. It is simple, easy
to use, and absolutely safe ; there is no danger of any harmful
result following its use, or evil being caused by it. The rem-
edy has been successfully used in a number of diseases of
the throat and lungs, pneumonia, hay fever, asthma, laryn-
gitis, common colds, bronchitis, whooping-cough, catarrh, con-
sumption, etc. All cases of consumption in the first or second
stages where it has been used, have rscovered and are now
well. Consumptive cases require, in addition to the inhala-
tions, appropriate constitutional and supportive treatment on
the usual lines. It has failed to cure in the last stages of the
disease, but affords great relief to the sufferer. I have reason
50
PUBLIC HEALTH.
[July 4,
to believe tbat if used on the first appearance of any symp-
toms of consumption that comparatively few will die of this
much dreaded disease.
Pure drugs and careful manipulation in the process of man-
ufacture are necessary in order to attain an efficient remedy.
If made of poor materials, improperly combined, the remedy
will prove a failure ; but properly made it will prove to be all I
claim for it. I have therefore made arrangements with a firm
of reliable manufacturing chemists in Chicago to have it made
under my personal supervision, and I have removed to this
city for that purpooe. Every bottle which now goes out will
be guaranteed perfectly pure and of full strength. It will be
distributed by Mr. J. J. Russell, 167 Dearborn St., Chicago,
from whom the genuine remedy can always be procured. On
every bottle will be found the formula and none will be genuine
without my signature.
The remedy consists essentially of chlorin, deprived of its
suffocating, irritating qualities by an emollient corrective. The
value of the "corrective" is not so much due to the agents
used as to the process of manufacture in making the combina-
tion. Properly made the results will be satisfactory, if
improperly combined the results will be disappointing. This
is the result of my repeated trials and clinical experiments
carried on during a period of over three years. Two liquids
are used, which are for convenience named "Bracelin Chlorin
Bactericide," "No. One" and "No. Two." "B. C. B. No. 1"
is set free by the corrected chlorin in "B. C. B. No. 2." "B.
C. B. No. 2" is added to "B. C. B. No. 1" in the proportion of
one to five parts slightly warmed and the vapor inhaled as
directed. Some diseases, such as diphtheria and pneumonia,
require its use once each hour, others but four or five times a
day. I am now prepared to give my formula to the profession
for trial in the teatment of diphtheria and throat and lung
diseases, viz :
FORMULA OF BRACELIN' S CHLORIN BACTERICIDE.
Solution No. 1.
Solution Zinc chlorid 20 parte.
Solution Arsenic chlorid 30 parte.
Hydrochloric acid 1 part.
Water 49 parts.
Solution No. 2.
Solution chlorinated Soda, Standardized to 2.6 per cent,
available.
Chlorin 70 parte.
Corrective 30 parte.
Note : — The corrective consists of menthol, camphor, euca-
lyptol and salicylate of methyl dissolved in alcohol and water.
It will, I think, require no special argument to convince the
profession that so chemically unstable a compound can only
be prepared satisfactorily by careful and competent hands,
and as already stated, I shall hereafter personally supervise
its manufacture for the use of physicians.
P. M. Bracelin, M.D.
PUBLIC HEALTH.
Yellow Fever at Rio Janeiro. — The Revista de Ciencias Medicas
for May 20 states that there were 451 cases during the first
fortnight of March, with 395 deaths.
An Expensive Investigation. It was stated in the House of
Commons last week that the total cost of the Vaccination
Commission up to March 31 last, had been about §84,000.
Cholera in Egypt. — The Progres Medical, June 6, states that
the total number of cases of cholera reported that date is 3,030,
of which 2,523 resulted fatally. Malta has announced a seven-
day quarantine for ships from Egypt, extending it to twenty-
one days if there are passengers on board.
Board of Health Summer Corps. Fifty physicians, who will
serve in the summer corps, were appointed by the Board of
Health, of New York city at its meeting June 23. They are
employed to attend to the sick in the poorer quarters and
teach proper methods of sanitation. The announcement that
the President of the Board of Health has selected forty rear
tenements to be abated as nuisances shows that reform is at
last becoming something more than a mere name in New York.
Deleti ab Variola.— The Berlin correspondent of the Medical
Press and Circular, in his notes of the recent Jenner centen-
nial celebration in Germany, records that Professor Virchow,
who opened the proceedings in the name of the Committee of
Honor, said, in his address, that as an ethnologist he was im-
pelled to mention an ethnologic fact in the history of protec-
tive vaccination: ."All the peoples that had not been reached
by vaccination, or that had not accepted it had disappeared
from the face of the earth— destroyed by the 'smallpox" — a
statement which, if correctly quoted, must be subject to many
exceptions.
Poison in Black Hair Dyes.— The Journal D' Hygiene of June
11, warns the public that several black hair dyes recently
analyzed have been found to contain paraphenylenediamin, a
derivative of the nitro-analins, which accounts for the serious
eye troubles, boils and eczema which have been reported as
following occasionally their application. The subject recalls
the recent remark of an elderly Paris physician who was being
rallied upon his youthful locks : "You young doctors drive us
to dye our hair nowadays, as gray hairs no longer command
respect."
The Use of Salts of Copper in the Manufacture of Canned Vegetables.
— Professor Duclaux states that the public should be warned
of the dangers of using canned vegetables that have been col-
ored artificially with salts of copper. The natural yellow color
of cooked vegetables would be esthetic enough for most people
if they knew that there was peril in the bright green ones. He
urges hygieniste to secure the passage of an ordinance announc-
ing that while the salts of copper are not poisonous enough for
the authorities to prohibit their use, still they affect some per-
sons unpleasantly. Consequently the manufacturers must
use them at their own risk and be responsible for damages,
even when it is proved that the can contained no more copper
than others which produced no bad effects. — Semaine Medi-
cate, June 6.
Population of London In 1896.— The Lancet, June 6, has some
of the preliminary statistics of the census held in London on
March 29, 1896. The population then obtained by count, and
since then adopted by the Registrar-General, was 4,435,955, or
some 14,000 in excess of the estimate up for the middle of 1896.
This error is so small that for statistic purposes it might well
be disregarded. In Inner London, it was found that there
was an actual decrease in the total population, chiefly
caused by the absorption of old residential properties for bus-
iness purposes and the removal of families to the suburbs.
This is the first quiquennial census that has ever been taken
in London, all other previous ones having been at intervals of
ten years. It was authorized by special legislation matured
in 1894.
Another Shrinkage in "Estimated" Population.— Even the city of
London, it appears, has been over-estimating its population.
The recent census shows some 15,000 less than the estimate
formed on the basis of 1891. As pointed out by the St. James
Gazette the difference is small, but important, as it shows that
the previous fall in the rate of increase is maintained. The
population is growing at a less and less rapid pace. At the
beginning of the century it used to increase by more than 20
per cent, in the ten years between successive censuses ; in
1881-1891 that rate had fallen to 10.4 per cent., the lowest on
record ; and now it is still less. The movement is not part of
a general decline ; it is peculiar to London, and seems to indi-
cate that the huge overgrowth of the metropolis has begun to
1896. |
PUBLIC HEALTH.
51
We itself. No town can go on growing indefinitely, and even
on monstrous as it is— has not fulfilled the expectations
of earlier statisticians. Two hundred years ago it appeared to
owing s.. fast thai Sir William Petty, one of the earliest
pioneers in demographical research, reckoned that by 1840 the
population would reach 10,1)00,000, supposing it to continue at
the same rate. He thought however, that a natural limit
would be reached before then, and placed it in the year 1890,
by which time he calculated London would contain something
pwr 5,000,000 inhabitants and the rest of England only 4,500,000.
lie was very nearly right about the total, which actually was
ahout 0,000,000, but London accounted for less than one-half.
Since then it has nearly reached its maximum, which,
curiously enough, seems likely to prove a real natural limit-
For the four years 1871-74 the average birth rate was 35.2;
for the four years 1891-94 it was only 30.9. There has been a
gradual and almost continual fall from year to year, which has
not been counterbalanced by the simultaneous but slighter fall
in the death rate from 22.7 to 19.9. Fewer people die in pro-
portion to the population, but still fewer are born. This is
explained by the increasing disinclination to marry. The
marriage rates for the two periods contrasted are 19.6 and 17.3
respectively.
Bad Plumbing in New York.— The New York State Board of
Health was, on June 15, in receipt of a complaint from the
Board of Regents that the health of the 100 clerks, most of
whom are young women, was endangered by the vile odors
given off by the defective plumbing fixtures of the Capitol
building. The Secretary of the Health Office, Dr. Smeltzer,
is reported to have said that nothing can be done as there has
been no money set aside for sanitary repairs by the late legis-
lature. Incidentally, and in similar vein, complaints have
been heard in even higher official circles, regarding the char-
acter of the plumbing work done in the government buildings
belonging to the navy, at the navy yard and elsewhere. Cheap-
ness of work has for a long time been the order of the day.
drate labor has, as a rule, been employed and light
weight material has been put in ; and there is no expert
■ pection to pass upon the work before the bills are passed.
July Suicides. -Commenting upon the fact — again emphasized
bya recenf'blue book" — that attempted suicides occur in July
with far greater frequency than at the beginning or end of the
year, Hospital, June 20, say's it is a well known fact that in
July in consequence of the great heat and the stagnant condi-
tion of the atmosphere, the physical vitality is generally very
low and the depression of the nervous system has reached its
deepest. No laboratory experiments are required to prove
these contentions. Everybody is aware that in July he is for
the most part "played out," and is looking forward to his
annual holiday with eagerness. An important question is
whether or not anything can be done to combat the natural
depression of July. No doubt the earlier taking of the sum-
mer holiday would be a step in the right direction : only if
this be taken at midsummer a further fortnight will be needed
early in the fall, and that is costly in a double sense. The most
practicable remedy, according to Hospital, July depression is
a suitable nerve tonic ; and perhaps the best and most easily
obtainable of all nerve tonics for summer weather is the sluic-
ing of the head and spine with cold water every day, or even
twice a day. If any man who is disposed to commit suicide
will give himself a preliminary shower bath, it is highly proba-
ble that he will change his mind before the "toweling" is
finished.
No Shade for Greater New York. — At the first meeting in 1873
of the American Public Health Association, .the president, Dr.
Stephen Smith, read a paper on the "Effects of High Temper-
ature upon the Public Health of New York and Measures of
Prevention," in which he advocated the cultivation of shade
trees in the streets, on the ground that thoy would tend to
diminish the mortality caused by excessive heat, by affording
protection from the direct rays of the sun ; by preventing the
paved surfaces from becoming heated ; by enveloping the city
with an immense evaporating surface which tends powerfully
to cool the lower stratum of the air ; by equalizing humidity ;
by the absorption of malarial emanations from the earth; by
purifying the air in its absorption of gases deleterious to man
and the emission of gases necessary to his existence. Twenty-
three years later a society, called the Tree Planting Associa-
tion of New York, is formed for this very purpose. But that
ruthless iconoclast, the Neiv York Sun, summarily squelches
the project with the assertion that trees once abounded in New
York streets "as they still abound in Brooklyn and other semi-
rural towns, but they have succumbed to resistless forces, and it
is hopeless to try and restore them without a radical remodeling
of existing conditions." And so the denizen of the Greater
New York, which will, of course, not be a "semi-rural town,"
may no longer do the Tityrus act — sub tegmine fagi — but
must go abroad, even unto New Jersey for his shade trees.
Aftermath of the St. Louis Tornado. Already, according to the
Medical Review, the effects of the great tornado in St. Louis
are beginning to show their influence upon the death rate, as
foreshadowed in the Journal of June 6. The Review says a
number of deaths have been observed among young as well as
old, in healthy and in sick individuals, where death was
attributed to fear during and in consequence of the tornado.
Several suicides have been reported "which to an extent were
undoubtedly due to an intense disturbance of the psyche of the
unfortunate individuals by the storm and its direct destructive
consequences. The impression upon the nervous system of
susceptible individuals will probably not be entirely wiped out
for months or years, and the study of the nervous phenomena
resulting therefrom will be interesting, profitable and instruc-
tive. Nor will the subject be exhausted by the resulting affec-
tions of the nervous system alone ; but the direct effect of the
storm upon the course of other ailments and diseases will be
equally interesting to note." Dr. W. B. Outten, editor of the
Railway Surgeon, proposes to study these phenomena and has
sent a request to various physicians of the city to relate their
experience as to nervous symptoms manifested by their
patients in consequence of experiences in the tornado.
Smallpox in Texas.— Smallpox has been cropping out here and
there in Texas within the recent past, having been introduced
in the first place from New Orleans. It must be that there
has been a relaxation of the usual vigilance of the health
authorities of our sister State ; smallpox ought not to get out.
Instead of everybody shutting doors against an infection, the
infection must be circumscribed and not allowed to escape ;
the order is reversed from the old days of shotgun ; at least
that's the way it is done in Texas. As soon as a case appears
it is quarantined, and all who have been knowingly exposed
are quarantined also. In that way there is usually very few
secondary cases. But it got a good start in Smith county
before it was discovered ; and in all thirty-eight cases occurred.
What we wished to call attention to, though, in this connec-
tion, was the remarkably small mortality. Only one death
occurred out of thirty-eight cases treated, and that was in a
man of seventy-five years of age— a case of hemorrhagic variety.
Dr. D. H. Connally, the county physician of Smith county,
deserves much credit for such successfnl treatment. The
average death rate of smallpox is about 25 per cent. ; at Camp
Jenner, among the refugee negroes, it was nearly 30 per cent. ;
a fact attributable, no doubt, to the use of tents with two and
three cases in each, and the sides pegged down. The Texas
authorities do these things better ; treat smallpox as nearly in
the open air as possible — weather permitting. The scare is
about over, however, now, the last cases reported being in
52
NECROLOGY.
[July 4,
Liberty county ; infection supposed to have been carried from
Orange, where, we learn, the county physician employed a
negro doctor to do what he ought to have done himself. —
Texas Medical Journal, June, 1896. ■
Health Reports. — The following health reports have been
received in the office of the Supervising Surgeon-General
Marine-Hospital Service :
SMALLPOX — UNITED STATES.
Florida : Key West, June 25 to 29, 5 cases, 1 death ; Pensa-
cola, June 13 to 20 1 case.
SMALLPOX — FOREIGN.
Bombay, India, May 19 to 26, 17 deaths.
Calcutta, India, May 9 to 16, 3 deaths
Callao, Peru, May 17 to 31, 17 deaths.
Genoa, Italy, June 6 to 13, 3 cases.
Licata, Italy, May 31 to June 6, 3 deaths.
Madras, India, May 9 to 15, 2 deaths.
Madrid, Spain, June 6 to 13, 19 deaths.
Montevideo, Uruguay, May 16 to 23, 1 case.
Moscow, Russia, May 23 to June 6, 2 cases, 2 deaths.
Odessa, Russia, May 25 to June 6, 2 cases.
Prague, Bohemia, May 31 to June 6, 3 cases.
Rio de Janeiro, May 23 to 30, 1 case, 1 death.
Santiago, Cuba, June 6 to 20, 70 deaths. Smallpox epidemic
here — over 900 cases existing on June 20.
St. Petersburg, Russia, May 31 to June 6, 16 cases, 5 deaths.
Tuxpan, Mexico, May 31 to June 13, 4 deaths.
Warsaw, Russia, May 31 to 6, 4 deaths.
CHOLERA.
Alexandria, Egypt, May 29 to June 3, 49 deaths.
Cairo, May 29 to June 3, 152 deaths. Other Egyptian towns
June 3, 338 deaths. Prom beginning of epidemic to June 3,
there have been 3,112 cases and 2,597 deaths in Egypt.
Bombay, India, May 19 to 26, 22 deaths.
Calcutta, India, May 9 to 16, 120 deaths.
YELLOW FEVER.
Brazil : Rio de Janeiro, May 23 to 30, 23 deaths.
Cuba : Cardenas, June 6 to 13, 3 cases, 1 death ; Havana,
June 13 to 20, 25 cases, 11 deaths ; Sagua la Grande, June 6 to
13, 41 cases, 4 deaths ; Santiago, June 6 to 20, 12 deaths.
NECROLOGY.
A Tribute to the Memory of Dr. Wm. Anderson. — At a
regular meeting of the Indiana County (Pa. ) Medical Society
held May 12, 1896, Drs. James McMullen, Luther S. Clagelt
and I. P. Klingensmith were appointed a committee to prepare
a "Tribute to the Memory of Dr. Wm. Anderson" and forward
a copy of the same for publication in the Journal of the
American Medical Association.
Dr. Wm. Anderson was born June 6, 1825, in Green Township,
Pa. His parents immigrated to this country from County Derry,
Ireland, in 1817 and settled in the eastern part of Indiana
County where he passed his early life, working on the farm
and attending at intervals the district schools. A higher
course of instruction was entered upon at the Blairsville Acad-
emy and finished at a classical academy at Indiana. After two
years of office study with Dr. James M. Taylor of Indiana, he
entered October, 1850, the Jefferson Medical College, Phila-
delphia, graduating March 6, 1852, attending however a third
course at his alma mater in 1868-69. On graduating he located
at Indiana where he continued to reside until his death March
29, 1896, aged 70 years. His practice was general. He had been a
member of the Indiana County Medical Society since its organ-
ization in 1858, and was its first secretary, its second president,
and represented it at different times in the Medical Society of
the State of Pennsylvania and in the American Medical
Association. He had been a member of the State Society
since 1862, was one of the vice-presidents in 1864 and the presi-
dent in 1865. Since 1868 he has been a member of the Ameri-
can Medical Association and was a member of the Interna-
tional Medical Congress that met at Philadelphia in September,
1876 ; a member of the Ninth International Medical Congress
which met at Washington, D. C, September, 1887, and also
of the Pan-American Medical Congress which met at Washing-
ton, D. O, September, 1893. Several months before the date
of his death, Dr. Anderson was seized with an attack of la
grippe, which persistently clung to him and brought about his
demise. He was connected with the United Presbyterian
Church from youth. Being of a mild genial disposition every-
body loved him and he had words of encouragement for all
with whom he came in contact. He was noted for his industry
in the societies and associations having for their object the
free interchange of opinions on medical subjects. He was a
frequent contributor to the medical literature of his day.
Among his more notable productions are his monographs on
Sclerosis of the Nerve Centers, Ozena, Nervous Diseases,
Bacteria, Tobacc»and Hygiene, in which much original research
and thought is shown. The most valuable, perhaps, of Dr.
Anderson's literary labors is entitled, "A Brief Biographical
Sketch of the Medical Profession of Indiana County, Pa.,"
published in 1892. It contains 269 biographies.
In Dr. Anderson were happily combined calmness of manner
with firmness of character, strictly honest with his patients
and honorable with the members of his profession. His strict
conscientiousness was one of his most marked characteristics.
Thomas Ferris Cock, M.D., of New York City, member
of the American Medical Association since 1848, died June
11, at his country-place at Cold Spring Harbor, Long Island.
He was a native of New York City, born there July 1, 1819.
His father, Dr. Thomas Cock was for more than thirty years
an officer, and part of the time president, of the College of
Physicians and Surgeons, N. Y. He was graduated in arts
from Haverford College ; LL.D. at the same in 1886 ; M.D., at
University of Pennsylvania in 1840. He settled in New York,
and made obstetrics his special life-work. He was early a
member in the New York County and State Medical Societies,
and assisted in the formation of the Academy of Medicine and
Pathologic Society. He served for a time at the Northern Dis-
pensary. He was on the Visiting staff at Bellevue Hospital as
early as 1849, going thence in 1855 to the city hospital, in whose
service he remained at the time of his decease on the consulting
staff. He was consulting physician at the asylum for Lying-in
Women since 1841, and at the New York Infirmary for Women
and Children since 1854, and at the State Hospital for women
since 1855, about which year h§ issued his little manual of
obstetrics. For the past ten years he had not been in active
practice.
Walter Fisher, M.D., assistant-surgeon and Captain U.
S. A., died at Fort Meade, S. Dakota, June 8. He was at one
time stationed at Fort Columbus, Governors Island, X. Y.
His remains were interred at Oswego, N. Y.
Thomas Hun, M.D., at Albany, N. Y., June 18, aged 88 years.
In 1827 he entered the medical department of the University of
Pennsylvania from which he graduated in 1830. He then
returned to Albany and began practice. In 1833 he went to
Paris to complete his education and remained six years. He
returned in 1839 and accepted the professorship of the institute
of medicine in the Albany Medical college.
Henry Salzer, M.D., at Baltimore, Md., June 19, aged 55
years. He was born in Germany and educated in the Univer-
sities of Wiirzburg and Giessen, graduating at Giessen in 1866.
He practiced in Germany about three years and then came to
Baltimore, where he had since practiced.
Louis Octave Huard, M.D. (Tulane University Medical
Department, New Orleans, La., 1857), at New Orleans, June
17, aged 67 years. He spent ten years in Paris, where he
acquitted himself with highest honors, and was one of the few
survivers of the famous French medical practitioners in Lou-
isiana. Dr. Huard was honored with the red cross of Geneva
for his devotion during the epidemic in France.
Frank M. Temple, M.D. (Western Reserve University Med-
L896.]
SOCIETY NEWS.
53
ical I >t'p;irtment,Cleveland, Ohio, 1890 and Department of Med-
icine of the University of Pennsylvania, Philadelphia, Pa.,
at Knirview, Pa., June 17, of pneumonia. T. D. Ker
nan.M.D. i Department of Medicine University of Pennsylvania,
Philadelphia, Pa., 18531 at Marion. Va., June 18. George
11 Calkins, M.D. (Northwestern University Medical School,
Chicago, Ills., 1866) at Waupaca, Wis., June 25, aged 66 years.
Prof. 1'. Stoltz. Sixteen years ago he retired from active
life as an eminent obstetrician and instructor at Strasburi: miuI
Nancy, to the picturesque mountain village where he was
born. He was so popular, however, that many patients fol-
lowed him there, from all parts of the country, till his death
last month, at the aire of 92. One of the addresses at the fun-
eral was by a former pupil, whose father had also Been Stoltz's
pupil in his day.
SOCIETY NEWS.
The North Missouri Medical Association at its meeting in
Moberly, Mo.. June 17. elected the following officers: Presi-
dent. C. A. Jennings; First Vice-President, W. MacAllister;
1 Vice-President, J. D. Brummel ; Treasurer, Robert
Hale} : Recording Secretary, George N. Lance; Correspond-
ing Secretary, G. O. Cupaidge ; Executive Council, J. H. P.
Baker, W. T. Lindley. C. P. Clapp, D. R. Stratton. The next
meeting will be held in Moberly in June, 1897.
The Allegany County Medical Society at its annual session, held
in Cumberland, Md., June 18, elected the following officers
for the ensuing year : President, M. A. R. F. Carr, Cumber-
land ; First Vice-President, C. C. Jacobs, Frostburg : Second
Vice-President, E. T. Duke, Cumberland; Third Vice-Presi-
dent. S. A. Boucher, Barton: Secretary, H. W. Hodgson,
Cumberland; Treasurer, W. J. Craigen, Cumberland.
The Maryland State Medical Society, at its annual meeting elected
officers for the ensuing year as follows : President, N. D.
Blake, of Martinsburg, Secretary of State Board of Health ;
Vice Presidents, D. C. Louchery, of Clarksburg; W. W.
Golden, of Elkins; L. D. Ruppert, of Nutallsburg, and H. B.
Stout, of Parkersburg ; Secretary, G. A. Aschman of Wheel-
ing : Treasurer. J. W. Johnston of Davis.
The American Microscopical Society (formerly American Society
of Microscopists i. — The next meeting of the Society will be held
at Pittsburg, Pa., August 18-20, 1896. The Society will be the
first National Society to meet in the new Carnegie Library
building. A preliminary program will be published on July
15. 1896, and the Society requests communications of anything
new or interesting. The officers are : President, A. Clifford
Mercer, Syracuse, N. Y. : Secretary, William C. Krauss, Buf-
falo, N. Y. ; Treasurer, Magnus Pflaum, Pittsburg, Pa.
Mississippi Valley Medical Association, meeting at St. Paul,
Minn., Oct. 20, 21, 22, 23, 1896. H. O. Walker, President,
Detroit, Mich. ; Merrill B. Ricketts, First Vice-President, Cin-
cinnati. Ohio : William F. Barclay, Second Vice-President,
Pittsburg, Pa. ; H. W. Loeb, Secretary, 3559 Olive Street, St.
Louis, Mo. ; Harold N. Moyer, Treasurer, Chicago, 111. C. A.
Wheaton, Chairman Committee of Arrangements, St. Paul,
Minn. Executive Committee : Wm. N. Wishard, Indianapolis ;
X. C. Scott, Cleveland : Geo. J. Cook, Indianapolis ; J. M.
Mathews, Louisville : I. N. Love, St. Louis ; A. M. Owen,
Evansville ; Wm. T. Belfield, Chicago ; C. S. Cole, New York ;
C. A. L. Reed, Cincinnati ; R. Stansbury Sutton, Pittsburg.
Colorado State Medical Society. This Society held its annual
meeting at Denver, Colo,, June 16, 17, 18, I. B. Perkins, Presi-
dent, in the chair. Dr. Perkins in his address spoke briefly of
the progress that had been made in bacteriology and of the
success that had been met with in the use of antitoxin. The
speaker expressed his regret that more success had not been
met with in their efforts to have a national sanitarium estab-
lished in Colorado and urged the committee to continue their
work in that line. Among the papers read were the following :
" Bicycle Hernia," Geo. W. Miel ; "A Rapid Method of Cas-
tration," W. P. Munn : "Radical Operation for Inguinal
Hernia," W. W. Grant ; 'Symphysiotomy," T. Mitchell Burns ;
"The Management of Puerperal Sepsis," W. A. Jayne;
" Supernumerary Oviducts and Typical Hydatid of Morgagni,
with a Large Fibroid Uterine Tumor Hysterectomy," H. G.
Wetherill; "The Diagnosis of Tumor of the Brain," J. T.
Eskridge. The following officers were elected for the ensuing
year : Robert B. Levy, President : H. R. Bull, First Vice-
President ; Dr. Finney, Second Vice-President ; S. D. Van
Meter, Third Vice-President ; H. R. Whitney, Corresponding
Secretary ; Laura Liebhardt, Recording Secretary ; W. F.
McClelland, Treasurer. The various standing committees
were reappointed.
The Northern " Tri-State" Medical Association will hold its annual
session at Algola, Ind., July 21. The following papers will be
read : "The Need of Abdominal Section as an Aid to the Gen-
eral Practitioner to Diagnose Obscure Abdominal Troubles,"
J. H. Carstens, Detroit, Mich. ; " Salicylate of Sodium in Sep-
tic Conditions," HugoO. Pantzer, Indianapolis, Ind. ; "Modern
Brain Operations," Allen DeVilbiss, Toledo, Ohio; "Some
Considerations in the Treatmentof Acute Otitis Media," E. A.
Bulson, Ft. Wayne, Ind.; "Embryonic Miscarriage," J. R.
Dodge, Hudson, Mich. : "Management of Vesical Calculus," F.
J. Hodges.Anderson, Ind. : "The Cause and Treatment of Color-
Blindness," F. C. Mayson, Hillsdale, Mich. ; "Purpura Hem-
orrhagica," Frank M. Guyer, Hillsdale, Mich. ; "The Differ-
ential Diagnosis of Insanity," C. B. Burr, Flint, Mich. ;
"Diffuse Cellulitis of Hand and Forearm," W. W. Brand,
Toledo, Ohio; "A Case of Brain Tumor, with Exhibition of
Specimens," G. W. McCaskey, Ft. Wayne, Ind. ; "Asepsis and
Antisepsis— Which or Both," J. B. Greene, Mishawaka, Ind. ;
"Aseptic Technique in Pelvic and Abdominal Operations Out-
side of Hospitals," C. N. Smith, Toledo, Ohio; "Conservative
Surgery in Tuberculosis of the Testicle," J. B. Murphy,Chicago,
111.; "The Differential Diagnosis of Insanity," C. B. Burr,
Flint, Mich. ; "A Case of Brain Tumor, with Exhibition of
Specimen," G. W. McCaskey, Ft. Wayne, Ind. ; "Obstruction
of the Bowels," Hal C. Wyman, Detroit, Mich. ; "Diagnosis
of Typhoid Fever," W. C. Chapman, Toledo, Ohio.
The Minnesota State Medical Society held its twenty-eighth
annual meeting at Minneapolis June 17, 18 and 19, Dr. Frank
Allport, Minneapolis, President. There was a large attendance
and much.enthusiasm was evinced. President Allport in his
address referred to the present coroner system as a relic and
of no use.
The Society adopted the following resolutions concerning
anti-vivisection :
Whereas, Science within recent years has received untold
benefit and has made phenomenal progress from the legitimate
practice of vivisection ; and
Whereas, Humanity has profited and is destined to profit
immeasurably by the discoveries in physiology, pathology and
bacteriology which have been made possible by the scientific
use of living animals ; and
Whereas, Certain organizations, self-styled anti-vivisec-
tionists, inspired by motives more sentimental than sound,
with minds moved by emotional influences and hysterical argu-
ments rather than by scientific facts, are seeking to strike a
blow at the interest of science by the introduction into the
Congress of the United States a bill restricting or abolishing
vivisection in the District of Columbia; and
Whereas, The introduction of this measure is but a step
preparatory to the presentation of other and similar measures
in our State legislatures ; therefore, be it
Resolved, That this Society denounces such attempted legis-
lation as mischievous to the medical profession, as suicidal to
the interests of society, as destructive to science, and as per-
54
SOCIETY NEWS.
[July 4,
versive of those moral standards which maintain a true rela-
tionship of things ;
Resolved, That this Society petitions the senators and
representatives of this State in Congress to use their utmost
efforts for the defeat of this obnoxious measure.
It was decided to hold the next annual meeting at Mankato.
Officers were elected as follows : President, W. D. Flynn of
Redwood Falls ; First Vice-President, David O. Thomas, Min-
neapolis ; Second Vice-President, D. M. Jones, Gaylor ; Third
Vice-President, Dr. Williams, Lake City ; Secretary, Ignatius
Donnelly, St. Paul, re-elected ; Treasurer, R. J. Hill, Minne-
apolis, re-elected ; Censors, W. W. Mayo, Rochester, and
Franklin Staples, Stillwater.
The Association of Surgeons of the Louisville, New Albany and
Chicago Railway System held a meeting at West Baden Springs,
June 4. Seventeen surgeons employed by the company were
present. Dr. John G. Davis was elected president, Dr. Dudley
S. Reynolds, vice-president and Dr. Samuel L. Ensminger,
secretary and treasurer. Dr. George F. Beasley of Lafayette
reported the case of a youth who had compound fracture of
the frontal bone, with loss of bone and extensive injury to soft
parts two years ago and recently became epileptic. Pulsation
could be felt over the point of injury and pressure caused pain.
On making incision and raising the parts covering the opening
in the cranium he found the soft parts all intimately connected
in a cicatricial mass and adherent to the brain integument.
Occipito-frontalis muscle fascia, dura and pia mater firmly
united and cicatrized. The bony edges of the opening were
irregular and thickened with nodulated growths turned inward
pressing on the brain. He carefully separated the brain from
the adherent cicatrix, removed the exostoses and used gold
foil as a covering for the brain and to prevent union again with
the cicatrix. The operation was performed under strict anti-
septic rules and succeeded so well that at the time the Doctor
reported the case, about two weeks subsequently, there had
been no more epilepsy, and the wound had healed without dis-
charge of any kind and the patient was in a manner well.
Dr. Dudley S. Reynolds of Louisville briefly recited the case
of a negro boy, 16 years of age, who had frontal headache and
was suddenly seized with edema of the eyelids and the left side
of the face. The eyes did not seem to protrude from the orbit,
although the edema was such as to firmly close the lids.
Examination of the left nasal passage showed exudation of
pus at the anterior extremity of the middle turbinate. Careful
examination of the locality from whence the pus came, with
the symptoms already described led him to suspect abscess of
the frontal cells. Using a bone drill 4 millimeters in diameter,
an opening was made at the external anterior attachment of
the middle turbinate, when a large quantity of offensive,
cream-colored pus escaped. The cavity was injected with a
solution of bichlorid of mercury and chlorid of sodium. The
next day the edema had disappeared from the face and the
eyelids were opened by the voluntary efforts of the patient,
though still somewhat swollen. He had Hutchinson's teeth,
and was given 10 grains iodid of potassium every four hours.
He appeared at the clinic irregularly for about three weeks and
was then lost sight of. Four months later he returned with a
tender swelling at the base of the nose. On discovering fluc-
tuation an incision was made, followed by the discharge of a
large quantity of cream-colored pus and a sequestrum of bone
of irregular outline about one-eighth of an inch thick in its
heaviest portion ; about three-fourths of an inch in length
and between three-eighths and one-half inch wide. This was
removed, the incision enlarged and the cavity freely washed
with the bichlorid solution. He was cautioned about the
necessity of taking the iodid, which had been abandoned.
The wound continued to discharge for about six weeks, when
a uniform depression of the whole extent of the left half of
the frontal bone came on. He has no bony projection of the
brow, owing to the loss of the supra-orbital process ; but has
recently begun to suffer with epilepsy and it is supposed that
cicatricial changes in the meninges at the site of the abscess
may account for the epilepsy.
The report and discussion of cases engaged the attention of
the Association until the close of the session. The meeting
was one of unusual interest and profit to all present. The
Association will hold its next meeting at Cedar Lake, July
8-9, 1897.
The Ohio State Medical Society and Anti-Vivisection Legislation.
James E. Pilcher. M.D., Ph.D-> Captain in the Medical
Department of the United States Army, Professor of Military
Surgery in the Ohio Medical University, in his remarks before
the fifty-first annual meeting of the Ohio State Medical Society,
May 27, 1896, said : Humanity is fallible. The most striking
example is the existence of the absurd anti-vivisection move-
ment, which has attained an unreasonable prominence through
the success of its advocates in getting before the United States
Senate a measure directed against vivisection, under the mis-
leading title of "A bill for the further prevention of cruelty to
animals in the District of Columbia." This movement of the
self-styled anti-vivisectionists has gathered so much momentum
in its misdirected career of misrepresentation that the medical
profession must, in self-defense, take a decided stand for the
preservation of its own liberties and the best interest of suffer-
ing humanity. There is no profession in which humanity is so
much a part of the daily life of its practitioners as medicine.
The absurdity of placing such persons in the attitude of defense
against an accusation of cruelty or inhumanity of any kind is
evident to every one.
The most rabid anti-vivisectionist will masticate his cutlet of
veal or his shoulder of lamb, all regardless of the joyous young
life that has been rudely terminated merely to gratify the ani-
mal appetite of the alleged defender of our dumb animals.
The sportsman inflicts untold agony upon the victims of his
prowess, but we hear of no movement looking to the prohibi-
tion of hunting. The anti-vivisectionist nestles luxuriously in
his furs and his wife waxes gorgeous in her headgear garnished
with the plunder of feathered songsters — both the spoil of the
rapacity and cruelty of man ; while the shoe trade, based
entirely upon the products of the death of millions of God's
most harmless creatures, is prosperous in the extreme.
When the anti-vivisectionist becomes a strict vegetarian ;
when he avoids all amusements resulting from animal slavery
or suffering ; when he clothes himself entirely in garments of
vegetable and mineral composition ; when he suppresses all
practices, sportive and mercenary, by which pain is inflicted
upon animals, he may properly begin to inquire into vivisection
with a view to ascertaining whether it is humanitarian or cruel.
In the war of the rebellion, 3,273 out of 3,717 cases of wounds
of the intestines were fatal. It was demonstrated a few years
ago by experiments on dogs that abdominal section and intes-
tinal suture in such cases was a feasible and successful
operation, and the operative procedure was experimentally
elaborated, so that by it the mortality in gunshot wounds of
the intestines has been reduced from 90 down to 10 per cent.
The brain, which as well as the abdomen, was formerly
regarded as forbidden ground to the surgeon, has, by the vivi-
section experiments of Ferrier and others, been brought within
the realm of curative art. The work of Aristotle, Realdus
Columbus, Andreas Caesalpinus, William Harvey, and Mar-
cello Malphigi in discovering the circulation of the blood was
entirely conducted by experiments upon lower animals. The
experiments of Vesalius, Hooke and Lower gave us artificial
respiration. Transfusion of blood was directly the offspring of
vivisectional experiment. The entire system of antiseptic and
aseptic surgery, the greatest humanitarian triumph in the
world's history, is based upon the practice of vivisection. The
bacillus of anthrax, the bacterium of tubercle, the micro-
1896.]
MISCKLLANY.
55
organism of diphtheria, the spirillum of relapsing fever, the
streptococcus of erysipelas and puerperal fever, and many
Other specific agents in disease have been discovered entirely
through experiments upon lower animals. The antitoxin
treatment of diphtheria, the Pasteur inoculation cure of hydro-
phobia, the prevention of smallpox by vaccination, and many
Others of the most important therapeutic p»ocedures of modern
medicine are due to vivisection, while still many more are the
subjects of observation, which will ultimately result in the dis-
covery of curative procedures.
While vivisection experiments are always beneficial they are
never cruel. Even were the medical student the heartless
creatine represented bj the anti vivisectionists, he would pre-
fer for his own convenience, to silence the cries and subdue
the ill IMlns of his subjects by an anesthetic. All this empha-
the deceptive and incorrect character of the efforts to
embarrass, if not prohibit, the future of these genuinely philan-
thropic as well as scientific studies. The dangerous movement
looking to this end. initiated in the District of Columbia, has
nut with astounding success, and it behooves all true lovers of
scientific progress to unite in the attempt to prevent the enact-
ment of the bill now before the United States Senate for this
purpose : for, should this movement be successful in the Dis-
trict, it would not only put an end to most important work in
various scientific departments of the government and the med-
ical schools of Washington, but it would be the beginning of a
movement jeopardizing scientific study throughout the entire
Union.
The Ohio State Medical Society adopted the following reso-
Resolved, That the Ohio State Medical Society earnestly
joins in the protest of the American Medical Association as
expressed in the resolutions adopted at the recent meeting of
that representative body of American physicians and surgeons
held in the city of Atlanta.
Resolved, That a copy of these resolutions be sent to the
Senators and Representatives of the State of Ohio in the Con-
,,{ the United States, and that they are hereby requested
to use their influence in opposition to the proposed legislation,
"unless it shall first be shown by an impartial investigation
that cruel and unnecessary experiments are being performed in
the District of Columbia, and that existing laws do not provide
suitable punishment for cruelty to domestic animals."
The following amendment, proposed by Dr. L. B. Tucker-
man, of Cleveland, was accepted by Dr. Pilcher, and the reso-
lutions as amended were unanimously adopted :
Resolved, That a delegate be appointed by this society to go
to Washington and interview the Senators and Representatives
in person in behalf of these resolutions, and that one hundred
dollars be appropriated to pay his expenses.
• MISCELLANY.
Ivy Poison. — Recent experiments show that the poison of the
poison ivy is a volatile oil. Hence, water will not remove the
poison from the surface as well as alcohol.
Disturbed Equilibrium.—" Isn't that too much mustard for so
little meat?" exclaimed Charles Lamb ashe noted the approach
of the plaster.
Argon in the Breath. -Kellas concludes from his experiments
that exhaled air contains more argon than before inhalation ;
from this he infers that it is an important element in the ani-
mal economy.
Dr. J. H. Kellogg, of the Battle Creek Sanitarium, formally
opened and dedicated the Workingmen's Home and Medical
Sanitarium in Chicago, June 28. Addresses were made by Dr.
Bayard Holmes and others.
Physical Degeneration in Italy.— A Milanese writer asserts that
JUS per cent, of the young men of Italy are unable to enter the
military service on account of their lack of the physical
requirements.— Revista de Ciencias Medicas, May 20.
His Consolation. It is related of the late Professor Sappey,
who was far from being an orator, that he used to console him-
self with the remark that his diffidence in speaking only caused
suffering to himself alone, while the fluency of some physicians
causes countless others to suffer. — Journ. de Mid. de Paris,
June 7.
Not Chemicals. — The supreme court of Louisiana is of the
opinion that soda, seltz and similar drinks are not chemicals,
and it holds, in the case of the Crescent City Seltz and Min-
eral Water Co. v. City of New Orleans, April 6, 1896, that the
making of soda, seltz and similar drinks is not the manufac-
turing of chemicals, within the constitutional exemption of
that State of property employed in manufacturing chemicals.
A Rare Effect of Tobacco.— J. W. Scott. M.D., reports a case of
convulsions, epileptiform in character, due to the use of
tobacco. For two months he had one or two convulsions a
week and they were growing progressi vely worse in spite of
treatment. With the discontinuance of tobacco the convul-
sions ceased and have not returned. — Southwestern Medical
Record.
Correction. — In issue of June 20, it was stated that "Dr.
Curran Pope will lecture upon Diseases of the Mind and
Nervous System ; Dr. Pope resigns from the Hospital College
of Medicine where he held the same position as the one in the
Louisville School." This is an error, as he now holds a
regular full professorship in the Louisville Medical College.
A Cockade and Crests Preferred ! -The subjoined advertisement
appears under "special" in the Glasgow Evening News. It
is too good to be buried in the columns of a daily newspaper :
"Doctor's Cockade. — Wanted from Cab Owners, by Doctor
who has recently become surgeon in a Volunteer Regiment,
estimates for hire of a Brougham three hours a day ; driver
must wear a Cockade : Brougham with one or two crests on
doors preferred. Apply No. 10,737, News Office."
The Treatment of Cystitis.— L. Grant Baldwin, M.D., says;
"Having excluded in the diagnosis, as causative factors, new
growths, foreign bodies and tuberculosis, if the case is an acute
one, example an operative case where a catheter has been used
in an uncleanly manner, 1 have found that relief can be
obtained in twelve hours and often in a much shorter time by
the administration of sandalwood oil, together with benzoic
acid, and a cure is practically obtained in from two days to a
week." — Brooklyn Medical Journal, June, 1896.
Latent Gonorrhea. — Dr. Rosenwasser says of the gonococcus
of Neisser : The locations of choice are the urethra and vaginal
portion of the cervix. A person may in time become accus-
tomed to his own brood of germs so that they cease giving
trouble. Transplant them to new soil and they at once effect
the recipient with pristine vigor. Then if these regenerated
germs are returned to the original owner they will initiate as
vicious action as though they had never been there before.
This is his explanation of "latent" and "recurrent" gonorrhea.
— Cleveland Medical Gazette, June, 1896.
International Bacteriologic " Concours."— As a memorial to Pas-
teur, the Circulo Medico Argentina of Buenos Aires, offers
prizes of $400 and $200 for the best original and unpublished
bacteriologic investigations or studies reported to the Presi-
dent, Senor Gregorio Aroaz Alfaro, before May 31, 1897. The
reports to be in Spanish or French. For further particulars
see the Crdnico Midica of Lima, April 15.
Improved Eye Glasses for School Children and Artisans.— The
Revue Gin. d'Ophtalmologic for May, describes some specta-
cles for school children which have a celluloid trap cover for
each glass that falls down over them whenever the head droops
forward, and springs back into place as soon as the head is held
upright. The other is a working glass for cases of excessive
myopia. It is a metal plate pierced with stenopeic openings in
56
MISCELLANY.
[July 4,
the direction of the twelve principal meridians, radiating from
around the pupil. It improves the sight to such an extent
that myopia of 10 D. is corrected to 1 and — 4 D. It also
proves useful in irregular astigmatism.
The Academic de Medecine of Paris.— At the session of the
Acad^mie held June 9, M. Roux was named as a member vict
M. Pasteur deceased. At the same session Dr. Marcel Bau-
doin in the name of the Medical Press Association of France,
M. Cornil, President, asked the Academie to become repre-
sented at the Fete to celebrate the fiftieth anniversary of the
discovery of anesthesia. This fete will be held on the occasion
of the meeting of the French Congress of Surgery in October
next. In response the Acade"mie has designated M. Cornil as
its representative on that occasion.
Serum Treatment of Diphtheria in Cracow. — Dr. Stapa has pre-
sented to the Cracow Medical Society a report of the results
obtained by the serum treatment of diphtheria in the Chil-
dren's Hospital of that city. During the year 1895 the num-
ber of children subjected to it was 258. Of these the mortal-
ity was 22 per cent. This compares very favorably with the
mortality in the ten previous years, which was as high as 56.3
per cent., there being 709 deaths out of a total of 1,354 patients
who were treated by other methods. Laryngeal croup occurred
in 165 cases, and a rash having the appearance of scarlet fever
and lasting from two to sixteen days in fifty-eight cases. It
was noticed that certain samples always produced rash. No
effect on the occurrence of albuminuria by the serum could be
shown.
Parenchymatous Goitre Treated with Hypodermic Injections of
Durante'* Solution of lodo-lodid. — Reyes, of Palermo, has treated
twenty-eight cases of parenchymatous goitre in this way, and
the goitre rapidly subsided in size, the general health visibly
improved, the patient gained in weight, while there were none
of the nnfavorable results that sometimes occur with thyroid
medication. The formula used was that proposed by Professor
Durante, of Rome, for tuberculosis, "solution iodo-iodur^e,"
given in the Semaine Midicale, 1894, p. 252. At first two injec-
tions of two to five grams each were made during the week,
then one, and later one in two weeks. — Semaine Mddicale,
May 13.
Substitute for Yellow Phosphorus in the Manufacture of Matches.
Gurowitz announced at the meeting of the K. K. Ges. der
Aerzte of Vienna, May 15, that he had discovered a substitute
for the dangerous yellow phosphorus in matches, which is per-
fectly harmless, is easily applied to wooden and wax matches,
lights on any rough surface, and has a very high self-lighting
point, 150 to 160 degrees C. It is made by melting together
pulverized without danger and the other ingredients are entirely
sulphur and red phosphorus ; the substance thus formed can be
'harmless. The members of the board of health were so pleased
with their investigation of it that they at once petitioned the
government to forbid henceforth the use of the poisonous
phosphorus altogether. — Wiener klin. Rundschau, May 24.
Medical Appropriations by the Fifty-Second Congress. An act of
Congress (No. 213) making appropriation for sundry civil
expenses for the year ending June 30, 1897, appropriates the
following sums for the purposes named : For preservation and
repair of buildings, etc., at U. S. Marine Hospital and Quar-
antine Stations, $30,000 ; special for Marine Hospital at Bos-
ton, Mass., $1,850; at Chicago, 111., $8,950; at Cincinnati,
Ohio, $1,000; at Detroit, Mich., $1,300; at Louisville, Ky.,
$1,500 ; at New Orleans, La., $2,150 ; at PortTownsend, Wash.,
$6,150 ; at San Francisco, Cal., $300 ; at St. Louis, Mo., $1,860 ;
at Wilmington, N. C, $1,200; at Vineyard Haven, Mass.,
$1,500. Special Quarantine Stations at Reedy Island, Del.,
$1,200; at Brunswick, Ga., $800; at Gulf, $350; at South
Atlantic, $15,750; at San Diego, Cal., $350; at San Francisco,
Cal., $5,000; at Port Townsend, Wash., $3,500. Ordinary
expenses of the quarantine service, including pay of officers
and employes, $131,000 ; Government Hospital for the Insane,
Washington, D. C, $293,851: Garfield Memorial Hospital,
Washington, D. C, $19,000; Providence Hospital, Washing-
ton, D. C, $19,000. For pay of surgeons, attendants, and
other expenses of the hospitals at the National Homes for Dis-
abled Soldiers at Dayton, Ohio, $55,000; at Milwaukee, Wis.,
$28,000; at Togus, Me., $25,800; at Hampton, Va., $30,000:
at Leavenworth, Kan., $30,000 ; at Santa Monica, Cal., $20,000 ;
at Marion, Ind., $24,000. Hospital at Leavenworth (Kansas)
prison, $28,000. Index catalogue of the library of the Sur-
geon-General's office, $12,000. The President is also author-
ized in case of epidemics of cholera, etc., to use the unex-
pended balance of appropriation of March 2, 1895, in aid of
State and local boards of health, or otherwise in suppressing
the spread of the same.
The Harvard Medical Alumni Association held its sixth annual
banquet at Boston, Mass., June 23. The meeting was of
unusual interest because of the presence of Theobald Smith,
M.D., pathologist of the Massachusetts Board of Health and
the new professor of comparative pathology in the Harvard
Medical School. Dr. George B. Shattuck, President of the
Association presided and opened the post-prandial exercises.
He said the Association now numbered 1,321 members, seventy-
six having joined since June 1, 1896. He continued : "I can
not, as your president, refrain from all mention of this very gen-
erous, useful and intelligent endowment in the medical school.
Let me read you the text of the donor's deed of gift that you
may know just what his wishes and objects were in creating
this foundation. 'It is my wish to testify to my deep interest
in the advancement of medical science and the higher medical
education; an interest originating in the fact that my father
was a physician. I therefore offer to the President and Fel-
lows of Harvard college the sum of $100,000 in cash, payable
July 1, 1896, as a fund for the endowment of a professorship of
comparative pathology in the medical department of Harvard
University. I desire that this fund shall be forever known as
the fund, in memory of my father, M.D.,1 and that
the professorship shall also bear his name. It is furthermore
my wish that the income of the fund shall be applied first to
the payment of the salary of the professor of comparative
pathology, who shall also be a member of the medical faculty
and appointed to office in the same manner as are other profes-
sors in that body, and who shall devote his time to the duties
of his professorship, not engaging in private practice without
the recommendation of the medical faculty and consent of the
President and Fellows.'" Dr. Theobald Smith was intro-
duced. He read a technical paper on "Comparative Pathol-
ogy in Its Relation to Human Medicine." In conclusion he
said he considered it most advisable for the members of the
medical profession to take a more active interest in public
affairs. The following officers were elected : Dr. Shattuck,
President, and Dr. Walter Ela, Secretary, now occupy-
ing office for a three years' term ; Vice-Presidents, Drs. Gus-
tavus L. Simmons, Sacramento, Cal. ; William W. Seymour,
Troy, N. Y. ; John W. Parsons, Portsmouth, N. H. ; Alternate
Vice-President, Dr. Thomas W. Huntindon, Sacramento ; Sec-
retary, Augustus Thorndike, Boston; Councillors for term
ending 1900, Lincoln R. Stone, Newton ; J. T. G. Nichols,
Cambridge : Robert W. Lovett, Boston.
Wanted Improved Pocket Cuspidors. The Journal de Mid. et
de Chit: for May, asks why it is not possible to educate the
public until every one with even a catarrhal cold or influenza
will no more think of leaving the house without his pocket
expectorator than he would go without his handkerchief. Inva-
lids who have learned to use the portable cuspidors of a sani-
tarium are never content without one afterward. But their
' The name of the donor was withheld at his request.
1896.]
MISCELLANY.
57
comparatively high price, $1.60, and the difficulty of procuring
them, has prevented their general adoption. Only one store
in Paris was found where they were for sale. Something
cheap, light and inconspicuous is needed, and there is a for-
tune waiting for the inventor who will provide something that
will And favor in the eyes of an expectorating world, and be
the means of saving the lives of thousands yet unborn. The
sanitary spit mugs now in use in some hospitals, although orna-
mental and useful, are scarcely attractive enough for the gen-
eral public.
Two New Parasitic Cutaneous Diseases in Russia. Recent num-
bers of Wratsr/i i IS. .">•_!. 3) contain descriptions of a skin dis-
ease produced by the larva of a fly (Gastrophilus hamorrhoid-
alis L. or Q. pecorum Fb.) which prevails in the provinces
near the Volga. Exposed places, the face, hands and neck,
are affected in lines. 15 cm. long, resembling the scratch of a
needle, and in each is found the 1 mm. long larva. The hair of the
skin is frequently covered with the eggs, which wash off easily,
so that only a few of the larv» find their way under the skin.
One writer has found the lesions in the mouth, nose and beneath
the conjunctiva. The disease resembles Neumann's •' creep-
ing eruption." In the province of Twer there is still another
parasite that affects the skin, a still undescribed rilaria several
inches long. It burrows in the hand, producing a boil, and
resulting sometimes in extensive inflammation, anchylosis and
even gangrene of separate fingers. — Centralblatt f. Chirurgie,
Mav 23.
Practical Xotes.
Optic Atrophy. Dr. Culbertson recommends glonoin in con-
junction with strychnin, in all forms of optic atrophy, retinitis
pigmentosa, hereditary atrophy, atrophic choroiditis and all the
toxic amblyopias. Dose, 1-50 grain given internally. — Am.
Jour, of Ophthalmology, June, 189(5.
Erysipelas and its Treatment. — Dr. Bedford Brown says
England Medical Monthly, June, 1896) symptoms
usually attributed to inflammation of the brain are probably
due to blood poisoning from the ptomaines of the streptococ-
cus, after having been rapidly absorbed and transmitted
throughout the circulation.
Treatment of Menstrual Nervous Troubles with Ingestion of Ova-
rian Tissue. — Landau stated at the meeting of the Berlin Med-
ical Association, June 3, that he had been administering
ovarian tissue from animals to patients suffering from the
nervous disturbances caused by the suppression of the menses
after extirpation of the uterus or its annexes, or the meno-
pause. In each case it had been followed by the disappear-
ance of the nervous troubles, at least temporarily.- Reported
in theSenwune Midicale of June 10.
Pseudo-Erysipelas after the Instillation of 1 120 Grain of Atropin.
H. Mel. Morton, M.D., reports a case: The infiltration of
both upper and lower lids was so great that the oculo-orbital
and oculo-malar sulci were completely obliterated, and the
cheeks were intensely swollen to the angles of the mouth.
There was much pain of a severe, burning character. The
great amount of infiltration and the redness looked not unlike
rhus poisoning. The patient has not been out of the house,
however, and the relation of cause and effect was too marked
to permit of any doubt as to the cause of the trouble. The
trouble disappeared in a few days, under cold compresses, and
a solution of lead, water and laudanum. -Annals of Ophthal-
mology and Otology, June, 1896.
Plenge's Method of Hardening with Formaldehyde and Making
Frozen Sections for Rapid Diagnosis.-— 1. A piece of the tissue as
thin as possible is hardened in a 4 per cent, solution of formal-
dehyde for one-half to one hour, or longer if thick. 2. The
frozen sections are made with Jung's lever microtome. 3.
They are taken up in water which has been boiled to expel the
air, or better, in 50 per cent, alcohol. 4. They are stained with
the analin dyes. 5. They are rinsed with water, alcohol, oil
or Canada balsam. This method is used with admirable
results at the Heidelberg Path.-Anat. Institute. It is not
adapted, however, to normal placentas, pure fatty tissues,
solid bones, bone marrow, papillary tumors, normal testes and
the small intestines, nor to normal lung tissue which is diffi-
cult to treat in this way. — Centralbl. f. Chir., April 25, from
Munch. Med. Woch., No. 4.
Extensive Resections for Tuberculosis of the Foot and Wrist. —
Bardenheuer and Wolff substitute extensive resections for
amputations in a large proportion of cases of tuberculosis of
the foot and wrist. Their method of resecting the wrist
insures a much more solid union between the metacarpal
bones and the bone of the forearm than is the case with the
usual methods. They cut the upper end of the metacarpal
bones in the shape of a wedge, with a wedge-shaped surface
to correspond on the end of the bone of the forearm. This
secures an exceedingly close and secure junction and a strong
bony anchylosis is formed, which is much to be preferred to a
movable joint with nothing to support it. They have per-
formed the operation eight times with complete success in
each.— Prom the "Chirurgencongress," in the Semaine Midi-
cale, June 6.
An Ideal Exclpient for Ophthalmic Unguents.— Dr. Allen
Jamieson of Edinburgh reports in the British Journal of Der-
matology, April, the following combination as an ideal oph-
thalmic salve : Lanolin (Liebreich), 3 drams ; almond oil, %
dram ; distilled water, % dram. Mix. If smeared thinly on
the lids this occasions no unpleasantness, and it may be
employed when it is desirable to use a salve to prevent the lids
becoming glued together by an increase of the lachrymal secre-
tion. It is, however, better as a rule to add a couple of grains
of boric acid to correct any slight tendency to rancidity,
though this is not prone to happen, even if the ointment be
kept for a time. In eczema of the lips the salve forms an
excellent medium for the yellow oxid of mercury so beneficial
in such conditions. Two grains may be added to the half
ounce. According to the testimony of patients, the salve gives
a pleasant sensation of coolness without trace of smarting or
irritation. Its curative influence, the author says, is equal if
not superior to that of any other eye salve prepared with other
bases.
Some Common Affections of the Heart and Their Treatment.— -Dr.
H. W. Rogers says : In regard to those cases considered purely
functional, it may be a question whether many of them do not
initiate the more serious lesions found later in life. Usually
no murmurs are found on auscultation, but almost invariably
a marked accentuation of the second sound at the aortic ori-
fice which means loss of elasticity in the aorta. There are few
conditions of the pulse pathognomonic of a particular car-
diac lesion. The nervous mechanism plays an important part
in its modification. In most cases, however, a rapid pulse
means a weak myocardium. A slow pulse, on the contrary,
means a heart which is overburdened by some form of resis-
tance in the circulation, but a myocardium which in most
instances is essentially strong. Of the diet he says : Limita-
tion of starchy foods and sweets and the employment of rap-
idly appropriated proteids is the general plan. Digitalis he
considers the ideal heart tonic. Strychnin is one of the most
potent remedies, but its action is rapid and there is danger if
used too frequently or too long. No better combination than
morphin, strychnin and nitroglycerin can be employed in acute
attacks, especially those designated as angina pectoris. — Cleve-
land Journal of Medicine, June, 1896.
Hospitals.
Metropolitan Throat Hospital, New York.— The 29th
annual report shows the number of new patients who received
treatment at the hospital during the year was 2,286, and 610
58
MISCELLANY.
[July 4, 1896.]
surgical operations were performed. Dr. Clinton Wagner is
medical superintendent.
Appointment. — Dr. J. Clement Clark has been appointed
by the board of directors first assistant physician of the Mary-
land Hospital for the Insane at Spring Grove, Md., to succeed
Dr. J. Percy Wade, who has been made superintendent.
Infants' Summer Hospital. — The formal opening of the
Infants' Summer Hospital at Ontario Beach, Rochester, N. Y.,
took place June 23. This is its tenth season of beneficent
work.
Philadelphia.
Dr. A. C. Abbott has been elected professor of hygiene in
the faculty of the University of Pennsylvania, to succeed Dr.
John S. Billings, resigned.
Dr. Joseph McFarland has been elected professor of path-
ology in the Medico-Chirurgical College to the place made
vacant by the resignation of Dr. E. B. Sangree.
Prof. William Thomson has resigned the chair of Ophthal-
mology in the Jefferson Medical College after twenty-four
years connection with the school.
The Medical Council of Pennsylvania^ which through the
State Boards of Examiners, and Licensers, examines all phy-
sicians who wish to enter upon medical practice in this State,
including graduates of our own schools, has adopted a rule
that all students matriculating in medical colleges of the State
of Pennsylvania, who intend after graduation to practice
medicine in this commonwealth, will be obliged, on and after
the term beginning in the fall of 1896, to provide themselves
prior to matriculation with a certificate of preliminary exam-
ination. The preliminary examination which is now made
compulsory and uniform in its application, requires attainment
of a satisfactory average in the following branches : Arith-
metic, grammar, orthography, American history and English
composition. However, the diploma of a college, academy or
seminary, normal school or high school, a teacher's permanent
certificate, or a student's certificate of examination for admis-
sion to the freshman class in any college, shall be accepted in
lieu of examination.
At the June meeting of the Philadelphia Chapter of the
Alumni Association of the Jefferson Medical College, Dr. Eman-
uel J. Stout read apaperon "Extra-Genital Chancres ;" Dr. J.
Abbott Cantrell reported upon the "Clinical Aspects of the
Tubercular Syphiloderm." Dr. John Lindsay read a communi-
cation on the "Treatment of Syphilis" which lead to a general
discussion of the subject by Drs. Horwitz, J. M. Barton,
Joseph Hearn, L. Wolff, J. Chalmers DaCosta, E. E. Graham,
W. S. Jones and H. W. Stelwagon. A reception at the Penn
Club and a social entertainment concluded the evening's
exercises.
The Philadelphia County Medical Society held its last
meeting for the season June 27, when Dr. A. J. Downes exhib-
ited his collapsible and removable bobbins for all forms of
intestinal approximation. He also demonstrated a new con-
tinuous double-knot intestinal suture and a new abdominal
retractor. Dr. Aug. A. Eshner read a communication entitled
"Progress in Organotherapy."
The Trustees of Jefferson Medical College on the 29th
ult., elected Dr. George E. DeSchweinitz, Professor of Oph-
thalmology, to succeed Dr. William Thomson. Drs. D.
Braden Kyle and W. S. Jones were made Clinical Professors
of Laryngology and H. F. Harris, Assistant Professor of Bac-
teriology and Pathology, at the same meeting.
Mental Automatism. — The annals of the Coroner's office
contain many interesting and remarkable cases of suicide which
may be made to contribute something toward the solution of
psychologic problems, and especially that of automatism and
the imitative faculty or power of example in influencing human
action. A middle-aged woman in this city, becoming dis-
heartened, recently ended her life by the very unusual method
of swallowing hydrochloric acid. A man living in the same
neighborhood, after attending the funeral, purchased some of
the same corrosive poison in a drug store on his way home and
soon after reaching his own house swallowed the poison and
soon afterward died. The connection of the two cases seems
to have been merely accidental and there is nothing to warrant
the idea that there had been any previous agreement between
the two.
THE PUBLIC SERVICES.
Army Changes. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
June 20 to June 26, 1896.
Capt. Walter D. McCaw, Asst. Surgeon (Ft. Ringgold. Texas), is granted
leave of absence for one month, to take effect on or about July .">.
Major Louis M. Maus. Surgeon (Ft. Sam Houston, Texas), is granted
leave of absence for two months, to take effect on or about August
1,1886.
Major Daniel M. Appel, Surgeon, is relieved from duty at Ft. Porter, N.
Y., and ordered to the new post near Little Rock, Ark., for duty.
Capt. Aaron H. Appel, Asst. Surgeon, is relieved from duty as examiner
of recruits at Chicago, 111., and ordered to Ft. Porter, N. Y., for duty.
Navy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending June 27, 1896.
Asst. Surgeon S. B. Palmer, detached from the New York laboratory
June 29.
P. A. Surgeon George Rothganger, detached from the "Independence."
July 15, and ordered to the " Oregon."
Marine- Hospital Change*. Official list of changes of station, and
duties of Medical Officers of the U.S. Marine-Hospital Service, for
the twenty days ended June 20, 1896.
P. A. Surgeon W. P. Mcintosh, to proceed from Louisville, Ky., to Cin-
cinnati. Ohio, to inspect unserviceable property; then to rejoin sta-
tion, June 18, 1896.
P. A. Surgeon J. C. Perry, granted leave of absence for twenty days,
June 20, 1896.
Asst. Surgeon C. H. Gardner, order of May 27. 1896, directing him to
report for examination, is revoked, June 5, 1896.
Asst. Surgeon Rupert Blue, to proceed from San Francisco, Cal., to
Angel Island quarantine station for duty, June 18, 1896.
Change of Address.
Altoif, C. D., from Hartford, Conn., to Undercliff, Lake Placid, N V
Busey, B.C., from Washington, D. C, to Atlantic Hotel Narragansett
Pier, R. I., until Sept. 1, 1896; Brown, R. A., from Tupelo, Miss., to Pun-;
Tenn.
Donelson, C. P., from 818 Warren Avenue to 927 Monroe Street, Chicago.
Gates, W. S., from 1279 Wolcott St. to 2725 N. Lincoln Street, Chicago.
Henderson, H. C, from Chicago to Milford, 111.
Isbester, R. T., from 686 Washington Boul. to 1928 Indiana Avenue
Chicago, 111.
Meadows. J. E., from Lisbon to Manghan, La.
Polhler, F. T„ from Minneapolis to Waseca, Minn.; Packard, J H
from Devon to 26 So. 18th Street, Philadelphia, Pa.
Rhoden, J. C, from Ponca, Neb., to Elkpoint, S. Dakota.
Wilson, A. M., from 27 Union Depot to 229 Park Ave., Kansas City Mo.
LETTERS RECEIVED.
Alport, * rank, (2) Minneapolis, Minn.; Atkinson, W. B., (2) Phihul. !
phia, Pa.; Apollinaris Company, Ltd., The, (2) London, England; Acker
T. J., Croton-on-Hudson, N. Y.
Bodine, J. M., (2) Louisville, Ky.; Brown, Bedford, Alexandria, Va ■
Belt, E. Oliver, Washington D. C.
Cleary, W. P., New York, N. Y.; Cox.C. C, College Park, Ga.; Chilton
E. Y., Howard Lake, Minn.; Cole, A. B., Washington, D. c.: Claiborne
J. Herbert, New York, N. Y.; Carpenter, J. G., Stanford, Ky.; Carroll'
C. C, Poughkeepaie, n. Y.
De Hart, J. N., Round Lake, N. Y.; Davis, Stebbins, & Co., Boston
Mass.; David, Alfred, Atlantic Mine, Mich.
Edmonson. G. J., Maroa, 111.
Fuerth, Geo.. Detroit, Mich.; Farwell & Rhines, Watertown, N. Y
Guthrie, W. A., Franklin, Ky.; Garceau, Edgar, Boston, Mass
Hayes, R. H., Union Springs. Ala.; Holmes, Bayard, Chicago, 111 •
Howe, Lucien, Buffalo, N. Y.; Hill, Warren B., Milwaukee, Wis • Ham-
ilton, Hugh, Harrisburg, Pa.
Johnson. H. L. E., Washington, D. C; Jonas, A. F., (2) Omaha, Neb
Krause, Wm. C, Buffalo, N. Y.; Klingensmith, I. P., Blairsville Pa
Larkins, E. L., Terre Haute, Ind.; Lloyd, Wm. 8., Philadelphia, Pa •
Lee, Elmer, Chicago, 111.; Lord, J. P., Omaha, Neb.; Loeb, Hanau W St
Louis, Mo.
Marshall, John S., (2) Kankakee, 111.; Mouton. G. C, Rayne La •
McCartney National Bank, The, Green Bay, Wis.; Moore, J X Atlantic-
Mine, Mich.; Montgomery, E. K., Philadelphia, Pa.; McCurdv S L
Pittsburg, Pa.: Mills. H. B., Philadelphia, Pa.; Moore, C. T., Marissa 111"
Nicholson, Wm. Perrin, Atlanta, Ga.
Prewitt, T. F., St. Louis, Mo.; Parke. Davis & Co., Detroit, Mich
Parmele, Chas. Roome, New York, N. Y.; Pilcher, Jas. E., Columbus'
Ohio; Paquin, Paul, St. Louis, Mo.
i. c A <■■ V. , \. •Mn.n, j <,., .ijuiiii, v<. v,., muslin, lexns; scnine-
lin & Co., New York, N. Y.; Savage, A. D., New York, N. Y.; Slaughter
A. W., (2) Green Bay, Wis.; Sehwalbe, J., Berlin, Germany
Tiffany. Flavel IS., Kansas City, Mo.
Whittaker, Thos., New York, N. Y.j White, J. L., Blooniingtoti III •
Wyckoff, R. M. (2) Brooklyn, N. Y.; Waxham, F. E.Denver Colo'-'
Ward, M. R., Pittsburg, Pa.; Whitford, Wm. Chicago, 111.; Wilkinson \"
D., Lincoln, Neb.; Wood, H. D., Angola, Ind.
The Journal of the
American Medical Association)
Vol. XXVII.
CHICAGO, ILL., JULY 11, 18%.
No. 2.
ORIGINAL ARTICLES.
\
CLINICAL NOTES UPON SPASMODIC TOR-
TIOOLIS; WITH SPECIAL REFER-
ENCE TO TREATMENT.
K«wi Iii i! on Prmotlce of Med loin*, »t th< Pony-teventt
Annual Mtn-tiiipof the American Medical Asftoctfttfou.
held nt Atlanta, i. «.. Muv 5 8, 1806.
HV ASA FLANDERS PATTEE, A.M., M.D.
MKvii.i SETTS MEDICAL SOCIETY; president BOSTON TIIRRA-
Pt IT HA I. SOCIETY : PROFESSOR EMERITUS OF MATERIA NIKDH'A.
ESI OF PHYSICIANS AMI PCKOBONS. AND CUNSl'I.TINli
PHYSICIAN TO ONION GKNItRAL HOSPITAL.
BOSTON, MASS.
Torticollis ( wryneck) is due to a spasmodic condi-
tion of the cervical muscles, chiefly those supplied by
the spinal accessory nerves. The name is derived from
two Latin words, tort)/*, twisted, and collum, neck.
The terms tie rotatoire, Nickrampf, etc., are used as
expressive of the spasm, muscles affected, tenacity, etc.
This abnormal contraction of the cervical muscles
is directly the result of irritation of the external cervi-
cal branch of the spinal accessory nerve, which bav-
ins' two different origins, a spinal and cerebral, has
two distinct functions. The spinal or motor branch
supplies the motor power to the sterno-cleido-mastoid
and trapezius muscles, and communicates with the
first, second, third, and fourth cervical nerves, its roots
being traced between the anterior and posterior roots
of the first five cervical nerves. As we have seen,
wryneck proper is an affection of the sterno-cleido-
mastoid and trapezius muscles, but in cases of long
standing and great severity, especially in bilateral
affections, the splenius capitis, scaleni and platysma
myoides may become implicated from continuity of
nerve fiber, and contiguity of muscle tissue.
This affection presents the objective phenomena
peculiar to all spasmodic conditions of the muscles
supplied by the peripheral nervous system. The
most frequent and simple exhibition of other nervous
irritation of the same nature may be seen in the facial
spasm of the trigeminus, upper third, in spasmodic
cli isure of the eyelids, with twitching and contortions
of the forehead.
To torticollis proper, medical literature has devoted
comparatively small space, the sentiment being con-
veyed that wryneck, being of reflex origin and gener-
ally an obscure and complicated one, when it is once
well established in the individual, is the condition of
a lifetime. Its clinical history is certainly that of
permanency.
Wryneck may be divided into three classes, depend-
ent upon the degree of severity, nature of spasm, and
muscles involved. The partial or limited contraction
of the cervical muscles due to cold, exposure, strain or
rheumatism, and which disappears after a period more
or less brief, under the administration of heat, lini-
ments, friction, etc., is a condition commonly known
as "stiff neck"; a painful state with which all are
familiar, most of us having had personal experience,
and does not come within the province of torticollis
proper: the former being a condition of the muscle
substance itself, while the latter is dependent for its
abnormal condition upon the nerve.
In this affection we have the two forms of spasms,
the tonic, which is a state of permanent rigidity and
immobility of the muscles, and the clonic or tetanic
spasm, which consists in alternate contraction and
relaxation. The movements are varied and accentu-
ated in accordance with the muscles involved. If it
is the trapezius, unilaterly, the head is drawn back-
ward against the shoulder of the affected side, the chin
is twisted to the opposite direction, and if the spasm
assumes the tonic form, the head is permanently fixed,
and can hardly be forced into its normal position; nor
will it remain so under any restraint the patient may
be able to endure. If the splenius be affected we find
the head drawn back against that side, and the enlarged
muscle may be felt protruding beyond the cervical
edge of the trapezius.
While tetanic spasms are due to the irritability of
the peripheral nerves, and may attack any one or part
of the superficial muscles of the head or face as well,
and their duplicity of action leaves no doubt that all
spasms of the external superficial muscles are of the
same nature, and are directly due to the same cause,
this should by no means warrant us in the conclusion
that they may all have the same origin, primal or
remote ; on the contrary, I think, we may properly
make the assertion that irritability of the superficial
nerves is the result of causes not always easily ascer-
tained; being sometimes very remote, the nervous
irritability being a symptom in the strictest sense of
the word. Nerve irritation may be at any point of its
course, and the spinal accessory being a complex
nerve, having its action in the medulla as well as in
the spinal cord, renders it a very difficult matter to
locate the exact place of irritation ; and owing to the
complexity of the nerve branches and their anastos-
moses with the pneumogastric, we may have a reflex
action from gastric disturbances, or by some lesion of
the upper cervical vertebra?. In such an event the
cause may be sufficiently obvious to enable one to act
intelligently in attempting a cure, while in very many
other instances we are obliged to grope in the dark. In
this, as in all other peripheral neuroses, pathologic
proof is absent.
Contraction of any muscle must be recognized as an
exhibition of contractile fiber in response to nerve
stimulus, and it is only when it ceases to become
rhythmic in its action, or refuses to act altogether,
that we have what we term a pathologic condition.
The only visible result of nerve irritation that we have
to go by is change in shape and mobility of muscle as
a whole. Wryneck, as with the majority of peripheral
nerve affections, is more convincing in its identity
than the raisoii d'etre.
60
SPASMODIC TOETICOLLIS.
[July 11,
Case 1. — My first case of torticollis was in 1857, the last year
of my student life, and occurred in a woman aged 33. Her
trouble came on without any apparent cause ; first showing
itself in merely a tendency to stiff neck at times and without
any appreciable provocation. It had continued for about seven
years, increasing in severity. At the time I saw her the neck
was drawn around with a combination of tonic and clonic form
of spasm, being twisted with a jerk and remaining in the tonic
condition for a day or two, never assuming the normal state,
but would be working back and forth. Her general health was
fair ; objective symptoms nothing to require attention with the
exception of a large ulcer inside the left leg. This ulcer was
not of the varicose form, but was what is termed by the laity a
"fever sore" ;• it was two inches by two and one-half, and had
been in existence for three years ; a non-irritable, chronic
ulcer. There were no varicose veins, no history of syphilis, no
disease of the periosteum. The best of surgical and medical
skill had been employed. As an incentive for me to do my best
I was told that if I cured Mrs. B. I should have my room rent
free for the next six months.
Without regard to etiology or pathology I began the follow-
ing treatment : A poultice of pulverized ginger, mustard, cap-
sicum, cloves and cinnamon, mixed with cold water and applied
to the spine twice daily, from the first cervical down six inches,
for one hour at a time. This was for the purpose of promoting
counter-irritation, and also by the absorption of the oils these
ingredients contained, to promote stimulation of the deeper
nerves, carrying it by reflex action back to the nerve roots.
For internal medication I gave the following :
R. Pulv. capsici,
" myrrhae iia 18 (gr. iij)
" cinnamomi
" asafetidae aa 2.00 (grs. xxx)
" sapo
Mix. Divide into thirty pills. Take ten pills after every
meal.
This dose seems almost cruel as we prescribe to-day,
but we must remember that this was an incident of
thirty-nine years ago, a period very different from the
present time of concentrated medicines; but a period
too, which had remedies quite as efficient in their
action as at the present time of artistic preparations. I
dressed the ulcer with an ointment made up of lard
and powdered cinnamon, of each half a pound, with
sufficient quantity of whale oil to make it of proper
consistency. This was applid to the ulcer twice daily.
This treatment was kept up for months without
change, and the result was a perfect and permanent
cure, both of the torticollis and the chronic ulcer of
the leg.
While the origin of torticollis may be sometimes as
apparent to the physician as the door-plate on his own
door, yet I intend to show in the following cases that
it may be so swaddled about by the environments of
disease obscurely located, that treating for an ordi-
nary cause may result in ignominious failure, as shown
in the following:
Case 2. — An American woman, aged 35 ; mother of three
healthy children, had been troubled with spasmodic torticollis
for three years, or since the birth of her last child. Reckoning
from that period as the beginning of her trouble, one would be
very liable to attribute the cause to some lesion, more or less
imDortant, of the generative organs. Such had been her expe-
rience with those whom she had consulted. And her symptoms
were typical of such a trouble, only rather more exaggerated
than ordinarily met with. Her head would give a sudden and
emphatic jerk to the right, then turn as quickly toward the left,
where it would remain a minute, then as quickly be jerked
back into the normal position. Here it would remain for about
ten minutes, generally, though sometimes it would rotate back
in a minute or two, and go over the same routine again ; keep-
ing up a constant succession of these motions. She was com-
pelled to wear a leather collar buckled tightly around the neck,
embracing the face up to the ears, and fastened with a strap
under her arms to keep her head in position. But even with
this appliance the muscles were in a state of clonic spasm most
of the time, unless under the influence of a powerful opiate,
which she was compelled to take at night in order to obtain
any rest at all. Her treatment had been varied, prompted by
all sorts of theories as to the origin of the trouble, but the bene-
fit had been slight, and only temporary at the most. As this
period antedated the day of hysterectomy, and ovariotomy was
almost unknown, her womb and ovaries were not removed. Xo
definite cause had been assigned. I had the advantages accru-
ing from the experiments of those who had attempted a cure
in her case; and it certainly abridged whatever experimenting
I might otherwise have done. She had her own teeth, but
upon examination it was shown that although few were miss-
ing, nearly every one was more or less in a state of decay ; still,
as they had never troubled her to any great extent it was not
surprisingthat as a cause of her trouble they had been over-
looked. Examination then determined me to act upon the
decidedly strong suggestion which their appearance seemed to
offer. I extracted all of her teeth, gave a mouth- wash of ■ 1
per cent, solution of potassse chlorate, and internally, .07 (1
grain) of sulphate of zinc in two ounces of water, after every
meal. In less than one week, or as soon as the soreness had
subsided, a great improvement became apparent. She contin-
ued the treatment for three weeks, at which time the gums had
completely healed ; the clonic spasms had nearly disappeared,
and in three months from the time her teeth were removed she
was perfectly well, and there was no relapse. There is no
question as to the cause being anything else than reflex irrita-
tion from the decayed teeth.
Case 3. — Mrs. S. , aged 25, had spasmodic torticollis dating
from birth of child, six years previous. She had been under
treatment of specialists at different times for months together.
The patient seemed to be well nourished, and all the organic
functions normal. The bowels were regular, no indigestion, no
headache, no spinal irritation, no laceration of uterus or peri-
neum, and appetite good. I gave a pill composed of zinc sul-
phate .07 (1 grain), extract of valerian .12 (2grains). One to be
taken after every meal. A poultice of mustard, ginger, cayenne
pepper, cinnamon and cloves was applied to all of the back, be-
hind the ears, over the chest and throat the greater part of the
day ; keeping it on one spot sufficiently long to irritate the
part, then removing it to another, the object being to keep every
inch of the skin in a constant state of irritation, from the first
dorsal vertebra upward and the same region in front. The
poultice was mixed with cold water. Improvement commenced
after the treatment had been in operation for two weeks, and at
the end of four months the patient was well. There was no
assignable cause for this case, and I would not have been sur-
prised to see a relapse, as a result of cold or exposure ; but the
cure remained complete.
Case 4. — At the risk of repetition I now present another case
to further illustrate what decayed and decaying teeth will do
for a person of nervous temperament (or any other tempera-
ment, as for that) ; as such apparently simple causes are gen-
erally overlooked ; and, again, to show that it is not always
necessary that the process of decay should have advanced to
any very perceptible degree in order to produce the mischief.
This was a case of trigeminal neuralgia of three years' stand-
ing, in a woman of 28, and had resisted every means employed
by competent physicians. The teeth were apparently all sound,
and she had her full complement ; but they were quite crowded,
owing to size. From, some seemingly trivial indications, but-
which from previous experience I considered to be fraught
with meaning, I ordered their extraction. The mouth was
washed with a 1 per cent, solution of potassas chlorate every
two hours. The neuralgic condition began at once to disap-
pear, and in three weeks she was well. No relapse. This
shows what may be brought by sound teeth when they press
upon the terminal nerves.
Case ii. — Another case in the same category will, I trust, be
sufficient for my purpose. This was a case of facial paralysis
with partial paralysis of the left arm, cured by extraction of all
the teeth in both upper and lower jaw. They were nearly all
carious. The paralysis was caused by reflex irritation from the
carious teeth.
Case 6'. — Mr. W. S., aged 25; a drummer for a silverware
manufactory. Family history good ; no symptoms of gout,
rheumatism, or tuberculosis on either side of the house. He
had never had any illnes, and habbits were good ; organic func-
tions all perfect. After riding several hours on a hpt, dusty
day, and sneezing a great deal from irritation caused by the
dust on the mucous membrane of the nose, he began having
slight contraction of the scaleni muscles. He paid little atten-
tion to it for several months, when it became very annoying ;
he then applied to a physician for relief. He was given some
sort of stimulating liniment, and anti-rheumatic remedies;
these he used for several weeks, but without any appreciable
benefit. He then took a two months' course of massage.
After this he tried faradic, galvanic, and static electricity for
several weeks, but the spasms still continued unabated. When
I first saw him he had been experimenting for over a year. It
1896. ]
SPASMODIC TORTICOLLIS.
(51
seemed that as the various new-fangled fads etc., had all been
jr UmI : there was little left to be employed but good judgment
and common sense. The only treatment I gave- as his general
health seemed to be perfect was a hot shower bath night and
morning, fifteen minutes at a time on the neck and shoulders.
This treatment brought about the most brilliant results, and at
the end of six weeks he was perfectly free from trouble, and
there has been no relapse.
;. Mr. ,7. I.. W.. aged 38, a banker, had been ill with
Spasmodic torticollis for two years. He had been under numer-
ous forms of treatment, and particularly the celebrated mud
baths. This was quite a unique case in one respect, viz. : A
part of the time the trouble would be confined to one side
lusively for two and three weeks, when itwould turn to the
other side for the same period, leaving the previously affected
side apparently as well as ever it was. \
1 began treatment by giving hypodermically one drop of the
following solution :
K. Aurii et sodii chloridi 1 gr. (IT
Sodii arsenias 1 gr. 07
iii bromidi 3 grs. 19
Aquse dest 1 oz. 31 IX)
Mix.
Injecting five drops of this into the belly of the muscles twice
a day in rotation : going over the same muscle on each side,
ir instance, at the origin of the muscle and gradu-
ally going over its whole length, then taking up another in the
me way. The strictest antiseptic precaution was observed.
He had considerable brachial neuralgia; otherwise was free
from pain. No inflammation or abscess was ever produced by
these injections, and but slight pain. This treatment was con-
tinued with great regularity for five weeks; the improvement
was gradual, but even and permanent, and resulted in a com-
plete cure, without any recurrence at the end of fifteen months.
1. J. B., a boy aged 9 years, was playing "leap frog"
when by accident he was kicked in the neck ; but from all ap-
pearance he was not particularly injured, and made no com-
plaint until about two weeks afterward, when his head began
to twitch backward, yet so slightly that it was hardly notice-
able ; but in the course of several weeks it became a continual
cause of complaint. He was under treatment for six months
with various mixtures of liniments, ointments, oils, plasters,
electricity, etc.. previous to my seeing him ; but they had pro-
duced no perceptible benefit. Stomach and bowels in good
condition, urine normal. I applied the following ointment to
his neck :
R. Aurii et sodii chloridi 5 grs. 132
Ammonii hydrochloras 10 grs. |64
Aquse, well rubbed in 1 arm. 100
Adipis benzoas 1 oz. 3100
Mix, and apply about ten grains three times daily.
R. Ammonii hydrochloras grs. v .32
To be taken every three hours in a wineglass of water.
This treatment was continued for six weeks with marked
Improvement. Then ammonia hypophosphite was substituted
for the hydrochlorate, in three grain doses for two weeks.
Considering the severity of the case his recovery was unusu-
ally expeditious, a cure being affected in six weeks.
Case '■>. H. M., a man of 76 years. This man had been em-
ployed in a granary for ten years ; previous to that he had been
in a brewery, and I think there was reason for supposing his
blood had become contaminated by micrococci from diseased
grain. His face was bloated, and he was always more or less
asthmatic. Aside from this, there was a red blotch over his
hands and arms. He complained of constant pain in the region of
neck and shoulders ; the brachial region was the nervous part
affected. Soon after first seeing him he was exposed to a severe
March s*torm, and aside from the wetting he was chilled.
Driving all day had strained this part of the muscular system,
and when I saw him that night I found a condition of acute
muscular rheumatism, as one would naturally expect. Proper
treatment removed the acute symptoms, but in their place was
established, right before, my eyes, as it were, a decided case of
bilateral torticollis, implicating the whole brachial region (as
had the previous attack of rheumatism, which had been
removed apparently to give place to this condition). His suf-
ferings were intense ; not for one moment during the twenty-
four hours was he permitted to rest, save when under the tem-
porary influence of powerful anodynes. In addition to this a
persistent cough set in ; his breathing became very labored,
I8howing, to my mind, a complication of the phrenic nerve, to
which might be traced the spasmodic condition of the cervical
plexus. The treatment was the following :
R . Fl. ext. cimicifugae
Tr. gelsemii
Tr. guaiaci aa gtt. x .65
Mix.
The above amount to be given every three hours in a wine-
glass of milk. Hypodermic injections of hot water, to which
.65 (grains x) of salt were added, were made every day into the
clavicular origin of the sterno-cleido-mastoid muscles of both
sides. This course of treatment was continued every day for
two weeks, with marked improvement. After that time the
injections were discontinued, but the internal treatment was
kept up for three months, and at the end of that time there was
no further medicine required for he was perfectly well.
( hue ID. Thomas W., a sober, working man of 45, was sud-
denly leveled to the ground and randered unconscious by some
means then unknown to him, one night in December, 1894.
(It was afterward shown that he was struck by a sandbag.)
Consciousness returned after about forty-eight hours, but with
it the inability to move his head. Constant pain was felt in
the occiput and down the back and sides of the neck, extend-
ing by flashes down his arms to the elbows, with numbess of
the finger-ends. Upon being lifted in bed he was seized with
spasms which twisted his head from one side to the other in
quick rotation, then backward over the scapula, with such
force that it seemed his neck would be broken. This condition
lasted for twenty-four hours, when the patient became uncon-
scious from exhaustion. There must have been some irritating
lesion of the spinal cord, extending to the cortical substance of
the brain, and the question might be raised whether this was a
case of torticollis proper, or of spasms caused by injury to the
brain. The pulse and temperature were normal throughout.
I gave 4.00 (1 dram) of liquor ammonii acetatis with .65 (10
drops) of tinct. gelsemium every three hours. Hot compresses
to the occipital and cervical regions were constantly applied.
In about five hours the spasms were very decidedly abated, and
in the course of a couple of weeks the pains had all ceased ;
but there was still to be noticed a tendency to spasmodic con-
traction of the muscles. I ordered tincture of lobelia be rub-
bed on the parts, and had him take .32 (5 drops) of the same
every three hours. This seemed to act so nicely that in the
course of a week the spasmodic tendency had disappeared ;
but I continued the treatment one week longer, so as to ensure
a perfect recovery.
In conclusion, I will copy the following case from
one reported in my paper, on " Nerve Vibration and
Excitation," as read in the Section on Practical Med-
icine, Materia Medica and Therapeutics, at the thirty-
sixth annual meeting of the American Medical As-
sociation, held in New Orleans, La., April 29, 1885 :
A married woman, aged 29; of extremely nervous
temperament, and suffering from mental trouble
brought on by death of a child. Electricity had been
applied by a competent person, but this seemed only
to aggravate the case. The muscles of the right side
were affected. This condition had existed for several
months. Not only the sterno-mastoid, but the deeper
groups of muscles were involved. As the motor fila-
ments of the pharyngeal branches of the pneumo-
gastric are derived from the spinal accessory, I
directed my treatment to the base of the occipital
bone, across to the upper part of the sterno-mastoid,
following the course of the nerve as closely as
possible.
The treatments were daily, and of fifteen minutes
duration. The percuteur was firmly held against the
surface, though not pressed down, so that the whole
force of the blow might be obtained. Eight cells of
the battery were employed, and I used the olive-
pointed hammer, tracing the course of the nerve up-
ward and downward, and over the clavicular portion
of the trapezius muscle. At the end of the first sit-
ting the muscles of the neck were a trifle relaxed, the
patient being able to turn her head slightly ; but the
next day found the old condition almost reinstated.
However on going over the same treatment I found
the improvement still more marked than that of the
day previous, and, to cut a long story short, the con-
dition steadily improved under every treatment, the
deterioration between times being less noticeable. At
the end of three weeks the patient presented no signs
62
DISEASE OF GASTRO-INTESTINAL TRACT.
July 11,
of wryneck, and the corresponding muscles of the
other side had regained their normal condition,
varied the treatment somewhat, as the case progressed,
by passing the hammer down either side of the spin-
ous processes, pausing a moment at each. The entire
cerebro spinal nervous system seemed to respond
favorably to this treatment, and the result was com-
plete restoration to health, and no inclination to return
of the torticollis, so far.
This patient had already gone through the usual
list of nerve remedies. I ordered that all accessory
treatment should be stopped, save good nourishing
food, pleasant surroundings, and all other necessary
and proper hygienic conditions.
While it is patent to the practical physician that in
the treatment of disease in general there can be no
prearranged method which shall be applied with pos-
itive certainty to all cases, the routine of treatment
fitting the condition as surely as a certain size of glove
will fit a correspondingly sized hand, this uncertainty
is still yet more apparent when we have to deal with
diseases of the peripheral nervous system, and is most
plainly illustrated in wryneck. I have seen many
cases in which treatment has been a complete failure;
cases which had been submitted to braces and various
complicated devices; but they were used without
accomplishing the desired result. The surgeon's knife
has also been powerless to help. Nor am I alone in
my experience and consequent conclusions. Physi-
cians of wide repute and acknowledged skill corrob-
orate my opinion. Dr. A. McLane Hamilton says on
the subject: Braces and apparatus are often worse
than useless, increasing not only the patient's discom-
fort, but aggravating the malady. This opinion is
also expressed by Dr. James Ross, Dr. M. Rosenthal,
Dr. Gower, and many other acknowledged authorities.
Professor Erb. in speaking of the various devices, and
surgical operations says : The division of the nerve is
an objectionable proceeding, partly on account of the
resulting paralysis, and partly because it has been
tried and has failed in effecting a cure, and has
increased the spasms with unabated violence.
Dr. C. M. Barr says: Instruments intended to forci-
bly check the spasms can not be worn any length of
time. . . they do no good. I have in my own
practice seen ten cases that have had various opera-
tions performed on the nerves and muscles, and the
result has been the reverse of successful, in fact,
disastrous.
I have collected statistics from many sources,
amounting to between four hundred and five hundred
cases in which surgical operations in one way and
another have been performed in torticollis, without
deriving the slightest benefit therefrom; in fact the
conditions were worse than before the operation.
THE FREQUENT DEPENDENCE OF INSOM-
NIA, MENTAL DEPRESSION AND OTHER
NEURASTHENIC SYMPTOMS UPON
DISEASE OF THE GASTRO-
INTESTINAL TRACT.
Read in the Section on Practice of Medicine, at the Fortv-seventh Annua]
Meeting of the American Medical Association, at
Atlanta. Ga.. May 5-S, 18%.
BY BOARD MAN REED, M.D.
ATLANTIC CITY, N. J.
The group of nerve derangements formerly classed
under the terms nervous exhaustion and nervous pros-
tration, and of late more appropriately labeled neuras-
thenia, is after all a rather vague and indeterminate
entity. It has not yet any recognized pathology, and
even its etiology is still in dispute. There are not
wanting authors, now, who insist that neurasthenia is
only another name for toxemia, and that the ptomaines
and leucomaines absorbed from an infected or diseased
alimentary canal are responsible for all the symptoms
which it has so long been the fashion to ascribe to
mental overstrain, sexual excesses or other prodigal
waste of the vital and nerve forces.
Still others believe that too much food and too little
exercise — too much alimentation and not enough oxy-
genation— cause an overcharging of the blood with
uric acid, as well as other products of suboxidation,
and that hence arise all or most of these nerve ills
which, as is well known, afflict chiefly persons who live
a luxurious, or at least a sedentary life, being rela-
tively uncommon among those who use their muscles
largely, while they eat and drink abstemiously. Haig,1
the great exponent of the uric acid theory, believes
that butchers' meat, especially when taken in excess,
is the most active cause, and he brings forward a very
strong array of evidence in proof of his views; but it
is probable that he goes too far.
My own belief is, that while any of the various
influences just recited may, even singly and alone,
produce, under certain conditions, some of the forms
or manifestations of neurasthenia, especially in per-
sons who have inherited a tendency thereto, a num-
ber of them have usually combined to develop the
more aggravated types. Granted, that there are always
predisposing conditions, it must now be admitted that
the role of the indigestions and other morbid states
of the alimentary tract, is most important in the
causation of these nerve ails. It is an every day
observation of physicians who have much to do with
nervous patients that their well-being and comfort
depend largely upon the condition of their stomachs
and bowels.
To give this discussion a more definite and practi-
cal character, it will be best to consider here a few of
the more marked and familiar symptoms of neuras-
thenia, rather than that elusive entity as a whole.
Let us take, for instance, the mental depression,
nervous erethism and insomnia, some one or all of
which may always be observed in the severer cases.
In the hundreds of neurasthenics who have annually
come under my care in that Mecca of American inva-
lids, Atlantic City, the symptoms just named have
usually been the most pronounced and troublesome.
They may arise as a result of any of the graver
forms of gastro-intestinal disease, such as cancer, gas-
tric ulcer, chronic gastritis and dilatation of the stom-
ach, through the lowered nutrition which sucn affec-
tions induce. Whether this be brought about directly
as a result of a starving of the nerve centers, the blood
which nourishes them having itself become impover-
ished, or whether the poisoning primarily of the blood
and secondarily of all the tissues, by products of the
fermentation, putrefaction and sub-oxidation which
such diseases of the alimentary canal greatly promote,
is a question which need not be entered upon here.
My object in this paper is the more practical one of
emphasizing the importance of the part played by
stomach and intestinal diseases in a large and most
important class of nervous affections.
Cancer and ulcer are apt to be recognized and to
receive special attention at a comparatively early stage
IMS BASE OF GASTRO-INTESTINAL TRACT.
63
of their progress, on account of the pain and frequent
romiting which they usually evoke. Gastric catarrh,
however, is unfortunately often allowed to proceed to
a late and serious stage before it is diagnosticated and
the proper treatment begun; while atony and dilata-
tion of the stomach, when only moderate in degree,
aiv very generally overlooked, except by the specialist.
This is much to be regretted, since, while generally
Durable, or at least capable of great amelioration, in
the beginning, they are very intractable, as well as
sadly afflicting, in their more advanced stages. More-
over, there is no reason now. why every practitioner
who is fairly adept in the art of percussion, should
not be able to recognize them even without the use of
a tube or other intra-gastrie instrumentation. A
method of establishing the diagnosis in such cases,
as well as in the various forms and degrees of gastrop-
tosis. or stomach displacement, by external examina-
tion, has been described by me in a previous contri-
bution."
Constipation and its immediate sequelae have disas-
trous and far reaching effects in causing disturbances
of the nervous system, among which the neurasthenic.
symptoms now under consideration are prominent.
This would of itself furnish abundant material for a
separate paper, and can only be mentioned here in
passing, though it will be referred to again under the
head of acid dyspepsia, which is one of the conditions
upon which it most frequently depends.
The so-called gastric neuroses, that is, on the one
hand, a diminished secretion of hydrochloric acid with
or without a decrease of the other constituents of the
normal gastric juice, and on the other hand, an exces-
sive secretion of hydrochloric acid, along with usually
a hypersecretion of the digestive ferments as well, are
also of importance in this connection.
The former condition is admittedly very infrequent
in comparison with the latter. Diminished or absent
secretion of the gastric juice, especially of its acid
constituent, is constantly found as a result of advanced
gastric catarrh. It means, then, an organic and virtu-
ally incurable disease, though by the proper adminis-
tration of the acid and pepsin artificially, much can
be done in such cases toward compensating for the
defect. It is possible that in many cases in which the
absence of hydrochloric acid has been observed for
short intervals, alternating with periods of excess of
the same acid, such absence has been the result of
the prolonged and free administration of alkalies,
either in substance or in the form of the Carlsbad and
other mineral waters which are very rich in the soda
salts. These salts, too long given, are known to have
such an effect.
It so happens that in a large number of chemic
examinations of the stomach contents, I have rarely
ever found an absence of free hydrochloric acid, with-
out either a coincident gastric catarrh or cancer. Two
notable exceptions were one case of sea-sickness and
one of brain tumor.
It was an early observation of mine that neuras-
thenic patients, while they generally craved nervines
and narcotics, and had sometimes taken too much of
them before going to the seashore, rarely made any
permanent favorable progress as aresultof the admin-
istration of such drugs, and that, on the other hand,
they often gained remarkably in nerve tone and in the
ability to obtain sound and refreshing sleep after
having been put on a restricted diet together with
calomel, even in the smallest doses, to correct a furred
tongue and remove the congeries of symptoms popu-
larly known as biliousness. Hydrochloric acid given
with the same purpose, often brought about the same
wonderful improvement in their sleep and mental con-
dition. The appetite and digestion were helped at the
same time, and following up the treatment with such
nerve tonics as iron, strychnin and the phosphates or
hypophosphites, often assisted in making very grati-
fying oures.
A series of such favorable cases, in which insomnia
and the associated nervous phenomena were very
promptly relieved by the administration of hydro-
chloric acid, awakened hopes that an unfailing remedy
had been discovered for all that class of ailments.
Then came a number of cases in which hydrochloric
acid not only gave no relief whatever, but even seemed
to aggravate the trouble. Not being familiar at that
time with the vagaries of the gastric secretion and
their intimate connection with deranged intestinal
peristalsis, autointoxication, uricacidemia and other
abnormalities of digestion and assimilation, I was
wholly at a loss to explain these diverse effects of the
same drug in the same doses, upon patients suffering
from apparently identical symptoms.
But we all know now that very often there is an
excess of hydrochloric acid in the gastric juice. This
is true not only in many cases of manifest and clearly
recognized disturbance of stomach function, especially
those in which pains or marked discomfort after eat-
ing are the chief symptoms, along with constipation
as a rule, but also in the cases of nervous patients who
claim to have good digestion and insist that they can
eat anything. The latter may have large appetites,
often amounting to bulimia, and though they suffer
from intestinal flatulence, emphatically object to being
considered dyspeptics.
The German writers call this form of disordered
secretion hyperacidity, and the French term it hyper-
chlorhydria. English authors have described it under
the name of acid dyspepsia. The administration of
hydrochloric acid in the usual manner after meals in
this affection, can scarcely fail to increase still further
the amount of acid in the already too acid chyme
about passing on into the bowel, where it is destined to
work all manner of mischief, inhibiting or greatly
diminishing the activity of the pancreatic and intes-
tinal ferments, and probably provoking such a spastic
condition of the peristaltic apparatus as to bring about
the constipation which is so constant an accompani-
ment of hyperacidity. The interference with intes-
tinal digestion favors the development of the fermen-
tation and putrefaction which are the plague of
patients thus afflicted. The poisonous products thus
engendered not only absorb directly into the blood,
causing anemia, with disastrous effects as well to the
nerve centers and many other structures, but also the
gaseous portion of them over-distends the intestines,
exciting colics, or at least sleep-disturbing pains,
besides, when allowed to go on long enough, so para-
lyzing the muscular coats of the bowel and perma-
nently dilating the tube as to render the constipation
very difficult if not impossible to cure.
My note books show that a very large preponder-
ance of the nervous patients who have come under
my care and whose cases seemed serious enough to
warrant the analysis of their stomach contents, after
the usual Ewald test breakfast, were found to have an
excess of hydrochloric acid.
By its great relative frequency, its insidiousness
64
DISEASE OF GASTRO-INTESTINAL TRACT.
[July 11,
and often unsuspected beginnings, and its serious
results when not actively combatted, hyperacidity is
probably the cause, directly and indirectly, of more
nervous derangements and ill health generally, than
any other one disease of the gastro-intestinal tract.
Hence this form of indigestion merits here a some-
what more detailed consideration.
When the gastric juice contains an excess of hydro-
chloric acid, the first symptom ordinarily observed,
apart from gastric pain or discomfort, which may or
may not be present, is usually constipation. My notes
show that this is almost constant and proportioned in
degree to the amount of the hyperacidity, though very
exceptionally I have observed cases in which the bowel
movements were regular or even excessive. In seek-
ing for a rational explanation of the manner in
which constipation is caused in these cases, I have
been led by a large number of observed facts to infer
that in the earlier stages of the affection the super-
acid stomach contents, as already intimated, often
excite contractions of an irregular or spastic character
in the muscular coats of the bowels, thus interfering
with the normal peristaltic action. By careful palpa-
tion one can often feel contracted portions of intestine
as hard cords under the fingers. Experienced mas-
seurs sometimes report the same observation to me in
these cases of hyperacidity. Such patients usually
do not respond well to the ordinary purgatives, and
even the milder laxatives, unless combined with alka-
lies, as in the popular aperient waters, are apt to pro-
duce unsatisfactory results with much griping pain.
Rough massage with the usual exciting accompani-
ments of slapping, percussion, etc., often fails to effect
any good results, while neutralizing the acidity by
substantial doses of alkalies given one or two hours
after meals, with the help of mild galvanic treatment
and gentle rubbing and kneading of the abdomen, often
overcomes the constipation without the administration
of any laxative medicines whatever.
Left to itself, or wrongly treated, this constipation
of hyperacidity causes intestinal flatulency, retention
and absorption of the various products of fermenta-
tion and putrefaction, with a resulting endless chain
of nervous derangements and other morbid effects.
The autointoxication thus originated may provoke not
only insomnia, mental depression and many other
functional disturbances, but also, according to Bou-
chard3 and his followers, various other diseases as well.
Pressure of the fecal masses upon the lower abdom-
inal and pelvic nerve plexuses, as well as, in the case
of women, upon the ovaries, probably effects a more
direct injury in many cases, and is at least the cause
of numerous reflex symptoms. Hyperacidity is the
nearly constant accompaniment of gastric ulcer, and
is doubtless a factor in its causation. It also tends to
develop in time, if severe and uncontrolled by treat-
ment, the serious condition known as Reichmann's
disease, or a continuous hypersecretion of the gastric
juice, as well as ultimately the still worse state of
marked dilatation of the stomach.
Recent experiments by Turck,4 of Chicago, demon-
strate that in at least that form of acute gastritis
which can be set up artificially in animals, there is
■constantly found an excess of hydrochloric acid dur-
ing the earlier stages of the morbid process. Boas5
and some of the other recent German authors now
admit the existence of an acid gastritis which they
look upon as a separate and exceptional form of
inflammation of the stomach; but it is a question
whether, in view of Turck's observations and the
analogies afforded by catarrhal processes in other
organs, this form does not constantly precede the
more familiar atrophic type of chronic gastritis.
It might be inferred with considerable plausibility
that hyperchlorhydria is only the congestive stage at
acid gastritis and the earliest stage of chronic gas-
tritis glandularis; and possibly this may be true. But,
unquestionably, such a hyperemic condition of the
gastric mucous membrane with excessive secretion,
may exist temporarily as a result of the generally
hyperesthetic state of the nerve centers and many of
the nerve endings so frequently observed in the worst
forms of neurasthenia.
Hyperacidity of the gastric juice merits especial
consideration in this connection for the further reason
Ihiit some of the methods of treatment which are must
in vogue in cases of insomnia, mental depression, etc.,
tend directly to increase the secretion of the hydro-
chloric acid and thus in the end to aggravate the
malady. Thus, the tonics and stimulants which are
almost universally prescribed as a matter of routine
in neurasthenia, are probably all or nearly all excitants
of gastric secretion, and therefore when the nervous
affection is either dependent upon, or complicated
with, hyperacidity, the result must often be disap-
pointing. Mathieu6 asserts very positively that alco-
holic liquors, spices and condiments of all kinds, and
such drugs as the iodids, bromids, ferruginous salts
and the mineral and organic acids, all excite an
increased secretion of hydrochloric acid. It is more
than probable that strychnin, phosphorus, arsenic and
the other metals in their usual therapeutic doses, have
the same effect. In regard to several of these, I have
myself noted in numerous cases an increase of hyper-
acidity while they were being administered.
For the determination of the amount of hydro-
chloric acid in the gastric juice there has not yet been
discovered any reliable method except the quantitative
chemic analysis of a definite number of cubic centi-
meters of a sample of the stomach contents obtained
at a certain interval after a test meal, usually one hour
after the Ewald test breakfast, which consists of two
ounces of bread and a half pint of either water or
weak tea. In Germany especially, many elaborate
experiments have been made with the view of finding
some fixed relation between the acidity of the urine
at different times of the day and the proportion of
hydrochloric acid in the gastric juice, but so far with
only partial success. Both Boas7 and Riegel8 quote
the experiments of Quincke, Sticker and Huber in
this direction, but do not consider the claim estab-
lished that the relation is sufficiently constant to be a
safe guide. I have tested the matter in a number of
cases and found the results too varying to be reliable.
Chemic and microscopic examinations of the
stomach contents need to be made also at times dur-
ing the treatment of hyperchlorhydria to note the
results. It is especially important during the ad-
ministration of large doses of alkalies (which have
proved one of the most effective means of relieving
as well as curing this affection), to watch the
results very carefully. It is well also to test the
urine frequently to see that it does not become entirely
alkalin, and even to make an occasional microscopic
examination of the blood, since a too prolonged or
vigorous pushing of even the milder alkalin salts is
capable of doing harm.
But the treatment of either neurasthenia or any of
L896.]
ASCITES.
65
the digestive disorders with which it is so generally
associated, forms no part of the scope of this paper.
My purpose will have been fully accomplished if the
suggestions already offered shall lead to a fuller rec-
ognition, in our every day work, of the intimate con-
nection existing between the functional nervous
affections and diseased conditions in the alimentary
canal, as well as show the great practical importance
of a more exact study of the latter by the recent
scientific methods.
llllll.IOORArHY.
i Factor In the Causation of Disease," by Alex. Haig,
. ISM.
hanges in the Size, I'osltion, and Motility ol
ses where Intragastric Instruments can not !«■ I'sed,"
rdman Reed, M.D. The Medical News of Jan. IS, 18WI.
ni, .n In Disease," by Ch. Bouchard, M.D., Phila-
I "Gastritis Glandularis Chronica." by Fenton B. Turck. M.D. The
inril I. 18SW.
Mik u. Therapie iter Maitcnkrankheiten." von Pr. I. Boas,
H of the Stomach and Intestines." by Uberl .Mathieu.
cit.
I "Die Brkrankungen >!<■> Magens," by von Prof. F. Rlegel, Vienna,
THE RELATION OF ASCITES TO DISEASES
OF THE KIDNEYS, AND PARACEN-
TESIS ABDOMINALIS AS A
REMEDY.
Read in the Section on Practice of Medicine, at the Forty-seventh
Vnnual Meeting of the American Medical Association, at
Atlanta. On.. May 6-8, 1886.
BY W. F. McNUTT, M.D.
SIN FRANCISCO, CAL.
The accumulation of fluid in the abdominal cavity
with or without dropsy was recognized by the earliest
medical writers. Hippocrates was, from his many
references to the subject, evidently familiar with
dropsy and the accumulation of fluid into the serous
sacs. Erasistratus's master, Chrysippus, must have
been a contemporary of Hippocrates. According to
Galen this famous physician, Erasistratus wrote a
work on dropsy and taught that all varieties depended
upon obstruction of the liver. Galen himself taught
that diseases of other organs might also be responsible
for dropsical effusions, and that they not infrequently
had their origin in the morbid state of the blood.
Asclepiades, who seems to have been a voluminous
writer, according to what can be gathered of his views
from Celsus and Galen, divided all dropsies into acute
and chronic, not designating the particular viscera
whose disease caused the dropsy. Probably Avicenna
in his " Canon Medicinae," is the first to include dis-
ease of the kidneys as a cause of dropsy. It is ques-
tionable whether he (from postmortem examinations)
had a definite knowledge of the connection between
pathologic conditions of the kidneys and dropsy. He
makes the statement, however, that the kidneys from
the induration of their structure fail to separate urine.
hence dropsy. We have no knowledge as to what
means he had for diagnosing diseases of the kidneys.
While many writers since the days of Willis have
been particularly interested in dropsy and effusions, it
iiite safe to say that before Dr. Bright's time the
relation between diseases of the kidneys and dropsy
with effusion into the serous cavities was very vague
Scattered through the literature of dropsy one finds a
reference here and there to disease of the kidneys as
use, but from the vague language of the writer it
Iisy to see he had no definite knowledge of the
relations. Hippocrates says: "The most of them
[dropsies] commence from the flanks and loins, but
le from the liver; in those which derive their ori-
gin from the flanks and loins the feet swell, pro-
tracted diarrheas supervene, which neither remove the
pains in the flanks and loins nor soften the belly."
Adams thinks: "Hippocrates refers one species of
dropsy to disease of the parts situated in the loins, by
which Galen and Stephanus agree that he means the
jejunum, mesaraic veins and kidneys." iEgeneta
says: "For the most part it [ascites] arises from
hardness and scirrhus about the spleen and liver and
from chronic defluxions about the intestines." Are-
beus says: "Dropsy is sometimes occasioned sud-
denly by a copious cold draught, when on account of
thirst, much cold water is swallowed and the fluid is
transferred to the peritoneum; by which means the
innate heat in the cavities is congealed, and then
the dropsies which formerly were converted into air
and dissipated, flow into the cavities." Aretaeus no
doubt diagnosed ovarian tumors as ascities. " This
other form of dropsy is known. Small and numerous
bladders, full of fluid, are contained in the place where
ascites is found; but they also float in a copious fluid,
of which this is a proof; for if you perforate the
abdomen so as to evacuate the fluid, after a small dis-
charge of the fluid, a bladder within will block up the
passage; but if you push the instrument farther in,
the discharge will be renewed. This species then is
not of a mild character, for there is no ready passage
by which the bladders might escape. It is said, how-
ever, that in certain cases such bladders have come
out by the bowels. I have never seen such a case,
and therefore write nothing of them; for I am
unable to tell whether the discharge be from the colon
or the stomach." To Bright, more than to any other
writer, are we indebted for the establishment of the
relations between the diseases of the kidneys and
dropsy. He described the structural lesions of the
kidneys that give albuminous urine. Every writer
and practitioner now recognizes the important part
that diseases of the kidneys play in dropsy and the
frequency of effusion into the serous sacs in cases of
renal anasarca. No writer, however, seems to have
given the proportional frequency of ascites, hydro-
pericardium and hydrothorax in renal dropsy. No
one is surprised to find ascites developing in hepatic
or right heart obstructions or in peritonitis or cancer of
any abdominal organ for instance, but in the absence
of any of these conditions, why should ascites occur
in renal lesions more frequently than does hydro-
thorax or hydropericardium; yet the daily experience
of every practioner finds it to be the fact. In renal
diseases, barring the inflammations, pleuritis, peri-
carditis, arachnitis and peritonitis, we find effusions
into the abdominal cavities much more often than
into any of the other cavities; to be sure, in some
cases of ascites with Bright's there may also be an
indurated or nutmeg liver or a chronic peritonitis
which a postmortem would be necessary to reveal.
The heart in the following case is normal and there
is not an indication of disturbance of the liver.
The patient, a man of 58, blonde, family history
good, rather muscular, temperate habits, but has had
a life of exposure, first in the United States army as
a young man during the late unpleasant episode in
our history, and since as a mining prospector and
owner. By the aid of his wife and a friend he was
brought to this city, thinking, as he expressed it,
there might be another straw to grasp at. When I
saw him last, September 30, there was an extreme
anasarca, great abdominal distention from ascitio
66
ASCITES.
[July 11,
fluid, the most distressing dyspnea, respiration fifty-
five, pulse feeble and very rapid, face cyanosed, head-
ache and vomiting. Urine, twenty-five ounces per
day, light colored, 1012 specific gravity and coagulated
almost solid in test tube; epithelial and granular
casts; he weighed 185 pounds on the hotel scales. It
seemed scarcely possible that the man could live
many days. I returned to my office and got a trocar,
put him on the bed on his side, well braced up, as he
could not lie down, put a Kelly pad under him and
tapped him. The trocar remained in for several hours
and the fluid continued to run from the opening for
three days, when it ceased, by which time the anasarca
had disappeared and the patient weighed 130 pounds,
having lost fifty-five pounds in the three and one-half
days. The abdomen soon commenced refilling, and
on October 15 he was again tapped, draining off the
fluid, eight quarts. It promptly collected again, and
on the 20th we obtained six and one-half quarts.
Prom this time he began to improve in strength and
the urine increased to forty ounces, and for a few
days to seventy. The fluid was again collecting, but
more slowly this time, November 19 we again tapped
him, this time getting eight and one-half quarts; by
the 27th he was again quite distended and was again
tapped; the canula was left in thirty-six hours, during
which time we collected thirteen quarts of ascitic
fluid. December 10, I tapped him again, not leaving
the canula in this time, and taking off six and one-
half quarts; eight days afterward, viz.: December
8 it was necessary to tap him again; the canula was
left in forty-eight hours and fluid escaped from the
opening twenty-four hours more, most of it was con-
ducted into a bucket by the Kelly pad; we collected
eighteen quarts and the bed clothes were several
times saturated. It is safe to say that in those three
days twenty quarts of fluid escaped from the abdomi-
nal cavity. December 22 we drew off eight quarts.
By January 8 it was again necessary to tap him; left
the trocar in four days and collected thirteen quarts,
and on the 28th we got four quarts; February 10 I
drew off four quarts. I have not been able to find an
explanation in any of our pathologies of this morbid
propensity of the peritoneum in Bright's. In this
individual case the peritoneum poured out 506 fluid
ounces from December 1 to December 8, eight days;
over two and one-half ounces per hour; and no dis-
coverable obstruction to the portal circulation, and no
effusion into any of the other serous cavities. It
scarcely seems possible that we could have obstruc-
tions to the portal circulation sufficient to produce or
assist in producing ascites and that the urine should
be light in color and of light specific gravity. In
order to make ourselves believe that we understood
this form of ascites and anasarca we call it hydremic,
which conveys about as much exact knowledge of
this morbid process as that convenient word, idio-
pathic, gives us in regard to the real cause of the dis-
ease. Never having been able to find any satisfactory
explanation of this renal ascites and why it occurs so
much more frequently than hydrothorax and hydro-
pericardium, I have watched this case with a great
deal of interest. No doubt the hydremic condition of
the blood and the nutritive disturbance of the capil-
laries are factors in renal dropsy, but only secondary
factors, the primary factor is mechanical, though not
in the same sense as in obstruction of the heart and
liver. The peritoneum in Bright's pours out fluid
more often than does the pleura or pericardium,
because it is more pendent, it requires more arterial
force to drive the blood through the capillaries of the
peritoneum into the veins than through the capillaries
of the pleura or pericardium. The abdominal veins
are numerous and without valves, and edema into the
abdominal walls seems to obstruct the venous circu-
lation. When a dropsical patient sits up all day his
feet are greatly swollen at night owing to their pend-
ent position; after remaining in bed all night the
swelling has disappeared by the morning. The
patient is hydremic, but the fact that swelling occurred
during the day when the feet were pendent and dis-
appeared when the patient was in a horizontal posi-
tion shows that this form of dropsy, too, is primarily
at least, mechanical. With hydroperitoneum and
perhaps with all dropsies there are two mechanical
factors, the one as we have seen, pendent — gravity;
the other is compression. No sooner has the blood
serum escaped from the distended, weakened capilla-
ries and veins than its accumulation in the lymph
spaces outside the capillaries faster than it can be
taken up by the lymphatics compresses the capillaries
and offers mechanical resistance to the passage of the
blood into the veins. In this case I noticed that as
soon as the abdominal walls would become edematous
the accumulation of fluid in the cavity was rapid.
After the tapping of January 8 I packed the abdomen
with hot applications of alcohol and water and band-
aged, making quite a little compression. I thought
by supporting the abdominal walls by bandage and
stimulating the blood vessels by alcoholic stupes we
might prevent the rapid pouring out of fluid by the
mural peritoneum. It will be noticed in the next
twenty days, only four quarts of fluid were obtained
by the tapping of the 28th and from the 28th to Feb-
ruary 10 we had only four quarts. During all the
time the urine averaged about forty ounces with from
1 to 2 per cent, of albumin, and about two hundred
grains of urea daily. The ascitic fluid usually con-
tained about one-half of 1 per cent, of albumin.
Since the first tapping, when the patient lost fifty-five
pounds in the three and one-half days, we have taken
by the various tappings sixty-eight quarts, 136
pounds, which added to the 55 pounds makes 191
pounds. From September 30 to February 10, 132
days, or 3,168 hours, the 191 pounds is 3,058 ounces,
almost an ounce an hour. The patient has not been
tapped since February 10, is still weak (April 10) but
much better than he was before the first tapping. His
diet has been largely milk and a prescription of car-
bonate of iron and sulphur is the only medicine that
seems to agree with his stomach or to be of use to him.
He always feels better while taking this prescription
and the urine falls off when it is stopped. Too fre-
quently, tapping is resorted to by many practitioners
as a last resort; to my mind and in my experience it
is the most important remedial measure we possess in
these cases of renal ascites and anasarca, stimulating
stupes and bandaging and gentle friction and massage
are remedies for the prevention of the accumulation
of ascitic fluids in Bright's disease. In this case the
fact that the patient is living .is owing entirely to
tapping. He could not have lived many days in the
condition in which I found him, nor would it have
been possible to relieve him by cathartic medicine.
There is still nearly 1 per cent, albumin in the urine,
but it is not impossible for the kidneys to recover.
In one case of cirrhosis of the liver, in which I was
called in consultation, with the idea that tapjDiiig
L89t>. ]
CHRONIC TUBERCULOUS PERITONITIS.
67
ought to be done as a last resort to prolonging life,
after repeated tappings collateral circulation was
established and the patient lived three years. Paulus
evidently approved of tapping and gives explicit
directions as follows: "And it having been there
shown that ascites alone falls tinder the province of
surgery, we are now going to give an account of it.
Wherefore we must make the patient stand erect, or
if that can not be done, we must cause him to be
seated, or if lie is so weak that this can not be done,
we must abandon the operation entirely. If then the
man be standing erect we give orders to the assistants
standing behind to press with their hands and push
downward the swelling to the pubes. Then taking a
sharp- pointed knife or lancet, if the dropsy is among
the intestines, in the perpendicular line of the navel,
and about three fingers' breadth distance from it we
divide the hypogastrium as far as the peritoneum.
But if the liver be primarily affected we must make
our incision on the left side of the navel, or if the
spleen, on the right, for we must not make an incision
in that part on which the patient is disposed to lie.
And having dissected with the point of the instru-
ment the skin that lies over it, we divide the perito-
neum a little above the first incision until the
instrument comes to an empty space. After this we
introduce through the incision of the abdomen and
peritoneum a copper tube, having an opening like
those of writing pens, and by this we must abstract
the fluid in proportion to the strength; feeling the
pulse and then removing the tube, we stop the flow
of fluid ( for it will stop immediately from the altera-
tion of the incision) and, for the sake of security, we
introduce a twisted tent into the incision of the
abdominal parietes alone; and having placed the man
in a recumbent posture and recruited him, we may
next day again evacuate through the tube a small
quantity of fluid proportionate to his strength; and
thus in like manner, until very little be left, avoiding
by all means a sudden evacuation, for some ignorant
persons having evacuated the vital spirit with the
fluid have immediately killed the patient."
REPORT OF A CASE OF CHRONIC TUBER-
CULOUS PERITONITIS
WITH REMARKS ON DIAGNOSIS AND TREATMENT OF
THE DISEASE.
Read in the Section on Practice of Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association,
at Atlanta. Ga., May 5-8, 1896.
BY H. W. McLAUTHLIN, M.D.
PKOFK*SOR OF MEDICINE IN THE UNIVERSITY OF COLORADO; ATTENDING
PHYSICIAN TO THE ARAPAHOE COUNTY AND ST. LUKE'S HOSPITALS.
DENVER, COLO.
A. S., male, age 55, born in the United States, occu-
pation laborer, was admitted to the Arapahoe County
Hospital, Denver, Jan. 10, 1896. His father died
from violence and his mother from old age. One
sister died of tuberculosis. He had been strong and
robust up to three years before, having spent much
of his life on the Western plains. He contracted
syphilis when a young man. For many years he
drank whisky more or less continuously. Three years
previous to admission he noticed that the abdomen,
reel and legs were swollen, and that he was short of
breath. Some abdominal swelling had existed off
and on since that time.
About a week before admission, while doing some
heavy work, he was taken suddenly with sharp pains
in the back and abdomen, especially in the lower
part. He was obliged to take to his bed. On admis-
sion to the hospital, lie still complained of pain, espe-
cially in the back. There was considerable ascites
but no swelling of the feet and legs. The body was
considerably emaciated, the face thin and the eyes
sunken; there was no jaundice although the eyes
looked muddy. The liver dullness was moderately
increased upward. The ascites prevented any satis-
factory abdominal examination. The examination of
the heart, lungs and urine was negative. The pulse
varied between 80 and 100. The temperature was
usually below normal, and never rose above 100. The
respirations were from 20 to 26. Within ten days
after admission, the ascites had increased very con-
siderably, and jaundice was plainly apparent over the
whole body. As the ascites and jaundice increased,
he grew progressively weaker, and more emaciated.
He was inclined to be drowsy. The scrotum, feet
and legs became quite edematous. The superficial
veins of the abdomen and thorax were enlarged. He
vomited occasionally after eating.
A report was requested, but not obtained, on the
bacteriologic examination of the contents of the
stomach after a test meal. As a rule there was no
severe pain excepting in the lower part of the back.
One attack of severe abdominal pain occurred, lasting
about twenty-four hours and requiring turpentine
stupes. The bowels moved regularly under sodium
phosphate, which was being administered. The
stools were clay colored after jaundice developed.
One examination of the urine showed a faint trace of
albumin with hyalin casts; the other examinations
revealed nothing abnormal but bile pigment. He
stated that frequent and difficult urination had troub-
led him previously at times.
The treatment was palliative. The attending sur-
geon was asked to withdraw the abdominal fluid in
order to give some relief possibly to the patient, and
to aid in the differential diagnosis. The surgeon,
however, counseled against it. Death occurred Feb-
ruary 11 from gradually increasing asthenia.
AUTOPSY.
The following autopsy was performed twenty-four hours
after death by Dr. E. R. Axtell, pathologist to the hospital :
The body is that of an adult male, apparent age between 50
and 60 years. The body is well developed, but poorly nour-
ished. The skin shows much jaundice. Postmortem staining,
and rigidity well marked.
On opening the abdomen, fully a gallon of serous fluid,
deeply stained with bile, escapes, while apparently half that
quantity remains behind in the dependent portions. Within
the chest, the heart, lungs and pleurae are found normal, ex-
cepting that all the tissues of the chest, especially the aorta,
are bile stained.
The intestines are matted together into a mass the size of a
child's head and lie in the middle line on the spinal column.
They are only slightly distended, and the serous surface is
studded with miliary tubercles varying in size from a millet
seed to a grain of wheat. This tuberculous infiltration extends
over all the abdominal organs as well as over the anterior wall
of the abdomen.
The omentum is rolled into an elongated mass, twice as long
as it is wide, and lies across the upper part of the abdomen
underneath the stomach and just left of the portal fissure.
On section this mass shows tuberculous infiltration, but no
cheesy areas are found.
The liver is normal except for a large scar, undoubtedly syph-
ilitic, on the upper surface of the right lobe. The spleen is
normal. The stomach is normal except that the serous sur-
face shows less tuberculous nodules than the surrounding
tissue. The kidneys seem normal to the naked eye. The
brain and cord were not examined. Cause of death tubercu-
lous peritonitis.
68
CHRONIC TUBERCULOUS PERITONITIS.
[July 11,
A positive diagnosis was not made during life. It
was supposed to lie between cirrhosis of the liver
and cancer accompanied by limited peritonitis. In
favor of cirrhosis were the following points: 1, his-
tory of steady indulgence in alcohol and of having
had syphilis; 2, the development of marked ascites
with only slight and slowly developing edema of other
parts; 3, gastro- intestinal symptoms and jaundice;
4, the hepatic facies; 5, the increased liver dullness;
6, the length of time from the first symptoms to
death.
Opposed to cirrhosis were the following points:
1, the history of swelling of feet and legs occurring
simultaneously with the previous attack of ascites
three years before ; 2, the rapidly increasing jaundice
toward the close of life would scarcely be expected
excepting with the hypertrophic or biliary cirrhosis,
a form not borne out by the other symptoms.
In favor of cancer were the following points: 1,
age; 2, marked cachexia and wasting at the last;
3, negatively, the inability to exclude tumor in the
gastric region on account of the ascites.
Opposed to cancer were : 1, the slow course of the dis-
ease (three years); 2, the absence of tumors in other
parts of the body; 3, the extent to which ascites
developed, which is usually slight unless associated
with cirrhosis.
Had aspiration been resorted to, as it unquestion-
ably should have been, it is more than likely that
the omental tumor lying across the upper part of
the abdomen, together with the smaller masses, some
of which must have been palpable, although such
conditions occur in both cancerous and tuberculous
peritonitis, would have turned the balance in favor of
tuberculous peritionitis as a diagnosis, all the evi-
dence being taken into account, although opposed to
it was the fact that no tuberculosis of the lungs or
other parts could be demonstrated.
According to Strumpell, tubercle bacilli are not
usually present in the exudation of tuberculous peri-
tonitis, so that a bacteriologic examination of the
ascitic fluid would probably have been useless as a
diagnostic point.
It is interesting to study the probable starting
point of the disease in this case. It could not have
been part of a general tuberculous process. In such
cases the peritoneum is usually affected through the
intestines and mesentery. As in women, the disease
often extends from the Fallopian tubes, so in man the
prostate gland and seminal vesicles may be the start-
ing point. The age, the history of frequent and
sometimes difficult urination, and of the pain being
especially located in the lower abdomen and back
seem to point to the possibility of these structures
having been the commencing point of the disease in
this case. However, it is not improbable that the
peritoneum as a whole may have been the primary
seat of the process.
Out of 357 cases collected from literature in Vol. II
of Johns Hopkins Hospital reports, only twenty-five
were over 50 years of age. The present case was 55
years old.
The absolute covering of all tissue in the abdominal
cavity by tubercles was an interesting feature in this
case, as well as the tumor-like masses, especially the
omental tumor in the upper part of the abdomen.
Indeed the condition was not far removed from the
one described by Osier where "In rare cases the tumor
formations may be due to great retraction or thicken-
ing of the intestinal coils. The small intestine is
found shortened, the wall enormously thickened, and
the entire coil may form a firm knot close against the
spine, giving on examination the idea of a solid mass.
Not the small intestine only but the entire bowel,
from the duodenum to the rectum, has been found
forming such hard nodular tumor." In this case a
large solid mass of intestinal coil was removed and
exhibited in the lecture room.
Tuberculous peritonitis is of special interest in a
diagnostic point of view from the great diversity of
symptoms it presents, as well as from its simulation of
other diseased conditions. It has repeatedly been
found present in abdominal and pelvic operations
without having been suspected. On the other hand,
the onset may be so sudden and the symptoms so
severe as to be considered ordinary acute peritonitis
or even hernia. The ascites is usually limited in
amount, but when it is large, cirrhosis of the liver
may be simulated and suspected particularly if the
patient has been an alcoholic. Moreover, cirrhosis
often becomes complicated by tuberculous peritonitis
before death. Again with moderate continuous
fever, slow development, tympany and abdominal
pain, typhoid fever, is simulated; while in some cases
a peculiar pigmentation of the skin has caused the
diagnosis of Addison's disease to be made.
Perhaps the most difficult feature of the diagnosis
of tuberculous peritonitis arises from the frequent
occurrence of tumors or tumor-like masses in the
abdominal cavity. Osier in his text book on medi-
cine speaks particularly of them. The rolled up and
hardened omentum which may lie across the upper
portion of the abdomen or below this region may
simulate cancerous peritonitis although this condition
is far more likely to occur in the former disease than
the latter. When the fluid is sacculated, it is apt to
be located in the middle zone of the abdomen, and in
women ovarian tumor is simulated. The singularity
must be great, for Osier says that in fully 33 per cent,
of the recorded cases of laparotomy in tuberculous
peritonitis, the diagnosis of ovarian cyst had been
made; moreover tuberculous peritonitis is often asso-
ciated with tuberculous disease of the tubes. Rotch
in his pediatrics says " that most doubtful cases of
abdominal tumors in children are tubercular. "
Great diagnostic importance is placed on the per-
sonal history and on finding evidence in other parts of
the body of old tuberculous lesions especially in the
pleura, the apex of one lung, the testis in the male
and the Fallopian tube in women. No reliance can
be placed on the personal appearance, as a patient
with this disease may appear well nourished and in
good health.
Regarding treatment, the concensus of opinion to-
day seems to be that it should be both medical and
surgical; that if after rest and appropriate constitu-
tional treatment, there is no progress and especially if
the ascites increases or is already considerable, aspira-
tion or siphonage should be done. If after one or two
withdrawals, the fluid tends to return, especially if
the case seems to be at all desperate, laparotomy
should be resorted to. At times after withdrawing
the fluid the cure seems complete, at other times
there is temporary improvement, while again it hap-
pens that the tuberculous process is arrested in the
peritoneum only to break out afresh in some other
and probably more dangerous tissue.
1896.]
INTESTINAL ANTISEPSIS IN EPILEPSY.
(59
QJTESTINAL ANTISEPSIS, DIET AND CAS-
ITRATION IN RELATION TO EPILEPSY.
Konii in die Section on Practice of Medicine, at the Forty seventh
Annual Meeting of the American Medical Association held at
Atlanta. Ua., May &-*>, 189(5.
BY EVERETT FLOOD, M.D.
■CFUINTINDKNT Or HOSPITAL COTTAGKS FOR C1I1LDKKN.
KA1.DWIN8VILLK, MASS.
The effort has been in the present paper to offer as
briefly as possible some individual conclusions as to
the advisability of employing the three methods enu-
merated in the title.
Pages have been filled, and can be again filled, with
observations and statistics relating to the epileptic
symptom. I leave aside now all that class of work
and present these three as newer methods and those
whieh to my mind promise, especially in young cases,
rather better results than any plan with drugs as
usually employed.
The first attack in many instances is after excessive
eating, as in the following case : A girl of 14 ate heart-
ily and hastily at dinner, then took a pint of peanuts
on her way to school and, soon after the session opened,
had a fit. She vomited large chunks of beef and a
great quantity of other food. A second fit occurred
three months later after another, though less, over-
indulgence in food; and they recurred at intervals,
always with a similar apparent cause, though after the
establishment of the habit the excess required was
slight.
The person manifestly, in order to guide against
excess and putrefaction as much as possible, ought
from the outset of the child's life to have suitable food
in right amount at proper intervals.
The gluttony of this class of persons is well known.
Unrestricted they nearly all overeat. A sample sup-
per recorded from an actual case, taken at random
when no restraint was used was as follows: Boy of 14,
six slices of bread and butter; one bowl of hulled corn
and milk: three saucers of apple sauce; two cups of
oocoa; three cookies.
Many such instances might be cited, though I am
fully aware that the initial attack, when not traumatic,
is not always traceable to the digestive overbalance.
To regulate and control the food of the child, when
there is known to be danger, are rational methods of
treatment and have actually proved effective in many
instances. I have tested many drugs to a degree and
still have observations going on, but I believe more
fully in prevention of this trouble than in a possible
cure, and the suggestion has many times presented
itself as to whether or not the good effects of certain
drugs in special cases may be more due to their tend-
ency to correct either putrefactive changes or para-
sitic influences than to any other quality. With this
in view I have a number under various methods of
drug treatment, but not as yet conclusive results to
record. Auto-intoxication in diseases has received
much well merited attention.
We are taught in the main merely a suitable choice
of food, cleanliness, right living and to prevent putre-
factive changes as far as we can by drugs or other
methods. We have merely the same principles to
follow when putrefaction takes places instead of whole-
some digestion as in the instances where we seek
relief from parasitic products and from other sepsis or
ti ixins.
Intestinal parasites are unquestionably common.
They are not conducive to the health of the child and
it would be well if all could be removed. Doubtless
such forms of life have their place in the economy of
nature; but inside the human subject that place should
eventually be taken by nutrient solutions, unsapped
by even microorganisms, for the strengthening of the
surrounding body. Dog breeders well know that all
dogs have worms and that vermifuge will prevent or
cure fits. The relatively longer intestinal tract in
dogs very likely increases the animal's liability to have
a fit. Chickens from incubators are apt to be abnor-
mal, to have fits, deformities, etc., but I can not say
that they have fewer intestinal parasites than the
ordinary chicken. It is claimed that no dog can be
reared free from such residents, whatever precaution
may be taken with food and care; but I am of the
opinion that no case has, as yet, been adequately
tested to determine this point.
For purposes of disinfection and for destroying a
part of the parasitic life large injections into the
bowels, large draughts of water and perhaps the use
of the ozone preparations give promise of some favor-
able results. Keeping the bowels open by suitable
food and manner of life, massage of the abdomen,
baths to aid digestion, and the measures before out-
lined, will certainly afford us a better outlook than the
over-medication which has hitherto prevailed.
I have twenty-two cases of castration to report,
twenty in males and two in females. I was first led
to do a castration by my desire to do something to
prevent masturbation in certain few boys who were
also epileptic, and the habit is not as likely to become
offensive in the non-epileptic. Castration as well as
circumcision, which, if not God-given rites, are cer-
tainly worthy to have come from the mind of Deity
conscious of the need of correcting a structural error,
have bitter opponents. I would not be so unreason-
ing as to expect all men to agree even upon the most
self-evident proposition. The opponents of vaccina-
tion are howling with as much persistency in the face
of the most convincing statistics as they did at the
beginning of the century when Jenner was promul-
gating his beliefs. The operation is old. I need not
go into its history though a volume might be written
thereon.
There is no doubt that the custom prevails in East-
ern countries, as formerly, of emasculating certain
youths to serve as safe attendants upon the royal
women, and among another class for the purpose of
keeping the youthful qualities of the voice.
As to the method of operation I may be allowed
briefly to suggest that it seems an advantage to make
one very small incision in the median line of the
scrotum and then squeeze out each testicle successively
through the opening. The cut is then easily closed
with one stitch and the place being painted with co.
tr. benzoin, always heals at once. There will be some
induration of the stumps beneath the surface but this
gradually absorbs and in a very few days the patient
is in a safe position. I hardly dare to claim priority
of use of this operation, but I certainly originated and
used it without knowing of its application in any
other quarter.
The effects of castration are, as far as I have observed
them, as follows: The masturbation, which is the
most important, finally ceases in all cases. Sometimes
it persists for months with varying intensity, but it is
not obtrusive even in these instances and eventually
the habit is dropped. The boy gets plumper and has
a clearer complexion. The voice is milder and pleas-
70
DIAGNOSIS OF CARCINOMA OF THE STOMACH.
[July 11,
anter and remains so if the case is a young one, at least
for a few years, and probably permanently. The boy
is less inclined to violence and domineering. The
possibility of reproduction is of course eliminated. I
consider this a most useful safeguard. I can not
understand why any parent having such a son as we
are considering should hesitate to have him castrated
even if there were no other object than the last one
named. No parent understanding the probability of
inheritance in such a nervous case, ought to care to
run the risk of becoming a grandparent. Sentiment
is very wrong on most matters until set right by rea-
son and education. So it is here. There is, however,
some hope for spread of intelligence in such a matter
as this, but judging from past progress I conclude
that a hundred years of deliberation is likely to leave
the public in much the same state of intelligence as
at the present day. There has always been some
fear among medical men that a male masturbator
being castrated would fall into lasciviousness or
into some other immorality worse than his first state.
I do not find this fear substantiated in my cases. We
had two boys who were kleptomaniacs as well as epi-
leptic masturbators. For some weeks after the opera-
tion this manifestation was exaggerated, but it sub-
sided entirely in a few weeks and only slight and
infrequent traces have appeared for a year in one case
and two in another. I find that these boys after
operation do not entice other boys to masturbate.
They have no tendency to think of sexual matters.
The smutty story mania disappears and other unpleas-
ant and gross manifestations are hajipily wanting.
The effect upon the force and frequency of the fits
seems in all cases to be noticeable. There have been
the same periods of fits and about ^he same length of
period, but each fit has been less in time and milder
in type.
Two females have been under my observations both
of whom were castrated between the ages of 16 and
20. Certainly no general deductions can be made
from so few cases but so far as my experience goes
with them, I feel that the operation is not as thor-
oughly useful as with boys. There are, however,
plenty of arguments to show that it is fully justifiable
and might even be very desirable. To prevent con-
ception is a very great desideratum, but to encour-
age the woman to safe and indiscriminate indulgence,
which such a case would often be inclined to, would
certainly be bad. The first two of these methods cut
off in the offspring much of the unintellectualized
emotional life which eventuate in the various neurotic
disorders. The last is especially adapted to all those
instances where we feel certain that marriage would
never be proper.
DISCUSSION.
Dr. G. W. Webster, of Chicago— I assume that in the light
of the most recent pathology, epilepsy may be said to be a con-
dition of cortical instability. That is its essential underlying
condition. It is characterized during the attacks by convul-
sive seizures, attended by loss of consciousness. If, then, we
have, as a basis of the epilepsy, cortical instability, we must
further recognize the fact that cortical instability may be influ-
enced in many ways, directly, by the blood circulating in the
cortical portion of the brain ; and probably by uric acid and
other waste products from the blood. This has led Haig and
his supporters to hold that a large number of cases of epilepsy
are due to uric acid circulating in the blood. The cortical
portion of the brain may not only be influenced directly in the
manner stated, but also by trauma, producing Jacksonian epi-
lepsy. It may be influenced reflexly, and it is a matter of com-
mon knowledge that certain errors of refraction may produce
epilepsy, and it was for this reason that a certain gentleman in
New York a few years ago offered glasses or division of ocular
muscles for the cure of all cases of epilepsy. We also know that
in young boys irritation of the penis may result in epileptic
seizures. I have seen the case of a child who was having as many
as twelve to eighteen attacks in twenty-four hours, thathad con-
tinued for a year and a half, cured simply by circumcision, we
must remember, then, that we may have epilepsy as a reflex
condition excited from the genital organs, from the eyes, from
the intestines.
Dr. Louis Paugeres Bishop, of New York— It seems to me
that in discussing epilepsy as a reflex result of irritation we are
going backward. Epilepsy is an essential disease of the cortex
of the brain, and the fact that a certain small proportion of
cases are aggravated by local irritation is acknowledged by all.
But I think the stund taken now in the Vanderbilt clinic,
where they have seen many thousand cases of epilepsy, and
they have been referred to various specialists for various kinds
of treatment. We have had them circumcised, trephined, the
nose and eyes treated, and so on. We think that a reflex cause of
epilepsy is a very small factor and that it is hardly justifiable
even to trephine. Our cures from trephining have all been
temporary, and certainly if you trephine in a case where the
source of irritation is right at the cortex, and you find that in
spite of removal of that area the cure is only temporary, you
would feel that anything like castration was hardly justifiable.
Dr. Webster, of Chicago— The point which I insisted upon
in the beginning of my remarks was, that the essential condi-
tion in epilepsy is one of cortical instability. That that brain,
and the individual of which it forms a part, is what it is from
two sources, heredity and environment : and that, given a child
with a "brain in this condition of cortical instability, treatment
of the eye, castration, or anything else, will not change it, and
we must recognize this cortical instability to begin with.
EARLY DIAGNOSIS OF CARCINOMA OF
THE STOMACH BY MEANS OF
CHEMIC ANALYSIS OF THE
GASTRIC CONTENTS.
Read in the Section on Practice of Medicine, at the Forty seventh
Annual Meeting of the American Medical Association, held at
Atlanta, Ga., Mav 5-8, 1896.
BY W. C. WEBER, M.D.
VISITING PHYSICIAN TO THE GERMAN HOSPITAL.
CLEVELAND, OHIO.
The question of how to arrive at an early diagnosis
of cancer of the stomach is certainly one which has
attracted considerable interest in recent years, and
hence concentrated efforts in the study of this pecu-
liarly interesting disease. The reason of this becomes
apparent in view of the fact that not infrequently
cases come under one's observation which present few
and indefinite objective symptoms and a vague sense
of disturbance in the digestive process as the only
subjective symptom of ailments which in their later
stages prove unmistakably to be cancerous.
To proceed in the ordinary way, to palpate, percuss
and gather the history of the case, is insufficient and
often ends in negative and disappointing results.
Such failures can, to a great extent, be obviated by
supplementing the usual method of diagnosis with a
process of chemic analysis to which the stomach con-
tents are subjected.
The time was, not long since, when the absence of
hydrochloric acid from the stomach contents was
regarded as a symptom almost pathognomonic of car-
1896. |
DIAGNOSIS OF CARCINOMA OF THE STOMACH.
71
oinoma. This symptom in itself does not now receive
the diagnostic prominence it did in the past, for the
reason that this acid may be absent in both acute1
and chronic gastritis in which no neoplasm exists as
a causative factor.
At the present time there is a tendency to attribute
at diagnostic importance to the existence, in the
gastric contents, of lactic acid. It may scarcely seem
necessary to say that the presence or absence per sc
of one or the other of these acids is no positive sign
of the existence or non-existence of cancer of the
stomach. The constant absence of hydrochloric and
the contstant presence of lactic acid, in connection
with certain other symptoms or conditions are of the
highest diagnostic import. This point I shall en-
deavor to emphasize by the citation of a case or two,
further on, which at the same time illustrates char-
acteristics of cases most difficult of diagnosis.
Preparatory to the investigation of the gastric juice
all medication is to be excluded for a day or two pre-
vious to the administration of the test breakfast which
isists of a light biscuit or small piece of toast and
a cup of weak tea or glass of water (it is well to note
here that after the test breakfast the HC1 may be
absent and may reappear when a meal of steak, potatoes
etc.. is used); this should lx' given from one to two
hours before the removal of the stomach contents
which should be forced, or expressed, through the
stomach tube without the addition of water and the
stomach may then be lavaged in the usual manner
before the tul>c is withdrawn.
The quantity of the expressed gastric contents is
noted, then filtered and the reaction determined; if
this lie neutral or alkalin no acid tests need be
applied; if acid, the total acidity may at once be
ascertained by the process of titration; or one or more
of the te.-ts for free hydrochloric acid maybe used.
Those most commonly employed are the anilin dyes
of which (iiiiizburg's test dimethylamidoazobenzol,
Congo-red and tropeolin are preferred. Tropeolin,
an orange colored powder, is dark yellowish red in
saturated aqueous or alcoholic solutions and in the
presence of free HO (1 in 4,000) changes to a dark
brown; the acid salts give it a light straw yellow.
Congo-red is changed to a sky blue by the pres-
ence of hydrochloric acid. It is more delicate than
tropeolin and is not affected by acid salts. A paper
has been prepared containing this substance and is
used in the same manner as litmus paper.
The first mentioned test, Gtinzburg's," possesses
several important advantages over those just described.
This reagent has a pale yellow color and is fairly
hie when kept in a dark place. Its superior value
chiefly lies in the simplicity of its application, the
reliability of its action, which is not interfered with
by the presence of albuminates, giving it in this latter
respect a distinction accorded to none other of this
group; it has no effect on salts or organic acids. To
a drop of the reagent in a porcelain dish is added a
drop of stomach contents and slowly heated over an
alcohol lamp; if free HC1 is present, even in so
minute a quantity as 1 in 20,000, there is produced a
bright red tinge along the edges or delicate stripes
through the drop. Overheating, especially when
lbuminous matter is abundant, produces a brownish
r reddish coloration in the center of the drop, which,
owever, is easily distinguished from the characteris-
i Kwald.p. 290.
2 Phlorogluciu 2, vanillin 1, and absolute alcohol 80.
tic reaction of HC1. Should there be any doubt as
to the character of the reaction it is advisable to make
use of a control test which may consist of an indefin-
itely dilute hydrochloric acid solution. This reaction
is always a distinctive one though varying from a
bright red to a pale rose color, depending on the
degree of hydrochloric acidity. By a little further
detail the test can be rendered quantitative by dilut-
ing the gastric contents one-third, one-sixth, one-
tenth and so on with water, noting between what two
successive dilutions the reaction no longer appears
the limit of which we know to be in the neighborhood
of 1 in 20,000. Another test which has lately come
to our notice is the dimethylamidoazobenzol.3 It
consists of the addition of one or two drops of the
reagent to one or two drams of the stomach juice,
which changes to a red color when HC1 is present.
The stability of the reagent, its delicacy and extreme
simplicity of application, make it one of the most, if
not the most preferable of all tests.
As a high degree of acidity of the stomach contents
does not in itself indicate the presence of HC1, yet
possessing pathologic significance, it becomes impor-
tant that the total acidity be determined. This is
accomplished by the process of titration which is as
follows: A deci-normal soda solution is allowed to
flow from a burette, drop by drop, into a small glass
beaker containing 5 or 10 c.c. of the filtered stomach
contents and one or two drops of phenolphthalein
solution. When the acid reaction is overcome the
contents in the beaker changes to a red color, and the
reading from the burette indicates in c.c. or fractions
thereof the amount of the standard solution required
to neutralize, from which the percentage of acidity
can readily be calculated. To illustrate: Suppose it
would require 8 c.c. of the deci-normal soda solution
to neutralize 10 c.c. of gastric contents; it is thus
apparent that the total acidity is 3 or in other words
30 per cent. In place of the phenolphthalein, litmus
paper or better the litmus pencil can be used, but
these require more labor and care. The normal total
acidity ranges from 40 to 65 per cent, and a deviation
in either direction from these figures is regarded as
abnormal.
As it is not intended in this paper to dilate on the
significance of a high or low degree of acidity of the
gastric juice, and omitting the citation of the class of
diseases occurring in each condition, we come to the
consideration of lactic, the principal of the organic
acids. The presence of the organic acids in the early
stage of gastric digestion may be and usually is normal;
it is, on the contrary, when found in the later stage of
the digestive process, attributed to morbid influences.
This is not difficult to comprehend when it is remem-
bered that the prolonged sojourn of food tends to fer-
mentation in the stomach due to pathologic altera-
tions, notably such as occur in carcinoma of this viscus.
But inasmuch as we do not at this time wish to deal
with the etiology and pathology of cancer of the
stomach, it is perhaps sufficient to^state that there is a
preponderance of evidence indicating the presence of
lactic acid in cancerous diseases of this locality fully
as often as the demonstrated absence of the hydro-
chloric.
Boas, in 1893, was first in calling attention to the
value of lactic acid in the diagnosis of the disease
under consideration. He further made the observation
that this acid is produced in all test meals in which
8 Fisher and Philipp, Anal. Pharm. 28, $ 434.
72
DIAGNOSIS OP CARCINOMA OF THE STOMACH.
[July 11,
bread or meat enters as a constituent; and he there-
fore resorts to a breakfast of 1 to 2 liters of a thin oat-
meal gruel sprinkled with a little sodium chlorid;
this is expressed from the stomach an hour later and
Uffelmann's test applied. This test is based on the
reaction of lactic acid on a diluted neutral ferric
chlorid solution.- It is a very simple method and the
reagent can be freshly prepared for every application
in the following manner: To 1 dram of a 5 per cent,
aqueous carbolic acid solution add one or two drops
tinct. ferri chloridi which turns it to a beautiful
amethyst blue. When a solution containing lactic
acid is brought in contact with this reagent thus pre-
pared it assumes a canary yellow. The reaction is
very characteristic and limited experience will enable
the tyro in this line to make the proper distinction
between this and various other shades of yellow which
may be caused by such substances as sugar, alcohol,
and particularly the phosphates. When the stomach
juice has a decided yellowish color, the test may be
unsatisfactory, necessitating a modification which can
be effected by obtaining an ethereal extract, which is
then subjected to the usual method. The fatty acids
react to Uffelmann's reagent by giving a tawny yellow
with a reddish tinge. This is particularly so in the
case of butyric acid which can also be demonstrated
by the presence of minute oily drops forming in an
aqueous solution of the residue of an ethereal extract
to which calcium chlorid has been added.
Acetic acid can best be detected by the sense of
smell unless present in a very minute quantity. Pep-
tones and propeptones (test applies to both) may be
readily demonstrated by the biuret reaction. This
consists of the action of a dilute cupric sulphate solu-
tion on the peptones or propeptones, producing in an
alkalin medium a purple red color, while albumin
simply shows a bluish violet.
In this connection it was interesting to note in my
work that when the heat and acid tests showed large
quantities of albumin, a correspondingly feeble biuret
reaction took place, and vice versa, so that by testing
for the one the presence or absence of the other could
be quite accurately predicted. It seems that peptones
are formed whenever pepsin is contained in acid con-
tents, though HC1 be absent. Hence no great diag-
nostic significance attaches to these products.
Examination of the blood will often lend very mate-
rial aid in differentiating carcinoma of the stomach
from the pernicious anemia caused by atrophy of the
glandular apparatus of the stomach. In cases of can-
cer of the stomach that have reached a stage where it
may be confounded with the pernicious anemia depen-
dent upon glandular atrophy, there is always a poly-
nuclear leucocytosis of varying degree, poikilocytosis,
a considerable loss of hemoglobin, a diminution of the
number of red cells, which, however, is not as marked
as in cases of pernicious anemia of glandular atrophy.
The practicable application of the foregoing at once
becomes apparent when we recall experiences in diag-
nosis of stomach diseases where, for example, a car-
cinomatous affection has been called in turn, " a little
stomach trouble," "dyspepsia," "chronic catarrh,"
etc., until the disease has made such progress in its
development that longer failure in its recognition
would be almost impossible. For, does it not seem
reasonable that an organ having undergone structural
changes, should first evince that fact by an alteration
in its function? If so, we may reasonably expect
pathologic changes in the secretions at a compara-
tively early period, the clinical significance of which
is now more correctly interpreted.
As before stated, it is common knowledge that for
some years too great a value has been placed on the
absence of HC1, the hitherto almost certain symptom
of gastric carcinoma. Now, it is generally recognized
that any morbid process which involves the deeper
structures, and especially the peptic glands of the
mucous membrane, may be followed by the cessation
of the formation of this acid, and therefore can not
be regarded with the importance of the past, for it is
also a well-known fact that in a great majority of
cases of hepatic cirrhosis there is a complete absence
of HC1.
It has been stated, too, that the production of lactic
acid was caused by stagnation, and Boas and his fol-
lowers affirm that in no disease in which stagnation of
stomach contents occurs is there so much lactic acid
ferment developed as in cancer of the stomach. Not-
withstanding, this observation has been corroborated
by other authority, to unqualifiedly assert that the
absence of the mineral and the presence of the organic
acid is positively indicative of cancer, would be too
strong a statement. In support of this view it is
pertinent to call attention to the case of Noorden,* of
Frankfort. He found HC1 absent and lactic acid pres-
ent in enormous quantity in a case of gastric ulcer
that had perforated into the pancreas.
In chronic gastritis and atrophy of the mucosa due
to any cause, there may be a diminished or entire
absence of HC1; and if the latter acts merely as an
antiseptic, as has been suggested, thereby preventing
the formation of lactic acid, it may readily be seen
that the acid symptoms are insufficient in themselves
for positive diagnosis. But when these are associated
with any one or twd of certain other symptoms, as
cachexia, loss in weight, pain or tumor, scarcely a
doubt remains as to the nature of the disease. Unfor-
tunately, it often happens that none of the last men-
tioned symptoms become manifest until the disease
has progressed toward its fatal end, the time having
long gone by when surgical means might have offered
the only avenue of escape from the inevitable doom.
When vomiting, great diminution in weight, tumors,
etc., have declared themselves, the disease has passed
beyond human intervention. In view of the fore-
going, the time may not be far distant when tumors
(cancers) will be removed from the stomach with far
greater frequency than they are at the present time.
And to make this possible is, I believe, the province of
medicine — to clear and illumine the way on the line
indicated.
To give statistics illustrative of what others have
accomplished in this field, would no doubt be inter-
esting, but time forbids. We will therefore conclude
this paper by citing two cases which quite accurately
represent a large proportion of cases in which none
of the symptoms formerly relied upon are visible, but
whose gastric juice nevertheless, in connection with
the conditions before mentioned, bears us a message
of great diagnostic value.
Case 1.— Mr. E. M., aged 68, normal weight 200, tall and
complexion light, married and father of several children. Lived
an active out-door life and enjoyed good health until the time
of the illness of which we are writing. With the exception of
being an excessive smoker, personal habits were good. Hered-
ity, negative. The existing difficulty first manifested itself
nine months ago. The first symptom noticed was a disturbance
in the digestive process ; then sour eructations, loss of appetite
* Medizlnische Blatter, Feb. 7, 1895, No. 6, p. 87.
1896.]
DIAGNOSIS OF CARCINOMA OF THE STOMACH.
73
ud constipation ; later, diminution in weight, fatigue and antip-
athy to meats. These symptoms were variously characterized
as dyspepsia, catarrh of stomach, etc., and of course empiri-
cally treated. At this time, the chief subjective symptoms
were anorexia, general weakness, increased flow of saliva, and
a rague sense of disturbance in the epigastrium ; had vomited
I few times. Examination revealed no tumor and no cachexia ;
the I lilies showed no abnormality and the liver occupied its
normal relation, but the heart action was weak.
The stomach contents were expressed at intervals of once or
twice a week and tested for HC1 and lactic acid: the former
as alwavs absent, and the latter invariably present. The
total acidity averaged 50 per cent. Under the influence of the
and carefully directed diet with strvchnia, the patient
Bade considerable improvement subjectively, but the circula-
tion continued feeble. A month later, there was vomiting of
the characteristic coffee-ground variety. An induration of
small size could now be made out in the epigastric region.
Left kidney was movable and easily defined. An abundance
of uric acid was in the urine.
From this time on the ease progressed rapidly in developing
tumor and cachexia, reaching its fatal termination on Dec. 21,
tration. In a short time vomiting, fever and thirst supervened,
for which large quantities of ice and morphia had been admin-
istered, though he had at no time complained of pain. Ema-
ciated rapidly, and soon vomited enormous quantities of a
grumous material at frequent intervals.
Examination revealed no tumor, no pain, only tenderness in
the epigastrium on pressure.
The circulation had become enfeebled to such an extent that
patient died from exhaustion on June 10, 1895. The gastric
contents contained neither HC1 nor lactic acid, though the
tests were applied daily. The following shows6 both the
chemic and microscopic analysis of the stomach fluid :
Hydrochloric acid, Giinzburg's was negative, dimethyla-
midoazobenzol was negative ; degree of alkalinity, 36 (Ewald's
method); lactic acid, negative; albumin, present; peptones,
negative ; propeptone, negative ; blood, present ; bile pigment,
negative.
Microscopic examination : White and red blood corpuscles,
present ; flat and cylindric epithelium, present ; several varie-
ties of bacteria, but no sarcinae ventriculi.
f.
/
TV o'A.'.i
1895. The autopsy revealed carcinoma involving approximately
one third of the stomach from the pyloric end. on the posterior
side. The pylorus was a hard mass, and on opening, a concen-
tric tumor became visible which completely filled that end of
the stomach. To the posterior surface of the cardiac extrem-
ity of the stomach the left kidney was adherent, and on the
latter when removed, appeared a cyst one and one half inches
in diameter containing a clear fluid. The stomach was con-
siderably dilated.
( 'us,- ;>. Saw this case first on June 6, 1895, when the fol-
lowing history was furnished : Mr. J. C, aged 40, of slender
build and light complexion ; married five years and father of
our child. Patient has never had any serious illness. During
the last two or three years his general appearance was not
indicative of good health. For about two months he mildly
W unplained of a stomach difficulty. For this he received treat-
ment and his family the assurance of his early recovery. All
this was promised up to within three days of his death, when
the case came under my observation. Patient was confined to
his bed since the 18th of last May, when he experienced a
gnawing sensation in epigastric region and considerable pros-
Autopsy showed three inches of the pyloric extrem-
ity of stomach to be a carcinomatous mass with the
characteristic blue and gray color and thick gritty
hardness. The pylorus was almost closed and the
stomach considerably dilated. Photograph No. 1
presents a good anterior view, and No. 2 the interior,,
the incision being through the posterior surface.
Finally, I will state with confidence that the diag-
nosis in Case 1 was made on evidence furnished by
the chemic analysis of the chyme, in conjunction with
the only constitutional symptom present — general
weakness which refused to be modified in the least
degree by medication. The method crudely outlined
necessitates increased labor and the knowledge of cer-
tain technique, which will yield results, I believe, that
o For the preparation of this table I am indebted to the kindness of
Dr. R.J. Wenuer.
74
PHARMACY AS A LIBERAL PROFESSION.
[July 11,
will amply justify the efforts expended in so fascin-
ating a field as this one.
DISCUSSION.
Dr. James B. Hebbick, of Chicago — I believe it is true that
Congo-red has been proven to be a reliable test for free hydro-
chloric acid, and negative results may be assumed to exclude
this acid as well as other mineral acids. I am glad to see that
the author does not rely alone upon examination of the con-
tents of the stomach for proof of the existence of carcinoma.
He justly calls attention to the value of blood examination and
the presence of leucocytosis as confirmatory of the diagnosis
of carcinoma. The presence of cachexia and other signs must
not be ignored. He calls attention to the fact that free hydro-
chloric acid is frequently absent in many other affections than
carcinoma, and it is also true that some of the later writers
have found lactic acid in the stomach contents where no car-
cinoma was present. For instance, in Professor Osier's clinic
there was a case of non-malignant obstruction of the pylorus
in which lactic acid was found. So we are forced to look upon
examinations of the stomach contents, at least in so far as
hydrochloric and lactic acid are concerned, chiefly as confir-
matory tests.
Db. Wainwriqht, of Kansas City, Mo.— I have had some
experience with analysis of the stomach contents the past four
or five years in clinic work. Several times I have made an early
diagnosis based on a chemic analysis of the contents of the
stomach, but I have never yet been able to induce a patient to
be operated upon with only such evidence of carcinoma of the
stomach. Later when a tumor could be felt and there was
cachexia, making the diagnosis very plain to all, the patients
were willing to submit to an operation, but it was too late to
derive any benefit. The most satisfaction which I have
• derived from this analysis has been in cases of obscure tumors
of the abdomen. During the past winter my attention was
called to two or three cases of tumor located in the left hypo-
chondriac region which every physician who examined the
patients pronounced tumor connected with the spleen or other
organ beside the stomach, yet by analysis of the gastric con-
tents, etc., I was able in each instance to positively locate the
tumor in the walls of the stomach, and this diagnosis was
afterward confirmed by autopsy. If we are able, as I believe
we are, to make a diagnosis of carcinoma of the stomach in
the early stage by careful analysis of its contents and func-
tions, I think the time will soon come when surgeons will
relieve these cases by operating early.
Dr. Paul Paquin, of St. Louis — Although we have many
maladies of the stomach, we are yet hardly in a position to
make a proper diagnosis. Perhaps the time has not yet
arrived for making a positive diagnosis of the diseases of the
stomach purely by chemic or bacteriologic analysis ; yet in my
judgment such analysis is of the greatest importance, espe-
cially as giving confirmatory evidence. Such analysis has
been a part of my work for some years past, and I am delighted
to know that we are progressing in that line. I am, however,
of the opinion that we are inclined sometimes to neglect physi-
cal symptoms, and to consider too much and too strongly the
results obtained by analysis. We must consider that in no
other organ except the alimentary canal do we get such chemic
changes as are produced by the ingestion of food, beverages,
and so on, and we can not depend upon the findings of the
chemist and microscopist as a basis for therapeutics. But
before this analysis was introduced in the work of the physi-
cian for the purpose of diagnosis, he certainly was a great deal
more at sea than now, and we have to-day workers like the
essayist who are leading up to the ground which we must finally
occupy in order to diagnosticate many of the diseases of the
alimentary canal.
Dr. Webeb — It is gratifying to observe the endorsement of
this paper as indicated by the discussion which leaves little or
nothing to be added. It may be emphasized, however, that
when you find a well defined tumor, cachexia, and great loss of
weight, that patient is past surgical or any other help, and most
of us will decline to resort to operative measures at such a
stage. The second case which I reported, was most interesting
for the reason that no tumor was discoverable by palpation or
physical means to within a day of death, and, contrary to the
rule, there was absence every day of lactic acid. Another
case to which I referred showed enormous quantities of lactic
acid, and the autopsy proved it to be an ulcer of the stomach.
Hence the conclusion in my paper seemed justifiable — that the
acid symptoms in themselves are not always reliable, but when
taken in connection with other facts are of the greatest value.
THE PRACTICE OF PHARMACY AS A LIB-
ERAL PROFESSION.
Delivered in the Section on Materia Medica. Pharmacy and Thera-
peutic?, at the Forty-seventh Annual Meeting of the American
Medical Association, at AtlanU.Ga., May 5-8, 18SW.
BY F. E. STEWART, M.D.,PH.G.
CHAIRMAN OF SECTION ON MATERIA MEDICA, PHARMACY AND
THERAPEUTICS. DETROIT, MICH.
Pharmacy is a branch of medical science and prac-
tice. It belongs to that part of medical science
formerly known as pharmacology, or the science of
drugs. Unfortunately the term pharmacology has
been used in a restricted sense, being applied more
particularly to experimental vivisection of animals for
determining the physiologic effects of drugs. The
word pharmacodynamics more properly describes that
branch of medical science. Gould defines pharma-
cology as "A treatise on the nature and properties of
substances used as medicines, or those employed in
their preparation," and according to the same author-
ity, pharmacodynamics is "The science of the powers
and effects of medicines."
H. C. Wood, in the introduction to his classic work
on materia medica and therapeutics, clearly defines the
meaning of terms used in this connection by saying,
"Although pharmacy, or the science of preparing
medicine, is entirely distinct from therapeutics, or the
science of the application of medicine to the cure of
diseases, it is evident that some acquaintance with the
former is necessary to the correct appreciation of the
latter. Further, as a basis of both studies, must first
come a knowledge of materia medica or the substances
used as medicine. Pharmacology is the general term
employed to embrace these three divisions."
Hermann, professor of physiology in the University
of Zurich, and one of the leading authorities in
experimental vivisection, in the introduction to his
" Experimental Pharmacology," a hand-book of
methods for studying the physiologic action of drugs,
says: "Pharmacology in its widest scope embraces the
study of drugs from all possible points of view, and
the information thereby acquired may be useful under
the most diverse conditions; to the physician, to
enable the recognition and proper treatment of cases
of poisoning, or to permit of the use of drugs for thera-
peutic purposes; to the public, to permit the avoidance
of noxious substances; to the physiologist and pathol-
ogist, to enable the application of information derived
from the study of the action of poisons to the advance-
ment of their sciences. The study of pharmacology
can therefore be limited according as one or more of
these points of view occupy the first place in the mind
of the investigator. The public desires to know only
what substances are poisonous, that they may be
avoided, while their modus operandi is a matter of
ISW.J
PHARMACY AS A LIBERAL PROFESSION.
75
indifference. Those poisons which are suitable for
use at the bedside will prove most interesting to
clinicians."
••Pure pharmacology is best advanced by the avoid-
ance of any special stand-point, in order that all of its
bearings may lie equally appreciated, and still more,
since the advancement of pure science is always
retarded by a search for that only which promises
Immediately practical results. The history of the
progress of the sciences teaches that nearly all the
most important discoveries, even those subsequently
of the greatest practical value, resulted from investi-
gations untrammeled by a continuous mindfulness of
the merely practical. Thus physiology has rendered
such inestimable assistance to the progress of practi-
cal medicine that she can well be regarded as her
handmaid: but, nevertheless, physiology is a pure
science, which, like physics and chemistry, should be
studied for its worth, without being hampered by
doubts as to whether its results are immediately appli-
cable to practical medicine or not. So also pharma-
cology is slowing more and more worthy of occupy-
ing a similar position, though it must be acknowl-
edged that as yet. it is not bounded by such sharply
drawn lines as to constitute a distinct science. Much.
however, can be gained in this direction by constantly
bearing in mind that pharmacology has for its object
the recognition and study of all changes which a
foreign body can undergo or produce, otherwise than
traumatieally. in the organism, while the questions as
to whether the Bubstance under study can be ever
likely to prove a poison to man, or whether it has
properties which warrant its use as a medieant, should
be kept in the background."
"Consequently every substance which possesses any
active properties should prove of interest to the invest-
igator in the domain of pharmacology, while naturally
those substances will be preferred which are either
quite unknown, which show results entirely novel, or
whose action admits of predetermination from a
theoretic point of view, as from the stand-point of
chemical composition. And it should, moreover, be
remembered, that even substances which themselves
evoke no symptoms in the organism, may form worthy
subjects of pharmacologic investigation as throwing
possible light, in the changes which they undergo in
the system, on the behavior of other more active
poisons."
If pharmacy is a department of science, its practice
is a medical art. It therefore follows as a natural
sequence that pharmacy must be regarded in the light
of a medical specialty, and the pharmacist is under
the same obligation to science, to the profession, and
to suffering humanity as the physician.
Now medicine is a liberal profession. It is distin-
guished from a mercantile pursuit in that service to
humanity (not money-making) is its primary object.
What business or profession is there like medicine in
this respect, viz., that it seeks to remove the cause for
•ry existence. And yet we behold such unselfish-
ness and devotion to humanity in preventive medi-
cine, which leaves no stone unturned to ascertain and
subdue the causes of disease which the physician
gains a livelihood by treating. Indeed, medicine owes
its high position among the vocations of men to its
philanthropic aim, seeking in every way to relieve and
prevent human suffering, devoting itself to original
research, and publishing its results for the benefit of
science, constantly sacrificing self-interest to aid
others, and neglecting, for philanthropic reasons, to
take advantage of many opportunties for gain.
If what I have said is true then pharmacy can never
be recognized as a liberal profession, until it becomes
part of the medical profession, for it can not, from the
very nature of things, become a profession by itself.
Pharmacy is directly dependent upon therapeutics,
and is like a body without a soul when divorced there-
from.
Pharmacy can find its higher advancement, not by
catering to an unenlightened public, unfitted to appre-
ciate it either from a scientific or professional stand-
point, but by working with physicians to a common
end. that end being the promotion of progress in
pharmacology as a science, the advancement of phar-
macy as a profession, and the study of means to pre-
vent and alleviate human suffering. By serving this
end pharmacy will find its true position among the
liberal professions.
As a trade pharrhacy would seek to create a
fictitious demand for drugs by exaggerating their
importance as curative agents, thus pandering to the
morbid tendency of the public to dose itself for real
or imaginary diseases. As a profession it will join
with the medical profession in efforts to relieve the
public of the necessity of taking medicine. Coopera-
tion between the physician and pharmacist is abso-
lutely indispensable to the advancement of pharma-
cologic science, for as already said, neither therapeu-
tics or pharmacy as science or practice can exist
alone.
The science of medicine professes to exhibit wdiat is
actually known, or may be learned, in the forms of
exact observation, precise definition, fixed termin-
ology, classified arrangement and rational explanation.
To promote the progress of the science of drugs it is
therefore necessary for both professions to publish
the results of their discoveries for the benefit of
science. It is just as reprehensible for physicians to
neglect the publication of the results they obtain from
the use of drugs, or their preparations, as it is for the
pharmacist to restrain the knowledge of the same
from general use, by means of secret formulas, pro-
tected from legitimate competition by fanciful names,
which latter are registered as trade marks, at the
Patent office in Washington. How can the demands
of science be satisfied unless the knowlege of every
substance used in medicine, together with its method
of preparation and application to the cure of disease
is published, and its manufacture and sale open to
legitimate competition ?
"In every civilized country1 there is some recog-
nized official list of drugs and their preparations
known as the pharmacopeia. In most places this
being prepared with the sanction of the government,
partakes of the nature of a law, but in .the United
States conformity to it depends upon the voluntary
action of the professions, of medicine and pharmacy
by a representative convention of which it was origin-
ally prepared and is decennially revised."
The position and responsibility of the physician
and pharmacist in relation to the pharmacopeia is the
next point to which I desire to call your attention.
On the analysis of 27,000 prescriptions recently made
by Prof. Patch, President of the American Pharma-
ceutical Association, it was shown that the pharma-
i.\ treatise on Therapeutics comprising Materia Medica and Tox-
icology by H. C. Wood, Jr., M.D. Third Ed., p. 17, Philadelphia. J. <fc B.
Llppineott & Co., 1860.
76
PHARMACY AS A LIBERAL PROFESSION.
[July 11,
copeia was sadly neglected by physicians. Only
seventeen vegetable drugs were prescribed, and more
than one hundred drugs of vegetable origin neglected.
Ten metals were honored, but more than ten were left
out in the cold. In fact the entire materia medica
comprised by these 27,000 prescriptions consisted of
the following drugs and preparations, viz:
Acetanilid; antikamnia; antifibrin;- antipyrin;
aristol; phenacetin; acid arsenious; acid boric; acid
carbolic; acid hydrochloric; acid salicylic; acid
sulphuric; acids, twenty-five other kinds; aconite and
its preparations; ammonium salts, chlorid, carbonate,
bromid, etc.; belladonna, its preparations and alka-
loids; bismuth salts, principally the subnitrate;
brandy; camphor and its preparations; cascara sagrada
and its preparations; chloroform, its preparations and
combinations; cinchona and its preparations, combina-
tions and alkaloids; digitalis and preparations; gentian
and preparations ; ginger and preparations ; glycyrrhiza
and preparations; hyoscyamus and preparations; iodin
and preparations; lead salts and preparations; mer-
cury, its salts and preparations; nux vomica, its prep-
arations and alkaloids; potassium salts and prepara-
tions; rhubarb, its preparations and combinations.
In this study of 27,000 prescriptions from nineteen
drug stores distributed between Chicago, Philadelphia,
Bayonne, N. J., Boston, Washington, Baltimore,
Denver, San Francisco, New Orleans, Cincinnati and
St. Louis, 11.25 per cent, were proprietary articles,
not including many elixirs, pills, tablets, fluid extracts,
etc., which were of specified manufacture.
An analysis of 10,000 prescriptions, made by the
committee on revision of the United States Pharma-
copeia of the Illinois Pharmaceutical Association,
shows that in 2,613 prescriptions, or about one-fourth
of the whole number, proprietary remedies were pre-
scribed. Many proprietary articles are of the great-
est value. They are often the products of manufact-
uring houses provided with the very best facilities of
manufacturing. Many of them represent the researches
of the most learned chemists, extended over years of
careful investigation. In fact it is fair to assume
that some of our proprietary medicines advertised to
the medical profession in the medical journals repre-
sent the van of progress in pharmacy. To be sure,
some of them are of comparatively little value, and
should find a place in the lumber room with the trash
in company with much of what is now official in the
pharmacopeia. But that is no argument against those
that are of value in either case.
Now assuming that the proprietary medicine re-
ferred to are valuable pharmaceutic preparations, it is
evident that a place should be found for them in the
next revision of the pharmacopeia. It is equally evi-
dent that they can not be admitted as proprietary
medicines, unless the medical profession shall endorse
a system which withholds from general use that
entire class of preparations. Such an endorsement
on the part of the medical profession would be a com-
plete surrender of the altruistic ideal that distin-
guishes the practice of medicine as a liberal profession,
and an endorsement of a most dangerous form of
commercialism.
From what has been said above, it is very evident
that affiliation between physicians and pharmacists is
of first importance to promoting progress in the
knowledge of pharmacology, to improving our phar-
macopeia, and to the rescue of medical and pharma-
ceutic practice from the grasp of the proprietary
medicine trade, which is now encroaching upon the
domain of the pharmacist and the physician. But,
you say, there are unsurmountable obstacles to affilia-
tion between the pharmacists and physicians. They
are at war with one another everywhere. Physicians
charge that pharmacists prescribe over the counter,
and that the practice is unjustifiable, as they are not
competent to do so either by education or training,
and it is an unwarranted interference with the physi-
cian's prerogative to treat the sick. But the pharma-
cist can urge with equal propriety that the physician
is not competent, either by education or training to
compound and dispense his own medicine, and for
him to do so is an unwarranted interference with the
prerogative of the pharmacist. But there is a great
deal of difference between the deep blue sea and the
dry land, though one overlaps the other on the beach.
Now it seems to me that this question of interference
between the pharmacist and physician is something
of the same nature. Both may wade with impunity
in the shallow waters along the shore, and do no real
harm to each other, or to the public at large. But
there are depths in pharmacy capable of drowning the
venturesome physician; and the pharmacist who
attempts io climb the high mountains of diagnosis
and treatment is sure, sooner or later, to fall and break
his neck. Yet in some countries these prerogatives
are protected by law, and both physician and pharma-
cist must keep on his own side of the fence.
But, say the physicians, we can never unite with
pharmacists until they no longer renew our prescrip-
tions without our authority. It is damaging to our
reputation and purse, and a very unfriendly act to say
the least about it. But physicians lose sight of the
fact that both professions are servants to the public,
and if the patient is refused the privilege of having
his prescription renewed, he will seek another physi-
cian and another pharmacist. Not until the public is
educated to appreciate the necessity of consulting the
physician before renewing prescriptions will the pre-
scription-renewing nuisance be abated. Pharmacists,
to a great extent, are powerless in the matter. And
the medical profession has done much to foster the
abuse by prescribing ready-made nostrums, so the
fault is not entirely with the public either.
Physicians complain bitterly that pharmacists sell
"patent" medicines and thus make themselves the
agents of the nostrum monger. But the proprietary
medicine business owes its present standing in the
community more to the medical profession than to the
pharmacist. More than ten per cent, of the medicine
prescribed by the physicians in the United States are
so-called "patent" medicines, and the physician is just
as much to blame for prescribing them, as the phar-
macist for selling them. I can see no good reason
why harmony can not be restored between the phar-
macist and physician. Once in touch, and working
for a common object, many of the evils now com-
plained of will rectify themselves in time, and the
public will soon feel the influence of a united profes-
sion, and respect the calling of both physician and
pharmacist more highly in consequence.
Two questions naturally present themselves at this
juncture, 1, How can cooperation between physicians
and pharmacists be secured? 2, What are the best
plans for promoting progress in the science of phar-
macology, and the useful arts of pharmacy and thera-
peutics? The answers to these questions merge into
each other, so we will consider them together.
ism;.]
PHARMACY AS A LIBERAL PROFESSION.
77
First of all. State medical ami pharmaceutic
societies would do well to imitate the example of the
national medical and pharmaceutic societies in the
matter of interchange of delegates. Sections on
pharmacology should be established in State societies,
and physicians and pharmacists should join in debate
regarding drugs and their properties. Local pharma-
ceutic societies should be formed, to meet in confer-
ence with the local medical societies at least quarterly .
In places where that is impractical, the local pharma-
cists might be invited to attend the meetings of the
county medical societies, and join in debates on sub-
jects of mutual interest. These interesting debates
when published in the medical and pharmaceutic jour-
nals would benefit the entire profession. Collective
investigations of new drugs and preparations Ixith
pharmaoeutioally and therapeutically might be under-
taken in which both professions could take part. The
manufacturing houses might be invited to join in this
work, by establishing scientific departments for
original research, and members of these departments
invited to join in these conferences. By means of a
common object, harmony would be secured between
all concerned. The result of such cooperation in
promoting progress in our knowledge of drugs upon
the next revision of the pharmacopeia can easily be
conceived. The next move of importance would be
the abolition of the proprietary system as applied to
medicine. The existence of the proprietary system
as a legal factor seems to be due to a misunderstand-
ing of the patent and trade mark laws, not only by
pharmacists and physicians, but by the courts as well.
That such a misunderstanding exists will be apparent
on considering the verdict of the House Committee
on Patents on this important matter.
A few years ago I accompanied a committee from
the State Pharmaceutical Society of Delaware to
Washington, for the purpose of asking the United
States Congress to define a trade mark, and inform us
in regard to its application. We were referred to the
House Committee on Patents, of which the Hon.
Benj. Butterworth was then chairman. After listening
to our petition and considering the matter during
more than two hours' debate, the following verdict
was reached:
1. The registration of an alleged trade mark does
not make it valid. Registration is merely to give
notice that the thing registered is claimed as a trade
mark. The validity of the claim can only be settled
by the courts.
2. The proper use of a trade mark in no wise re-
stricts the free use by others of the article of mer-
chandise to which it is affixed. It confers on the
user no privilege to the exclusive use of an invention
of the kind conferred by the patent law, otherwise we
should have the anomaly of laws diametrically oppos-
ing one another. The patent law grants to the in-
ventor the exclusive use of his invention for a limited
time, and then only on the publication of exact
knowledge of the invention by a proper application
for a patent, whereby the public may manufacture it
when the patent expires. The use of a trade mark on
the contrary, is unlimited in duration, and no publi-
tion is required when it is used on an invention.
3. The public has a perfect right to manufacture
and sell any article of commerce not patented, and to
do so under its proper or generic name whether a
trade mark is used in connection with the article or
not. For this reason courts have held that names
describing articles can not be used as trade marks on
the articles they describe. Otherwise the use of trade
marks would be a hindrance to competition, while the
proper use of trade marks promotes competition by
distinguishing between one brand of an article and
another brand of the same article, thus stimulating
manufacturers to improvement in processes and
methods of manufacture for the purpose of excelling
each other in producing the same articles of a better
quality and at a lower price.
4. While not constituting itself an interpreter of
law, yet the House Committee on Patents as individ-
uals, did not hesitate to affirrri the position above
described, and so instructed the Associated Press
reporter who was present.
The question why the courts have so frequently
made contrary decisions is not a difficult one to
answer. There are several reasons to account for it.
Judges, as well as doctors, often make mistakes in
diagnosis, and one is not more infallible than the
other. Again many cases of alleged infringement of
trade mark have been decided against the defendants
because of the element of fraud involved. It is man-
ifestly unjust for the courts to protect an alleged
trade mark when it consists of the only name by which
an article (not patented) is known to the market,
because, by so doing, the manufacturer is given an
unfair advantage over the public in the making and
selling of an article to which all have equal right.
On the other hand it would be rank injustice both
to the manufacturer and the public to permit the
counterfeitng of trade marks, labels and packages, to
the injury of all parties concerned. The question
that has been decided in most cases brought before
the courts, has been whether the goods were counter-
feit, not whether the alleged trade mark was a valid
trade mark. In the "Syrup of Figs" case the ques-
tion was decided on its merits, Judge Swan rightly
maintaining that the name "Syrup of Figs" was either
deceptive or descriptive. If the former the plaintiff
had no standing in court, if the latter no infringe-
ment of trade mark existed.
The principle that underlies the subject, however,
is the copyright or right to copy. The House of
Lords, and following the precedent, the Supreme
Court of the United States, decided that authors and
inventors have no natural right, or right at common
law, to prevent others from copying their respective
writings and discoveries. The right, when it exists at
all, is a creature of statute and of grant, and subject
to the terms of the statutes and grants. The other
side of the bitter controversy known as the "copyright
war," claim that authors and inventors have a natural
or common law right to their writings and discoveries,
irrespective of the copyright and patent laws. Judges
who believe the latter will naturally be influenced in
their decisions accordingly, and may grant a protec-
tion never intended by our law makers.
But as one learned author truly said, if the right to
the exclusive use of writings and discoveries is a
natural right, then it existt forever, for who can limit
it? Then the inventors of pens, ink, paper, and every
article of commerce, ought to have been protected in
their alleged "rights" for all time, and the' same
"rights" should have been continued to their heirs.
This would have created an aristocracy that would
have owned the entire property of the world in time,
and the remainder of mankind would have been the
slaves of those great monopolists. Either that or the
78
PHARMACY AS A LIBERAL PROFESSION.
[July 11,
remainder of mankind, being in the majority, would
have finally revolted, and put an end to the monopoly'.
And what is the use of a "right" if it can not be main-
tained?
If we are to have patented medicines, let there be
appointed a medical board in connection with the
patent office to see to it- that the patent law is made
to promote progress in science and practice, not to
hinder it. Grant no patents except when new and
useful articles are really invented, and do not permit
patents on mere aggregation of old and well-known
drugs, that any pharmacist or physician, with a proper
knowledge of his art, would naturally devise in prac-
ticing his profession. And let there be an end to the
registration as trade marks of the only names by
which articles are known, for it creates and maintains
perpetual monopoly and such monopoly is contrary
to the very spirit of the American constitution.
The latest move by the proprietary medicine manu-
facturers is to prevent what they call substitution
upon the part of the druggists. The recent action of
the analin dye house of Bayer & Co., in relation to
phenacetin, illustrates one phase of this. That house
is undertaking what the Chemist and Druggist (an
English drug periodical) calls a "monopoly crusade."
Having registered the word "phenacetin" in Germany
that house now proposes to force the entire world to
recognize it as a trade mark, and to prevent other
manufacturers from making and selling the article
under the name, phenacetin.
The Chemist anil Druggist says that "no rights
granted to Messrs. Bayer & Co., by the German Impe-
rial Patent Office can effect their claims in this country
(England). Strange though it may seem, the British
Patent and Trade Marks Act are not yet 'made in
Germany,' nor is Britain as yet in the position of a
tributary state to the Fatherland." But when one
considers that the United States Patent Office granted
Bayer & Co., a patent on phenacetin as a product, and
recognized the word as a trade mark, it seems strange
indeed that we did allow our patent and trade mark
laws to be "made in Germany" and actually become
tributary to a German analin dye house.
Now a word about that tribute. Phenacetin can
be purchased in England for $1.25 a pound or there-
abouts, but in the United States we are forced to
pay $16.00 a pound for it. In other words we are
paying a tribute of over fourteen dollars a pound to a
German house or to its American agent for phenacetin,
when we can import it, or make it in this country to
sell with fair profit at about a dollar a pound.
If any pharmacist attempts to import phenacetin
into the United States, he is at once arrested for
smuggling. If he makes it for sale he has a law suit
on his hands for infringement of patent. He can not
offer for sale any phenacetin except that of Bayer &
Co., without falling into the clutches of the law. Of
what law? Of the law of the United States which
ought to protect American citizens, not foreign as
against American interests.
Are these our patent and trade mark laws? Either
the laws are not clear, or the fault is with the patent
office and the courts; or possibly all are at fault. The
fact that some of the best judges in America give
decisions opposed to any such rendering of the law
shows the confusion existing on the subject.
Now, what is substitution? Messrs. Bayer & Co.
tell us that it is the use of any other brand of phena-
cetin in place of their brand of it. The druggist who
protests against this outrageous monopoly, and
attempts to furnish our patients with some other brand
of phenacetin at a reasonable price, is guilty of sub-
stitution, and should be condemned by the profession
as a criminal, according to the rendering of the law,
and in that rendering every proprietary medicine con-
cern in the world will say, Amen. That is no exagger-
ation, and before we condemn druggists for substitu-
ting where proprietary medicines are prescribed, we
ought to understand what is meant by substitution, or
we may find ourselves endorsing a scheme of which
we may have cause to be ashamed.
Is phenacetin a trade mark? How can it be and
yet be the only name by which the article is generally
known? Is it not a proper and descriptive appella-
tion of the article ? It is an axiom in law that the
descriptive name can not be a trade mark. As its
proper or descriptive name we have regarded it, not
dreaming for a moment that we thereby necessarily
specified the brand of Bayer & Co., by using the
name phenacetin in our prescriptions, thus endorsing
a gigantic monopoly. This is our only excuse as
physicians. We have been deceived. But let us be
deceived no longer. Let us arise and demand that
the true working forumla of every medicine we pre-
scribe shall be published, and that phenacetin and
every other preparation shall be provided with names
free to all pharmacists under which they can be made
and sold. Then if each manufacturer chooses 1 1 <
employ a fanciful "coined" word of his own devising
as a trade mark thereon it can do no harm, for no
monopoly of the product is engendered thereby, and
competition will restrain the price within reasonable
limits; while at the same time the trade mark will
truly be what it was designed to be, viz., a protection
to the public against counterfeits and substitutes.
The well-known names of the preparations now on
the market have become by use descriptive and should
be so regarded. I can see no objection to the use by
Bayer & Co., of a fanciful designation as a trade
mark on their brand of phenacetin if the true name
of the article always appears on the label, and its use
is free to all other manufacturers.
Laws against the adulteration of foods and drugs
are excellent aids in helping along the common cause,
if properly enforced. But they are calculated to do
much harm if manipulated by politicians for personal
ends. The same applies to a national law to prevent
the transit of adulterated products from State to State.
The proper enforcement of such laws would finally
end in abolishing secrecy in medicine altogether — a
most desirable end. The patenting of pharmaceutic
machinery, processes and appliances, may not be open
to serious objection, but locking up medicinal sub-
stances themselves to exclusive monopoly should never
be permitted.
In my paper read before the Section of State Medicine
last year,2 1 suggested a compromise measure for the
purpose of permitting an inventor of a new and useful
compound to retain the name and secret of manufacture
of his invention for a limited time, provided the true
working formula thereof be placed in the hands of a
national committee of physicians and pharmacists, and
the article marketed only under the sanction of the
committee. I suggested that the system remain as it
now is, only with the exceptions that a censorship
shall be exercised over the market by a committee of
2. The Proprietary System and Its Remedy. Joubnalofthe American
Medical Association, Sept. 14, 1885, p. 450.
L896. ]
PHARMACY AS A LIBERAL PROFESSION.
79
competent physicians and pharmacists, the monopoly
to be limited in time, and the system to be made
scientific by providing it with a proper nomenclature
and by the final publication of every invention where-
by all pharmacists may manufacture the same when
the patents expire.
1 also suggested that every manufacturing house open
a scientific department manned by competent physi-
cians and pharmacists, who can be held responsible
to the profession for their utterances, and for the rep-
resentations made by respective houses in labels, in
circulars, in advertisements, and in contribution of
these houses to scientific literature.
Now as to the complexion of the committee. I
BUggested that it consists of one member each of the
American Medical and American Pharmaceutical
Associations, and one member each from the medical
department of the Army. Navy and Marine Hospital
service, to which might be appropriately added as
Chairman the Commissioner or Secretary of Public
Health, if such an office is finally created by Con-
gress.
Commenting on this compromise. Dr. Henry D.
Bolton in his Address on State Medicine, delivered
at Baltimore, May, 1895, said: "The question of pro-
prietary medicine which interests every family of the
land, is an evil which in spite of the continuous
maledictions that have been hurled against it by all
scientific medicine, both as organizations and as indi-
viduals, has continued to thrive, until at the present
time it is intrenched behind millions of money and is
held in high esteem by the people because of its
ability to hide its worthless character or possible
dangerous combination behind a trade mark. If the
manufacturers of these nostrums were obliged to
deposit with the Public Health Department, under
certain restrictions, as suggested by Dr. Stewart, the
formula from which they are prepared, it would do
more to eradicate this stupendous swindle from the
land than all the fulminations that could be hurled at
it for centuries: it would have an equally elevating
effect upon the science of pharmacy which is so
indispensable to our success."
The following excerpt from the President's address,
delivered at the annual meeting of the Pharmaceu-
tical Association of the Province of Quebec, held
in Montreal. June 11, 1895, contains in a nutshell a
great deal of truth in regard to "patent" medicines
and also suggests another plan for curtailing their sale :
"Patent medicines are a curse to the physicians,
the pharmacists and the public. They are an unjust
and direct opposition to the physicians by preventing
the sick from obtaining proper advice; they deprive
the pharmacist of the sale of his own preparations,
and force him to keep in stock a large number of
preparations which have only a limited sale, and they
are injurious to the public which allowing itself to be
cajoled by the certificates of cure which are the com-
pliments of the advertisement, purchases the famous
remedy which oftener does more injury than good."
"We should have in this country, as in most
European countries, a commission composed of phy-
sicians and pharmacists. All demands for copyrights
or patents for medicinal preparations should be sub-
mitted to this committee, with the formula, and after
examination a report should be made to the govern-
ment recommending or rejecting the demand. This
would diminish the number of patent medicines, and
the public would know that those the sale of which
was allowed, would be of superior quality and incon-
testable value."
The introduction of a line of simple household
remedies bearing the true formula of each prepara-
tion on the label, to be used in place of secret nostrums,
would be a step in the right direction. Such a line
might be added to the National Formulary. The
adoption of the United States Pharmacopeia and the
National Formulary as a text-book in all medical and
pharmaceutic colleges would certainly do much to
elevate medical and pharmaceutic practice and cause all
parties to adhere more closely to recognized standards.
In my paper, read before this Section at the Mil-
waukee meeting, in 1893, 1 suggested that a laboratory
be established in Washington for the purpose of
investigating the materia medica of the world under
the auspices of the Government. The paper was well
received by the American Medical Association and
a memorial was sent to the U. S. Congress praying
that the plan be carried into effect.
It has also been proposed that a National Depart-
ment of Public Health be created, and a Secretary of
Public Health be added to the President's Cabinet.
Now all these suggestions have merits and objec-
tions, and the same may be said concerning any plan
that can be devised by human ingenuity. In consid-
ering these plans it may be well to refer for a moment
to the objections and the objectors. One class of
objectors own stock in proprietary medicines. They
may be divided into three classes, viz., proprietary
medicine manufacturers themselves, stockholders in
proprietary medicine corporations engaged in the
practice of medicine and pharmacy, and professional
men who either hold stock in the names of their
wives or other members of their families, or whose
wives have invested some of their own capital in the
business. I have been met with objections from all
three classes. Another class of objectors are always
looking "for a nigger in the' wood pile." No matter
who reads a paper on the subject, they always insist
that he has "some ax to grind." But it is time for
us to rise above the level where self-interest and petty
jealousy paralyze endeavor. Something ought to be
done to check the demoralizing drift of the times.
This section was originally organized for the pur-
pose of elevating pharmacy and therapeutics, and
promoting progress in the science of pharmacology.
It represents in delegate capacity the entire medical
and pharmaceutic professions of the United States. I
hope therefore that my paper may be honored by a
full discussion and referred to a committee in which
both professions are represented. And I hope this
committee will formulate a set of resolutions worded
in language that can be endorsed by the entire press of
this country, medical, secular and religious, express-
ing the sense of the Association in regard to the true
place pharmacy should occupy in its relation to medi-
cine. It is not my object to attack gentlemen engaged
in the patent medicine business or to cast reflections
on any one. As business men, physicians, pharma-
cists, teachers, writers, journalists, we should all
condemn the proprietary system because it hinders
the progress of medical science and arts.
A series of resolutions formulated in the spirit of
devotion to humanity which we are supposed to pos-
sess, as members of a learned and liberal profession,
could not fail to meet the approval of all right-think-
ing men everywhere. Such a set of resolutions offici-
ally sent to the State and local medical and pharma-
METHODIC DESCRIPTION OF A SURGICAL DISEASE. [July 11.
ceutio associations would be of value in guiding
physicians and pharmacists in their relation to each
other and to the public at large, and if written in a
spirit of fairness to all would do much in the educa-
tion of the public to a higher appreciation of medical
science and practice in both departments, pharma-
ceutic and therapeutic.
THE METHODIC DESCRIPTION OF A
SURGICAL DISEASE.
BY EDMOND SOUCHON, M.D.
PROFESSOH OF ANATOMY AND CLINICAL SUEGEBY, Tl'I.ANE INIYERSITY,
NEW ORLEANS, LA.
No art, no study has ever become a science until it
had evolved its methods and its laws. The great
effect and the use of these are to cover and govern a
multitude of details which otherwise have to be
remembered separately; also to facilitate the under-
standing between writers and readers.
Students sorely need a methodical guide to lead
them in the intricate labyrinths of surgical descrip-
tions, and yet those labyrinths are really only so
because we lack the knowledge or the charts of their
construction, or an Ariadne's thread which will be a
sure guide in, through and out of the apparently
innumerable turns and meanders. Upon close study
it is found that in the diseased as in the healthy state
nature's laws are less numereus, less complicated,
more simple than we think, after we have succeeded
in recognizing them, reading them, understanding
them and remembering them.
Another object of this method is to assist students
in remembering thoroughly, easily and intelligently;
also how it is done and should be done. Although
most likely and truly imperfect to the mind of many
readers, the following description can not fail to assist
the student of surgery; the thread may be coarse, may
be made up of pieces, different materials tied together,
but it is a thread none the less and as such most
precious if constantly held in hand. The best of all
methods or guides would be the one which all would
agree to follow, however susceptible of improvement
it might be.
The innumerable and complicated facts of surgical
diseases can be better learned and remembered by
adopting a uniform and rigorous method in their
description. The guide should be inexorably syste-
matic and always the same for each and every surgical
disease. This may be dry, monotonous and hard but
it will be of the greatest assistance to those who have
to learn and to remember. Indeed all text-books on
surgical diseases have almost the same great divisions
and headings in describing a disease, but it is in the
details and smaller things under those headings that
the students need systematic and uniform assistance.
It is to be borne, in mind that the students of surgery
who read a text book are to remember for ever all he
reads; therefore, all superfluous words, remarks and
•dissertations had better be omitted so as to leave the
the facts as simple and prominent as possible; but the
guide must not interfere with extensive descriptions
when deemed desirable. Students of ordinary intelli-
gence can readily supply in their own minds connect-
ing words and even sentences.
The guide describing a surgical disease should be
followed more or less closely, according to the impor-
tance of the disease or of the facts connected with it.
If some facts are of no importance they should be
skipped and stress should be laid up on those facts
only which present a practical bearing or scientific
interest. It is essential to follow the guide systemat-
ically, as one fact is so intimately connected with the
following one that the place where to say it can not
very well be altered without disturbing the harmony
of the whole. There is a place for everything and
everything should be said in its place. We should
say at the beginning what belongs there and not say
it in the middle of the description. Again, we must
say in the middle of it what belongs there and not say
it at the end. It is most discouraging to read a fact
concerning the prognosis, for instance here, then
another a few lines further and a third one a few
lines further again, separated by facts relating to
symptoms, cause, etc.; instead of saying together
all that pertains to prognosis where it should be said.
It may seem difficult and complicated at first, but
after the guide has been committed thoroughly to
memory, so as to have it at the tongue's end without
hesitating to think, it will be seen how smoothly it
works and how much it will assist. It is impossible
to forget or skip anything as every few words almost
in the guide call for an answer at its proper place,
which answer is easily remembered by one who has
studied the disease two or three times with this severe
system and training. Students in surgery must learn
how to spell, read, write and remember surgery as
children learn how to spell, read, write and remember
the language they speak.
According to cases, the course of the whole descrip-
tion or of a part of it only may be changed or inverted,
but this should be done as seldom as possible so as to
preserve the general application and utility of the
method, even at the cost of a little apparent awkward-
ness, which will disappear with time and custom.
The order of description may jar against the pres-
ent accepted ideas and some just objections will be
made, some facts may seem to be forced in, but on
the whole they are few and are fully compensated by
other gains.
GUIDE TO DESCRIBE METHODICALLY A SURGICAL
DISEASE.
(An ordinary or typical and uncomplicated case.)
We will first describe the guide or course to be fol-
lowed in describing methodically a general surgical
disease. The type adopted should be an ordinary or
uncomplicated case. This means that all points and
features which are not observed frequently in the dis-
ease should be left out, to be described with all other
rare or exceptional points and features, with the
forms, varieties and complications of the disease.
This is very important as it relieves the description of
many confusing and apparently contradicting state-
ments which so harass and perplex students. Yet
these points being often of importance must be studied,
but by themselves and where the attention is laid on
them with all profit.
The description should begin by the synonyms or
various names of the disease and their etymology.
The History is often most interesting as showing
the efforts required to bring the knowledge of the dis-
ease to the present state. When possible it should be
divided into periods marked by, and named after, the
great steps which have characterized positive progress.
The names of the investigators and writers must be
given with the date of their contributions and the
points or features they have specially investigated and
IS*H>. !
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
81
cleared. It is but sheer justice to the pioneers who
have contributed to build the knowledge from which
«e ;ire now deriving reputation and profit. This
teaches the reader and student that by thus profiting
by the labors of their predecessors they are incurring
the obligation to make efforts to contribute themselves
to the common stock for those who follow.
The definition of a disease is described after its
cause or its pathology, its symptoms, course, duration,
termination, prognosis, or after several of these fea-
tures combined.
The frequency should be described here in a gen-
eral way. only, as this feature will often return in
describing the causes, lesions, symptoms, etc. The
division of the disease or subjeet into various parts is
important if it is at all complicated. A general
description should be made of all the points common
to the various diseases and then each division should
be described separately as a separate disease.
ETIOLOGY OR CAUSES.
The etiology or causes of diseases should be
divided into the two great divisions, the external and
the internal causes.
The external causes are all those originating out-
side of the patient. They comprise the following
headings. The geographic, meteorologic and atmos-
pheric causes include the mention of the effects of
latitude, longitude, altitude, climate, seasons, rains,
storms, changes, sudden or slow, of the effects of the
thermometer, barometer, hygrometer: of the influence
of day and night air, etc.. as a cause of the disease.
Telluric causes call for the description of the action
of dry soil, damp soil, wet soil, marshy soil, defec-
tive drainage, sandy soil, clay soil, calcareous soil.
Zymotic, microbic, infectious, contagious, epidemic,
endemic, sporadic causes should be mentioned Spec-
ially ; also the presence or absence of parasites as
causes. The physical causes or agents may be trau-
matic (blow or fall), or may be the action of direct
heat or cold, or of dampness or of wet on the part
diseased. Chemical causes or agents call for the
statement of the action of the various gases, fluids,
solids, metals or metalloids, organic substances sus-
ceptible of producing the disease. Hygienic causes or
agents comprise the description of the effects of the
various characters and conditions of the air we
breathe, the water we drink, the food we eat, the
clothing, the housing, and all such. Therapeutic
causes or agents are those which cause serious disor-
ders or real diseases by their action in overdoses,
or in normal doses, but on subjects of peculiar
susceptibility.
The internal causes include all those which are
inherent to the patient himself. They comprise the
following headings: Sex. Age: Congenitality, in-
fancy, childhood, youth, maturity or manhood, mid-
dle age, old age and decrepit age. Races. Nationali-
ties. Anatomic causes or peculiar conditions of the
part as a cause of the disease; of the skin, connective
tissue, adipose tissue, tendons, muscles, fascia, perios-
teum, bones, medulla, arteries, veins, capillaries,
lymphatic vessels, lymphatic glands, nerves, organs
special to the region. The side most commonly
affected must be mentioned. The weight, the height,
the breadth of neck, shoulders, chest at inspiration
and at expiration, the abdomen, the hip. Physiologic
causes include the effects of the constitution, tempera-
ment, idiosyncrasies, heredity (ascending, descending,
collateral), trades, professions, habits, social condi-
tion, mental and psychic conditions (such as emo-
tions, fright, antipathy, suggestion, grief, anger).
Pathologic causes form the group of symptomatic
diseases or diseases due to other diseases, directly or
indirectly, i. c, due to previous diseases, medical or
surgical, of which the actual disease may be a sequel
or a consequence, or to traumatism, or injuries, or
surgical operations. These diseases may be of some
of the organs or of the blood or fluids of the body
(hematologic causes); each organ and fluid and its
diseases should be reviewed and its effects noted as a
cause of the present disease. Metastatic causes must
be here mentioned.
All the above causes may be predisposing or deter-
mining; exciting, or instrumental, or controling, or
final, or ultimate; efficient or not; or primary, or idio-
pathic; or secondary, or symptomatic.
For each cause we must state its frequency and
degree of importance.
. PATHOLOGY OR PATHOLOGIC ANATOMY.
The lesions of each stage should be described as
those of a separate disease.
The lesions are macroscopic or microscopic.
The lesions of the main diseased organ must be
first described; they comprise the following: 1, the
description of the alterations of the normal physical
characters, i. e., of the size, situation, direction,
mobility, shape; the alterations of the normal struc-
ture, i. e., of the color, consistency, envelopes or coats,
stroma, proper tissue (cells, fibers, tubes), capillaries;
the alterations of the normal chemic composition of
the parts (inorganics, organics). All these may be
decreased, increased, perverted. 2, the alterations
due to new pathologic products. These may be gas-
eous (traumatic emphysema in fractures without
lesions of the air passages); they may be fluid, serous
(edema, dropsy) or due to blood or pus; they may be
solid or semi-solid (exudations or deposits of fibrin,
fibrino-plastic lymph or matter, or false mem-
branes); they may be . new envelopes (where none
existed before), new stroma, new cells and arrange-
ment, new fibers and arrangement, new deposits
(granular, fatty, calcareous, pigmentary, melanotic;
germs; parasites), finally new capillaries and new
nerve fibrils. 3, alterations due to new chemical ele-
ments, inorganics, organics; gases, fluids, solids,
metals, metalloids, etc.
The lesions of the region, i. e., of the neighboring
organs, comprise the lesions of the skin, connective
tissue, adipose tissue, tendons, muscles, fasciae, perios-
teum, bones, medulla, arteries, veins, capillaries,
lymphatic vessels, lymphatic glands, nerves, of the
organ special to the region, if any. These we must
describe as above, lesions of each stage, of the nor-
mal physical characters, etc. The lesions of the dis-
tant organs, or the organs at large, comprise those of
the organs of circulation ( blood and lymphatic sys-
tem), respiration, innervation, urination, digestion,
generation of special sense (eye, ear, nose, taste, skin).
In each we must describe the lesions of each stage, of
the normal physical characters, etc. For each patho-
logic feature we must state the frequency and the
importance.
PATHOLOGIC PHYSIOLOGY.
Diseased organs have altered functions. The phy-
siologic alterations of each stage should be described
as a separate disease. The possible lesions are the
82
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
[July 11,
following: 1, the alterations in the normal characters
of the physical or mechanical phenomena of the func-
tions of the organ; these usually affect the movements
or contractions of the muscular fibers ; they are
decreased, increased or perverted; 2, the alterations in
the characters of the chemical and vital phenomena,
or action of the peculiar secretions and excretions,
which will be more fully described further; 3, the
alterations by new or abnormal phenomena, which
may be physical, chemical or vital; 4, the alterations
in the functions of the region, i.e., of the neighboring
organs, which may also be physical, mechanical, chem-
ical or vital; 5, the alterations of the functions of the
organs at large, i.e., organs of circulation, respiration,
etc. ; 6, the mode of repair or of reproduction of in-
jured and lost parts.
For each phenomenon, state the frequency and
importance.
SYMPTOMS.
The symptoms to be described are local, regional
and general.
The local symptoms may be subjective, physical,
functional.
The subjective symptoms are those felt by the
patient only and which can not be detected by the
surgeon ; they consist in pain, sensations of heaviness,
of heat, of cold, of pricking.
The physical symptoms are those detected by the
sight, touch, hearing, smell, taste.
By the sight we detect and describe the general
appearance of the part, its attitude, the muscular
movements, the color, transparency, shape (form or
deformity of the parts); the sphygmographic tracing
of the part, of the pulse, of the heart; we make the
comparison with other side.
By the touch and by palpation we detect and describe
the temperature, the consistency, the presence of
emphysema, crepitus, crepitation, fluctuation, mobil-
ity of the part, of pulsations with or without expan-
sion, of displacement. By mensuration we determine
and describe the changes in the normal length or
breadth or circumference of the parts. By probing,
the course, depth and bottom of a sinus and the pres-
ence of a foreign body. By percussion we detect and
describe the presence or absence of resonance, the
dullness, the absence of elasticity. By the exploring
needle we determine the presence of a liquid, and of
its nature by its macroscopic and microscopic exam-
inations.
By the hearing or auscultation, we detect and
describe the alterations in the character of the normal
sounds of the diseased part, and the alterations due to
new or pathologic sounds.
By the smell we may detect the alcoholic breath, the
fetid breath of diseases of the mouth, throat and lungs,
the fetid sputum, the odor of supjmration under a
dressing, the odor of blood, of incontinence of urine,
of fecal matter, of gangrene, of peculiar remedies.
The fluids or secretions, normal or abnormal, pre-
sented by the diseased parts, must be described (see
description of a fluid, further), also the microscopic
examination of the secretions or of particles of tissues
(as described in pathologic anatomy). In some cases
the condition of the blood must be described (as a
fluid).
Tests with inoculations, with hypodermic injections,
and graftings, with fluids or particles, before or after
cultures, on the same subject or other subjects, or the
lower animals, must be described as parts of symp-
tomatology.
The functional symptoms are produced by the
impairment of the functions of the diseased parts;
they are physical or mechanical, chemical or vital,
they are decreased, increased or perverted (as above).
For each symptom state the frequency and importance.
The regional symptoms or symptoms presented by
the neighboring organs are subjective, physical, func-
tional, and should be described after the same method
as explained above.
For each of these symptoms state the frequency
and the importance.
The general symptoms are those presented by the
facial expression, the general attitude of the patient;
by the organs at large, organs of circulation, respira-
tion, etc. They may be subjective, physical, func-
tional; they must be described as above explained.
For each of these symptoms also state the frequency
and importance.
The symptoms of each stage of the disease must
be described; they are also local, regional, gener-
al; and in each of these cases subjective, physical,
functional. For each also we must state the frequency
and importance.
The stages are the premonitory, the prodromic, the
incipient or d6but; the developed or established state
(as described above), the terminal stage, whose synq)-
toms vary with the termination.
COURSE.
The course of the disease must be stated as sur-
acute, acute, subacute, subchronic, chronic or long
chronic, stationary. State the frequency and impor-
tance of each.
DURATION.
The duration must be described in considering the
disease as a whole and then of each stage; state the
most frequent duration and the duration of each stage.
TERMINATION.
The termination must be described as cure, station-
ary, chronic state, death. State also the frequency
of each.
DIAGNOSIS.
The diagnosis presents the following parts to
describe :
1. Enumerate the diagnostic signs by which the dis-
ease may be recognized; these are derived from fre-
quency, causes, symptoms, course, duration; also from
the effects of the treatment. State the frequency and
importance of each. Pathognomonic signs must
always be given precedence above the others.
2. Enumerate the other diseases resembling the
disease under study.
3. Make the differential diagnosis between these
diseases by comparing and weighing the importance
and value of each sign in each disease (frequency,
intensity, peculiarity).
4. Diagnose or establish the stage, the course, the
duration, the tendency to termination without or with
proper line of treatment, the form and variety, the
complications.
5. The diagnosis may be a diagnosis by anticipation
when animals are inoculated to determine the true
nature of the supposed case and determine what is to
be expected in the case of the patient who has been
subjected to the same cause, as for inoculations in
rabies and in tuberculosis with tuberculin.
6. The retrospective diagnosis, that is the diagnosis
of the true nature of the disease with which a patient
1896.]
MEDICAL LONDON.
83
has been affected, is based upon the clinical history
ami the sequela' or consequences of the disease: spots,
oioatrioes, impairment of the functions, etc.
PROGNOSIS.
The prognosis must state the general prognosis of
the final termination of the disease; of its duration;
the possibility of relapses and of sequelae; for each
we must state the frequency and importance of each
point.
TREATMENT.
The description of the treatment of the disease
embraces the following points: The prophylactic and
preventive treatment, the abortive treatment, the
removal of the offending cause, the specific treat-
ment, the curative, the palliative, the symptomatic
treat ment or the treatment of the symptoms, or treat-
ment on general principles.
In eaeli ease state the means employed. These may
be hygienic (diet, rest, etc.); they may be medical
and remedial (medicines of all kinds); they may be
surgical (topical or operative, of a minor or a major
nature ). The treatment may be by the mouth, by the
rectum, by enema, by hypodermic injections, by intra-
venous injections. State the efficacy of each. The
description of the treatment of each stage is indicated
above.
RELAPSES. SEQUEL.E, CONSEQUENCES, RECURRENCES.
The description of relapses, sequelae and conse-
quences must be stated carefully; state also the fre-
quency, causes, symptoms, course, duration, termina-
tion, diagnosis, prognosis, treatment, sequela? and
consequences of sequelae, forms and varieties, com-
plications of sequelae, recurrences; in a word, describe
them like separate diseases.
(To be continued.)
MEDICAL LONDON.
NOTES FROM MY SKETCH BOOK.
BY L. HARRISON METTLER, A.M., M.D.
CHICAGO. ILL.
It is demonstrably true that distance lends enchant-
ment, for three thousand miles of ocean does increase
one's transatlantic veneration. Europe and America
are veritable El Dorados when viewed respectively
from the opposing shores. The philosopher of Chel-
sea would have been less of a hero- worshiper had he
been more of a traveler. Plato's Republic was a
beautiful thing to dream of in the groves of the
Academy, but out here in America it seems to have
drawbacks that reveal many imperfections. A med-
ical code of ethics is "a thing of beauty and a joy
forever" until — well, until you discover your high-
code neighbors underbidding for your patients.
Medical matters are strictly scientific abroad, you
fondly imagine, until you plant your feet upon foreign
soil. London with its hundred and thirty or more
hospitals is far from being the medical Elysium for
everybody there, as we had foolishly fancied. The
wail of our insular brother against hospitalism is
quite as loud and lugubrious as our own. "Too many
hospitals and too man} dispensaries" is the first
response of the unhappy practitioner, when asked to
tell us something of medical London. And yet with
all this hospital material, post-graduate education is
not what it might be. Absence of governmental con-
trol and encouragement, over-intense individualism,
and want of proper centralization are given as a few
of the causes of the inferiority of London as a post-
graduate medical center. As compared with Ger-
many, laboratory teaching in England is sadly defi-
cient. There are no endowments; there is no
university teaching. There is abundance of hospital
material, but it is not made use of as it should be.
In the Poor-law infirmaries there are no less than
12,000 beds unused for the clinical teaching of the
students. The same is true of many of the fever hos-
pitals. All of which goes to show that medical mat-
ters in London are as much in need of readjustment
as they are with us. The particular attraction for an
American physician in the metropolis is the large
number of special and general hospitals and the
abundance and variety of clinical material that may
be observed.
Every tourist, upon first arriving in London, sets
out at once to visit Westminster Abbey and the Par-
liament buildings. As he approaches the end of
Westminster Bridge, the view from which inspired
Wordsworth to exclaim, "Earth has not anything to
show more fair," he looks away across the river and
immediately inquires about the magnificent row of
buildings rising from the Albert Embankment,
directly opposite the Parliament Houses. If he is a
physician his interest will be quickened upon being
told that those seven elegant, modern-looking struc-
tures constitute the famous St. Thomas's Hospital,
an ancient Foundation by Richard, Prior of Ber-
mondsey, in the year 1213, for Converts and Poor
Children. In 1215 it was remodeled by Peter de
Rupibus, Bishop of Winchester, for canons regular.
Like other religious houses, it was surrendered to
Henry VIII. in the thirtieth year of his reign, pur-
chased by the citizens of London in 1544, and opened
for the reception of patients in November, 1552, under
a charter from the Crown. The ancient site of the
hospital was in the borough of Southwark, at the
southern extremity of the famous old London Bridge,
near Guy's Hospital. In 1862 a railroad corporation
bought the site and the hospital removed temporarily
to Newington in Surrey. It was in 1868 that the
foundation stone of the present magnificent edifice
or edifices was laid with royal ceremony by the Queen.
Her Majesty opened the hospital June 21, 1871. It
contains about 600 beds and is prepared for the recep-
tion of all kinds of cases. Surgery receives special
attention under its roof. The income of the hospital,
derived largely from rents and donations, is about
£45,000, but from this a large deduction has to be
made, leaving about £33,000 for hospital purposes.
The lover of the historical will find much to entertain
him within a few steps of the hospital. Lambeth
Palace, for six centuries and a half the city residence
of the Archbishops of Canterbury, the famous Lol-
lards' Tower and Prison full of sad memories, the
Chapel, the gay and notorious Vauxhall, Bedlam,
Astley's Amphitheater, Lambeth Ferry made famous
by Macaulay in his description of the midnight flight
from Whitehall of the Queen of James II and her
infant son, and Vauxhall Bridge, erroneously associa-
ted with the name of Guy Vaux or Fawkes of the
notorious Gunpowder Plot, are all in the immediate
vicinity.
A few steps to the southwest of St. Thomas's stands
the famous Bethlehem or Bethlem Hospital, vulgarly
84
MEDICAL LONDON.
[July 11,
called Bedlam. Even the general physician will visit
this institution, if for no other reason than its
remarkable history. Its name is derived from a
priory of canons belonging to the Order of the Star
of Bethlem, established in a monastery near Bethle-
hem, and caring especially for the sick and the insane.
The badge of the order was a star worn on the man-
tle. The hospital was founded at the Dissolution, by
Henry VIII. , upon the endowments of a priory estab-
lished by Simon Fitz-Mary, a sheriff of London in
1246, who gave to it all the land he owned in Bishops-
gate Without, and there in Liverpool Street erected
the first Bethlem Hospital. More correctly speaking
it was a "dungeon house" for furious lunatics, whence
it became popularly known as Bedlam. It was only
large enough to contain sixty patients and it was the
first institution devoted to the insane in England of
which there is any record. In 1675 it was removed
171 patients were discharged as benefited and 139 as
actually cured. Such results were never obtained by
the old restraining and torturing methods of treat-
ment. The income of the hospital in 1888 was over
£25,000. A small number of male and female
patients are now admitted on a uniform payment of
JL2, 2s per week. The name of Bedlam used to be
synonymous with all the horrors and tortures of the
Inquisition. The complete change in the modern
method of treating the wretched inmates, the employ-
ment of gentleness, kindness and persuasion with all
the corresponding better results, have hardly yet
sufficed to remove the odium attached to the name.
Bedlam. The earliest legislation in regard to the
insane poor was in 1744, George the Second's time,
when any two justices were given the power to arrest
pauper lunatics found at large and to chain and in-
carcerate in "some secure place" within their parish
ST. THOMAS' HOSPITAL, LONDON.
to Moorfields, where a building was erected to accom-
modate one hundred and fifty-two inmates. After
many additions had been made to it from time to
time, it was thought best in 1814 to change its site
again and to erect the buildings which it now occu-
pies in St. George's Fields, Southwark. The archi-
tecture of the main structure is imposing. Its cupola
resembles that of St. Paul's Cathedral. The hospital I
now accommodates about 400 patients of both sexes, j
and it receives fjratis, all poor lunatics who are likely |
to be cured within one year and who are not fit appli- 1
cants for a county lunatic asylum. The better class
of educated patients are preferred, and the treatment
is along the lines of kindness and consideration. The
women are provided with pianos, needlework, em-
broidery and knitting; the men with bagatelle and
billiard tables, newspapers and periodicals. In 1888,
of settlement. Up to this time enactments were
made only for the custodial care of the insane con-
sidered too dangerous to be at large. They were
allowed to overrun the country much to the annoy-
ance ofttimes of the people and to the distressing
neglect of themselves. Shakespeare avails himself of
this state of affairs to enable Edgar in King Lear to
assume a disguise :
, .„ "Whiles I may 'scape,
I will preserve myself ; and am bethought
To take the basest and most poorest shape,
That ever penury, in contempt of man,
Brought near to beast ; my face I'll grime with filth •
Blanket my loins ; elf all my hair in knots ;
And with presented nakedness out-face
The winds and persecutions of the sky.
The country gives me proof and precedent
Of bedlam beggars, who, with warring voices,
Strike in their numb'd and mortified bare arms
,
1896.]
MEDICAL LONDON.
85
Pins, wooden pricks, nails, sprigs of rosemary ;
And with this horrible object, from low farms,
Poor pelting villages, sheep-cotes and mills,
Sometime with lunatic bans, sometime with prayers,
Enforce their charity."
Until a very few yours ago the lunatics of Bedlam
were one of the exhibitions of the metropolis. In
Hogarth's "Rake's Progress" the last scene represents
a number of fine ladies screening with affected
prudery by means of their fans, a half-naked, fettered
madman whom they have come to see. Henry Carey,
an author who lived a century earlier and who wrote
"Sally in our Alley," speaks of Bedlam as one of the
most popular resorts. Once he followed, out of
curiosity, a gay young cockney couple — such as Sally
and her lover — through their day's festivities and
noticed that the latter treated his sweetheart seriatim,
to the following amusements, namely, "a sight of Bed-
lam, the puppet shows, the flying chairs (? swings)
and all the elegancies of Moorfields." This exhibi-
tion of the insane, heavily manacled and chained, or
kept in cages of iron, afforded Bethlem Hospital a
considerable revenue in fees, down to the year 1770.
To further add to the funds of the hospital in the
olden time, partially convalescent patients, with
badges affixed to their arms and known as "Tom-o'-
Bedlams" or "Bedlam Beggars," were turned out to
wander and beg in the streets. The practice was
stopped, however, before 1(575.
A short walk northeastward from Bethlehem Hos-
pital brings one to the southern extremity of old
London Bridge and the famous old Borough of
Southwark. Who does not recall with dear old
Chaucer
" That, in that seson on a day,
In Southwerk at the Tabard as I lay,
Redy to wenden on my pilgrimage
To Canterbury with devoute corage,
At night was come into that hostelrie
Wei nine and twenty in a compagnie."
and who does not remember Tooley Street where
dwelt the three tailors who began their petition
to Parliament- with "We the people of England?" In
this Borough the immortal Sam Weller was first dis-
covered to the world officiating as " boots" at the
White Hart Inn: here also stood the church of St.
George's and the Marshalsea Prison so familiar to poor
Little Dorrit. Not far away rises the church of St.
Mary Overy, second in interest only to Westminster
and containing the graves of the poet John Gower, of
Edmund Shakespeare brother of the dramatist, of
Fletcher, of Henslow and of Philip Massinger. Ah!
but this is a famous old district and the medical tour-
ist who is fond of historical memories and literary
anecdotes will be sorely tempted to divide his atten-
tions between Guy's Hospital, which lies in the heart
of old Southwark and the other sights of the borough.
Passing down St. Thomas's Street (named from St.
Thomas's hospital that used to stand here) one soon
comes in front of an old-fashioned archway and a row
of old-time buildings. The hospital forms a hollow
square in the midst of a noisy, odoriferous, bustling
part of London and surrounds a quiet, well-shaded
courtyard. It was founded in 1721 by Thomas Guy,
the son of a lighterman at Horselydown, who became j
a bookseller in Lombard street and made a large for-
tune by printing and selling Bibles and by specula-
tion in the South Sea Company. At first Guy gave
much money to St. Thomas's hospital but he after-
ward bought (at a rental of £30 a year) of the gov-
ernment of that Hospital a lease for 999 years of the
land on which he built Guy's Hospital at a cost of
nearly £20,(XX). At his death he bequeathed to it
£210,499. The testator's benefactions constituted the
largest sum that had ever been given up to that time
by any one person for charitable purposes. A very
pretty way to ease one's conscience in the disposal of
wealth obtained by the discreditable practice of pur-
chasing the prize tickets of seamen at a large discount
and subsequently investing them in South Sea stock!
Soon after Guy's death, the executors procured an act
of parliament, incorporating themselves and 51 other
gentlemen, named by the founder, as president and
governors of the hospital. At first the number of pa-
tients amounted to 402. In 1829 a further endow-
ment was made to the hospital of nearly £200,000 by
a Mr. Hunt of Petersham, thus making accommoda-
tion for 100 additional inmates. Other benefactors
have bestowed about £10,000 more. Until quite
recently the annual income of the hospital amounted
to £40,000, but through the depreciated values of
property and landed estates it is now scarcely £25,000.
Nevertheless the expenditure for hospital purposes is
£34,600, The wards contain some (iOO beds. The
out-patient departments are especially rich in clinical
material and owing to the location of the hospital a
large number of accident cases are received daily.
The yearly average of patients received in the hospital
is 3,000, while the out-patients that are relieved
amount almost to 50,000.
Situated in the heart of an old, malodorous, thickly
populated district of London, the dispensary work of
this famous hospital interested me exceedingly. The
hospital building consists of two quadrangles, with
two wings extending from the front to the street. The
west wing is quite elegant and uniform in its archi-
tecture but the rest of the edifice while regular is
rather ancient looking. The courtyard might be kept
in a little more attractive state with flowers and lawns,
though the noble old trees give it an agreeable shade.
The medical school associated with the hospital is one
of the best in London and contains about 400 students.
The anatomical museum especially awakened my
admiration. It is unusually rich in specimens and its
arrangement is unique, affording the greatest amount
of facility for the study and examination of its con-
tents. In the Chapel of the Hospital is an admirable
statue of Thomas Guy in marble and the grave of Sir
Astley Cooper.
St. George's Hospital, near the gay and fashionable
Hyde Park Corner, was founded in 1733, contains 350
beds, has associated with it a very good medical school,
and is chiefly interesting to visitors as the place where
the renowned John Hunter practiced and died (1793).
The London Hospital dates from 1740 and expends
about £51,000 per annum in the relief of suffering.
It contains 790 beds. There are many other hospitals
deserving more than a passing notice, but those I have
already mentioned are the most renowned and must
suffice.
The practitioners of London have their offices in
their residences, and usually upon the ground floor.
They make less effort than we Americans do to adorn
them with attractive hangings and luxurious furnish-
ings. With crowded desks, piles of journals, charts,
scientific apparatuses and other paraphernalia lying
about, the offices of our London confreres have a
distinctively professional and business-like appear-
The London medical man dislikes exceedingly
ance.
86
PERIHEPATITIS.
[July 11,
to talk " shop " outside of his office, whereas within
his sanctum I have invariably found him full of med-
ical chat and medical opinions. Certain parts of the
city, notably in and around Cavendish Square, seem
to be the favorite haunts of the medical fraternity.
Here are to be seen many modern as well as old-time
residences, upon whose doors hang many an old-fash-
ioned brass knocker and ample brass plate bearing the
legend "Mr. A." or " Dr. B." to indicate the home of
the surgeon or physician. With proper introductions
one will find the medical profession of London a
most hospitable set of men. A morning call will be
equivalent to staying and taking lunch with the whole
family; an invitation to accompany your host to an
operation will probably mean a drive to several hospi-
tals with your generous host as guide and informant;
a polite request to " drop in " upon a certain evening
is an indication that you are expected to come in full
dress and participate in a reception. The cordiality of
our English cousins is shown by the invitations, pro-
grams, announcements of social events and society
meetings that are poured in upon you during your
stay in the capital. Many London physicians make a
habit of keeping open house upon a special evening
of each week. A table is set and the ladies of the
household assist in entertaining. There is a fine
esprit de corps amongst the London medical men, as
is shown in many ways, but especially in the matter
of fees. There is very little if any underbidding.
Consultants are extremely considerate of those by
whom they are called. An unusual courtesy is extended
to one another, both in public and in private. Profes-
sional etiquette and gentlemanly demeanor are never
lost sight of, as I had frequent opportunity to observe
in the various medical society meetings and social
relaxations.
At one of the meetings of the Royal Medical and
Chirurgical Society which I attended, I was impressed
with the comfortable furnishing of the apartment on
Berners Street, the dignity and appropriate ceremo-
niousness of conduct, the courteousness yet freedom
of debate, and the friendly sociability after the meet-
ing had adjourned. In the middle of the well car-
peted and heavily-draped room stood a great tall, old-
fashioned stove in which blazed and crackled a cheer-
ing log fire. At the head of the room stood the
throne-like president's desk, having above it a large
shield ornamented with the royal arms. On either
side were the desks of the secretary and treasurer.
The readers of the papers and most of the audience,
which numbered about fifty, were in full evening
dress suits. Sir E. H. Sieveking occupied the chair,
presiding in a most courtly and dignified manner.
One of the papers was upon gastro-enterostomy, and
as an American I was naturally much gratified to hear
the author pay a high compliment to our American
surgeons, especially to our fellow citizen, Dr. Nicho-
las Senn. He said that the latter had now made the
operation so perfect that scarcely any more could be
desired or suggested. The second paper was upon
cicatricial transplantations and was most liberally
illustrated with photographs and patients. After
adjournment we all assembled in a neighboring room
and partook of the light collation of sandwiches and
coffee, which served to banish any stiff formality.
This is a fair illustration of the average medical
society meeting in London. One of the most active
and interesting societies to attend is the British
Gynecological Society, which holds its meetings fort-
nightly in a building in Chandos Street, near Caven-
dish Square. The gynecologists I found to be a pug-
nacious set of men and to be an observer of one of
their fortnightly tilts is as exhilarating as to have
been present, I presume, at a medieval tourney.
What with the Clinical Society of London, the Med-
ical Society of London, the Obstetrical Society of
London, the Hunterian Society, the Harveian Society
and a host of others, one need never be at a loss for
a battle field whenever he may feel medically pugna-
cious while staying in London. He will always find
there able combatants and strong bulwarks ready to
entertain him.
4544 Lake Avenue.
REPORT OF A CASE OF PERIHEPATITIS
AND PLEURISY RESULTING FROM
INJURY.
Read by Title lu the Section on Practice of Medicine at the Forty-
seventh Annual Meeting of the American Medical Asso-
ciation, at Atlanta, Ga.. May 6-8. 1896.
BY J. M. G. CARTER, M.D., Sc.L>., Ph.D.
PROFESSOR OF PREVENTIVE AND CLINICAL MEDICINE IN THE COLLEGE OF
PHYSICIANS AND SURGEONS, CHICAGO: FELLOW OF THE AMERI-
CAN ACADEMY OF MEDICINE, ETC.
WAUKEGAN, ILL.
The case which is the subject of this paper was
that of a farmer's daughter of German descent, aged
15 years. She was in good health although rather
under weight as compared with girls of her age, and
had passed the period of puberty. Her parents were
strong robust people.
On Sept. 15, 1895, she fell from a tree a few feet,
10 or 12, and struck her right side against a stone,
receiving an injury which stunned her. At the time
I saw the patient, two hours after the accident, the
pulse was 130, respirations 40, temperature normal.
The seventh and eighth ribs on the right side were
fractured.
A bandage was put around the thorax, and remedies
administered to secure rest. On the following day
the pulse was 120, temperature 102 and respiration 30.
Considerable tenderness was manifestedover the liver
and injury of that organ was suspected. The succeed-
ing day all the symptoms were increased in severity.
Perihepatitis was diagnosed. In a week icterus
occurred. The symptoms were those of perihepatitis
with disturbances of respiration especially marked.
No points of peculiar interest presented and it was
hoped that two weeks would see the case fully
convalescent.
At the end of two weeks the temperature had not
subsided; the pulse was 130, respiration 30. The
skin was clear, bowels in good condition, but the urine
was high-colored and contained indican in excess
with some increase of urates. The ribs seemed to be
united and the perihepatitis had apparently subsided.
What could account for the continued elevation of
temperature and rapidity of pulse and respiration?
Careful examination of the right thoracic region had
been made frequently but no marked evidence of
pleurisy had appeared. Could it be inflammation
deeply seated in or about the liver or an obscure
pleurisy? A thorough examination was instituted to
determine this point. Finally, I thought I could
detect that there was a slight reduction of the clear-
ness of the respiratory mumur. Believing I had to
deal with secondary pleurisy, I placed the patient on
appropriate treatment. The pulse, respiration and
temperature remained high. In two days from time of
LSSHi.1
GUNSHOT WOUND OF THE CHEST.
87
diagnosing pleurisy, the symptoms and physical signs
were well marked, and the patient passed along as in
an ordinary case of secondary pleurisy, the only
peculiarity being a gradual increase in the rapidity of
the pulse. At the end of ten days, < )otober 11. nearly
four weeks from the time of the accident I decided
thai it was necessary to remove the effusion. The
family, objected. Tuesday she had a chill; the
family consented to let me perform paracentesis.
Wednesday, October 16, I operated removing two
quarts of pus. All the symptoms abated and the
chills ceased. The temperature fell to 99.5. The
pulse, which had reached 160, dropped to 120 in the
minute. Nov. 2. 1895, the temperature was 102.5,
respirations It), the pulse 150. I decided to operate the
second time. 1 plunged a trocar and canula between the
sixth and seventh ribs, just posterior to the axillary
line. The first operation was performed with an aspira-
tor; hut as I wished to introduce a drainage tube, the
second operation was performed as described. The tro-
car was withdrawn and the canula left in place. Three
pints of pus were removed and a No. 7 (Am.) soft
rubber catheter passed through the canula into the
pleural cavity, under proper aseptic precautions. The
canula was withdrawn leaving the tube in place. A
safety pin was passed through one wall of the catheter,
a string tied to each end of this and the strings held
in place by strips of adhesive plaster. The tempera-
ture and rapid respirations abated at once and within
two or three weeks both were normal and the pulse
had fallen to 120.
.Malt, cod liver oil and iron tonics were administered
and she gradually improved. It was not until Jan. 2,
1896, that the pus ceased flowing and only one inch
of the tube remained within the chest wall; the tube
was removed and the opening closed antiseptically.
The patient has remained well, but the adhesion of
the pleural walls has left the right side smaller than
the left and cause the right shoulder to fall consider-
ably below the level of the left; improvement is
noticeable however, and at the present writing (April)
she has very little deformity.
GUNSHOT WOUND OF THE CHEST; RE-
PORT OF A CASE; RECOVERY.
BY J. LUE SUTHERLAND. M.D.
GRAND ISLAND, NEB.
Fritz Thavenet, aged 9 years, by the accidental dis-
charge of a small target rifle in his own hands, conse-
quently at close range, was shot through the chest
from front to back. The ball, a 22-caliber, conical,
entered one inch below and one-half inch to the left
of the tip of the ensiform cartilage and almost touch-
ing the costal arch at a point exactly opposite the
costo-cartilaginous articulation of the seventh rib. It
ranged upward, backward and a very little outward,
•emerged between the ribs, at the point shown in pho-
tograph,and lodged in the trapezius muscle from which
it was easily extracted. ■ A line drawn horizontally
around the chest at this point is just four and one-
half inches above the entrance wound. His condi-
tion one hour after receiving the wound was, pulse
84. respiration 26 and rather shallow; temperature not
taken, but seemed to be slightly subnormal and there
was a gen feral pallor of the skin, but no vomiting; and
-when asked if he felt sick at the stomach replied, "not
much." Hemorrhage was slight. Air escaped with
a bubbling sound when the ball was cut down upon
and removed. The first dressing consisted in render-
ing both wounds as aseptic as possible, loosely plug-
ging them with iodoform gauze, covering with large
thick pads of gauze and absorbent cotton and the
application of a roller bandage around the chest suffi-
ciently firm to slightly restrict respiratory movement.
This dressing was not disturbed for twenty hours,
during which time, and for forty-eight hours after, he
wns given nothing but liquids in very limited quanti-
ties, and he was kept in a recumbent position with
head and shoulders elevated. At the second dressing,
the wound in the back was covered with fresh pads
and allowed to close, but the entrance wound was
cleansed and plugged at each dressing for eight days.
His recovery was rapid and without event; the tem-
perature at no time was above 100 F. and at the pres-
ent writing, sixteen days from the receipt of the
injury, he says he feels as well as ever, there being no
pain or discomfort. The wound in the back is com-
pletely healed and the one in front, having been
burned with the powder, suppurated a little and is
not yet closed. He was permitted to be up on the
fourth day, was out of the house the greater part of
the time after the sixth day, came to town, a distance
of over a mile, on the tenth day.
SILK LIGATURE IN URETHRAL STRICTURE.
[July 11,
A study of the anatomy of the parts will show that
it is possible that the stomach was not wounded, but
the question naturally arises, where was the left bor-
der of the liver at this time? If either of these
organs were wounded, notwithstanding the smallness
of the missile, there certainly would have been symp-
toms indicative of the fact.
The apparent miraculous escape of the stomach
from injury can be accounted for by an anatomical
fact and a physical condition, viz: The patient being
only 9 years old the natural position of the stomach
approaches more nearly the perpendicular than it
does in adult life; consequently instead of the supe-
rior curvature we have an irregular oblique line, the
upper third of which lies to the left of the median
line. In harmony with this in this particular case is
the fact that his breakfast that morning was small,
consisting wholly of wheaten pancakes, and as full
four hours had elapsed before the shooting, stomach
digestion had advanced to such a degree as to leave
that organ almost empty, but whatever of its con-
teuts there was yet remaining, it was in the most
dependent part and by its weight would thus aid in
dragging the stomach downward, diminishing the
size at the cardiac extremity, increasing its per-
pendicularity and carrying the entire organ toward the
left, as the boy was standing at the time of the
accident.
Taken in all its bearings it was a narrow escape
between the stomach on one side and the left border
of the liver upon the other. The descending aorta must
have been uncomfortably near the track of the bullet
also, not to mention other minor but none the less
vital organs in the immediate region of the wound.
THE SILK LIGATURE IN URETHRAL
STRICTURE.
BY J. D. THOMAS, M.D.
Professor Genito-Urinary and Venereal Diseases Western Pennsylvania
Medical College, Medical Department Western University; and
Genlto- Urinary Surgeon to South Side Hospital.
PITTSBURG, PA.
Recently in operating upon a case of -urethral stric-
tures in conjunction with my colleague, Dr. H. R.
O'Conner, at the South Side Hospital, we met with a
difficulty somewhat out of the ordinary. The case
was one of urinary fistula— the fistula opening upon
the left side of the scrotum and due to the strictures.
Beginning two inches from the meatus and involving
the urethra from this point backward for the distance
of another inch was a stricture that would admit
nothing larger than a filiform ( "a filiform stricture" ) .
After the filiform was passed through this and into
the bladder an opening was made in the perineum.
An effort was now made to pass a tunneled Maison-
neuve urethratome (No. 6 F. ) over the filiform in
order to cut the anterior stricture internally, but the
stricture tissue was found so rigid that the shaft of
the urethratome could not be made enter the lumen
of the stricture with ordinary pressure. As a dernier
ressort an attempt was then made to divulse the stric-
ture by pushing the instrument with sufficient force to
accomplish the object in view, but this proved a fail-
ure, for, instead of the Maisonneuve entering the
stricture the penis (rather a small one) was simply
crowded backward into the perineum. The filiform
was now withdrawn and after the removal of the
tunneled tip from the urethratome the regular screw
guide was attached, thus giving the entering part of
the instrument more of the wedge form, but with this
change no better success was met with. This instru-
ment again was removed, a filiform passed and the
smallest tunneled instrument in our possession used,
hoping to divulse or dilate sufficiently to allow the
cutting instrument to pass. This, again, was a fail-
ure. It now suggested itself to me that to pass a
silk ligature through the urethra the stricture might
be sawed (Abbe's method for the esophagus) suffi-
ciently to permit the urethratome to pass. This
proved a success and was accomplished by tying a
small-sized ligature around the bulbous end of the
filiform, already in the urethra, and drawing the fili-
form with the thread out through the perineal opening.
This left one end of the string projecting from the
meatus, the other from the perineal wound, and by
taking hold of these two ends and resorting to a saw-
ing motion while an assistant made pressure on the
under surface of the penis at the location of the
stricture, we were soon able to secure sufficient room
for the introduction of the Maisonneuve urethratome.
The ligature was threaded through the tunneled end
of the urethratome and utilized as a guide.
77 and 79 South Thirteenth Street.
ISM.]
SOCIETY PROCEEDINGS.
SOCIETY PROCEEDINGS.
Twenty-fifth Animal Congress of the Surgeons
of Germany,
The quadrieentennial "Chirurgeneongress" was celebrated
at Berlin in May with great festivities ; among them we note a
scries of tableaux in the Opera House, representing the history
of surgery in Germany. The Association formally adopted the
proposition to cooperate in the formation of an International
Congress of Surgery. The six opening addresses were all on
subjects that have been created or revolutionized in the last
two decades, and presented by the men who have contributed
most, perhaps, to their development.
Professor Bruns reviewed the
OLUTION OF THE MODERN SURGICAL TREATMENT OF GOITRE
from the time only twenty years ago when Li'icke wrote that
••Surgeons generally dread and avoid an operation" and the
lirst tedious process of extirpation, requiring sometimes 200
ligatures, to the popular Billroth-Koeher total extirpation, an
absolutely certain, bloodless and artistic operation. Then
came the loss of life from cachexia strumipriva after these
supposed successful operations. Bruns himself was the first
to become convinced that the insignificant thyroid gland was
after ail an important secreting organ, and that the organism
suffered severely when its secretions were withdrawn. In the
revulsion that followed this discovery, an old method was
revived, producing atrophy of the thyroid gland by ligating
the thyroid arteries. This method not proving satisfactory,
■enucleation, attempted by Porta in 1840, was improved by
Socin, and now comprises with resection and partial extirpa-
tion, the modern surgical treatment of goitre, varied or com-
bined to suit individual cases, and no longer considered danger-
ous. In Bruns' 400 cases since 1883, the fatalities have only
been l1^ per cent, with none in his last 150 cases. Partial
extirpation is very frequently followed by a return of the
goitre, but seldom to such an extent as to necessitate a second
operation. Only a dozen cases are known in 800 operations
<Socin. Kronlein, Kappeler, &c). He considers therefore the
present surgical treatment of goitre as eminently successful,
but still more valuable is the thyroid medication, which has
proved a prompt and certain cure for hyperplastic goitre. In
300 cases of goitre of various kinds, 100 were effectively
relieved and the growth materially diminished. In another
100 cases the growth was only relatively diminished, but the
accompanying troubles were relieved until an operation became
unnecessary. Thyroid medication is also an invaluable pre-
liminary to an operation, especially to enucleations and resec-
tions. It decreases the amount of blood in the region and
effectively prevents hemorrhage. As was stated in an article
in the Joubnal, April 4, page 662, Bruns considers that the
success of enucleations depends upon finding, and enucleating
the capsule without injury to the surrounding tissue. It is
the standard operation in well developed cystic and nodular
goitre, and it is indispensable in double goitre, where the
remaining tissue must be carefully preserved. But it must be
strictly avoided if the nodules are not distinctly separate from
the surrounding tissue, or if there are extensive adherences.
In such cases there is sure to be profuse and almost uncon-
trollable bleeding, and it is often impossible to complete the
operation. Bruns' experience in 200 cases of enucleations was
that the bleeding was scarcely noticeable in 70 per cent. ; con-
siderable in 20 per cent, and so profuse in 10 per cent, that
the operation had to be abandoned. Post-operative hemorrhage
followed in 8 per cent. Enucleation may also seriously affect
the functions of the gland if the nodules are very numerous,
requiring many ligatures. Resection is to be preferred in such
cases. Hemorrhages can be controlled with it and sound
tissue preserved, while the operation can be varied and modi-
fled in many ways to suit each case, leaving the hilus, the
isthmus or the upper or lower pole as may be required, and
combined with enucleations if necessary. Bruns concluded
with the statement that the experiments he had been making
on goitrous animals with Baumann have thrown some light on
the finer processes which occur during thyroid medication.
Professor Esmarch of Kiel, announced that his amputa-
tions of limbs and external genital organs were absolutely
bloodless, owing to his
METHOD OF DRIVING THE BLOOD OUT OF THE LIMB AND PREVENT-
ING ITS RETURN UNTIL THE OPERATION IS COMPLETE,
and the final bandage applied. He uses a thin bandage of pure
brown rubber, winding from below upward, although linen or
cotton bandages wound on dry, and afterward wet, will answer
the purpose. If there is any inflammation or thrombosis, he
first holds the limb in a perpendicular position until it grows
pale. He arrests the arterial blood with a woven rubber
bandage 5 cm. wide and 140 cm. long, strong enough to com-
press the femoral artery in the most muscular man to such a
degree that no blood can flow into the limb, fastening it with
a buckle. He restricts the use of the rubber tube he invented
for this purpose to operations on the scrotum and penis, and
to exarticulations of the hip and shoulder joints or amputa-
tions below them. After an amputation the larger blood ves-
sels are seized with the torsion forceps and ligated. After the
wound is closed and a well-fitting, firmly compressing bandage
applied, the limb is held perpendicularly and the elastic band-
age rapidly removed. The patient is then placed in bed with
the limb still held in this position for fifteen minutes longer,
when it is lowered to a horizontal position, and there is usually
no question of hemorrhage. If the bandage over the wound
has not been properly applied it may be stained by blood
trickling through, but this can almost always be stopped by a
pad of cotton laid over the place, held firm with a rubber band-
age if necessary. In the majority of cases the blood that exudes
is found later when the permanent bandage is removed, in the
form of a thin narrow red strip lying over the healed wound.
No knowledge of anatomy is required to wind up a limb with an
elastic bandage like this, while considerable skill is required to
apply a tourniquet so as to do good and not harm, which is the
great advantage of the former in cases of traumatism when
unskilled hands render the first aid. Many lives have already
been saved by them, and especially with the elastic suspenders
Esmarch invented and described at the time the Czar Alex-
ander II. died from this cause. Many operations on the inter-
nal organs, the uterus and rectum, have been much facilitated
by this method of driving the blood from part of the body to
another, and it is in itself a cure for certain aneurysms (W.
Reid), for pseudoarthrosis (Helferich, Dumreicher), for local
tuberculosis (Bier), for snake bites (Fayrer) and it prevents
death from excessive hemorrhage by autotransfusion, sending
the blood back to the heart (P. Muller).
ProfessorWolfler reviewed the history and achievements of
SURGERY OF THE STOMACH AND INTESTINES
in a comprehensive address. He said of the Murphy button
that it would certainly be exclusively used if it were not
for the objection that the side anastomosis can not be made
deep enough on account of the swell of the button, and that
there is danger to the organism from the presence of an unre-
solvable foreign body. He consequently advises Winiwarter's
method of side apposition of the separated and closed ends of
the intestine, as his own experience with it has been very
favorable. The union secured is the strongest and most perfect
we have. He recommends Madelung's needle for suturing and
adds that all agree that as broad spaces as possible should be
left, the stitches taken in sound tissue, and the mucous mem-
brane included in the suture, while the special resistance of
the submucosa must be borne in mind. The statistics of resec-
90
SOCIETY PROCEEDINGS.
[July 11,
tion of the intestines are 39.5 per cent, mortality in total of
cases ; or 42 per cent, in 85 resections during 1875 to 1888, and
36 per cent in 161 resections during 1888 to 1895, which shows
an improvement of 6 per cent, during the latter period. Exam-
ining these statistics we find that out of'221 resections, 84 were
of the small intestine, with a mortality of 30 per cent. ; 69
were ileocecal resections, with a mortality of 42 per cent., and
81 resections of the colon, with a mortality of 49 per cent. —
the proportion of successes diminishing with the length of the
mesenterium. Beside these figures Korte has had no fatality
in 9 cecum resections and Czerny only one in 8 cases. The
figures of resection with artificial anus are 78 cases, with 78
recoveries. Goetz reports 68.2 per cent, recoveries in 71 cases,
and another report mentions 63 per cent, cures in 127 cases.
Resection for tuberculosis of the intestines shows 73 per cent.
recoveries in 34 cases, 65 per cent, cured in 20 cases of cicatri-
cial stricture, and 46 recoveries in 114 resections for neoplasms
of the intestine. The mortality was greatest, 54 per cent, cases
of carcinoma, and least with artificial anus. Rydygier reports
a mortality of 23 per cent, in 17 resections for chronic intus-
susception. The favorable results obtained in local or sub-
serous tuberculosis of the cecum are worthy of note, the oper-
ative mortality being only 8 to 10 per cent. Many surgeons
report the permanency of the cure effected, some of their
successful operations dating from one to seventeen years, most
of them cases of carcinoma. Equally promising are the
reports of recovery without relapses in tuberculosis of the
cecum, dating from one to five years. The classic method of
resectio pylori is practiced with increasing success by the most
experienced surgeons. Some prefer the Kocher modification,
which implants the duodenum in the stomach, instead of the
circular union of the open ends. It is still to be seen whether
this is a permanent improvement over the old method. The
operative results of resectio pylori have improved so much
lately that there is no longer any discussion as to the relative
merits of this operation and gastroenterostomy. The indica-
tions for each are entirely different, but resectio pylori lengthens
life more than the other, even when a relapse occurs. Wolfler's
statistics include the experience of fifteen operators beside him-
self. In a total of 92 cases of resectio pylori the mortality was 56.4
per cent. From 1888 to 1896 the percentage was only 21.2 per
cent in 173 operations. This favorable showing is due to the
fact that some of the operators, Kocher, Kronlein, Gersuny
and Mikulicz secured immediate recovery in 84.75 per cent, of
their cases. Resectio pylori on account of cicatricial forma-
tions has a more favorable showing than the cases of carcinoma
— 10 per cent. The proportion between them is as 25 per cent,
to 31.9 per cent. It is interesting to know that the cicatrix
formed at the pylorus after resection assumes the function of
the physiologic pylorus, as Rosenheim has demonstrated. Also
that the motor function is improved in carcinoma, while the
secreting function of the mucous membrane is not improved.
It would be of great service in forming a final opinion on this
subject to learn the experience of those patients whose diges-
tion has continued good for years after resection of the stom-
ach. As to the permanent results, it is established that patients
operated upon for carcinoma of the pylorus have survived many
years in undisturbed good health. I find twenty-four cases on
record where patients have lived from two to eight years after-
ward. Time has restricted the indications for resectio pylori
and enlarged the scope of gastroenterostomy. All are in accord
in regard to the suture in the latter ; the only question is the
entering point. Some, like K6nig, Hahn, Lauenstein, cling to
the original method, gastroenterostomia retrocolica (Hacker's).
TLe immediate results of each are about equal, 45 to 42 per cent.
If in gastroenterostomia antecolica a loop of the small intestine
with a long mesenterium is taken, the colon is not compressed
and the contents of the stomach will not escape. This also
prevents the formation of the dreaded spur. When the front
wall of the stomach is diseased, or the mesenterium of the
small intestine is too thin, the Hacker or Brenner method is to
be preferred. It is impossible to decide at present which is to
be the operation of the future, the retrocolica or the antecolica.
The results of gastroenterostomy reported up to 1888 show a
mortality of 55.6 per cent, in the 45 operations (against 56.4
per cent, in resectio pylori). Since 1888 the mortality in the
219 operations has been 36 per cent, (against 31.2 in resectio
pylori). The mortality in 195 cases of carcinoma was 30 per
cent. Without cicatricial formations 20.9 per cent, in the last
eight years. But single operators have secured much more
favorable results than this.
Cases of carcinoma in which the stenosis appears early and
death is imminent, call for a prompt operation, and Wiilfler
described several cases where he had relieved patients actually
at the point of death from starvation, and restored them to
their usual occupations for 11.2 and 2f4 years afterward. Any
one who has witnessed the gratitude of such a patient will
never abandon gastroenterostomy. As is generally known it
produces a normal chemic action of the stomach in cases of
benign stenosis, and conduces to permanent recovery. The
results of entero-anastomosis (Maisonevue-Hacker operation of
incomplete scraping out of the intestine), stand in the same
proportion to those obtained in resection of the intestine, as
the results of gastroenterostomy to resection of the pylorus.
The most conservative treatment of stenosis of the pylorus or
intestines is evidently plastic surgery. In Wolfler's collection
of 50 cases the mortality is only 26 per cent. There are no
reports on record of relapses. Unfortunately its application is
limited, as the rule is inevitable here too, that the stitches
must be taken in sound, tissue. The last ten years have also
seen much improvement in the lesser operations on the stom-
ach and intestines. A better and more easily closed fistula is
produced now in gastrotomy, partly because we make it smaller,
but principally because we have transformed it into a canal
opening upward and easily closed. (Witzel, Prank). As aeon-
sequence there can be no question now of opening the stomach
a second time. The immediate results have also become much
more favorable. Mannaberg states that the mortality from
1849 to 1883 was 66.7 per cent, in 162 cases. From 18a3 to 1886
36.9 per cent, in 111 cases. The mortality from cicatricial
stenosis of the cardiac orifice of the stomach is much less, and
Wolfler's own experience has been that these figures are too
high, and he believes that the next few years will see them
very much reduced. In regard to colostomy the progress has
been that now, instead of the tedious lumbar colostomy we
make colostomia iliaca, and divide the intestine obliquely
(Madeling and Schinzinger, 1881), or in some other way ensure
that the part leading to it is separated from the part leading
away from it, while we keep the opening of the latter open
(Maydl) by scraping and draining the rectum in the modern
sense of the term. The part leading to it must be continent of
course. There does not seem to be much difference between
the results of intra or extra peritoneal colostomy. Both show
less operative infection as methods improve with time. Up to
1877 the mortality was 42 per cent ; to 1887 29 per cent, and to
1895 27 per cent. The experience of 120 years with colostomy
in cases of carcinoma shows that 18 persons survived three to
six years, 28 lived three years, 43 lived two years, and 36 died
within eleven months of the operation, out of 120 cases collected
by Bryant. The farther down and nearer the rectum that the
carcinoma is located the longer the patient survives. Wolfler
dismissed jejunostomy with the remark that it was yet too
untried for a final judgment, but that it was indicated in cer-
tain forms of stenosis of the pylorus and cardia.
Professor Langenbuch, "the inventor of cholecystectomy,"
terminated his sketch of
SURGERY OF THE BILE SYSTEM,
with the suggestion that the arteria mesenterica superior should
1898. |
SOCIETY PROCEEDINGS.
91
be Ugated in operation on the liver, as ligatiug the portal vein
produces ■ congestion of the intestinal walls that may lead to
collapse and death. It is easy to' find the strongly pulsating
artery by lifting the colon and pushing the small intestine to
the left, when it will protrude between the pancreas and the
small intestine. It is also advisable to ligate this artery as a
preliminary measure to ligating the artery and veins of the
, liver.
Among the numerous other speakers was KOnig, "Tubercu-
losis of the Joints;" Sonnenburg, "Appendicitis" (with a
record of 900 operations) ; Kehr, "Surgery on the Gall Mad-
der" i record of 200 cases operated I : "Jiirgens on his discov-
ery of the "Sporozoa of Certain Kinds of Sarcoma," with
which he has successfully inoculated animals, in spite of the
difficulty that sporozoa will not develop 'on the usual mediums,
and Angerer on the "After results of Thiersch's Extirpation
of the Trigeminus; twenty-six cases." In sixteen cases, four
years have passed since the operation, seven have been perma-
nently freed from pain, there were seven relapses, while three
required a second operation. Krause's intracranial operation
is indicated if the pain continues after the trigeminus is extir-
pated. Angerer recommeuds extirpating the sound branches
also as a preventive measure. Helferich advises extirpat-
ing the nerve as far in as possible, as the central end is the
one affected, and warns against allowing the nerve to escape
from the forceps. He mentioned a desperate case in which he
had performed a Krause operation on the Gasserian ganglion
with success. Krause added that more than half of the cases
Of nerves extracted terminated in a relapse, and he believed
that fully as good results were attained by simple section or
resection as with the Thiersch operation. It can also be
resorted to later if necessary.
Professor Hasse described his successful treatment of
Inoperable carcinoma with parenchymatous injections of alco-
hol. In four cases declared inoperable by eminent surgeons
he had extirpated the breast and then prevented relapses with
his injections of alcohol, securing complete recovery.
Mitchell District Medical Society.
Mi tting held at shclbi/ciltc, Ind., June 29 and 30, 1896.
Dr. Edmund Andrews of Chicago, the President, in the
chair. In the absence of the Secretary, Dr. Geo. W. Burton
of Mitchell, Dr. J. W. Rvcker of Shelbyville, was made
Secretary pro tern.
The first three papers on the program were read and dis-
cussed together. The first by Dr. J. A. Thompson of Cincin-
nati, was a scientific but clear and practical paper on "The
Diagnosis and Treatment of Acute Purulent Otitis Media."
The writer opposed the use of leeches and the ordinary
methods of irrigating the ear, favoring incisions in the tym-
panic membrane and packing the canal with iodoform gauze.
The next paper, by Dr. P. C. Heath of Indianapolis, was a
brief statement of the peculiarities of "Influenza Otitis" and
some remarks upon its treatment. Dr. Max Thqrner of Cin-
cinnati, then followed with an instructive paper on "Serious
Complications of Suppuration of the Middle Ear." He showed
that from one-third to one-half of all brain abscesses are of
otitic origin. Among the other complications mentioned were
sinus thrombosis, meningitis, cades, necrosis, hemorrhage and
the general cachexia from a protracted suppuration.
The discussion was opened by Dr. Dudley Reynolds of Louis-
ville, who opposed the use of water, leeches, hot or cold appli-
cations, favoring peroxid of hydrogen, paracentesis, politzera-
tion and the internal use of the salicylates.
Dr. Thompson in closing defended his method of incising the
membrane. Dr. Heath held that the satisfactory results
obtained more than justified the use of water, leeches, hot and
cold applications and other measures advocated in his paper
His position was endorsed by Dr. Thorner, who also showed
that incising the membrane may cany infection into the
middle ear, an epidermal surface being extremely difficult to
disinfect.
Dr. J. (J. SHKKRiLLof Louisville, presented the subject of
"Intestinal Anastomosis." He favored lateral anastomosis by
means of the clamp devised by Dr. H. H. Grant. Its advan-
tages are : 1, no change in the direction of the fecal circulation ;
2, no foreign body ; 3, less danger of. contraction of the gut ; 4,
nearest to the natural method of repair ; 5, means of perform-
ance always at hand.
Dr. Eastman of Indianapolis, expressed his preference for
end to end anastomosis, using iron-dyed silk in the Czerny-
Lembert suture.
Dr. Hall of Cincinnati, thought the method advocated by
the essayist better than the Murphy button in emergency work
and less likely to cause impaction. As to suture he would use
catgut, running stitch.
Dr. Ransohoff of Cincinnati, had lost several cases with the
Murphy button and while they were bad cases and might have
died under any method, he believed the button was a foreign
body and likely to cause obstruction.
Dr. Matthews of Louisville, believed the tendency was now
toward lateral anastomosis and that Dr. Grant's method was
sure, clean and easily learned.
Dr. Katto of Decatur, 111., spoke of a method of end to end
anastomosis by invagination.
"The Necessity for Opening the Cranium after Injuries
Producing Coma and Convulsions," was the subject of a paper
by Dr. W. B. Fletcher of Indianapolis. He exhibited a num-
ber of calves' brains and skulls, showing lesions principally at
the base of the brain from blows on the top of the head and
marked shattering of the inner tables of the skull where there
was little evidence of injury outside. The paper was discussed
by Drs. Reynolds, Parsons, Sherrill and Ransohoff, who cited
cases confirming the writer's statement's.
Dr. S. C. Ayres of Cincinnati, presented a thoughtful
paper on "Artificial Ripening of Cataract." His method is
trituration of the cornea with the smooth-rounded handle of a
Graefe knife, previously moistened with Pavy's solution.
Dr. Reynolds feared injury to cornea by this method and
preferred applying a needle directly to the lens. He claimed
good results however in extracting immature cataracts.
Dr. Rice of Indianapolis, objected to the method of Dr.
Reynolds as liable to cause sympathetic ophthalmia. He said
that Puchs had shown that contact was all that was necessary,
the essential thing being separation of fibers of the lens to
allow infiltration of aqueous or vitreous. Dr. Ayres in clos-
ing said that there need be no fear of injuring the cornea if the
method he advocated was carefully carried out.
A case of gallstones was reported by Dr. Edwin Ricketts
of Cincinnati. The main point in the discussion was as to
their location, Dr. Eastman contending that they were always
in the cystic duct while Dr. Ricketts held that they were
found, occasionally at least, in the common duct.
In the evening a very enjoyable reception was given by the
Shelby County Medical Society. It was attended by a large
number of the citizens.
At the morning session, second day, President Andrews
read his address on the
NEW WEAPONS IN WAR AND THEIR EFFECTS ON MILITARY SURGERY.
He showed that the new smokeless powder is effective at
greater distance than the old. The guns are far more destruc-
tive. All open ground can now be swept with a storm of bul-
lets. The famous old charges of cavalry and infantry can
never occur again. The new tactics require thinner and longer
lines. Each company has men trained in first aid to the
wounded. The surgeons' camps and field hospitals must be
92
SOCIETY PROCEEDINGS.
[July 11,
in gorges, hollows and behind hills to avoid the long range
guns.
There are new difficulties in bringing up ammunition as
well as disposing of the wounded. The question of antisepsis
and asepsis is a grave one. The dependence must be on hot
water, granite pans, rubber pouches, sublimated gauze, etc.
The paper was briefly discussed by Dr. A. W. Brayton of
Indianapolis. Following this, Dr. Joseph Ransohoff of Cin-
cinnati read an essay on "The Radical Cure of Umbilical Her-
nia by Omphalectomy." Four cases were reported operated
on within the year without recurrence, up to date. The sal-
ient features of the operation proposed are excision of the ring,
suture of the recti and buried metallic sutures. This paper
was brief, clear and well received.
Under the title "Credulity and Skepticism in Medicine,"
Dr. W. G. McFadden of Shelbyville vigorously opposed the
general use of new remedies until their true qualities were
proven by those using them in hospitals, and censured the
over-zealous gynecologists. In the discussion by Drs. Culbert-
son, Ricketts, Sterne, Reamy, Reynolds and Hall, issue was
taken with the author, especially by the gynecologists.
In the afternoon session Dr. W. M. Catto of Decatur, 111.,
reported twelve cases of "Puerperal Eclampsia" seen in
fifteen years, about one to every 150 confinements. Most of
these recovered. The treatment advocated was elimination by
bleeding, purging, diuresis and diaphoresis.
Dr. Reamy opposed bleeding as dangerous treatment and
advocated veratrium viride as safer and as effective. Dr. C. K.
Bruner of Greenfield reported his experience with veratrium,
confirming Dr. Reamy. In closing, Dr. Catto said he feared
the drug more than the lance. The following paper was also
read : "The Value of Certain Therapeutics in Functional and
Organic Diseases of the Nervous System," by Dr. Curran
Pope of Louisville; "Cerebral Arterio-Sclerosis and Its Rela-
tion to Apoplexies," by Dr. A. E. Sterne of Indianapolis;
"Treatment of Typhoid Fever," by Dr. J. C. Cclbertson of
Cincinnati; "The Similarities between Albuminuria and
Glycosuria" by Dr. Guido Bell of Indianapolis, and "Nico-
tin Amblyopia," by Dr. R. C. Heflebower of Cincinnati.
The election of officers resulted as follows : President, Dr.
Samuel Kennedy, Shelbyville, Ind. ; vice-president, Dr. J.
Garland Sherrill, Louisville ; corresponding secretary, Dr. J.
W. Rucker, Shelbyville ; permanent secretary, Dr. Geo. W.
Burton, Mitchell ; chairman program committee, Dr. F. C.
Heath, Indianapolis : executive committee, Dr. S. C. Ayres,
Cincinnati, Dr. Thomas T. Whiting, Nokomis, Dr. Dudley S.
Reynolds, Louisville, Dr. F. C. Heath, Indianapolis, and Dr.
A. J. Banker, Columbus, Ind.
British Orthopedic Society.
This society met at Birmingham, Eng. , on May 30, 1896. The
New General Hospital, the General, the Children's and the
Royal Orthopedic Hospitals were visited by the members.
Mr. Wm. Thomas showed cases of congenital torticollis,
severe lateral curvature in a male adult, congenital abscence of
metacarpus and phalanges, double congenital displacement of
the hip and talipes treated by tarsectomy.
Dr. Warden showed a case of partial abscence of the fibula,
marked lateral bending of the tibia, associated with congenital
talipes valgus.
Mr. E. Luke Freer brought before the meeting a case of
double congenital talipes equinovarus which was successfully
treated by tenotomy, wrenching and manipulation. He also
shewed a case of rhachitis adolescentium. The girl was aged
16 years and had been under his care for severe genu valgum
when 4 years of age, and had worn instruments for four years
with no material improvement. A double osteotomy was then
done and she continued to wear supports for three years more.
Mr. Freer then lost sight of her for eight years and a few
months since she was brought to him again in a condition of
pronounced genua vara. He also showed a case of knock -knee
which had been treated by osteotomy, and another case of very
severe congenital talipes equino-varus.
The above cases were discussed by Mr. Keetley, who stated
that in his opinion Mr. Thomas' case of lateral curvature in
the male adult was probably due to sciatica. Mr. Openshaw
referred to cases of congenital dislocation which had been
under his care in which he had operated by Lorenz's method
with success, except in one instance, in which he carried out
Hoffa's procedure, the patient dying from shock.
Mr. Robert Jones brought forward a case of recrudescent
rickets and gave the following history. The patient, a girl of
16 years, was admitted into the Southern Hospital, Liverpool ;
the family history was good. She was the second of four
daughters and her sisters were of moderate physique, strong
and free from deformity. She passed an uneventful childhood
and there was never any suspicion of rickets. At the age of 7
she felt rather poorly and was ordered change of air. On her
return, twelve months later, it was noted she had developed
knock-knee. She had no fever and no particular ailment when
first attacked, but since the genu valgum appeared her back
had been painful. Up to two years ago she was able to walk
comfortably, but since then her symptoms had been much
aggravated and she had been quite unable to stand or walk.
She had always been a dainty feeder and was said never to
have made a good meal. On examination it was found that
the left parietal bone was slightly flattened, so that the head
was asymmetrical. The sutures were closed but the sulci
were well marked, especially that between the frontal and
parietal bones. The palate was arched and all the teeth except
the wisdoms were present. The lower jaw was thickened at
the angles and pointed at the chin. The circumference of the
head was twenty and one-half inches. The chest was somewhat
barrel-shaped, the ribs were beaded, and Hatrison's sulcus
was marked. The heart and lungs were normal. There was
also some rib deformity, due to a slight lateral curvature. The
abdomen was large and prominent ; the abdominal muscles
were flabby. In addition to a lateral curve to the left, there
was very marked lordosis, accompanied by rigidity. The
angles of the scapula; were prominent. There was nothing
very noticeable about the clavicles or humeri. The radii were
enormously thickened at the lower end so that the appearance
was somewhat that of a very bad Colles' fracture. Supination
was much interfered with, pronation to a slighter degree.
The arms were very thin and poorly developed, but she had a
fairly good grasp. The pelvis appeared to be normal '; there
was considerable enlargement of the lower end of the femora,
and the internal condyles were very prominent and elongated
so that on extension of the limbs, there was an exceptional
knock-knee, the leg forming an obtuse angle of 135 degrees
with the thigh. This deformity was more marked on the left
than on the right side. There was also flexion deformity of
the knees and it was impossible to get the legs perfectly
extended. Flexion perfect and the knock -knee disappeared.
Further, there was flexion deformity of 25 degrees at the hips.
The feet were in varus position and this was due to an acute
bend at the lower end of the tibia just above the ankle joint,
and also to a great thickening at the lower ends of the fibula.
The sacrum was curved and prominent. The child was very
stunted in growth and small for her age, and ill nourished.
She was fairly intelligent, but could not walk or stand at all.
There was one ninth albumin in the urine.
Mr. Jones— Attention has been drawn in this country to
either late or recrudescent rickets by Dremitt, Clutton, Lucas
and others, and the rarity of the condition has been generally
admitted. I am convinced, however that its rarity is over-
stated. Without being able to verify the precise number I
ISW.]
SELECTIONS.
93
have certainly seen between twenty and thirty eases. In most
of these the lower extremities are alone affected. In some,
as in the present ease, the head, chest and upper extremities
participate in the deformities. In all, the enlargements are
more or less shared by the epiphysial ends of bone. They
therefore differ from the cases of Clement Lucas in the fact
that the deformities are not confined to the shafts of the bones.
C'lutton, in the description of his case, draws attention to the
fact that the shafts of the bones of the forearm were not bent
and that this was another confirmation of the fact that the
upper limbs bend in infantile rickets from the inability of the
little patients to assume the erect position. In the case I
report, the forearms are characteristically bent ; the deformi-
ties starting long after the patient had ceased to crawl. This
bears out several observations I have made with regard to the
etiology of knock-knee ; the deformity characteristic of rickets
arising and developing while the patient remained in bed. In
none of the reported cases do I note any reference to flexion
deformities at the hip and knee, symptoms which I have fre-
quently observed. From my experience I should conclude
that : 1, late rickets is generally recrudescent ; 2, that epiphys-
eal enlargements are an essential feature ; 3, that while static
influences bear an important part in the production of the
limb deformities they are not essential factors ; 4, that in
addition to the common deformities of rickets, flexion deform-
ities are found in the hip and knee and frequently limitations
of movement in other joints ; 5, that contrary to the experience
gained from the cases of Clutton, Pitts and others, the skull
and face may exhibit rhachitic deformities ; 6, that the sacrum
generally presents an angular projection about its middle.
Mr. A. H. Tubby remarked that although late rickets was
accepted by many authors as a veritable disease, yet he had
not come across any microscopic examination of the epiphyses
of bones proving its identity with rickets of infancy.
After votes of thanks were passed to the Birmingham mem-
bers for their hospitable reception and to the Birmingham
Medical Institute for allowing the use of the rooms, the pro-
ceedings terminated.
SELECTIONS.
Exploration of the Duodenum by Intubation. — In the Bulletin of
the Julius Hopkins Hospital, April, Dr. J.C. Hemmeter reports
that he has been engaged in working out a new diagnostic pro-
cedure, which he calls "Intubation of the Duodenum." This
is not an analogous procedure to the passage of a rigid tube
into the larynx in occlusion of the lumen of that passage by
pseudo-membrane or edema. It is possible that intubation of
the duodenum may be interpreted as meaning the insertion of
a rigid tube through the pylorus, to secure permeability in the
duodenum in cases of stenosis resulting from cicatricial con-
traction or of stenosis resulting from neoplasm. The intuba-
tion referred to in this report, however, is simply the passage
under normal conditions of a tube through the mouth, esopha-
gus, stomach and pylorus into the duodenum. Dr. Hemmeter' s
explanation is as follows :
"The possibility of this procedure occured to me during a
long series of experiments in the biologic laboratory, in which
it was attempted to get a method of registering the peristalsis
of the stomach upon the kymograph. We use a deglutible
apparatus which consisted of a very soft rubber bag having the
shape of the stomach kymograph, which was passed into the
stomach in the collapsed state and then blown up so that it
applied closely to the walls of the organ. In this manner the
muscular contraction of the stomach, the impulse of the aorta
and the respiratory movements were registered through a
writing apparatus connected with a manometer to which the
esophageal tube leading into the intragastric bag was attached.
In one or two cases it was discovered beyond a doubt that this
intragastric bag had slipped the duodenum, which was
evidenced not only by the length of the tube, but also by the
fact that when the bag was blown up the stomach was not dis-
tended, the patient complaining of pain in the region of the
gall bladder by the distension. From a large number of very
accurate measurements on living and dead subjects, male and
female, it has been found that the average length of the esopha-
gus, or rather the length from the incisors to the deepest part
of the stomach, is 59 centimeters. The average length of the
stomach in its longest direction is 18 to 22 centimeters. The
greatest width is 7 to 8 centimeters. Under normal conditions,
therefore, there is no physical reason why a tube can not be
passed into the duodenum, presuming that the tube does not
kink or turn in the stomach, which it will unfortunately do.
The esophagus takes a nearly perpendicular course until near
the bifurcation of the bronchi it begins its spiral turn, which
brings it to the left of the aorta. In that region it has a very
gradual swelling, so that it there assumes a spindle shape.
About the level of the tenth thoracic vertebra the esophagus
begins to narrow down until its narrowest portion is reached,
at what is called the hiatus. The foramen esophageum is about
8 centimeters behind the articulation which the sternal end of
the tenth rib makes with the base of the ensiform cartilage.
From this point the subphrenic portion of the esophagus passes
decidedly to the left, expanding in a funnel-shaped manner.
This deviation causes a deflection of the tube. To avoid this
deflection it occurred to me to fill the stomach with a rubber
bag, the superior surface of which contains a groove running
longitudinally. After the bag is inflated the tube is passed
down and finds its way along the groove and enters the pylorus.
Now the sphincter of the pylorus is not an absolute sphincter.
The sphincter of the bladder will retain water ; not so the
pyloric sphincter."
In the discussion that followed in the Hospital Medical
Society, Dr. Howard A. Kelly briefly referred to his two diag-
nostic intestinal instruments, the sigmoidoscope and the proc-
toscope. He said, "My practical interest is entirely in
endoscopic progress at the other end of the body. As I have
had some questions to discuss relative to priority lately, I
realize how important it is to get on record in time, so I will
show you what I have done to meet Dr. Hemmeter. Those of
you who have been in my clinic have seen my proctoscope and
sigmoidoscope in use. They have been very successfully
employed in a number of cases in diagnosing and treating dis-
eases of the whole of the rectum and a large part of the sig-
moid. The following case illustrates their use : A doctor in
New York swallowed his teeth one night. They stayed in his
stomach quite a while and then he felt them pass the pylorus ;
then they rested at the ileo-cecal valve for a long time. Then
they were traced from the ileocecal valve to the sigmoid flex-
ure, where they lodged. Here they could be felt by the doctor
himself as well as by Dr. Wyeth. He came down to Baltimore
to me one evening for an examination by my method, but as
the rectum was too full of fecal matter for an examination at
that time I ordered an active purge. The next day he came
and I passed a long coloscope into the rectum, while he was in
the knee-breast position ; he felt the instrument strike his ribs
and was well satisfied that he had passed the teeth during the
night on account of the purge. I certainly found nothing
abnormal. The difficulty usually is that the expansion of the
bowel ceases in the sigmoid. I now have an instrument in my
operating room which is made to reach from the anus to the
splenic flexure. The plan of construction is this : A long metal
tube with a piece of glass in the proximal end has set in one
side a small electric lamp which is connected with a storage
battery. On the other side is an opening attached to a David-
son syringe with which the bowel can be inflated ; under infla-
tion we can follow the bowel up to the splenic flexure, and
94
SELECTIONS.
[July 11,
sometimes with a prism we can see around into the transverse
colon."
The Recent Serum Tragedy at Berlin ; Official Report. — Professor
Ehrlich's official report on the serum used in the sad Langer-
hans case has been published by the Prussian Cultus-minister.
Ehrlich comes to the conclusion that the serum was entirely
normal in its constitution. He says : "In the Langerhanscase
No. 216 of the Hochst works was used. This No. 216 had been
officially tested on December 16, 1895, and passed on for sale
on December 18, the examination having demonstrated the
required 100 .immunizing units per cubic centimeter, perfect
sterility, and the prescribed admixture of carbolic acid.
Immediately after the announcement of the death this serum
was subjected to a careful reexamination. As the legal author-
ities had disposed of the remainder of the bottle used for the
injection, samples of the same pass number that had remained
at the station were taken, and also bottles of the same number
from the stock of the Charite Dispensary, where Professor
Langerhans's bottle had come from. The serum again showed
the required 100 units per cubic centimeter, and bacterio-
logic examination proved it to be free from germs, so that
there can be no question of any subsequent formation of
poisonous bacterial products. By a number of experiments on
animals the admixture of carbolic acid was shown to be no
higher than permitted. Thus, on reexamination too, the
serum answered to the tests exacted. Nevertheless, it seemed
important to ascertain whether, perhaps, toxic effects produced
by this number had been noticed anywhere else. About 1,300
portions of this serum had been brought on the market, and if
it really contained toxic substances it seemed extraordinary
that no one had drawn attention to the dangerous qualities of
this particular number. Researches were made in the hospi-
tals that had received No. 216 serum from the Hochst works
(serum depot of the Royal Charity Dispensary, Julius Hospital
in Wiirzburg, General Hospital in Hamburg, sick club of the
Royal Dockyards in Kiel, Municipal Hospital in Madgeburg,
Krefeld Hospital) ; in none of these places had any special, much
less any toxic, effect of the serum been observed. According
to the statement of the director of one of these hospitals, a
child of 18 months had been given a dose of 16 c. cm. without
showing any alarming symptoms. This is at least ten times
the dose used for Professor Langerhans's child. The director
of the Hamburg Hospital gave an account of immunizing
experiments on children. He says that four bottles of the No.
216 serum were used for immunizing children in the eye
department ; not only were no ill effects observed, but it might
be confidently asserted that none existed. Thus the clinical
communications also contradict the assumption that substances
of strong toxic action were contained in the serum. On the
contrary, the No. 216 serum has shown itself to be a prepara-
tion answering to all the tests at present exacted, and perfectly
normal in its constitution." — British Medical Journal.
Orphol. — Dr. Edmond Chaumier, physician to the Sanatorium
of Touraine, and director of the Animal Vaccine Establish-
ment of Tours, Prance, has written an article on the use of
orphol for intestinal antisepsis, and in surgery, of which the
following is a summary :
All the various substances employed for the purposes of
intestinal antisepsis, calomel, carbolic acid, creosote, boric
acid, carbon, iodoform, etc., are useful : but all have their dis-
advantages. Thus calomel, whilst it has an antiseptic action
and cleans out the putrefying matter, may lead to a catharsis
and an absorption of mercury that may be dangerous.
ISaphthol has none of these drawbacks, and possesses certain
important advantages of its own. In typhoid fever it keeps
the tongue moist, lessens the stupor, delirium, subsultus, and
all the ataxo-adynamic symptoms of auto-intoxication. Its use
diminishes the number of microbes in the intestinal tract.
Together with naphthol, Dr. Bouchard employed the salicy-
late of bismuth. This causes ringing of the ears, on account
of the absorption of the salicylic acid into which it is decom-
posed in the intestines. The caustic taste of the naphthol
renders it necessary to administer it in capsules ; given other-
wise it is vomited.
These inconveniences have led me to try another naphthol
compound, orphol, which is a naphthalate of bismuth. It is a
grey powder that has neither the penetrating odor nor the
burning taste of naphthol. Jasenski's experiments have
shown that orphol is decomposed in the intestinal canal into
naphthol and bismuth. The naphthol acts as an antiseptci,
and, if there is a diarrhea at the time, the bismuth set at lib-
erty controls, but does not cause the obstinate constipation
that the other bismuth salts do. • Orphol stops the develop-
ment of microbic life in the intestines, yet is perfectly harm-
less; 10 gms. (150 grains) given daily to dogs, and 5 gms. (71
grains) daily in the human subject have done no harm, even
when continued for weeks. Jasenski recommends the drug in
all maladies, acute or chronic, of the digestive tube. Hugo
Engel regards it as the best intestinal antiseptic, and has
given it in large doses both to children and to adults.
Orphol contains 26.5 per cent, of naphthol, and 73.5 per cent,
of oxid of bismuth. Bouchard having demonstrated that to
obtain intestinal antisepsis in the adult, 2.5 gms. {"Xi% grains)
of naphthol daily are required. Ten gms. (150 grains) of orphol
would be the quantity necessary to obtain a like result. This
dose can be given without difficulty ; but experience has shown
that 5 gms. (75 grains) daily has almost always been sufficient.
In cancer of the stomach antisepsis necessarily plays a large
part in the treatment ; and orphol is to be employed in prefer-
ence to all other drugs, from the fact that it in no way irri-
! tates the diseased tissues. It may be given in half gm. iT1.,
grains) doses dry in capsules or with syrup. It may also be
employed in suspension for lavage of the stomach. Ten gms.
|150 grains) in suspension in a liter (1 quart) of water used after
washing with plain water and repeated twice a day. In
gastric ulcer it has been highly recommended by Wilcox, and
may be used in capsules, or in suspension, as in cancer.
As an antiseptic and germicide it is commended in all mor-
bid conditions of the stomach and intestines due to fermenta
tion, putrefaction, or the infection by special germs.
Wilcox has found great benefit from the use of orphol in
typhoid fever. Dr. Hueppe recommends orphol in cholera, he
having treated a large number of cases with it in the hospitals
of Hamburg. Nencki, Schubenke, Blackstein, and Petke-
witsch have administered it with success in the choleriform
diarrheas. Jasenski, in six cases of intestinal catarrh, effected
cures in two to five days. It was successful even in old
chronic cases.
For surgical antiseptic applications orphol would seem to be
especially indicated, in the place of iodoform, salol, etc. The
accidents so common with iodoform would certainly not occur.
It should be very useful also in burns. Being antiseptic, it is
as efficacious and more useful than bismuth. I have used it
as a powder in the treatment of the ulcerations of the thighs
and genitals in children, either pure or mixed with taicum. In
impetigo I use orphol with vaselin, 1 to 10, with much suc-
cess.
The Dangers of Diphtheria Antitoxin. — At a meeting of the
Soeie'te' Medicale des Hopitaux (Semaine Medicate, April 29,
1896) held on April 24, M. Variot made a brief communication
concerning a case of death following the use of antitoxic serum.
A child aged 18 months had a slight attack of pharyngeal
diphtheria, followed by croup, with spasm of the glottis. In-
tubation was resorted to, and 20 c.cm. of antidiphtherial serum
was introduced in two doses ; the child died in forty-eight
hours, with a temperature of 104.9 F. On postmortem exam-
1896.]
PRACTICAL NOTES.
95
ination DO special cause for tlio death was found in the pharynx
or larynx, from which the membrane had disappeared. With-
out affirming that the antidiphtherial serum was the cause of
death in this ease M. Variot suggests that it may possibly have
had something to do with the production of the high tempera-
ture, and throws out the suggestion that there may be, in cer-
tain serums, a fever-producing body which can not, however,
be recognized by chemical analysis. Fully recognizing, as he
dous, the enormous value of this serum, he desires to have this
point settled at once. A colleague, M. Sevestre, who has had
very extended experience of the use of serum, has never ob-
i any such accident among his cases, and he thought that
this must be looked upon as quite an exceptional case; he
therefore did not think it right, until the proof of the nexus
between the serum and the high temperature could be more
fully demonstrated, that the serum should get the blame.
There can be little doubt that with some serums, and in the
hands of some physicins, a larger percentage of high tempera-
tures have been observed than in others. This statement does
not apply to the slight initial rise of temperature which fre-
quently follows the introduction of antitoxic serum and pre-
cedes the fall which is now by most people looked upon as a
somewhat favorable sign, indicating as it does that the serum
is exerting its specific effect on those cells that have been over-
stimulated and paralysed by the toxin. It applies rather to the
secondary fever which is usually associated with the rashes,
the joint pains, and the other sequela?, which are said to be
lated with the use of this subtance, and which appears to
be due to the fact that the skin may be stimulated to excrete
the products formed by the tissue cells under the influence of
the antitoxic serum, and perhaps also of the toxin. The second
possibility is that there may be some irritant matter in the
serum, under certain conditions, which may determine these
results. In view, however, of the fact that only one patient in
every two or three ever has the slightest symptoms which
could in any way be ascribed to the serum, and as some physi-
cians treat case after case without the occurrence of any such
symptoms, only one occurring here and there, may it not be
that idiosyncrasy plays an important part in determining the
effects mentioned? Coming, however, to the special cases in
which death has been ascribed to the injection of antitoxin, it
must be borne in mind that diphtheria has always been looked
anon as one of the most treacherous diseases with which a
physician ever has to deal. Patients who appear to be on the
' high road to recovery have succumbed with symptoms of heart
failure, of pyrexia, and various forms of paralysis. It is too
much to hope that antitoxin, especially when administered in
the later stages of the disease, can prevent the fatal issue of a
number of such cases of diphtheria that come up for treat-
ment. The death rate will be and has been diminished by the
use of the remedy in the early stages of the disease even in
severe cases, but when .not given until the later stages we must
always expect a certain proportion of accidents similar to those
with which we have hitherto been only too familiar before the
introduction of antitoxic serum. — British Med. Jour.
The "Open air" Treatment of Phthisis. — At a recent meeting of
the South Eastern Branch of the British Medical Association,
Dr. Arkle read a paper on this subject, with special reference
to HeUanstaUen or sanatoria. He drew attention to the great
number of cured phthisical cases which were observed by per-
sons who made a large series of postmortem examinations on
old town dwellers, male and female, and remarked that it was
almost usual at such necropsies to find, either from old cica-
trices, calcareous nodules or old caseous foci, evidences of an
attack of tubercle in early life. Probably the majority of these
patients had thrown off the attack without any special treat-
ment. Could anything be learnt from observations on
the life-history of the tubercle bacillus in the laboratory or
from a study of the disease as it was seen clinically? Points
of importance seemed to be the somewhat limited range of
temperature at which this particular organism flourished in
the laboratory, the dangers which arose from the dissemina-
tion of the bacillus or its dried spores in every day life, and
the ease with which these latter could be counteracted. Clin-
ically, the very considerable amount of digestive disturbance
which was so common in cases of phthisis was referred to, and
the great repugnance these patients had to fatty foods. Prom
the observation of these two points, in the natural history of
the disease, the author urged that treatment in a sanatorium
Offered the best prospects of success. The essentials of a good
sanatorium were then enumerated, special reference being
made to the facilities for keeping the patients in the open air,
in the construction1 of such an establishment, and to the care
which must be taken to disinfect all sputa and other dejecta.
Attention was also called to the system of "hardening"
patients which was carried on in these institutions. In the
climatic treatment of phthisis the sea, the dry land, moun-
tains and valleys, hot dry air, cold dry air, all varieties
of elevation, temperature, and situation had their advo-
cates, but without doubt the most important quality must
be the purity of the air in the locality where the patient
was treated. The author considered that with proper care
and selection suitable places could be found in the Brit-
ish Isles. In the matter of diet and medicinal treatment
the digestive functions were kept active and vigorous,
as much milk taken as possible in addition to a good full
diet, the patient being kept as long as possible in the open air
in the day and with the windows of his sleeping room open at
night : little then remained to be done except to prevent him
contaminating his surroundings with sputa or other tubercu-
lous dejecta. Inasmuch as pure air, antisepticism and nour-
ishment were the chief potent factors which were offered
(under certain restrictions) by any health resort, due thought
ought to be given to every individual case before it was decided
to banish such patients from our shores. — Brit. Med. Journal.
Practical Xotes.
Rubella. One of the most interesting features of rubella is the
constant presence of glandular enlargements. So constant is
the occurrence of this symptom that the diagnosis should be
made with caution when it is not present. The glands most
frequently involved are the cervical, the post-cervical, and the
sub-occipital. A nest of small glands found low in the neck
behind the sterno-mastoid is especially characteristic of this
disease. Although rubella is an extremely mild disease, the
peculiar glandular enlargements, the marked eruption, and its
close simulation of other more serious diseases render it of con-
siderable interest. — Arch. Pediatrics, June 1896.
Cystin.— Dr. E. Cutler says of cystin : It is not as rare as
thought and is of clinical importance. Cystinic rheumatism is
so called because cystin predominates in the blood. It is prob-
ably a normal body if kept in solution in the blood by sufficient
water supplied to the system. Cases where cystin is found
oftenest are those in which sulphur has largely entered into
the food i.e., yolks of eggs. Treatment of the condition con-
sists in removing sulphur foods as far as possible from the diet.
Supply menstruum in abundance ; distilled water is best. Give
lemon juice as a solvent. — Med. Bulletin, June 6.
Sponge Grafting in the Orbit for Support of Artificial Eye.— Dr.
E. Oliver Belt has performed the operation in five cases with
fairly good results. He says : The operation is a simple one,
and is performed as follows : The eyeball is removed by the
ordinary method under strict asepsis. After all hemorrhage
is arrested, the socket is washed out with formalin solution,
1 in 1,000, followed by sterilized salt solution. A globe of fine,
soft, sponge about three-fourths the size of the eyeball (previ-
96
PRACTICAL NOTES.
[July 11,
ously sterilized in 5 per cent, formalin solution and rinsed in
the salt solution) is then inserted into the socket, or capsule of
Tenon. The conjunctiva is brought together and sewed with
rat- tail sutures. The eyelids are then closed with compress and
bandage. In a few weeks the sponge is filled with new tissue,
which in time hecomes firm, solid flesh, making a full orbit and
a fine support for the artificial eye. The sponge fibers are
apparently absorbed.— Medical News, June 27.
Transient Bulbar Paralysis Caused by Malaria.— Orlandi describes
in the Riforma Medica, several cases of apparently severe
progressive bulbar paralysis, following an attack of pernicious
malaria, all cured by large hypodermic injections of quinin.
Treatment of Acute Infectious Diarrhea in Infants.— Dr. H. M.
McClanahan says : Stop the food supply. Remove the products
of imperfect digestion from the intestinal tract by irrigation,
continued until the water returns free from admixture of fecal
matter. Inject solution of 20 grains of tannic acid in a pint or
more of sterilized water and have it retained in the bowel about
an hour. When vomiting persists the stomach should be
washed out also. To neutralize the toxins calomel in 1-10
grain doses hourly for the first twenty-four hours is recom-
mended. First among antipyretics is the cooled bath. When
watery discharges continue after the irrigation, hypodermics
of 1-100 grain of morphin and 1-800 grain of atropia can be
given. Stimulants are indicated in the severe cases and
whisky is the best that can be given. After the urgent symp-
toms have subsided the child can be nourished with the white
of an egg stirred in cold water, or the mixture recommended by
Jacobi : Five ounces of barley water ; the white of one egg ;
one or two teaspoonfuls of brandy or whisky ; some salt and
sugar. A teaspoonful every five or ten minutes as indicated.
No milk should be given for several days.— Am. Jour, of Obstet-
rics and Diseases of Women and Children, June 1896.
The Differential Diagnosis of Vascular and Muscular Tinnitus
Aurium.- One variety is caused by the flow of blood through
the irregular-calibered blood vessels of the internal ear and
those in the neighborhood, producing vibrations by the passage
of the blood. This I have named vascular tinnitus aurium.
The other variety is produced by the action of diseased mus-
cles of the middle ear, producing vibrations by alternate con-
tractions and relaxations. This I have named muscular tin-
nitus aurium. Many persons, who are partially deaf and
experience excessive noise in their ears, will hear a conversa-
tion in a moving railroad coach better than in a quiet room.
This is positive proof that all such persons are afflicted with
muscular tinnitus aurium. The sound or sounds that are
formed in the internal ear and its neighborhood, i. e., vascular
tinnitus aurium, will not be decreased in any degree by extrin-
sic noises of any kind. It is often of the utmost importance
to be able to differentiate between the two kinds of tinnitus, for
a treatment or procedure that would be of great value to a
patient suffering from the muscular variety would be decidedly
injurious, if not disastrous, to one suffering from the vascular
variety, and vice versa.— Thos. F. Rumbold, M.D., in St. Louis
Medical and Surgical Journal, June, 1896.
Rapid Cure of Soft Chancres by Electric Heat (Not Cautery).— The
Paris correspondent of the London Lancet sends the follow-
ing note to the issue for June 6, under the title of a new
treatment of soft chancres by heat :
Dr. Audry, of the Toulouse Faculty, has devised a modifica-
tion for the heat treatment of soft chancres introduced three
years ago by Dr. Welander, of Stockholm. Dr. Audry employs
radiant heat supplied by the thermo-cautery, the button of
which is held for a few seconds at a distance of three or four
millimeters from the sore previously washed and dried. Should
the point of the thermo cautery be fine it must be brought to
a white heat ; if larger, to a dull red heat. Exposure to this
radiated heat for the period indicated has the effect of thor-
oughly drying the ulcer, on the edges of which there now
raising of the surrounding epidermis and a reddening of the
skin. A single seance is stated to be usually sufficient to trans-
form the chancre into a simple ulcer, which soon cicatrizes
under the influence of any antiseptic powder. The rapidity
of the healing is due to the absence of the scab that always
follows the direct application of actual or chemic heat. The
pain is said to be quite endurable, being less than when the
actual cautery is employed.
Symptoms of Incipient Exophthalmic Goitre. — It is very important
to be able to distinguish this disease from the first, instead of
waiting for the exophthalmus and goitre to appear. An arti-
cle in the Journ. des Pract. for May describes several early
signs by which it may be recognized. Principal among them
is a series of ocular troubles, a lack of synergic action in the
lid and brow when the ball is turned abruptly upward, incom-
plete occlusion of the palpebral fissure, pulsation in the lids,
muscular paralyses and sometimes diplopia or photophobia.
There are also disturbances in the nervous system ; beside a
general irritability ; there are often cramps, neuralgias, hyper-
esthesias, insomnia, choreic movements and sensations of
excessive heat. The tremor, which is rarely absent from the
first, has a specific character in its rapid vibrations. If there
are no accompanying symptoms of hysteria, this tremor is of
great diagnostic value. The general symptoms that may occur
are numerous and various, from dyspepsia, bulimia, gastric
and diarrheic crises to genital troubles and edema resembling
myxedema. Other disturbances indicate the participation of
the medulla oblongata, suffering from lack of the normal secre-
tions of the thyroid gland, polyuria, albuminuria and dyspnea.
Pregnancy is one of the most important predisposing causes of
this disease, and it may also appear as a complication of
neurasthenia, chorea, epilepsy, paralysis agi tans, syringomyelia,
general paralysis and various psychoses, especially tabes and
hysteria. It is also a possible complication of diabetes, sclero-
dermia, acromegalia, mollities ossium and chlorosis.— Revue
Int. de Mid. et de Chir., June 10.
The Limits of Vaginal as Compared with Abdominal Exploratory Sec-
tion— Dr. Henry C. Coe says his experience leads him to select
the abdominal method of exploration in the following condi-
tions : "1. In the case of neoplasms or obscure enlargements
which are situated in the abdominal cavity, or have risen above
the pelvic brim, especially if they are more or less adherent.
2. In ascites of doubtful origin, more particularly when tuber-
culous or malignant disease is suspected. 3. In cases of dis-
ease of the adnexa in which the latter are situated near or
above the pelvic brim, as established by bimanual palpation.
4. In cases in which the history and symptoms point to general
intestinal adhesions, and above all, when appendical complica-
tions are suspected. 5. In ectopic gestation before rupture,
when the sac is high up, at the side or in front of the uterus,
instead of in Douglas's pouch. 6. In case of intractable pelvic
and abdominal pain of obscure origin, including the so-called
neuroses. On the other hand, explorative vaginal section
should be preferred : 1. In all cases in which the presence of
pus within the pelvis is suspected, as in pyosalpinx, pelvic
abscess proper, suppurating dermoids and cysto-adenomata,
and hematocele. 2. In the case of small intra-pelvic tumors situ-
ated in the pouch of Douglas, or at least readily accessible from
below. Impacted ovarian cysts, dermoids, and fibroids belong
to this category. 3. Adherent adnexa situated in the true
pelvis. 4. Unruptured ectopic sacs in the same locality. 5.
Circumscribed exudates and indurations in the broad liga-
ments or behind the uterus, especially when associated with
displacement and fixation of the lateral organ." — N. Y. Poly-
clinic, June, 1896.
Epiphysial Separation of Lower End of Femur.— Dr. Richard H.
Harte says in regard to diagnosis: There are two forms of
injury with which it is likely to be confounded, i. e., disloca-
appear sanguinolent striae. Too long exposure determines a I tion of the knee joint and fracture of the femur above the con
18%.]
PRACTICAL NOTES.
97
dyle. Traumatic luxations of the knee are a rare injury in
early life. If the separation is compound there is little diffi-
culty in diagnosis ; when simple the abnormal mobility will
serve to distinguish it from dislocation in which the move-
ments of the leg on the thigh are restricted in a marked degree.
Fractures in this part of the Iwne are rare at any time of life
and especially so in persons under maturity. The age of the
individual and the character of the crepitus will assist in
determining the position of the injury. If the crepitus is of
the dry, grating character, it can be easily distinguished from
the soft moist crepitus caused by rubbing the diaphysis against
the cartilaginous head of the tibia. American Journal of
Mtdical Sciences, June, 1896.
Artificial Ear Drum Membranes.— Dr. Vincent Gometz says :
The artificial drum membrane was first used by the laity in
1640 and afterward by the profession. It has been made of
a variety of materials. Tearsley, in 1841, selected a cotton
pellet for the purpose. It is first slightly moistened and placed
in the same position where it will best improve the hearing.
This will be found by experiments. Toynbee, in 1853, intro-
duced an artificial membrane, consisting of a thin rubber disc
attached to a fine wire. Lucas has covered the wire with rub-
ber tubing to prevent the unpleasant rattling in the ear.
Oruber uses a similar piece of rubber as that of Toynbee but
attaches to it a piece of silk thread to withdraw it from the
ear. Artificial drums are sometimes made of tin foil, used in
the same manner as cotton. Ordinary blotting paper answers
the purpose very well. The indications for the use of the
artificial drum membrane are as follows : 1, when a drum cav-
ity needs protecting from the air ; 2, whenever the ossicula are
detached from each other, the result of destruction of their
ligaments or from failure of the membrane to keep them in
proper contact, or even a severance of continuity consequent
on relaxation of the ligaments or absence of the incus, with a
gap existing between the membranes and the stapes (the latter
also may be in a state of subluxation from relaxation of its
annular ligament), the artificial membrane keeps it properly in
position. — Mete Polyclinic, June, 1896.
Treatment of Antrum Disease. -Dr. John E. Bacon describes
his method of operation. It consists in cleansing and medicat-
ing the cavity through a small puncture in its inner wall in
the inferior meatus of the nose, which can be made without
general anesthesia and without pain. The instruments are
a steel trocar and canula, two silver tubes, a silver wash tube,
and a hard rubber syringe with rubber tube connections made
to fit the canula and wash tubes. Cleanse the nares with the
antiseptic spray, cocainize the inferior turbinal and floor on
the side to be operated upon, insert a rubber operating specu-
lum well into the nostril and place the trocar beneath the infe-
rior turbinal about one and one-fourth inches from the skin
margin ; by bending the septum to the opposite side the point
of the trocar will point obliquely into the cavity of the antrum.
A slight tap with a leaden or rawhide mallet will cause the
trocar to penetrate the thin bone which constitutes the inner
wall of the cavity. Care must be taken not to penetrate too
deeply and so wound the opposite side of the antrum, as serious
hemorrhage might result. In most cases the trocar can be
pushed through the thin bony wall with the fingers alone, and
this should be done, when possible, to avoid the mental shock
which the blow with the mallet sometimes gives. The trocar
may now be withdrawn, leaving the canula in place, and the
rubber tube may be attached to the canula and the cavity syr-
inged out with warm sterilized normal salt solution. The
fluid will escape into the nose through the ostium maxillare
and bring with it pus if any be present After the cleansing,
the trocar- may be replaced and the nut removed, when the
canula may be withdrawn over the trocar ; now a silver tube
is slipped over the trocar and the latter is withdrawn, leaving
the silver tube in place, and this may remain as long as
required without any irritation. This tube is exactly fitted by
the silver wash tube, and the cleansing may be repeated with-
out inconvenience. A solution of menthol and camphor in liquid
albolene may be easily sprayed through the tube and aristol
or other non irritant powder may be blown into the antrum by
the same means. It is imperative to thoroughly sterilize all
instruments used, and to use only warm sterilized fluid in each
case, to prevent infection. The Am. Therapist, June, 1896.
Clinical Experience with Benzosol. — Concerning this remedy,
which is a benzoate of guaiacol, the June issue of the Ameri-
can Therapist has a clincal report by Dr. J. V. Kofron of
Cleveland, Ohio, which states that he has found the follow-
ing favorable features : 1, the avoidance of the unpleasant
eructations which so frequently occur after the administration
of pure creosote or guaiacol, and 2, the liberation of the
antiseptic guaiacol in the intestine where its action is espe-
cially desired in the treatment of septic conditions of the intes-
tinal tract attended with fermentation. In the treatment of
tubercular affections, the administration of benzosol affords a
most pleasant and efficient method of obtaining the constitu-
tional effects of creosote without the many unpleasant features
of the latter drug. As it is entirely free from unpleasant taste
or odor and is almost invariably retained by even a sensitive
stomach, one can by this remedy push the dose much higher
than when creosote itself is employed. In cases of incipient
tubercular phthisis with considerable cough and expectoration,
slight evening elevation of temperature, loss of appetite, furred
tongue, etc., the administration of benzosol gr. iv four times a
day serves to relieve the cough, reduces the amount of expec-
toration, brings down the hectic temperature, clears the tongue
and increases the appetite. Similar results have been observed
in cases of chronic bronchitis in which severe cough, profuse
expectoration and dyspeptic symptoms have been predominant
features. Very surprising to me have been the results obtained
from the use of benzosol in the treatment of cases of tubercu-
lar diarrhea, in which the remedies usually administered
proved of little value. In intestinal catarrh with flatulency,
benzosol speedily and effectually checks undue fermentation,
and it also affords a valuable intestinal antiseptic in cases of
typhoid fever. In three cases of this latter disease in which
this remedy was used exclusively, the following satisfactory
results were noted : Temperature never rose above 103, tongue
quite clean and usually moist, none of the patients exhibited
tympanites or suffered from diarrhea, and none of them suf-
fered from a relapse. " I have been desirous to test the effici-
ency of benzosol in the treatment of diabetes mellitus, as
advocated by von Jaksch, Piatkowski and J. Blake White of
New York city, but have not as yet had the desired opportun-
ity. In conclusion, I wish to express my belief that we have
in benzosol a valuable substitute for creosote in pulmonary
affections, a safe and efficient intestinal antiseptic for the
treatment of gastro-intestinal disorders attended with fermen-
tation, and a useful remedy in sterilizing the bowel in typhoid
fever."
On the Symptoms and Treatment of Angina Pectoris. — Sir Benja-
min Richardson, in his Asclepiad, describes this affection as a
disease of the sympathetic system rather than as a specific
organic change in the heart or its vessels. He says, first,
regarding the symptoms, that in the paroxysm the condition is
simply terrible. It is in the chest that suffering seems to be con-
centrated. The chest is, as it were, pierced or transfixed through
and through. The breath is held, and, as more than one of
the sufferers has expressed it, it is as if the chest were in a
vise, one blade of which was on the center of the back and the
other on the sternum at its center. The chest feels as if it
were filled and dilated with air which it is impossible to expel.
The chest, in fact, can not be emptied, neither can it be
98
PRACTICAL NOTES.
[July 11,
dilated or filled ; and the coldness of the surface of the body,
the whiteness and the fixity of the features, the condensation of
water on the brow and running down the cheeks and the appa-
rently rigid state of the limbs, all testify that there is no true
breathing power. Yet it is not asphyxia that presents itself ;
it is rather syncopal unrest ; and, indeed, there appears to be
no exhaustion of air or any change for the better until there
is a certain degree of relaxation of the diaphragm and of the
muscles of the intercostal spaces. As to the treatment, nitro-
glycerin and nitrate of amyl, made into a mixture, so that it
could be taken by the stomach slowly, he thinks, gives better
effects than when it is inhaled, because when it is swallowed it
seems to act favorably on the whole course of the sympathetic
nervous system. As a mixture he has usually combined it
with glycerin, putting 3 minims to a dram of glycerin, adding
3 drams of water and ordering that quantity, diluted further
with an agreeable quantity of water, to be taken at intervals in
the course of an hour. The effect of either of the remedies
described above is, he says, often strikingly beneficial. Their
action is to take off blood pressure and relax the arterial system,
so that blood can flow more readily through the lungs, through
the heart and through the general circulation. He fears
neither remedy exerts a true curative action, for if it did we
should really cure, whereas, as a rule, we only give relief.
Roentgen Photographs of Vesical and Renal Calculi. — D' Arson val
presented at the meeting of the Academie de Medecine, June
2, some Rontgen photographs of calculi taken by Gaiffe for
Dr. Lavaux. In their experiments reported last February,
they announced that it was possible to distinguish between
the silhouette cast by a calculus and that cast by a rib, which
was confirmed later by Chappuis and Chauvel. But these
latest photographs possess an importance which will be readily
recognized as they demonstrate that it will soon be possible to
diagnose calculi in the urinary passages with absolute exact-
ness. They not only show the existence of a calculus in the
bladder, kidney or ureter, but it is possible to distinguish the
substances of which it is composed, whether it is homogeneous
or formed of different layers, whether the kernel is small or
large and of what it is composed. The most interesting photo-
graph from this point of view showed : 1, the silhouette cast
by a calculus of pure uric acid ; 2, that of a calculus the same
size as the first, but composed exclusively of phosphate of
ammonia and magnesia : 3, that of a calculus much larger than
the others, formed of several distinct layers of uric acid in the
center, with an outer layer, 4 mm. thick, entirely different in
color, and composed exclusively of the triple phosphate ; 4, the
silhouette of a bone 1cm. thick, and another of the index finger
of one of the experimenters. The differences in the depth of
shadow in this photograph are so marked that it is impossible
to mistake the characteristics and kinds of the calculi. The
tiny kernel of uric acid is distinctly visible, while the outer
layers of the large calculus are represented by clearlv defined
rings. A second photograph showed another calculus with a
kernel formed of urate of soda, inclosed in an outer layer of
the triple phosphate, both very clearly defined in the photo-
graph. A third represented a number of uric acid calculi
lodged in the parenchyma of a kidney, one-half of which was 5
cm. thick. The rays passed through this thick layer of tough
tissue and the calculi alone showed in the photograph. It will
be a very simple matter, therefore, preliminary to an operation,
to take the photograph of similar calculi, and then compare
them with the results of photographs taken through the
patient. This will provide most important points of compari-
son, as the results differ with each Crookes' tube. A recent
special publication states that the indications for an operation
vary according as the calculus is of primary or secondary for-
mation. An exact diagnosis thus made preliminary to the
operation, will be of great value, especially in the case of
elderly persons and " prostatics," to determine beforehand the
exact location and composition of the calculi. The progress
accomplished in the last few months promises a speedy solution
to the entire problem. — Bulletin de V Acadimie de Midecine,
June 2.
Actinomycosis Treated by Iodid of Potassium.— A well-written
and laborious essay is one on the above subject in the London
Lancet for June 6, by Mr. Malcolm Morris. The author is
not only the editor of the Practitioner, but surgeon to St.
Mary's Hospital, and his paper appears as a model of its
kind in its care of preparation, in its judicial attitude and its
utility to students. By one thing, it may be added, it has a
bibliography extending beyond seventy numbers. The case,
in brief, which responded favorably to the treatment, had the
following salient points : "A single woman aged 59 years came
under my care at St. Mary's Hospital on Nov. 18, 1895, with a
large swelling over the lower jaw on the left side. About Octo-
ber 10 she first noticed a small nodule behind the ramus: it
was just underneath the skin, and in about seven days began
to discharge. It was very painful and continued to increase
until she came to the hospital. The patient had for the
greater part of her life been in service as a housemaid, but for
about a year she had made her living as a needlewoman.
She stated that she had never had to do with horses, cows
or other animals nor with grain, hay or straw. There was no
history of a blow or other injury and she could throw no light
on the origin of the disease. Her record of previous illnesses
showed nothing thatcould be interpreted as having any bear-
ing on her condition, nor was there anything of significance in
her family history. She had a large, dark red, nodular tumor
with a sharply circumscribed edge on the left side of the (ace.
It extended from the angle of the lower jaw forward to the
corner of the mouth, upward to the zygomatic arch, and down-
ward over the sterno-mastoid for about two inches. On the
most prominent part, in the temporo-maxillary region, the sur-
face of the mass was irregularly raised into nodules varying in
size from a split pea to a small bean, each having a small open-
ing at the top, the position of which was marked by a yellow
bead of pus. On squeezing the nodules a little sero-purulent
matter escaped. In this discharge were found firm yellowish-
gray granules which microscopic examination showed to be
masses of actinomyces or ray fungus. The skin over the whole
mass was brawny and reddened. To the touch the swelling
at first gave the impression of cartilaginous hardness, but on
firm pressure between the fingers it was felt to be elastic.
There was no fluctuation. Narrow spurs of infiltration also
extended upward behind the lobe of the ear and backward to
the posterior border of the sterno-mastoid. A hard lump of
the size of a large hazel nut could be felt under the buccal
mucous membrane. The structures forming the cheek were
infiltrated and firmly fixed to the jaw, especially toward the
angle, but the bone itself was not implicated. There were no
teeth in either jaw except the left superior external incisor and
canine. No enlargement of glands, either concatenate or
supra-clavicular, could be felt on the left side of the neck,
and there was no evidence of secondary growth. There was
no trismus, but the patient complained of great pain, particu-
larly on mastication, and the nodules were tender on pressure.
She had a poor appetite and slept badly, but otherwise there
was no disorder of the general health. The microscopic exam-
ination was conclusive ; apart from this, however, the situa-
tion and appearances of the swelling were characteristic. The
internal administration of iodid of potassium was begun on
November 21, when the following mixture was ordered to be
taken three times a day : Potassii iodidi, 15 gr. ; spiritus
ammonia; aromatici, 20 minims ; decoct, cinchona? ad gj. For
the first three days after the commencement of the treatment
the pain was worse and the discharge was profuse, but after
that the good effect was soon manifest. The pain abated,
the swelling became paler and softer and began to shrink.'
After ten days of the treatment only slight traces of the fungus
could be discovered in the discharge, which was very scanty.
On December 16 the dose of iodid of potassium was increased
to 20 gr., and on Jan. 27, 1896, to 30 gr. three times a day.
The improvement continued, and, in short, the history of the
case from the time the patient was brought under the influ-
ence of the iodid was a record of uninterrupted progress
toward a cure. Together with the retrocession of the local
process appetite and sleep returned and the woman felt better
than she had done for a considerable time. At the beginning
of February the swelling had nearly disappeared, the sinuses
had healed up and only a trace of the disease was left." When
last seen (May 28) the patient was well, but was still taking the
iodid.
1SSM5.J
EDITORIAL.
9y
THK
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to await call.
SATURDAY, JULY 11, 1896.
THK CELLAR IN ITS HYGIENIC ASPECT.
The Legislature of the State of New York has for
some time been considering the subject of bake-shops
and bakers, the remedial enactments effected having
had primarily the interests of the employes in view,
with which as physicians we have no especial con-
cern: but incidental to the investigation as to the
hours they were required to work (one hundred to
one hundred and thirty-two a week, the limit now
fixed by law being sixty), it was discovered that one
thousand and forty-nine of the one thousand and
fifty-nine bake-shops investigated were in cellars, and
that in seven hundred and thirteen of these the
height from floor to ceiling was less than eight feet ;
and when it is further stated that six hundred and
twenty-three of the number were found to be absolutely
unhealthy and only fire positively clean, it does
become a matter with which physicians have most
especial concern.
The word microbe has become domestic as well as
professional, and parents and children discuss their
deadly tiny enemies as glibly as learned professors
describe their cultures and death-points. It is the
age of the Lilliput and the terror inspired by these
diminutive foes makes them indifferent to the visible
presence of lusty Brobdingnagians. Theoretical
speculations concerning germicides and blind depend-
ence upon disinfectants cause people to forget the
simple precautions of common sense hygiene and lose
sight of the abundant store of health-preservers and
germ-destroyers at hand with no other cost than the
trifling labor of admitting them in the shape of air
and sunlight.
The ingenuity of civilized man has been but little
exercised in the direction of habitable homes for the
intelligent product of centuries of education. The
masses are gathered into buildings, where everything
that can be is being done to enfeeble the inmates and
dwarf their offspring, and to this end it seems to
matter little what system of house-building prevails
or in what locality.
Of all the abominations of modern residences, the
cellar or underground basement, which characterizes
our old cities, is the vilest. The city of Philadelphia,
for instance, is completely undermined by these sub-
terranean, dark, damp, moldy, foul-smelling receptacles
for all kinds of household refuse, as well as coal, prob-
ably stowed wet, wood in the same condition and
perishable provisions. The atmosphere of these murky
underground apartments has a characteristic nauseous
odor. Excepting a minority in first-class residences,
they have either rotting wooden floors or none at all
and the walls are the rough, untrimmed foundations
of the house, seldom whitewashed or calcimined, and
affording myriads of angles for the deposit of dust
and molds. Many of these cellars are further con-
taminated by imperfectly closed and leaking drains
and soil-pipes. The writer has in the course of many
a sanitary inspection, to which the tenant was abus-
ively hostile, discovered a condition of things, which
while cement and whitewash might temporarily
relieve, only a heavy fine could permanently remedy.
To the professional man, who is acquainted with
the willful blindness of the many to their sanitary
interests and their insane dependence upon drugs to
nullify the mischief their neglect invites, it is not
surprising that they not only allow their own homes
to be endangered by a foul cellar, but are indifferent
to the existence of other unhealthy cellars with which
they have more or less direct relation. The under-
ground bake-shop is an instance. Any passer-by
can get a glimpse of the dirty, low-ceiliriged hole in
the ground, in which bread, cakes, patisserie and
confectionery are prepared, from materials which have
been stored there indefinitely, by unclean men from
whose unwashed rags drops the sweat of heat and
fatigue into the mixture they are molding. The
official announcement that there were only five posi-
tively clean in over one thousand (1,049) investigated
ought to provoke a revolt against any form of under-
ground bakery or confectionery. Professor Vaughan
rendered inestimable service to the community by
showing some of the unclean ways by which ice-cream
becomes poisonous, but is it not really a matter of sur-
prise that any ice-cream manufactured in a cellar
daily wet from melting ice and soiled by spilled flour,
starch, eggs, sugar, gelatin, milk and other uncertain
100
THE HEMATOZOA OF MALARIAL FEVERS.
[July 11,
ingredients, can be anything but poisonous? It was
a wise sanitary advance which placed the kitchen in
the uppermost stories of certain hotels and restaurants,
but these are few beside the numerous sub-basement
kitchens where weary cooks compound their culinary
mysteries. The ordeal of fire is assumed to settle the
mischief-making power of the ordinary microbe, but his
coadjutor ptomaine is not so easily disposed of, and
many a savory mess has endangered life, when the
abused oyster, clam, lobster, prawn or frog had no
prior claim to toxicity.
The investigation referred to showed another source
of dirt and disease in the over-crowded underground
sleeping-quarters of employes, which they further
shared with dogs, cats and other domestic animals and
noxious vermin — a state of things repulsively nasty if
not positively dangerous. It is bad enough to have
your morning roll and loaf of bread delivered by the
dirty-handed driver of the baker's cart, but this is
trivial beside the possible contaminations during the
foul stages of their concoction.
The list of cellar nuisances can be greatly extended.
It is the chosen home of the rag-picker and bone-
gatherer. The corner grocer keeps his vegetables
there which are unsold from day to day. The writer
has encountered under-ground meat and game shops;
and since the advent of the Italian fruit-peddler, he
has made it his storage-place for bananas, grapes
and the like, from which he wipes, in his own filthy
fashion, the street dust of the day and the mold and
mildew of the night to tempt unwary buyers on the
morrow.
The alert modern sanitary inspector has no sinecure.
Upon the proper housing of the population of a great
city depends its vital condition. A local newspaper
reporting a young witness in a great murder trial
described her as " a typical New York flat-house child.
Her face is slender and her limbs fragile. Although
she is eleven years old, she could easily pass for eight
or nine. Her voice was such a mere shred of articu-
lation that it could not be heard a few feet away,"
and she was the daughter of a family of the better
class, but she slept in a little cell dimly lighted from
a shaft or well like others in which so many hundred
thousand little children are being slowly smothered.
The "apartment" has no cellar, but the same culpable
defiance of common sense sanitation develops the
typical flat-house child, and health authorities should
wage war both upon the contracted windowless bed-
room in which little Mary Cunningham was murdered
and upon the dark damp cellar of the dwelling-house.
An old medical officer of one of the national services,
inspecting a large Government Hospital, astonished
the junior officers by giving scant attention to the wards
on which they had devoted so much time of prepara-
tion, while he pried into every corner of the basement
and every cranny in the attic, and when they expressed
their disappointment that he had only glanced at the
especial objects of their pride, he said to them,
"when the cellar and garret are in good condition,
there need be no doubt about the rest of the build-
ing. " Garrets are as apt to be neglected as cellars,
but the greater inconvenience of access in a measure
protects them from becoming receptacles of perish-
able articles and their very elevation secures better
hygienic conditions. The cellar is the chief pesti-
ferous site and the health officer should see that
decayed flooring is replaced by cement, that the wTalls
and ceilings are scraped and then thoroughly and
repeatedly white-washed, that all leaking drains, soil
and water pipes are repaired, that every destructible
accumulation is removed, that the cellar-doors and
other apertures are wildly opened in clear weather,
and that when industrial occupations are permitted
in them by law (and the effort should be made to
reduce these to a minimum) they should be subjected
to the most thorough weekly inspection, and the rig-
orous imposition of penalties upon landlords and ten-
ants for neglect to remedy the nuisances reported.
Perhaps the most effective way of having sanitary
defects properly removed is for the health department
to do the work required as it should be done by its
own employes, the cost being charged to the delin-
quent owner or occupant.
THE HEMATOZOA OF MALARIAL FEVERS.
When Laveran in 1881 announced the discovery of
a malarial hematozoon which in its full development
was as large or larger than a red corpuscle, decorated
with pigment granules often arranged in the form of a
corona, and provided with flagella which stirred the
neighboring blood discs by their oscillations, the
medical world was probably more amused with the
announcement than impressed with its value. Beside
the perfected micro-parasite this French army sur-
geon described and figured a crescentic or banana
shaped form which he considered an imperfect devel-
opment, and oval or spherical, non-fillamented, degen-
erative or cadaveric forms, all containing pigment
granules loosely scattered or variously aggregated.
When it is remembered that Heschl in 1850, and
Planer and Frerichs in 1854, described pigment
granules in the blood of malarial cases and noted their
aggregation in cells or in small masses bound together
by a hyaline connective it seems surprising that so
little effort was made to verify Laveran's observations.
At the time, however, every trained microscopist was
looking for the bacillus malarice. Klebs and Tomassi-
Crudeli were credited with having found it, and as
the likelihood was considered to be all in this direc-
tion, Laveran's work was undervalued. He was cred-
ited with having mistaken degenerative characters in
the blood corpuscles for phases in the life history of a
hematozoon. In 1882 Richard came to his support
L896.]
THE HEMATOZOA OF MALARIAL FEVERS.
101
with observations on Algerian remittents, and three
years Inter Makchiakava ami C'kli.i in Italy, and
Councilman and Abbott in this country, verified
many of the observations. About the same time
Golgi, in studying quartan agues, discovered in the
red corpuscles colorless plasm ic bodies which as they
(grew larger became dotted with melanotic particles.
He Found that in a short time the normal constitu-
tion of the invaded red corpuscle became lost in its
transformation into a colorless globule containing pig-
ment. The dark particles became aggregated in the
center and the colorless plasmic substance underwent
fission in lines radiating to the circumference. The
resulting Begments or cellules, together with the cen-
tral pigment, were then liberated into the current of
the blood, and when this stage was reached a febrile
paroxysm was imminent. After Golui's announce-
ment the subject attracted general attention and the
existence of LavKRAN's organism was acknowledged.
The latest study of the Plasmodium comes from
the Medical Clinic of the Johns Hopkins Hospital
as "an analysis of 616 eases of malarial fever with
special reference to the relations existing between
different types of hematozoa and different types of
fever, by William Sidney Thayer, M.D., and John
HbwBTSON, M.D." These investigators describe and
figure three types of micro-parasite, one associated
with tertians, a second with quartans, the third with
estivo-autumnal fevers. In their observations a clean
cover-slip was brought lightly in contact with a drop
of blood from the lobe of the ear. It was then
placed on a perfectly clean slide and pressed gently
to have the corpuscles spread side by side between
the two surfaces.
In tertian ague a small hyaline body is found in the
interior of the red corpuscle. It is actively ameboid,
changing from a disc to a cross or star and sometimes
to a ring by the fusing of pseudopodia. In a short
time pigment granules, also having an active motion,
appear in its substance, and the latter continues to
increase until it fills and distends the shell of the red
corpuscle. The pigment meanwhile collects in the
center and segmentation by striation of the protoplasm
takes place, the segments apparently becoming the
small hyaline bodies which invade the red corpuscles
for a new cycle of growth. Often the plasmic mass
escapes from a ruptured cell before the segmentation is
perfected. This parasite requires about forty-eight
hours to complete its development, and is associated
with relatively regular tertian paroxysms lasting ten or
twelve hours, and usually presenting the classic
stages of chill, fever and perspiration. Infection with
two groups of tertian organisms maturing on differ-
ent days gives rise to quotidian paroxysms.
In quartans the hyaline bodies are smaller than in
tertians, but they are more refractive, the ameboid
movements slower, and the pigment granules larger,
darker, motionless and generally peripheral, but some-
times star-shaped and central. Ultimately the red
corpuscles become filled, but not enlarged as by the ter-
tian organism, and segmentation follows as described by
Golgi. A period of about seventy-two hours is required
for this development. Infection with two groups causes
a double quartan with intermission on the third day;
with three groups a quotidian. In both of these forms
some of the full grown organisms become flagellate or
vacuolated as described by Laveran. The nature of
the flagella has not yet been determined. Their dis-
coverer considered them appendages of the perfected
organism; later observers regard them as degenerative.
The organism of estivo-autumnal fevers when fully
developed is rarely half the size of the red corpuscle.
During its growth crenation of the corpuscle, brassy
color, retraction of hemoglobin, and sometimes cen-
tral aggregation of pigment are found ; but probably the
greater part of the development, including the segmen-
tation, is carried on in the spleen and other internal
organs. The cycle of development lasts from less than
twenty-four to more than forty-eight hours. After the
infection is five to seven days old the ovoid and crescen-
tic bodies observed by Laveran in the remittents of
Algeria are discovered. Quinin has less power over
these than over the other forms. The Johns Hopkins
investigators are satisfied that the crescents represent,
a very resisting form of the organism and that they
may develop into the flagellate forms. Further obser-.
vation is needful to determine their significance.
The presence of the plasmic bodies in the blood
has been generally acknowledged, but occasionally
there arises an investigator who questions their
accepted meaning and denies their parasitic nature.
The latest of these objectors is Surgeon Lieutenant-
Colonel E. Lawrie, who has been studying the sub-
ject at Hyderabad. From similarity of appearance,,
he considers the white blood cell of the frog to be the,
escaped nucleus of its red blood corpuscle, and he,
therefore concludes that the leucocytes of human
blood are the nuclei of red cells liberated in the.
spleen by its blood forming action. The theory which
he builds on this assumption, is that the spleen in its
disabled condition in malarial disease is unable to,
turn out perfected non-nucleated red blood corpuscles,
and that the plasmic bodies are merely the embryonic,
or nucleated, corpuscles which escape from it into the
general circulation; the plasmodium being, therefore,
not a cause but a consequence of malarial fever.
The form in which these organisms exist outside
the body, as in malarious soils, water or air, and the
mode or modes of their entrance into the human sys-
tem are wholly unknown. Laxcisi and McCullough
explained the causation of malarial djseases on the-
theory of a miasmatic exhalation which disorganized
the blood. Our modern researches recognize the
disorganization of the blood, but call, fqr a specific*
102
SIR HENRY HALFORD AND THE REVIEWER.
[July 11,
entity as the cause. Investigation into the influence
of the ameboid forms, so common in marsh waters on
the corpuscles of living blood, appears to be
order.
now in
SIR HENRY HALFORD AND THE REVIEWER.
Noticing Dr. William M. Munk's "Life of Sir
Henry Halford," who was by his enemies dubbed
the "Eel-backed Baronet-' on account of his deep and
oft-repeated bows, the Saturday Review (June 13)
recalls the story told by Mr. Bransby Cooper, in his
"Life of Sir Astley Cooper," of Sir Henry's three
profound formal bows to Lord Liverpool when he
entered the room in which his lordship was lying on
a sofa, utterly insensible, under the attack of apoplexy,
from the effects of which he eventually died. The
Review says that he seems to have contributed
nothing to the science which, after all, lies behind
the practice of medicine; he relied chiefly on his
soothing manners and on what he delighted to call
the vis medicatrijc naturcv, and, in nearly every
respect, he might be taken as the "glorified example
of the successful medical tradesman." On the other
hand, in one respect his profession remains indebted
to him ; during the long period that he served as
President of the College of Physicians he labored
hard and successfully to further the dignity and
advantages of that great corporation. He was physi-
cian to four successive sovereigns, George III.,
George IV., William IV., and Queen Victoria.
For twenty-four years he was President of the Royal
College of Physicians. In the first year of his prac-
tice his professional receipts amounted to £220.
They increased annually, and in 1809, his eighteenth
year of practice, they reached £9,850, thereafter
always exceeding ten thousand a year.
We presume the Saturday Review has some good
authority for the assertion that Sir Henry Halford
was the court physician mentioned by Bransby Cooper,
but that writer does not say so. The exact quotation
for my conduct. He seemed, however, but ill pleased
at what he considered a want of proper courtesy
toward himself."- The action of the court physician
toward Mr. Cooper, which was evidently the occasion
of his record of the bows, is easily explained when we
recall that Sir Astley Cooper had been summoned,
and being absent, his nephew, Bransby Cooper, then
an unknown young man, responded. It must have
been a shock to one so long accustomed to the punc-
tilio of the court. It is by no means clear from the
record that Sir Henry, if indeed the court physician
mentioned was Sir Henry Halford, was aware, on
entering the room, of the comatose condition of the
Premier. At any rate, it is a curious instance of the
democratic tendency of the times, when we see a tory
publication make bold to pillory a man seventy years
after his death for an observance of the ordinary eti-
quette of the earlier half of the century.
Sir Henry Halford was one of a very distin-
guished family of brothers, the sons of Dr. James
Vaughan, a physician of Leicester. This gentleman
had his sons educated with peculiar judgment, and
expended his entire income in so doing. It is men-
tioned that not one of them asked or received further
pecuniary assistance from the father after finishing
their education and commencing their efforts in pro-
viding for themselves. Henry Vaughan was gradu-
ated B.A. at Oxford in 1788 and M.D. in 1791. He
had acquaintances and friends enough to borrow
£1,000 on coming to London, and in 1793 was
appointed physician to Middlesex Hospital, and was
elected a Fellow of the College of Physicians in 1794.
Such were his talents and abilities that at twenty-
seven he was appointed Physician Extraordinary to
the King. Having inherited a large property on the
death of the widow of Sir Charles Halford, his
name was changed from Vaughan to Halford. His
skill in practice was acknowledged by his contempo-
raries, although no one ever claimed for him the merit
of original discoveries. There are many physicians of
is as follows: "He had been seized with a fit of exceeding skill and learning who are not discoverers,
apoplexy while at breakfast. I felt his pulse, and was
at once convinced of the necessity for bleeding, and I
immediately bled him. He seemed somewhat relieved,
for the pulse was less labored, but he did not speak.
Shortly after this operation had been performed,
one of the court physicians entered the room. He at
once made three profound formal bows to Lord Liv-
erpool as he lay senseless on the sofa, to which we
had now removed him, and then, turning to me, asked
if I were aware of the grave responsibility I had taken
upon myself in bleeding the Prime Minister of Eng-
land before his arrival. I replied that I thought I
should have incurred a far greater had I hesitated in
doing that which was evidently necessary, and further
that. I had the sanction and support of Dr. Drever1
i Lord Liverpool's family physician.
and few of large practice have the time to devote to
path-finding. As an orator, he may without question
be given the highest rank of any British physician, and
in elegant literature he has had few superiors. His
orations were models of elegant Latin, particularly
the Harverian oration, delivered October, 1800, show-
ing the connection between literature and medicine,
and touching with pleasing reference the most illus-
trious characters of British medicine from Linacre to
Warren. The stately oration in dedication of the
new building of the Royal College of Physicians lias
the stamp of genius, and no one can read the scholarly
essay "On the influence of some of the diseases of the
body on the mind" without becoming deeply im-
2 Life of
II., p. 222.
Sir Astley Cooper, Bart., by Bransby Blake Cooper. Vol.
L896.]
AN IMPERFECT LIST.
103
pressed with the innate goodness of the man and his
uniabilitj .
The sneer of the modern reviewer can not now
seriously disturb the record of the life of one whose
long and useful career was so many years connected
with that of the Royal College, and to whom, if for
nothing else, the modern medical man is indebted for
a type of medical man distinguished above his fellows
for deep Learning, eloquence, wisdom and that polite-
ness which comes from natural amiability and sweet-
ness of temper.
COMMITMENT OF THE INSANE IN THE STATE OP
XKW VORK.
On July 1. the new law, or codification of laws on
the above subject, that was enacted by the Legislature
of 1896, went into effect. It has generally been felt
that that law handed the insane over bodily to the
politicians; but the enactment is apparently thought
by the Commissioner in Lunacy to be less malign in
its probable future operation than has appeared at
first sight. He hopes for the best; but it is probable
that he will soon feel " the clutch of the ring. "
Under the new law, the procedure for commitments
will be. in brief, as follows:
Application for the commitment of an alleged
insane person may be made by any person with whom
such insane person may reside or at whose house he
or she may he. or by his or her father, mother, hus-
band, wife, brother, sister or child or other next of
kin, or by the superintendent of the poor of the
county, the commissioners of charities of the counties
of New York and Kings, or the overseer of the poor
of the town or city wherein such insane person may
lie. The procedings are to be initiated by a petition
of the applicant containing a statement of the facts
upon which the allegation of insanity is based, signed
and verified by him, to which must be annexed the
certificate of lunacy executed by two legally qualified
medical examiners. Such papers must then be pre-
sented to a judge of a court of record. i. e., a justice
of the supreme court, a county judge, a surrogate, or
certain judges of city courts which are declared by
statute to be courts of record.
Notice of the application should be served person-
ally upon the alleged insane person, and if made by
a county or municipal officer, upon the husband or
wife, father or mother, or next of kin, if there be any-
residing within the county, of said person. The
judge may dispense with sia-li personal service, or
direct substituted service ii\h>ii some person named by
hi in. In such case the judge is to attach to such
petition a certificate, stating his reasons for dispen-
sing with personal service, or if substituted service is
directed, the name of the person to be served. The
commissioner says:
" It is not expected that the examiners will do
more than properly fill out the certificate of lunacy,
as has been the custom heretofore, and the new form
of certificate is substantially the same as has hereto-
fore been in use. The examination must be made by
two qualified medical examiners, jointly, and the cer-
tificate must be executed and dated upon the day of
such joint examination. The order of commitment
must he grunted within ten days from the date of the
certificate,
"The petition, the certificate of lunacy, and the
various necessary orders, are printed as one form, and
will be known as form 472 of the forms of the State
Commission in Lunacy, and in ordering blanks it will
only be necessary to refer to this form number. The
parts of this form, five in number, while they are
bound together, are so arranged as to permit of the
insertion of additional papers of reference when
required, and care should be taken that the page and
line where matter is to be inserted are carefully
indicated.
"It should be noted that the law requires that the
petition and all the papers relating to the commit-
ment of an insane person must be made only upon
forms prescribed and furnished by the commission.
"It is respectfully suggested that in proceeding
under the new statute it should be carefully read and
its contents understood before final action is taken,
and attention is particularly called to Section 60, of
Chapter 545, Laws of 189(5, which among other things
provides as follows: No idiot shall be committed to
or confined in a State hospital. "
AN IMPERFECT LIST.
In the May-June issue of the Bulletin of the Johns
Hopkins Hospital there is given what should be a
very useful list of the scientific medical journals in
public and private libraries in Baltimore. It includes
besides medical journals a large number of scientific
publications which are, as the compiler says, "some-
what remote from scientific medicine and biology,"
and omits many medical journals. In fact it is much
fuller as regards foreign than American journals, and
here it is open to criticism. A list purporting to be
that of the "scientific medical journals," by wilful or
inadvertent omission of certain journals that ought to
be available in series in Baltimore libraries, while
including others no better entitled to the term scien-
tific, is open to the accusation of making invidious
distinctions. Certainly some of the less than thirty
existing American medical journals here included are
no better entitled to be designated as scientific than a
large number of those omitted of the series ought
to be found in Baltimore libraries.
The phrase "somewhat remote from scientific med-
icine" covers the astronomic and mathematic publica-
tions included in the list, though the adjective
"altogether" would have been more appropriate.
The numerous natural history and physical publica-
tions may have a remote relation to medicine or may
contain articles of some medical interest, and their
appearance here is less objectionable.
The list is interesting, not only for its omissions of
American medical journals, but also on account of
104
CORRESPONDENCE.
[July 11,
some of the European deficiencies. There is, aside
from transactions, etc., a notable dearth of Italian and
Scandinavian literature, and some special and general
journals of note among the German and French pub-
lications are lacking. Such deficiencies are of course
of less consequence in Baltimore, only forty miles
away from the great medical library of the Surgeon-
General's Office, but one can not help noticing them,
if they occur in a city that has so many claims to be
considered a center of medical learning and progress.
It is probable, however, that the list is incomplete and
will very soon need thorough revision; but as an
experiment it is useful and suggestive. It would be
well could it be followed by other similar publications
of the resources of other centers in medical literature,
more carefully and discriminatingly prepared and
covering a wider field, including not only the foreign
periodicals but a full series of those published in this
country. There are undoubtedly some American
medioal publications of only moderate scientific inter-
est, but there are many more than seems to be recog-
nized at Baltimore that are indispensable to a refer-
ence library with any claims to completeness.
CORRESPONDENCE.
The Pa 11- American Medical Congress.
Topeka, Kan., June 27, 1896.
To the Editor: — Only yesterday my attention was called to
the very Invective letter under caption of the "Second Pan-
American Congress," written by David Cerna, M.D., Ph.D.,
and published in the Journal May 30. I have been a reader
of the Journal for a number of years, but by some coinci-
dence I failed to notice this strange correspondence and was in
blissful ignorance of all that had been written about me and
my paper. One would suppose that I was guilty of some
awful crime committed over two years since from reading this
unkindly letter. The editor of the Kansas Medical Journal,
published in this city, had requested me to write an editorial
regarding the Pan-American Medical Congress, and when I
handed the copy to the editor he kindly referred to the Cerna
letter and asked if I had seen it. Had it not been for this
coincidence I would probably not have seen it.
This is my first experience in public notoriety and I do not
take very kindly to this method of getting my name before the
public, but when a man, claiming to hold important positions
in the profession, writes for publication such an article of
unkind innuendoes without quoting a single word that I had
written regarding my friends in Mexico, it is certainly my duty
to at least acknowledge having carefully perused said letter,
and perhaps ought not to give it any further consideration.
However, when such grave charges as are found in this ver-
bose letter, are made against a member of the profession, and
not a word of information relative to the alleged crime, what
answer can one give? The excuse made that space would not
permit him to quote any part of my paper is the most unkind
hit of all. Justice to myself would demand that the entire
paper referred to be republished and furnished the profession,
that they might judge for themselves regarding the enormity
of the crime committed, but I will only briefly refer to some of
the most emphatically incorrect points. Before doing this,
however, I wish to preface this by saying that I have been
appointed by Dr. Liceaga, and also by Dr. C. A. L. Reed, to
act as vice-president for Kansas for the Second Pan-American
Medical Congress. I accepted the appointment and this
explains the editorial which I will again refer to in this letter.
I spent nearly three years in the Republic of Mexico, and I
wish to say they were three years of great pleasure. During
most of this time I held an official position, which brought me-
prominently in contact with the best people of Northern
Mexico, and I have never had cause to complain of the con-
stantly courteous, and I might say universally considerate,
treatment of the rich as well as the poor people of that coun-
try. More than this, I have never, by written or spoken word,
desired to convey to any one, that the Mexican people are not
the most courteous and kindly in the human family, not even
excepting our Southern neighbors. In this paper so kindly (?)
referred to by Dr. Cerna, I had only the highest praise for the
Mexican physicians as gentlemen and as scholars, and only
spoke of their methods in the treatment of patients as being in
many respects entirely different from our way of doing and
jocularly referred to their easy-going habits and, perhaps, care-
less customs, but in every instance only brought out these
facts to illustrate some thought. What I said was true,
David Cerna, M.D., Ph.D. to the contrary notwithstanding.
Having on several other occasions spoken in public of the
kindliness of their people, it was but fair to history and fair to
the profession of that country and ours, to speak of some
features of the practice on that side of the Rio Grande which
had not been before mentioned by any one, and I can assure
my Mexican friends that it never occurred to me that I was
not treating them in all respects fairly. I took that particular
aspect of the subject which, perhaps, was not the most pleas-
ing one, but with no intention of doing any one harm.
I have never had the pleasure of the acquaintance of David
Cerna, M.D., Ph.D., but trust that I will meet him in Mexico,
and feel assured from my slight knowledge of men and things,
that he will fail to find me quite the wild and woolly animal
that he has so invectively pictured me to be. Dr. Cerna' s
tactics in dragging Dr. Warfield into the controversy regarding
the Pan-American Medical Congress, because the doctor found
it served his purpose in writing a paper on "Typhus Fever of
Northern Mexico," to speak of the habits of some of the peo-
ple of that country, is absolutely reprehensible. Dr. Warfield
can defend himself, if he should need any defense, but I do
not think he does, as he told the truth, and any one doubting
his statements may satisfy himself by a personal contact with
the lower class of Mexican people. What has this fact to do
with the success of the coming Congress? What has been said
of Mexico may truthfully be said of other peoples, and of our
own, under some circumstances.
In an article published in a monthly periodical which has an
extensive circulation in Mexico and the United States, writing
under the caption of "Mexico as a Field for Physicians and
Surgeons," I had this to say of the country and people;
"Never before in the history of this country have such oppor-
tunities been offered for the investment of money and the
building of permanent homes by foreigners, as at the present
time. Much may be said in explanation of this statement.
Suffice it to say, that there are two special reasons for this
happy condition of affairs : First, nearly every part of the
republic has most magnificent railroad accommodations and
telegraphic facilities, making the country completely civilized,
and giving its inhabitants every modern accommodation for
travel and communication ; secondly, the government of
Mexico, with that magnificent statesman and philanthropist,
President Porfirio Diaz, and his loyal cabinet, who so ably
manage the general government, together with the judiciary,
among the most scholarly to be found anywhere on the conti-
nent, to say nothing of the governors and other officers who
are loyal to their country, make this one of the most stable
and law-abiding republics under the sun.
1896J]
CORRESPONDENCE.
105
"The Mexican people are extremely confiding in their nat-
ural disposition, ami at the same time they must be entirely
satisfied regarding the sincerity of people who are strangers
before complete confidence can be secured. In other words,
the\ arc very sagacious and discreet, making it necessary for
physicians locating in any part of their republic to so conduct
themselves that the poor as well as the rich may have no cause
to question their good intentions. hi all tin- cities ami lar./n-
towns ma// be found a sufficient number of native physicians
In inert every ordinary demand. Many of tins,- physicians
air very scholarly ami in every way competent to treat suc-
ccssfiilh/ the diseases prevalent in that country. The require-
ments in their colleges are far in advance of American colleges,
so far as the number of years of attendance is concerned.
There is, however, an inexplicable fascination which takes
sion of the people of that country in favor of foreign
physicians, who have established a reputation for unusual
skill, both in the practice of medicine and surgery. There
has been a very serious prejudice on the part of the more edu-
cated against American physicians, but it is rapidly disappear-
ing, the result of the marked advancement on the part of our
medical colleges in the past few years."
The foregoing does not sound much like the "bear" Dr.
Cerna would make you believe that I am. In the editorial,
written before I saw Dr. Cerna's correspondence, and which
will be published next week. I have the following to say :
"Dr. Milo Buel Ward of Topeka has received the appoint-
ment by both the American and Mexican authorities of the
Pan American Medical Congress, of vice-president for Kansas,
and has been furnished a liberal supply of literature to be dis-
tributed to any who desire to contribute a paper or attend the
meeting, which will be held in the City of Mexico, November
lt» to 19. of this year. This literature includes special and gen-
and regulations and ap]>ointment blanks, and will be of value
and interest to all who intend to contribute or attend the meet-
ing. Dr. Ward will gladly supply these papers to all who desire
them. This Congress will be a meeting of medical men of great
renown from all parts of America and should be attended by
every lover of his profession who can possibly go. The
extremely polite and ever courteous Mexican insures to all who
attend thisi;reat meeting a most delightful entertainment and
an ever to be remembered pleasant occasion. No one can
appreciate the painstaking courtesy of the Mexican people and
their ability to make the stay of their friends pleasant and
highly enjoyable, unless they visit that country and learn these
facte from personal intercourse with them.
"There is no doubt whatever but the second Pan-American
Medical Congress will be one of the most enjoyable and profit-
able meetings of the medical profession which has ever been
held on this continent. Kansas should certainly have a liberal
number of representatives at this meeting, and the Kansas
Medical Journal urges the members of the profession through-
out the State to at once notify Dr. Ward if they will furnish
a paper or attend the meeting. It is desirous on the part
of the General Executive Committee that all who are plan-
ning to go shall notify them through their local vice-pres-
ident, in order that the Executive Committee in Mexico may
plan to entertain their visitors. Let us again urge our
readers to act promptly and decisively regarding this import-
ant matter, that our great State with its large number of
prominent and active workers in the medical profession
may have honorable representation at the second Pan-American
Medical Congress."
No further reply to the unkind accusations of David Cerna,
M.D., Ph.D., seems to me necessary. I am very fond of that
country and admire the intelligent, educated Mexican very
much and expect to attend the Congress, and feel assured that
my time will be pleasantly and profitably spent, and that all
the members of the profession who can find it possible to
attend will be repaid for the time and money spent.
Respectfully, Milo B. Ward.
Location of Journal .
Chicago, III., July 1, 1896.
To the Editor: — I wish to change my vote to Washington,
D. C., for the reason that, having maturely considered the sub-
ject, I am of impression that the Journal would gain a great
deal by being published where its editorial rooms might be in
close proximity to the Army Medical Museum, the great Army
Medical Library, and the Smithsonian Institution. Finan-
cially, as I notice from the advertising columns, the principal
support of the Journal comes from east of the Alleghanies, I
do not see that the Association would be any worse off ;
beside that, the editor might have the advantage for the Asso-
ciation of the bright writers of the many scientific depart-
ments of the Government, in addition to those now upon the
staff ; beside that, the power and influence of the Association
in the matter of medical legislation would be very much
greater with the Journal published at the Capitol, where
copies could be sent to members of committees of the House
and of the Senate. It seems probable that but a short time
will elapse before the Association will be compelled to have a
standing committee on Congressional bills, like the British
Medical Association, which now has a standing committee on
Parliamentary bills. It must be obvious that in the neutral
ground of the Capitol the Journal could develop its greatest
strength easier and more conspicuously than in any other city.
As it can never be a local journal owing to its very nature, and
as it is not in competition with local journals, it is all the more
necessary that a neutral place of publication be selected. For
these reasons, I wish my vote changed from Chicago to
Washington. E. J. Doering, M.D.
Apply the Baconian Method.
Denver, Colo., July 3, 1896.
To the Editor: — In the name of scientific medicine I feel it
to be a duty to protest against the promulgation of such ideas
as those advanced under the heading "Lycopersicum Cardio-
pathia" in the issue of the Journal for June 27. In this
article three pages of theory are offered us without, so far as I
am able to find by careful examination, any facts whatever as
a basis. In the first place, the substance which produces such
dire results, acidum lycopersicum, is not mentioned by either
Gould, Dunglison, Fowne, Roscoe and Schorlemmer or any
authority that I have consulted, while the article itself gives
no further proof of its existence than the bare statement that
it has been found in the tomato.
I submit that a single case, carefully observed and recorded,
of any disturbance of any kind, if such ever existed, from the
ingestion of this universally used article of food, would be
worth infinitely more than pages of mere theoretic twaddle as
to the effect of the acid with the long name. I doubt if any
ill effects have ever been noted, by any competent observer,
from the use of the tomato, other than may be accounted for
by ordinary indigestion, fermentation, or personal idiosyncrasy.
It is time for some one to call attention most vigorously to the
point that we will make of medicine more nearly an exact
science only by collecting facts and reasoning from them, or,
in other words, by following the methods pointed out by Bacon,
adherence to which methods has been the sine qua non of
progress in all branches of scientific knowledge since his time.
If I speak warmly, it is only because I feel that the occasion
calls for vigorous denunciation of such pseudo-science.
Yours very truly, J. N. Hall, M.D.
Multum in Parvo. — Dr. J. P. Crozer Griffith reports a case of
varicella gangrenosa, diphtheria, rubeola and varicella existing
at the same time in a child aged 22 months, admitted to the
Children's hospital of Philadelphia. — Med. and Surg. Reporter,
June 27, 1896.
106
PUBLIC HEALTH.
[July 11,
PUBLIC HEALTH.
Health in Michigan. Consumption was reported present in
June at 208 places ; measles at 78 places ; scarlet fever at 49
places ; typhoid fever at 43 places, and whooping-cough at 36
places.
Street Noises Injurious to Health.— It is stated on the authority
of prominent physicians that nervous disorders in New York
City are on the increase. Unnecessary street noises are believed
to be responsible in a great measure for this condition.
Medical Examiners Appointed.— Gov. Lippitt of Rhode Island
has appointed new medical examiners as follows : Dr. Jay
Perkins for Providence, Dr. R. G. Reed at Woonsocket, Dr.
Charles H. French at Pawtucket, Dr. Nelson Reed at Warren,
Dr. John Winsor at Anthony.
Health of New York State. -The monthly bulletin of the State
board of health shows the total number of deaths for the
month was 9,541, which is an average of about 308 a day.
The prevalence of diphtheria has slightly increased, but is con-
fined to the maritime districts. But one death from smallpox
was recorded and that was from New York city.
Wisconsin State Board of Health. The semi-annual meeting of
the State board of health was held June 24, at Milwaukee.
Dr. Solon Marks is president, and U. O. B. Wingate, secre-
tary. An analysis of the water at Ashland is being made every
day by the health officers for the purpose of showing the effi-
ciency of a new method of filtering and the results show a
steady improvement.
Typhoid Fever In Plymouth, Pa.— The number of typhoid fever
cases in Plymouth is growing alarmingly large, and fears of
another epidemic, such as visited the town in 1885, are being
entertained by a number of people. The memories of that
time are still fresh in the people's mind, and it is no wonder
that they dread another such visitation— a visitation that made
a hospital of the school house and brought weeks of suffering
and death to many homes. There are now in that town up-
ward of twenty-five typhoid cases.
Smallpox and Yellow Fever in Cuba. The report to the Surgeon-
General of the Marine-Hospital service from the United States
Sanitary Inspector at Santiago, Cuba, is that smallpox is raging
epidemically, and the cases, which can be counted by the hun-
dreds, are increasing daily. "Malarial affectionsof the most
deadly character are very common, especially the remittent and
pernicious form." From Sagua la Grande the report is that
yellow fever is on the increase among the troops at that point.
Cienfuegos reports forty deaths from smallpox and increasing
yellow fever for the week.
Ireland's Unapproached Record for Legitimacy.— The Scalpel for
May refers to the low birth rate of Ireland as being partly due
to the large emigration of able-bodied adults. Of the children
born in 1894, 53,922 were boys, and 51,433 were girls ; the pre-
dominance of the male sex being thus equal to nearly 21.. per
cent. "The chief feather in Ireland's cap is the comparative
infrequence of illegitimate births. So great, indeed, is this
distinction that the Registrar-General draws special attention
to the fact by remarking, somewhat inconsequentially, that ' it
is unnecessary to say the proportion compares very favorably
with the returns from most other countries.' The illegitimate
birth rate for the entire country was 2.7 per cent, of the total,
but it varied greatly in different provinces. In Ulster 39 chil-
dren in each 1,000 were born out of wedlock ; in Leinster, 27,
in Munster 22 ; while in Connaught the number fell to one.
We are certainly of opinion that, instead of most, the official
dictum might well have been all other countries."
Hygiene Pays. — That public parks in cities are good invest-
ments from a sanitary standpoint goes without saying. That
they are also profitable as a pecuniary investment is shown in
a recent report by J. Clyde Power, landscape engineer, recom-
mending extensions of the park system of Indianapolis. He
cites New York as a notable instance of the great increase of
value accruing to land in the vicinity of parks. In 1856 the
assessed valuation of the three wards adjoining Central Park
was 820,429,565 ; in 1873 it was 8236,081,515, a gain in seven-
teen years of 8215,651,950. The natural average increase of
three other wards in the city, taken from all the wards, except
the ones adjoining the park, showed only 853,000,000, making
the earning capacity of the park 8183,081,515. In Brooklyn,
in 1864, Prospect Park, 515 acres, was acquired and the increase
in valuation in three years was 38 per cent.
Annual Quarantine Orders. In accordance with the quaran-
tine laws authorizing the Surgeon-General to promulgate such
additional regulations as may be necessary for the disinfection
and detention of vessels from ports suspected but not posi-
tively known to be infected with yellow fever, the usual order
has been issued. It provides that during the active quaran-
tine season, continuing until November 1, all vessels from ports
in the West Indies, on the east coast of Mexico, Central and
South America, as far south and including ports in the Rio
Platte ; ports in Peru, Ecuador, Columbia and on the west
coast of Central America and Mexico, arriving at the national
quarantine stations, shall be detained and treated in accord
ance with the provisions of the quarantine regulations for
domestic ports.
Dangers from Sewage Farms. An outbreak of typhoid fever
in the village of Wycombe Marsh, Eng., which seems directly
traceable to the pollution of a river by the effluent from a sew-
age farm, leads Hospital, June 20, to conclude, first, that
sewage farming demands a high degree of skill and care in
order that non-poisonous effluents only may be turned into
running streams ; and, second, that village wells which are in
any close contiguity to sewage farms should, if possible, be
closed, and an adequate supply of water obtained elsewhere.
Civilisation must get rid of its sewage ; and sewage farms,
when scientifically and conscientiously managed, are excellent
methods of sewage disposal. But it is probable that in no long
time they will have to be submitted to competent periodical
inspection by a sanitary authority in order that such calami-
ties as that which has overtaken Wycombe Marsh may, as they
ought to, become impossible.
A Scottish Sanitarian's View of the English Disregard for Jenner.
The Olasgoic Sanitary Journal, for May, says editorially :
"It is a trite saying that the world knows little of its great-
est men, and in a very considerable degree that the world has
only a short memory for its chief benefactors. The reason is
not far to seek. A century after a great danger to public
health has been removed, it is difficult to realize the greatness
of the danger when it did exist, and the very success of the
preventive means is apt to cause forgetfulness of the value of
the original benefaction. In Germany, in the present day,
vaccination and revaccination are compulsory and smallpox is
unknown. How can a German housewife be expected to feel
acutely her indebtedness to Jenner when smallpox, to her, is
merely a name, and the sore place on her baby's arm is for a
day or two a troublesome reality? But in Germany there is a
different legislative system from ours. There is an autocracy,
not a democracy, and the result is that vaccination continues
to be enforced independently of universal knowledge of its
benefits. In this country we are under the democracy, and the
democracy is apt to have a short memory. Thus it is that
within recent years there has been a tendency to decry and
neglect the protection against smallpox which was given to us
by Jenner. But the very neglect is already resulting in a fresh
acquaintance with smallpox, and a fresh appreciation of the
value of cowpox. Nowhere in this country has the neglect
been so great as in Gloucester, and nowhere in this country has
there been recently such a return to the Jennerian pract i
in that city, whose cathedral contains a statue of the Berkeley
village doctor. He is fortunate in his wisdom who is wise
through the experience of others, and in some defaulting dis-
tricts the Gloucester experience is causing a return to vaccina-
tion. A year or two ago in Bristol there was an exhibition of
1896. ]
PUBLIC HEALTH.
107
.lenner relics, and in some important centers of population in
both tin' now world and the old the centenary day of .lenner's
tirst vaccination has been suitably celebrated. It is a curious
example of human folly that in the city of Gloucester the cele-
bration should have to take the form of a smallpox epidemic."
Those of us who behold the "celebration" from a safe dis-
tance are moved to add : It is a form of poetic justice, the like
of which we do not often see !
On the Management of the Tuberculous at Hotels.— The Pennsyl-
vania Society for the Prevention of Tuberculosis, under the
presidency of Dr. Lawrence P. Pliek, has published some circu-
lars of information for gratuitous distribution. The third tract
of the series treats of the duties of hotel-keepers in relation to
their infected and non-infected guests. Among the points
brought out are the following : The linen, etc., of consump-
tives should lie washed separately and should always be well
boiled before being washed. The persons to whom such
articles are given to wash should be properly instructed as to
what to do in order that they too may be protected. As far as
practicable, consumptives in the advanced stage of the disease
should be aligned to separate tables, in order that their table-
ware and linen can be kept apart from those of the other
tables and washed separately. All such tableware should be
boiled before washing.
•All parts of a hotel or boarding house which are likely to
be frequented by consumptive guests should be well supplied
with cuspidors in which there should be at all times a germi-
cidal fluid. This fluid should be changed once a day and the
cuspidors should be thoroughly scalded with boiling water.
In conspicuous places throughout the house and especially in
the rooms assigned to consumptive guests there should be
notices requesting guests never to eject sputa into any place
other than the cuspidor, and suggesting that a handkerchief
should never under any circumstances be used for the recep-
tion of such sputa where a spittoon is at hand. When out
upon the lawn or in any place where a cuspidor is not of con-
venient access, the sputa should be ejected into paper handker-
chiefs, these to be placed, upon returning to the room, in a re-
ceptacle furnished for that purpose :such handkerchiefs should
not be thrown into the ash bin but burned by the chamber-
maid. After a room has been occupied by a consumptive, it
should be carefully cleansed before another guest is assigned.
Where the rules already laid down have been observed, wiping
the walls, floor and furniture with a sponge dampened with a
germicide solution, whisking the rugs with the same solution
and sending the sheets, blankets and pillow cases and counter-
panes to the laundry, will be all that is necessary. Where,
however, no care has been observed and the consumptive has
been careless about spitting on the floor or into linen, silk or
muslin handkerchiefs, or where the bed clothing has been
visibly soiled with broken down tubercular tissue, it will be
necessary to carefully rub the walls with fresh bread and then
wash them with a strong germicide solution, to wash the floors
and furniture with the same strong solution, to have all the
bed linen and blankets thoroughly boiled and to have the rugs
and other articles which can neither be subjected to strong
germicide solution nor boiled, sent to a renovating place and
steamed."
Sensational Statements Regarding Consumption. — In a paper pre-
pared for the recent meeting of the American Climatologic
Association and published in the Boston Medical and Surgi-
cal Journal (June 25), Dr. V. Y. Bowdich earnestly protests
against the sweeping statements made as to the contagiousness
of consumption and the barbarism and brutality which the
laity are thus led into showing in their treatment of the con-
sumptive. He considers the physician who asserts that con-
sumption is "as contagious as smallpox" and that "hospitals
for consumptives are a source of danger to the whole sur-
rounding community" is making perfectly unwarrantable
statements which can not be borne out by facts; and cites
observations made in the communities near two of the largest
sanitaria for consumptives in the world, namely, Gorbersdorf
in Silesia and Falkenstein near Frankfort, to prove that con-
sumption has lessened in amount in the entire population since
the introduction of the sanitaria there, largely due to the strict
hygienic rules which are used at the sanitaria for the disposi-
tion of sputa and which are taught to the inhabitants in the
surrounding villages. He admits that it is, doubtless, per-
fectly true on the other hand, that in various "open resorts"
for consumptives where strict methods for the disinfection of
the hotels and boarding houses are not enforced the death rate
among the inmates from consumption has increased greatly,
the most striking cases being those of Men tone and Nice where
according to statistics consumption has greatly increased
since the places have become such a common resort for phthis-
ical patients, many of whom through carelessness or ignorance
become sources of contagion to others. Referring to the exper-
iments of Delepin and Ransome (Journal of the American
Medical Association, Vol. xxiv, page 450. British Medical
Journal, Feb. 16, 1895) with reference to the germicidal
effects of various agents upon the bacilli of tuberculosis,
exposure to the direct rays of the sun for a comparatively
short time prove to be the the most effective. As a result of
these experiments Dr. Bowdich thinks "it is certainly a legiti-
mate doubt to come to our minds as to how far we need fear
infection from sputa which are expectorated onto the open
ground exposed to the full rays of the sunlight. Not that I
would relax one iota in the restriction of the disgusting habit
(to say the least) of spitting publicly anywhere ; it is only a
question as to its danger under the condition of exposure to the
sun's rays. Thus we have scientific facts to help us in trying to
show the laity that the consumptive need not be treated like a
leper, or as one affected with the plague, but that moderate
measures will prevent his being a source of danger to those
about him."
The Bubonic Plague at Hong-Kong, in 1894.— Dr. J. G. Adamiin
the Montreal Medical Journal for June, gives an admirable
digest of the five principal essays of Japanese, French and
English writers that thus far have appeared on the above sub-
ject. The closing paragraphs of Dr. Adami's paper are the
following : The Hong Kong epidemic of 1894 has gained for
itself a place in medical history, from the fact that during its
course the bacillus of the plague was discovered first by Kita-
sato, and independently, after a brief interval by Yersin, while
Lowson and Aoyama have given us the fullest studies yet made
of the clinical features and the pathologic anatomy of the dis-
ease. We have little or no accurate information concerning
the plague in China in early times. It is true that medieval
writers ascribed the origin of the terrible Black Death (hemor-
rhagic plague) to China, but apparently without full cause. It
has, however, been known to be endemic in one of the south-
ern provinces, Yunnan, for more than twenty years, as also at
Pakhoi, on the southern coast. Early in 1894 it appeared at
Canton, causing the death of more than 60,000 individuals in
the course of a few weeks. Hong Kong, situated as it is at the
mouth of the Canton river, and having a population, in the
main Chinese (about 150,000 out of a total of 163,000) became
infected, most probably from Canton, and, at the latest, early
in May. In June the disease was at its height, and it contin-
ued through the next two months. After August, cases were
few and far between. Altogether, according to Lowson's sta-
tistics, which confessedly do not include all the Chinese cases,
more than 2,600 persons were admitted to the hospitals, of
whom 2,485 died, an appalling mortality of more than 93 per
cent. The Chinese were in the main affected. The mortality
among the Japanese (10 cases) was 60 per cent. Among Euro-
peans (11 cases) 18.2 per cent. How many Chinese died unre-
corded in their quarter of the town will never be known.
Aoyama himself suffered severely from the disease and Lowson
gives a full report of his case :
"The disease possessed all the typical characters ; numerous
dead rats and mice encumbered the infected quarters. After
an incubation period of three to nine days, the infected indi-
vidual became the prey of a sudden intense fever, accompanied
108
NECROLOGY.
[July 11,
often by delirium, but without noticeable rigor. From the first
day of the fever a bubo was noticeable, at first in general soli-
tary, later other glands, situated more centrally, became
enlarged. In some of the severest cases death occurred before the
bubo had time to develop ; in such there were frequent subcu-
taneous and submucous hemorrhages, recalling the Black Death.
In 75 per cent, of the cases (Yersin) the bubo was of the nature of
an 'emerod in the secret parts' being situated in the inguinal
region, more correctly in the femoral chain ; the axillary glands
were the next most frequent seat of primary enlargement. The
swollen glands attained the size of a hen's egg. Aoyama points
•out that all the Japanese patients had axillary buboes, and from
this fact, and from the centripetal extension of the glandular
enlargement, he concludes that infection is most often through
wounds of the extremities, the Chinese going barefoot, the
Japanese being booted. Lowson, however, points out that all
the men of the Shropshire regiment infected had femoral or
inguinal buboes, and yet they were well booted — a fact which
throws some doubt upon the theory of the Japanese professor.
.Everything, however, points to the disease being of the nature
■of a soil infection rather than that conveyed by water, and
Aoyama' s theory fits in best with the fact that in most cases
the disease first manifests itself in a solitary peripheral gland.
Inasmuch as necropsies in some cases demonstrated the
primary affection of abdominal glands, the possibility of intes-
tinal infection must also be acknowledged. Death occurred
at the end of forty-eight hours, frequently sooner. If the dis-
ease continued for five or six days the prognosis was hopeful.
In such cases the tense buboes became softened and suppura-
tive and relief was obtained by operative discharge of the pus.
At autopsies performed upon those dying from this disease,
the swollen glands were found to swarm with minute bacilli.
These bacilli resemble those found in the hemorrhagic septice-
mias of the lower animals, the bacilli of chicken cholera for
example, staining more deeply at the poles, so that when not
deeply stained they appear to be diplococci. They decolorize
by Gram's method and grow easily in various media. In
preparations made from the tissues they frequently appear as
though surrounded by a capsule ; grown in broth they often
form short chains, and, indeed, the appearance of broth cul-
tures resemble those of the streptococcus pyogenes. Mice,
rabbits and guinea pigs inoculated either with material from
the infected corpse or with pure cultures die in from one to
four days. Pigeons are unaffected. The bacilli are to be
found in the blood and spleen, though not in such numbers as
in the buboes. Preserved in dried films at 28 to 30 degrees C.
they die in four days or so. The action of direct sunlight
killed them in a few hours. In mice and other small animals
the main features discovered at the necropsy are the develop-
ment of a reddened edema at the point of inoculation, swelling
of the nearest lymph gland or glands with profusion of bacilli,
congestion of the kidneys and supra-renals and great swelling
of the spleen. In man, as shown by Lowson and Aoyama, the
chief anatomic changes are very similar, namely, enlargement
of one or more lymphatic glands, due to multiplication of
lymphoid cells, surrounding reddened gelatinous edema, some
enlargement with softening of the spleen, increase in the num-
ber of white corpuscles in the blood. The liver and kidneys
are congested with parenchymatous degeneration. There can
therefore be no doubt that the causative agent of the bubonic
plague has been discovered. In general the descriptions given
of the plague contain no reference to infection of cattle, but
in Yunnan the destruction of these animals has been a dis-
tinctive feature, and Yersin determined the presence of the bacil-
lus in cattle in a most virulent form. Lowson failed to obtain
more than local results upon inoculating cattle and pigs, and
suggests that the cattle suffer from a disease common in Yun-
nan and due to a similar microbe, namely, the Rinderpest."
Health Reports. — The following health reports have been
received in the office of the Supervising Surgeon-General
Marine-Hospital Service :
8MALLPOX — UNITED STATES.
Florida : Key West, July 1 to 5, 7 cases.
Louisiana : New Orleans, June 20 to 27, 5 cases, 4 deaths.
SMALLPOX — FOREIGN.
Athens, Greece, January 1 to May 31, 19 cases, 5 deaths.
Bombay, India, May 26 to June 2, 16 deaths.
Calcutta, India, May 16 to 23, 4 deaths.
Callao, Peru, May 31 to June 7, 7 deaths.
Genoa, Italy, June 13 to 20, 2 cases.
Guayaquil, Ecuador, June 5 to 12, 1 death.
Madrid, Spain, June 9 to 16, 10 deaths.
Montevidio, Uruguay, May 23 to 30, 2 cases.
Odessa, Russia, June 6 to 13, 5 cases, 1 death.
Osaka and Hiogo, Japan, May 23 to 30, 32 cases, 16 deaths.
Prague, Bohemia, June 6 to 13, 4 cases.
Rio de Janeiro, Brazil, May 30 to June 6, 9 cases, 4 deaths.
St. Petersburg, Russia, June 6 to 13, 18 cases, 6 deaths.
CHOLEEA.
Osaka and Hiogo, Japan, May 23 to 30, 1 case.
Bombay, India, May 26 to June 2, 12 deaths.
Calcutta, India, May 16 to 23, 97 deaths.
YELLOW FEVER.
Cuba : Sagua la Grande, June 13 to 20, 60 cases, 4 deaths ;
Cardenas, June 13 to 20, 4 cases, 2 deaths.
Brazil : Rio de Janeiro, May 30 to June 6, 12 deaths.
BOOK NOTICES.
Transactions of the Southern Surgical and Gynecological Association,
Volume VIII, Eighth Session, held at Washington, D. O,
Nov. 12, 13 and 14, 1895. 8vo, pp. 303. Published by the
Association. 1896.
Dr. John A. Wyeth, in his paper, "Dr. J. Marion Sims and
his Work," says of that distinguished surgeon: "It is safe
to say that Marion Sims attained the highest position ever
achieved in the history of our profession. He stood alone in
this ; his reputation as a surgeon was so world-wide that in
any capital, in any country within the domain of civilization,
he could command at any time a lucrative practice. Assur-
edly there does not exist in the history of surgery another such
distinction. In New York, London, Paris, Brussels, Berlin,
Vienna, Rome, Madrid, Lisbon and St. Petersburg he found
himself everywhere sought after, not only by the patients he
could benefit, but by the leading members of his profession,
who were anxious to pay tribute to his wonderful genius. Born
amid the most humble conditions in a backwoods county of
South Carolina, he died the foremost surgeon of his country
and the world."
NECROLOGY.
Thomas L. Hough, M.D., the senior member of the medical
faculty of Elizabeth, N. J., died June 12, aged 68 years. He
was graduated from Jefferson Medical College, class of 1856.
He was one of the founders of the Union County Medical
Society, and a member of a variety of charitable organizations,
and has been in the forefront of most of the public-spirited
movements of the enterprising city during the past forty years.
His funeral was very largely attended by the prominent citi-
zens and officials.
J. L. Selman, M.D. (University of Louisville Medical
Department, Louisville, Ky., 1882), at Chattanooga, Tenn.,
June 23, aged 36 years. Dr. Selman was city physician of
Chattanooga ' at the time of his death. The Chattanooga
Medical Society held a meeting and passed appropriate reso-
lutions.
Joseph T. Scott, M.D. (Missouri Medical College, St.
Louis, Mo., 1856), at New Orleans, La., June 25, aged 63 years.
During the civil war Dr. Scott served as surgeon of the First
Missouri Infantry ; surgeon in Guibard's Battery of St. Louis,
and was chief surgeon on the staff of 'General Frost of St.
Louis, also surgeon in Van Dorn's Cavalry regiment. At the
time of surrender, in May, 1865, at Shreveport, he was surgeon
in General Dick Taylor's Louisiana regiment. Dr. Scott was
a member of the Howard Association, and rendered valuable
help during the terrible epidemic of yellow fever in 1878. He
was some years ago, a member of the board of directors of the
Charity hospital.
George C. Shattuck Choate, M.D. (Harvard University
Medical School, Boston, Mass., 1849), at Pleasantville, N. Y.,
June 26, aged 70 years. He was for ten years superintendent
of the Massachusetts State asylum for the insane at Taunton,
Mass. Thirty-six years ago he established his private asylum
L896 ]
SOCIETY NEWS.
109
near Pleasantville. It was in this sanitarium that Horace
Greeley died.
\ nil u (i. Ki nny, M.D. (Albany Medical College, Albany,
V v., 1877), of Watervliet, N. Y., at the Troy Hospital,
June 26,
T. li. Wiley, M.D. (Rush Medical College, Chicago, 111.,
1874), at Gibson City, 111., June 30, aged 52 years.
ASSOCIATION NEWS.
Headquarters of the American Medical Association. -According
10 a resolution adopted at the Atlanta meeting of the Ameri-
can Mkimcai. Association, the members are to determine by
tote where the permanent home of the Association shall be
located. The ballots have now been distributed to the mem-
bers, who have until July 31 to cant their votes. As soon as
the count is completed the result will be announced in the
Journal. Members may vote for any place they desire, but it
is probable that the choice will be practically limited to either
Washington or Chicago. Certainly the former would seem to
be the appropriate home for a national organization. The
other representative association of the practitioners of America,
the Congress of American Physicians and Surgeons, has always
held its triennial reunions in Washington, and this society
would be wise to follow suit. — Medical Record.
SOCIETY NEWS.
The Fourth Annual Russian National Medical Congress was held
this year at Kiew and was attended by over a thousand physi-
cians, who discussed various hygienic and social questions as
well as the more strictly scientific subjects. The city was
en f?te in honor of the convention, and the general enthusiasm
speaks well for the prospects of the International Congress to
be held at Moscow next year.
American Public Health Association. The twenty-fourth annual
meeting of this association will be held in Buffalo, N. Y.., Sep-
tember 15 to 18. The following topics will be taken up for con-
sideration : "Pollution of Water," "Disposal of Garbage and
Refuse." "Animal Diseases and Animal Pood," "Nomenclature
of Diseases and Forms of Statistics," "Protective Inoculations
in Infectious Diseases," "National Health Legislation,"
"Cause and Prevention of Diphtheria," "Causes and Preven-
tion of Infant Mortality," "Car Sanitation," "Steamship and
Steamboat Sanitation," "Transportation and Disposal of the
Dead," "Use of Alcoholic Drinks from a Sanitary Standpoint,"
"Centennial of Vaccination," "Relation of Forestry to Public
Health," "Transportation of Diseased Tissues by Mail,"
"River Conservancy Boards of Health," "Prevention of the
Spread of Yellow Fever." The President of the association is
Dr. Eduardo Liceaga, City of Mexico, Mexico ; First Vice-
President, Lieut. -Col. Alfred A. WToodhull of the Medical
Department of the United States army, Denver, Colo. ; Second
Vice-President, Dr. Henry Sewall, Denver, Colo. ; Secretary,
Dr. Irving A Watson, Concord, N. H. ; Treasurer, Dr. Henry
D. Holton, Brattleboro, Vt.
Congress of Dermatology. The third International Congress
of Dermatology will meet in London, from August i to 8, of
this year. The general program has been published in a recent
number of the Journal. There will be a museum of drawings,
casts, models, naked eye preparations, microscopic specimens,
works and atlases pertaining to diseases of the skin. There
will also be an exhibition of clinical cases and demonstrations
of the same at 9 a. m. and 2 p. m. of August 5, 6 and 7, and at
9 a. m. of August 8. Anyone having anything to contribute
to this department, will please address Dr. Jas. Galloway, 21
Queen Anne Street, Cavendish Square, W. There will be an
exhibition of cultures and microscopic preparations of organ-
isms connected with the skin and its diseases. Any communi-
cations in regard to this department should be addressed to
H. G.Plimmer, Esq., Wunderbau, Sydenham, London. The
social side of the Congress will be : 1. An informal reception
at the International Hall, Piccadilly Circus, on Augusts, from
9 to 12 p. m. 2. A reception by the Lord Mayor and Lady
Mayoress at the Mansion House, on August 5, from 9 to 11 p.
m. 3. A Dinner to the Foreign Members at the Hotel Cecil,
on August 7. It is advised that foreigners should arrive in
London not later than Sunday, August 2, as Monday the 3d
inst. is a public holiday. Information in regard to hotels will
be furnished on application to George Pernet, Esq., 77 Upper
Gloucester Place, London, N. W.
George Thomas Jackson, M.D.,
Foreign Secretary for the U. S.
International Periodical Congress of Gynecology and Obstetrics. —
The date of the opening of the Second International Con-
gress of Gynecology and Obstetrics at Geneva, has been fixed
for Aug. 31. The Congress will continue one week, closing
Saturday, Sept. 5, 1896. The success of this scientific reunion
seems assured. The eminence of the Honorary Presidents,
the scientific prominence of the referees and the number of
members who have joined, guarantees its success. The ses-
sions of the Congress will take place in the Grand Aula of the
University. The first general session, that of the morning of
the first of September will be honored by the presence of the
President of the Swiss Confederation, as well as the Chief of
the Department of Public Instruction of the Canton of Geneva
who will inaugurate the Congress by addresses.' Morning
sessions will continue from 9 a.m. until noon. Afternoon ses-
sions from 3 to 6. The former will be devoted to the discus-
sion of official questions, the latter to other communications.
In order to make the first most interesting, the Committee of
Organization will endeavor to publish and distribute among
the members a synopsis or the "Conclusions" of the Referees.
Manuscripts must be delivered to the Secretary at the end of
the session at which they are read, and members taking part
in the discussion must also present to the Secretary a synopsis
of their remarks. An International Exposition of gynecologic
and obstetric instruments will be opened during the Congress,
and all objects entered for this Exposition should arrive in
Geneva prior to August 10, addressed, University, Rue de
Candolle, Geneva. Members are advised also that as the Con-
gress coincides with the National Exposition of Switzerland, it
will be prudent to engage rooms in advance. For that purpose
you may address hereafter : "La Commission officielle des loge-
ments ayant son bureau a la gare de Cornavin." Members of
the Congress arriving in Geneva without being inscribed can
still obtain a membership card, Sunday morning, August 30,
and thereafter in the Office of the Treasurer of the University.
Ladies' cards will be issued admitting to the receptions and
festivities.
program.
Monday, 3 p.m. — Reunion of the Permanent Committee and
of the founders of the International Congress. At 9 p.m. —
Reception at the Palace Eynard.
Tuesday. — Opening of the Congress by President Reverdin.
Address by President Lachenal. Addresses by Mons. Richard,
Chief of the Department of Public Instruction and Official
Delegates. 3 p.m.- Discussion of the First Official Question,
viz: "Treatment of Pelvic Suppurations." Referees: Sanger,
Kelly, Bouilly. Discussion by A. Martin, Richelot, Lawson
Tait, Jacobs, Delettretz, Henrotin, Hartman, Rouffart, Tour-
nay, Henrotay, Desguins, Guilloud, Caromilas.
Wednesday. — Discussion of the Second and Third Official
Questions: "Surgical Treatment of the Retro-deviations."
Referees : Kustner, Polk and Pozzi. Discussion by A. Martin,
Bouilly, Lawson Tait, Jacobs, Edebohls, Gill Wylie, Henry
Byford (Chicago), Delettretz, Stopfer, Paul Pettit. "Most
110
MISCELLANY.
[July 11.
Successful Method of Closing the Abdomen." Referees:
Granville Bantock, La Torre. Discussion by Messrs. Martin,
Lawson Tait, Richelot, Jacobs, Edebohls, Gill Wylie, Byford,
Delettretz. 3 p.m. Miscellaneous papers.
Thursday. This day will be entirely devoted to promenade
on the Lake at Vevay and excursions to Montreux-Chillon.
Special program will be distributed indicating the details of
this excursion.
Friday. — Discussion of the Fourth Official Question : "Rela-
tive Frequency and Most Common Forms of Pelvic Contrac-
tions in Different Races, Groups of Countries and Continents."
Referees ; Fancourt Barnes, Dohrn, Fochier, Kufferath, Lusk,
Rein, Pawlick, Pestalozza, Treub. Discussion to be opened
by Berry Hart. 3 p.m. — Miscellaneous papers.
Saturday. — Discussion of the Fifth Official Question :
"Treatment of Eclampsia." Referees: Charles, Charpentier,
Halbertsma, Veit, Mangiagalli, Parvin, Byers. Leaders in
discussion: Tarnier, More Madden, Lindfors, Godson. 3 p.m.
— Miscellaneous Papers. 5 p.m. — Closing Business Session.
8 p.m. — Final Subscription Banquet.
Sunday. — Various Excursions, International Regattas, Fire-
works, etc. President, Auguste Reverdin ; Secretaries, Gyne
cology, Dr. C. Betrix ; obstetrics, Dr. Cordes.
The General Secretaries are: Dr. Betrix, for Gynecology:
Dr. Cordes, for obstetrics ; Treasurer of the Committee, Dr.
Bourcart. Secretary General for North America (through
whom all correspondence and business will be directed) : Dr.
Fernand Henrotin, 353 LaSalle Avenue, Chicago, 111.
The Cleveland Medical Society held its last meeting for the
summer and adjourned until September 11. Dr. J. F. Hobson
read a paper on "A Report of a Case of Pott's Disease of the
Spine." Dr. W. E. Wirt read a Paper on "An Original
Method of Using Dry Heat of High Temperature in the Treat-
ment of Chronic Joint Affections."
MISCELLANY.
Appointment. — Mayor Swift has appointed Dr. John B. Ham-
ilton a member of the Board of the Public Library of the city
of Chicago.
Delegate. —Dr. George Ben. Johnston, of Richmond, Va., has
been appointed one of the eight delegates on behalf of the
government of the United States to attend the session of the
International Periodical Congress of Gynecology and Obstet-
rics, to be held at Geneva, Switzerland, September, 1896.
Antiquity of the Truss. Poncet has an interesting historic
sketch of the evolution of hernial bandages in Mid. Moderne,
No. 11, with a description of a recently discovered ancient
Phenician statuette of a god, at least 3,000 years old, which
represents " unmistakably" several ruptures on the abdomen,
with a double hernial bandage resembling those now in use. —
Centralblatt f. Chirurgie, April 11.
Cross of the Iron Crown. A cablegram has just been received
from Buda-Pest, Hungary, announcing that Mr. Andor Sax-
lehner, of the firm of Andreas Saxlehner, of that city, proprie-
tor of the Hunyadi Janos natural aperient water, has been
decorated by Francis Joseph I., Emperor of Austria and King
of Hungary, with the Cross of the Iron Crown, Order III, on
the occasion of the Hungarian Millenial Celebration now being
held in Buda-Pest.
Medical College Appointments.- The following appointments in
the faculty of the Albany (N. Y. ) Medical College are noticed
in the catalogue for 1896 97 : Herman Bendell, clinical profes
sor of otology : Andrew McFarlane, professor of physical diag
nosis and microscopy ; John B. Henessey, lecturer on materia
medica ; George Newman, lecturer on symptomatology ; Clem-
ent Theisen, instructor in throat and nose ; James M. Moore,
instructor in physical diagnosis and clinical microscopy ; James
Thomas McKenny, of Troy, instructor in physiology ; James M.
Mosher, instructor in neurology. The Bender laboratory will
be in charge of George Blunner, late assistant in pathology and
bacteriology at the Johns Hopkins University.
Practicing without Diploma.— Suit for practicing medicine with-
out a diploma and without registration was brought against
Edmund Duff of Harrisburg, Pa., by Col. Oliver B. Simmons,
Chairman of the Sanitary Committee, and the defendant
waived a hearing for trial at court. The action was brought
before Mayor Patterson, after Colonel Simmons and the Mayor
had heard a report from Sanitary Officer Block, who had inves-
tigated the matter and found that Duff was practicing without
compliance with the law. The failure to report a case of
diphtheria, treatment of which caused the trouble, was also
brought out, but Duff asserted that the disease had not been
diagnosed until Friday, when the patient died, and the Mayor
dropped the case, there not being enough evidence to hold the
defendant. Duff made no defense to the charge of practicing
without registration and was held under $300 bail.
A New Biologic Laboratory.— The corner stones of the new Hull
biologic buildings of the University of Chicago were laid July
3. The laboratories will consist of four three-story structures,
of Gothic design, and are the gift of Miss Helen Culver, in
memory of her uncle, C. J. Hull. The gift amounted to
$1,000,000, of which $300,000 was to be used for the buildings
and the remainder to serve as an endowment fund. Since then
Miss Culver has given $25,000 more for the buildings, which
makes the cost of the structures $325,000. The address of the
day was delivered by Prof. George Lincoln Goodale, LL.D., of
Harvard. He spoke of the development of the bacteriologic
laboratory, its aims and requirements. At the conclusion of
the address President Harper spoke of the prospects of this
department and said that the erection of these buildings
marked the beginning of the long-looked for medical school.
The assemblage then moved in procession to the site of the
new buildings, where the corner stones were laid with appro-
priate addresses.
Higher Preliminary Education. A congress of Missouri physi-
cians met at St. Louis, June 27, and adopted resolutions look-
ing to the higher preliminary education of medical students.
The movement was started by the University Medical College
of Kansas City, whose president, Dr. J. M. Allen, called a
meeting of the fifteen medical schools of the State. Twelve
of these schools were represented at the gathering. Dr. J. M.
Allen, of Liberty, Mo., presided, and Dr. A. E. Mink, of St.
Louis, was secretary. Among others present were: Dr. A. L.
Burger, secretary, and Dr. J. P. Jackson, dean, of the Uni-
versity Medical College, Kansas City ; Dr. Mark Edgerton,
ex-dean of the Kansas City Homeopathic Medical College ;
Dr. Batey, of the University College of Kansas City ; Dr. F. J.
Lutz, Dr. L. C. McElwee, Dr. Bond, Dr. Steele, Dr. Loeb and
Dr. Hypes.
Varices of the Leg. — Dr. Alexander Hugh Ferguson (< 'hicago
Medical Recorder, June, 1896), describes his method of opera-
tion. He first ties the saphenous vein in two places near the
femoral above the abnormal condition and a section of the vein
is removed. Then a semilunar incision is made through
healthy skin and extended as far down as is necessary to go
until all the varices are partly surrounded, the incision is then
deepened to the fascia lata. In the line of this incision all the
venous supply is cut off. When the incision is completed
down to the deep fascia the" entire flap is raised and dissected
up. The veins, normal and pathologic, are raised with the
flap and the varices and branches dissected from its under
surface. In raising the flap the venous communications with
the deep veins are severed and ligated. This is a modification
of Schede's operation.
IWW.]
MISCELLANY.
Ill
Hayseed Sprouted in the Ear. Dr. Macnaughton Jones reports
where the i >;i t i»-n t had been suffering from noises in the
car for some years, ami Had other evidences of middle ear
deafness, lie sought advice for the deafness, being quite uncon-
scious of the presence of any foreign body. On examining the
meatus, what appeared to be a pink sprouting mass of fungus
was seen with the transmitted light. The appearance was
most pOTsling, and it was not until the sprouting hayseed was
withdrawn that its nature was discovered. It wasouite tirmly
attached to the wall of the meatus, being removed clean with
the lever forceps. The patient then remembered having, over
two years previously, at harvest time, suddenly felt as if some
thing had entered his ear, and the tinnitus began. Jour, of
Laryngology, Rhinology and Otology, .lune, 1806.
Oxygenized Chloroform. Dr. Charles S. Elder (Col. Med. .lour.
June. 1886) says of the new anesthetic: Few patients are
gotten Completely under the anesthetic by this process. They
seldom have perfect relaxation of muscles and loss of corneal
reflex To this tirst is to be attributed the rapid recoveries
unattended by nausea and vomiting. It is not true that
patients keep rosy lips and cheeks during the anesthesia any
more than they do with chloroform, nor do they recover any
better or quicker, provided the narcoses be of equal depth and
duration. Chloroform as ordinarily given is a more powerful
anesthetic than when given by the new process, therefore the
anesthetic is apt to l>c more profound unless it is administered
with more care. But to argue that oxygenized chloroform is
safer for this reason is to insist that it is better because it is
less efficient.
The - Unsurgeonlike Horrors" of Hunter's Time.— The Clinical
Sketches, in treating of the days before chloroform, reminds of
the stern courage that then was demanded of surgeons. It
remarks that in studying the histories of surgeons of a bygone
age. we are frequently reminded of the horrors of their art
before the days of chloroform. "It is not surprising to read
that Abernethy 'had a most unsurgeonlike horror' of opera
tions. and that both Cheselden and Hunter entertained similar
feelings. Of Sir Astley Cooper's uncle William it is recorded
that when about to amputate the leg of a man at the hospital,
the patient, seeing the instruments being got ready, suddenly
jumped off the table and hobbled away, whereat the surgeon
expressed himself as greatly relieved : ' By Gad,' said he, 'I
am glad he has gone!' "
Women in Medicine.— Jacobi, of New York, has a bright letter
in the Deutsche Med. Woch. for June 18. replying to a request
for his opinion in regard to women in the medical profession.
He evidently thinks they have come to stay, a phase of the
struggle for existence governed by economic laws, unaffected
by individual or social preferences or prejudices. He expresses
.his regret that there are too many female medical colleges in
this country, some of them which are not up to the standard
•of the rest, and approves of co-education as stimulating and
■elevating the male students. He states his impression that the
incomes of female physicians average higher than those of the
men, and speaks with the greatest respect of those he knows,
ridiculing the idea that because a woman is not so large nor so
strong as a man, she should therefore be debarred from the
medical profession, any more than an undersized man, "as if
any of us were Apollo, Hercules and Methusaleh combined."
Heroism of the Daughter of Dr. Herman Knapp. -Dr. Knapp, the
well-known ophthalmologist of New York city, met with a nar-
row escape from death by drowning on June 20. He would, with-
out doubt, have lost his life but for the presence of mind and
heroic conduct of his daughter Ida, a young lady of 20, who
was with him at his summer cottage at Monmouth Beach, New
Jersey. As the day was unusually warm he decided to take
his first ocean bath of the season, and his daughter watched
him from the shore. Dr. Knapp is an expert swimmer, and
went out some distance in the water, but as he was on his way
back she noticed that he showed signs of distress. Immedi-
ately she secured a life preserver which was lying near by
on the sand, and having tied a line to it, plunged with it,
dressed as she was in house attire, into the sea. Wading in
the water up to her neck she just managed to throw the life-
preserver to a point where her father, who by this time had
sunk twice, was able to grasp it. She then struggled bravely
for the shore, carrying the line with her, and both she and her
father were dragged to land in an extremely exhausted con-
dition by some fishermen who had come to the rescue from a
distance.
Not Liable for Removal of Injured Employe. — One of the grounds
on which recovery of damages was sought to be had in the case
of York v. Chicago, Milwaukee and St. Paul Railway Company,
which was before the supreme court of Iowa May 25, 1896, was
because the company's surgeon, who was employed and paid
by it, to treat its injured employes, as an act of charity or
humanity, wrongfully and negligently moved an injured
employe from another doctor's office to a hotel, which act, it
was alleged, contributed to produce his death. It was not
contended that this surgeon was not a skillful one, or that the
company did not exercise due care in employing him. Under
these circumstances, the supreme court of Iowa holds the
company not liable. It says that it understands the rule to be
well settled by a large number of cases that, under such cir-
cumstances, the defendant is not liable for acts of negligence of
the physician who is employed to treat gratuitously its injured
employes.
Cancer of the Pregnant Uterus. Dr. George H. Noble gives
details of 166 cases occurring since 1866, and concludes:
"A summary shows that vaginal hysterectomy should be safe
in the early months of pregnancy and the puerperal state, when
there is a reasonable hope for the mother. The abdominal hys-
terectomy should be done under the above conditions when the
uterus is too large to be rapidly and safely removed through
the vagina. That at or near the end of pregnancy Ccesarean
section (conservative) should be resorted to when the child's
interest is to be considered. That Cesarean section with
Freund's operation is permissible when the disease is confined
to the uterus and the child viable. That in doubtful cases
cutting of the cervix and rapid delivery may be judicious when
the incision can be made in unulcerated or non infiltrated
tissue. That as there are four chances to one against the life
of the fetus, and as an equal or greater number of mothers
may be ultimately cured in the early stages of the disease, the
safety of the fetus should not be allowed to hazard the life of
the mother. And that, upon the other hand, the futile efforts
directed to the interest of the mother when her case is hopeless
should not jeopardize the safety of the fetus in the latter
months of pregnancy."— Amer. Join: of Obstetrics and Dis-
eases of Women and Children, June, 1896.
Study of the Thermodynamics of the Muscles.— Storring pub-
lishes in the Arch. f. Phys., 1895, page 499, the results of his
thermoelectric measurements of the generation of warmth in
the muscles during isotonic and isometric contractions, with
stimulus of varying strength and frequency, prefacing his
report with a description of the Fick-Gad theory in regard to
the muscles. He states that the so-called "negative variations
in warmth" are only produced by defective manipulation of
the instrument, thus agreeing with Heidenhain in opposition
to Danilewsky. The results of his investigations are that the
amount of warmth generated increases proportionately to the
amount of tension during isometric contractions with increas-
ing stimulus. During isotonic contractions it is more rapid
at first, but with strong stimulus it is in proportion to the
"height of lift." (Nawalichin and Danilewsky.) The mus-
cles were also measured after having been slightly fatigued by
112
MISCELLANY.
[July 11,
ten to fifteen contractions, this condition being the same as
when the first increased height of lift had returned to its
original condition. Heidenhain had stated that the amount of
warmth generated diminished more rapidly than the height of
lift in fatigued muscles, but these investigations resulted dif-
ferently, increased warmth being generated in the fatigued
condition. The article concludes with a discussion of the
possibility of applying these results in confirmation of theFick-
Gad theory, as an explanation of the processes that occur
during contraction. — Centralb. f. Phys., May 2.
Therapeutic Value of Scopolamin It is the best of our mydri-
atics. It acts promptly and efficiently, dilating the pupil ad
maximum within fifteen minutes and paralyzing the accommo-
dation within one hour. In almost every case the patient
regains the ability to read within seventy-two hours. In its
effect upon the accommodation, scopolamin stands midway
between homatropin and atropin. The cyclopegic effect of
homatropin lasts about twenty-four hours ; often it fails to
paralyze the accommodation. Atropin will paralyze the
accommodation with certainty, and the effect lasts ten days,
often two weeks. Repeated instillations of homatropin or
atropin are necessary. In the case of scopolamin one instilla-
tion of one drop of a one-fifth per cent, solution will do the
work. Less conjunctival irritation follows scopolamin than
the other drugs mentioned. As a mydriatic for refraction
work it is facile princeps. It is even more useful in iritis ;
one drop twice a day will often dilate the pupil when
repeated applications of atropin fail. Do not use this drug
lavishly, for it will produce toxic symptoms if applied care-
lessly. In the strength of one-fifth of 1 per cent, use only
one small drop. In children and in delicate adults a weaker
solution, one-tenth of 1 percent, will be sufficient.— Dr. James
Moores Balls in the Tri-State Monthly for June, 1896.
Rupture of Quadriceps Extensor.— Dr. J B. Walker says : In
comparing the averages of 255 cases of rupture of the quadri-
ceps extensor muscle and its tendon above and below the
patella, we find that under the mechanical mode 72.5 percent,
recovered completely, 12.5 per cent, in three months and 32
per cent, within six months. Whereas under the operative
method 86 per cent, recovered completely ; 50 per cent, within
three months, and 100 per cent, within six months. In recent
cases where there is not much effusion and the joint is
apparently not opened, where the separated ends can be approx-
imated and detained by suitably adjusted pads, the mechanical
treatment may be carefully considered. In the hands of the
intelligent general practitioner this method may be expected
to bring about a complete recovery in the larger number of
cases. From nine to twelve months will be required to rees-
tablish fully the normal functions. The skilled aseptic sur-
geon who primarily resorts to the operative method in suitable
cases (but the age and vitality of each patient must be most
carefully considered) may quite reasonably hope to obtain a
better result in a larger number of cases and save his patient
three to six months' time. Catgut, kangaroo tendon or silk-
worm gut should be used and when there is much effusion
drainage should also be employed.— Am. Jour, of Medical
Sciences, June, 1896.
Authority to Employ Physicians for Indians.— The provision in
Section 5 of the Appropriation act of Congress approved
March 3, 1875, to the effect that the number and kind of
employes at each agency shall be prescribed by the Secretary
of the Interior, the United State circuit court of appeals holds,
in the case of United States v. Patrick, decided March 30, 1896,
furnishes ample authority for the Secretary of the Interior
to employ physicians to attend Indians. It also holds that by
approving the vouchers and directing the payment of the bills
for a term of years of a physician employed by an Indian agent
from time to time during those years to treat the Indians in
need of medical services, the Secretary of the Interior suffi-
ciently prescribed that one of the employes at the agency in
question should be a physician, to be called by the agent from
time to time, to render such medical services as the Indians-
required. And the court further holds that the Secretary of
the Interior having authority to employ physicians, for the
United States, at an Indian agency, and his subordinate, the
Indian agent at such agency, having employed them, and the
Secretary having approved their bills, and directed the agent
to pay them out of the public funds, the United States and the
Secretary were bound by his acts, both because they thus
ratified them and because, by their action, they induced him
to expend money for this purpose which he would not other-
wise have disbursed.
Superintendent's Power to Employ Physician and Nurse.— The
physician called by a man injured while in the employ of
an electric light and power company testified that he called on
the superintendent or general manager of such company and
told him that he would have to have a nurse, and that the
official told him to employ one, and that they would see to the
physician's bill and the nurse's bill. This conversation the
official denied. The trial judge instructed the jury, when an
action was brought by the nurse to recover from the company
for his services, that so far as the question of authority was
concerned, he could not say that there was no evidence from
which they might infer that the superintendent or manager
referred to was not authorized to make a contract, but thought
that they might draw the inference that he was authorized to
make such contract as the plaintiff contended was made.
This the Supreme Court of Michigan decided, June 2, 1896,
Hodges v. Detroit Electric Light and Power Company, was
correct. The court now clearly favors the view that it is
within the general scope of the employment of such an official
to make such a contract as that for the employment of the
nurse or physician, a proposition upon which, in a railroad
case, it some years ago was equally divided. Nor does it think
that the question of power is affected by the fact that the
injured man was cared for at his own home. But it does not
think that the physician should be allowed to testify that he
charged, upon his own books of account, his services to the
company, lest the jury regard that as evidence that the con-
tract was made as contended.
Courts of Equity Refuse to Restrain Board of Health. — Upon the
question of judicial interference by injunction to restrain the
abatement of what the landowner or occupant denies to be a
nuisance, the cases are comparatively few, and most of them
deal with obstructions to streets, highways or waterways. A
patient examination of the whole course of decisions on the
general subject of the police power and the summary abate-
ment of nuisances, Chancellor Nicholson, of the court of chan-
cery of Delaware, says has left with him no doubt that a court
of equity, upon an application for an injunction to restrain a
board of health or other municipal body from the summary
abatement of what it has adjudged to be a nuisance detrimen-
tal to the public health, will decline to restrain the proposed
action of the local body unless it is made to appear clearly
that it has acted wantonly and in bad faith, or has transcended
its jurisdiction. He also says that the adjudication by the
board of the fact of nuisance will not protect it as will the judg-
ment of a court, and in all cases it acts at its peril. In this
case, Liebig Manufacturing Co. v. Wales, decided March 14,
1896, the court of chancery refused to grant a preliminary
injunction which would restrain the city board of health from
abating the emanation of odors or gases from a manufacturing
establishment which it had declared to be a nuisance, detri-
mental to the public health, especially in view of the fact that
the almost unlimited range of human ingenuity, in the present
age of scientific discovery, seems to be equal to rendering
18%.]
MISCELLANY.
113
almost any trade innocuoui in almost any locality, and in view
of the further fact, that of it not being shown that the odors or
gases in question were not or could not be a nuisance, whereby
the public health was or might be injured.
Skiagraphy. Dr. W. \V. Keen, referring to plate made by Dr.
A. W. Qoodspeed of the University of Pennsylvania, said:
"Due of the most important points to be obsorved about the
skiagraph is that the upper opening of the pelvis is so clearly
seen that a measurement could be made with absolute accu-
racy in order to determine whether a fetus could be delivered
or not in the case of a deformed pelvis. If the dimensions of
the skiagraph should not be absolutely the same as those of
the original pelvis, a proportionate allowance could be readily
made by measuring the distance between the crests of the ilia,
which could be measured with accuracy on the body or taken
I standard. Any fracture or deformity of such a pelvis
could be determined very readily. Osteo-sareomaof the ilium,
fracture, or any other disease or injury altering its outlines
would be perfectly demonstrable. It is doubtful whether dis-
ease of the hip-joint itself could be made out from such a skia-
graph : but fracture of the neck of the femur or of the greater
tuberosity could be determined very readily." International
Mtili'-al llagaxvM, June, 1896.
etiology and Pathology of Cancer. Five chief theories have been
advanced to explain the etiology of cancer. 1. Conheim's
theory of the origin of tumors in inclusions of embryonic
tissue: 2, a specific bacterium: 3, protozoa: 4, yeasts: 5, a
vegetative cell. The theory that has received the most atten-
tion for the past few years is that cancer is caused by protozoa.
Ruffer has described the appearance of cancer bodies which he
regards as sporozoa : spherical bodies with small nucleus and a
distinct capsule. It is generally in the center of a parasite.
Many of the appearances of certain kinds of cancer bodies may
be explained by cell invagination. The history of the path-
of cancer differs from most other diseases in that we
have had no analogy in other diseases to lead us. There are
no bacteria which produce results similar to an epithelial
tumor. One of the boldest conceptions of the nature of cancer
is that of Adamkeivicz, who states that what we regard as
epithelial cells are really parasites and that what has been
regarded as round cell infiltration around the growth is the
space of the parasite working its way into the tissues. The
part that the glands take in The pathology is not determined.
Some trace the source of cutaneous cancer to the sebaceous
glands, some to the rete mucosum of the epidermis and some
to the sweat glands. We find blood changes in carcinoma, but
no observations have so far been made to determine whether
these changes precede the development of the tumor or not.
The cancerous cachexia is sometimes attributed to the presence
in the blood of a toxin produced by the so-called sporozoa. —
Dr. Charles J. Foote in Yale Medical Journal, June, 1896.
A Study of the Blood in General Paralysis.— Dr. Joseph A.
Capps summarizes his researches as follows : In general
paralysis, 1, the hemoglobin and red corpuscles are always
diminished ; 2, the specific gravity falls slightly below the
normal ; 3, most cases show a slight leucocytosis, amounting
on an average to about 22 per cent, above the normal. Early
cases may have no leucocytosis whatever. 4, in the differential
count a decrease is found in the lymphocytes along with
a marked increase in the large mononuclear cells. The
eosinophiles in a few cases are very numerous. In convulsions
and apoplectiform attacks, 1, the red corpuscles and hemo-
globin are usually increased at the time of a convulsion.
During an apoplectic attack of long duration they are both
somewhat diminished. 2, the specific gravity is variable, some-
times increasing, sometimes diminishing at the time of an
attack : 3, there is a leucocytosis after convulsions and apo-
plectic attacks, which is as sudden as it is usually pro-
nounced. It certainly does not appear until within a very
short time preceding the convulsion, probably not before it
actually takes place; 4, the degree of leucocytosis and the
period of its continuance, as a rule, vary directly with the
length and severity of the attack ; 5, in the production of the
leucocytosis the large mononuclear cells are increased rela-
tively more than any other variety ; 6, the fact that after con-
vulsions and apoplectic attacks in general paralysis there is
not only an increase in the number of white cells but a change
in their character, as shown by the differential count, and at
times abnormal cells appear, is an argument against the theory
that leucocytosis is merely a change in the distribution of the
white corpuscles.— The Am. Jour, of Medical 8cienoe$, June,
1896.
Another Death from Antitoxin. Dr. W. J. Nolan of Chicago
writes the following to the New York Medical Journal:
285 Loomis St., Chicago, June 24, 1896.
To the Editor of the New York Medical Journal:
Sir : In view of the discussion now going on in the Journal,
of which I have been three years a reader and subscriber, I
frankly indorse the views of Dr. Winters in regard to antitoxin
in diphtheria. Of one case I must write in terms of strong
condemnation. The facts are as follows : I was called to see
a boy, 8 years old, pulse rapid, temperature 105 degrees, and
the laryngeal appearance quasi-diphtheritic. I began the
ordinary treatment, in which quinin, carbolic acid and iron
formed chief parts. The result next morning was very satis-
factory ; all alarming symptoms were decidedly not much in
evidence. Some time in the evening of this better day, our
antitoxin friends raided the house and began their injections
a Voutrance. They did not inform me, I need scarcely say ;
but like birds of evil omen, they swooped down on a defense-
less widow and daughters, and injected mightily, nay, as the
sequel proved, mortally. Need I express an opinion after this
on the discovery, or at least its manipulators?
W. J. Nolan, M.D.
Mastoid and Intracranial Complications of Middle Ear Suppuration.
— Otoscopy affords one of the most valuable means of diagno-
sis. If the deeper portion of the canal is narrowed by the sink-
ing of the superior and posterior walls, mastoid inflammation
almost certainly exists. Of almost equal value is the tender-
ness of the mastoid on deep pressure over the region of the
antrum. In palpating the mastoid the pressure should be
made so as to communicate no motion to the auricle. If the
case is seen early an attempt may be made to abort the attack
by means of cold applications, but they should not be con-
tinued longer than forty-eight hours. The gravity of the mas-
toid operation has been greatly overestimated. Under proper
aseptic precautions it is absolutely free from danger, and in
doubtful cases is justifiable as a means of diagnosis. All soft-
ened bone should be removed from the channel leading from
the antrum to the tympanic vault in order to establish free
drainage through the artificial opening. The signs of intra-
cranial inflammation are obscure in the early stages. When
the process is acute a purulent collection within the brain sub-
stance is characterized by considerable temperature elevation.
Intracranial complications are almost invariably fatal unless
relieved by surgical interference. Operations should be per-
formed early. — Dr. E. B. Deuch in Am. Jour, of Obstetrics
and Diseases of Women and Children, June, 1896.
Diluting the Blood in Infections.- Very large doses of artificial
serum have been found to be extremely beneficial in serious
conditions, retarding death and rendering most important ser-
vices, while perfectly harmless. If the kidneys are still work-
ing well, an injection of several liters will attenuate the infec-
tion and perhaps extinguish it altogether. Intravenous
injections produce the most rapid results ; several may be
needed, and to secure the most complete results it is well to
supplement them with small subcutaneous injections every
two hours. Lejars recently performed a laparotomy upon a
young man for ruptured intestine in the midst of acute perito-
nitis, keeping the strength up and attenuating the infection
114
MISCELLANY.
[July 11,
by injecting 26 liters of serum, resulting in complete recovery.
He reports also a case of acute osteomyelitis of the femur,
with continuous fever at 104 degrees and abscesses, which
received 14 liters in five days ; the fever declined, the infection
diminished and the patient is now recovering. A man of 52,
run over by a train and severely injured ; fever, delirium,
double amputation, etc. Fourteen and one- half liters were
injected in five days and patient made a fine recovery. A
young woman operated upon for an immense ovarian cyst, with
every symptom of rapid, fatal termination, received an injec-
tion of 3 liters of serum at one time, and 2 more liters two
hours later. Improvement followed at once and patient is now
almost recovered. Charrin protests against the use of the
word serum to express the simple aqueous solution used for
this purpose, saying that the physiologic serum differs from it
so completely that it is unscientific to designate them by the
same term. He calls attention to the different results attained
by administering the solution in varying quantities and ways.
He has found that even a few c.c. will retard the death of ani-
mals infected by a microbe or intoxicated by the secretions of
bacteria ; large amounts possibly produce their effect by modi-
fying the osmosis in some way. — La Semaine Midvale, May 13.
New Investigations of Cholera "Antitoxin." Pfeiffer and his
adherents believe that the toxins of the comma bacillus reside
in the bodies of the bacteria, and do not pass unchanged into
the culture fluids, while Behring's pupil, Ransom, asserts that
the choleraic toxin is present in solution in the dead bouillon
cultures. The results of recent experiments at the Paris
"Institut Pasteur," based on the principles of Behring's anti-
toxin, confirm this latter view. Large animals, especially
goats and horses, were immunized with cholera filtrates until
in three to six months their serum became distinctly antitoxic.
One c.cm. administered with a fourfold fatal dose of the tox-
ins was sufficient to neutralize its fatal effects, although not to
prevent the appearance of symptoms of intoxication. Experi-
ments with young rabbits inoculated with 4 to 8 c.cm., and then
fed with cholera vibrios a few days after, resulted in the sur-
vival of 56 per cent, and the disease noticeably attenuated in
the rest. Sixteen per cent, of the rabbits not treated with
serum succumbed at once to the infection. Some experiments
with serum presented by Pfeiffer resulted in the survival of 45
per cent, when the serum was injected simultaneously with
the toxin per os, and 24 per cent, of the control animals
resisted the infection. But if injected twenty-four hours after
inoculation, or with the appearance of the first symptoms of
the disease, the animal could not be saved at all. The results
of the series of experiments are so far from satisfactory that
no attempt is made in the report to apply the conclusions to
cholera in human beings. — Deutsche Med. Wocli., June 11.
Protracted Simple Continued Fevers.- Dr. J. M. DaCosta says
that: "It is a mere matter of surmise what, in any of the
varieties of the prolonged simple continued fever, causes the
fever. That it is due to a disturbance of the heat centers
seems certain. But what gives rise to this disturbance? Is it
one cause or are there several? Leaving out the hysterical
cases and those of nervous origin, it appears to me likely that
the fever originates from causes within the body ; that either
as the result of fatigue or overwork, or from impure water, or
some preceding digestive disturbance, leucomaines form from
vitiated secretion?, of a character to disturb the heat-centers.
Whether in the continued fever of the tropics heat acts also in
this way, or more directly, or through blood-changes produced,
is a matter on which we can, with our present knowledge, only
sneculate. Both here and in all these prolonged continued
fevers there is a great field for chemical research, especially in
the leucomaines of the uric-acid group. The treatment of the
prolonged simple continued fevers is purely symptomatic.
Quinin has no effect on them, nor have the ordinary antipy-
retics more than a temporary influence. Phenacetin and salol
do most good, particularly in cases with headache. They are
best given in small doses, a grain or two, frequently repeated,
until their effect is manifest. Better still, where it can be
efficiently carried out, is the cold-bath treatment, not only to
lower temperature, but for its revulsive and alterative influence.
Purgatives, unless contraindicated by weakness, always form
part of judicious treatment." — The American Journal of the
Medical Sciences, June, 1896.
Dentists can not Prescribe Whisky for "Toothache." — On a Sunday
of last year a resident of Hendersonville, N. C, had an aching
tooth, and went to a dental surgeon, licensed by the State
Dental Association, and asked him for a prescription for
whisky. The doctor examined the tooth, and told the man
that he would give him a prescription for half a pint ; but, on
the man's insistence, he finally gave him a pint. The sequel
of this was the indictment and conviction of the person who
filled the prescription for selling liquor on Sunday illegally.
Appeal was taken to the supreme court of North Carolina.
April 21, 1896, it rendered its decision of "No error." All
turned on whether a dentist is a physician, or not, within the
meaning of a statute prohibiting the sale of liquor on Sunday,
unless prescribed by a "physician." The court quotes the
definition of Webster's Dictionary: "A physician is one
authorized to prescribe remedies for and treat diseases : a
doctor of medicine." A dentist or dental surgeon, it says, is
one who performs manual or mechanical operations to pre-
serve teeth, to cleanse, extract, insert, or repair them. The
statutes of North Carolina recognize that dentists are not
included in the term "physician," by providing separate
enactments for each.
If dentists came within the term "physician," as used in
the statute above mentioned, the court goes on to say that
"toothache" would become more alarmingly prevalent than
"snake bite;" and that it would with usage become more
dangerous, it says, is evident from the fact that the very first
dental surgeon's prescription for toothache, coming before the
court, is for "one pint of whisky." The size of the tooth was
not given, nor whether it was a molar, incisor, eye tooth, or
wisdom tooth ; and yet, the court takes judicial cognizance that
there are thirty two teeth in a full set, each of which might
acheonSunday. The duties of a dentist are limited, isthe con-
clusion, to the "manual or mechanical operations" on the teeth.
Whenever the use of liquor is necessary, it being a remedy to
act on the body, and only indirectly in any case for the teeth,
within the purview of the statute, it must be prescribed by a
"physician," to authorize a sale on Sunday, under such a
statute.
Hack's Truss Improved by Wolfermann.— The Centralbl. f. Chir-
urgie, for April 11, describes a truss for inguinal hernia which
absolutely prevents the escape of the intestine in all positions,
according to the inventor. The principle followed in its con-
struction was to approximate as closely as possible the effect
produced when the hernial sac is pushed into place and held
with the fingers. The pad of porous rubber, extremely soft
and elastic, is not fastened as usual, directly on the long spring
that embraces the pelvis from the crest if the ilium to the
trochanter. It has two plates at the back, exactly similar,
one fastened to the pad as usual, while the other, on which the
long spring is mounted, is only connected with it by a hinge at
the outer end. A double coiled spring near the hinge tends to
hold the two duplicate plates apart. Thus the only actual
connection between the pad and the long spring is the hinge
between the duplicate plates at the outer end. The spring
between them therefore imparts an extra elasticity to the free
pad, which enables it to adjust itself automatically to any
position of the wearer, even the most unusual. The two plates
are not exactly flat, but present a slightly convex surface
L896.]
=
toward the abdomen. None of the trusses in use produce an
even, gentle, incessant compression of the inguinal canal its
entire length, such as is secured with this one which Wolfer-
mann hopes will open ;i new scientific era in the treatment of
hernia. Ho ridicules the old fogy way in which it is still
heated, the only reason he says, wh) 1 hick's truss has not been
universally adopted. He has secured many complete cures
Pwith this truss worn day and night, as it produces absolutely
normal conditions for the intestine. It is only contraindicated
in cases tfhere there are adherences or inflammation, which
require more radical treatment. In cases of congenital hernia,
he applies this truss even to infants a month old. if the testes
can be forced into the scrotum by pressure on the inguinal
canal, but there is no use in applying a truss if the testes are
still in the inguinal canal. In cases of old ventral hernia when
the abdomen can not contain the viscera, he orders a suspen-
■orium buttoned to a sling around the neck.
Sequel of the Langerhans Case. After a long delay the official
report ol the postmortem examination in the case of the child
of Professor Langerhans, who died suddenly after an injection
of diphtheria antitoxin, has been published in the Berliner
Kliniache Wochenachrift. The Berlin correspondent of the
London Lancet (June 30 says the examination was performed
by Professor Strassmann and Dr. Mittenzweig, medical officers
to the Berlin law courts. The report states that previous to
the fatal injection the child had taken hi* dinner, followed
shortly afterward by some milk and cake. Death took place
during a severe tit of coughing, and the necropsy showed that
the trachea and bronchi were entirely filled with a gray sub-
stance, which was proved, by microscopic examination, to con-
sist of particles of food, a good deal of the same being still
I 'resent in the stomach. The uvula was swollen. The medi-
cal experts, therefore, declare that the child died from suffoca-
tion. They are of opinion that the boy vomited after the
injection and that, being in a fainting state from the pain of
the injection, he was not able to get rid of the vomited matter,
but drew it into his larynx in the act of inspiration. They did
not find any embolus of air in the pulmonary artery, as was
Buggested, nor was there any confirmation of the opinion that
death had occurred from syncope. They therefore advised the
court not to hold anyone responsible for the child's death.
According to the statement of the Control Office the serum
was of normal quality and the injection was, in the official
opinion, justified by the present state of medical knowledge.
A Rare Form of Pseudo Parasitic Infestation The Paris letter of
the London Lancet for May 9. narrates a curious incident
growing out of an unusual form of acarus infection. A young
girl, native of Ba'rfleur, came on a visit to her parents from
Cherbourg, where she was in service. During her stay at
home she consulted a medical man with a view of ridding her-
self of a parasite which she had brought from Cherbourg, and
which, having multiplied with prodigious rapidity, had infested
the house of the patient's parents and also that of a /relative.
Sulphur was burnt in the house, and the linen and flooring
was washed with sublimate solution. The plague, continuing
with undiminished intensity, the neighbors ceased visiting the
infected houses and sent the denizens thereof "to Coventry."
The authorities then took the matter in hand and delegated M.
Edmond Perrier, member of the Institute and Professor at the
Museum of Natural History of Paris, to investigate this myste-
rious malady. He soon discovered that the origo mali was the
glyciphagus domesticus, an acarus closely allied to the acarus
scabiei, but, unlike the latter, provoking scarcely any itching
or cutaneous lesions in its hosts. This acarus is, it appears,
very commonly present in houses, and it is frequently met with
in the interstices of hair combs which are badly kept. It
multiplies especially in houses in which organic debris accum-
ulate. In groceries an acarus, the glyciphagus prunorum,
MISCELLANY.
115
which is perhaps identical with the glyciphagus domesticus,
often flourishes on dried fruits, such as prunes and figs.
Feeding exclusively on organic matter it is only a pseudo-
parasite. Besides the glyciphagus domesticus there was dis-
covered in these same contaminated houses at Barfleur a false
scorpion, the othonius, which had invaded them in the train of
the first named parasite. The othonius, otherwise called the
puce d»s b ibliotheques, is the declared enemy of the glyciphagus
domesticus, upon which it feeds exclusively. Three millimeters
long, and resembling a tailless scorpion, it is recognizable by
its long fore-claws shaped like a lobster's. The patient had at
Cherbourg been a servant in a pork-butcher's, and it was
probably at the charcuterie that she became infected. Her
scalp was so full of acari that when she shook her head a cloud
of them fell on her shoulders. Her father, a respectable fisher-
man, had his eyebrows attacked, the only symptoms being a
slight irritation. A garment left by the girl at an aunt's had
sufficed to infect an exceptionally clean house. M. Perrier
ordered the evacuation of the houses and sulphur to be burnt
during six hours in the sealed-up rooms, with the result of
killing every acarus, as also the othonius. An eau de cologne
and sublimate lotion relieved the persons of the sufferers of
the parasite, although the treatment had to be prolonged in
the case of the girl. The case is interesting in that the acarus
caught at a pork-butcher's, had lain dormant for some time
on the hair-comb, and transferred thence to the scalp had
thriven therein for a period of eighteen months and invaded
consecutively the garments. From the garments the parasite
had spread to two houses and their inhabitants, and the
othonius had promptly followed in pursuit.
No Appeal from Commitment of Private Patient. The supreme
court of Michigan holds, in case of Sparrow v. Ingham Circuit
Judge, decided May 12, 1896, that section 6,779 of Howell's
Annotated Statutes of Michigan, which provides that "In all
cases not otherwise provided for, any person aggrieved by any
order, sentence, decree or denial of the judge of probate, may
appeal therefrom to the circuit court for the same county," does
not apply to an order declaring a person insane and committing
such person to one of the State asylums as a private patient.
The supreme court says, among other things, that he would be
very obtuse who did not perceive that the chief object of the
statute of 1895, under which the commitment is authorized, is
to furnish in the early stages of the disease the best medical
treatment available, in order to effect a cure and prevent, if
possible, the terrible result of permanent insanity. If appeals
are allowed in these cases, they may not reach a trial and
determination in the circuit court for one or two years. A
writ of error will then lie to the supreme court. If error is
found, a new trial must be granted, and it may be years before
a final determination can be reached. Meanwhile the sick per-
son, unless dangerous to the lives and property of others, must
remain without treatment, and permanent insanity may result,
where prompt treatment by skilled physicians might cure the
malady. It is not reasonable to suppose or infer that the leg-
islature intended to provide for any such condition of affairs.
The argument that, holding the inquest of the probate court
final will result in confining sane persons to a living grave
within the walls of an asylum, the supreme court declares has
no merit, and the thing itself scarcely possible, under the
humane provisions of the law of that State. Its theory is that
neither the court nor the physicians have any object in adjudg-
ing a sane person insane, nor have the skilled and learned
physicians in the asylums any object in keeping any sane per-
son within their walls. Furthermore, the court calls attention
to the fact that one of the humane provisions of the law under
consideration is that it permits the person who has been
adjudged insane to appeal to the probate court to determine
whether he is healed, and that from that adjudication, if favor-
able, there is no appeal.
116
MISCELLANY.
[July 11, 1896.]
Dr. Jenner's Poesy. -A recently discovered file of Jenner's
letters shows that that eminent man occasionally dipped into
versification. One of these letters written circa 1789, to a lady
to whom he had sent a couple of ducks, reads as follows :
"I've dispatched, my dear madam, this scrap of a letter
To say, as Miss Kent is so very much better,
A regular doctor no longer she lacks,
So I've sent to attend her a couple of quacks."
The lady replied :
"Yes, 'twas politic, truly, my good friend,
Thus, 'a couple of quacks' to your patient to send,
Since there's nothing so likely as 'quacks,' it is plain,
To make work for a regular doctor again."
Right of Experts to Extra Pay. — A decision of importance to all
persons who are liable to be called upon to go on the witness
stand as experts has been rendered by the supreme judicial
court of Massachusetts in the case of Barrus v. Phaneuf, May
21, 1896. The principles which it discusses and lays down
apply to medical experts, with full force, although this action
was brought by a civil engineer. He had been engaged by the
defendant to go into court at a future day and testify for him
as an expert in regard to a matter which he had examined as
such. This engagement was made about six weeks before the
trial. He talked over the matter, and went into court and
testified, and during the progress of the trial advised the
defendant's attorney in regard to the questions to be asked of
himself and of the other witnesses, though he was not asked
any questions which called for his opinion as an expert. To
further complicate matters, he was, at some time after the
agreement was made, regularly summoned by the defendant
as a witness, and was paid the statutory fees, and made no ob-
jection thereto, and made no claim for extra compensation.
Was he entitled to recover any extra compensation as an expert?
The defendant contended that he was not, and that if there
was an express promise to pay him extra, it was without con-
sideration, and that the witness did no more than he was
legally required to do under his subpena. That a court would
be without power to require the attendance of a professional
or skilled witness, upon a summons duly served, and with pay-
ment of the statutory fees, although he was unacquainted with
the facts, and could testify only to opinions, the court declares
it would be slow to admit ; but such power would hardly be
exercised unless, in the opinion of the court, it was necessary
for the purposes of justice ; and the one summoned would per-
form all that the court could require of him if he should hold
himself in readiness to be called upon to testify to such opin-
ions as he might have when his turn should come. In this case,
however, the court holds that the evidence showed a sufficient
consideration to support a promise to pay a reasonable compen-
sation, in addition to the statutory fees, and that the jury was
warranted in finding a promise to that effect, or a mutual
understanding that the expert was to be so paid. If such prom-
ise was made, or such understanding existed, it further holds
that the expert's right to recover would not be taken away or
lost by his omission to claim or demand extra compensation, or
to notify the defendant that he should make such claim, or by
his acceptance of the statutory fee without objection, or by the
omission of the defendant at the trial to put any question to
him as an expert witness, and the consequent omission on his
part to testify as an expert. What would have been his right
without such promise or understanding, the court studiously
avoids stating except as above, though at the same time shows
the trend of authorities would be against allowing any extra
compensation.
Hospitals.
Erie County Hospital, Buffalo, N. Y. — The following
appointments have been made on the staff : Consulting genito-
urinary surgeon, D. W. Harrington ; attending physician,
B. H. Daggett ; consulting surgeons, M. Hartwig, H. C. Frost ;
consulting physician, A. T. Bull ; attending obstetrician, L. J.
Hanley ; attending gynecologist, H. D. Ingraham ; attending
physicians, George W. Lewis, C. S. Jewett ; eye and ear, Ar-
thur S. Bennett ; children's physicians, Maud J. Frye, John
D. Flagg.
House of Mercy Hospital Dedicated. — The formal dedi-
cation of the new House of Mercy Hospital at Springfield
Mass., took place June 23, in the chapel.
THE PUBLIC SERVICES.
Army Chmtxes. Official List of changes In the stations and duties
of officers serving in the Medical Department, U. S. Army, from
June 27 to July 3, 1896.
Col. Charles T. Alexander, Asst. Surgeon-General, is granted leave of
absence for two months, to take effect on or about July 8, 1896, or as
soon thereafter as practicable.
Capt. William B. Davis, Asst. Surgeon, will in addition to his present
duties, take charge of the medical supply depot in New York city,
during the absence on leave of Col. Charles T. Alexander, Asst.
Surgeon-General.
Navy rhanges. Changes in the Medical Corps of the U. S. Navy for
the week ending July 4, 1896.
Surgeou L. G. Heneberger, detached from the marine rendezvous, New
York, and ordered to the hospital. Widow's Island.
P. A. Surgeou E. S. Bogert, ordered to the New York navy yard, July 2.
P. A. Surgeou T. C. Craig, detached from the New York navy yard, July
2, and ordered to the marine rend zvous, New York.
P. A. Surgeon W. F. Arnold, detached from special duty in China and
Japan and ordered to return home.
Asst. Surgeon H. F. Parrish, ordered to the naval laboratory, New Y'ork
City.
(Ilanitc of A(ldr«iM.
Cummings. W. M., from Las Animas to Trinidad, Colo.
Davis. Jr., N. S., from 326 Superior St. to 291 Huron St., Chicago, 111.
Getzlaff. B„ from Wapakoneta, Ohio, to Attapulgus, Ga.
Houston, I. M., from 428 Ellis St. to 707 Sutler St., San Francisco, Cal.
Harris, John J., from 1605 Tower Grove Ave. to 5252 Shaw Ave., St
Louis. Mo.
Lewellyn, P. W., from Clarinda, Iowa, to Ragosa Springs, Colo.
Patch. Wm.. from Cooksville, to Sibley, 111.
Rees, II., from Chicago, 111. to Scandinavia, Wis.
Southern California Practitioner, from 107 N. Spring St. to Suite 248-
246 Bradbury B'ld'g, San Francisco, Cal.
LETTERS RECEIVED.
Atkinson, W. B., Philadelphia, Pa.; Allport, Frank, Minneapolis,
Minn.; Ashby, T. A., Baltimore, Md.; Ashmead, A. S., (2) New York,
Bartlet', J. C, Chicago, 111.; Boehringer, C. F. & Soehne. New York
N. Y.; Baker, John C . Co., Philadelphia, Pa.; Batman, W. F., Lebanon
Iud.; Burr, C. B., Flint, Mich.; Bullington, T. A., Louisville, Ky •
Bluhm, Geo. I., Chicago, 111. ' '
Cullen. G. I., Cincinnati, Ohio; Christopher, H., St. Joseph, Mo.;
Cleveland. E. F., Dundee. 111. ; Columbus Phaeton Co., Columbus. Ohio
Chesman, Nelson & Co., St. Louis, Mo.; CofTman, G. L, Thaver Kan ■
Coppedge, W. E.. Oak Hill. Mo. ; Cerna, David, Galveston, Texas.
Doliber-Goodale & Co.. Boston, Mass.; Delavan.B. Bryson. New York
N. Y.; Dick. J. K.. Chicago. 111.
Eagleson, J. B.. Seattle, Wash. ; Elliott, A. R., New York, N Y
Fritzinger, R. J., Philadelphia, Pa.; Farbert, McCassy, Dayton, Ohio
Gates, Geo. W.. St. Louis, Mo.; Gibson, Maris. Wilkesbarre, Pa
Harrison, W. H.. Harrisburg, Pa.; Horner, Frederick, Marshall, Va.;
Hummel, A. L., Advertising Agency, (4) New York, N. Y.; Hardesty,
T. 0„ Kampsyille. 111.: Hollister, J. H„ Chicago, 111.: Heath, F. C.
Indianapolis, Ind.: Hummel, C. C, Mechanicsburg, Pa.: Hamblin.J M
Westboro.Mo.: Hogler. Elmer E., Springfield, 111. ;TEJarris,T. C. Raleigh,
N. C; Haldensieiu, I.. New York, N. Y.; Hogan.H. H„ Reno, Nevada.
Ingals, E Fletcher, Chicago, 111.
Jones, H. P., New Orleans, La.; Johnson, H. L. E., (2) Washington,
'Klelnschmidt. C. H. A., Washington, D. C: Kleene, F., Chicago, 111.
iasw Z-i-W.?r,?,aw,\N- Y'; Luce- C- R-- Washington, D. C; Leffing-
wejl, Wm. E., (2) Watkins. N. Y.; Larew.John T., St. Louis, Mo
Mumaw, H. A., Elkhart, Ind.; Malcolm. John W.. Courtney, I T •
Morgan, K. E., Fort Wayne, Ind.; Mulford. H. K..& Co., (2) Philadel-
J&V1' P«-\.Mark8,TAc,A" New York' N- Y-i McKee, E. S., Cincinnati,
Ohio; McMurtry, L. S., Louisville, Ky.
Nixon, J. W Soldier Kan.; Newton, Richard C, Montclair, N. J.
Ott, Isaac. Philadelphia, Pa.
Page. L. F, Indianapolis, Iud. ; Pollette, E. E„ Westerly R I
Ryman. H.M , New York, N. Y.; Ross, A. A.,Hochheim, Texas; Reed,
R. Ha' vey, Columbus. Ohio.
tnl'"t?0r•■ L£; L^n<iQD"^ Texas: Smart, Chas.. U.S.A.. fSI Washing-
ton, D. c Scott W A . Swanton, Ohio ; Sargent, Andrew. Hopkinsville,
«yw Sn„1ib,.n- Mr-,'>Da0vi8J W'Jai: Sellors, W.. Wausaukee. Wis.; Simms.
h&> D^n,vl}ir-,JU-i Smith- F- S.. Nevada, Iowa; Smith. E. B., Detroit,
Mich ; Scheiffelin & .Co.,N™ York, N. Y.; Sharp, W. H., Parkersburg
W. Va. ; Schering & Glatz. New York, N.Y.
Uran, B F., Kankakee. 111.
w™!*.*""??' w d- """oln Neb.; Wenzel, H. P., Milwaukee, Wis.:
Wyckoff. R. M.. Brooklyn, N. Y.; Weaver, H S Philadelphia Pa ;
Woods, T. J.,Batesville,Ark.; Willard, Lee k" Merrill, wfsP' '
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., JULY 18, 1896.
No. 3.
ORIGINAL ARTICLES.
MALARIA.
BY ELLSWORTH D. WHITING, A.B.
(Dm L. P. C. Freer l'rize Essay, Rush Medical College, 1896.)
UKORA, ILL.
Malaria, or paludisni, is a non-contagious, infec-
tious disease, characterized by typical paroxysms, the
principal pathologic changes being in the blood, liver
and spleen. Its etiologic factor is a specific proto-
zoon. the plasniodium malarire of Laveran, which can
generally be demonstrated in the red blood corpuscle.
Malaria may be considered a primitive disease, that
is, one found in newly settled countries. It attacks
the settler when he turns the soil for the first time,
when there is no drainage and when the shallow wells
fill from the surface. As soon as the swamps are
drained and the wells freed from surface water the
"chills and fever'7 disappear.
As to the geographic distribution of malaria, it is
quite extensive, being found in tropical, subtropical
and temperate zones. In the northern part of Africa
malaria is endemic. It was there that Laveran made
his first discoveries. In Europe, southern Russia
and Italy are the common seats of the disease though
it is found to some extent in England, France and
Germany. On our own continent malaria is endemic
in the South, Mexico, Texas, Arkansas, Louisiana
and Missouri, and more common in the North than
was formerly supposed. In the West Indies it exists
in its most malignant forms.
As to the manner in which the parasite affects
entrance into the human body medical opinions differ.
Until a few years ago there was a consension of opin-
ion that malaria was an air-borne disease, the lungs
being the only infection atrium. Those who upheld
this theory based their opinions upon the fact that
malaria was common among people living in low,
marshy regions abounding in vegetable growth.
These men claimed that the organism had its hab-
itat in the soil, from whence, under favorable condi-
tions, it was disseminated through the atmosphere
and thus readily reached the air passages and circula-
tion of the human organism. They claimed also that
while moisture was not necessary to the development
and spread of the disease it greatly aided it in its
growth. They maintained for this reason that night
air was much more heavily charged with malarial
organisms than the air during the day.
Within the last few years other investigators have
gone so far as to state that malaria is not an air-borne
disease in any sense of the word. After extensive
investigations these gentlemen have proven to their
own satisfaction that this disease is purely of water-
borne origin. To maintain their position they have
brought to bear very strong evidence. They cite
numerous instances where gangs of laborers working
in the same malarial districts were dissimilarly
affected, those drinking from the surface water suffer-
ing from the disease, while those drinking boiled
water, or that obtained from deep wells, were unaf-
fected. These men all breathed the same air both
night and day. This is a strong argument in favor of
the water-borne theory. It may be argued that the
vitality of those drinking the pure water was suf-
ficient to resist the action of the organism, even had it
gained entrance into the body through the air pas-
sages, while the vitality of those drinking the surface
water was naturally lower. This objection would h ;2d
good were only one case cited, but it must necessarily
fail when hundreds of similar cases are given.
Another proof of the probability of the water-borne
infection is demonstrated by the fact that here, in the
midst of Chicago, in the heart of winter, when there
is no building and excavating, malaria is present in
almost every hospital in the city. The writer has
demonstrated the presence of the organism in the
blood of Cook County Hospital patients this winter
who have not been away from the city in many years.
The air-borne theory does not explain clearly these
midwinter infections while the water-borne theory
does. Many streams flow into Lake Michigan from
the flats of Illinois and Indiana. These streams teem
with malarial organisms. They empty their polluted
waters into the lake and the currents flowing north-
ward find their way into the cribs and thence to the
dwellings of the citizens of Chicago. It is a note-
worthy fact that not only is malaria found in the
wards of Cook County Hospital but also among fami-
lies living on the finest boulevards. Taking into con-
sideration the array of testimony on either side, the
writer is inclined to lean toward the water-borne
theory, yet granting that in some cases infection by
air seems highly probable.
Formerly many held that the organism gained
entrance into the body through the stings of insects.
This theory is upheld by but few to-day.
As a rule malaria is most prevalent in the spring
and fall, yet the disease is present to some extent
during all seasons of the year.
Under like conditions malaria is no respecter of
persons as to sex. It is, however, more common
among men than women, because of their manner of
life, as they are more exposed to its etiologic factor.
Children under one year of age rarely have the dis-
ease.
There can be but little doubt as regards the differ-
ence in degree of personal receptivity. All per-
sons of lowered vitality are readily susceptible to the
disease, nevertheless in men full of health there is
great difference in the degree of immunity. This
immunity may be natural or acquired. Persons going
into a malaria district seem to acquire immunity after
a lapse of years, while those born in the malarial
atmosphere are often never affected by the disease.
118
MALAEIA.
[July 18,
The negro is much less affected than the white man,
the ratio being as three is to one.
The history of the discovery of the plasmodium
malarise and the various theories set forth by the dif-
ferent observers as to its character furnish interesting
matter for study and investigation.
At first thought it would seem as though a recapit-
ulation of the theories and observations of students
interested in the malarial organism would be superflu-
ous, but to understand fully the following pages such
a resume' will be of great advantage.
Perhaps the greatest honor is due Laveran, after
whom the parasite is named; however, extensive
investigations and discoveries have since been made
by Golgi, Marchiafava, Celli and others.
Although Lewis, in 1879, discovered hematozoa
in the blood of warm-blooded animals, Laveran, a
French military surgeon, in 1880, was the first man to
demonstrate living organisms in the blood of individu-
als suffering from malarial fevers. At this time
Laveran was stationed in Algeria, where malarial
fever was prevalent. This afforded him excellent
opportunity for studying the disease and the parasite.
Laveran made his first discovery in November of this
year. While examining the blood of a malarial
patient he observed, floating in the plasma among the
corpuscles, motile pigmented bodies provided with
actively moving filaments or flagella. The next
month, in the examination of forty-four cases of sup-
posed malaria, in twenty-six the parasite was demon-
strable. As a result of his studies he describes the
parasite under three forms.
1. Crescentic or ovoid forms 8 or 9 m in length and
2 ^ in diameter. These bodies are colorless and trans-
parent except for small clumps of pigment in the cen-
ter, or at the ends of the organism. The pigment
granules assume the form of wreaths. The bodies
are practically non-motile and in some instances pale,
protoplasmic filaments appear to connect the extremi-
ties. Laveran believed that the crescentic forms
originated in the ovoid or spherical flaggellate forms,
next to be described, and had the power of returning
to the spherical shape.
2. Bodies which in repose are spherical and trans-
parent, 5 to 7 m in diameter and contain rings of
rounded pigment granules of equal size. When these
bodies are found in motion they are provided with
from three to five long, thread-like processes which
he calls "flagella." The organism appears to use
these as a means of locomotion. In length they are
two or three times that of the diameter of a red cor-
puscle, the ends of the filaments being enlarged.
When the parasite is in motion the protoplasm seems
to be greatly agitated, as is evidenced by the rapid
rotating and dancing of the pigment granules within.
He describes the flagella as being developed outside
of the organism and detached when complete in their
development. He observes particles of pigment to
emanate from the organism through these flagella.
3. Laveran describes a third form which he sup-
poses to be dead organisms (cadavers). These are
of spherical form, from 8 to 10 ^ in diameter, granu-
lar, non-motile, not provided with flagella and con-
tain irregularly arranged pigment granules. At times
he finds in these bodies granules which are fiery red
or blue in color.
Later, in 1881, Laveran added a fourth form to his
classification. He describes bodies transparent and
spherical containing both motile and non-motile pig-
ment granules. These bodies are as a rule small,
varying in size from one-sixth to the full size of a red
corpuscle. In the smallest there is but one granule
of practically non-motile pigment. In the larger
bodies from eight to ten motile pigment granules are
present.
In summing up his discovery, Laveran says:
"There exists in the blood of patients suffering from
malaria parasitic elements which have hitherto been
confounded with melaniferous leucocytes. The pres-
ence of these parasites in the blood is probably the
cause of the manifestations of paludism."
As to the nature of the organism Laveran concludes
that forms 1 and 2 consist of an accumulation of cysts,
formed in the corpuscles by extra corpuscular organ-
isms represented by the flagella. These, developing
at the expense of the red corpuscles and acquiring
motility, separate themselves from the products of
their activity and live independent lives.
In 1882 the discoveries of Laveran were corrobo-
rated to a great extent by Richards, who also studied
the parasite in Algeria. Richards describes the
earlier stages more accurately than Laveran. He
notes a form in which there is no pigment and
advances the theory that this form precedes the stages
in which little pigment is found. He discovers that
as the organism increases in size and the pigment in
quantity, that the corpuscle expands and loses its
color and finally the cell wall breaks. He agrees with
Laveran in that the organism in its perfected state
consists of the flagellate form and finally concludes
that the parasite is extra corpuscular although he
was at first inclined to consider it as endoglobular.
He advocates the theory that the number of organ-
isms increase until the beginning of the paroxysm.
He says "they produce the fever, the fever kills the
parasite, and falls in its turn, the process of reproduc-
tion going on between paroxysms."
At this time in Italy investigations of a different
nature were being carried on by such noted biologists
as Klebs, Tomassi, Crudeli, Marchiafava, Gaule and
Celli. These men, looking at the origin of malaria
from the bacteriologic standpoint, were convinced
that they had demonstrated a micrococcus which,
when present in the human organism, produced symp-
toms of malaria. They found small round bodies in
the blood of malarial patients which stained with
methylene blue. They found also ring-shaped bodies.
These they claim to be of bacterial origin. They dis-
tinguished also the pigmented bodies of Laveran and
Richards, but consider these granules as degenerated
debris caused by the action of the bacterial organisms
upon the red corpuscles. They explain the existence
of filaments described by Laveran and Richards as
resulting from the temperature and show by actual
experiment that normal red corpuscles heated from 40
to 48 degrees C. show these filaments. They account
for the crescents by claiming that they are caused by
the discoloration of a portion of the periphery of the
red corpuscle, the rest retaining its color. In 1885
Marchiafava and Celli withdrew this theory of the
bacterial origin and agreed with Laveran and his
parasitic theory. They carefully studied all the organ-
isms noted by Laveran and Richards, and furthermore
describe organisms containing abundant pigment,
within which they are able to detect a differentiation
into smaller bodies. In some of these cases the pig-
ment is collected in the center, and evidence of seg-
mentation is present in the surrounding protoplasm,
1896.]
MALARIA.
119
while in others the pigment seems to be arranged
in the center and segmentation complete. The fact
that they observed small hynline forms greatly influ-
enced them in their change of position. These smaller
hyaline forms they describe as consisting of two
•/.ones, an outer or thicker more refractive zone, and
an inner more granular and less refracting one. These
organisms they describe as ameboid and provided
with filaments issuing from the outer zone. They
disagree with Laveran in the position of the organ-
ism. They hold that the organism is endoglobular,
while Laveran still held to the belief that they were
attached to the external surface of the corpuscle.
Therefore to Marchiafava and Celli must be given the
great credit of being the first to demonstrate segmen-
tation and to bring forth the theory of the endo-
globular existence of the parasite. Although they
are unable to prove their belief, they state as highly
probable that the process of segmentation is one of
reproduction. Laveran also believed that the small
forms which he discovered were of embryonal nature.
These men ridicule the cystic theory of Laveran and
the existence of separate crescentic types.
Subsequent to the discoveries of Laveran, Richards,
Marchiafava and Celli, many investigations were
made, confirmatory to the observations of these men.
In 1885 Councilman and Abbott made extensive
research. They demonstrate the presence of the
organism in the capillaries of the . brain, liver and
spleen in two cases of comatose, pernicious malaria.
These organisms are both pigmented and non-pig-
mented. and within and outside the red corpusles.
Summarizing the investigations up to this date
(1885) we must describe the malarial organism as
consisting of a small, hyaline, ameboid, endoglobu-
lar parasite which on development shows fine, actively
moving pigment granules. These bodies, eventually
filling up the red corpuscle, decolorize, and finally
destroy it. Having reached the adult stage the
pigment becomes collected in the center of the organ-
ism while segmentation is observed in the surround-
ing protoplasm. The small hyaline bodies, according
to Laveran, have the power of taking the form of
crescents from which pigment and flagella develop.
Laveran believes that the flagella are the organisms,
that they are of extra corpuscular nature and the body
containing the pigment the result of cystic degenera-
tion. On the other hand Marchiafava and Celli hold
that the pigmented body is the true organism, that it
is endoglobular, and the flagella simply pseudopodia.
Up to this time there had been no disagreement as
to the relation of the organisms to the clinical features.
It was ceded by Laveran and his followers that the
various forms observed were all of the same organism.
Laveran says himself: "I do not believe that there
exists a constant relation between the forms under
which the hematozoa exist in the blood and the clin-
ical manifestations of paludism. One can only say
that certain forms of the parasite are more often seen
in certain cases, the crescents, for example, in relapses
and in malarial cachexia, as I have often demon-
strated."
In 1885, when Golgi published an account of his
discoveries, the theories which he set forth caused a
division among students of malaria. Two factions
sprang up. At the head of one was Laveran, while
Golgi was the leader of the second. Laveran asserts,
as has been said, that there exists no relation between
the clinical manifestations of the various types of the
fever and the several forms of the parasite. Golgi,
however, holds that there are probably many distinct
types of the parasite and that there is a distinct and
readily recognizable relation between the form of
parasite and clinical manifestations.
Golgi's theories are based upon the study of the
parasite found in quartan ague. Although Marchia-
fava and Celli note in a few cases that segmentation
was seen during the paroxysm, Golgi was the first to
demonstrate the fact that segmentation of a group of
organisms could always be seen during a malarial
paroxysm. He also proves conclusively that the
severity of the attack is in direct proportion to the
number of segmenting organisms. In the study of
the parasite of quartan ague during the first day after
the paroxysm a small, hyaline, non-pigmented body
in the red corpuscle is observed. This body is motile
but sluggish in its movement. On the second day
the body is increased slightly in size and a few gran-
ules of pigment are present in the center. The gran-
ules of pigment are large in size, of a brownish red
color, and move about slowly in the organism. This
organism gradually grows until six hours before the
next paroxysm, when signs of segmentation become
apparent. At this stage the organism has practically
filled but has not distended the corpuscle. Pigment
granules are still few in number and their movement
sluggish. Before segmentation the pigment collects
into the center; soon radiating lines divide the organ-
ism into from eight to ten segments, forming the
so-called marguerite forms of Golgi. Soon the organ-
ism is seen to divide and the hyaline forms to pass
out into the plasma. At the same time hyaline forms
are seen to appear in the red corpuscle. Although
Golgi did not see these hyaline forms enter the red
corpuscles, he was firmly convinced that they were
one and the same. In cases of quotidian paroxysms
he demonstrates the presence of a triple infection,
that is, the presence of three distinct groups of para-
sites segmenting on different days. Thus, one group
segments every day, causing daily paroxysms. In
like manner he proves the cause of the tertian
paroxysm(?)
These observations have been in most instances
proven by many careful and conscientious students.
Antolisei agrees with Golgi in the main, but insists
that the paroxysm is caused by the segmentation and
the rupturing of the red corpuscle and not by the
entrance of the hyaline bodies into the corpuscles as
is held by Golgi. He proves his point by showing
that quinin, even when administered in full doses
shortly before a paroxysm, will not stop the paroxysm
or segmentation, but will prevent the hyaline bodies
from entering the corpuscles.
Golgi, after having extensively studied the parasite
of quartan ague, demonstrates also the presence of an
entirely different type of organism as productive of
the symptoms of tertian malaria. He studied this
organism carefully for three years (1886 to 1889) and
concludes from the result of his researches that the
embryonal form of the tertian parasite is similar to
that of the quartan. This form, he says, "consists of
a small, round, non-pigmented, transparent, motile
body in the red corpuscle, which reaches its adult
stage in forty-eight hours. At the end of this time
an abundance of pigment is present and segmentation
with accompanping paroxysm takes place with the
appearance of hyaline bodies in the red corpuscles."
Golgi moreover notes other differences between the
120
MALARIA.
[July 18,
tertian and quartan parasite which may be tabulated
as follows:
Motion. The tertian organism in both its hyaline
and adult forms is more active than the quartan.
Pigmentation. 1. The number of granules in the
tertian type is greater than that in the quartan. 2.
These granules are much smaller in the tertian. 3.
Their movement is more pronounced: and 4. Their
color is lighter in shade.
Size. As the tertian organism grows it distends
the corpuscle, which loses its color, while in case of
the quartan parasite the corpuscle does not swell and
is but slightly decolorized. In fact, the corpuscle
containing this organism seems to shrink. The adult
tertian parasite is much larger than the quartan.
Segmentation. 1. During segmentation the tertian
organism is seen to divide into from fifteen to twenty
segments, while the quartan divides into from eight
to twelve. 2. The segments of the tertian parasite
are smaller than the quartan. 3. During the segmen-
tation of the quartan parasite Golgi demonstrates the
presence of a central refractive area, but is unable to
find such an area in the tertian. This refractive area
appears to have a definite wall of differentiated proto-
plasm and contains the pigment granules during seg-
mentation. As regards the destiny of this latter area
Golgi is uncertain. He presents two theories; one to
the effect that the body remains active and enters the
red corpuscle and reproduces its like, the other theory
being that it is consumed by phagocytes.
Beside the methods of segmentation common to the
tertian and quartan forms Golgi demonstrates another
form. In this the pigment is seen to collect in the
periphery of the organism, leaving a clear center in
which one or two spherical, sporelike bodies appear.
In order to disprove this form of segmentation
Antolisei spent much study and experimentation. He
finally decided that the process was one of degenera-
tion and that the spherules discerned by Golgi were
vacuoles. When the organism had completely destroyed
the corpuscle Antolisei observed a spherical area in
the center of the organism near its periphery. "Soon,"
he states, "a transparent, distinctly outlined sphere
appears in the area, and about this sphere vacuoles
appear which constantly multiply in number and
seem to decrease in size. Surrounding these vacuoles
is motionless pigment, while the pigment removed
from the central area seem to increase in motion.
Sometimes the enclosing membrane bursts and a
hernia of the contents of the organism results. In
this cut-off or fragmented portion the same process of
vacuolization continues. This process goes on until
finally the organism is completely filled with minute
spherules, separated by motionless pigment granules
and enclosed within a membrane which is probably
the cell wall. Finally this wall bursts and throws the
contents of the parasite into the plasma." Antolisei
concludes that vacuolation, fragmentation and flagel-
lation are all forms of degeneration. He bases his
theory upon the fact that he finds all these changes in
organisms of the same size. He also claims that true
segmentation rarely takes place in the circulating
blood, but generally occurs in the internal organs.
He bases this belief upon the fact that segmenting
organisms found in the circulating blood are seldom
larger than the red blood corpuscles, while the true
segmenting forms found in the internal organs are
much larger. He believes that the larger forms found
in the circulating blood are dead organisms undergo-
ing vacuolation or segmentation.
The comparative examination of blood taken from
the spleen and peripheral circulation has been carried
further by Bastianelli and Bignami. They deter-
mined that during apyrexia the number of organisms
in the spleen and peripheral circulation was the same,
but that during, and just before the paroxysm, many
more organisms were found in the spleen than in the
periphery. They explain this fact upon physiologic
grounds, stating that when the corpuscles are intact
there is naturally no tendency for them to collect in
the spleen, but when they are the subject of path-
ologic change these disabled cells immediately seek
the spleen for removal.
These men set forth the theory that in quartan ague
the distribution of the organism is more uniform than
in the tertian type. They explain this by stating
that in this type there, is less disturbance in the con-
tinuity of the corpuscle while it is being destroyed.
They also discovered bodies provided with a small
amount of pigment, surrounded by from five to ten
round sporelike bodies. These they term organisms
of a shorter cycle, since they found them in irregular
and anticipating quotidian fevers. They agree with
Antolisei as to the probable nature of vacuolization,
flagellation and fragmentation, and furthermore sug-
gest that the severity of the fever is in inverse ratio
to the number of these organisms present.
Councilman, in 1887, first associated with irregular
and continuous fevers another organism clearly dis-
tinct from the quartan and tertian types. He discov-
ered a crescentic and elongated body which he found
to be constant in remittent fevers. Thus he declared
that he was always able to distinguish an intermittent
and remittent type by the blood examination. In
1889 the discoveries of Councilman were corroborated
by Marchiafava and Celli and Pietro Canalis.
The description of this type given by Canalis
divides it into two classes: 1, the rapid cycle and
2, the slow or crescentic cycle. He terms this latter
type the semi-lunar type.
Canalis determined that the first class generally
matures in less than forty-eight hours, though he
points out one case in which there is a complete cycle
of only twenty-four hours. Two or three hours after
the first attack Canalis notes small, spherical, ame-
boid organisms in the red corpuscles. About the per-
iphery is a clear rim of ectoplasm surrounding a more
shaded endoplasm which resembles a nu leus. This
endoplasm at times is fragmented, resembling several
nuclei. As the organism grows it becomes more
active, when there appears in the periphery fine dark
red or black pigment granules. As the organism
reaches the adult stage the pigment gathers in the
center in the form of a densely packed clump, and
segmentation occurs as observed by Golgi in quartan
ague. This form differs from the other forms in that
it decolorizes the corpuscle even less than the quar-
tan, contains rarely more than six granules of pigment
and divides into only five or six segments.
The second or slow cycle of Canalis takes from three
to five days to complete its development. It is rarely
found in combination with the first, and when this
does happen it is after the latter has been unsuccess-
fully treated. Canalis says that this form begins very
much as does the first, but soon the organism assumes
an elliptical form and pigment collects in the center.
This gradually takes on a cresentic form, decolorizes
the corpuscle and at times shows presence of double
contour, thus giving evidence of a surrounding mem-
1896. ]
MALARIA.
121
Inane. These oresoentio forms are seen to assume
ovoid or crescendo forms, though the organism in
Borne instances passes directly from the hyaline form
into the adult spherical form .without passing through
the intermediate cresentie stage. Canalis states that
lie has noted the segmental ion of ereseents. In this he
is upheld by Antolisei and Angelini. The pigment
of these forms is non-motile, arranged concentrically
in a closely (lacked clump, crown or wreath. He
describes sporulation as taking place in the spherical
stage. During sporulation the ectoplasm breaks up
into from eight to ten spherules. These spherules
an1 small and resemble the hyaline forms of the first
cycle. On rupture of the organism its contents are
» thrown into the blood stream, the pigment granules
being scattered through the plasma separately or in
a clump surrounded by a membrane. Canalis notes
that paroxysms occur during this process and accord-
ingly calls it true sporulation.
Canalis differentiates between the process of sporu-
lation and degeneration in the following points:
1. In tin' degenerating organism, there is no color,
the ashy yellow tinge being replaced by a colorless
highly refractive body.
'2. The degenerate organism shows spherules, varying
in size which may on close and continued observation
he seen to coalesce. Thus all the spherules in an
organism may unite into one. In sporulation the
spores are equal in size. . .
'■'>. The sporulating organism has a clearly defined
double contour while the spherules of degeneration
never do.
4. Degenerating forms are found in apyrexia and
their appearance does not precede the presence of
hyaline forms in the red corpuscles as in the case of
sporulation.
Canalis demonstrates the presence of flagellate
bodies in many cases of the second cycle. In every
instance he finds them in the spherical, adult form of
the parasite shortly before the paroxysm. From this
fact he comes to the conclusion that flagellation is
one of the last stages in the development of the
organism.
Experiments of Marchiafava and Celli corroborate
in a great measure those made by Canalis. They
account for the prolonged and irregular paroxysms,
not from the fact that there may be a large group of
organisms which on segmenting cause this condition,
but from the irregularity in the length of the cycles
of different organisms. Thus, at certain times groups
of organisms may segment one after the other. This,
they contend, accounts for the continuous fever, the
chill being covered up by the preceding pyretic stage.
They conclude that the crescent is associated with
pernicious forms. They cite grave cases where the
crescents could not be demonstrated and also cases
where this organism is present but no temperature
exists. The latter phenomenon they do not attempt
to explain.
These gentlemen, Marchiafava and Celli, describe
the organism practically as does Canalis, noting the
fact that pigment is small in quantity and appears
very suddenly before the paroxysm. They state that
in some instances they have seen organisms pursue
the whole course of their existence without the devel-
opment of any pigment. In this they are upheld by
Antolisei and Angelini. They note also that the col-
oring matter of the corpuscle seems to collect about
the periphery of the organism, being itself early
decolorized at its own periphery. This coloring matter
they describe as taking on a peculiar brassy hue.
They claim to have found many instances where the
corpuscle was greatly crenated even when the organism
was still in its hyaline form. In a few cases they were
able to demonstrate segmentation in the circulating
blood, but always found it in the internal organs and
in severe cases in the capillaries of the brain. These
investigators recognize the crescents but are not able
to corroborate the observations of others as to its seg-
mentation. They believe that the degenerative
changes are present.
As a result of these investigations Marchiafava and
Celli in common with Canalis claim the existence of
a new type of material organism, characterized by an
irregular length of cycle, hyaline, crescentic and spher-
ical stages associated with a continued pernicious and
irregular course occurring chiefly in the summer and
fall and unamenable to treatment. On account of
the time of appearance of this type they have termed
it the "estivo-autumnal type."
Marchiafava and Bignami later made interesting
observations in regard to the estivo-autumnal type.
They note as does Canalis two types of parasites which
they term "quotidian" and "tertian or malignant."
They describe the "quotidian" as consisting prima-
rily of a small, ring-like hyaline body seen in the red
corpuscle. The organism completing its cycle in
twenty-four hours and undergoing segmentation with
the development of little or no pigment, closely
resembles the first cycle of Canalis.
The second form of Marchiafava and Bignami, in
the commencement of its cycle, appears much the
same as the quotidian but takes about forty-eight
hours for development, always exhibiting pigment and
at times associated with crescents.
In both types few organisms are found in the cir-
culating blood but are abundant in the internal
organs. Also in both types the corpuscle is shrunken
and of a brassy hue and segmentation takes place
while the corpuscle is yet intact. The tertian organ-
ism is much larger than the quotidian; segmentation
is observed earlier and there is greater activity in the
former than in the latter.
These forms differ from the ordinary spring quo-
tidian and tertian forms, in that they are much
smaller; present ring-shape hyaline forms; contain
much less pigment which is practically inactive; divide
into fewer segments; shrink instead of distend the
corpuscle — which turns to a brassy hue; and show
the presence of crescents, which are never seen in the
ordinary tertain forms.
As to the peculiar paroxysms caused by these
organisms the theories of Marchiafava and Bignami
are, to say the least, unique. They account for those
types of estivo-autumnal fever in which the parox-
syms are quotidian in character as caused by the first
described organism. The fact of irregularity is
explained by a tendency toward retardation and anti-
cipation of the organism in segmenting. Thus they
explain the almost continuous fever and the fever
which borders upon the tertian form. In like manner
they explain the irregularity of the tertian form asso-
ciated with which are more severe constitutional
symptoms and the presence of crescenst.
The observations of Golgi in Rome in regard to the
lestivo- autumnal fevers go to disprove the observa-
tions of Marchiafava and Bignami. Golgi asserts,
that the pathologic process is not understood and that
122
MALARIA.
[July 18,
the classification of Marchiafava and Bignami is
entirely hypothetical. He finally concludes that the
presence of the organism in the blood is more acci-
dental than a direct cause of the disease. He states
as highly probable that the observed organisms are
the beginnings of cycles, the length of which is at
present little understood. Golgi notes three stages
of development: The first, an ameboid non- pig-
mented hyaline body seen in circulating blood. The
second stage consists of small or large pigmented pre-
segmenting bodies found in the internal organs. The
third stage consists of segmenting bodies. He de-
scribes three forms of segmentation. The first is
similar to that seen in quartan and the ordinary
forms, differing in that there may be as many as fifty
segments. In the second form the segments do not
number more than eight or ten. In the third form
the organism varies from one-third the size of a red
corpuscle to even larger than the corpuscle. Seg-
mentation in this latter instance takes place in the
form of an irregular mulberry mass which surrounds
the centrally located pigment. Golgi is of the opin-
ion that these organisms are often found in phago-
cytes, in which they grow, segment and reproduce.
In summing up his observations regarding malarial
fevers, Golgi gives to the world the following
classification :
1. Fevers the cause of which lies in the existence
in the blood of parasites whose habitat is principally
in the circulating blood: a, the tertian parasite; b,
the quartan parasite.
2. Fevers the cause of which lies in the existence
in the blood of parasites whose habitat is principally
in the bone-marrow and spleen. The parasite in this
group he confesses his inability to classify completely
and refers to the crescents as "forms the biology of
which has not yet been well determined."
As a result of the investigations of other men we
have many and various classifications of the organism.
An ingenious classification is proposed by Grassi and
Felletti, who give five separate types:
1. Haemamoeba prsecox, a quotidian type with ten-
dency toward anticipation.
2. Haemamoeba immacula, a similar organism, but
more rapid and generally non-pigmented.
3. Haemamceba vivax, the organism giving rise to
tertian fever.
4. Haemamceba, the organism of quartan fever.
5. Laverania malarise, giving rise to irregular fevers.
These observers are confident that their classifica-
tion is the same as the quotidian type of the aestivo-
autumnal classification of Marchiafava, and agree
with Canalis, Golgi, Antolisei and Angelini that seg-
mentation may occur in the cresentic forms.
Sacharoff describes a parasite found in irregular
forms which corresponds to the aestivo-auturnnal par-
asite of Marchiafava, except that it is more fre-
quently found in the circulating blood. He gives
the following classification:
1. Haemamceba prsecox (Gra.).
2. Laverania (Gra.).
3. Haemamceba febris tertianae (Gol.).
4. Haemamceba febris quartanae (Gol.).
Later Mannaberg after extensive study of the para-
site, gives the following classification which he claims
to have vindicated.
1. Malarial parasites with sporulation without
syzygia: a, quartan parasite; b, tertian parasite.
2. Malarial parasites with sporulation and syzygia:
a, pigmented quotidian parasite; b, non-pigmented
quotidian parasite; c, malignant tertian parasite.
The last and perhaps the most complete study of
the organism of malaria has been made by men of
our own country, Thayer and Hewetson of Johns
Hopkins University, Baltimore. Their investiga-
tions divide the organism into three classes:
1. Tertian.
2. Quartan.
3. Estivo-autumnal.
With the exception of one investigator no one has
been able as yet to cultivate the plasmodium malariae
upon medium used in the culture of bacteria. This
one, Coronado, claims that he has cultivated the para-
site in water taken from a source whence many per-
sons had contracted the disease. He claims, more-
over, to thus have traced the entire development of
the organism. He claims also to have seen the devel-
opment of the flagella from the pigmented forms
which becoming free broke into from ten to fifteen
parts, which began anew the cycle of the organism's
existence. These experiments, however, we can not
accept as facts, as many other competent and distin-
guished men have been unable to obtain like results.
Positive results, however, have been obtained in
attempts to preserve the activity of the organism out-
side of the body. Sacharoff succeeded in preserving
the estivo-autumnal organism for seven days by means
of the use of ice. The parasite at this time retained its
ameboid movements and staining qualities. In the case
of the tertian parasite, at the end of forty-eight hours
all the adult forms had disappeared, only the hyaline
bodies remaining.
Inoculation experiments have been successfully
made. Gerhardt was the first to show that malarial
fever could be produced by inoculation. In two cases
he produced quotidian paroxysms by infusing blood
from a patient suffering from this form of the disease.
The stages of incubation were respectively six and
sixteen days. Later Marchiafava and Celli, and
Manotti and Ciarrochi made successful inoculations.
In each case they found in the blood of the inoculated
persons the same form of the organism as was present
in the blood of the patient from whom the inoculation
organisms were taken. The time of incubation was
from eight to fourteen days.
Gualdi and Antolisei made inoculations from the
blood of patients suffering with quartan fever, and
obtained the estivo-autumnal form. From this they
claim to have proved their theory that different
types of the organism are not associated with dif-
ferent clinical manifestations. However, it was later
proven that the patient from whom the blood had
been taken had but shortly before the inoculation suf-
fered from estivo-autumnal fever. The existence of
the estivo-autumnal type in the inoculated person is
explained by the theory that the latest estivo-autum-
nal organisms reaching at this time their development,
overpowered the quartan parasites.
This experiment leads to interesting observations
made by Di Mattei, who injected the blood of a patient
suffering with quartan fever into one suffering from
estivo-autumnal fever. In sixteen days there was no
evidence of the existence of the estivo-autumnal par-
asite, none but quartan being present. He also inoc-
ulated a patient suffering with quartan fever with the
estivo-autumnal organism. In ten days the quartan
had disappeared, being replaced by the organism of
the estivo-autumnal type.
1896.]
PHARMACY IN MEDICAL COLLEGES.
123
Oalandruooio, who had never suffered from malaria,
successfully inoculated himself with the tertian organ-
ism In the case of other patients he obtained posi-
tive results from inoculations of estivo-autumnal
organisms.
Uein in his experiments found that he often obtained
by inoculation from a quartan fever one of the tertian
type, and also from the tertian the quotidian type.
From the above experiments we may draw the fol-
lowing conclusions : »
1. The plasmodium malaria? can be transmitted by
inoculation.
•_'. The same type of organism is always obtained.
3. The average length of the period of incubation
is from eleven to twelve days.
4. When more than one type of organism is present
at the same time, the symptoms are produced by one
variety alone, the growth of this type being associated
with the disappearance of the other.
In the preceding digest of the works of the most
prominent men engaged in the study of the parasite
of malaria, the writer has endeavored to give some
idea of the theories which have thus far been given
to the scientific and medical world. At times these
theories are in harmony, but perhaps oftener are
opposed to one another.
It will be the object of the writer to separate from
this chaos those theories which he has been able to
establish through his own personal research. He will
also aim, as far as possible, to set forth those theories
which he has been unable to attempt to corroborate,
but which have been accepted by the most competent
investigators of to-day.
(To be continued.)
BE
HOW MUCH PHARMACY SHOULD
TAUGHT IN MEDICAL COLLEGES?
Read in the Section on Materia Medica. Pharmacy and Therapeutics, at
the Forty-Seventh Annual Meeting of the American Medical
Association at Atlanta. Georgia, May 5 8, 1896.
BY G. WALTER BARR, M.D.
Professor of Materia Medica. Therapeutics, etc.. in the College of Phy-
sicians and Surgeons, Keokuk, Iowa; Physician to Mercy
Hospital; Member Illinois State Pharmaceutical
Association, etc.
QUINCY, ILL.
Notwithstanding modern tendencies, the main
question is not how long the college course, but what
and how well it is taught. The real value a student
gets out of his college life depends upon the curricu-
lum and the thoroughness with which things are
learned, not upon how much of one thing he learns.
The balancing of the curriculum is the most neglected
as well as the most important consideration occupying
the attention of faculties. Too often that professor
who is most energetic in his college work has the
most of the students' time, and the laziest professor is
seen least at the college. Some colleges in America
turn out pathologists, some surgeons, others chemists,
and a few dermatologists, the graduates in each case
being weak in other equally important departments of
medical knowledge.
Again, each chair should lay out its work according
to a definite plan in which each part receives exactly
the proper emphasis, so as to teach the most valuable
things pertaining to that department in the time
allotted it; the surgeon should not teach the pathology
of tumors completely and say little about fractures
and dislocations; nor should the chair of materia
medica teach botany to twice the extent of physio-
logic' action. That these truisms, so axiomatic when
formulated, really need to be called to the attention of
many teachers is proven by the work actually being
done in colleges which are rightly considered first
class institutions of medical learning. While they
deserve extended consideration, they are stated here
simply to logically lead up to the question which
touches the interests of every medical man and is the
title of this paper.
Whether the course be two or twelve years long, the
chair of materia medica and therapeutics can not
cover the whole field of accepted knowledge in its
department of science, because the bacteriologists, the
dyeworks, the African savages and the psychologists
are all combined to furnish grist for the mill far
beyond its capacity to utilize. The teacher must
first separate the wheat from the overwhelming mass
of chaff, and then again choose those grains which
will afford the most valuable pabulum to his students.
The need of these students is something to enable
them to practice medicine scientifically, safely and
esthetically. Pharmacy is an ingredient of each and
all of these requisites.
Scientific medicine requires training in and the
practice of great accuracy. Pharmacy conduces to
this by its very character. The number of prescrip-
tions written so as to be chemically or pharmaceutic-
ally incompatible should be no greater than the num-
ber containing mistakes in therapy or indicating
errors in diagnosis. It is just as discordant to the
cultured ear to hear a reference to green iodid of mer-
cury, to have the fluid extract and the extract of nux
vomica spoken of as two entirely different drugs as
regards their dynamism, or to be informed about the
tincture of pilocarpin, as it is repugnant to the edu-
cated mind to read of Bright's disease, surgery with-
out anesthetics, or the humor pathology of boils.
In both cases it is not merely the nomenclature which
excites our derision, but the lack of real knowledge
back of the terms used, as evidenced by the language
itself. The physician who makes a diagnosis of
Bright's disease and bases his therapeutics thereon is
not giving the patient the advantage of the common
scientific knowledge of the day; and neither is the
physician who prescribes fluid extract of pilocarpus
when pilocarpin is needed. It is not true that all of
the galenical preparations of a given drug always
have the same dynamic action; to know when differ-
ences arise in the action of different official prepara-
tions requires a knowledge of pharmacy, and not to
know is to be unscientific in one's therapeutics. A
widely diffused knowledge of pharmacy within our
profession would at once cause the death from finan-
cial starvation of most of the proprietary medicines
which now have almost as large a sale to physicians
as their predecessors in the patent medicine field had
to the laity thirty years ago. That this is equivalent
to an immense increase in scientific therapeutics goes
without saying.
The element of safety in prescribing and dispensing
touches pharmacy at several points. Incompatibility
with dangerous results is perhaps the least important.
The difference between the intentions of the physi-
cian and the actual administration of the medicine at
once suggests itself. The basic function of the Phar-
macopeia and the National Formulary is to attain
uniformity of definition of drugs and their combina-
tions, so that the patient shall receive from the phar-
macist exactly what the physician had in mind when
124
MATEEIA MEDICA AND THEKAPEUTICS.
[July 18,
the prescription was written. Very much of the dis-
satisfaction with the work of the pharmacist comes
from the physician writing for' one thing and the
pharmacist putting up what the scientific world has
agreed should be so denominated, while the physician
had in mind quite another thing as the definition of
the noun he used. In the cases — which the writer
believes to be comparatively rare — where there is
actual dishonesty upon the part of the pharmacist, a
comparatively slight knowledge of pharmacy would
detect the fraud and conduce to the safety of the
patient.
The question of esthetics in the administration of
medicines has practically been decided by compulsion
from the patients. We were forced to meet the
homeopaths on their own ground some time ago in
this respect. But there is a higher motive in palata-
ble prescribing than to please the patient. Palatable
prescriptions are taken more regularly, the exact
dosage is maintained better, and the psychic effect
is not to be ignored. None of these advantages can
be attained without a knowledge of pharmacy unless
we fly into the arms of the patent medicine purveyors
to the profession.
What has been said about prescribers applies with
even greater force to those physicians who dispense
their own prescriptions. The pharmacist notes the
error in the written prescription and telephones the
doctor, who insists that there is no error and orders
the prescription changed. The dispensing physician
has not the advantage of this proofreader. The phy-
sician who writes prescriptions ignorantly receives
the punishment himself in the contempt of the phar-
macist who fills them: the dispenser, ignorant of the
pharmacal art he is practicing, causes the innocent
patient to suffer the effect of his pharmaceutical mis-
takes.
Admitting the value of pharmacal knowledge to the
practicing physician, the question of how much he is
to be taught must have due regard to the time that
can be allotted to the subject in the college which
teaches him. The teaching of pharmacology should
come at the beginning of the course in materia med-
ica. The experience of the writer, harmonized with
his opinions above set forth, is that the subject should
be given a full year. This means that the freshman
year should be devoted in this department to pharma-
cology; the time may be shortened enough to admit
teaching the methods and times of administering
medicines in the same year. The second and third
years may be then devoted to dynamic action and
therapeutics; three years of a four-year course is all
that the chair should be allotted in the curriculum.
Not much pharmacy, comparatively speaking, can
be taught in the hours allotted to one chair for one
year; but it is approximately enough for the physi-
cian; it should be apparent that the latter does not
need so- much as the professional pharmacist. The
next consideration is, what part of pharmaceutic
knowledge is most important to the physician and
should be taught him. The opinion of the writer is
expressed in the following syllabus :
Definition of various general terms; definition and
description (with history) of the United States Phar-
macopeia and National Formulary; valuable unofficial
drugs, and why not admitted ; the relation of proprie-
tary preparations to scientific medicine; when they
may be rationally used; nomenclature; the classifica-
tion of the pharmacopeia, including definition, modes
of preparation, and peculiarities of each class of prep-
arations, beginning with crude drugs, every detail
being actually performed by the student in the labor-
atory assumed to be attached to the chair under a
competent demonstrator; posology; prescriptions, the
construction of; chemic and pharmaceutic incom-
patibility; esthetic prescribing (all illustrated by the
student's own work in the laboratory).
This schedule does not trespass upon the domain of
the chair of chemistry, and in actual application has
given excellent results. Students who return as
experienced practitioners express a high opinion of
its value to the physician, and not one complains that
the time could have been devoted better to other
things. The one drawback to it has been the absence
of adequate textbooks, the latter being either too ele-
mentary or else too complete in their pharmacology.
It is a disadvantage to render necessary even one
more textbook for the modern student. The works
on materia medica and therapeutics, except Potter's
textbook, slight the subject under consideration as a
rule. There has lately been issued a textbook upon
pharmacy which is really more than its title implies.1
It is really such a comprehensive treatise upon medi-
cal chemistry, that many professors of chemistry will
be very willing to adopt it as a text for that depart-
ment, while it leaves little to be desired as a textbook
correlative to the work under the chair of materia
medica outlined above; its double use in this way
will obviate the most serious defect in the writer's
plan with which he has had to contend.
The response to the expected inquiry as to why
this paper was not presented to the American Medical
College Association instead of to this section may as
well be made in advance. It might as well be admit-
ted that the curricula of colleges is largely dependent
upon what the general profession demands. Hygiene
and sanitation will not be given much attention in
colleges, in spite of State boards and legislation, until
the profession is more generally awakened to the
importance of this subject; bacteriology is as a rule
sufficiently taught because the profession realizes its
importance in the modern practice of medicine; what-
ever the profession thinks is the proper amount of
pharmacology needed by the practitioner, that much
will be taught in the generality of colleges. The
question, which is the title of this paper, is therefore
brought directly to the power which will make the
final decision in the matter.
THE TEACHING OF MATERIA MEDICA
AND THERAPEUTICS IN RUSH
MEDICAL COLLEGE.
Read in the Section on Materia Medica. Pharmacy and Therapeutics,
at the Forty-seventh Annual Meeting of the American Medi-
cal Association, at Atlanta, Ga., May 5-8, 1896.
BY DANIEL R. BROWER, M.D.
PROFESSOR MENTAL DISEASES. MATERIA MEDICA AND THERAPEUTICS,
RUSH MEDICAL COLLEGE.
CHICAGO.
The teaching of materia medica and therapeutics
in Rush Medical College is done in a lecture room,
recitation rooms and the laboratory of materia medica.
I have associated with me in the work eight assist-
ants; one is the director of the laboratory, one gives
the didactic lectures in materia medica and the others,
as instructors, hear the recitations and assist in the
laboratory work.
1 A Treatise on Pharmacy by Charles Caspari, Jr., Ph.G., Philadel-
phia, 1895.
TUBEKCLE ANTITOXIN OR ANTI-TUBERCULIN.
125
The materia mediae is taught in theseoond year of
the college course (a four years' course), beoause it is
necessary, iu my judgment, that the student should
have a freshman's knowledgeof chemistry and physi-
ology to enable him to do good work in this branch.
As an introduction to the course one hour a week in
the last half of the freshman year is devoted to a
lecture on medical pharmacy, by I. A. Patton, M.D.,
the director of the laboratory.
The subject of materia medifea is divided into
twenty-eight topics, and one week given to each. The
subject is introduced by two didactic lectures, one
hour each, given by S. L. Weber, M.D. This is
followed by two hours of laboratory work and this by
one hour of recitation. Five hours a week are there-
tore given to each topic. The whole class attends the
lectures in one of the lecture rooms.
The class is divided into sections of from forty to
rifty students for the laboratory and recitation work.
The instructor who conducts the recitation of the
section, is the assistant to the demonstrator for that
section in the laboratory work.
In the laboratory work each student is furnished
with a manifold copy of his day's work. He has
already had two hours of didactic teaching on the
subject matter. He now examines the physical prop-
erties of tin' drugs, makes such tests as are desirable
to determine purity and show incompatibilities;
either makes a pharmaceutic preparation or com-
pounds a prescription, and at each exercise either
writes a prescription in both English and metric sys-
tems or criticises a prescription written by the demon-
strator.
There are three examinations in course during
the term on the didactic, recitation and laboratory
work, and one week is given to each. The student's
final average is made up from his general recitation
and laboratory work, and these three examinations.
The course in materia medica, therefore, consists of
140 hours' work in the college.
Materia Medica Laboratory. — During the course
each student has examined over three hundred crude
and finished drugs regarding their physical, chemic,
pharmaceutic and medicinal properties. Twelve phar-
maceutic preparations have been made during the
course illustrating liquors, tinctures, wines, syrups,
compound syrups, infusions, liniments, pills, oint-
ments, etc. Thirty compound prescriptions have been
written, corrected and returned. Twenty prescriptions
have been compounded, illustrating most all kinds of
prescription work. Three hundred or more tests of
incompatibility have been made; calculation of dosage
for prescriptions, of percentage solutions by weight
and volume; comparison of apothecary and metric
systems, etc. Desk room for sixty students to work
at one-time and cabinet space for 120 complete sets of
apparatus is provided in the laboratory.
Therapeutics is taught by didactic lectures and
laboratory work. The didactic course consists of sixty
hours of work. The materia medica, as far as
practicable, is grouped around the great functions of
the body and their diseases. The course begins with
those substances acting on the digestion, nutrition
(tissue waste and repair), calorification; then are
considered those acting on the nervous system, organs
of circulation, sexual organs, alimentary canal, those
acting on the various secretions. The therapeutics of
the principal disease of each of the organs and func-
tions is made the central feature of each lecture.
The laboratory course consists of twenty-two hours
instruction, the first half of which is devoted to
electro-therapeutic appliances, as follows: General
physics of electricity and theories of battery con-
struction; electrolysis, cataphoresis ; physiologic action
in general; catalysis, electro-diagnosis, cautery, elec-
tric light, faradic batteries and currents, static and
alternating machines. These exercises are illustrated
by the use of batteries, electric machines, etc. The
students construct the batteries, if possible. The
remainder of the course is given to massage, lavage,
enemata, colonic flushing, preparing articles of diet
for the sick, to pneumotherapy, blistering, cupping,
leeching, wet packing and hypodermic medication.
Throughout the course use is made of dispensary and
hospital patients for the purpose of illustrating all
possible points.
The class is divided into sections of twenty; to each
is assigned an instructor and the demonstrator directs
the whole. A special instructor, Miss Mabel Hayes,
who is the teacher of cooking in the Illinois Training
School for Nurses, gives the lessons in preparations
of foods for the sick.
I am very sure that since the introduction of these
two laboratory courses, our students go out better pre-
pared in materia medica and more familiar with thera-
peutics than ever before. These laboratory courses
are still in a developmental state, and I presume each
year will witness a lengthening of the time given to
this work, and a possible lessening of the time given
to didactic teaching.
TUBERCLE ANTITOXIN OR ANTI-
TUBERCULIN.
Read in the Section on Materia Medica, Pharmacy and Therapeutics
at the Forty-seventh Annual Meeting of the American Medical
Association, held at Atlanta. Gar, May 5-8, 1896.
BY PAUL PAQUIN, M.D.
ST. LOUIS, MO.
It is probably to Richet and Hericourt1 that the
principle of sero-therapy is due, because they were
first in formulating it fairly in their researches on the
micrococcus pyosepticus. All other investigations, due
chiefly to the initiative of Behring, have confirmed
the almost prophetic possibilities of the claims of these
two investigators, particularly on the general activity
of serum as a living microbicide power.
But it is not on its general antiseptic property that
the therapeutic value of serum rests, for it is incon-
stant. It rests on a physiologic problem, long com-
bated, viz.: phagocytosis, so clearly elucidated by
Metchnikoff . The microbicide power of serum is un-
questionable. It opposes the development of certain
microorganisms, but it does not exercise the prepond-
erant influence of serum in its specific application in
disease. The prevention or cure of a microbic disease
rests on acquired immunity, and, immunity even
natural, is not conferred by the germicide property of
the blood. As evidence of this fact, we have the dog,
whose blood serum is not bactericide in presence of
the bacillus of anthrax, and yet this animal is compar-
atively immune to this affection. On the other hand,
the serum of the rabbit is bactericide in presence of
this germ, and yet this animal is exceedingly suscep-
tible to anthrax. A seemingly conclusive argument
that the bactericide virtue of serum is not the basis of
immunity, or of the special therapeutic properties it
i I acknowledge many thoughts to D'Achalme, Hericourt and others
in preparing this article
126
TUBERCLE ANTITOXIN OR ANTI-TUBERCULIN.
[July 18,
may possess, is the evidence that heat at 55 to 60
degrees C. destroys this power, without modifying the
physical, chemic or therapeutic constitution of serum.
The efforts of Hankin, Buchner, Ogata, Josuhara
to isolate the bactericide substance, or substances,
from serum were negative, and to-day there are think-
ers who associate it with the globulicide property,
which is probably an inconstant but a more or less
potent factor when it does exist.
The therapeutic property of serum has been desig-
nated by the name, antitoxic, which is, in my mind,
an unfortunate selection, because it implies, or at least
suggests to the mind of the practitioner, that sero-
therapy depends on the chemic neutralization or
destruction of the microbic toxins. The general
practitioner is usually a busy man and has but little
time and few opportunities to investigate, minutely,
the intricate understructure upon which organic ther-
apy is being raised. He almost necessarily arrives at
conclusions on the significance of the words and lan-
guage of the reports of scientists and bases his appli-
cation of the remedies thereon. As a consequence,
numerous practitioners think that the antitoxin of
diphtheria kills the germs in the body very much as
bichlorid of mercury would kill them in a beef broth
culture, and destroys their toxins by some direct
chemic action.
No one yet knows the nature of the actual element
underlying the antitoxic power. Notwithstanding
their splendid work, neither Tizzoni, Aronson, nor
Hammersten have demonstrated that they have ob-
tained it in purity. But very practical deductions
have resulted from the remarkable achievements of
Kitasato in sero-therapy of tetanus; of Behring and
and Roux in diphtheria, and it seems that we can not
disassociate the antitoxic power, so-called, of thera-
peutic serum from what is termed its immunizing
property.
Metchnikoff has made very convincing researches
on the fundamental questions involved in the problem
of immunity. Among other things he has demon-
strated that rabbits, vaccinated against hog cholera,
produce a serum which is both preventive and cura-
tive in new subjects. And yet this same serum was
found to possess neither a bactericide nor an antitoxic
property of the nature that is said to exist in diph-
theria antitoxin. The influence of this therapeutic
serum at least was not directly on the germs or their
products. And even diphtheria antitoxin, which was
supposed to act directly on the toxins and their crea-
tors, because of the apparent loss of vitality of the
latter when mixed with the former before their injec-
tion into the system of experiment animals acts indi-
rectly after the treatment. It certainly does not
destroy the germs for they are often found in their
virulence in the mouth of recovered cases, weeks after
the last injection of antitoxin.
It is then to nature herself that we must look for
the explanation of the questions involved in the action
of serum in therapeutics. A necessary factor is the
natural forces of the organism experimented with or
treated against a microbic disease. Men or beasts
sometimes recover from a usually fatal germ disease,
such as diphtheria, smallpox, tuberculosis even. What
produces the cure? Nature's elements to arrest the
development of the germ and antagonize the effects
of their poisons. What are the forces producing
these elements ? The phagocytes. They are the chief
defenders of the body, both in a physical sense and a
restricted chemic manner, for the germs are antagon-
ized in their development by the phagocytes, and
their toxins are antagonized in their nocive power,
probably by a cellular diastase.
Anti-tubercle serum is, like any other antitoxin, the
product of nature to antagonize the encroachments of
germ life in the system. It is produced by the organ-
ism subjected to a continuous, progressive system of
saturation of the economy with the toxins of the
bacilli of Koch, especially to antagonize the parasitic
life of this germ. It is the defensive power which
fights its advancement, step by step. Occasionally, a
case of tuberculosis recovers without medical assist-
ance. This is due to natural properties within the
economy, the defensive and defense-producing forces,
assisted or not by the action of outside influences,
such as climate, nourishment, etc. The production of
tuberculous antitoxin is due to the action of tubercu-
lin, the germ poison in the body. Tuberculin irri-
tates the cells; the cells retaliate by augmenting the
power of the phagocytes. In other words, the action
of tuberculin in a susceptible organism, consists of a
reaction, more or less severe, if administered in more
or less heavy doses. During this reaction, nature pro-
duces the antitoxin in the blood. Then this anti-
toxin or the anti-tubercle serum, or anti-tuberclin,
is filtered out and used in man by hypodermic
injections, thus infusing into his blood the very
antagonist which nature creates or exalts in power
to arrest tuberculosis.
The theory is beautiful; the facts are demonstrated.
Bertin, Picq, Maragliano, Behring, Foa, have all
experimented with naturally or artificially immune
serum in the treatment of tuberculosis and the last
three scientists have obtained favorable results in man
and beast. It was in our country, however, that the
horse was first immunized against tuberculosis and
his serum used successfully on a large scale against
all forms of tuberculosis. The serum produced in my
laboratories is the result of several years of investiga-
tion of tuberculosis in man and beast, at the State
University of Missouri, and subsequently, in private
and in the special institution under my control. It
consists of clear amber serum of horses having under-
gone the process of immunization from three to six
months, the usual time to reach a non-reactionary
point, by daily injections of tubercle toxins, from
liquid beef cultures, at the progressive dose of 2 c.c. to
20 c.c. daily. The toxins of the germ cells, themselves,
dessicated, may be used also to increase the intensity
of the immunity, when the toxins cease to react before
three months of injections.
The horses are always kept under observation sev-
eral weeks and then examined, and tested for glanders
before subjecting them to the injections of toxin for
immunization. Consequently, no danger exists of
transmitting animal diseases, or disease toxins of the
horse to man. Furthermore, our system of filtration
precludes the possibility of any germ remaining in
the serum if any should be present when the blood is
withdrawn from the animal.
The physiologic effects of serum, some of which
are undesirable, are well known. Any serum, immu-
nized or not, may produce erythema, urticaria, artic-
ular pains and swellings, oligocythemia, oligochrome-
mia, local cellulitis, swelling, etc., without being in
the least impure from a bacterial standpoint.
Certain elements in the serum, none of which hav&
yet been isolated, are more or less poisonous and pro-
18%.]
TUBERCLE ANTITOXIN OR ANTI-TUBERCULIN.
127
duee various kimls of intoxication, with varying
symptoms and pathologic phenomena. Some exhibit
symptoms of nervous disturbance; others of interfer-
ence, more or less pronounced, of the circulatory sys-
tem. Again, there sometimes occurs in protracted
treatment a curious, sudden flushing of the face,
apparently due to a disturbance of the vasomotor sys-
tem. All of these untoward effects are usually mild
and ephemeral and none of them militate against the
use of serum, although sometimes, in refractory cases,
one must use it very cautiously, in very small doses
at first, and even substitute rectal injections for hypo-
dermic medications.
All the efforts made so far, abroad and in our labor-
• atorv. to establish a precise and constant mode of
measurement of the antitoxic or therapeutic neutral-
izing power of anti-tubercle serum, have failed to
produce results reliable enough to constitute a sound
basis of estimation. The Behring law can not as yet
be applied with assurance. The effects of anti-tuber-
cle serum ii'i man or beast vary according to the stage
and nature of the affection, the amount of special or
general tuberculous intoxication, the microbic mix-
tures in the diseased organs, and the nature and
progress of the lesions. So far, the estimation of the
tubercle antitoxin is based chiefly on the neutralizing
influence of a given quantity of it mixed with a given
quantity of tubercle of a given strength, the mixture
being afterward injected in small animals and results
noted. But the fact that these small animals have
different powers of resistance to tuberculin vitiates
the system. So far, the best gauge we have to deter-
mine the value of anti-tubercle serum is our experi-
ence with the results obtained with a certain class of
horses, immunized three to six months, with a pro-
gressively declining reaction until it is nil, and our
results in our clinics in tuberculous patients and in
our laboratory in experiment animals.
Paquin's anti-tubercle serum is absolutely free from
microbes. It is put up in small vials of one-half
ounce, labeled with date of production and test.
Dose, 10 to 60 drops, hypodermically, every day or
alternate days. As much as 120 to 240 drops have
been administered, repeatedly, in successive days in
special cases, with good results. Per rectum, 30 to
240 drops daily, may be safely given. The results by
this method are not yet sustained by many reports,
but there seems to be no doubt that rectal injections
of antitoxin result in perfect absorption. Dr. Chan-
temesse of the Pasteur Institute, Paris states that
diphtheria is as readily controlled by rectal injections
of antitoxin or by hypodermic exhibitions and some
other antitoxins make similar reports.
DISCUSSION.
Prof. Edwin Klebs — There is quite a new and astonishing
development of interest in internal pathology in consequence
of the now generally adopted theory of the bacterial nature of
all infectious diseases ; the idea to search for bacterial remedies
has originated and fixed itself in the minds of physicians and
also become popular with the laity. We will find in no other
way a sure weapon against these destructive inhabitants if a
certain pathological process is nothing more than a combat
between the human organism and certain microbes vegetating
in the body. The surgeon has profited more by these
researches than the physician by the possibility of asepsis or
preventing the introduction of the germs in the operations on
the body. We, the physicians, find the microbes established
in the body, often for a very long time. In chronic diseases
such as tuberculosis there exists moreover a sort of symbiosis
between the two organisms, in which the forces of the germs
and of the human body are more or less counterbalanced. An
old phthisical patient may live long, seeing his wives and
all his offspring die before he pays his duty to nature.
That is no mere latent disease, but an actual affection, poisonous
to others, but not poisonous for its own body. We say in such
cases that the human organism is immunized against the
germs that have taken possession of it. I remember some of
our best writers, as Schiller and Stevenson, living and working
wonderfully under such conditions. Women have gained
under the influence of the more or less latent disease often-
times, an unsurpassed lovliness, often celebrated by poets and
highly esteemed by high minded men.
We observe many peculiar features of the disease, and
standing for long years, not at all offensive. I have seen
lately the case of a celebrated botanist, the disease latent for
fifty years, whose long career has been an uninterrupted chain
of good deeds.
All these remarks are pointing somewhat to the not yet
written psychology of tuberculosis, one of the most interest-
ing chapters of human biology. They will show that my long
contested thesis of self-immunization in this disease is proved
by daily observation as well as by animal experiments.
This fact opens a broad field for possibilities of healing, but
also renders the task of the physician difficult, as such persons do
not always realize their abnormal condition or are not willing to
acknowledge it. Such patients fill all health resorts, and not
always living as they should when there.
If we ask the conscientious physician what are the effects
of climatic or general treatment, he will concede probably
that they have more of a retarding than a healing influence.
The question will arise : Can we do more for these patients?
I am quite sure that the bacterio-therapy of tuberculosis will
afford us better methods.
The first principle of this therapeusis must be contained in
the demonstrated possibility of killing the germs in the body ;
the second in the not quite solved question of immunizing the
organism and of antagonizing the toxic effects of the germs.
The one problem does not exclude the other, but in chronic
diseases the first principle is of far greater importance than
the second.
Dr. Paquin, searching to solve the second problem, as
Viquerat before him, has given us some good results of the
serum treatment, which I do not think are at all doubtful ; but
to establish the fact in a scientific manner, clinical cases alone
are not sufficient. Every new treatment shows quite a number
of healed or improved cases. In man it is not possible to find
enough comparable cases, and the final effect can not be ascer-
tained in an unquestionable manner. Such thesis must be
proved by animal experiments, in which we can use absolutely
normal animals for infection and treatment ; whether we have
attained our object or not the postmortem will show. I have
endeavored to fulfill this task in a great number of experi-
ments with tubercle serum, taking daily temperatures and
weights through many months, but I could not effect the cure
of one animal, although the infection was slight and the doses
of tubercle serum large. Nevertheless, I do not say that there
will be no antitoxic effect from this treatment ; but unfortu-
nately this point is not sufficiently cleared up.
On the contrary, with germ-killing substances, prepared from
the tubercle-cultures I had far better healing results in animal
tuberculosis. I may say that they have given me the only per-
ceptible results.
In the guinea pig, the animal most susceptible to tuberculous
infection, the greatest deposits are found in the liver and spleen.
The two organs are swollen enormously and filled with yellow
tuberculous matter. Even such large deposits can be healed
by bacterial products. The liver shows deep fibrous scars with-
out any tuberculous deposit, otherwise quite normal except a
128
ATTENTION, AN ADJUVANT IN THERAPEUSIS.
[July 18,
little hypertrophic tissue. The spleen can be reduced to nearly
normal size except always a little hypertrophy in consequence of
the cirrhosis of liver, but it is quite free from tuberculous tissue
and tuberculous bacilli,as also are the other organs. Such results
can be obtained in three or four months treatment, whereas
the control-animal, infected with the same quantity of tuber-
culous bacilli, without treatment died in two or three weeks.
These results are now confirmed by a long and careful clinic
observation I had in Europe. In 72 cases 70 (93 per cent. ) healed
or were very much improved ; Dr. von Ruck reports in 182
cases treated in the Winyah Sanitarium 59(32.4 per cent.)
apparently recovered cases, 56 (30.8 per cent. ) greatly improved,
29 (16 per cent.) improved. Therap. Gazette, 1896, No. 5. That
other physicians had similar results, is stated in many published
observations, also indicated by the extensive use of antiphthisin
in the last year, amounting to more than 50 liters of 1 percent,
organic matter.
I have devoted myself in the last year especially to a renewed
study of the healing and immunizing properties of the differ-
ent compounds of the tubercle cultures. I found that my first
preparation, tuberculocidin (The causal treatment of tubercu-
losis, 1894) has an immunizing power, in a higher degree than
antiphthisin,2 the same as with tuberculin.
The immunizing power is conveyed to this preparation by
certain substances contained in the bacilli, whereasantiphthisin
is only prepared from the culture fluid. As the latter is the
mildest form of tubercle-killing substance from tubercle cul-
ture, I think it best to commence the treatment with anti-
phthisin and later, if there is no fever, use the tuberculocidin.
As the latter is more liable to produce fever than is the former,
it must be given in smaller doses, from 0.1 to 1.0 c.c, and also
more cautiously. The most successful cases that I have seen,
were treated in this mixed manner. (I regret that Dr. von
Ruck in his publication does not give separately the cases
treated with antiphthisin alone, and antiphthisin and tuberculin,
but I hope he will later report these cases separately and in a
more detailed manner.)
ATTENTION. AN ADJUVANT IN THERA-
PEUSIS.
Read in the Section on Materia Medica. Pharmacy and Therapeutics.
at the Forty-seventh Annual Meeting of the American Medical
Association, held at Atlanta, Ga., May 5-8, 189ri.
BY GEO. V. I. BROWN, D.D.S., M.D., CM.
DULCTH, MINNESOTA.
A careful scrutiny of the pathway along which has
traveled to us, almost from the beginning of history,
the knowledge of that state known variously as hyp-
notism, mesmerism, bradism, animal magnetism,
electro-biology, etc., on through an almost intermin-
able list of isms, ics and ologies, brought forward
from time to time by its many champions, now bright
with the brilliance of popular excitement and appro-
val, again darkened with the severity of general con-
demnation, hailed as a universal deliverance from
all the ills of mankind's heirdom, or crushed under the
ban of responsibility for crime or direful mental
injury, must, I think, convince most students that the
answer of the scientific bodies of to-day can be but
slightly different from that given by the Roi Medical
Society and the French Academy of Sciences, at
Paris in 1778, which, as everyone knows, was a refusal
to accept the so-called truths en masse. Yet there is
something about this subject that will not down, and
even though the whole may be full of fallacies and
fraught with danger, still there are facts concerning
* Dr. von Ruck says in regard to this point, I.e. : The two preparations
are practicallv identical and, so far as I have been able to observe, the
therapeutic effects are the same.
certain mental influences from which the therapeut-
ist has no escape. They must and do influence his
every effort, and the question at issue is simply:
Shall he try to ignore them and trust to a haphazard
effect, or will he guide and encourage this mental and
nervous action, for the furtherance of that which his
medical knowledge dictates to be beneficial?
After many years of study and experiment, I find
my objection to the general use of hypnotism in
no wise diminished. Out of the mouths and through
the pens of its warmest supporters have come to me a
confirmation of my feelings of distrust, and for some
time past my efforts have been directed toward the
accomplishment of possible usefulness in mental
treatment, without the necessity of inducing the
hypnotic state; hence this article, "Attention, an adju-
vant in Therapeusis." Attention because it brings
us nearer to the essential principle involved.
The one thing upon which all writers agree, irre-
spective of their other views, is, that without the
attention of the subject hypnosis would be impossi-
ble, and it matters but little whether the attention be
engaged with a flash of light, the sound of a gong,
fixation of gaze, or words of command, by musical
sounds, animal magnetism or any other manner, so
long as the flight of thought be arrested and concen-
trated upon the desired object.
Suggestion would be useless without the attention
of the subject, although suggestion is the most use-
ful means of producing mental impressions. Adju-
vant, because as a helper in cooperation with other
well-established remedies, psycho-physics can be safe
and useful, as it could not be in the light of a cure.
The simple facts to which I desire to direct your
attention are:
1. By a proper concentration, and the guidance of
the subject's attention nearly everything beneficial can
be accomplished that might be possible in the hyp-
notic state without hypnosis, and therefore without
its dangers.
2. The loss of conciousness is not always necessary
for anesthesia, or action upon any particular nerve
centers, and the parts under their control.
3. Much valuable assistance can be given to other
therapeutic measures in a great variety of ways, not
alone by stimulating the beneficial effect, but also in
the arrest and avoidance of antagonistic mental influ-
ence which so often aborts the intended value of
other treatment.
A brief study of certain mental and physical phe-
nomena will bear out as at least reasonable the prop-
osition stated, and practical evidence brought forward
in the cases cited will commend themselves to your
consideration in support of the deductions advanced.
We know that under quite natural conditions one can
become so absorbed in a good book or in a certain
line of thought that familiar sounds, ordinarily dis-
tinctly audible, will pass unheard. Yet there is no-
reason to suppose the auditory apparatus does not
carry the vibrations to the brain in the usual manner,
but no consciousness of the fact exists, because one
portion of the brain is inactive while the other parts
have perhaps unusual activity. This we recognize as
a sub-conscious state.
Wm. Romaine Newbold suggests the term, dis-ordi-
nation, as the opposite of coordination, and says the
fact that a mental state can exist dissociated from the
others, and without a personal consciousness, leaves
no room to doubt that many may be simultaneously
18%.]
ATTENTION, AN ADJUVANT IN THERAPEUSIS.
129
dissociated, or even the entire mental system dissolved
into a chaotic mass. That under these conditions
there would be no memory, because memory is
dependant upon association of ideas.
He describes hypnotism as a state of disordination
produced by the subject being put to sleep with the
sound of the operators voice constantly in his ears,
bis being made aware of his presence by the sense of
touch, or in some other manner, until all the elements
of normal consciousness are disordinated and more or
loss extinguished, save the one group governed by
the consciousness of the hypnotizer. That portion
lias had no opportunity to sleep, and naturally sus-
ceptibility to all other stimuli being lost, this one
group acts with an accuracy impossible in the waking
siatc. Epilepsy, shock, hysteria and trance state are
all forms of disordination.
Disordination from shock has been remarkably
illustrated in my own practice recently. A young
lumberman, of good habits, was kicked in the face by
a horse, his upper lip cut in the median line and the
upper jaw fractured on both sides, including also the
root' of the mouth. This occurred on Monday at
about 7:<i0 P.M., and he has no recollection of any-
thing that happened until the following Wednesday
evening, when his lip was sutured without pain,
though no anesthetic of any sort was used, and his
tirst taint glimmer of a returning memory was a hazy
recollection of the pins being stuck through his lip;
but the remarkable part is that in this interval he
had traveled fourteen miles in a sleigh and about one
hundred miles (from Ely to Duluth) by rail, was able
to walk about and attend to all his wants, and accord-
ing to his friends' testimony, was quite rational, told
about his case and answered all the questions cor-
rectly. No pain was felt until Thursday, when he
became fully cognizant of all things about him; then
his Buffering was of course quite severe.
It is a matter of frequent notice that after unusual
excitement of any nerve centers, as by study pro-
It mged sufficiently to cause fatigue, the brain will
continue to go over and over the particular line of
thought, even though all the other portions of the
brain are at rest, or a particular strain of music may
reverberate in the same manner, in short, any impres-
ts m that may have reached the brain may be repeated,
perhaps in dreams, possibly in moments of sub-con-
sciousness, but without any voluntary effort to start
its cerebral elements. This condition, known as
automatism, is noticeable in a variety of ways and
certainly gives justification to the idea that the repe-
tition of words intended to act upon certain centers
to produce some particular effect must excite vibra-
tions that will act automatically, and in time produce
the desired effect. This, as I will endeavor to show,
is precisely what does occur.
Professor Ladd of Yale University says of the
mechanical theory of nerve conduction, that messages
are transmitted by a series of wave motions, just as
light, heat, electricity and sound, which may be
accelerated or retarded by outward influences.
In certain moments of high nervous tension pain is
intense, thoughts are transmitted quickly, all sensa-
tions are acute, in other words, the vibrations are
more rapid, the pitch is higher, just as the tone of a
tightened violin string. On the other hand, with
nervous tension relaxed, all transmissions are less
rapid, the human violin string is loosened. Upon
these and kindred pecularities of brain and nervous
action depend all methods of physical treatment of
disease, and all of them are dependant upon attention
in some form or other for existence.
John Hunter, in 1838, said: " I am confident I can
fix my attention upon a part until I have a sensation
in that part," and told how he prevented a magnetizer
from affecting him by fixing his attention upon his
big toe, moving it about constantly.
Of the influence of expectant attention, Carpenter
says: " The contrast between the volitional and auto-
matic states of attention is particularly well shown in
the effects of painful impressions upon the nervous
system. It is well known that such impressions as would
ordinarily produce severe pain, may for a time be com-
pletely unfelt, through the exclusive direction of the
attention elsewhere." Continuing, he says: "Now
just as the organic impressions, which make them-
selves felt in pain when the sensorium is receptive of
them, may exist without consciousness if the senso-
rium be otherwise engaged, so it may be affirmed, and
on precisely the same evidence, that the organic
changes which are concerned in the automatic pro-
duction of thought, and of which we become con-
scious as ideas when the sensorium takes cognizance
of them, may go on without consciousness if the sen-
sorium be otherwise engaged."
Tuke says: "Attention may be definitely directed
to the parts affected accompanied by the expectation
of a certain result without the administration of
drugs," and cites a large number of cures thus effected.
In further support of this theoretic superstructure,
the authorities that one might cite are almost limitless.
Ladd, Sully, Luys, Newbold and other investigators
in mental physiology and psychology speak of these
various attributes of the action of the brain and nerv-
ous system, and recite many peculiarities that have been
strikingly brought to light, particularly as to cures
effected by expectant attention and the imagination.
As for records of hypnotism, the various faith and
other cures, their funds of examples are inexhaustible, a
fair proportion of which are unquestionably authentic,
but for practical purposes, I shall confine my illus-
trations to just the things that have been accom-
plished within my own experience, and only such of
these as will tend to show the subject in its various
aspects of usefulness.
In a former paper, published in the Chicago Dental
Review, I described some cases in which without
other assistance I had reduced the temperature of
patients suffering from febrile disorders, inducing
restful slumber by stroking the head and extremities,
as in gentle massage. One of these, a typhoid
patient, whose life was dispaired of by the physician
in charge, with the temperature taken just before
and twenty minutes after treatment had been begun,
showed a decline of three degrees, the restless tossing
about had ceased and sleep came to her relief, which
whenever she awoke was induced again, and so con-
tinued until morning. Nature, thus assisted, soon
brought about entire recovery. A case of hysteria
and another of dysmenorrhea, in which the symp-
toms were particularly distressing, were reported as
having been successfully relieved in the same man-
ner, and the painless performance of many minor
operations in analgesia, produced by suggestion, were
also referred to at the time, but I particularly called
attention to the fact that under certain states of hyp-
notic influence, while operations can undoubtedly be
painlessly performed, the danger of shock is much
130
ATTENTION, AN ADJUVANT IN THERAPEUSIS.
[July 18,
greater, and more to be dreaded than under natural
conditions, even though the suffering might be intense.
I am more than ever convinced of this fact and
find myself less willing to try to put a patient into a
condition where helpless to resist; there may yet be a
susceptibility to shock, extremely aggravated by the
disordered mental condition.
James R. Cook, M.D., thus describes his own sen-
sations upon being hypnotised for the first time :
When told by the operator: " You can not open your
eyes," says, " I was conscious that while one part of
my mind wanted to open my eyes another part did
not want to, so I was in a paradoxical state." In my
opinion patients are frequently in a paradoxical sate.
I was called by the present Secretary of this Sec-
tion, Dr. W. B. Hill of Milwaukee, to take charge of
one of his patients, a man of about 45 years, and at
my request, Dr. Hill has written a description. of the
case, which is as follows:
"Mr. G., a stationary engineer, came to me during
the fall of 1894, suffering from insomnia, anemia and
general neurasthenia. Circulation was very poor, cold
extremities, rapid and feeble heart, muscular twitch-
ings and pricking sensations all over the body.
" Tonics and nerve sedatives were ordered, but
patient could not bear any medication. Dr. G. V. I.
Brown was called in the case with me and recom-
mended massage, a suggestion which was carried out
by him with marked benefit to the patient.
"An examination of the rectum revealed a large inter-
nal hemorrhoidal tumor about one and a half inches
from the sphincter ani. I decided to operate by liga-
tion and use cocain as a anesthetic. After all pre-
cautions were made, inadvertently, the cocain solution
was spilled and I asked Dr. Brown to go to the
patient's head. The operation was performed under
hypnotic anesthesia produced by Dr. Brown, Xhe
patient experiencing absolutely no pain or discomfort
either during the operation or the time the wound
was sloughing off and granulating, but was given
suggestions daily for several days thereafter. All
symptoms of his former trouble disappeared, the
patient feeling better and more vigorous than for
some years.
"About two weeks (nine months later) there was a
recurrence of the trouble to a slight degree ; an exam-
ination showed another small tumor in the same
region. I again operated, under the influence of
cocain (Dr. Brown not being present), the operation
was not without pain this time, although I had the
same happy result as far as neurasthenia was con-
cerned."
In addition to what Dr. Hill had kindly stated, I
wish to give the following facts: The treatment
given was general massage for fifteen minutes every
evening at bed time, attention directed to the parts in
which the circulatory process was most inefficient,
with the purpose of augmenting and continuing for
a longer time the effect of the increased blood supply,
due to the rubbing. In the abdominal region he was
massaged to cause peristaltic action and his attention
directed to the part with instructions to have a pass-
age one-half hour after breakfast. The massage con-
cluded, he was made comfortable for the night, and a
gentle stroking about the occiput and frontal region
soon caused drowsiness. Over and over again were
repeated, in a monotonous yet impressive manner, the
words, "Sleep, sleep well, all night long. If you
awaken, go right to sleep again; havje a passage from
your bowels half an hour after breakfast." Upon
several occasions when he was particularly restless
his gaze, with eyes upturned, was fixed upon my fin-
ger for three or four minutes to assist concentration
of his thoughts, and twenty deep, full breaths were
taken, but at no time was the process carried so far as
to produce hypnosis; the sleep, when he fell asleep,
was apparently a natural one. As strength returned
active movements were prescribed, and the idea of
self-help inculcated to arouse his will. In exactly
seven days from the first treatment the patient
returned to his work, having been unable to do so for
some three months. His rest was regular, digestion
improved, and every morning at the appointed hour
he had an evacuation from his bowels, which was
remarkable in view of the fact that for many months
it had been his custom to give himself an enema for
this purpose and all natural effort seemed to have
ceased. Anesthesia was produced during the opera-
tion upon the rectum by having the patient hold my
hands, instructions having been given to keep a strong
pressure as possible in order to keep his thoughts
fixed upon the effort, which we were successful in
doing. Not only was he conscious all the time, but
in no respect did he show himself to be influenced
except in the desired absence of painful sensation.
Relief was given another patient who was suffering
from intestinal catarrh and had severe pain at certain
hours in the day. She was instructed to lie down
at about the hour the pain was expected, close her
eyes and take twenty long breaths, filling the lungs
quite full and exhaling slowly. The centering of the
mind upon the breathing after a little training put
her to sleep so readily that she was seldom able to
reach the twentieth breath. The nap gave rest and
quiet to her nerves, beside tiding over the painful
period. Mrs. A., about 28 years old, with a history of
supra-orbital pain of an intense paroxysmal character,
lasting for a few moments at a time and varying from
ten minutes to four hours apart, ever since she was 8
years old, night and day. Pour hours was the longest
period of freedom of pain remembered, except upon
two occasions; once, after an overdose of some drug,
five hours' rest; and after a thirty-mile sleigh ride
she slept five hours. Opiates had been taken con-
stantly, sometimes in very large doses. All varieties
of treatment had been tried, both in this country and
in Germany. Resection of the supra-orbital branch
of the trigeminus had given no relief, pain return-
ing the moment the effect of the anesthetic had passed.
The day I was called she had fallen upon the floor in
a stupor from exhaustion. As a preliminary step, all
drugs of whatever nature were prohibited, and after
about two or three weeks daily treatment, intervals of
five, six, seven, eight, nine, ten, and even fourteen
hours without pain were not infrequent. General
health and spirits were, of course, improved, and fairly
undisturbed rest at night was the rule. Had not
treatment been unavoidably interrupted there seems
every reason to have expected much greater improve-
ment; certainly any change for the better was the
most severe test. The attention was guided, but not
to a hypnotic state.
As to the exact manner of practical application but
little can be said, save in a general way.
In my own experience, the individual peculiarities
encountered require a great diversity of methods; par-
ticularly among the hysterical is there a latent perver-
sity which sets itself against one's prime object, and
IS-n; |
PRACTICAL USES OF SUGGESTIVE THERAPEUTICS.
181
■0 it frequently happens that I use the word, sleep,
quite sure that suoh a patient will not sleep, yet, with
the mind centered upon not going to sleep, other sug-
gestions incidentally brought forward are usually
quite readily effective.
loeutration of gaze five minutes, followed by
twenty full, rapid inhalations and exhalations are
usually sufficient for operations that can bequickly per-
formed, such as an opening of an abscass or extracting
a tooth, hut the breathing must be continued without
stopping until the operation is finished.
For patients suffering from digestive disturbances,
insomnia, tinnitus auriuin (when aggravated by ner-
vousness) or any affection for which it may be desir-
able to prescribe home treatment, the method of lying
with the eyes closed and breathing as before described
is by all means the best, Respiratory effort is of
itself a beneficial exercise, easily understood and
readily adopted by reason of its simplicity.
I have treated hypnotism as a disordinated state
quite different from natural sleep, in which the sub-
ject is not open to suggestion and would awaken if
suggestion were attempted, for, though denied by
some, this distinction is well supported by eminent
authorities, and accords fully with my own observa-
tions.
The objectionable features to hypnotism, Christian
science and many methods of psycho-physics are:
To say nothing of the dangers of hypnotism as
regards crime and physical injury, which, notwith-
standing its repeated denial by ardent advocates, is
still supported by a great amount of evidence. There
is beyond question the fact that repeated hypnotiza-
tion causes a dangerous susceptibility. Bernheim,
Binet and Feret, Luys, Faveau, DuConormeilles, Hart,
Cocke and many others all admit this fact, though
some claim the danger can be avoided by suggestion ;
nevertheless, Hart took several of Luys' patients that
had been given the usual suggestion not to let others
hypnotize them, and in the presence of several relia-
ble witnesses, induced the hypnotic state without
difficulty ; but assuming for the nonce, every physi-
cian to be equal to the harmless management of these
difficulties from the point of view of the therapeutist,
the essential and vital difference between the treat-
ment here recommended and the hypnotic suggestion
is. the one tends to build up, foster and encourage the
will force and judgment of the patient, teaches self-
reliance, and increases mental power. Whereas, the
other weakens and destroys, in a measure at least, the
inherent wdl power, takes away self-reliance and the
valuable notion of personality. What physician, with
the patient reduced to a mere automaton, subject to
every word, every gesture, every look of the hypno-
tizes can tell the exact physical state; when the
patient, told that he is better, repeats; "Yes, I am
better to-day," or marks any improvement that may
be suggested to him, notwithstanding the fact that
the disease may at the very moment be on the increase,
with all the symptoms masked by his mental state.
Who is prepared to become "his brother's keeper,"
to say, "my mind is all right; I see and know all
things clearly; I will be responsible for other minds
and my own also?" Surely no one who has studied
deeply into psycho-logical mysteries.
• The so-called healers of Christian science, while they
have clone wonders in developing the field of mental
treatment, deal in just this manner. Perhaps I
speak a little bitterly, but I have in mind a friend of
mine, who was buoyed up with the false hope and
fancied improvement suggested by those charlatans,
until a cancer had stolen its way so deeply into his
vitals that at least' a number of years of his life, that
otherwise might have been spared him by correct
early diagnosis and the knife, had been lost.
The one thing that retards progress is a tendency
to deception, particularly in this connection. Rec-
ords of psycho-physics abound with lists of cases in
which the patients have been deceived in this or that
manner, given bread pills and water instead of the
expected remedies, etc., throughout the familiar
tricks. Now, while this may be very interesting in
the light of experiments, lying and deception make,
to say the least, a very unstable foundation upon
which to build a therapeutic structure.
I have tried to strip this subject so far as possible
of odious associates, believing that if accepted at all
by the medical profession and accorded the place I
feel it ought to have among legitimate therapeutic
measures, its advance must be in a strictly conserva-
tive manner, without mysticism, and viewed only in
the light of natural mental science.
BIBLIOGRAPHY.
Hi in'!, and Feret: Animal Magnetism
Dr. Bernheim ; Suggestive Therapeutics; translated by Christian A.
Harter, M.D.
Cocke, J. R. : Hypnotism ; How it is Done ; Its Uses and Dangers.
Newbold. William Romaine.
DuConormeilles: Hypnotism.
Moll, Albert: Hypnotism.
Brown, George V. I. : High, Light Shadow and Middletone of Hyp-
tism.
Hotchkiss, Elizabeth : Metaphysical Magazine.
Post, C W. : I Am Well : Natural Suggestion, or Scientia Vitae.
Luys, J.: The Brain aud its Functions.
Carpenter, William B.: Mental physiology.
Tuke, Daniel Hack : Influence of the Mind upon the Body.
Hart, E. : Hypnotism, Mesmerism and the New Witchcraft.
Sully, James: The Humane Mind.
Ladd, George T. : Outlines of Physiological Psychology.
Newbold, William Romaine: Suggestibility, Auiomatism and Kin-
dred Phenomena: Normal and Heightened Suggestibility; Hypnotic
States. Trance and Ecstacy. Published in Appleton's Popular Science
Monthly, December, 1895, to April, 1896, inclusive.
THE PRACTICAL USES OF SUGGESTIVE
THERAPEUTICS.
Read in the Section on Materia Medica, Pharmacy and Therapeutics, at
the Forty-seventh Annual Meetingof the American Medical Associa-
tion, at Atlanta. Ga., May 5-8, 1896.
BY WILLIAM LEE HOWARD, M.D.
BALTIMORE, MD.
I conceive it to be your desire to have a plain state-
ment of the uses and limitations of suggestion, and I
shall confine myself to this conception. To those of
you who desire a more comprehensive statement of
the psychologic side of the subject I refer to my paper
read last year before the Neurologic Section of this
Association.1 In this paper I shall avoid as
much as possible the misnomer hypnotism, as we
shall see later on that often curative effects of sugges-
tion are produced without inducing hypnosis. To
anyone familiar with modern pathology the limita-
tions of the therapeutic uses of suggestion will be
readily understood. To those familiar with the trend
of modern psychology its application for harmful
effects will be fully appreciated. In treating patients
by suggestion it is necessary to remember one funda-
mental factor, i.e., the subjective state of the patients.
Without this latter condition you will seldom succeed
in effecting your object. Without doubt the reputa,
tion and success of most physicians is due to sugges,
tion, often unconsciously made. The great factor in
the large number of cases reported by Bernheim is
i Hypnotism, its Uses, Abuses and Medico legal Relations. Jour,
Am. Med. Asso., Nov. 80, 1895.
132
PRACTICAL USES OF SUGGESTIVE THERAPEUTICS.
[July 18,
due to the explicit confidence in him by his patients.
We all know what a difference it makes in our suc-
cessful treatment of patients when they have
unbounded confidence in us; how soon they will
respond to our suggestion; where, with a stranger, or
one in whom they have little faith, treatment has
apparently but slight effect. The same medicine
given the patients by the physician with whom they
are en rapport will have a far greater effect than if
given by a stranger, provided that the former makes
some simple but forcible suggestions regarding the
effect of such medicine. When we start at the funda-
mental facts of suggestion it all appears very simple.
To illustrate the force of suggestion I will give you
a simple example. Let A., B. and C. agree to meet D.
at different times and places during the day. Let them
be men in whom he has confidence. On his way
down to his office D. meets A.; A. exclaims: " Look
here, D., what's the matter with you? You look very
ill." etc. This suggestion acts with sufficient force to
cause D. to drop in to a public place and consult a
mirror. He soon sees that his face is pale and begins
to feel weak. He throws off the idea for a while, but
it will return to him at intervals. He then meets B.
whose suggestions are more forcibly made; and after-
ward the third party. By this time, D. is in reality
psychically ill, goes to his home and sends for his
physician, who will find a rapid pulse and a generally
disturbed condition. This is a fact that I have often
demonstrated. Now, suggestion can act reversely.
Hypnotism in all its stages is now an undisputed
fact. Suggestion is a justifiable method in certain
cases. In those obstinate and disagreeable cases of
hysteria in all its forms; in insomnia, drug habit, and
immoral practices which so often disrupt once happy
homes, we here have a therapeutic, remedy; and any
physician, who, after he has made a correct diagnosis
and failed to cure after using all his other resources,
refuses to use suggestion either with, or without the
aid of hypnosis, is not giving his patient that care
and attention that he has a right to expect.
Unfortunately, through the daily press the subject
has been placed in such a light as to have caused its
beneficial factors to have been forgotten, and the older
practitioner, with little or no knowledge of modern
physiologic psychology, has looked askance at the sub-
ject. About this branch of medicine there has been
too much haste, inaccuracy, fallacious reasoning, con-
fused or contradictory ideas by a large number of our
profession. I will now give you the practical side of
the subject, leaving speculation and theory strictly
alone. If I appear dogmatic it is only because I quote
the reports of the most eminent and reputable men of
science; and have not gone beyond the deductions
derived from experience. I shall give you only the
digest of the subject as reported the last twelve
months.
The practical uses of suggestion are numerous. In
certain forms of functional disturbances cures can be
effected. The pains that often accompany organic
diseases can be abolished. While suggestion will have
no effect on organic disturbances per se, the relief of
the accompanying pain is of vast importance, as it
gives comfort and rest to the patient. The sensation
of pain takes place in the cerebral cortex; it is a men-
tal condition, it implies consciousness and hence, by
an alteration in our state of consciousness as is induced
by suggestion, pain can be abolished. Several cases
have been reported of the cure of organic diseases of
the cord. It is only necessary to say that either the
observers were mistaken in the diagnosis, or allowed
their enthusiasm to warp their judgment. The inter-
nal capsule, the thalamus, the motor convolutions, the
sensory tracts in the cord once destroyed are not to be
restored by any form of interference. It would appear
at first thought that any such self-evident fact men-
tioned here was superfluous ; but from the large num-
ber of letters I receive from the profession I judge
that this matter is not always understood.
I find, however, that I can greatly relieve a patient
suffering from organic disease. The removal of
anxiety, the implantation of new ideas, the removal of
the habit of introspection, are oftentimes the means
of breaking those vicious circles so common in the
pathologic states, and removing the unpleasant psy-
chic accompaniments. In my experience, insomnia
offers the practitioner his best field for the treatment
by suggestion. We can here see how it acts as a cur-
ative agent in so many functional disturbances. I
generally see the patient at my office several times
before attempting to produce hypnosis. After I have
gained the confidence of the patient, and am satisfied
as to the functional cause of the insomnia, I begin to
suggest sleep. The symptoms of sleep are readily
called up, they are familiar and natural, and therefore,
a patient without possessing very great confidence in
the operator can, without much difficulty, be made to
believe that sleep has come upon him. This much
gained, the patient's confidence in your powers are
secured, and the field is ready for you to plant such
suggestions as the conditions call for.2
Having your patient go to bed at the usual hour, you
continually but forcibly suggest sleep. If you have suc-
ceeded in your tentative efforts you will be surprised to
see how readily the patient will respond to your sugges-
tions. Then I suggest how long she shall sleep, and that
she will awaken refreshed and hungry. Be sure you tell
her to sleep until a certain hour, for a subject under
your perfect control will not always awaken unless the
operator tells her to do so. One of my earlier experi-
ences will illustrate. I was called to treat Mrs. M.
who had been suffering from insomnia for several
months. She responded to suggestions readily, and
soon was in a state of hypnosis. About 9 o'clock the
next morning there was a furious ringing of my door
bell, an excited woman rushed in and said I had killed
Mrs. M. Her family and friends had been trying for
two hours to arouse her. Going immediately to the
house I found family, physician and neighbors with
their suggestions all there. Every method known to
layman and doctor had been tried, but it was impos-
sible to arouse Mrs. M. Going up to her I said firmly:
" You must wake up now, Mrs. M.; wake up, wake up!"
She opened her eyes and soon arose. It was her first
good sleep for eight months, and the last time I ever
forgot to suggest the duration of sleep to a patient.
The suggestive sleep by the Nancy method is harm-
less, and as far as my experience goes is a normal
sleep produced by suggestion. The harm that comes
from such a condition is due entirely to the purport
of the suggestion made while in this receptive condi-
tion ; evil suggestion can be given and will, to a cer-
tain extent, be accepted, as well as good.3 ' Hence,
we can see the importance of regulating the practice
so that it can only be used by reputable and skillful
men. Next to insomnia suggestion is most useful in
2 See Dr. Schofleld's Lectures, Victoria Institute, London, 1896,
" Relation of Mind and Body, or the Powers of Unconscious Mind."
lS'.tf.. i
PRACTICAL USES OF SUGGESTIVE THERAPEUTICS.
133
hysteric seizures. In those troublesome hysteric
contractures of the extremities, suggestion during
hypnosis seldom fails to give relief. Care must be
taken, however, not to attempt to correct contractures
of long standing, for as Charcot has said, when con-
tracture has long existed, it becomes incurable. Hys-
teric amaurosis is readily relieved by suggestion dur-
ing hypnosis. This is readily understood when we
realize that hysteric amaurosis is nflt a systematic
paralysis but a purely psychic amaurosis; a neutral-
ization of the object perceived by the imagination.
Dr. Hugh Patrick reported to this Association at its
last meeting at Baltimore a case of hysteric blindness
ami pseudo-meningitis cured by suggestion.6 The
long and tedious list of the different phases, typesand
isomorphic forms of hysteria are all more or less
amenable to treatment by suggestion. Cephalalgia,
intellectual obnubilation, pseudo-hemi- and paraple-
gias are conditions that are benefited by suggestion.
It is not always that the hysteria itself can be cured,
but the symptoms can be removed.67 The treatment
of dipsomania by suggestion is now being quite
extensively used. At the present time we are not in
the position to make any dogmatic statement regard-
ing its certainty as a remedial agent. I have had
excellent results with cases that have tried about every
other known treatment. The fact that you can abol-
ish the nervous insomnia, eliminate the anorexia, and
.stop the tremors and other concomitants following
an alcoholic debauch, is sufficient evidence to cause
one to treat these cases by suggestion. With these
functional disturbances controlled I use continued
suggestion regarding the use of alcohol while the pa-
tient is in a state of hypnosis. The result has been
very gratifying. Bushnell, Surg. U. S. A., says: "I
have never failed to hypnotize a patient who sought
treatment for alcoholism."8
Dr. Am. De Jong reports very good results by this
method of treatment during the last two years.''
C'rothers "' advises its employment whenever possible,
and says: " Clinical experience furnishes many facts
which seem to prove that in certain cases its value is
very marked, also promising from more exact studies
greater results. " Dill " gives a list of eight
- of dipsomnia treated successfully by sug-
gestion. Green " gives a case of a man addicted to
the abuse of alcohol, bromids and chloral cured by
four hypnotizations. What I have said concerning
the alcohol habit refers also to the drug habits.
Sexual perversion as a disease has been but little
studied in this country; but experience has proven to
me that it is quite prevalent here. Suggestion is the
only method of treatment so far known that has any
effect on these cases. I refer to the acquired condi-
tion, not the congenital; the latter in my hands has
never been benefited. Masturbation in both sexes is
generally well controlled by suggestion. It would be
a work of surplusage to enter into details upon this
subject when we have such classic works as those of
Kraft-Ebing, Schrenck-Notzing, Moll, Ellis and many
others." Hypnotism will never supplant, in its pres-
3, * See Tukey, Brit. Med. Jour. 1890, Vol. 12, 442-444. William Lee
Howard, N. Y., Med. Jour., March 9, 1895, 298-300.
5 Jour. Am. Med. Asso., Feb. 8, 1896.
e Claus. A. et F. Jacobs. Un cas d'hysterie chez uue flllette de hult
ans: guerison par suggestion. Anu. Soc. de Med. d' Anvers. 1896.
^Kochs: Phenomeoes hypnotiques chez une hysterique. Allgem.
Zeitsch. t. Psychiatrie, t. 1. fasc. 5, 1894.
» Med. News, Phila.. 1894, xiv, 887-343.
» Inebriety and Its Treatment by Hypnotism.
10 Jour. Am. Med. Asso., Nov. 30, 1895.
ii Dipsomania and Hypnotism, by John Gordon Dill, M.A., M.D.,
Quart. Jour., Inebriety, October, 1895.
ent status, the existing anesthetics. Local and com-
plete anesthesia can be produced by suggestion, but it
is not available in an emergency case, unless the
patient happens to be one in whom we have at prior
times produced complete anesthesia by this method.
In minor operations when the time for operation can
be extended for a few days we can attempt to get our
patient into that state of receptivity that will allow of
producing a suggestive anesthesia. This can be sel-
dom accomplished at the first attempt. When this
anesthesia can be produced it is far superior to our
present anesthetics; being devoid of any danger. Up
to the present time we have had but one reported
authentic case of death from suggestion, and that
death was due to the purport of the suggestion, so
forcibly made as to bring about the very result that
was suggested, i.e.. death.15 A case was reported last
year from Paris as a death due to hypnotism. Prof.
Bernheim gives the following explanation. " A man
aged 37 years whom he had hypnotized to relieve the
pain due to phlebitis of the leg, and whose death fol-
lowed two hours afterward, was only an unfortunate
coincident; as the postmortem showed death to be
due to embolism of the pulmonary artery.'"6 I have
often operated in minor cases after putting the patient
in a state of suggestive anesthesia. A large number
of authentic cases have been reported. Wagner17
gives twenty-one cases of minor surgical operations
done under suggestive anesthesia, and three obstetric
cases. Major operations have also been done under the
same conditions. It is very useful in obstetric cases.
Here to be of any value you must have frequently
hypnotized your patient, and have become certain that
she will respond to your suggestions at any time. The
advantages of suggestion in parturition are the
removal of consciousness of pain, regulation of posi-
tion of limbs, body and attitude, and increase of uter-
ine contraction of voluntary muscles. In dentistry,
for the extraction of teeth, it is a most satisfactory
method of painlessly operating.
What percentage of persons can be controlled by
suggestion? Authorities differ. The result will depend
upon the individual operator, as in any other branch
of medicine and surgery. A conservative estimate
would be about 25 per cent. I succeed in about 30
per cent. What class of patients is most susceptible
to suggestion? Phthisical patients; children between
the ages of 5 and 15 years of age; those of a neurotic
temperament; last and most difficult is the hypochon-
driac and the melancholic. The insane, imbecile and
idiots seldom, if ever, respond to suggestion in any
form. A certain class of normal intellect can not be
controlled by suggestion. To use a hibernianism,
they will insist on keeping awake to see how you will
put them to sleep. What are the requirements to be
successful in using suggestion? The tact, judgment,
diagnostic ability and confidence in one's self and all
that makes the successful physician. Suggestive ther-
apeutics is no " royal road" to success. It involves the
same application, severe attention and experience that
is necessary in all branches of medicine and surgery.
Until you have had some experience you will not have
la C. Theo. Green, M.R. OS., L.R.C. P.. Quart. Jour., Inebriety, Octo-
ber, 1896.
u l'Bychopathia Sexualis von Kraft-Eblng: Suggestive Therapeutics
in Psychonathia Sexualis, von Schrenck-Notzing. Sexual Perversion,
Albert Moll ; Sexual Perversion, William Lee Howard, Alienist and Neu-
rologist, January, 1896.
A Case of Heredity. W. L. Howard, Md. Med. Jour., April 28, 1890.
is See Author's paper in Jour. Am. Med. Asso., Nov. 80, 1895.
16 Revue Medicale de l'Est., Feb. 1, 1895.
i' N. Y. Med. Jour., xlix.
134
THE ANTITOXIN OF TETANUS.
[July 18,
that full confidence that is necessary to impress your
patient. There is no such thing as " will power,"
"animal magnetism," or any other so-called occult
force employed. Get your patient in a state of men-
tal receptivity by having him look at some small
bright object distant about six inches from the pupils
and a little above them. When the eyelids begin to
close, or a fibrillary motion commences, close them
gently, and in a low but emphatic tone of voice sug-
gest sleep. Once in this state the therapeutic sugges-
tion should be made. In a large number of cases it
is not necessary to produce complete hypnosis to get
satisfactory therapeutic results. If the patient is
only in a state of lucid lethargy he will often accept a
suggestion with good results. A new idea of the
explanation of the phenomena of hypnotism has just
appeared.18 This is no place for psychologic discussion
or polemics, but as this idea has only been put before
the profession the last few days I will call your atten-
tion to it. Dr. Henry Stark of Boston says: " Hyp-
notism is a pathologic process depending for its origin
on contagium, probably specific in character, although
unrecognizable by any of the five senses."
Suggestion as a therapeutic method of treatment is
only an adjuvant, often a powerful one, to go hand in
hand with other rational means of hygienic and med-
icinal treatment, and is not to be understood as by any
means being a certain cure for all ills and complaints
that man is heir to. It is not a catholicon, a philos-
opher's stone, as many enthusiasts would have us
believe.
Psycho-physiology 19 has placed suggestion on a
sound scientific basis, and those who step from this
basis and make claims that have no psychologic foun-
dation, are those seized with the vertigo of the super-
natural and condescend to serve as vouchers for the
most absurd aberrations.
THE ANTITOXIN OF TETANUS.
Read in the Section on Materia Medica, Pharmacy and Therapeutics at
the Forty-seventh Annual Meeting of the American Medical
Association, at Atlanta. Ga..May 5-8, 1896.
BY SAMUEL S. KNEASS, M.D.
ASSOCIATE IN THE WILLIAM PEPPEH CLINICAL LABORATORY, UNIVERSITY
OF PENNSYLVANIA.
Among the many principles on which are based our
modern theories of the etiology and therapeutics of
disease is that of the vaccinating or immunizing
power of attenuated cultures of specific microorgan-
isms. Although this principle is forecast by Jenner's
discovery of the vaccine against variola, it is to the
great Frenchman, Pasteur, that should be ascribed its
first scientific development.
In 1880 this investigator showed that an attenuated
culture of the microbe of chicken cholera, injected
into animals, would produce a mild attack of the sep-
ticemia, and would leave them immune against a sec-
ond attack. This was the first experimental fact to
which numerous laboratory workers have been adding
during the last fifteen years. Disease after disease
has been added to the list, anthrax, hog cholera, ma-
lignant edema, hydrophobia, diphtheria, the infec-
tions due to the staphylococcus, the streptococcus
and the pneumococcus, typhoid fever and tetanus.
It is not the purpose of this account to go into the
is Psychic Infection; Remarks upon the Probability of a Mental
Contagium, N. Y. Med. Record, April 18, 18%.
19 (Jrocq fils : V hypnotisme Scientifique. Rapport a M. le ministre de
1 Interieur, a de i'instruction Publique. Introduction de M. le Prof
Pitres, 1896.
history of the subject or the various theories of im-
munity except so far as they bear on, the subject in
hand, the antitoxin of tetanus and its use in the treat-
ment of tetanus in the human being.
The bacillus of tetanus, first discovered by Nicolaier
in 1884 in tetanic animals, and afterward by Rosen-
bach in 1885, in the local lesion in man, was finally
isolated and studied by the Japanese, Kitasato. Since
then, these results have been approved by so many
investigators, that we say definitely that it is proved
that Nicolaier's bacillus is the specific cause of teta-
nus in all its clinical forms, traumatic, idiopathic,
rheumatic, puerperal and of the new-born. It is the
type of the specific intoxication. The bacillus grow-
ing only at the initial lesion there elaborates its toxin.
An important point to remember is the extreme tox-
icity of the products of secretion of this bacillus.
A 1-1,000 c.c. is sufficient, when injected subcuta-
neously, to kill an adult guinea pig. Evaporated to
dryness this is represented by 0.000,025 (25-1,000,000)
gm. A mouse succumbs to a dose of one-hundredth
this quantity, 25-100,000,000 gm.
Brieger had found and isolated a ptomaine from
tissues of a fatal case of tetanus, which he named
tetanin. This was obtained also from cultures of the
bacillus by Kitasato and Weyl. This substance kills
animals with the characteristic symptoms of tetanus.
But this is not the substance to which is due the
intense intoxication of tetanus, and Brieger himself
obtained a toxalbumin of much greater toxicity. This
toxalbumin, the chemic relations of which we do not
know, is probably only an impure form of the specific
toxin; a mixture of the precipitated albumins and the
toxin.
Brieger and Cohn (1893) were able to make a step
in advance in the separation of a purer toxin. They
used an intensely virulent veal-bouillon culture of
tetanus bacillus. This they supersaturated with
ammonium sulphate, and removing the supernatant
precipitate, dried it on porcelain in a vacuum. Of
this, 1 gm.was obtained for 1,000 c.c. of bouillon; and
1-10,000,000 gm. was sufficient to kill a 15 gm. mouse.
But it was still impure. It was dissolved in water
and was treated with a small amount of ammonia and
basic acetate of lead to precipitate the albumins;
dialyzed from twelve to forty-eight hours in running
water to get rid of the peptones, salts, etc., and evapo-
rated in vacuo at a temperature of 20 to 22 degrees C.
This gave slightly yellow, transparent scales, odorless,
with aromatic taste and soluble in water. It gave no
reaction to Millon's fluid, nor responded to the xantho-
proteic or biuret test. A slight violet color resulted
with cupric sulphate and sodium hydrate; and no
precipitation with the albumin precipitants, except
ammonium sulphate. There was no phosphorus, and
but a trace of sulphur. It is not, therefore, to be
classed among the albumins. Of this substance but
1-20,000,000 gm. is sufficient to kill a mouse; or,
assuming the action of the toxin to be similar in
degree upon the human being, but about \ mg.
would be fatal to a man weighing 70 kg.
Brieger and Boer have lately been able, by another
method to procure a purer and more concentrated
form of toxin, and also of antitoxin. Instead of alco-
hol or sulphate of ammonium they used salts of zinc,
the sulphate or preferrably the chlorid. The filtered
tetanus bouillon or the serum was diluted with five
volumes of water and to this was added two vol-
lumes of a 1 per cent, solution of the salt. After
L896
THE ANTITOXIN OF TETANUS.
135
standing a short time a precipitate formed. The anti-
toxin precipitate is dissolved in slightly alkalin
water, a stream of carbonic acid passed through it.
With the sulphate, the antitoxin is again precipitated;
with the chlorid, it remains in the nitrate, free from
the zinc salt. Any traces of the metal are further
washed out by treatment with ammonium sulphid.
They obtained from 10 c.c of serum about 0.1 gm. of
an antitoxic powder easily soluble, in water. The
toxin could not be freed from the metal. One liter of
bouillon gave :! gm. of the zinc combination, which
contained about ()..*5 gm. of organic matter and repre-
sented the full strength of the original filtered
culture.
^\Volinsky made Ins cultures in a non-albuminous
medium composed of water, glycerin, sodium chlorid,
magnesium sulphate, potassium phosphate, ammo-
nium lactate and sodium asparaginate. The filtered
culture in this medium gives a faint Millon's and
xanthoproteic reaction, a slight cloudiness with phos-
phor wolframic acid, and no immediate precipitate
with acetic acid and potassium ferrocyanid; only after
six to seven minutes is there a greenish cloudiness
formed. He recognized that he had but a very im-
pure principle, but claims that it "appears to belong
to the proteid bodies and that it has great similarity
to the ferments.'"
This fact that the toxin is essentially a diastase or
zvmose was already put forward by Tizzoni and
Catanni, a view afterward adopted by Vaillard and
Vincent. E. Roux, Faber and others finally demon-
strated by Courmont and Doyon. These authors called
attention to the important fact that after the injection
of the tetanus toxin, there is always a certain period
of delay in the development of symptoms — a distinct
period of incubation. They show that this is uninflu-
enced by and bears no relation to the amount of toxin
injected. Two hundred c.c. were injected into a dog
without the immediate appearance of tetanus, which
only developed on the third day. An injection of 4
c.c. gave the same period of incubation. The blood
and tissue juice of this dog, however, produced in an
injected animal an almost immediate tetanic intox-
ication.
In an extensive comparison of the chemic and other
relations of the several known ferments and toxins,
Fermi and Celli combat this idea and try to show
that the toxin of tetanus is not to be ranked among
the ferments. In reading their work, however, one
is not sufficiently convinced of the error, considering
the similarity of many of the chemic reactions, which
even they show; considering the fact that the toxin
in its purity is as yet not isolated, but may still be
intimately mixed with some albuminoid body, and
considering the clinical facts put forward by Cour-
mont and Doyon, one may, I think, adopt the view
that the toxin of tetanus is, at least, akin to the fer-
ments (the zymoses) and that it is by its action on
the blood and tissue juices of the organism that the
true active intoxicant is produced. At any rate it is
justified as a working hypothesis.
Behring and Kitasato in 1890 first report the cure
of tetanus and resulting immunity of animals treated
with the serum artificially immunized animals. Rab-
bits rendered immune by their method, bore without
. fatal result the injection of a virulent culture of the
tetanus bacillus (10 c.c), the minimal fatal dose of
which for a non-treated animal was 0.5 c.c. They
showed that there was in the blood serum of artifi-
cially immune animals a substance that in some way
antagonized the action of the bacillus or its toxin, an
antitoxin. To quote: "A mouse has been rendered
tetanic, it has contracture of its extremities, and
seems about to die; it is sufficient to make this injec-
tion for a cure to follow so surely and rapidly that a
tew days after the animal is perfectly well." Their
conclusions, however, as to the therapeutic effects
were not realized.
Later Behring published his method. At first, fol-
lowing the inoculation, injections of the trichlorid of
iodin were made. But it was better to previously add
this attenuating substance directly to the culture
before injecting.
Five cubic centimeters of a virulent culture con-
taining 0.25 per cent, of the trichlorid were injected
into a rabbit. After a lapse of three or four days,
another injection of 5 c.c. containing 0.2 per cent, of
the iodin. Another pause and another injection con-
taining less iodin, and so on for some six weeks, at
the end of which time a degree of- immunity was
reached equal to 1 in 400 or, according to Ehrlich, to
10 immunity units. That is, of the serum injected
into a 20 gm. mouse 0.05 c.c. or 1-400 of the body
weight would protect it against the minimal fatal
dose of the toxin. Horses were immunized in the
same way by using a beginning dose of 10 c.c. of
carbolized cultures with 0.25 per cent, of iodin tri-
chlorid added and very gradually increasing the
amount of toxin and decreasing the amount of the
iodin salt. The degree of immunity reached was 1
to-5,000.
This, however, is only when the injection of the
serum is made shortly after that of the toxin. If it
is done before, the proportion is larger; instead of 1
to 5,000, it would be 1 to 25,000. Again, it refers to
the minimal fatal dose. If stronger doses of the
toxin are given, say one hundred times the minimum,
the serum must be used in larger amounts, one thou-
sand times as much as before or 1-1,000 of the body
weight. This is of interest in the treatment of
human tetanus, in which the amount of toxin elab-
orated, possibly often far exceeds the smallest fatal
dose.
Tizzoni and Catanni, soon after the first work of
Behring and Kitasato, were able to immunize a dog, a
comparatively resistant animal, by injections of small
amounts of tetanus toxin and slowly increasing the
dose. Unfortunately they were unable to agree with
Behring and Kitasato as to the therapeutic success of
the antitoxic blood serum. "The development," they
say, "of the tetanic symptoms is in no wise hindered
when the serum is not injected before their appear-
ance." This result, obtained upon experiment ani-
mals, is one that they would do well to apply in the
cases of tetanus, in man, which were treated with
their antitoxin. Kitasato himself later agreed that
the greatest efficacy was observed when the injections
of antitoxic serum were made before or immediately
after that of the toxin.
Brieger, Kitasato and Wasserman made use of a
a bouillon made of thymus gland in which to pro-
duce an attenuation of the virulence. Successful in
preventing tetanus in only 40 per cent, of the ani-
mals experimented on, they show that this thymus
extract has a distinct toxin-destroying action.
Another method of the attenuation is by means of
heat. Vaillard uses filtered cultures that have been
heated to 60, 55 degrees C. and so on, gradually dimin-
136
THE ANTITOXIN OF TETANUS.
[July 18,
ishing the temperature and increasing the amounts.
Finally Vaillard and Roux make use of a solution of
metallic iodin, Gram's solution, commencing with
doses in the proportion of one of the iodin to three of
the filtered culture and by gradually increasing the
ratio were able to completely immunize rabbits. A
detailed account of their method is as follows : For
about seven weeks a mixture of equal parts of toxin
and Gram's solution was injected into a horse in
doses increasing from 0.5 c.c. to 10 c.c. Then for a
while 4 c.c. increasing to 10 c.c. of toxin and Gram's
solution in the proportion of 2 to 1. An injection of
1 c.c. of pure toxin was now given and repeated in
increasing amounts until at the end of three weeks
the animal could stand 22 c.c. After a rest of a few
days 4 c.c. of toxin was given directly by the jugular
vein. Five weeks after 70 c.c. could be injected intra-
venously without ill effects. At the end of a month's
interval the serum had an antitoxic power of 1 to
50,000. Treatment was resumed and pushed until
90 c.c. of pure toxin was being injected into the jugu-
lar vein. After a pause in the treatment for two
weeks, or about seven months from the beginning, the
serum was shown to be protective to the extent of 1
to 1,000,000.
How does this toxin act? Many experimental
facts have been brought forward to elucidate this
point. Roux, and also Buchner, show that a mixture
of the toxin and antitoxin retains the properties of
the two ingredients; that a mixture neutral and with-
out effect upon a mouse is still toxic for the more sen-
sitive guinea pig. Animals treated with certain
microbes, such as prodigiosus, cholera, streptococcus,
etc., lose some of their resisting power and become
more sensitive to a mixture, which in their normal
state would have no effect. This serum then, accord-
ing to them, is not, strictly speaking, an antitoxin. It
does not directly or in vitro destroy the toxin. But
it exercises, as Roux puts it, a stimulative action upon
the cells of the organism, which augments their
energy and they become able to resist the poison.
Behring has shown that an animal may become
" over-sensitive," a condition occurring in the process
of immunization in which the animals seeming at
first immune, succumb to the tetanus toxin, although
the blood serum is in a high degree antitoxic. The
blood of such an "over-sensitive" horse may, in doses
of 4 c.c, immunize another animal.
On the other hand, in a highly immunized sheep
the antitoxin may after a time disappear from the
blood, without any diminution of the immunity. It
is probable that tissue immunity and the formation
of antitoxin are not directly related.
On the other side, Fodoroff found that with large
doses of the toxin, as sixty times the minimal fatal
dose, a certain proportion of the serum necessary to
prevent the development of tetanus (3 to 1 in the
case of white mice), when previously mixed, had no
effect when injected at different points, even when
done simultaneously. Animals were injected with
antitoxic serum, a dose of 0.02 mg. of which was suffi-
cient to immunize against the minimal fatal dose of
toxin in amounts varying from 50 to 200 mg., given
in three to five injections. These were found to be
resistant to doses of 3, 6 and even 8 mg. of toxin, the
minimal lethal dose of which was 0.001 mg., but
invariably succumbed to injections of 12 mg., even
when given immediately after the immunizing serum.
White mice which had received three daily injections
of 50 mg. of dried serum, were given, some a mixture
of 50 mg. of serum and 12 mg. of dried filtered teta-
nus toxin, and others the same amounts of the same
substance, but injected at different points. The
former animals were unaffected, the latter all suc-
cumbed to tetanus. From these experiments Fodoroff
assumes that the antitoxin has a toxin-destroying
action.
The hypothesis upheld by Courmont and Doyon
seems to lend itself more than others to the explana-
tion of these often contradictory facts. The symp-
toms are produced not directly by bacterial secretion,
but by a substance which is the result of the action
of a bacterial enzyme. Once this true toxin is formed
in the organism, it is doubtful how much it can be
affected by the antitoxin, at least directly. It is
upon the ferment itself, however, that the antitoxin
acts, inhibiting or modifying its action, either directly
or by stimulating a cellular resistance.
But these experiments have all been made with the
so-called toxin of tetanus. It is the study of the
effect of the serum upon animals inoculated with the
bacilli themselves, that cause us further to limit its
action. The work of Beck is here of interest. He
used instead of filtered cultures, small splinters of
wood inoculated with tetanus bacilli. A splinter 0.5
cm. long and 2 mm. thick killed a guinea pig of 400
gm. in three to four days. In a series of some twenty-
six guinea pigs so inoculated, twelve recovered from
more or less severe tetanic symptoms, six died from
pneumonia, after an improvement of the tetanus. A
series of five pigs which twenty-four hours before the
splinter inoculation, were injected with 5 c.c. of a
serum of an immunizing power of 1 to 4,000,000, all
recovered from mild attacks. Reinoculated some
three weeks after, they all died in about four days,
showing that the immunity thus produced is of short
duration.
Of thirty-eight pigs injected with 5 c.c. of serum
at periods varying from one hour before the inocula-
tion to twenty hours after, fourteen died of tetanus;
all but one that were injected sixteen hours and over
after the inoculation succumbed. The deductions we
may draw from his work are that after a given period
after the tetanus toxin has once developed in the
organism the serum, in animals at least, is powerless.
And now the subject of human tetanus. Approach-
ing it from the laboratory one can not but feel some-
what skeptical in regard to what is claimed for the
serum by its most ardent adherents. The difference,
however, of the pathologic reactions of the human
and other animal organisms show us that we must
look at this side of the matter from the clinic stand-
point only. In general, do statistics show any reduc-
tion in the mortality in tetanus treated with antitoxin,
or does such treatment seem to have any effect upon
the symptoms in individual cases?
The mortality from tetanus is difficult to determine.
Poucet reports 713 cases with a mortality of 90.6 per
cent.; in the Civil War it was 89.3 per cent.; Richter
gives 88 per cent.; Somain, 56 per cent.; Roux and
Vaillard 50 per cent. ; Knecht 45 per cent. ; Albertoni
24 per cent.; Behring 20 per cent.; Verneuil claims
50 per cent, recoveries with large doses of chloral.
In some thirty-five cases that I have collected from
the current literature, the mortality is about 40 per
cent. The higher percentages have been taken gen-
erally from war records, and are therefore too high;
and, on the other hand, Albertoni's statistics seem too
l&HS.J
low. It is probable the figures adopted by Roux nnd
Vaillard are nearly correct, say from 45 to 50 percent^
17 per cent, is the average of the various percentages
u. I have collected from the recent literature
sixty-eight eases that were treated with the various
antitoxins. Among these there have been thirty deaths.
siring a mortality of nearly 47 per cent. But we can
judge better it' we examine more in detail.
Etichter and Rose give the mortality in tetanus, in
which the symptoms have appeared within five days
after the inoculation, as (.M*> per cent.: the Surgical
History of the War says that 85 per cent, died in the
first week: of twenty eases with a mortality of 45
per cent., the death rate of those in which the period
of incubation was from one to five days was. 100 per
it.: from six to eight days s0 per cent.; from nine
days or more 0 per cent.
We may safely say that cases developing during the
first week rarely, if ever, recover, and cases, the incu-
bation of which is over two weeks, rarely die. Of the
sixty-eight eases here collected, which were treated
with the antitoxic serum, but sixty-one have been
recorded with sufficient detail from which to draw any
conclusions. The mortality of the whole number is
41 per cent. Of the sixty-one cases thirty-six recov-
ered, giving also a mortality of 41 per cent. A com-
parison of this with the probable percentage of deaths
in eases treated by other means, 50 to 45 percent.,
leads us to no verdict but that of not proven.
The following condensed table shows mortality of
Bfls arranged according to the period of incubation:
Period of Percentage of
Incubation. Death*. Recoveries. Mortality.
1 to 5 days 7 1(?) 87.5 (?)
6 to 14 davs 16 25 38
15 davs and over . . 2 (?) 10 16.66 (?)
THE ANTITOXIN OF TETANUS.
137
to their incubation
Of eight in which
only one recovered.
the physician as of
When the disease
The cases classed according
periods show a like similarity,
this was from one to five days,
and this ( 32 ) was regarded by
somewhat doubtful character,
developed in from six to fourteen days after the infec-
tion there is a much lower death rate. Of forty-one
. twenty-five recovered and sixteen died. And
with an incubation period of fifteen days, two of
twelve cases succumbed. These two were cases in
which the period of incubation is extremely doubt-
ful. In one the first appearance of symptoms took
place fifteen days after the extraction of a number of
teeth. In the other the patient, who was a stableman,
had gone on attending to his duties in the stable for
three weeks after his injury. In all probability the
inoculation in these cases took place at a much shorter
time from the development of the tetanus. If this is
so, the mortality of this period would be nil.
The only conclusion it seems to me is that those
- in which the symptoms appear before the sixth
day die. in spite of any antitoxic treatment, and that
those in which the development of the disease is
delayed beyond the second week would recover with-
out any such treatment. Possibly the number of
cases as yet reported is too small to warrant this gen-
eral statement, but the results are not encouraging.
There seems to be no relation in the severity of the
.symptoms to the prognosis. The temperature which
is generally normal or subnormal, rises more often in
the fatal cases (nineteen times in twenty-seven) but
this is no criterion. The shortness of the incubation
period and the rapidity of the onset are two important
TABLE SHOWING THE DAYS AFTER THE APPEARANCE Of SYMPT0M8 ON
WHICH THE INJECTIONS OF SERUM WAS BEGUN.
Period of Incubation.
Date of Disease when Injections
began.
1 to 5
5 to 14
15 and over
Died. Rec.
Died.
Rec.
Died.
Rec.
(i
1
1
1
1
4
5
1
2
1
1
8
2
2
jj
1
2
,
8
3
4 •■...'
2
8
S
2
1
1
1
,s.
;i
lc> '
2
ii :.:.:.::::::
u
18 ..........
2
1
11
7
1
16
25 j 2
10
factors. When we remember the experimental proof
that the sooner after inoculation the antitoxic serum
is injected, the more likelihood there is of some bene-
ficial result, we should expect, if there be any such
effect, to find it among those cases in which the treat-
ment was earliest begun. A glance at the table will
show that this is not the case. Of the sixteen fatal
cases, whose period of incubation ranged from six to
fourteen days, fourteen had the treatment begun dur-
ing the first four days, and of the twenty-five in which
the serum was injected before the fifth day, fourteen
were fatal. Among the sixty-eight cases but twenty-
two are reported as causing an immediate improve-
ment in the character of the symptoms, and in many
of these the injections were begun so late in the course
of the disease that one hesitates to ascribe this
improvement to anything but a coincidence. This
agrees with many of the authorities. Berger says
that "without rejecting the injections of antitoxic
serum in the treatment of tetanus, we can have but
the most limited confidence in its curative efficacy."
Roux has said that he has never seen the serum have
the least effect upon the course of the disease.
Then the early treatment after the appearance of
symptoms has no appreciable effect. The symptoms
are caused by the action, of tetanus toxin already
elaborated and producing its intoxicant effect upon
the cells of the organisms. It is then too late to hope
for either any antitoxic or any immunizing action.
Could we but make the injection soon after the time
of inoculation we might expect some result, but
unfortunately this is impossible.
Another thing we notice in examining the several
cases, and that is the small amounts given. Beck
shows that with the Behring's serum of 1-4,000,000
immunizing power which he used in his experiment,
1-100 of the body weight must be injected. This for
a man of 60 kg. would be at least 600 c.c. of serum.
Much of the serum used in human tetanus is much
less powerful than this.
Tizzoni and Cattani claim an immunizing power
of 1 to 100,000.000 for theirs. However, Htibener
has shown it to be much less, at least as furnished by
Merck, and Behring and others say it is completely
worthless. Roux has recently prepared a serum with
an immunizing power of 1 to 1,000,000,000.
There is one department in which the serum has
been of value, and that is in veterinary medicine.
Dr. Nocard of Altorf gives some very favorable
138
TOXIC ACTION OP DISSOLVED SALTS.
[July 18,
reports. These come from veterinarians and others
throughout France, who have used the serum imme-
diately after operations on animals. Among 375 ani-
mals (327 horses, 47 lambs and 1 ox) the injections
were successful and not a case of tetanus occurred.
During the same time fifty-five cases of tetanus
were observed among non-inoculated animals. Two
injections of the serum are given, of 20 c.c. and 10 c.c.
with a fifteen days interval between.
Picard records that, during 1891-94, fifteen horses
succumbed; during 1895, in which year he used the
antitoxic serum, none. Coret lost, previous to 1895,
from thirty to forty horses yearly by tetanus; in 1895
none succumbed. Before the use of antitoxin he lost
an average of fifteen horses each semester; in 1895,
fifty-four suffered from wounds both accidental and
operatory, and none died. During the same semester,
among non-treated animals seven died from tetanus.
Therefore eight horses were saved by the use of the
antitoxic serum.
Following traumatic lesions in animals, tetanus is
not such an uncommon accident as it is in man, and
we may expect, as seen by the above, some definite
results in its use in such cases, the more especially as
it is given as soon as possible after the injury.
But in the human race we can not say that it has
had that success which we first hoped for it. We
should not yet condemn it, but await the results of
larger doses and more powerful serum.
ON THE TOXIC ACTION OF DISSOLVED
SALTS AND THEIR ELECTROLYTIC
DISSOCIATION.
Read in the Section on Materia Medica, Pharmacy and Therapeutics at
the Forty-seventh Annual Meeting of the American Medical
Association at Atlanta, Georgia, May 5-8, 1896.
BY LOUIS KAHLENBERG, Ph.D.
RODNEY H. TRUE, Ph.D.
AND
LABORATORIES OF THE SCHOOL OF PHARMACY, UNIVERSITY OF
WISCONSIN.
During the last decade, work in physics and chem-
istry, -especially in physical chemistry, has been
characterized by a thorough and systematic study of
solutions from both the theoretic and the experi-
mental point of view. As a result of the activity
along this line, our knowledge of the conditions of
dissolved substances contained in solution has been
greatly extended. Thus Van't Hoff of Amsterdam,
basing his argument upon the osmotic experiments
of Pfeffer of Leipzig, extended the principle of
Avogadro to dilute solutions showing that equal
volumes of dilute solutions having the same osmotic
pressure and the same temperature contain an equal
number of molecules. When Avogadro put forth his
hypothesis that equal volumes of all gases under the
same conditions of temperature and pressure contain
an equal number of molecules, facts were found that
apparently were strongly adverse to this view. Thus,
when the vapor density of the chlorid of ammonium
was determined, it was found to be only a little more
than half as great as was required by the principle of
Avogadro. This fact caused at first much opposition
to Avogadro's views, but this opposition was finally
cleared away when it was shown that, in the vapor of
chlorid of ammonium, we have not simply the mole-
cules of that salt, but also hydrochloric acid and
ammonia molecules, the products into which the
chlorid of ammonium in the vapor form is to a large
degree broken up or dissociated.
The theory of Van't Hoff has had a similar diffi-
culty to contend with. As he himself showed, his
theory did not represent the facts when working with
aqueous solutions of salts, acids and bases, in short,
with solutions that are conductors of electricity.
In his mathematical formulae, Van't Hoff introduced
a factor to overcome the departure from his theory
presented by such solutions. Soon, however, Arrhenius
from the interrelation between the lowering of the
freezing point of the solutions and their electrical
conductivity, came to the conclusion that in aqueous
solutions, salts, acids and bases are to a greater or less
extent broken up or dissociated into part- molecules
or ions ( a term originated by Faraday ) . These ions
are charged with electricity each gram-equivalent
bearing 96,540 coulombs. This latter figure is derived
from experiments on electrolysis. It has well been
termed the constant of Faraday's law.
Arrhenius published his theory of electrolytic dis-
sociation in 1887 and all investigations made on salt
solutions, including those of acids and bases, have
confirmed this theory. In addition to the lowering
of the freezing point and the electric conductivity,
the elevation of the boiling point, the specific volume,
as well as the optical and thermal properties, all
strongly support the views of Arrhenius. This
theory has given a clear insight into the processes
going on in voltaic combinations and makes it pos-
sible to calculate with accuracy in advance what will
be the electromotive force of a voltaic combination.
In the hands of Ostwald, it has placed analytic
chemistry on a firm scientific basis. In short, all
the physical and chemical properties of aqueous
solutions of electrolytes are well explained by the
assumption that in these solutions, the dissolved sub-
stances are split up into part-molecules or ions, and
that the various properties of the solutions are due to
the properties of the ions. The more dilute the solu-
tion, the more is the dissolved substance dissociated
and at infinite dilution, this dissociation is complete.
In the case of many salts, however, namely those of
the stronger bases, the dissociation goes on very
rapidly with the increasing dilution so that in case
an equivalent in grams is dissolved in about 1,000
liters of water the dissociation is practically complete.
Viewing these things in the light of the theory of
Arrhenius we, have, for example, in a solution of
sodium chlorid, sodium ions and chlorin ions beside
a certain amount of dissociated sodium chlorid mole-
cules. Experiments on the electrical conductivity
show that in this case, dissociation is practically com-
plete when one gram-molecule (i. e., 23+35.5=58.5
grams) of the the salt is dissolved in 1,000 liters of
water. We have at this dilution not NaCl molecules
in solution but Na ions and CI ions; we denominate
them in the usual way, -f~Na and — CI.
The question has often been raised : In what way
do Na and CI in the ionized state differ from ordinary
sodium in the metallic state and ordinary chlorin,
respectively? The difference lies in the energy
possessed. Ten grams of sodium ions, for instance,
contain less energy than do ten grams of metallic
sodium. Supply the energy to the ions, as in the
case of electrolytes and we convert the ions to the
metallic sodium. Sodium ions and metallic sodium
are, therefore, not the same. The lack of under-
standing on this point caused a tardy acceptance of
the dissociation theory at first, notably on the part of
English chemists.
1896.]
TOXIC ACTION OF DISSOLVED SALTS.
139
Hydrochloric acid dissociates into -f-H ions and
— CI ions; the H ions bearing the positive charge
ami the (.'1 ions bearing the negative charge. There
exists in the solution necessarily as many positive
ions as negative ions in order that electric neutrality
may be preserved. A dilute solution of sodium
ohlorid and one of hydrochloric acid have in common
C9 ions, their difference is due to the fact that the
positive ion of the former is Na, and of the latter, H.
To this difference is to be ascribed all the differences
seen in the properties of the two substances. In
general, solutions of all acids contain hydrogen ions,
solutions of all chlorids contain chlorin ions, those of
the sulphates contain SO, ions, those of the nitrates
contain NOs ions. Salts of copper contain copper
ions, salts of lead contain lead ions. In general, if
we let BA represent the formula of a salt, B repre-
senting the basic radical and A the acid radical, then
in dilute aqueous solutions, this compound is to a
greater or less extent dissociated into the ions B and
A and all the physical and chemic properties that
such a solution possesses are due to the properties of the
ions in the solution. If it is true that all the physical
ami ehemic properties of aqueous solutions of salts,
acids and bases are due to the properties of the ions,
plus those of the undissociated substances they con-
tain, does it not seem probable that the physiologic
properties of such solutions are also due to these?
This thought, simple as it is, has to our knowledge
never before been expressed.
Many investigations have been made on the phy-
siologic action of aqueous solutions of salts on
bacteria and higher forms of plant life as well as on
animals. The strength of the solutions with which
these experiments were made has always been ex-
pressed in per cent, and it is probably for this reason
that general considerations have entirely escaped
observation. If a very dilute solution of sodium
chlorid differs from a dilute solution of hydrochloric
aciil only in the fact that the former contains sodium
ions and the latter hydrogen ions, then the poisonous
action of the latter is plainly due to the hydrogen
ions present. In like manner comparing a very
dilute solution of sodium nitrate with a similar solu-
tion of nitric acid, the poisonous nature of the latter
would be due to the hydrogen ions present. In gen-
eral, if the solution is sufficiently dilute so that the
acid dissolved is practically completely dissociated
and the acid radical is of such a nature that in this
concentration its ions have practically no poisonous
action, the toxic value of the acid solution is due to
the hydrogen ions present.
Now strong acids are highly dissociated in watery
solutions, thus rendering them relatively rich in
hydrogen ions. Weaker acids are less dissociated
since their solutions contain less hydrogen ions. It
must always be borne in mind that the salt remain-
ing undissociated is present in the solution as well as
the ions. That these undissociated remainders and
the ions of the acid radical also exert an effect, is not to
be denied but in many cases, such as that of the CI
ions in hydrochloric acid, the action is practically
nil at the strength at which hydrochloric acid is
effective, since a solution of common salt containing
as many CI ions as the HC1 solution in question, is
ineffective. The same reasoning may be applied to
nitrate of sodium and nitric acid; also to sodium
hydroxid and common salt. In the latter case, the
solutions differ from each other in that the former
contains OH ions, whereas the latter contains CI ions.
All solutions of the bases (lyes) contain OH ions and
their toxic action is due to their OH ions alone pro-
vided the metal or corresponding radical, the cathion,
is itself harmless at the particular concentration used.
We see then that H ions and OH ions have toxic
properties. That it is the ionized condition that
brings this about, is shown by the fact that in the case
of water where we have these constituents in practi-
cally an undissociated state there is no toxic action.
The poisonous property of a very dilute solution is,
then due to the ions it contains, and if at the partic-
ular dilution in hand only one physiologically active
ion is present, the effectiveness of the solution is to
be attributed to that one ion. Solutions of hydro-
chloric, nitric and sulphuric acids are nearly com-
pletely dissociated when an equivalent in grams is
dissolved in 1,000 liters of water. Hence such, or
more dilute, solutions of these acids, when chemically
equivalent quantities are dissolved, ought to have the
same toxic effects, the CI, NO„ and SO< ions in such
dilution being harmless. That these radicals are
harmless is shown by the effect that like concentra-
tions of the sodium salts of these acids are harmless.
We have tested this point experimentally for the
higher plants by ascertaining the strength of solution
in which the roots of the ordinary field lupine ( Lupi-
nus albus) will just live. We have found that the
limit of these acids is reached in a solution containing
one equivalent in grams in 6,400 liters of water. We
may say, then, that one gram of hydrogen ions dis-
tributed through 6,400 liters of water will give a solu-
tion in which roots of the lupine will just grow. It is
entirely immaterial at this dilution whether we take
hydrochloric, nitric or sulphuric acids, the toxic action
of the solutions is the same provided the solutions
contain the same amount of hydrogen ions. The
molecular weight in grams, or simply gram-molecule,
of acid sulphate of potassium in 6,400 liters would
contain as much ionized hydrogen as a gram molecule
of hydrochloric acid and should therefore have the
same effect toxically. This was confirmed by
experiment.
The action of about forty acids was investigated
and the results point to the fact that in many of them
the poisonous effect is due in great part to the hydro-
gen present as ions. In some of these acids, dissocia-
tion is not complete at the concentration-limit found;
in other cases, the harmful influence of the anion can
not be neglected.
The following table shows in the first column the
names of acids investigated; in the second column is
the concentration just allowing growth, expressed in
fractions of a gram-equivalent of the acid per liter of
water.
Acids.
Hydrochloric,
Nitric,
Hydrobromic,
Acid potas. sulphate
Sulphuric,
Phosphoric,
Chromic,
Hydrocyanic,
Formic,
Acetic,
Propionic,
Butyric,
Valeric,
Benzoic,
TABLE I.
Concentra-
Concentra-
tion-limit.
tion-limit.
Equivalent.
Acids.
Equivalent.
1-6400
Malonic,
1-3200
1-6400
Potas. acid oxalate,
1-3200
1-6400
Ortho-nitro- benzoic
, 1-6400
*, 1-6400
Meta-nitro-ben zoic,
1-12800
1-6400
Para-nitro-benzoic,
1-12800
1-6400
Mono chlor-ace tic,
1-6400
1-12800
Di-chlor-acetic,
1-6400
1-12800
Tri- chlor-ace tic,
1-12800
1-6400
Mono- brom-ace tic,
1-12800
1-1600
Cinnamic,
1-12800
1-3200
Meta-oxy-benzoic,
1-3200
1-3200
Para-oxy-benzoic,
1-1600
1-3200
Hippuric,
1-6400
1-6400
Gallic,
1-6400
140
THE TOXIC ACTION OP DISSOLVED SALTS.
[July 18,
Salicylic, 1-6400 Protocatechuic, 1-3200
Oxalic, 1-3200 Citric, 1 3200
Succinic, 1 1600 Aspartic, 1-6400
Tartaric, 1-6400 Glycolic, 1-6400
Fumaric, 1-6400 Malic, 1-3200
Maleic, 1-3200 Lactic. 1-3200
A glance at the results shows that the concentra-
tions at which the plants survive vary from 1-1600
gram-equivalent to 1-12800 gram-equivalent.
For mineral acids and other strong acids in which
at the dilution under consideration the anion exerts
practically no influence, the concentration at which
the lupines survive is determined solely by the hydro-
gen ions present. The concentration found is 1-6400
gram-equivalent per liter. When the lupines live in
a greater concentration than this, dissociation, even
in the great dilution used, is not complete. In the
cases where the limit lies at 1-12800 gram-equivalents
per liter, the influence of anion and in some cases,
HCn, for example, the dissociated remainder of the
acid, has to be taken into account.
Since this is to be regarded as a preliminary report,
a discussion of the action of the individual acids is
not given. This may be sought in the complete
report which is to appear later.
Of especial interest is the conduct of boric acid.
This is a very weak acid and is but slightly disso-
ciated even in dilute solutions and lupine roots sur-
vive in a concentration of 1-25 gram-equivalent per
liter. When mannite, which in itself is not harmful
to the plant, is added to the boric acid, boro-mannitic
acid is formed which is stronger than the original
acid. Its solutions contain more hydrogen ions and
hence should be more deadly to the plant. Experi-
ment corroborates this since the limit-concentration of
the boro-mannitic acid was 1-100 gram equivalent of
the boric acid to the liter.
The following table shows a list of the salt solu-
tions investigated. The first column enumerates the
salts, the second column is the concentration
expressed in gram-equivalents per liter at which the
plants just survived. In the case of FeCl3, the con-
centration is otherwise indicated.
TABLE II.
Salt. Concentration-limit.
AgNC-3 1-204600 equivalent,
Ag2S04 1-204600
HgCl2 1-12800
HgCn2 1-51200
KCn 1-6400
CuCl2 - . 1-25600
CuSo, 1-25600
Cu (C2H302) 1-25600
NiS04 1-25600
FeSO« 1-12800
PVPi ^ Fe. 0.0025 gram per 1.
beUa } CI. 0.0047 " "
CoS04 1-12800
Co(NC-3)2 1-12800
Cd(N03)2 1-102400
From the above we see that the lupines just sur-
vive in a solution of silver sulphate containing 1-
204600 gram-equivalent per liter. Since the same is
true of silver nitrate, it follows that the silver in these
solutions is the active constituent. Moreover, it is
silver in the ionized state. To show this, silver
nitrate was treated with potassium cyanid in slight
excess so as to just dissolve the precipitate. It is well
Known that such a solution contains the ions + K and
— AgCn; that is to say, there are almost no silver ions
present in such a solution, the silver being combined
with the Cn radical to form the complex ion AgCn.
It was found that such a solution containing as much
as 1-12800 gram-equivalent of silver per liter still
allowed the plants to grow. The copper salts, the
sulphate, chlorid and acetate, all gave the same con-
centration limit, viz., 1-25600 gram-equivalent per
liter. There can be no doubt that here the copper
present does the work. A Fehling's solution con-
tains copper but, as has been recently shown, is poor
in copper ions. We found that a Fehling's solution
containing 1-200 gram-equivalent of copper per liter
still allowed growth. This Fehling's solution was not
made in the usual way, but, to avoid the presence of
salts in overabundance, cane sugar, copper sulphate
and just enough caustic potash to dissolve the precip-
itate were mixed.
The limit for cobaltic nitrate and cobaltic sulphate
was found to be again at agreement at 1-12800 gram-
equivalent per liter. This is a measure of the poison-
ous effects of cobalt ions. The corresponding limit
for nickel ions is 1-25600 gram-equivalent per liter.
From Table II, the corresponding figures for Fe
ions is 1-12800 gram -equivalent per liter; for cad-
mium, 1-102400, for mercury, 1-12800; HgCn is tox-
ically more active because the Cn ions in themselves
are poisonous as is also the undissociated HgCn2.
In the case of silver and copper, it has already been
shown that when these metals are present in the solu-
tions in compound ions the toxic action is much
diminished. When to mercuric chlorid, dextrin in
excess is added and then enough caustic potash to
precipitate the mercury present under ordinary con-
ditions, no precipitate forms. We have here, as it
were, a Fehling's solution containing mercury instead
of copper. The mercury is not present in the solu-
tion as ion but is bound to the dextrin with which
it forms a complex ion which is of much less poison-
ous action than the mercury ion. Indeed, such a
solution as that just described may contain 1-3200
gram-equivalent of mercuric chlorid and still permit
growth. The corresponding limit for mercuric chlorid
alone is 1-12800 gram-equivalent per liter, or one-
fourth as strong.
The results obtained with iron salts are of interest,
Dialyzed iron chlorid containing 0.0477 grams of Fe
and 0.0047 grams of chlorin per liter, just allowed
plant growth. A solution of ferric chlorid first
allowed growth at a much greater dilution. The
limit-concentration contained 0.0025 grams iron and
0.0047 grams chlorin per liter. The dialyzed iron
contains hardly any ferric ions as is shown by the
fact that potassium ferrocyanid produces no precipi-
tate in such a solution.
Again, solutions of potassium ferrocyanid contain
K ions and FeCn6 ions; potassium ferricyanid solu-
tions contain K ions and FeCn„ ions. Here we get
the effect not of the Fe- ions, nor of Cn ions but of
the complex ions mentioned. These are weak toxic-
ally as shown by the fact that in potassium ferrocy-
anid solutions lupines live in a concentration of 1-200
gram-molecule per liter.
These results are collected in Table III.
TABLE III.
METALS IN COMPLEX IONS.
Substance. Limit.
AgNOs 1-12800 grm. equivalent per 1.
HgCl2 13200 "
CuS04 1-200 " "
KaFeCne 1-200
K4FeCn6 1-200
FeCl3
Fe. . . 0.0477 " " "
CI 0.0047 " " "
ISiHi.]
JOINT PHARMACOLOGIC INVESTIGATIONS.
141
METALS IN SIMPLE IONS.
8ubsunoe. Limit.
km NOs • ..... . 1 -20401)0 grrn. equivalent per 1.
HgCl 1-12800 "
CuS04 1-25000 "
KCn 1 0400 "
FtCU
Fe 0.0025 "
CI 0.0047 "
Here the decided contrast, at times very striking,
speaks for itself.
These results have in n large measure been con-
tinned by Mr. F. D. Henld, Fellow in Botany at the
University of Wisconsin, who investigated the action
of like substances on various other plants.
That the modern theory of solutions would throw
light on the physiologic action of solutions was to be
expected. We have shown that, in the case of plants,
solutions of the electrolytes derive their toxic action
from the ions into which they split up in great dilu-
tions, the undissociated parts coming into account
mly when dissociation is not practically complete.
,*e have here a recognition of the theory of electro-
lytic dissociation by the organic world. Any one
inspecting Miiiuel'stableoftheefficiency of antiseptics
in Sternberg's "Manual of Bacteriology" at the same
time bearing in mind the theory of Arrhenius will,
although concentrations are given by per cent, instead
if chemie equivlents, be able to see the corroboration
of this view.
In seeking to apply this modern theory of solutions
to the physiologic action of the same, we have dealt
only witli the higher plants thus far. Investigations
along this line in bacteriology are now in progress at
the University of Wisconsin, and their extension to
animals is contemplated.
By working along this line, it is hoped to place the
knowledge of the physiologic action of solutions of
electrolytes on a better basis than the empirical one
on which it has thus far rested. It seems not too
much to expect that the effects of such study will be
felt in agriculture, whereas its application to bacteri-
ologic study will be highly important to our knowl-
edge of antiseptics. The systematic study of the
effects of solutions on animals from the stand
point of the new theories bids fair to yield results for
the therapeutist. For example, if, as we have found,
silver ions are very harmful to plants, then we can
readily see why silver foil placed upon a wound
should act as an antiseptic. The small amount of
silver ions that are formed, suffice in cases to prevent
putrefaction.
It is clear that the mere presence of a metal in a
solution does not warrant us in drawing conclusions
concerning its physiologic strength; we must also
know whether the metal exists in the solution as sim-
ple ions or combined with other radicles to form a
complex ion. If the addition of certain substances
to a solution containing a physiologically active ion
forms a complex ion of much less powerful action, it
follows that these additional ingredients give us a
means of reducing, so to speak, the physiologic action
of the simple ion.
This paper is intended simply as a preliminary
report on the work already done. The results are
soon to be published in full together with the details
concerning the methods employed. We shall also
take this opportunity to call attention to the further
applications of this view of solutions to physiologic
problems.
JOINT PHARMACOLOGIC INVESTIGATIONS
BY THE AMERICAN MEDICAL ASSO-
CIATION AND THE AMERICAN
PHARMACEUTICAL ASSO-
CIATION.
Read in the Section on Materia Medlca. Pharmacy and Therapeutic
at the forty-seventh Annual Meeting ol the American Medical
Association held at Atlanta, Ga., May 5-8, 1896.
BY H. H. RUSBY, M.D.
NEW YORK.
When one examines the pharmacologic portions of
the many ponderous volumes composing the index to
the Surgeon-General's library, and those of the Index
Medicus, by which the former has been succeeded,
remembering that a very large part of pharmaceutic
literature is not here represented, the conviction is
forced upon him that our knowledge of the practical
utility of medicinal plants is small beyond all reason-
able comparison with the amount of time that has
been bestowed upon their study. This fact is not
difficult to explain, at least in part. It is largely
due to the method, or rather want of method which
has prevailed, by which partial investigations have
been made by individuals without regard to their
relation to the complementary parts, these being
left undone, the part performed remaining unutil-
ized and becoming finally buried and forgotten.
This neglect has been made farther operative by
the habit of investigators of failing to search the
work of previous investigators in the same lines
before performing their own portion, so that the same
work has been duplicated over and over again, and in
such a way as not only to fail of confirming, refuting,
or of supplementing conclusions already reached, but
in very many instances of unnecessarily and mis-
chievously coming into conflict with them. This
charge against investigators is fully and eloquently
sustained by the small subscription list of the Index
Medicus for many years past, throughout its entire
history in fact. No class is more culpable for this
neglect than medical editors, whose duty of criticising
and weeding out contributions on these lines has
been almost utterly neglected. This again is in a
large degree due to the great number of medical jour-
nals, run almost confessedly for the most part as
advertising sheets, and recognizing quantity with
little regard to quality in the contributed matter.
An almost equally responsible factor is the narrow
view which physicians, and especially medical teach-
ers, have been taking of their responsibilities in the
department of pharmacology. In leaving to the phar-
macist the practical details connected with botany
and pharmaceutic chemistry, they have gone to the
extreme of ignoring these subjects almost altogether
in principle as well as in fact, and have as an inevit-
able consequence become incapable of utilizing the
rich materials which have been placed within their
reach by pharmaceutic investigators. In the investiga-
tion of pharmacology pharmacy has, during the last
decade, very far outstripped medicine. "Why does
not the medical profession catch up," would have
been a very pertinent, even if not wholly respectful
title for this communication.
The joint section of materia medica and therapeu-
tics of these two associations, which section should
change its name to "The Joint Section of Pharma-
cology," is altogether the most competent and appro-
priate agency for correcting the defects to which ref-
142
PRESCRIPTION WRITING.
[July 18,
erence has been made, and it is this which constituted
the chief hope in its establishment by its leading pro-
moters. To the great majority of observers in both
professions it has never appealed from this standpoint.
They appear to have seen in it merely an influence for
the promotion of cordiality between physicians and
pharmacists, either from sentimental considerations
merely, or to accomplish the negative result of check-
ing the friction which was apparent in certain quarters.
In this direction it has justified our expectations
and we are satisfied that it has proven a success. But
it must begin to do something more positive if it
would not soon begin to act as a dead weight. This
is to promote a new method of undertaking and carry-
ing out pharmacologic investigations.
When the writer expected to act as chairman of the
delegation from the American Pharmaceutical Asso-
ciation to this meeting, he planned to propose certain
changes, having this object in view, in the manner of
carrying on our joint work. Although absence
prevents his official action in this direction, it
appears desirable that his ideas should be informally
presented.
The chairman of this Section and that of the dele-
gation have followed the ordinary custom in such
bodies, of contenting themselves with attending to
the routine business of their offices and issuing gen-
eral invitations to the members to present contribu-
tions. As a result the proceedings have been some-
what heterogeneous in character. While it is desir-
able that members should be left free to select any
subjects they prefer, and while nothing could or
should be done by a chairman to deter any one from so
contributing, yet it would seem very desirable that at a
meeting so peculiarly adapted as this is to the perform-
ance of joint work, some such work should be specially
arranged for in advance by concerted action by the
two chairmen. The chairman of the Section is elected
at the preceding meeting, but the chairman of the
delegation is appointed by the president of the Amer-
ican Pharmaceutical Association, and it has not been
customary for this appointment to be made until quite
late in the year. Selection of the delegates has thus
to be made by correspondence, extending often over a
long period, and when arrangements are perfected
there is no time left for special investigation work to
be done by the members of the delegation, of such a
character that it would fit with related work done by
the members of the Section.
The writer would therefore suggest that the presi-
dent-elect of the American Pharmaceutical Associa-
tion should appoint the chairman of the delegation
during the session of the American Pharmaceutical
Association at which he is elected, and that chair-
man should proceed immediately to act with the
president in making up a list of delegates. The
chairman should then at once confer with the
chairman of this Section in regard to undertak-
ing one or more definite pharmacologic investi-
gations, to occupy one or more members of each
of the contributing bodies. The members to do
the work should be selected and after acceptance
should place themselves in correspondence with one
another for carrying out the work in a manner calcu-
lated to reach some definite and completed result.
An instance of failure in such an attempt in the
case of the present meeting will illustrate the princi-
_ pie involved. It was the desire of the writer to
have the subject of the viburnum barks investi-
gated. A thorough chemical study of V. prunifo-
lium was first to be made and the constituents isolated
in sufficient quantity to admit of physiologic experi-
ment by some member of this Section. The active
constituent or constituents being thus determined,
the related species were to be examined with reference
to the possession of such constituents, as well as of
others, so that a just conclusion could be reached as
to their claims for recognition by the Pharmacopeia
and, if recognized, then as to their recognition sepa-
rately or under one definition. When the attempt
was made to put this plan into execution, it was
found impossible to complete the work in time for the
meeting, though this would have been possible had
it been started at the beginning of the preceding
year. There is no reason why such a plan of work
by the proposed method should not run through two
or more years, if its completion in one year were
found impracticable. The writer believes that impor-
tant practical results would follow the adoption of
this plan, or some modification thereof.
PRESCRIPTION WRITING AND PHARMACY
AS PRACTICED IN OUR LARGE HOS-
PITALS AND DISPENSARIES.
Read In the Section on Materia Medica, Pharmacy and Therapentics,
at the Forty-seventh Annuai Meeting of the American Medical
Association, held at Atlanta, Ga., May 5-8, 1896.
BY HENRY R. SLACK, Ph.M., M.D.
SECRETARY GEORGIA BOARD OF PHARMACY.
I.A ORANGE, GA.
My attention was first directed to this subject by
an editorial in the American Medico-Surgical Bulle-
tin from the able pen of Dr. Wm. Hy. Porter, in
which he very forcibly portrayed the evil of stock
prescriptions in the hospitals. At first I rather
thought, that like most reformers, he had represented
the practice and the evils thereof in somewhat extrav-
agant terms, but closer personal observation has con-
vinced me of the correctness of his views.
Vibration is nature's law; everywhere do we notice
action and reaction, condensation and rarefaction,
crest and trough. Even the forces that apparently
move in straight lines, when more closely studied, are
found to be an aggregation of an infinite number of
minute vibrations too small for the unaided eye to
measure.
The noble art and science of medicine is no excep-
tion to nature's law of vibratory motion; indeed, not-
withstanding her boasted conservatism she is largely
the creature of fashion. Fortunately for suffering
humanity, her styles do not change quite as often as
the seasons, and when they do, there are usually a few
facts, some reasons and more theories to explain the
revolution than are produced in defense of the cut of a
coat; but the reaction comes just the same. .
At present we are in the midst of a season of expect-
ancy, as a natural reaction from the polypharmacy
hypertherapy of the past. Serotherapy and animal
extracts seem to be the coming fad, though the quack-
ish methods adopted by some of its promoters and
manufacturers have somewhat chilled the ardor of the
regular profession. It matters little whether we float
on the crest of expectancy or struggle in the trough
of empiricism, we find good company in both situa-
tions. Hippocrates and Celsus, Trousseau and
Sydenham, Chapman and Todd, Osier and Wood rep-
resent different ideas in medicine, but are names we
all honor. Wherever we are, let us "act well our
18%.]
PRESCRIPTION WRITING.
143
part, for there all the honor lies." Whether clinicians
or therapists, when medicines are used the prescrip-
tions should he properly written and accurately filled.
Four months spent as a student and visitor in the
largest and best equipped medical colleges and hos-
pitals in New York, Philadelphia and Baltimore, has
convinced me that there is more room for improvement
in prescription writing and pharmacy than in any
other art there practiced.
Being interested in this department, I visited the
pharmacies of these colleges and was surprised at the
careless, almost slovenly, manner in which the pre-
scriptions were written, and as might be expected, the
rilling was no improvement on the writing.
Analysis of 100 prescriptions found on the files of
each of the five leading colleges in the East and three
in the West may be of interest.
Metric
system
Correctly
Incorrectly
Stock
used.
written.
written. Symbols. yt.
\
0
52
48
45 45 Pa.
B.
6
64
36
36 36 J. H.
B.Dis
4
33
67
65 65 J. H. D
O.
0
90
10
3 13 Jef .
D.
5
96
4
2 6 P. G.
E.
1
98
2
0 2 P. C.
Western Colleges.
F.
40
65
35
90 N. W.
O.
8
33
67
3 P. G.
R.
0
All symbols. 100 R.
The analysis of the prescriptions from the western
colleges were made by my friend and pupil, Mr. W.
8. Davis, now a student in Chicago.
From a consideration of these figures it will be seen
that the art of prescription writing is rather below
par. even in our oldest and youngest and strongest
medical colleges.
Although the physicians are presumed to be famil-
iar with the metric system, it is used in less than 3
per cent, of the prescriptions filled in the eastern hos-
pitals. In this respect the West shows her progres-
sive spirit, for there we find the metric system used
in 24 per cent, of the prescriptions. The conserva-
tism and training of the East shows in the correct-
ness of the prescriptions as written, for here we have
72 per cent, correct while in the West only 49 per
cent are placed in that column. How far short are
our colleges and hospitals in both sections in this
important particular appears when we consider that
nearly one-third of all the prescriptions are incor-
rectly written.
The chief error lies in the careless use of symbols,
not chemic, but abbreviations understood only by the
pharmacist, standing for some stock prescription,
such as:
R H. S. 3i
for
E
Hydrargyri bichloridi 0.065
Potassii iodidi. . . . ■. 30
Aquae purae, q. s '30 c.c.
Mix. Sig.
or
R M. G. A.
for one of Dr. Pepper's favorite prescriptions:
B Tr. nucis vomicae . 4 cc.
Tr. gentianae co 45 c.c.
Sodii bicarbonatis 8
Aquae menthae pip., q. s .• 180 c.c.
Mix. Sig.
Using signs and stock remedies gets the prescriber
into the very careless and harmful habit of fitting his
symptoms to his remedy, instead of the treatment to
the disease. This is one cause of the rapid growth
of that most injurious form of all nostrums, so-called
physician's formulas, the ingredients of which are not
known either to the physician or the pharmacist, and
are used to the detriment of the former's brains and
self-respect, and the letter's skill and profit.
This careless prescription writing is an injustice to
the students, especially the post-graduates, many of
whom graduated five or ten years ago, when only two
courses were required. These men, feeling the defi-
ciency in their early training, or wishing to brush up
in some particular branch, go to the large schools and
hospitals for thorough training and instruction.
Imagine their surprise when after a half hour's thor-
ough examination of blood, heart, lungs, liver,
stomach and kidneys, a prescription is hastily scrib-
bled off thus:
R M. G. A giv
Sig., 3ii t. i. d.
S. M.D.
Inquiring as to what these cabalistic letters repre-
sented, they receive the following reply: "Oh, that
is a splendid thing for stomach troubles, and Dr. M.
has made quite a reputation by its use. It contains
some tr. nux vomica, gentian, soda, etc., but I have for-
gotten the proportions. You can find out from the
pharmacist." " Doctor, wouldn't a little sanguinaria
be beneficial in his case?" suggests one of the post-
graduates. " Yes, I think it would, but we haven't
time to write individual prescriptions for each case "
Thanking the interne or instructor for his kindness,
they go to the pharmacy. This seems to be against
the rules, but one of their number is an alumnus of
the same college of pharmacy as the pharmacist, so
they gain admittance. There they find a very intel-
ligent Ph.Gr. busily engaged in mixing medicines by
the gallon, and from these large bottles bearing the
cabalistic signs he fills a dozen or more one, two or
four ounce vials, which he corks and puts in rows
ready for the labels. When asked for the U. S. Phar-
macopeia he did not have one, but gave us instead a
sixteenth edition of the U. S. D., a book nearly ten
years behind the times. No metric weights were vis-
ible and only two metric graduates. When asked
about this deficiency, he said: "Only one man in
this hospital, Dr. T., uses the metric system in his
prescriptions, and for these I can use fifteen grains
for the gram." One of the company expressed dis-
appointment at the neglect of the metric system by a
school where so many of its teachers were graduates
of European universities, and one whose name stood
for progress in every department of university educa-
tion; and they went to the pharmacy of the hospital
proper. Here they found a younger man in charge,
also metric weights (though very little used), a U. S.
Pharmacopeia and some other standard works on
pharmacy.
The other pharmacies visited revealed nearly the
same condition of affairs, though three were not so
bad for stock prescriptions, and one presided over by
a doctor of pharmacy was well arranged and properly
equipped.
In three out of five were found the U. S. P. and
the U. S. D., and in two the Nat. Dispensatory. In
all but one there was great room for improvement
It is to be hoped that our colleges now requiring four
years instruction will teach their graduates to write
their prescriptions correctly and the use of the metric
system. At present, prescription writing and phar-
144
STANDARDIZED DRUGS.
[July 18,
macy, as practiced in our large college hospitals and
dispensaries, leave much to be desired by way of
improvement.
STANDARDIZED DRUGS.
Read iu the Section on Materia Medica, Pharmacy and Therapeu-
tics at the Forty-seventh Annual Meeting of the American
Medical Association, at Atlanta, Ga., May 5-8, 1890.
BY HENRY B. GILPIN, Ph. G.
BALTIMORE, HD.
It is interesting to study, in the evolution of the
methods of drug administration, the various forms
that have obtained. Beginning with the crude drug,
the first step apparently was the recognition of the
fact that, as a rule, the soluble principles of a drug of
vegetable origin, were its therapeutically active ones.
Hence it was but natural that solutions — made with
hot or cold water — in the form of infusions, decoc-
tions, etc., should have resulted. It was found, how-
ever, that the proneness of these to decomposition,
and the relatively large doses necessary to secure
therapeutic effects, made them objectionable. The
next step was the making of tinctures, fluid extracts
and similar products. The final advance has been
the assaying or standardizing of the more prominent
drugs and galenical preparations, such as those of
cinchona, opium and nux vomica, as directed by our
Pharmacopeia, and a score and more of other alka-
loid-containing drugs that manufacturers themselves
have adjusted to certain standards.
In these days of scientific accuracy, it would seem
hardly necessary to put forth any plea in favor of
standardized drugs, and yet the variability in active
constituents of what are commercially regarded as
good-quality drugs, makes it essential that the agita-
tion in favor of higher standards be continued. It
may be of interest to state that in over 500 assays
made of six prominent drugs — which, by the way,
were of the best commercial quality — the following
percentages of alkaloids were obtained:
Aconite root 0.21 to 0.80 per cent., belladonna
leaves 0.23 to 0.50 per cent., conium fruit 0.10 to 0.53
per cent., hyoscyamus leaves 0.11 to 0.20 per cent.,
nux vomica 1.6 to 3 per cent., gelsemium root 0.3 to
0.4 per cent. What is true of variations in strength
of these drugs is equally true of many others. From
the above it will be seen that the varying alkaloidal
strength between extreme limits in the above men-
tioned drugs, is sometimes several hundred per cent;
notably is this the case with aconite root. For
example, to illustrate the possibilities of this varia-
tion : two minims of an unassayed tincture of aconite,
in one case, may have the same amount of alkaloids
as eight minims of a tincture made from another
crude root. Five minims of a tincture of belladonna
made from an unassayed drug may have only one-half
the alkaloids contained in the same amount of a tinc-
ture made from another sample, or, if it be required
to give ten minims of tincture of nux vomica, the
unassayed product may contain only one-half the
alkaloids it contains at another time. In other words,
there is no safety for the physician in unassayed
drugs; he must have the most uniform and reliable
tools with which to work, or he will measurably
fail. This is true for a number of reasons, the main
one of which is, that practical medicine is not an exact
science. The medical man has to deal with condi-
tions that are far from being exact. " The human
body is a wonderfully intricate piece of mechanism
with such various and varying factors to govern its
cellular activities that rational medical practice can
only develop most slowly. " Now, if with the factor
of a varying human economy the physician has to
deal with varying drugs and preparations of drugs,
he is doubly handicapped in his work. If on the
other hand, he can be assured that the means he
wishes to employ to combat disease are always defi-
nite and sure, he can ignore the factor of a possible
variation in the strength of the drug as an explana-
tion of its want of action, and assume that the use of
the drug itself was not indicated, because its use failed
to give certain results. But when he uses a drug of
unknown strength, and fails to produce certain results
he may be in doubt as to whether it was the fault of
the drug, whether it was not pushed to the full limit
of tolerance, or whether its application was not
indicated.
So, from every point of view, the physician should
be interested in obtaining the best and most uniform
drugs, if he wishes to obtain, as far as possible, the best
and most uniform results in medical treatment, and in
this connection let me say, that the educated pharma-
cist is just as anxious as the physician to have prod-
ucts that shall be reliable and uniform.
What is true with regard to the value of accurately
assayed drugs, is also true with regard to the value of
accurately assayed preparations of drugs. Whether
it is better for the pharmacist to buy assayed drugs,
and make his own tinctures, fluid extracts and the
like, or to buy the assayed preparations of a manu-
facturer, is a question to which we think, there can
only be one right answer. It is better for the phar-
macist to buy assayed drugs, and make his own
preparations, for the reason that it encourages the
development of legitimate pharmacy — gives the phar-
macist a deeper knowledge of the drugs he is hand-
ling— and he can personally guarantee the quality of
his products. He can not personally vouch for the
quality of another's preparations. It may be retorted
that the pharmacist can not vouch for the strength of
commercially assayed drugs, but he has this advan-
tage: he can readily verify the claims made, and make
a physical inspection of the products before convert-
ing them into preparations. When he buys a fluid
extract, he buys a finished product, and knows noth-
ing of the physical condition of the drug from which
it may have been made.
But whatever difference of opinion may obtain
concerning this point, there can be little question as
to the reprehensibility of the practice sometimes fol-
lowed by pharmacists of making tinctures by simply
diluting fluid extracts. Fluid extracts, assayed or un-
assayed, differ from tinctures in the relative amount
and kind of their proximate principles, and while it
may be possible to so adjust the alkaloidal strength of a
diluted fluid extract to make it correspond to the
proper alkaloidal strength of a tincture, it is not possible
to so adjust the other proximate principles, because in
the vast majority of cases, there exists no known
methods of assay for them. Further, that tinctures
contain relatively a larger amount of proximate prin-
ciples than do fluid extracts, is shown by the fact,
known to every physician, that the dose of a drug in
the form of a tincture is less relatively than is the
dose of a fluid extract, and exhibits the physiologic
effects of the drug in a correspondingly less dose.
The increased use of synthetic chemicals and the
18%.]
THE McINTYRE ELEPHANTIASIS CASE.
145
decreased use of tinctures of vegetable drugs, by the
physicians of to-day, may be due, in part, to the fact
that some pharmacists buy commercial fluid extracts
juul make tinctures from them by simple dilution
with varying quantities of tdcohol and water, instead
of using, as the Pharmacopeia directs, drugs with
which to make thorn; and physicians have failed to
achieve the results recorded by their forefathers.
Modern physicians have thrown aside the old and
tried, to welcome the new synthetic compounds;
but in so doing, is it not possible that the old may
ss merits that make them equally as worthy as
the new, if not more so?
THE McINTYRE ELEPHANTIASIS CASE.
BY G. LAIDLAW, M.D.
CHICAGO.
In this world of phenomena it is not strange that a
physician and surgeon, practicing his profession for a
numlvr of years, should occasionally meet with path-
ologic conditions more or less rare, but it is strange
that sonic should meet the most remarkable cases at
every turn, so to speak. In this connection I am sure
that it is the privilege of very few professional men,
outside of very large hospitals, to deal with more
extraordinary cases than have come to the notice and
care of my much respected friend and colleague, C.
J. Mel nt vie. CM., M.D. As a partial proof of the
foregoing assertions, I take great pleasure in present-
ing to the reader four different views of a patient
whom the doctor has had for several years, together
with a few brief remarks upon the history of this
particular case and the disease with which the lady is
afflicted.
The good-natured, intelligent and respectable
woman, who so kindly allowed us to divest her of all
metallic substance and garments and pose before the
searching eye of the camera obscura, that by so doing
we might obtain further light in medicine and be
able to present to your view these pictures from life,
is a native of America, and was born in Wisconsin.
She is now 45 years of age and the mother of ten
children, to five of whom she has given birth since
the disease from which she now suffers began.
Eighteen years ago, while engaged in a laborious
task, she sustained an injury of the abdomen, near the
umbilicus, which was followed shortly after by chills
and vomiting. The cutaneous and subcutaneous
tissues of the affected part presented redness, tumefac-
tion and infiltration. In a short time the acute symp-
toms disappeared, leaving a well-marked hypertrophy,
which gradually increased until two years later, when
the left leg began to be covered with scales and to
enlarge somewhat. She was at this time in the fourth
month of gestation with her sixth child. The abdom-
inal trouble grew gradually worse, but the leg remained
in about the same condition until seven years later,
when she fell from a step-ladder and sustained a
wound from a rusty nail on the right leg, just above
the ankle, where, by reference to Figures 1 and 2, the
mark of its point of entrance may still be seen. This
accident occurred on July 5, and on August 15 she
was attacked with chills and vomiting. The seat of
the wound burned and throbbed and her suffering
was great. The symptoms, as she described them,
appear to have been those of tubular lymphangitis.
At the end of two months from the date of the acci-
dent she had recovered from the lymphangitis and, as
she remarked to us when relating the history as above,
"was ready for more trouble." She did not have long to
wait, for in November of the same year she again fell,
this time into a register hole, and wounded her left
leg, which, as we have stated, was the one on which
the scales appeared two years after the abdominal
injury. For a third time she was attacked with chills
and vomiting, on the second day after the fall. Her
physician pronounced the case, when he saw it, one
of erysipelas. The entire limb from toe to knee was
involved, and she was very ill for four months. The
tissues never returned to their normal proportions,
not even to the size which they were when the acci-
dent occurred, but, on the contrary, continued to
increase in size, the trouble extending all the while
further and further up the limb.
Some time after this, but just how long the patient
does not remember, the right leg, which had been
injured by the nail, began to enlarge.
We have now passed roughly over the first ten years
of the history of this case, giving the story substan-
tially as the patient related it from memory.
Dr. Mclntyre began to see the case about this time
and has now been the patient's physician for about
eight years, during which time he has had to deal
with indolent, unhealthy and ever-increasing ulcers,
the secretions from which have been composed of
serum and pus, and very disagreeable to the sense of
smell. The epidermis has at times become fissured
and cracked; papillomatous excrescences of no mean
size, made up of conglomerations of many smaller
ones, have appeared, while the lymphatics have
exuded lymph in large quantities. When the fissures
and ulcers have reached deep-seated nerves Dr. Mc-
lntyre has had to assuage the great pain which the
patient would experience; and there have appeared at
many places, but particularly on the inner aspect of
the left leg (seen in Fig. 2), quite large and deep-
seated abscesses, calling for evacuation and the insti-
tution of proper treatment to prevent septic absorp-
tion. Meeting all indications as they have arisen
from time to time, and supporting the patient in a
proper manner amid conditions which at times have
seemed hopeless, Dr. Mclntyre has cared for the
patient until now, when the case has assumed an
insidious and chronic form. Large areas of vessels
have become affected, and such wide-spread oblitera-
tion of them has resulted as to block up permanently
their flow of lymph, thereby producing an everlasting
lymphedema of the affected parts. From the his-
tory of the case it would appear that there resulted
from the abdominal injury many years ago an ordinary
erysipelas or reticular lymphangitis, and that from
the invasion of the lymphatic channels at this time
the disease dates. Later on we find one leg affected
with eczema, the other with a septic wound, and finally,
the eczematous one, after an injury, becomes the seat
of a traumatic erysipelas. At these three seats of
original attack there have occurred successive attacks
of diffuse lymphangitis, each recurrence causing an
aggravation of the already bad condition. Thickening
and induration of the skin and connective tissue have
taken place, the dilatation and multiplication of the
blood vessels keeping pace with the general connect-
ive tissue hypertrophy, until we have now a case of
elephantiasis Arabum which, in some respects at least,
is the most wonderful on record. In support of this
last remark I wish to state that it has been made
after a careful examination of a great many works
146
THE McINTYRE ELEPHANTIASIS CASE.
[July 18,
on the subject under discussion, among which may
be mentioned those of Hebra, Neumann, Kaposi,
Ziemssen's Encyclopedia (the volume on Skin Dis-
eases), Crocker, the London Lancet since 1878, A. H.
Buck's Refer. Hand-book Medical Science, Keen and
White's American Text-book of Surgery, Hooper's
Dictionary, published in New York in 1847 by Harper
& Bros., Stephen Smith's Surgery, Dr. Titley in the
Lancet, Vol. xx; M. Clot-Bey, A. J. Howe, etc. Fel-
kin's case in the Edinburgh Medical Journal, 1889,
page 779, is the only case I have found which very
closely resembles the Mclntyre one. In this instance
the patient was an Eurasian woman.
In a general way I may close my remarks regarding
this case by saying that the patient is a most hopeful,
good-natured and happy woman, who, if it were not for
Figure 1.
the asthma, with which she has suffered much at times
for the last six years, would not complain at all, not-
withstanding the fact, that in addition to her terrible
state, she has no husband to care for her and is in the
most destitute circumstances, with several children
still requiring the care that none but a mother can
bestow.
By reference to Figs. 2 and 3 a very interesting
demonstration of a commencing lymphangiectasis
may be seen on the lower part of the abdomen near
the line of the groin. This condition is to the
lymphatic vessels what dilatations and varicosities are
to their congeners, the veins, and should the condition
here seen, by confluence and aggregation, form dis-
tinct tumors, we will have what is called lymphan-
gioma.
Extending downward from the umbilicus, corre-
sponding to the linea alba, there is at present a fissure
about four inches in length, and two and one-half
inches in depth (best seen in Fig. 3), the sides of
which are in a state of ulceration and discharge a
disagreeable-smelling mixture of serum, pus and
lymph. During the past year the labia majora and
minora and clitoris have become involved, but are not
as yet enlarged to any great extent, in fact, there is no
chance for any considerable enlargement, for the
abdomen as it hangs, or rather protrudes, downward
is as stiff and unwieldy as any elephant's belly on
earth. To the sense of touch, moreover, there is
nothing that I know of which feels more like the hide
of an elephant than this does. There is very little
:
feeling in this thick, rough, wrinkly, unctuous and
void-of-hair skin. In the edema produced by other
diseases and other causes there is pitting on pressure,
but no part of this growth pits, even when great
pressure is applied. The blood recedes to quite an
extent from the point of pressure to return very slowly,
indeed, but that is all.
While elephantiasis Arabum, the synonyms of
which are pachydermia, Dal fil, Barbadoes leg, Ele-
phantenfuss, mal de Cayenne, etc., may be considered
a pandemic disease, we must consider it when
appearing in this climate and from the causes which
appear to have been responsible for it in this case, a
very sporadic malady. Authors of the present day speak
of elephantiasis Grsecorum as lepra, and elephantiasis
1896.]
THE McINTYRE ELEPHANTIASIS CASE.
147
Aratuun as simply elephantiasis or pachydermia, it
being now certain that the two are distinct. I think
that when we have a case like the one under discus-
sion and springing up in this part of the world from
causes similar to those which appear to have been at
the bottom of this case, the simple term lymphedema
would be the best to employ, reserving the terms
elephantiasis Grseoorum for the leprK type, and ele-
phantiasis Arabum for those cases found in hot
climates near the tropics, particularly in Egypt, on the
coast of the Mediterranean, the west coast of Africa.
the Antilles i Barbadoes), Brazil, Malabar and parts
of India, in all of which sections of the world it- is
most often met with and where, almost alwTays, the
cause of it is the entrance into the blood and lymphatics
Figure 3.
of the embryo of a nematode worm, the name of which
is filaria sanguinis hominis, from its discovery in the
human blood. For much of our knowledge in regard
to this we are indebted to Wucherer, Salisbury, Lewis,
Bancroft, Manson, e t al.
With us in this country the disease probably always
appears after chronic or frequently repeated acute
inflammations of the blood and lymph vessels or any-
thing which hinders the flow and favors the escape of
the lymph in the lymphatics; and whether it be pro-
duced by an inflammation of the blood vessels or of
the lymphatics themselves, or from external pressure.
it matters not, we will have lymphedema, and follow-
ing it there will be cell-proliferation and consequent
increase in the surrounding tissues.
In tropical countries, but particularly on the Guinea
Coast of Africa, the home of the filaria sanguinis
hominis, every native into whose lymphatics the filaria
gains entrance is not affected with elephantiasis. In
some it produces chyluria, and in some it does not
appear to affect the health at all. This fact, therefore,
goes to prove that there is not in this parasitic worm,
/'</• 86, any special poison the presence .of which is
necessary in order that either chyluria or elephantiasis
may exist. For, unless the parasites block, by their
presence, the lymph channels, there will not be
chyluria; and unless they develop in sufficient num-
bers to produce stagnation in the lymph vessels, there
will not be, from them at least, an elephantiasis. It
is, therefore, apparent that it is not necessary that we
should have in this country, in order to produce gen-
uine cases of chyluria or elephantiasis, the worm
which Manson has so well studied for us, and we do
not believe that the filaria sanguinis hominis had any
part in the cause of the Mclntyre case which we have
just reported.
Manson says that this parasite resembles a delicate
thread of catgut, animated and wriggling; and W.
Essex Wynter tells us that the female has a diameter
of about 1-100 of an inch and a length of 3 to 3|
inches. As yet no perfect specimen of the male has
been found. The mouth is circular, without papillae;
there is a narrowing at the neck, and the tail is bluntly
pointed. The parent worm is necessarily only found
during operations involving the affected tissues, or in
148
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
[July 18,
autopsies. On the other hand, the embryos occur in
immense numbers and are readily found in blood
obtained by pricking the skin. They appear as active
organisms, each being contained within a delicate
sheath which projects slightly at one or the other end
of the worm. Its length is about 1-90 of an inch
and its diameter 1-3200.
Dr. Manson obtained ova consisting of oval bodies
1-500 by 1-750 of an inch. These are too wide to
traverse the channels of the lymphatics and conse-
quently become impacted and thus give rise to the
conditions of elephantiasis and chyluria.
The mosquito plays a part in the spread of this dis-
ease in hot climates. Dr. Stephen Mackenzie's experi-
ments showed that the embryos only occur in the
cutaneous vessels while the patient is asleep, whether
by night or day. As to what becomes of them during
the period of activity of the patient nothing certain
is known. During sleep, however, while the filaria
embryos circulate in the blood of the sleeper the
mosquito fills himself with the infected fluid and flies
to some stagnant pool of water, his natural haunt,
ujion the surface of which he drops to die. The
embryos of the filaria contained within the blood are
thus set free and become ready to enter the circulation
of the next thirsty mortal who drinks the water.
THE METHODIC DESCRIPTION OF A
SURGICAL DISEASE.
BY EDMOND SOUCHON, M.D.
PROFESSOR OF ANATOMY AM) CLINICAL SURGERY, TULANF. UNIVERSITY,
NEW ORLEANS, LA.
( Concluded from page S3. )
FORMS, VARIETIES, COMPLICATIONS AND RECURRENCES.
The description of the forms, varieties and compli-
cations of the disease comprises that of all the points
and features which are not commonly met with and
the description of which would embarrass or obscure
the description of the most common or frequent
appearance of the disease.
Those forms, varieties and complications must be
stated as due to peculiar causes; to pathologic peculi-
arities, to peculiar symptoms, course, termination,
duration, diagnosis, prognosis, complications, relapses,
sequehe or consequences. Complications may be local
or regional or general. . The local and regional com-
plications may be due to malformation, to softening,
induration, neurosis, injury, congestion, inflammation,
gangrene, ulcer, fistula, tumor: they may affect the
skin, connective tissue, adipose tissue, tendons,
muscles, fascia, periosteum, bones, medulla, arteries,
veins, capillaries, lymphatic vessels, lymphatic glands,
nerves, an organ special to the region. The general
complications may affect the organs of circulation,
respiration, etc. For each form, variety or complica-
tion state the frequency and importance.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS
FURNISHED BY THE SIGHT, TOUCH, HEARING.
The methodic description of the local symptoms
furnished by the sight, touch and hearing are much
facilitated by arranging them methodically according
to each disease or group of diseases. Hence the fol-
lowing separate methodic descriptions:
The classification here adopted and advocated is
based on the clinical manifestation which is visible
and at once recognizable by the student, and which
leads to the pathologic and etiologic characters which
themselves lead to the diagnosis, prognosis and treat-
ment.
These diseases are: Malformations, injuries, neu-
roses, softenings, indurations, congestions, inflamma-
tions, gangrenes, ulcers, fistulse, tumors.
They may affect the skin, connective tissue, adipose
tissue, tendons, muscles, fascire, periosteum, bones,
medulla, joints, arteries, veins, capillaries, lymphatic
vessels, lymphatic glands, nerves, an organ special to
the region, in all or only one of its component parts.
This plan corresponds to descriptive anatomy, a fair
knowledge of which is previously necessary to study
profitably general anatomy, which studies the tissues
and organs of the same nature regardless of their situ-
ation and relative position. The same, in the study
of surgical diseases, a descriptive and clinical knowl-
edge is necessary before undertaking the study of the
diseases from the point of view of causes or nature,
irrespective of the clinical forms they may assume
and the location they may affect, such as diatheses,
gout, struma, tubercles, syphilis, etc. It would seem
that the study of the general diseases should precede
the study of their local manifestations, but experience
teaches that that study is much more profitable after
some clinical knowledge has been acquired.
We must here beg for indulging in repetitions which
can not very well be avoided in a new subject where
clearness and precision must have precedence over
style and grace.
METHODIC DESCRIPTION OF FUNCTIONAL SYMPTOMS.
The methodic description of functional symptoms
comprises the following features:
1. The alterations in the physical, i. e., mechanical
phenomena of the functions; they usually consist in
alterations of movements, i. e., contractions of the
muscular fibers of the part or of the organ. We
must state the alterations in the capacity or extent of
the movements (including reflex, if any), in their
duration, in their rhythm or order of succession, in
their frequency or rapidity, in their intensity; the
alterations in the sounds presented by auscultation, if
any, stating the cause, intensity, rhythm.
2. The alterations of the chemical and vital phenom-
ena, comprising the description of the alterations tak-
ing place in the contents of the organs; alterations of
character, of losses, by gains; the alterations in the
presence or action of the peculiar agent which is usu-
ally present in the organ (such as pepsin).
3. The alterations of the secretions of the organ.
which should be described after a separate guide
explained below.
4. The alterations in the composition of the blood
in the afferent vessels: also of the efferent vessels;
these must be described after a separate method, as
explained below.
5. Alterations of the nerve actions and of the nerve
centers which preside over the functions.
METHODIC DESCRIPTION OF THE PATHOLOGIC
ALTERATIONS OF A NORMAL FLUID.
These present to state: 1. The alterations of the
physical characters, i.e., quantity, color, smell, taste,
consistency and specific gravity. For each state fre-
quency and importance. 2. The alterations of the
chemical characters and of the composition, i.e., of
the reaction, of the qualitative analysis, of the inor-
ganics (water, gas, salts), of the organics (albumi-
noids, carbonaceous, of the characteristic or pecu-
liar substances usually present in the secretion,
1896.]
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
149
such as ptyalin. pepsin), of the qualitative analysis of
each component part. 3. The alterations of the ana
tomie elements or solid components, i.e., shown by the
microscope, such as salivary corpuscles, blood corpus-
cles, etc. We must state the quantity or number.
dimensions, color, shape, structure, chemical composi-
tion (histo-ohemistry), their development and organic
changes. 4. The alterations in the physiologic func-
tions of those fluids or secret ions. 5. The alterations
in the origin or development of the secretions. <>.
The alterations of the nerve action or nerve centers.
METHODIC DESCRIPTION OF A NEW OR PATHouooic
fluid.
This includes the following: 1. The physical char-
acters: quantity, color, smell, taste, consistency or
specific gravity, temperature. 2. The chemical char-
acters or composition, including the reaction, the
qualitative analysis, inorganics I water, >jas, salts);
organice (albuminoids, carbonaceous, characteristic
organic substance, if any): quantitative analysis. 3.
The anatomic or microscopic analysis or characteris-
tics of the solid elements; quantity or number, dimen-
sions, color, shape, structure, chemical composition,
physiologic functions, development or origin of the
solid elements. 4. The pathologic functions or uses
of the pathologic fluid. 5. The development, origin,
changes, etc., of that fluid. 6. Action of the nerves
and nerve centers on the secretion of the fluid.
METHODIC DESCRIPTION OF A CONGENITAL MALFORMA-
TION OR DEFORMITY.
This must state if it consists in the absence of the
organ, partial or total, or if the organ is double; if it
is an arrest of development, such as fissures, fistulas
if it is atrophy or hypertrophy, and state if it is gen-
eral or bilateral; if it involves the whole region or
organ or if it is partial, i.e., involving a part only,
or one side, unilateral: if it is homogeneous or hetero-
geneous, i.e., of the same nature or character or not,
all over; if its anatomic site is in the skin (pigment,
hair, cuticle, cutis, sebaceous glands, sweat glands,
vessels, nerves), or in the connective tissue, adipose
tissue, tendons, muscles, fascia, periosteum, bones.
medulla, arteries, veins, capillaries, lymphatic vessels,
lymphatic glands, nerves, or an organ special to the
region.
If the malformation is a deviation or asymmetry,
we must state if it is directed upward, downward,
laterally, backward or in an intermediate direction:
METHODIC DESCRIPTION OF AN ACQUIRED OR POST-
NATAL MALFORMATION.
The same course must be followed as for a congen-
ital malformation. We must further state if it is
characterized by the destruction of the organ, partial
and total, also the cause in each; softening, indura-
tion, neurosis, injury, inflammation, gangrene, ulcer,
fistula, tumor, operation, cicatrix; and whether they
affect the skin, connective tissue, etc.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS OF A
SURGICAL NEUROSIS.
(Sensory neuroses; pain, neuralgia; motor neuroses,
paralysis, spasms or convulsions, contractions, retrac-
tions, contractures. )
Here the subjective symptoms often occupy a con-
siderable place.
The subjective symptoms present to state the fol-
lowing: 1. The frequency of the attack, daily, weekly.
2 Whether the neurosis is spontaneous, or provoked
or increased by the function of the part. 3. The seat
or tract of the neurosis, i.e., the spot where it begins,
the line or tract which it follows as traced by the
patient; the spot where it ends; state if there are
spontaneous painful spots or a spot or place where the
symptom is greater; also the breadth or width of the
tract or course of the neurosis. 4. The intensity,
degree or force; slight, moderate, great, very great.
5. The character of the pain, if any; lancinating, bor-
ing, acute, dull, sharp, burning, etc.; note the com-
parisons made by the patient. 6. The course or
rhythm of the neurosis, i.e., if the intensity is always
the same; if not, describe how it is, then state the time
of onset, of maximum, of decrease and of cessation;
the influence of morning, noon, evening, night, mid-
night, dawn; state if there are remissions or intermis-
sions during the attack, or if the neurosis is continu-
ous until the attack is over; state the duration of the
remissions or of the intermission; state if attacks are
periodic. 7. State the effects of pressure by the tip
of the finger or a broad surface; of light pressure or of
great pressure ; of short or of continued pressure. 8.
State the effects of hot or cold applications; of cold
weather with or without dampness; the effects of baro-
metric changes. 9. State the mode of termination of
the attack; abruptly, rapidly, gradually; if there are
any critical symptoms. 10. State the duration of an
attack; hours, days, etc.
The physical symptoms are the following: Erup-
tions or not along the course of the affected nerve or
parts. Pressure on peculiar spots, at points of emer-
gence of nerves through fascia and bones. Effects of
pricking with a pin, of hot and cold applications,
of electricity, with the patient's eyes closed; effects
of threats to use painful methods of treatment (blis-
ters, hot iron, etc.). Effects of fictitious medication;
bread pills, hypodermics of water, of air.
The functional symptoms present to describe the
alterations of the normal phenomena, of the functions
of the part (as above), and the alterations by new
phenomena; new position of the part, of the patient.
The regional symptoms comprise specially the irra-
diation of the manifestations; the sensations of heat
and cold, of heaviness, of prickings of the region, of
spasmodic clonic contractions, of tonic contractions
or contractures.
Describe the condition of the patient immediately
after an attack, the local and the general symptoms.
Describe also the condition of the patient during
the intervals of an attack, the local and the general
symptoms.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS OF AN
INDURATION, A SWELLING, A TUMOR.
The following methodic description is applicable
alike to an induration, a swelling, a tumor. It com-
prises the description of the subjective, the physical
and the regional symptoms.
1. The description of the subjective symptoms, i.e.,
symptoms felt by the patient oidy, must be made
according to the general description ; they usually con-
sist of pain, of jteculiar sensations, of heat, of cold,
heaviness, prickings, etc.
2. The physical synqDtoms, comprising the number
of the lesions, situation (region, superficial, deep),
dimensions (relative, absolute), direction, shape. The
description of the superficial surface includes the
extent or dimensions, shape or form (plane, convex,
concave, in a vertical or transverse direction); color
150
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
[July 18,
as
(red, blue, etc.) ; projections (vesicles, lobules, lobes);
depressions (grooves, sulci, ulcers, fistula?); relations
with the skin (loose or adherent); consistency (fluc-
tuant, hard, soft, pulsatile without expansion, pulsatile
with expansion); effects of pressure on tumor, artery
and vein above and below, edema or pitting; effects of
percussion. The description of the borders includes
the extent or limits (circumscribed, diffused); shape
or form (plane, convex, concave, regular, irregular,
etc.); color, projections, depressions, relations with
skin, consistency, etc. (like for the superficial sur-
faces). The description of the deep surface includes
the mobility on the deep soft parts, also on the bones;
the extent of the mobility; sessile or pediculated.
The auscultation of the part should be described as
above. The secretions, if any, from the ulcerations,
also as above.
The functional symptoms must be described also
as above explained.
The regional symptoms or symptoms presented by
the neighboring organs must be described as explained
above also.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS OF
SOFTENING, A BURN, A FKOST-BITE, A CONTUSION,
A SPRAIN, A CONGESTION, AN INFLAMMA-
TION, A GANGRENE.
The subjective symptoms must be described
explained in the general guide.
The physical symptoms comprise the description of
the following points: The number of lesions, the
situation, the dimensions or extent, the direction, the
shape. The surface presents to study the color, pro-
jections, depressions; the relations" with the skin
(loose or adherent); the consistency, hard, fluctuant,
soft, pitting under pressure of the finger, crepitant,
pulsatile without expansion, pulsatile with expansion,
effects of pressure on the parts, of pressure above,
below and around on the skin, connective tissue, adi-
pose' tissue, tendons, muscles, fascia, arteries, veins,
capillaries, lymphatic vessels, lymphatic glands, nerves,
an organ special to the region; effects of percussion.
The borders present for study the dimensions or
extent, direction (straight or sinuous), shape (circum-
scribed or diffused), color, projections, depressions,
relations with the skin (loose or adherent), consis-
tency, fluctuant, soft, pitting under fingers, hard, crep-
itant, pulsation without expansion, pulsation with
expansion, effects of pressure above, below, all around,
on skin, connective tissue, adipose tissue, tendons,
muscles, fasciae, arteries, veins, capillaries, lymphatic
vessels, lymphatic glands, nerves, an organ special to
the region; effects of percussion. The deep surface
of the affected parts presents to study their mobility
on the deep soft parts and on the bones; the extent
of the mobility. Auscultation presents to study the
points explained above. The secretions of the affected
parts must be studied as described above also.
The functional spmptoms should be described
according to the guide above explained.
The regional symptoms also.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS OF A
PUNCTURED WOUND, A STING, A FISTULA.
The subjective symptoms call for no special guide
here.
The physical symptoms present for study the fol-
lowing points: The number of lesions; each should
be described separately. The external or superficial
orifice presents for mention its situation, size, shape,
direction, color, invertion or evertion, its smooth or
ragged appearance; its projecting, depressed or sunken
contour, if it is hidden or not by a fold ; its consis-
tency (hard or soft) ; if it is circumscribed or diffused;
its mobility (loss of parallelism); if it is clogged or
free, and dry or oozing (blood, serum, pus, special
substances). The tract or course of the wound or
fistula presents for consideration its direction toward
the deep parts, upward, downward, backward or in an
intermediate direction; the anatomic point toward
which it seems directed; if it is straight, curved or
tortuous; the cord-like sensation of the tract. The
internal orifice or bottom of the wound presents for
study its situation, depth or point of exit; if this ori-
fice is visible or can be felt it should be described as
the external orifice; state if it has or not penetrated,
i.e., injured any important structure, tendons, muscles,
fascia?, arteries, veins, large lymphatic vessels, lym-
phatic glands, nerves, an organ special to the region;
state the symptoms by which each lesion is recognized.
State the presence or absence of any foreign body,
part of instrument, bone, etc.
Describe the secretions of the wound, if any, accord-
ing to the guide as above explained.
The functional symptoms should be described
according to the general guide above.
The regional symptoms also.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS, IF
AN INCISED, A LACERATED, A GUNSHOT, A
BITE WOUND.
The subjective symptoms should be described as
in the general guide.
The physical symptoms present for description the
following points: The number of the lesions. The
external solution or orifice presents for statement its
situation, size, shape, direction, color; its inversion or
eversion; its smooth or ragged appearance; its pro-
jecting, depressed or sunken contour; its consistency
(hard or soft); if it is bruised or not; its mobility
(loss of parallelism); if it is closed by a clot or ooz-
ing (blood, serum, pus, special substances). The
depth or course toward the deep parts, upward, down-
ward, forward, backward, intermediate direction; state
toward what anatomic point it seems directed. The
internal orifice or bottom presents to study its situa-
tion and depth; state if it has or not penetrated
beyond the fascia of the region and has or not injured
the important structures, tendons, muscles, fascia,
arteries, veins, capillaries, lymphatic vessels, lymphatic
glands, nerves, organ special to the region, and state
the signs by which each lesion is recognized, also its
extent; state if there is or not any foreign body (piece
of the instrument, clothing, etc.) in the wound.
Describe the secretions of the wound, if any, accord-
ing to the guide above. When there is hemorrhage
describe it according to the guide for a normal fluid.
The functional symptoms should be described
according to the general plan.
The regional symptoms also.
METHODIC DESCRIPTION OF FOREIGN BODIES IN WOUNDS.
ENUMERATION.
They may be broken points, broken blades, bullets,
wadding, clothing, dirt, pieces of wood, etc. State
the number, size, depth, duration of stay in the wound,
changes or alterations they have undergone therein.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS OF A
DISLOCATION AND OF A FRACTURE.
The subjective symptoms require here no special
guide.
189(5.]
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
151
The physical symptoms present to study the follow-
ing points: The number of the lesions, situation,
dimensions ( extent or swelling), duration. The shape;
sometimes there exists a characteristic deformity, or
the parts have a peculiar position and shape, or there
is a shortening of the limb or part. The surface pre-
sents for statement the color; the projections or depres-
sions, which sometimes exist on both sides of the parts,
in which case they alternate; the relation with the
skin (loose, stretched, tense, adherent); the consis-
tency of the parts (hard masses, movable upon each
other or immovable, edema or pitting, fluctuation).
The borders or edges <*f the fracture are circumscribed
or diffused. The deep surface presents to state the
mobility of the bones at points where they should be
continuous, the extent of the mobility and the crepi-
tation, if any. tine, coarse, easily produced or not.
The functional symptoms call here for no special
description.
The regional symptoms call for the description of
the shortening of the limb or part, the peculiar posi-
tion of the limb or part, or of the patient himself in
relation to the part; also the symptoms presented by
the skin, connective and adipose tissues, tendons, mus-
cles, fascia, arteries, veins, capillaries, lymphatic ves-
sels, lymphatic glands, nerves, organ special to the
region, etc.
METHODIC DESCRIPTION OF THE LOCAL SYMPTOMS
OF AN ULCER.
The subjective symptoms call for the mention of
the presence or absence of pain (indolent ulcers).
The physical symptoms present the following points
to be described: The number of ulcers, situation,
dimensions or extent (length, breadth, depth), direc-
tion, shape. The surface presents for description the
color, the projections, depressions, consistency. The
borders call for mention of the color, thickness, direc-
tion (perpendicular, slanting), regular, sinuous, dis-
section of the skin (undermined). The secretions,
blood, serosity, pus, ichor, should be described as a
fluid, as indicated above.
The functional symptoms should be described as
indicated in the general guide. The regional symp-
toms also.
The tabulation of those methodic descriptions will
greatly assist in understanding them thoroughly and
remembering them more easily.
METHODIC DESCRIPTION OF THE SURGICAL DISEASES
AND INJURIES OF A REGION.
When the region of the body, such as the neck, for
instance, presents several smaller regions, we must
first describe the diseases of that region as a whole
and then the diseases of each smaller region.
It must be assumed that the student of regional
surgery is conversant with the general surgical dis-
eases, and to avoid useless and often confusing repe-
titions we must, in regional surgery, confine the
descriptions to the following points:
1. Describe the peculiarities only presented by the
diseases which may affect any region of the body when
they affect that region, in whole or in part. By pecu-
liarity is meant a feature or a point not common to
all the regions of the body or of all the regions of
that part. All the points or features common to all
regions properly belong to the description of the dis-
ease in general, and should be carefully omitted under
penalty of useless repetition. The peculiarities of the
diseases of a region are due to, or depend upon, fre-
quency, causes, pathologic anatomy or physiology,
symptoms, course, duration, termination, diagnosis,
prognosis, treatment, relapses, sequela?, forms or vari-
eties and complications; it may be complicated by
other diseases, or it may be complicating other less
crave diseases. The peculiarities must be carefully
described in that order, so that upon reading of the
peculiarities due to the symptoms, for instance, the
student may rest assured that there are no peculiari-
ties relating to frequency, causes, etc.
2. Describe the diseases special to the region, if
any, i.e., not. met with anywhere else or rarely so, or
enumerate the diseases which are most frequent in the
region, or which begin by the region to spread from
there over the other regions.
3. Describe the surgical operations of the regions.
If these are the same as met with in other locations,
the peculiarities or modifications alone which the
region calls for must be mentioned. If the operation
is one special to the region it must be described with
particular care and thoroughness.
4. Each region presents to study the same diseases
as described above, i.e., malformations, neuroses, soft-
enings, indurations, etc. Those diseases affect the
skin, connective tissue, adipose tissue, tendons, mus-
cles, periosteum, fasciae, bones, arteries, veins, capil-
laries, lymphatic vessels, lymphatic glands, nerves,
organ special to the region. The diseases of a region
must be described after the methods or guides elab-
orated above.
THE METHODIC REPORT OF A SURGICAL CASE.
The methodic report of a surgical case comprises
the description of the history of the patient, of the
present state, of the diagnosis, of the course and treat-
ment, of the termination and sequela?, and lastly, in
case of death, of the postmortem examination.
HISTORY OF THE PATIENT.
1. Note the sex and the age of the patient.
2. Note the race, the nationality.
3. Note the family history, i.e., the age and the
condition of health of the parents, if living; when
any parent is in bad health, ascertain the name and
nature of the disease and its course and duration, if
possible; if dead, the age at which death occurred and
the cause of death. This applies to the ancestors
(father, mother, grandfather, grandmother, both on
the paternal and the maternal side), to the collaterals
(uncles, aunts, cousins), to the descendants (children,
grandchildren); note the parent the patient resembles
the most or takes after physically.
4. Note the place of birth, also the various places
where the patient has lived; the duration of his stay
in each place.
5. Note the effects, if any, of the various causes
described above in the methodic description of a
surgical disease, i.e., of the geographic, telluric,
zymotic, physical, chemical, hygienic, therapeutic,
anatomic, physiologic, pathologic (including the dis-
ease through which the patient has gone) ; note the
cause to which the patient attributes his disease.
6. Note the condition of health previous to the
attack, also the date and mode of debut, the premon-
itory and prodromic symptoms (subjective, physical,
functional, regional and general); note the order of
succession of the symptoms, the duration of this
period, the treatment undergone and the effect, the
course of the disease up to the present record.
152
METHODIC DESCRIPTION OF A SURGICAL DISEASE.
[July 18,
PRESENT STATE.
The description of the present state includes actu-
ally the mention of all the symptoms presented by the
patient, the subjective, physical, functional, regional,
general; the guides detailed in the methodic descrip-
tion of a surgical disease should be here followed
closely. Note the intensity of each symptom.
DIAGNOSIS.
The diagnosis is now made in the following manner:
1. Make a resume' of the salient points or signs of
the case derived from all sources, sex, age, race, nation-
ality, place of birth, places where he has lived, effects
of the various possible causes of the disease, course,
actual symptoms and duration of the disease.
2. Note the diseases resembling the case.
3. Differentiate them as explained in the methodic
description of a surgical disease and also further.
4. Diagnose the stage, the tendency to termination.
5. Diagnose the forms or varieties, the complica-
tions.
COURSE AND TREATMENT.
The course and treatment call for the recording of
the date, day, hour when any changes of any conse-
quence take place in the symptoms (subjective, phys-
ical, functional, regional, general), or in the treatment
(hygienic, medical, surgical, etc.), as set forth in the
methodic description of a surgical disease. Note
relapses (date, causes, symptoms, etc.); also recur-
rences.
TERMINATION OF THE DISEASE.
The termination of the disease should be well noted;
the sequelae or consequences, if any, should be care-
fully mentioned.
POSTMORTEM EXAMINATION.
The postmortem examination should be conducted
after the rules laid down in the methodic description
of a surgical disease; that is, the lesions of the main
organ should be described first, then those of the
region, then those of the distant or general organs;
the macroscopic and microscopic lesions should be
noted, etc.
PINAL RECORD.
The final record must be complete; it must include
all the above, also the various charts (temperature,
pulse, respiration, stethoscopic, plessimetric, sphyg-
mographic); microscopic slides, if any, should accom-
pany the record; the pathologic specimens should be
deposited in a museum with a distinct number for
reference; the label should explain the main features
of the case; photographs also.
RULES TO BE OBSERVED BY THE RECORDING SURGEON.
1. Put the questions with politeness and solicitude;
kindness and gentleness will accomplish more than
any other policy. 2. The phenomena should guide
toward the solution sought; do not shape the phe-
nomena toward a desired solution; be led by the
answers, do not lead them. 3. The number of ques-
tions must not be too numerous nor too few. 4. Use
plain, simple words and expressions which the patient
will understand. 5. Do not propound complex ques-
tions which bear on several points at the same time.
6. Put the questions in such a manner that the
answers should be simply yes or no. 7. Do not allow
the patient to indulge in too minute details which
usually end in useless prattle; however, patients must
be allowed a free statement ; when they digress too
much from the main point, bring them back to it, but
gently and with care, otherwise they may become
scared or nervous or sullen; some resent it by willfully
giving false answers. 8. When the surgeon doubts
the veracity of the patient or when the answers lead
to an extraordinary fact, the surgeon should change
the terms and forms of the questions; he should cross-
examine; he should return to this same point later
again in the examination; sometimes it is better to
return to it the next day or some other day; should
the patient then give different answers on the same
point, he should be reminded gently of his former
answers; the version he finally adopts is usually the
true one, or the fraud, if any, is more easily detected.
9. Put as few questions as possible in cases where
quiet and silence is necessary, great pain, shock, etc.
10. Proceed with gentleness in the physical examina-
tion, especially of the organs of generation and of
the anus, particularly in the female. 11. Do not
expose the patient any more than absolutely necessary,
on account of modesty and also because exposure may
cause cold. 12. Questions relative to syphilis must
be put with care; never in the presence of the wife
or conversely, or of other parties objectionable to the
patient. Avoid questions, words, movements or facial
expressions which might convey an unfavorable
impression to the patient. Take in consideration the
social position and the character of the patients in
examining them, as some are more nervous and sensi-
tive than others.
METHODS OF INTERROGATION.
There are two methods for interrogating a patient.
The first method consists in beginning to review
all the possible features of the case, following closely
the order above described. This procedure is long
and tedious, because the local trouble is only discov-
ered when the turn of the organ comes in the exam-
ination, but in obscure cases it is the safest and most
preferable.
The second method consists in well determining
the debut and let the patient narrate what he feels
and knows, so that he will himself guide the surgeon
to the affected organ, which will then be thoroughly
examined, and afterward the organs at large.
METHODS OF DIAGNOSIS.
The method by hypothesis consists in taking up at
once the first disease which the symptoms suggest to the
mind and to see if all the important signs fit it or not;
if they do not correspond, then the next disease which
suggests itself is considered, and so on until a disease
is found that corresponds to all or most all the impor-
tant signs.
The method by exclusion consists in precising the
salient signs of the history; in noting the diseases to
which those signs may belong, thus eliminating at
once all diseases where those signs are not usually
observed; in determining the diseases to which the signs
do not correspond thoroughly and eliminating them
one after the other according as the signs corres-
pond less and less, so that in the end the only disease
retained is the one to which the signs correspond best.
Remarks: 1. In cases where the data are insuffi-
cient, all the regions and organs of the body must be
examined one after the other before the diagnosis can
be reached, as in cases of general injury with no
special localization, or where the patient is incapable
of precising in any way or gives contradicting or
vague, worthless answers, with a view either to deceive
the surgeon, or because of a lack of intelligence, or
1896.]
SELECTIONS.
153
because of the absence of any predominating sensa-
tions, or when there is unconsciousness, delirium,
intoxication, coma. The diagnosis is reached only by
the general result of such signs as have been gathered
in this way. "2. The diagnosis of a disease may be
difficult or impossible at the outset or during all its
course down to the termination, favorable or unfavor-
able, or when the surgeon is called at" the time of
impending death, or when the patient simulates a dis-
ease or dissimulates the disease with which he is
affected. :>. In eases of disease presenting attacks or
exacerbations, it is important to seethe patient at the
time of the paroxysm.
SELECTIONS.
IS
A si tiilKSTlON AS TO TREATMENT OF
GUNSHOT WOUNDS OF THE
LUNGS.
BY G. H. STOVER, M.D.
EATON, COLO.
When a ease of gunshot wound of the lung
received into a hospital, the surgical treatment of the
wounds of entrance and exit is now-a-days most care-
ful. The wounds are asepticized, a sterile gauze or
an air-tight dressing is applied, and as a rule they
heal nicely if the patient survives the shock and
hemorrhage of the injury.
The point to be made in this communication is
that a ease of gunshot or other penetrating wound of
the lung should never be placed in a general surgical
ward, even should the general condition be excellent
and the patient not need a special nurse.
Numerous investigations of the bacteriology of the
air in surgical wards have uniformly and conclusively
shown that the air is strongly contaminated by bac-
teria: these investigations are so well known and
their results so generally accepted that it is unneces-
sary to refer to the literature.
Now. in a penetrating wound of the chest involving
the lung, we have our one or more external wounds
which we can protect, by dressings, from contamina-
tion. But there are also the wounded air vesicles and
bronchi : respiration is continually bringing the bacte-
ria-laden air of the ward into contact with this
wounded and only partially protected lung tissue;
infection is pretty liable to take place; its develop-
ment may be slow, it may not produce noticeable
symptoms for a long time, the patient may recover
bom the immexliate effects of the injury and leave the
hospital apparently in health, only to succumb, after
weeks or months, to pulmonary inflammation.
These patients should be placed in separate rooms,
with as little atmospheric connection with other
wards as it is possible to obtain, and careful measures
taken to keep the air of the room clean. If such iso-
lation, etc.. be impossible, a respirator, which may be
a very simple one, should be constantly worn. In
either case the nose, mouth and pharynx should be
frequently cleansed with antiseptic sprays or washes,
I do not know if many hospitals place this class of
cases in general wards, but I have known it to be done,
and in one case that I now recall the patient, pre-
viously a robust healthy man, died some months after
leaving the hospital, of pulmonary suppuration, and I
often thought this might have been avoided had he
been isolated and treated as above.
Let us have a Department of Public Health!
Rush Medical College- -Annual Dinner. Remarks of Prof. John
B. Hamilton :
Mr. President, Fellow Alumni, and invited Guests :— We
celebrate to-night the Fifty-second Annual Commencement of
Rush Medical College. We see around us many of our class-
mates of twenty-seven years ago, many fratres of earlier or
later classes. Men are with us as our guests, distinguished
above their fellows in education, in oratory and in affairs.
They are here to testify their sympathy with Rush Medical
College in its aims toward higher medical education, and to
rejoice with us in the steps already taken.
I am not commissioned by the Faculty to make any author-
itative statements, nor have I had time to examine the college
records, so that any remarks I may make to-night are to be
regarded entirely as an individual expression. I speak to-night
as an alumnus, not as a member of the Faculty.
The history of the progress of Rush Medical College, from
its foundation in 1836 to the present time, is full of interest
and suggestion, and when we consider that the ultimate test
of education is its value to mankind, it must be admitted that
Rush Medical College stands that crucial test well. There is,
and has been from time to time, a criticism of our own and
other schools, as to the insufficiency of the medical teaching.
These critics rarely stop to think that the character of the
education of the Rush student has heretofore been based
scarcely less on his environment than upon his own necessities.
When a statue is made, the niche which it is to fill, frequently
governs its size, and when the young graduate had to settle
among tillers of the soil and villagers without special education,
what need was there for a high preliminary entrance test, that
would require him to waste years in the acquirement of a
knowledge of the superstitions of the ancient Greeks? When
there was little education of the people generally, why should
the doctor so far outstrip them?
When Daniel Brainard and James Blaney taught surgery
and chemistry in the old Dearborn Street school, they were
furnishing the essentials, but year by year the terms have
lengthened ; the amount of instruction given, has increased.
With the increase of days and hours of instruction in the Med-
ical College, the necessity for higher preliminary education
has become apparent. The development of some of the
specialties, such as chemistry, physiology and ophthalmology,
require for their proper understanding, a fair knowledge of
physics and mathematics. To properly understand anatomy
and embryology as now taught, some preliminary knowledge of
the Greek and Latin tongue is absolutely necessary, because
scientists throughout the world have to a limited extent agreed
to a common nomenclature.
These new requirements, these changes, have come with
equal pace with the developments of the high school, the
academy, the college and the university. The young doctor
when he leaves the medical school was and is still equal to his
best neighbors in general education, plus a medical education.
When he goes too far into medical realms he lives in another
world, quite too remote to keep in touch with his neighbors.
This is the key with which to explain the failure of the young
professional man, who deeply desirous of more knowledge, and
more culture, goes abroad, remains a few years, returns, lives
in a different mental atmosphere from his neighbors, is mis-
understood, unappreciated, naturally becomes misanthropic
and fails.
Although it is evident that those responsible for the curri-
culum of Rush Medical College have kept steadily to the line
of utility in medical teaching, and borne in mind the nature
of the environment of the graduates from year to year, yet for
the last few years it has become apparent that some of the
154
SELECTIONS.
[July 18,
teachers at least have not agreed that everything should be
sacrificed to mere utility, and, as is well known, the emotional
side of the man should be developed. We have seen the don-
ning of the cap and gown, the establishment of athletic games,
the organization of college secret societies (the Nu Sigma Nu
and the Phi Sigma Rho) and the affiliation with the Young
Men's Christian Association. But there is a danger line in
these extraneous educational aids, beyond which the student
becomes a general rather than a special student. Music,
painting, sculpture and poetry appeal to and develop the
emotional side of man, but as Herbert Spencer said "these
efflorescences of civilization, should be wholly subordinate to
that knowledge and discipline in which civilization rests, and
as they occupy the leisure part of life, so should they occupy
the leisure part of education."
It was my good fortune, Mr. President, to be present at the
opening of that noble building completed by the Faculty of
this college on the corner of Dearborn and Indiana streets in
1867. At that time there was no medical college building
equal to it, and the old building which it adjoined was
remodled and given up to anatomic and chemic instruction.
The mayor of the city, the Hon. J. B. Rice, made a speech at
the opening, in which he said on behalf of the trustees and
the Faculty : "We erect here a grander temple than was of
old erected to yEsculapius or Hygeia, for it shall be devoted
and dedicated to the sacred cause of humanity." How well
this college has fulfilled its trust ! The purposes of that dedi-
cation I verily believe, have been kept steadily in sight from
that day to this.
The storms and financial difficulties through which this col-
lege has successfully passed, give eloquent tribute to the
courage and faithfulness of the faculty and trustees. The
new building of 186.7 was destroyed by (he great fire of 1871,
in the opening week of the college term. The professors of
that day, undismayed by the great calamity, bravely took upon
themselves the erection of a temporary building on Eighteenth
street, in the grounds of the County Hospital, and there—
"under the sidewalk"— they taught without interruption, and
during that time planned a new building, the present one, cor-
ner of Congress and Wood streets. When this building was
finished again the professors became personally liable for the
funds necessary to construct it and without a murmur they
met the obligations as they fell due. A short time elapsed
when it was observed that the school could not control the
clinical teaching in the County Hospital, and the arrangements
were not in accordance with their views ; whereupon they gave
away the unused portion of their grounds, without regard to
future needs, mortgaged the college building for 845,000 hospi-
tal bonds, and the magnificent Presbyterian Hospital is the
result of that beginning. In the year 1891, when nearly every
Eastern medical college had been aided by the hand of private
philanthropy, to erect a laboratory for the study of the new
field of bacteriology, no aid was visible here, but the Faculty
once more devoted the entire earnings of the school for a
period of three years toward the erection of the present beau-
tiful structure on Harrison street, and taught without fee or
salary.
When it is remembered that no member of the Faculty has
any right to the college property, and also that the sole title to
Rush Medical College and its equipment is held in trust by the
trustees and their successors in office forever, the benevolent
character of these repeated personal sacrifices by the members
of the Faculty is apparent.
Here is an institution that without endowment, gift, or out-
side encouragement beyond the confidence of the people, and
the love and respect of its alumni, has advanced step by step,
in the face of uncommon difficulties, to a position equal to any
American institution of its class, and in some respects equal to
any elsewhere.
What nobler tribute can be paid to Brainard, the founder,,
his coadjutors and their lineal successors, than the history and
record of Rush Medical College? I stand here not to eulogize^
this noble institution, but simply to place on record these facts.
Many of the Eastern medical colleges have had buildings
given them, and chairs endowed. Philanthropists and moneyed
men have vied with each other in wise liberality toward their
medical colleges, but here the hand of Sir and Lady Bountiful
has never been opened in the direction of its oldest medical
college. The college has flourished, but at the expense of the
life labor of its teaching faculty.
But we came here, Mr. President, not to eulogize or con-
demn, but to sing gently the praises of our Alma Mater, to
have our annual reunion, to fraternize and to enjoy this hour,
which, unfortunately, only comes once a year ; so now with
music, song and the eloquent speeches which are to follow, let us
be happy. If our local philanthropist, like some of the blooded
kine amid pastoral scenes, shall fail to yield milk even to the
hand of the experienced milker, let us forget out wants and
leave the matter to Posterity- -Posterity, the sweet child !
We well know who its father is and our faith in its stock leads
us to believe that its burdens will be well borne. Let us to-
night indulge in pleasant reminiscences and recall that Brain-
ard in his day received the prize at the Paris Academy, that
DeLaskie Miller was president of the Section of obstetrics at
the International Medical Congress at Washington, that Senn's
Latin thesis obtained Magna Cum Laude at Munich, and that
Lyman, Hyde, Senn and Ingals have written books which are
as lamps to the wayfarer. Last but not least, the announce-
ment has just been made that the Rush diploma has had its
just recognition at the hands of the Board of Examiners of the
Royal Colleges of Physicians and Surgeons of England.
Finally, as we have so much to be thankful for, let us con-
clude in the language of the Bohemian Club of San Fran-
cisco, "May the Lord love us, and not call us too soon."
Corpuscle, July.
The Procedure of " Blood-Washing " in Infectious Diseases.—
According to the Medical Press and Circular, June 10, Dr.
Henri Barre" has recently made an important communication
to the Paris Obstetrical Society on this subject. The process,
to which Dr. Barre' has given the name of "disintoxication of
the blood," is derived from simultaneous employment of two
therapeutic means already made use of in medicine ; the one
very ancient, bleeding ; the other very modern, the intravenous
injection of artificial serum. The aim of this treatment is to
combat the phenomena of general intoxication which manifest
themselves in the course of or toward the end of many diseases,
and which in themselves put in peril the life of the patient.
Before this treatment is begun there ought to be brought to
bear the ordinary methods at the disposition of the physician :
purgatives, diuretics, stimulants, sedatives, etc., and it is not
until the insufficiency of these is evident that as a last resort
resource is to be had to " disintoxication of the blood." This
is most often indicated in the following maladies : Uremia,
eclampsia, diphtheria — when antitoxic serum does not suffice —
infectious pneumonia, capillary bronchitis, malignant icterus,
general acute peritonitis, cerebrospinal meningitis, typhoid
fever, measles, smallpox, scarlet fever, puerperal fever, cere-
bral complications of rheumatism and gout, poisoning by
alkaloids, extensive burns of the skin, etc. ; in short, in all
cases in which there may be expected danger as much or more
from general intoxication as from actual lesions of the organs
themselves. In all these diseases there is to be noted a con-
siderable diminution, if not a complete cessation, of the uri-
nary function, and the disintoxiation of the blood has for its
immediate purpose : 1, to eliminate artificially a certain
quantity of toxins ; 2, to help to achieve complete elimination
by reestablishing the secretion of urine. The instruments
1896. ]
SELECTIONS.
155
mvessary consist essentially of two india rubber tubes, termi-
nating at their extremities hj a needle of a diameter a little
gtMter than that of a Pravaz syringe. The longer of these
tubes (about one and one-half inches) conducts into the veins
of the arm the artilicial serum from a graduated vessel placed
at a position more or less elevated in accordance with the
degree of force with which the How of liquid into the venous
system is required. The second tube (1 meter), of which the
needle is inserted in a vein of the other arm, has its free end
in a graduated vessel, and thus serves to extract blood. The
How of the two liquids by this arrangement can be so regulated
that no more serum enters than blood flows out and thus the cir-
culatory system, being always equally full, arterial tension need
not lie diminished, as it is a consequence of ordinary bleeding.
"The quantity of serum introduced and the quantity of diluted
blood withdrawn may vary between 500 grains and one liter for
an adult in accordance with the degree of intoxication. As
will be seen, this method of disintoxication of the blood dif-
fers materially from another method which has been styled
•washing the blood,' and which has been for some time applied
by preference in cases of surgical infection. The difference
consists mainly in the contemporaneity of the injection and
bleeding. This prevents any severe interference with the cir-
culatory system, and allows, if death from intoxication seems
imminent, the withdrawal of the greatest quantity of blood,
consequently disintoxication with the least danger to the
patient. The exchange of liquids is made very quickly (in
thirty to fifty minutes), so that no sharp reaction ensues ;
grave symptoms insensibly diminish, gradually disappear and
are soon followed by refreshing sleep. On waking, the patient
desires to pass water. Sometimes sweating accompanies the
reestablishment of urination as in natural crises. In the three
cases (two of uremia, one of infectious pneumonia) in which
Dr. Barre has applied his method, cases in which everything
had proved useless and in which death appeared imminent, he
obtained improvement as rapid as that just described. Not
only did the most serious symptoms cease, but at the end of
the urinary crisis they did not reappear and the patient pro-
gressed 6teadily toward cure. Dr. Barre1 expounds the follow-
ing theory to explain the phenomena of the cure : 1. There is
elimination of the excess of toxins, which constitute the imme-
diate danger ; 2, the good effects continue because the bulk of
blood is not diminished in volume in the system and does not
need reforming at the expense of the fluids of the economy,
and the arterial pressure not being diminished no obstacle to
diuresis is created ; 3, not only are toxins eliminated which
appear to have an inhibitory action on the urinary action, but
the toxins which remain become diluted and less powerful for
evil ; 4, as recent researches have proved, the alkalin salts
have a favorable action on the bactericide power of the blood,
and the method thus provides the economy with a new means
of fighting successfully against the microbes. Dr. Barrg
believes the method will be found of enormous advantage in
veterinary as well as human pathology."
Phagocytosis in Malaria. — According to the Bulletin of the
Johns Hopkins Hospital, April, the above subject has been under
discussion before the medical society of the hospital. This dis-
cussion was participated in by Drs. Barker, Sydney Thayer
and Osier. The first named speaker took for his text the
microscopic observations that were had of his fatal cases.
Certain of the leucocytes are the main phagocytes, then the
endothelial cells of the blood vessels, the cells of Kupffer in
the liver, then the splenic cells of the pulp cords. Their con-
tents vary ; there may be red corpuscles, sound or injured,
infected or fragmented ; ateo pigments of the blood and of the
parasites ; also other phagocytes.
There is manifestly a division of labor among the phagocytes,
since certain of them tend to take up one set of the above
named ingesta, while others contain another sort. In one of
his cases, that which is ordinarily regarded as a rare occur-
rence, there was a marked tendency on the part of mononu-
clear leucocytes to take on phagocytosis ; in all the tissues
parasites were found inside the large mononuclear leuco-
cytes. It is just possible that they have taken up these
parasites postmortem. Dock and others having pointed out
that the malarial parasites cease their development soon
after the death of the host. No blood examination was made
during life. If this phagocytosis on the part of the mononu-
clear elements occurred during life they could not have failed
being detected in the fresh blood. He also referred briefly to
the physiologic question of the relation of phagocytosis in
malaria to bile production is of much interest. The phagocytes
can be seen passing from the spleen, which seems to be the main
cemetery of red blood corpuscles, laden with broken-up capsules
and with pigment ; then the blood pigment is seen in the endo-
thelial cells of the liver, next in the Kupffer cells, and finally
in the liver cells themselves, as though this were a method of
transportation of raw material from the spleen to the liver for
purposes of bile manufacture.
With reference to the relation of phagocytosis to natural
resistance and to spontaneous cure nothing can be decided.
The strife is still going on between those who favor the doc-
trine of the phagocytosis and those who see in the blood serum
the main protecting mechanism.
"As regards the form the parasites assume inside the phago-
cyte, it is easy to make out that a great many of the parasites
rupture after inclusion, and one can see the lines of pigment
running from the parasite out into the protoplasm of the
phagocyte. Golgi thought that the parasites could multi-
ply within the phagocytes, and Bignami still believes that
latent infection is to be explained in many cases by the long
continued life of the parasite within the phagocyte. Certainly
forms of bacterial infection are described which have analogies
with this view. Then, finally, as to the inclusion of some
phagocytes by other phagocytes. It makes a very interesting
picture to see a huge phagocyte containing within it one, two
or several of the cells of the body. Sometimes phggDcytes are
included along with non-phagocytic cells, and sometimes a
phagocyte is seen inside of a phagocyte, which in turn
is within a third larger phagocyte. Sometimes the huge
phagocytes look degenerated ; in such a case we can conceive
of a young phagocyte going into the large phagocyte after its
contents or even to eat up the dying protoplasm. On the other
hand, sometimes the included phagocyte looks degenerated, in
which case we can think of the large, active phagocyte taking
up the small one into its substance — eating up its neighbor.
There curious phenomena, which I have perhaps too fancifully
spoken of as the cannibalistic and thieving tendencies of
phagocytes, are among the many attractive problems connected
with the sociology of cells which the future has to solve."
Dr. Osier's remarks touched upon the subject of the rarity
of cirrhosis of malarial origin. He said that so far as he could
glean, that affection is remarkably rare in this country. "No
well-marked instance of it has ever fallen under my observa-
tion. I have frequently looked for it at the Philadelphia Hos-
pital, where we had a very large malarial material, and I think,
with the exception of the one case mentioned by Dr. Welch, I
do not know of any instance in the North in which the condi-
tion has been found. We have had only one case here in which
clinically we suspected that the cirrhosis might be malarial.
"With reference to the irritation of the malarial pigment as a
cause of fibrosis, it is interesting to call to mind the observa-
tion which Dr. Welch brought before us here a few years ago,
namely, a form of anthracotic cirrhosis in which the fibrosis in
the liver seemed to be due to the amount of pulmonary carbon
which had reached the liver in roundabout ways."
A foot-note further refers to the contention of clinicians as
156
PRACTICAL NOTES.
[July 18,
to this alleged malarial sequela, and says that the dispute has
been of the warmest. Dr. Osier in his writings has insisted
upon "the necessity of considering other etiologic factors, e.g.,
alcohol, syphilis, tuberculosis, even when malaria appears to
stand in a direct relation to the disease. Of the many persons
who have had malaria, very few of them have developed cir-
rhosis of the liver afterward. Dr. Welch states that in his
autopsies in New York he met with only one case of cirrhosis
of the liver that could be said to be due to malaria ; that
occurred in an Algerian. Bignami, the most important writer
on the changes in the tissues in malaria, thinks that malaria
may undoubtedly lead to subsequent cirrhotic processes, and
he traces with great acumen the changes that gradually occur
as a result of repeated attacks of malaria."
Dr. Thayer asserted that there is as yet no absolute proof
that the "malarial parasite produces a toxin, and yet there are
observations which are rather suggestive, particularly those by
Brousse and by Roque and Lemoine, who have shown an
increased toxicity of the urine just following the attack ; and
by Queirolo, who has shown that the sweat during the sweat-
ing stage is much more toxic than that obtained under other
circumstances. It must be said, however, that Botazzi and
Pensuti have shown that much, if not all of this increased
urinary toxicity may be accounted for by the increased excre-
tion of certain potassium salts and urobilin, as well as by the
presence of peptone. Taking into consideration, however, the
various symptoms of malarial fever, there is, by analogy to the
other similar conditions, every reason to believe in the exist-
ence of some soluble toxic substance. The fact that in certain
severe cases they were present in such small numbers in the
peripheral circulation led Baccelli to think that in some
instances a small number of parasites might produce the grav-
est symptoms owing to their excessive virulence. In their
recent admirable article Bastianelli and Bignami rather dis-
pute this and say that in no case of pernicious fever in which
they have studied the tissues postmortem have they failed to
find a total very large number of parasites ; very few perhaps
in the peripheral circulation, but numerous in the spleen,
brain, liver, or gastrointestinal tract."
PRACTICAL. NOTES.
Non-excretion of Pathogenic Microbes with the Perspiration.— Kri-
kliwy describes in Wratsch, Nos. 8 to 10, his experience with
cats inoculated with anthrax bacilli and then injected with
pilocarpin. Microscopic examination of the profuse sweat
induced was entirely negative in any discovery of the bacilli,
although they were found in the blood and tissues.
Cocain Intoxication. — Several cases of poisoning from cocain
are collected in the Therap. Woch. of June 21, most of them
produced by injections in the urinary organs. In one case a
syringe of 20 per cent, solution was injected into the bladder,
followed by immediate death. The dose in the other less seri-
ous cases was 2 grams cocain to 30 grams water. In another
case 0.5 grams injected in two doses was followed by transient
edema of the eyelids.
Boards of Health and Cemeteries. — A law was passed in New
Jersey, which was approved March 5, 1896, that provides that
no new cemetery shall hereafter be established, nor shall any
cemetery now existing be enlarged or any lands not now used
for cemetery purposes be used for such purposes in cities of
the first class, in that State, without the consent of the com-
mon council and board of health of such city, to be expressed by
resolution and the approval thereof by the mayor of such city.
Effect of Local Warmth on the Secretions of the Stomach. Some
experiments by Prof. Tschudnowsky on normal persons with
hot compresses or a Japanese heater, applied to the region of
the stomach from three-quarters to three hours, showed that
the general secretions and activity of the stomach were
increased, with more free hydrochloric acid, and an increased
power of assimilation and motor activity of the organ. These
effects persisted from several hours to several days. — Medicina,
Nos. 3 and 4.
Cresocbin. — Under this name a non-alkalin cresol disinfectant
is prepared which is stated to be a neutral combination of
tricresyl sulphonate and quinolin with tricresol. It contains
33 per cent, of quinolin and 17 per cent, of tricresyl. It is not
caustic and is soluble to the extent of 1 to 25 in water. It is
specially indicated as a disinfectant, since, being free from
alkali, it does not set free ammonia from nitrogenous organic
matter. Druggists' Ore. and Chem. Gazette, July, 1896.
A New Appliance in Intestinal Surgery. — Dr. M. L. Jamison, in
the Medical Sentinel, June, 1896, calls the attention of his
Pacific coast brethren to the fact that they can secure appo-
sition of the divided intestine just as successfully by using
a roll of half-cooked biscuit or bread dough. This can be
rendered aseptic, and after using the Lembert suture, can be
slipped either down the intestine or left in situ. There is not
the slightest occasion for any expensive "buttons" of any kind.
What is the matter with a bread stick?
Hot Compress for Ulcers. — Noureaux Remedes for June 24,
quotes a Russian periodical in which Yakovlef announces his
successful treatment of atonic ulcers with moist hot compresses,
during the last three years. They will, according to Yakovlef,
cure where all other kinds of treatment have been ineffectual.
He ascribes their success to their favoring local hyperemia,
thus improving nutrition, while being moist they do not adhere
or irritate.
Surgical Instruments and Appliances Out of Place.— The follow-
ing cases of foreign bodies left in the abdomen after laparotomy
are cited in the last number of our Spanish contemporary, El
Siglio Medico: "Sir Spencer Wells twice forgot forceps in
the abdomen ; Pilatte, a compress ; Terrillon, a forceps ; Quenu,
a compress ; Michaut, a roll of iodoform gauze ; Severnao, two
binders of 1.30 meters long. The utmost care of instruments
should be taken during a laparotomy, for, as Pozzi says, a pair
of forceps may slip into a basin or be carried off attached to
the tumor or to a sponge without being perceived and lead to
the opposite error. H. C. Coe, on two occasions, reopened the
belly to search for a sponge that had fallen into a pail."
New Hydrostatic Exploration of the Body.— At the meeting of
the Academie de Me'decine, June 16, Marc See announced a
new and effective method of abdominal palpation. When a
person reclines in a bath, the front abdominal wall is lifted by
the water until it can almost be said to float, while the muscles
are so relaxed that the whole abdomen becomes flaccid, ren-
dering pal Ration an easy matter. See states that he has been
able to palpate in this way in the water the entire abdom-
inal cavity, even to the spine and the sacro- vertebral angle,
through the viscera. — Bidletin, June 16.
Pericardotomy. The superiority of pericardotomy to puncture
in the treatment of pericarditis with effusion is confirmed
again by its success in a case recorded in the Arch, de Mid. et
de Ph. Milit., Nos. 1 and 2. Four punctures into the serous
effusion were ineffectual, but complete recovery followed peri-
cardotomy with local cocainization, in the fourth left inter-
costal space, although broncho-pneumonia of the left side
intervened. — Centralbl. f. Chirurgie, June 13.
Tolerance of the Pregnant Uterus.— Ozenne has a study of the
effects of traumatism on the pregnant uterus in the Bulletin
Midicale for June 21, which confirms its surprising tolerance
to injuries. Accidental or surgical traumatism in the neigh-
borhood of the uterus often has no influence on the evolution
of the pregnancy. It is more liable to affect it if in the genital
zone, but in all cases it is by no means unusual to have the
pregnancy continue to a natural-close, and the surgeon is jus-
tified in any operation on or near the pregnant uterus, not
only when it is urgent, but also when it is for the purpose of
1896.]
PRACTICAL NOTES.
157
removing any cause liable in the future to interfere with the
normal evolution of the pregnancy. In two cases in which he
had removed a large polypus from the neck of the uterus, the
pregnancy continued uninterrupted.
Treatment of Diabetes Mellitus with Rectal Injections of Pancreatic
Glands. -Lissere has treated two cases of diabetes mellitus with
fresh pancreatic glandschopped fine and left twenty- four hours
in a saline solution. As the stomach refused to tolerate this,
he administered it in rectal injections once or twice a day. The
results were that the polyuria was very much diminished, as
also the amount of sugar in the urine. Both the sugar and
the diuresis returned to their original conditions whenever the
Injections ,vere suspended. They also exerted a favorable effect
upon the general health ; the patients gained in weight and
lost their excessive thirst — Nouveaux Remedes, June 24, from
Med. Oboxr., No. 4.
Neuritis from Compression of the Ulnar Nerve by the Bicycle.
I.ii Province Mid. of June 20 describes the experience of Dr.
Destot after a long ride on the bicycle when he was obliged to
grasp the handle with especial firmness for some reason. It
produced pronounced neuritis of the ulnar nerve with paresis.
It adds that it is very important to have the handle of the
bicycle constructed on physiologic principles. The body is
supported and balanced by the inner edge of the hand, and if
the put of the handle grasped is perpendicular to the axis of
the hand, the contracted flexor muscles of the fingers form a
series of elastic cords which act like a cushion to prevent
injury to the nerves from compression and the incessant jar of
the machine. But if the handle is oblique to the axis of the
hand the lower end presses against the root of the thumb and
also compresses the pisiform, the flexor muscles no longer act
in the same way and serious injury to the ulnar nerve may
result.
Helfericb on the Indications for an Operation in Appendicitis.— It is
universally conceded now that the only treatment of a well-
developed perityphlitic abscess is the prompt use of the knife.
It is indicated by swelling in the iliac fossa, and diminished
percussion, except when there is a layer of intestine above or
gas in the abscess. Cutaneous inflammation is rare, while
edema of the cellular tissue during the inflammation is frequent.
McBurney's sign is of more importance in diagnosing
chronic appendicitis than in an abscess. Roux considered a
certain infiltration of the cecum as important. Lennander
has not always observed Madelung's sign of the difference
between the rectal and axillary temperature. Helferich
advises scrupulous care in exploring, not to split the wall of
the abscess. He recommends exploratory puncture only when
the operation can follow immediately. It is important to
examine also the rectum and vagina, as the abscess may present
itself in the small pelvis and even in parts still more remote.
It may even penetrate into the pleura, or any of the hollow
organs of the body, when it is usually fatal. He advises
prompt operation in recurring appendicitis, as it may turn into
perforating peritonitis at any moment— Centralb.f. Chirurgie,
June 20.
Surgical Treatment of Acute Diffuse Peritonitis. — John Y. Brown
says that prominent among the factors leading up to success in
the management of intraabdominal inflammation has been the
acceptance of the doctrine that peritonitis, whether local or
general, is from its inception a condition demanding the care
of the surgeen. He draws the following conclusions : 1. That
septic peritonitis is a surgical condition, and should at the
earliest possible moment be put under surgical supervision.
2. That all cases of acute diffuse peritonitis are not necessa-
rily fatal, and while the mortality following operation must be
great, many of these cases can be cured by prompt resort to
the knife. 3. That success in these cases will depend on (a)
early operation, (o) careful cleansing of the abdominal cavity
by sponging and irrigation, (c) by drainage by means of glass
drain, supplemented if necessary by gauze. 4. That all such
cases should be operated on. No surgeon should fail to give
his patient the benefit of the chance afforded by operation, no
matter how desperate the condition may be ; they all die with-
out operation, and many desperate cases are cured by prompt
surgical interference. — Medical Mirror, May, 1896.
Formalin In Ophthalmic Practice. Dr. Swan M. Burnett men-
tions the property formalin has of diffusing itself through living
as well as dead tissues, a property not possessed in the same
degree by any other drug. Sublimate coagulates albumin and
limits its own field of action. Formalin should be more useful
than other germicides for the class of infections in which
the microbes penetrate the substance of the tissues. Excel-
lent results have been obtained from its use in infecting ulcers
of the cornea and purulent conjunctivitis. The corneal ulcer
can be touched with a solution of 1 to 200 or 1 to 500, once
every day, and for general use as an antiseptic a collyrium of
1 to 1,000 or 1 to 2,000. Satisfactory results have been obtained
with it in muco-purulent and purulent conjunctivitis. In the
more severe forms silver nitrate is used in addition. In acute
catarrh of the conjunctiva (pink eye) it has acted most promptly
when used as a collyrium of the strength of 1 to 1,000 or 1 to
2,000 applied every four hours. — Nat. Med. Review, July, 1896.
Treatment of Gastric Crises in Tabes with Cerium Oxalicum. — The
serious vomiting periodical in tabes is sometimes relieved by
morphin, but its continuous use in chronic cases is not advis-
able, and some, like Hoffmann, have not been successful with
it. Professor Bechterew, of St. Petersburg, has been using
cerium oxalate for this purpose, and reports marked success with
it. The vomiting seizures during the day were reduced from
200 to six in two days. The act of vomiting was rendered much
easier, while the pain, thirst and nausea vanished to a great
extent. The psychic conditions were also much improved,
restlessness subsided and sleep returned. Urinating became
slightly more difficult, but not enough to require a catheter.
The most important improvement, however, was that the food
could be retained, the vomiting after eating having been
so much reduced. The Therapeut. Wochensch. of June 21
describes a couple of severe typical cases relieved by this
treatment. The dose was the same as in hyperemesis gravida-
rum, from 0.5 to 0.10 or even 0.15 three to four times a day.
Chaput on the Treatment of Cancers of tbe Rectum. — In ten.
resections of the rectum for cancer, Chaput has had eight recov-
eries and two deaths (one due to broncho pneumonia from
ether, and the other to laceration of the ureter in an almost,
inoperable case). Two cases were followed by a speedy relapse,
but three others have shown no signs of a relapse in the two to
five years since. Another has had a relapse, but it has had no
effect on the general health. In two cases there was no pro-
lapsus ; in one of them he had made a circular suture, in the
other he had twisted the upper end according to Gersuny. In
two cases in which he had not taken these precautions, there
was prolapsus. He considers cancer of the rectum as one of
the least liable to a relapse. Technique : He advises a pre-
liminary anus made in the transverse colon a couple of days
beforehand. Y-incision ; resect the coccyx and respect the
sacrum ; make as nearly a circular suture of the two ends aa
possible ; if impossible, twist the upper end a la Gersuny ;
ligatures are unnecessary ; the skin is not to be sutured. Pack
the wound with aseptic gauze, impregnated with a weak phenic
solution. Hochenegg's method (invagination of the upper
into the lower end) should be absolutely rejected. Indications :
Cancers of the recto-vaginal septum, remove with a perineal
incision ; close the upper end of the rectum in a cul-de-sac ;
ensure evacuation of matters with a definite iliac or transverse
158
PRACTICAL NOTES.
[July 18,
anus. Cancers of the lower part ; circumscribed ; circular
incision with Denonvilliers incision and resection of the coccyx
(Verneuil, Terrier), suture to the skin of the upper end twisted
a la Gersuny. Hartmann's method (ablation by the natural
route) is highly to be recommended. Diffuse ; combine the
perineal and the sacral incisions. Cancers of the middle
region : the sacral route is preferable to the vaginal. High
cancers must be attacked through the abdomen, while recto-
colic cancers are best removed by the abdomino-sacral route.
— Bulletin Medical, June 21.
The Micrococcus of Articular Rheumatism. — The Gaz. degli
Ospedale e delle Clin, for June 20 contains a description of the
micrococcus discovered by Maragliano and his assistants in the
blood of typical cases of acute articular rheumatism. He
found two microorganisms, but one, resembling a bacillus, is
not pathogenic. The other produced in rabbits the symptoms
of the acute form of the disease, polyarthritis, pericarditis,
pleurisy with effusion, endocarditis, etc. An injection of J^to
1 c.c. of bouillon culture resulted in death after sixteen days.
Some healthy rabbits placed in the cages formerly occupied by
the inoculated rabbits succumbed to an epidemic of arthro-
pathy with exudation. This new micrococcus resembles the
staphylococcus, but it is only half the diameter (0.5 m) of the
aureus. It is massed in groups of six to ten, except in bouillon
cultures, when it occurs in short chains or united by twos. It
stains readily by the Gram method and with all the usual
anilin stains. It forms an oval culture on a gelatin plate,
finely granulated, with even edges, pale yellowish at the sur-
face and growing more yellowish as it descends. In the gela-
tin tube culture a thin layer forms on top while the extension
below rather dries up the gelatin than liquefies it. The
growth is more scanty as it works downward. In old cultures
it resembles a flower with notched petals, the stem spreading
out above into an enlargement resembling an ovary. In agar
and serum it is whitish, and the edges are even, as is also the
case on potato. Cloudiness is noticeable in bouillon after the
second day, which indicates that it is motile. It does not
coagulate milk ; it develops at the usual temperatures, but
especially at 98 degrees.
The Causes of Retroversion and Retroflexion of the Uterus. — Dr.
Hunter Rabb says that (Cleveland Med. Gazette, July) in the
causation of backward displacements of the uterus the follow-
ing factors may be concerned :
1. Congenital defects. A short vagina necessitates a forward
position of the cervix ; this tends to bring the fundus and ante-
rior surface of the uterus under the direct line of abdominal
pressure. The ordinary distension of the bladder now throws it
backward, thus causing a displacement. A congenitally long cer-
vix can not rest with its long axis crossing that of the vagina, but
must accommodate itself to this axis ; this also tends to throw
the fundus backward. Where the cervix is long the body of the
uterus is apt to be small and short. In such case the normal
position of the uterus is in retroversion.
2. Extreme distension of the bladder throws the fundus far
back in the pelvis behind the median line. When this happens
often the malposition is liable to continue.
3. Impacted feces in the rectum extending up above the
ampulla push the cervix down in the vagina, and thus change
ah anteversion into a retroversion.
4. A sudden severe strain put upon the abdominal muscles,
especially when the bladder is full, brings about a retroflexion
by forcing the uterus down when the pelvic floor yields.
5. Of all causesof retropositions the most frequent is arelax-
ation of the vaginal outlet : the relaxed outlet must be regarded
as a deficiency in the pelvic floor, which leaves a smaller or
larger surface over which no counter-resistance to the intra-
abdominal pressure remains. Every act accompanied by intra-
abdominal pressure tends to thrust out the adjacent vaginal
walls ; when these have once entered the orifice they continue
to be forced down, wedging the posterior wall further away
from the symphysis. While the parts below give way the
uterus is forced toward the outlet. The fundus rotates so far
back that the pressure is finally spent on the anterior surface
of the uterus and complete retroversion or retroflexion is
established.
6. Finally retroversion and retroflexion may be caused by
inflammatory changes in the uterine support, or by dragging
of adhesions resulting from pelvic peritonitis.
The Decadence of the Gargle. — An editorial in the American
Therapist, for June, discusses the question of the future of
the gargle, based upon the views recently expressed by Mr.
Lennox Browne, at a meeting of the British Laryngological
Society. That gentleman, who is the senior surgeon of the
London Throat Hospital, stated that his experience pointed
distinctly to a conclusion that the time had now fully come
when the gargle should be abolished in the treatment of dis-
eases of the throat. He aimed to show that fluids were not
brought into effective contact with the posterior surface of the
pharynx, if used as gargles in the ordinary way. The editor
of the Medical Press and Circular is inclined to support this
view, with the following argument: He says, "It is to be
feared that the time-honored gargle has outlived its usefulness,
and that even its antiquity, coeval though it be with the poul-
tice and the leech, can not blind us to the fact that it necessa-
rily falls short of the mark when the diseased tissues are on a
plane behind the posterior pillars of the fauces. Even a casual
study of the conditions which obtain in the act of gargling as
usually understood, will show that the fluid is kept in front of
the lowered soft palate, so that it is impossible for any effects
to be exercised on tissues posterior to that structure. A gar-
gle, as ordinarily employed, is, therefore, only a mouth wash.
Under these circumstances, it is really surprising that it should
have been reserved for Mr. Lennox Browne to enter a protest
against the continuance of a practice which is not only useless
but, in presence of actual inflammation, is exceedingly painful
and may be injurious.
"Mr. Browne describes, however, another method of gargling,
using the term gargling in the sense of trickling a fluid through
the mouth into the pharynx which is free from one, at any rate,
of the objections already alluded to, viz., the method of Von
Troelstch, for which the directions are as follows : 'Take a
tablespoonf ul of the gargle in the mouth, hold it in the back of
the throat with the head thrown back, then, closing the nose
with the finger and thumb to prevent entrance of air, open the
mouth and make the movements of swallowing without letting
the liquid go down the throat.' By this means the medicated
fluid can, it is true, be brought into contact with the pharyn-
geal tissues, but the process is by no means easy to carry out
in an effectual manner, and in the majority of instances it is
quite out of the question. Gargles, again, are quite inadmiss-
able in cases entailing the dorsal decubitus, such as diphtheria,
in which cardiac failure has to be sedulously guarded against.
Another obvious objection to gargles is, that they must per-
force comprise only the most harmless ingredients, if we are to
avoid subjecting the patient to the danger of poisoning in the
not improbable event of any portion of the fluid escaping con-
trol and finding its way down the esophagus. Moreover, solu-
tions thus employed must not contain any considerable quan-
tity of an active ingredient, because they will come in contact
with vastly more healthy than diseased tissue. The moral is,
that gargles should give place to more scientific and precise
methods of applying topical agents to diseased surfaces, espe-
cially in children, to whom gargling of any sort is virtually an
impossibility. The future, therefore, is toward irrigations,
sprays, lozenges, and, in the case of children, to medicated
confections."
18%.]
EDITORIAL.
159
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THE EATING OF ICES.
There has been some outcry lately against the eat-
ing of ices. Hands have been thrown up in astonish-
ment because certain ice cream has been found to
contain certain adulterations, and not infrequently the
deadly ptomaine. There is no question that many
food products are adulterated, but that ice cream is
more frequently adulterated than other articles of
diet, we disbelieve. A sneer has become habitual
with many when speaking of the Americans; and the
American fondness for ice water and iced confections
has passed into a proverb.
The truth is, however, that the Americans are sim-
ply following classic models. When our European
confreres smile at our imbibition of chilled fluids, we
can remind them that the old Greeks and Romans
were even more addicted to the use of ice water than
any of the moderns, if we may judge from the pains
taken to preserve the ice. Athen^eus, quoting Chares,
declares that when Alexander the Great besieged
Petra, a city of India, he filled thirty trenches with
ice, which being covered with oak boughs, preserved
it a long time. The establishment of large ice houses
in Rome is usually accredited to the Emperor Nero,
although the custom of preserving ice was common
among the Romans. Seneca, in writing of this,
exclaims, "The Lacedaemonians banished the oint-
ment sellers and commanded them to be gone with the
utmost speed out of the country; what would have
been done had they seen shops to reposit and preserve
ice" ? Plutarch relates that ice was usually preserved
by being wrapped in cloths and straw. The luxuri-
ous Nero introduced the use of snow, and wine was
cooled by pouring it through a strainer ' filled with
snow (coin in iiirariitm). Occasionally the wine was
diluted by pouring snow-water into it,2 but there must
have been some unpleasantness attending the use of
snow water, for Pliny3 states that "It was the
Emperor Nero's invention to boil water, and then
inclose it in glass vessels and cool it in snow, a method
which insures all the enjoyment of a cold beverage,
without any of the inconveniences resulting from the
use of snow. Indeed it is generally admitted that all
water is more wholesome when it has been boiled; as
also water when it has once been heated will become
more intensely cold than before — a most ingenious
discovery. The best corrective of unwholesome water
is to boil it down to one-half. Cold water, taken
internally, arrests hemorrhage. By keeping cold
water in his mouth, a person may render himself
proof against the intense heat of the bath " (Bostock's
Translation).
But there has always been a prejudice against the
use of cold liquids and cold confections. This preju-
dice must have been the exclusive property of the
minority, for the custom has survived and we go on
drinking our ice water and eating our frozen friandes
as Nero did more than eighteen hundred years ago.
The intermediate attempts to write down the cus-
tom having failed, it must be clear that something
more than a mere desire for luxurious living has con-
tinued its use. The Code of Health of Salernum
said nothing against it; on the contrary, as a means
of reducing cerebral hyperemia from inebriety, the
advice is given :
"To drink cold water let him not refrain,
Because it hinders all that hurts the brain."
— Holland's Translation Flos Medicines.
Brueyrinus insists that Gonzages, Duke of Man-
tua, was killed by drinking ice water, and Valangin
mentions the case of a nobleman, whom he describes
as being in every respect a manly character. He was
a great advocate for the cold bath, and in general for
everything that could harden the body, and imagined
that cold " applied internally must be as salutary as
when applied externally. He often drank his liquors
out of ice and ate plentifully of ice creams of various
kinds. After having one day taken a greater quantity
of these than usual, a fatal inflammation, which at
once affected the stomach, the intestines and the kid-
neys, notwithstanding the assistance of three of the
most eminent physicians, who did not leave him an
instant, made him fall a victim to his favorite opin-
ion." 4
Most of the alleged fatalities following the ingestion
i Potter. Grecian Antiquities. Vol. 2, p. 258.
2 Adums' Unman Antiquities, p. 421.
3 National History. Hook 81. C. 24.
« Sinclair. Code of Health, Vol. 1. p 3fi-V
160
PHYSICAL TRAINING IN THE ARMY.
[July 18,
of ice cold drinks except in large quantity rest on no
better foundation than the cause in the case cited by
Valangin, which, viewed in the light of modern
pathology is simply absurd.
The profession need not ignore the object lesson
that appears under their very eyes every day, namely,
that unadulterated ices taken in moderation are bene-
ficial and healthful.
We trust that one of our esteemed contemporaries
which recently published a diatribe against the use of
adulterated and fictitious ice cream, will not assert
that this Journal favors the impure product. Let
us throw every safeguard against the sale of impure
food and drink of every sort, and then when the sun
is hot and cooling shades invite, let us eat our ices
and drink our lemonades unmixed by fears of linger-
ing poison in form of microbe or ptomaine.
PHYSICAL TRAINING IN THE ARMY.
It is only of late years that the value of physical
training has been recognized in the Array of the
United States, although the country as a whole for
the past fifty years has participated more or less in
the modern revival of physical culture Some of our
schools adopted the German system of gymnastics,
others the French system of calisthenics and others
again the athletic sports of the English. The first
gives muscular development, the second grace and
suppleness, the third grit, energy and determination
to win. All are needful to the proper development of
the soldier. At most of our military posts foot-ball
and base-ball are played when the weather is favor-
able, but such sports do good to but few besides the
players, and at many posts where the winters are long
it has been reported that the only exercise of the
men has been shoveling snow and distributing fuel.
What is required at every post is a gymnasium with
appliances and graded exercises. At West Point, as
at most of our colleges, attention has been given to
this subject for a number of years and four years ago
a handsome gymnasium was completed and fitted up
with every desirable appliance. The fourth class
cadets receive instruction three times a week from
October to June, each lesson forty minutes. The
training is> based on the German system with such
additions from other systems as seem advisable to
develop activity and grace as well as power. Gym-
nasiums have been extemporized at several of the
posts by fitting up an unused barrack-room or hall
with the needful appliances, and in some instances
when the post provided no facilities company com-
manders have introduced systematic training into
their barracks.
This movement has of late received a hearty im-
pulse by the energy of Major General Miles, com-
manding the Army. Last year while in command of
the Department of the East he issued several circulars
calling attention to measures intended to promote the
physical development of the soldiers in his depart-
ment. One gave instructions in methods to be
adopted at posts where there were few facilities, sub-
mitting a series of exercises for the use of instructors.
Another outlined a system for perfecting the training
where every facility was at hand, giving due weight
to the necessity for medical supervision, not only to
prevent overstress but to determine the general line of
exercise in particular cases where the development of
the individual was unequal. A third gave instruc-
tions for training in swimming, in rescuing those in
danger of drowning and in restoring those apparently
dead, Sylvester's method being that recommended.
Since assuming command of the Army the efforts of
General Miles have been devoted to extending this
work to all the Military Departments. Hence for
instance, on June 26 last there were issued from Head-
quarters, Department of Dakota, General Orders
enjoining that all possible facilities and encourage-
ment be extended to officers and enlisted men for
indulgence in gymnastic and athletic exercises and all
manly pastimes and field sports that tend to develop
bodily activity, foster a spirit of emulation and give
added interest and attractiveness to the soldier's life.
These orders require that a gymnasium be established
at each post and an officer designated to superintend
the systematic practice of the troops in gymnastic
exercises for thirty minutes a day three times a week
for nine months of the year (General Miles calls for
half an hour every day for nine months) and to initi-
ate and manage all games and contests. Among indoor
exercises for inclement weather are mentioned: boxing,
fencing, vaulting, swinging clubs punching the bag,
jumping either for distance or height with or without
pole or spring board, and the use of dumb-bells, parallel
and horizontal bars, swinging rings, the trapeze, the
ladder, etc. For out-door practice there will be in
addition to the above, the passage of ditches, fences,
walls, houses and other obstacles; running, wrestling,
bicycle riding, throwing the hammer, putting the
shot, rowing, swimming, skating, snowshoeing and
the like, according to season and facilities. General
participation in such games as foot- and base-ball,
quoits, tennis, golf, polo, etc., is also to be heartily
encouraged:
This interest in physical training in the Army will
result in many advantages. It will make life more
interesting to the men now in the ranks and will tend
to bring into the service a better class of young men
than heretofore. It is the present advantage also of
keeping the men at home in barracks and away from
evil resorts. It is to be expected that the percentage
of injuries will be increased but this will certainly be
more than offset by a lessening of the number dis-
abled as the result of dissipation. The special
objective is however the improved condition of the
1896.]
THE NEURON.
161
troops. These systematic exercises will make our
■oldiera able to answer the call to special duty at any
moment by keeping them always in training; and
they will no doubt give an impetus to the physical
improvement of many individuals in civil life by
attracting attention to the methods adopted by the
military authorities, by increasing the care given to
this subject at the many universities and colleges
having military instructors detailed from the Army,
mid by stimulating the interest which the members
■of the National Gaunl have hitherto shown in their
military and athletic training.
THE NEURON.
Those of the JOURNAL readers — and we are glad to
state they are steadily increasing in number — who
studied anatomy and histology some lustrums ago,
and supposed that these branches of medical science
were at a standstill, are occasionally nettled to find
nowadays that in some departments, especially neu-
rology, rapid and even phenomenal advances are being
made. In the place of our old acquaintances, the
nerve fibers and nerve cells, we are confronted with
neurons, axons, dendrites and other unfamiliar appel-
lations. We learn that instead of the nervous system
being composed of two kinds of tissues, the vesicular
or gray and the fibrous or white, it is made up of a
-series of independent morphologic and physiologic
units which have been named neurons by Waldeyer.
Each neuron is composed of: 1, a nerve cell; 2, pro-
toplasmic processes or dendrites; 3, its axon or axis
cylinder passing into the nerve fiber; and 4, its end-
ing in a branched tuft. In the neurons of the ante-
rior roots of the spinal nerves the protoplasmic
processes are short and the axis cylinders long; in
the posterior roots these conditions are reversed, the
axis cylinders are short, the protoplasmic processes,
on the contrary, are long, reaching to the periphery
from which impulses are collected. These conditions
are explained by Lenhossek's discovery in the earth
worm. In this animal there are no nervous organs
like the spinal ganglia, but sensory cells or gangio-
blasts are dispersed through the integument with long
processes reaching internally to the central nervous
system and short filaments reaching externally. It
would seem as if during the evolution of the higher
forms, the gangioblasts have been withdrawn from the
exterior and thus pulled their collecting filaments
into the long process.
We learn also that the transmission of nervous
impulses does not require a continuous physical struc-
ture without breaks. "Substantial continuity does
not exist," says Ramon y Cajal,1 "the currents are
transmitted from one cell to another by contiguity or
contact, as in the joining of two telegraph wires.
This contact takes place between the terminal
i Lea Nouv. Idees sur la Struct, du Syst. Nerveux.
branches or collaterals of the axis cylinders of one
side, the cellular bodies and the protoplasmic branches
of the other." Instead of afferent and efferent, or
centripetal and centrifugal, to denote the direction of
the nervous currents, Cajal has introduced the terms
cellulipetal and cellulifugal. For example, the end
tufts of the neuron are stimulated by impressions
from the exterior; this impulse is transmitted to the
nucleus of the nerve cell (cellulipetal); from there it
is conveyed to other terminal tufts, say in muscle
fibers (cellulifugal).
According to Cajal,3 "the probable direction of the
nervous movement is cellulipetal in the protoplasmic
prolongations and cellulifugal in the axis cylinders."
Golgi, the distinguished Italian histologist, believed
that the Deitersian or protoplasmic processes preside
over the nutrition of the nerve cells, collecting nutri-
ment for them. GtERLuch- was of the opinion that
the terminals were collected into a fine network, inter-
lacing with each other and forming a support for the
gray matter. It is now thought beyond question that
the protoplasmic processes are for the transmission of
nerve impulses and nothing else.
The simpler reflex acts can be produced by impulses
from without, being transmitted along a neuron to
others in the spinal cord 'and immediately back to a
muscle fiber. It is not likely this ever actually occurs,
but that the reflex acts are of a more complex charac-
ter requiring the interposition of secondary neurons.
The practical application of this neuron theory lies in
the fact that nerve fibers are now to be looked upon
as processes of the nerve cells themselves. We can
therefore understand the influence of diseased condi-
tions of the fibers on the nerve cells better than in
1857, or when Waller announced his law: "Degen-
eration occurs along the whole extent of any nerve
fiber which is cut off from the cell which governs its
nutrition." This cell, His has shown us, from his
embryologic researches, is in every case the cell from
which the fiber originally grew, a conclusion we can,
from our present knowledge of the neuron, readily
understand. It was formerly supposed that the prox-
imal part of a severed nerve, with its cell body, did
not undergo degeneration but remained normal.
From time to time, in patients who had suffered
amputations, examination showed that these cells
instead of remaining normal had undergone more or less
degeneration. These clinical observations have been
supplemented by experiments. Nissl, for instance,
has severed the facial nerve in rabbits and found
definite alterations in its nucleus in twenty-four
hours, consisting of a fine granular degeneration and
rarefaction of its ganglion cells. Flatau has con-
firmed these experiments by some others on the motor
oculi of cats.
We can understand if the nervous system is made
2 Loc. cit.
162
PARESIS AND PSEUDO-PARESIS.
[July 18,
up of cellular units, like the liver, kidney, etc.,. it
must be subject to like cellular changes. Future
researches will entirely recast the pathology of the
nervous system and place it on a firmer basis. This
will no doubt require much time and labor, but the
field will abundantly repay the workers in it.
PARESIS AND PSEUDO-PARESIS.
Within a few years the literature of paresis or gen-
eral paralysis of the insane has been enriched by
numerous papers, and some different conceptions of
the disorder than those that have hitherto prevailed,
have been suggested. Not only its pathology and
etiology, but also its symptomatology have been ques-
tioned, and the consequent confusion has induced at
least one author to say that " as it at present stands,
general paralysis would appear to be best defined as a
progressive disease which begins anyhow but ends
somehow." Whether this pessimistic conclusion is
justified may be a question, but the fact illustrates the
confusion that these later aspects of the question have
created.
For a long time it has been the practice to recog-
nize paresis as a marked entity, varying somewhat
in its symptoms and rather uncertain in its in-
timate pathology, but always or generally readily
recognizable. With this, however, it has been claimed
exist other conditions closely resembling it but nev-
ertheless entirely different, but with almost identical
symptomatology that embarrasses the diagnosis and
tends to make confusion in certain special cases.
Such are the pseudo-pareses due to alcohol and lead
and some conditions following fevers, malarial or
otherwise, insolations and especially syphilis. This
latter has been the cause of pseudo-paresis par excel-
lence in the classification of certain authorities, fol-
lowing Fournier, the author of the term " syphilitic
pseudo-general paralysis," who, however, has himself
apparently since abandoned the idea of its being a
distinct entity apart from the genuine disease. Still
another form, mimicking paresis in some of its earlier
phases, at least, is occasionally met with in neuras-
thenia, and this seems to have been generally over-
looked by those who have written on the subject,
notably so by Dr. Hyslop, the author already quoted,
who has recently discussed these causes of confusion
and who rather caustically criticises the common indefi-
niteness of medical notions in regard to paresis.
There is no question but that there is quite a wide
range of variation in the symptoms of this disorder,
and that it is impossible to make any absolutely typical
syndrome to which all cases must conform. This fact
has, however, long been recognized, and some have
maintained that we have in this so-called disease sev-
eral distinct disorders. It is also true that there are
several conditions that more or less resemble it but
differ in their prognosis, such as the temporary
pseudo-paresis of alcoholism, saturnism, malaria and
neurasthenia. These can not indicate a permanent or
serious lesion of the brain, but there is no doubt that
their occurrence means a functional involvement of the
same cortical regions as are implicated in true paresis.
The one is due to a temporary intoxication, the other to
destructive and irreparable lesion, but there is no reason
why the toxic agents that usually cause only transient
disorder can not, under certain conditions, induce the
permanent and progressive lesions of the true disease.
In this way we may perhaps account for an occasional
case of paresis with no other known causal factor
than alcoholic excess, over- worry or work or lead pois-
oning. There would be no good reason for calling
such an actual progressive case pseudo-paresis, even
if it were positively known that it had no other ori-
gin than one of those above enumerated. The desig-
nation should be dependent on the actual condition,
not on its cause, but there is no propriety in includ-
ing transitory functional disorders in a disease which
is essentially and typically progressive. We can prop-
erly speak, therefore, of an alcoholic, neurasthenic or
saturnine pseudo- paresis, and possibly also of a syph-
ilitic pseudo-paresis, limiting the term in this case to
a purely transient disturbance of the cortical func-
tioning without any serious or irreparable lesion.
Whether such cases often occur is exceedingly doubt-
ful, but the exceptional instances are probably
accountable for the rare cases of cures reported of
progressive paresis.
Although, as already stated, Fournier seems to
have abandoned the idea of a syphilitic pseudo-pare-
sis, this is still maintained by many, and the more
strenuously that the conviction has been growing of
late years among alienists that nearly all, if not all
cases of paresis are of syphilitic origin, or at least
have had syphilitic antecedents. This, which is in its
way, if true, a very decided advance in the pathology,
meets with strong objections from some quarters.
Syphilis being considered a disreputable disease, is
not, to many, a very acceptable origin for a disorder
that is becoming increasingly frequent in civilized
society. Some of the efforts to discredit it as a
cause have been so much overdone as to call out the
sarcasm from Fournier that, according to their sta-
tistics, a man should acquire syphilis in his youth to
insure against paresis in middle age. An English
exchange attributes the confusion as to what is pare-
sis or general paralysis to the growing belief in its
specific origin, and speaks virtuously against the dis-
position to accept assumptions for facts and post hoc
ergo propter hoc arguments in medicine. The fact in
itself, however, that this theory of the causation of
the disease has steadily grown in favor in spite of
sentimental objections, is a strong argument for its
validity, and at present it is beginning to claim both
numbers and the weight of scientific authority on
THE VACCINATION COMMISSION.
163
its ude, though it can not yet be aooeptedas an abso-
lutely proven or universal truth. The cases that are
not syphilitic arc coming to be admitted as probably
the rare exceptions; and the term "syphilitic pseudo-
paresis " will probably soon be limited to those forms
occurring after recent syphilis and amenable to spe-
cific medication. Even these cases can not be always
definitely delimited, and the elements of time and
continued observation should always be taken into
Consideration in the diagnosis.
A possible cause of confusion is the occurrence of
senile changes in the brain. Undoubtedly there have
been \oo many cases of paresis diagnosed in men over
50 or (K) years of age, and some cautious alienists have
declined to recognize it as occurring after the latter
limit. It is very possible, with an atheromatous con-
dition of the vessels, for cortical degenerations to
occur that may produce symptoms very closely resem-
bling those of genuine paresis, and this should there-
fore always be reckoned with in making the diagnosis
at any age.
While the occasional difficulties of diagnosis of
paresis may be admitted and the possible occurrence
of pseudo forms acknowledged as actual or probable,
it would be no advance to question or give up its
reality as a separate and well-marked disease. It may
be often simulated, its characteristic of incurability
may even be now and then discredited by some well
observed case, it may have long and puzzling remis-
sions, its pathology may be in doubt in some impor-
tant regards, but as a cortical disease characterized by
a general, steadily progressive mental and physical
deterioration, it exists as indisputably as any other
affection with which mankind is cursed.
"THE GREAT UNREADY" VACCINATION
COMMISSION.
The editor of the Practitioner, in his masterly
lenner number for May, recalls the fact that his
reat nation has been waiting seven years for the
Royal Commission to speak. The courts are in a
measure "tied up, " waiting for a decision; while the
medical profession is almost dreading a decision.
The editor is moved to compare the situation with
that of which Horace wrote when he told about the
peasant who took his seat on the bank of a river to
wait and see the stream flow past. Or, as another
writer has shaped it, " The report will not appear
until just after the Greek Kalends."
One good point is made in the article to which we
refer, and one that should never be lost sight of,
namely: It is always the poor, the ignorant and the
helpless who suffer from the fads of faddists;
we and ours are relatively free from danger.
Through epidemics and rumors of epidemics the
Royal Commission on Vaccination still sits in sphinx-
like silence. Smallpox may come and smallpox may
go, but it goes on forever. In appointing the Com-
mission, on May 29, 1889, the Sovereign gave its
members the following injunction : " And our further
Will and Pleasure is that you do, with as little delay
as possible, report to Us under your hands and seals
or under the hands and seals of any five or more of
you, your opinion upon the several matters herein sub-
mitted for your consideration." The manner in which
these " right, trusty and right well-be-loved " gentle-
men have carried out this injunction entitles them to
the gratitude to at least one section of the community,
to- wit, the antivaccinists. Owing to the delay in issuing
the report, vaccination has almost died out in many
parts of the country. Nearly a hundred Boards of
Guardians have decided not to prosecute for refusal to
obey the law, and in other cases where the Guardians do
their duty in the matter magistrates hesitate to punish
until the Commission has issued its pronouncement.
A magistrate waiting for this event seems to be like
the countryman in Horace, waiting for the river to
flow past. Meanwhile the public mind is necessarily in
a state of suspense from which it is from time to time
roused by such incidents as the present outbreak at
Gloucester. In whatever sense the Commission
reports, it will now, I take it, be impossible to enforce
compulsory vaccination — at any rate, until a series of
epidemics once more teaches people the value of the
protection they now make light of. "' He jests at
scars and never felt a wound." Well, we who know
how to safeguard ourselves and those under our
charge can look forward to the wrath to come without
fear; but it is sad to think of the helpless children of
deluded, ignorant, or careless parents.
In this connection, the Medical Press and Circular
calls attention to the fact that vaccination has its
friends in the House of Commons: "Despite the
delay, and the supposed opinions expressed, in the
forthcoming report of the Royal Commission on Vac-
cination, it is evident that the House of Commons is
a strong center favorable to vaccination. In reply to
a question last week in the House as to the recalci-
trant action of a particular Board of Guardians,
which had rejected a solution to enforce the Vaccina-
tion Act. the President of the Local Government
Board stated that he had addressed a communication
to the Board in question pointing out to them that
by failing to enforce the provisions of the Act they
were incurring a very grave responsibility. This
announcement, it is especially worthy of note, was
received with cheers, thus showing, unmistakably,
that the results of the Gloucester epidemic have not
been lost upon the Members of the House of Com-
mons. The Gloucestershire Chronicle recently pub-
lished some interesting statistics respecting the
visitation of smallpox to the town to which some
reference may be made, and here it may be said that
the inhabitants of Gloucester owe a large measure of
164
CORRESPONDENCE.
[July 18,
gratitude to the editor of our contemporary for the
unvarying, convincing and disinterested manner in
which he has pointed out to his fellow townsmen the
right course to take in regard to vaccination. In
temperate language he has consistently advocated
vaccination, simply because he has honestly satisfied
himself that there was no other alternative to adopt
in the presence of the terrible epidemic which was
raging in the town'. The statistics, moreover, which
appeared in a recent number of our contemporary,
regarding the epidemics, form a strong argument
showing the utility of vaccination. The mortality
among the total number of cases attacked was 21.7
per cent.; of the unvaccinated cases, 41.4 percent.;
of the vaccinated only in infancy, 8.5 per cent. ; and
of the uncertain cases, 32.2 per cent.
CORRESPONDENCE.
Testimonial to Dr. Davis.
Philadelphia, Pa., July 6, 1896.
To the Editor:— The note of Dr. Overlook in the number
for July 4, relative to a medal demands some information. The
medal to which he alludes is that ordered by the Association
in 1875 ; see Vol. xxvi, page 35. In accordance with the instruc-
tions then given, 1 had a number of the medals struck off and
sent to those who forwarded the money. The date on the
medal does not mean that when it was issued, but the date of
the origin of the Association. Although Dr. Davis was quite
prominent in the work of organizing the Association, yet at
that time no thought existed of having a medal issued with his
likeness on it. The meeting of the profession to organize a
national society was held in New York, as stated in the note in
the Journal, but Dr. Lewis Williams was not present. I
make this mention with no captious spirit but to keep history
straight. Yours very truly,
Wm. B. Atkinson M.D.
Another Explanation.
Montgomery, Ala., July 6, 1896.
To the Editor:— 1 am sorry to have to trouble you with
another explanation. But please allow me to say that I did not
advocate before the Conference of State Boards of Health any
such scheme of organization as that which you ascribe to me,
nor anything in any way resembling it.1 You are certainly
writing under the influence of information that is entirely
incorrect. This will be plain when the official Report of the
Proceedings of the Conference of State Boards are published.
The proposed bill has not taken definite shape. Only its larger
provisions have been decided upon. It is some little time yet
before Congress meets ; and ever since the session of the Asso-
ciation in Atlanta I have been in a most miserable condition
of health ; during the last two weeks I have been in bed. Under
these circumstances I have not been able to push this work as
I otherwise would have done. I have been in correspondence
with leading physicians in several states and have made some
progress toward the proposed enlargement of the Committee.
In the meantime I take this opportunity to say through the
Journal of the Association that my Committee and myself
will be greatly obliged for any suggestions looking to the com-
pletion of a wise and judicious bill ; and this invitation is espe-
cially extended to the Editor of the Journal.
Yours truly, Jerome Cochran, M.D.
Chairman of Committee.
1 Our information was in writing, and from a member of the Con-
ference.—Ed.
If She Had Only Been Batteyized.
San Diego, Cal., July 9, 1896.
To the Editor: — Apropos of recent contributions to the>
Journal by Drs. Boal and Daniel suggesting castration as a.
punishment for certain derelicts (degenerates?) I enclose an.
excerpt from a reliable source :
"Prof. Pellmann of Bonn University, who makes a special
study of heredity, has been tracing the career of the descendants
of Frau Ada Jurke, a notorious drunkard, who was born in 1740-
and died in 1800. Her descendants have numbered 834, of
whom 709 have been traced from youth by Prof. Pellmann. Of
these, 7 were convicted of murder ; 76 of other crimes ; 142
were professional beggars : 64 lived on charity, and 181 women
of the family led disreputable lives. The family has cost the
German Government for maintenance and cost in the courts,
almshouses and prisons, $1,250,000."
The details are quite as startling as those connected with the
history of a colored female crook, which were published in
Massachusetts some years ago. Herein is food for reflection.
Yours truly, C. M. Fenn, M.D.
Not Antitoxin.
Chicago, July 13, 1896.
To the Editor: — In the Journal of 11th inst. p. 113, appears
the following :
"Another Death from Antitoxin. — Dr. W. J. Nolan of Chi-
cago, writes the following to the New York Medical Journal:
"285 Loomis St., Chicago, June 24, 1896.
"To the Editor of the New York MedicalJournal : Sir: —
In view of the discussion now going on in the Journal, of
which I have been three years a reader and subscriber, I
frankly indorse the views of Dr. Winters in regard to antitoxin
in diphtheria. Of one case I must write in terms of strong
condemnation. The facts are as follows : I was called to see a
boy, 8 years old, pulse rapid, temperature 105 degrees, and the
laryngeal appearance quasi-diphtheritic. I began the ordinary
treatment, in which quinin, carbolic acid and iron formed
chief parts. The result next morning was very satisfactory ;
all alarming symptoms were decidedly not much in evidence.
Some time in the evening of this better day, our antitoxin
friends raided the house and began their injections a l'outrance.
They did not inform me, I need scarcely say ; but like birds of
evil omen, they swooped down on a defenseless widow and
daughters, and injected mightily, nay, as the sequel proved,
mortally. Need I express an opinion after this on the discov-
ery, or at least its manipulators? W. J. Nolan, M.D."
On reading the foregoing in the New York publication of
the 4th inst., inquiry was at once made as the facts, with
results which led to the following correspondence :
"Chicago, July 6, 1896.
"To the Editor of the New York Medical Journal: Sir: —
Not so much in defense of antitoxin — which hardly needs any
—as in common justice to its 'manipulators' in this city, as a
correspondent, Dr. Nolan, styles them in his letter published
in last week's Journal, I ask your publication of the enclosed
statement of the facts in the case he therein refers to.
Faithfully yours, F. W. Reilly, M.D."
"Chicago, July 6, 1896.
"F. W. Reilly, M.D., Assistant Commissioner of Health.
Dear Doctor: — Referring to the letter in the New York Med-
ical Journal of July 4, by Dr. W. J. Nolan of 285 Loomis St.,
I find by the notes in my visiting list I was called May 27 to
that case by Dr. Bergeron who had been called and finding it
was a severe case of diphtheria, referred the people to me say-
ing he would prefer not to treat diphtheria. On my arrival
I found the case extremely severe, advanced beyond the fourth
day, Klebs-Lofner bacilli and also strepto- and staphylo-cocci
in abundance, and every evidence of septicemia. I gave an
unfavorable prognosis but injected antitoxin with a forlorn
hope ; and also immunized all the other five children in the
family. Then I was informed by the mother that Dr. Nolan
had been called on Sunday, May 23, made his second visit on
Monday, and then abandoned the case. Thereupon they sent for
Dr. Bergeron and by him the case was referred to me. The
case was strictly a charity one and so known to be by Dr. Ber-
geron, and I was compelled to furnish medicine at my own
expense. The child died as I predicted on my first visit. None
1896.]
SOCIETY NEWS.
165
of the children immunized contracted the disease. The
Mother, who was not immunized, contracted diphtheria, was
treated with antitoxin and promptly recovered.
i did not see the case nor was antitoxin administered until
July 27, the second day after Dr. Nolan had abandoned it.
The mother 'the defenseless widow' had given him the last
dollar she had in the house. She is eminently satisfied with
what I did for her child, as are all of the family, and unstinted
her condemnation of Dr. Nolan for his 'heartless neglect,'
she terms it. Respectfully submitted,
E. P. Murdock. M.D., Medical Inspector."
1 am this morning in receipt of the New York Medical Jour-
il of the Uth inst.. but fail to find therein any mention of
)r. Murdoek*s statement of facts and am, therefore, compelled
i appeal to your sense of editorial justice to say whether the
uption "Another Death from Antitoxin" now seems to you to
warranted. F. W. Reilly, M.D.
Our Journal.
Tecumseh, Mich., July, 4, 1896.
To the Editor: The Journal of the American Medical
Association was born and passed through its early infantile
life in Chicago, arrived at robust manhood in that city, and in
Chicago 1 vote for The Journal to remain, where it will be in
touch with cosmopolitan schools and hospitals.
Respectfully, J. F. Jenkins, M.D.
NECROLOGY.
Charles Styer, M.D., a graduate of the University of
Pennsylvania. Medical Department, of 1862, died at his home
CHARLES STYEB, M.D..
in Philadelphia, July 6, aged 46 years. He was surgeon to the
'th Regiment, P. V., and in June, 1867 he entered the regu-
*r army as assistant surgeon, served on the frontier in the
outhwest mainly, until he resigned June, 1878, to engage in
private practice. In 1885, he was appointed Acting Assistant
Surgeon in the United States Marine-Hospital service at Phil-
adelphia. For several years he was also one of the Medical
Staff of the German Hospital of Philadelphia. He was a
prominent member and medical examiner of several social and
beneficial orders, being Surgeon-in-Chief of the Royal Arcanum.
He was also a member of the Grand Army of the Republic
and has been Post Surgeon, Post Commander, Medical Director
of the Department of Pennsylvania and Surgeon-General of
the National Encampment. Dr. Styer leaves a widow and
two sons. His death was found to have been caused by an
aneurysm.
Sir George Johnson, M.D., whose death has recently been
nounced, was a man of mark in his day and generation, in
tie great metropolis where his life-work was done. Sir George
was born in November, 1818, at Goudhurst, in Kent, and was
educated at the Grammer School there. At 19 he was appren-
ticed to a relative, a general practitioner, residing in Cran-
brook, Kent, and two years later, in October, 1839, he entered
the Medical School at King's College, London, where he
greatly distinguished himself as a student, gaining many
prizes. In the wards he was a clinical clerk under Dr. Todd,
and a dresser to Sir William Ferguson, and after qualifying,
he filled the post of house physician and house surgeon. In
1844 he received his degree of M.D. from the University of
London, after having passed through a creditable university
career. The position to which he had attained as a prominent
alumnus of his medical school at once marked him out as a
likely candidate for an appointment on the staff of his hospital,
and in 1857 he was elected one of the assistant physicians, suc-
ceeding Royle as Professor of Materia Medica and Therapeu-
tics. In this appointment he continued until 1863, when he
became Professsor of the Principles and Practice of Medicine,
which appointment he resigned in 1876 when he became pro-
fessor of clinical medicine. His connection with the Royal
College of Physicians began when he became a member of
that body in 1846. Four years later, an unprecedently short
period, he was elected a Fellow of the College, and subse-
quently he held the offices of Examiner in Medicine, Junior
Censor, Senior Censor, and Vice-President. The blue ribbon
of science was conferred upon him in 1872, when he was elected
a Fellow of the Royal Society. The following are further
honors of which he was the recipient : In 1884, the Presidency
of the Royal Medical and Chirurgical Society ; in 1889, physi-
cian extraordinary to the Queen ; in 1892, knighthood.
Dr. George W. Ryan died at the Betts Street Hospital,
Cincinnati, July 11, of cirrhosis of the liver after a lingering
illness. Dr. Ryan was born in Louisville, Ky., thirty-six years
ago and graduated with honors from the university of that
city. For a number of years he was connected with the Hos-
pital of the Ruptured and Crippled of New York, where he
achieved a national reputation for his surgical work. He came
to Cincinnati about twelve years ago and at once commanded
a large and lucrative practice. At the time of his death he was
a member of the surgical staff of the St. Mary's and Presby-
terian hospitals, also a professor in the Ohio Medical college.
Dr. Ryan was a whole-souled fellow well met and a gentleman
who counted his friends by the hundreds. He was a single
man and one of the most popular members of the University
club. The remains were shipped to Louisville Saturday, where
interment took place.
James S. Hope, Passed Assistant Surgeon United States
Navy, who had been on duty at the Pensacola Navy Yard for
two years past, died July 1, in Roosevelt Hospital, New York,
after a surgical operation had been performed upon him for a
tumor. The remains were carried to Surgeon Hope's old home,
Norfolk, Va.; for interment. He graduated from the University
of Virginia, medical department, Charlottesville, Va., in 1887.
SOCIETY NEWS.
New York State Medical Association Second District Branch.
— The twelfth annual meeting convened at Albany, June 26.
Ten counties were represented.
The Tri-county Medical Society of Ford, Iroquois and Ver-
milion, 111., met at Paxton, 111., July 7.
State Board of Medical Examiners of New Jersey.- -The annual
meeting of this Board was held at Asbury Park, N. J., July
6. Dr. William Perry Watson of Jersey City was elected
president, Dr. E. L. B. Godfrey of Camden secretary, and Dr.
A. Uebelacker of Morristown treasurer. The next examina-
tions of this Board will be held at Trenton, September 15 and 16.
166
PUBLIC HEALTH.
[July 18,,
West Virginia State Medical Society. -The officers elected at the
annual election of this Society were published on page 53 of
the current volume, but by some inadvertence the item incor-
rectly made reference to the "Maryland State Medical
Society."
Scott County (Iowa) Medical Society. — The regular quarterly
meeting aod annual election of officers was held at Davenport,
Iowa, July 2. Officers elected for the ensuing year : Presi-
dent, Dr. J. H. Kulp ; vice-president, Dr. E. Strohbehn ; sec-
retary, Dr. Adella R. Nichol ; treasurer, Dr. Jennie McKown.
American Dermatological Society. -The next meeting will be
held at Hot Springs, Va., September 5 to 10. Everything will
be done to make the meeting a success and several papers
on interesting subjects have been already promised. Dr.
White will open a general discussion on the subject: "What
Effect do Diet and Alcohol Have upon the Causation and
Course of the Eczematous Affections and Psoriasis." Charles
W. Allen, M.D., Secretary, 126 E. 16th Street, New York.
Eastern Iowa District Medical Association. — - The twenty fifth
annual meeting was held in Fairfield, Iowa, July 25. Papers
were read by Drs. J. H. Etheridge, of Chicago ; W. B. La
Force, of Ottumwa; R. M. Lapsley, of Keokuk; D. W. Over-
holt, of Columbus Junction, and T. J. Maxwell, of Keokuk.
The following are the officers elected for the ensuing year : Pres-
ident, Dr. W. H. Holliday, of Burlington ; vice-president, Dr.
Snook, of Fairfield ; secretary and treasurer, Dr. M. C. Car-
penter, Fairfield. The Association will meet next at Columbus
Junction in November.
BOOK NOTICES.
The Student's Medical Dictionary, including all words and phrases
generally used in medicine, with their proper pronunciation
and definitions based on recent medical literature. By
George M. Gould, A.M., M.D., with elaborate tables of
the bacilli, micrococci, leucomaines, ptomaines, etc. ; of the
arteries, ganglia, muscles, and nerves ; of weights and meas-
ures ; analyses of the waters of the mineral springs of the
United States, etc. Tenth Edition, rewritten and enlarged.
Philadelphia. P. Blakiston, Son & Co. 1896. 8vo, cl.
Pp. 701. Price S3. 25.
"The present volume," says the author in his preface, "is
an entirely new one and is designed to take the place of the
'New Medical Dictionary' and the 'Student's Medical Diction-
ary,' the plates of which have been destroyed." This work is
intended for students, and as an introduction to the larger and
more expensive "Illustrated Medical Dictionary."
Few works have attained popularity more speedily than the
dictionaries of Dr. Gould, and deservedly so. The early
acceptance of the orthography advocated by the American
Association for the Advancement of Science, and the undeviat-
ing way in which it has been carried out, have doubtless had
much to do with their extensive sale. The only feature that is
open to criticism, for the Journal four years ago adopted the
spelling advocated by Dr. Gould, is that of pronunciation.
Anyone who may listen to any half dozen readers in our med-
ical societies will likely hear the common medical terms differ-
ently pronounced by each. Surely the time has come when
medical men may, as Dr. Foster has shown, adopt that pro-
nunciation, which will enable them, without regard to nation-
ality to give a common pronunciation to all words in common
use by the profession. We commend this work as we had the
pleasure of commending its predecessors by the same author.
Quain's Elements of Anatomy. Edited by Edward Albert
Schaefer, F.R.S., and George Dancer Thane. In 3 Vol-
umes. Appendix, Superficial and Surgical Anatomy, by
Prof. G. D. Thane and Prof. R. J. Godlee, M.S. Illus-
trated by 29 engravings. 8vo, pp. 76. Tenth edition. Long-
mans, Green & Co. London, New York and Bombay. 1896.
While anatomy should not be studied "superficially," yet
superficial or topographic anatomy can not be too deeply graven
into the brain of the student and practitioner; indeed, the
more attention paid to superficial anatomy, the "landmarks,"
as Holden termed them, become more clearly visible, the diag-
nosis is more easily made, and error is farther removed.
The student, and as well the surgeon, will find his knowledge
increased and his hand steadied by the careful perusal of this
appendix to Quain's well-known elements of anatomy, prior to
making a new dissection or undertaking a new operation.
(I) Whittaker's Anatomic Model. (2) The Anatomy of the Human
Head and Neck. A Pictorial Representation of the Human
Frame and its Organs. Graphically illustrated Vy means of
superimposed plates, with descriptive text by Dr. Schmidt.
English translation by William S. Furneaux. New York :
Thomas Whittaker (1, 3 and 5 Bible House) Publisher.
These books are pictorial representations showing the ana-
tomic relations of the parts. The plates are superimposed
very ingeniously, and are intended for students in general,
whether in medical classes or engaged in the study of anatomy
as collateral to other studies. The coloring, while not alto-
gether natural, is not so far off as to be violent, and the rela-
tions of the parts are as accurately shown as may be on a
plane surface. We commend the works for the purposes for
which they are intended, and as an aid to the teaching of anat-
omy in the public schools their value can scarcely be over-
estimated.
Keil's Medical, Pharmaceutical and Dental Register-Directory, with
special medical, pharmaceutic and dental departments con-
taining detailed information of colleges, hospitals, asylums,
societies, with street lists, etc., for Pennsylvania, New York,
New Jersey, Maryland, Delaware and District of Columbia.
Fourth edition. George Keil, Editor. Philadelphia : Burk
& McFetridge Co., Publishers, 308 Chestnut Street. 1896.
This directory has the merit of being up to date and is one
of the most complete of its kind. Its rather lengthy title fully
explains its scope. Every editor, teacher and writer, and as
well the general practitioner finds such compilations extremely
useful.
PUBLIC HEALTH.
Chicago Health Report for June shows total number of deaths
in the month as 1,895. The annual death rate on the basis of
the school board's census for the year ending June 30 was
14.83 per 1,000 of population. Last month's rate was 1.17.
Utah State Board of Medical Examiners.— This board, which has
been but temporarily organized since its appointment by Gov-
ernor Wells, met June 29 and effected permanent organization.
Dr. Bascom was elected president, Dr. John T. White secre-
tary, and Dr. Dart treasurer.
Baltimore (Md.) Health Statistics for June.— Health Commis-
sioner McShane's summary for June shows that during that
month 647 deaths occurred in Baltimore, a decrease of 136 as
compared with June, 1895. Of these 467 were whites and 180
colored. Forty-two died of infectious diseases and 76 of
consumption.
Will the Consultant get His Fee? Probably Not.— A curious
episode has arisen from a difference of diagnosis between two
practitioners in a burgh in the west of Scotland. Dr. A. cer-
tified a case of enteric fever and sent the patient to a burgh
hospital. Admittance, however, was refused, as Dr. B. who
had charge of the hospital, diagnosed the case as one of men-
ingitis. Dr. A., in no wise convinced of this view, sent for
Dr. C, a consulting physician from Glasgow, who had no
doubt the case was really one of enteric fever. Now Dr. A.
maintains that Dr. C.'s fee of ten guineas is an expense to
which he had been put by the burgh medical officer, and
accordingly he claims that the town council ought to refund
him this sum.
1896.]
PUBLIC HEALTH.
167
The Chinese Women and Their Feet.— The cruel and ungainly
practice of com pressing human feet in China has called forth
sonic official medical remarks on the subject to the Chinese
Maritime Customs. When questioned closely, not one woman
in a hundred will deny that she is a constant sufferer owing to
the tight bandages. Many foreigners in China Jmagine that
after a woman reaches maturity she is free from pain, but it is
contended that this is not the case. Dr. Macartney, the
writer of the report, never found an elderly woman who did
not complain of pain. Women with compressed feet can not
stand for any length of time without great suffering ; in addi-
tion to the agony endured in the early period of binding, paral-
ysis of the legs frequently ensues on the practice, and in every
case treated by him the patient recovered rapidly when the feet
were unbound and left free.
An Echo from Russia; " Let us have a Department of Public
Health." The Russians have taken up the cry, and are urging
the creation of a minister and department for this purpose,
which is said to be more needed in Russia than in any other
country for many reasons. The present arrangements for epi-
demics, etc., are utterly inadequate. Leviteky states that the
total medical supplies received at one large station in the Ural,
where an epidemic of cholera and typhus was raging recently,
amounted in all to one ounce of sublimate, one kilogram of
impure phenic acid, 20 grams of tincture of valerian and 20
grams of " Inosemzev' Drops." The present annual appropri-
ation for hospitals in the provinces is the same for each ($400-
$500) irrespective of the size, so that one with 595 beds receives
no more than one with 45. — Bulletin Midicale, June 21.
Duluth i Minn.) Water Supply. -The epidemic of typhoid fever
that carried off many of the citizens of Duluth a year ago
is brought to mind by a hearing which is called for Monday
before Attorney General Childs. Ellsworth Benham, corpora-
tion counsel for Duluth, will appear before the attorney gen-
eral and make an application for a writ of quo warranto to
compel the Duluth Gas and Water company to appear in the
supreme court and show cause why its charter should not be
declared forfeited to the city. The ground on which the appli-
cation is made is that the company failed to comply with the
requirements of its charter, in that it did not supply good and
wholesome water to the city. The application charges the
company with wilfully placing its intake pipe close to the sew-
age discharge from the city of Duluth, so that it received the
sewage and surface waters of Lake Superior, and that as a
result of the use of the water by the residents of Duluth sev-
eral epidemics of typhoid fever raged in the city and hundreds
of people died.
Food Laws In Pennsylvania.— The Pennsylvania State Depart-
ment of Agriculture has just issued formal decisions regarding
the provisions of the food laws. Truth and precision in the
labeling of foods are insisted upon, and adulteration is dis-
tinctly defined. Goods sold as "pure" must be pure, if mix-
tures they must be marked " compound" in a conspicuous
place on the label. A very wise provision is that in any "mix-
ture" or "compound" there must be no fraudulentor worthless
article, only such as are designated " ordinary articles or ingre-
dient of articles of food." "Salicylic acid is prohibited as a pre-
servative." This acid has been largely used as a preservative
for catsups, mince-meats, etc. Coloring is allowed in food pro-
ducts (except milk, which must contain no coloring matter or
preservative) provided the material used is not injurious, but
when used in canned vegetables the package must be distinctly
and plainly marked "artificially colored.-" Spices do not admit
of any foreign matter and therefore can not be sold as "com-
pounds," or placed upon the market in an adulterated condition.
The Pennsylvania market for ground cocoanut shells, corn meal
and other standard adulterants will fall off under this construc-
tion of the law. Definite limits are prescribed for vinegar, pickles,
lard, preserves, jellies, etc. All the fifteen formal decisions are
plain, honest and just. They permit harmless admixtures when
definitely stated, but prohibit fraud, misrepresentation and em-
ployment of any materials whatsoever which are a menace to
health. Pharmaceutical Era, June 25, 1896.
Illinois State Board of Health.— The regular quarterly meeting
of this Board was held in Chicago, July 7. Dr. F. W. Reilly
of the Chicago Health Department presented rules regulating -
the practice of midwives and proposing to grant greater author-
ity to municipalities in this matter, which were favorably
received by the Board. A committee was appointed to draft
resolutions on the death of Dr. O. O. Baines. A request was
made that the diplomas of the Harvey Medical College of Chi-
cago, be not recognized as it is alleged that this college does
not fulfill the requirements of the Board. The matter was
referred to the committee on the administration of the Medical
Practice act. The Secretary made statement concerning the
" Illinois Health University" of Chicago, to the effect that an
opinion had been asked of Attorney General Moloney as to the
possibility of prosecuting this fraudulent institution under the
statute. This concern being chartered may under the law issue
medical diplomas, but they are not recognized by any State
Board of Health and a number of persons have been victim-
ized. In case this can not be done it is hoped that the legisla-
ture will see fit to enact a law which will apply to cases of this
kind.
Do Files Spread Tuberculosis? — Dr. W. R. Aylett, {Virginia
Med. Semi-monthly, June 26, 1896) gives details of investiga-
tion : " I smeared a cover-glass with sputum from a well-
advanced case of tuberculosis and placed it upon a clean sheet
of paper, placing around it seven or eight clean covers. The
paper and covers were then placed where flies could have ready
access and soon quite a number were feeding on the sputum.
An inverted tumbler was lowered over them, making them
prisoners without their knowledge. One of the prisoners soon
deposited a 'speck' on one of the clean covers. To prevent
this becoming contaminated by their feet, I removed it at once.
Within an hour or two all of my covers were specked. The
covers were then put through the regular cover-slip prepara-
tion, carbo-fuchsin being used for the bacilli with methylene
blue as a contrast stain. On microscopic examination, the
specks were found to contain from one to three thousand bacilli
tuberculosis each. I have not yet tested the virulence of
bacilli so obtained, but they show no signs of disintegration,
seem as perfect and stain as readily as those from pure
cultures."
Death from Eating Ice. -In the annals of the Health Office and
Registry of Deaths, of Philadelphia, a half century ago or more,
occurs several times, the diagnosis of "Death from drinking too
much ice water." In these days of free refrigerated drinking
fountains and universal use of ice in the household, there may
occur, each year, a number of such cases ; but they are
recorded now under a pathologic and not under an etiologic
heading. Last week, however, the coroner, who had investi-
gated the death of two children in one family, gave a certifi-
cate of death from dysentery occasioned by the excessive use of
ice. As they had indulged freely in so called "snow-balls,"
made with shaved ice flavored with fruit syrup, it was sug-
gested that the fruit syrup might have contained some poison-
ous ingredient or adulterant, but the coroner's jury basing their
opinion on the results of Prof. Leffman's analysis of flavoring
syrups last year, which showed them to be harmless, came to
the conclusion that the eating of- so much shaved ice was the
real cause of the fatal illness. In view of the fact that children
are constantly buying and eating these balls of shaved ice, during
the hot weather in our large cities, it is pertinent to inquire as
to the purity of the ice, since Prudden and others have shown
that polluted water is not made pure by freezing and that vari-
168
MISCELLANY.
[July 18,
ous pathogenic germs are contained in ice coming from a con-
taminated source. Infected ice is capable of communicating
infection and causing local epidemics of disease. Typhoid bacilli
survived freezing in the epidemic at Plymouth, Pa., some years
ago. Pus organisms and the streptococci of erysipelas are
commonly found in ice coming from a source contaminated by
drainage, as well as many bacilli allied to the comma bacillus
or spirillum of cholera. With these observations in mind, it
would be well for the guardians of the public health to take
into consideration the ice supply of large cities, as well as that
of milk, and especially to prohibit the sale of ice to be eaten by
young children, unless it is of good quality. There are as good
reasons for having sterilized ice as exist for the use of sterilized
water or milk ; for children's use these should be of the best
quality and above suspicion.
Washington State Medical Examining Board. — The regular semi-
annual meeting of the Washington State Medical Examining
Board was held at Spokane, Wash., July 7 and 8. But six
applicants for license to practice within the State appeared
before the Board, one of whom failed to pass.
Washington State Board of Health Favors a Department of Health.
— At the last regular meeting of the Washington State Board
of Health the following resolution in favor of a national depart-
ment of health was unanimously adopted, viz. :
Resolved, That this Board is in favor of the establishment
of a national department of health upon the broadest and most
comprehensible grounds possible. That we do not endorse the
action of the National Conference of the States Boards of Health
held in Chicago in June last. Believing that this does not
represent the views of the majority of the boards of health of
the various States, the secretary is hereby instructed to corre-
spond with the boards of other States and also with other
boards of health, with the view of ascertaining the opinions of
the various boards upon the advisability of the establishment
of such department by the national government.
MISCELLANY.
Serum Treatment for Sheep Rot. — A member of the Pasteur Insti-
tute of Algiers has discovered a serum that will prevent "sheep-
rot." All animals "vaccinated" either escape or have a mild
form of the disease, from which they invariably recover.
University of Vermont. — The 43d annual commencement exer-
cises of the medical department of the University of Vermont
were held at Burlington, Vt., July 6. The graduating class
numbered fifty-two. The valedictory was delivered by Dr. J.
L. Marshall. The address of Rev. P. M. Snyder was on the
Relation of the Physician to the Preacher.
The Roentgen Rays in the Witness-Box.— We note that the trial
of an action for damages at Nancy, in France, the surgeon who
had charge of the injured plaintiff was accused of having
caused the damage by mistaking a dislocation for a fracture.
The accusation was sustained by producing in court a Roent-
gen photograph, which showed clearly the bones in the dislo-
cated position without any fracture.
New Apparatus for Anthropometric Measurements of Criminals. —
An anthropometer and craniograph invented by a lawyer,
Anfosso of Possano in Italy, are commended by Lombroso for
their extreme simplicity compared to Bertillon's complicated
apparatus, besides their other advantages. The Gaz. degli
Ospedale e delle Clin, of June 20, adds that every police sta-
tion should be supplied with them.
Roentgen Ray Visible to Insects. -The Centralbl. f. Physiologie
of June 13, describes some experiments with insects placed in
a box, one side of which was of wood and the other of lead,
and exposed to the direct Roentgen ray. The insects all
assembled on the side of the box permeable to the ray, except
those that had been blinded. The assumption is that it was
visible to them and attracted them.
Missouri Rule as to Burden of Proof of Insanity.— The supreme
court of Missouri holds, in the case of State v. Wright,
decided June 2, 1896, that the burden is on a defendant who
interposes a plea of insanity to sustain that defense to the
reasonable satisfaction of the jury. It says that it is in the
nature of a plea of confession and avoidance. It confesses the
homicide, but denies the crime of it. The court also holds
that a medical expert was very properly permitted to give his
opinion respecting the sanity or insanity of the defendant, hav-
ing for a basis the hypothetical case, together with what he
had learned from an examination of the defendant.
Treatment of Acute Pneumonia with Injections of Artificial Serum.
— Bassi of Lucca has found intravenous injections of artificial
serum of benefit in acute pneumonia, when a fatal termination
is imminent. He describes several cases in the Gaz. degli
Ospedale e delle Clin, of June 6, and dwells upon the impor-
tance of gaining time with them until the crisis is past. The
amount injected was from 120 to 250 grams ; the instrument
used was a Pravaz syringe connected with a reservoir, and
the injections were made in the median basilic vein of the left
arm, the day before the crisis was anticipated when possible.
Filters for Army Use.— Coccone has a study of the best portable
filter for use in the army in the Giornale Medico der R. Eser-
cito for April, and recommends the-Berkefeld-Nordtmeyer as
the most practicable for the purpose, using two alternately, a
day each, and boiling the one not in use in a camp kettle for
an hour. He suggests a few slight modifications to add to its
solidity and capacity. — Gaz. d. Osp. e d. Clin., June 11.
The Whale Cure for Rheumatism. — It is reported that at the
town of Eden, a place in Australia, which stands on the shores
of Twofold Bay, there is a hotel where rheumatic patients con-
gregate. Whenever a whale has been taken the patients are
rowed over to the works in which the animal is cut up, the
whalers dig a narrow grave in the body, and in this the patient
lies for two hours as in a Turkish bath, the decomposing
blubber of the whale closing around his body and acting as a
huge poultice. This is known as the "whale cure for rheuma-
tism."— Annals of Hygiene, July, 1896.
Anomalous Case of Cinchonidia Poisoning. — Dr. William Pepper
relates the case of a patient suffering from paroxysmal tachy-
cardia, in whom a pill of digitalis and cinchonidia sulphate —
one grain of the latter — produced, within three hours, severe
abdominal pains, nausea, extreme weakness and areas of angio-
neurotic edema. The hands and feet especially were much
swollen, the color varied from moderate congestion to extreme
pallor ; there was intense itching, the pulse was hard during
the period of intoxication, in marked contrast to the soft pulse
previously noted. The conditions continued about twenty-
four hours. — University Med. Mag., July, 1896.
Li's Bullet Located by the Roentgen Rays. — While in Germany
recently, the Chinese statesman, Li Hung Chang, took advan-
tage of an opportunity to have the bullet which he carries in
his cheek located by the Roentgen Rays. It will be remem-
bered that when in Japan, arranging the treaty of peace
between that nation and his own, he was assaulted by a would-
be assassin, who, it was feared at that time, had been only too
successful in taking the life of this truly great man. The
picture secured shows the tract of the wound through the
tissues of the cheek and the encysted missile slightly below
the point of entrance.
A Million Dollar Prize. — The following curious notice has
recently appeared in the New York City newspapers: "One
Million Dollars Reward. — To Physicians, Surgeons, Scientists,
Wise Men, and all others whom it may concern : Be it known
that I, Charles Broadway Rouse, who possess considerable
wealth, hereby agree to pay the sum of §1,000,000 to any
human being who restores to me my sight." The advertiser is
18%.]
MISCELLANY.
169
an eccentric Virginian who has done business in New York
since the late war, and who is suffering from atropy of the
Optic nerve. Some time ago he discovered that one of his
former employes, a man by the name of Martin, was affected
in the same way as himself. He took a great interest in his
case and was very kind in securing the best medical treatment
for him and otherwise providing for his welfare fed comfort.
Out of gratitude for this kindness he has offered to subject
himself to any kind of treatment that is thought worthy of
trial, and any one who believes that he has a chance of win-
ning the million dollar reward must first test the efficacy of his
treatment on Martin.
(iunshot Wound of the Stomach. --Dr. L. A. Woodson (.Vox/i-
i'///c Jour, of Med. mid Siny., June, 1896) reports a case,
male. SB, operated on sixteen hours after wound was received.
The patient was weak from loss of blood and abdomen dis-
tended from internal hemorrhage. The ball, 38-caliber,
■entered the stomach at the cardiac end and had severed the
gastro epiploica sinistra artery, which was still bleeding. The
ball emerged to the right of the esophageal opening, then
made another perforating wound, an inch long, in the pyloric
■end of the stomach. The ball was not located but the direc-
tion of its course indicated lodgement in the liver. Tempera-
ture the day after operation, 98.5 degrees. He was discharged
<.'ured on the twenty-first day. The points of interest in this
•case were the rapidity of healing and completeness of cure,
the absolute absence of fever after the operation was per-
formed, notwithstanding its gravity and extent, and finally
that an artery the size of the one severed should have remained
unsecured for sixteen hours and not have resulted in death
from hemorrhage.
The Therapeutics of Exercises. Dr. Randolph Faries says :
Many physicians prescribe exercise, never dreaming that they
are already adding coals to the fire of the disease. For exam-
ple, one physician will tell a patient who is suffering from brafn
overwork to take riding lessons, forgetting that mental opera-
tions are required to learn to sit properly and guide the animal
at first ; another will advise bicycle-riding which also requires
mental effort. Prescribe an involuntary exercise and the blood
will be drawn from the brain to the part employed because
wherever there is movement there we shall find the blood flow-
ing in greater quantities ; and in this way we deplete the over-
charged blood vessels in the cerebral mass. — Annals of
Hygiene, July.
No Duty to Provide Specialist.- -Jones v. Vroom, decided by the
court of appeals of Colorado, May 11, 1896, was brought
against a firm of physicians to recover damages for the loss of
an eye, alleged to have been caused by the negligent and
unskillful treatment of the defendants. They had been
employed to treat the plaintiff for typhoid fever. There
was no evidence, and in fact no complaint, that they did not
bestow upon her all the attention and skill which the nature of
the disease and her condition required. Indeed, she stated
herself that she was cured of the fever as a result of their
treatment. The only charge in the complaint which was
proven was that one of the defendants failed to send her an
occulist after he had promised to do so. The court holds that,
under the circumstances, a nonsuit was properly granted. It
says that the defendants were employed to treat the plaintiff
for fever, and their employment imposed no duty upon them
to provide her with a specialist for her eye. The court took
into account, furthermore, that she seemed to have had no
difficulty in procuring one when she set about it, and says that
presumably he could have been gotten just as readily at first.
A Consulting Surgeoncy Declined.— Dr. Thomas H. Manley
has lately declined the appointment tendered him in behalf of
the University Medical College of New York, by the Commis-
sioners of Public Charities. Dr. Manley was among the twenty-
eight members of hospital staffs, summarily removed a year
ago, by the reform government. It has since transpired,
that the move was not in any sense political, but was the out-
come of a medical college combination to secure all the clinical
material. Hence, at the last meeting of the County Medical
Association of New York charges of violation of the code of ethics
of the American Medical Association were made against
tho faculties of the three regular medical colleges. It seems as
that only one medical college of New York has remained loyal
to the National organization — Bellevue — that must stand the
brunt of attack in this investigation, as the College of Physi-
cians and Surgeons and the University Medical College, it is
said, recognize no code. The outcome of this investigation will
be watched with interest, for since the beginning of the medical
upheaval of last year in the New York Hospitals the Journal.
has maintained that wrong and injustice was committed.
Study of Hematocatharsls. The Gazette Midicale de Paris,
June 20, reports some recent experiments by Delbet on the
effects of diluting the blood with saline solution. He found
that intoxication was prevented by it in only one case out of
eight. This was a dog to whom three grams of sulphate of
strychnin in a thousand solution had been injected. Immedi-
ately afterward 910 grams of saline solution were injected, and
the animal was not poisoned by the strychnin, but recovered.
He passed 530 grams of urine. The same dose administered
later to the same dog without the saline injections, resulted in
death twenty minutes later. Delbet found that where there
were four millions of red corpuscles before the saline injections
there were only three million afterward, but they were larger.
No difference was observed in the white corpuscles. He finds
that it is impossible to increase the pressure when it is normal
or above, concluding from this that dilution is authorized even
in cases of elevated pressure, as in eclampsia. On the other
hand, a diminished pressure is brought up to normal by intra-
venous injections of saline solution, and it is not even neces-
sary to inject an amount equal to what has been lost, as vigor-
ous animals can lose a certain amount of blood without dimin-
ishing the arterial pressure, showing that they have a reserve
of blood. Further experiments with dogs poisoned with
atropin, and the pneumogastric consequently paralyzed, showed
that the pressure of the blood could be diminished by hemor-
rhage and afterward increased by saline solutions, which proved
that these phenomena were not dependent upon the pneumo-
gastric.
Latent and Disguised Tuberculosis.— Maragliano's address with
this title, delivered at the recent congress at San Remo, is
published in Oaz. degli Ospedale e delle Clin. No. 47. It
repeats the statement that traces of tuberculosis are found in
one-third to one-fourth of all the necropsies. They may never
have developed beyond the first original tubercle, as the
organism may have proved strong enough to keep them in sub-
jection by secreting the necessary antitoxins, and they may
remain latent all through life. But debility from any cause,
pregnancy, traumatism, may diminish the power of the organ-
ism to combat them, and they at once assert themselves, when
an established case of tuberculosis is the result. To another
category belong the cases of unsuspected tuberculosis infection
of the blood which does not reveal itself in any of the usual
ways, but only produces progressive anemia, emaciation, loss
of appetite, suspension of the menses and other symptoms of
what he calls dystrophic disguised tuberculosis. He distin-
guishes also another form, the trophic, with fever, intermit-
tent or remittent, resembling typhus sometimes, with dis-
turbances in the innervation, and even tumor of the spleen or
exanthema. To this cause may be due the so-called "growing
fever" of older children. It is very difficult to distinguish
these forms of tuberculosis as the ordinary physical and bac-
teriologic tests fail. Maragliano has only attained certainty
170
MISCELLANY.
[July 18,
by inoculating rabbits with the serum of suspected cases, or
by inoculating the patient with tuberculin, as in testing ani-
mals.
Antlvlvlsectlon.— Resolutions adopted at the Keystone Veteri-
nary Medical Association, Philadelphia, June 9, 1896 :
Whereas Believing that the best interests of humanity are
served by the judicious permission of experimental research on
the lower animals, whereby the value of certain methods of
surgical interference can only be determined, and the worth
of certain lines of remedies, which at this particular time in
history of medical progress, seem to be based on more
exact deductions than ever before, and the wisdom of fully
testing these remedies on the lower animals demands no com-
ment from any intelligent, thoughtful person ;
Resolved .That we therefore believe that Senate Bill No. 1,552
is calculated to throw around these investigations unnecessary
ana unjust restrictions, and for these reasons merit our disap-
proval and we call upon our Representatives from this section
to manifest our condemnation of this measure by their voting
against the same. John R. Hart, President.
V\ . L. Rhodes, Secretary.
Are the Bones Shaped by the Pressure of the Muscles? Hirsch
asserts that the internal and external structure of the bones as
well as their shape, is determined by their functions, and that
the pressure of the muscles and tendons is not responsible for
the hollows or shape. The groove at the rear of the lower
extretmty of the tibia is an example of an apparent rut worn
by friction, but in reality it is exactly the opposite, as the
groove does not extend into the inner spongy part, and is not
really a depression, but is produced by a couple of ridges thrown
up to protect the bone. This same process occurs wherever
there is friction, which explains the formation of the sesamoid
bones, etc. To confirm his statement that these grooves were
not the direct result of friction even in the course of genera-
tions, Hirsch examined the oldest neolithic skeletons in the
museums, finding the two ridges even more pronounced on
them than is the case at present. Another argument is that it
is a mistake to suppose that all the muscles fit close to the
bones, the biceps for instance ; and it is drawn still further
away when contracted. Hirsch asserts also that the bones are
not injured by severe pressure as much as by gentle continu-
ous pressure, such as the growth of a tumor, compressing and
closing the circulation in the periosteum, while they are con-
structed to resist the strong pressure of walking, lifting, etc.—
Centralb. f. Chirurgie, June 20.
" Physicians" Who Can Not Recover for Services.— The object
of the Nebraska statute providing for a State Board of Health
to regulate the practice of medicine, etc., the supreme court of
that State says is the protection of the sick and afflicted against
the knavery of quacks. For this reason the court holds, in the
case of Maxwell v. Swigart, decided June 3, 1896, that the pro-
vision that "no person shall recover in any court in this State
any sum of money whatever for any medical, surgical or obstet-
rical services, unless he shall have complied with the provi-
sions of this act," etc., (Comp. St. 1893, Ch. 55, Art. 1, Sec.
15), negatives the right of recovery for such services where
there has been a failure to file the certificate of the State Board
of Health with the county clerk of the proper county, as
required by the statute. To illustrate : The plaintiff in this
case alleged that on or about Sept. 4, 1891, he had made neces-
sary proofs upon which a certificate had been issued to him by
the Nebraska State Board of Health, and that when his ser-
vices were performed for the defendant between Oct. 15 and
Nov. 29, 1892, he was one of the persons authorized by law to
be registered. On April 20, 1893, the certificate of the State
Board of Health referred to was filed in the office of the county
clerk. After this the plaintiff brought this action to recover
for those 1892 services, and recovered judgment in the district
court for $275, the latter holding that the registration before
suit brought, though after the services were rendered, was a
sufficient compliance with the statute to entitle the holder of
the certificate to recover the value of his services. But the.
supreme court holds otherwise and reverses that judgment, on
the ground that the construction the district court put upon
the statute was so foreign to the general scope of the entire-
act that it could not be tolerated.
A Case of "Death from Chloroform," Improperly so Called. Dr.
Wilkinson, of Birkenhead, England, reports in London Lancet,
June 6, a case that very well illustrates a form of the reckless-
allegations which get into the public press concerning the use
of anesthetics. To report this death as one of "death under
chloroform" was entirely unjustifiable. The true cause of
death, as shown by the clinical history and by necropsy, was
that of rupture of the uterus consequent upon placenta previa.
The case, as abbreviated from the report in the Lancet, was as
follows: " When called to the case I found that there had
been some severe hemorrhage. Under anesthetics version was
performed. The hemorrhage then ceased, and as I felt the
placenta loose in the vagina I removed it with my fingers.
Chloroform was given only at intervals and was ceased before
the delivery of the head. Six drams were given. The patient
rallied, took some ergot and assisted us with the placing of the
binder, and asked if all was over. She then became restless,
and after about twenty minutes we saw that death was threat-
ening and informed the friends. The restlessness had brought
on fresh hemorrhage. More ergot was given and ice was placed
in the vagina, and the uterus felt for from the outside. Owing
to the abdominal fat, however, it could not be felt. The pulse
was 96 and hardly to be perceived, partly on account of the
superimposed fat. The patient died two minutes after we had
informed her friends. No transfusion apparatus was at hand.
The friends, supposing that she had died under chloroform,
charged us with her death and, becoming maniacal, assaulted
us. They seized the ornaments and attempted to strike us.
The midwife (who sent for help immediately on seeing the-
case) was seized and would have been hurt but for our inter-
ference. At last we were obliged to send for the police to assist,
us to recover our belongings and extricate the midwife from,
the corner of the room where she was penned up. It was-
reported to the police and to the whole neighborhood that we-
had murdered the woman with chloroform. On this account I
thought it best that an inquest should be held ; otherwise I
should have given a certificate. At the necropsy a rupture-
of the cervical and uterine tissues was found four inches in,
length and opening into the right broad ligament. The extrav-
asated blood separated the layers of this, and I believe that
during the subsequent restlessness the peritoneal covering
burst, as was found. The immediate cause of death was hem-
orrhage. The delivery took me about an hour and a half to.
accomplish, during which time bleeding continued at intervals.
After the arms were brought down I felt the os and it was then-
intact. The rupture, which I did not suspect, must have been,
caused by the passage of the large head, probably by the face-
(which was born first) passing over that site. The papers had.
the case reported as 'death under chloroform,' but the-
resumed inquest entirely relieved me from this charge, though.
the report has certainly done me harm."
The Murder of an English Physician in North Africa.— The Lon-
don Graphic has the following account of the apparently
causeless massacre of a physician and his family in Tunisia.
Dr. Leach was for a time a resident of New York city, about
ten years ago :
"Dr. and Mrs. Leach, who, with their little son, were mur-
dered at Sfax, in Tunisia, last week, were for about five years-
missionaries of the North Africa Mission. After residing for a
few months in Algiers they removed to Tunis in the summer of
1891, and with the help of other missionaries, carried on an
important medical mission among the Mohammedans and Jews-
of that city. A few ' months ago Dr. Leach requested the-
council of the mission to permit him to open a new station at.
Sfax, one of the most important cities of Tunisia, about two.
18%.]
MISCELLANY.
171
hundred miles south of his former sphere. At the present
tinii' it has a population of about forty thousand Mohamme-
dans, a few thousand Maltese, Italians and Greeks. Dr.
Leach removed from Tunis about the middle of March this
year, and had since been occupied in getting his house and
mission premises ready for work. Hewroteon April 27 to the
effect that the people were beginning to inquire when he
would be ready bo see patients, and he hoped to begin very
shortly. It is difficult to understand the motive of the mur-
der. Dr. Loach was a quiet and somewhat reserved man,
*acj patient and kind in his dealings with the people. Both
In- ami his wife spoke French, and he had a fair command
of Arabic. So far as is yet known, it is thought that the
crime was committed by Europeans with a view to robbery ;
but it seems impossible to be quite sure who the murderers
were. The boy was about 5 years of age. The little girl, 18
months old, is the only member of the family who has been
spared. Dr. Leach was born in 1860, at Rangoon, and was the
second surviving son of Mr. William Leach, of the Medical
Department of Her Majesty's Indian Army. He was educated
in the military school at Fort St. George, and at Bishop Cor-
rie's Grammar School, Madras, and studied Medicine at Edin-
burgh, where he qualified. He held the post of resident sur-
geon to the Children"s Hospital, Birmingham, and afterward
took one or two voyages as surgeon on the boats of the Clan
Line. Then for two vears he practiced at Forest Gate, East
London. Subsequently he went to America to gain experi-
ence in medical mission work, under Dr. Dowkontt, of the
International Medical Mission Society, to whom he was
strongly recommended by the late Pastor C. H. Spurgeon. In
1889 he proceeded to Algiers with two American friends, and
in 1891 joined the North Africa Mission."
The r.ii£li>ii l.anicuajce.
We'll begin with a liox, and the plural is boxes.
But the plural of ex should l>e oxen, not ozes.
Then one fowl is a goose, hut two are called geese.
Yet tile plural of mouse should never he mees,-;
You may rind a lone mouse or a whole nest of miee.
But the plural of house is iiouses, not hiee.
If the plural of man is always called men.
Why shouldn't the plural of pan lie called pen?
Tlie" eows in the plural may be cows or kine.
But a bow if repeated is never called bine.
And the plural of vow is vows, never vine.
If I speak of a foot and you show me your feet.
And i give you a boot would a pair lie called beet?
If one is a tooth and a whole set are teeth.
Why should"! the plural of booth be called beeth?
If the singular's tins and the plural is these.
Should the plural of kiss ever be nicknamed keese?
Then one would be that and three would be those,
Yet hat in ttie plural would never be hose,
And the plural of cat is cats, not cose.
We speak of a brother and also of brethren
But though we say mother we never say methren,
Then tile masculine pronouns are he. his and him.
But imagine the feminine she, sliis and shim.
So the English, I think, you all will agree.
Is the queerest language you ever did see.
— The Commonwealth.
The Economic Season.— Benham : "I wish you would ask Mr.
and Mrs. Jones around to dinner to-morrow." Mrs. Benham :
"What is your hurry about it, all of a sudden?" Benham:
"I heard Jones' doctor telling him to-day that he mustn't eat
any solid food for a week." — Texas Siftings.
Cincinnati.
The mortality report for the week ended Friday, June 10,
1896, shows : Deaths from all causes 112, annual rate per
1,000 16.64, deaths during the preceding week 116, deaths dur-
ing corresponding week 1895 118.
Hydrophobia. — A case of hydrophobia was discovered in
the city last week and the patient died in horrible agony.
The following have been added to the staff of the Betts
Street Hospital : Drs. R. C. Heflebower, oculist ; H. D.
Hinckley, surgeon, and W. E. Kiely, general medicine.
At the last meeting of the staff of the Cincinnati Hospital
the following were elected : Chief of staff, N. P. Dandridge ;
secretary, John Oliver ; librarian, P. S. Conner ; custodian of
records, P. A. Marchand.
Dr. F. W. Hendley has been presented with an office desk,
chair and set of instruments by the staff and employes of the
Cincinnati Hospital.
The Obstetrical Society has adjourned until September.
At the last meeting the papers read were : "Inflammation of
the Endometrium," by E. W. Mitchell; "Pelvic Inflamma-
tion," by Charles Bonifield ; "Technique of Curettage," by
George E. Jones ; " Pudendal Hematocele," by M. A. Tate.
Dr. William Pepper, President of the International Execu-
tive Committee, will spend the summer at a Spanish hacienda
in California.
It is understood that arrangements are practically com-
pleted for two special trains of cars to be specially constructed
for the Mexican trade. A dining-car will be provided for
every three coaches. A lady's maid will be provided for each
coach. Those desiring accommodations on these trains should
address Dr. C. A. L. Reed of this city.
Meals fob Hospitals.— The several thousand patients in
the various State Insane Asylums and the Epileptic Asylum
will eat a uniform breakfast, dinner and supper hereafter. At
a meeting of the superintendents of the various State institu-
tions at Columbus it was decided that the six months' bill of
fare will be the same for all the institutions except that the epi-
leptics for hygienic reasons are not allowed the full quantity of
meat. A sample day's bill of fare is : At breakfast, beef stew,
with three to five ounces of meat to each person, three ounces
of potatoes, fruit ad libitum, bread with one-half ounce of but-
ter, one-half ounce of coffee, and all the milk needed ; dinner,
chicken potpie, six ounces of the fowl to each patient, mashed
potatoes, five ounces each, stewed tomatoes, pie or pudding,
bread and butter, coffee and milk ; supper, sweet cake, fruit,
oatmeal, bread and butter, tea and milk.
Dr. Joseph F. Chau of Cleveland, has applied to the State
Board of Examiners for registration. He is said to be a grad-
uate of the Hong Wo College, of O'Moon, China.
The State Board has adopted the report of the investigat-
ing committee recommending the non-recognition of the
Hygeia Medical, The American Eclectic, and the Campbell
Vitapathic College.
Philadelphia.
Dr. John H. Packard having resigned from the surgical
staff of the Pennsylvania Hospital, the board of managers
elected William Barton Hopkins as his successor. Dr. Hop-
kins is a graduate of the University of Pennsylvania, and has
served as resident physician and surgeon to the out-patient
department of the Pennsylvania Hospital for a number of
years. He will enter upon his new position August 1, when he
will take charge of the wards for the fall term. Dr. Hopkins
is a nephew of Dr. John Rhea Barton, and possesses much of
the mechanical genius of his distinguished relative, who for-
merly occupied a prominent position in the surgical staff of
the same institution.
Louisville.
House of Reform. — At a meeting of the trustees of the
House of Reform appointed by the Governor, held recently,
the following officers were elected : Mrs. Nellie G. Cheatham,
wife of Dr. Wm. Cheatham, of this city, president; W. P.
Walton, Stanford, secretary ; D. H. Howard, Lexington, treas-
urer. The other members of the board are the following :
Mrs. Lunsford Yandell, widow of the late Dr. Lunsford P.
Yandell, of this city, Mrs. M. Charles and B. T. Conway, of
Lexington. Propositions for buildings and sites for the loca-
tion of the houses are being received by the board and no
decision has as yet been reached.
Medical LAWS.^The county attorney of Christian County
has caused the arrest of over 100 physicians of that county
charged with the violating of one of the laws which requires
each physician to file a report with the county clerk before
January 10 of each year containing a record of the births and
deaths which have occurred in his practice for the year previ-
ous. Only one physician complied with the law, and the
others claim that they were in ignorance of there being such a
law on the statute books, though it has been in existence for
twenty yearB. One doctor was fined $20 and costs, as an agreed
case, and it will be carried to the court of appeals.
172
MISCELLANY.
[July 18, 18%.]
City Hospital. — Superintendent Barbour states that at
present there are 150 inmates to the hospital, an excess of fifty
over the number usually there this time of the year. The
increase has been caused by the unusual prevalence of dysen-
tery and allied troubles among the poor at this season.
St. Mary and Elizabeth Hospital. — This hospital is located
very near a switch of the Louisville Southern Railroad and the
inmates have been very much annoyed of late by the unneces-
sary whistling of the locomotives. It was made the subject of
a complaint by the officials, and as there is a law against the
whistling of a locomotive within one-half mile of any hospital,
it will be stopped without its being necessary to carry it to
court.
Washington.
Weekly Report of the Health Department. — The report
of the Health Officer for the week ended July 4 is as follows :
Number of deaths (stillbirths not included), 153; death rate
per 1,000 per annum, 28.3 ; death rate per 1,000 per annum
for the corresponding week last year, 23.97. There was a
further increase in the number of deaths in the city during
the past week. As shown by the reports to the health depart-
ment the mortality reached 153 as compared with 146 in the
week previous, and the death rate rose accordingly from 27.04
to 28.33. The principal causes were diarrheal diseases from
which 47 deaths occurred, and consumption, of which 17 per-
sons died. Of the mortality 91 were of children under 5 years
old. While there was a slight increase in the number of fatal
cases of brain and heart disorders, there was an entire absence
of those of the lungs in an acute form. With the exception of
diphtheria, the contagious maladies remained in abeyance.
Of diphtheria 3 deaths occurred, 6 new cases were reported, 8
houses were reliered of quarantine, and 11 remained placarded.
Of scarlet fever no death occurred, but 1 new case was
reported, quarantine was raised from 3 houses, leaving 3 still
in isolation.
The Deficiency Appropriation Bill. — The Deficiency
Appropriation bill contains the following item: Pan-Ameri
can Medical Congress : To meet the expense of distribution
of printed report of the transactions of the first Pan-American
Medical Congress, at Washington, 1893, to be appropriated out
of the unexpended balance of the appropriation for the enter-
tainment of the delegates provided by the Sundry Civil Act,
March 3, 1893, $900. All of the copies for foreign distribution
have been mailed, the net cost of which amounted to $400.
Pan-American Medical Congress. — The Auxiliary Com-
mittee of the Second Pan-American Medical Congress to
represent the District of Columbia at Mexico is composed of
the following-named physicians : Drs. H. L. E. Johnson,
Chairman ; John R. Wellington, Secretary ; S. C. Busey, G. C.
Ober, G. M. Kober, S. S. Adams, C. H. A. Kleinschmidt, W.
S. Bowen, J. D. Morgan, L. Eliot, C. N. Richardson, G. L.
Magruder, G. W. Cook, H. H. Barker, Walter A. Mills, Sur-
geon Generals Sternberg and Tryon.
Appointments by the International Executive Commit-
tee.— Among the recommendations of the first Pan-American
Medical Congress was the appointment of an International
Committee on Quarantine and one on Public Health. The
executive committee have appointed the Surgeon General
M.-H. S., chairman of the International Committee on Quaran-
tine and Dr. H. L. E. Johnson, chairman International Com-
mittee on Public Health, with Drs. William Pepper and C. A.
L. Reed as coadjutors. Dr. H. L. E. Johnson has been given
charge as chairman of the Committee on Transportation.
Dr. L. Eliot has notified the committee that he will attend
the Congress and read a paper on the treatment of hemorrhage
by acetate of lead.
Home for Incurables. — Plans are now under way for the
construction of a new wing to the Home for Incurables. The
new wing will be three stories in height, the same as the
present building, and will be located near the northwest corner
of the present structure. The plans have already been drawn
up by Architect Walker and have been submitted for approval.
The new wing will be erected out of a legacy left the institu-
tion by Mrs. Walcott, and will be devoted entirely to th&
accommodation of children afflicted with spinal trouble.
Hospital for Foundlings. — A novel complaint has been
filed at the District building against the Washington Hospital
for Foundlings, at No. 1715 15th Street, N.W., to the effect
that the crying of the babies is a nuisance to the neighborhood.
Board of Medical Supervisors for the District. — The-
board of medical supervisors for the District of Columbia has
been chosen and consists of Drs. C. H. A. Kleinschmidt,
president of the board of regular practitioners; J. B. G.
Custis, president board of homeopathic physicians ; Thomas-
Robinson, president board eclectic physicians, with Messrs.
J. J. Darlington and John Redout.
New Oleomargarin Law. — The new law governing the sale
of oleomargarin is being rigidly enforced, and three prominent
dealers were, upon conviction, sentenced to imprisonment and
heavy fines for recent violations.
A New Dental Society. — The alumni of the National Uni-
versity Dental School have recently formed a new dental soci-
ety. A large membership is expected.
THE PUBLIC SERVICES.
Navy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending July 11, 1896.
Medical Inspector J. C. Wise, detached from the Washington navy yard,
and ordered as a member of the board of inspection and s'urvey,
July 15.
Medical inspector R. A. Marmion, detached from the board of inspec-
tion and survey July 15, and ordered to the Washington navy yard.
P. A. Surgeon S. S. White, detached from the naval academy and ordered
to the "Thetis."
P. A. 8urgeon G. A. Lung, detached from the "Thetis," ordered home
and granted two mouths' leave.
Surgeon P. A. Lovering, detached from the New York naval hospital and
ordered to the " Oregon."
P. A. Surgeon C. H. T. Lowndes, detached from the Washington navy
yard and ordered to the naval hospital at Philadelphia.
Surgeon C. U. Gravatt. to Norfolk with draft of men and then home and
three months' leave.
Asst. Surgeon K. G. Brodrick, to the " Franklin."
Change of Address.
Adams, S. 8., from Washington, D. C, to Mountain Lake Park, Md.
Carpenter, Julia W., from Cincinnati, Ohio, to Omena, Mich.
Eads. S. E., from Science Hill to Somerset, Ky.
Goodrich, E. C. from Dyer Building to 807 Broad St., Augusta, Ga.
Ingold, Mattie B., from Baltimore. Md., to Hickory, N. C.
Kempker, J. F., irom Keokuk to Valley Junction, Iowa.
Lukens, Auna, from New York, N. v., to Wentworth Hall, Jackson.
N. H.
Lauam. J. H„ from Edinburg to Franklin, Ind.
Parker, W. T.. from Grovelaud, Mass.. to Toronto, Can.
Roseberry, B. S., from El Paso, Texas to Catskill, N. M.
Wlggin, F. H.,from New York, N. Y., to Litchfield, Conn.
Woodbury. Frank, from Philadelphia to Glen Summit, 1'a.
LETTERS RECEIVED.
Automatic Cycle Seat Co., Grand Rapids, Mich. ; Alden, C. H., Wash-
ington. D. <:.; Allport. Frank. (2) Minneapolis, Minn. ; Armstrong, C. L.,
St. Louis. Mo. : Ana Pharmacal Co., St. Louis, Mo.
Bennett, A. L., Knulder. Colo. : Bailey, S., Mt. Avr, Iowa; Bernd. Henry.
& Co., St. Loui*. Mo.
Coone, Berthena. Peoria, 111.; Columbus Phaeton Co.. Columbus, Ohio:
Craig, G. G„ Rock Islai d. 111.: Chaille, S. E..(2) New Orleans, La. ; Can-
ton Surgical 2nd Dental Chair Co., Canton, Ohio.
Dletz, R. E.. Co., New York, N. Y.
Edwards, Walter E.. Cadley, Ga.; Eads, S. O.. Somerset, Kv.
Fairchild Bros. & Foster, New York, N. Y.; Faradizer Co., the, Indian-
apolis, Ind. ; Fite, C. C, New York, N. Y.
Gibbs, W. E.. New York, N. Y.; Graham, H. G., Chicago, 111.: Gotham
Co., The, New York, N. Y.
Holekamp-Moore lustrumeut Co., St. Louis, Mo.; Hollopeter, J. S.,
Houston, Ohio; Harris, John J., St. Louis, Mo.; Hardy, F. A., & Co.,
Chicago, III.
Koelling & Klappenbach. Chicago, 111. ; Kelly, W. R., Watonga, O. T. ;
Kolb. M. G., Cleveland. Ohio : King, F. R., Wiota, Iowa.
Liceaga, E., Mexico City. Mexico; Littig, L. W., Iowa City, Iowa.
Maddeu, John, Milwaukee, Wis.; Martin, J. A., Palestine, 111.; Mar-
tin. E. J., St. Louis, Mo.; Meadows, Ira E.. Mangham, La.; Maclean,
Donald, Detroit, Mich.; Manley, Thos. H., (2) New York, N. Y. ; McAlis-
ter, Alex., Camden, N. J.
Newton. R. C. Montclair, N. J. ; Nye, Geo. L., Wythville, Va.
Ott, Isaac. Philadelphia, Pa.
Packer Mfg. Co.. New York, N, Y. ; Publishers' Collection Agency, St.
Paul, Minn.; Pasteur-Chamberland Filter Co., The, Chicago, 111.
Reed, R. Harvey, Columbus. Ohio.
Spencer, George A., Haverhill, Mass. ; Schachner, August, Louisville
Ky.
Van Etten, C. S. Rhinebeck, N. Y.
Ward, Milo B., Topeka, Kan.; Ward, M. R., Pittsburg, Pa.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., JULY 25, 1896.
No. 4.
ADDRESS.
CHAIRMAN'S ADDRESS.
Delivered In the Section on Obstetrics and Diseases of Women at the
forty-sovi'iuh Annual Meeting of the American Medical
Laaoctatlon, held at Atlanta, Ga , May Mi, 1896.
BY JOSEPH TABER JOHNSON, M.D.
WASHINGTON, D. C.
T run required by the rules of the Association to
open our session with an address, reviewing the
gynecologic and obstetric work of the year. To
something on all the topics of interest in these
two great departments of medicine would consume
all the time allotted to one session. I shall only
attempt to briefly draw your attention, therefore, to a
few of the most prominent subjects in which we are
all interested.
1HERPERAL INFECTION.
Its causation and treatment has been the cause of
much writing and discussion during the year. While
.something has been added to our scientific knowledge
of the histon and behavior of certain pathogenic germs
- the general course of treatment of these cases has
been simplified and shortened, instead of amplified
and broadened as has been the tendency heretofore.
One of the principal points made by Lusk of New
York, in his recent paper before the Obstetrical Society
of Philadelphia, on " Puerperal Infection, " was
" that the more these cases are let alone and the more
simple the treatment the more likely they are to get
well. " Absolute cleanliness of the physician, nurse
ami patient is insisted upon and greater stress than
ever is being laid upon the injunction to make as few
examinations as possible after learning the nature, of
the presentation. In ordinary cases, where there is
no rise of temperature, douches are not now recom-
mended at all. Where chill occurs, followed by a
rise of temperature preceded by putrid discharges, it
is still recommended to ascertain if the uterus is
entirely emptied of shreds of membrane and decom-
posing clots. The best instrument in use is now, as
it always has been, the index finger, with which por-
tions of after- birth or membranes can be removed,
rising, if necessary, bimanual pressure under ether.
Curetting was condemned by Lusk as likely to
open sinuses and blood vessels, and create raw sur-
faces, all favoring quicker and more thorough absorp-
tion, and doing in this way more harm than good.
While Baldy, Hurst and others, insisted in this dis-
cussion, that the wise and cautious use of the cur-
ette was a great advantage to the patient, accom-
panied by at least one thorough antiseptic irrigation.
The long continued, frequent irrigation of the uterus
seems to be condemned from all quarters.
Hysterectomy for puerperal infection seems to be
gaining ground, notwithstanding the opposition of
Lusk, Price and a number of other prominent men in
this country and abroad; though the cases where it
is indicated are very few. In a recent paper by
Mordicai Price the operation is absolutely condemned
as unnecessary in the first place, and moreover always
fatal. He claims that the mortality of hysterec-
tomy for puerperal infection is 100 per cent. Others,
however, have reported successes, and it would seem
as if advancement ought to be made along this line,
so that cases surely doomed to death without surgical
interference might possibly be saved. The great
difficulty is to select the caset>. So many apparently
desperate cases have finally recovered that it takes
great experience and wisdom to be able to say in any
given case that this woman will die if her uterus is
not removed, and that she will probably live if it is
taken out.
The operation is useless where the infection has
passed beyond the uterine walls. If colonies of
germs are growing and multiplying in the general
vascular or lymphatic circulation the removal of the
uterus could do no possible good, but would add
shock and useless suffering to the patient. The great
point in the management of puerperal cases is now,
as it ever will be, in the prophylaxis. Prevention here
as everywhere else is better than cure.
Lying-in hospitals, which were formerly hot-beds
of infection, are now under modern antiseptic man-
agement reporting a mortality of only six-tenths of
one per cent. The whole system of prevention is
summed up in two words, cleanliness and ventilation.
SYMPHYSEOTOMY.
Since its revival it has been gaining prominence as
a substitute for the difficult high forceps operation,
craniotomy and Csesarian section. In perfecting the
technique of the operation, the aim has been to
deliver the child without laceration of the parts about
the urethra, and to so secure the separated symphysis
that perfect union would result. In a number of
cases, however, it has come to the knowledge of the
writer that copious hemorrhages have taken place
from laceration of the vascular tissues about the
urethra; sometimes the urethra itself being torn, and
too many patients were unable to walk after recovery
without serious limping, which continued in some
cases indefinitely. Unless these two slips in the tech-
nique can be overcome or prevented the modern
Caesarian section may be preferred by abdominal
surgeons to the revived operation of symphyseotomy.
PLACENTA PREVIA.
The treatment of placenta previa is always a sub-
ject of great interest. Nothing especially new seems
to have been added to our armamentarium during the
year, except the suggestion that hysterectomy be
done for the control of the hemorrhage. The diag-
nosis of these cases is generallv not made until the
occurrence of the hemorrhage. The patient is then
either not in labor at all, or she is in labor and the
cervix is not completely dilated, or we may find her
with a completely dilated cervix.
174
CHAIRMAN'S ADDRESS.
[July 25,
There is little difference of opinion in regard to
the axiom that " when the placenta is previa the
uterus should be emptied. " There is no wisdom or
safety in delay. No one can tell when the next hem-
orrhage will occur and whether it may not prove fatal
before the arrival of the physician. It is, therefore,
our duty to act wholly in the interest of the mother
and relieve her from a condition equally as dangerous,
as if " the famous sword of Damocles were actually
suspended over her head." If the hemorrhage is pro-
gressing, with little or no dilatation, in the absence of
pains, the vagina should be so thoroughly tamponed
as to completely arrest the flow of blood, and con-
tractions of the uterus encouraged. In a few hours
the tamponade can be removed, the vagina antisep-
tically douched, and if little dilatation has occurred
and hemorrhage is still going on, the vagina should
be again packed. When the cervical dilatation will
permit, the fetus should be turned by the combined
external and internal manipulation, known as the
Braxton-Hicks' method, and one leg brought down
into, and plugging up the cervical canal, thus arresting
the hemorrhage, by making the child serve as a
tampon. Hemorrhage, the main dangerous element in
the case, being eliminated, very little else remains to
be done but to watch, wait and guard further progress
of the labor. Rapid extraction of the child is to be
condemned as unnecessary and injurious. It is not
only dangerous to the child but to the vascular tissues
of the cervix, which are not in a condition favorable
for rapid dilatation. A number of cases have been
reported of the safe delivery of the child, but in which
the mother died soon afterward from hemorrhage
produced by laceration of the vascular cervical
tissues. The only time in the management of these
cases when haste is indicated is at the beginning.
Hemorrhage once arrested, the principal danger is
averted. It is believed that many patients have been
lost by the excited, nervous, hasty and too vigorous
efforts which have been made to rapidly extract a
child in cases of placenta previa.
A case of puerperal diphtheria treated by anti-
toxin has been reported by Nisot. He claims it to be
the first on record in which the Loefner bacillus was
found to be the sole cause, and in which antitoxin
constituted the only treatment. Symptoms of puer-
peral diphtheria are stated with much exactness and
no doubt exists of the correctness of his diagnosis.
Three days after using injections of antitoxin the
abnormal temperature disappeared entirely.
SURGICAL TREATMENT OF UTERINE DISPLACEMENTS.
The surgical treatment of uterine displacements is
attracting more attention this year than last. Num-
erous articles have appeared in the journals during
the year advocating a variety of surgical procedures
for their relief. Prominent among which was a paper
read at a recent meeting of the New York Academy
of Medicine, comparing the relative merits of the
Alexander operation, ventral- fixation and vagino-
fixation. Munde, after an experience of ninety-seven
Alexander operations with eighty-seven permanent
cures, gave his adherence to that operation, and closed
his paper with a series of valuable conclusions.
Edebohls spoke in favor of ventral fixation and
closed his remarks with the following conclusions:
1, vaginal fixation of the uterus does not come within
the sphere of legitimate operations in women liable
to subsequent pregnancy; 2, the indications for
ventral fixation of the uterus should be limited to the
utmost degree in women liable to subsequent preg-
nancy; 3, ventral fixation is never indicated in uncom-
plicated retroversion of the uterus; 4, inability of an
operator to perform the shortening of the round liga-
ments may be an indication for ventral fixation, but
not in the case of one claiming to be a specialist in
gynecology; 5, ventral fixation is indicated as an
adjuvant in the performance of combined operations
for prolapsus uteri et vaginae ; 6, ventral fixation is
indicated as a closing step in all celiotomies in which
the adnexa are removed and the uterus is left; 7,
ventral fixation may be indicated under exceptional
conditions in cases of adherent retroversion with
tubes and ovaries in good condition; 8, ventral fixation
may be indicated in the most aggravated cases of
uncomplicated, sharp retroflexion.
Vineberg spoke in terms of enthusiastic praise of
the vaginal fixation operation and reported forty-eight
cases with eight relapses. Four of these cases subse-
quently became pregnant, one ending in abortion.
Vineberg believes " that vagino-fixation is indicated
in all backward displacements of the uterus, with or
without adhesions, and with or without diseases of
the adnexa in which surgical interference for one rea-
son or another is demanded. It is particularly indi-
cated when the backward displacement is complicated
by moderate prolapsus of the uterus and prolapsus of
the anterior vaginal wall. It finds an undisputed field
in very fat subjects with thick abdominal walls, in whom
the ventral fixation constitutes a serious affair, and in
whom an Alexandrian operation is extremely difficult of
accomplishment. The same holds good in very thin
subjects with thin and yielding abdominal parietes, so
far at least as ventral fixation is concerned. The oper-
ation," he claims, "can be performed in nulliparae and
even in virgins." He urges that not enough stress has
been laid on the large percentage of failures, and the
mortality following the Alexander operation, or upon
the frequency in which it was followed by hernia.
In the discussion of these papers by Noble, Boldt,
111, Goffe and others, Alexander's operation was fav-
ored in cases where the indications existed, ventro-
suspension in exceptional cases where the Alexander
operation could not be done, while vagino-fixation
was condemned, unless the patient had passed the
menopause and was not liable to pregnancy.
Duhrssen, who was among the first to perform
vagino-fixation, as one of the legitimate outgrowths
of anterior colpotomy, in a paper read before the
Berlin Gynecological Society, opposes the intra-
peritoneal vaginal fixation, but substitutes a much
more irrational procedure by recommending a trans-
verse incision in the anterior fornix of the vagina, to
which he sutures the plicae vesicas, while the uterus is
united to the peritoneum of the plica. Duhrssen had
observed after vaginal fixation twenty-eight cases of
pregnancy with seventeen normal confinements. The
abnormal cases present a variety of serious complica-
tions. He also reports 148 intraperitoneal vaginal
fixations with only one death and one relapse.
Leipold, when this subject was discussed in the
Dresden Gynecological Society, opposed vagino-fixa-
tion of the uterus, but recommended its ventral fixa-
ation. He had performed seventy-three ventral
fixations and had never witnessed serious complica-
tions during pregnancy or labor. He thinks in cases
where trouble has occurred during gestation, that it
was due to faulty technique, whereby the uterus was
L896.]
CHAIRMAN'S ADDRESS.
175
fixed too near the umbilicus, or immediately above
the bladder, that the fundus phis the posterior
uterine wall was fixed to the abdomen or with sutures
of non-absorbable material. The proper technique
consists in fixing the uterus about one inch above the
symphysis, and the sutures, two in number, should be
passed through the anterior and upper portion of the
corpus uteri, differing from the suspensio uteri
operation as recommended and performed by Dr.
Kelly of Baltimore, who passes his sutures through
the posterior wall of the uterus, thus suspending it as
it were, in a sling. Leipold also performed eight
Alexander operations, and although he experienced
no difficulty .in finding the round ligaments, and
placing the uterus in a normal position, he found
that the patients frequently complained of pain in
walking, and in the inguinal canal, and he also
I observed that the healing of the wounds was often
protracted.
and free from danger of including the ureter or
knuckles of intestine, as has been done when the
blades of the clamp were thrust up through the pos-
terior and anterior incision, to be guided in the dark,
only by the ends of the fingers. The separation of
the posterior vaginal wall can, in this way, be made
the last act of the operation, and all septic contami-
nation of the pelvic tissues prevented.
VAGINAL VERSUS ABDOMINAL OPERATIONS.
ANTERIOR COLPOTOMY.
In the discussion of the vaginal method of reach-
ing pelvic troubles, another operation has been
evolved by Duhrssen of Berlin, a confrere of Martin,
which they, with Mackenrodt, have performed several
hundred times. This operation, anterior colpotomy,
consists, as you all know, in a transverse or vertical
incision above the cervix, when the tissues are peeled
back, the bladder separated, generally by the finger,
which with the ureter is pushed back, then held up
out of harm's way by a retractor, to permit the examin-
ing finger to be passed into the peritoneal cavity, and
the condition of the pelvic organs thoroughly
explored. A good-sized uterus can be drawn through
this opening, dragging with it the appendages, after
the separation of any existing adhesions. Martin is
enthusiastic in his praise of this operation in an
article in the Annals of Gynecology for October,
1 895, in which he reports "109 successful operations, a
remarkable point about which was the loss of so small
an amount of blood that no ligatures or pressure for-
ceps were required, until the abdominal cavity had
been opened." Martin recommends this operation in
a of simple myomatous tumors, movable retro-
flexed uteri, for the breaking up of peritoneal adhe-
sions fixing the uterus, for cases of procidentia, for
small cystic ovarian tumors, and also for the treat-
ment of various diseases of the tubes, including pyo-
salpinx, hematosalpinx and tubal pregnancy. He
reported four of the last mentioned operations.
When the uterus is drawn down through this incision
Martin insists that both ovaries and tubes follow on
the posterior surface, as soon as they are freed from
adhesions. He states that the adhesions are easily
broken up unless they are fixed to the posterior sur-
face of Douglas' pouch — which he still recommends
should be reached through the abdomen.
-Martin states that "the wound takes only from
eight to ten days to heal, so that by the twelfth day
the patient may be allowed to leave her bed. No
local treatment is required; feverish reaction was
unknown in his cases. All of the 109 cases recov-
ered.'' "In the majority urine was passed spontan-
eously from the first." This operation of anterior
colpotomy presents also advantages in cases of vaginal
hy.-terectomy, making it possible even in cases of
cancer of the cervix to draw down the fundus of the
uterus into the vagina, thus enabling one to ligate or
clamp the tubes, ovaries and broad ligaments in sight,
I do not wish to anticipate the discussion on vagi-
nal versus abdominal operations, from which I expect
very much of interest and profit for the Section, but
even a very partial review of the progress of abdominal
and pelvic surgery for the year would be incomplete
without reference to this very important subject.
While P6an, Richelot and Doyen of Paris were pio-
neers in the vaginal operation in France, Jacobs of
Brussels has done more to popularize and create
enthusiasm in this country by broadening the indica-
tions for vaginal hysterectomy. He has been ably
seconded in the United States by Sutton of Pitts-
burg, Polk of New York and Henrotin of Chicago.
The paper by Garceau of Boston, in the March num-
ber of the American Journal of Obstetrics, is one of
the most descriptive and comprehensive which have
appeared during the year. Equally enthusiastic
claims are made, however, by advocates of the abdom-
inal and vaginal methods of operating; each claiming
advantages over the other both in facility of method
and in immediate as well as remote results.
Women are more likely to prefer the vaginal opera-
tion when its claims are presented and their judgment
convinced that the cure would be equally safe and
permanent. The avoidance of the abdominal wound,
the stitches, dressings, bandages, the scar, the sup-
porter for six or twelve months, and the liability of
ventral hernia, are all controlling arguments to the
average female mind.
The increasing intelligence of the laity on these sub-
jects, and their familiarity with abdominal and pelvic
operations is no less true than surprising. Hardly a
week passes by that the writer is not asked by some
lady requiring an abdominal operation whether this
work could not as well be done through the vagina,
thus avoiding all the above-mentioned troubles. The
average medical mind is likely, also, to be influenced
by such statistics as are presented by Garceau in the
paper above referred to, for very much the same rea-
sons. Probably the same operators, however, who
could perform 166 vaginal hysterectomies, with only
four deaths would be equally successful when operat-
ing by the abdominal route. P6an in Garceau's
table of statistics reports 150 vaginal hysterectomies
with only 1 death; Richelot 103 vaginal hysterec-
tomies with only 7 deaths; Landau 30 with no
death ; Pozzi 14 with no death ; making with
others in the same table, 724 operations with 34
deaths, giving a mortality of 4.6 per cent., while the
mortality for vaginal hysterectomy for fibroids of the
uterus is equally striking. These operations were
mostly performed for small tumors, but P6an, Riche-
lot and others have operated by morcelment on
fibroids reaching to the umbilicus^
The following statistics are given by Garceau
of hysterectomy for fibroids: P6an, 200 hysterec-
tomies with only four deaths; De Ott, 100 hysterec-
tomies with no death; Richelot, 43 hysterectomies
176
TUBERCLE CULTURES.
[July 25,
with 1 death; making, with others in the same table,
406 operations with only 7 deaths, and giving a mor-
tality of 1.7 per cent.
While these operations, presenting such favorable
results, are done by the most skillful men, who have
gained their experience in abdominal surgery, it is
probable that their success would have been quite
as great, with most of these cases, had they performed
celiotomy instead of vaginal hysterectomy. The
great argument, it seems to me, in favor of the vagi-
nal operation, is its completeness, the greater advan-
tages of drainage, the avoidance of the shock occa-
sioned by handling and exposing the intestines,
infecting the peritoneum with pus, the abdominal
wound, the stitches and the liability to hernia.
FIBROID TUMORS.
The evolution of the treatment of fibroid tumors is
marching on, not only "from Atlanta to the sea," but
around the world, wherever surgery is practiced, our
technique and statistics are constantly improving.
Martin of Chicago, my immediate predecessor in this
chair, has recently, in a series of valuable papers in
the Association Journal, exhaustively treated the
electrical, medical and surgical aspects of this subject.
Myomectomy, morcelment, the various methods of
extraperitoneal treatment of the pedicle, pan and
vaginal hysterectomy, have all received much atten-
tion during the year. The statistics of hysterectomy
mortality are now showing as favorable percent-
ages as have been acquired in ovariotomy. The
family practitioner has no longer any excuse for
advising a patient suffering from pain, pressure and
hemorrhage of a growing fibroid, that the change of
life will cause its disappearance or a sure cessation of
their troublesome symptoms. Those of us who have
examined the subject have reported quite a large
number of cases of fibroids growing after the meno-
pause, giving rise to as disagreeable symptoms as
before the change of life set in. Instead of disap-
pearing, as was formerly supposed, they frequently
take on a more rapid growth and degenerate into cysts,
abscesses, calcareous deposits or malignancy. These
unfavorable changes, in my experience, occur more
frequently after the menopause than before. Instead
of a mortality of 80 per cent, resulting from hyste-
rectomy for fibroids, as formerly, it is now our proud
satisfaction to be able to say to the family, as well as
to the family doctor, that while a growing and bleed-
ing fibroid ought to' come out, the mortality accom-
panying the operation in good hands, is not above 10
per cent., and in early, uncomplicated cases is likely
not to be more than 5 per cent.
The writer takes pride and satisfaction in stating
that within a comparatively short time he has per-
formed hysterectomy for fibroid tumors of the uterus
twenty-five times by the Baer method with but one
death, and that occurred five weeks after the opera-
tion from intestinal obstruction. Other reports, still
more favorable, have been published in the medical
journals recently, showing as good, if not better,
results than an equal number of ovariotomies.
As this subject in several of its phases, is to receive
attention at this session, from several distinguished
delegates, I will not delay you longer by saying what
will be so much better said by the authors of the papers
upon our program. I desire, however, to call your atten-
tion to one or two improvements which have been made
in the general management of desperate cases requiring
surgical interference. The literature of our Section
has been enriched since our last meeting by a num-
ber of papers suggesting improvements in the pre-
vention of suffering and the saving of human life.
The transfusion under the skin, or directly into an
open vein, of a pint or more of the normal salt solu-
tion has undoubtedly saved a number of valuable
lives, not only during a prolonged operation, where
there has been a considerable loss of blood, but sub-
sequently from secondary hemorrhage. This method
of transfusion has been of service also in the restora-
tion of patients from shock where little blood has
been lost. The writer feels that he would recently
have lost a case, from secondary hemorrhage, follow-
ing the removal of the clamps, after a vaginal hyste-
terectomy. at the end of forty-eight hours, if it had
not been for the transfusion of nearly a pint of nor-
mal salt solution under each breast.
A paper upon our program suggests greater safety
and comfort from improved methods in anesthesia.
While a death from the anesthetic is as rare as it is
horrible, there are many discomforts and some dan-
gers following the administration of ether of chloro-
form in cases of parturition and also in our abdomi-
nal, pelvic or gynecologic surgery. If the author has
a method or a combination which will avoid the
occurrence of nausea, vomiting and nervous excite-
ment following operations we shall all be very grate-
ful to him. All patients and most operators, have
been tormented with anxiety on account of long-con-
tinued vomiting following difficult operations, lest
stitches should give way, ligatures separate and hem-
orrhage come on, when quiet and calm are so desira-
ble and necessary to the safe conduct of the case. We
have fortunately in the chlorid of ethyl and the
muriate of cocain local anesthetics which are fre-
quently preferred by the patients as well as operators
for minor operations of short duration.
The present Chairman hopes that his successor
may be able to report great developments and improve-
ments in the diagnosis of abdominal and pelvic dis-
eases of women, from the evolution and perfection of
the Xrays, about which we have heard so much of late.
If its promises are fulfilled we ought to find little dif-
ficulty hereafter in our diagnosis of extra-uterine preg-
nancy, pyosalpinx, fibroid, dermoid or ovarian tumors.
LECTURE.
ON HEALINC AND IMMUNIZING SUB-
STANCES OF TUBERCLE
CULTURES.
Lecture delivered at the meeting of the Delaware District Medical
Society, Dunkirk, Ind., June 17, 1896.
BY EDWIN KLEBS, M.D.
PROFESSOR OF PATHOLOGV IN HU8H MEDICAL COLLEGE, -AND IN THE POST-
GRADUATE MEDICAL SCHOOL OF CHICAGO.
CHICAGO.
I have proven in my book on "The causal Treat-
ment of Tuberculosis," (Leipzig, 1894) that it was
possible to heal, perfectly, tuberculosis of guinea pigs
and man by certain products of tubercle bacilli,
advancing the theory that this effect was obtained by
a secretion product of these organisms, found mostly
in the fluid portion of the cultures. If this opinion
is a correct one the healing process in this disease
would find an analogue in a great series of well known
biologic processes, such as uremia, cholemia, etc. It
18%.]
TUBERCLE CULTURES.
177
must be acknowledged as a general law that every or-
ganism forms substances poisonous to itself, it' they are
not secreted or separated from the body by the action
of glandular secretion as by the kidneys, liver, etc.
The first substance having this property of destroy-
ing tubercle bacilli, I obtained from the, whole cul-
ture, and gave it the name tuberoulocidin (or tuber-
cle-killer). It was prepared by the precipitation of
the poisonous products of the tubercle culture and
contained substances from the fluid parts of the cul-
tures and such as were extracted from the tubercle
bacilli. It could be shown that these substances were
poisonous for tubercle bacilli, and wholesome for
tuberculous animals and men. But it was not yet clear
whether these healing influences were derived from
the tubercle bacilli or contained in the culture fluid.
The further researches had therefore to be directed
toward the preparation of still purer substances for
lealing purposes. The second step in this direction
was the separation of a substance with healing prop-
erties from the fluids alone of ripe tubercle cultures,
which I prepared in the same manner as tuberculo-
cidin. but exclusively from the fluids after having
separated the tubercle bacilli. I named this sub-
stance antiphthisin, and could demonstrate its effect
upon both animals and men. In this country the
experiments with antiphthisin could be made on a
larger scale, and the effect claimed for it, established
beyond question. The animal experiments made by
me in the Winyah Laboratory afford sufficient guar-
antee of its success. But it still remains questiona-
ble if we have attained the highest possible residts by
the use of this substance.
To attain this last aim of our scientific work we
can not rely alone on the results of clinical observa-
tion, as it is wholly impossible to obtain cases enough
that are quite equal as to the intensity of the infec-
tion and the degree of resistance in the bodies of the
infected persons. These researches can only be com-
pleted by experiments on animals.
I. IMMUNIZATION IN TUBERCULOSIS.
That there exists a very high power of resistance
against tuberculous processes in normal animals has
been shown by myself and others, through the differ-
ent intensity of infection in the various animals. I
have also demonstrated that the greater number of
tubercle bacilli injected in the blood are destroyed
there ; in rabbits not more than seventeen of a thou-
sand bacilli, injected into the blood vessels will find
the opportunity of forming tuberculous knots in the
tissues. I regard the nidulation (Nestbildung),
which we call tubercle, as the first step in tubercu-
losis. These nests may be developed in very small
number, and the tuberculosis can remain for a very
long time in a dormant or latent state, as in a single
tubercle of the brain, the bones, or the lungs. The
spreading of tubercle bacilli from these nests is
undoubtedly a consequence of an alteration of the
general health. The tubercle bacilli in such nests
will not develop without some help from the body of
the infected person. If these organisms which lay
dormant many years in their nests, begin all at once
to increase in number and then propagate by deten-
tion in the blood or lymphatic vessels, there must be
a diminution in the power of resistance, produced by
other diseases (measles, influenza, etc.) or by the
poisonous products of the tubercle bacilli. If this is
true, there can be no doubt that a great number of
the intermissions of the tubercular process, so often
remarked by all physicians and patients, are effected
by the natural or by the disease acquired immunity
of the body. But why is this acquired immunity not
developed in all cases of long standing tuberculosis?
First it must be remembered that in nearly all cases
of tuberculosis the first years of the disease have not
the same deleterious character as the later phthisical
period, so that for a long time the phthisis has been
taken for a different affection. After having noted
the unity of all these affections by the presence of
the same organism, we conclude the difference must
depend upon a change in the diseased body, whose
resisting power is diminished.
From another side also this point of view is remark-
ably sustained. The therapeutics of tuberculosis
show us clearly the helpful, sometimes healing influ-
ence of all improvements in the general health,
whether they be effected by climatic, dietetic or other
treatments working in this direction. But all these
methods of treatment will prove inefficient if the
poisonous effects of the tubercle bacilli on the
strength of the organism has reached a certain point.
There are certainly two indications for therapeutics
necessary in tuberculosis, the one toward the destruc-
tion of the bacilli; the other toward fortifying the
infected organism. In their practical application the
one without the other will not produce the highest
possible effect.
The first question now on all lips will be: Can we
arrive at the immunization of the normal organism,
so that no tubercle bacillus will grow in such an
immunized body ?
My own researches to confer immunization against
tuberculosis were first instituted by injecting dead
tubercle bacilli into normal guinea pigs, secondly by
injecting the glycerin extract of tubercle bacilli,
thirdly by injecting Kochs tuberculin. The mode
of preventive injections and of the following infec-
tions with living tubercle bacilli were varied in a
manifold manner.
With tubercle bacilli two series of experiments were
instituted, the first made Dec. 27, 1894, was com-
menced by myself, but executed in my absence by
others. It embraced twelve guinea pigs, that received
daily injections of small quantities of a suspension
of dead tubercle bacilli in kresolwater in the propor-
tion of 1 to 10. The three first animals Nos. 1 to 3
received for five days 0.2 c.c. of this mixture, together
with 0.1 gm. dead tubercle bacilli; the second three,
Nos. 4 to 6, 0.2 c.c. of the mixture for ten days, with
0.2 gm. dead tubercle bacilli, the third three, 0.2 c.c.
of the mixture, for fifteen days with 0.3 gm. dead
tubercle bacilli, the fourth three 0.2 c.c. of mixture
for twenty days, with 0.4 gm. of dead tubercle bacilli.
These experiments were impaired by the cold
weather of the winter and by other circumstances not
necessary to state here. The worst condition was
that the inoculation following with living tubercle
bacilli was instituted with . a material not at all effi-
cient, as was proven by injections of the same in
other, not preventively treated, animals. The tuber-
cle bacilli were imported from Europe enclosed in a.
bottle without air, and were thus killed, a fact of some,
interest. If one encloses them in a glass tube, the,
ends of which are closed by cotton, and dries them
by a stream of air deprived by sulphuric acid of its.
moisture, one can conserve their life a very long time..
From the above cause I was obliged to make a sec-
178
TUBERCLE CULTURES.
[July 25,
ond infection with living tubercle bacilli after my
return from Europe, on March 25, three months after
the commencement of the preventive inoculations.
Of the above twelve animals only four could be used
for the experiment, of which two had received 1 deci-
gram, one 3 decigrams, and one 4 decigrams of dead
tubercle bacilli.
Guinea pig No. 1, with one-tenth gram dead tuber-
cle bacilli, was killed fifteen days after the second
efficient infection ; it showed fresh spreading miliary
tuberculosis of no great extent. Guinea pig No. 2,
with also one-tenth gram dead tubercle bacilli, died
fifty-three days after the tubercle infection. Its tem-
perature rose to 105 F., and there were found older
tubercular changes in liver and spleen, partly cica-
trized, and a slight spreading of fresh miliary tuber-
culosis in the peritoneum and lungs. The animal
had received from the nineteenth to fortieth day after
the tubercle infection six injections of Paquin's serum
(£ to 1 c.c. per dose) evidently without any effect. It
is clear also that the preventive dose of one-tenth
gram dead tubercle bacilli was not sufficient to give
the animal an absolute immunity against tuberculosis
three months after the preventive inoculations. The
dose of living tubercle bacilli used for the infection
was a large one, nearly 8 centigrams. Some milli-
grams of the same tubercle bacilli have killed the ani-
mals in from two to three weeks. A certain retarda-
tion of the affection of the tuberculous development
can be conceded as possible in these cases. The third
animal, No. 8, received 3 decigrams dead tubercle
bacilli and the same quantity of living tubercle bacilli
at the same time as the others. It died eleven days
after the tubercular infection without any sign of fresh
tubercular formation, whereas a control-animal No.
50, inoculated the same date (March 25) with the same
quantity of the same tubercle bacilli died after thir-
teen days with all the signs of miliary tuberculosis.
As this animal No. 8 received no treatment, we can
affirm with greater security than before a delaying influ-
ence which was apparent three months after the pre-
ventive injection of 3 decigrams (5 grains) of dead
tubercle bacilli.
The fourth animal of the series (No. 10) received
twenty preventive injections, with 4 decigrams dead
tubercle bacilli, and was infected in the same manner
and at the same time as No. 8. After the fever com-
menced it received Paquin's serum, but died with
miliary tuberculosis, twenty-seven days after the
tubercular inoculation, which proves that this manner
of preventive inoculation is not effective in all cases.
As in this whole series it was not clear whether the
injection of dead tubercle bacilli had proved fatal in
so many cases (an inexperienced observer thought
even that the deposition of dead tubercle bacilli in
lymphatic glands as proved by Mitchell Prudden and
Hodenpyl, could be interpreted as spreading of active
tuberculosis), I resolved to repeat the experiment in
a somewhat changed manner.
Five new guinea pigs (Nos. 52-56) received, the first
one, the others two injections of dead tubercle bacilli,
0.714 gm. The whole quantity was much larger than
in the first series and the frequent repetition of trau-
matism avoided. Not one of these animals died in
consequence of the preventive injections. All were
inoculated with living tubercle bacilli from ten to six-
teen days after the preventive injections; the first three
with 5 eg. and the two last animals with 1 dg. One
of these animals (No. 52) died sixteen days after the I
ai-
to
cle
nt.
see
Lay
ter
id
,
.4
tubercle infection (| dg., nearly 1 grain of living
tubercle bacilli having been injected). The cause of
death in this case was accidental, escape of illuminat-
ing gas. As all these animals showed fever ( 102 to
103 degrees F. ) and loss of weight after the tubercle
infection, the first four received a different treatment
In another publication the history of all these case
will be related in an extended manner. Here it maj
be sufficient to remark that No. 52, which died after
sixteen days, had no signs of tubercular development.
No. 54, which died after thirty-six days, was free from
infection in the internal organs, some glands were
caseous, containing tubercle bacilli. No. 55, which
died on the thirty-third day after tubercular infection,
showed all inner organs free with the exception of the
spleen, which was of normal size but contained two
very small gray nodules; some lymphatic glands also
contained caseous matter with tubercle bacilli. A
small part of the right axillary gland was implanted
in a normal guinea pig, No. 82. The animal died,
though treated with large quantities of horse blood
tubercle serum forty-nine days after the inoculation
and proved evidently tuberculous.
We see also that there were infectious tubercle
bacilli in this seemingly nearly healed case (No. 55).
But it may be that the previous injection of dead
tubercle bacilli had a retarding influence on the devel-
opment of tuberculosis.
The last animal of this series, No. 62, received 1.
gm. dead tubercle bacilli and was ten days later
infected with 1 dg. living tubercle bacilli. It died
thirty days after this infection. The axillary gland
of the side of injection proved caseous and contained
tubercle bacilli. The inner organs were wholly free
from tubercles with the exception of the spleen, which
contained a small quantity of gray nodules. The con-
clusions from these experiments are:
1. That the injection of greater quantities of dead
tubercle bacilli is not at all deleterious to the animal.
2. That a quantity of 3 grams dead tubercle bacilli
to 1,000 grams weight would be very effectual to
retard the development of tuberculosis, introduced ten
days after the preventive injection in the animal.
It is clear that this result, so interesting from a
scientific view, has no practical value. If the dosage
just given is available for men, a full-grown man
weighing 120 pounds would need 180 grams, more
than 10 ounces of air-dried tubercle bacilli. We must
therefore search whether we can isolate the immuniz-
ing substance from the tubercle bacilli. This was the
object of the third series of experiments, instituted
with the watery-glycerinic extract of tubercle bacilli,
for brevity named tubercle extract. This fluid itself
would not be suitable, because it is too much diluted.
It is therefore precipitated by strong alcohol; the pre-
cipitate, soluble in any quantity of kresol-water (i per
cent. ) can be prepared in any desirable strength. I
use it at present in 0.5 and 1 per cent, solutions.
In this series nine guinea pigs of 500 grams received
2£, 5 and 1\ c.c. tubercle bacilli extract subcuta-
neous injected in from one to sixteen days. Three
animals received the same dose. In each division two
animals remained after the infection without treat-
ment. The whole series was progressing exactly
parallel to the first series with dead tubercle bacilli.
The first infection in January was ineffectual; the
second was instituted on March 25 with the same
material as in the first series (7.85 cgr. air-dried
tubercle bacilli and 2.15 cgr. cinnabar). Three ani-
1896.]
TUBERCLE CULTURES.
179
mals. Nos. 15, 17 and 21, died previous to the effective
tuberculous infection. These preventive injections
therefore proved much less dangerous than the paral-
lel cases with dead tubercle bacilli. Now we observe
the results in the animals without any treatment:
Guinea pip No. 14, tubercle bacilli extract 2i c.c,
tuberculous infection three months later; died twenty-
three days after the tuberculous infection. Weight,
686 grams January 9, 635 grams March 25 (tubercu-
lous infection), 505 grams April 15 (loss, 80 grams
day before death).
Postmortem — Liver yellow infarcts and few gray
nodules; spleen not much enlarged, smooth, miliary
tubercles; lungs free from infection; glands slightly
.swollen, not caseated; peritoneum: some old, but very
flight fresh tuberculous development.
V 18, 5 o.o. tubercle bacilli extract; tuberculous
infection three months later; died twenty days after
the tuberculous infection. Weight, 520 gms. Jan-
uary 9, 690 March 10. 630 March 26, 535 April 13;
gained 15 i;ms. Died April 11.
Postmortem — Liver red, flabby, contains few small
gray nodules; spleen slightly swollen (1 9-16x13-16
inches i. weight 1.85 grains, pale, a few gray nodules;
lungs congest ed, free from tubercles; glands not swollen;
peritoneum: the masses of cinnabar and tubercle
bacilli in this case injected directly into the peritoneal
cavity are lying under the liver; they contain great, hard
fibrous masses, very few miliary tubercles only on the
mesentery; mesenteric glands slightly swollen, not
caseated. Slight development of fresh tubercles.
No. :2(>. 7i c.c. tubercle bacilli extract; tuberculous
infection three months later. Died nineteen days
after the tuberculous infection. Weight, 520 gms.
January 9, 720 March 18, 645 March 26. Died
April 13.
Postmortem — Liver not enlarged, surface smooth,
yellow tinge (fatty degeneration), few miliary tuber-
cles on surface: spleen not enlarged (1 5-16xg inch),
weight 1.37 grams, free from nodules; lungs partly
collapsed, pleuritic exudation, in the right side par-
ticularly, some suspicious nodules in the thickened
pleura, substance of lungs free; peritoneum: few
nodules on the right side near the injected masses of
tubercle bacilli and cinnabar: glands not swollen, not
tuberculous.
//; all three eases was a very slight development of
miliary tubercles, no deeper tuberculous alterations
of the greed glandular organs (sjileen, liver, lungs),
as usually found in so intense infections after three
weeks' standing. Tubercle bacilli extract proves
therefore in a high degree immunizing.
That this conclusion is a correct one is proved by
three control-animals, guinea pigs, Nos. 26, 49 and 50,
infected with the same material in equal quantities,
on March 25, without undergoing preventive injection
of any kind. I give the results in the same manner
as before:
No. 26, tuberculous infection 0.0785 c.c. with cin-
nabar March 25. Died April 14, twenty days after
tuberculous infection (ineffectual injection January
6). Weight, 500 grams January 18, 480 March 22,
105 April 14; loss 95 grams.
Postmortem — Subcutaneous tissue contains an
enormous infiltration with caseous masses spreading
from the abdomen to the inguinal region and back,
ulcerating at the sacral region . Peritoneum : In the great
net, large nodules of firm caseous tissue, containing
cinnabar in the center; some exudation, beside miliary
tubercles in great number at the left side of perito-
neum ; tuberculous infiltration of lymphatic vessels near
the great nodules; enormous tuberculous infiltration
of mesenteric glands. Liver greatly enlarged, contains
numerous masses of yellow tubercles, nowhere cica-
trization; spleen enlarged (Hxl), firm, gray; lungs
congested, somewhat collapsed (pleuritic effusion on
both sides), contain numerous gray tubercles; glands,
inguinal and crural, swollen, caseated.
No. 49, tuberculous infection 0.0785 c.c. with cin-
nabar March 25. Died April 14, twenty days after
tuberculous infection. Weight, 560 grams March 26,
445 April 14; loss 115 grams.
Postmortem — Peritoneum: omentum majus forms
a string of yellow nodules, two of them containing
cinnabar, from here a spreading of tuberculous masses
all over the mesentery and the right kidney; liver
much enlarged, filled with yellow masses, no cicatri-
zation; spleen somewhat enlarged (l§x| inch), weight
1.88 grams, gray, firm, with many gray nodules on the
surface; lungs: right lung totally gray, consolidated,
in left some nodules. The injection in this case was
made intermuscular on the right side of abdomen.
No. 50, tuberculous infection 0.0785 c.c. with cin-
nabar 0.0215 gm. March 25. Died April 4, twelve
days after tuberculous infection. Weight, 580 grams
March 26, 495 April 13; loss 95 grams.
Postmortem — Peritoneum: injection mass forms a
protrusion of peritoneum, free from infection on this
part, but on the great net many deposits of cinnabar,
part with gray tuberculous formations, the same in
the gastro-hepatic ligament, in the mesentery of spleen
and in adhesions of the omentum to the liver and
left kidney; liver not enlarged, contains numerous
small and large nodules, the latter yellow, the former
gray, sometimes containing cinnabar; lungs free,
edematous; glands: substernal glands swollen and
reddened.
We remark that the same tuberculous infection
having made such small alterations in the animals
previously injected with the tubercle bacilli extract,
has without this, produced in twelve days a far dis-
seminated peritoneal tuberculosis, the origin of which
is clearly demonstrated by the cinnabar taken up with
the tubercle bacilli by leucocytes and conveyed by
them all over the peritoneum. In the farther progress
of this affection we note in the first two control ani-
mals occur the greatest possible tubercular alterations
of the liver, spleen and lungs. The same progress is
made also by the tubercle bacilli, enfeebled by the
preventive injections of tubercle bacilli extract, but
not with the same effect. As this is the only differ-
ence in these six cases, we must say with as much
certainty as is possible to obtain in animal experi-
ments, that the glycerin extract of tubercle bacilli
produces a very high degree of immunization, prov-
ing effective three months after a very high degree of
tubercular infection. As the greatest injected quan-
tity of tubercle bacilli extract was 7.5 c.c. to 500 gms.,
containing 7.5 centigrams of organic matter, the requi-
site quantity for men would be probably 15 eg. to one
kilo., 7.5 grams for 50 kilo., or half an ounce for 100
pounds, a quantity of organic substance, dissolving
readily in 50 c.c. kresol- water (0.2 per cent.). Such
a small quantity would immunize a full-grown man
for more than three months.
The clinical observations made by the use of tuber-
culocidin, that contains a large quantity of bacillus
extract, agree with these results. The most succets-
180
TUBERCLE CULTURES.
[July 25,
ful cases that I have seen in Europe and in this land,
"were those in which the application of tuberculocidin
and tubercle extract followed the antiphthisin treat-
ment.
The same conviction resulted from animal experi-
ments I instituted in the last year, for the compar-
ison of pure antiphthisin treatment and a mixed
treatment with antiphthisin and tubercle bacilli
extract. The tubercle-killing power of antiphthisin,
proved by new experiments, must be diminished by
immunizing, probably also by antitoxic influences. I
will speak later about the best methods of the com-
bined treatment. Now it may suffice to demonstrate
the fact, that by such treatment the gravest tubercular
changes in guinea pigs, namely the enormous tuber-
cular development in liver and spleen, can be entirely
healed. The differences in the two cases of guinea
pigs, now to be related, may partly depend on a
different power of resistance, but partly also on the
different quantity of tubercle bacilli extract they
received, the antiphthisin treatment being nearly the
same.
The two animals, Nos. 109 and 110, of more than
300 grams weight, had received, before the tubercu-
lous infection, injections of tubercle toxins, prepared
by digestion of tubercle bacilli with pepsin and pan-
creatin, which proved non-effective, but caused high
fever. Immediately afterward infected with one dg.
air-dried tubercle bacilli, a very large dose, the typical
tuberculous fever is developed ten days afterward,
rising to 102.3 and 103 degrees average temperature.
The treatment commenced on the twenty-second
day after the tuberculous infection with small doses
of antiphthisin, 2 to 3 eg., sometimes 2 dg., per day,
and such of tubercle bacilli extract 2 eg. No. 109
received in fifty-eight days 1.75 grams antiphthisin
and 0.06 c.c. tubercle bacilli extract. No. 110 in fifty-
nine days 1.51 grams antiphthisin and 0.12 c.c. tuber-
cle bacilli extract. The daily average temperature
varied from 100 to 101 degrees. During this time
enormous alterations of the liver and spleen were
developed; in No. 109 the spleen measured at the
time of death, 142 days after tuberculous infection,
two and one-fourth inches in length, one and five-
eighth inches in breadth, and seven-sixteenths of an
inch in thickness, whereas in No 110 this organ
at the same time measured no more than one and
three-sixteenths inches in length and thirteen-six-
teenths of an inch in breadth. The first contained a
great number of yellow spots, the second was quite
free from tuberculous matter.
The liver is very much enlarged in the two cases,
but contains in No. 109 hardly any normal substance,
being very hard and' fibrous throughout with many
yellow spots, a little more conserved liver tissue in the
left lobe. In No. 110 the liver consists of quite normal
hypertrophic tissue, forming flat projecions between
deep fibrous scars.
The lungs of No. 109 contain in all parts white
nodules. In No. 110 the lungs are quite free from
any tuberculous deposit.
The abdominal cavity is free from tubercles in both
animals. The glands firm, fibrous; only in one
inguinal gland of No. 109 was found a small purulent
deposit, containing very few degenerated tubercle
bacilli. A few more tubercle bacilli were found in
the nodules of the lungs of the same animal. No.
110 was quite free from tubercle bacilli, so far as can
be demonstrated by microscopic research.
:
No. 109 was very anemic, a consequence, as it seems,
of the deep degeneration of liver and spleen.
But now we return to the clinical history of the
cases. On the ninety-first day after the infection, ten
days after discontinuing the first series of treatments,
probatory injections with my tuberculotoxin 0.3 gm.
were instituted. No 109 gave a reaction to 102, No.
110 no reaction.
In consequence of this result it seemed desirable to
institute a new series of antiphthisin injections. In
this was used a method that had effected good results
in other cases. Commencing with small doses, one
gives, every day, a little more until a very large dose
is reached. One recommences then with small doses,
increasing to larger as long as the temperature is ele-
vated. In No. 109 we increased from 2 to 20 eg. in
eighteen days and decreased the temperature from a
maximum of 102.4 degrees to 99.6 degrees average
temperature, the second time from a maximum of
101.2 degrees to an average temperature of 99.7
degrees. In No. 110 there was scarcely any change
of temperature, the average being between 100 and
101 degrees. It is true that this temperature was
higher than normal, but we find the same elevation in
nearly all healed cases; it seems that in such animals
the pyrogenic toxins remain a longer time in the body
than the living tubercle bacilli, and the tuberculous
tissue may be deposited in some irrecognizable resi-
dues of dead tubercle bacilli.
The difference in the healing process in these two
animals may depend partly upon a different normal
resistance of the two organisms, but perhaps the more
prolonged use of tubercle bacilli extract has had a
beneficial influence on the healing process in No. 110.
II. THE COMPOSITION OF TUBERCLE BACILLI.
The highly immunizing effect of the glycerin extract
of tubercle bacilli must direct our attention more to the
composition of tubercle bacilli. My researches have
given me up to this time, the following results:
1. The tubercle bacilli contain a very great quan-
tity of fatty substance, a fact first remarked by Ham-
merschlag and Neusky, then confirmed by Dr. von
Schweinitz of Washington, D. O, who made the first
quantitative determination; he found 25 per cent. fat.
I commenced my researches before knowing of this last
valuable work. I found not more than 22 per cent, fat,
but this percentage depends very much on the degree
of dryness of the bacilli. As they contain a great
quantity of glycerin, a fact noted by Prof. Abell of
Baltimore, in the alcoholic ethereal extract, which
explains their high hygroscopic quality. The pure
ethereal extract gave me a firm red colored fat melting
at 42 O, 20.5 per cent, of the whole mass. But besides
this fat the tubercle bacilli contain a white fatty sub-
stance that can be extracted by benzol and is not sol-
uble in ether; this fat is harder than the first, the
melting point higher, if I remember rightly above 50
degrees C. The quantity of this benzol fat was 1.14
per cent.
The second point regarding the tubercle bacilli-fat
is that this substance is the single cause of the specific
staining of the tubercle bacilli. The separated fat
gives the fuchsin staining not destroyed by mineral
acids, and tubercle bacilli deprived of this fat do not
stain in the same manner. The granules stained by
fuchsin in the so-called degenerative forms of tubercle
bacilli are nothing but remains of this fat. They are
therefore better called atrophic tubercle bacilli.
1896.]
TUBERCLE CULTURES.
181
2. The greater part of tubercle bacilli is formed of
nuclein. After extracting the fat by ether and ben-
7.0I and digesting the residue by pepsin and chlor-
hydrie acid, the nuclein can be dissolved in alkalin
fluids and precipitated by alcohol. After repeated
solution and precipitation we obtain a pure nuclein,
containing 8 to 9 per cent, phosphorus, as much or more
than was found by Miescher in the eggs of salmon.
This tubercle nuclein and the fats have no influ-
ence on the tuberculous process, that I could see in
a large number of varied experiments on animals.
:!. The third constituent of tubercle bacilli is the
glycerin extract containing a substance precipitable
In alcohol, giving biuret reaction. Whether this sub-
stance is a simple one or not, whether it acts in its
totality in immunization or whether it contains only
ferments with immunizing power, must be determined
by further researches.
III. THE TllSERC'LE KILLING POWER OF ANTIPHTHISIN.
I will here add a short note about an experiment
fundamental to my theory, now repeated with some
change. In my book on page 174, I had reported an
experiment (No. 23) showing that fresh tubercle
bacilli are killed, if treated by a mixture of tuberculo-
eidin and erethin (similar to tubercle toxin) pre-
pared from the bismuth precipitation of culture fluid.
Tubercle bacilli treated in this manner six days proved
totally inoffensive, whereas the same, untreated bacilli
killed animals by tuberculosis in fourteen days. One
of the animals, that had received tubercle bacilli
treated with tubercle culture lived more than a year
and was found quite free from tubercles (No. 4).
I repeated this experiment with pure antiphthisin
in the following manner:
Jan. 12. 1896, 25 c.c. antiphthisin with 1 per cent,
organic matter was precipitated by absolute alcohol,
the precipitate firmly adhering to the walls of the
bottle: the alcohol was poured off, the residue was
slightly warmed, washed with ether, the latter evap-
orated, the residue was dissolved in 2.5 c.c. freshly
distilled water. Each cubic centimeter contained 0.1
gram dry antiphthisin.
In this fluid I suspended under aseptic measures a
large quantity of tubercle bacilli taken from a full
grown culture.
Three guinea pigs received from this emulsion
injections of the same quantity, No. 146 after one,
No 118 after two, and No 150 after three days. Two
control animals of the same weight (186 to 252 gms.)
were observed in the same manner, the weight being
taken in the morning, also the temperature at 5 o'clock
p.m. No. 148 infected with living tubercle bacilli on
February 2, weighed January 13, 252 grams; Febru-
ary 5, 325 grams; March 19, 242 grams. It died on
this date after long continued high fever (102.6 max.)
forty-three days after the tubercle infection, and
proved highly tuberculous; in liver and lungs many
gray tubercles, the glands caseated; at the injection
point innumerable tubercle bacilli; in the organs
also were great quantities of them.
No. 147 remained totally free from infection and
showed the following weights: January 13, 186
grams; February 5, 249 grams; gain 63 grams;
April 19, 430 grams; gain 181 grams. Total
increase of weight in 97 days 244 grams.
No. 146 having received February 13 tubercle
bacilli, treated twenty -four hours with pure antiph-
thisin, showed the following weights: January 13,
186 grams; February 5, 210 grams; gain 24 grams;
February 25, 195 grams; loss 15 grams. It gained in
43 days 9 grams. It died on February 25 and Bhowed
on postmortem the external lymphatic glands enlarged
and slightly caseous. In the inguinal and subclav-
icular glands were found a few degenerated tubercle
bacilli; in the other glands none. The inner organs
proved quite free from tubercles and tubercle bacilli.
The temperature reached on one day 100 degrees F.,
was generally between 99 and 100.
No. 149 having received January 15 tubercle bacilli,
treated seventy-two hours with pure antiphthisin
weighed: January 13, 183 grams; February 5, 209
grams; gain 26 grams; April 19, 300 grams; gain 91
grams. Total gain in 97 days 117 grams.
No. 150 having received February 14 tubercle
bacilli, treated forty-eight hours with pure antiph-
thisin, weighed: January 13. 323 grams; February
5, 365 grams; gain 42 grams; April 19, 469 grams;
gain 104 grams. Total gain in 97 days 146 grams.
The temperature of the two last animals was in
April higher than normal, varying from 100 to 102
degrees. The average temperature (5 o'clock p. M.)
from April 1 to 19 was in No. 149, 101.20 degrees; in
No. 150, 100.78 degrees. I think that these two ani-
mals were also tuberculous, but in such a slight degree
that after 100 days their growth in comparison with
the normal animal was but slightly retarded; in No.
149 (gain 117 grams) by 127 grams; in No. 150 (gain
146) by 98 grams. This proves that antiphthisin, in
twenty-four hours, has a marked debilitating influ-
ence on living tubercle bacilli. I have noticed that
such bacilli can kill an animal in twenty-two days,
but with very slight tubercle development and with-
out fever.
The treatment of tubercle bacilli with antiphthisin
for two or three days gives a far better result, as these
animals lived more than one hundred days after the
injection of the treated tubercle bacilli.
That the absolute killing of tubercle bacilli in
antiphthisin requires a longer time (in -my experi-
ment with tubercle culture six days were required)
must be explained by the large proportion of fatty
matter contained in the tubercle bacilli, diminishing
in a high degree the osmotic power against watery
solutions. The destruction of the tubercle bacilli in
the living body by tuberculocidin or antiphthisin is
a much more complicated process. I think that here
the chemiotaxis is of decided influence; the leuco-
cytes, assuming these substances transport them
to the diseased parts and forcing them into the inte-
rior of the tubercles, destroy their vitality, at first
dissolving the fats, then digesting the protoplasm of
the tubercle bacilli.
As the tubercle bacilli extract has sixteen times
higher power of chemiotaxis than antiphthisin, I rec-
ommend the addition of the tubercle bacilli extract to
the antiphthisin treatment or the use of tuberculocidin
alone in the treatment of human tuberculosis without
higher inflammatory processes and fever. As antiph-
thisin is the mildest form of tubercle bacilli products
and has no injurious effects, it should, in such cases,
commence the treatment. Two hundred c.c. anti-
phthisin, 75 to 100 tuberculocidin and 50 c.c. extract,
taken in six to seven months seems to be a sufficient
dose in most cases.
Let us have a department of Public Health !
182
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
[July 25,
ORIGINAL ARTICLES.
TUBERCULOSIS OF THE MALE GENITAL
ORGANS.
Bead by title at the meeting of the American Surgical Association, at
Detroit, Mich., May 26-28, 1886.
BY N. SENN, M.D., Ph.D., LL.D.
CHICAGO, ILL.
The male genital organs are the seat of as yet im-
perfectly understood conditions which predispose
them to tubercular infection. The literature on tuber-
culosis of these organs is scanty as compared with
tubercular affections of other organs, such as the lungs,
pleurae, peritoneum, lymphatic glands, bones, joints,
meninges and skin. A careful search of what has
been written on tuberculosis of the male genital organs
will convince the searcher for truth and instruction
that this subject has not received the attention its
importance demands. The observations of many clin-
icians in this comparatively new field of surgical
pathology present no uniform and many times diame-
trically opposite results. The deductions drawn in
the postmortem room by professional pathologists
likewise lack uniformity, and the different results
obtained have often been taken as a basis to fortify
the opinion of individual surgeons. This department
of surgical tuberculosis is in its primitive stage and
offers many inducements and opportunities for care-
ful clinical observation, and bacteriologic and patho-
logic research in the future. .The great obstacle to a
more perfect development of the surgical aspects of
tuberculosis of the male organs of generation, in the
past and to a certain extent at the present time, has
been, and remains, accuracy in diagnosis. Since the
mystic term scrofula has been almost completely elim-
inated from the present nomenclature of surgical
affections it has been found that many of the chronic
inflammatory diseases of the male organs of genera-
tion are of tubercular nature. The important ques-
tions whether the male genital organs are the seat of
primary tuberculosis, or whether the disease extends
to them by a progressive infective process from the
upper portion of the urinary system have not been
definitely settled; each side can show its exponents
whose views command respect. For my own part I
am firmly convinced that in a fair percentage of cases
the male genital organs are the seat of primary tuber-
culosis, the tubercle bacilli finding in the blood ves-
sels of the complicated genital apparatus a favorable
condition for their mural implantation, growth and
reproduction. These are the comparatively rare cases
of hematogenous primary tuberculosis of the male
genital organs caused by the deposition, growth and
reproduction of tubercle bacilli floating in the general
circulation, locating in some part of the genital appa-
ratus without a discernible tubercular lesion in any of
the other organs. Such cases occur, but are few as
compared with instances of secondary tuberculosis
complicating tubercular affections of other organs or
occurring in the course of extension of a tubercular
process by continuity of surface from the urinary
organs. It is my purpose on this occasion to call your
attention to some of the salient points in the etiology,
pathology and clinical aspects of tuberculosis of the
male genital organs on the hand of the current surgi-
cal literature and shall emphasize some of the topics
which have attracted my attention by my own personal
observations.
Tuberculosis of the Penis. — The frequency with
which tubercular affections of the female organs of
generation occur has recently received the well mer-
ited attention of gynecologists. The observations
which have been made in this direction have reminded
the surgeon of the possibility of direct inoculation dur-
ing coitus. That such an occurrence is beyond the
range of imagination no one can deny. Years ago
Verneuil ( Hypothese sur l'origine de certaines tuber-
culeuses genitales dans les deux sexes. Gaz. liebd.,
No. 14, 15, 1883) expressed the opinion that primary
genital tuberculosis, which does not depend on scrof-
ula is probably caused by direct infection during coi-
tion, that is, by the wandering of tubercle bacilli
through the external genital organs to a point of the
apparatus in which favorable conditions for their
localization and reproduction exist. Poncet (La
MMecine Moderne, Paris, July 29, 1890) reported to
the French Congress for the Study of Tuberculosis an
article on tuberculosis having its origin in the penis.
Three varieties are mentioned: 1, balano-preputial
tuberculosis; 2, tuberculosis of the mucous mem-
brane (this variety usually showing itself first in the
deep urethra), and 3, tuberculosis of the urethra
which consists of fungous masses involving the peri-
urethral tissues, thereby allowing the urine to infil-
trate the penile structures. I have reason to believe
that many of the cases of destructive lesions of the
penis treated by amputation of the organ in which no
recurrence followed the disease was not carcinoma as
surmised, but of a tubercular character. During the
last two years I have seen two cases of extensive
destruction of the penis from what I believed to be a
tubercular process. One of the patients under the
care of Prof. Scales in Mobile was a colored man
about 35 years of age, single, with no history of syph-
ilitic infection. The ulceration commenced upon the
external surface of the prepuce several years ago and
was not attended in the beginning by enlargement of
the inguinal glands. The ulceration and sloughing
extended successively to the glands and body of the
penis and finally resulted in almostcompletedestruction
of the entire organ. Later the inguinal glands and skin
covering the scrotum became involved. The inguinal
glands became caseous and several well-marked tuber-
cular abscesses developed. When I saw the patient
he was confined to his bed and the discharge from the
extensive ulcerated surfaces-had resulted in inoculation
tuberculosis which covered a considerable area of the
gluteal regions on both sides. Some of the ulcers
would heal from time to time when the new scar tis-
sue would again break down and give place to an
ulcerative process. No signs of syphilis could be
detected upon any part of the surface of the body or in
any of the internal organs. The patient had been sub-
jected repeatedly to antisyphilitic treatment with
various preparations of mercury and iodin without
any improvement; in fact, such treatment appeared to
aggravate the local conditions and still further impair
the general health of the patient. Under anti-tuber-
cular treatment, local and general, consisting in the
use of antiseptics, balsam Peru, and later iodoform,
repeated curettage, and the internal administration
of guaiacol and cod liver oil, the disease was arrested,
the ulcers healed rapidly, and the general health,
which had been precarious for several years, was so
much improved in the course of a few months that the
patient was able to resume light work. I had no
opportunity to make a microscopic examination of
the tissues or to search for the bacillus in this case,
1896.]
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
183
but I have but little doubt both from the clinical his-
tory of the case, as well as the character of the local
lesions, that the affection was one of primary tuber-
culosis of the skin which extended rapidly to all of the
tissues of the penis and later to the lymphatics, and
finally to neighboring parts exposed to contamination
from the profuse discharge from the ulcerated sur-
5. The very fact that the lymphatic glands were
converted in whole or in part into cheesy masses speaks
for the diagnosis of tuberculosis and against syphilis.
It is well known that in the negro tuberculosis often
pursues an exceedingly rapid course. In a few weeks
tubercular glands break down and suppurate, a condi-
tion often associated with quite extensive phlegmonous
inflammation of the surrounding connective tissue,
the consequence of a mixed infection with pyogenic
organisms. It is therefore not surprising that in rare
vases tuberculosis of the penis should result in exten-
sive destruction or complete loss of the organ under
the influence of a double infection in persons pecu-
liarly susceptible to the ravages of this disease.
For a full report of this case, I am indebted to Pro-
fessor Scales and Dr. Fonde:
John Mitchell, mulatto, aged 31. Entered City Hospital of
Mobile. IVe. •_'-J, 1893, with an ulcer on the balano-preputial
fold and extending on the glans penis. The ulcer was cauter-
ized with nitric aeid and an iodoform dressing applied. The
patient improved slightly and at the end of two months left
the hospital. He returned again, after an absence of six
months with the entire penis destroyed, and with a large ulcer
on the nates which rapidly extended. He suffered great pain,
showed serious pulmonary complications, was greatly emaci-
ated and confined to bed for six months. During this time the
actual cautery was applied, followed by dressings of a 5 per
■cent, solution of balsam Peru in castor oil, and also a short
course of guaiacol. After the first two cauterizations there
■was decided improvement in the ulcer, but the third and last
were followed by no benefit, the ulcer continuing to enlarge.
He was, however, sufficiently improved to enable him to leave
his bed for an hour at a time. The patient's condition
remained about the same for four or five months, when he
seemed to steadily grow worse. Dressings of iodoform were
applied daily from this time until Jan. 15, 1895, when Prof. N.
Senn saw the case and delivered a clinical lecture in the hos-
pital amphitheater to the students of the Medical College of
Alabama. The patient's condition was desperate at this time.
The ulceration had extended by numerous ulcers closely
adjoining and finally coalescing, the whole being purulent
until the whole perineal region, coccygeal fissure and both
nates were denuded, and in some places the destruction
extended deeply. The bladder was emptied through several
perforations in the perineum, and single shallow ulcers appeared
on the scrotum. The entire extent of the ulceration on the
nates measured ten inches vertically by nine inches trans-
versely, being greater on the left buttock.
Dr. Senn advised a thorough course of guaiacol and tonics
until the general condition of the patient would permit a
thorough and radical removal of all infected tissues by
curettement.
Guaiacol was commenced in doses of gtt. v, well diluted in
milk, three times a day, and gradually increased until the
patient was taking ten drops four times daily. He was also
given a course of syrup of iodid of iron. Patient improved
sufficiently in three months to leave bed and lounge around for
most of the day, and slept and rested well, which he had not
been able to do since his arrival at the hospital, unless under
an opiate. He still suffered pain the greater part of the time.
Curettement May 31 ; surgeon, William M. Mastin. Patient
was anesthetized and the whole field of infection carefully and
deeply scooped out, and edges trimmed with scissors. Some
of the pockets extended deeply into the nates and some bur-
rowing far under the skin. One at the gluteal creases pene-
trated nearly to the femur in the adductor muscles. A dress-
ing of iodoform was then applied. Rapid healing followed
and pain was almost entirely absent when patient recovered
from the immediate effects of the curette.
Curettement July 10; surgeon, William M. Mastin. The
condition very much better and healing had taken place in
considerable part of the field of the ulcer. Was again thor-
oughly curetted with the same marked relief and improvement
following.
Curettement August 7 : surgeon, William M. Mastin. An
occasional fresh breaking down in the cicatricial tissue beneath
the surfaco invariably yielded to the curette and healed rapidly.
Curettement Aug. 30, 1895; surgeon, William M. Mastin.
The same marked improvement. The main portion of the
field showed healthy and pliable cicatrix.
Curettement Sept. 6, 1895; surgeon, William M. Mastin.
Treated as before with same benefit.
Curettement October 31; surgeon, T. S. Scales. There
were several small and shallow ulcers in the coccygeal fissure
and in the inguinal fold on each side the scrotum, in addition
to the large and deep one which remained in the gluteal crease.
These were carefully scraped and iodoform thoroughly rubbed
in. Followed by improvement.
Curettement Jan. 20, 1896 ; surgeon, James A. Abrahams.
There were two remaining ulcers, one next the scrotum in the
coccygeal fissure, and the other in the gluteal crease, which
again received a careful and extensive removal of the involved
tissue, iodoform rubbed thoroughly in, followed by healthy
granulation at the bottom of the ulcer and rapid healing.
Curettement Feb. 20, 1896 ; surgeon, James A. Abrahams.
There was steady improvement, the only large ulcer remaining
was the one in the gluteal crease, which was filling up rapidly.
Scraped and treated as before, improvement following.
Since the second curettement the patient has been able to
do work around the hospital and acted as nurse for some time.
He is six feet tell, weighs 185 pounds. Pulmonary symptoms
have disappeared and he is robust, very strong and healthy.
He suffers no pain. The only remaining ulcer is the one at the
gluteal crease, which is now about the size of a half dollar and
is shallow. This will be scraped again in a few days.
Very recently I have had an opportunity to exam-
ine quite a similar case in the service of Dr. Bouffleur;
at the Cook County Hospital. In this case the lym-
phatic glands in the groins became involved after a
considerable portion of the penis had become
destroyed by ulceration and sloughing. Syphilis
was suspected, but the most energetic treatment made
no impression on the progress of the disease. Local
and general anti-tubercular treatment with excision
of the enlarged lymphatic glands, effected a speedy
and permanent cure. Many sections of the diseased
tissue were examined for bacilli with negative results,
but the existence of isolated multinuclear giant cells
furnished an additional proof of the tubercular nature
of the primary disease and the secondary glandular
complications. In both of these cases the base and
borders of the ulcers were not indurated, the surface
covered with pale, flabby, edematous granulations, the
margins undermined, the overhanging skin of a bluish
tint. The spongy and cavernous portions of the
penis appeared to yield alike to the tubercular destruc-
tion. In neither of these cases did the disease involve
the urethral mucous membrane above the level of the
ulcerated surface. The strongest argument in favor
of the turbercular nature of the destructive process
is the fact that vigorous anti-syphilitic treatment not
only failed in arresting the disease, but resulted in
aggravation of the local conditions and general health
of both patients, while the anti-tubercular treatment
yielded the most prompt and satisfactory results.
Tuberculosis of Urethra—Surgeons are familiar
with the well-known clinical fact that foreign sub-
stances when introduced into the urethra are very
prone to travel in the direction of the bladder unaided
by any vis a tergo. It is reasonable to assume that
microorganisms lodged in the meatus are conveyed in
a similar manner along the urethral tract and unless
they become arrested upon a soil propitious for their
growth and development, they produce no symptoms.
There can be but little doubt that direct infection of
the urinary tract with the bacillus of tuberculosis
occasionally takes place in this manner. Primary
tuberculosis of the urethra is exceedingly rare, and
when it occurs it takes place in a part of the urethral
184
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
[July 25,
mucous membrane prepared for the reception and
growth of the bacillus by some antecedent injury or
disease. Tuberculosis of the urethra must be men-
tioned especially as an affection which is prone to
exist in cases of vesical and prostatic tuberculosis in
consequence of a direct extension of the infective
process from either of these organs to the mucous
membrane of the urethra. It may occur in the pros-
tatic, the bulbous, or any other part of the urethra. It
is found more frequently in young females suffering
from bladder tuberculosis than in men. It appears
in the form of ulcers and is often attended by incon-
tinence of urine. What English has designated as
tubercular periurethritis is in reality a tubercular
perineal abscess which can take its origin as well
from a tubercular Cowper's gland as a tubercular
urethral ulcer. I have now under my care at the
Presbyterian Hospital a boy, 14 years of age, who
about a year ago manifested the first symptoms of
renal tuberculosis. In the course of a few months a
large tubercular paranephric abscess developed on
the left side which was incised but never healed. Soon
after he was admitted to the hospital symptoms
appeared which indicated that the tubercular process
had reached the bladder. A few weeks later a ureth-
ritis set in, characterized by a profuse discharge.
The meatus presented the same appearance as during
the early stages of a gonorrheal urethritis. As soon
as the disease reached the urethra incontinence of
urine appeared and continued until the acute symp-
toms subsided. Four guinea pigs were inoculated
by injecting a hypodermatic syringe full either into
the peritoneal cavity or the loose connective tissue in
the groin. All of the animals died in the course of
five or six weeks and the postmortem in each instance
revealed diffuse miliary tuberculosis. In this case
the tubercular inflammation extended from the kid-
ney over the entire urinary tract in the course of a
year. Long before the infection reached the bladder
and urethra, the tubercular nature of the primary
renal affection was established by the detection of
numerous tubercle bacilli in the urinary sediment
obtained from the centrifuge. Tubercular urethritis
gives rise most contantly to retention and inconti-
nence of urine. Owing to the irritation caused by
the urinary secretion, which will be voided the more
frequently in proportion to the irritation of the blad-
der present, the inflamed mucous membrane will be
kept in a constant state of disease, and the more so as
in these situations the tubercular infiltration is not
usually eliminated, but on the contrary, steadily
increases in quantity, and on this account not only
excites catarrhal inflammation in the adjacent healthy
mucous membrane, but also affords an increasing im-
pediment at the deepest part.qf, the urethra to the
flow of urine, and the most appropriate local surgical
treatment only suffices to check in some measure the
retention of the urine. Retention eventually leads to
incontinence.
Michaut (Sur un cas d'ulce>ation tuberculeuse de
l'urethre consecutive k une tuberculose resale primi-
tive. Bulletin de la Soc. Anat. de Paris, 1887)
observed a case of tubercular ulceration of the urethra
in a man the subject of pulmonary tuberculosis. The
disease appeared as a hard induration five centime-
ters behind the meatus which simulated clinically
closely a hard chancre. Later tubercular granulations
appeared around the meatus and upon the surface of
the glans penis. The postmortem revealed tubercu-
losis of the kidneys, and a descending tubercular
process which finally reached the urethra. The part
of the urethra affected was indurated and the fossa
navicularis was the seat of deep ulcerations. In the
differential diagnosis of urethral chancres it is well to
bear in mind tubercular lesions which may so closely
resemble primary syphilitic infection.
Anal^cot (Ann. des Maladies des Organes g£nito-
urinaires, November, 1893) records a rare case of
secondary tubercular ulcer surrounding and involving
the meatus, about the size of a ten cent piece. The
patient was a boy 14 years old and had been circum-
cised eight days after birth. The appearance of the
ulcer and the absence of induration excluded the
idea of a hard chancre. The smooth base, absence of
suppuration and the regularity of its border excluded
chancroid. It was not painful. The patient had for
three years been suffering with bladder trouble. Mic-
turition was frequent, painful, and at times bloody.
Although no bacilli could be detected in the ulcer,
inoculation with debris taken from it nevertheless
produced tuberculosis in guinea pigs, and so demon-
strated its tubercular nature. The ulcer had remained
stationary for nearly a year.
Ahrens (Die Tuberculose der Harnrohre. Beitr.
zur Klin. Chir. Bd. vill, p. 312) succeeded in finding
the reports of only four cases of tuberculosis of the
urethra in women. It is more common in men, but
its relative frequency is estimated differently by dif-
ferent authors. Krzywicki believes that the urethra
is affected in 1 per cent, of all forms of tuberculosis,
and in 17 per cent, of all cases of urogenital tubercu-
losis. In the majority of cases it is affected second-
arily both in the ascending and descending forms of
urogenital tuberculosis, and with few exceptions the
prostate gland is simultaneously implicated. In
exceptional cases it is met with as a primary affec-
tion, and in that event is nearly always mistaken for
a primary syphilitic ulcer. In the primary form the*
infection takes place either through the general circu-
lation, or by inoculation, the latter mode of origin
was demonstrated experimentally to a certain extent
at least by Baumgarten by his experiments on rabbits.
As a pathologic curiosity must be mentioned tuber-
cular stricture of the urethra. Such a case is described
by Ahrens. (op. cit.) The patient was a boy 16
years of age who was at the same time the subject of
tubercular coxitis. The stricture could only be
passed with a filiform bougie. The patient died six
days after his admission into the hospital in conse-
quence of retentio urinse and rupture of a diverticu-
lum at the base of the bladder. The postmortem
showed a caseous exudate upon the surface in the*
posterior part of the urethra as far as the pars caver-
nosa. The bladder, testicles, seminal vesicles, ureters,
and most of the internal organs were the seat of
recent tubercular infection. In primary tuberculosis-
of the urethra, when the disease is accessible, the
most energetic local treatment should be resorted to-
with a view of eliminating the tubercular material,
while its occurrence as a secondary affection to
tubercular affections of other portions of the urogen-
ital organs calls for palliation and improvement of
the general health of the patient by appropriate
treatment.
Tuberculosis of the Spermatic Cord. — The sper-,
matic cord or vas deferens is the connecting channel
between the essential organ of generation in the male,
the testicle, and the seminal vesicle. It is never the.
1896.]
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
185
leal of primary tuberculosis. In tuberculosis of the
testicle the disease usually manifests an intrinsic ten-
dency to advance in an upward direction, implicating
the cord and, if life is prolonged for a sufficient
length of time, eventually reaching the seminal vesi-
cle. The cord becomes enlarged, indurated, and usu-
ally nodular, so that when it passes between two
fingers it presents somewhat the outlines of a rosary.
In Boine cases the cord enlarges to the size of the little
finger. The swelling is either cylindrical, nodulated,
or spindle-shaped. The mucous membrane is most
thickened, then the muscular coat and last the
ndventitia. Perforation of the wall leads to tubercu-
lar abscess around it. Pain is usually absent and
tenderness on pressure slight. In cases of primary
tuberculosis of the seminal vesicles the infective pro-
cess frequently descends along the cord to the epi-
didymis. The surgical interest in tubercular sperma-
tids centers in the operation for the removal of a
tubercular testicle. In all cases in which the cord is
affected the inguinal canal should be laid open freely
as far as the internal inguinal ring and by gentle
traction and the use of dull instruments as much as
possible of the cord should be made accessible and
removed. It has been shown that with proper care
the cord can be liberated in this manner and excised
to a point very near the seminal vesicle.
Tuberculosis of the Seminal 1 resicles. — The seminal
vesicles are occasionally the seat of primary tubercu-
losis, but in the majority of cases the disease is asso-
ciated with similar affections of other parts of the
genital organs, most frequently the testicle and pros-
tate gland. Guyon believes with Lancereaux that
the tubercular process begins very frequently in the
vesica he seminales. Of twenty-six autopsies made
with reference to show the frequency with which the
seminal vesicles are primarily affected, he found this
to be the case in two cases; in ten cases these were
involved, but the prostate was simultaneously affected;
in one case the prostate alone was implicated. Of
thirty-six cases of disease of the seminal vesicles col-
lected by Dreyer (Beitr. zur Pathologic der Samen-
bldschen. Inaugural Dissertation Gottingen, 1891),
in eighteen the affection was of a tubercular nature.
Of these cases one- half occurred in persons over 40
years of age. In three cases the vesicles were prim-
arily affected, and in twelve the disease presented
E at a stage in which the organs were hard and
nodular without any softening, while in six cases it
had passed into the second stage characterized by
caseation and liquefaction of the caseous material,
that is, the formation of tubercular abscesses. In
three cases the disease had extended beyond the cap-
sule of the gland and had invaded the pelvic connec-
tive tissue. In one case the disease was complicated
by tubercular peritonitis. Pulmonary tuberculosis
was absent only in two cases. As a rule, different
portions of the urogenital tract and distant organs
were found impbeated. The seminal vesicles can be
palpated most satisfactorily by placing the patient in
the knee-elbow position. In tuberculosis of one tes-
ticle the seminal vesicle on the corresponding side is
frequently found affected, and in tuberculosis of both
testicles the subsequent affection of the seminal ves-
icle is often bilateral. The existence of hard nodules
in different parts of the organ which are not very ten-
der on pressure is very suggestive of the tubercular
nature of the disease. The close proximity of the
seminal vesicles to the peritoneum in case these
organs are tubercular must occasionally lead to peri-
toneal tuberculosis.
A number of surgeons have made bold attempts to
eradicate one or both seminal vesicles by operative
interference. Ullmann reports from Albert's clinio a
case of extirpation of the tubercular vesiculae semi-
nales in a patient 17 years of age, who had been
castrated for tubercular orchitis. Zuckerkandl's
semilunar incision between the scrotum and anus was
made and the space between bladder and rectum,
exposed, and the posterior wall of the former made
prominent by the use of a steel sound. The vesiculae
seminales and vasa deferentia were now freely exposed
and could be readily dissected out as well as the upper
left angle of the prostate which contained a small
abscess. Only the left, apparently healthy vas deferens
was left. The hemorrhage during the operation was
free, and this, as well as the secondary hemorrhage
which occurred on the evening of the same day, had
to be arrested by a resort to the iodoform gauze tam-
pon. Healing of the wound took place quickly with the
exception of a small urinary fistula. The fistula was
supposed to have been caused by division of the ejac-
ulatory duct in the substance of the prostate. The
patient left the hospital with a small urinary fistula
and claimed to have experienced erections at different
times. Ullmann regards primary tuberculosis of the
seminal vesicles and unilateral secondary infection in
the course of testicular tuberculosis as legitimate indi-
cations for a radical operation. In two cases of secon-
dary tubercular vesiculitis Roux (extirpation de la
vesicale seminale. Congres Francais de Chir., 1891)
followed castration for tuberculosis of the testicles by
excision of one of the seminal vesicles which had
become involved by the tubercular process. After
the removal of the diseased testicles and suturing of
the wounds he brought the patient into lithotomy
position, lying on the affected side, and made an
incision 2-3 cm. from the median line as far as the
ischium, exposing the rectum and penetrating finally
as far as the affected vesicle. By pressure with the
finger in the rectum from above downward the edge
of the vesicle was made to appear in the upper portion
of the wound. By the use of a traction ligature the
vesicle was drawn further down, separated, and with
the stump of the vas deferens, was divided close to
the neck of the bladder. The patient recovered from
the immediate effects of the operation, but the remote
results of the procedure are unknown.
Weir (Medical Record, Aug. 11, 1894) reports a
case in which he removed both seminal vesicles
through Zuckerkandl's transverse perineal incision.
Schede (Deutsch Med. Wochenschrift, Feb. 15, 1894)
successfully removed a tubercular seminal vesicle and
cord. He prefers the method of Rydygier, which
consists of a lateral incision extending along the
border of the sacrum to that of Dittel, which is the
same as that which Schede employs for extirpation of
the prostate, namely Zuckerkandl's transverse curved
perineal incision.
Perhaps the most complete operation for tubercular
vesiculitis has been performed by Fenger. ( Personal
communication. )
The patient was 22 years of age with a good family history.
One year before his admission into the German Hospital he-
contracted gonorrhea which persisted for six weeks. During
the latter part of this disease he complained of rheumatic pains
beginning in the left foot and passing from there to the hip on,
same side, and later to the left knee and right ankle. At first
the joints were not swollen, but about a week later the knee-
186
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
[July 25,
joint began to swell and he was confined to his bed where he
remained for two weeks. At the end of this time he recovered
almost completely from the joint affection. In November, 1894,
he noticed that the left testicle was swollen, the swelling
increased slowly until in about four weeks it was as large as
the fist of an adult. When the patient came under Fenger's
care the left testicle was firmer and slightly larger than the
right. The epididymis was hard and nodular and slightly
tender to pressure. Digital examination of the rectum showed
no enlargement of the prostate, but the left seminal vesicle
was felt as a hard mass, not tender to pressure. Reducible
right inguinal hernia. General health not impaired. Opera
tion April 25, 1894, in two steps, first removal of testicle and
accessible part of the cord, and second, extirpation of the semi-
nal vesicle on the same side through Roux's incision. In
removing the cord after previous isolation of the testicle, the
incision was carried as far as the internal inguinal ring, where
the vessels were tied and the cord teased out of its canal as far
as possible before dividing it. The wound was packed with
iodoform gauze and sutures introduced, but not tied until
after the completion of the second step of the operation. Dur-
ing this part of the operation the patient was turned on his left
side and the knees drawn up and rectum' lightly packed with
iodoform gauze. Roux's incision was then made on the left
side of the rectum four inches in length. A sound was intro-
duced into the bladder to serve as a guide in making the deep
dissection. The seminal vesicle was located by the finger in
the rectum as an olive-shaped body. Access to the vesicle was
difficult owing to the small size and great depth of the wound.
Bleeding was not as profuse as was expected and was easily
controlled by the use of large hemostatic forceps. The seminal
vesicle was found close to the bladder and was drawn down-
ward with Museux's forceps. During the dissection the pro-
state and levator ani muscle were seen and recognized. The
vesicle was not encapsulated, as was anticipated, and was acci-
dentally opened and the contents of the tubercular abscess
escaped. By careful dissection with Kocher's director and
scissors the vesicle, with about 1% inches of the vas deferens,
was removed without injuring the bladder or opening the peri-
toneal cavity. The prostate gland was found slightly enlarged.
In the left lobe a whitish spot was seen which was incised and
proved to be a small tubercular abscess. The abscess cavity
with a portion of the lobe of the gland was excised. The
wound was sutured and drained at each angle with tubular
and gauze drains. The first wound was then closed and drained
in a similar manner. Duration of operation two and one-
quarter hours. The wounds healed kindly and the patient
remains in perfect health, more than a year after the
operation.
This case appears to show more conclusively than
any other on record that a timely operation for sec-
ondary tuberculosis of the seminal vesicle, following
an ascending tuberculosis of the testicle, may succeed
in preventing the extension of the disease to the blad-
der and other portions of the urinary tract, and may
even result in a complete and permanent cure. If
the surgeon intends to remove both seminal vesicles,
there can be but little doubt that Zuckerkandl's
incision is the safest and renders the diseased organs
more accessible than any other. The operation is
greatly facilitated by placing the patient in the ven-
tral position with the pelvis elevated.
Tuberculosis of the prostate. — Sir Henry Thomp-
son (The Diseases of the Prostate, their Pathology
and Treatment, London, 1861, p. 283) is of the opin-
ion that the prostate is never the seat of primary
tuberculosis. He says: "It would appear that at no
period of the disease is the prostate affected alone.
Some other part of the genito-urinary tract is the pre-
liminary seat of the affection. In most cases the
deposit appears to take place first in the kidney, or,
at all events, to be present there in an early stage.
The organs next in order of liability to the disease,
among the genito-urinary group, is the testicle. Thus
in 18 cases collected by myself, in which the results
of postmortem inspections have been recorded, tuber-
culosis of the kidney is reported in 13, and of the
testicle in 7. The state of the lungs has, I suspect,
not always been recorded, but in 10 of these cases they
are stated to have been diseased."
Marwedel (Aus der Heidelberger Chirurgischen
Klinik des Prof. Czerny. Ueber Prostatatuberculose,
Klin. Beitrane, Bd. ix, p. 537) has written a valuable
monograph on tuberculosis of the prostate in which
he describes four cases that occurred in Czerny's
clinic, in two of which the disease appeared as a pri-
mary tuberculosis of this organ, and both were suc-
cessfully treated by laying open and curetting the
fistulous tract. In the other two cases temporary
benefit resulted from incising the periprostatic abscess
in front of the rectum and through the incision nearly
the whole sequestered gland could be removed. In
these cases the destructive process had extended to
the urethra, a considerable portion of which was
involved. Another fatal case was not subjected to
operative treatment; it was complicated by pulmonary
and testicular tuberculosis. These, as well as other
cases of a similar nature that have been recorded,
prove that the prostate may become the seat of pri-
mary tuberculosis. Tubercular disease of the prostate
is as a rule met with in young adults. Out of 26
cases collected by Socin, 13 were less than 30 years
of age. It can, however, occur in men advanced in
years. In one of Socin's cases the patient was 72
years old, who was suffering from the consequences of
an enlarged prostate, and several months later the
symptoms revealed extension of the tubercular process
from the prostate to the seminal vesicles, bladder and
ureters, resulting in death after a long period of
intense suffering. The primary nodules are situated
first in the vicinity of the tubules (Rindfleisch), and
not, as was formerly supposed, in their interior. By
confluence and caseation of the miliary gray nodules
large masses and cavities are formed which may be
found in one or both lateral lobes, while the middle
lobe is more rarely affected. The softening of the
caseous material leads to the formation of tubercular
abscesses which may rupture into the urethra. In a
case observed by Adams the abscess ruptured at the
same time externally in the perineum. Socin ob-
served two cases which terminated in rupture into the
bladder and in one case into the peritoneal cavity.
The abscess may also discharge itself into the rectum.
Much less frequent than softening is calcification of
the tubercular mass with arrest of the disease. It is
difficult to ascertain whether or not tuberculosis of
the prostate appears as a primary affection. Besides
the cases cited above Beraud and Pitha have observed
cases in which this appears to have been the case.
Postmortem examination, however, usually reveals
additional tubercular affections in adjacent or distant
organs. In cases of tubercular abscess of the prostate
it is difficult to ascertain the exact chronologic order
in the presence of additional tubercular lesions.
Socin saw two cases of what appeared to be primary
tuberculosis of the prostate. The patients were
respectively 28 and 30 years of age, both of whom had
contracted gonorrhea before symptoms of prostatitis
appeared. Examination revealed well-marked chronic
prostatitis without additional tubercular complica-
tions. One of the patients died of an acute renal
affection of only ten days' duration. The postmortem
showed disseminated cheesy foci in both lateral lobes
of the prostate, ulcerative nephritis and miliary tuber-
culosis of the peritoneum, the right pleura and liver.
In the other case, months after the appearance of
symptoms indicative of prostatitis and vesical catarrh,
18%.]
STENOSIS OF THE CERVIX.
187
bectio fever set in with symptoms pointing to renal
disease which rapidly proved fatal. The prostate was
found completely destroyed and its place occupied by
a tubercular abscess which communicated with the
urethra. The vesical mucous membrane was the seat
of numerous small ulcers, and at a point correspond-
ing with the orifice of the left ureter, a deep ulcer;
the left kidney was greatly enlarged: in the pelvis
large ulcers; in the substance of' the kidney many
small abscesses containing cheesy material. In two
other eases the tubercular prostatitis occurred in
phthisical patients. Socin is of the belief that in all
these cases the prostatic disease was primary. Of 26
eases of tuberculosis of the prostate collected by
Socin, of which ti came under his own observation,
the postmortem showed in 24 tubercular disease in
other parts of the genito-urinary organs, and only in
2 cases tuberculosis of distant organs, the lungs and
bones. .Most Frequently the bladder and kidneys
were found implicated, less frequently one or both
testicles. In one case in which the epididymis was
unquestionably the primary seat of the tubercular
process, the lobe of the prostate on the corresponding
side was similarly affected.
Symptoms. — There are no symptoms which are,
strictly speaking, characteristic of this affection of the
prostate. Undue frequency and pain in passing
urine, occasionally blood in the urine, and at times
the signs of cystitis, are commonly experienced.
Wasting and extreme debility slowly show themselves.
The symptoms present many things in common with
other forms of chronic prostatis. Only in oases in
which the disease is complicated by tuberculosis of
other organs are observed hectic fever, rapid loss of
strength, and marked emaciation. Adams has called
attention to the similarity of the symptoms with
those produced by stone in the bladder. Catheteriza-
tion is always very painful and should not be unnec-
essarily resorted to. In one case Socin observed soon
after it septic cystitis. Hematuria is often present,
but of no particular diagnostic value. Incontinence
of urine, which often appears during the advanced
stage, indicates extension of the disease to the
sphincter vesicae muscles. Marwedel found tubercle
bacilli in the urine in all the four cases reported from
Czerny's clinic. In one case they were also detected
in the urethral discharge.
Treatment. — Czerny obtained good results in two
cases which had terminated in abscess by laying open
the fistulous tract and vigorous use of the sharp spoon.
In cases in which the disease has not advanced to
abscess formation he advises Zuckerkandl's perineal
incision for exposing and removing the caseous foci.
Sir Henry Thompson advises conservative treatment,
avoiding instrumentation which, he claims, provokes
irritation and aggravates the disease without confer-
ring upon the patient any benefit whatever.
Horteloup ( De la Tuberculose g6nitale. Gaz. mid,
ilc /'oris, Nov. 25, 1892) recommends in the treatment
of isolated tuberculosis in any part of the genital
tract, with a view of preventing further extension of
the disease, the injection of a few drops of Lanne-
longue's solution of chlorid of zinc. In two cases of
tuberculosis of the prostate he made the injections
through a boutonniere incision, but the communica-
tion was made too soon after the treatment was sus-
pended to judge of its curative effects. During the
early stage of primary prostatic tuberculosis par-
enchymatous injections of iodoform glycerin emulsion
would appear to be indicated and might possibly
prove a valuable addition to the treatment of this
obstinate and unpromising affection.
(To be continued.)
A NOTE ON STENOSIS OF THE CERVIX
A FACTOR IN UTERINE DISEASE.
AS
Read lu the Section on Obstetrics and Diseases of Women, at the
forty-seventh Annual Meeting of the American Medical
Association, at Atlanta, Ga., May 5-8, 1886.
BY HENRY P. NEWMAN, A.M., M.D.
CHICAGO, ILL,
Twenty years ago, the subject of this paper was one
of the topics of leading interest in gynecologic cir-
cles. The literature of the day abounded with learned
and exhaustive treatises upon the pathology and treat-
ment of the affection.
The reputations of many of our pioneer gynecolo-
gists were founded largely upon their successful meth-
ods of operating for stenosis and the instruments they
invented to correct the condition, as to-day they often
depend upon the technique of the major surgical
procedures.
J. Marion Sims, Montrose A. Pallen, Sir Spencer
Wells, Savage, Greenhalgh, Barnes, Graily Hewitt,
Sir J. Y. Simpson, Peasely, Emmet, Routh and Ave-
ling, all these names and many more are associated
with the rise and progress of the phenomenal career
of a disease which is scarcely noticed in modern
literature.
For, notwithstanding the amount of literature that
was formerly written upon this subject, the hundreds
of operations recorded by older gynecologists, and
the nicely adapted instruments that remain as evi-
dences of the reality of stenosis of the uterine cervix,
there are some modern authorities who go so far as to
deny the very existence of this affection as an ana-
tomic fact.
Between this absolute negation and the over-zealous
devotion of years past there is a happy medium wherein
we may assign this undeniably important condition to
its rightful place as a causative factor1 in much of the
gynecic disease which abounds.
Stenosis of the cervix is anything but a rare affection.
The text-book classification names the congenital
and acquired forms. We are getting to know, more
and more, that nature makes few mistakes, and that
the abnormal conditions to be found at birth are
extremely rare. Malformations of the internal organs
of the fetus are still more rare than the various ortho-
pedic lesions of the exterior body.
Such cases as we have been in the habit of listing
as congenital are for the most part merely the persis-
tence of the normal natal condition, and should prop-
erly be called acquired.
This brings us in accord with the modern move-
ment toward the development of preventive medicine.
It may be said without fear of contradiction that
whatever may be acquired can be prevented.
This puts a great responsibility upon specialists in
all fields, and enlarges the scope and province of each
until the dividing line is nearly lost. Particularly is
this true of gynecology in its relation to pediatrics
and to obstetrics, since, with the exception of the rare,
malformations, and diseases due to specific infections,
and unusual traumatisms, nearly all gynecologic dis,.
eases have their origin in the physical errors of child,.
i Clinical Gynecology, Keating and Coe, page 201.
188
STENOSIS OF THE CERVIX.
[July 25,
hood and puberty, and the accidents or mismanage-
ment of the puerperium.
I have said that stenosis of the cervix is not rare.
It is a narrowing of the caliber of the canal, and may
be situated at the external os, the os internum, or may
include the whole extent of the canal.
This condition is recognized as causing sterility
and dysmenorrhea, by offering a mechanical obstruc-
tion to the entrance of the fecundating element, and
by preventing the free discharge of the menstrual
fluid. It is of its importance in this last respect that
I wish particularly to speak, and to call attention
more forcibly to our obligation to the science of
prophylaxis.
Whether, as some hold, menstruation has been
developed in the human female as a result of civiliza-
tion, a periodic protest against the progressive evolu-
tion of the higher attributes of the race at the expense
of the lower, or whether it is indeed a higher mani-
festation of a function associated with the reproductive
system in almost all varieties of animals, it is gener-
ally allowed that any abnormal disturbance of this
function is detrimental to the health of woman, and
a fruitful cause of gynecologic disease; particularly
does stenosis give rise not only to functional derange-
ments and actual structural disease in local organs,
but various neuroses, frequently of a most serious
character.
Dr. Montrose A. Pallen, in a prize essay read before
this Association in 1867, enunciated these proposi-
tions: "1. Menstruation irregular in its character is
always coincident with uterine disease. 2. All uterine
abnormalities tend to a deformity of the organ, either
in its neck or in its body, or both."
Ten years afterward the same writer gave to the
New York County Medical Society a resume' of the
subject, in which he states: " These propositions are
correct in the main, without being absolutely and
invariably true, particularly with regard to the first,
as irregular menstruation may depend upon systemic
causes, wherein the uterine disease is but functional
and symptomatic.
" However, so correct is the principle that we may
accept it without cavil, when we remember that the
healthy functioning of any organism necessitates a
healthy condition for its performances.
" No unhealthy cause can produce healthy effects;
therefore from a uterus abnormal can no healthy men-
strual flux proceed."
The pathology of Pallen and Schroeder is nearly
thirty years old, but it is still so acceptable that I
quote 'it here:
"The uterus undergoes involution every month
during menstrual life, and if this process be retarded
in consequence of congenital defect of development,
or from pathologic accident, the woman's condition is
in no wise ameliorated, unless pregnancy should super-
vene or art interfere.
" After a longer or shorter period of monthly ago-
nies, the tissues of the cervix become indurated, fre-
quently atrophied, the recently formed connective
tissue becomes cicatricially retracted, the vessels
become imperforate and the young mucoid connec-
tive tissue becomes firm and infiltrated.
" The Uterus again diminishes in size, and on sec-
tion exhibits an exceedingly firm, almost cartilaginous
tissue, which creaks under the knife and has an ane-
mic, cicatricial appearance. Whenever this condition
exists, either in the intra-vaginal cervix or at the
internal os, we may expect to find stenosis of the
canal with a very small os externum."
A cervix, therefore, presenting these peculiarities,
must exert a very injurious influence on a woman's
health in so far as it depends upon the regular and
normal performance of the menstrual function.
In a uterus which seems to have a fairly free outlet
at the cervix, the hyperemia which accompanies the
monthly molimen may bring the walls of the cervix
so closely into apposition that the flow is materially
retarded and the secretions more or less retained.
Retention of the secretions gives rise to an elaborate
sequence of gynecologic evils, chief of which are
endometritis, metritis, salpingitis, oophoritis, etc.
When we observe the sufferer from chronic endome-
tritis with her long train of general and special ills; her
dyspepsia, neuralgia in different localities, headache,
backache, anemia, her many nervous symptoms and
her very natural mental depression, we can not but
be convinced of the grave importance of all causative
factors which can be traced in the etiology of her
trouble.
In the milder types we know what these conditions
mean, either a prolonged course of routine and palli-
ative treatment, or the more radical surgical pro-
cedures.
In the graver degrees where there has been exten-
sion to the tubes or ovaries, oophorectomy, ovariotomy
or hysterectomy may become necessary, to remove the
local effects of disease, but not always with hope of
the reestablish ment of normal health in a constitution
injured and disturbed by long presence of diseased
conditions.
In other branches of medicine rapid strides have
been made of late in the theories of the causation of
disease.
Ophthalmology, for instance, has invaded the
schools and with the help of public sanitation has
insisted upon the better lighting of study rooms and
public buildings.
The public are now looking to the medical profes-
sion with awakened interest as the conservator of the
nation's health, and are offering cordial encourage-
ment to the progressive effort for better conditions of
physical life.
In our large universities there are already great and
liberally endowed departments for the study of phys-
ical and sanitary problems, and the educational depart-
ments are no longer content with the old system of
cramming the head with a conglomerate assortment of
samples of many kinds of knowledge.
Instead, there is instituted the study of psychome-
try and psychology, with physics and the education of
the child practically begins back in the embryonic
period. Shall gynecologists be looked upon as a class
who exist merely to batten on the ills of womankind,
and who find their excuse for being, in the evils
resulting from ignorance of the laws governing the
hygiene and development of the female generative
organs?
The place of rightful occupation for this specialty
of ours is the highest we can hope to attain, and no
higher could be desired, as custodians of woman's
health and the leaders in the advance movement for
improving all social and educational conditions which
are mainly operative in the production of disease. To
accomplish the needful reforms in this direction we
must insist upon the better hygiene of puberty. In
this I am convinced we would have generous public
i
1896.]
STENOSIS OF THE CERVIX.
189
!
recognition and cooperation. There is among the
higher educational circles already a tendency to
demand for girls the same physical advantages that
an- in vogue in our boys' colleges. But the higher
private institutions can reach but the outer edge of
this universal necessity. In our public schools and
workshops the girls of 12 to 1(5 years of age are still
plodding many times a day up and down long flights
of stairs, sustaining the working hours of the day with
food into which little real nutritive value enters.
They are still housed up in over-crowded, ill-venti-
lated apartments, when they should be breathing free
draughts of vitalizing air and exercising their grow-
ing muscles in unobstructed sunshine.
I have said that at this period nature is supremely
concerned with the development of the generative
organs.
In the rapid transition from childhood to maturity
the activities here generated demand full general
nutrition and conservation of the entire physical
constitution.
But at this period the growing woman is pushed to
her utmost to support the intellectual and emotional
faculties.
The rich current of the young circulation is turned
into the channels opened by music, science and art,
and being insufficient for these, the physical organs
must suffer positively or relatively.
It is at this age, too, that the feminine organism
begins to come under the dominance of the destruc-
tive power of custom in conventional dress and
manners.
The first corset is put on and the growing body
thereby constricted and deprived of the necessary free-
dom of respiration and circulation.
Is it any wonder that the process of pelvic develop-
ment is often summarily interfered with and the
infantile uterus with its small body and long conical
cervix which should have changed entirely in con-
tour and dimensions, remains as it was, with elongated,
constricted canal and partially developed tissues inade-
quate to perform the functions so soon to be demanded
of if?
In the radical changing of these conditions lies
the rational basis of the treatment of cervical stenosis.
This is a most striking instance of the importance of
preventive treatment, and I appeal to my colleagues
to use the same diligence to bring about a better
environment for the developmental period of puberty
as you have done in eradicating the causes of the once
dreaded puerperal infections; the same zeal you have
shown in establishing upon its present high plane the
greatest prophylactic factor in modern surgery, clean-
liness, and as our colleagues in general medicines are
showing in their struggle for the prevention of all
contagious and other diseases which arise from the
wide-spread ignorance and neglect of nature's laws.
34 Washington Street.
DISCUSSION.
Dr. Wm. A. B. Sellman, Baltimore — At the last meeting of
this Association I discussed this subject, and the relation
which it bears to other pelvic diseases. I thought at that time
that diseases of the cervical canal between the external and
internal os were very often the cause of most serious trouble.
We find many young women suffering from painful menstrua-
tion due to retained menstrual fluid. If we do not recognize
painful menstruation as due to mechanical obstruction it is
impossible to relieve it. At the last meeting I spoke of a
means of curetting these cases, and I said that dilatation was
of little or no avail, because the tissues would contract again,
so that the good accomplished by dilatation is overcome by the
involution which takes place after the next menstruation. My
idea in these cases is to remove a portion of the tissue. The
tissue is undeveloped on account of various causes, due to bad
nutrition and bad habits during girlhood. The question is
how to remove the diseased membrane which brings about the
various conditions. It is not normal mucous membrane ; it is
converted into denser fibrous tissue, and my method is to
remove it, not by dilatation, but to ream it out by the reamers
which I showed at the meeting last year, and my results have
shown that the dysmenorrhea is overcome. Girls who have
suffered month after month have been relieved after the second
or third month. The canal is sensitive after the removal of
this tissue, but after the second or third month perfect
relief is secured, provided a reamer large enough has been used.
Dr. I. S. Stone, Washington, D. C— I think there are
many cases of dysmenorrhea that are not relieved or cured by
dilatation. For instance, a young girl, 19 years of age, in
which dilatation was carried to such an extent that I could
introduce my index finger and it would pass through the inter-
nal os. She has no apparent ovarian disease, yet suffers very
much every month. I fail to see why Dr. Sellman's instru-
ment is any better than a curette in skillful hands. With a
sharp curette we can remove the same amount of tissue,
whether we do it in the same manner or not.
Dr. Rufus B. Hall, Cincinnati — I think the most essential
and difficult point to determine is the selection of cases in
which we expect to afford relief either by dilatation of the
cervix or by the operation proposed by Dr. Sellman. If we
expect to cure dysmenorrhea by dilatation of the cervix or
reaming it, as he terms it, by making the cervical canal larger
in all cases, I think we will be disappointed in our results. It
is not always possible to say that in a given case there is not
local trouble above the cervix as a cause of the dysmenorrhea,
and the narrow cervix of the patient may only play a minor
part in the causation of her suffering, and it is not always
possible to say that the cervix has nothing to do with the
patient's suffering. We must go back and find out where the
real trouble is. It may lie in non-development of the parts. I
can see where we might, by curetting away sufficient cervical
tissue to leave a large opening, bring about a still worse condi-
tion than we would have following dilatation of the cervix or
the reaming-out process by the formation of cicatricial tis-
sue. Therefore, in either operation, dilatation or the reaming-
out process, or stretching the cervix, can we expect to relieve
all of these cases? I do not think it is possible to differentiate
every case before we operate, that is, to exclude trouble above
the cervix, or a neurotic condition which has been the cause
of the patient's suffering.
Dr. Newman (closing) — There is little more to be said. Here-
tofore the treatment of stenosis of the cervical canal has been
considered by gynecologists as unsatisfactory. It is true that we
accomplish a great deal by operative procedures and by instru-
ments judiciously employed, but the condition returns unless
auxiliary treatment is instituted. The object of the paper
was to get behind the local treatment and remedy the evil
before it began. This is the first responsibility of the profession.
The little instrument that I have passed around is designed
for the class of cases we have with us, and presumably will
have, in spite of any precautions, for all time. It has a pur-
pose, but it is not intended by any means to supplant other
treatments that are now in vogue.
A Lesson in Prognosis. — Boston Mamma : "Suppose you have
four bunches of grapes, Willie, and eat three, then what
would you have?" Boston Boy: "Appendicitis." — Up-to-
Date.
190
HOW TO KEMOVE PUS TUBES WITHOUT KUPTURE.
[July 25,
HOW TO REMOVE PUS TUBES WITHOUT
RUPTURE.
Read in the Section on Obstetrics and Diseases of Women, at the
Forty-seventh Annual Meeting of the American Medical Associa-
tion, held at Atlanta, Ga., May 5-8, 1896.
BY I. S. STONE, M.D.
WASHINGTON, D. C.
The contents of pus tubes may not be infectious,
but it is desirable to avoid the usual soiling of peri-
toneal and wound surfaces wTith any kind of pus. It
is, therefore, in the opinion of the writer, better to
make a longer incision, to tie the ovarian and ovaro-
uterine arteries and free the specimen at one or both
ends or sides before attempting enucleation.
The method about to be described can be used in
any case; the simple ones are always easy work, but
it is in the difficult cases, where there are many adhe-
sions and a large quantity of pus present, that the
writer has found the greatest satisfaction in-adopting
the following plan:
METHOD.
Clamps are placed upon one of the tubes, closely
hugging the uterus. The clamp may embrace about
one inch of the broad ligament in its bite. The
ovarian artery is either tied or clamped as near the
pelvic wall as possible. A ligature may be placed on
each severed end or placed before section if preferred,
the incision to be made between these points. No
bleeding of importance can occur after this, while
the surgeon can leisurely enucleate the tube or ovary
with contents safely, and with infinitely greater ease
than after the ordinary fashion. In many instances
the appendages can not be as readily rolled out from
behind as from the front, and the separation from
the broad ligament is often easier than from the
bowel if strongly adherent. But the most important
assistance given the operator by this method is the
great amount of space afforded. There is plenty of
room to work, as the tube comes right up when sepa-
rated from the uterus. Quite naturally many pus
sacs rupture easily, and this method will not prevent
soiling the peritoneum in every instance, but that
it will do so in most instances I know from frequent
observation. Finally, a very serious defect in the tech-
nique of many operations is found in the large and
infectious stump of the tube left after removal of
the adnexa. Here an exsection of the cornua is
demanded and is provided for in the beginning of
the operation. The ovaro-uterine artery is ligated, the
forceps removed and another deeper ligature used if
much bleeding occurs. Then the exsection and sutur-
ing of the cornua is rapidly and easily done. The
same technique is used on the remaining side and
needs no further demonstration. The operation is
easier in the Trendelenburg posture with a good light.
I have used no flushing or drainage in any case of
this kind for the past five months, and have had
no sepsis in the wound or rise of temperature, or
peritonitis or other trouble consequent upon this
technique. In some cases rupture will occur in spite
of the greatest care, but if a sponge is properly placed
all the pus can be caught and flushing and drainage
avoided.
SUMMARY.
This methed gives more space for careful enucle-
ation. The larger blood supply is tied off at once.
Smaller silk or catgut can be used as no en masse
ligatures are used. The ligatures and sutures are
not infected. No sinus will be formed. There can
be no possible danger of hemorrhage after operation.
No ligatures can slip. If rupture is avoided there
is no need of flushing or drainage save in very rare
instances, when time can not be given to careful
suturing, which must be the rare exception. It facili-
tates enucleation by affording another point of cleav-
age, namely, from the anterior surface of the pus sac.
Finally, it facilitates exsection of the uterine cornua.
The sketch gives a good idea of the steps of the
operation and the appearance of the uterus and broad
ligament after operation. The uterus can be removed
in addition to the adnexa if the surgeon so desires.
The specimen here exhibited was removed on the 20th
ultimo. It is very large and came from the left side.
The right tube was small and a small amount of pus
escaped before I knew I had a pyosalpinx to deal
with. The patient recovered without trouble of any
kind.
DISCUSSION.
Dr. John M. Duff, Pittsburg — I feel that with our modern
experience in dealing with pus tubes, especially where the
infection is of gonorrheal origin, that the patient would have
been in less danger of infection and the subsequent history of
the case would in all probability have been much better if these
pus tubes had been removed through the vagina.
Dr. Charles P. Noble, Philadelphia — 1 think all who are
operating on pus tubes after the method of Tait, and who
have adopted this method or one similar to it, can appreciate
the great advantage which both the patient and operator have
in such a method. I have been operating very much in this
way for a year and a half and have been able to remove the
great majority of pus tubes without rupturing. The method I
have used is the same in principle. I agree with the author
of the paper as to the facilities with which we can remove pus
tubes in the majority of cases by this method without rupture.
The author of the paper said nothing about special precau-
tions except using a sponge in case the pus tube be ruptured.
My own practice is to pack off the peritoneal cavity with folds
of gauze, also to have some dry gauze packed behind the pus
tube, so that should it rupture we will be in a position to get
any pus that should be discharged. It is seldom necessary to-
rupture pus tubes unless they are down in Douglas' pouch.
There are cases in which this technique is not feasible. We
would necessarily rupture a certain percentage of them. Fre-
quently I find it not only necessary to take out the pus tubes
but the uterus as well. It has been said that leaving the
uterus behind causes the patient no special difficulty. My
own experience has been different from that of many writers
on this point. By ligating the uterine arteries as well as the
ovarian, we can do without drainage, when otherwise we would
have to employ it.
Dr. L. S. McMurtry, Louisville— I call the attention of the
Section to one point in connection with the class of cases under
discussion, Which I am sure all familiar with them will recog-
nize as the most difficult that are encountered in operations —
cases of suppurative salpingitis and complications that result
are certainly most difficult of all cases in pelvic surgery for
operation ; and they present, at the same time, the very great-
est variety of almost any class of cases we have to deal with
in an operative way. The number of cases of suppurative
salpingitis must be comparatively limited where the method
that Dr. Stone has described and practiced so successfully can
be applied. It is very common for these adhesions to be so
firm that you can almost lift a patient off the table by them.
It is also common for adhesions to the bowel, to the uterus, to
the floor of the pelvis to be very strong, and these refinements
of operative technique just described are difficult of applica-
tion. If we endeavor to apply Dr. Stone's method generally
1896.]
HOW TO REMOVE PUS TUBES WITHOUT RUPTURE.
191
wi- will meet with many disappointments. I am sure that any
technique which contemplates dealing with large accumula-
tions of pus in the pelvis, with the degenerations and cheesy
deposits to take place, and dispense with irrigation au.l drain-
age will be followed by a large number of disasters. Further-
more, the very character of the tissues themselves that are
rotten from disease, in a large proportion of cases, forbids such
a nice dissection as has been described.
1>k. E. E. Montgomery, Philadelphia This is a class of
•cases that render pelvic operations much more difficult than
any witli which we have to deal, but in dealing with such cases
1 should much prefer to remove the pus tubes through the
vagina rather than by the abdominal method. We have in
"these eases large collections of pus, where the tube from its
weight gravitates into and fills up the pelvis, is shut off more
or less from the general peritoneal cavity, and can be entered
and reached through the vagina prior to the operation for
the removal of the mass itself. Having in this way thoroughly
evacuated and irrigated the cavity, we have then to deal with
the tubes, shell out the sac and the uterus itself. The rea-
son why I prefer to go through the vagina in the treatment
of these cases is that we are not only able to remove the
tubes and ovaries but also the uterus. After removal of both
ovaries the uterus is no longer an organ of any special advan-
tage to the individual. More than this, the trouble has orig-
inated in the uterus, and from it the disease has extended to
the tubes and ovaries, and the increased connective tissue
suits subsequently in a decrease in size of the organ, with
more or less contraction of the nerves in the uterine walls.
Patients frequently, after successful removal of the ovaries
ad tubes, suffer for months and perhaps years. The uterus
then should be removed along with the ovaries and tubes in
these cases.
Dk. R. S. Sutton, Pittsburg — There is no doubt but that
the method which Dr. Stone has illustrated here is an improve-
ment over the method of Tait in getting under the pus tube
and shelling it out, when prolapsed and adherent, but does it
follow that the pus contained in these tubes is very frequently
infectious pus. Any gentleman who has endeavored to find
the gonococcus in pus following gonorrheal infection will
remember how often he has failed. He will often fail to find
•either the staphylococcus or the streptococcus. He may find,
as Etheridge has done, the pneumococcus occasionally, or the
bacillus coli communis. I endeavor, when I am operating in
a case of pus in the pelvis, to have a bacteriologist in the oper-
ating room, give him a little of the material removed, wait a
moment or two and then he tells me whether there are any pus
producers found. If there are no pus producers I shut the
cavity up. If there are pus producers in the cavity and you
do not insert a drainage tube, you will lose your patient. The
man who does the operation by the vaginal method under these
circumstances will not lose his patient.
Dr. Noble tells us that he takes out the uterus in these
but tells me that he leaves the cervix in. That is not
taking out the uterus. It is amputating the uterus at the
upra-vaginal junction, and amputation of the uterus at the
supra-vaginal junction and total extirpation of the uterus are
two different things, mechanically and pathologically.
Dr. J. W. Bovee, Washington, D. C. — I have found in some
of these cases that there is a great deal of exudate around the
outer end of the pus tube or around the ovarian artery, and
sometimes there is danger in ligating the outer end of this
mass in the womb first. I operated in this way recently and
after I had ligated the stump containing the ovarian artery
and had cut it off, grasping the other end with the forceps, I
found I had cut off the ureter. It was in the stump. In
eparating the adhesions the ureter had been lifted • up. I
ad nothing left to do but to take off the ligature, extirpate
eyond the ureter and do an end-to-end anastomosis.
Dr. Howard A. Kelly, Baltimore — My plan in the removal
of pus tubes is, in all of those cases where there is a pus
sac, to aspirate and empty it as much as possible ; then free
the tube and surround it with gauze packing made of many
thicknesses to prevent further contamination during the
handling. In the rest of the enucleation I take out the tube.
If the other side is diseased I take out the other, with it by
supra-vaginal amputation. But I rarely do that. The impor-
tance of this matter hinges on the bacterial contents of the
tube, and while in all cases we ought to be very careful, the
dangers of contamination are slight. Two years ago, in Jan-
uary, without knowing similar work was being done on the
other side of the water, I had a microscopist in my operating
room to examine under the microscope any pus which appeared
to contaminate the peritoneum in any way. If no microorgan-
isms were found, no drainage. If the gonococcus was found,
no drainage. If found abundant, probably staphylococci or
streptococci, drainage in all cases.
Dr. A. Vander Veer, Albany — I do not intend to discuss
this excellent paper, but I feel like asking Dr. Stone if he has
examined the contents of this tube. (Tube on exhibition in
Section. )
Dr. Stone— I have not.
Dr. Vander Veer — Are you absolutely sure it contains pus?
Dr. Stone — I am. I know it does.
Dr. Vander Veer— It looks to me like a hydrosalpinx. In
operating for pus within the pelvis, I have no reason to deviate
much from the method of operating in these cases, as I do
nearly the satne operation that I did years ago. We must
remember that this is one of the simplest forms of pus tubes
we have to deal with. The adhesions are not so strong but
that you can loosen the tube. If one could have a bacteri-
ologist present to tell him the kind of microorganisms that
are found it would help matters very materially. But these
cases do not have much bearing upon the serious cases of pus
tubes that have gone on for two or three years and in which
you have extensive adhesions to the intestines, to the rectum,
and a long-standing condition of perhaps recurrent pelvic
peritonitis. When you attack these cases you have some-
thing far more serious to deal with. This operation must
be limited to few cases. There are not very many cases in
which the doctor will be able to turn out so neatly such a
beautiful specimen as he has presented here.
Dr. Rufus B. Hall, Cincinnati — This technique can be
carried out only in exceptional cases. We can remove large pus
tubes easier than smaller ones which are imbedded in adhesions
in the cul-de-sac. We all know the great danger of secondary
hemorrhage after these operations, particularly in desperate
cases of suppuration. Several years ago I had to reopen the
abdomen of a patient on account of hemorrhage coming on.
She had been vomiting for some ten or twelve hours after
operation. The case was one of large pus tubes and the
pedicle was half cut off. In all of those cases where the
tissues are soft, instead of transfixing the pedicle I place a
ligature on the outer side of the tube and ovary, including
the artery from the pelvic side, then another separate liga-
ture beside the uterus, then I feel sure that the possibility
of secondary hemorrhage, from slipping of the ligature, or
cutting of the pedicle from tension on it will be obviated.
Dr. Stone— When I first began to operate on these cases
my technique was not as good as it is now. I do not drain
as much as I formerly did. If we can dispense with drainage
in these cases it is very desirable.
In reference to the "remarks made by Dr. Kelly, I will say
that if I can remove a vicious, malignant abscess without
soiling the peritoneum, I do not care whether a bacteriologic
examination is made of its contents or not. If we have an
infected pus tube, I think it is difficult to enucleate all of
the so-called infectious germs or germs of any kind. There
is more or less shock following irrigation and handling of
the intestines which is necessary in every case. I believe I
am correct in saying that all pus cases are not infectious.
192
PRESENT STATUS OF ECTOPIC PREGNANCY.
[July 25,
THE PRESENT STATUS OF ECTOPIC PREG-
NANCY—A SURGICAL DISEASE.
Read in the Section on Obstetrics and Diseases of Women, etc.,
at the Forty-seventh Annual Meeting of the American Med-
ical Association, held at Atlanta, Ga., May 5-8, 1896.
BY WILLIS G. MACDONALD, M.D.
ALBANY, N. T.
The surgery of ectopic pregnancy is mature rather
than old. It is little more than thirteen years ago
that Mr. Lawson Tait first deliberately performed an
abdominal section to rescue a woman dying from a
ruptured ectopic pregnancy. The influence of this
triumph in surgery is immeasurable. The number of
lives saved is innumerable. The literature of the
subject in text book, transaction, monograph and
journal is stupendous. Methods of operation have
been so far perfected that further progress in that
direction is not likely to occur. However, women are
yet dying the world over without any effort being
made for their relief, or even the condition being rec-
ognized during life.
In view of the great interest taken in ectopic preg-
nancy these deaths should, for the most part, be
avoided. Investigation will show that much of the
literature is controversial in character. The disputed
pathology and methods of treatment in ectopic preg-
nancy have already employed too much type to the
detriment of sound diagnosis. While fine anatomic
and pathologic distinctions are abstractly valuable in
abdominal surgery, yet they do not always possess
life-saving qualities. The minds of those who have
studied carefully at the operating table and in the
laboratory the intra-abdominal conditions found are
often harassed by serious doubts. The demonstration
of beautifully made, frozen sections do not always
convey to every mind correct impressions. It is a
sad commentary to have a man argue the probability
of ovarian pregnancy with you while his patient is
bleeding to death in the next room. He has lost the
nucleus of the thing; it is the bleeding, not the pos-
sibilities, that demands action.
After all that has been said and written, I am
inclined to the belief that, stripped of their contro-
versial portions, the lectures of Mr. Lawson Tait, pub-
lished in 1888, present about all there is concerning
the matter. Mr. Tait wTas direct in his language; his
■ pathology was simple; his operative technique was at
once rational and successful. Further progress lies
along the lines of simplicity in pathology, clearness
in diagnosis, and definiteness in treatment. The gen-
eral practitioner must be made to do this part, but first
he must be taught the clinical history and diagnosis.
Discussions of jwimary abdominal ectopic pregnancy,
the living placenta, or electricity, are of no value
when measured by diagnosis. It is upon these points
that it is my purpose to dwell.
How much of fully demonstrated pathology is really
useful in diagnosis and subsequent treatment of
ectopic pregnancy? That all ectopic pregnancies are
primarily tubal is demonstrable with so few excep-
tions that they need not be considered in the subse-
quent management of the condition. They remain
tubal until rupture or abortion occurs. Tubal abor-
tion, or the expulsion of the developing ovum from
the fimbriated extremity of the tube into the abdomen
may occur at any time between the second and eighth
week of gestation. It is neither a complete discharge
into the abdomen or incomplete, being arrested in the
fimbriated extremity, and gives rise to the so-called
tubo-ovarian, or tubo-abdominal pregnancies. Rup-
ture at the site of primary attachmant is, however, the
more common mode of tubal delivery, occurring at
any time between the second and sixteenth week.
Rupture is coincident with the period of greatest pos-
sible distention of the Fallopian tube. If the ovum
develops in the uterine end of the tube and uterine
tissue is involved in the walls of the gestation sac, the
pregnancy is said to be interstitial; if in the middle
portion, infundibular; if in the fimbriated extremity,
ampullar. With rupture the ovum is, either wholly
or partially, discharged into the broad ligament or
the peritoneal cavity, and its life usually destroyed by
the accompanying hemorrhage. Where the intra-
peritoneal delivery is incomplete or it occurs between
the folds of the broad ligament, gestation sometimes
continues until secondary rupture and renewed hem-
orrhage or term is reached. Hemorrhage into the
membranes of the ovum may occur while it is yet
within the Fallopian tube, and lead to fetal death
and the development of a tubal mole. Bleeding more
frequently destroys the fetus than the mother, in the
first four months of gestation.
The contention that all ectopic pregnancies con-
tinuing until viability are developed between the
folds of the broad ligament, is not borne out by con-
ditions found on the operating table or in the labora-
tory. Repeated hemorrhage without secondary rup-
ture of the gestation sac may destroy abroad ligament
pregnancy at any period of gestation. Suppuration
within the sac may lead to the discharge of the fetal
bones and other detritus into adjacent cavities, or
through the abdominal walls. Anqther termination
is the formation of lithopedion and adipose. The
child dies during or at the conclusion of spurious
labor. The death of the placenta is not always coin-
cident with that of the fetus. There are a number of
cases illustrating this fact, one of which in my per-
sonal observation will be reported in connection with
this paper.
The children who have been delivered living from
ectopic gestation sacs, have many of them shown lit-
tle post-natal vitality, fully half dying in the early
days, and very few living beyond a year. Again,
many of them show gross deformities, hemiplegia,
spina bifida, cleft palate, hare-lip, contractions of the
limbs and club-foot.
The uterus always undergoes sympathetic enlarge-
ment, and from its mucous membrane develops a
decidua, corresponding very closely to that of early
uterine pregnancy.
From a careful analysis of my own cases, and the
experience of others, I believe that the foregoing
pathologic statements are all that are fully demon-
strated, and further, they are all that are needed for
the proper understanding of the diagnosis and treat-
ment of the condition.
DIAGNOSIS.
The importance of diagnosis can not be overesti-
mated in ectopic gestation, yet its difficulties are at
once serious, if not at times insurmountable. The
history of ectopic gestation is largely that of opera-
tions undertaken after rupture and hemorrhage, or
after viability. Those operations done before rupture
were often a matter of accident, or the patients were
in unusually favorable circumstances. That most
cases of ectopic pregnancy are first seen by the gen-
eral practitioner, will not be disputed. Here is the
189H.J
PRESENT STATUS OF ECTOPIC PREGNANCY.
193
point : Tlic general practitioner is bound to possess a
knowledge of the natural history and diagnosis of this
disease that will keep in his mind the possibility in
every woman, married or single, during her child-
bearing period of this condition. Suspicion, with
competent consultation, is the best substitute for pre-
cise diagnosis with which I am familiar. The pro-
fession at large have suspicions of appendicitis under
proper conditions, and if under other circumstances
their suspicions of ectopic pregnancy can be aroused
and skilled assistance called, then will a considerable
advance have been made. The reason is obvious. In
appendicitis, a clear, unmistakable and unequivocal
statement of facts have been so briefly and repeatedly
made, that all are familiar with and governed by them.
All the statements are not absolutely or entirely true.
There are exceptions to many of them, but they are
sufficiently general in their application to form a uni-
versal basis for opinion and action. What is wanted
is a similar primer of ectopic pregnancy. On reflec-
tion, it will be seen that the difficulties attending such
a plan are many. There are general considerations
which apply to the condition. That all women suf-
fering from ectopic pregnancy have previously suf-
fered from some disorders of the organs of generation
is a fallacy. In three of seven cases reported at the
conclusion of this paper, there was no history of prior
generative disorders. One with a baby, the youngest
of rive children •. another with a good previous history
a few months married, and still another the mother of
three young children. The other cases present a
variety of conditions, sterility, displacement and
inflammatory disease.
In order to discuss the diagnosis intelligently, sub-
divisions must be made. Clinically the most natural
ones are: 1. Before rupture or tubal abortion. 2.
After rupture has occurred. 3. The fetus a, living
and viable, or b, dead.
The difficulties of diagnosis before rupture or tubal
abortion are very great, and its possibility will not be
admitted by all. The greater number of cases are not
seen by a physician until rupture or abortion occurs.
A minority come to the operating table for inflamma-
tory disease of the appendages. There is a lack of
symptoms pointing to the condition. The patient
either believes herself normally pregnant, or has no
suspicion of it. Nausea and vomiting may be pres-
ent, with amenorrhea and mammary changes. The
metrorrhagia of ectopic pregnancy does not occur, in
the majority of cases, until after rupture or symptoms
of impending rupture present. The one particular
point upon which diagnosis depends may be stated as
follows: Any woman who during her child-bearing
period presents symptoms of disease of the organs of
generation, of recent origin, either new or entirely
different from those heretofore experienced, if associ-
ated with any of the probable early symptoms of
pregnancy, demands at once a careful examination.
If this point can be made sufficiently clear, many
more cases will be operated on before rupture occurs.
When rupture or tubal abortion occurs other symp-
toms arise which at once brings the physician to the
bedside. There that general rule, "Pain in the abdo-
men calls for careful investigation," always applies.
The clinical history is of exceeding value in making
cle,ar this point. The pain associated with rupture
or abortion can only be mistaken for appendicitis,
biliary or renal colic, acute intestinal obstruction, or
uterine abortion. With a full clinical history and a
careful physical examination, the diagnosis will be
positive. Very few errors have been made and the
abdomen opened to find another condition present.
Few exploratory incisions are made in ectopic preg-
nancy.
Too great dependence can not be placed upon the
expulsion from the uterus of decidual membranes.
In a recently reported case where the diagnosis was
chiefly based on that fact, no ectopic pregnancy was
found at the operation. Membranous dysmenorrhea
is associated with the expulsion of similar uterine
casts. It is valuable rather than pathognomonic.
Collapse is always an important symptom, and its
source is to be carefully studied whether it arises
from simjjle pain or pain associated with hemorrhage.
It is not to be forgotten that many intra-abdominal
conditions may give rise to collapse. Pain as a source
of collapse is not always easily differentiated from
bleeding or extravasation, with pain. In collapse
from pain or fright, the administration of anodynes
and the application of local heat is followed by reac-
tion. The collapse from progressive bleeding is con-
tinuous, with little disposition to reaction.
After primary rupture, the fetus yet living, if the
woman does not die or the fetus is not destroyed by
the hemorrhage, gestation proceeds until the viability
of the child becomes a contingency, or secondary
rupture occurs. Very few of this minority ever reach
term.
Defective clinical histories may make diagnosis
very difficult. The bi-cornate uterus, uterine fibroids,
may make the diagnosis difficult or impossible, and
exploration of the cavity of the uterus unwarrantable.
Under such conditions the patient ought to be under
the most favorable auspices and in bed.
A sufficient number of cases of current intra- and
extra-uterine pregnancy have occurred to keep its
possibility in the mind of the surgeon. The preg-
nancies may date from entirely different periods.
The most serious form of ectopic pregnancy is
undoubtedly the interstitial. Unfortunately it gives
rise to fewer direct symptoms than any other variety,
yet when the rupture does occur the attack is explo-
sive. The woman quickly bleeds to death within her
abdomen. Four hours of inaction is quite sufficient.
TREATMENT.
What are the indications for. treatment in ectopic
pregnancy? The question may be conclusively an-
swered by the phrase — a diagnosis. There are excep-
tions, but they are for the personal opinion of the
experienced surgeon. What is the treatment? This
also can be answered briefly in the interest of the
patient — operative. Competent operators are so
numerous and so successful in every part of this land
that no excuse can be offered for non-surgical inter-
ference. When shall we operate? As soon as a
diagnosis is made. Time forbids entering into the
discussion of injections into the gestation sac to
induce the death of the fetus, or the application of
electricity in the treatment of ectopic pregnancy.
These plans have been so repeatedly discussed and so
universally condemned that nothing is to be gained
by further consideration. If there be an advocate
(there are a few yet living) of the use of electricity
present, I can not hope to convince him, and admoni-
tion does no good.
It is quite superfluous to enter into the detail of'
operations to be undertaken at any period of ectopic-
194
PKESENT STATUS OF ECTOPIC PREGNANCY.
[July 25,
pregnancy, but certain subjects inevitably confront
us : The position that vaginal celiotomy will assume
in the treatment of ectopic pregnancy, the control of
hemorrhage during operations undertaken at all peri-
ods, the time of operation, the child living and viable,
the management of the placenta in operations under-
taken after the sixth month, the management of cases
where operations are to be undertaken for the removal
of the dead fetus, either disintegrating or degener-
ating, the management of the general condition of the
patient at the time of the operation.
The patient's general conditions and surroundings
will influence the time and place of operation. Where
rupture and progressive hemorrhage are not coinci-
dent, operation is to be undertaken deliberately under
the best hygienic conditions. Progressive hemor-
rhage into the free peritoneum is emergency surgery,
and operation must be done without delay. An oper-
ation can be well under way an hour after the diagno-
sis is made. In many cities there is an ambulance
service. You call it from the nearest telephone and
at the same time order the sterilizers lighted, and
other preliminary preparations made. The patient is
wrapped in blankets and is taken from the ambulance
directly to the table. During early anesthesia the
abdomen is prepared for incision. The direct or
intermediate transfusion of normal salt solution is a
valuable measure in collapse, far more than the hypo-
dermatic administration of stimulants, and can be
employed at any period by very simple apparatus.
The experience of many operators has repeatedly
shown the life-saving properties of saline transfusion.
The control of hemorrhage is the first indication in
most operations undertaken in the early months of
ectopic pregnancy. The first efforts of the surgeon
are directed to that end, and with all the speed com-
patible with good surgery. First determine the side
of the ruptured tube, and place a clamp on the broad
ligament close to the uterus. When the pregnancy is
interstitial, clamp both broad ligaments. These
measures will control the bleeding at any period of
gestation. The subsequent steps of the operation can
be undertaken with greater deliberation. Usually
they are simple enough, enucleation or suture of the
gestation sac into the lower angle of the wound, the
removal of the damaged appendage. In interstitial
pregnancy, complete or supra-vaginal hysterectomy,
or the resection of the horn of the uterus will be
required. The choice of method will depend upon
the experience of the surgeon and the condition of
the patient. Hemorrhage during the later months of
ectopic pregnancy from the site of living placenta,
the fetus often dead and macerated, is most difficult
in management.
Out of a large number of cases delivered at or about
term the most serious difficulty experienced was in re-
lation to the placenta. Two plans have been suggested :
its removal with multiple ligature, and tying the
cord close to the placenta, closing the abdomen in the
hope that subsequent abortion will take place. Both
methods have succeeded and failed. A third plan has
suggested itself to me: first preliminary ligature of the
ovarian and uterine artery on the side from which the
placenta receives its blood supply, second the placing
of Mickulicz tampon of sterile gauze over the placenta
establishing -pressure atrophy; third, preliminary
suture of the abdominal walls, the sutures to be tied
after the removal of the tampon and plaeenta. Such
a tampon may be safely left for three days, and then
removed with the placenta, and the sutures tied. I
want to add that in two cases where the fetus had
died, become macerated and disintegrated, that oper-
ations undertaken through the rectum were followed
by fatal hemorrhage from a yet living placenta. Both
of these cases should have been attacked by abdomi-
nal section.
The child living and viable, what shall be done? A
considerable number of mothers have been already
sacrificed while waiting for term to arrive. A surgeon
recently described as a triumph in surgery, the saving
of a child suffering from pressure hemiplegia and spina
bifida. Another civilization of another and less human
age conducted such to the unknown early in their
careers. To-day the number of children a year old and
undeformed, who had their origin in an ectopic gest-
ation sac, can be counted on the fingers of one hand.
The living child is subsidiary to the living mother.
Vaginal operations undertaken for the relief of
ectopic pregnancy will always be limited, yet early
cases may often be remedied by this method. Where
suppuration in broad ligament pregnancies has
occurred, there can be no doubt of the value of this
method in many cases, an abscess, incision and drain-
age through the vagina.
There remains yet another topic in relation to the
treatment of this condition, that of the opposite ovary.
No question can arise where gross pathologic changes
have already occurred. It is worthy of our attention
that subsequent ectopic pregnancies have occurred
in appendages left at operations. The other ovary
and tube should be carefully examined and removed
if any evidences of disease are found to warrant the
procedure. The question is placed largely on the
same basis as unilateral removal of the appendages
for inflammatory conditions.
In conclusion, the histories of seven cases of ectopic
pregnancy are given with the results of treatment,
five recovered and two died. One death to be attri-
buted to an improper operation advised by me, the
other (easel) to carelessness or want of knowledge
upon the part of the gentlemen who were in attend-
ance during the earlier period of gestation. I believe
that the clinical histories given, together with the
results of the physical examination, lead to an irresist-
ible diagnosis of- the condition.
Case 1. — Mary R., aged 38, married, native, wasseenAugust
16, 1894. This patient was seen only a few hours before death.
Between the second and third month of a supposed normal
pregnancy, she had a severe attack of abdominal pain with
fainting and uterine hemorrhage. The pain was confined
principally to the left side of the abdomen. An abortion was
supposed to have occurred at this time. She recovered from
this illness after two weeks, and was able to attend to house-
hold duties. A month subsequently a second illness, supposed
threatened abortion, occurred. There was at this time a sharp
attack of peritonitis. Another physician in attendance dis-
covered an abdominal tumor thought to be ovarian in charac-
ter. She again improved and was able to be about. At the
sixth month she "felt life" and was satisfied that she was
pregnant. All uterine hemorrhage had ceased.
The onset of labor was delayed until about the three hund-
redth day of gestation. She was under the care of a midwife
for two days, during which time labor pains were severe, but
no progress was made toward delivery. Dr. Brierly was called,
and he was soon able to determine that some serious abnormal
condition was present. He called Dr. Andrew MacFarlane to
his assistance, and they dilated the cervix, and determined
that the uterus was empty. A diagnosis of extra-uterine preg-
nancy was now established. Dr. J. P. Boyd saw the case, and
an hour later we met in consultation. An active general peri-
tonitis was now present. Pulse could hardly be felt in the
radial artery and was very rapid. Her general condition for-
bade operation. She died in a few hours.
I
I"
1896.]
PRESENT STATUS OF ECTOPIC PREGNANCY.
195
She was the mother of five children, had had oneal>ortion in
1892, was suffering from no uterine disease at the time of this
pregnancy. Autopsy : The abdomen when opened discharged
several (lints of foul, blood stained, ttoculent serum. The
normal anatomical relations of the viscera were greatly dis-
arranged. The intestines were distended and their coats dis-
colored. All the evidences of acute septic peritonitis were
present. The gestation sac was opened and the child delivered.
An effort was made to determine the source of the sac and its
relations, as well as the attachments of the placenta. The
intimate union of intestine, omentum and mesentery made
this most difficult The left broad ligament and uterus formed
a part of the anterior wall. The posterior and superior walls
were formed by adhesive, inflammatory material, intestine and
omentum.
The placenta had its attachment in the pelvis, to the rectum
and folds of small intestines. It could not have been removed
during life without causing a fatal hemorrhage. The left
ovary was not to be found, and undoubtedly formed a part of
the wall of the gestation sac. The left Fallopian tube was
traced with a probe some distance along the wall of the sac.
0a*« 8. A. G., aged 27, married, native. April and May,
lSi»2. she missed two menstrual periods and presented the usual
early symptoms of pregnancy. At about the tenth week there
was an attack of uterine hemorrhage, associated with abdomi-
nal pain. She did not improve. Breasts continued to enlarge
and contained milk. Soon a diagnosis of tumor was made.
The uterine hemorrhage continued and repeated attacks of
abdominal pains occurred. Early in September a localized
peritonitis was associated with partial intestinal obstruction,
rigors and high fever. A few days later a discharge of puru-
lent matter from the rectum was observed. Some small fetal
bones were discovered in the discharge. Dr. Beach found a
distinct opening into the rectum through which a portion of
the fetus was removed. This was followed by considerable
bleeding, although the utmostgentleness was employed. Dur-
ing the afternoon of the day I was called ; without any inter-
ference, a second and fatal hemorrhage from the rectum
occurred.
Autopsy, eighteen hours after death : The local conditions
revealed a gestation sac made up of omentum, mesentery and
uterus, cemented together by plastic lymph, containing a
macerated fetus of about the fifth month, and a living placenta
attached to the intestines and pelvic wall.
The attempts made to remove the fetus through the rectum
had made a partial separation of the placenta, and it was from
this source that the fatal hemorrhage came.
Case 3. — Mrs. Mary R., aged 28, married, native, was seen
January 16, 1896. She was taken suddenly with "colic" early
in the afternoon. At the time of my visit, the pain was so
severe that repeated hypodermic injections of morphia were
required. The pain was intermittent in character, or like
labor pains, located chiefly in the left ovarian region. Her last
menstruation occurred November 20-24, 1895, and was normal
in character. About January 1 she suffered from nausea, and
her breasts began to swell. She believed herself pregnant
from her experiences in previous pregnancies. She suffered
from a degree of uterine prolapse since her first child.
Physical examination showed an enlarged uterus, soft, with
a patulous os. To the left of the uterus was a tense tumor the
size of a small orange. Temperature normal, pulse one hun-
dred and of good quality. I believed that I had an ectopic
pregnancy with impending rupture. The next day uterine
hemorrhage commenced and continued for two weeks. Shreds
of decidual membrances were expelled. There was evidence of
pelvic peritonitis for a few days. No indications for operation
occurring, the patient was kept in bed. After four weeks
there were no physical signs of disease in the pelvis, other than
uterine prolapse.
I am of the opinion that tubal abortion occurred within the
four hours between the onset of the symptoms and my second
visit, and that the ovum was discharged into the peritoneum,
died and was absorbed.
Case 4. — Caroline S., aged 42, married, native of Germany,
entered the Albany Hospital, February 19, 1895. She suffered
from metrorrhagia, which at times had amounted to severe
flooding. This symptom was of six weeks duration. The
beginning of the flooding was associated with severe pains in
abdomen, and syncope. The pain has continued at intervals
since. There was a mucous discharge from the rectum and
partial obstruction of the bowels. Was unable to leave her bed
without fainting. Last normal menstruation in December,
1894.
Her previous health had been good. First menstruation at
16, always regular ; married at 26, mother of six children, the
youngest 3 years old. All her labors were normal. Physical
examination showed a distended abdomen, resonant on percus-
sion, and quite tender, particularly in the lower portion.
Investigation showed a tumor in the right lower abdomen,
coming from the pelvis, rather larger than a child's head. It
was tender, slightly movable, and gave no sign of fluctuation.
Vaginal touch revealed an enlarged and softened cervix with
uterine hypertrophy and lateral displacement ; to the right, a
tumor continuous with the horn of the uterus, and bi-manually
it was found to be the lower segment of the one already men-
tioned. The uterus moved with the tumor. The finger intro-
duced into the rectum discovered a band-like stricture, and
almost complete obstruction by the tumor. There was no
distinctive changes in the breast. She had suffered from
morning nausea somewhat early in January, and had had at
least three severe attacks of pain. There was no evidence that
decidual membranes had been expelled from the uterus.
The history presented lead to the probable diagnosis, extra-
uterine pregnancy, and the operation for its relief undertaken.
The abdomen was opened and the relations of tumor explored.
It occupied the folds of the right broad ligament. The liga-
ment was incised and a large blood clot and the placenta
removed. Both weighed four pounds. No fetus was found.
Conditions showed that the hemorrhage had been intermittent.
The borders of the incision were sewed in the lower end of the
abdominal wound, and its cavity drained and tamponed after
bleeding vessels were controlled by ligature. The subsequent
history of the case was uneventful. She left the hospital well
April 13, 1895, and is now in good health.
This woman had consulted many physicians before entering
the hospital, and many diagnoses had been made — cancer,
uterine-fibroid, uterine polypus, and miscarriage. Since, she
has given birth to a fully developed child, after normal gesta-
tion. The labor was uncomplicated.
Case 5. — Frances G., aged 24, married, native of Italy,
entered the Albany Hospital, May 2, 1895. Pain and discom-
fort in lower abdomen, irritable bladder, uterine hemorrhage,
great prostration, and subsequently fever. The duration of
this illness had been more than two months. She had not
menstruated in January or February, 1895, had nausea and
considered herself pregnant. About the middle of March she
suffered from a severe attack of colicky pain in lower abdomen,
associated with flooding. It was regarded by the physician
called as a miscarriage. The patient growing no better, Dr.
L. F. Neumann came in charge of the case in the early part of
April, and at once became suspicious of the true condition.
Her first mepstruation was at fourteen, and normal. Mar-
ried at sixteen, mother of three children, the youngest two and
one half years old. Had suffered in the meantime from no
menstrual or uterine disorders. Her general health had been
good. There is no apparent heredity. Physical examination
revealed a tumor in left lower abdomen, the size of a cocoanut.
It was solid, tender and quite movable. The cervix was found
enlarged and softened, the os patulous, the uterus displaced
to the right as an appendage of the tumor. This history indi-
cates that the patient had two attacks of hemorrhage before
the operation.
May 3, 1895, the removal of the gestation sac from the left
broad ligament was undertaken. The enucleation was tedious
and associated with free bleeding. The right ovary and tube
were removed on account of gross pathologic changes. Drain-
age was employed for three days after the operation. The sub-
sequent history was uneventful and the patient returned home
in three weeks, her wound soundly healed. An examination of
the gestation sac revealed the point of rupture in the tube, a
small portion of permeative placenta, but no parts of the fetus.
The health of the woman is now good.
Case 6. — Florence S., aged 26, native, married, entered the
Albany Hospital, May 20, 1895. Pain and distension of abdo-
men, fever and chills, general weakness. The beginning of the
illness was on April 26, 1895, when she had a severe attack of
abdominal pain and immediately began to flood, although it
was not the time for normal menstruation. She was confined
to her bed much of the time until May 10, 1895, when she sat
up. This slight exertion brought on a second attack of pain
more severe than before, associated with symptoms of collapse.
Abdominal distension and tenderness came on, associated with
diarrhea and fever. May 18, 1895, Mrs. S. had a well-marked
rigor followed by high temperature and partial intestinal
obstruction. This was repeated on May 19, and her condition
became serious. I saw her on this date and aspirated a swell-
ing in left lower abdomen, with drawing five pints of very foul,
blood like fluid, mixed with gas. The abdomen was generally
distended and very tender. By vaginal touch nothing could
be made out ; everything was matted together. There was a
very foul discharge from the vagina.
Her previous health had been fair. First menstruation at
196
RUPTURED TUBAL PREGNANCY.
[July 25,
sixteen, normal until eighteen, when it became scanty, irregu-
lar and painful, married at twenty-two, one child living, two
and a half years old. Mother died of puerperal fever. Father
living. There is no history of tuberculosis or tumor in the
family.
She was brought to the hospital May 20, 1895 ; an abdominal
incision was made. Adhesions were universal. A large cavity,
including the pelvis and left side of the abdomen, was filled
with decomposing blood clot and pus. This cavity was washed
as clean as possible, and filled with iodoform gauze. There
were no distinct walls to the cavity. Agglutinated intestines,
omentum and mesentery enclosed it for the most part. She
was taken from the table in severe shock. However, she ral-
lied and after forty-eight hours the gauze tampon was removed
from the pelvis, a large glass drain introduced, and the
abdominal sutures tied for the first time. An enema was
ordered shortly after and it came immediately out of the glass
drainage tube. For two weeks all the bowel motions were
through the drainage tube. Careful attention to the fecal
fistula, repeated irrigations daily, enabled us to avoid any gen-
eral infection. June 2, only a small fistula remained and the
patient returned home. The bowels now acted naturally.
Late in September she returned to the hospital for relief of
the fistula, but after exploration and curettement it closed
with little trouble. She is well and strong.
Case 7. — Mrs. Anna DeR., aged 34, married, native, was
seen July 10, 1895. She had been in bed for some time suffer-
ing from abdominal distension and pain, fever, rigors and
sweating. Menstruated March 24, 1895, for the last time. In
the latter part of May she was suddenly attacked with severe
abdominal pain, and noticed a small tumor in the left groin.
This disappeared in a few hours, but the distress continued.
A week later a similar attack was experienced, after which
nausea was experienced and continued. Her family physician
at this time discovered a hernia which was treated by a truss.
The abdominal pain continned. On June 29, an attack of
vomiting, great pain and fainting occurred. She went to bed
and remained there until removed to the Albany Hospital
June 30, 1895. Three weeks before entering hospital flowing
began and a membrane was expelled from the uterus, supposed
to be a "false conception." Just prior to entering the hospital
she had a chill lasting for twenty minutes. Physical examina-
tion showed the usual signs of ectopic gestation with rupture.
On July 20, she was removed to the hospital for operation the
following day. During the night an attack of hemorrhage
occurred and her condition became serious. The operation
was made early the next morning. Blood clots and fresh blood
flowed from the incision, which was at once arrested by a
clamp placed on the left broad ligament. The blood, fetus and
placenta were at once turned out of the abdomen. The broad
ligament was immediately tied and the remnant of the left
appendage removed. After the peritoneum was cleared the
abdomen was filled with normal salt solution, and closed with
drainage — a glass tube. The subsequent history is unevent-
ful. The woman is now in good health.
SYMPTOMS, DIAGNOSIS AND TIME FOR
OPERATION IN RUPTURED TUBAL
PREGNANCY.
Read in the Section on Obstetrics and Diseases of Women, at the Forty-
seventh Annual Meeting of the American Medical Association,
at Atlanta, Ga., May 5-8, 1896.
BY JOSEPH PRICE, M.D.
PHILADELPHIA, PA.
Careful study of the physiologic, anatomic and
pathologic conditions of cases coming within our
experience, while such study has not altogether
removed from controversy very many subjects con-
nected with gynecology, it has led some of us to posi-
tive convictions and to the adoption of well denned
lines of practice. We are concerning ourselves less
about theories, though we are not able to dispense
with them altogether, but we are growing to base our
rules of practice more upon the results of our obser-
vations and experiences. Pathologic systems are con-
tinually changing, one system succeeding another in
quick and confusing succession. There should be no
element of mere conjecture in our every day working
experience. After the surgeon has discovered and
relieved conditions which his experience, his observa-
tion, has taught him to detect with almost mathemat-
ical certainty, the pathologist can step in and display
his science in explaining cause and effect.
The occurrence of tubal pregnancy is regarded in
widely different light by the theorist and the surgeon
who has learned to deal with it practically, and who
has accordingly come to understand , the manifold
directions in which speedy disaster may troop down
upon unfortunate women subjected to this calamity.
The argument that many cases get well of themselves,
in the presence of the multitude of disasters possible,
and in the light of the horror of some of these very
recoveries, is so puerile that the surgeon of practical
and positive bent can not regard them with compla-
cency, nor consider that those who advance them have
any authority from which to speak more positive than
the vaporings of fancy. As to the causes of aberrant
gestation, we are to consider them both as anatomic
and moral. They may have their origin in anatomic
loss of structure or in perversion of function, such as
absent ciliary motion in the epithelium, or in absolute
disease of the tube, or, as I have had more than once
called to my attention, in the fright of illegitimate con-
ception. Causation can rarely be determined with cer-
tainty; there are many agencies which operate to pro-
duce the trouble. The character of the attack, the
whereabouts of the patient, at what employed, are
always interesting considerations. The attacks are
exceedingly sudden. A vigorous woman may in a few
minutes look pale and exhausted and have a very feeble
pulse. Any effort to change position increases the
pain and she will start with a scream; the pain may
be quite general and not confined wholly to the abdo-
men. The rational symptoms of pregnancy are not
very marked. Morning sickness is never very prom-
inent. For weeks they may complain " on and off "
of sharp pain in one groin or the other. These pains
are followed by bloody discharge; the odor of the
discharge is also characteristic. Later the sharp and
severe pain is followed by faintness and increased flow
mixed with shreds and debris. Ruptures with large
effusions are easily recognized upon examination. The
finger detects an ill-defined boggy tumor, the uterus
enlarged and posterior or pushed well to one or the
other side. If the rupture is quite recent it iriay be
difficult to determine a tumor of any character ; there
is simply a feeling of general resistance. In exam-
inations made one or two days after rupture it is easy
to define the irregular boggy, tumor, also to locate the
uterus, determine its size, position and mobility.
There is very frequently associated with these cases
a history of sterility, inaptitude to conception and
mild forms of pelvic disease, abortion or doubtful
abortion antedating the pregnancy some four or five
years, absence of one or more periods. Very fre-
quently there is peculiar nervous disturbance, morbid
apprehensions, irritability followed by acute pain,
severe and recurring, pain of a variety rarely associ-
ated with other troubles. Usually the pain is followed
by anemia or symptoms of concealed hemorrhage;
the common symptoms of loss of blood are prominent.
It is then other symptoms develop, intra-pelvic or
perineal tumor due to clot or pressure, there is char-
acteristic vesical and rectal disturbance, peculiar cen-
tral fullness of the abdominal walls. Slight disten-
sion, tympany and marked tenderness rapidly follow
the first rupture, recurring hemorrhage and all symp-
toms become more marked. The restlessness of the
patient is alarming; probably 25 per cent, die in twenty
18%.]
RUPTURED TUBAL PREGNANCY.
197
hours, where there has not. been prompt and skill-
ful surgical relief. Hemorrhage is the real cause
of death : they die both early and late in the history
of the trouble; early, from rupture of tube, late or at
levin in primary sections done for saving both mother
and a viable fetus. The uon-contraetile tissue of the
tube favors free and continuous hemorrhage. Rup-
tures on the outer half of the tube or about the
pavilion extremity are the least fatal. As the rupture
nears the uterus the hemorrhage is most fatal. These
points have been demonstrated in the experience of
every one who has done any considerable number of
sort ions. So marked has been my own observation
of these farts that I commonly allude to it in my
oases, exhibiting it as an object lesson to those wit-
nessing the section, and these facts have led me to
classify the oases; first, ruptures in the outer half of
the tube belong to the surgeon; the second or inner
half go to the coroner or coroner's physician. Rarely
can you improve volume, quality and frequency of
the pulse in such cases where all the symptoms are as
I have narrated.
It is my conviction, fortified by my own experience,
count ing now one hundred and twenty-eight cases with
five deaths, that the operative treatment is the only
one to be considered. I am fully satisfied also that
these pregnancies are rarely, if ever, in the broad
ligament. In the case of fetus gone to term, in my
own direct and indirect experience, the child has in
no instance been in the broad ligament. I regard the
chief danger of the operation as that of hemorrhage.
If the patient is found so weak as to render operation
an almost certain failure. I resort to salt water trans-
fusion in order to restore the arterial tension.
Rupture with fatal hemorrhage is the most frequent
termination; pyemia, septicemia and peritonitis are
much rarer.
Relating to such cases Groupil says: "It is but
true, I fear, that we are authorized in saying that all
the eases of intra-peritoneal hemorrhage arising from
extra-uterine pregnancy end in death, and although
death has been delayed for six months, it is wholly
exceptional. This was absolutely true in my own
ex] icrience until I was emboldened — I say it — until I
was shamed by Mr. Hall Wright's case into opening
the abdomen and saving their lives."
The consensus of opinion by those who are compe-
tent to speak from results must be for early operation.
But there are, in addition, those cases to be consid-
ered in which, after primary rupture, the fetus has
still lived and advanced to full term. Here the ques-
tion is one of operation with the view of saving both
the life of the mother and that of the child. If one
is to be lost, it is my belief that it should be that of
the child; that the life of the mother is of paramount
consideration. The chief danger to the mother in
the operation at term in tubal pregnancy is the removal
or accidental detachment of the placenta. It is easy
enough to remove the child and save it, if it is viable,
hy operating at or near term ; but the danger of fatal
hemorrhage from vascular walls that can not con-
tract, as do the uterine structures, is the vital ques-
tion of the operation, so far as the mother is con-
cerned. If we do not remove the placenta the risk of
septic infection still remains.
The old and non-surgical rule of leaving the pla-
centa to slough away is too dangerous and prolonged
to be practiced. The placenta should be removed in
every case, or washed and hermetically sealed, thus
favoring its healthy digestion and avoiding gangrenous
separation and detachment. Secondary rupture of
broad ligament, discharge of placenta and fresh adhe-
sions, or the second implantation or grafting of the
pfacenta, have never occurred in my experience, nor
have I any knowledge of such cases except that con-
veyed through the literature on the subject. Basing
the conclusions of my judgment upon my own clini-
cal experience, I must hold to the tubal origin and
the intra-peritoneal rupture. All that follows tubal
rupture is within the pelvis and peritoneal cavity,
and not within the leaflets of the peritoneum forming
the broad ligament.
It must be admitted that the removal of a growing
and almost universally attached placenta is one of the
most difficult procedures in surgery. The hemor-
rhage is profuse and sometimes uncontrollable ; the
contraction of all tissues to which it is attached sim-
ulates that of uterine tissue. Rapid separation, heat
and firm pressure will commonly succeed in control-
ling it. As to choice of time for the operation, I am
of the strong conviction that there is but one choice,
and that is prompt removal when the accident is first
recognized.
It is better to act promptly. The steps of proce-
dure are clear and should be completed at any risk.
It is better to contend primarily with the loss of blood
than later with overwhelming sepsis. Tubal preg-
nancy is dangerous throughout its existence; the sub-
ject is never safe until surgically relieved. Excep-
tionally, is the trouble recognized before rupture. I
have never recognized one before rupture, all before
is conjecture rather than knowledge.
An important element of the history connected with
these cases is that few of them are kept under obser-
vation with the definite purpose of removing the via-
ble child at the period of spurious labor; alarming
symptoms develop and subside, and consultation with
a specialist, if they are at any time consulted, follows
the death of the child, it rarely antedates it. Then
all the conditions are found greatly aggravated by
delay or neglect, or that which is infinitely worse than
either or both, inexcusable ignorance. Consultations
for suspected extra-uterine pregnancy are quite com-
mon in those peculiar cases of much-attenuated uter-
ine walls in normal gestation, but the ectopic cases
are permitted to pass through the primary rupture,
recurring ruptures, almost constant pain and spurious
labor, entailing impaired general health, without sus-
picion of the patient's peril.
An English authority has stated what, in connec-
tion with these cases, should be accepted as sound
dictum : " As all know, the Fallopian tube is, in the
vast majority of instances, the starting-point of extra-
uterine gestation; the most common result of this is
that rupture occurs usually at the second month,
through some part of the tube covered with perito-
neum; a result almost universally fatal if left alone,
and as invariably curable if operated on in time by
abdominal section."
DISCUSSION ON PAPERS OP DRS. MACDONALD AND PRICE.
Dr. Joseph Eastman, Indianapolis — So far as I am able to
judge from reading the literature of this subject and from
experience, there is but one treatment for extrauterine preg-
nancy, and that is surgery. I will refer to one case which came
under my observation because it was an extraordinary one,
and it illustrates still further the futility of packing with ice
and the use of electricity. A man supposed to be a competent
electrician and well posted in the treatment of extrauterine
198
DISCUSSION.
[July 25,
pregnancy by electricity tried for six months to kill the fetus
and failed. He then tried packing with ice for three weeks
more. When the patient was in extremis there was a change
of physicians. On opening the abdomen, I found the sac con-
taining a living child in such an advanced gangrenous condi-
tion that I could not for a moment think of leaving it. Fol-
lowing the rule which I always insist on, that we shall first
find the uterus, if possible, I slipped my hand down, found the
origin of the tube toward the uterus, believing that all cases of
extrauterine pregnancy are primarily tubal, seized the tube at
the cornu of the uterus, which felt fully as large as my wrist,
and in doing so I detached a portion, of the placenta from the
gangrenous sac. Blood poured out freely ; my assistant had
gone to resuscitate the child, leaving me with a couple of nurses
to do the best I could under the circumstances. Crushing
down the sac (as you would crush a cherry-stone out by squeez-
ing the cherry) with clamped forceps which I have with fingers
like my own, I seized the sac below, then to my own astonish-
ment I found the sac was adherent in a number of places to
the intestines. With this clamp attached, after applying six
ligatures around the points of hemorrhage, we got the gangren-
ous sac out, then quilting with iodized silk, we had the pedicle,
to the cornu of the uterus, covered with iodoform collodion.
Where we find a dead or living child with a gangrenous sac,
the proper way to deal with such cases is to get at the cornu of
the uterus either with clamps or ligature, shut off the blood
supply, and remove the sac. I do not believe that it is good
practice to leave the placenta to slough out. I do not believe
there is a case where such men as Dr. Price would be induced
to leave a gangrenous sac. I believe the sac can be removed
in many cases with less risk to the patient than in leaving it or
the placenta to slough out, or both combined.
Dr. C. A. L. Reed, Cincinnati — My experience has led me
to attach particular importance to the symptom of shreddy
metrorrhagia as an early manifestation of this condition, and I
have not been able to verify the fact that this symptom occurs
only after the symptoms of rupture. On the contrary, I have
found that it has occurred among the earliest manifestations
of pregnancy, and no doubt it has occurred when there were no
symptoms of pregnancy, and I was prompted on one occasion to
make a careful study of a case and a diagnosis before rupture by
following the case as suggested by the symptom, and that was
one case in my experience in which a diagnosis was made before
rupture, was operated upon before rupture had taken place,
and the diagnosis subsequently verified by careful microscopic
examination of the specimen removed. Therefore we did have
in this one instance a confirmation of the fact that a shreddy
metrorrhagia may occur prior to the symptoms of rupture.
It has fallen to my experience to observe so few instances,
that I hesitate to allude to them, for the reason that their
example has led to many errors and many fatal delays ; but I
have seen a number of cases in which primary rupture had
occurred in the broad ligaments, for the reason that there was
a definite extension of the tumor downward, and no particular
extension of it upward, although its upper margins were defi-
nitely outlined. The tumor became stationary and disap-
peared. This was manifestly a hematocele. You may say
that I had no evidence that it was a case of ectopic pregnancy,
but if we are justified in saying that given cases upon which
we operate were cases of ectopic pregnancy by virtue of the
existence and persistence of certain sypmtoms which lead to
the diagnosis, and which diagnosis is confirmed by operation,
certainly we are justified in interpreting as having similar con-
sequences a similar aggravation of symptoms, and these symp-
toms did exist in the few cases that I saw. While that is true,
I believe it is a dangerous expedient to rely upon absorption.
The maximum of safety is upon the side of operation at the
earliest practicable moment, and if we have such primary rup-
ture with such limitation of hemorrhage, the safest expedient
is to avail ourselves of the quiescent interval and proceed to
operate when we can do it without serious complication, and
without being forced to deal with an exsanguinated patient.
Dr. James F. Baldwin, Columbus, Ohio— There was one*
point made by the first essayist which is of prime importance,
and that is with reference to educating the general practitioner
to suspect the existence of ectopic pregnancy, and thus lead to
a thorough examination and to a diagnosis. It has been my
fortune within the last few months to have seen seven cases of
ectopic pregnancy. Two of these were seen in my own prac-
tice, the others in consultation. In five of them the diagnosis-
was made before rupture and operation performed. The diag-
nosis was subsequently confirmed, and the five patients are
well to-day. Two of these cases occurred in the same patient
at an interval of six months. In each I made a presumptive-
diagnosis of ectopic pregnancy and operated. In two other
cases no suspicion had occurred to the attending physician 'of
ectopic pregnancy until I suggested to him that in the five cases
mentioned the diagnosis had been made by the general practi-
tioner. This case was one of ectopic pregnancy, the diagnosis
confirmed, and the woman operated upon. In two cases the diag-
nosis was not made until repeated hemorrhages had occurred.
The eighth case was one that was sent to the hospital during^
my absence, and the physician who sent the patient had made-
a diagnosis of peritonitis. The patient died within forty-eight,
hours after admission to the hospital from peritonitis. A post-
mortem was made which revealed a normal uterus and tubes,,
but an ectopic gestation sac in the cul-de-sac of Douglas which
had ruptured, producing a considerable amount of hemorrhage
which resulted in peritonitis. This is an exceedingly rare con-
dition, one which is denied by many pathologists.
We have educated the general practitioner to make a diagno-
sis in a large number of cases of appendicitis, and I think if
we impress them in the matter of ectopic pregnancy until they
suspect its existence when they have anything abnormal dur-
ing the early weeks of pregnancy, they will make a diagnosis
then or will have a suspicion sufficiently well grounded to send
for an expert to make a thorough examination. When the-
general practitioner is educated up to this point cases of ecto-
pic pregnancy will be diagnosed much earlier than they are-
now, and before rupture, and then the operation will be com-
paratively simple and few deaths will occur.
Dr. A. Vander Veer, Albany — Papers of this kind are les
sons in object teaching. They teach the general practitioner
regarding the matter of an early diagnosis in these cases.
With reference to general peritonitis, inflammation of the-
bowel, etc., I have lived long enough to hear papers on idio-
pathic peritonitis, and in abdominal surgery the comparison or
difference between these terms and appendicitis have been and
are presented in their true light. The general practitioner has
been taught that pelvic hematocele will be absorbed, that it
will disappear. Does it disappear? Look at the cases of pelvic
abscess— cases where a portion of bone protrudes through the>
vagina and rectum. Look at the cases of secondary hemor-
rhage and death which occur before you are fairly in the house.
Some of these cases if diagnosed early and operated upon imme-
diately would be saved. So many papers have been presented
in the past that they have mystified the general practitioner as
to the classification of this condition, as to the true pathologic
state present. What is the use of standing before the general
practitioner and arguing with him as to the form of ectopic
gestation. If you keep it up for twenty minutes your patient
is beyond relief. When the clinical symptoms are presented
the general practitioner must know that an operation is abso-
lutely necessary, and we have the authority of one man who has
perhaps operated more than any other in America in these
cases, and he tells us emphatically what ought to be done.
Stress should be laid upon the sympathetic symptoms. The
general practitioner should be educated in this matter as much;
ism.;.]
DRAINAGE IN ABDOMINAL AND PELVIC SURGERY.
199
as he is in regard to eases of appendieitis, and in case he does
not w ish to operate himself he should call in a specialist to
share the responsibility with him. I rind that when we teach
the general practitioner what to do he is not slow in following
our advice.
I)n. P. J. Yager, Campbellsburg, Ky. — I am a general
practitioner, but I am firmly convinced that in these cases of
ectopic pregnancy as soon as a diagnosis is made we should
operate. If the general practitioner feels that he is not suffi-
ciently expert to undertake the operation himself he should
call in a specialist The more we study these cases the more
we are convinced that delay is dangerous.
Db. KiKis B. Hall, Cincinnati —My experience leads me to
believe that a large percentage of these cases have a history of
some pelvic trouble. I have known pelvic trouble to precede
tubal pregnancy for at least five years in some cases. The
cases are few in number in which we do not get a history of
long continued pelvic trouble. We have a shorter space of
time in which the patient has considered herself not entirely
well since her last labor. A number of cases do not have these
symptoms, but when we take the large number of cases oper-
ated on, a large per cent of them have pelvic symptoms follow-
ing some uterine or appendiceal trouble preceding their ectopic
pregnancy. 1 have seen two women die inside of ten hours
from ruptured pregnancy, before the third month of tubal
gestation, as subsequently proven by autopsy. One patient
lived twelve minutes after I reached the house. The time to
operate is as soon as the diagnosis is made. In making a diag-
nosis we should not disregard the possibility of tubal preg-
nancy occurring in an unmarried woman, I have had two cases,
one in a widow, who denied the possibility of pregnancy until
after operation.
Dr. J. G. Carpenter, Stanford, Ky. — The model practi-
tioner is a diagnostician the world over. If the general prac-
titioner knows his business he makes a diagnosis and brings
his patient to the abdominal surgeon if he does not want to
operate himself. If he is the practitioner that he ought to be,
he should be prepared to operate on the patient himself,
because the best abdominal surgeons are made from the best
general practitioners. Early diagnosis is the thing of prime
importance, followed by prompt surgical interference. Oper-
ate before the patient bleeds to death from hemorrhage, before
secondary lesions are set up. The patient is often unaware
that she has had long standing uterine trouble. As soon as
the diagnosis is made the patient should be promptly operated
upon. If this was done a large number of cases that are now
lost would be saved.
Dr. Milo B. Ward, Topeka, Kan.— We all agree that it is
absolutely essential to resort to early operative interference in
cases of ectopic pregnancy, particularly before rupture has
taken place, if possible. The general practitioner must be
educated to the point that in cases of ectopic pregnancy it is
necessary to operate as soon as a diagnosis is made. Operative
interference must not be postponed. I would like to report
two cases which illustrate the danger of postponing surgical
interference, but I will not do so at this time.
Dr. W. G. Macdonald, Albany — Regarding the general
practitioner, I will say that in those cases which I have seen
the matter of diagnosis or suspicion of ectopic pregnancy by
him has been the exception, and not the rule. We must edu-
cate the general practitioner that we have in these cases cer-
tain definite symptoms.
When we are called in consultation we sometimes give dia-
metrically opposite advice in regard to what is best to be done
after the diagnosis has been made, and this puts the general
practitioner in trouble. We want to act together in these mat-
ters and establish uniformity of opinion.
Dr. Joseph Price, Philadelphia— The subject is not so diffi-
cult to understand, and a study of differential diagnosis is
rather easy. From a general standpoint, the general practi-
tioner is a very much better diagnostician than the specialist.
You are in the habit of calling in specialists to do your special
work ; sometimes after studying your cases two or three days
you come to a positive diagnosis by exclusion, and now I am
going to rebuke you for permitting the specialist to take the
attitude which he commonly does. After studying your case
you summon a specialist, he examines your patient, shrugs his
shoulders, looks wise, and says he will tell you what the condi-
tion is when he opens the abdomen. The general practitioner
is as good a diagnostician in a great many cases as a specialist,
and when his attention is once called to a subject he recognizes
and realizes its importance. I have the greatest respect for
the general practitioner, and in ninety-nine times out of one
hundred I have found him usually right. If we save these
patients, there is no time for the specialist to be called in,
because the operation must be done before the specialist
arrives. I have said that at least 25 per cent, of the cases die
within twenty-four hours. The symptoms are simple, physi-
cal characteristics are prominent. There is an absence of one
or two menstrual periods, a delayed menstrual period, and
along with this we have the characteristic agonizing pain.
The attack of pain differs from any pain to which your atten-
tion has ever been called. We have the characteristic shreddy
iMbris which is nearly always present ; a rapid pulse, and the
symptoms of concealed hemorrhage. In some cases the pulse
may not be bad, and the symptoms are not alarming ; but if the
case is an acute and typical one, cut down upon the peritoneum
only, and it will be found to be black. You have only gone to
the peritoneum to make a diagnosis. You will find black
blood beneath it in a large number of cases.
With reference to general practitioners making a diagnosis
in these cases, I will say that nurses occasionally after listen-
ing to discussions in the operating room and taking a record
of the case, will make a correct diagnosis. I have had nurses
who have sat by the bedside of patients for some time tell me
that the case looks like one of extrauterine pregnancy.
GAUZE AS DRAINAGE IN ABDOMINAL AND
PELVIC SURGERY.
Read in the Section on Obstetrics and Diseases of Women at the Forty-.
seventh Annual Meeting of the American Medical Asso-
ciation, held at Atlanta, Ga., May 5-8, 1896.
BY MILO B. WARD, M.D.
T0E1"KA,KAN6.
Human life so frequently depends upon the tying-
of a ligature, the use of one more suture, the perfec-
tion of an operation in every minute detail, that the
subject of peritoneal drainage, which is, perhaps, the.
most vital of all questions connected with the always
grave procedure of opening the peritoneum, should
never become too trite to demand careful consideration,
even though much has already been written on this,
subject, and every phase of the question thoroughly
discussed.
Viewing my failures retrospectively, I am forced to
the confession that no one feature of my work has.
given so much cause for regret as that of insufficient
drainage.
It is idle to say that drainage is needed only when
the work has been carelessly done. However perfect,
the technique may be, it is still a fact known to every
operator, that there are cases whose recovery depends
entirely on the drainage employed after the surgical
toilet is made. The only question for consideration
then is: What kind of drainage shall be used in a
given case? It is so frequently necessary in choos.
ing the material for drainage to provide means of con-
trolling hemorrhage, thus filling two important func-
200
DRAINAGE IN ABDOMINAL AND PELVIC SURGERY.
[July 25,
tions at the same time, that the problem is at once
solved whenever we have suitable method to meet the
dual requirements. The kind of drainage so often
depends upon the customs of individual operators
that it is impossible to lay down any rule to govern
all alike. This statement holds good in the use or
non-use of drainage, for some operators use drainage
in almost every case and others seldom if ever use it.
Another important fact to be borne in mind in con-
sidering a question of this magnitude is, no one kind
of drainage can be expected to meet the indications
in every individual case. The object of this brief
paper is merely to urge the importance of the thor-
ough use of gauze, in a large variety of complications,
as the material meeting the most indications and
tending to save lives that would, I think, be sacrificed
if other methods of drainage should be employed.
My experience in the use of gauze has been so pleas-
ing, in a large number of cases presenting the grav-
est complications, that I can not refrain from recom-
mending with great emphasis this important feature
in abdominal and pelvic work.
It is not my intention to deprecate in the least the
usefulness of other forms of drainage; neither would
I be understood as urging the use of gauze drainage
to the extent of making a hobby of this practice,
because there are a number of reasons why gauze
should not be employed unless its use is absolutely
demanded. The most potent objection to this kind
of drainage is the large opening necessary through
which to remove the drainage material after it has
performed its proper function. Another objection to
its use is the pain caused by removing the gauze, and
in some cases necessitating the use or an anesthetic.
These objections, however, apply only to cases where
the gauze has been introduced through the abdominal
parietes, because the removal of gauze from the vag-
inal opening does not usually cause suffering. Fre-
quently it is necessary to employ lavage subsequent
to the operation, where the field is primarily septic.
In this class of cases the gauze drainage will be found
the most useful, because it leaves sufficient opening
to convey the fluids to the septic area.
Much has been recently said relative to the poison-
ous tendency of iodoform gauze when used as drain-
age, but I have never experienced the least untoward
symptom, even when used in large quantities. Per-
haps there is a difference in the kind of gauze used.
My method has been to use the Johnson & Johnson
moist gauze, as it is furnished in glass jars. How-
ever if there is the least question of absorbing enough
of the iodoform to poison the patient, this gauze may
be used in the form of a sac to come in contact with
the peritoneum, and the carbolated or borated used
for the filling.
It would be quite improper for me to suggest to
this learned body anything regarding the minute
technique of the use of gauze, and, therefore, I have
only to suggest that it be used freely, and that the
entire surface made raw by the separation of adhe-
sions be covered with the gauze. In operations in
the peritoneum through the vaginal route, it is very
essential that a free opening should be made, thus
enabling a generous amount of gauze to be used
without packing it too tightly. It has been suggested
by a number of operators that the gauze should be
cut in long strips, so that the distal end will reach
below the plane occupied by the proximal end, but I
have not found this plan at all essential in order to
ensure perfect drainage. Gauze applied externally,
coming in contact with that which is introduced into
the abdomen, carries on the drainage quite as well,
and does not require so large an amount of material.
The most natural interrogation is: What charac-
ter of cases demand gauze as drainage? My answer
is, almost all seriously complicated conditions of the
pelvic and abdominal peritoneum, especially when the
intestines are involved, and also in all cases where the
peritoneum is opened through the vagina. There are no
objections to the use of rubber or glass tubes in connec-
tion therewith, but I have never found it necessary to
employ anything but the gauze. Where this kind of
drainage is used for the purpose of controlling oozing,
the result of separating adhesions, it is my custom to
introduce silkworm gut sutures, and remove the gauze
in twenty or twenty-four hours, and then tie the
sutures, thus securing primary union of the incision.
This plan may be carried out in nearly all cases of
sepsis by tying a part of the sutures and introducing
a smaller piece of gauze for continuous drainage.
In conclusion, I beg to state that it is my convic-
tion and experience that many patients will undergo
surgical operations and recover, when gauze is freely
used for drainage, who could not survive with the
use of any other material to perform this important
function.
DISCUSSION.
Dr. Howard A. Kelly, Baltimore — I no longer drain for
tubercular peritonitis, and these cases practically all get well.
The cases I drain stay in the hospital on an average of fifty-
nine days, while those in which I do not drain remain on an
average only thirty-nine days. The cases where I drained had
fistulous tracts. When I drain I use gauze, for the reason that
a glass drainage tube may do harm by introducing septic mate-
rial, by its perforating the intestine, producing a fecal fistula.
In the second place, it does not drain. I find pockets of fluid
within half an inch of the tube walled off by intestinal adhesions.
I advocate gauze drainage because it covers a large area. Any
quantity can be used, and it can be employed in curved and
angular spaces, and a constant capillary action is kept up. The
disadvantages of the gauze drain are that the drainage is apt
to stop after a while unless watched, and there is the further
disadvantage in removing it because of the pain it causes to
the patient. It is my plan to remove the gauze very soon if it
has been used for hemorrhage ; but if for sepsis, to leave it in
for five or six days.
Dr. Charles P. Noble, Philadelphia — The more I operate
the less I drain. In the beginning I drained a larger percent-
age of cases than Dr. Kelly, but the longer he operates the less
he drains. Of the first hundred cases upon which I operated
about ninety were drained. I did not feel comfortable about
my early cases unless a tube was inserted. If my patients
recovered where drainage tubes had been used 1 felt happy.
If they got well Without drainage, I felt it was a fortunate acci-
dent. Further experience taught me that it was not necessary,
and at present I drain but little. My experience is that
gauze drainage does not drain. The serum collects in the
gauze, and if you do not get it out in any other way it stays in
and poisons the patient. I insert a glass drainage tube in the
middle of the gauze to get the fluid out. I am quite sure after
the first day that gauze does not drain by capillary action, it
simply becomes impregnated with the fluid which is in the pelvis
and retains it. If the case is actively septic, unless the infected
gauze is removed the patient dies. In my opinion the chief
function of the gauze is to pack off the infected area. I have
never found it necessary to use drainage for hemorrhage, and
I think that with the patient in the Trendelenburg position it
can always be controlled. In a case in which it is necessary
18%.]
DISCUSSION.
201
to employ drainage for this purpose I would prefer a glass
tui»> for twenty-four hours.
Dr. Rufus B. Ham.. Cincinnati — Where I use gauze to pack
oil' raw surfaces in the pelvis, I also insert a glass drainage
tube to remove the accumulated fluid. I do not use gauze for
■drainage as frequently as some operators. I think gauze is
indicated in pus cases where we have large denuded surfaces,
because it keeps the intestines from becoming soiled, or where
they will become adherent I have employed it in many in-
stances only to keep the intestines away from the soiled area
until it was walled off. As to the best time for removal, if you
remove it sooner than the fourth day the patient complains of
pain. After the fifth day it hurts but very little. The lymph is
not reabsorbed before the fourth day. I never think of using
gauze tor drainage alone, as I am so confident that it will not
drain pus and blood clots. I would not use it without a glass
drainage tube alongside of it, or in the meshes of the gauze
where it would take up extra Huid.
Dr. Henry O. Marcy, Boston- It is unnecessary for me to
rehearse the long battle some of us have had in reference to
drainage. For many years I stood alone on this question and
I am glad to see others coming to my views. I have laid down
two rules for my own guidance. If the case is aseptic, no
drainage ; if septic, drainage. The reason I think gauze
sometimes ceases to drain is because the operator tries to drain
uphill. The proper place to drain is not through the abdom-
inal wound, but through the vagina, and a large opening
should be employed.
An objection to the application of gauze through the abdom-
inal wound has not been referred to. The gauze will adhere
to lymph if it is not disturbed. Even if it is loosened you are
liable to displace organs, as lifting a considerable piece of
gauze out through the abdominal opening is quite sure to dis-
locate the restored omentum, and if you are not very careful
you have complications in consequence that are serious.
Therefore, when we drain, let us drain properly, by which I
mean drain by the vagina in such a way that you may profit by
gravity. Let your opening be sufficiently large for drainage
purposes. He who makes a small opening through the vagina
and packs it tightly with gauze will certainly fail. If he makes
an opening not larger than my little finger and wedges it tightly
with gauze he has practically made a plug of it and has pre-
cluded the possibility of capillary drainage.
Dr. George M. Sternberg, Washington, D. C. — In regard
to the general question of destruction of bacteria in wounds,
the views of surgeons have been modified. Lister commenced
years ago with the idea of killing the germs in the air, and then
various propositions were advanced by hygienists to destroy
bacteria in the water closet, and the discharges of normal indi-
viduals were to be disinfected. Now we have precise informa-
tion as to what agents will destroy bacteria and in what pro-
portion, and this precise data has been utilized by surgeons
who are now very well informed upon this matter. They know
that the particular micro-organisms which they have to fear
are the staphylococcus aureus and the streptococcus pyogenes,
and they know that the ordinary saprophytic bacteria which
may drop upon the surface of a wound are not likely to do any
great harm. Fortunately nature will provide for a certain
number of bacteria, and even the most virulent varieties of
the pus cocci are destroyed by nature. When you have a viru-
lent streptococcus, such as you may get from the abdominal
cavity of a woman who has died of puerperal fever, why then
you must beware. The attenuated varieties, such as are found
not infrequently upon the surface of the mucous membrane in
the vagina of healthy women, must be kept out of wounds.
You must take every precaution to do this, but nature will
render harmless a limited number. Infection depends upon
two or three things. 1, a virulent micro-organism ; 2, a sus-
ceptible individual. All individuals are probably susceptible
to wound infection, but there is a difference in the suscepti-
bility. Any woman who has lost considerable blood may be
more susceptible to infection than another. Experiments have
shown that alcoholics are especially susceptible and those who
have been suffering from inflammation have a predisposition to
infection. A streptococcus of slight virulence might produce
infection, and one may have a streptococcus with increased
virulence which would be extremely dangerous for a person in
poor health. You are familiar with the various chemical
agents used to destroy these microorganisms.
Dr. Wigoin, Connecticut— I think drainage in ordinary
abdominal troubles is a mistake. It is true we have a moder-
ate amount of infection, but in breaking up adhesions it has
been my practice to shut off the general cavity before the adhe-
sions are ruptured and to use peroxid of hydrogen in fifteen
volume solution strength, and after allowing a little time to
elapse, washing out the cavity with a normal saline solution
and closing the wound. By following this method I have no
cause of regret. I have no septic peritonitis.
Dr. H. O. Pantzer, Indianapolis— I performed my first lap-
arotomy in 1888, in which I resorted to the use of a drainage
tube. I have not used it since and I have no reason to regret
it. It is a clinical fact that the peritoneum is a tissue quite
different from the tissues that we meet with it in wounds in
other parts of the body, and it acts differently from those cavi-
ties which contain pus. The peritoneum is able to take charge
of a certain amount of infection. Gauze packing is quite
unnecessary, and pernicious when used to a great extent. It
might be necessary in some cases to use a single layer of it, at
most a double layer applied to the infected area. In most
aseptic cases I use only a little bit of iodoform gauze and I
have no reaction in most of my septic cases. I think iodoform
gauze has a danger which has not been touched upon, namely,
that of producing fistula. I know of one surgeon who has had
at least one hundred cases of intestinal fistula which followed
packing by gauze. I infer that the fistula? were established
here because of the violence with which the gauze packing was
removed. There is an incentive to remove the gauze rapidly
and violently because of the pain it produces. I would sug-
gest the use of peroxid of hydrogen to loosen the gauze from
its attachments. It acts admirably.
Dr. A. P. Clarke, Cambridge, Mass.— Dr. Sternberg brought
out one point that ought to be emphasized. It was recognized
some years ago before antiseptic surgery came into use. Many
years ago I recognized the fact that in cases where there was
great loss of blood there was a tendency on part of the absorb-
ents to rapidly absorb everything, and that in such cases where
there was absorption of pus we could predict that pyemia would
follow. Even in these days in cases with little loss of blood
and good health drainage is unnecessary. On the contrary, in
cases where there is great loss of blood, drainage should be
used. An alcoholic solution should be given to restore the cir-
culation as rapidly as possible if the germs can not be absorbed
from the wounds. This is a matter of vital importance. We
must distinguish between those cases which require drainage
and those which do not. It is not a local trouble, but a general
condition of the system. If the members will review their
cases and note which ones have become poisoned, they will find
it was those in which there had been great loss of blood and
the patients very much reduced in health.
Dr. Henry P. Newman, Chicago— This matter of drainage
is of great interest, and I think some of the statistics are a
little misleading in regard to its use, even those of Dr. Kelly.
We do better operating than we did formerly, and our last one
hundred cases are showing this. It is not to be ascribed in all
instances to either the use or the non-use of the drain. Our
work is cleaner ; the tissues are better protected ; the surfaces
are less abraded ; there is less handling of the intestines, less
exposure, etc. Consequently we do not need to drain as much
202
HOW TO CURE RHEUMATISM.
[July 25r
as formerly, and necessarily we have better results. Then, too,
the resisting power of the structures is correspondingly great
as they are less manipulated and exposed, or brought under
the influence of trauma.
With reference to the material used for drainage, I have
used for the last six or eight years properly prepared wicking,
which I have found far superior to gauze. It can be used in
large quantities. Its threads are continuous and very easily
removed. The capillary action is better and it is easier to
introduce and remove. This ordinary lamp wicking is pre-
pared very much the same as iodoform gauze, and it can be
made antiseptic with any of the germicides. The advantage
of this material in the abdominal cavity means simply more
than drainage ; it protects abraded surfaces and prevents adhe-
sions of the intestines. I think we are learning to do away
with the drain through the abdominal wall and shall soon use
it exclusively through the vagina. The bugbear of vaginal
infection is fast fading away.
Dr. Ward— We are mostly agreed that we should not use
drainage if it is not absolutely necessary. Gauze does not
drain after twenty- four hours. A glass tube does not drain
after twelve hours, therefore, we have gained twelve hours
after that method by the gauze. Gauze will carry away all
the material thrown out in the abdominal cavity. The por-
tion on the outside will be filled with clotted blood. I believe
that we should drain through the vagina where it can be done.
The gauze must not be packed too tightly if we expect good
drainage.
HOW TO CURE RHEUMATISM.
Read in the Section on Practice of Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association, held at
Atlanta, Ga., Mav 5-8, 1896.
BY ELMER LEE, A.M., M.D., Ph.B.
Vice-President American Academy of Medicine; Chairman Section on
State Medicine American Medical Association. Chicago.
The names of diseases are determined, principally
by the prominence of a certain group of symptoms.
The disease under consideration follows the general
rule. Special names are attributed to particular
groups of symptoms, all of which, however, constitute
merely varieties of one disease.
Rheumatism is acute when it is recent, and chronic
when the disease has extended over a longer period;
articular, when the manifestation is chiefly in the
joints ; inflammatory, when the whole body exhibits
the symptoms of inflammation and pain ; muscular,
when relating to the striated and non-striated tissues;
sciatica and lumbago belong to the same family; even
gout is itself closely related in its orgin, differing only
in its symptomatology.
The present paper is concerned with a practical
review of the author's system of managing this disease
in its various forms.
Disturbance of nutrition with consequent impair-
ment of the solids and fluids of the body, always pre-
cede rheumatism. Invasion of the soft tissues can
not take place unless the functional activity of both
structures is impaired. It is impossible to name the
first symptom in the series of alterations of the ele-
mentary forms. But in almost all cases which have
come under observation, certain functions are almost
uniformly abnormal. Variation in the volume as well
as the nature of the fluid elements of the body, and
changes in the quality and proportion of the solids,
are constant factors in the pathology of rheumatism.
The influencing or producing causes of these changes
in the body are, indeed, hard to exactly discover. But
fortunately, they are not indispensable to successful
treatment of the condition that requires remedial aid.
Whenever there are functional changes they consist
for the most part, of abnormal muscular action in some-
portion of the body, principally with reference to the
capillaries and small arteries. The same condition
may be an exciting cause of other diseases, the pecu-
liar spmptoms determining the character of the affec-
tion, being dependent upon the state of the general
system of the individual. Thus a given influenc&
may produce in different individuals quite contrary
symptoms. With disturbed nutrition, alteration of
the fluids and solids of the body are accompanied by
obstructions in the circulatory and excretory systems.
Lowered vitality is the necessary result, which is the
basis upon which rheumatism is determined. If func-
tional activity remains normal, the vital resistance of
the soft structures prevent retention of the impurities.
There is no one portion of the economy which suffers-
alteration so readily as the circulating fluids. Upon
the relative maintenance of the normal proportion of
the fluids and solids, the health of the body depends.
It has been found by examinations of the blood that
there is a loss of balance between the fluid and solid
ingredients. It has also been determined by scientific
investigation, that the origin of diseases lies largely
in the imperfect circulation of the fluid elements of
the body through the capillaries, altering in turn the
functional activity of the lymphatic vessels. Conges-
tion is a disturbance, or, an obstruction in capillary
circulation, whether it be in the surface of the body
or in some internal organ. The consequent result,,
which follows even a slight interruption in these
minute passages, produces obstructions which in turn,
undergo changes that are fatal to the life of the ele-
mentary cell. If the harm done is slight, and the bal-
ance of the circulation is quickly regained, the symp-
tom of this disturbance may not be even appreciable
to the central nervous system. If, however, a great
number of slight disturbances in the capillary circula-
tion occur, the resulting evidence is determined by
symptoms which are noticeable. There are many
causes which may produce impeded vascular circula-
tion in the minute spaces, the chief of which is some
form of exposure of the body to external influences.
The first impression upon the system is necessarily
received by the nervous system, and through it the
influence is carried to the muscular structures. If'
the vitality is sufficiently strong the evil influence is
scarcely appreciable, for it is the natural tendency of
the system to recover from disturbed equilibrium.
Few individuals there are whose physical condition
is normal; consequently, the result of even a slight
cause of physiologic disturbance is often productive
of disaster. The point of my argument, at this time,,
is to establish the value, in the maintenance of normal
health, of the part which is performed by preserving-
the quality and the volume of the ch dilating fluids..
The capillaries are so exquisitively small, that even
the red cells themselves are unable to enter them.
The watery element of the blood alone finding its way
through the millions and millions of these diminutive ^
channels. The ultimate cell depends for its nutri-
tion upon the albumin, the fibrin and the salts which
are held in solution by the water of the blood. Ever-
so small a disturbance in capillary circulation inter-
rupts the processes of nature, and, if these instances,
occur sufficiently frequently, morbid products are
retained in the lymphatics and the intercellular spaces..
The efforts of physiologic action to remove and expel,
these products when retarded, constitutes the first.
is%.-)
HOW TO CURE RHEUMATISM.
203
element in inflammatory processes. The accumula-
tion of these minute centers of interrupted notion,
establish an appreciable area of disease, which spreads
more and more according to the state of the tissues.
When tlie area of inflammation is sufficiently large,
and destruction of cells is advanced, the heat of the
body is augmented, both by the decomposition of the
morbid products, and by the physiologic disturbances
produced throughout the system, constituting an
inflammatory fever. With the determination of the
fever, other symptoms appear which hitherto were not
present in our picture of pathologic changes.
The exact pathology of rheumatism is undeter-
mined. The analyses of the blood indicate no chemio
or organic changes. The cellular structures are iden-
tical with those of usual conditions found in health.
Lactic acid and uricacid and other ohemic substances
are not found to prevail to a greater degree than at
other times. The only change that is discoverable, is
tin- diminution of red corpuscles. The various theo-
ries concerning the cause and origin of rheumatism,
in the light of the exact knowledge, determined by
physic and ohemic analysis of the blood, are not satis-
factory. The exact knowedge on the subject consists
in the single, positive statement that there is altera-
tion in the number of red cells of the blood. In addi-
tion to this it is also able to be definitely stated that
there is diminution in volume of the fluid element of
the blood. These facts would seem to throw the
responsibility upon the capillary circulation rather
than upon change in the blood chemistry. It is upon
recognition of the foregoing physical alterations of
the blood that my practice in the treatment of rheu-
matism is founded.
Postmortem examinations reveal no changes not
found in other diseases. Chenric analysis of the fluids
and the solids of the rheumatic body are also negative
in showing the origin of this disease. The flow of
urine is greatly diminished and through this condi-
tion, it is able to determine that the volume of the
blood is also diminished, corresponding precisely to
the symptom of scanty urine. The average number
of cases, in which the urine has been calculated as to
the quantity, shows a uniform decrease as well as an
increase in color and specific gravity.
After very careful examination of the extensive
literature on the subject of rheumatism, my con-
clusions are as follows: that rheumatism is, so far
as the conditions of the solids and fluids of the
body are concerned, a disease not dependent upon
ehemic changes of the fluids; nor is it due to any
particular chemical that may be found, either in the
fluids or the solids of the body. The only definite
knowledge that is irrefutable, is that there is a change
in the physical character of the blood, consisting of
an alteration of the relative proportions of fluid and
solid elements.
The inflammatory processes which take place are
similar to those in other diseases, under similar con-
ditions. The differences in the forms of rheumatism
are produced by variations of the intensity of the
disease, and the state of health at the time of attack,
of the individual. The three principal symptoms of
rheumatism, namely, pain, fever and swelling are able
to be explained by my hypothesis. The condition of
impaired nutrition, and functional derangement of the
bowels, either constipation or diarrhea, is almost
constant.
Clinical experience teaches me, therefore, that the
first indication in the treatment of this disease is
the supply of proper and sufficient nutrition. The
next indication is attention to the processes of elimi-
nation by which the system is relieved of dead mat-
ter. Nature is the greatest remedial influence in the
cure, and whatever introduces new strength and saves
the vitality is the safest therapeutics. Next in order
in the line of remedial measures, is to restore and pre-
serve the normal volume of the blood. If there is a
reduction in the number of red blood corpuscles, that
reduction, it is found, is only relative, for there is a
consequent loss of serum. This condition is exactly
determined to be true, by quantitive estimation of the
urine of each twenty-four hours. The high specific
gravity of urine, which is referred to as a prominent
symptom in febrile diseases, is evidence that there is
deficiency in the liquid element of the blood. Noth-
ing could be more natural than a waste through the
kidneys in proportion to the volume of blood serum,
so that this symptom is so slight in importance, rela-
tive to the ease with which it can be corrected, that it
is a surprise, that so much is made of it in referring
to the symptoms of disease.
Every one of these pathologic and physiologic
changes which have been enumerated in the paper,
are directly amenable to control by the proper use
of hydriatics. There is no question as to the fact.
It has been so many times proven in my clinical
work during the past period of six years, that
it is no longer subject to the least doubt in my
mind. It is not. altogether an easy matter for those
not acquainted with hydriatics, to give full credence
to such positive statements, unsupported by clinical
demonstrations in hospital wards. Neither is it an easy
matter to learn the various processes which constitute
intelligent and common-sense use of water, pertaining
to the cure of this disease.
Before detailing the plan which is regularly followed
in my practice, it is my wish to lay before you some
therapeutic measures which were recently employed
in the treatment of a case of acute rheumatism in one
of the Metropolitan hospitals. The recital of this list
of remedies may be instructive, as it furnished me
many points for thought and criticism of the prevailing
measures in vogue to-day, in the treatment of -rheu-
matism. The list comprises the following drugs and
remedies used upon one and the same patient, the
result of which was the fatal termination of the patient:
Here it is: Salicylic acid, salicylate of soda, gaul-
theria, salol, salophen, antipyrin, iodid of potassium,
wine of colchicum, iron, arsenic, strychnin, bicarbo-
nate of soda, epsom salts, bromid of sodium, mor-
phin, turpentine, lanolin, lard, digitalis, cod- liver oil,
whisky, and menthol in alcohol. Great stress was
placed upon the fact that 15 grain doses of salophen,
combined with 15 grains of bicarbonate of soda, were
borne by the patient at intervals of every two hours.
The patient grew steadily worse from the inception
of the treatment, and it would be strange indeed, had
it been otherwise.
The criticism of this plan of treatment is not owing
to a lack of an orthodox education, or to ignorance on
my part of the recommendations of the materia
medica. The practice of therapeutics has been going
on for a period of, perhaps, over three thousand years,
and while the list of remedies presented above does
not represent the sum total of our ability in the treat-
ment of rheumatism, neither does it reflect creditably
upon the education and the intelligence of a learned
204
HOW TO CURE RHEUMATISM.
[July 25,
profession, and it is not strange that odious compari-
sons are instituted by the laity between the advance-
ment of surgical treatment compared with that of
medicine. There is some excuse in the allied sciences
of electricity and other departments of physics, for
imperfect processes, and room for further scientific
development, but it seems to me there is hardly the
same excuse for a class of highly educated, broad-
thinking men who have had so many centuries during
which to work, and in which to perfect the treatment
of diseases of the human body.
We must remember that steam and electric energy
are discoveries of comparatively recent years, and
that further improvements are in order and perfectly
natural; but we must also remember that the
human body with its physiologic and pathologic
nature has been known and practiced upon for more
than thirty centuries. What hope for the future
would there be if the foregoing list of remedies should
be taken as the total of oui ability in the treatment
of this disease? If our science was no older than
steam or the telephone, our mistakes would be but
natural and pardonable. It is not wholly the fault
of the physician that such an incongruous and con-
tradictory collection of substances should be used in
the treatment of rheumatism. The education of the
people and the use of drug remedies from childhood,
almost force physicians to employ them in the treat-
ment of their cases. Beside this, the circulation of
enormous quantities of spurious medical literature by
commercial agents, advocating and urging the use of
their patented and proprietary preparations, has a
harmful and misguiding influence upon the younger
members of the profession, who are eagerly seeking,
and ready to receive information which purports
to represent the very latest ideas in therapeutics.
It is not my purpose to condemn or to harshly criticise
any one in particular, but rather, in a sympatheti-
cally critical attitude to point the way to the truth.
The treatment of rheumatism by hydriatic processes
is based now upon an experience in practice during a
period of six years. The plan which is pursued is
satisfactory to the highest interest of the patient and
the physician. It is something that is definite; it is
reliable, and the gains that are secured in the progress
of the treatment are real, and can be determined with
an accurrcy approaching true science. The only diffi-
culty that is experienced in pursuing the hydriatic
plan, lies in the fact that it is considered by the
patient and friends as novel and, therefore, to be
guarded against. Besides, the support of the profes-
sion, is withheld, owing to misunderstanding, by reason
of clinical inexperience, lack of actual knowledge, and
doubt, which operates to the disadvantage or both
the physician and his patient. It takes a great many
clinical experiences to establish the courage of one's
own convictions, and until belief is based upon many
carefully conducted experiments, there is always room
for a question whether it is right or wrong. The dis-
position is, among clinicians, to prove each point in
practice and to lean toward conservatism. For my
part, my courage is established, and the practice of
hydriatics, according to my experiences, is now
approaching a definite and scientific system of therapy.
For the purposes of clinical practice the gross
symptoms of rheumatism are sufficient in all cases to
determine the line of treatment. It is only where
experiments for scientific purposes are instituted that
differentiating instruments and chemic tests are
employed. When first called to see a patient it is of
course impossible in most cases to exactly determine,
even to my own satisfaction, the precise nature of the
affection. The first inquiries that are made of the
patient refer to the general condition, followed by
questions and examinations to determine the details-
concerning the physiologic functions. Inquiry is
especially directed to the excretory system, with ref-
erence to the quantity of urine which is passed, the
condition of the bowels, the appearance of the skin
and the mucous membrane, and especially the state
of the appetite, the kind of food taken, and the habits
with reference to the nature and the quantity of fluids
taken as drink. The temperature of the body, the-
movements of the pulse and the subjective symptoms
of the patient, constitute a list of inquiries suffi-
ciently to determine the treatment. The physiologic
requirement of the system is two litres of water per
day. In no single instance of a case treated has this
quantity been consumed by the patient prior to his
sickness.
The treatment is begun by prescribing regular, defi-
nite doses of pure, soft water at frequent intervals.
Each dose of water contains some harmless remedy
to satisfy the notions of the patient and his friends.
The amount of water which is prescribed at each
dose is scientifically determined by the whole weight
of the body, the age of the patient and the degree of
the fever. Starting upon the basis of an average man,
two to four litres of pure water is prescribed every day,
in properly apportioned doses, to avoid mistakes and
excessive use of water at any one time. If the patient
were of seventy-five pounds weight my estimate would
be that one and one-half to two litres of water would
be absorbed per day with comfort and advantage. The
next process in the use of hydriatics is irrigation of
the bowels if circumstances favor it. One teaspoonful
of elixo, a liquid soap, is mixed with the water used
for irrigations. Many cases have been treated by me,
in which it was inconvenient or undesirable to practice
irrigation of the bowels. It is therefore, established
clinically that while irrigation is in all cases an aid to
treatment, still it is not indispensable.
The third hydriatic process is the use of water upon
the surface of the body. If the patient is agreeable
to direction and conveniently located, the full bath is
recommended. The temperature of the water should
be a few degrees below the temperature of the body.
When the toilet room is inaccessible or it is incon-
venient to remove the patient, three bathing pro-
cesses are followed in my practice: 1, sponging the-
body with water from a basin; 2, the wet pack; and
3, the use of my sprinkle-bath. The sprinkle-bath
consists of cool water applied to the surface of the
body, at intervals of two or three hours, during the
day and evening, by means of a small sprinkle nozzle
attached to the end of the tubing of a fountain
syringe, which is suspended from a chandelier, bed-
post or a nail in the wall. Swelled and painful joints
are packed in a compress of cold water until relief
comes. Briefly speaking, the foregoing measures have
availed in the treatment of rheumatism. The precise
detail work must necessarily vary in every case. The
food is immaterial; whatever is the most simple, the
easiest to provide and which is agreeable to the patient,
is all that is required. Purposely the recital of cases
has been omitted. Such recitals are tedious, and for
this reason are omitted from this paper.
103 State Street.
18%.]
MALARIA.
205
DI8CC88ION.
Dr. Louis Fauoeres Bishop, of New York I do not think
we ought to pass over the subject of rheumatism without any
consideration of the fact that in all probability acute rheuma-
tism is of miasmatic origin. I think that any one who studies
the whole literature of the subject will come to that conclusion.
Further discussion was interrupted by the lateness of the
hour.
MALARIA.
BY ELLSWORTH D. WHITING, A.B.
AURORA, ILL.
(The L. P. 0. Freer Prize Essay, Rush Medical College, 1896.)
[( 'mithnit'fl from pope 18S. )
Before entering upon a systematic study of the
organism, a description of the manner in which speci-
mens are obtained may be of advantage.
The technique of obtaining specimens for a fresh
examination, though simple in theory, presents many
■light, but annoying, difficulties in actual practice.
The main points ever to be kept in mind are cleanli-
ness, quickness and skill of hand and eye. The
instruments necessary are a small lancet, two pairs of
blood forceps, slides and cover slips. The site of
puncture should be thoroughly cleansed, first with
soap and water to remove dirt, secondly with alcohol
to remove oily materials, and then allowed to dry.
Blood for examination may be taken from any part
of the body. In adults the finger tip or lobe of the
ear is most satisfactory. The writer has had most
success in taking specimens from the lobe of the ear.
Here there is practically no pain; a very minute punc-
ture only is required to obtain the necessary amount
of blood; it is out of the sight of the patient; immo-
bility is easily obtained and infection is not liable to
follow. The puncture of the finger tip is painful;
being in the sight of the patient much annoyance is
caused in children and hysteric subjects and there
is more danger of infection. In infants the most
desirable site is the inner surface of the heel.
Great cleanliness should also be observed in the
preparation of the slide and cover slip. Both should
be thoroughly cleansed immediately before using.
In preparing the cover glass it should first be allowed
to stand in 25 per cent, sulphuric acid for one half
hour. It should then be washed in alcohol and finally
dried with a perfectly clean and dry silk or linen hand-
kerchief. In the preparation of the slide such precau-
tions are not necessary as cleanliness can be secured
by brisk rubbing.
If it is convenient it is of great advantage to have
the slide as near body temperature at possible. This
may be obtained by the judicious use of the alcohol
lamp or by friction at the hands of an assistant.
The site of operation and the necessary articles being
in readiness, a slight puncture, directed upward, is
made in lowest point of the lobe of the ear. The lobe
is then turned upward and the blood allowed to flow
without pressure. The first few drops are wiped away
when a cover glass held in blood forceps is touched
to the summit of the following drop as it emerges
from the opening. The slip is then quickly trans-
ferred to the slide. In order to guide and steady the
hand that the cover may not touch the skin, the fol-
lowing procedure may be followed. Let the left hand,
which is holding the lobe of the ear, rest against the
neck of the patient, then by placing the ringers of
the right hand, in which the cover slip is held, lightly
upon the left hand, steadiness and accuracy of tactile
sense may be acquired to a remarkable degree. It
is also of advantage to hold the forceps as near the
cover slip as possible.
If the cover slip and slide have been perfectly
cleaned; if the operation has not taken too long and
the cover glass has not touched the skin nor the drop
been too large, the blood on touching the slide will
immediately spread out between the slide and cover
glass. No pressure should be applied. On micro-
scopic examination the corpuscles will be seen to lie
separate and distinct side by side and unaltered in
the surrounding plasma.
Often in spite of the most careful preparations the
drop of blood will not spread, a condition which the
uninitiated will be at a loss to explain. This may be
explained in four ways at least:
1. After immersing in sulphuric acid, the acid may
not have been entirely washed away. Especially does
this occur when a number of slips are washed at the
same time. Long cleansing in water is necessary to
thoroughly remove the acid. When the acid can not
be tasted it will do no harm in the spreading, fixing
and staining processes.
2. A raveling may be found lodged in between the
slide and cover dip, which prevents the hugging of
the slide by the cover glass.
3. The surface of the slide may be uneven.
4. The slip may be warped.
Blood prepared in this manner will keep from one
and one-half to two hours without crenating and may
be kept longer by annointing the edges of the cover
slip with vaselin or glycerin. In the examination of
blood for the organism of malaria a one-twelfth oil
immersion objective with ocular number five is rec-
ommended. These high magnifications are not abso-
lutely necessary. Laveran made his first observations
with dry lenses of low powers.
The preceding methods are the simplest and most
practical for clinical work. Some observers use
methods much more complex. Hayem's slide is used
to some extent. This consists of a hollowed out slide.
The drop is placed in the depression and protected by
a cover slip. Plehn describes a most elaborate
method by which he keeps microscope, slide and
specimen at body temperature. He mounts his speci-
mens in parafin and thus keeps them intact for three
hours.
In the preparation of dried specimens for future
staining the technique is the same except that instead
of placing the drop collected on the slip upon the
slide, it is placed upon a second slip, held likewise
with blood forceps. The slips are left in contact from
one to two seconds when they are drawn apart being
continually held by forceps and the lines of force
kept parallel. They are then set aside to dry with
the clean side down. The drying process takes but a
few moments.
When it is necessary to take dried specimens with-
out aid, the operator is compelled to fall back upon
devises which may best suit the circumstances. The
writer has been very successful in the pursuance of
the following plan. One cover slip is placed upon a
clean piece of paper at the very edge of a table while
the second cover when the drop of blood is
collected is placed upon the first. As the blood
cements the slips together both are raised by lifting
the one in the grasp of the forceps when they may
easily be separated.
Before specimens can be stained they must be
206
MALARIA.
[July 25,
fixed. Fixation consists in bringing about some mol-
ecular change in the corpuscles in which condition
certain elements take certain stains. The nature of
this process is not known. Some say that the change
is that of coagulation of the albumin, but this can
hardly be true as carbolic acid does not fix blood.
Fixation is probably simply a process of dehydration.
There are many methods by which blood is fixed.
This may be accomplished by passing through a
flame, heating at 120 C, immersing slips in picric
acid, mercuric chlorid, absolute alcohol, osmic and
glacial acetic acid or alcohol and ether, equal parts.
The writer has been most successful in the use of the
latter method. He generally leaves the specimens in
the fixing agent for twelve hours but good results
have been obtained after one-half hour's fixing.
Unsuccessful attempts at fixing with alcohol and
ether often arise from the fact that the alcohol is not
absolute or contains enough acid to destain the speci
men. Commercial alcohol is rarely pure. The
reagents used in the fixing of blood should be distilled
for the purpose and kept in an air-tight container.
Results obtained from heating on the graduated
bar are variable, due to the fact that it is exceedingly
difficult to keep the bar at an even temperature. In
this method of fixing, an ordinary one-burner oil stove
is used. Across the top of the stove is placed a copper
bar two feet in length, four inches in width and one-
eighth of an inch in thickness. After the bar has
attained a stationary degree of temperature, the boiling
point is determined. This is accomplished by drop-
ping water upon the bar and noting the point at
which it boils. At this point a line is drawn across
the bar and a row of slips, smear side down, are
placed one inch within this line. The specimens are
permitted to remain at this temperature from one to
three hours. Although simple of description this
method is open to many criticisms. The apparatus
must be continually watched, as a rise of temperature
ruins the specimens. It is best to protect the bar as
much as possible from drafts and to determine the
temperature every few moments with water.
Many investigators have used an oven in which the
temperature may be accurately regulated. By means
of this devise good results have been obtained.
The parasite of malaria takes the stain of all basic
anilin dyes. It is unaffected by the acid dyes except
when they are of great strength and left in contact
with the organism a long time. These facts have
given rise to a host of methods of staining, a descrip-
tion of all of which would be futile; therefore a few of
the more important ones will be described.
An exceedingly interesting and ingenious method is
given by Celli and Guarnieri, who succeeded in
staining the parasite while alive. For this purpose
they employed aseptic ascitic transudation in which
methylene blue was dissolved. They placed this solu-
tion over the site of the puncture, allowing the blood
to flow with the fluid, which was quickly transferred
to the slide. It was then kept in a warm moist cham-
ber for three hours, when the organisms were seen to
be well stained. This method, however, does not pro-
cure permanent specimens.
Chenzinsky successfully stained specimens which
had been previously fixed and dried by placing them
for five minutes in a mixture composed of a 50 per
cent, aqueous solution of methylene blue, and an
equal amount of 5 per cent, of eosin, in 60 per cent,
alcohol.
A cumbersome yet ingenious plan has been devised
by Feletti. After allowing a 25 per cent, alcoholic
solution of methylene blue to dry upon a slide he
places upon it a cover slip upon which a drop of blood
has been collected. He then surrounds the cover slip
with parafin. The serum of the blood dissolves the
methylene blue, which stains the organisms.
Mannaberg, after fixing the specimens in alcohol
and ether, equal parts, for half an hour, stains them
in a concentrated aqueous solution of methylene blue
for an equal length of time. After having been
washed and dried in water, the specimens are left for
thirty minutes in a 2 per cent, solution of eosin in 60
per cent, alcohol. They are then washed, dried and
mounted in balsam.
The method described by Romanowsky is effective
yet impracticable for routine work. Immediately
before using, he makes a fresh solution composed of
one part of a filtered, saturated, aqueous solution of
methylene blue, to two parts of a 1 per cent, watery
solution of eosin. The specimens, fixed by heat, are
floated smear side down upon this mixture, contained
in a watch glass. The specimen is covered by an
inverted glass and the whole enclosed in a moistened
beaker. The specimens are allowed to remain in this
solution from one-half hour to three hours. By this
method Romanowsky claims that he stains the red
corpuscles red, the parasites blue and the nuclear chro-
matin violet.
Mannaberg has devised a method by which he
brings out in great clearness the finer structure of the
parasite. At first the dried specimens are floated for
a few moments upon distilled water, and after being
dried are bathed in dilute acetic acid until there is a
complete disappearance of the hemoglobin. The
specimens are then permitted to float for two hours
upon the following fixing solution:
Concentrated aqueous picric acid ... 20 c.cm.
Distilled water 30 c.cm.
Glacial acetic acid 1 c.cm.
The specimens are next placed in absolute alcohol
for twenty-four hours. After this they are stained
from twelve to twenty-four hours in a solution con-
sisting of one part of hematoxylin (hematoxylin
grams 10 to 100 c.c. acid alcohol) to two parts of a .5
per cent, ammonia alum solution. The specimens
are destained in acid alcohol (hydrochloric acid 25
per cent., alcohol 75 per cent.) and ammonia alcohol
(three drops of ammonia to lO c.cm. 75 per cent, alco-
hol). They are then washed in 8 per cent, alcohol
and mounted in balsam. By this method the parasite
and leucocytes are stained blue, the red corpuscles
being colorless.
The preceding methods and numerous others have
been used since the discovery of the organism by
Laveran and the staining methods set forth by him.
Moreover, the method advised by him, although the
simplest and oldest, is most practical and efficient
for ordinary use. Laveran fixes blood in alcohol and
ether equal parts. He first places the specimen, for
thirty seconds, in concentrated aqueous eosin, and
after washing and drying, stains for thirty seconds in
concentrated aqueous methylene blue.
In his experimentation with staining the malarial
organism the writer, although he has used the meth-
ods of Laveran to considerable advantage, has been
most successful in the use of methylene blue alone.
He finds that as the organism is endoglobular, its out-
line is blurred to some extent by the eosin. Speci-
1896.]
MALARIA.
207
mens stained in aqueous solutions are more easily
decolorized by washing in water than those stained in
alcoholic solutions.
No definite limit can lie given to the length of time
and strength of dye required to properly stain a speci-
men, even when the strength of the staining reagent is
known. These points can be accurately estimated for
normal blood, but as it is a rare occurrence for two
pathologic specimens to be physiologically the same,
their staining is necessarily a subject of great vari-
anee. To procure a properly stained specimen it is
necessary to obtain its stain- absorbing qualities by
making a test specimen. This is accomplished by
applying a stain of known strength for a certain
noted time. Using this as a guide, a good specimen
may be obtained by varying the strength of the stain
and Length of the time of its application. A good
standard for comparison may be found in the leuco-
cytes. When the small lymphocyte's take a deep blue
stain and the large polynuclear neutrophiles a faint
blue, the methylene blue is of proper strength. When
the leucocytes are thus colored the malarial organism
will be distinctly stained and therefore recognizable.
The eosin should but faintly color the red cor-
puscles.
When the staining is completed previous errors, if
they exist, are brought to light. If acid is present,
specimens refuse to stain. If the specimen is thick
individual corpuscles are not distinguishable. If the
blood has been allowed to dry before separation of
the slips the corpuscles are not arranged evenly, but
in concentric circles and rows. If the blood was
forced from puncture there will be a large amount of
plasma present which will obscure the field. If fixing
material has not been pure, the specimen will not
stain. If the heating apparatus has become over-
heated the corpuscles will be ruptured, charred and
disintegrated.
In the examination of blood for the " plasmodium
malaria* " most satisfactory results are obtained by
examining fresh specimens. The great advantage of
this method lies in the fact that the ameboid move-
ments of the organism may be observed.
The organism must be differentiated from, 1, blood
plaques; 2, vacuoles; 3, discs of red corpuscles; 4,
crenated corpuscles; 5, oil globules (?).
1. The blood plaques are colorless, extra-corpuscular
and might be readily mistaken for hyalin forms of
the organism, were the ameboid movement not con-
sidered. The plaques are more translucent, their out-
lines more clearly marked and irregular than hyalin
bodies. There is a tendency toward the grouping of
the plaques in grape- like clusters. On staining they
take the methylene blue, as does the organism, and
must be differentiated by position and contour.
2. The vacuoles are lighter in color, translucent,
outlines distinctly marked, are non-motile and always
spherical in form.
3. Discs of red blood corpuscles are spherical and
when present are usually found in large numbers and
situated in the center of the corpuscle, except in cases
of poikilocytosis. These discs are of indistinct out-
line, non-motile, and when present in small numbers
they can only be differentiated from resting hyalin
bodies by staining methods.
i. Crenated corpuscles appear as coarsely spiculated
balls. These spicula are caused by the irregular con-
traction of the cell wall of the red corpuscle(?).
Although colorless these spicula appear black when
viewed through reflected light, and on this account
are often mistaken for pigmented organisms.
•"). It is scarcely necessary to differentiate hyalin
bodies from minute, spherical, translucent, rapidly
moving bodies which are frequently seen in the blood
of malarial patients. These particles are found in
normal blood and their nature is unknown, but they
probably consist of oil globules from sebaceous glands,
commingled with the blood during its exit from the
puncture.
It is of vast importance in the differentiation of the
hyalin bodies from the foregoing bodies to note the
kinds of motion visible under the microscope. In the
field can be seen distinct currents, probably produced
by heat radiation. These currents give to the cor-
puscles a vibratory, oscillating and rotary motion,
wdiich is in turn transmitted to the contents of the
corpuscle. These movements are possessed by all of
the previously described bodies, plaques, vacuoles,
discs, crenated corpuscles, and oil globules, and must
not be confounded with the ameboid movements of
the malarial organism, which is entirely independent
of currents; is slow and characterized by a change in
form of the parasite.
Through the opportunities afforded by the medical
clinics of Rush Medical College and the medical wards
of Presbyterian and Cook County Hospitals the writer
has been able to observe and study the blood changes
in many malarial patients. The classification pro-
posed by Thayer and Hewetson will be adopted in the
following description :
In describing the tertian parasite the writer will
make use of a series of specimens taken from a patient
in Cook County Hospital, exhibiting tertian par-
oxysms. Specimens were taken every four hours,
night and day, for forty-eight hours. In this manner
a complete cycle of the life of the organism was
obtained. By a microscopic examination of these
specimens stained with methylene blue the entire
development of the organism was traced with remark-
able accuracy. Fresh specimens were examined as
far as possible. The patient's history is taken from
history sheets of the hospital, and the temperature
recorded by the writer at the time the specimens were
taken. The blood count was made after the series was
completed.
James W., admitted Feb. 2, 1896 ; age 31 ; born in Scotland ;
single ; carpenter by trade. Family history : father had stroke of
paralysis some years ago, but is still living ; otherwise negative.
Personal history : has been in Chicago eighteen months ; drinks
occasionally, smokes, habits regular, no venereal history ; has
been working of late in Brighton Park. Previous illness : measles
and whooping cough. Present illness : had first chill last
April, which was followed by chills every other day. These
disappeared upon the administration of quinin, but reappeared
late in September, occurring every other day. The attacks
were again stopped by quinin. The last attack began February
1 and patient has had a chill every other day since. Chills
occur between 6 and 8 o'clock in the morning. During the
chill the patient complains of great pain in the back, head, left
side and shoulder ; the chills are followed by high, burning
fever, profuse perspiration and great prostration. Appetite poor
and bswels regular.
Physical examination. -Body well nourished; mind, clear:
eyes and pupils normal ; tongue, clean ; pulse, full and strong ;
thorax, well developed ; heart negative ; lungs, negative. Abdo-
men : liver normal ; spleen (palpable) is situated in mammary
line from sixth rib to one inch below costal arch. Limbs, neg-
ative; no adenopathy. Hemoglobin, 67'^ per cent. ; red cor-
puscles, 4,500,000 ; white corpuscles, 5,000.
In this description of a serial examination the writer
shall attempt to follow out the development of the
organism, commencing with the group of hyaline bodies
208
MALARIA.
[July 25,
. .1 ^ V-
IV
nf-1"
i- - m\.
T <U.x
4* 1%
^"
,_--i_s,--<^
i -vt - H*
lo-RlA
/C
t--M"V
II
•v W-'1V
t,- r>f\
PLATE IX.— THE PARASITE OF TERTIAN FEVER.
Explanatoey.— 1 , 2, 3, Hyaline Forms ,4,5, Beginning Pigmentation and Appearance of Nucleus ; 6, Appearance of Nucleolus :
7,8, 9, Further Development of Organisms: lu, Full-grown Organism; 11, la, Segmenting Forms. Magnification— Zeiss, Obj. 112 oil
immer., Oc. 6. From James W., C. C. H., W. 4. See ulso Plate XIV.
present in the first specimen. However, he wishes it I
distinctly understood that he does not for an instant j
intimate that the separate stages of the parasite J
described include all the organisms present in the
blood at the stated times. As a matter of fact, in
every slide examined adult, intermediate and hyaline
bodies were demonstrable, although these latter forms
in some instances were present in small numbers. In
the great majority of cases of malaria examined by
the writer he has been able to demonstrate every
form of the organism at any time during the
course of the disease. This fact has therefore led him
to conclude that pure forms rarely or never exist.
The symptoms are caused by larger groups of
organisms.
The first specimen (Plate ix, Fig. 1) was taken Feb-
nf4 )M U-fc.
-* ■* * *• '-5 '< 1 ^- te lo 4 -■- d -3
Te^cS^S^^^^r^^Ja^
'•T t c 2 1 E t n £ e c c r
^Za.KK>i.ili!«cfLftiVj«<3
., ^- __::: -i_ft
^ j-f-
/.. s ^1
k ct
*. - V -T —
-I— S ± 3
^ A
\ £
^^ /
"v r"
v- r^ mmm "^ *~"* V _"
■
PLATE XIV— INTERMITTENT TERTIAN FEVER, TEMPERATURE CHART.
James W., Cook County Hospital, Ward 4, February 24, 25 and 26, 1896. See also Plate IX.
18%.]
MALARIA.
209
ruarv 24 at 10 o'clock in the forenoon, one hour after
tin- chill, the temperature being 104 degrees P.
On examination of fresh specimens, many organ-
isms were present in various stages of development,
the hyaline forms, however, being in the greatest num-
bers. These consisted of small, round, endoglobular
motile bodies. The ameboid movement at this stage
W«S marked, a complete change of shape taking place
in a few moments. These forms have been described
as colorless, hut this is probably not strictly true, as
they seem to possess a very faint shade of color simi-
lar to that of the red corpuscle. The borders were
indistinct, the blending thus produced often making
it difficult to distinguish the point where organism
ended and corpuscle began. Although there were
organisms within and outside the corpuscles, none
were seen in the act of entering, a circumstance which
has never been observed. At this stage no nucleus
could lie demonstrated in the fresh specimen.
Specimens were also stained with methylene blue.
The periphery of the organisms took a greenish-blue
stain, fading toward the center into a lighter shade of
the same color, indicating the embryonic nucleus. In
this specimen, beside the adult and hyaline bodies
many degenerate forms of the organism, together with
degenerate red corpuscles and free pigment granules,
were present.
The second specimen (Plate ix, Fig. 2), taken the
same day at 2 p.m., the temperature having fallen to
100.4 F., showed a large number of hyaline forms
somewhat larger than those observed in the first
specimen. These possessed the same activity, no pig-
mentation was demonstrable. A marked decrease in
the number of adult organisms was noticed, also the
absence of free pigment.
The third specimen (Plate ix, Fig. 3), taken the
same day at 6 p.m., the temperature being 99.4 F.,
showed the same characteristics as the foregoing,
except that the hyaline bodies were larger and a more
clearly defined nucleus was present. This nucleus
nearly filled the organism. In most instances it was
round, regular and distinctly outlined. On staining
with methylene blue, while the surrounding proto-
plasm took a deep greenish-blue color, the refractive
nucleus showed a faint blue. No nucleolus was
demonstrable.
Specimen four (Plate ix, Fig. 4) taken the same
evening at 10 o'clock, temperature 97 F., showed that
the organisms had increased in size, and for the first
time an increase in size of the red corpuscles was
noted. Slight pigmentation was also observed in
the periphery and pseudopodia. This pigmentation
consisted of small brownish granules or rods, closely
resembling bacilli. These were in rapid motion. This
motion was not brownian in character, as the granules
appeared to pass from one portion of the organism to
another. The nucleus was well marked. By careful
focusing, a small area at the side of the nucleus,
encroaching upon the cell body, was observed in stained
specimens. This area, which is composed of
chromative filaments, stains with methylene blue and
corresponds to the nucleolus of Mannaberg, Feletti
and Grassi, and was demonstrated in only a few in-
stances. At this stage the peculiar forms which the
parasite assumes were very apparent. At times the
organism would lengthen out into a long, curved,
crescented shape. Again it would assume a spherical
contour, or the form of a cross.
The fifth specimen (Plate ix, Fig, 5) showed a pro-
gressive growth in both size of organism and number
of granules. There was also present a pronounced
increase in the size of the corpuscle with a noticeable
decrease in its coloring matter. However the most
marked new feature was the decided prominence of
the nucleolus which though scarcely perceptible in the
former specimens could be easily seen in this one.
The chromatin fibers in one instance filled up fully
one-eighth of the nucleus while a few could be traced
to the nuclear membrane.
Specimens six, seven and eight (Plate ix, Figs. 6, 7
8) showed a decrease in the number of organisms
present. However, in those present there was noted
an increase in pigmentation, size of organism and
corpuscle.
On examination of specimen nine (Plate ix, Fig. 9)
several startling facts were brought to light. As if
by magic the field teemed with organisms in numer-
ous instances, as many as ten organisms being present
in the same field at the same time. The explanation
of this phenomenon, that is, the great difference in
the number of organisms present in so short a time,
probably is that the parasites were collected in the
internal organs when specimens six, seven and eight
were obtained. These organisms showed especially a
great growth of nucleus and nucleolus. In many
cases the ectoplasm, or portion surrounding the
nucleus, staining deeply and containing the pigment,
formed but a narrow band around the nucleus. The
nucleus often seemed to be double, consisting of two
equal or unequal portions. On close observation and
careful focusing it was possible to distinguish narrow
bands of ectoplasm stretching over the nucleus or
endoplasm, but not through it. Some organisms of
normal size and appearance were present which
appeared to possess no nucleus, but here again very
often careful focusing showed that we were probably
looking upon that portion of the ectoplasm which
covers the endoplasm. In some instances organisms
of this description showed no nucleus whatever.
There were moreover, many large extra corpuscular,
irregular, granular, pigmented bodies having no nuclei
which were probably degenerated organisms. These
bodies were often filled with vacuoles.
In specimens ten, eleven and twelve (Plate ix, Figs.
10, 11, 12) were found many adult forms which in
size equaled that of red corpuscles. These were endo-
globular or free in the plasma. When intra-corpus-
cular the corpuscle was greatly enlarged and decolor-
ized, the cell wall showing as a thin film. The
pigment granules were motionless.
In specimens eleven and twelve (Plate ix, Figs.
11-12) segmentation was observed in two forms. In
the first a very large nucleus was observed, in which,
and partially filling it, could be made out faintly
staining, sporelike bodies, numbering from fifteen to
thirty. The second form showed the organism dif-
fusely and faintly stained throughout, in which pig-
ment granules and sporelike bodies were scattered.
This second form was probably a later stage of the
first described, and resulted from the rupture of the
nuclear membrane, setting free the sporelike bodies
or daughter-nucleoli into the ectoplasm. These bodies
seemed to contain distinct nuclei, and though non-
motile while in the organism, appeared to acquire
motion on reaching the plasma of the blood. In no
instances was fragmentation observed, nor Golgi's
rosette forms.
Thus we have followed the tertian organism through
210
RADICAL CURE OF INGUINAL HERNIA.
[July 25,
the cycle of its existence, and have once more arrived
at the hyaline forms.
As regards the function and mode of reproduction
of the elementary parts of the organism there is to-day
a difference of opinion. Grassi and Feletti are of the
opinion that the process of reproduction originates in
the nucleolus. This, on dividing, is at first sur-
rounded by the nuclear juice, a semifluid substance,
which, together with the fibrils running from the
nucleolus to the nuclear membrane forms the nucleus.
In a short time these daughter nucleoli receive mem-
branes and constitute the spores. The pigment is
developed and retained in the surrounding ectoplasm.
These pigment granules he supposes are formed from
the hemoglobin of the corpuscle, but do not react to
tests for iron.
Romanowsky goes ■ so far as to say that by the use
of eosin and methylene blue he has been able to dis-
tinguish karyokinesis during segmentation.
Mannaberg, in speaking of the development of pig-
ment, agrees that it is first seen at the periphery of
the organism in the outer plasma or ectoplasm. His
theory of reproduction is unique. He holds that the
nucleolus shortly before segmentation entirely disap-
pears, withdrawing from the nuclear portion of the
organism into the ectoplasm. It soon reappears in
the nucleus and segmentation progresses as described
by Grassi and Feletti. Investigators agree that repro-
duction is in all probability accomplished in the same
manner in the parasites of tertian and quartan fever,
but in the estivo-autumnal type no nucleus has as yet
been demonstrated.
There is to-day, as there was at first, a difference
of opinion in regard to the nature of the flagellate
bodies. The two theories still exist, Laveran and
his associates contending that these forms are repro-
ductive in their functions, while Golgi and his follow-
ers insist that they are degenerate. The theory that
they are produced by thermic influences has been
generally abandoned.
(To be continued.)
A NEW OPERATION FOR THE RADICAL-
CURE OF INGUINAL HERNIA.
BY GEORGE TULLY VAUGHAN, M.D.
P. A. SDEGEON, U.S. M.-H.S. ; IN COMMAND UNITED STATES MARINE-HOSPITAL
SKKVICE AT PHILADELPHIA, PA.
Of the various operations for the radical cure of
inguinal hernia, I believe it is generally agreed that
those of Bassini and Halsted respectively are the best;
as to the choice between these two methods there is
some difference of opinion.
Unquestionably the method of Bassini comes nearer
to restoring the tissues to their original condition and
relations before they were stretched and distorted by
the protruding viscus than any other operation now
before the profession, and the number of relapses fol-
lowing this operation when carefully done is probably
less than from any other.
Halsted's method has the appearance of strengthen-
ing a naturally weak place in the abdominal wall by
increasing its thickness beneath the cord by the
addition of the aponeurosis of the external oblique
and some fibers of the internal oblique and transver-
salis muscles, but he brings the cord straight through
the entire thickness of the abdominal wall (except
the skin and fascia) at a point slightly higher and
more external than the normal position, dividing par-
tially the external, internal, and transversalis muscles
in order to do so.
In the operation proposed the normal inguinal
canal is obliterated, the cord is placed deep, next the
peritoneum and passes through the abdominal wall
both obliquely and where it is strongest, more than
half the circumference of the anterior opening being
formed by bone and tendon.
Another advantage is that the two ends of the
inguinal canal are placed nearer on the same level, so-
that a viscus engaging in the posterior end would not
have the same tendency, not being aided by gravity,
to descend through the canal, as it does when the
anterior opening is lower than the posterior.
Two objections would naturally be suggested to
this operation ; 1, that division of the muscles form-
ing the conjoined tendon weakens the abdominal wall,
and 2, that the new position of the cord may produce-
constriction and harm the testicle. To the first objec-
tion it may be said that with aseptic care and accurate
approximation the muscle unites through the medium
of muscular tissue not connective tissue. ( See Senn,
Principles of Surgery 1896, p. 46, and others) and is
probably as strong as ever.
So far as I have heard, Halsted has had no trouble
from dividing the muscular fibers above the internal
ring and relapses from Halsted's operation, judging
from my own experience, are owing to the cord being
brought straight through the abdominal wall instead
of obliquely, and, that this opening is Surrounded by
yielding muscle unsupported by bone or tendon. In
reply to the latter objection I can only say that there
has been no interference with the integrity of the tes-
ticle in any of my cases. The objection to bringing
the cord out over the symphysis pubis in a more
exposed position is of no importance.
The operation is performed as follows:
1. Make an incision over the inguinal canal from the
internal abdominal ring to the center of the symphysis-
pubis through the skin and fascia; then split the
fibers of the aponeurosis of the external oblique,
exposing the cord and hernial sac.
2. Separate the sac from the cord, ligate or sew
across well within the internal ring and cut off the
redundant part.
3. Divide the conjoined tendon through it's mus-
cular part four or five centimeters above its insertion
including the internal pillar of the ring, down to the
peritoneum, avoiding the deep epigastric artery.
Separate by blunt dissection the conjoined tendon
from the rectus and pyramidalis muscles down to the
pubic bone and place the cord in this position between
the conjoined tendon and rectus. The cord still passes
through an oblique canal at its anterior portion, as
the conjoined tendon overlaps the rectus and pyra-
midalis for two and a half centimeters or more, being
inserted in front of these muscles. Unite the divided
ends of the conjoined tendon and of the internal pil-
lar with mattress sutures, and accurately approximate
them with continuous or interrupted sutures.
4. Close the old inguinal canal with interrupted
sutures, uniting Poupart's ligament to the conjoined
tendon, and in the outer part including the transver-
salis fascia over the cord. I usually pass two or three
of these sutures through the conjoined tendon to-
include the edge of the rectus.
5. Unite the superficial structures with a continu-
ous suture and the skin with a subcuticular suture.
Kangaroo tendon is the best suture material to be
1SW.]
SELECTIONS.
211
QSed throughout the operation. The cord is thus
placed next tlie peritoneum and brought obliquely
through the abdominal wall at the strongest point.
This operation is more difficult and requires rather
more time in its performance than that of Bassini. I
have performed it only five times hut so far as known
the results an' all that could he desired. One patient
was seen five months after the operation. He had
been at work and was then in good condition. The
others have not been heard from though they were
requested to write to me in ease of relapse.
SELECTIONS.
Pica or Dirt-eating Among Children. In Volume I of the Edin-
burgh Uospitnl Reports for 1895, Dr. John Thomson publishes
a study of this morbid habit in the various parts and periods of
our planet. It is his belief that the dirt has a well defined
hygienic value, and is eaten by children for medical purposes.
The physical ailing which brings on the appetite for dirt is in
most cases anemia, which simply means a running down of the
system. In these cases, the habit might be formed from an
instinctive craving for earthy salts, such as iron and lime, just
as a cat or dog, when needing a little physic, will eat a blade or
ao of grass. The eating of substances of various kinds which
are not wholly indigestible, but are also devoid of any natural
attractiveness of taste, is a morbid habit which has often been
•observed both in human beings and among certain of the lower
animals. Many names have been applied to this craving, such
as pica or kitta (the Latin and Greek words for a jay or magpie),
geophagie, allotriophagia, malacia, mal d'estomac ; and it has
been observed to occur under a considerable variety of conditions.
From his experience and that of others in the reported cases
collated by him, Dr. Thomson formulates the following eight
principal points of the natural history of this affection : 1.
Surroundings and upbringings. Some of the patients had been
much neglected in every way ; but quite as many of them were
evidently, so far, at least, as their bodily condition was con-
cerned, most carefully tended. The moral training may, per-
haps, have been deficient, however. 2. Bodily condition. In
many of the cases diarrhea existed, in some otorrhea, and
other minor complaints. In most there was no sign of organic
disease, no special anemia, and no indication of the presence
of worms. Xo connection could be traced between the com-
mencement of the habit and the state of the teeth, or of the
diet in any case. 3. Mental condition. All the children
seemed quite normal mentally, and there was no other bad
habit constantly, or even frequently, found associated with this
one. 4. Beginning of the habit. When the pica began it was
often difficult to fix the time exactly, because it had attracted
so little attention at first ; but the age given varied from four
to eighteen months. Probably this depended chiefly on the
chances the child had of getting at the forbidden articles, his
freedom from restraint, and his powers of locomotion. 5. Ces-
sation of craving. It is interesting to notice that in those cases
where the habit was formed in early infancy, and where the
patient was some time under observation, the craving ceased
entirely (in all but one instance) at about the age of three years.
This seems probably connected with the growth of the child's
intelligence and the widening of its interests. 6. Substances
eaten. In some cases only one or two abnormal things are
eaten ; in many, almost anything within reach is swallowed.
From the cases reported here and elsewhere it seems that the
variety of the unnatural substances craved for is much more
limited in cachectic cases than in those beginning in young
babies. 7. Physiognomy. Children who have suffered from
pica for some time usually have a peculiar look about the face.
Their complexion has has not the rosy tint of healthy child-
hood, it lacks clearness, and is dull and unhealthy looking. 8.
Results of the practice. In those of the cases in which the
children were allowed to indulge their craving to any great ex-
tent, there was always some diarrhea, and occasionally obstruc-
tion from impaction of hard bodies in the rectum. In none of
his cases was the patient ever seriously ill as the result of the
habit, but instances have been recorded which have ended
fatally. Under the head of treatment, the author holds that
medication plays but a small part, while a modification of the
morbid environment is t*he main issue, and in this relation the
following summary will point out the chief indications: 1.
Keep the child away from the substances for which he has a
morbid craving. All habits are strengthened by practice, and
their hold slackens under disuse. 2. Improve the condition of
the digestion. It seems more than likely that local uneasiness
often plays some part in the etiology. 3. Improve the general
health. It is to the weakly that such cavings come, and the
strong readily throw them off. 4. If possible, change the child's
surroundings and take his mind up with new things, and let
him be kept busy and happy. 5. The small amount of dirt
eaten by children will do little harm of itself, but the great
danger is that they will ingest semething poisonous or some
parasite which, once entering the stomach will reverse the
operation by preying upon the patient.
Diagnosis and Indications for Treatment of Intra Abdominal Injuries
Without External Evidence of Violence.— Dr. John B. Deaver says :
In severe intra-abdominal injuries there are a few symptoms
common to all, and in the majority of cases warrant immediate
operation. Most prominent of these is pain accompanied by
shock. The pain is not like that of ordinary intra-abdominal
affections, but is accompanied by consciousness of impending
death. When vomiting is associated with agonizing pain and
tympanites is also present, indications point to intestinal or ves-
ical rupture. Collapse with evidences of rapid exsanguination
point to hemorrhage from rupture of one of the larger vessels
liver or spleen. There is often a characteristic rigidity of the
abdominal walls, due to intra-abdominal irritation. It is
sometimes so pronounced as to call to mind the checker-board
appearance of the normal abdominal wall as represented in
sketches by artists of former times. This condition of the
walls is invariably associated with some form of serious lesion.
In injuries of the abdomen in the female, pregnancy normal or
extra-uterine, ovarian tumors, pyosalpinx, etc., must be borne
in mind. Rupture of any of the solid viscera is usually followed
by fatal hemorrhage.
The symptoms of rupture of the liver are usually great livid-
ity of the skin, marked embarrassment of respiration, disten-
tion of the abdomen which is not altogether tympanitic,
itchiness of the skin, and, if the patient survives the immed-
iate effects of the injury, jaundice. Rupture of the gall-bladder
or biliary ducts may occur as the result of blows upon the
abdomen, especially if the gall-bladder be filled with gall-
stones. The commonest seat of rupture of the biliary organs
is the cystic duct. Peritonitis follows rupture of the gall-
bladder or ducts. If the tear be small and the leakage slow,
the escaping bile may become encysted and the peritonitis
remain localized. If rapid, there will be general peritonitis and
death. If there be no rapid extravasation, there will be col-
lapse, vomiting and dyspnea and abdominal pain. If the bile
escapes into the general peritoneal cavity, there will be prompt
general acute peritonitis, with intense jaundice and clay-
colored stools. When the gall-bladder has been ruptured
death almost invariably follows.
The treatment of laceration of the liver, gall-bladder, hepa-
tic, cystic, or common duct resolves itself into prompt surgical
interference.
If a tear of the liver be superficial, by early operative inter-
ference we are enabled to remove the blood and bile which
212
SELECTIONS.
[July 25,
have escaped into the peritoneal cavity, to surround the rent
with strips of gauze with a twofold object : 1, to prevent a
second invasion of the peritoneal cavity by blood or bile ; and
2, to invite adhesions between the liver and parietal peritoneum.
The hemorrhage can be controlled by searing the torn surfaces
with the actual or thermal cautery or packing with gauze
strips. When the tear in the liver is of such a character as to
permit of suture, the latter, which should include the capsule,
should be used. If there is doubt as to the thorough control
of the hemorrhage by the sutures, the wound should be treated
by the open method, gauze strips being placed between the
liver and the parietal peritoneum to the outer side of the line
of suture. When the gall-bladder, the hepatic, cystic, or com-
mon duct has been torn alone or in connection with injury to
the liver, it may be necessary to establish a biliary fistula ;
however, the attempt, if possible, to suture the bladder or duct
should be made.
Injury to the splenic artery or vein is invariably followed by
sudden death. The symptoms of ruptured spleen are those of
exsanguination, precordial pain, gasping and shortness of
breath (air-hunger), weak, rapid pulse, vomiting and thirst.
When the spleen has been the seat of the injury under consid-
eration its removal should follow.
Rupture of the kidney varies in intensity and location.
Laceration of the pelvis or ureter is not immediately fatal as
hemorrhage is not profuse. The inflammation following oblit-
erates the duct, consequently there will be developed in a few
days a hydronephrosis, with a corresponding tumor of the loin.
The kidney will sometimes become a multilocular abscess after
long periods of time when the impervious ureter atrophies.
Collapse invariably follows severe injury of the kidney and is
accompanied by pain in the lumbar or hypochondriac region,
vomiting and an anxious countenance.
If there is a history of severe injury to the abdomen or loin,
followed by faintness, anxious countenance, coldness, vomiting
and severe abdominal pain ; if the urine contain blood in quan-
tities, either clotted or mixed, immediately or within a day or
so after the accident ; if in several days pus appear as well as
blood ; if there is a rigidity of the lumbar or abdominal
muscles and ureteral pain with retraction of the testicle ; and
if these symptoms are followed by enlargement of the lumbar
and hypochondriac regions, with percussion dullness, we may
be fairly sure that extensive renal laceration has occurred.
Rupture of the ureter is extremely rare ; in a few cases reported,
the tear was so close to the hilus of the kidney that practically
they may be considered as rupture of the kidney itself. The
symptoms are the same and the treatment identical.
There are many symptoms common to both gastric and intes
tinal rupture and can be described together. The immediate
symptoms are faintness, collapse, agonizing pain, either local-
ized or general, weak, rapid pulse, thirst, vomiting, tympanites,
and rigidity of the abdominal walls accompanied by extreme
tenderness. The facial expression is indicative of the serious
nature of the intra-abdominal lesion. We should never wait
for secondary symptoms if the patient's condition warrants
operative interference. Where operation has not been resorted
to the above symptoms may redevelop at a later period in an
insidious and unexpected manner, and the patient suddenly
expire from either shock or general septic peritonitis due to
intestinal perforation from pressure necrosis. Incomplete
tears of the stomach do no produce sufficient symptoms to
render their recognition possible. When the wound is in the
immediate neighborhood of the pylorus, and particularly if it
is longitudinal, it will be necessary to introduce the sutures in
the line of the long axis of the stomach in order to avoid con-
striction of the orifice. The early recognition of rupture of
the bladder is of paramount importance to a successful termi-
nation of a case. The introduction of a catheter will definitely
settle the question of its rupture. If no urine escapes, but
instead a few drops or a considerable quantity of blood, the
inference should be that the organ has been torn. Before the
catheter is withdrawn a measured quantity of boric acid or
normal saline solution should be injected, when if the full
amount thrown in is not recovered there can be no question of
the nature of the injury. If the tear be intraperitoneal more
liquid than that thrown in may be recovered or perhaps less.
Where the tear is so small as to prevent the free escape of the
injected fluid or where the opening in the bladder is valve-like,
occasioned by a loop of intestine becoming herniated through
it, this means of diagnosis may fail. In either event the pre-
vesical space should be immediately opened, when it can be
decided whether an extra- or intraperitoneal rupture exists.
When the rent in the bladder is extraperitoneal, it is neces-
sary to drain the prevesical space by a drainage-tube carried
through the abdominal incision ; if the urine has found its
way along the sides of the pelvis, drainage should be intro-
duced laterally through an incision above and to the outer
side of the middle of Poupart's ligament. The bladder is also
to be opened by a lateral incision through the perineum. The
diagnosis of injury to the vascular system is unsatisfactory at
best, as the injury to the vessel may be complicated by an
injury to the abdominal viscera, entirely overshadowing the
blood vessel lesion. The prognosis is grave under all circum-
stances, even when there has been only a contusion ; there is
the possibility of future aneurysm from weakened vessel wall,
the result of the trauma. — University Med. Mag., July.
Malarial Parasitic Infection Diffused by Air-Currents as Well as by
Water. — Dr. P. Manson has given in the London Lancet, a clear
and concise statement of his views regarding the spread of
malarial fevers, inclusive of his original theory that the mos-
quito is the intermediate host of Plasmodium or malaria, with
many observed facts and his conjectures dovetailing in with
those facts, in order to complete the parasitic cycle. "It can
not be doubted," he says, "that there are many cogent reasons
for believing that the Plasmodium malarias on leaving man,
and as a normal step in its life history, becomes parasitic in
the mosquito, and that in this insect it enters some cell — as
any gregarine or coccidium would do — and probably develops
into its reproductive sporulating form just as it does in the
blood corpuscles of man. What then? How can its spores get
out of the mosquito so as to increase and multiply and preserve
its species from extinction when, in the course of nature, the
mosquito dies? How, too, does it spread over the land and
how does it get back to man again? Before attempting to
answer these questions, I must first describe very briefly a pas-
sage in the life of the mosquito. The female mosquito, after
she has filled herself with blood — the male insect is not a
blood-sucker— seeks out some dark and sheltered spot near
stagnant water. At the end of about six days she quits her
shelter and, alighting on the surface of the water deposits her
eggs thereon. She then dies and as a rule falls into the water
beside her eggs. The eggs float about for a time and then in
due course each gives birth to a tiny swimming larva ; these
larvse, in virtue of a voracious appetite, grow apace, casting
their skins several times to admit of growth. Later they pass
into the nymphal stage during which, after a time, they float
on the surface of the water. Finally, the shell of the nympha
cracks along its dorsal surface and a young mosquito emerges.
Standing, as on a raft, on the empty pelt the young mosquito
floats on the surface of the water while its wings are drying
and acquiring rigidity. When this is complete it flies away.
The young mosquito larvae to satisfy their prodigious appe-
tites devour everything eatable they come across, and one of
the first things they eat, if they get the chance, is the dead
body of their parent, now soft and sodden from decomposition
and long immersion. They even devour their own cast-off
skin3. In examining mosquito larva? one often comes across
18%.]
PRACTICAL NOTES.
213
specimens whose alimentary canals are stuffed with scales,
fragments of limbs, and other remains of the parental insect.
As we have seen that the mosquito larva devours its own and
its neighbor's exuvia?, we can readily understand how, once
gregarines have been introduced into a pool of water, the lar-
val mosquitoes in that particular pool become infected by the
parasite. Hut as the mature mosquito, when she quits her
nympha husk, also contains numerous gregarines we can also
understand how she, too, carries the infection with her,
scattering it about the country in her feces or conveying it to
any other pool where she may lay her eggs and afterward die.
Her body is then devoured by her progeny, or by any other
mosquito larva- that already chance to be in the pool. Along
with her body the larva* swallow any gregarine germs it may
contain, if they have not already been picked up by the larvae
when feeding on the mud at the bottom of the pool. Does not
this little story of the gregarine indicate the way, or a way,
in which that other mosquito sporozoon, the Plasmodium
malaria", multiplies? Does it not indicate how this para-
site, in which man is so much interested, passes from mosquito
to larva\ from larva? to mosquito in never-ending series? Does
it not indicate how the Plasmodium disease of mosquitoes
spreads from pool to pool and is scattered broadcast about the
country, and does it not indicate how it may get back to man
again? We can readily understand how the mosquito-bred
Plasmodium may be swallowed by a man in water, as so many
disease germs are, and we can readily understand how it may
be inhaled in dust. Mosquito-haunted pools dry up. The
Plasmodium in the larv* and those that have been scattered
about in the water finding themselves stranded by the drought
and so placed in a condition unfavorable to development, pass
into a resting stage, just as they do, when by quinin or other
means, man is rendered temporarily unsuited for their active
life. The dried specimen of the pool, blown about by the
winds and currents of air, is inhaled by man, and so the Plas-
modium finds its way back again to the host from whom its
ancestors had, perhaps, started generations back. I would
conjecture that on entering man and on entering the larval
mosquito it develops into a flagellated spore similar to the
flagellated spore into which it develops in the mosquito's
stomach. In this way it would be enabled to penetrate the
mucous surfaces and get into the human blood-cell. Many
mosquitoes die without getting to water ; all male mosquitoes
die without seeking water. They may die far from water,
blown away, as we know mosquitoes are, by winds. The
bodies of such mosquitoes fall in time on the soil and decom-
pose. The parasites they contain pass into the resting stage,
and in this form they also may be carried into the air by cur-
rents, or be blown about as dust, or be shaken out by man
when he disturbs the soil. In this way the Plasmodium may
find a route back to man again. In this way, too, we may
explain the occurrence of those cases of malaria which appa-
rently, though not really, are unconnected with swamp or
stagnant water. Such is my view of the life history of the
malaria parasite, and the role of the mosquito with regard to
it, and the process by which man becomes infected."
Pyelopblebitis; Operation; Death. — The May Scalpel reports
that Dr. Godlee has operated in two cases of hepatic abscess
due to the above-named cause. A warehouseman, aged 41,
had an acute illness in June, 1895, which left him with pain in
the region of the liver, for which he was seen in September.
He had a hectic temperature and one rigor. There was obvious
swelling of the liver. The diagnosis lay between suppurating
hydatid and abscess. The abdomen was opened on October 18
and a large abscess found at the front of the liver. A drainage
tube was inserted. There was a slight improvement for a day
or two, which was not maintained. Postmortem, there was
old inflammation about the cecum, clotting of the right branch
of the portal vein, and the corresponding part of the liver was
riddled with abscesses. The left portal vein was patent, and
the left lobe of the liver was free from suppuration. The
patient had also purulent meningitis. Remarks were made on
the pathology and treatment of this condition. A somewhat
similar (fatal) case, a previously healthy Scotch manufacturer,
aged 58. Disease began insidiously a month before he came
under notice ; there was very rapid enlargement of the liver
accompanied by rigors. An abscess was found upon the under
side of the liver, containing about one pint and a half of stink-
ing pus. The patient was very feeble before the operation
and died of shock. Mr. Arbuthnot Lane recalled the case of
a patient who had suffered from attacks of what at first
appeared to be biliary colic, but the distension of the gall
bladder was associated with tenderness over that region and her
temperature rose to 103 degrees F. He made out the presence of
stones in the gall bladder, and cut down and removed them. It-
was adherent to a large intestine. He left a tube in, though
he made no attempt to see whether there was anything in the-
transverse fissure, owing to the numerous adhesions. More-
over, there was no jaundice. He saw her a morning or two-
after the operation just after an attack of the old pain had
come on. Her temperature was then normal, but it rapidly
ran up to 107 F. , and she died seven hours later. Postmortem
they found an abscess behind the portal vein, and the liver
was filled with large hemorrhagic patches. Although no open-
ing into the vein could be made out it seemed absolutely cer-
tain that the abscess had burst directly into it or one of its
branches.
PRACTICAL NOTES.
Massage In Treatment of Post-operative Intestinal Obstruction. — A
Ernest Gallant, M.D., says that by early massage we can give-
immediate relief, independent of the use of laxatives or ene-
mata, and that in these cases the bowels move more readily and
with less stimulation than when massage is delayed. Laxa-
tives tend to increase gas formation and intensify peristalsis,
thus adding to the pain and discomfort. Enemata can not
reach above the ileo-cecal valve, and cause colitis, rectal tenes-
mus and proctitis, followed by exhaustive diarrhea. Intestinal
cramps from gas or too active cathartics may be relieved by
repeating the rubbing at frequent intervals. Infection of the lin»
of wound union or damage to structures involved in the opera-
tion by massage thirty hours after operation is not likely to-
occur. — Mathews Med. Quarterly. July.
Identification of Morphia in Toxicologic Cases. — J. B. Nagel-
voort reports results of experiments to determine the stability
of morphin under certain conditions. A practical test seemed
to be needed to determine how small a quantity of morphin
could be isolated and identified ; the sensitiveness of morphin to-
different reagents being well known, % grain was taken. This
was dissolved in a plate of soup, selected to imitate volume and
contents of a human stomach in natural condition. The next
step was to mix 0.050 gram morphin with a suitable portion of
refuse meat, fat and some bulk of vegetable matter. Ten mix-
tures of this kind were left to putrefy for fifty days, in a warm
room, covered with a glass jar. Three mixtures of the same-
quantity of morphin with human flesh, furnished by the med-
ical school, were also left to putrefy. At the end of the fifty
days' exposure morphin was searched for in all the mixtures
by the methods of Dragendorff, Stas-Otto and Graham (the-
dialysation process), due precautions being taken against con-
fusion in the chemic reactions. Characteristic morphin reac-
tion was obtained in each case. No better conclusion can be-
drawn than that a popular belief in the destructive power for
alkaloids, of the decomposition of cadavers, has no foundation
in the facts. — Am. Jour, of Pharmacy, July.
214
PRACTICAL NOTES.
[July 25,
Infantile Scurvy. — Lack of fresh food is the most important
cause of infantile scurvy, the use of the proprietary foods and
condensed milk produces more than all other causes combined.
Even fresh milk in small proportions is not sufficient to insure
protection. It has been shown more recently that proprietary
foods, condensed milk, and cow's milk too freely diluted are
not the only offenders, but that sterilization or prolonged boil-
ing of new milk of good quality is sometimes an important fac-
tor in the development of infantile scurvy. The diagnosis of
this disease is a matter of some moment, the more so since the
failure to institute treatment early is often followed by fatal
results. The diseases for which it is most apt to be mistaken
are rickets, rheumatism, stomatitis, congenital syphilis, in-
fantile paralysis, osteitis and sarcoma. As a rule, however,
symptoms of scurvy are so pronounced that there is but little
difficulty in making a diagnosis when the condition is borne in
mind. On the treatment of the disease there is but one opin-
ion, and that is that the best results are secured by the prompt
substitution of " living food," such as fresh milk, fresh beef-
juice, and orange-juice for proprietary food, condensed milk and
sterilized milk.— University Med. Mag., July.
Tbe Lewaschew Method of Substituting the Effusion in Pleurisy
with Equal Amount of Salt Solution.— This method was first
announced at the Berlin International Congress, but further
success with it impels L. to recommend it in still stronger terms,
as he has now a record of fifty-two cases, all followed by marked
relief and prompt recovery. Thoracocentesis is first performed
and as the effusion is gradually aspirated, it is replaced by
physiologic salt solution, which prevents the collapse of the
organs into the empty pleura, while the solution is gradually
absorbed and exerts a general tonic and local antiseptic effect.
The Therap. Woch. for June 28 devotes ten pages to a complete
resume" of the results and technique of this treatment.
Diabetes In Early Infancy. — W. B. Bell, in the Edinburgh Med.
Journal, reports the following case : A. B., aged 3 months 5
days ; parents noticed that the child was very restless, suffered
from a very intense thirst, and required a large quantity of
fluid in addition to the breast. They also noticed some increase
in the amount of urine, and that there was a good deal of
cutaneous irritation around the genitalia and thighs. Occa-
sionally the child was very drowsy, and his breath had a pecu-
liar odor. The child was born as a face presentation and the
labor was protracted and difficult, but not instrumental.
Parents both alive and healthy ; one sister healthy ; one aunt
on the father's side, died from diabetes mellitus. The patient
is a well-nourished male child. Urine in excess, but amount
not estimated or specific gravity ascertained. Clear and with
a sweet taste, containing a large amount of sugar by Fehling's,
Moore's and Johnson's tests. Marked weeping eczema of the
privates and thighs, especially in the folds. Patient fretful
and restless. Breath normal, excessive thirst, bowels regular.
Head-Swaying in Children. — Dr. William Osier, in the Montreal
MedicalJournal, June, has the following case to report of a
neurotic affection that is well-nigh unique. He says: "Among
the curious coordinate movements in children , head-nodding and
head-banging are among the most interesting. The following
case presents an interesting condition, which I do not remem-
ber to have seen described, in which the head is swayed from
side to side in a rhythmic manner : E. C, female, aged 5, third
child ; always healthy ; when born was not a blue baby and
instruments were not used. Developed naturally and had no
trouble with teething. Both mental and bodily growth were
normal and she is now a well-nourished, healthy-looking child,
very bright and intelligent. She is a Hebrew, and many mem-
bers of the family are excitable and nervous. The parents are
bright, intelligent people. From the time the child sat up it
was noticed that she moved the head from side to side, or
dropped it on the shoulder and this habit has persisted. The
father states that it was noticed from the very earliest infancy.
She never has had any other movements ; never any rotation of
the head, or head-nodding, or any twitching of the muscles of
the face or of the arms. She is not a mouth-breather and she
sleeps quietly. At times, however, she is very restless and gets
on her hands and knees in her sleep and bores her head into the
pillows and climbs up until she knocks her head against the
foot of the bed, as her father says, ' rooting about like a pig.'
She never has had spasms, and has been a very healthy child
in every respect."
Dolphin Oil in Acne.— Dr. Boeck, in Annates de Determatologie,
says that dolphin oil inhibits the growth of bacteria in the
skin, and consequently he finds the following useful : Cam-
phorae 0.30, acidi salicylici 0.50, sulphuris precipitati 10,
zinci oxidi 2, saponis 1, olei delphini 12. Misce. Make the
application each night ; wash the face in the morning with
soap and warm water.
Local Treatment of Diphtheria with Sodium Hyposulphite. — Dr.
Henry A. Wickers writes to Lancet, for June 3, that in his
opinion, the above named treatment has been too much neg-
lected by his medical confreres. He has for some time been
using a solution of sodium hyposulphite as a local application
in diphtheria and has been well satisfied with the results,
three or four applications having generally been sufficient to
clear away the false membrane. The solution is prepared for
use by mixing equal parts of pure glycerin and a saturated
solution of hyposulphite of sodium in water, and is applied
with a brush to the exudation and inflamed fauces once or
twice daily or as often as may be deemed necessary. The gly-
cerin by its adhesiveness keeps the solution longer in contact,
and also, by its well-known local action, helps to relieve that
engorgement of the mucous membrane which seems especially
favorable to the growth of exudation. It is probable that the
hyposulphite has a continuing action as a germicide in the fol-
lowing manner : Chemic decomposition is first set up by con-
tact with the acid secretions of the mouth and throat, sulphur
and sulphurous acid in a nascent state being set free ; the lat-
ter being gradually converted by oxidation into sulphuric acid,
would in the same manner decompose further portions of
unchanged hyposulphite, and so on until the hyposulphite was
exhausted. This local treatment will not interfere with the
general treatment, which must be adapted to the necessities
of each individual case.
Lactation Atrophy of the Uterus. Dr. Hiram N. Vineburg says :
"Whether or not puerperal hyper-involution apart from lacta-
tion frequently occurs must be left to future investigation. To
its non-occurrence may be attributed many of the gynecologic
cases seen in private practice. By examinations up to the
twelfth puerperal week the condition can be recognized, if
existing, and the ill consequences of deficient involution
averted. Care should be taken that the hyper-involution does
not become permanent." He summarizes his observations as
follows :
1. Modern researches tend to prove that post-puerperal invo-
lution consists chiefly in a retraction and contraction of the
individual muscle-fibers whereby the whole uterus is reduced
in size.
2. When involution goes on to its full completion the uterus
is reduced to a size smaller than that of the non-parous organ.
3. This condition of complete involution is known as post-
puerperal hyper-involution. It is principally seen in nursing-
women, and from this circumstance has received the cognomen
of lactation-atrophy.
4. The so-called lactation-atrophy is a normal and desirable
condition. -It is temporary in its duration ; but very rarely,
under unfavorable circumstances, may become permanent.
5. When the parturient is unable to perform the function of
lactation it is the duty of the physician to endeavor to bring
about hyper-involution by other means at his disposal. An
observance of this course will prevent many a woman from
developing a host of gynecologic affections which frequently
result from imperfect involution. — Am. Jour. Med. Sciences,
July, 1896.
1896.]
EDITORIAL.
215
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SATURDAY, JULY 25, 1896.
THE JOURNAL ITSELF.
Owing to the increase in the number of pages
of the Journal and the larger issue, we are obliged
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fore request correspondents to send their commun-
ications so as to reach us not later than Tuesday
instead of Wednesday as heretofore. We herewith
append the detailed statement of the circulation for
the last six months:
Jan.— 1st week. . . 6,500 April— 3d week . . 6,800
Feb.
2d "
3d " .
4th "
-1st week. .
2d " .
3d "
4th " .
5th "
Mar. — 1st week .
" 2d " .
3d " .
4th "
April — 1st week .
2d " .
6,700
.6,800
.6,800
. 7,000
. 7,000
. 7,000
.7,200
. 7,200
.8,100
.8,000
. 7,900
.8,100
. 7,800
. 6,800
May-
4th " . . 6,900
-1st week . . 7,000
2d " . . 8,000
3d " . . 8„000
4th " . . 7,200
5th " . . 7,100
June— 1st week . . 7,000
2d " . . 7,100
3d " . . 7,100
4th " . . 7,200
Total 188,300
Weekly average for
six months, 7,242 4-13
Our members should be reminded that the Treas-
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Chicago, is ready to receive the annual dues; and to
those not present at the Atlanta meeting, who have
not already responded to the Treasurer's call, we wish
to remind them that their great weekly costs vastly
more money than it did a few years ago, and that
prompt payment of dues and subscriptions are more
than ever necessary. Let every member help us
obtain a new member, and we can celebrate the semi-
centennial at Philadelphia with one of the strongest
medical organizations in the world.
THE ANNUAL REPORT OF THE SANITARY COMMIS-
SIONER WITH THE GOVERNMENT OF INDIA.
We have read this document with more than ordi-
nary interest and pleasure, for it shows how keenly
alive the British Government of India have become
to its sanitary interests.
The report deals not only with the sanitary situation
in India, but gives the returns of sickness and mor-
tality among the European and native troops and
prisoners in India for the year 1894. With the last
we can have only a passing interest, but with the
progress of sanitation in India, the whole world is
interested. We have been included among those who
have frequently animadverted on the indifference and
neglect of the ruling power in that empire. We
have urged that any nation was responsible for main-
taining endemic cholera and yellow fever centers
within its jurisdiction. We have set forth this sin of
omission as an infringement of the jw gentium, that
should be recognized in international law. The spe-
cific examples, the bad object lessons, were Spain in
its failure to arrest yellow fever in Cuba, and Great
Britain in its failure to stamp out cholera in India.
The world has suffered untold misery from these pre-
ventable diseases, and the nations responsible for
their maintenance have been apathetic. Spain is now
suffering the loss of the flower of her army. Regiment
after regiment sent to Cuba becomes decimated and
leaves most of its gallant membership in eternal
sleep. The febre amarilla, rather than the bullets of
the patriots, plays havoc with Castilian and Aragonian
alike. The expenditure of a few millions in carrying
out sanitary measures would make Cuba one of the
most healthful spots on the globe. Spain has delib-
erately shut her eyes to this fact, and allowed the
island to become a land of death to all comers. If
that were all! This insanitary apathy has cost this
and other countries thousands of lives, and incalcu-
lable loss to commerce both by sea and land. If
Spain shall lose Cuba at this time, every civilized
country will rejoice, because, with other and different
government, " yellow Jack " will cease to prey upon
the world's commerce from Cuban ports.
English rule in India should be welcomed by the
world, so far as advances in civilization are concerned,
but up to a very recent period, it is questionable
whether, in view of her neglect to carry out sanitation,
the world would not be much better off with Russia
in full control. Russia knows how to stamp out chol-
era and plague within her dominions, and she not only
has the power to enforce sanitary regulations where
necessary, but never yet has failed to exercise it.
Such being the general views held by hygienists in
216
HEMATOZOA IN THE LOWER ANIMALS.
[July 25,
this country, it is a great pleasure to take up the
report of the Commissioner and see that great work is
now being done throughout the Empire.
The water supply is being looked into, and it seems
at last likely that renewed energy will be shown in
the next succeeding reports. The enormous mortality
from cholera throughout India and Burma is stated
by the Commissioner (Surgeon-Major General Cleg-
horne), page 168, to be 529,049 as against 218,113 in
1893 and 762,695 in 1892.
What may be done in the matter of prevention of
cholera by proper management is well shown by the
result of the precautionary measures taken in the
Northwestern provinces. We quote from the report:
"Turning now to the Magh Kumbh of 1894. In
view of the large assemblage expected, special arrange-
ments were made as soon as the site for the fair could
be definitely fixed. This, owing to the direction of
the main stream of the Ganges after the heavy rains
in the hills in October, 1893, could not be done until
late in December. It was decided to layout the main
site of the fair on the Cantonment land on the right
bank of the river, between it and the Beni embank-
ment, which runs north from the fort to the village of
Daraganj. It was arranged that the religious broth-
erhoods or akharas should be encamped on an island
in the bed of the river near the left bank, their encamp-
ment being connected with the main site, on the other
side of the Ganges, by a bridge of boats. The general
site, on alluvial land, immediately north of the fort,
comprised a broad street of shops, and to the north
of this again, an extensive camp, with broad thorough-
fares and lanes which left the main roads at right
angles. On the island a broad road running eastward
from the bridge of boats divided the camp in two. At
the general site the municipal water was laid on, the
numerous standposts, each surrounded by a platform
of flagstones, being situated at a convenient distance
from each other. All wells were closed and fenced in,
so that no one could use water from them. It was
not practicable to supply the municipal water to the
camp on the island, but arrangements were made for
a supply from the main stream of the Ganges, access
to the back waters being prevented by a cordon of
police. Conservancy was thoroughly carried out.
At the general site, dry earth latrines were used, solids
and liquids being collected in separate vessels and
conveyed to a distant trenching ground by means of a
light tramway. On the island there were trench
latrines, round which were placed police cordons.
Ample urinal accommodation was provided. Rubbish
and sweepings were removed in carts, except when
the accumulations were very large, when they were
burned at convenient places. Provision was made
for the prompt removal of the sick to hospital for
treatment. For police, sanitary and medical purposes,
the general site was divided into five areas and the
encampment on the island into two, and arrangements
were made for continual patrolling by day and night.
The Deputy Sanitary Commissioner was placed in
executive charge."
The result was that out of the vast multitude com-
prising more than one million five hundred thousand
persons assembled on February 5, only 185 died from
January 9 to February 20. Of these deaths 47 were
due to fever, 59 to dysentery and diarrhea and only 3
deaths to cholera.
There is no longer any doubt that with the steady
improvement of the water supply and the prevention
of pollution of the supply, cholera may be eradicated
from India as thoroughly as from England itself.
The report on inoculation by Haffkine, which was
submitted to the government August 25, 1895, is
printed in full, with a rather noncommittal comment
(see p. 269). Altogether the report shows wonderful
sanitary progress.
HEMATOZOA IN THE LOWER ANIMALS.
The recent discovery by Surgeon-Captain Bruce
of the Indian army that the tsetse fly of Africa acts as
the carrier of living virus is of interest from a double
standpoint : First, to the student of human and com-
parative pathology, in clearing up the origin of a mys-
terious disease; and, second, as furnishing another
instance of an insect carrier of contagion. For the
last fifty years, from the time of Livingstone, suc-
cessive travelers have regaled us with accounts of the
ravages of this fly. We learn that it is a terrible
scourge to live stock and that it is one of the greatest
obstacles to colonization in the central part of the
"dark continent." The tsetse fly (Glossina morsi-
tans) is slightly larger than the common house fly; it
has a slender proboscis, nearly twice as long as its
head, and is able to puncture with great force. Its
bite is fatal to the ox, horse, ass, sheep, dog, and ele-
phant; the goat, buffalo, antelope, zebra and man
himself are not seriously affected by it. In fatal
cases, after an incubation of short duration, the ani-
mals have fever, followed by marked anemia, maras-
mus and dropsy for several weeks or even months.
The geographic distribution of the insect is exten-
sive, though rather erratic. It is found in localities
here and there over Central Africa from the Transvaal
to the Zambesi, on the right bank of the latter, and
from Zanzibar as far inland as Ugogo. In these situ-
ations it is to be found in low-lying localities, the
borders of marshes and water holes, and in beds of
reeds. The fly makes a loud buzzing noise which is
said to cause more terror among domestic animals
than the lion's roar. Horses which have passed
unscathed through the fly country and become
immune are called "salted," in South African par-
lance, and command extraordinary prices.
Up to the time of Bruce's discovery the nature of
its virus was unknown. Livigstone, who was one
of the first to give an accurate description of the
insect, attributed it to the glandular secretions; other
observers to germs of some description. Megnin was
of the opinion that the fly carried anthrax virus from
one animal to another. Bruce has discovered that
the fly itself has nothing to do with the disease save
as the carrier of a living virus from infected to healthy
18%.]
WATER SUPPLIES.
217
animals. This virus is a flagellated infusorian, appar-
ent ly identioal with the Trypanosoma Evansi, which
was the oause of a similar disease among the live
Btook in India. Some ten years ago Railliet had
Marly solved the problem, for he wrote: "In reality
the tsetse oan merely be regarded as a carrier of virus
and its bite is only dangerous when its proboscis has
been previously infeoted. With regard to the virus
thai it habitually inoculates, it is difficult in the pres-
ont state of our knowledge to say what it actually
is." etc.
Bones, mules and camels in India are attacked by
, pernkkTOB anemia to which the name "surra" dis-
ease has h,vn -iven. The disease, which is invariably
fatal is characterized by fever, rapid emaciation,
extreme debility and death, in marasmus and coma,
oeeurs in from ten to sixty days. The mortality from
the disease in India and Burmah1 is enormous. Blood
drawn during life has an increase in the number of
white cells with a diminishing number of the red;
the latter are mostly crenated. In the midst of the
corpuscles is seen an organism with a long, flexible
tail ETAN8, who tirst discovered it, supposed it was
a spirillum; Crookshank, after a minute examination,
recognized it as a flagellate infusorian, and Balbiani
■mve it the name of Trypanosoma Evansi. A similar
flagellate organism is found in the blood of rats and
hamsters in Kngland and on the continent of Europe.
Wording to Lingard the Indian trypanosoma is
innocuous to Indian rats, in the blood of which it is
found The disease is inoculable. Dogs and mon-
keys have been successfully inoculated; rabbits are
very susceptible, though the disease is not so fatal in
them. Dogs appear to be spontaneously affected and
die. (Fleming.)
The question arises, is there any relation between
these three forms? This might be partly settled if
experiments with the European trypanosoma showed
it "to be pathologic for horses. However, while the
Indian form is only feebly pathologic to the ox, the
\frican form is deadly. A writer in the British Med-
)rul .Journal1 suggests that "the European, Indian
and African trypanosomes, although closely resemb-
ling each other morphologically and biologically, yet
differ in their pathologic properties, the trypanosome
of Europe being innocuous in the case of all animals,
the trypanosome of India, if deadly to certain domes-
ticated animals, being almost innocuous to the ox of
that country, while the African trypanosome is deadly
to nearly all four-footed domestic animals, the ox
included. Seemingly, the pathologic qualities of the
three varieties are graded, as it were, by climate or by
breed or by other circumstances. A similar peculiar-
ity has long been known to exist in connection with
the bacillus of anthrax, which, though fatal to the
sheep of Europe, does not affect the Algerian sheep."
It seems that the hematozoa in the lower animals
play fully as important roles as we know their con-
geners do in man.
Ts^DiK^iitTde Mid. Chir. et Hyg. V<H*rin, xii, ParU, 1885.
2 May 16, 18»6.
WATER SUPPLIES.
We seldom notice a new book editorially, but we
have at present before us one which fills a long felt
want: Wm. P. Mason's "Water Supply, Chemical and
Sanitary," as announced by the gold lettering on its
handsome red cover, but "principally from a sanitary
standpoint," according to the title page. Our health
officers and sanitary men have been waiting for sev-
eral years for a book of this kind. If W. Ripley
Nichols had lived they would have had it several
years ago, for he gave them its nucleus in his article
on "Drinking Water and Public Water Supplies" in
1879, in the first volume of Buck's "Hygiene," and
this nucleus, but for his untimely death, would have
expanded pari passu with the extension of his experi-
ence. De. Smart of the Army published excellent
directions for sanitary water analysis in the Reports
of the National Board of Health, and in the same vol-
umes the account of Mallet's investigation into the
value of the processes of water analysis presents a
fund of information concerning the analytical results
given by waters of known quality. Dr. Smart's arti-
cle on water in Wood's Reference Handbook of the
Medical Sciences was also of value. Dr. Floyd
Davis of Des Moines, Iowa, and Dr. Leffmann of
Philadelphia, gave us excellent little books on the
sanitary analysis of water and Professor Mason him-
self contributed a booklet, known to but few because
it was printed mainly for the laboratory, use of his
students, and yet from the precision of its directions
it was worthy of a more extended publication. Nor
must we forget the valuable work of the State Board
of Health of Massachusetts on filtration, published in
recent annual reports, nor the many special reports on
the water supply of particular municipalities by health
officers and special committees. In England we have
had new editions of Wanklyn's book condemning
waters on the ammonia and albuminoid ammonia dis-
tilled from them; of Frankland's condemning them
on the absolute quantities of the organic elements;
the relation between the carbon and nitrogen and the
skeleton of sewage as represented by the nitrates in
solution in the water; articles by Tidy on the oxygen
required to oxidize organic matter and by Ekin on
the dangerous character of waters containing more
than so many milligrams of nitrates per million of
the water, and so on. But all these publications, with
the exception of Nichols' article, dealt merely with
the laboratory work of analysis and the more difficult
work of translating the results of the analysis into an
opinion on wholesomeness or unwholesomeness that
could be understood by the laity. These authors took
the water supply into the laboratory and told us all
218
SECRET CURES OF INEBRIETY.
[July 25,
about it from the laboratory point of view, so that we
came to know this quite well; but what we did not
know, yet wanted to know, what we could not find out
from chemic and medical books, was how the water
supply came to be a water supply. In Washington
we knew all about the dam and the conduit, the reser-
voir and distributing mains, and in Chicago about the
tunnels, but about the methods of water supply and
its purification in other cities we were ignorant,
because the publications mentioned gave us nothing
from the engineering and financial points of view.
Fortunately Professor Mason went to Europe and
enlarged his experience, not only of laboratory meth-
ods, but of methods of purification on the wholesale
scale for municipal supplies. As a result of his
European trip and his earnest desire to promote
purity of water supplies for home consumption, his
small but valuable laboratory brochure has blossomed
into what may without flattery be called the best work
on water supplies in the English language. The
author is modest; he speaks of his work as a compila-
tion, which he hopes will prove of interest to several
classes of men quite widely separated in tastes and
occupations ; to the physician, who wishes to keep in
touch with this particular phase of sanitary science,
but whose time does not permit of his undertaking
such investigations personally; to the hydraulic engi-
neer, whose professional duties prevent his sifting out
from the mass of recent bacteriologic and chemic
results such facts as bear upon his specialty ; to the
water analyst or the chemic student, who may seek to
employ analytic methods widely used and largely
based upon the report of the Committee of the Amer-
ican Association for Advancement of Science, and
finally to the general reader, who as a water consumer
feels a natural interest in the continually recurring
water problem of the day.
Critics have on several occasions stated that medical
men in discussing a professional subject are never
satisfied unless they go back to Hippocrates and
drag it along through the ages to show their perfect
familiarity with it. Professor Mason starts from
Hippocrates, but in his defense it is to be noted that
he does place M.D. after his name and that although
he does begin away back he does not fail to bring his
subject up to date. He shows the connection between
water supply and such diseases as malarial fever,
typhoid fever and cholera, citing the instances on
which the argument is based instead of dealing with
vague assertions of the belief of certain medical men.
He describes the filter bed system so common in
Europe, so practically unknown here, not only from
chemic, bacteriologic and sanitary points of view, but
from the practical and financial. Rain, ice and snow
water; river, stored and ground waters; dug, driven
and deep wells, receive full consideration, and our
knowledge of them is brought up to date. But it is
needless to go over the whole subject. The volume-
will be of value to all those mentioned by the author
in his preface as bringing to their notice matters that
could be found heretofore only by hunting over the-
entire field of sanitary literature.
SECRET CURES OP INEBRIETY IN BELLEVUE HOS-
PITAL, NEW YORK.
The commissioners of charities in New York have
considered it their duty to place two wards of Bellevue
Hospital at the disposal of a physician who has a
secret cure for inebriety. This physician is not a
member of the hospital staff or board, and apparently
proposes to prove to a skeptical public that his rem-
edy is of such value that the authorities must adopt
it at once. But literally he has secured a golden
opportunity to pose before the public as a great deliv-
erer and benefactor. The newspaper accounts from
day to day of the treatment, and the interviews and
statements of cured men, far exceed the wildest
dreams of any gold-cure specifics in the past. The
superintendent and the various reporters, together
with some of the political managers, assume that it is-
wonderful. Even the mayor is impressed and con-
vinced, and altogether it is the most startling exhibi-
tion of therapeutic wisdom and knowledge, outside
the profession, seen for many years. Several weeks
have past, and the cured cases are still posing in let-
ters to the public as examples of this marvelous cure,
which, strangely, is veiled in mystery. In the mean-
time the physician visits the wards three times a day,
administers the drug and the reporters call regularly
to write up the results in the dailies. The public
write letters to the hospital authorities and physicians-
for information to the extent of hundreds daily. The
next step will be the endorsement by some leading
clergymen, and the sale of privileges to use it in other
hospitals. This is said to be an experiment which
the authorities feel justified in conducting, but where
are the medical board and hospital staff? Are they
considered incompetent for this work? Perhaps they
are aware of the nature of the remedy and are willing
the trial should be invested with mystery and quack-
ish glamour; or perhaps they are powerless in oppo-
sition to the hospital authorities, and dare not protest
for fear of losing their places. At all events their
silence is strange and unaccountable, and the sus-
picion which gathers about such an effort should be
dispelled by some authoritative statement of their
position. If the ky authorities of a hospital arrange
for and conduct therapeutic experiments outside of
its medical board we shall expect a new era. The
various specifics and empiric cures will seize this new
method of advertising and utilize it to its greatest
extent. The moribund gold-cure speculators awake and
listen to the glowing accounts of this Bellevue experi-
ment, and turn away with anguish that such an oppor-
1896.]
CORRESPONDENCE.
219
tunity did not OOOUT in their day. On the other hand
the new armies of quack curers watch with breathless
interest this pioneer effort to turn the wards of great
charity hospitals into places for advertising their
drugs. Two New York medical weeklies have pro-
tested against this movement, while a third journal,
which is usually very outspoken, has preserved a dig-
nified silence.
We shall follow with great interest this experiment
and shall hope its results will come to us by other
mediums than the daily press and the hysteric asser-
tions of its so-called cured victims.
CORRESPONDENCE.
An Open Letter to the Members and Friends of
the Medical Profession i Regular) In Michigan.
Detroit, Mich., July 20, 1896.
An organization calling itself "The Michigan Medical Leg-
islative League" has, in a printed circular, appealed to you
and to me for aid and comfort in its efforts to accomplish a
certain self-imposed task, namely : "To secure through organ-
ized effort just and equitable laws regulating the practice of
medicine in Michigan and to promote the interests of the
medical fraternity." Truly a noble object and worthy the
utmost effort of every lover of science and friend of humanity.
The Executive Board of the League consists of three irregulars
and two members of the regular profession.
For almost a quarter of a century in this State, I and my
professional associates have labored and waited and hoped for
the accomplishment of this, which is plainly declared to be
the main "object" of the "Legislative League." It is needless
to say that its attainment is as dear to our hearts to-day as it
ever was. We stand ready now as in times past to do anything
and everything within the bounds of honor and decency to
secure legal medical protection for the sick and suffering, It
is therefore with extreme sorrow that we feel compelled to say
that the course of procedure and policy publicly avowed by the
"Legislative League" is. in our opinion, deserving only the
pity and contempt of every true friend of regular medicine and
every individual who sincerely wishes to do what he can for
the relief and protection of the sick and hurt. The plainly
avowed ultimate "object" of the so-called league is the securing
of an act of the legislature as follows :
A bill to establish a Board of Registration and to regulate
the practice of medicine, etc. Of this proposed bill Section 1
reads: " The people of the State of Michigan enact that the
Governor shall appoint nine physicians, residents of the State,
not more than four of win tin shall be regular, two homeopathic,
two eclectic, one physiomedical (whatever that may be) who
shall constitute a Board of Registration in Medicine."
Section 3 reads: "All persons engaged in the practice of
medicine and surgery in any of its branches and all who wish
to begin the same in the State shall apply to this Board to be
registered and for a certificate of such registration."
If this bill had originated with non-professional politicians,
or with quacks and irregulars, the pitiful degree of recognition
accorded the adherents of true science and the followers of
every great and noble name in medicine and surgery from Hip-
pocrates to Pasteur and Lister might have been dismissed with
a smile of ridicule and contempt ; but coming, as it appears to
come, from men who still profess loyalty to honest scientific
medicine, words fail us to adequately express our amazement
and sense of humiliation. The regular profession of Michigan
numerically exceed all other so called schools or sects in the
^portion of two to one. In the matter of talent, education,
■fcU'i- and influence the difference is surely immensely
"jAter i
greater. Can it then be possible that the representatives of
the great profession of honest scientific medicine in this State
are ready and willing to join forces with every quack and pathy
and sect for the purpose of securing a law which in the most
practical and unmistakable manner declares the inferiority of
regular and the superiority of irregular medicine? Many years
ago the profession of this State submitted to a severe rebuke
at the hands of the American Medical Association for having
even thought of a somewhat similar proposition. Can it be
possible that at this late date the regular profession in Michi-
gan feels itself so feeble and unable to maintain itself that it
stands ready to defy the public professional sentiment of this
and all other lands and in the hope of obtaining a little milk
and water degree of protection {for themselves rather than their
patients) enter into a combination and unholy alliance with
its most insidious and meanest foes, and place the balance of
power in the hands of the enemy?
The occasion is, in our opinion, critical. The honor and the
good name of the profession in Michigan is at stake. It is not
yet too late to rescue that good name and keep it safe from
disgrace and misfortune. For myself and others who love and
honor our profession, we earnestly implore the members to
come forward at this time and openly approve the only atti-
tude consistent with the honor and best interests of the pro-
fession. Let us earnestly and persistently oppose any and all
legislation which tends to increase the power of the quack, the
charlatan and the sectarian, and which at the same time
degrades and humiliates the only real school of medicine,
namely, that school which rises above all pathies and all sects
and seeks only the welfare of the sick and suffering and in
doing so eagerly accepts anything and everything which holds
out reasonable hope of being practically useful. Let us as a pro-
fession demonstrate by our lives and our works our claims
to legislative recognition and convince the people that our inter-
ests are their interests.
Legislation so earned and secured would be a glorious
triumph for science and for humanity. Legislation obtained
by compromise and abdication and unholy alliance with every-
thing and every creature in the shape of a medical parasite
only confers upon the latter undeserved honor, while it stamps
the word shame upon the brow of each one of us in Michigan
who claims to be, to the best of his ability, the representative
and the exponent of the noblest of all professions.
Perfection can not be claimed for any man or set of men,
and we have no choice but to confess to many failures and
imperfections on the part of the regular profession in this
State and everywhere else. Nevertheless the fact remains that
our aims are avowedly higher and in practice our record incom-
parably grander than that of all the other so-called schools and
sects combined.
Why, therefore, in the name of all that is true and good,
should we condescend to join hands with any sect, school or
pathy, thereby uplifting that which we condemn and despise
and at the same time dishonoring that for which we have always
been willing to do our utmost to protect and save?
Donald Maclean, M.D.
Leprosy.
New York, June 23, 1896.
To the Editor: — I inclose a letter just received from Dr.
Wm. Havelburg, the Director of the Bacteriologic Laboratory,
Hospital dos Lazaros, Rio Janeiro, Brazil, which will be of
interest to American dermatologists.
Yours truly, Albert S. Ashmead.
"Rio de Janeiro, May 26, 1896.
"Dear Dr. Ashmead :— I take for granted that you are con-
versant with the German language, in which I can express
myself so much more easily. Accept my best thanks for your
many different messages, either of a literary or other charac-
220
CORRESPONDENCE.
[July 25,
ter, and I beg you will excuse me for not having rendered my
thanks to you before, as I have been prevented by very sad
private occurrences.
"Your different publications have interested me very much.
In regard to the modern way of doctors concerning serum-
therapy, I am thoroughly skeptical. Perhaps diphtheria has,
for some time been your field ; in regard to leprosy, we hardly
could talk of such, as long as the culture of the lepra-bacillus
has not been made. Those experiments made in Colombia
(with Carrasquilla serum) appear to be very naive. I neither
believe in nor trust them.
"You mention a proposition made by Dr. Goldschmidt,
regarding a leper congress. That gentleman is known to me
by name and by many publications. Although I have not had
the same experiences of therapeutics as those which Dr. Gold-
schmidt has published, I feel with regard to a congress that a
real motive is wanting. The increasing danger of leprosy is
well known. The Culture States, in their administrations
take due regard of hygiene and protect themselves, and those
States which do not do so, can or will not, and they do not
understand the affair. Particular progress in our knowledge
of leprosy and its treatment has, in the last years, not been
made. Therefore, what are we going to do with a special con-
gress? He who in this matter wants to talk about it, finds
ample opportunity in the general congresses (Interior Medical
Dermatologic Hygiene, or the International Congresses).
"I am just about undertaking a journey to Europe for
study's sake, and intend to visit the leper hospital in Bergen.
I would be highly interested to learn how much knowledge
they have there in regard to lepra.
"While in this way answering some of the points of your
letter, which has greatly interested me, I greet you and sign
myself always your devoted friend, Wm. Havelburg."
A Cure for Whooping Cough.
Gainesville, Fla., July 16, 1896.
To the Editor .-—In Keating's Cyclopedia of the Diseases of
Children, the assertion is made that one-fourth of the infant
mortality of London is caused from whoopfng cough, and from
a study of the vital statistics as published in Public Health
Reports issued by Supervising Surgeon-General Marine Hos-
pital-Service I believe that the same ratio will hold good in
many other cities. Having for a number of years used, with
such happy results in this affection, a combination of old and
approved remedies, I feel it to be my duty to publish the for-
mula, feeling assured that almost any case can be cured in a
week if the remedy be properly used. Where the doctor can
not supervise the administration of the medicine and thinks
it not advisable to push the drugs to their physiologic effects
the length of time necessary for a cure may be longer than a
week, but the distressing paroxysms and dangers to life will
have been quickly overcome.
This is the formula as I usually write it :
R . Tinct. belladonna? 3iv to 5vi
Phenacetin . 5iiss
Spirits frumenti Ji
Fl. ext. castanese (chestnut leaves) . . . q. s. ad Jvi
M. Sig. : Shake well.
Dose : From 10 drops for a one-year-old to teaspoonful for
ten-year-old child, every two to six hours.
I am inclined to think that the substitution of atropia; sul-
phate for the tinct. belladonna} would be a more elegant pre-
scription, but I have had such good results from the formula
as written above that I have had no occasion to change it.
This remedy should be given every two hours or oftener
until the flushed face or dilated pupils show that the physio-
logic effects of the belladonna has been obtained, then the
dose can be lessened or the interval between doses lengthened,
but the effects must not be allowed to die out until the parox-
ysms of cough have ceased which will usually be after a very-
few hours.
When one member of a family has developed the disease-
others who have been exposed can be prevented from develop-
ing any unpleasant symptoms by administering a few doses of
the remedy. R. A. Lancaster, M.D.,
Ex-President Florida Medical Association.
Typhoid Secondary Infection.
Woodhull, III., July 20, 1896.
To the Editor: — It was with considerable pleasure and satis-
faction that I read the decision of the court of appeals of"
Colorado, Jones vs. Vroom, reported in our Journal, July 18,
page 169. The reason it is interesting to me is that I have a
case pending, to come in the October term of court, where I
have been sued for the loss of an eye from typhoid fever. My
case was one of four cases that got their contagion in the same
locality. Three different physicians treated the four cases.
They were all extremely bad cases and they all died except
this one case which lived, but has lost the sight of one eye
from sloughing of the cornea. The case you reported appears
to be very similar to mine, except the fact that they promised
to provide a specialist and did not, while I simply did the best
I could, never claiming to be a specialist. If you know of a
record of any similar cases to the one you reported, or mine,
and could advise me where to find the record, it might do me
some good in my coming trial. My case is on the streets, fat
and apparently well, but blind in one eye.
Respectfully, W. S. McClanahan, M.D.
The Business Committee.
Chicago, July 15, 1896.
To the Editor: — I wish to call the attention of the members-
of the Association to a recommendation made at the last meet-
ing by the Business Committee. The recommendation was not
presented to the Association until the last session and was
then, through a misapprehension I am sure, laid on the table.
The belief that those who voted to lay the resolution on the
table, would have voted to adopt it had they understood its
provisions ; and the belief that it is much easier to consider a
proposition of this kind between meetings, than it is in the
hurry of a session is my excuse for presenting it now. The
recommendation was as follows : (See Journal May 16, 1896.
Page 988).
" Resolved, That there be made an Executive Council of five,
consisting of the three officers of the Executive Committee,
and two members chosen by election. Of this Council of five,
one must belong to the Section on Practice of Medicine and one
to the Section on Surgery and Anatomy. To this Executive
Council shall be delegated all the duties of the Executive Com-
mittee, during the intervals between its meetings."
The resolution is perhaps a little ambiguous, but the intention
is very simple. It only gives permission to the Executive Com-
mittee to delegate their regular duties to a smaller committee of
theirown number, during the intervals between the meetings. It
is impracticable for the whole committee to meet, but a sub-com-
mittee of five could meet and would be of great service in pre-
paring for the annual meetings, and in attending to such mat-
ters as would naturally come before them. No new powers or
duties are delegated to this committee. They only act upon
such questions between the annual meetings as come under the
jurisdiction of the Business or Executive Committee during
those meetings. Those being questions that do not particularly
belong to any other officer or committee, it would be a decided
gain to have some one with proper authority to consider and
act upon them at any and all times. The ambiguity in the res-
olution as presented from the Executive Committee is in the
first sentence. Had that been something like this, the resolu-
tion would probably not have met with opposition :
1896. 1
BOOK NOTICES.
221
"Resolved, That there be made an Executive Council of five,
consisting of the three officers of the Executive Committee, and
two other members of that committee to be elected by the Exe-
eutive Committee from theirown number." This certainly does
not involve a change of the constitution. It scarcely involves
the necessity of reference to the general session, as it is a sim-
ple delegation of powers by a large committee to a smaller com-
mittee of their own number.
Very truly yours,
Horace M. Starkey, M.D.
Drops Ills Membership.
Rockford, Iowa, July 20, 1896.
'/ic Editor: — I have been a member since the New
Orleans meeting in 1885, but now drop it to get membership in
the Medical Society of the Mississippi Valley, whose meetings
are usually more easily reached. Yours truly,
Luther Brown, M.D.
quarter. The editor has wisely abstained from any sugges-
tions whatever. This is as it should be. But the silence has
been broken by Dr. Newton of New Jersey. If electioneering
is in order there may be a thousand members who would like
to have a say. Shall we say it? If so extend the time of vot-
ing a month or two and keep everything else out of the Jour-
nal and we will have a picnic. I move that there be no
further electioneering allowed in this matter.
Yours truly, A. C. Simonton, M.D.
BOOK NOTICES.
.Location of the Journal.
Chicago, III., July 13, 1896.
To the Editor:— In the Journal of the 11th inst. a Chicago
correspondent wishes to change his vote on the permanent
location of the Journal to Washington, D. C, and in stating
his reasons, si»ys : "Financially, as I notice from the advertis-
ing columns, the principal support of the Journal comes from
east of the Alleghenies, I do not see that the Association
would be any worse off." Such a statement led me to exam-
ine the facts on which it should rest. Doubtless the adver-
tisements in the Journal vary more or less from week to week.
In actually examining the advertisements in the Journal con-
taining the letter of your correspondent I found considerably
more advertising space occupied from west of the Alleghenies
than from the east. Then turning to the more important
source of financial support, that from members and subscribers,
I found the last complete list of paying members and subscrib-
ers was published in December, 1891. A fair count showed
the total number of members and subscribers in the United
States at that time to be 5,028. Of these only 1,967 were from
east of the Alleghenies, allowing Alabama, Georgia and Flor-
ida to be included in that division : while 3,061 were from west
of the mountain range. Indeed, the seven States usually
called northwestern, viz., Ohio, Indiana, Illinois, Iowa, Minne-
sota, Michigan and Wisconsin furnish more members and sub-
scribers than all the Stales east of the Alleghenies from Maine
to Florida. And Illinois alone furnishes one-third more
patronage to the Journal than all the six States east of New
York.
In regard to your correspondent's allusion to the proximity
of the Journal in Washington to the Library of the Surgeon-
General's Office, the Army Medical Museum and the Smith-
sonian Institute, it is sufficient to say that the medical libraries
A System of Medicine, by many writers. Edited by Thomas
Clifford Allbutt, M.A., M.D., LL.D., F.R.C.P., F.R.S.,
F.L.S., F.S.A. Volume 1. New York: Macmillan & Co.,
66' Fifth Ave. London: Macmillan & Co., Ltd. 8o, cl.
Price $5.00.
This is the beginning of an elaborate "system," which is
destined to become a very important addition to our literature.
The work is a pioneer in many directions, as will be seen by
glancing at the synopsis of this volume.
The first division contains articles on : 1, Medical Statistics ;
2, Anthropology and Medicine ; 3, On Temperament ; 4, On
the "Laws of Inheritance in Disease; 5, Medical Geography of
Great Britain ; 6, Inflammation ; 7, The Doctrine of Fever ;
8, General Pathology of Nutrition ; 9, General Pathology of
New Growths ; 10, Principles of Drug Therapeutics ; 11, Cli-
mate in Treatment of Disease ; 12, Artificial Aerotherapeutics ;
13. Balneology and Hydrotherapeutics ; 14, Medical Applica-
tions of Electricity ; 15, Massage : Technique, Physiology and
Therapeutic Indications ; 16, General Principles of Dietetics
in Disease, or the Feeding of the Sick ; 17, Diet and Thera-
peutics of Children ; 18, Nursing ; 19, Hygiene of Youth : 30,
Life Assurance.
After these comes the second division, devoted to " Fevers,"
of which part I consists of 11 pages on sunstroke, and part II
is on the infections. This is disposed of in sixteen separate
articles as follows : 1, General Pathology of Infection ; 2,
Septicemia and Pyemia ; 3, Erysipelas ; 4, Infective Endocar-
ditis ; 5, Puerperal Septic Disease ; 6, Furuncle, Carbuncle ;
7, Epidemic Pneumonia ; 8, Epidemic Cerebrospinal Menin-
gitis ; 9, Influenza ; 10, Diphtheria ; 11, Diphtheria ; 12, Teta-
nus ; 13, Enteric Fever ; 14, Cholera Asiatica ; 15, Plague ; 16,
Relapsing or Famine Fever. The volume concludes with a
very full index. The illustrations are excellent. No library
will be complete without this work. In the treatment of diph-
theria, Herringham views favorably the serum treatment, but it
is only mentioned as a special treatment. His usual treatment
in practice is set forth on p. 744, and is seen to consist of the
usual topical and general remedies. Sulphoricinic acid receives
a favorable mention, although we are instructed (p. 745) no
and institutions in Chicago, with the ample list of exchanges drug -lg a speciflC) « an(j the indications for their use must be
and new publications coming to the JouRNAL'sown office, afford ]eft to the ju(jgment of the practitioner who is directing their
a wider field for reference and study than its editorial corps
can find time to cultivate. And his allusion to proximity to
congress, and the influencing of congressional legislation, fairly
raises the question whether it is more desirable to have the
Journal converted in a few years into an organ of medical
politic* and specialism, or to keep it as it is, the strictly pro-
fessional organ of the great body of practitioners of medicine
in the United States. Yours truly, N. S. Davis, M.D.
San Jose, Cal., July 8, 1896.
To the Editor:— Permit me a word on the question of per-
manent location of the Journal of the Association. This
question has been submitted to the members of the Associa-
tion, and each one should have been allowed to come to hit
own conclusion and cast his ballot in accordance therewith
without any attempts at electioneering or log-rolling from any
The best way of giving chlorate of potash, he says, is
by the old-fashioned chlorin mixture. A foot note states that
chlorin vapor was recommended by J. Johnstone as early as
1779.
In enteric fever, Dreschfeld mentions the antiseptic treat-
ment, calomel receiving the first notice. Of this drug he says,
p. 852 : "Of its antiseptic virtue there can be no doubt, and
experimental investigations have shown that it readily kills
bacteria, that it prevents butyric acid fermentation— a fermen-
tation brought about by microorganisms, that it checks the
formation of products of decomposition usually found in the
digestive tract (indol, skatol), and that it does not interfere
with the action of the unorganized ferments of the saliva,
gastric and pancreatic juices (Wasseljeff)." Concerning use
of perchlorid (bichlorid) of mercury he says (p. 852) : "One-
half to 1 drachm (2 to 4 c.c.) of the solution of perchlorid of
222
BOOK NOTICES.
[July 25,
mercury, with 1 or 2 grains (.06 or .12) of quinin given every
four hours for several days, has been highly recommended by
Sir W. Broadbent, especially when the motions are offensive
and accompanied by much gas, the abdomen much distended
and the fever high. Calomel and perchlorid of mercury are
only to be given for a few days ; but within the last few years
more thorough antiseptic treatment has been advised, and
numerous drugs have been recommended, not so much with
the object of checking the action of the typhoid bacilli which
have already passed the intestines and reached the internal
organs, as with that of acting on any toxins as yet unabsorbed,
and particularly of checking fermentation and the action of
numerous microorganisms found in the alimentary canal, the
growth and development of which are favored by the presence
of the typhoid bacillus, and the product of which may be
absorbed through the ulcerated surface of the intestines." In
conclusion he says : " My own experience from a number of
cases in which the various antiseptics have been tried, makes
me think well of this treatment, though it is certainly inferior
to the cold water treatment."
Lack of space alone prevents a more extended notice of the
highly scientific articles which make up this first volume, and
give it character as an able exponent of fin de siecle British
medicine.
year 1896. Published By the Society, 1896 ; 8o, cl. ; pp. 544
We notice with pleasure the following remarks of the Presi-
dent, Dr. Koswell Park, in his inaugural address, Transactions,
p. 15: "It is now more than fourteen years since an event
in the history of this society, which has had a most marked
influence not only upon its affairs, but upon professional
matters throughout the land. I allude to the differences of
opinion which brought, about a separation of this organization
from the American Medical Association. Whatever the
causes which operated at that time to cause this deplorable
state of affairs, it is certain that they have since been made less
operative. I am sure that a majority of members of the
national body long to see this society restored to its early
affiliation, and I am sure that a majority of our own members
would gladly welcome the day when harmony might be
restored, and when the national Association would again
receive our delegates with their old-time cordiality. That day,
it seems to me, draws ever nearer, and were it not for the ill-
advised and much-deprecated animosity of a few opponents of
peace and good will, would be plainly in sight. I would urge
upon our members the importance of hastening by all judicious
means the restoration of former relations and the election once
more of delegates to that Association just as soon as we are
assured that they will be received in the same spirit in which
they are sent. Only the prejudices of a comparatively small
number of men stand in the way of this most desirable
accomplishment. I urge no lowering of our dignity ; only
that the actions of fifteen years ago by men who did not then
understand our position, and who are perhaps not yet moved
by the liberal spirit of the age, be forgotten, and that brothers
of the noblest of all professions again clasp hands across the
breech which was not of their own making." The committee
to whom was referred the President's address reported on the
foregoing recommendation as follows: "That this society
approves of the sentiments expressed in the President's
address concerning the relations of the Medical Society of the
btate of New York and the American Medical Association
and is ready to cooperate in any plan compatible with the dig-
nity of both organizations whereby existing differences could
be adjusted in the interests of professional harmony and in
accordance with the liberal spiritof the age."' In addition to
the numerous scientific articles, the volume contains a bio-
graphic sketch of Dwight Morgan Lee by D. A. Gleason
memona of Judson C. Nelson by Frank H. Green, and a
memorial of Erastus D. Chipman.
■ Transactions, p. S7.
Le Gonocoque. Par le Dr. Marcel See, Ancien Interne des
Hopitaux de Paris. Cl. 8o. Pp.359. Paris: Felix Alcan.
This monograph gives an exhaustive study of the gonococcus,
and the results of several years of study of that interesting
object. The literature of the subject has been diffused in the
pages of medical journals and in different languages. The
author has gathered in this volume all the important facts
concerning the microbe of Neisser. The work is divided into
two parts, viz. : Experimental and Clinical. There are four
chapters in the first part, viz. : I. Microscopic Examination.
II. Cultures in (a) Albuminoid Media, (b) Acid Media. III.
Biology of the Gonococcus. IV. Inoculations. The second
part is divided into eight chapters, viz. : I. Microbes of the
Urethra. II. Importance of the Gonococcus in Urethral
Pathology. The Urethrites Non-Blennorrhagic. III. The Pro-
cess of Blennorrhagic Urethritis. I V. Complications by Direct
Propagation of Urethral Blennorrhagia. V. Blennorrhagia of
the Genito-Urinary Organs of Woman. VI. Blennorrhagia
Inoculated Within the Genital Organs. VII. Gonorrheal Me-
tastases. Generalized Blennorrhagia. VIII. Conclusions Rela-
tive to the Biology of the Gonococcus in the Organism and Its
Diagnosis. General conclusions. There is also an appendix
in which is given the details of many experiments and obser-
vations and a fairly complete bibliography since 1893.
In Sicknessand in Health, a Manual of Domestic Medicine and Sur-
gery, Hygiene, Dietetics and Nursing. Dealing in a Practical
u^u1*^ th.e Problems Elating to the Maintenance of
Health the Prevention and Treatment of Disease, and the
Most ^nective Aid in Emergencies. Edited by J. West Roose-
velt, M.D., late physician in charge of Seton Hospital for
consumptives ; visiting physician to Bellevue Hospital, and
attending physician to Roosevelt Hospital, New York. Com-
plete in one volume of over a thousand pages, illustrated
with four colored plates and numerous engravings. Full
analytic index. Sold only by subscription. D. Appleton &
doVh^OO S' 72 Flfth Avenue' New York- Price,
What a vast gulf between the old domestic medicine of a
quarter of a century ago and this highly scientific one under
the reviewer's notice I It is questionable whether notwith-
standing the great advances made in popular education, this
work will not prove too scientific ; and with perhaps the excep-
tionally practical chapter on hygiene by Dr. Armstrong, be
passed over by the average lay reader as too technical. The
large class of college-bred men and women will find it exactly
adapted to their needs. The others will find it valuable for
reference, but probably will not read it seriatim.
The precepts are sound, the theories correct and the advice
given is uniformly excellent, and in accord with the latest
teachings of medical science. No attempt is made to supplant
the family physician, as it is obvious that the treatment of dis-
ease and the operations mentioned can only be instituted by a
trained physician.
Philadelphia Hospital Reports. Volume III. 1896. Edited bv
George E. De Schweinitz, A.M., M.D., member of the
1896 Pmi<221 a PriDted by M' H' P°Wer-
These reports are carefully written and reflect credit upon
the authors and editor. There are some twenty-five original
articles, exclusive of tables, by such well known physicians as
Tyson, Packard, Anders, Deaver, Bevan, Horwitz, E. P. Davis,
C. K. Mills, Sinkler, Dercum, Lloyd, Stellwagon and others.
Transactions of the American Association of Obstetricians and Gyne-
Wm' ?'nVoL Y\lL F-°,r the year 1895- Philadelphia.
Wm. J. Dornan. 1896. Pp. 404. Cl.
The abstractof the proceedings of the interesting annual meet-
ing, which forms the subject matter of this volume, was duly
published in the Journal, Oct. 5, 1895. We have now only to add
The notice of the appearance of this volume, and to congratu-
late the society and its veteran secretary, Dr. Wm. Warren
Potter, on the appearance of this carefully edited and hand-
i
1896.]
PUBLIC HEALTH.
223
some volume of Transactions. The volume includes portraits
and obituary sketches of Franklin Townsend Jr., of Albany,
J. Edwin Michael of Baltimore, Thomas Keith of Edinburgh,
and L. Oh. Boisliniere of St. Louis.
PUBLIC HEALTH.
Health Report of Salt Lake, Utah. The Board of Health report
for June: Number of deaths 52, against 27 for same month
last year ; death rate per thousand 8.91, against 4.62 last year.
Definite Diagnoses Required.— The Board of Health of Spokane,
Wash., at the meeting of July 6, passed a resolution that in
future the health officer shall not accept "heart failure" and
other indefinite terms as the sole cause of death in returns.
This rule will be strictly adhered to by the health officer in the
future.
Smallpox in Cuba. Reports to July 14 from Cuba, show that
smallpox is proving more deadly than yellow fever. The fever
is epidemic at the seaport towns, where the Spanish troops are
garrisoned, but the smallpox is virulent throughout the inte-
rior. A recent letter from Dr. Caminero, United States sani-
tary inspector at Santiago de Cuba, says there are 2,000 cases
in that city, which has 16,000 population.
Colorado State Board of Medical Examiners. — The Colorado State
Board of Medical Examiners, July 7, granted licenses to prac-
tice to seventy-eight physicians who presented their diplomas
from reputable medical colleges, date of graduation being in
each case indicated. The annual election of officers of the
board was then held, which resulted in the choice T. J. For-
han, M. D.,of Rouse, as president, and T. A. Hughes, M. D., of
Denver, for secretary and treasurer.
Crusade on Rear Tenements In Jersey City, N. J.— The Board of
Health of Jersey City, have begun a crusade against poorly
ventilated and improperly drained tenement houses, particu-
larly rear tenements. During the last three weeks diphtheria
has raged in the city and twenty-three deaths have resulted.
On July 13 seven new cases were reported, and July 14 eight
more. The outbreak is believed to be due to poor ventilation
and bad drainage.
Vaccinate the Children. — An old and valued correspondent of
the Journal, who is one of the most efficient health officers in
the United States, writes to us as follows : Now is a good time
to begin a systematic effort to arouse the profession to the
truth (so much obscured by the battle against humanized vac-
cine by the commercial methods used to further the various
" brands" of animal vaccine) that given, a typical vaccine, it
must be properly used to be efficient and to avoid "accident"
which is as a rule caused by a broken vesicle admitting the
infection of septic or other foreign disease cause. I wish you
would fire a shot in that direction, for it is a fact that physi-
cians avoid vaccinating now where, when we were students,
they considered it a simple duty, in infancy.
New Health Laws Desired in Indiana. — Dr. J. N. Hurty, Secre-
tary of the State Board of Health, has sent out a letter to the
doctors of the State, outlining a proposition of the Board to
bring about at the next session of the Legislature the enact-
ment of a new health law, the present one being considered
inadequate. It is proposed to have a State Board of seven
members appointed by the Governor, with no salaries attached
except for the commissioner chosen by the Board, who shall be
experienced in sanitary matters, chemistry and bacteriology.
A sanitary laboratory shall be established where all necessary
sanitary analysis and bacteriologic examinations and all health
work may be done for the people without charge. A modern
health board without a sanitary laboratory in charge of skilled
and learned specialists would be almost helpless. County
health boards shall consist of two physicians and a lawyer or
business man, appointed by the commissioners. One of the
physicians to be made secretary and county health officer.
Secretary to be paid $10 a year for each 1,000 of population,
except in counties of over 100,000. The other two members to
receive no salary. Expenses to be paid by the county. Duties
and powers to be carefully defined.
Health of Buffalo, N. Y.— Buffalo's death rate for the first six
months of this year is reported at 11.67 per thousand. The
Buffalo Enquirer enumerates the causes of the reduction of
mortality, some of which are of interest : Frequent examina-
tion of all lodging and tenement houses ; the maintenance of a
bacteriologic laboratory at which free tests of all suspected
cases of diphtheria and consumption may be made ; the sani-
tary inspection of schools ; a weekly examination, chemic and
bacteriologic, of the public water supply ; the prompt report-
ing of contagious diseases by telephone at the expense of the
city ; the placarding of houses in which there are cases of
diphtheria or scarlet fever ; the medical and sanitary inspec-
tion of all premises exposed to infection ; a health office open
day and night for the reception of reports and complaints ; the
publication of reports concerning work done by the several
bureaus ; the examination of the premises of all milk dealers
by sanitary officers and plumbing experts ; the registration of
all dairy herds from which milk is supplied to consumers,
showing by the certificates of a veterinary surgeon whether
the cows are free from tuberculosis ; a register containing
reports concerning all cases of disease on each milkman's
delivery route. Particular attention is given to the milk
business.
Regulation of Mldwlves in Chicago.— In this Journal of May
2, 1896, there was published the action of the Illinois State
Board of Health concerning the practice of midwifery, based
upon a communication from Dr. Frank W. Reilly, Assistant
Commissioner of Health of Chicago. This action authorizes
municipal health authorities to prescribe rules and regulations
governing mid wives in their respective jurisdictions, which
rules, when approved and adopted by the Board, have the force
and effect of law, as do all rules and regulations of the Board.
Dr. Reilly has acted promptly on this authorization and has
submitted to the Board a code which, if judiciously enforced,
can not fail to save many lives and curtail the fast- growing
encroachment of the midwife upon the legitimate field of the
practitioner.
That there is need of some such regulation is shown by a
recent brief search of the records of the coroner's office which
discloses no less than thirty-four cases of unfortunate women
and girls who have come to an untimely and cruel end through
the unregulated practice of midwives in Chicago. Mention
was made of one of these in the Journal article above referred
to ; another came to light on the 24th ult, when a woman was
arrested for the third time in seven months for procuring abor-
tion resulting in death. Under instructions the woman was
discharged on the ground, as alleged, that there was "no use
in holding her to the grand jury, since she had been twice
acquitted on trial, although she once admitted in the criminal
court that she had used the catheter (found on the postmortem)
pushed through the uterus and lying in a bed of pus in the
omentum." Close on the heels of this came the arrest of two
most notorious abortionist midwives— the postmortem of their
victim showing lacerations of the fundus and a perforation
through which a loop of intestine had been dragged down, torn
apart and the fecal contents filling the cavity. The details of
some of the cases are simply sickening— the least offense, but
the most frequent, being failure to remove the placenta and
consequent death from septic peritonitis. In only thirteen of
these thirty-four cases was there any clue to the operator ; but
this is of minor importance, since in no case was any punish-
224
PUBLIC HEALTH.
[July 25,
ment inflicted and the women are allowed to continue their
nefarious pursuits unhampered by any restriction or regulation.
It is obvious that the midwives' victims who find their way to the
morgue and become the subjects of a coroner's inquest repre-
sent but a small number of the total, whose deaths are attrib-
uted to other causes.
The rules and regulations follow, in effect, the lines of the
Austrian code which, in a modified form, have been approved
and urged for adoption in Great Britain. They are as follow :
RULES AND REGULATIONS FOR MIDWIVES IN THE
CITY OF CHICAGO.
Under the authority and with the approval of the State
Board of Health of the State of Illinois, the Department of
Health of the City of Chicago hereby prescribes the following
rules and regulations for the practice of midwives within its
jurisdiction.
Wilful violation of any of these rules will be visited by
prosecution under Section 12 of the State Medical Practice Act,
or by suspension of the right of practice, according to the
gravity of the offense.
Rule 1. — No person shall practice midwifery in the City of
Chicago unless authorized so to do by the State Board of
Health of the State of Illinois. If authorized to practice only
midwifery the certificate of said Board conferring such authority
shall be kept in view in the office or reception room of the mid-
wife, for the information of those seeking her services and for
the inspection of the proper city officials. For the purposes of
these Rules and Regulations all such duly authorized persons,
and none other, shall be known as midwives.
Rule 2. — Within thirty days after the approval of these
Rules and Regulations by the State Board of Health, every
midwife then engaged in the practice of midwifery in the city
of Chicago shall register her name and address with the Med-
ical Inspector of Midwifery, Room 2, City Hall, and shall
exhibit to said medical inspector her certificate from the State
Board of Health. And thereafter no midwife shall engage in
practice in Chicago until she has so registered.
Rule 3. — Midwives shall attend cases of natural labor only.
In any case which is not " natural" as hereinafter defined, the
midwife shall at once tell the family that the assistance of a
physician is necessary. The family shall be asked to choose
the physician ; but, if too poor to pay, the midwife shall imme-
diately send for the nearest Department physician. A list of
Department physicians who will assist in such cases without
pay must be kept by every midwife. The list may be obtained
at Room 2, City Hall.
" Natural labor" is hereby defined to be one which occurs at
or near full term (nine calendar months) ; one in which the
head and no other part presents; and one in which there is
none of the conditions specified in the following :
Rule 4. — A midwife must seek the assistance of a physician
in any of the following conditions :
A. During Pregnancy. — 1. When she has discovered or sus-
pects a narrow pelvis. 2. When there is hemorrhage. 3. When
the patient is threatened with an attack of any illness of a
serious nature. 4. When a pregnant woman dies suddenly.
B. During Labor. — 1. In all cases of unnatural position of
the child and if possible before the liquor amnii escapes. 2. In
presentations of hands or feet, or when the cord presents with
the head. 3. In every case where, from the smallness of the pelvis
or largeness of the child's head or from any cause whatever, the
descent of the head is interfered with. 4. In disturbance of the
labor pains, leading to delay of birth ; or in cases of excessive
pains followed by exhaustion ; or where a child, whose head has
already deeply descended, is not delivered for two hours after
the opening of the mouth of the womb and the escape of the
liquor amnii. 5. In bleeding, at whatever time in labor it may
occur. 6. In presenting placenta. 7. If the afterbirth be not
expelled an hour after the birth of the child, even if no bleed-
ing has occurred. 8. In all cases of rupture or tear of the
perineum as soon as such occurs. 9. In all cases where abor-
tion or premature labor is threatened or has occurred. 10. In
twins or multiple births when there is delay of more than half
an hour between the deliveries or when there is any complica-
tion, and in all monstrosities. 11. In all cases of apparent
sickness or threatened danger, as well as on the sudden death
of the woman. 12. In the apparently dead newborn child.
13. In all cases of stillbirth, no matter what the stage of
development of the child.
C. During Childbed. — 1. In the lying-in woman when there
is a rise of pulse or temperature (101 degrees F. or over) rigor,
tender abdomen, stoppage of the lochia or bad smell of the
same. 2. In all cases of illness attacking the newly born child,
ier
and especially if the eyes show redness or other signs of inflam
mation.
When a physician is sent for to a protracted labor the mid-
wife shall, when possible, send a written description in a fe'
words of the cause of the delay, such as "narrow pelvis wi
head presentation," "cross presentation," "hemorrhage du:
ing the afterbirth period," and so forth, so that he may kno
what it will be necessary for him to take. If a patient or her
relations wish a physician called in, even if the midwife does
not see any abnormal symptoms, she is not to object or try to
persuade them not to do so. The choice of the physician
except in the case of a Department physician —rests with the
patient or her relations, and the midwife is not to express any
opinion unlsss requested to do so. The midwife must inform
the physician truthfully and accurately of all she has observed
about the case previous to his arrival and stay as long as he
wishes, to assist him and conscientiously carry out his orders.
Rule 5. — Under no circumstances shall any midwife have in
her possession a set of obstetric forceps, or any other instru-
ment for the performance of an obstetric operation nor any
diug or instrument or other article which may be used to pro-
cure an abortion or to cause or hasten the expulsion of a fetus,
whether at term or otherwise. Nor shall any midwife give
chloroform, ether or any other anesthetic, except by the advice
and in the presence of a physician. Nor shall any midwife
give or advise the use of any drug or medicine, except the
simple domestic remedies commonly used in the household.
Any violation of this rule shall be considered evidence that the
midwife performs operations and practices medicine in viola-
tion of Section 10 of the Medical Practice Act, and is subject
to the penalties prescribed in Section 12 of said Act.
Rule 6.— Every midwife, in addition to her usual equipment,
must be provided with a case book, in which she shall keep a
full and correct record of all cases of labor attended by her.
This book shall be subject to inspection by the Department
Medical Inspector, and shall be open to the physician (if one
is called in), who may write therein, and sign, his own remarks
upon the case in hand.
Rule 7. — Every midwife shall make and keep a registry of
each birth at which she professionally assists or advises ; and
shail report the facts thereof to the Department of Health on
the blanks furnished by the Department within five (5) days
after each such birth.
Rule 8. -Midwives must keep themselves and all their appli-
ances scrupulously clean and must avoid contact with sick
persons and decomposing substances of every kind, so that
their fingers, appliances or clothes may not contain any infec-
tive material which might be conveyed to the lying-in woman
during examinations and thereby produce puerperal or child-
bed fever. They are strenuously enjoined before touching a
lying-in woman to wash their hands and instruments thoroughly
with a disinfectant. It is particularly dangerous for a midwife
who is attending a lying-in woman, or any sick person, where
there are foul-smelling emanations, to go direct to another case
without first thoroughly cleansing her hands and appliances
and changing her clothing. Unless the cleansing process be
thoroughly carried out even after a healthy confinement there
will be remains of blood and other fluids on the fingers, and
especially under the nails, which will there decompose and be
dangerous to the next case attended. The midwife must,
therefore, keep her nails cut short and preserve the skin of her
hands from chaps, injuries and indurations.
Rule 9.- -After assuming charge of a lying-in case the mid-
wife must not leave the patient during delivery and must stay
with the woman at least one hour after the expulsion of the
afterbirth in a natural labor. In cases of other labors or in
threatened danger she must always await the arrival of the
physician and remain with the case so long as he thinks neces-
sary and faithfully carry out his instructions. The midwife
shall see to the proper ventilation of the lying-in room, and to
the keeping of the bed and body linen in a thorough state of
cleanliness. She shall be responsible for the cleanliness, com-
fort and proper dieting of the mother and child during the
lying-in period, which in a normal case means the time occu-
pied by the labor and a period of ten days thereafter.
Rule 10. — No midwife shall visit— much less nurse or attend
— a case of chicken pox, diphtheria, erysipelas, measles, mem-
branous croup, scarlet fever, smallpox, whooping cough or
other contagious or infective disease. If she should unfor-
tunately be exposed to such contagion or infection, she shall
report the fact to the Department and shall not attend or
visit a lying-in case until she has thoroughly disinfected her
person and clothing and has been pronounced safe by the
medical inspector. In the case of a lying-in woman contracting
puerperal fever or any septic condition whatever the midwife
must abstain from attending any other woman at the same
1S%.]
SOCIETY NEWS.
225
time. A midwife must not under any circumstances assist in
the laying out of dead bodies.
Rule 11. In apparently dead-bom children at or near term,
in whom no sign of putrefaction has developed, the midwife,
in the absence of the physician, who must be summoned at
O&ce, should practice the methods of resuscitation taught her
until the child breathes regularly or for at least half an hour.
HuK- 12. Midwives must conscientiously guard the secrets
of their patients and must only divulge them if the law requires
them to d<> so.
Health Report. The following health reports have been
received in the office of the Supervising Surgeon-General,
Marino Bospita! Sen ice ;
SMALLPOX- UNITED STATES.
New Orleans, La.. June 1 to 30, 11 deaths.
Shelby County, Tenn., June 1 to 30, 3 cases.
Mobile County, Ala., June 5 to July 5, 2 cases.
SMAI.I.l'OX FOREIGN.
Bombay, India, June 9 to 16, 8 deaths.
Calcutta, India, May 30 to June 6, 1 death.
Coruona, Spain, June 13 to July 4, 1 death.
Genoa, Italy. June 27 to July 4, 1 case.
Madrid, Spain, June 83 to 30, 11 deaths.
Matanzas, Cuba, July 1 to 8, 3 cases.
Montevideo, June 6 to 13, 1 cases.
Moscow, Russia, June 13 to 20, 1 death.
Nogalea, Mexico, July 4 to 11, 6 cases.
Odessa, Russia, June 20 to 27, 9 cases, 2 deaths.
Osaka and Hiogo, Japan, June 13 to 20, 86 cases, 27 deaths.
Prague. Bohemia, June 20 to 27, 2 cases.
St. Petersburg, Russia, June 20 to 27, 7 cases, 6 deaths.
Tuxpan, June 20 to 27, 2 deaths.
Warsaw. June 13 to 27, 5 deaths.
CHOLERA.
Bombay, India, June 9 to 16, 5 deaths.
Calcutta. India. May 30 to June 6, 49 deaths.
YELLOW FEVER.
Matanzas, Cuba, July 1 to 8, 63 cases, 39 deaths.
SOCIETY NEWS.
Wayne County, New York, Medical Society. — The annual meeting
•of this society was held at Lyons, N. Y., July 14, and was
largely attended. The opening address was made by President
'T. H. Hallett, of Clyde. The following officers were elected for
the ensuing year : President, J. W. Atwood, of Marion ; Vice-
President. Alice Brownell, of Newark ; Secretary, A. A.Young,
of Newark : Treasurer, Darwin Colvin, of Clyde.
Iowa and Illinois Central District Medical Association. Tin- annual
meeting of this association was held at Davenport, Iowa, July
9. The guest of tbe meeting was Dr. Frank Billings, of the
Chicago Medical College, who read an interesting paper on
pyelitis and exhibited plates illustrative of the subject. The
following officers were elected for the ensuing year : President,
Charles M. Robertson, of Davenport; Vice-President, J. R.
Hollowbush, of Rock Island ; Secretary, E. S. Bowman, of
Davenport ; Treasurer, A. W. Cantwell, of Davenport.
The Winnipisiogee Academy of Medicine held their first annual
meeting at Laconia, N. H., July 6. The following officers were
elected for the ensuing year: President, A. W. Abbott,
Laconia: Vice-President, P. S. Foster, Laconia; Treasurer,
Joseph Theriau It, Laconia; Secretary, George H. Saltmarsh,
Lakeport. The post-prandial exercises were presided over by
President A. W. Abbott, and included addresses by Governor
Busiel, Dr. Conn and others. Dr. Conn gave an able and
interesting address on "Tbe Progress of Antiseptic Surgery,"
in which he contrasted surgical methods of to-day with those
of forty years ago. In closing he said :
"The triumphs of surgery are very startling to the laity, and
in fact, the profession must keep step to the music else they
are in danger of being considered a back number. The time
has gone by when any one can imitate Mr. Bergh, who was
a great friend of the animal creation and took every occasion
to stand up for their rights. He was throughout his life the
acknowledged leader of the anti-vivisectionists in America.
In a lecture on this subject, after describing the experiments
of Dr. Robert McDonald, who successfully practiced the trans-
fusion of animal blood into the veins of a dying person, Mr.
Bergh comments as follows : ' In other words, this potentate
has discovered the means of thwarting the decrees of Provi-
dence and snatching away from its Maker a soul which He had
called away from earth.'
"To us as a profession it seems as if the above was the utter-
ance of an insane person, but we are told that Mr. Bergh was a
thoroughly honest, upright man, and believed that he was
doing a good work. We will grant that his intentions were of
the beat, that he was heartily in sympathy with the brute
creation, that his object in life being the saving of animals
from any unnecessary suffering he had a great work to per-
form. At the same time any man who would express himself
as he is recorded to have done, and at the same time not
express any sympathy for poor suffering humanity, muBt have
been without some of the common instincts of human love, or
else he had delusions, of which devotion to the brute animal
was one, and complete disregard of the rules governing the
good Samaritan was another."
NECROLOGY.
Adolph Oldendorff, M.D., at Carlsbad, June 16, in bis
65th year. Founder and editor of the new periodical, Zeit-
sehrift f. Sociale Medicin, and a prolific writer for medical
journals, encyclopedias, etc.
Luigi Villa, M.D., Professor at the Institute Sieroterapico
at Milan. The promising career of this talented devotee of
science was closed abruptly last month, by an accidental
scratch on the finger received while inoculating an animal with
some virulent culture (glanders). Death ensued in about a
fortnight.
Leloir, Professor of Dermatology and Syphilology, at Lille,
France. Although only in his 41st year the list of the various
articles and works he has published, as given in the Prvgris
Midieal of June 27, nearly fills two closely printed pages
W. Schlesinger, M.D., at Vienna, in his 58th year; editor
of the Wien. Med. Blaetter until recently and founder of the
" Ambulatorium" for poor sick women.
Joseph Barkley, M.D., died at his home in Leesburg, Ky.
after an illness of less than a week, aged 69 years, on the
11th inst.
Samuel Sexton, M.D., died in New York city on July 11.
He was born in Ohio in 1833 ; a graduate of the University of
Louisville in 1856, and five years afterward was appointed an
assistant surgeon of the Eighth Ohio Volunteers, and served
in Virginia. He came to New York after the war and estab-
lished himself as a successful aurist. He lectured in the New
York Eye and Ear Infirmary and was a member of many soci-
eties besides having been decorated in 1889 by the Venezuelan
Government for services in the cause of public education. He
was the author of numerous reports and pamphlets on aural
and dental subjects. He was Past-President of the American
Society of Otologists, a fellow and office bearer in the Academy
of Medicine, and an interested member in a number of scien-
tific and patriotic organizations.
M. S. Thomas, M.D., at Leavenworth, Kas., July 9, aged 66
years. He graduated from the University of Maryland School
of Medicine, Baltimore, Md., in 1853. The diseased came to
Leavenworth in 1856, and at the commencement of the late
Civil War he was a surgeon at Fort Leavenworth. At the
breaking out of actual hostilities, however, he resigned this
position and entered the Confederate service as a surgeon,
serving in the Army of North Virginia throughout the war.
At the close of the struggle he returned to Leavenworth and
resumed the practice of his profession. He was physician in-
charge, St. John's Hospital and St. Vincent's Orphan Asy-
lum, Leavenworth, member of the Kansas State and Eastern
Kansas Medical Societies and President of the Leavenworth
County Medical Society.
2 as
MISCELLANY.
[July 25,
R. L. Dunn, M.D. (Tulane University, Medical Department,
New Orleans, 1859), at Yazoo City, Miss., July 10, aged 60
years. A. J. Rutherford, M.D. (University of Buffalo, Med-
ical Department, Buffalo, 1889), at Milwaukee, Wis., July
11, aged 36 years. Samuel H. Griswold, M.D. (Castleton
Medical College, Castleton, Vt. 1844), at Rutland, Vt., July
13, aged 78 years.
MISCELLANY.
Oliver N. Huff, M.D., has resigned his position as Medical
Superintendent of the Palmyra Springs (Wis. ) Association, and
will resume his practice in Chicago.
Free Medical Tuition.— Governor Atkinson announced nineteen
appointees to the Augusta (Ga. ) Medical College, July 9. A num-
ber of years ago the State gave $10,000 to this college with the
understanding that the governor should be allowed thereafter
to send two pupils from each congressional district in the State
each year free of tuition. This privilege was not taken advan-
tage of for a number of years as the law was overlooked.
New York Post-Graduate Medical School.— The fifteenth annual
announcement of the New York Post-Graduate Medical School
and Hospital has just been issued. Five hundred and forty-
two physicians from all over this continent have attended the
courses at the institution during the past year. More than
one thousand operations were performed in the hospital, which
is one of the largest in the city, containing special wards for
babies and children, while nearly twenty thousand patients
were treated in the outdoor department.
Extension of the Bertillon System in New York State. The work
of establishing the Bertillon system of identifying criminals has
just been begun at Sing Sing prison. On July 3 Mr. George
Porteous, formerly the chief of the identification bureau at
Chicago, arrived at Sing Sing with a supply of the instruments
used for measuring bones, cranial angles, etc., and after
instructing the officials there in the manner of measuring
criminals and classifying the descriptions he will proceed to
Brooklyn, where it has been decided to introduce the method
into the Kings County penitentiary.
Intoxicants and Sunstroke in Australia. — The Medical Neics
states that during the month of January there occurred over
three hundred deaths from sunstroke in Australia. When
called upon to offer suggestions relative to its prevention the
Board of Health promptly informed the Colonial Government
that of all predisposing causes none was so potent as undue
indulgence in intoxicating liquors, and in its treatment nothing
seemed to have a more disastrous effect than the administra-
tion of alcoholic stimulants. After this precaution, sugges-
tions were offered regarding the selection of proper cloth-
ing, etc.
Connection between Articular Rheumatism and Pneumonia. Oliva
describes in the Gaz. degli Ospedale e delle Clin., No. 60, a
couple of cases of typical pneumonia appearing as a tardy com-
plication in acute articular rheumatism. In one case Franker s
diplococci were found in the sputa. He concludes that artic-
ular rheumatism, in certain cases, is evidently produced by
Franker s diplococci. Maragliano also notes (No. 74) broncho-
pneumonia as a complication in the course of various
kinds of infective diseases, in most of which Franker s diplo-
cocci were observed in the sputa.
Plural Ectopic Gestation. -P. Minehard, M.D., reports a case
with the following points of interest : At the time of rupture
the tube contained two fetuses, each with its individual
placenta. One fetus was small (two and a half inches long)
and flattened. The other fetus was normal in appearance and
about thirteen inches long. At the time of rupture the patient
had not menstruated for nearly nine months. The patient
never had any symptom that indicated disease of the uterus
or of the appendages. The tube on the opposite side was
healthy in appearance. The patient is now in the fourth
month of uterine pregnancy and does not present any sign of
tubal or ovarian disease. — Am. Jour, of Obst. and Dis. of
Women and Children, July.
Human Actinomycosis. — The Nordisk Med. Arkiv, 1895, No. 27,
reports the number of cases treated in the hospitals of Sweden
to date as 84, but Ljunggren adds 27 in his own practice in the
province of Schonen, where it is also quite prevalent among the
cattle. He ascribes it to the common habit of chewing grains
of corn. The location was the cheek, mouth or neck, except in
one case of peritoneal actinomycosis, and another that affected
the general health. All recovered after the indicated treat-
ment : Extensive incision, curetting and rinsing the infected
focus, and drainage.
The New Religion Pasteurism. — The Journal de M4d. de Paris
ridicules the way in which the French and some others have
installed the antitoxin treatment as a fetish, putting up statues
to Roux in Paris, and offering all kinds of sacrifices on his
altar. It remarks in its usual sarcastic style that the Parisians
consider the Institut Pasteur a sort of Olympus, with Roux
and Marmorek for the gods, who promise their followers health
and happiness in this world instead of waiting for the next.
It concludes that in five years antitoxic serums will have had
their day and been relegated to oblivion, quoting Auerbach :
"Behring's serum is more dangerous than useful" (Cbl. f. Inn.
Med. No. 18); Gottstein: "It does not confer immunity, and
has no prophylactic action" (Therap. Monatsch. No. 5), and
Soerenson, "It is useless in cases of croup" (lb. No. 3).
Action of Porcelain Filters on Viper's Venom. — Porcelain filters
do not allow the ferments and toxins of microbes to pass
through them, nor the toxic elements in the venom of vipers.
But it is known that this filtered product is not entirely with-
out physiologic action, as it raises slightly the temperature of
animals inoculated with it. Phisalix reports that he inoculated
guinea pigs with strong doses of the filtered product, which
would have been immediately fatal if they had not been fil-
tered. Twenty-four hours later he injected a fatal dose of the
unfiltered venom. The control animals promptly succumbed,
while the others resisted perfectly. They had therefore been
effectively vaccinated. These experiments showed that the
toxic and vaccinating elements are distinct substances. Their
separation by the filter is an additional support of the theory
of vaccination by specific substances. — Semaine M6dicale,
June 24.
A Cactus Alkaloid, Pellotin. — From a species of cactus, known
to the Mexicans as "pellote," Dr. Hefter, of Leipzig, has sep-
arated the active principle which he has named pellotin. Pro-
fessor Jolly of Berlin has made a number of experiments with
it upon patients in Charito Hospital, Berlin, following those
previously made by Dr. Hefter upon animals and himsslf. He
found that three-quarters of a grain would almost always cause
several hours of sleep, and that no subjective symptoms fol-
lowed its use beyond a little giddiness in about 20 per cent, of
the patients. He observed, however, a marked influence upon
the pulse rate, which was ten to twenty beats slower during
sleep, but returned to normal on waking. It is estimated that
half a grain is equivalent to fifteen grains of trional or thirty
grains of chloral hydrate. The alkaloid is quite insoluble,
hence the hydrochlorate is always employed. — Medical News,
July 4.
Budapest Exposition. -We are pleased to advise our readers
that at the Milleniel Exposition now going on at Budapest,
the owners of the Franz Josef Natural Aperient Water have
established a special department for the convenience of all
medical practitioners visiting the Exposition. Copies of the
leading medical journals of the world are kept on file there and
1896.]
MISCELLANY.
227
arrangements are provided for the reception and care of all
mail matter, and those contemplating visiting the Expo-
sition are cordially invited to make this department their
headquarters for receiving their letters, conducting their cor-
respondence, meeting their friends and consulting the various
mtdirnl journals while on the Exposition grounds. Letters
may be addressed care of the Franz Josef Aperient Water
Kxhibit, Milleniel Exposition, Budapest, Austro-Hungary.
Any inquiries of those intending to visit the Exposition may be
addressed to the American representative of the Spring, Eli-
jah J. Molloy, 101 Beekman St., New York City.
Indications for Radical Cure in Inguinal Hernia of Children. -First
try and reduce the hernia with a light and suitable bandage,
which may alone produce a cure. If the hernia is accompa-
nied by ectopic testis, the bandage must be made specially for it.
The latter alone only indicates an operation when it is found
impossible to protect the testes from the pressure of the band-
age. If difficulties arise in the application of the bandage, then
surgical intervention is inevitable. With incarcerated hernia the
radical cure should always follow herniotomy. The radical cure
m nst a 1 ways be performed without regard to the age of the child,
in eases of very large scrotal hernia. Under 6 years it consists in
ligating the hernial sac and then tamponing the hernial cavity,
according to Karewski's method. Above this age, Kocher's
method is to be preferred. — Schoenfeldt in Memorabilien,
April.
Hennig's Successful Treatment of Diphtheria with Lime Water and
Ice. — Commenting on the statistics gathered by the govern-
ment, of serum treatment in diphtheria, showing a mortality of
12.9 per cent. Hennig states that he has only lost 3.06 per
cent, during the last eighteen years, 59 out of 1,927 cases.
His method is the prompt and continuous use of pure lime
water every fifteen minutes night and day, freely gargled and
some swallowed, made fresh each time, with an ice bandage
applied to the throat outside. He uses for the latter a beef's
esophagus, as lighter, cheaper and better for other reasons
than a rubber bag. It is filled with ice and extends from ear
to ear, securely fastened at the ends to prevent the escape of
water. He insists also on absolute cleanliness, nourishing
food, with egg lemonade and vanilla ice cream, and alternate
doses of liq. ferr. sesquichlorat. and sol. kal. iod. He treats
nasal and laryngeal complications with lime water also, sprayed
from a Richardson atomizer for several minutes at a time, into
the patient's wide open mouth while he breathes tranquilly. —
Therapeutische Wochenschrift.
The Toxin of Tuberculosis. — Numerous experimenters have
endeavored to separate the disease producing principle or toxin
in tuberculosis, and their observations may be summed up as
follows : Prudden and Hodenpyl have ascertained that the
poisonous substance (or substances) is not present in the nutri-
ent media in which the bacilli are grown, but fixed in the
bodies of the bacilli themselves in a very resistant form. The
poison is not altered when within the body, for a consid-
able length of time, so that a person will recover from tubercu-
losis only after the dead bacilli are gotten rid of, or the poison
rendered harmless. Maffucei claims that the toxic substance
evolved by the tubercle bacilli acts only after a long period of
time has elapsed. Riechet and Hericourt have separated a
toxic substance from these bacilli which is poisonous to tuber-
cular rabbits, but has no effect upon healthy ones. Thomas
Weyl has succeeded in separating an extremely poisonous sub-
stance from cultures of the tubercle bacillus, and to which he
has given the name toxo-mucin. — Dr. Chas. F. Craig in N. E.
Med. Monthly, July.
Rupture of the Uterus ; an Unusual Case. — Dr. Sherwood Dunn
reports a case which he saw at Professor Richelot's clinic,
Paris : On opening the abdominal cavity M. Richelot found a
soft tumor intimately adherent to the peritoneum which he
first thought to be a neoplasm of the ovary, and then, by rea-
son of its soft, mushy consistency, a possible pyo-salpinx, or
caseous or dermoid cyst. On carefully separating the adhe-
sions and following it downward, it was thought to be attached
to the uterus. On circumscribing the pedicule he discovered
that it was not attached to, but really protruded from a rup-
ture, opening into the uterine cavity about the size of a silver
dollar. He enlarged the opening and carefully detached and
removed the mass ; and not until then was it found to be a
placenta weighing from one to one and one-half pounds. The
patient passed a comfortable night with but little chloroformic
vomiting, but the following day the temperature became ele-
vated and she died on the evening of the second day after the
operation. It is probable that the placenta, when expelled
through the ruptured uterus, came in immediate contact with
the peritoneum, and an adhesive membrane was thrown out
which protected the neighboring organs from contamination.
When this protection was removed, both from the peritoneal
surface and the uterine cavity, the septic material caused
blood-poisoning to which the patient succumbed. — Pac. Med.
Jour., July.
Vesical Tumor.— The Clinical Journal, May 13, quotes from
Annates des Maladies des Organes Gtnito-urinaires the fol-
lowing case : Dr. Ferria has observed the case of a patient,
aged 24, who complained of painful micturition and hematuria.
This latter symptom had been two years in existence, hemor-
rhage occurring at considerable intervals at first ; latterly more
often, with increased pain and frequent urgent desire to empty
the bladder. The hemorrhage occurred more abundantly at
the close of the act of micturition till shortly before advice was
sought, when severe pain occurred at the beginning of the act
and bleeding on almost every occasion, and only at the begin-
ning also, the remaining urine being limpid. On examination
it was determined that there was a considerable degree of
retention, and that while the prostate and seminal vessels
seemed normal, the sound, when introduced, on approaching
the neck of the bladder came in contact with a surface appar-
ently irregular and friable. On relieving the retention the
catheter enabled Dr. Ferria to recognize a tumor in the blad-
der. Suprapubic cystotomy was performed, and a papilloma
found on the anterior bladder wall to the left side, about three
finger breadths from the urethral orifice. The pedicle was
slender, 2 and 1% centimeters in length, and the tumor was of
half a walnut, with a prolongation on one side which reached
the neck of the bladder and penetrated the prostatic urethra.
Discontinuance of "Climate and Health." —
U. S. Department of Agriculture, Weather Bureau.
Washington, D. C, June 22, 1896.
The discontinuance of the publication, Climate and Health,
is announced to take effect with the end of the present fiscal
year, June 30, 1896. Vol. II, No. 3 (four weeks ended March
28, 1896), will be the last issue of Climate and Health. It has
been deemed necessary to take this action in view of a doubt
having arisen as to whether the publication of Climate and
Health was authorized by the act making appropriation for
the Department of Agriculture for the fiscal year ending June
30, 1897. With the discontinuance of Climate and Health will
also terminate the weekly collections of the statistics of mor-
tality and morbidity that have heretofore been published
therein, and the physicians and health officials who have
cooperated with the Weather Bureau in collecting these statis-
tics are requested to return, by mail, under the Departmental
frank, all blank forms and franked envelopes on hand upon
the receipt of this announcement. The Chief of the Bureau
wishes to express to all cooperators his sincere appreciation of
their voluntary services rendered in connection with the pub-
lication of Climate and Health. It is the intention of the
Chief of the Bureau to have prosecuted during the coming
fiscal year a number of special climatologic studies, and it is
expected that the statistics collected during the present fiscal
year will be of much value in this connection. The results of
these special researches will, if their importance justifies the
so doing, be published in the form of special bulletins, at such
times and in such shape as the circumstances may warrant and
make necessary. Willis L. Moore, Chief of Bureau.
228
MISCELLANY.
[July 25,
Puncture in Hydrocephalus.— Schilling reports in the April
Memorabilien his experience in four cases of hydrocephalus
treated with puncture, two of which recovered. Ages, seven
weeks to a year and a half. The oldest child was taken with
convulsions a month after an attack of influenza, with vomit-
ing, strabismus and absence of spastic phenomena. Head
increased in size to 57 Cm. The left ventricle was punctured
and aspirated, and 300 c.cm. was removed, followed by violent
convulsions and collapse. A week later another puncture
removed 270 c.cm. and the head measured only 45 cm. Phos-
phorus treatment and recovery. Three years have passed
since, and the head now measures 52 cm. The youngest child
was relieved of 2 c.cm. of a bloody serous fluid from the right
ventricle, although puncture of the left ventricle had been
barren. Marked improvement followed, but strabismus and
vertical nystagmus later ensued. There was a suspicion of
meningitis in this case, due to septic infection from the rite of
circumcision. The cases not benefited were congenital hydro-
cephalus and tubular meningitis. Schilling recommends punc-
ture of the side ventricle as an easily performed operation. A
broad elastic bandage should be applied to the head afterward,
and phosphorus administered.
Fallopian Tube Tabloids Among tbe Latest Therapeutic Innovations
from London. — The Medical Press and Circular, June 10, con-
siders with all due seriousness the alleged innovations of
extracts of extra-glandular origin. It says: "Although it is
discordant with medical opinion that any of the tenets of hom-
eopathy should have a place in educated medical practice, we
admit that the most modern phase of therapeutics trends in
this direction. The fashion just now is to prescribe for the
disease of any organ an extract from the active principle of
that organ itself. Thus it happens that the firms which cater
for advanced therapeutic ideas of this sort are offering to the
profession suitable preparations of such active principles.
Messrs. Burroughs, Wellcome & Co., for instance, announce
that they are ready to supply : Salivary-gland tabloids for use
in amylaceous dyspepsia ; pineal-gland tabloids for softening
of the brain, etc. ; nuclein tabloids for nervous prostration,
etc. ; kidney substance tabloids for diseases depending upon
disturbance of the renal functions ; cervical lymphatic-gland
tabloids for glandular swellings, etc. ; Fallopian-tube tabloids
for neurotic affections ; liver-substance tabloids for uremia,
etc. ; spinal-cord tabloids for brain diseases. They have
retained the services of a former pupil of Pasteur, who devotes
his whole attention to this branch of the business, and who
maintains that the active principles can be thus isolated and
preserved in perfection. No doubt, if disease does not 'mock
the meat it feeds on,' these preparations will prove effectual."
The New York County Medical Association — At the June meet-
ing of that society the special committee on hospitals made a
report condemning the action of the appointing powers in the
city institutions, in part as follows: "The committee desires
to report that though it has used its best endeavors to secure
a just balance of evidence in the hospital patronage affair, yet
the testimony given before our body has been given entirely by
the profession and not by the colleges. The faculties have
ignored our communications and have kept strangely silent
Yet the very fact of their casting honorary positions broadcast
among those physicians who were unjustly removed from places
long and ably filled is circumstantial evidence that injustice was
done at the instigation of the colleges, and that peace offerings
are now necessary. The campaign of the colleges is one of
deception, and in order to make such a campaign successful it
was necessary to ensure no medical man being appointed a
Commissioner of Public Charities, as the whole scheme would
have been transparent to a physician. Several members of the
faculties waited upon the Mayor and urged that 'no doctor should
be a commissioner, as that would break up the harmony between
the colleges and the board.' Having thus rendered deception
less easy of discovery, they proceeded to hoodwink the Mayor
and the board, making many statements which you have seen
exposed as perfectly ridiculous by the medical journals. The
latest plan is to give a sop to complainants for quieting pur-
poses, and then to address the commissioners with the idea
that the profession was satisfied. These sops are appointments
as consulting physicians. As is well known such an appoint-
ment is only a superannuation and practically is of no value to
anyone ; but the idea seems to be to convey to the commis-
sioners the impression that injustice has been righted, while
concealing the fact that the appointees are not returned to their
old places, but are expected to be satisfied with positions that
exist only on paper."
Investigation of the HCI Secretion and Motility of the Normal
Stomach. — Schiller has been investigating the action of the
healthy stomach. He finds that the quantity of free and com-
bined HCI varies very much at times in the same person and
in different persons. The maximum of free acid is between
0.05 and 0.2 per cent. ; of acid in combination, between 0.012
and 0.11 per cent. ; and of total acidity, between 30 (0.11 per
cent.) and 70 (0.26 per cent). When the free acid amounts to
more than 0.22 per cent, and the total acidity is over 70, there
is hyperacidity. (This limit is too high for some persons. )
The figures refer to Ewald's test meal ; the time required for
digesting it was found to be from 45 to 75 minutes. Pent-
zoldt's statement was confirmed that acid was secreted later
with solid foods than with broths, etc., but was then more
concentrated. Meat and milk were found to be about equal in
inducing the secretion of the acid, while porridge and potato
soups were followed by a smaller total amount of acidity. The
effect of various medicines and foods was also studied. Salt,
five grams, produced no effect on the digestion, while sixteen
grams diminished the HCI secretion and interfered with the
peptic action of the gastric juice. Twenty-four grams first
stopped and then stimulated the secretion of HCI. Bicarbon-
ate of soda first stopped the secretion of acid, but this was fol-
lowed later by an increase in the secretion, which rose then to
normal and above. Repeated doses of it (7-1-2-2-1 grams)
resulted in permanently diminishing the amount of acid
secreted, while increasing the amount of mucus. Bismuth
subnitr. was found to be a genuine antiacid, and it diminished
the amount of acid secreted without any subsequent increase.
HCI medication produced no apparent effect on the degree of
acidity. The motility of the stomach was studied by means of
fistulas on dogs, 17-27 cm. below the pylorus. It was found
that the temperature of the food had a great influence on the
emptying of the stomach. Three hundred grams of spring
water at 18 degrees C. had all gone from the stomach in ten
minutes, while water at 28 and 40 degrees retarded the motility
of the stomach to a marked degree. Ice water first retarded
it for fifteen minutes, and then stimulated it, the first retard-
ing effect extending to the muscles of the pylorus. Solid
ingesta remained longer in the stomach than fluid foods.
Milk can leave the stomach almost as rapidly as water (dogs).
Carbonic acid in statu nascendi diminishes the motility, to
which Schiiler ascribes the favorable effect of bicarb, sod. a
few hours after meals, in some gastric affections. From the
Zeitschr. f. Min. Med. xxviii and xxix., in the Centralblatt /.
Phys. April 4.
The Action of the Pupil and its Relation to Disease. Irritation
myosis is found in all inflammatory affections of the brain and
meninges. In these affections, when the myosis gives way to
mydriasis, it has the same significance as in opium and chloro-
form poisoning, i. e., it indicates paralysis and a probable fatal
termination. We find this form of myosis in apoplexy, which
may thus be distinguished from embolism. It occurs early in
the development of tumors near the oculomotor center or
1896.]
MISCELLANY.
229
none It is seen in the beginning of an hysteric or epileptic
attack, in neuroses of the parts supplied by the fifth nerve and
in morphia habitues. Paralytic myosis is found in those
conditions affecting the integrity of the spinal cord above the
dorsal vertebrae. The scleroses, destruction of the cord by
traumatism, tumors, caries of the cervical spine, late stages
of this portion of the cord, etc., cause this form of myosis. In
■cute mania the appearance of this form of myosis following
mydrio8is is prognostic of dementia. Irritation mydriosis is
found in hyperemia of the cervical cord, irritation of the cerv-
ical cord by morbid growths, or from spinal anemia and in the
primary stages of tabes. An increase of intra-cranial pressure
and sensory excitement by. intestinal worms will cause it;
physical influences produce it in mania, melancholia and
paretic dementia. What is known as Rampoldi's signs of
phthisis is a fluctuating irritation of mydriasis. Paralytic
mydriasis is found in progressive paralysis, and diseases of the
base affecting the third nerve : Knapp saw it late in thrombosis
of the cavernous sinus ; orbital and intraocular tumors and
glaucoma cause it by destroying the ciliary nerves. Diseases
at the periphery of the afferent apparatus have this form of
mydriasis as a symptom if the process has destroyed their
functional activity. This form of mydriasis sometimes comes
as a post-diphtheritic paralysis.- -E. C. Ellett, M.D.,in Memphis
Moliciil Monthly, June, 1896.
Problems In Army Medical Administration.— Lieut. -Col. A. A.
Woodhull, Chief Surgeon. Department of Colorado, has lately
been testing the ability of the medical officers of his depart-
ment to deal with active service conditions. He has issued a
series of problems in which the surroundings of a command
with all the observable conditions affecting the troops are par-
ticularized, and the medical officer is required to state what
would be his course of action and to give his reasons for
adopting it instead of some suggested alternative. He has
ample time to mature his views in solving the problems, as
although the last series, No. 4, was issued June 30, 1896, the
time limit for solution is December 31, next. In active serv-
ice prompt action is often imperative, as in the selection of a
camp when two sites are available, each of which has its
advantages more or less offset by insanitary conditions. The
time given to the consideration of the arguments for and
against each site in the hypothetic case will assuredly be pro-
ductive of good resuls should the officer who has solved such a
problem be confronted hereafter with the necessity of choos-
ing. Colonel Woodhull's last series consists of the three fol-
lowing problems : 1. A regiment of regular cavalry, with two
lieutenants of the medical department attached, is cooperat-
ing with a brigade of infantry against a large body of outlaws
carrying on a guerilla warfare. The troops are armed with the
modern small-bore firearms, and the outlaws with large-bore
muzzle and breech-loading rifles, shot-guns, muskets for buck
and ball, and a few modern weapons. The climate of the
region corresponds to that of Arkansas in the summer ; the
country is broken and wooded, interspersed with prairies of
moderate size : there are numerous small streams with rocky
beds the hills and alluvial banks in the lowlands ; there is
freedom from swampland, but the banks of the lower streams
are marshy ; the country is sparsely settled and not well culti-
vated but there is grazing for the animals ; the villages are very
small and the population, generally speaking, is disaffected.
There are no available railroads and few good country roads.
As a rule the cavalry will be broken up into troops or smaller
bodies engaged in running down the guerillas who have
descended from the hills, in cutting off their escape into the
hills and occasionally in penetrating the hills in pursuit or
search of them. There will be few collisions of masses, but a
number of harassing encounters with resulting casualties. At
the end of threo months the outlaws will have been disarmed
or will have surrendered. A base hospital for the infantry, to
which cavalry may be admitted, will be established on a stern-
wheel boat on a navigable stream fifty miles by land from the
average line of the mounted operations. State in a general
way what supplies would be required for three months' field
service, especially the kind of tentage and the transportation
for the disabled. What detachments of the Hospital Corps
would be necessary? How will the sick list proper probably
be made up, and what proportion and character of casualties
may be anticipated? How will the medical service generally
be rendered, bearing in mind that the cavalry will usually
operate in detached bodies of a troop or less? As the senior
of the two officers, indicate what you would anticipate and how
you would provide in advance for the sanitary, the medical
and the surgical care of the troops without drawing upon the
infantry in the field. 2. A division of newly-raised infantry
volunteers recruited in the central Western States, goes into
three brigade camps, a mile apart, on the left bank of the
Ohio, above Fort Thomas, June 1. The camp was originally
intended only for temporary purposes, but circumstances pro-
longed its occupation until September 30. The usual diseases
affecting such troops prevailed in due course, but by July 10
the sick list represented 10 per cent, of the strength and there
had been ninety deaths in camp. Visiting the camp as a med-
ical inspector, July 15, and continuing as such for these and
other troops until this camp was broken up, what would you
expect to find the medical condition had been and to be at the
time, what diseases would you fear might arise or continue to
prevail, and what result would you hope to attain should your
advice be followed, with reasons. Give in this connection a
carefully prepared schedule of the advice proper to be tendered
for the preservation of the health of these troops. 3. A gen-
eral engagement has occurred between forces of nearly equal
fighting capacity and equipped with modern arms. During
the night the enemy, who has been on the defensive, retired,
leaving his dead, a large proportion of his severely wounded
still on the field, and his hospital two miles in rear of the line
of battle with 300 badly wounded. With these there were left
five officers and twenty-five enlisted men of his medical corps,
with tents, medical supplies and subsistence for one week, but
no transportation. The army that held the field went into
action with 30,000 men of all arms (divided into two corps) pres-
ent, of whom 25,030 were actually engaged. The battle
occurred in October in latitude 38° 30' north, ten miles south of
a river navigable for fair-sized steamers. The field base was
on that river against which the defeated army had been
advancing. The country is fairly level and moderately wooded
with three good country roads five miles apart, but with no
railroad between the base and the battlefield. The medical
director was informed twenty-four hours in advance of the
probable site and time of the battle. What arrangements
should be made for the field and base hospitals? What num-
ber of wounded should be expected and how would they be
divided, in anticipation, among those requiring no transporta-
tion, those who could be carried in army wagons and those for
whom ambulances would be necessary? Explain the arrange-
ments made for the medical department, assuming that the
full complement of medical officers and men is with the troops
and that the base hospital is independently equipped. The
army moves forward at daylight after the battle and antici-
pates contact with the enemy's rear guard, leaving one regi-
ment of infantry to guard the hospitals and for urgent outside
fatigue. The Medical Director remains throughout the day
and rejoins the army in the night. Explain in such detail as
convenient how he will have been engaged through the day
and write out the principal orders he will give for the disposi-
tion of his own wounded and those of the enemy. It may be
assumed that it will rain hard within twenty-four hours after
the battle.
230
MISCELLANY.
[July 25, 1896.]
Gleanings.— (Semaine Mid., June 24.) Efficacy of faradiza-
tion of the uterus in accelerating delivery and arresting post-
partum hemorrhage. Three cases. (Revue Int. de M. et de
C. June 25.) All that is sold for entire wheat flour is not
always what it pretends to be. Capsules keep the thyroid
gland fresh longest. A new operation for hemorrhoids removes
the tumors if the skin does not adhere to them, ligates and
divides them and sutures the skin again. An inguinal hernia
is described, 55 c. long, 40 in diameter and 95 in circumference.
3 000 boils and carbuncles successfully sprayed with hot phenic
solution a la Verneuil. Athetosis found to be almost invari-
ably preceded by diphtheria. (Therap. Woch., June 28.)
Recovery from abdominal extirpation of a large myoma and
duplex uterus. (Progris Mid., June 27.) Able illustrated
article on the lesions found in multiple neuritis. (Gaz. Mid.
de Paris, June 27.) Colibacilli found in the blood of gastric
fever cases. Intense hemophilia in female infant. ( Union
MM. de Canada, July.) Milk diet with cream of tartar lem-
onade, absolute prophylaxis of puerperal eclampsia.
(Deut'sch. Med. Woch., June 25.) Beneficial effect of the con-
stant current in a few cases of traumatic peripheral paralysis.
(Nouveaux Remedes, June 8.) Painting the nipples with
cocain will suppress the lacteal secretions. ( Wiener Klin.
Rundschau, June 28.) Efficacy of compresses wet with alco-
hol in incipient phlegmons. Case of gallstone causing sup-
puration and finding its way into the pleura and bronchus,
until the stone and pus were coughed up. Demonstration
that sulphureted hydrogen is formed in the mouth during
mastication, which digests alone certain vegetables. (Cbl. f.
Chir. June 27.) Fraenkel's method of narcosis: Before
administering the chloroform, he injects 1 c.cm. of a solution
of morph. muriat. 0.15; atropin sulph. 0.015; chloral hydrat.
0 25 He has never had a fatal case nor severe asphyxia in
twenty-two years. Artificial creation of bone tissue by
implanting calcined bone. {Medittina, No. 8.) Cholera
found to produce grave lesions in the brain. ( Tidsskrift for
den Norske Laeg., June 15.) Beneficial action of antispasmin
in whooping cough confirmed. Dose under 1 year 0.01 to 0.015
three or four times a day, 0.02 under 3 years, and 0.04 over 3.
Or by this formula: Antispasmin, 2; aquas dest., 900; elixir
pectoral, 98.
Louisville.
Death Report. — There was a total of seventy deaths for the
past week and eight stillbirths. Consumption was the cause
of nine. One case of diphtheria and four of scarlet fever were
placarded.
Dr. H. Horace Grant will deliver the annual address on
Surgery at the next meeting of the Mississippi Valley Medical
Association.
Board of Safety. — Impeachment proceedings have been
instituted against the Board of Public Safety by the Common
Council and the trial will be by the Board of Aldermen.
Amonf the charges submitted by two members of the council
to the Board of Aldermen are the following: General and
intentional disregard of the enforcement of the laws of the
State against gamblers and gambling, pool rooms, and houses
of ill-fame ; the ordering a discontinuance of a list of these
houses which is required to be kept by the police department
under orders from the above board ; the creating of great con-
fusion in the financial accounts of the city hospital and alms
house by causing the discontinuance of all the financial books
of the institutions, making it impossible to tell the cost per
month or year of either institution, and making it possible for
unjust and false claims to be brought in against them, and the
bringing in of claims which should be charged to another year ;
the wilful violation of an ordinance passed by the council pro-
viding for the number of officers in charge of the Eruptive Hos-
pital by their wrongfully increasing the number of paid em-
ployes and fixing illegal salaries, without the consent or
approval of the mayor or council and to the injury and preju-
dice of the city treasury and the city service, for all of which
they claim the Board is guilty of usurpation in office for which
they and each of them ought to be removed from office.
THE PUBLIC SERVICES.
Army Changes. Official List of changes In the stations and duties
of officers serving in the Medical Department, IT. S. Army, from
July 11 to July 17. 1896.
Major Clarence Ewen, Surgeon , leave of absence on account of disabil-
ity is extended one month on account of disability.
Col. Dallas Bacbe, Asst. Surgeon-General (Hdqrs. Dept. of the Platte), is
granted leave of absence for two months, to take effect on or about
July 15, 1896.
Major James C. Worthington, Surgeon, extension of leave of absence
granted on account of sickness is further extended one month on
account of sickness.
Wavy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending July 18, 1896.
Surgeon R. C. Persons, orders to duty at naval hospital revoked an
ordered to continue on present duty.
P. A. Surgeon H. N. T. Harris, ordered to the Pensacola navy yard.
Surgeons. H. Dickson, ordered to the "Texas."
Asst. Surgeon J. M. Moore, detached from naval hospital, Norfolk, and
ordered to the " Texas."
Asst. 8urgeon A.Farenholt, detached from the " Monterey " and ordered
to the Mare Island hospital, Cal.
Marine-Hospital Changes. Official list of changes of station, and
duties of Medical Officers of the U. S. Marine-Hospital Service, for
the period from June 21 to July 15, 1896.
Surgeon George Purviance, to assume temporary command of Service at
Philadelphia, Pa., for thirty days, July 3. 1896.
P. A. Surgeon C. T. Peckham, placed on waiting orders, July 3.18%.
P. A. Surgeon J. H. White, to proceed from New York, N. Y.. to Key West,
Fla., for special duty. July 10. 1896.
P. A. Surgeon G. T. Vaughan, granted leave of absence for thirty days,
July 7. 18%.
P. A. Surgeon W. G. Stimpson.to assume temporary command of Service
at Port Townsend, Washington, July 3, 1896,
Asst. Surgeon E. K. Sprague, to proceed from Boston, Mass., to New York,
N. Y., for temporary duty, July 10, 18%.
Asst. Surgeon H. w. Wickes, granted leave of absence for twenty -seven
days, July 8. 18%.
Asst. Surgeon J. B. Greene, to proceed from Baltimore, Md., to Pt. Pleas-
ant, N. J., for physical examination of crews of life saving service,
July 13, 1896.
Asst. Surgeon W. M. Jordan, to proceed from Birmingham, Ala., to New
York, N. Y., for temporary duty, July 13, 18%.
PROMOTIONS.
Asst. Surgeon J. A. Nydeggar, commissioned by the President as Passed
Assistant Surgeon, July 7, 18%.
Asst. Surgeon W. J. S. Steward, commissioned by the President as
Passed Assistant Surgeon, July 8, 18%.
APPOINTMENT.
William M. Jordan, of Alabama, commissioned by the President as
Assistant Surgeon, July 7, 18%.
>
Change of Address.
Baughman, J.N., from Flat Lick, Ky., to 617 Chestnut St., Evansville, Ind
Caldwell, J. R., from West Liberty, W. Va., to St. Clairsville, Ohio.
Collins, R. G., from 5059 State St. to 5189 Wabash Ave., Chicago.
Guyon, E. P., from Peudletou, Ore., to Montpelier. Idaho.
Kellogg, G. M., from Las Vegas, N. M., to 2310 Indiana Ave., Chicago.
Kellogg, W. H., from Oakland to Palo Alto, Cal.
Lewis, W. M., from 154 N. Spring St. to 248 Wilcox Building, Los
Angeles, Cal.
Mi-Daniel. E D., from Mobile, Ala., to Milton, Fla.
Osborne, G., from 75 Rush St. to 181 Michigan St., Chicago.
Roy, G. G., from I'A Edgewood Ave. to 20 E. Ellis St., Atlanta, Ga.
Seller, Carl, from Philadelphia, Pa., to Saranac Lake, N. Y.
LETTERS RECEIVED.
Abrahams, R.,New York, N. Y.; Appleton, D. &Co., Chicago.
Battle & Co., St. Louis, Mo.; Brown, F. F., New York, N. Y'.; Brumme,
Carl, Detroit, Mich.; Bartlett, Edward P., Springfield, 111.
('an ton Surgical and Dental Chair Co.. Canton, Ohio; Castle, Wilmot
&Co .Rochester, N. Y. ; Cone, Andrew, New York, N. Y.; Chart Co., The,
Bond Hill, Ohio.
Doliber-Goodale ife Co., Boston, Mass. ; Dietz, R. E., Company, New
York,N.Y.; Dick, E. B., Oakville. 111.; Davison, F. B., Fleetville. Pa.
Eads, S. O., Somerset, Ky. ; Eichelburger, W. C., Terre Haute, Ind.
Fletcher & Hudson, Mt. Clemens. Mich.; Foster, Eugene, Augusta,
Ga.; Fairchild Bros. & Foster, New York, N. Y.
Gihon, A. L. 2), New York, N. Y.
Hamilton, E. E.. Wichita, Kan.; Hamilton, Augustus, Coleridge, Neb.;
Hosmer, A. J., Vieuna, Austria: Hubbard, Thomas, Toledo, Ohio;
Hummel, A. L.. Advertising Agency (2), New York, N. Y.
Ingals, E. Fletcher, Chicago.
Johnson. H. L. E., Washington, D. C.
Klebs, Edwin, Chicago; Kruell. T. J., Los Angeles, Cal.; Kegan, Paul,
French, Trcibner & Co., Ltd., London, Eng.
Levy. M., Paris, Friuce; Lancaster, R. A. Gainesville, Fla. ; Leighton,
N. W., Brooklyn, N. Y.
Mauley, Thos. H. (2), New York, N. Y.; Merrick, M. B., Passaic, N. J.;
Maltine Mfg. Co., New York, N. Y. ; Marks, A. A., New York, N. Y.;
Minor, J. C, Hot Springs. Ark,; Mettler, L. Harrison, Chicago; McDan-
iel, E. D., Milton, Fla.; Mulford, H. K.. Co., Philadelphia, Pa.; Macey
Co,. Fred, The, Grand Rapids, Mich.; Mellier Drug Co., St. Louis, Mo.';
Maclean, Donald. Detroit, Mich.; Mackie. L. V. G., Brant Rock, Muss.;
Miehle Printing Press and Mfg. Co., Chicago; Murray. N., Rye Beach, N.H.
Pasteur Chamberland Filter Co., Chicago; Press Clipping Bureau, The,
Boston, Mass.; Paquin, Paul, St. Louis, Mo.; Publishers' Collection
Agency. St. Paul, Minn.; Parker, W. T., Cleveland, Ohio; Parkhill,C. S.
(2). Hornellsville, N. Y.
Rio Chemical Co., St. Louis, Mo.
Slagle. Jacob, Portsmouth, Onio; Stearns, F.. & Co., Detroit, Mich.;
Summerfield, J. E., Atlanta, Ga. ; Sutherland, J. Lue, Grand Island,
Neb.; Scott, J. W., Springfield, 111.; Schachner, August, Louisville. Ky.;
Smo<g. D. P., New York, N. Y.: Scott, W. A.. Swanton, Ohio; Stechert,
G. E., New Y'ork, N. Y. ; Smart, Charles, Washington D. C.
Tuley, Henry E.. LouiRville, Ky.
Wyckoff.R. M„ Brooklyn, N.Y'.: West, C. J., Washington, D. C; Wid-
man, J. F., McGregor, Iowa; Wilkinson, Geo., Omaha, Neb. ; Walker, A,
B., Canton, Ohio; Ward, M. R., Pittsburgh, Pa.; Warrield, Clarence,
Galveston, Texas.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., AUGUST 1, 1896.
No. 5.
ORIGINAL ARTICLES.
PIKRPERAL FEVER; ITS PROPHYLAXIS
AND TREATMENT.
the Section on Obstetrics and Diseases of Women, at the Forty-
uth Annual Meeting of the American Medical Association,
at Atlanta, Ha.. May 5-8, 1896.
BY E. E. MONTGOMERY, M.D.
PHILADELPHIA, PA.
The mysterious condition known as puerperal fever
has been a prolific theme for discussion. Its insidi-
ous character, its multiple lesions and its grave mor-
tality sometimes depopulating lying-in hospitals or
causing the death of every parturient women in a
district, have naturally directed interest to its study.
When we review the conflicting theories as to its
genesis we find they may be resolved into two views;
the one, the more simple and concrete, but less satis-
factory, which seeks to associate the disease with the
discovered anatomic lesion. With the development of
the anatomy the distinction of the lesions has become
inure delicate and is limited to the tissues, as peri-
tonitis, adenitis and the various abscesses of the pelvis.
This is the localization theory. The other theory is
that known as the essential doctrine, that the disease
is due to some special miasm or infectious poison
from which has been evolved the microbic etiology.
The repetition of cases of similar character in the
same institution, or the same district naturally led to
the recognition that it was an infectious disease and
to the supposition that it was due to a special miasm.
The specific identity of this poison was ably champ-
ioned by Fordyce Barker, who claimed that puerperal
fever was a distinct disease.
The researches of Pasteur rendered it probable that
it was due to the presence of microorganisms which
were conveyed to the victim by contact, through the
atmosphere, or had developed as ferments in her body.
Siredey as early as 1875 determined the absolute
similarity between surgical and puerperal infections,
and further asserted that puerperal peritonitis was
secondary to a uterine lymphangitis. The continuous
association of certain forms of bacteria in the uterine
discharges of puerperal fever, the ability to develop
similar septic conditions in the male by the injection
of these organisms or their products, demonstrate the
certainty of their baneful influence. Bumm, as a
result of his researches into the microorganisms of
puerperal sepsis accepts two forms of infection; 1,
putrid infection, produced by retained portions of
placenta, decidua or blood clots infected by the sapro-
phytes, various bacilli and cocci, developing a condi-
tion know as sapremia; 2, the septic form, the result
of the presence of the pyogenes, the streptococcus
and staphylococcus. Widal claims to have seen a
fatal case of puerperal suppuration which was appar-
entlv due to the bacterium coli.
The investigations of Doleris have demonstrated
the identity of the streptococcus of erysipelas with
that which results in puerperal fever, or sepsis.
Careful investigation no longer leaves a doubt that the
puerperal inflammation is induced by a streptococcus
identical in its characteristics with the streptococcus
of erysipelas and the pyogenes. It can not be denied
that inflammation of a less intensity may develop
from infection by the staphylococcus. Some cases of
peritonitis and puerperal lymphangitis are undoubt-
edly produced by the bacilli of putrefaction. Rarely
the bacillus coli communis may engender a suppura-
tive peritonitis. The process of infection is greatly
facilitated by obstetric traumatisms, the existence of
previous attacks of gonorrhea, and the presence of
bacilli in the vagina.
The streptococcus conveyed to the patient by the
finger of the physician, or nurse, or by instrumental
manipulation during or following labor, makes its hab-
itat in the debris of the mucous membrane, in the
lymphatic fluid and blood clots at the situation of the
placenta, in the material which forms the lochia, or
vaginal discharge following parturition. The canals
of mucous glands, tears of the cervix, vagina and
vulva afford opportunity for further development;
without producing marked effect upon the uterine
or tubal surfaces the infection may pass through these
organs and produce violent and dangerous infective
processes in the ovaries or peritoneal cavity. The
writer has seen one case in which there was developed
an abscess of the ovary without any uterine or tubal
complication. In this case, the uterus and tube
afforded access of infection to an ovary which was
probably rendered more vulnerable by the existence
within it of the corpus luteum of pregnancy. The
infection proceeds by continuous extension through
the Fallopian tubes to the peritoneal cavity, but in
addition it extends through the lymphatics and blood
vessels. The multiplication of germs results in the
formation of ptomain or toxin products. The
increase of the toxin results in irritation, swelling,
congestion and the exudation of liquid plasma into
the cellular tissue. The presence and multiplication
of the germs results in the destruction of the vitality
of the infected tissue, the necrosis in mass of large
layers of tissue, producing a superficial acute gangrene,
or pseudo-diphtheria. The condition is always pus-
producing and septic.
Clinically we find the disease varies in different
patients. This is due to the varying immunity to
the microorganisms. The varying power of resistance
in different individuals produces different types.
These have been resolved into three: first, inflamma-
tion, and local suppuration; second, inflammation
and migratory suppuration, and third, hypertoxic
infection without suppuration. The point of infec-
tion varies in labor and abortion. In the latter, the
placental site, and erosions of the cervix will generally
be the avenue through which the infection has found
232
PUEKPEKAL FEVER.
[August 1,
entrance, while in the former entrance may be pro-
vided by lesions of the vulva, as lacerations of the
fourchette, lateral wall, or anterior commissure, an
injury of the duct of Bartholin, adenitis, lacerations
of the vagina, laceration or desquamation of the cer-
vix by the fetal head. The previous conditions of the
tube may render puerperal infection certain, or dis-
placement of the uterus, presenting an obstruction to
drainage, may present a favorable soil for infection.
The combat between the invading infection and the
powers of resistance in the patient may result in the
limitation of the disease to local inflammation or
suppuration occurring in abscess in the labium,
cellular tissue of the pelvis, wall of the uterus, or in
the Fallopian tube. Barriers of limitation are pro-
vided, immunity against farther invasion is early
secured. Second, the inflammatory processes result
in migration of the inflammation; sometimes exclu-
sively by way of the mucous lining of the tube to
the peritoneum, which is rare, or it extends from
without inward, resting upon the external layer, or it
may be mixed, involving the mucous membrane, the
blood vessels and the lymphatics. Migration by the
mucous membrane exclusively, will produce a puer-
peral salpingitis, by the external part a phlebitis,
while the mixed migration results in a multiplicity of
lesions. In some cases, the entrance of infection is
so rapid, and the power of resistance so slight, that a
toxemia results, which produces a rapidly fatal term-
ination with slight or no indications of the formation
of pus.
The fatal termination in puerperal infection may
be occasioned by profound organic vices anterior to
the confinement, which render the power of resistance
faulty. Second, by a regular progression of the
lesion, and invasion of its economy by the poison,
continually augmented in quantity and toxicity.
Here there is a struggle and the forces of nature are
finally beaten down. Third, the virulent character of
the toxic force results in a paralysis of the nerve
forces. Here the multiplicity of the microorganisms
is at the maximum, with minimum resistance.
Treatment. — The first and most important consider-
ation in treatment is prophylaxis. With a correct
knowledge of the source of danger, we are the better
prepared to meet or avoid it. As the contagion in the
majority of cases is conveyed by contact, scrupulous
aseptic or antiseptic precautions should be preserved.
The nearer the measures of the careful surgeon can
be imitated and practiced, the less will be the danger
to the patient. The physician in general practice
who is in attendance upon sepsis or erysipelas can
not be too rigid in his measures of preparation;
indeed, it is a serious question whether he should go
from a virulently infected patient, whether it be with
sepsis or erysipelas, to the lying-in chamber. During
the writer's term as resident physician in the Phila-
delphia Hospital in 1875, he went from the surgical
ward, where he was in attendance upon cases of ery-
sipelas, to the obstetric department; no special pre-
caution outside of cleanliness of hands and person
was practiced. An epidemic of puerperal sepsis
developed, in which twenty patients became seriously
sick, and four lost their lives.
The measures particularly to be practiced are the
removal of the coat, baring of arms to the elbows,
careful washing of the hands with soap and hot water,
with diligent use of the nail brush, hands should be
immersed in 1 to 500 bichlorid and subsequently in
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Temperature sheet of patient with puerperal Infection, showing
effect of use of streptococcus antitoxin.
1696.]
PUERPERAL FEVER.
233
alcohol. The bedding and personal clothing of the
patient should be clean. tluv vulva should bo washed
with soap and hot water, the bowel emptied by an
enema and an antiseptic douche given. Digital vagi-
nal exploration should be infrequent and only after
careful disinfection of the hands. Instruments should
be sterilized by boiling. Long continued manipula-
tion, instrumental delivery or manual delivery of the
placenta, should be followed by antiseptic intrauterine
irrigation.
The parts should l)c carefully cleansed subsequent
to delivery, the placenta carefully observed .to make
sure no portion remains, and the uterus should be
left firm and well contracted. Laceration of the
vagina and vulva, unless the tissues are bruised or
the vitality destroyed by long continued instrumental
delivery, should be at once sutured; excoriations may
be cauterized by carbolic acid. The vulva should be
covered with an antiseptic pad which should be
changed as frequently as it becomes soiled. With
each changing, the vulva should be cleansed with an
antiseptic solution. Aside from the immediate post-
partum irrigation mentioned, intrauterine or vaginal
douching should not be practiced.
But physicians will reply that they have attended
large numbers of confinement cases without«such pre-
cautions and no had results have followed. This may
he true. With ordinary precautions the chances are
favorable, and much depends upon the condition of
the patient. Not every jjatient, fortunately, to whom
Contagion is conveyed, yields to its influence. The
normal secretions of the vagina are unfavorable for
germ culture. The tract is irrigated by discharge of
the liquor amnii and swept clear by the passage of
the fetus. Many eminent obstetricians, among whom
may he named Lusk, are content to depend upon these
conditions in ordinary cases; still, the preliminary
douching does not seem useless.
Treatment of infection may be considered as, first,
maintenance of the powers of resistance; second, pro-
duction of immunity: and third, the resort to surgical
procedures for relief of local manifestations. This
classification of treatment has reference to septic con-
ditions. Sapremia or putrid intoxication is relieved
by removal of the decomposing placenta, portion of
membrane or blood-clot, and subsequent irrigation
and drainage. The diagnosis is determined by the
character of the lochia and the digital exploration of
the uterine cavity. Decreased or absent lochia, ele-
vation of temperature, rapid pulse, depressed, anxious
countenance, should betoken the suspicion of begin-
ning sepsis. It may or may not be accompanied by
local tenderness. Exploration of the uterine cavity
reveals a smooth surface, which should confirm the
diagnosis. The rapidity with which the vital forces
are depressed contraindicates the use of depleting
agents, unless it be the moderate use of purgatives to
aid in elimination. Early resort should be made to
the use of tonics, stimulants and easily assimilated
and nourishing food. The most efficient stimulant
will be found in strychnin, which should be given for
effect, and may be administered hypodermically in
doses of gr. 1-15 every two or three hours, where
there is much depression. Opium, morphin and anti-
pyretics should be given with great circumspection.
For the control of temperature, cold sponging or the
cold pack should be practiced. Pain, whenever pos-
sible, should be relieved by the ice bag. The natural
tendency of disease germs is to develop toxins which
are toxic to themselves, and render the individual
immune to further ravages. The better the nutrition,
the more the strength is sustained, the earlier immu-
nity will be secured. In many cases, however, the
progress of infection is so rapid, the intoxication so
profound, that the patient can not survive until immu-
nity has become established. As we can not foretell
in any individual the virulence of the infection, nor
the possible powers of resistance, the use of an anti-
toxin should be considered as indicated wherever
infection is recognized. This is best given by hypo-
dermic injection. These injections of streptococcus
antitoxin should be given in doses of 25 c.c. once daily
for four days. They may be made into the cellular
tissue of the abdominal wall, or into the buttocks or
thighs. Of course, every precaution must be prac-
ticed to render their use aseptic.
Bacteriologic study should be made of the secre-
tions, but as the large majority of septic troubles arise
from the presence of the streptococcus, valuable time
may be saved by immediate use of the antitoxin.
The following history is of interest : A young
woman gave birth to a child February 18, at 6:30 p.m.
Twenty-four hours later her temperature was 103.8
degrees, pulse 130, the next evening 104.2 degrees.
Her husband at the time was suffering from numerous
boils, and her physician, the day following her con-
finement, developed an onychia of the right index
finger. The writer saw her upon the sixth day, when
her temperature was nearly 102 degrees; the uterus
was large, situated to the left side, quite tender, and
vaginal examination disclosed some induration in the
left broad ligament. The vagina was inflamed and
filled with thick muco-purulent material with no espe-
cial odor. The vagina was carefully irrigated and
scrubbed, the uterine cavity cleansed and packed with
iodoform gauze, an opening made into Douglas' pouch,
some flakes of lymph removed by irrigation and a
gauze drain inserted. Her symptoms improved for
two days, and then became aggravated. An erysipel-
atous blush was noticed extending from the vagina
to the buttocks, and the vulva much swollen. This
extended in a wave-like course until the entire body
became involved. March 11, over three weeks from
her confinement, the temperature had been but twice
below 100 degrees and now was nearly 104 degrees,
with a renewal of the erysipelas at the vulva. The
antitoxin was now begun and given daily for five days
after the first dose, and the temperature subsided and
convalescence was subsequently uninterrupted.
Surgical Measures. — Curettement is advised early.
If the condition is due to putrid intoxication this
procedure, followed by irrigation and drainage, will
give prompt relief. In streptococcus infection the
germs are imbedded in the mucous membrane, sinuses
and wall of the uterus, so that a curettement would
not accomplish their complete removal, and affords
more surf ace for ptomain absorption. Hysterectomy
has been advocated, but it is a question whether in
this form of infection the tissues have not been
invaded to such a degree that the removal of the
uterus would be ineffectual. The first aim should
be the establishment of immunity, then local mani-
festations should be treated as they make their
appearance with the assurance that farther spread
will be avoided.
Let us have a Department of Public Henlth!
234
PUERPERAL INFECTION.
[August 1;
PUERPERAL INFECTION; ITS PATHOLOGY,
PREVENTION AND TREATMENT.
Read in the Section on Obstetrics and Diseases of Women at the
Forty-seventh Annual Meeting of the American Medical
Association, at Atlanta. Ga„ May 5-8, 1896.
BY R. R. KIME, M.D.
ATLANTA, GA.
The term "puerperal fever" should be abandoned,
as it is too broad and includes conditions which are
not peculiar to the puerperal state, hence misleading.
Puerperal septicemia as used by many is also objec-
tionable; it should be limited in its application and
used only to indicate cases of true septicemia. Text-
books and lexicons define "puerperal fever" as an
acute infectious disease due to septic inoculation.
Some authorities apologize for the definition, and well
they may under the present light and knowledge of
these conditions.
In writing upon this subject, some five years since,
for the Tri-State Medical Association I endeavored to
demonstrate the existence of two general classes of
puerperal infection. Such a view then met with strong
opposition and some of bur best authorities wrote me
such a distinction could not be maintained. To-day
I am more fully convinced than ever that we have a
septic and a putrid infection occurring during the.
puerperal state and that they can be distinguished
bacteriologically, pathologically and clinically. We
may have cases of mixed infection, as in other dis-
eases, but that does not justify the wholesale group-
ing of all these cases under the cloak of septicemia as
is done by many authorities, even at the present time.
As our knowledge of puerperal infection becomes
more accurate, our bacteriologic demonstrations more
definite and our clinical histories more minute, we
will find the distinction between putrid and septic
infection broadens in the same proportion.
Putrid infection, or sapremia, is due to the
absorption of ptomains developed by putrefactive
bacteria or saprophytes; the bacilli remain localized
in the dead tissue; the alkaloid, being absorbed, pro-
duces constitutional symptoms in proportion to the
amount imbibed, is not contagious nor inoculable
from case to case, except where foreign substances are
retained in the uterus. Putrid infection can not graft
itself in healthy tissue, foreign or dead tissue must
exist as a nidus for its development.
Septic infection or septicemia is due to invasion of
septic germs producing constitutional and local dis-
turbances by their presence and invasion of new tissue
with absorption of leucomains, their alkaloidal devel-
opment. They enter living tissues; migrate from
point to point, entering the circulation; are highly
contagious and inoculable from case to case. Strep-
tococci are said to travel one centimeter1 per hour,
penetrate the tissues and spread by the lymphatics
and blood vessels. A variety of germs are capable of
producing septic infection; among the most frequent
are the streptococci and staphylococci. The infection
may be local, affecting the endometrium (Bumm),
extending, may involve the lymphatics (lymphangitis)
or the venous channels (-thrombo-phlebitis) with
various complications and general systemic infection.
It is here we may have the much-talked of pelvic cel-
lulitis, with or without abscess formation, salpingitis
with or without pyosalpinx, pelvic peritonitis and
even general peritonitis, while the thrombo-phlebitic
variety may result in multiple abscesses in the uterine
wall.
1 J. W. Williams, M.D., Amer. Jour., Obs., February, 1896.
Prevention of puerperal infection is accomplished
by strict asepsis in obstetric practice, as well as thor-
ough emptying the uterus and securing proper con-
tractions with repair of lacerations. All recognize
the necessity of strict cleanliness of physician, nurse,
patient, bedding and everything that comes in con-
tact with the patient. We do not desire to sing the
old song of "antiseptics in obstetric practice," but for
the sake of suffering women desire to urge the neces-
sity of strict asepsis and often of disinfection. Even
after the physician's hands have been scrubbed with
soap, warm water and brush the application of ammo-
nia, solutions in proper strength of creolin, lysol, car-
bolic acid or mercuric chlorid can do no harm and
will often add to the safety of the patient. The
patient should have a warm bath, vulval region washed
with soap and warm water and a disinfectant will add
to her safety. She should be dressed in clean clothing
suited to the occasion, placed in a clean bed properly
arranged, bowels moved and bladder emptied, then
she is ready for labor.
As to use of the antepartum douche there is a
difference of opinion, which has been well presented
by Charles Jewett, M.D. (April issue American Gyn-
ecological and Obs. Journal). He states that the
statistics at the Dresden Clinic (Leopold) show that
of 5,784 cases douched, 82 per cent, were free from
fever ; of 4,088 cases not douched, 94.8 per cent, were
free from fever, which goes far to establish the claim
that the antepartum douche is useless and it should
not be used, especially in private practice, except for
cause. In hospital practice among the lower classes
there is greater necessity for its use. If diseased con-
ditions be present, indicated by a "yellowish, greenish
or fetid discharge, especially of excoriating character,"
then prophylactic vaginal disinfection is required.
Unless such conditions be present nature's protective,
lubricating, disinfecting vaginal secretion is too
important a factor in labor to be interfered with.
Postpartum douches, as a rule, are to be condemned
as useless and frequently injurious, by exposing the
patient unnecessarily and increasing the risk of infec-
tion.
After labor cleanse the patient externally with an
antiseptic solution and apply antiseptic vulval pad.
The antiseptic pad properly applied and attended to,
adds to the comfort and safety of the patient, lessen-
ing the risk of infection, especially if any cough be
present. The vulval region should be cleansed two
or three times a day with 1 per cent, solution creolin,
lysol, 3 per cent, carbolic acid, 1 in 2,000 mercuric
chlorid or saturated solution of boric acid. As few
vaginal examinations as possible should be made.
The patient, unless some special contraindication
exists, should be lifted up over a vessel in bed for the
bowels to move or kidneys to act, thus favoring vaginal
drainage. The thorough emptying of uterus and
securing proper contractions of the same are preven-
tive measures of great importance, as the presence of
placental tissue, membranes, blood clots, etc., is an
inviting field for germ development and essential for
putrid infection. The repair of lacerations, especially
of perineum, should not be overlooked, as such repair
closes raw surfaces and closes avenues for infection.
The treatment of puerperal infection is a subject of
grave importance and especially so at the present
time, when hysterectomy and abdominal section for
these conditions seem to be a fad. I am confident
that a far greater number of cases of infection occur
1896. J
PUERPERAL INFECTION.
235
than the general profession are willing to admit and
that many eases of mild infection are overlooked or
attributed to other causes; severer forms are treated
as other diseases and when the patent dies the death
certificate reads typhoid fever, malaria, inflammation
of bowels, etc. The recorded deaths do not represent
the actual number, much less the vast number of
cases of infection that either recover or go through
life maimed.
If the obstetrician could follow up his work closely
he would frequently rind results of infection which he
bad overlooked or attributed to other causes, but his
services usually cease with the puerperal period and
later the patient seeks the specialist for advice and he
frequently finds results due to infection after labor or
abortion.
Drainage is the most essential factor in the treat-
ment of puerperal infection. It is a process of elim-
ination from the uterine cavity, alimentary canal and
abscess cavities by tubular or capillary drainage and
cathartics. For uterine drainage the tubular form is
the best, and salines for alimentary drainage. During
pregnancy we have a hyperplasia of tissue with con-
sequent increased vascularity of the generative organs,
which must be reduced after the uterus is emptied by
a process of retrograde tissue metamorphosis requir-
ing great activity of the lymphatics. This process,
with an open placental site, accompanied by the trau-
matisms of labor render the parts very vulnerable to
the entrance of germs and absorption of toxic princi-
ples. We have as a natural result of labor or as an
acquired pathologic result a discharge from the
uterine eavitv. following delivery, in which nature'
throws off waste material by a process of elimination
or drainage. This discharge contains cellular ele-
ments of the blood, leucocytes and other debris which
can not be drained off by gauze. We tampon with
gauze to check hemorrhage and wall off septic material
in abdominal work. Shall we tampon the uterus with
gauze, checking nature's process of elimination, chok-
ing up nature's channels with dehris and dead leuco-
cytes ladened with septic germs, by placing an
impenetrable barrier in the way of their exit, or shall
we imitate nature and give free egress to all noxious
material? Does the successful surgeon tampon a
large abscess cavity with a small opening with gauze
alone, especially where there is a septic process and
necrotic tissue!* As a rule, abscess cavities have a
protective wall around them which lessens dangers of
absorption, thus favoring the use of gauze, but not so
in septic infection. Large opening and free drainage
is the rule in surgery. In puerperal infection one
can not secure a large opening or free drainage with
gauze tampon. Again the dangers of gauze packings
art' very greatly increased by curetting off the endo-
metrium, especially in septic infection. The curette
should rarely, if ever, be used in septic infection; it is
too dangerous and deleterious in its results. .
Frequently we hear physicians say, "I curetted, dis-
infected and tamponed yet the patient died" ; and it
might be added as a result of the treatment. If a
curette is used at all it should be a large dull one and
used simply to hook up tissue which, as a rule, can
be more readily removed by forceps, and not used
with a view of removing endometrium or even adher-
ent tissues, as is done by some. In putrid infection
the curette can be used vigorously, the uterus tam-
poned and yet the patient reco.ver regardless of the
treatment; but nature is not so well able to overcome
such treatment in septic infection, and it is frequently
a method of manufacturing cases for hysterectomy.
These remarks are applied to cases of infection
after labor and not cases of abortion prior to the fourth
month. Infection after incomplete abortion, in the
majority of instances, are typical cases of putrid infec-
tion and easily relieved by the curette, disinfection
and tampon, because we have different conditions to
deal with.
To make a clinical distinction and give separate
treatment for putrid and septic infection would make
this paper too lengthy, so we will briefly consider
them collectively.
As soon as puerperal infection is diagnosed, irrigate
the uterine cavity with a disinfectant fluid, then
remove any foreign substances that are present by a
method least likely to injure the endometrium and
best suited to the individual case and dexterity of the
operator, then irrigate freely again. If much hemor-
rhage, irrigate with very hot water containing comp.
tr. iodin or alum; never tampon except for serious
hemorrhage, but introduce as large-sized drainage
tube as cervix will admit. Soft rubber tubing is as
efficient as any and may be used in the form of a f or
loop with perforations in the uterus, and the T or
free ends of loop left in the vagina, which ends should
also be perforated to allow free egress.
If capillary drainage is also desired a strip of gauze
can also be carried up into the uterus by the side of
the drainage tube with free end left in the vagina or,
if desired, may be carried out to antiseptic vulval pad,
but I prefer at this time to dispense with the pad,
using a pledget of absorbent cotton, so as not to
obstruct drainage. The end of the strip of gauze in
the uterine cavity may be saturated with pure cam-
phorated phenol before introduction, so as to prolong
disinfection of the uterine contents and is far better
than any suppository for such purpose. Boric acid,
pure, may be also carried into the uterus on the
gauze, and a tablespoonful left in the vagina is effi-
cient. Drainage tube should be removed once or
twice in twenty-four hours, uterus irrigated with dis-
infectant solution, not too strong ; carbolic acid, boric
acid and creolin are best. If uterus is relaxed or there
is hemorrhage, a solution of compound tincture iodin
should be used. It may be added to carbolic solution.
Weak solutions should be used, as strong ones will
interfere with nature's process of repair. If the tube
is removed but once a day a vaginal douche should be
used midway between times. The drainage should be
continued until patient has fully recovered. At com-
mencement salines should be given to produce free
catharsis, thus eliminating poison, relieving pelvic
hyperemia and abdominal distension and pressure.
The combined use of drainage tube and salines will
control temperature far better than antipyretics and
relieve pain better than opiates, beside they are cura-
tive by relieving the cause and more permanent in
results. The coal tar derivatives, as antipyretics and
opiates for pain, only combat symptoms, depress the
patient, interfere with elimination of effete material,
assimilation of food and obscure symptoms; in short,
injure more patients than they benefit. They should,
never be used except in extreme cases of high tem-
perature or severe pain as a palliative measure until
other treatment can be instituted. Sulphonal is the
best soporific. Viburnum and the bromids act well
in some cases. Quinin in ten grain doses at four hours1
intervals at first, later in smaller doses, is efficient in
236
GONORRHEA IN THE PUERPERIUM.
[August 1,
checking germ development, counteracting toxic
principles, sustaining vitality of the patient and con-
trolling the tendency to chills. Strychnia given every
four hours, combined with pepsin, disinfectants and
bitter tonics best suited to the individual case, are
essential as well as good nourishing diet given sys-
tematically. In debilitated cases stimulants are
needed and frequently artificial foods will be required
to keep up the vitality of the patient. Of these I have
found beef peptonoids, panopeptones and malted milk
most reliable. After acute symptoms have subsided
some of the most assimilable forms of iron are bene-
ficial. Frequent alcoholic baths with or without quinin
are useful in tranquilizing the patient, stimulating
cutaneous surfaces and checking profuse perspiration.
If the above outlines of treatment with the efficient,
systematic, persistent use of the drainage tube are
carried out, surgical measures will rarely be required
in puerperal infection. I found from inquiry of eigh-
teen leading gynecologists and obstetricians, five were
opposed and thirteen in favor of hysterectomy for
puerperal infection. Of fifteen cases reported by them
up to that time, eight died, making a death rate of
53| per cent. The advocates of hysterectomy advise
it for disease limited to the uterine body, such as
septic metritis, multiple abscesses in uterine wall,
uterine thrombo-phlebitis and gangrene of uterus.
The diagnosis of such limitation of septic processes is
very difficult and mistakes are frequent, with disastrous
results. In a majority of cases of septic infection the
septic process has extended beyond the uterus, involv-
ing other tissues with systemic infection which can
not be reached by hysterectomy, but when it is local
such an operation is indicated. Most gynecologists
that favor hysterectomy advise to curette and tampon
the uterus, and if the patient does not improve or
grows worse, then remove the uterus. With them it
is not a question of diagnosis, but a failure of a cer-
tain line of treatment to give relief, which indicates
hysterectomy, and that line of treatment frequently
creates the demand for the operation in cases of sep-
tic infection. Pus accumulations in the pelvis can
frequently be relieved by vaginal drainage, as advised
by Dr. Henrotin of Chicago, thus saving lives that
would be sacrificed by more heroic measures. Pyosal-
pinx, ovarian abscess, etc., the secondary localized
results of infection, should be dealt with on the same
principle as when produced by other causes.
In conclusion, I again emphasize the fact that use
of the drainage tube, with treatment as outlined above,
will save more patients than all surgical measures
combined; and more important, the uterus, tubes and
ovaries will be preserved for future usefulness and the
surgeon's conscience left more at ease.
GONORRHEA IN THE PUERPERIUM.
Read in the Section on Obstetrics and Diseases of Women, at the Forty-
Seventh Annual Meeting of the American Medical Association
at Atlanta. Georgia, May 5-8, 1896.
BY ALBERT H. BURR, M.D.
ATTENDING PHYSICIAN PROVIDENT HOSPITAL.
CHICAGO.
In these latter days of widespread knowledge of
aseptic measures for shielding the parturient woman
from harm, the occurrence of puerperal sepsis is
looked upon, even by the laity, as evidence that some
one has blundered, and the attendant is fortunate if
he escapes the charge of criminal negligence or inex-
cusable ignorance. If the infection of the lying-in
nti-
ion,
woman happened only during labor, or her subsequent
stay in childbed, the charge might be sustained with
justice, but we are convinced that it happens more
frequently than is apprehended that an infection has
antedated childbed by weeks or months, if indeed it
has not preceded conception itself and invaded terri-
tory absolutely beyond the reach of any possible anti
septic treatment.
With a unilateral pyosalpinx, or a tubal infectic
existing before pregnancy, or a subsequent gonorrheal
infection of vulvo- vaginal glands or urethra, who can
be certain, even though forewarned, that he can be
effectually forearmed against such dangerous and hid-
den foes?
I confess to a feeling of insecurity in every
approaching case of confinement where I know
beforehand, or have reason to suspect, the existence of
gonorrheal infection, either active or latent. In an
obstetric experience of five hundred cases I have had
three fatalities, each of which is directly traceable to
gonorrhea. In many of the remaining cases of puer-
peral sepsis, more or less severe, I have found by clin-
ical history or by microscopic verification, the pres-
ence of a gonorrheal infection. An epitome of the
M
ft
Plate 1 ; Case V.— Gouococcl
after birth.
hthalmia neonatorum, fifth day
fatal cases, with a few added cases of non-fatal sepsis,
culled for their instructive features, may serve to
emphasize dangers too often ignored by the unwary.
Moreover, it may comfort the troubled soul of some
good brother who, believing he has neglected no rea-
sonable precaution for the safety of his patient, has
met with disaster where it was least expected. It
may enable him in the future to trace the offending
cause and place the responsibility where it rightfully
belongs.
Case 1. — Elizabeth B., single, aged 20; French Canadian;
primipara of vigorous physique, progressed in labor without
incident until the separation and expulsion of the placenta
brought with it a gush of most offensive fluid, the stench of
which drove other attendants from the chamber. No odor
was present at the rupture of the amnion. Nothing abnormal
was apparent in the secundines. The child was robust. Here
was a case of encysted septic material behind the placental
attachment which no possible foresight or treatment could
have reached in preparation for an aseptic confinement. Thor-
ough infection of the whole placental site and of the parturient
canal with a most deadly poison was instantaneous and inevit-
able. Peritonitis developed in thirty-six hours and ran its dis-
tressing and fatal course in less than a week, despite anti-
septic uterine irrigations and other recognized treatment. In
the absence of an autopsy the only logical conclusion is that
the location of the decidua over the cornua had converted an
1896. 1
GONORRHEA IN THE PUERPERIUM.
237
infected tube into a closed sack which discharged its sapro-
phytic contents into the uterus when the detachment of the,
placenta had freed its uterine orifice. The vocation of
the woman makes gonorrhea the most probable cause of a
pinx.
Case ■'■ Km ma M., aged 20 years; German; married ten
months: remarkably strong in physique; consulted me soon
after marriage for metrorrhagia. Examination revealed an
acute vaginitis, characteristic of gonorrhea. Subsequent
examination of the husband showed an acute urethritis.
symptoms in the wife yielded promptly to treatment
ami pregnancy soon put an end to metrorrhagia. Both hus-
band and wife, however, had recurrent attacks of sub-acute
gonorrhea during the wife's pregnancy. Confinement was
normal, on March 12, 1888. Antiseptic vaginal irrigation was
practiced for several days. No untoward symptoms.resulted
until March 20, the eighth day, when a severe chill occurred
followed by high fever, but without pelvic symptoms which
never became a factor throughout her fatal illness. General
lie intoxication, however, persisted to a high degree.
Knowing the previous history, uterine irrigation was prac-
ticed twice daily. On March 24 temperature suddenly arose
to his degrees, which was quickly reduced by cold packs and
antipyrin. Or. H. W. Byford saw the case in consultation the
follow ins; day and curetted for diagnostic purposes, with nega-
tive results. March 30 temperature reached 108.5 degrees with
delirium and typhoid state, severe arthritis of shoulder and
hip joint, followed with temperature of 103 to 104 degrees,
till fatal termination April 5, on the seventeenth day of fever
Plate I; (use V.— Gonococci from cervical discharges, ten weeks
after childbirth. Subinvolution.
and twenty-fourth day from confinement. The good health of
the patient at childbirth, the sudden onset of high fever, the
absence of bowel symptoms, exclude typhoid fever. My dis-
tinguished consultant concurred with me that gonorrheal infec-
tion was the most probable direct or indirect cause in this
most singularly virulent case.
Case 3.— Luella B., American, single, aged 18, consulted me
because she had not menstruated for several months. Under
a suspicion of pregnancy an examination was obtained, reveal-
ing a four months' pregnancy and an acute vaginitis, believed
to be gonorrheal. The case was lost sight of until summoned
to her confinement. Labor was normal in all respects. On the
fourth day there was a chill followed by high fever from an
acute metritis. This was controlled after two or three days
and patient was dismissed on the eighth day. In one week
there was a recurrence of symptoms which again responded to
treatment as before. Patient was about the house again when
she had a second recurrence, under the care of another physi-
cian, and died, as I learned, one month after childbirth.
The following three cases of puerperal sepsis are
interesting on account of microscopic verifications.
Case 4. — Ida H., four months married, was delivered at full
term by a midwife. On the fifth day after the confinement I
found her with a temperature of 105 degrees and an acute
arthritis of hip joints with immobility of lower extremities.
The child was suffering from acute ophthalmia. The pus,
from which a slide was prepared, showed the gonoccocus in
abundance. The father acknowledged having had gonorrhea
a few months before marriage. Mother and child made a good
though tedious recovery under appropriate treatment.
Case 5. — Mrs. Ida T., age 21; ten months married. Labor
normal. On the fifth day child developed ophthalmia of
gonorrheal infection. (See plate I.) The condition was at
once explained to the father, who stated that he had an attack
of gonorrhea four months before marriage, but considered him-
self cured at the time ho wedded his wife. He remembered
having had some gleet (?) afterward. On the seventh day the
mother had a chill with fever and acute arthritis of shoulder
joint of right side. As pelvic symptoms were absent, no irriga-
tions were given. Mother and child were discharged conva-
lescent on the twelfth day. Ten weeks later the mother came
to my office suffering from sub-involution. Microscopic exam-
ination of cervical discharges showed gonococci. (See plate II.)
Case yielded promptly to treatment.
Case 6'. — Mrs. Amelia S., age 26, primipara, was well
advanced in second stage of labor when seen for the first time.
Labor terminated without incident. Child developed gonor-
rheal ophthalmia on the fifth day. (See plate III.) On the
tenth day the mother was dismissed, after a good recovery,
much to the relief of an anxious medical attendant. Two
days later an urgent call in the early hours of morning cut
short my slumber and dispelled my sense of security. Patient
had a violent chill in the night, followed by high fever, with
acute metritis and pelvic pain reflected to the diaphragm, caus-
ing dyspnea and a sense of suffocation. Before making intra-
uterine irrigation a slide from the cervical discharge was
obtained and the inevitable coccus came to light. (See plate
Plate 3; Case VI. — Gonorrheal ophthalmia in babe five days old.
IV.) The husband being an actor an investigation behind the
scenes was undertaken, disclosing a history of infection a few
weeks before the confinement of his wife, whom he unfortu-
nately infected also before he was aware of his own condition.
This complication was almost a fatal experience, but finally
yielded and the mother was again convalescent in one month.
The ophthalmia in the child was also quite obstinate for some
time, though daily applications of silver solution, grains xxx to
the ounce, was faithfully and thoroughly applied with brush to
the whole conjunctival sack.
This list of well determined gonorrheal sepsis in
childbed could be extended, but enough has been
detailed to serve our purpose.
To summarize: All the above cases were primiparse
much above the average in physique and general good
health. Their delivery was without complication or
instrumental interference. All necessary examina-
tions or manipulations were guarded against sepsis.
In no case was there more than the usual slight lacer-
ation. In all, the presence .of gonorrhea is closely
proven except in case 1, where the tubal abscess is
believed to have been the result of a gonorrheal infec-
tion previous to conception. Three of the cases
developed rheumatoid arthritis during the pyrexia.
This is a well known complication due to systemic
infections of the gonorrheal germs or their ptomains.
238
GONORRHEA IN THE PUERPERIUM.
[August 1,
No doubt exists in my mind from the evidence in the
cases above enumerated and others which I could add
to the number, that the microscope and other means
of investigation as to the gonorrheal infection would
clear up the etiology of many septic complications
and fatalities in childbed. These unnecessary woes
too frequently attendant on motherhood, and the sad
lessons taught on the tables of our gynecologists, take
away the bliss of. ignorance from our profession and
add to our knowledge the responsibility and impera-
tive duty of vigilant measures for prophylaxis. Every
case of gonorrhea in the male should be treated as a
matter of serious import, for even though it may
seem trivial to him, it may blight the lives of those
to whom he may and probably will transmit the dis-
ease. Who of us having daughters do not look with
apprehension as to their future health and safety in the
relation of wives and mothers? If "whatsoever a man
soweth, that shall he also reap," were harvested by
himself only, the baneful results were evil enough,
but when he sows pathogenic seed to germinate in
the organisms of innocent, unsuspecting, unprotected
mothers and babes the calamity is ten fold, for the
perils of death, of invalidism, of sightless eyes, are
Plate 4; Case VI. — Gouococci fiom cervical secretions, twelve days
after confinement. Acute metritis and pelvic cellulitis.
far beyond the dangers he willingly hazards to gratify
his sinful lusts.
To what extent these things prevail can not be fully
known, but every physician who is not stupidly ignor-
ant or wilfully blind to the fact, knows that they are
of very frequent occurrence. When we consider that
the majority of males (Ricord estimates 80 per cent,
for France; Noeggerath believed the same ratio held
good for New York City) have been affected at some
period of life with a gonorrheal experience more or
less persistent, how can it be otherwise, under the
present sociologic conditions, that a large number of
prospective mothers in or out of wedlock, innocent
victims or particeps criminis, become the unfortunate
hostesses of pathogenic germs that place them in
dire perils at childbirth, perils which are all the more
deplorable because unnecessary and preventable.
Noeggerath believed that "90 per cent, of males
affected with gonorrhea remain uncured, and of every
hundred women who had married men formerly
affected by gonorrhea hardly ten remain well." These
may seem like extreme views, but even liberally dis-
counted the figures would still show a lamentable
state of affairs.
:
Prince reported that 60 per cent, of the blind in the
asylum in Jacksonville, 111., were the victims of oph-
thalmia neonatorum.
Noeggerath gave us the warning that gonorrhea
was the most fruitful cause of woman's pelvic woes
long before Neisser discovered the specific diplococcus,
so beautifully demonstrated in the photo-micrographs
exhibited with this paper.
Man is so constituted as to remain indifferent to
many evils by reason of their frequent and long-
accustomed occurrence. He is also averse to any
measures that curtail the indulgence of his animal
instincts, , regardless of consequences to others, but
the day will come in that higher evolution of prevent-
ive medicine when an enlightened public will demand
protection by quarantine, by restrictive legislation
and by penal enactments against individuals infected
with this loathsome and dangerous disease.
It will be a righteous advance when the State shall
afford some protection to the innocent by placing
legal barriers to the marriage of all individuals who,
by competent medical inspection, can not present cer-
tificates of freedom from all contagious and hereditary
diseases. Nor should the line be drawn on the male
sex only. The advanced medical woman could con-
fer no greater boon upon her sex and humanity than
the accomplishment of reforms along these lines.
2036 Indiana Avenue.
DISCUSSION ON PAPERS OF DBS. MONTGOMERY, KIME AND BURR.
Dr. E. E. Montgomery, Philadelphia — In regard to the
treatment suggested by Dr. Kime, I must agree with him as
to the inadvisability of using the curette in cases of puerperal
sepsis. I do not believe it has any special advantage, because
the streptococci are buried in the tissues to such a degree that
they are not removed by an instrument, and an increased irri-
tation is produced by the curette which furnishes a more fav-
orable soil for the development of the trouble. I believe that
the future treatment of puerperal diseases will be in the use
of serumtherapy. It is believed that an individual can be
rendered immune to further ravages of germ products, and
that the first thing to be done in the treatment of such cases,
after a diagnosis of sepsis or sapremia has been made, should
be the administration of antitoxin in such doses as will render
the patient immune to further ravages. The local manifes-
tations should be treated without fear of further development.
Dr. Randell, Baltimore — I had quite an extensive expe-
rience in the management of severe cases of puerperal sepsis.
A large number occur in the practice of every general practi-
tioner that are simply mild infections due to putrefactive or-
ganisms ; a number of cases occurring after abortion are of
this variety, and the only thing necessary is to thoroughly
clean out the uterus, making some antiseptic application to
the endometrium. Under the various methods that are used
the cases recover after one local treatment. But we have a
large number of cases in which there is either a mixed infec-
tion or in which the streptococcus plays usually a very im-
portant part in the uterus of women after confinement, and
these cases have to be attacked most energetically or they will
die. If any practitioner will keep actively at work in treating
them, he will cure a large proportion. A great many cases of
puerperal sepsis which have come under my observation and
care have been severe ones. My treatment has been similar to
that which has been advanced in the paper, with some slight
modifications. Some of these patients can be saved by washing
out the uterus with an antiseptic solution every six hours, if
the infection has not advanced too far. In some of the cases
you may have a superficial gangrene at the placental site, due
to streptococcus infection, and you should use the curette in
1896. ]
UTERINE FIBRO-.MYOMATOUS GROWTHS.
239
order to remove the gangrenous material, then apply inside the
uterus a 15 per cent solution of carbolic acid and 10 per cent
of iodin.
Dk. Joseph Eastman, Indianapolis — I believe that many
cases of puerperal infection are largely due to the filthy
poisonous syringes that are used by midwives. I recall an
instance where I jokingly asked if they had a good syringe
that I could use. Ves, was the reply. It was one that had
been used by the neighbors for three or four years. Taking
syringes and dipping them in bichlorid of mercury solutions is
. The nozzles of such syringes should be sterilized by boil-
; before they are used. But far better than that is the idea to
i the patient sufficiently in bed to empty the uterus by vital
lone. Drainage by packing with gauze and curetting are carried
> extremes. Savage, in his work on the "Anatomy of the Female
Pelvic Organs," long ago taught an important physiologic
principle. It is this : If there is a foreign substance in the
cavity of the uterus, the cervix contracts tightly to hold it in.
If there is a foreign body in the cervix, the fundus forcibly
contracts to expel it. With the fundus continually contracting,
the hyperplastic tissue is reduced and the absorption of septic
material is interfered with.
I protest against scraping the cavity of the uterus with a
sharp curette. I would not think of using anything sharper
than a dull wire curette in the puerperal uterus.
The gentleman who read the last paper made an important
point ; one we can not mention without some feeling of concern.
It almost makes one shudder to think of the number of young
men who are not permanently cured of gonorrhea. There may
be a granular patch in the urethra, or a stricture above it, and
the poison is conveyed to the virgin wife after marriage.
Dr. J. T. Priestlev, Iowa — I desire to say a few words from
le standpoint of a general practitioner. I practiced the
obstetric art before the introduction of the antiseptic practice
midwifery, and I have practiced it since with very much
better results than before. 1 thank Dr. Montgomery for the
stion of serum therapy. I think it a good one, and if
carried out will be of benefit in many cases.
I prepare myself for attendance upon an obstetric case the
same as I do for an abdominal operation. I think the same
cleanliness of hands and other things brought into contact
with the patient should be carried out. I do not use any
intrauterine antepartum douche. I insist that when the
douche is given the point of the nozzle of the syringe should
be boiled. I do not hesitate to go from a case of scarlet fever
or any contagious case, and attend a case of midwifery, if I
have time to prepare myself.
My practice covers a territory in which women are largely
attended by midwives during confinement, and I see many
cases in which there is elevation of temperature after delivery.
I do not wait to find out whether it is sapremia or septic infec-
tion, but take a Munde curette, which is very large, almost
the size of the curve of my finger, and use it to curette the
uterine cavity. It has no sharp cutting edge, and with it the
uterus can be easily scraped. At the same time I flush it with
sterilized hot water. I formerly put 'm guaze packing. I did
not realize at first that there was a difference between tam-
poning and draining by the use of gauze. Where tampons are
used we simply do much harm. If a piece of wicking is used
we can establish drainage and do good, in many of my cases I
drain with ordinary iodoform wicking, after cleansing the
uterine cavity with a dull curette. I think I have benefited
a great many of my patients by this procedure.
Dr. Henry P. Newman, Chicago — In regard to the uterus
in the puerperal condition it is usually large and flabby and
will fall with the turning of the patient to either side, or if the
patient is lying on the back it is very apt to be more or less
retroverted. Here is where I object to the use of the tube,
excellent as it is alone, it does not drain. In other words, you
do not drain with a tube up-hill. If you supplement your
drainage with iodoform wicking, you will find that it is
more efficient and you will accomplish much more than by
means of a tube. It is my practice to use wicking rather
firmly in the upper part of the uterus. I do this not for drain-
age alone, but to stimulate uterine contractions in the lower
half as it approaches the internal os. It is placed simply for
drainage and not for the purpose of a tampon in any sense. It
is applied loosely and a single strand projects from the surface.
Under these circumstances drainage is efficient either with or
without the rubber tube.
With reference to the use of the curette I am not partial to
a sharp one, although a dull one or the finger may be used to
remove debris in puerperal cases. However, in a patient after
abortion I resort to curettage and use it in conjunction with
mopping out the uterus the same as in a non-puerperal uterus,
and 1 rely more upon swabbing than irrigation. If the micro-
organisms are beyond the reach of the curette, they are
assuredly beyond the reach of the ordinary antiseptic wash.
But with stronger solutions than those mentioned, namely,
phenol or iodized phenol, which is practically 50 per cent,
each of iodin and carbolic acid, I swab out the entire uterine
cavity, and follow this with washing by sterilized water.
These cases are not disturbed if the temperature does not rise,
or symptoms of a grave order do not again manifest themselves.
Irrigation, if it is done at all, I believe, is necessary in gonor-
rheal infection.
Dr. R. R. Kime, Atlanta — I would call attention to and
emphasize the fact that drainage can not in all cases be
attained by gauze, and in some instances it is necessary that
the gauze be supplemented with a drainage tube. If you have
a large flabby, retroverted uterus, you may introduce a strip
of gauze and you will not drain the hemorrhage. If you put
in a strip of gauze by the side of the tube, you may carry off
the liquid and solid materials. We should remove the septic
condition.
Dr. A. H. Burr, Chicago— The object of my paper was to
call attention to a matter which seems to have been neglected,
and which is an important factor in puerperal complications.
Perhaps all of the infection that occurs to innocent women is
the result of ignorance on the part of the husband, or he who
later becomes the husband. There are thousands of young
men who never would become the subjects of gonorrheal infec-
tion if they were properly enlightened, and if perhance they
contracted this disease, certainly would not infect the inno-
cent. I do not think it right that we should dismiss this sub-
ject in a trivial manner, by any means. I do not suppose we
can wipe out this matter of gonorrheal infection by legislation
any more than we can wipe out original sin by legislative
enactment. But we can educate the young men as to the
dangers of gonorrheal infection. I believe I am within bounds
when I make the assertion, that if it were not for gonorrhea
and its sequelae, the gynecologists would lose half their
patronage.
DEGENERATIVE CHANGES THAT OCCUR
IN UTERINE FIBRO-MYOMATOUS
GROWTHS.
Read in the Section on Obstetrics and Diseases of Women, at the
Forty-seventh Annual Meeting of the American Medical
Association held at Atlanta, Ga„ May 5-8, 18%.
BY AUGUSTUS P. CLARKE, A.M., M.D.
CAMBRIDGE, MASS.
The presence of uterine fibroid growths has for the
past few years given rise to much discussion among
gynecologists; the consideration of the surgical treat-
ment they have demanded has received much atten-
tion, and measures of procedure, in some instances
apparently opposite, have sometimes been adopted.
240
UTERINE FIBRO-MYOMATOUS GROWTHS.
[August 1,
The success attending the removal of fibroid growths
either by partial or total hysterectomy has brought
the subject of such neoplasms more prominently
before the profession and has stimulated to such an
extent inquiry into the necessity of adopting the more
radical, surgical expedients that only the most careful
clinical experience and pathologic investigation will
be found capable of furnishing the data for determin-
ing the proper solution of the question.
It was formerly believed that when a fibro-myoma-
tous growth underwent a retrograde process from
electrolysis, or from other measures of treatment, or
from spontaneous action, the conditions thus induced
were always favorable; later experiences have shown
the fallacy of such inferences, for certain pediculated
subserous fibroids in taking on such phases become
harder and mere unyielding from the presence of the
excess of the fibrous over the muscular element and
from the consequent calcareous deposits occurring in
the interstices. The pressure of such a mass on one
or both ureters may cause contracting kidney and lead
to a fatal result. Such growths, when not entirely
pediculated or wholly subserous, may cause partial
occlusion of the ureters, that may result in renal com-
plication. Cases with the history of such sequela?
have occurred in my own practice; notes of autopsies
made in my earlier practice clearly show that meas-
ures of relief could have been effected by merely
resorting to abdominal incision and ligation of the
pedicle or enucleation of a partially subserous mass.
The single as well as the multiple interstitial variety
of fibroid growths may, besides giving rise to exhaust-
ing hemorrhage, be productive of baneful results of
pressure upon important vessels and structures. Sup-
puration is another sequel that may appear; contrac-
tion and the consequent cutting off of the arterial sup-
ply may lead to suppurative changes and liquefaction
of the mass, as occurred in a case in which I resorted to
total hysterectomy for relief. The patient had for a long
time suffered from repeated chills, febrile reaction,
sweating and other constitutional symptoms as the
result of the morbid changes that had gradually taken
place in the growth.
In another case the patient, a married woman aged
47 years, had suffered for a considerable period. At
the time I was called, the constitutional symptoms
were unusually marked; the fibro-myomata were
interstitial and had evidently undergone such serious
alteration as to preclude the possibility of adopting
operative measures for relief. A resort to surgical
procedure for the removal of the growth in an earlier
stage would undoubtedly have been attended with
success.
In another case there was a history of gradual
development of the growth which had been produc-
tive of uterine hemorrhage. The growth proved to be
a large submucous fibroid in a state of advanced gan-
grene and had given rise to a marked septicemic con-
dition of the organism. After some difficulty I suc-
ceeded in effecting the removal of the sloughing mass
and in overcoming the constitutional disturbances
that had supervened. These cases differ materially
from those of the submucous variety, in which a mere
dilatation of the lower segment of the uterus may be
effected and in which the removal of the growth by
morcellation with the curette and scissors suffices for
a cure.
Fibroids, though liable to increase from excitation
of the menstrual periods and during pregnancy, espe-
cially those of the submucous variety and those akin
to the myxomatous class, may, nevertheless, undergo
marked diminution after parturition, and may appar-
ently disappear, from contraction of the uterine tissue
during its normal involution stages. I doubt, how-
ever, whether such growths when once firmly estab-
lished in the uterine tissue ever wholly disappear,
unless their extrusion takes place through the medium
of the various channels by hyper- physiologic constric-
tion set up in the muscular element enclosing the
neoplasm; they may for indefinite periods remain
unaffected, but they are liable to become the foci of
malignant or semi-malignant degeneration. Clinical
observation and suspicions aroused from circumstan-
tial evidences that fibroids may assume after the lapse
of time a malignant degenerative change, have opened
new fields for investigation. The teachings of the
older pathologists were for the most part to the effect
that fibroids were benign growths.
The advance made in pelvic and abdominal surgery
have led to most careful scrutiny of the pathologic
and histologic elements presented by the various
stages of these growths; they have strengthened the
view that had for some time been entertained that
these neoplasms are subject to malignant change.
The results obtained in the majority of instances can
not be satisfactorily explained by regarding such
growths as being benign in character but having
nevertheless their development complicated more or
less with that of malignant formations. The record
of cases coming in my own practice shows unmistak-
ably that the malignant degenerative changes to which
these growths are prone are not of rare occurrence.
The history of uterine morbid processes is often help-
ful in reaching just conclusions respecting the genesis
of the disease. The favorite haunt of uterine cancer
is in the cervix uteri; it often shows its development
in the fissures of the lacerated portion. This may
occur trom long continued and repeated irritation to
which the parts have been exposed. From this center
the morbid process may radiate and extend to the
upper segments of that organ. The characteristic
symptoms of the disease with the cachexia of malig-
nant invasion are early accompaniments. In malig-
nant degeneration of fibro-myomata the morbid pro-
cesses leading to the development present other
aspects. The early appearances of fibroids may not
be attended with any definite constitutional peculiar-
ities. There will be no facies of a distinctive type;
except for the results that may be attendant on metror-
rhagia or menorrhagia, the occurrence of the irregular
outline of the growth and the consequent pressure or
other annoyances experienced the patient may have
the appearance of being in almost perfect health. In
the unmarried or in those who have not suffered from
cervical laceration the lower section of the uterus may
be entirely free from the morbid invasion. The same
freedom in this part of the uterus may continue after
a uterine fibroid has assumed malignant phases until
the development has extended downward. Martin of
Berlin has reported cases of uterine fibroids that had
undergone cancerous as well as sarcomatous degener-
ation. Boetticher reported cases of this character as
early as 1884 and Schroeder also collected cases which
have been reported. In some instances there had
been a proliferation of the adenomatous mucosa to
the deeper parts of the growth which gave rise to
adenoid cancerous change. Emmet, prior to the dates
above mentioned, reported instances under observa-
1896. 1
UTERINE FIBRO-MYOMATOUS GROWTHS.
241
Won in which the tissue of a single fibroid wholly
underwent the metamorphosis into sarcoma. He
mentions also oases in which cancerous development
had taken place; he refers to Klebs, who had made
mention of fibro-myomata of the uterus, in which
the myxomatous and sarcomatous development had
occurred. Klebs, according to Emmet, had held to the
view that genuine cancer can only "proceed out of
fibromyomata in those cases in which the formation
of the tumor extends to the surface of the mucous
membrane." Emmet refers to the possibility of an
aneurysmal development upon a uterine fibroid by the
dilatation of some of the principal vessels. Some two
years since there came into my own practice the case
of a woman in whom a sarcomatous growth, as a sec-
ondary development, had occurred in the omentum.
At times I could make out marked pulsations and a
purring thrill; an abdominal section made a little
later did not, however, reveal an aneurysmal sac. The
conclusion reached was that the pulsation must have
been imparted by the deeper vessels.
Fatty degeneration is another change which fibroids
may undergo. This alteration may occur under the
influences of pregnancy, which may take place, not-
withstanding the existence of a large myomatous
growth. A seemingly practical disappearance of the
growth may partly result while the patient is in the
pregnant state; in such an event the alteration may
be hastened along with the occurrence of the involu-
tion of the adventitious uterine tissue. Such trans-
formation is more likely to take place in cases in
which the growths have been of myomatous forma-
tion. In my own practice I have met with a few such
eases. I have always entertained, however, the con-
viction that they were remnants of the retrograded
neoplasms which might become the source of further
morbid change. In some cases the liquefied contents
of the growth may be absorbed while the more solid
constituents may remain and become walled off by
the development of indurated tissue.
In other cases in which the growth continues, there
will be beside myomatous tissue much fibrous ele-
ment: the fluid portion may in part be absorbed leav-
ing cavities of varying size within the growth.
Neoplasms in this condition, though often termed
fibro-cystic. do not belong to the classification of
cystic developments since the cavities thus formed are
destitute of a lining of epithelium.
Another form which has a practical significance to
the abdominal surgeon is that resulting from the
occurrence of enormously enlarged vessels or capil-
laries; these vascular elements may develop at the
expense of the connective and muscular tissues of the
tumor. The occurrence of these teleangiectatic myo-
mata may be a fruitful source of hemorrhage and thus
threaten or destroy the life of the patient. Early
surgical interference offers the best opportunities for
relief. The growth with excessive development of
lymphatic vessels and dilated lymph spaces, termed
myoma lymphangiectodes, is not, so far as I am aware,
of common occurrence. The extensive edema accom-
panying such cases necessitates at times prompt sur-
gical treatment.
Inflammation in the tissue of a fibroid may extend
to the arterial coats (producing arteritis) and lead to
the obliteration of the lumen of those vessels (endarte-
ritis obliterans) and consequent deprivation of nutri-
tion of the growths; this may cause them to slough
and to become gangrenous. Sloughing or gangrene
may occur in large interstitial fibroids by their being
subject either spontaneously or otherwise to excessive
intra parietal contraction. Rupture of its connection
by the direct expulsion of the mass may lead to the
same condition. Colloid degeneration may take place
in the deeper portion and may give rise to conditions
similar to those in which the tumor becomes liquefied.
Sudden hemorrhage, or an apoplexy (as the rapid
extravasation of the sanguineous fluid is sometimes
termed) may produce cavernous spaces that become
occupied by coagula or serum ; this sometimes leads
to a disorganized condition. The contents may in
part be absorbed; the residue remains quiescent for
an indefinite period or becomes the focus of suppura-
tion or of other advanced secondary changes. The
amount of blood with which fibromyomata are sup-
plied varies to a considerable extent. In most tumors
of this character the vascular element is not plentiful,
The capillaries in some of the forms are prominent
while in others special artificial injections that are
made show that but few vessels permeate the mass.
The irritation and hyperemia with which the adjacent
mucosa may be subjected are undoubtedly the cause
of the hemorrhagic tendency; this condition may
induce ulceration and sloughing. When fibroids are
present in cases of pregnancy they may offer an im-
pediment to the normal development of the uterine
tissue and so lead to profuse hemorrhage and abor-
tion. Beside the occurrence of the degenerative
changes as above mentioned there have occurred the
formation of melanotic deposits that have shown a
close relation with the development of malignant
disease.
Calcification of fibromyomatous growths as already
stated is an occasional sequel; so also is the produc-
tion of tissue resembling cartilage, which as a sec-
ondary result has occurred in the mass. One of the
most frequent transformations, which without doubt
fibromyomata may undergo, is their contraction and
atrophy after the cessation of their normal develop-
ment. Myxomatous changes and submucous altera-
tion tend to the destruction of the growths. The inter-
parietal contractions to which they are subject serve
to hasten the production of polypi and the commence-
ment of extrusion from their normal sites. All these
several kinds of secondary transformations occurring
in fibromyomata are productive of further expulsive
processes that often require only timely surgical inter-
ference as measures supplementary to the effecting of
their complete removal.
DISCUSSION.
Dr. W. G. Macdonald, Albany — The most important point
connected with this paper is in relation to the matter of devel-
opment of malignancy as associated with tumors of the uterus,
ordinarily said to be flbromatous in character, that condition
with which our literature is full, a condition developing from
the mucous membrane of the body of the uterus, a malignant
endometritis, or adenoma, which is to a certain extent confus-
ing. There is no tumor of the uterus, fibrous or fibrocystic,
which is malignant. If a tumor presents clinically all of these
conditions, macroscopically and under the microscope, which
we- ordinarily term a fibroid tumor, if after its removal there
develops from the pedicle a subsequent tumor, the tumor
was not a fibroid. It was a sarcoma. It may not have been
primarily so, but it was subsequently, or at the time of
removal. We can make this matter of malignancy always very
simple as associated with the uterus and with all other bodies
of the organism when we say that malignancy in tumors only
242
PUERPERAL ECLAMPSIA.
[August 1,
manifests itself in the two conditions of sarcoma and carcinoma.
When a fibroid tumor at the menopause is quiescent for a few
months, then within a period of three or four months shows a
disposition to increase, we may reasonably conclude that it is a
malignant tumor, and the probability is that there is grafted
upon it an irritation in the uterus, a condition of sarcoma.
These tumors, under the peculiar malignancy which occurs,
take upon themselves the condition of sarcoma, and in six
months they increase more than they have in sixteen years.
When you have a supposed fibroid tumor of the uterus which
has shown little growth under your observation for a period of
three or four years, and then begins to increase in size, you can
not too soon remove it. It is an important consideration in
relation to these changes that they occur in fibroid tumors.
Dr. Charles P. Noble, Philadelphia — It has been my expe-
rience to have operated on a large number of cases of fibroid
tumors, and many of the women did not know they had them
until after the menopause. They probably existed, but were
small and gave rise to no symptoms until after the menopause,
so that my own experience amply supports one point in Dr.
Clarke's paper, that fibroid tumors which have given no symp-
toms before the menopause very frequently take on rapid
growth after it, give pressure symptoms or cause hemorrhage
after the menopause.
I distinctly recall three cases of tumors which became sarco-
matous after having been operated on. Two of the patients died
from recurrence. Another case has a recurrence at this time,
so that of the three cases of sarcoma two are dead, and in the
other death will follow sooner or later. These cases at the
time of operation were designated by a pathologist as myxoma-
tous, but subsequent development showed that the tumors
were sarcomatous. The second case was one of spindle-cell
sarcoma, and in the last case the tumor was necrotic and sar-
comatous. We find carcinomatous changes after fibroids, but
I have not seen a carcinomatous change in the tumor itself. I
believe that is extremely rare. I have seen a number of cases
of carcinoma of the cervix as a complication of fibroid of the
uterus. We are all familiar with the necrotic changes in
fibroids. We have to operate on sloughing fibroids. This
change is most common in Uie submucous variety and the
sloughing is due to efforts on the part of the uterus to throw
off the tumor, so that traction takes place on the capsule and
shuts off the bloodsupply. I have operated on necrotic fibroids
that were not submucous. No doubt, this change occurs before
as well as after the menopause. We can not dwell too strongly
upon these facts in the history of fibroids, and can not con-
demn too emphatically the old teaching, that after the meno-
pause uterine fibroids will disappear.
Dr. Clarke — I do not know that there is much more for me
to say on this subject. I recognize the fact that the changes
which I have dwelt upon in my paper are the more important
parts of what I intended to bring out. I have met with cases and
followed them up for many years. Some of the cases of fibroid
tumors were treated by electricity and other methods, and it
was said that the tumors would undergo contraction and
diminish in size, but subsequently would become larger and
larger, causing death of the patient. I collected a number of
these cases in my earlier experience. I have been very much
interested in this question for years and am satisfied that
fibroid tumors do take on a malignant change, and it is not
owing to the original disease mentioned. A woman with a
cancerous uterus is not likely to survive for ten or fifteen years.
We know for the most part, that when it occurs in the uterus,
two or three years are about the limit of cancer, and that it goes
on from bad to worse, unless operation is resorted to. Sarcoma
rarely lasts for five or six years, and these cases can not be
regarded as sarcomatous or cancerous all this length of time.
When a woman, seemingly in good health and of good florid
complexion, with no cachexia, no cancerous or malignant
appearance, has a tumor which suddenly takes on malignant
changes, we can not remove it too soon if we would prolong
the patient's life.
SOME SUGGESTIONS IN THE PROPHY-
LAXIS AND MANAGEMENT OF
PUERPERAL ECLAMPSIA.
Read in the Section on Obstetrics and Diseases of Women at the Forty-
seventh Annual Meeting of the American Medical Association at
Atlanta, Ga., May 5-8, 1896.
BY H. D. THOMASON, M.D.
ALBION. MICH.
My experience in the prophylaxis, treatment and
management of puerperal eclampsia has been con-
fined in recent years entirely to private practice, yet
it has been within my province to observe a sufficient
number of cases to form some deductions and con-
clusions. However, I shall lay no actual claim to
originality in inception. My suggestions are gathered
from applications largely original with others.
The pathology and etiology of puerperal eclampsia
is still an unsettled question — theories are numerous
as well as contradictory; the text-books, and chairs
in medical schools are brimming over with them, but
nothing as yet has been positively proven, settled, or
definitely accepted by the profession as a whole. As
practitioners at the present time we necessarily
occupy the position of clinicians awaiting instruction.
Until pathologists are able to present to us true indis-
putable pathologic facts we must fall back upon our own
clinic experiences. But to properly apply and employ
even these we must have some definite ideas of our
own relative to the etiology and pathology of puer-
peral eclampsia. The probabilities are that not
every case of puerperal eclampsia is the result of the
same pathologic cause. We find ardent advocates
who maintain that nephritis and its resulting uremia,
either apparent or disguised, is alone the offending
cause, still closely agreeing with Lever, who, in 1842
supposed albuminuria to be the casus belli.
Others maintain with Lusk that albuminuria may be
a physiologic, even a diagnostic feature of pregnancy
and that puerperal eclampsia is the result of renal insuf-
ficiency and albuminuria and uremia have nothing
whatever to do with the matter. Again, others take
the position instigated by Cohen of Hamburg, that
there exists a cerebral eclampsia, organic cerebral
lesions; while opponents to this belief declare these
lesions to be the result of congestion and other
causes, and at best are but secondary. A plausible theory
has recently been advanced by Poe (Transactions
Louisville Academy of Medicine) that puerperal
eclampsia is the result of obstruction to the portal
circulation due to hepatic cirrhosis causing peptone-
mia and producing either uremia or anemia. That
there is an undue portal pressure during the period
of gestation he claims to be proven because of hemor-
rhoidal enlargments during this stage and that all cir-
cumstances that increase tension, increase liability to
eclampsia, as instanced by its frequent occurrence in
primipara, and the older the primijDara the greater
the liability. With others he also recognizes that
peripheral nerve irritation alone may be the sole
cause of convulsions. King and others advocate as
the cause of eclampsia pressure of the gravid uterus
upon the inferior vena cava, the iliac veins, and upon
the kidneys, thus producing passive congestion.
While Halbertsma in 1883 introduced a theory which
perhaps at the present time is received with as much
favor as any other, that puerperal eclampsia results
from pressure of the gravid uterus upon the ureters,
thus to a great extent occluding the caliber, seriously
interfering with their function and producing urinary
1SW.1
PUERPERAL ECLAMPSIA.
243
stasis. But to review or discuss the various theories
of the causation of puerperal eclampsia is not within
the Boope or purpose of this paper. As already inti-
mated puerperal eclampsia is not to be attributed
to one identical cause in every case, so it is
possible that each of the advanced explanations
and theories may have more or less ground for truth
when applied to certain individualized cases. For
the impose of this discussion let us broadly assume
that puerperal eclampsia arises, 1, from the retention
and absorption of toxins, no matter from what patho-
ogic Bource, but due to the pregnant state; 2, from
he result of peripheral nerve irritation; 3, from hys-
erio causes.
Unsatisfactory and uncertain as the pathology of
this affection is, by far the larger number of cases are
the result of the first cause, and to this group, princi-
pally, we will confine our attention, for to this class
prophylaxis is the more important. It should be the
rule ol practitioners to educate their clientele to the
importance of placing themselves under medical
observation in the early stages of pregnancy, for it is
the duty of the physician systematically and fre-
quently to maintain a close observance of these
patients during the period of gestation. Eclampsia
■eldom comes unheralded — the cases are indeed rare
that do not show some prodromic indications if looked
for by a careful observer. Frequent urinary analysis,
ohemic and microscopic, should be resorted to. The
presence or absence of albuminuria or casts and other
abnormal conditions should not only be determined,
but the quantitative analysis as to urea and other
urinary elements be made to establish the presence or
absence of renal insufficiency, and the daily quantity
of urinary excretion carefully observed. When we
find urinary abnormalities during the stage of gesta-
tion it is sufficient to place us on our guard, but when
this is coupled as it often is with edema, functional
cardiac disturbance, impairment in vision, headache,
or other well recognized prodromic symptoms there
can be no mistaking the probabilities and dangers,
and the advisability of prophylaxis is unquestioned.
My habit is to have these patients placed upon an
exclusive milk diet, urge them to drink large quanti-
ties of sterilized water, stimulate the excretory func-
tion of the skin by steam and hot vapor baths, and
see that the bowels are kept abnormally active; a
most successful method to accomplish the latter result
is a daily enema of a saturated sulphate of magnesia
solution. By this management, briefly outlined, I
have seen the prodromic indications greatly modified,
and in some instances entirely disappear and the
patient tided through to full term and a normal deliv-
ery. If we have reason to believe that the prodromic
condition of the patient is the result of pressure of
the gravid uterus upon the ureters, thus occluding
their caliber and producing renal stasis, upon theoret-
ical grounds it would seem that a daily catheteriza-
tion of the ureters according to the Howard Kelly
method, as practiced by him for other renal affections,
would be applicable here as a prophylactic measure.
I confess I have never yet employed this means, but
it is my purpose to do so when a suitable opportunity
presents. But when despite all ordinary prophylaxis,
the prodromic condition of the patient does not im-
prove, when we have every reason to believe that if
allowed to go to full term the patient must face the
horrors and dangers of eclampsia, then the advisa-
bility of inducing premature labor as a prophylactic
agent is to be seriously considered. Doubtless like
other members of this section it has been my lot upon
various occasions, having watched the prodromic
symptoms as the period of gestation advanced, grow
more and more apparent, to feel with misgivings that
just so soon as the pains of labor advanced, at full
term, just so sure would it be necessary to meet the
responsibilities and emergencies of eclampsia.
Though taken by surprise at the unexpected appear-
ance of convulsions when prodromic symptoms were
not expected or recognized, seldom have I been mis-
taken in my anticipations when the symptoms have
been previously present. It is in such cases as these,
when we are convinced that if allowed to go to full
term the patient will be subjected to the ordeal of
convulsions, I hold to the opinion that when we are
satisfied of the viability of the child, we are not only
justified but it is our duty to bring about premature
labor: 1, for the ground of safety and comfort
of the mother ; 2, for the welfare and safety of the
child.
A case coming under my own observation will
illustrate : Primipara, aged 26; history of fatal nephri-
tis in both father and mother ; at fifth month of preg-
nancy exhibited prodromic symptoms, which steadily
increased to full term, albuminuria, casts, scanty
urine, excessive edema, headache, weak, rapid heart,
disturbed vision. At the beginning of second stage
of labor was attacked with violent convulsions; rapid
delivery by forceps was accomplished, convulsions
continued after the delivery of a dead child, and
chloroform, chloral and veratrum viride barely saved
her life. Convalescence was slow and tedious, com-
plicated with phlegmatia dolens extending over six
months, and traces of albuminuria could be detected
for three months longer. Two years later patient
became pregnant again; the same prodromic indica-
tions of equal severity presented at the same stage as
in first pregnancy, and despite ordinary prophylaxis,
increased steadily ; patient was tided along until the
middle of the seventh month when in view of previ-
ous history induction of labor was decided upon.
This was accomplished under strict asepsis; while
under anesthesia one slight convulsion occurred at
time of dilitation of os, but patient was delivered of a
live child and recovery was uninterrupted and com-
plete.
When the viability of the child is unquestioned
and the procedure is accomplished under strict aseptic
conditions I am of the opinion that this is an impor-
tant prophylactic method too often neglected. Why
should a woman be subjected to six or eight weeks'
unnecessary sepsis, accumulation and absorption of
toxins? Is it not reasonable to infer that the safer
course is induction of labor, prevent accumulative
toxemia, and remove the exciting cause. The same
arguments can be advanced in regard to the child. It
is very well established that there is a relation exist-
ing in puerperal nephritis bearing upon the nutrition
of the fetus. While the arterioles in the maternal
kidneys are undergoing occlusion by products of dis-
ease, a similar occlusion and change is taking place in
the placental vessels, thus jeopardizing and interfer-
ing with the blood supply to the fetus. This is one
factor that accounts for infant mortality in eclampsia,
and it is a reasonable conclusion that the same tox-
emia that threatens the mother also threatens the
child. Dr. Barnes (British Med. Asso. 1888) claims
maternal albuminuria to be the cause of infra-uterine
244
PUERPERAL ECLAMPSIA.
[August 1,
•death — whatever the cause, a viable child's chances
■are better extra utero than when exposed to intra
utero toxic influence, accumulative degenerative
■changes in its source of nutrition, the jeopardy of vio-
lent maternal convulsions and delay in delivery at
full term. My experience has necessarily been lim-
ited to a few cases where this prophylactic method
has been adopted, but I have had no cause to regret
its employment, and in properly selected cases believe
it to be a valid and useful prophylactic measure. The
fact that cocain applied to the os, as treatment for
eclampsia, suggests its use as a prophylactic when
convulsions are anticipated, the rationale based upon
the fact that pressure upon and dilatation of the os
act, in at least some cases of eclampsia, as an exciting
cause. We are led to believe from clinical experience
that this is an important factor in certain cases. We
doubtless can all recall instances where we have
excited the convulsions simply by a digital examina-
tion, passing a finger through and perhaps dilating
the os. Theoretically, at least, cocain may have its
place as a prophylactic. My experience in its use
has been limited to normal labor. When in some
cases I have used it with apparent good effect just
prior to the full dilatation of the cervix to alleviate the
so-called agonizing stage of labor, I have had no rea-
son to presume that it acted as a prophylactic, as in
none of them was eclampsia anticipated. Under the
head of reflex causes for eclampsia the bladder may
play an important part. An instance is cited in the
American System of Obstetrics (Vol. II. page 79),
taken from La Motte's observations, where violent
and threateningly fatal convulsions were instantly
controlled by relieving pressure of the fetal head upon
the bladder and drawing off a large accumulation of
retained urine. An instance came under my observa-
tion, a case of placenta previa in a multipara, age 28
years; labor was terminated by podalic version and
resulted in loss of child, but the mother in fair condi-
tion, save some necessary exsanguination. Case was
left in charge of inexperienced hands. According to
reports there had been difficulty in urination follow-
ing delivery, and on the sixth day convulsions
appeared. When I saw the patient she was in deep
coma with rapid and thready pulse. The unusual
size of her abdomen attracted my attention, and urine
had been passed continuously, drop by drop. The
catheter relieved the bladder of an immense amount
of urine, but the patient was so exhausted from com-
bined influences of placenta previa, distended bladder
and convulsions she did not rally, and died in a few
hours. Whether death was due to peripheral nerve
irritation from distended bladder or uremia, was not
determined, but the case suggested to my mind a
practical prophylactic measure, to be assured in all
cases of pregnancy and during the puerperal state
that the bladder is emptied at proper intervals. So
much prophylaxis authorities and experience teach,
that eclampsia is most frequent during labor and less
frequent after, but the relation is not definitely deter-
mined for the reason that labor often comes on as a
direct result of the convulsions and many attacks that
rightfully belong to the period of gestation are
recorded as occurring during labor. The manage-
ment of puerperal eclampsia depends upon the period
in which the convulsions occur. If prior to fetal via-
bility we must remember our duty to the child as
well as to the mother, and so far as we can, in justice
to the latter, adopt expectant methods, endeavoring
by all means at our command to tide the crisis on to
months of viability, but under no circumstances must
the mother's life be jeopardized by fatal delay, or
allowing continuance of frequent convulsions. The
statistics of Lantos and Lohlein demonstrate tha
convulsions cease after the emptying of the uterus
69 to 80 per cent, of cases, and Duhrssen, the power
ful advocate for the active method of immediate deliv-
ery, establishes the fact that even the severest opera
tions, Csesarean section included, properly performed
under asepsis and complete anesthesia, does not ren-
der the prognosis less favorable. Therefore, in cases
where convulsions persist, and we are convinced that
toxemia or some condition due to pregnancy is endan-
gering maternal life, no time should be lost in empty-
ing the uterus, and the child sacrificed for the welfare
of the mother. When months of fetal viability have
been reached, at the first suggestion of eclampsia it
seems to me there should be no diversity of opinion
as to the advisability of at once securing evacuation of
the uterine cavity.
A recent contribution of Zweifel (Centralblatt fur
Gynekologie, Nos. 46-47-48, 1895) demonstrates the
superiority of this active treatment, advocated by
Duhrssen, as contrasted with the expectant method.
Of 129 cases of eclampsia treated in the Leipsig
clinic, 49 were treated by the latter (expectant)
method, with a resulting mortality of 16, or 32.6 per
cent., and 80 cases by the active method, with a mor-
tality of 12, or 15 per cent. Objections have been
urged against the active management on the grounds,
1, that even when the uterus is emptied there is no
guarantee that convulsions will cease, and 2, that
the manipulation and difficulty in securing evacuation
aggravates the condition and further endangers and
complicates the case. The fact that approximately
80 per cent, actually do cease when the uterus is
emptied is a sufficient reply to the first objection, and
the second objection is more apparent and anticipa-
tory than real. I have not as yet encountered any
serious difficulty in promptly evacuating the uterus
of its contents. I have never had to resort to even
slight incisions of the cervix; I would not hesitate to
do so if necessary. I have never failed to secure dila-
tation of the cervix by the Barnes dilator attached to
the Allen surgical pump or some of its modifications.
On several occasions, under anesthesia, full cervical
dilatation and delivery by forceps were both accom-
plished in less than an hour, when there was no evi-
dence of uterine contractions, or any sign whatever of
beginning of labor. I begin with this instrument
familiar to you all, then follow by this modification
of a Barnes dilator, and so on until in a short time the
cervix will admit the hand for version or forceps for
cephalic delivery. In primipara I found more time
consumed in delivery by the forceps than in dilating
the cervix. A case taken from my record will serve
as a type of several others. Mrs. V., aged 16, primi-
para, unusually small and girlish form, suddenly
attacked with eclampsia middle of seventh month of
pregnancy; had one convulsion after another before
seen. Catheterization of the bladder resulted in with-
drawal of scanty and high-colored urine, loaded with
albumin. No uterine contraction, and os closed.
Chloroform was administered, the surgical pump and
Barnes dilators employed; dilatation was accomplished
without incisions, the forceps applied, and within
forty minutes from beginning of operation a live
child was delivered. Coma continued several hours,
PUERPERAL ECLAMPSIA.
245
but no more convulsions; the catheter had to be
employed for several days, but patient made rapid
ami complete recovery. In antepartum convulsions,
where ohild is viable, time is precious; I no longer
waste it temporizing with venesection, veratrum
viride, pilocarpin, chloral or any other means, but
proceed with all possible haste to the evacuation of
the uterus and in a great majority of cases nature
assumes her eliminatory functions and little if any
further therapeutics are required. In those cases
when' eclampsia continues after delivery, or when the
onset is post partum, the indications for management
vary, depending upon the condition or type of the
patient. If the plethoric, with full bounding pulse,
and other symptoms, all pointing to congestion, we
have no remedy that can compare in its potency to
venesection. We have no time to wait for the action
even hypodermically of veratrum or pilocarpin, for
at this time they are but poor substitutes for venesec-
tion, though they may be utilized as adjuncts. In
this type venesection, thorough and sufficient, is the
remedy par excellence, and other eliminatory means,
such as hydragogue, catharsis, diaphoresis, etc., are not
to lie neglected. On the other hand, when the type is
anemic, pulse weak, rapid and thready, we should
hesitate to employ venesection. Here veratrum in
20 or 25 minim doses hypodermically administered is
applicable: pilocarpin, while highly recommended,
has failed to inspire the confidence we have in vera-
trum. The intravenous injection of one-half to one
mart of normal saline solution, strongly advocated by
ft. Emory Lamphear of St. Louis, has in my hands
yielded satisfactory results, though experience with
it lias been limited.
Since the advent of asepsis in obstetrics and gyne-
alogy, we are emboldened to adopt more active and
effective measures in the treatment of eclampsia than
formerly. The results have been good, and we have
grounds to hope that the march of progress in the
future will still lessen eclampsic mortality, and render
this complication less to be feared by the obstetrician.
DISCUSSION.
Dr. Augustus P. Clarke, Cambridge, Mass. — With regard
to albumin in the urine in these cases, I think it can be reason-
ably said that it is not as important a factor as some physicians
would have us believe. In some cases in which no albumin is
found the kidneys may be in a state of advanced disease. Such
a case came under my observation some time ago. The patient
had been examined for disease of the kidney. The urine was
examined by several experts and pronounced free from albumin,
and the kidneys were considered to be in good condition. In a
little while the woman died, and postmortem examination
showed advanced cystic degeneration in one kidney. The other
was healthy. The lesson this ease teaches is that we must not
rely too much upon albumin in the urine, or upon the micro-
scope, but must judge by the symptoms, and if we find edema
or symptoms pointing to kidney trouble we can infer where the
site of the difficulty lies, and if the prophylaxis is properly
carried out there will be perhaps no need of further treatment.
Dr. Joh.n M. Duff, Pittsburg— If I understand the essayist
properly, he suggests that as a prophylactic against puerperal
eclampsia, where we have the premonitory symptoms, he would
produce premature labor as soon as the child was viable. In
a very large number of cases of albuminuria during pregnancy,
and where the premonitory symptoms of eclampsia exist, the
woman goes on to term and is easily delivered without eclampsia.
Only last week I had a case of this kind. Two physicians
brought the patient to me last fall and begged me bring on
abortion. They again brought her back when she was seven
months advanced in pregnancy, and I said to them, wait until
she has a convulsion, and I will bring on labor. I attended
her last Tuesday night, and I have never had a nicer case of
labor in my life. I think it is bad teaching to have our young
men go out and practice medicine with the idea that whenever
a woman has the premonitory symptoms of puerperal eclampsia
premature labor should be produced. You will find a great
many cases in which it is not necessary. I could give quite a
number of cases illustrating and emphasizing this point.
Dr. J. W. Bovee, Washington, D.C. — There are a great
many cases of puerperal eclampsia in which there is never
found a trace of albuminuria, while there are others in which
traces of albumin are found in the urine, but the albumin does
not come from the kidneys. It is true there are a great many
cases in which the albumin comes from the kidneys. If we find
traces of albumin in the urine we should beat least suspicious ;
if we find renal casts we should be still more suspicious, but
we should not be very much alarmed until we find a diminution
of the solids in the urine. If you have a small amount of
urine, or a normal amount in twenty-four hours, with a dimin-
ished amount of solids, and this will be indicated approximately
first by the specific gravity then we have reason for alarm.
Methods should be put in vogue for an increase of excretions.
The method of giving sterilized water and milk is very good,
hydragogue cathartics are used for this purpose with hot baths,
and anything which will produce an increased exudation of
solids by compensation, because we may not get the kidneys to
do their full duty. I would say in cases where Bright's disease
exists before pregnancy and it becomes worse during labor we
will have edema of different parts, probably, and some effects,
such as headache, retained solid matter, urea and urates and
others, then the idea of bringing on labor is more important in
that class of cases. During pregnancy, while the patient is
doing fairly well we should not bring on premature labor until
puerperal convulsions have appeared ; and even in these cases
by using the hot pack, jaborandi and bleeding, with transfusion
of normal salt solution at the same time, coupled with hot
baths and hydragogue cathartics, we can stop the puerperal
convulsions and the case will often go on to the full term of
delivery. This is practiced in the hospital with which I am
connected very successfully and we do not think of bringing
on labor unless the convulsions are severe.
Dr. J. R. Rathmeix, Chattanooga— To take such a broad
position as to bring on labor in all of these cases is not, in my
opinion sound teaching. In many of them there is a chance of
saving the fetus and the mother. Apropos of this discussion
I recall a case which came under my care wherein it was not
necessary to bring on premature labor. I believe we would be
justified in dealing with these cases in the manner that has
been outlined if pregnancy is near its close. It is comparatively
safe to interfere within two weeks of the time of full term, but
if it is longer than that, five weeks, as it was in this case, it
seemed in the judgment of the consultants wise to let the
patient alone when she was under the influence of the remedies
that have been mentioned and was free from convulsions within
twenty-four hours, during which time she had five, and in four
weeks from that time she gave birth to a living healthy child
under the most favorable circumstances.
Dr.W. G. Bog art, Chattanooga— I want to protest against the
idea of producing abortion or premature labor in all of the cases
where convulsions present themselves. Just before I left home
I saw a case in consultation. The lady had been suffering for
some weeks. On examining the urine I found it heavily loaded
with albumin. I expected convulsions in this case. The patient,
was then within a week of her confinement. She had a very-
difficult confinement. When she gave birth to her first child,,
she passed through two and a half or three hours of hard labor-
without any convulsions. The second child was a shoulder-
246
FIBROID TUMORS OF THE UTERUS.
[August 1,
and hand presentation and became impacted. The patient was
in labor from 8 to 11 p.m., and finally the labor was so difficult
that we had to deliver the child. She passed through labor
without a single convulsion or even a symptom of one. I left
the patient in a rather critical condition three or four days
after confinement. I present the case simply to show that the
urine was heavily loaded with albumin and yet no convulsions
occurred. This case is not the only one that I recall.
Dr. Fish, Milwaukee, said it was his custom, as soon as his
services were engaged, to make an examination of the urine of
the pregnant woman in order to determine the presence or
absence of albumin. Cases were cited to show that the pres-
ence of albumin was not always a safe criterion alone for bring-
ing on premature labor. In the treatment he never uses pilo-
carpi, as recommended, for the reason that it is liable to
produce edema of the lungs, and on this account he considers
it a dangerous remedy. In one case of puerperal eclampsia,
the woman had a pulse of 140, but under the continued use of
veratrum viride and morphia it dropped to 70. He believes
that if the pulse is reduced to that point and kept there con-
vulsions will not return.
Dr. Gillespie, Tennessee — I use a little chloroform until I
get the woman well under the influence of veratrum. I have
used Norwood's tincture, commencing with 15 minims hypo-
dermatically, which is repeated in three to five minim doses,
and sometimes it requires four or six doses, but very often the
second dose is sufficient to stop the convulsions. After the
patient is under the influence of the veratrum I stop the
administration of chloroform.
As to prophylaxis, I think most cases can be prevented by
keeping the bowels well open, attending to the diet, prescrib-
ing the proper amount of exercise, and giving the patient
something to act on the kidneys. If there is one remedy that
I use more than any other it is the hyposulphite of soda in
dram doses every three or four hours until it acts on the bowels.
When it does not act freely I give a dose of salts. It not only
acts on the bowels, but kidneys, and prevents auto-intoxication.
Dr. B. M. Hypes, St. Louis, Mo. — In my opinion, the
weak point of our practice as general physicians is that we are
constantly allowing our patients to go into the hands of sur-
geons and consultants by not properly caring for them during
pregnancy, and I hope that all physicians will take their
patients in their own hands the moment they are pregnant,
watch them, and not permit a month or even two weeks to go
by, after they are six months advanced in pregnancy, without
making a thorough examination of the urine in order to ascer-
tain whether the kidneys are acting normally or not. The
urine of the pregnant woman should be frequently examined
and the quantity passed in twenty-four hours measured. The
solid constituents of the urine should be measured also, in
order to determine whether the urates are properly eliminated,
and when you use proper remedies and apply them in time you
prevent puerperal eclampsia.
Physicians do not always make a proper distinction between
the character of different forms of puerperal eclampsia. We
have hystero-puerperal eclampsia, and epileptiform eclampsia.
Furthermore, we have eclampsia during pregnancy from cere-
bral disease, but it is my belief that 99 cases out of 100 of
eclampsia during pregnancy and the puerperal state arise from
insufficient action of the kidneys in eliminating the poisons or
the toxins in the blood of pregnant women. The different
kinds of convulsions must be separated in order to be properly
treated. No one would think of giving veratrum viride in a
case of hysterical convulsion ; neither would the author of the
paper attempt tb induce premature labor without properly sep-
arating and classifying his cases. Much will depend upon the
severity of the symptoms or convulsions. Premature labor is
produced with the idea of saving the mother first, or both the
mother and child if possible.
Dr. Thomason — I desire to thank the members for the free
discussion of my paper. I think I have been partially misun-
derstood. I do not wish the members of the Section to enter-
tain the idea for a moment that because albuminuria is pres-
ent in the case of a pregnant woman it is a sufficient cause for
the induction of premature labor. I do not regard albumin :
a pathognomonic symptom of approaching eclampsia. But we
all feel safer if the urine does not show albumin in these case
Its presence is suspicious. I should want other evidence thar
the presence of albumin in order to bring on premature labor.
In the paper I have presented to you I have merely given my
own experience, and I must say that I have better results if I
bring on premature labor, particularly when the prodromic
indications are sufficiently severe to warrant it.
FIBROID TUMORS OF THE UTERUS, WHEN
AND HOW TO OPERATE.
Read in the Section on Obstetrics and Diseases of Women at the Forty-
seventh Annual Meeting of the American Medical Association,
at Atlanta, (ia., May 5-8, 18%.
BY ALBERT H. TUTTLE, M.D., S.B.
CAMBRIDGE, MASS.
It is but a short time ago an opinion was more or
less universally maintained that fibroid tumors of the
uterus were benign growths. The fact that hysterec-
tomy had such a high mortality at that period made
the "cure worse than the disease," and probably did
much to place these tumors in this relatively false
position.
With improvements in technique and correspond-
ingly excellent results in the removal of the uterus, it
is no longer necessary or wise to wait until life is in
immediate danger before recourse to the radical treat-
ment of fibroids by surgical measures, but before the
health of the patient is reduced by hemorrhage,
inflammation, chronic suppuration and pain, to a deli-
cate condition, and the dangers of the operation are
further increased, as well as the difficulties by the
complications of inflammation — pus and adhesions —
to say nothing of the degenerative changes, the
increase in the size of the tumor, and the effects of
pressure on the ureters, there must be a time when
certain indications exist for the truly conservative
removal of these growths.
That this period for active surgical interference
varies greatly in the opinion of various operators from
the radical view of Jacobs, who considers that the
presence of a fibroid tumor is itself sufficient reason
for the removal of the uterus, to the conservative
extremes of the electro- therapeutists, needs only to be
mentioned, and it is this fact that has prompted me
to express the conclusions derived from my personal
experience in the treatment of these growths.
Small sub-serous tumors, when they give rise to
pain and tenderness, interfere with motion and loco-
motion, produce reflex and nervous disturbances, or
directly by pressure make more or less troublesome
the functions of menstruation, defecation and mictur-
ition, should be removed. They are best extracted
through the abdominal route, by enucleation. The
peritoneal flaps are sewed together with fine animal
sutures and the uterus dropped into place.
Whenever an interstitial fibroid has reached any
considerable development, or a number of small ones
have increased the size of the uterus above that of the
fist, the uterus and fibroids should be removed en
masse, to prevent changes which sooner or later will
surely result from the constant pressure exerted upon
L896
CONSTIPATION.
247
the uterus. Bner's supra-vaginal amputation of the
uterus in the simplest operation.
Whenever the fibroid condition is complicated by
inflammatory changes, either in the growth itself, the
pelvic cellular tissue, uterus, tubes or ovaries, a total
extirpation should be performed. I know of no bet-
ter met hod for the complete removal of the uterus
than the vagino-abdominal method, which I have
devised and already described. Unless the symptoms
are urgent 1 would recommend a long period of rest
ami local treatment as a preliminary to surgical treat-
ment (six weeks to two months), as by this means
much of the infiltration and subsequent danger of
auto- in feet ion will be avoided.
Whenever the common complications of a fibroid
tumor, pain, hemorrhage and serous discharges are
anoontrolable, the uterus should be removed. Unless
there are extra-uterine complications, Baer's supra-
vaginal amputation should be preferred.
When a fibroid uterus is complicated with preg-
nancy, and one or more nodules rapidly increase in
size, early interference is demanded. Often the
fibroids can be removed without disturbing the con-
tents of the uterus; but an early removal may necessi-
tate killing of the fetus, in which case operators will
become divided in their course of procedure; some, to
give the mother the best chance for life, will remove
uterus and fibroids early, or the contents of the uterus,
others will wait until near term and do a Caesarean
or Porro's operation, while a few will do nothing until
labor sets in, when they will attempt to raise the
tumor out of the pelvis so as to admit the passage of
the child. Each case demands special consideration;
a multi-nodular fibroid uterus is less likely to be dis-
abled to the extent of complete incapacity for per-
forming the function of expulsion of a fetus, and at
most make the condition of delivery simply one of
inertia uteri; a single fibroid is apt to increase to
dimensions sufficiently great for the mechanical
obstruction of delivery, and at term will nearly always
be found in the pelvis or the lower segment of the
uterus, a point it has reached from the force of grav-
ity, no matter where the place of origin.
One or more growths of hen's egg size may not
seriously interfere with full term delivery, but a
growth of this dimension in the early months of preg-
nancy is more than likely to attain dangerous propor-
tions before the time has arrived for the natural
expulsion of the child. If the growths alone are
removed a subsequent ventral hernia will usually
more or less rapidly follow the final delivery at the
site of the abdominal incision, and must be considered
among the indications for the removal of the fetus.
The danger of sepsis from auto-infection is increased
in the abortion of a fibroid uterus.
When a fibroid uterus is complicated with preg-
nancy, the problem to be solved is not one of comfort
or health, but the serious condition of life or death,
therefore surgical interference should not take place
until a study of the condition of the patient and the
relations of the tumor and uterus show clearly to the
operator that there are greater chances of life with
operation than without.
When failure in health occurs in a woman having
a fibroid uterus, and no cause for the same can be
found, unless it be the condition of the uterus, for
which the tonic and medicinal methods of treatment
are unsuccessful, hysterectomy, a supra-vaginal ampu-
tation, should be performed as dernier ressort.
CONSTIPATION; SOME OF ITS EFFECTS
AND ITS NON-MEDICINAL
TREATMENT.
Read in the Section on Practice of Medicine, at the Fortv seventh
Annual Meeting of the American Medical Association', at
Atlanta, (in.. May 5-S. UM.
BY E. S. PETTYJOHN, M.D.
ALMA, MICH.
The large number of people suffering from consti-
pation and its effects, and the clinical difficulty met
in obtaining relief therefrom, leads to the conclusion
that the full signification of this affliction and its
deleterious influence are not comprehended either by
the people or the profession.
In its reciprocal influence this condition sustains
both a causative and a resultant relation. Constipa-
tion as a functional disorder may be defined as an
abnormal condition of the great colon and the entire
intestinal tract, manifested by the unusual retention
of excrementitious material, both as to quantity and
time of evacuation. It may be owing either to dimin-
ished action of the muscular coat, to the diminished
secretion from the mucous membrane, or both, to
defective innervation, to habits and occupation, cli-
mate or diet, in addition to which there seems to be
an infinite variety of causes.
A study of the history of 300 cases shows that
about 60 per cent, of patients are suffering from this
ailment, and that the number is proportionately larger
among women than among men.
Congenital constipation may occur dependent upon
the anatomy of the colon, the water being absorbed
by a reduplication of the colon itself, especially the
descending part, as .that part is longer in infants in
proportion as compared with the ascending and trans-
verse, and hence liable, by being crowded down into
the pelvis, to flexures and reduplications that favor
impaction.
In adults the transverse colon is most liable to vari-
ation in length and position, and being smaller in diam-
eter than the ascending, aside from congenital malform-
ation, may be bent downward almost to the pubes by
long continued distension, forming a sharp bend at
the sustentaculum hepatis and at the splenic flexure,
as has been found in two cases under the writer's
observation.
In considering this condition, we regard individual
habit and idiosyncrasy and compare with the rule, as
persons do become constipated without notable or
sensible inconvenience to themselves, without mani-
festing any of the local symptoms, and while having
regular and apparently sufficient evacuations.
We come to the consideration of constipation more
on account of its relation to other ailments and the
entire system, than because of the mere inconvenience
induced. The intestines and colon and the rectum
are considered as digestive, eliminating and secreting
organs, and also as organs of absorption.
With their great extent of retiform tissue enclosing
a multitude of blood vessels and nerve ramifications,
with their mucus follicles and valves of retardation,
with their glands, lacteals, arteries and veins, the pow-
ers of retention and absorption belonging to this
tripod are beyond compare. The wonder is that all
the contents which enter are not taken into the
circulation.
While the colon and rectum have not the digestive
office we have long supposed, their absorptive power
is greater than has been thought, and the quantity
248
CONSTIPATION.
[August 1,
absorbed is in proportion to the time of contact and
concentration of the substance. While these organs
seem in a certain sense endowed with the power of
selection they do absorb digested aliment, medicines
and deleterious material with about the same avidity.
The intestinal nervous system is noticeably com-
plex. Filaments are received from the pneumogastric,
the sympathetic and from the lumbar cord. After
having been distributed to the plexus of Meissner
under the submucous coat and the plexus of Auer-
bach between the muscular planes, branches thence
supply the glands, muscles and blood vessels. Some
preside over the absorbents and secretions, others
over the peristaltic muscular movements, others over
the intestinal circulation. Not only do these medul-
lary and ganglionic systems direct the functions of
the intestines, but through them the nerve centers
of the brain have a direct influence over the entire
apparatus. Since all functional action in the system
is reciprocal, it follows that the functional activity of
the chylopoietic system must effect the nutrition of
the brain and entire nervous system.
We acknowledge that human life is a constant pro-
cessional activity of elimination and repair, metabolism
occurring everywhere. Observation is demonstrating
the part taken by bacteria and microbes in this pro-
cess in the mouth, stomach and intestines. In the
chemic, fermentative and putrefactive changes thus
occurring, ptomaines are being constantly produced
which, when absorbed as toxic and excrementitious
substances, produce retrograde changes in the quality
of the blood, diminution of the red blood corpuscles,
and by supplying an infected or imperfect nutriment
to the brain, become a prominent factor in the pro-
duction of cerebral anemia and nervous debility only
limited in its effect by the shortening of the microbal
longevity from the effects of its own secretions. If
this deficiency of nutrition or the supply of toxic
material be continued, the increased nervous irrita-
bility is followed by a decrease, and withdrawal of
nourishment is followed by brain exhaustion.
From the normal intestine Babes isolated five spe-
cies of bacteria, whilst an enormous number of micro-
organisms were found in the large intestine and feces.
Bouchard says : " The conditions favorable for the
maintenance of putrefaction are so numerous that we
ask whether digestion can ever go on normally?"
While the hydrochloric acid of the stomach neutral-
izes the infectious agents, they are passed into the
intestines in a state of latent activity, when fermenta-
tion again begins. While the bile arrests fermen-
tation, it is also capable of putrefaction, which is no
doubt one of the causes of the offensive breath in
constipation. We thus find the small intestine, and
especially the large intestine, in a condition to pass
products of putrefaction and toxic substances into
the blood current. Since our most inoffensive and
most valuable foods (meats) produce toxic substances;
since the bile contains poison and the putrefactions
of undigested residue produce poison, and the fecal
matter is toxic, with all of these shut up in the intes-
tines and colon, how can the guilty (those who do
not believe in defecation), or even the innocent, escape
destruction? If the kidneys are acting well, some of
the toxics escape through the urine, and if the skin
is eliminating, it furnishes relief, but these are rather
remote sources of exit for so large a quantity of excre-
ment when the way to the outside world is so close at
hand.
Hypochondria, nervous depression, nervous head-
aches, functional neurasthenia, migraine, vertigo, dis-
orders of nerve sensibility, noises in the ears, dyspep-
sia and depression incidental thereto, with a long train
of psychic, nervous and nutritional troubles, are
directly or indirectly the result of constipation. Even
when many functional difficulties seem to be the pri-
mary disease, they only form an arc of a vicious circle
begun with the nucleus of constipation.
The mechanical pressure against mesenteric blood
vessels by over-distended bowels, especially if long
continued, causes increased flow of blood to the brain
and a temporary hyperemia with its concomitant
symptoms, like an Esmarch bandage about a limb, or
a sudden cooling of the surface of the body which in
winter is the cause of more frequent cerebral hemor-
rhages than at other seasons, or like the sudden sup-
pression of the menses or of an hemorrhoidal dis-
charge, or even the straining at stool, all of which
are to be avoided in apoplexy and cerebral congestion,
on account of the increased pressure of blood in the
brain which they produce.
The nervous system, as the master tissue of the
body, needs the highest nutrition, and hence is most
easily disturbed. It is fed in its truest sense by the
overflow of nutriment after its refinement and elabo-
ration in other tissues. Whether the nerves are nour-
ished by the plasma reaching the axis cylinder at the
nodes of Ranvier or not, we believe with Waller that
the nutritional activtiy of nerve fiber is in the direc-
tion of its normal physiologic activity. Any inhibi-
tion of this function will lower the nerve excitability.
A long period of repose not only lowers the excita-
bility but, if continued beyond a certain limit, atro-
phy and degeneration occur in the nerve substance
itself.
Continued unusual pressure produces excessive
activity of the nerve supplying the part, excitability
is finally abolished and exhaustion of the nerve occurs
locally (as in over-distension of the bladder), or it
may even produce a neuritis. A constantly over-
loaded condition of the bowels may produce either of
these local results on the nerve filaments themselves.
The effect of this travels backward to the controlling
ganglia in the lumbar cord -and defecation, to some
degree a reflex act, when its directing center is not
sensitive to the controlling impulse of the brain,
does not occur promptly, and the constipation thus
reacts upon the whole system.
In patients who complain of symptoms referable to
the spinal region, and where there is entire absence
of anatomic affections of the cord, and often when
these manifestations are united with cerebral symp-
toms and there is general disturbance of the entire
nervous system with a neurotic heredity, it is very
frequently a functional trouble. Such a case recently
came under my care (from the country), a Miss M.,
aged 32. She had previously been afflicted with con-
vulsions, supposed to be epileptic, at and since
puberty, but had had none for two years previous to my
seeing her. She complained of attacks of severe occipi-
tal pain when she would become nauseated and dizzy.
At the same time she would have a convulsive-like
attack with irregular tremors and a peculiar nodding
and swaying movement of the head, which she said
she was unable to control. She also had pain in the
cervical and lumbar region, deep-seated. These attacks
occurred irregularly from one to twelve weeks apart.
She was an invalid each time from five to fifteen days.
18%.]
RETRODEVIATIONS OF THE UTERUS.
249
She had been treated for several yours and informed
by her physicians that she had epilepsy and disease
of the spine. Thorough examination revealed abso-
lutely no signs of spinal disease nor anatomic dis-
turbance of the cord. After three months of treat-
ment she fullv recovered, beside having gained
eighteen pounds in weight. The late Dr. Jewell
believed and taught that the effect of constipation
might produce a condition of the brain akin to, or
that could be classified as. transient mania.
The first elements in curative treatment, I consider
good food and good digestion. The diet should con-
sist of coarser foods such as would leave a residue and
aid in increasing the bulk of fecal accumulations.
Broths, tish with the skin, fresh meats not too tender,
whole-wheat and graham bread, mush, hominy, corn
bread and all green and watery vegetables, baked
potatoes with skins, and cereals containing hulls and
tine seeds, prunes, figs, apples with the peeling and
all fruits generally. Rest in the recumbent posture
for a half nour or more both before and after eating
is of value.
Massage on anatomic principles I place first in the
mechanical treatment. The manipulations should not
be used until two hours after a meal. The thighs
should be flexed and the abdominal walls relaxed.
The treatment should be given dry, stimulating first
the skin, then the walls of the stomach, the different
sections of the colon and the intestines. Petrissage
given so as to impart an oscillating and vibratory
movement, combined with the varieties of tapotement,
are the best forms of treatment. Cases of obesity and
atony of the muscular coats and chronic intestinal and
gastro-intestinal catarrh are relieved in two to four
months. The intestinal secretions or increased obstruc-
tion of the bile duct is relieved, the peristaltic action
is stimulated, and the contents of the sigmoid flexure
and entire colon are pressed toward the rectum. If
there are biliary calculi no pressure should be made
on the adjacent parts, although usually pressure should
be made over the fundus of the gall bladder, to assist
the bile toward the intestine. The stimulation of the
skin, which is here supplied by the last seven dorsal
nerves the same origin as the splanchnics, as well as
the plexus of Auerbach, and the mechanical effect of
moving pressure do bring favorable results.
In the use of the cannon ball three or four pounds
in weight the patient or operator should be thorough
and systematic. The ball should be rolled over the
entire abdomen, being used for five or ten minutes
morning and evening, the treatment ending by the
patient balancing the ball for a few minutes on the
navel.
In gymnastics all movements that use and strengthen
the abdominal muscles, such as lying on the back and
raising the limbs perpendicularly, the flexion at
the hips, twenty or thirty times each morning and
evening.
Rowing, horseback riding and cycling are helpful
if used regularly. While it is best to have a definite
hour, that is not essential, but when a time is fixed, if
the preceding half hour is devoted to the voluntary
contraction of the anal sphincter muscles, the reflex
effect is to aid in stimulating the peristaltic action.
Time should be given, and one should go for relief on
the first prompting.
The faradic current of sufficient strength to pro-
duce contraction of the different portions of the intes-
tines and colon is helpful. The galvanic current; the
cathode in the rectum, large anode over abdomen,
repeated daily at the same hour is effectual.
Hydro-therapeutics have proven successful reme-
dies in the author's practice. Drinking large quanti-
ties of cold water on arising and an hour before meals,
and two or three hours after food, taking during the
day 70 to 80 ounces, beside that with the meals, is of
exceedingly great value. This remedy, with regulation
of habit, has cured many cases.
Fomentations to the bowels, stomach and liver daily
and a cold pack to the bowels at bedtime, have been
successful. Alternation of hot and cold to the spine
and the cool bath have shown results.
The difficulty I find in the use of any, or a combina-
tion of these measures, is to induce the patient to be
systematic and persistent in following directions. But
I am thoroughly convinced that by these means pro-
ducing constitutional and local effects, more satisfac-
tory results are obtained than with medicines, and
when the patient recovers, he stays well.
That constipation has a psychic and a moral effect
the laity recognizes, and we will all agree with the
author who says: "Those persons whose bowels are
freed by an easy, regular movement every morning,
so soon as they have breakfasted, are meek, affable,
gracious, kind, and ' no ' from their mouth comes
with more grace than ' yes ' from the mouth of one
who is constipated."
THE SURGICAL TREATMENT OF RETRO-
DEVIATIONS OF THE UTERUS.
Read before the New York State Medical Society, at Albany, Jan. 28, 18%.
BY AUGUSTIN H. GOELET, M.D.
PROFESSOR OF GYNECOLOGY IN THE NEW YORK SCHOOL OF CLINICAL
MEDICINE.
It will be admitted that a cure of retrodeviations of
the uterus is seldom, if ever, accomplished by the
ordinary methods of treatment and that they demand
more careful consideration than is usually accorded
them. The routine plan of inserting a pessary and
dismissing the case from further attention is an error,
unfortunately, too often committed. The pessary can
only be regarded as a splint which is serviceable as
an aid to other measures in bringing about the desired
result, but nothing more and will accomplish very little
unaided. It may be true that all such displacements
of the uterus do not require surgical intervention for
their cure, but when structural changes have taken
place in the walls of the organ nothing else will yield
a prompt and satisfactory result. A pessary might be
worn throughout the lifetime of these patients and
even if it maintained the uterus in a correct position
a cure would never result and she would never be able
to go without it, unless something else is done to
overcome the conditions which produce the displace-
ment or are consequent upon it.
These displacements do not necessarily require
always a grave surgical operation for their rectifica-
tion, since frequently a trachelorrhaphy or curettage,
or both combined, in conjunction with appropriate
after treatment will be sufficient in many cases. It is
only where there is fixation from adhesions that it may
become necessary to open the abdomen, break them
up, bring the uterus forward and suspend it from the
anterior abdominal wall.
On account of the difference in the pathologic con-
dition in the uterine wall, retroversion and retroflexion
should be dealt with differently. In retroversion one
250
RETRODEVIATIONS OF THE UTERUS.
[August 1,
of two conditions may prevail. The uterus is either
soft, being in a state of subinvolution, or it is hard,
the condition being one of sclerosis. The latter
is believed to be an advanced stage of the former, both
being regarded as different stages of metritis. In
retroflexion, if it has existed for any length of time
the condition of the anterior and posterior walls is
quite different. The anterior wall is put upon the
stretch and the posterior wall is contracted and
shrunken, its structure being dense and hard because
of interference with the circulation and nutrition
making the displacement permanent.
Associated with this condition of metritis there is
always an endometritis, in both retroversion and retro-
flexion. Therefore in both forms of displacement
dilatation with careful curettage is demanded as a
preliminary step in their treatment, but in retroversion
the uterus should subsequently be carefully packed
with gauze to secure depletion and drainage, and to
stimulate contraction, and in retroflexions a glass
drainage stem should be employed because it will act
as a splint and maintain the uterus in a straightened
position. With the aid of absorbent iodoform gauze
packed in the vagina this is readily accomplished.
TECHNIQUE OF CURETTAGE AND TREATMENT
OF RETROVERSION.
The patient is anesthetized after previous prepara-
tion which should include shaving the vulva and irri-
gation of the vagina with a hot solution of bichlorid,
Fig. 1.— Author's Speculum.
1 to 4000, or. a 1 per cent, solution of lysol, hot. She
is then placed in either the dorsal or lateral (Sims's)
posture, as is most convenient for the operator. The
speculum represented by the accompanying cut
(Fig. I)1 will answer equally well for either position.
The cervix is seized on the right side with the angular
Fig. 2.— Author's Angular Tenaculum Forceps.
tenaculum forceps (Fig. 2 ),2 which is held in the left
hand, and the dilator (Fig. 3)3 is introduced up to its
shoulder. The necessary degree of dilation should be
done slowly and gradually so as to prevent injury to
the parts, especial care being taken to prevent the
instrument slipping and producing laceration.
1 The author's speculum possesses many advantages over the Sims's
speculum or the bi-valve or tri-valve instruments, on account of the
convenience of manipulations afforded and because it is self-retaining
in both positions.
2 The special advantage of the author's angular tenaculum forceps
is that the strain is agHinst the curved sides of the points and not
directlv against the points as is the case with the straight instrument,
hence it does not cut out or slip and produce laceration of the tissues
seized by it.
3 The author's dilator is designed to effect slow gradual dilation
without Injury. The curve is less acute than that of dilators in general
use and the ratchet catch attached to the handle holds the dilatation as
it is accomplished, but at the same time it can be quickly relaxed at any-
time by pressure of the little finger upon the spring when the instru-
ment seems to be slipping.
The dilatation accomplished, the double current
irrigator (Fig. 4) is inserted to the fundus and the
cavity is washed out with a hot 1 per cent, solution of
lysol. The next step is the curettage, and it must be
done with special care. Every part of the cavity is
gone over and all diseased membrane is thoroughly
removed. Selecting a medium-sized rigid dull curette
the posterior surface is first curetted, commencing at
the left (patient's right) ; then the anterior and lateral
surfaces are treated in like manner. Substituting a
smaller curette the membrane is removed from each
cornu and the fundus. Then with a sharp curette the
<
I
hypertrophied tissue about the internal os is removed.
This being accomplished, the cavity is again thoroughly
irrigated with a hot solution of lysol and it is then
ready for the insertion of the gauze. This is best
accomplished by means of the applicator forceps
(Fig. 5). Iodoform gauze (20 per cent.) which has
been rendered absolutely sterile is used. A strip an
inch wide and a yard long is carefully introduced into
Fig. 5.— Author's Uterine Applicator Forceps.
the uterus leaving an inch or two of the end protruding
into the vagina. The vagina is then tamponed with
the same gauze (cut into strips two inches wide) in
such a manner as to maintain the uterus in a correct
position. Since the gauze will cease to act as a drain
when it becomes saturated it should be removed and
renewed every twenty-four hours. At the same time
the uterine cavity should always be thoroughly irri-
gated with the hot solution to remove all debris and se-
cretions. This after treatment should be continued for
a week, during which time the patient is confined to
1896.]
RETRODEVIATIONS OF THE UTERUS.
251
md. At the end of this time a vaginal pessary is
adjusted so as to maintain the uterus in a correct
position, ami the case is kept under observation for
several weeks, the uterine cavity being washed out
ice or twice every week as necessity demands. This
is to lie continued until a healthy condition of the
endometrium has been restored, as will be evidenced
by the absence of debris or mucus in the washings.
If these details are observed carefully there will be
no rise of temperature in these cases and the result of
{he curettage will be permanent. There is no neces-
sity for the complicated process of preparing the
graze which has been advocated by some writers. It
only necessary to insure its absolute sterility by
submitting it to the necessary degree of heat for a
sufficient length of time.
After this operation and the subsequent after treat-
icnt. the uterus will quite rapidly resume its normal
size and condition if it has been maintained in a cor-
rect position by the pessary which should be worn for
t'veral months.
TECHNIQUE OF THE TREATMENT OF RETROFLEXION.
The dilatation and curettage is done in these cases
the same manner as described for retroversion, but
istead of inserting gauze into the uterus a glass
drainage stem (Fig. 6) is inserted to serve as a splint
and maintain the organ in a straight position until a
normal condition of its walls can be restored. This
stem is two inches long, is perforated through the
enter for drainage and its size is No. 12, English
le.
Fig. 6.— Author's Glass Drainage Stem.
After curetting the cavity and irrigating with hot
lysol solution, the stem which has previously been
rendered sterile is introduced and held in position by
a tampon of iodoform gauze packed carefully around
the cervix. Additional, tampons of the same gauze
are inserted in front of the cervix forcing it backward
into the posterior cul-de-sac of the vagina, thus
throwing the uterus forward into a position of ante-
version.
The stem should be removed every day, the cavity
of the uterus washed out with lysol solution and after
cleansing it the stem is reinserted. At the end of a
week, during which time the patient is confined to
bed, a pessary is carefully adjusted to take the place
of the vaginal tampon and maintain the uterus in a
correct position. The stem is retained for a day or
two longer with only a loose wad of gauze against it
to prevent it slipping out. If it is found that the
pessary will sustain the organ in a proper position the
stem may be removed and the patient is permitted to
get up. The pessary must be worn for several months
until it is found that the uterus will retain a normal
position without its support.
Almost every case of retro-displacement of the
uterus not fixed by adhesion or exudation, is satisfac-
torily amenable to this method of treatment. When
slight or very recent adhesions complicate the case
they may sometimes be broken up by careful manipu-
lations through the vagina under anesthesia without
opening the abdomen. Then the above operative pro-
cedure is to be adopted as in those cases when
adhesions have not existed. When the organ is bound
down by exudation this should when possible be
removed first. When a lacerated cervix complicates
the displacement it should be repaired at the same
time, but in these cases the gauze packing will have
to be dispensed with because it might interfere with
proper union.
In dealing with retroflexion if it is necessary at the
same time to do a trachelorrhaphy, the drainage stem
can be used without danger of interfering with union
of the freshly united surfaces if the operator is careful
in making the denudation to leave ample room for the
new cervical canal, and not draw the sutures too
tightly. When the adhesions are firm and numerous
they should be broken up by the finger inserted into
the abdominal cavity through a small incision and the
uterus should be brought forward and suspended from
the anterior abdominal wall after the manner described
by Howard Kelly.
TECHNIQUE OF SUSPENSIO UTERI.
After proper preparation of the patient she is anes-
thetized, the bladder is emptied and an incision about
two and a half to three and a half inches long is made
through the abdominal wall just above the pubis
opening into the peritoneal cavity. Two fingers of
the left hand are inserted and the uterus is loosened
from its attachments and the fundus is brought for-
ward and up into view. The edge of the peritoneum
on each flap of the abdominal wound is next seized
with pressure forceps and drawn out. A curved needle
carrying a medium-sized silk ligature is inserted
through the peritoneum and subperitoneal fascia on
the left near the lower angle of the wound and is next
inserted upon the posterior face of the fundus and
then through the peritoneum and subperitoneal fascia
on the right flap of the abdominal wall, at a point
opposite its insertion on the left. When this ligature
is tightened it brings the posterior face of the fundus
snugly up against the anterior abdominal wall. A
second suture is inserted near the other on the abdom-
inal wall and just below the other on the posterior
face of the uterus. When this suture is tightened it
throws the uterus forward still more into a position of
anteflexion. These sutures are tied carefully so as to
maintain an equal strain on each, bringing the uterus
up snugly against the abdominal wall, and the abdom-
inal wound is closed in the usual manner.
One advantage claimed for this operation over that
of ventrofixation is that the uterus is not permanently
fixed in an abnormal position, but it eventually
recedes somewhat and remains suspended by two firm
fibrous cords in an easy position of moderate ante-
flexion and is fairly movable.
The patient is confined to bed for two or three
weeks and is directed to wear an abdominal support
at first upon rising. No pessary or additional sup-
port will be needed after this operation, but injuries
to the pelvic floor should be repaired at the same
time in all cases. When done in properly selected
cases this operation should be uniformly successful
and the mortality is nil.
Alexander's operation, which is only applicable
when the uterus is movable, is unnecessary, its chiei
disadvantage being the prolonged convalescence it-,
entails. The operation described above for movable,
displacements is preferable because it can be done,
quickly and necessitates only a week's confinement in,,
bed. It is a rational procedure because it aims at a.
cure of the coexisting metritis and endometritis which
is the maintaining cause of the displacement.
252
PREVENTION OF TUBERCULOSIS.
[August 1,
It has been suggested to apply Alexander's opera-
tion to fixed retrodisplacements after first incising the
posterior cul-de-sac and breaking up the adhesions.
This may be easy when the adhesions are not very
extensive, but the difficulty of securing thorough
asepsis by this route is certainly an objection as well
as the time which this and the added Alexander's
operation involves. All things considered, suspensio
uteri is to be preferred when" the organ is adherent.
Of the other operations recently suggested for over-
coming these displacements, that of incising the pos-
terior cul-de-sac of the vagina and bracing the uterus
up by means of gauze crowded into the peritoneal
cavity behind it, does not appear to be either wise or
justifiable. . A retroversion may be thus overcome but
I fail to see how it can maintain a retroflexion even
temporarily in a correct position. The chief objec-
tion to this procedure, apart from its faulty principle,
is that it substitutes an exudation for the utero-sacral
ligaments which are destroyed, and the cervix remains
fixed to the rectum, an abnormal condition for many
reasons objectionable.
Vaginal fixation does not appeal to me as either
rational or justifiable since it substitutes a fixed ante-
flexion for a movable displacement. The recent un-
favorable reports of protracted and complicated labor
when it follows this operation certainly constitutes a
very serious objection to it. Its originator, Mackin-
rodt, has abandoned it.
Upon the whole the operations described above for
movable displacements and suspensio uteri, when the
uterus is adherent or when disease of the adnexae
complicates, are I believe the most satisfactory and
the results, so far as my observation goes, bear me out
in this conclusion.
351 West 57th Street.
PREVENTION OF TUBERCULOSIS.
Read at the Pennsylvania State Medical Society, Harrisburg, Pa.,
May 19, 1896.
BY E. B. BORLAND, M.D.
Clinical Lecturer, Diseases of the Chest, Medical Department of the
Western University of Pennsylvania: Assistant Physician
to the West Pennsylvania Hospital, Member Amer-
ican Medical Association, etc.
PITTSBURG, PA.
Under the light of recent investigations, the old
theory of inherited tuberculosis is at best question-
able. Congenital tuberculosis is comparatively infre-
quent. The so-called hereditary predisposition is now
known to be general debility, which may arise from
many causes. Any weakling has this predisposition,
no difference what degree of health his parents
enjoyed. All weak persons, especially the young, are
liable to contract tuberculosis, if the three essential
factors of infection are present, viz., debility, abra-
sions and bacilli.
The three essential factors of infection. — In the
convalescence of typhoid fever, for example, we have
two out of the three essential factors of infection.
The same factors are present in the convalescence of
measles and whooping cough, viz., debility and abra-
sions of the mucous membranes. The third essential
factor of infection is easily supplied by the millions
of tubercle bacilli which can be found in almost every
public building, hospital ward, railway and, especially,
the modern chariots of Juggernaut and centers of
infection — the electric and cable cars, the floors of
which are regular cuspidors.
That the bacillus discovered by Koch in 1881 is the
specific cause of tuberculosis is not questioned by the
medical profession at the present day. The principal
routes of infection are the respiratory tract, mainly in
adults, and the alimentary tract in children.
Two principal sources of infection.— That raw milk,
and the air containing dried sputum, are the two
important sources of tubercular infection is selfevi-
dent to any painstaking observer. The former may
be held responsible for nearly one-fourth, and the lat-
ter more than one-half of all cases of infection. The
large number of cases of abdominal tuberculosis in
small children fed on raw cow's milk, is evidence of
the importance of this source of infection. Marfan
demonstrates the great danger of infection from spu-
tum, in the following observation: Twenty-two pre-
viously healthy factory employes worked for many
years together in one room. In the year 1878, two
men suffering from ulcerative pulmonary lesions were
added to their number, and these two latter expec-
torated freely on the floor. Between the years 1884-
89, thirteen of the original twenty-two died of tuber-
culosis. Was this an accident or the plain result of
the violation of a sanitary law?
Transmission of infection. — It is quite probable
that infection is often carried from its original source
to susceptible individuals by the common drinking
cup, the common communion cup, cigar makers, care-
less barbers, money, handkerchiefs, kissing, the long
skirts often worn by women, instruments, especially
dental instruments, which often do not get even a
rinsing with water until they have been used in sev-
eral persons' mouths.
Vitality of the tubercle bacillus. — It will withstand
freezing and dessication for weeks and months, and
has been found alive after being buried two years.
Koch produced tuberculosis by cultures nearly two
years old. It should be borne in mind that the germs
in fresh sputum or secretions are more virulent, that
is to say, more likely to infect and harder to destroy,
than after exposure to air and sunshine for several
weeks. Nuttell found not only millions but billions
of tubercle bacilli in the sputum of one patient in
twenty-four hours.
Measures to prevent infection. — It has been esti-
mated that about fifteen per cent, of milch cows are
tubercular. The question arises, how is this source
of infection to be controlled? The answer is, by
destroying all infected animals as soon as a diagnosis
can be made, and always sterilizing or boiling milk
before using.
The physician is the guardian of health in the
home, and it is his positive duty to teach his patrons
preventative medicine. If he is grounded in the faith
to a degree warranted by the facts, he can soon be the
means of molding public opinion so that it would be
decidedly unpleasant for any respectable person to be
seen expectorating on any floor or sidewalk. Church-
going people get along without expectorating on the
floors of their places of worship, and this is evidence
that all respectable people can do the same. Legis-
lation, making expectoration on floors and sidewalks
a misdemeanor, would control the vicious class.
A step in the right direction has recently been
taken by the New York Board of Health. It directs
the removal of carpets and mattings from the floors of
cars and boats, and the placing of cuspidors contain-
ing suitable disinfectants where needed.
The rule should be absolute, forbidding any or all
persons from expectorating on any floor or sidewalk.
1896.]
H. H. HOLMES.
253
Tat Lents with ulcerative pulmonary lesions should not
be allowed to expectorate in any place, either out or
in doors, except in vessels containing suitable disin-
fectants.
Heat, solution of corrosive sublimate, 1 in 500
(acidulated with tartaric acid to prevent the coagula-
tion of albumin), or carbolic acid, 1 in 10, will
promptly destroy the tubercle bacillus.
Large, well-glazed cuspidors with perpendicular
.sides should be used (surrounded, if necessary, by
bcreens) and cleaned daily, would protect public
buildings and homes. Public conveyances to be pro-
tected by suitable vessels filled with sawdust, damp-
ened with a 1 in 250 bichlorid solution. Patients with
ulcerative pulmonary lesions should carry a small,
wide-necked, glass-stoppered bottle containing a small
quantity of the bichlorid solution for a pocket cuspi-
dor, to be used only when out of reach of floor cuspi-
dors. Handkerchiefs costing not over one-eighth of
a cent apiece could be carried, in an emergency, and
burned after using.
Patients should be instructed to rinse out their
mouths frequently with warm water containing a lit-
lle essence of wintergreen. This precaution to be
attended to before eating, for the protection of the
patient, and after expectorating, for the protection of
others as well. Kissing should always be prohibited.
It has been estimated that a patient in the ulcerative
stage of pulmonary tuberculosis lives about two years.
During this period he is a constant source of danger
to his family and a menace to society. At a cost of
not exceeding $50 and a little trouble, his sputum
could be destroyed and his family largely protected
from infection. Latent tuberculosis needs no precau-
tions.
For the poor, hospitals especially designed for con-
sumptives, and for their exclusive use, should be pro-
vided by the State as a matter of humanity, economy,
and protection to the public health. The watchword
should be, isolation for the patient who can not or
will not be governed by the necessary sanitary regu-
lations.
The disinfection of rooms and houses in which
patients with ulcerative lesions live, or have lived,
within two years, is a matter of vital concern. For
this reason alone, tuberculosis should be classed by
law with the infectious diseases, and be placed under
the supervision of bureaus of health.
The Assembly of this Commonwealth now provides
for the supervision by health officials of ten conta-
gious and infectious diseases, viz., smallpox, diphthe-
ria, scarlatina, typhoid fever, typhus fever, yellow
fever, cerebro-spinal fever, Asiatic cholera, relapsing
fever and leprosy.
The last, two diseases in this list are so rare as to be
almost a medical curiosity, yet were added to the list
only last year; and an infectious and contagious dis-
ease which is the direct and primary cause of more
deaths (14 per cent.) than all of the above ten, with
measles and pertussis included, was omitted.
Ventilation is a much neglected measure of pre-
vention. It has been estimated that each adult indi-
vidual requires 3,000 cubic feet of fresh air per hour.
In a room containing 1,000 cubic feet the air should
be changed three times an hour to prevent the car-
bonic acid gas from rising above six parts in ten
thousand.
Probably not one room in ten will meet this require-
ment. While only a fraction of a cubic foot of car-
bonic acid gas is thrown off by respiration, an ordi-
nary small illuminating gas burner will throw off six
oubic feet an hour. A natural gas stove, without
chimney outlet, is one of the most pernicious air
poisoners ever invented. It renders the air in an
ordinary sized room unfit to breathe in a few min-
utes. The most efficient means of ventilation we
have in the average home to-day is the old-fashioned
fireplace. Provisions for the entrance of fresh and
escape of foul air should be made near the floors and
ceilings of every living room, in such a way as to
avoid draughts. Permits for the erection of all build-
ings should specify that ample means be provided for
ventilation, and official inspectors should see that the
specifications are carried out. Electricity is to be the
light and possibly the source of artificial heat in the
near future.
The knowledge that we now possess of the path-
ology, the three essential factors of infection, the
common sources of infection, the common routes of
infection, the means at our command to prevent infec-
tion, ought and can stamp out, if acted on intelli-
gently and promptly, more than one-half of the cases
of tuberculosis in the next twenty-five years, and 90
per cent, of all cases in the coming century.
Sentiment in intelligent, sensible, respectable peo-
ple can be aroused and cultivated. With the ignorant
and vicious nothing succeeds like an absolute fiat.
H. H. HOLMES.
BY EUGENE S. TALBOT, M.D., D.D.S.
FELLOW OF THE CHICAGO ACADEMY OF MEDICINE.
That Herman Webster Mudgett, better known as
H. H. Holmes, was a criminal par excellence is beyond
doubt, but how far and in what respects he was a
degenerate, in the accepted sense of the term, is-
worthy of serious consideration.
Few criminals have received more public attention,
but despite this, many essential details of his history
are wanting. Very little has been stated as to his
heredity. He claims to have come from a respectable
New England stock and to have been religiously and
carefully brought up. As a boy he does not appear
to have been a scapegrace, and no criminal charge
is there on record against him. He married at 18 or
20 and commenced the study of medicine at Burling-
ton, Vt. From there he went to the University of
Michigan, where he claims to have graduated in med-
icine in 1884.
According to his own account, after graduating he
taught school and practiced medicine in New Jersey
for about a year, but it would appear that before this
he had already, with a confederate, conspired to-
defraud life insurance companies, an industry he never'
entirely abandoned and which finally brought him to-
the gallows.
Just when he assumed the name of H. H. Holmes;
is not certain, but probably not long after this. He'
himself says it was done when he went before the-
Illinois Pharmacy Board in 1886. From that time he»
has been known by that name and under it started in
business as a druggist in the outskirts of Chicago,
where he went into rather extensive and complicated
transactions, chiefly of a crooked character. He man-
aged, however, to keep in fair standing with his
neighbors, and at one time was actively interested in
church and religious matters.
During this time he had abandoned his New Hamp-
254
H. H. HOLMES.
[August 1.
shire wife and child, and without divorce, married in
1887 a Miss Belknap. Some years later in the same
way he married a Miss Yoke in Denver under the
name of Henry Mansfield Howard. He is supposed
■also to have contracted another bigamous marriage
with Minnie Williams (one of his supposed victims).
Beside these he had irregular relations with other
women. In 1894, shortly before his final arrest for
the murder of Pitzel, he revisited his old home and
lived as husband for a few days with his first wife, to
whom he told a romantic fiction anent his absence.
Between 1886 and 1894 there is no full account of
his doings. They included an extensive series of
swindles and forgeries. His transactions covered
many parts of the country. He ranged from Canada
to Texas and Colorado, often in trouble but generally
managing in some way to escape the most serious
consequences of his crimes. These were in their way
often remarkable for their boldness and impudence.
He negotiated for the sale to a gas company of a gas-
H. H. HOLMES.
making machine which was actually running on gas
stolen from the company's own mains. He admits
" deals of a somewhat similar nature."
While his confessions, generally, have been unreli-
able,^ is probable that the above is safely inside the
truth. He was emphatically a man of affairs, but his
business transactions were so shady in their nature
that the obscurity that enveloped them has been dis-
persed as yet only to give a glimpse such as the
above.
It was during this period that he built his celebrated
castle, with its secret chambers and passages, dark
rooms, trapdoors, etc. Here he employed the female
type-writers and other employes whose mysterious
disappearance has done so much to make his popular
reputation as a murderer. As far as this crime is con-
cerned it must be admitted that the evidence against
him is altogether circumstantial, his confessions and
statements being notoriously and boastfully menda-
cious, in the main. Out of the twenty-seven murders he
admitted in his latest confession shortly before his exe-
cution, the majority of the victims are still living. Even
his dying admission that he had been responsible for
the sacrifice of two lives from criminal operations can
not be accepted as perfectly reliable, considering his
character for untruthfulness. He seems to have had
little or no regard for human life, and as a dealer in
"stiffs" and a defrauderof life insurance companies his
operations were often enough suggestive of murders,
even if these were not often committed.
The history of the Pitzel case, where it appears
he made away with his confederate and then later
with three of his children, and seemed to be planning
the deaths of the widow and remaining family, dis-
tributing the deaths about the country in such a way
as to avoid suspicion, must be fresh in the mind of
the reader.
Holmes in his personal appearance, like Wain-
wright (whom he much resembled in his criminal
career), presented nothing specially repulsive in his
appearance. He was quiet, mild in manner and voice,
fairly well educated, neat in dress and could pass any-
where for a respectable business or professional man.
During his long criminal career he appears to have had
no particular ambition, except to succeed in his
crooked operations and to ingratiate himself with
women, for whom he seems to have had a more than
normal inclination.
Mentally, there was no lack of acuteness. The fact
that he managed to escape justice so long is an evi-
dence of this. When he was finally arrested his
behavior was peculiar and shifty. He told contradic-
tory stories, and when his case came to trial he dis-
missed his lawyers and insisted on managing his own
defense. Though he showed some aptness in examin-
ing witnesses, he was finally obliged to recall his
counsel and give the case into his hands. The jury
found him guilty almost without leaving the box.
Perhaps the one witness whose testimony was most
convicting was his latest bigamous wife.
Holmes made numerous statements and confessions
to detectives and others and published a book while
awaiting trial which purports to give an account of his
life.
The most remarkable of these confessions, however,
was that published in the Philadelphia Inquirer oi
April 12, three or four weeks prior to his execution.
In this he reports the details of twenty-seven murders
and claims that he was a case of acquired moral idiocy ;
that he presented numerous facial stigmata of degen-
eracy that had grown upon him, during his criminal
career. Eighteen of the twenty-seven victims in this
confession are living. Its author acknowledged its
falsity within a day or two of its appearance.
It was not merely criminal vanity that prompted it,
for he received for it a very substantial condensation
of several thousand dollars. Throughout his impris-
onment, his acquisitiveness was shown in this and
other publications for which he received money, and
in propositions of blackmail for persons he contem-
plated involving in these confessions.
While in Philadelphia, Jan. 30, 1896, I had the
opportunity of making a careful physical examination
of H. H. Holmes, with the following results:
The subject was a 35 year old American, 5 feet 1-h
inches in height, weighing 150 pounds. The occiput
was asymmetrical and prominent, the bregma sunken
and the left side of the forehead was more prominent
than the right which was sloping. The hair was
brown, and on bodv and face excessive. The face was
1896. ]
H. H. HOLMES.
255
arrested in development. The zygoma was arrested
and hollowed on the right side.
The pictures of Holmes published in the daily
papers and in his book, do not, to my mind, portray
the features of the man as I saw him in his cell. Figure
1. ivmes the nearest as he appeared when I saw him.
His face was cleanly shaven, except moustache, very
thin and much emaciated, presenting the appearance
of being in a decline, due perhaps to confinement and
a tendency to consumption. Hehada cough, and the
chances are if he had been allowed to remain in con-
finement he would have succumbed to tuberculosis.
Figures 2 and 3 show the antero- posterior and lateral
shape of head. The right ear was lower than the left.
The nose was long and very thin; stenosis of nasal
bone very marked. The septum deflected to left, nose
to the right. The thyroid gland was arrested. Strab-
ismus in left eye, inherited. The left higher than the
right. Slight protruding of the upper jaw; arrest of
lower. The mouth on the left side drops lower than on
the right. The width, outside of first molars was 2.
Width outside first bicuspids 1.62. Height of vault, 63.
Figures 4 and 5 upper and lower jaw. The alveolar
process was normal with the exception of the process
about the second molar on right side which was hyper-
trophied. The teeth were normal in size and shape,
the third molar undeveloped.
Marked pigeon breast, left side more prominent
Figure k.
than right. Chest arrested with tendency to tuber-
culosis.
Arms: Eight normal. Left one and one-half inches
longer. He was right handed. His legs wTere long
and thin. The tibia flattened. The feet medium in
size but markedly deformed. Depression on left side
of skull at bregma, said to be due to fall of brick at
age of 30. Sexual organs unusually small.
The jaws were unusually long as compared with the
width, with a semi-saddle arch on the left side of the
upper jaw. The molars of the lower jaw and left upper
had been extracted in early life. The hypertrophy of
the alveolar process, the want of development of the
third molars and the general abnormal development
certainly display a very unstable nervous system in
his early life.
In twenty years' experience, I have never observed
a more degenerate being from a physical standpoint.
Holmes in his confession published, stated that ten
years ago he was examined by four men of marked abil-
ity and by them pronounced mentally and physically
normal and healthy. " To-day, I have every attribute
of a degenerate a moral idiot." Is it possible that the
crimes, instead of being the result of these abnormal
conditions, are, in themselves, the occasion of degen-
eracy? . . . within the past few months these
defects have increased with startling rapidity ; as is
made known to me by each succeeding examination,"
etc.
Holmes was examined ten years ago, not to ascer-
tain stigmata but for life insurance, and the Bertillon
system was not used at all since only criminals are
thus examined, for identification. When these exam-
inations are made, only one arm, finger and part of
the body are measured, and not both sides for com-
parison.
While I was making my examination, I called his
attention to a number of deformities which he was
not aware he possessed.
Being a medically educated man, he certainly should
have been better acquainted with these malforma-
tions, but he had evidently given this subject little
attention since he was quite ignorant of the cause of
two most marked deformities: The too deep depres-
sions in the left frontal and occipital region of the
head. These he claimed were due to a brick falling
upon him at the age of 30. The marked deformity
of the chest walls he claimed to be due to pneumonia.
Both deformities were stigmata of degeneracy.
Holmes, since his confinement, had no doubt lost
flesh, which made these deformities appear more
prominent. That they had developed as a result of
his criminal tendencies is perfectly absurd. They
must have developed with the osseous system, which
would be complete by the 26th year; nor will acro-
megaly account for them.
Holmes has been called an extraordinary criminal,
Left.
Figure
than
Right.
but he certainly was no more of a criminal
WTainwright,' who was well known in his time as an
essayist and better as a forger and murderer. From the
standpoint of literary and artistic culture Wainwright
stood higher than Holmes. Like Holmes, he attempted
to defraud insurance companies and there is no doubt
he poisoned a girl for this purpose. Holmes' habit-
ual criminality was modified by his education and
antecedents. He had sufficient ability and self-con-
trol to successfully pass for a respectable citizen and
to keep his criminal transactions so distributed as to
territory and covered that only the self-interested
perse verence of a life insurance company prompted
by a hint from an ex-prison acquaintance could reveal
them. His mental defects, so far as they existed,
seem to have been confined to his moral sensibilities.
He apparently had none of that sense of moral dicta-
tion which is a part of the constitution of every
normal individual. He acted entirely as an egotist,
perfectly capable of appreciating the possible imme-
diate consequences of his acts and more than ordina-
rily expert in managing in one way or another in
avoiding them, but utterly lacking in even the utili-
tarianism commonly expressed in the old adage that
honesty is the best policy. While the murders have
mainly created his popular reputation, they were but
incidents in his consistent criminal career. He had
i See Havelock Ellis' " The Criminal." p. 18.
256
H. H. HOLMES.
[August 1,
no regard for others' rights or lives. Doing away
with a mistress or a confederate when she or he
become inconvenient was an easy matter to him. His
education, his dissecting-room training and subse-
quent specialty helped to remove original supersti-
tious fears that might restrain the average criminal.
He seems to have been utterly lacking in any lasting
or sincere affection or attachment. A man who could
deliberately desert successively two wives with their
children would be capable of abandoning others whose
relations were less intimate.
Havelock Ellis remarks2 that whatever refinement
or tenderness of feeling criminals attain to reveals
itself in what we should call sentiment or sentimental-
ity. One of the characteristics of Wainwright's
essays is their sentimentality. Himself, when in
prison, he described as the possessor of "a soul whose
nutriment is love, its offspring art, music, divine song
and still holier philosophy." This sentimentality
cropped up in Holmes in the letters to his first wife
whose pathetic nature so impressed his counsel. It
was also shown in his successes with women.
Holmes was certainly a degenerate physically, as
the numerous stigmata he bore proved, but he was not
more of one than many moral men and good citizens.
There was, with the defects, undoubtedly a certain
defectiveness and want of balance of the nervous sys-
tem, but it can not be said that this necessitated the
career he chose. If he were a "born criminal" it was
not evident till after he had passed his minority and his
moral imbecility did not apparently reveal itself to any
very striking extent during his boyhood. He followed
the course of many young men, who, on leaving the
associations and restraints of home fall into evil courses,
only he went farther and under pressure, it may be of
want and misfortune, adopted to the fullest extent
the anti-social and aberrant career of a criminal.
There was, possibly, always a certain defect in his
moral constitution which was checked in its effects by
the restraints and training of his earlier years and
might have been overcome entirely had his will been
directed into proper paths. His case seems to be
largely, if not altogether one of acquired moral
obtuseness, not of complete congenital moral insanity.
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RntA ^ . vSl
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-i.i^i^ ■ '•^""■^r ^h
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Figure 4.— Lower.
His crimes were apparently all deliberate and cold-
blooded. In his arrangement of his building, " The
Castle," he made provisions for various kinds of
crooked work. Only in this way can be reasonably
explained this seemingly crazy piece of architecture.
There is no evidence in his record that Holmes was
insane in any way except it be morally.
In his apparent disregard for human life he was
less peculiar than would at first sight seem. When
a man has an object in view, which to him is a
supreme motive, nothing will stand in his way.
Holmes had no regard for the law if he could avoid
its punishments, no conscientious scruples to govern
his conduct. The taking of life was no more to him
than to the Sultan of Turkey, a hanging judge or a
military commander, who will sacrifice a forlorn hope
to gain an advantage. It is not so improbable, there-
fore, that he may have been a more or less wholesale
murderer, if he found people in his way. He may
have disposed of his victims and regarded it only as
an inconvenient necessity. There is nothing in his
character to make this intrinsically improbable.
i The Criminal, p. 152.
Figure 5.— Upper.
How far he was handicapped morally by his con-
stitution, is a question that can not be decided abso-
lutely, but probably not more than the average
criminal, who is generally of a more or less degen-
erate type. "_. ^
It has been assumed that his vanity and egotism
were excessive and evidence of his abnormal mental
constitution. First, however, it ought to be proven
that these existed to any such extent as is inferred.
This can not well be done from his history. He was
not obtrusive in his manner and his very choice of
life made it impolitic, to say the least, to such pub-
licity, and in his way he was very politic. He had
ample confidence in himself, as was shown by his
attempting his own defense. This may be taken as
evidence of egotism, but he can hardly be said to have
been obtrusively egotistic. His numerous statements
in regard to himself were apparently not so much
prompted by vanity as by a desire to make4a profit
from them. This was especially true of his last
noted confession, which was one of the best remuner-
ated productions of fiction based on fact that has
been brought out in the country.
1896.]
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
257
There was certainly one striking psychologic pecu-
liarity about the man; lying seemed to come naturally
to him. He did it sometimes apparently without
object. In this, however, he was not altogether unique,
but there are marked examples, never in their acts
passing over the line of legality.
Summing up the character of Holmes, we would
say that he was, first of all, a swindler, a chevalier
Industrie and a roue. Money and women seemed
to bo his objects in life, especially the former, and he
was perfectly unscrupulous in his methods of gratify-
ing his ruling passions. His professional and general
education, which he seems never after the first failure
to have attempted to utilize properly, only served to
make him the more dangerous and probably aided to
make him a murderer as well as a seducer, bigamist,
forger and thief. He may have had some congenital
deficiency in his moral make-up, but the absolute lack
of moral dictation of his later life, was due to or
greatly aggravated by his self-chosen environments.
TUBERCULOSIS OF THE MALE GENITAL
ORGANS.
Read bv title at the meeting of the American Surgical Association,
at Detroit. Mich., May 26-28. 1896.
BY NICHOLAS SENN, M.D., Ph.D., LL.D.
PRESIDENT OF THE AMERICAN MKDICAL ASSOCIATION, ETC., ETC.
CHICAGO.
(Concluded from page 187.)
Tuberculosis of the testicle and epididymis. —
Exoepl in eases of acute diffuse miliary tuberculosis
the essential organ of generation in man is seldom the
seat of primary tuberculosis. On the other hand,
primary localization of the tubercle bacillus not infre-
quently takes place in the epididymis, when the
infection often extends from here to the testicle.
There must be vascular conditions or other local pre-
disposing causes which are concerned in determining
hematogenous infection of a tubercular nature in the
epididymis which are absent or present to a lesser
degree in the testicle. The epididymis is more often
the seat of acute infective processes which prepare
the soil for the bacillus of tuberculosis than the testi-
cles which, to a certain extent, may explain the greater
frequency with which primary tuberculosis occurs in
the former than the latter. It must also be remem-
bered that in descending tuberculosis from the upper
portion of the urinary tract, the epididymis is exposed
first to infection, and the patients often succumb to
the primary disease and its complications before a
sufficient time has elapsed for the testicle to become
involved. There still prevails the greatest diversity
of opinion among pathologists and surgeons in regard
to the epididymis being most frequently affected in
cases of urogenital tuberculosis.
Councilman (System of Surgery, Dennis, Vol. i, p.
216) believes that in such cases the most common
seat of the primary disease is the epididymis. He
says : "It may be confined to this or the testicle may
be affected by continuity. The epididymis is con-
verted into a more or less firm, caseous mass. From
this the disease extends along thevas deferens, which
becomes enlarged, and on section the interior is found
to be lined with a whitish caseous tissue. In both
the vas deferens and epididymis, the seat of the dis-
ease is primarily in the epithelium, and later takes
the form of a tubercular inflammation. Seminal ves-
icles on the same side become affected in most cases,
or they may be passed by and the disease appear in
the prostate or bladder. Up to this point it is easy
to see how the infection has taken place. The exten-
sion has been in the direction of the secretion, and
the bacilli could be carried along with the secretion.
From the bladder the extension is in a direction oppo-
site to the flow of the secretion; with or without any
involvement of the ureter, infection of the pelvis"of
the kidney and of the adjoining kidney tissue takes
place. It is probable that the bacilli find suitable
conditions for growth in the ureter and grow along
the walls, just as on the surface of a solid medium,
until the pelvis of the kidney is .reached. There is
no other way for infection to take place from the blad-
der to the kidney than along the ureter. There is no
lymphatic or vascular connection. The proof that
this is the usual route of infection in genito-urinary
tuberculosis is shown by the certainty with which
the disease can be traced step by step, and the extreme
rarity of the disease in females as compared with
males. In some cases the disease appears to be pri-
mary in the kidney and the infection may take place
in an opposite direction."
My clinical experience corresponds with the views
of Councilman that in more than 50 per cent, of uro-
genital tuberculosis the disease has its primary start-
ing point in the epididymis.
We shall see in considering the etiology of this dis-
ease that there are many authorities who take the
opposite ground and affirm that urogenital tuberculo-
sis most frequently has its origin in the upper por-
tion of the urinary tract.
Etiology. — Aievoli (Eriberto sur la tuberculosi di
testiculo ed epididimo. Morgagni, p. 657, p. 728,
1891) made experiments on guinea pigs by injecting
into the testicle and epididymis tubercular material
and pure cultures of the tubercle bacillus. Only in
one case did he find tubercle bacilli in the lumen of
the seminal ducts, but in all instances there was pro-
duced an inter-canalicular proliferation, so that the
walls of the canals were perforated and large masses
with caseous centers were found in which pseudo
giant cells could be demonstrated. In some places
an attempt at cure by sclerosis could be found at the
same time, also tubercle production in the vicinity of
blood vessels and the interstitial tissue. He believes
that such an inter-canalicular tuberculosis is possible
without direct inoculation, as the bacilli may reach
the interstitial tissue through the lymph stream. The
results of these experimental reseaches are closely
allied with the observations of pathologists concern-
ing the gross pathologic anatomy of testicular tuber-
culosis. The disease in the epididymis is caused fre-
quently by a descending infection from the prostate
and seminal vesicles, but it may originate in the epi-
didymis primarily, as tubercle bacilli have been found
on several occasions in the seminal ducts in healthy
testicles in phthisical subjects. The process begins
in most cases in the epididymis in the form of con-
glomerate tubercles which are conspicuous for the
number and size of the giant cells. The tubercle ele-
ments are derived mostly from the interstitial con-
nective tissue, but part of the product may be fur-
nished by the epithelial cells and other tissues of the
seminal ducts. Infection may extend along the uro-
genital canal from the kidney to the testicle; as a
rule, however, tuberculosis of the testicle begins in
the epididymis. Sometimes the testicle and epidi-
dymis are affected simultaneously in cases of general
miliary tuberculosis. "The fact that the spermatic
258
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
[August 1,
artery divides when it reaches the epididymis may
account for the localization of the disease in the latter
organ; the slowing of the blood current always favors
bacterial growth. Infection may also occur through
the vas deferens. The conditions for localization of
the microbes after their entrance into the urethra on
their way to the vas deferens, are not so favorable as
in the latter organ." (White.)
The predisposing causes are: Inherited soil, ante-
cedent or coexisting disease of the testicle and trauma.
The disease begins more frequently in the globus
major than the opposite end of the organ. Later the
testicle and its envelopes are invaded by direct exten-
sion of the infective process from the epididymis to
those organs. Age appears to have a positive deter-
mining influence in the production of tuberculosis of
the epididymis and testicle. Salleron ascertained the
age in 47 cases of tuberculosis of the testicle with the
following result: 20 to 30 years, 36; 30 to 40 years,
6; 40 to 50 years, 4 ; 50 to 60 years, 1; total 47.
It appears that tuberculosis of the testicle is most
prevalent during the most active period of sexual
function, that is, in patients from 20 to 30 years of
age. Kocher remarks that the disease frequently
occurs in young men soon after marriage. This cor-
responds with my own personal observations.
Julien (De la tuberculose testiculaire. Arch. Gen.
1890) reports 17 cases of tuberculosis of the testicle in
children in the service of Lannelongue. Of these six
were less than two years of age; the remaining
patients were from two to thirteen years old. Hered-
ity could be traced in four of ten cases. The diseases
often appears in the acute form or at least with symp-
toms of a subacute orchitis. In twelve of these cases
the spermatic cord was affected. In four cases the
affection was complicated by hydrocele of the tunica
vaginalis, and in one case the prostate and vesiculae
seminales were implicated. In children there is lit-
tle, if any, tendency to the extension of the disease to
other organs. The affected organ is generally destroyed
either by ulceration or absorption, a complete resti-
tutio ad integrum being rare. In spontaneous cases
the organ atrophies and is usually covered by a pale,
adherent scar. Hutinel and Deschamps (Etude sur
la tuberculose des testicules des enfants. Arch. G6n.,
p. 257, 1891) maintain that tuberculosis of the testicle
in children is by no means infrequent. In children
the disease occurs most frequently in the form of an
acute infiltration. It is seldom a primary affection,
but forms a part of a general diffuse tubercular rjrocess.
The peritoneum especially is frequently involved.
The chronic form is often overlooked because it
occurs as a chronic, painless induration. Otherwise
the disease resembles the same affection in the adults,
resulting in caseation and abscess formation. It is
only in such cases that the authors favor an operation.
The results of castration in children are not encour-
aging. These authors are more inclined to conserva-
tive treatment by local applications and internal
medication.
Rintelen ( Ueber Hodentuberculose mit Beriicksich-
tigung des Doppelseitigen Auftretens derselben.
Inaugural Dissertation, Wtirzburg, 1881) collected
twenty-five cases of double tuberculosis of testicle
beside six cases which he saw in Rosenberger's clinic.
In fifteen of these sufficiently accurate data could be
obtained in reference to the course of the disease.
The right testicle was affected first ten times; in the
remaining cases the disease commenced in the left
testicle. In only one of these cases was the patient
less than ten years of age. Three of the patients were
from 20 to 30 years old, six from 30 to 40, and four-
teen more than 40. Of the last number most of the
patients were between 50 and 60 years of age.
Reclus ( Du tuberculose du testicule et de l'orchite
tuberculeuse. These. Paris, 1876) is of the opinion
that tuberculosis of the testicle can exist as a local
affection without any tendency to dissemination, local
or general. Clinical observation has shown that in
about one-half of all cases of testicular tuberculosis
pulmonary phthisis is absent, while autopsies show
that the lungs are not implicated in about one-third
of all the cases. In about 50 per cent, of all the cases
the disease is met with in persons before the age of
puberty, while it is found in about 2.5 per cent, of
all patients suffering from pulmonary tuberculosis in
persons over 15 years of age.
As exciting causes most authors enumerate trauma-
tism and chronic gonorrheal inflammation in the pos-
terior portion of the urethra and the epididymis.
Cryptorchism is mentioned by Nepveau and Kocher
as one of the most potent of the exciting causes.
Gonorrheal epididymitis is mentioned frequently as a
precursor and often imparts to the tubercular process
a very malignant type. Such a case is reported by
Birch-Hirschfeld. (Archiv f. Heilkunde, 1871, H.
6.) A soldier, 24 years of age, who was in perfect
health, contracted gonorrhea, which led to acute epi-
didymitis. In the course of eight days he died of
miliary tuberculosis. Miliary tuberculosis is found
in the peritoneum, especially well marked at the
internal inguinal ring on the side of the affected
testicle; miliary tuberculosis of the pleura?, lungs,
meninges, liver, spleen and kidneys. The epididymis
was found transformed into a cheesy mass. In the
testicle itself numerous intercanalicular miliary tuber-
cles were found and a few cheesy nodules the size of
a pin. According to Salleron (Arch. G6n. de Med.,
July and Aug., 1869), of fifty-one cases of tuberculosis
of the testicle, four times the testicle was affected,
thirty-seven times one epididymis, ten times both epi-
didymes. With the exception of tuberculosis of the
remaining genito-urinary organs, he saw tuberculosis
of other organs only in one case. Only in two cases
did the disease prove fatal. Of forty-seven cases,
thirty-six were from 20 to 30 years of age. It will be
seen from the statistics that have been quoted that
while no age is entirely immune to tuberculosis of the
epididymis and testicle, the disease occurs most fre-
quently in men from 20 to 30 years of age, at a time
when the sexual organs are in a state of highest phy-
siologic activity. As exciting causes figure most
prominently gonorrheal epididymitis and traumatism.
Sir Astley Cooper in his classical work (Observa-
tions on the Structure and Diseases of the Testis,
London, 1841, p. 162) gives the following pathologic
description of what he called scrofulous inflammation
of the testis: "Upon examining the epididymis and
testis, when affected with this disease, I have found
a yellow spot in the former, surrounded with a zone of
inflammation. When the spot ulcerates in the center,
the matter which it contains is not pure pus, but it is
composed of fibrin and serum, with a slight yellow
tinge. I have seen such spots in the globus minor,
but more frequently seated in the globus major of the
epididymis. In the testis there are generally several
similar spots, accompanied by the same inflammatory
zone; and yellow streaks are also found amidst the
lS-.ttV]
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
259
tulmli. Scrofulous abscesses in the testis are some-
times accompanied by a granular swelling, liko that
which exists in the simple chronic diseases."
That the tubercular nature of the majority of cases
of chronic inflammation of the testis has been admit-
ted only for a comparatively short time is evident
from a paper written in 1870 by B. Beck (Zur Kas-
igen Infiltration und multiplen Abscessbiklung des
Bodens. Deutsche Klinik, No. 1 u. 2, 1870). He
insisted that it would become necessary to separate
from what had formerly been included under the head
of scrofulous affections of the testicle some cases
which were of a tubercular nature. The tubercular
form of orchitis he claimed seldom, if ever, existed as
an isolated affection; the complicating tubercular
affections in other organs he regarded as an impor-
tant diagnostic aid in differentiating between the
tubercular and scrofulous forms of inflammation of
the testicle. Miliary nodules of the testicle he saw
only onee in the case of a child who died of miliary
tuberculosis.
Pathology. —The naked eye morbid appearances of
tubercular epididymitis and orchitis are fairly well
understood by the mass of the profession. We find
there as elsewhere the same retrograde metamorphoses
of the tubercular product, coagulation- necrosis, casea-
tion, and in the majority of cases liquefaction of the
caseous material, only exceptionally arrest of the dis-
ease and calcification of the degenerated products of
the tubercular inflammation. Some doubt still
remains in reference to the primary starting point of
the inflammatory process and the histologic structure
of the tubercle tissue and the manner of local dissemi-
nation of the disease. Reclus ( Du Tubercle du Testi-
cule et de l'Orchite Tuberbuleuse. These, Paris,
lSTtl ) makes a sharp distinction between tuberculosis
of the testicle and the epididymis. According to this
author tuberculosis of the latter nearly always occurs
in the caseous form. Occasionally it presents itself
in a reticulated form, composed of the sections of the
dilated convoluted tubules of the epididymis, the
caseous contents of which has fallen out. Very often
the vas deferens is affected, but according to Reclus
never farther than 5 to 6 ctm. from the epididymis,
an observation which does not correspond with ths
author's experience, who has repeatedly found the
entire cord involved from the epididymis to the semi-
nal vesicles.
Reclus recognizes the independent localization of
the tubercular process in different parts of the genital
tract and places little weight on the descending or
ascending theory of the infective process, as he has
repeatedly found tubercular nodules of the same age
and size in the epididymis and prostate. In 79 cases
he examind in vivo, he found the disease unilateral
in 21, while the seminal vesicles were invariably
affected on both sides. That this observation is not
entirely reliable becomes very evident from Fenger's
case related above. It is generally conceded that the
epididymis is much more frequently affected than the
testicle because reliance was mainly placed upon the
results of clinical examinations. In thirty-four
autopsies Reclus found the epididymis affected singly
in only seven instances, twenty-seven times simul-
taneously with the testicle. Tuberculosis of the tes-
ticle without a similar affection of the epididymis is
an exception, as he found only three such cases in
literature. In the testicle the tubercular process is
met with either in the form of caseous foci, miliary
infiltration, or both forms are combined. The arrange-
ment of the tubercles is usually symmetrical, corre-
sponding to the division of the seminal tubules. The
nodules are generally found in the periphery of the
organ, while the caseous foci are centrally located.
Fibrous tubercles which pursue a chronic course are
also found in the testicle. Microscopic examina-
tions have satisfied Reclus that the miliary form can
not be separated so easily from the caseous variety as
taught by Virchow. With Malassez, he locates the
primary nodules in the walls of the seminal tubules,
and not as was done by Tizzoni, Gaule and Steiner,
in the inter-canalicular connective tissue. He was
able to remove the nodules when he resected portions
of the seminal ducts showing their connection with
the ducts. He believes that the process begins in the
endothelial envelope which surrounds the tubules,
which according to Ranvier, constitutes a continuous
sheath of all tubules, and maintains that the interior
of the lumen is affected secondarily. During the
progress of the disease " granulations composers "
are found which can only be isolated with portions of
several tubuli seminiferi. While this histologic
process is regarded by the author as characteristic of
testicular tuberculosis, in the epididymis the process
begins in the subepithelial elements of the tubules.
The microscopic appearances of tubercle tissue in the
parenchyma of the testicle is the same whether the
disease occurs as a primary affection, or in conse-
quence of extension from the epididymis. In the
primary form the foci are few and large, varying in
size from a hazelnut to that of a walnut. During the
early stages of the disease the nodules are much
firmer than the surrounding normal parenchyma of
the organ. The mass is surrounded by a vascular
zone. Central caseation, softening, abscess formation
and perforation often follow in quite rapid succession.
If the disease of the testicle is secondary to tubercu-
losis of the epididymis the nodules are more numer-
ous and the disease presents more the appearance of
an infiltration. The tubercles are found between the
seminal tubules which are separated from each other
by the tubercular product. The interstitial connec-
tive tissue as well as the adventitia are infiltrated with
small round cells. The vascularity of the affected part
is at first increased, but as the nodules increase in size
the vessels disappear in the center and with them the
tubules. According to Rindfleisch, only the adven-
titia disappears, while the propria becomes edematous,
but remains and can be identified in the cheesy
product for a long time.
Curling (On Diseases of the Testis, Philadelphia,
1878, p. 335) in the later addition of his work has
expressed the opinion that the disease is originally
developed within the tubules of the testicle, and the
result of microscopic examinations have induced him
to adopt this view. He continues and says, "Ana-
tomic considerations indeed support the opinion that
abnormal nutrition in the cellular contents of the
tubes induces the formation of miliary tubercles in
their walls without at all negativing the development of
tubercle in the intertubular tissue as seen by Virchow,
or in the adventitia of the blood vessels as observed
byNepveau. Indeed, the discrepant views upon the
matter may be explained by assuming that different
observers have regarded. what has been found in particu-
lar cases as the result of some general law. With ref-
erence to this the suggestion of Klebs is valuable.
Admitting that in acute miliary tuberculosis where
260
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
[August 1,
the dissemination of the virus is effected by the vas-
cular system, the blood vessels and their surroundings
are the seat of the tubercles, he has seen preparations
by Langhans where the tubercles were in the interior
of the tubule, and Klebs adds that "It would be very
desirable to ascertain whether this was uniformly the
case in the so frequent extension of tuberculosis from
the older nodules in the epididymis to the body of the
testis."
Salleron (M6moire sur l'affection tuberculeuse des
organes g^nitaux de l'homme. Archiv Gen. de M6d.,
July and August, 1869) as early as 1869 observed in
his military practice fifty-one cases of tuberculosis of
the testicle. The testicle itself was affected only four
times, the epididymis on one side thirty-seven times,
on both sides nineteen times. Only in one case was
he able to ascertain intra vitam the existence of pul-
monary tuberculosis, a fact which is in opposition to
the experience of Curling and Louis, but which he
supported by nine accurately reported cases and two
autopsies. With the exception of the vas deferens
and the seminal vesicles, he found the remaining por-
tion of the urogenital tract free from tuberculosis.
Years ago Friendlander found miliary tubercles in
the testicle in cases in which no other organ was found
affected. (Sammlung Klinischer Vortrage, 1873).
Nepveau (Contribution a l'etude les tumeurs du tes-
ticule, Paris, 1872) found miliary tubercles upon the
walls of blood vessels in diseased testicles complicat-
ing secondary renal and primary pulmonary tuber-
culosis.
Rindfleisch calls attention to the unusual size of
tubercles in tuberculosis of the testicles which, accord-
ing to his observation, vary from the size of a pin's
head to that of a walnut. In the testicle the first
infiltration usually shows itself as fibroid tubercle, as
a light yellow or grayish white hard and tough nodule
in the parenchyma of the organ. In miliary granu-
lations the tubercle appears under the microscope as
described by Langhans, in the center a giant cell,
around this epitheloid cells, and in the periphery a
small round celled infiltration, the cellular elements
imbedded in a reticulum of connective tissue. Kocher
(Krankheiten des Hodens, Nebenhodens und Samen-
stranges. Pitha u. Billroth, Bd. m, p. 3, B. p. 273)
is also of the opinion that the primary starting point
of the disease in the epididymis is in the intertubular
connective tissue. The contents of the tubules are
increased by proliferation of the preexisting tissues of
their walls. The infection begins most frequently in
the globus major and extends from here to the re-
maining parts until the entire organ is transformed
into a hard nodular mass. Cheesy degeneration of the
contents of the tubules results in destruction of their
walls and coalescence with the intertubular- products,
when a tubercular abscess forms which frequently
ruptures spontaneously.
Gaule (Anatomische Untersuchungen ilber Hoden
tuberculose. Virchoic's Archiv, Bd. lxix, pp. 64 and
213, 1887) regards tuberculosis of the testicle as a
catarrhal inflammation of the epithelial lining of the
seminal tubules which leads to stagnation of the
secretions and caseous degeneration of the inflamma-
tory product which, owing to the thinness of their
walls, are prone to undergo ulceration. According to
this author the process begins in the epididymis and
later extends to the testicle, where it assumes another
character, as the intertubular connective tissue soon
takes part in the process of tissue proliferation. In
the epididymis the process is apt to remain circum-
scribed and favorable to the development of a fibrous
nodule limited to the interior of a single tubule.
While the contents of the nodule may undergo case-
ation, the existing irritation extends to the adjacent
intertubular tissue and gives rise here to fibrous' pro-
ducts frequently in the vicinity of the septa. Later
adjacent tubules are included in the process and
undergo similar changes, constituting the condition
described by Reclus as "granulations composees."
The local and general dissemination of tuberculosis
of the testicle and epididymis are well shown by the
observations of Guyon. (Clinique des maladies des
voies urinaires a Necker. La Castration pour Sarco-
cele; Ann. des mal. des org. gen. urin. p. 445, 1891.)
He found in twenty-eight postmortems on persons
the subject of tubercular disease of the testicle that
the lungs were affected in only eleven. In 222 clin-
ical observations on patients suffering from urogenital
tuberculosis which he examined during a period of
twenty-five years, forty were cases of isolated genital
tuberculosis, seventy-four of the urinary organs, and
only 108 of combined urogenital tuberculosis. Of
forty-two additional postmortems, one was a case of
isolated genital tuberculosis, fourteen cases of com-
bined tuberculosis of the urinary organs, and twenty-
seven of combined urogenital tuberculosis. Seldom
is the testicle or epididymis the only part affected.
He believes with Lanceraux that the tubercular process
begins very frequently in the vesiculae seminales.
In thirteen cases all of the genital organs were affected.
In 127 clinical cases in persons before the age of
puberty, suffering from urogenital tuberculosis, the
prostate was affected fifty-six times, prostate and sem-
inal vesicles eleven times, the epididymis alone two
times, all of the genital organs fifty-eight times.
Among these there were two cases in which it could
not be positively ascertained that the prostate was
involved and the same uncertainty existed in refer-
ence to the seminal vesicles in six cases. According
to these statistics the course of the disease in men is
therefore more in the direction from within outward
than from without inward, a fact which Guyon
advances as a warning against the too frequent per-
formance of castration. Not infrequently the tuber-
cular affection extends from the epididymis or testicle
to the tunica vaginalis.
Simmonds (Ueber Tuberculose der Scheidenhaut
des Hodens. Deutsche Zeitschrift f. Chir. Bd. xviii,
p. 157) made a careful examination ef eight tubercu-
lar testicles obtained from six patients operated upon
in the clinic at Kiel, and postmortem specimens
obtained from the hospitals at Hamburg, in all twelve
testicles. In eight of these specimens tubercles were
found in Ihe tunica vaginalis, in one case the testicle
was atrophied, while in three specimens the tubercu-
lar process was not far advanced. These cases appear
to prove the incorrectness of the statement made by
Klebs that the tunica vaginalis is never affected, at
the same time they call the attention of the surgeon
to the necessity of examining the tunica vaginalis
carefully and subject it to operative treatment, if the
disease has extended to it in cases of tuberculosis of
the testicle treated by castration.
Symptoms and Diagnosis. — Tuberculosis of the
testicle and epididymis is a very insidious disease. It
is often overlooked by the patient for a long time and
frequently erroneously diagnosticated by the phy-
sician. In the absence of tuberculosis of other por-
18%.]
TUBERCULOSIS OP THE MALE GENITAL ORGANS.
261
lions of the genital organs and the urinary tract, the
disease usually begins in the globus major of the epi-
didymis, much less frequently in the body or opposite
pole of the organ, as a hard, almost painless, swelling.
During the progress of the disease additional nodules
form and very frequently the patient's attention is
attracted by a more rapidly increasing swelling, a
complicating hydrocele. The absence of any well
marked symptoms during the incipiency of the dis-
is the reason why sueh eases come so rarely
under the eare of a surgeon at this time. From the
glolms major the disease spreads to the body and
globus minor and then extends along the vas deferens.
After an elaborate description of the signs and
symptoms of scrofula, Sir Astley Cooper (Op. cit. p.
160) gives a very vivid clinical picture of what was
then considered as scrofula of the testicle in the fol-
lowing language: "One of the testicles, even in very
young children, sometimes becomes enlarged and.
very hard, but without pain or any other inconve-
nience, and the disease is accidentally discovered by
the parents or servant. In this state of indolent
increase it remains for many weeks, months or years,
and then, under improvement of the general health,
the enlargement subsides and the gland resumes its
former state. More frequently it enlarges at the age
of puberty, and from that period to twenty years, and
not infrequently this disease appears in both testes,
marked by the same hardness, and such absence of
suffering, that the person does not for a length of
time seek any medical aid respecting it. The part is
free from pain as well as tenderness. The scrotum
is unaffected; its veins are not enlarged; and, but
from its bulk, the patient suffers no inconvenience,
but even in children, although more frequently at
puberty, the inflammation sometimes proceeds to
suppuration; this generally occurs within the globus
major of the epididymis, but I have known abscesses
form in the cauda or small extremity of that organ.
The body of the testicle but rarely suppurates, until
after the epididymis has ulcerated, when the testis
becomes affected and the scrotum puts on a livid hue.
Ulceration next ensues, indicating the presence of an
abscess, which discharges ill-formed pus and some
semen; if after the age, the opening under these cir-
cumstances is extremely difficult to heal, continuing
for months and even for years before it closes. In
some persons one abscess after another forms and dis-
charges, and when one testis has suppurated, if the
other has been hard, it is liable to put on the same
action, discharges itself and continues equally obsti-
nate, resisting all the means of treatment for a greater
length .of time. Ultimately the testes diminish,
secrete but a small quantity of semen, and they con-
tinue to waste until but little of them remains and
their function almost entirely ceases." Astley Cooper
and his contemporaries had no correct idea of the
intrinsic tendencies of tubercular inflammation of the
testicle to extend to the remaining organs of the gen-
ital tract and the urinary apparatus. The essential
clinical features of this disease have been elaborated
since their time.
Reclus (Op. cit.) is of the opinion that chronic
orchitis and epididymitis are often confounded with
tuberculosis. The abundance of interstitial connec-
tive tissue produced in the course of these affections
leads constantly to progressive atrophy. These con-
ditions are often characterized by a nodular condition
of the swelling which resembles so closely tuberculo-
sis.
They occur either in the course of an acute, or
begin as a chronic process. Usually, however, the
swelling is much more marked than in tuberculosis.
If the testicle alone is affected it finally is reduced in
size to that of a bean behind the normal epididymis.
Kocher regards as the most characteristic symptoms
of tuberculosis of the testicle and epididymis rapid
development of swelling and early softening of the
inflammatory product and the absence of acute sub-
jective symptoms. According to this writer the maxi-
mum swelling is often reached in eight days, or at
least in a few weeks which soon softens and perfor-
ates, resulting in the formation of a fistula which may
continue for years, the swelling remaining stationary.
Kocher's observations in regard to the acuity of the
local development do not correspond with the result
of my own experience. Such a course is an excep-
tional one.
Barling (Double Acute Tubercular Disease of the
Testis, London Lancet, April 9, 1892) describes a
case of double galloping tuberculosis of the testicle,
an affection to which Duplay called the attention of
the profession as early as 1876. The patient was 30
years of age, who five hours after a severe external
injury noticed quite a large swelling of one of the
testicles. One of the interesting features in this case
was the fact that the epididymis was free, the disease
being limited to the testicle. In a short time the
opposite organ became similarly affected. Examina-
tion of the testicles after castration showed in each
of them cheesy cavities, a large one in the right and
a number of small ones in the left. The immediate
vicinity of the cavities was occupied by a dense and
greatly increased connective tissue. In one place in
a cavity tubercular bacilli were found, but the most
patient search did not result in finding giant cells.
The whole process was characterized by an infiltration
with granulation and epithelioid cells combined with
catarrh of the seminal tubules, followed by caseation.
I can readily understand that in the event tubercu-
losis develops in a testicle or epididymis the seat of
an injury or antecedent inflammatory disease, that it
might in rare cases pursue such an acute course, but
in the majority of cases it is noted for its insidious-
ness and chronicity. The patient's attention is usu-
ally first attracted by slight pain or discomfort and
tenderness in some part of the gland, generally the
epididymis, which on examination is found to be
somewhat enlarged, prominent, nodular and indurated.
The state of the testicle is often marked by circum-
scribed effusions of fluid in the tunica vaginalis, the
surfaces of this membrane being partially adherent.
The disease often remains stationary for months, a
year or more. During the course of the disease one
of the prominences begins to increase, so as to be
observed externally, and to feel more painful and
tender; the skin over it becomes adherent, changes to
a livid color and ulcerates, when the softened cheesy
material is evacuated. The abscess formation is gen-
erally followed by a fistula which communicates with
the primary tubercular focus. Similar changes may
take place in other parts of the testicle, resulting in
two or more sinuses leading into the interior of the
gland. If all of the tubercular material is eliminated
in this manner, the sinuses after a long time may heal,
leaving the testicle usually in an atrophied condition.
The disease may remain limited to one testicle, or
after months or years make its appearance in the
opposite organ. As a rule, the vas deferens is early
262
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
[August 1,
affected, the infection often extending its entire length
in a short time. In primary tuberculosis of both tes-
ticles both vasa deferentia may remain intact. The
tunica vaginalis is usually implicated in the form of
an adhesive periorchitis. As this affection is not
attended by any well-marked clinical symptoms, its
existence can be surmised by the appearance of hydro-
cele. The hydrocele, usually of a serous type, may
attain a considerable size, but more frequently it is
circumscribed. In rare cases the vaginalitis is of a
suppurative type, and then makes its appearance under
the clinical picture of an acute abscess. Tubercular
affections of other organs precede or occur simultane-
ously with the tubercular orchitis. Next to the vas
deferens the disease extends most frequently to the
seminal vesicles, next the lateral lobes of the prostate
are most frequently implicated. From here the dis-
ease is prone to involve the urinary organs, first the
bladder, next the ureter, and finally the kidney.
In the differential diagnosis must be considered
acute and chronic inflammations of another type and
syphilitic affections. In tuberculosis the swelling in
the epididymis is usually larger than in other forms
of inflammation. Tenderness and pain are conspicu-
ous symptoms in gonorrheal epididymitis, absent or
slight in tuberculosis. If any doubt exists in the
diagnosis between gumma and tuberculosis the patient
should be given the benefit of the doubt, and should
be subjected for a sufficient length of time to an active
antisyphilitic treatment. The tubercular inflamma-
tion is clinically characterized by periodic exacerba-
tions. Examination of the remaining genito-urinary
organs for tuberculosis, as well as the more distant
organs in which this disease is liable to appear, is
absolutely necessary and will often clear up a doubt-
ful diagnosis. In tuberculosis the indurated vas
deferens is not tender to pressure and is usually nod-
ular, while f uniculitis caused by other forms of infec-
tion is attended by pain and tenderness.
Treatment. — The rational treatment of tuberculosis
of the testicle and epididymis must necessarily depend
on the location, stage and extent of the disease, and
the existence or absence of complications. In miliary
tuberculosis involving the organs on both sides, the
treatment must be supporting and expectant, as in
such cases a speedy fatal termination is inevitable
from the primary pulmonary affection or diffuse mili-
ary tuberculosis. In tuberculosis involving other
parts of the urogenital organs the treatment must be
directed accordingly. Tuberculosis implicating the
organs on both sides simultaneously, or in succession,
is almost positive proof of the existence of an older
tubercular process in some other organ, or the exten-
sion of the tubercular process along the genital tract
beyond the reach of successful surgical treatment.
The cases best adapted for successful local treatment
are those in which the disease appears as a chronic
affection and is limited to the organs on one side, with
limited or no extension along the vas deferens. Tuber-
culosis of the epididymis leads to impotence if both
organs are affected. If the disease is limited to one
side, function may remain unimpaired. Castration
must therefore be regarded as the normal procedure
in cases of uncomplicated, unilateral tubercular epi-
didymitis. This statement becomes more apparent
and forcible when we consider that reinfection can
always occur if the diseased organ is permitted to
remain. As positive contraindications to castration
must be considered the following:
1. Extension of the tubercular process to parts not
within reach of a radical operation.
2. Tuberculosis of both testicles, as the second
organ is usually involved by extension of the infec-
tion from one to the other through the vasa deferentia.
3. Tuberculosis of important adjacent or distant
organs.
Castration may become necessary as a palliative
operation for the relief of symptoms in cases where
the disease has resulted in the formation of tubercular
abscesses and suppurating sinuses. A great diversity
of opinion still prevails among surgeons regarding
the value of castration in the treatment of tubercu-
losis of the testicle and epididymis. The results fol-
lowing this operation appear to have been quite at
variance in the hands of different operators.
Terillon (Essai Critique sur la traitement de la
tuberculisation du testicule. Bull. Gin. Th4rap., p.
140, 1882) favors castration, and advises that the
operation should be performed before abscesses have
formed, as by removing the source of suppuration the
general condition of the patient is improved. He
regards pulmonary tuberculosis as an absolute contra-
indication to castration. Simultaneous tuberculosis
of the prostate and seminal vesicles may or may not
be regarded in the same light, according to circum-
stances. Richet is nearly of the same opinion in
reference to the indications for castration, only he
opposes the operation more decidedly when extension
of the disease to other parts of the genital tract has
occurred.
Stenger (Inaugural Dissertation, Berlin, 1889)
gives the result of thirteen cases of castration for
tuberculosis of the testicle which occurred in the
Royal Clinic at Berlin from 1883 to 1889. Seven of
the patients remained free from local recurrence or
evidences of infection of any other organ at the time
the report was made. In three of the cases tubercu-
losis of other organs existed at the time the operation
was performed, and in the last three cases the final
result could not be ascertained. In seven other cases
the tubercular product was removed by vigorous use
of the sharp spoon, in five with a satisfactory result,
and in two pulmonary infiltration existed at the time
the operation was performed, which progressed unin-
fluenced by the operation. From a study of these
cases he came to the conclusion that the timely remo-
val of the diseased organ, or a thorough local opera-
tion, is instrumental in preventing general infection.
Finkh (Ueber die Endresultate der Castration bei
Hodentuberculose. Beitrdge zur Chirvrgie, Bd. ii,
p. 407) has ascertained the ultimate results in twenty-
nine cases of tuberculosis of the testicle treated in
Brans' clinic at Tubingen by castration. Of these
cases the right testicle was affected twelve times, the
left eight times, and nine times both testicles were
diseased. At the time the report was made in 1886,
fourteen were living and free from relapse or tuber-
cular disease of any other organ. Among these were
nine in which one testicle was removed and five double
castrations. Of those that died, eight succumbed to
non-tubercular affections. Of these five were single
and three double castrations, the former with a period
of immunity varying between three-fourths to twenty-
two years, the latter with from five to thirty years.
To these must be added a case of double castration
in which death occurred twelve days- after operation
from exhaustion. Six died of tuberculosis, all single
castrations, and of these only in one case did the dis-
is;).;, j
TUBERCULOSIS OF THE MALE GENITAL ORGANS.
263
awe extend to other parts of the genital tract. In
one case life was prolonged for four years, and against
the six who died of tuberculosis stood thirteen who
remained well after five years and more. The infected
pelvic portion of the cord furnishes, according to this
author, no contraindication to an operation, as in seven
eases in which this condition was found the result of
the operation proved satisfactory. These results are
certainly more favorable than those which are obtained
by the average surgeon. In my own cases I have fre-
quently observed relapse in unilateral castration, and
in two cases of double castration the disease, after a
year or two, attacked the seminal vessels, prostate and
bladder, and finally death resulted from tubercular
pyelonephritis.
It seems to me that the cases are exceptional in
which double castration is justifiable. Castration
appears to have yielded satisfactory results in cases in
which the disease was unilateral and the testicle was
removed before the disease had extended to other
parts of the genital organs. The reports of a num-
ber of cases in which the disease was unilateral and
com plicated by tubercular vesiculitis, treated by cas-
tration and excision of the seminal vesicles and even
a portion of the prostate, resulted favorably. In the
removal of a tubercular testicle it should be taken for
granted that the vas deferens is infected, and as much
of this structure as possible should be excised.
Conservative operations of different kinds have
been made for a long time in the treatment of the so-
called scrofulous testicle. Malgaigne excised caseous
nodules with the bistoury; Delpech, Boyer, Velpeau,
Bonnet and Bouisson gave preference to chemical
caustics, such as chlorid of zinc, caustic potassa and
Vienna paste. Later Verneuil recommended the
actual cautery which was replaced later by the Paque-
lin cautery. The use of the therm o-cautery is strongly
recommended by Forgue and Reclus (Traits de Th6-
rapeutique Chirurgicale T. ii, p. 912) in cases in
which the cheesy deposits are few or single. The
same authors are in favor of iodoform-ether injections
10:90 when the affection is more diffuse. A few drops
of this solution are injected into each nodule and the
little punctures sealed with iodoform collodium. In
- not amenable to conservative treatment they
recommend without hesitation castration. I have
used for some time parenchymatous injections of iodo-
form glycerin emulsion during the early stages of
tubercular epididymitis with the most satisfactory
results. With a small trocar the epididymis is pene-
trated from end to end and the injection made slowly
as the canula is withdrawn. Under moderate pres-
sure from one drachm to a drachm and a half of the
emulsion can be injected, thus permeating the affected
tissues with the anti-bacillary agent. The injection
should be repeated every week or two. I' the disease
is complicated by hydrocele the fluid should be evac-
uated and a small quantity of emulsion injected. The
pain following this treatment only lasts for a short
time. For a few days the swelling increases and ten-
derness is more marked. The increased tissue prolif-
eration which is excited by the action of the iodoform
is a potent element in arresting the extension of the
disease and in preventing further degenerative
changes in the tubercular tissue.
Terillon (De l'intervention chirurgicale dans la
tuberculose testiculaire. Progres M6d., No. 3, 1886)
has given evidement and iodoform gauze tamponnade
a fair trial in the treatment of tuberculosis of the epi-
didymis advanced to the stage of abscess and fistula
formation, but on the whole he gives castration the
preference as he believes evidement, cauterization and
drainage as a rule yield only temporary beneficial
results.
Keyes (Animal of the Universal Medical Sciences,
1892, Vol. in, page 3.) removed by means of the
curette the whole tubercular epididymis, a section of
the spermatic cord being then found to be extensively
ulcerated; an inch and a quarter of that was removed.
The function of the testicle had been already destroyed
by cheesy foci along its course, and the patient knew
he was practically castrated before the operation was
undertaken, but he was much more pleased with the
result than if the testicle had been removed. The
wound healed rapidly by first intention, the relief of
the patient being complete.
Villeneuve {Marseille MMicale, July 30, 1889)
prefers thorough cauterization with the Paquelin
cautery to castration in the treatment of tuberculosis
of the testicle. He cites cases and defends his position
by what appears to be plausible reasoning. Kocher
uses the sharp spoon, followed by the application of
a solution of chlorid of zinc 1 : 4, or repeated applica-
tions of the strong tincture of iodin when the disease
has advanced to the formation of abscesses and fis-
tula?.
Lannelongue speaks highly of a solution of a chlorid
of zinc as a parenchymatous injection before suppura-
tion has occurred. The injection is made around and
not into the tubercular infiltration.
Ozenne (Gazette des Hopitaux, Feb. 23, Aug. 9,
1893) reports success in one case of tubercular epi-
didymitis and favorable progress in a few others, from
injections of 10 per cent, solution of chlorid of zinc,
after the method of Lannelongue. In the successful
case he injected at four sittings in seven different
places of the diseased area, 2 drops at each puncture.
Moderate, temporary reaction followed. Some months
later, one little tubercular nodule remaining, a single
injection was given. After the last treatment all
active signs of the disease disappeared. From what
has been said on the treatment tuberculosis of the
testicle it is evident that this subject remains an open
chapter. In recent cases of primary tuberculosis
parenchymatous injections of iodiform glycerin emul-
sion or chlorid of zinc deserve a trial. If this treat-
ment does not prove satisfactory after a fair trial,
castration should be performed before the disease
extends to additional organs. In limited abscess for-
mation the use of the sharp spoon and iodoform gauze
tampon may prove efficient, but if the disease resists
these measures castration is absolutely indicated. If
the disease is bilateral palliative treatment should take
the place of a radical operation in the majority of cases.
Castration is positively contraindicated when the
tubercular affection of the testicle is complicated by
tuberculosis of any important internal organ. Simul-
taneous tuberculosis of the prostate and seminal ves-
icles does not necessarily contraindicate castration.
Cascarin as a Substitute for Cascara Sagrada. — Cascarin is the
active principle of the bark of the rhamus purehiana, and is anal-
ogous to, if not identical with, the frangulin contained in the
bark of the frangula. Schoenlaub recommends it as a substitute
for cascara sagrada in habitual constipation, one to four pills at
night, each 0.1 gram. It produces a sure and certain effect,
while it never gripes. — Nouveauv Remldes, June 8, from Swiss
Woch. f. Chem. and Pharm., No. 12.
264
MALAKIA.
[August 1,
MALAKIA.
BY ELLSWORTH D. WHITING, A.B.
AURORA, ILL.
(The L. P. C. Freer Prize Essay, Rush Medical College, 189C.)
(Continued from page 210. )
In describing the quartan parasite the writer will
use as a clinical illustration a patient who came under
his personal observation.
Jan. 15, 1896, there appeared before Prof. H. M. Lyman's
medical clinic a case of malaria. Judging the case of more
than ordinary interest the writer made special investigations,
obtained a full history, made as many blood preparations as
possible and through the courtesy of Prof. James B. Herrick
obtained a thorough physical examination.
Peter A., age 34 years ; born in Germany. Came to America
fifteen years ago. Lived in Pittsburg five years. Since then
has lived continually in Chicago with the exception of short
visits to Jamaica, W. L, and Memphis. Single ; locomotive fire-
man by occupation.
Family history — Father and mother dead. Cause unknown.
Brother and sister died from a lingering disease. Personal
history — regular in habits of eating and sleeping. Drinks
whisky, tea and coffee moderately. Previous illness — when
twelve years of age had typhoid fever. Twelve years ago had
yellow (examination of the eye was made by Dr. Hinde). 7.
Tongue moist and slightly coated, mucous membrane red.
8. Ears normal. 9. Thorax— heart, relative dullness begins
at third rib, apex beat one inch inside nipple line in fifth inter-
costal space. Pulse, regular, strong, full ; 60 beats per min-
ute. Very slight systolic murmur over mitral area and pul-
monic area. No accentuation of aortic or pulmonic tones.
10. Abdomen— liver slightly enlarged. Relative dullness
begins in right border sternum at fifth rib. Flatness begins in
mammary line in fifth interspace. In full inspiration these
limits are lowered one and one-half inches. In mammary line
there is flatness to costal arch. On deep inspiration sharp
edge of liver can be felt. In paracostal line flatness extends
two fingers below costal arch. 11. Spleen — readily palpable.
Dullness begins at seventh interspase. 12. Legs — on right
shin is large pigmented scar said to have been produced by a
red hot iron. Three pale parchment-like scars higher up upon
same leg. On outer aspect of same leg is a linear non-pigniented
scar caused by a scythe. 13. Genitals— a nodule the size of a
hazelnut is found in left epididymis. 14. Reflexes — normal, no
ankle clonos. 15. Sensation normal. 16. Temperature 98.8° F.
Upon microscopic examination of the blood of this
patient a very interesting phenomenon was disclosed.
Although in small numbers, quartan parasites were
present, associated with many tertian forms. This
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Plate XV. — INTERMITTENT QUARTAN FEVER. TEMPERATURE CHART.
severe cold and spit some blood with great quantity of slimy
mucus. Seven years ago while in Memphis had malaria, which
easily succumbed to quinin. Two years ago had gonorrhea
with swollen testicle. Fourteen months ago had hard chancre
followed by adenopathy. No eruption or falling out of hair.
Had rheumatism to slight extent.
Present illness : July 4, 1895, while working on a railroad
tunnel in Jamaica, was stricken down with severe chill, which
lasted one and one-half hours. This chill was followed by a
burning fever, profuse perspiration and great prostration.
Patient was confined to the bed for one week and had a chill
every fourth day during July and August. During September
and October about once a week chill would occur every other
day. These chills increased in frequency until when he pre-
sented himself before the clinic he was suffering from quoti-
dian paroxysms. During the paroxysms patient complains of
frontal headaches, dizziness, ringing in the ears, spots before
his eyes and pain in the back and limbs. He is weak and
complains of dyspnea on exertion. Has taken some quinin,
which has had no effect upon the disease.
Physical examination: Jan. 17, 1895, 4 p.m. 1. Height 6
feet. 2 Weight 165 pounds. 3. Body well nourished, very
muscular, large boned and well developed. 4. Mind clear.
5. Skin — face, arms, neck and back tanned ; says back is
tanned from bathing. 6. Eyes, pupil moderately dilated,
react to light ; movements and retina normal ; sclera slightly
condition illustrates and corroborates the experiments
made by Di Mattei, who substituted one type of
malaria for another. There is probably little doubt,
as this patient was an intelligent man whose word
may be relied upon, but that this fever was primarily
quartan and that subsequent to the first a second
infection was incurred with a group of tertian organ-
isms. The latter parasites upon development, caused
the gradual extinction of the quartan forms produc-
ing paroxysms peculiar to their type. In the case
cited by Di Mattei the extinction of the original type
was accomplished in a much shorter time than in this
instance. (Plate xv.)
These two types of the parasite, in some cases lying
side by side, furnished excellent opportunity for
studying their points of difference.
As the tertian organism has been previously
described, a description of the quartan will be given
by comparing and contrasting the latter with the
former.
In the hyalin forms these types can not be differ-
1896.]
MALAKIA.
265
satiated, though the quartan is more refractive and
more sluggish in its movements. These appear dur-
ing and after the paroxysm, as in the tertian. (Plate
x, Figs. 1 and 2.)
As the organism grows and pigment develops,
the organism as a whole, is much slower than that'of
the tertian parasite as shown by the length of time
required in changing its shape. (Plate x, Figs. 6
and 7.)
As the parasite continues to grow the conditions of
W
Plate X. The Parasite of Quartan Fever.— 1.2, Hyalin Bodies; 8,4.5, 6, 7, Pigmented Bodies; 8, Fall grown Organism: 9, 10,11, Segment-
ing Forms; 12, Spores. MaguiflcationZ— eiss Obj. 1-12 oil, Oc.5.
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Plate XII. The Parabite of Akstivo-Autumnal Fever; Later Cycle.— 1,5, Free Crescents: 2, Ovoid Body in Corpuscle; 8,8, Free Ovoid
Bodies; 4,(1 7, Crescents in Red Corpuscles; 9, Spherical Body in Red Corpuscle; 10, Free Spherical Body.
6 ■
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Plate XII. Degenerate Forms ( ?)— 1, Flagellate Body, Tertian ; 2, Segmenting Body. Tertian ; 8, Vacuolization, Tertian
Quartan: 5, Segmenting Body, Quartan; (^Vacuolization, Quartan: 7, Flagellate Body, Aestivo-Autumnal: 8, Segmenting Body
9, Vacuolization in Crescent; 10, Phagocyte. Magnification — Zeiss. Obj. 1-12 oil, Oc.5.
marked differences are seen. In the quartan the pig-
ment granules are exceedingly large and few in num-
ber. They are of a brown, almost black, color and
possessed of a slow motion. In fact, the movement of
the enclosing corpuscle differs greatly from that seen
in the case of the tertian organism. Instead of becom-
ing swollen the corpuscle either remains of a normal
size or slightly shrinks and instead of becoming
266
MALARIA.
[August 1,
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decolorized takes on, in some instances, a deeper color
or a greenish yellow or brassy hue. The difference in
degree of refractive power, is more noticeable as the
organism increases in size.
The quartan parasite reaches its full development
in about sixty-four hours or eight hours before seg-
mentation. It is then round, slightly smaller than
the corpuscle, and contains a few granules of pigment,
arranged in the periphery of the organism. There is
but a thin layer of the body of the corpuscle appar-
ent, which may be overlooked on a casual examination.
(Plate x, Fig. 8.)
A short time after the organism has attained the
adult form, the pigment becomes motionless and signs
of segmentation appear. The manner of segmenta-
tion may be similar to that described in the case of
the tertian organism. In the segmentation of the
quartan organism the rosette forms of Golgi are more
often observed. The pigment granules form in a
block-like mass in the center of the organism while
radiating fibrils of differentiated protoplasm run from
the center to the periphery, dividing the parasite into
from eight to twelve segments. The segments acquire
nuclei and constitute the spores. ( Plate x, Figs. 8-12. )
In the case in question many extra-corpuscular
forms were present. These were probably degener-
ate bodies. They were granular, at times crystallin,
exceedingly irregular in shape, and contained blocks
of pigment, and were often filled with vacuoles.
The flagellate forms found in quartan fever show
similar characteristics as those in the tertian and
estivo-autumnal types with the exception of greater
sluggishness of movement. (Plate xii. Degenerate
forms.)
Fragmentation was observed in this case. A pseudo-
podium was observed to be thrust out from the para-
site, filled with slowly rotating pigment. Gradually
this portion of the organism was cut away when it
assumed a spherical form, the pigment continuing its
motion and seeking the periphery. (Plate xii.)
In quartan ague the length of the life cycle is
seventy-two hours, and the paroxysms generally
appear every fourth day. This rule is not without
exceptions as the paroxysms may be caused by differ-
ent groups of parasites having the same abode, but
segmenting at different times. When two groups
segment on successive days there is produced parox-
ysms for two successive days with one day of apyrexia.
This is termed double quartan fever. When three
groups segment on successive days, a quotidian inva-
sion results which is called "triple" quartan fever.
This may be easily mistaken for the ordinary quoti-
dian type when viewed purely from a clinical stand-
point.
In his study of the organism of estivo-autumnal
fever the writer has been fortunate in procuring spec-
imens from a patient suffering from this disease in
Cook County Hospital. The following history was
obtained from the records of the hospital:
Charlie F., aged 15 years, born in Chicago, where he has
lived all his life. School boy. admitted Sept. 30, 1895. Fam-
ily history negative. Personal history— does not drink, smokes
many cigarettes. Previous history — malaria, no venereal dis-
ease. Present history — has been sick three days. Had a chill,
headache and diarrhea with anorexia and pain in abdomen.
Physical examination — 1. Body — well developed. 2. Skin —
face flushed. 3. Eyes and ears — normal. 4. Tongue — dry and
coated. 5. Thorax — lungs, resonance imperfect over right lung
posteriorly ; no rales. Heart— rapid, second beat accentuated,
no murmurs. 5. Abdomen — walls rigid, very slight tympany ;
pain in left iliac region and both hypochondriacal zones ; "is
1896. i
MALARIA.
267
covered with brawny, macular eruption: no rose sixjte.
Spleen not palpable. Liver normal. G. Limbs negative. 7.
Reflexes normal. 8. (.Hands axillary enlarged. 9. Genitalia—
negative. 10. Urine— negative.
Estivo-autumnal ague is exceedingly rare in this
portion of the United States, there having been hut
a few oases in Cook County Hospital in many years.
(Plate xvii.)
In this oaso under observation but few of the hya-
lin tonus could be demonstrated. These forms (Plate
xi. Figs. 1-5). however, are more refractive and smaller
than those found in the tertiary and quartan forms.
They possess ameboid movements, and assume at
times a peculiar characteristic ring-like shape. This
appearance is probably caused by the thinning out of
the central portion of the organism, the corpuscle
showing through. Then again, the parasites appear
to have contracted into spheres. The shading disap-
pears from the center, appearing at the periphery. In
other respects they closely resemble the tertian and
quartan types, except that they arc not as active as
the tertian, but more so than the quartan.
As the organisms increase in size (Plate xi, Figs.
<J-9) minute granules of pigment appear in the peri-
syms, and have denominated them " pre-segmenting
forms."
Later in the course of the disease larger, spherical,
ovoid and crescentic bodies appear in the red corpus-
cles and free in the blood. These forms were espe-
cially abundant in this specimen. They were as large
or even larger than red corpuscles, the spherical forms
completely filling the corpuscle, while the ovoid and
crescentic expanded one side of the corpuscle, the
remnant projecting as a small segment of a circle
from the concavity of the organisms ( Plate xii, Figs.
1-10 A). In many cases ovoid and crescentic forms
are identical. This may be proven by rolling the
corpuscles upon the slide, when the ovoid bodies may
be seen to assume a crescentic form. In the colored
j specimens the corpuscle stained faintly with eosin,
' the body of the parasite faintly with methylene blue,
! while the periphery showed a deeper color, thus giv-
ing evidence of a double contour. In many instances
the periphery of the corpuscle was entirely decolor-
ized, while that portion next the organism still retained
some coloring matter. The pigment was generally
collected in the form of a wreath in the center of the
organism, encircling a light clear space and sur-
i.
i>.
f
it
II.
Plate XI. Thk Parasite of Estivo- Autumnal Fever, First Cycle.— 1, 2, 3,4, Hyalln Bodies; 5, 6, Ring-like and Spherical Bodie9 ; 7, 8, »,
Adult Pigmented Bodies; 10, 11. Segmenting Bodies; 12, Spores and Free Pigment. Magnification — Zeiss Obj. 1-12 oil, Oc. 5.
phery. These granules are few in number and slug-
gish in movement. In some instances pigment does
not appear during the course of the development of
the organism. This type is characterized by its small
size, even in the adult stage. In this stage it rarely
is more than one-half the size of the containing red
corpuscle, which remains normal in size and often
changes to the brassy hue observed in quartan fever.
The corpuscle eventually becomes crenated and rup-
tures, setting free the organism. Segmentation may
consist in an irregular breaking up of the organism
into from ten to twenty segments, similar to that
described as taking place in the tertian organism, or
the pigment may collect in the center, the process
occurring after the formation of the marguerite forms
of Golgi. Segmentation takes place most freely in
the internal organs, but it may be observed in the
circulating blood. (Plate xi, Figs. 10-12.)
The writer was also able to observe in this specimen
larger spherical forms with pigment granules collected
in a block-like mass in the center. The bodies of
these organisms stained faintly with methylene blue.
Thayer and Hewetson state that they have often found
these organisms from two to four hours before parox-
rounded by a yellow or golden halo. The granules
were very coarse and at times rod-like. These forms
have decided ameboid movements. They have been
seen to send out pseudopodia which are often cut off
and separated from the organism. (Plate xii.)
Owing to the fact that the ordinary forms of mala-
ria are not fatal, postmortem changes in these cases
are rarely reported. In fact, the pathologic findings
in the mild forms consist in the described blood
changes, and an enlargement of the spleen which, in
most cases, is plainly palpable. In the pernicious
and continuous forms, there is higher mortality, and
consequently a greater knowledge as to pathology.
Constant changes are present in many internal organs.
On gross examination the spleen is generally
increased in weight and size. It may in pernicious
cases be reduced in size and weight. This latter con-
dition is explained by the presence of interstitial
changes. The capsule is either thick and opaque, or
thin and presenting evidence of hemorrhage. The
organ is soft in consistency and of a dark brown or
reddish black color. It is with difficulty that the
Malpighian bodies can be distinguished. (Plates i
and ii.)
268
MALARIA.
[August 1,
On microscopic examination, the blood vessels of
the spleen appear to be distended, with at times evi-
dence of rupture into the pulp. Thrombi are pres-
ent, composed of fibrin, red corpuscles, parasites,
phagocytes and leucocytes of all types, ranging from
the lymphocyte to the giant cell with its budding
nuclei. The endothelial cells of the vessels are phago-
cytic in function, containing all foreign matter found
in the macrophages. These macrophages are most
abundant in the deeply pigmented pulp and contain
degenerated red corpuscles, free pigment, parasites,
fragments of hemosiderin, leucocytes and other phag-
ocytes. Thus the peculiar appearance of cell within
cell may be observed, and the enclosed cell may, in
fact, contain a third.
Macrophages may contain as many as fifty red cor-
puscles. The pulp cells present a hyalin appearance.
They are also phagocytic in function, containing leu-
cocytes, parasites and pigment. In these the pigment
granules often assume a very peculiar arrangement.
They form dotted lines which, interweaving back and
forth in the cell, completely hide the nucleus and at
On microscopic examination under low powers often
no pathologic changes are apparent. However, marked
dilatation of the inter- and intra-lobular veins and
capillaries leading thereto is present. Pigment is gen-
erally present. It is commonly found in the periphery
of the lobules. It may surround the hepatic vein
and swollen capillaries, or be evenly distributed
throughout the entire lobule. (Plate vii.)
On examination with higher powers the pigmenta-
tion is observed to be most abundant in the hepatic
cells and vessels. These cells generally appear gran-
ular and swollen. In some areas they are atrophied.
When this condition exists it may be accounted for
by the presence of dilated capillaries causing pressure.
The liver capillaries are engorged and are filled with
leucocytes, parasites and pigment granules. The leu-
cocytes contain organisms in all stages. Macrophages
are very numerous, varying in size from the large
mononuclear leucocytes to cells five times as large.
They possess either one or more oval, vesicular nuclei,
which stain feebly with nuclear stains. The nucleus
is placed eccentrically, as a rule, and although usu-
Plate I. Spleen. — Figure shows biood vessel containing red and
white corpuscles, macrophages, pigmeut granules and leucocytes.
Perivascular tissue shows iucrease of connective tissue and infiltration
with round cells and pigment granules. Zeiss Obj. DD, Oc. S. Tube
lengtn 160 mm.
times even pierce the cell wall. In these mitosis and
nuclear pigmentation is often observed. The Malpi-
ghian bodies are swollen, and show evidence of
lymphoid proliferation. They are, as a rule, compar-
atively free from pigmentation, but when this does
occur the pigment is found in the large cells, sur-
rounding the arterioles. The cells of the pulp cord
are often the seat of necrosis, showing evidence of
thrombosis. In these necrotic areas, degenerate, vacu-
olate and fragmenting cells are present.
On gross examination, the liver may be found to be
either larger or smaller than normal. It is generally
of a slate-gray color and normal as to consistency and
weight. The surface is smooth, and the capsule
thickened and opaque or thin and translucent, show-
ing beautifully the lymphatic network. On section
the color is a bronze or brown. The outlines of the
lobules are, as a rule, indistinct, with deep pigmenta-
tion about the portal vessels. The small capillaries
and bile ducts are often distended.
Plate II. Spleen —Figure suuws macrophages, leucocytes, para-
sites, pigment granules and iucrease of connective tissue. Zeiss Obj.
112 oil, Oc. 8. Tube leugth 160 mm.
ally oval in form, may assume any shape. This is
especially true when foreign matter is present in the
cell. In some instances the nucleus is entirely absent.
The macrophages may contain all of the substances
found in the blood stream, and appear more active
and capacious than those found in the spleen. The
red corpuscles may be normal or degenerate in appear-
ance, and contain simple pigment or the parasite intact.
The degenerate forms present the peculiar " globulare
rossi attonati " coloration of Grolgi, but do not, as a
rule, give the reaction for iron. When degeneration
has not gone too far, the blue color may be produced
with ferrocyanid. Leucocytes found in the macro-
phages present a degenerate appearance. They are
glassy and swollen and show signs of fragmentation
and vacuolation, and take but faintly the nuclear
stains. (Plate viii.)
The endothelial cells lining the capillaries here, as
in the spleen, show marked phagocytic powers. Under
the microscope they appear greatly swollen; in fact,
at times entirely occluding the lumen of the vessel.
189(5.]
PRACTICAL NOTES.
269
The cells of Kupfer, placed between the capillaries
■nd the hepatic cells, manifest great phagocytic pow-
ers, containing great quantities of pigment and pre-
senting a glassy, swollen appearance.
The spaces surrounding the capillaries show marked
round cell infiltration.
The parasite, wherever found in the liver after
death, appears somewhat shrunken. The arrangement
of the pigment is beautifully shown in specimens
hardened in alcohol and stained in hematoxylin and
eoein.
Plate VII. Liver.— Figure snows dilation of hepatic vein, which
contains red and white corpuscles and macrophages. Parasites are
seen in and between hepatic cells and in capillaries, where are also
many pigment granules. Capillaries are distended and contain many
leooocytas. Zeiss Obj. DD.Oc. 3. Tube length 160 mm.
Necrotic areas are common, and are associated with
increase of interstitial tissue and proliferation of bile
ducts. These changes may be the result of the necro-
sis, the presence of segmenting parasites or degener-
ating corpuscles, all of which produce toxic or irri-
tating products.
(To be continued.)
PRACTICAL NOTES.
Sterilization of Syringes.— Hofmeister has found that leather,
like catgut, can be effectively sterilized without^ the slightest
injury, by soaking it in a 2 to 4 per cent, solution of formalin
and then boiling it. Syringes that screw together instead of
being glued or cemented, are better adapted to this method.
The water in which they are placed to boil must not be hot
enough to crack the glass.— Cbl. f. Chir., July i.
Experience with Salicylic Medication through the Skin. Combe-
male reports nine cases of subacute articular rheumatism, tem-
perature 38 to 38.5 degrees C. , successfully treated with salicylic
medication through the skin, as described in the Journal,
April 25, page 847. The pains were relieved at once ; the fever
subsided after the first day, and no cardiac complications
appeared. — Bulletin Medical, July 1.
Nephrectomy with Clamp Forceps Instead of Ligatures.— Bobroff
of Moscow recommends compressing the hilum with clamp for-
ceps, instead of ligating it, in extra-peritoneal nephrectomy,
which materially shortens the operation. They must be curved
and grooved and left twenty-four hours, no longer. The Cbl.
f. Chir. of June 27, describes the cases and the numerous
experiments on animals from which Bobroff and Fedoroff
formulated these conclusions.
Intravenous Injections of Water and Strong Salt Solutions.— Bose
and Vedel announce that distilled water is fatal in intravenous
injections, either in large doses or small, while ordinary water
has no such effect unless over 120 c.c. per kilogram (dog) and
80 c.c. (rabbit) is administered. Instead of diminishing the
number of mictions, like distilled water, it increases them and
without hematuria. It also raises the temperature from a tenth
to one degree above normal. Experiments with 7 per cent,
solutions of salt introduced into the vein produced, in large
doses, an intoxication like that from strychnin or chloral, with
hemorrhages from all the parenchymas and intestines, espec-
ially from the meninges.— Semaine Midicale, June 24.
Cause of Suppuration with Catgut.— A new theory is advanced
to explain the suppuration that sometimes follows the use of
apparently sterilized catgut ; that it is a chemic instead of a
bacteriologic process. The chemic substance that causes it is
probably due to decomposition, and therefore only fresh catgut
should be prepared in the factory and demanded by purchasers,
and further search for efficient antiseptics for this purpose
abandoned, as well-made ordinary sublimate catgut has been
proved beyond question to be absolutely sterile — Cbl. f. Chir.
June 27.
Skiagraphy of the Emperor.— It is reported that the left arm of
the German Emperor has been " skiagraphed " by the Roent-
gen rays. The experiment revealed the nature of the malfor-
mation, and the result has been submitted to eminent surgeons
who believe, it is stated, that a simple operation may give par-
tial, if not complete, use of the hand and arm.
Physiologic Albuminuria. — Serum albumin may appear in urine
without any apparent structural change of the renal tissue.
It occurs in healthy persons when there is an excess of blood
plasma and after too free use of albuminous food. It is pro-
duced by conditions altering the blood pressure in the renal
vessels ; as after taking a cold bath or drinking copiously of
cold water. The withdrawal of salt from the food will produce
albuminuria, which will disappear when the salt is again given.
Proteid metabolism depends on the amount of proteids
ingested, for the greater portion becomes changed into circu-
lating albumin. When large quantities of proteid matter have
been ingested, what is not appropriated to the sustenance of
the system becomes waste material and is thrown off through
the excretory channels. It would seem then that albuminuria
does not represent a pathologic condition except when it is
associated with other and more reliable symptoms. — Dr. L. P.
Walbridge in Med. Mirror, June.
Effects of Complete Hysterectomy on the Vagina. — Dr. S. C. Gor-
don says : One of the objections urged to complete hysterec-
tomy is that it has a tendency to shorten and deform the
vagina and that it also destroys the arch by removing the cer-
vix which acts as a keystone. By the technique which he
employs in hysterectomy, the broad ligaments are constantly
drawn up (as soon as cut) by the over and over continuous
suture. When the operation is completed by this method, the
vagina is elevated above the normal position and closed by the
same suture continued from the broad ligament. By this sim-
ple operation the vagina is actually lengthened by so much as
it is drawn up by the suture. That this condition really
obtains he has demonstrated by examinations immediately
after the operation. During the past two years he has exam-
ined all cases possible that he had previously operated on and
found no case of shortening or other deformity ; but in two or
three cases where the cervix was not removed he found a
marked atrophy of the vagina. So far as he has been able to
learn from others, their observations agree with his. He
believes that the objection is one of theory rather than of
actual demonstration. — Jour. Med. and Science, July.
270
PRACTICAL NOTES.
[August 1,
Lannelongue's New Treatment of Inguinal Hernia. — Lannelongue
presented four boys at the Acad^mie de Mfdecine recently
whom he has been treating with injections of a few drops of
a one-tenth solution of chlorid of zinc for eighteen days. The
scrotum and inguinal canal are swollen and hard, forming a
natural truss to retain the hernia. Even when the boys cough
there is no shock in the region. The probabilities are that the
vas deferens will remain intact, which time alone will show.
The ultimate results of this treatment are awaited with
interest.
Formal in Urinary Therapeutics. — The British Medical Journal
on the above subject quotes Lamarque (Assoc. Franc, pour
l'Avancement des Sciences) who states that he has used for-
mal in 1 per cent, solution for washing out the bladder and
urethra, and in 5 per cent, solution for instillation in these
localities. In acute gonorrhea and in gonorrheal cystitis the
results have not been very encouraging ; in the chronic gonor-
rhea they have been better. It is particularly in cases of
tuberculous cystitis that the treatment has been successful.
The only disadvantage is the pain caused by the drug ; this,
however, though intense at first, quickly ceases. Daily wash-
ings with formal solutions have been effectual in stopping
hematuria, relieving pain, and lessening frequency of micturi-
tion in cases where every other treatment had failed.
Operation for Eversion of the Lower Eyelid. — Dr. W. N. Thomp-
son describes an operation for eversion, caused by a cicatrix
resulting from removal of a tumor from the lid. "I made an
incision a little longer than the eversion to be corrected and
parallel to the eye just above the cicatrix, and dissected up the
integument on either side of the incision, making a dissection
much farther under the edges near its ends than at the center,
so as to get full benefit of the sliding and elastic properties of
the integument near the extremities of the incision. The ends
of the incision were then brought together, and its edges held
in this new position by sutures, thus changing the original
transverse incision to a vertical one, and the distance between
the cicatrix and margin of the lid being increased to the length
of that of the incision, eversion was corrected and the lid in
its proper position." — Ind. Med. Jour., July.
Urobilin and Indican in the Urine.— Urobilin exists in normal
urine in small amounts ; in acute fevers it is increased four or
five times. Typhoid and septic fevers, where there is rapid
destruction of blood corpuscles, increase the amount. It is
also increased in cerebral hemorrhages, hemorrhagic infarction,
retro- uterine hematocele and extra-uterine pregnancy. It is
diminished in convalescence from acute diseases, hysteria and
nervous diseases. Indican is found in excess in exclusive
meat diet, Addison's disease, cholera, carcinoma of the liver,
chronic phthisis, central nervous diseases, typhoid fever,
dysentery and obstruction of the small intestines. — Dr. M. D.
Hoge, Jr., in Va. Med. Semi- Monthly, July.
Increasing Uses of Massage. — Our Russian exchanges are advo-
cating the application of massage to the most varied troubles,
from chronic heart disease to the ambulatory treatment of dis-
eases of the female genital organs, with which Rubinstein has
relieved or cured ninety cases of metritis, oophoritis and
abnormal positions of the uterus. (Eshenedelnik, Nos. 44 46.)
Dr. Hoadley of Chicago recommends the use of the cannon ball
for self-massage in cases of habitual constipation, as suggested
by Sahli in 1887. Before rising in the morning and at night,
the iron bail (covered with several layers of woolen cloth, the
first glued to the ball) is slowly rolled around on the abdomen,
following the course of the colon. In many cases this treat-
ment has effected a permanent cure. Any foundry will cast an
• iron ball for a few cents if a croquet ball or something of the
kind is supplied for a pattern, although an improvement upon
this is described in the Deutsch. Med. Wochenschrift for June
25, the addition of a wooden handle to the ball, which revolves
freely in the stirrup fitted to the handle. According to the
inventor, Oetker of Oeynhausen, this renders it much easier
to manipulate.
Codein and Swabbing the Larynx as Adjuvants to O'Owyer's Tube
in Membranous Croup. — Variot has found the tube effective in
conquering the glottic spasm in certain kinds of diphtheritic
laryngitis, removing the tube in three or four minutes, and
assisting the nervous system to control the tendency to spasm
by administering syrup of codein. Bayeux has also found
swabbing or scraping the larynx with the tube an effective
method of treating very membranous diphtheria. As the tube
is introduced the membranes dislodged fill it, and the child
chokes, when the tube should be withdrawn. The efforts to
cough will then expel the loosened membrane. Some children
have recovered after one operation ; others have required
another to complete the expulsion of the membrane or to con-
quer the glottic spasm. Out of the twenty-three children
treated, nine recovered, three required tracheotomy, and in
nine the tube had to be left permanently. There were eight
deaths, a mortality of 34.78 percent, in the twenty-three cases.
— Semaine Mid., July 8.
Treatment of Cholera Infantum with Subcutaneous Injections of
Serum. — According to Reinach, the treatment of cholera infan-
tum should aim to keep the blood from growing thick and rest
the intestines, while supplying strength to the organism. He
claims that all these conditions are combined in injections of
serum from a horse, as he administered it to fifteen infants, in
a dose of ten to twenty cubic centimeters. The effect was
remarkable : The collapse passed away, the cyanosis was
replaced by the natural color of the skin, the extremities grew
warm again, the pulse became stronger, and the temperature
rose. This improvement took place in six to seven hours and
the child was cured ; although in some cases a second dose
was necessary. No other medication was given except rice
water. The serum produces a fluidity of the blood, while it
is at the same time food for the child, as Reinach states that
twenty cubic centimeters of the serum contain one gram and
a half of assimilable albuminoid substances, equivalent to
fifty grams of cow's milk, or 150 grams of mother's milk. —
Rev. Int. de M. et de C, June 25 from Munch. Med. Woch.
Rheumatic Iritis.— "Rheumatic iritis," says Dr. Crittenden
Joyes, "is more serous than plastic, hence we are not so apt to
have adhesions as in other forms. The objective symptoms
are, pink circum-corneal injection, hazy, aqueous and change
in color of iris. The subjective symptoms are impairment of
vision, photophobia and pain in the orbital and malar regions,
forehead and top of head. The pupil is frequently dilated, but
is sluggish in action. The pain is sometimes greater than in
other forms of iritis. The prognosis as to vision is better than
in other forms ; but the duration is apt to be long. Treatment
consists of hot water and atropin, together with salol, salicy-
lates, iodid of potash or some other remedy for the rheumatic
diathesis." — American Practitioner and Nexcs, July.
Instrument for Removing Anastomotic Buttons Through the Mouth.
-Hagopoff has invented a flexible sound terminating in a bulb,
through which is passed a double silver thread ending in a loop
at the end of the bulb. It is for the purpose of drawing out
through the mouth a thread fastened to the button in gastro-
enterostomy. Later when the button is liberated, the sound is
reintroduced through the mouth and guided by the thread can
be pushed down to the button, and then withdrawn with the
thread and the button, as the bulb opens a pathway for the
latter. Chaput queries whether the introduction of the sound
during the operation will not produce vomiting which might
force alimentary matters into the peritoneum. Hagopoff has
also invented an anastomotic button similar to Chaput's but-
ton, but as yet it has only been tested on cadavers. — Semaine
Midicale, July 8.
18%.]
EDITORIAL.
271
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to await call.
SATURDAY, AUGUST 1, 1896.
CLIMATE AND HEALTH.
Since the earliest ages it has been a favorite theory
that diseases come upon mankind through the medium
of the atmosphere; and even at the present day
there are to be found some, who assume with Syden-
ham an epidemic constitution of the atmosphere to
account for the occurrence of certain wide spread dis-
eases. An enormous amount of work has been done
by doctors and others in observing and recording the
weather, but very little has been accomplished in the
way of collating these observations. It is so easy to
observe and place on record, but it requires much
time and labor and qualities of a different and higher
order to compare and generalize. Samuel Forry of
the United States Army collated in 1840 the meteor-
ologic observations made during the preceding twenty
years by the medical officers at the various military
posts of this country, but since then not much has
been added to our knowledge of medical climatology.
Accuracy has indeed been given to climatologic data,
but their application to concurrent conditions of
morbidity has been made only in special instances.
Of late years the bacteriologist has stepped in and
relieved the medical climatologist of many of his
subjects of study. Many of the causative agencies of
epidemic diseases have been trailed to their haunts,
and although some, such as typhus, yellow and
scarlet fevers, smallpox and measles, continue in their
old time obscurity the indications are that atmos-
pheric or climatic conditions exercise only an indirect
influence, powerful in some instances as in the dis-
appearance of yellow fever on the advent of frost, but
at the same time only indirect.
Although the tendency of modern research has
thus been to restrict the field of climatologic study
the factors of climate continue to have an importance
as factors of disease. The influence of heat, cold,
moisture and air movement in determining the
occurrence of disease is so great that the diseases
thus occasioned are known as climatic diseases. A
knowledge of these is of the highest importance; and
much good was anticipated when the Weather Bureau
of the Agricultural Department announced that it had
made arrangements for tabulating along with its
meteorologic observations the morbidity and mortality
statistics obtained from health officers and registrars.
Climate and Health, the monthly journal issued by
the Department was intended to be a repertory of
statistic and other information appertaining to climate
and its relations to hygiene, from which persons
interested in the subject of the influence of the
climate and weather upon health might obtain data
for making comparisons to determine the relative
therapeutic and hygienic merits of different climates.
Thus said its prospectus; and from the very energy
of the Bureau, which led it to step outside of ques-
tions of mere wind and weather, we hoped that a sec-
tions of the work, which in a country like the United
States of America should be done by a special Depart-
ment, would be begun by the Weather Bereau and
continued by it until Congress should breathe the
breath of life into a Department of Public Health
with ample powers to carry on its proper functions.
Climate and Health was begun and carried out suc-
cessfully. The work met with the earnest coopera-
tion of medical men and health officers. But its last
issue has been made (No. 3 of Vol. II for the four
weeks ended March 28, 1»96, issued June 22, 1896).
A doubt as to whether its publication was authorized
by the act making appropriation for the Department
of Agriculture for the fiscal year ending June 30,
1897 was the cause of its discontinuance. Credit
must be given to Professors Harrington and Moore,
who originated and carried out the idea and to Dr.
W. F. R. Phillips, who has so ably edited the suc-
cessive issues of the publication. They recognized
the needs of the situation and their own jwssible
ability to aid in sanitary work. But this country in
matters relating to the health of the people should be
independent of volunteer aid of this or any kind. It
should have all such work done by men specially
assigned to the duty under the direction of a Depart-
ment of Public Health.
Let us have a Department of Public Health!
272
SANITARY AND INSANITARY PLUMBING.
[August 1,
THE POISONS OF ALCOHOLIC DRINKS.
It is a very commonly accepted opinion that the
injurious effects from the use of alcoholic beverages
are due to the adulterations. Many temperance
advocates make this a strong reason for not using
spirits.
Recently a prominent physician condemned with
great severity the use of spirits to which various
poisons had been added. He enumerated several of
these poisons and seemed positive that here was a
source of danger overlooked before. Dealers in spirits
have found this an excellent theory from which to
prove the parity of their products and the risk of
buying others from a rival dealer. A number of
enthusiastic reformers have made exhausting chemic
analyses to discover these dangerous adulterants, but
without any results. One man spent two thousand
dollars in procuring samples and analyzing them in
New York City, but failed to find anything more
than water and some cheap coloring matters. The
Massachusetts Health Board examined this theory
years ago and gave it up, contenting themselves with
the examination of bitters and proprietary drugs and
the amount of spirits which they contained.
Notwithstanding the failure to find any of the so-
called adulterants, the idea has been kept alive and
repeated, as if it was a fixed fact. Recently the pro-
fession has been treated with circulars, containing
certificates of a chemist who writes M.D. after his
name, in which he announces that from a most ex-
haustive search he has been unable to find any
poisons in a certain brand of spirits. Then he vol-
unteers that this was unusual and rarely occurs in the
most reputable forms of spirits. A - few weeks ago
this subject came up before the Royal Commission
an Licensing Laws in session in London. This gov-
ernment commission composed of eminent statesmen,
physicians and business men, have been taking
testimony on all phases of the drink question, with
reference to license, from which they will report to
parliament the changes advisable and necessary in
new laws. Dr. Bannister, the deputy principal of the
government laboratory, was called on to give testi-
mony concerning the causes of drunkenness affirmed
to be due to the adulterations of spirits. He stated
very positively that in the examination of thousands
of samples of spirits, the only adulteration was water.
That adulteration of spirits by any other substance
was practically unknown. Also that age rendered
spirits more harmless was a delusion. The supposed
maturing of spirits by which the fusel oil was driven
off was untrue. He asserted that there was no differ-
ence in the physiologic effects of spirits made ten years
ago and to-day. Certain alcohols were the same
irrespective of age; also it was a mere question of
quantity, not of quality. The alcohols of commerce
used in beverages, were nearly all the same and had
the same physiologic action. One of the commission
was a distiller, and a rigid examination followed, con-
cerning beer and various mixed beverages, which
brought out the fact that alcohol was the only poison-
ous substance in any of these mixtures. Other very
curious facts were stated relating to beverages said to
be free from alcohol and contain nutrient and medi-
cinal properties which in nearly all cases were fortified
with spirits concealed in some form. Physicians who
discuss the alcoholic problem and believe in danger
from adulterations, will have to abandon this delusion
or make some original analysis to prove their state-
ments. Manufacturers and dealers who claim promi-
nence and purity, must do so by showing a small per
cent, of water.
Evidently there are many truths to learn in this
field.
SANITARY AND INSANITARY PLUMBING.
The Lancet (London, Eng.) has just published,
July 4, 1896, the results of an elaborate piece of work
conducted under its auspices, which will do much to
disseminate among laymen as well as among the
medical profession a knowledge of the system of pipes
usually found in English dwellings for the inflow and
distribution of water and its outflow contaminated
with all the wastes of the household. Its enterpris-
ing management instituted a Commission, which
investigated the faulty and dangerous conditions
that are most commonly found in city houses and
suburban cottages. In its report the Commission has
grouped these conditions in a description of three
houses, two four-story city dwellings and one subur-
ban villa, with a ground plan of each floor, illustra-
tions of many of the defects and a special discussion
in each instance not only of the defect but of the
remedial measures recommended. Although faults
in plumbing were found to be exceedingly common in
city houses, it is not to be supposed that all those
represented in either of the two houses given in
illustration were discovered in any one particular
house. The insanitary conditions found in many
houses are grouped under one roof merely for con-
venience of presentation and discussion. Three
reasons are given for the existence of so many insani-
tary houses. First, the prevailing indifference and
consequent ignorance of all classes as to the various
sanitary appliances by which they are surrounded.
This is being slowly corrected by the gradual educa-
tion of the public through the greater interest taken
in the subject by the medical profession; and this
very report of the Commission will be a powerful
factor to this end, as it. is not intended to confine its
publication to the columns of the Lancet. It reaches
the profession in this way, but it will hereafter be
published in book form to permit it to reach house-
holders, architects, contractors and plumbers. The
1896. ]
CONSANGUINEOUS MARRIAGES.
273
second reason given for the insanitary conditions
discovered is the bad work and cheap materials put
into houses by unqualified or unscrupulous men
pnoouraged by the dangerous practice of putting such
work up for the competition of all who may choose to
tender for it. In the anxiety of contractors to obtain
work it is undertaken at prices which would yield no
profit if efficiently executed; and when a work is entered
upon under such conditions the natural tendency is
to seek relief by scamping it in some form. It is
positively stated that since the general adoption of
the contract system houses are not as a rule substan-
tially finished and the work is not of a satisfactory
character. The third reason given is the cost of
rectifying insanitary work. Under this heading the
profit and loss of the plumber is discussed at consid-
eraMe length showing how a modest profit can not
ordinarily be made legitimately on small contracts.
Appended to each of the illustrative examples is a
detailed estimate for the alterations recommended,
that those who are interested in cost may have a
standard of comparison.
Prior to the publication of this report it was sub-
mitted to the Worshipful Company of Plumbers, who
appointed a committee to consider it. In transmit-
ting the criticism of this committee the company
desired that it be not held responsible for the work
of its specially appointed committee as the company
in its corporate capacity does not take any part in
what may be regarded as trade matters, but directs its
attention solely to those connected with the training
and registration of plumbers. This special Committee
considered the reasons given by the Commission for
the frequency of bad, defective and insanitary work
to be generally correct. It gave approval to the
recommendations for new and altered work in the
illustrative cases as being consistent with the require-
ments of modern sanitation and fairly representing the
sound plumbing practice of the present day. Finally
it characterized the report as " a unique work on the
subject of the efficiency and cost of plumbing work,
calculated if studied attentively to assist members of
the medical profession, sanitary authorities and others
in arriving at a more correct judgment than commonly
prevails as to the chief causes of the defective and
insanitary plumber's work frequently met with and
to afford them some useful information as to the cost
of plumbing work which is sound in construction
and sanitary in character. "
The report of the Lancet's Commission will
be studied with as much interest on this side
of the Atlantic as on the other, for many of the
defects and faulty arrangements described may be
found in our city houses; and the recommendations
submitted are in accordance with the views held by
our best sanitarians. It is to be observed that while
the English soil pipe is of lead and runs along the
exterior of the wall of the house the American pipe is
generally of iron and is retained inside the wall (on
account of our severe winters) until it makes its exit
as the house drain. It is to be observed also that the
English have an elaborate disconnecting chamber on
the drain in place of our fresh air. inlet on the house
side of the trap. Our English contemporary is
deserving of credit for this inquiry and report.
CONSANGUINEOUS MARRIAGES.
One of the questions of medical deontology that
still remains in dispute is that of the opinion that
should be given in regard to marriages between per-
sons closely related by blood. It is true, physicians
are not often consulted on this subject, but their
expressed or published opinions carry weight, and are
therefore of sufficient importance to deserve some
consideration. As it is they are to be had on both
sides of the question, both orally given, published
in medical treatises, as well as exemplified in actual
practice. It may be said to be still an open question,
as far as medical authority goes, whether a man should
marry his first cousin or not. As regards closer rela-
tionship, such as those of uncle and niece, or nephew
and aunt, though not a legal barrier in some countries,
they would, it may be assumed, be very generally or
unanimously considered objectionable in the United
States, or at least the greater majority of them.
At the present time the laws of many of the States
forbid the marrying of first cousins, but as long as
this rule is not universal it really amounts to very
little. The question may therefore be put before us
practically in any section of the country.
As a recent French writer on the subject, M. Paul
Perrin, states, there are three views extant at the
present time : 1 . That consanguineous marriages are
not generally harmful, but may, on the other hand, be
actually beneficial to the offspring and the race. 2.
That they are always dangerous to both, and should be
prohibited by law. 3. That they are dangerous in
any case with a family taint, but otherwise unobjec-
tionable. As regards the first of these, M. Perrin
decides that it is altogether too extreme a view, and
should be rejected at once. The experience indeed
of mankind is against it, the statistics of idiocy,
insanity, deaf-mutism and epilepsy, to say nothing of
those of the inheritance of other diseases and defects,
speak strongly enough in its condemnation. Even
the intermarriage of persons more distantly related
seems to have its perils, and a striking example of
them can be found in studying the history of the
royal families of Europe, which have nearly all been
for centuries intermarrying more or less closely, and
which show a record of degeneracy far surpassing
that of any equal number of families of the average
population. With all due consideration for their
numerous estimable and able members at the present
274
THE NEW NURSE.
[August 1,
time, there is hardly a single royal family into which
it would be good medical advice to counsel an honest
citizen of good heredity to marry.
The second view is also too extreme in its state-
ments at least, since there is no question but that
there have been many unions between near relations
without bad results, and it needs no further consid-
eration.
The third view is after all the only one that is of
practical importance, as it involves the forming of
an opinion in every individual case. We can admit
possibilities in either direction, but in advising for
future conduct, one has to weigh probabilities rather
than to consider chances more or less remote. If
human stirpiculture was on the same practical basis
as artificial breeding of the domestic animals, it is
easy to see how certain qualities might be cultivated by
inbreeding, but even were this possible experience with
the lower animals has shown that it impairs the
vitality and that as in the vegetable kingdom frequent
changes of soil and seed are essential to produce the
best results. With the artificial modes of life of
civilized mankind we have a still greater probability
of the production of degeneracy. The lack of know-
ledge of hereditary taint is no absolute proof of its
non-existence in any case and there are few individ-
uals who are aware of all the degenerative possibili-
ties in their own family histories. When the ques-
tion arises therefore, as to the advisability of inter-
marriage in a case where the heredity seems to be
good on both sides, an absolutely noncommittal posi-
tion, as advised by M. Perrin, is a prudent one, and,
as in most instances advice against marriage would
be at least useless, is probably the only practicable
one for the family physician. Where any taint
exists, whatever legitimate influence can be used
against the marriage should be exerted.
On the whole it would probably be well could the
restrictions in force in some of the States against
intermarriage of near relations be extended over the
whole country.
THE NEW NURSE.
The English journal, The Practitioner, has within
the past few months devoted considerable of its
editorial space to a consideration and criticism of
certain aspects or phases of the modern trained nurse.
It appears from its statements that in England there
has developed a very decided inclination amongst
nurses to magnify their office unduly and that the
present system of training tends then to produce "not
so much nurses, in the proper sense of the word, as a
lower order of medical practitioners who may be use-
ful or who may be dangerous, but who in any case are
superfluous." The editor pleads for a return to com-
mon sense in the training of nurses, and asks what
use it is for them to have vague notions of anatomy
or physiology in the practice of their legitimate work.
The old nurse, he says, was not a thing of beauty
altogether, and very imperfectly realized the ideal of a
ministering angel, but the new nurse is often too
good in her own estimation to confine herself to the
humble but useful subordination to the physician that
the situation actually demands. The latest editorial,
while a continuation of the others, seem to be especi-
ally called out by the fact that the first volume of
the " System of Medicine," edited by Dr. Clifford
Albutt, contains a contribution on nursing, written
by a nurse who thus reverses the professional situation
by assuming to instruct physicians.
While in this country the condition of affairs, at
least so far as anything is in evidence, does not seem
to quite correspond with that in Great Britain in bad-
ness, there is yet enough to suggest a little reflection on
the part of the medical profession. Human nature is
fallible and a nurse's training does not eradicate or
counteract all the tendencies to undue self-assertion
and overstepping proper limits that a little dangerous
semi-medical information would be likely to bring out
in many if not in all individuals. With the multipli-
cation of training schools (so-called) for nurses in
almost every hospital, sending out diploma'd graduates
every year, and the growing appreciation of their
services amongst the laity, it is easy to see how the
less wise among the nurses might come to have a very
decided overvaluation of themselves that might lead
to all the grievances of which the British editor com-
plains. Add to this the influence of women's clubs
and other female organizations, the unequal inability
of doctors to impress themselves on the average
female nurse and we have still further possibilities of
an American experience of the present trouble of our
British medical brethren. Perhaps our salvation will
be found in the much greater facility of medical edu-
cation for women in this country and the consequent
abundance of regularly educated female physicians
who would naturally resent the more quickly the
assumption of what The Practitioner calls " doubtful
demi semi doctors" of their own sex. The con-
ceited and injudicious nurse is much more likely to
be quickly snubbed by the physicians of her own sex
who would naturally, under the circumstances, be
more jealous of their professional dignity and would
lack the masculine consideration that a male doctor
might feel toward one of the opposite sex. If this
notion is correct we have reason, in view of the Eng-
lish developments, to be thankful for the female
physician.
It would be well for us, however, in the active com-
petition of hospital training schools, to give a little
thought as to the value of any very elementary instruc-
tion in such subjects as anatomy and physiology to
the trained nurse, and the possible inconveniences of
a little dangerous knowledge that are pointed out by
18W.]
CORRESPONDENCE.
275
the English editor. The trained nurse is, ns he says,
a parasite, in the scientific sense of the word, and ean
have no legitimate existence apart from the medical
profession to which she is subordinate. Any insub-
ordination or assumption of special and independent
functions is contrary to her purpose and dangerous to
her usefulness.
CORRESPONDENCE.
Typhoid Fever Treatment.
Poland, Ohio, June 15, 1896.
7'o the Editor:— I am always glad to have an opportunity to
say a word for the Woodbridge typhoid fever treatment. . .
1 am surpised and amazed at its success. The unusually dry
summer of last year in this locality caused our wells to go dry,
or nearly so, the average wells not having more than from six to
eight inches of water in them, the users exhausting the supply
nearly every day. This condition of affairs continued for some
time and the few slight rains that we had in the early autumn
washed the filth and garbage which had been decaying during
the hot summer from the surface of the ground into the wells,
and as a result the germs of typhoid infected the water and an
epidemic of the fever prevailed in our town of about 600 inhab-
itants. There were in all about twenty cases. All occurred
in families that I treated regularly and it fell to my lot to care
for them. I had Mr. Wilson McKeown of Youngstown make
an examination of the water these patients had been drinking
and he pronounced it to be chemically impure. The cases were
Marly all in one street and the wells were undoubtedly fed from
one stream as they were of about one depth, eighteen feet.
The attacks were of unusual severity from the very onset,
temperature rising rapidly and soon ranging from 103 to 103^
in the morning and from 104 to 105 at 6 p.m.
In the twenty cases, all except four had a temperature of 104
to 105 for days together. Delirium manifested itself early in
the course of the disease in six of the cases and continued
during the height of the fever. Rose-spots were apparent from
the seventh to the tenth day of the disease in twelve, in eight
this symptom was absent. Cephalalgia was present in all the
worst eases and continued from three to five days. Hemorrhage
from the bowels occurred in six cases ; one had seven hemor-
rhages : some others from one to four.
Owing to the severity of the epidemic, I did not succeed in
aborting the disease in all cases. One had an evening temper-
ature of 105 for eighteen consecutive days, and for three days
it did not vary from 105 ; this was the case that had the seven
hemorrhages. For two weeks I did not expect this patient
would recover; she was a naturally strong girl of 18 years.
During the height of the disease and throughout its long con-
tinuance she was able to take a liberal amountof nourishment,
which aided materially in tiding over the crisis. The long
continued high temperature produced such exhaustion and
emaciation that it was six months before she had recovered
sufficiently to leave the house and after she was well enough
to sit up it was two months before she could walk.
I followed faithfully and carefully the Woodbridge treatment
from beginning to end in all of the cases ; none died and all are
well to-day and following their usual vocations, light of heart
and buoyant in spirits, no dregs left behind as in the old
method of treatment. I think that had I treated these patients
by "the old method" I would certainly have lost five because
the disease was of such severity from the onset. I have treated
many cases of typhoid fever by this same old method in times
past and upon making a careful comparison aDd taking into
consideration the gravity of this epidemic I do not think I have
made an over-estimate of what the death rate would have been
had I not used the Woodbridge treatment.
My experience during the past two years with this treatment
teaches me that to be successful, all directions given by Dr.
Woodbridge must be carefully followed. When the clouds are
dark, do not allow yourself to be tempted to change methods,
but continue the antiseptic abortive treatment to the end, and
you will be rewarded by seeing your patients recover rapidly.
I have now treated forty-eight cases by this method and
have been successful in every instance. Average duration of
illness was eighteen days ; average duration of treatment
thirteen days. Most respectfully yours,
C. R. Justice, M.D.
Typhoid Fever.
Wavkrly, N. Y., July 20, 1896.
To the Editor: — Although much has been written upon the
subject of typhoid fever of late, it seems important that the
antiseptic treatment should be fully and extensively discussed.
If the results obtained by many observers be verified and sus-
tained by extensive experience, then indeed we have made
wonderful strides in the management of this formidable dis-
ease.
My experience with typhoid fever during the past thirty-five
years has convinced me that it is a self-limited condition or
disease, and it seems self-evident that many people are immune
to its toxic elements or the condition styled auto-infection,
and also the so-called "mixed infection," recovery taking place
after the gravest symptoms and without treatment. Many
persons seem to be immune against typhoid fever, leading
some observers to conclude that the disease is not infectious
or contagious. Now does it not follow, if this be true, that
some help in the way of rendering the system immune will
diminish the ratio of mortality? Dr. Quine says no one should
condemn measures claimed to produce this result, and I hold
similar views. In surgical practice we realize the importance
of internal asepsis in preventing auto-infection, well knowing
by experience that ptomains may be developed under condi-
tions of shock, which destroy the patient when the traumatism
in itself is not serious. Now, typhoid fever is usually accom-
panied with symptoms of nervous shock or depression ; then
does it not naturally follow that some principle of intestinal
asepsis will prevent the fermentation, putrefaction or septic
conditions which result?
Twenty-five years ago I adopted this view and at once dis-
carded nearly all the usual remedies. I might say all, with
the exception of calomel in small and oft-repeated doses dur-
ing the first few days of the fever, and aconite in small doses
to produce diaphoresis when indicated. I discontinued the use
of quinin, veratrum, digitalis, iron, stimulants, etc., unless
indicated by extreme exhaustion. My treatment thereafter
was Merk's lactic acid, usually combined with the syr. lacto-
phos. calcis, of the former two drams and of the latter six
ounces ; dose, a teaspoonful four times in the twenty-four
hours ; tinct. aconite in small and oft-repeated doses, when
the skin was dry ; no other remedies were used as a rule. I
seldom saw much tympany or the dry brown tongue, seldom
any sordes ; why? simply because lactic acid is one of the best
antifermente in the world ; it prevented putrefactive changes,
promoted assimilation, and the results were exemplified by
recovery in 95 per cent, of all cases treated during twelve
years— more than sixty cases. During the past twelve years
I have treated seventy-two cases without any fatality, and
in justice to Dr. Woodbridge, I should add that I have,
during the past year, combined the carbonate of guaiacol, as
recommended by him, with the treatment heretofore men-
tioned, in twenty cases, with most excellent results ; in nine of
the latter the disease being checked from the fourteenth to the
276
CORRESPONDENCE.
[August 1,
seventeenth day from the initial chill. In many of these cases
the symptoms for a few days were severe, indicating a grave
type of the disease, but almost invariably a lower plane of
fever, and a marked amelioration of all the symptoms was
established, the tongue and skin becoming moist, delirium
diminished or abolished, tympany disappearing and patient
sleeping and resting better. Occasional sponging seems to
assist materially in restoring the nervous equlibrium ; it has
not, however, been employed with the object of reducing fever.
I have given the carbonate of guaiacol in 1-6 gr. tablets
every hour through the day and three or four times during the
night if the patient is often awake, for several days, and every
two hours during the day thereafter while the fever continues.
I have observed the usual proportion of hemorrhage and
relapses ; the antiseptic treatment probably does not prevent
either, but I do think it establishes the fact that relapse is not
due to reinfection, but rather that the typhoid element is
held in abeyance in some of the glands or adjacent lymphatics,
manifesting itself after the subsidence of the first attack in a
similar manner as zymotic diseases are held in abeyance dur-
ing the latter period of pregnancy.
The etiology of typhoid seems to be a moot question.
Perhaps a majority do not consider it contagious, but the most
eminent authorities now, I believe, so consider it, and farther
claim that the bacilli are carried in the dust of the atmosphere
as well as in water ; this I believe to be true, and am equally
certain that they are given off in the exhalations from the
lungs, but perhaps not to the same extent as by the feces.
Now, has it ever been demonstrated that the typhoid bacilli
pass safelv through the stomach and enter by absorption the
glands, which, by a wise provision of nature, are intended only
for expulsion or secretion ; is it not a more reasonable theory
that they enter some of the unprotected organs and are con-
veyed through the lymphatics to those glands ; does not the
mysterious fact that they are found in remote organs tend to
establish such a theory? No observer has yet accounted for
their presence in such remote organs except by that route. It
has always seemed a strange phantasy that the stomach, with
its powerful secretion, should not be able to destroy any living
organism. It certainly does in the lower animals. Is it not a
more reasonable theory that the bacilli which prove virile
adhere to the mucous surface of the nose, throat or bronchi,
and find their way through the sewers or lymphatics to the
intestinal glands and other organs?
I do not claim priority in the antiseptic treatment of typhoid
fever, and while Dr. Woodbridge may not have originated
such treatment, he certainly deserves a monument for his
indefatigable efforts to convince the medical profession of its
efficacy and importance. R. Sayre Habnden, M. D.
A Reply to Dr. Donald Maclean's " Open Letter
to the Members and Friends of the Medi-
cal Profession (Regular) In Michigan."
Detroit, Mich., July 27, 1896.
To the. Editor:— The Michigan Medical Legislation League
is the outcome of a series of public meetings called (through the
newspapers) by the Wayne County Medical Society (regular)
for the purpose of enlisting the cooperation of all registered
practitioners of medicine in this State, in an effort to secure
from the next legislature a law to establish an adequate stand-
ard of qualification for all persons who may desire to practice
medicine in Michigan in the future. These meetings were
composed of all sorts of medical practitioners, many of whom
were " Regulars" good and true. The sentiments expressed in
Dr. Maclean's open letter are good ; but his sweeping censure
of the organization in question, would seem mal apropos,
because " The League" is merely a political body, with no
object or purpose except the one set forth, viz : that of promot-
ing legislation for the protection of the people from future
unqualified practitioners of medicine. The League is not
strictly speaking a medical organization. There is no ques-
tion of medical ethics involved in the issue before us, and no
creed to be assailed or defended. It is no more an " unholy
alliance" than a combination of Catholics, Lutherans and Pres-
byterians would be, when made for the attainment of some-
secular object. Now, then, as any person in Michigan, in pos-
session of any sort of medical diploma, can become a legalized
practitioner of medicine upon the payment of seventy -five
cents ; therefore each and every one who has thus registered
at the County Clerk's office is upon the same legal planet
Thus " before the law" as it now exists, the educated and the
ignoramus ; the Christian and the Charlatan ; the gentleman
and the drunkard are each on an equality ; and Legislatures, as
well as courts, do and always will recognize such vested rights !
Our (the regular profession) efforts at convincing the people,
and the politicians, of the wisdom of adopting measures which
we alone promulgate have repeatedly failed, as the history of
medical legislation, not only in this State, but in every other
State of the Union attests. It is therefore practically useless
to attempt the achievement of any medical legislation unless
the majority of all practitioners, of all sorts, acquiesce in the
movement. Obviously then, it would seem to be the jxitriotic
duty of every regular practitioner in Michigan to throw aside
Phariseeism and heartily aid this organization in its efforts to
promote legislation for the protection of humanity and the
elevation of the quality of medical practitioners in general.
The Doctor is in error when he states that there are but
two regular practitioners on the Executive Committee of the
League. On the contrary, there are five regulars, three
E. L. Shurly, M.D.
"homeopaths" and one "eclectic'
Legislation League.
Detroit, Mich., July 25, 1896.
To the Editor: — I was pained to see, in to-day's Journal, a
communication from Dr. Donald Maclean opposing the efforts
of the Medical Legislative League.
Some of his points are very good. We all admit them ; but
what shall we do? Dr. Maclean has been at the head of the
Legislative Committee of the regular State Medical Society
for twenty years, and has never accomplished anything. The
number of incompetent and irregular practitioners has steadily
increased. Illinois, Canada, Indiana and Ohio, in fact, all the
surrounding States, have passed laws to regulate the practice
of medicine, and the result is that Michigan has been the
dumping ground from the surrounding territory. Shall we
continue, or make some effort to limit this?
In the present state of the public mind we can not pass a
law favoring regular practice. We must be liberal and take in
all those now practicing medicine. By doing that, we can pass
a law which will be a great improvement ; it will not be per-
fect, but if we have a start we can easily improve and amend
the law, but it is very difficult to get a new law ; hence, we
have joined hands with everybody calling themselves doctors
to get a law passed preventing any ignorant and incompetent
physicians coming into the State hereafter. That will be a
great improvement. It will give the young men a chance by
preventing the intense competition.
It makes no difference to Dr. Maclean or myself how many
or how few quacks there are in the State, but it does make a
vast difference to the new beginner ; hence, I can not see why
any reputable, regular physician should oppose this movement,
and I am happy to say that it is the overwhelming sentiment
of all regular practitioners, of all so-called "homeopaths"
and of all the quacks of this State, that the further influx of
charlatans and quacks should be checked.
Respectfully yours, J. H. Carstens, M.D.
L896.]
PUBLIC HEALTH.
277
\ New Hemojjflobiiiomoter.
Chicago. July 23, 1896.
7'd the Editor:— In a paper rend by me before the Chicago
Academy of Medicine last January (and published in Medicine
March. 1890) on "Color Measurement and its Application in
Medicine and the Arts," I ventured the assertion that the
hemometera and hemoglobinometers now in use were decidedly
defective, for the reasons then and there set forth. 1 further
expressed my belief that a modification of Lovibond's "tinto-
meter" would be found more accurate and more easy of appli-
tion than any of the instruments (Fleischers, Gower's, etc.)
then in use, '
I was at that time conducting some experiments with the
tintometer as a measurer of blood tints and promised to relate
■q experiences with it when these were completed. I subse-
quently found that Dr. George Oliver had anticipated me in
•this matter and had, like myself, visited Mr. Lovibond's Color
Laboratories at Salisbury, England, for the purpose of invest-
igating certain questions in ehrouionietry.
The result of these investigations has been incorporated in
the Croonian Lectures for 1896, "A Contribution to the Study
■of the Blood and the Circulation," delivered last month by
Dr. Oliver. The purpose of the tintometer and especially its
value in hemometry are fully described in Dr. Oliver's third
Jecture, published in the London Lancet of June 20 last, and I
take the liberty of drawing the attention of the profession to
that particular issue.
For the further information of those who are interested in
■chromometry generally or in that division of it which includes
the determination of the chemic constituents of the blood by
variations in its color I would say that the agent for the tinto-
meter in the United States is E. B. Meyrowitz, Optician, 104
East 23rd Street, New York. Casey A. Wood, M.D.
A I hii in i ii Testing.
Greeley, Colo., July 22, 1896.
To the Editor:— In our Journal of April 11, 1896, p. 732,
Dr. J. \V. O'Neill describes a new apparatus for the cold nitric
acid test for albumin. A more available way, giving a large sur-
face of contact for the urine and acid, with very little mixing of
■the fluids, is to put the urine to the depth of about half an inch
into a beaker of suitable size, e. g., two inches in diameter.
Take up about m, xlv of the acid with a pipette. Put the
point of the pipette down through the urine to the bottom
■of the beaker and let the acid escape slowly, especially at
•first. One way to be sure that the acid escapes slowly is
to watch the top of the column of acid in the pipette.
If this goes down slowly one may be pretty sure that the
■stream of escaping acid is a gentle one. Close the pipette
tight again before taking it out to keep the small amount of
acid remaining in the pipette from mingling with the urine.
A little calculation will show that in a two-inch beaker the
^surface of contact is ten times the size of that in a five-eighths
inch test tube, which is the size in the O'Neill apparatus. I
think Prof. E. S. Wood of Boston, was the first to point out
the advantage of a large surface of contact.
One incidental point about the apparatus here described is
that it is cheap and of use for more than this one test.
C. D. Nelson, M.D.
Railroad Rates.
Dunkirk, Ind., July 20, 1896.
To the Editor: — Is it not about time we were agitating the
matter of railroad rates to the association. I have been think-
ing for some time that as a society or association we have been
practically ignored by the railroad companies. It is true we have
had the very liberal rate of one and one-third fare. A party
of ten going a hunting or fishing can get such a rate at any
time and on any road. Then look at the rates given other
society meetings, such as the Christian Endeavor, the B. Y.
P. U.,etc. Also the great political conventions of the day.
Within a few days of our meeting at Atlanta, the rate from
Cincinnati was one fare. When we consider that the railroads
get so much service from physicians and the only conpensa-
tion rendered is an insignificant pass over a few miles of road
we think it is about time to raise a howl about the rates given
to our annual meeting.
And now as our next convention will be held at Philadelphia
which is a great railroad center, let us investigate the matter
and see if we can not get better rates. Let us hear from others
on this subject. Yours very truly,
J. B. Garber, M. D.
PUBLIC HEALTH.
Poisoned with Belladonna Greens. — A family were poisoned
recently in a,suburb of Paris by a dish of greens gathered in
their own garden and served for dinner. Seeds of the bella-
donna had been sold to them by mistake for spinach seeds.
Brooklyn Health Report.— During the week ended June 18, there
were reported 674 deaths. The death rate was 31.3 per thou-
sand, in an estimated population of 1,125,000. Of the total
deaths reported 418 or 62.0 per cent, were of children under 5
years of age, and 333 or 49.4 per cent, were of children under 1.
Compulsory Rest for Working Women after Childbirth.— The
Progres M4d. of July 4 states that the laws of Germany,
Switzerland, Austria, Belgium and England compel working
women to a four weeks' respite from the factory, etc., after
childbirth. The Society of Public Medicine and Professional
Hygiene is advocating the introduction of a similar law into
France, with an allowance from the public funds during the
time of compulsory rest.
Germany Officially Investigates Colorado Climate. — Dr. Engel
Reimers, chief physician to the public hospital in Hamburg,
Germany, has been sent to the United States, and Colorado
particularly, to investigate the influence of the climate upon
tubercular patients. The doctor believes that the experiments
made with lymph and other alleged evires are as naught com-
pared with the outdoor treatment, and that the dry climate of
Colorado is ideal for that purpose. — Col. Med. Jour., July.
Water Supply of Allegheny and Pittsburg, Pa.--The report of the
bacteriologic examination of the water shows that the three
Allegheny samples contained from 1,600 to 6,250 bacteria to the
cubic centimeter, while the Pittsburg sample contained 656.
The water of Allegheny is much worse than that of Pittsburg,
but both are far beyond the limit of safety. These results fully
explain the high typhoid fever rate of the two cities.
Boric Acid in Milk.— While the addition of boric acid to milk
does not make it poisonous, it produces certain deleterious
effects, which should cause its use to be prohibited. Chem-
ically, the presence of borax not only tends to neutralize the
development of acids, which takes place during the presenco
of fermentation, but it precipitates and renders insoluble cer-
tain salts contained in the milk which gives to it a portion of its
value as an article of food. Beside this, its neutralizing action
upon the juices of the stomach tends to retard digestion. Bicar-
bonate of sodium, so frequently used by mothers and nurses
to keep milk sweet, has a similar action. — Pac. Med. Jour.,
July.
Decision Relative to Local Quarantine.— Judge Albright, Penn-
sylvania, declares that a municipality may rightly and prop-
erly be held responsible for the maintenance of families quar-
antined by boards of health, because of contagious diseases.
In making this declaration the court applies precisely the
principle of law which is currently acted upon in all cases
278
PUBLIC HEALTH.
[August 1,
where persons are deprived of their liberty through any legal
process. The decision will be most helpful, as well as a wise
and prudent determination of a pertinent question. It is
sound public policy, and its effects must ultimately tend to
secure more complete and valuable quarantine than could
otherwise have been attained.
Decision Relative to Rear Tenements in New York City.— Justice
Lawrence, in the supreme court, July 20, handed down a
decision denying the application of the board of health for the
appointment of appraisers to fix the value in condemnation
proceedings of certain rear tenements which were ordered
vacated by the board. It was asserted in the four cases on
which argument was heard several weeks ago that the court
could not name the appraisers, as the act under which they
were to be appointed was unconstitutional, as it limited the
powers of the appraisers within certain lines as to the value
they could put on the condemned properties. The decision,
while delaying the appointment of the commissioners, is really
a victory for the board of health in that the act is practically
declared to be constitutional. At the time of the hearing it
was admitted by the attorney for the board that certain legal
provisions had not been complied with in the petition, and an
effort was made to allow the board to amend and let the ques-
tion go to the court on its constitutionality alone.
Chicago Water Must Be Boiled.— The recent storms in the vicin-
ity of Chicago have caused a dangerous contamination of the
water supply of Lake Michigan, by driving the city sewage to
every intake crib, from whence it is carried through the mains
and used for domestic purposes. An analysis made July 27 of
the water shows the following conditions :
Nitrates
Free Albumoid and
Samples from Ammonia. Ammonia. Nitrites.
Fourteenth St. Station 001 .012 None
Chicago Ave. Station 001 .008 None
Hyde Park Station Trace .010 None
Lake View Station Trace .004 None
Laboratory tap Trace .012 None
Oxygen Sanitary
Samples from Chlorids. Consumed. Quality.
Fourteenth St. Station 66 .180 Bad
Chicago Ave. Station 65 .190 Bad
Hyde Park Station 65 .230 Very bad
Lake View Station 65 .190 Bad
Laboratory tap 65 .170 Bad
Owing to the inadequacy of the pumping facilities at Bridge-
port this contamination has existed for over four months, but
not to the alarming extent which has been developed during
the past week. Under these circumstances it is absolutely
dangerous to use the water for drinking purposes without
boiling. The Assistant Commissioner of Health Dr. Frank
W. Reilly has given an interview setting forth the foregoing
facts in the Tribune of July 28.
"Spitting" in Indiana.-The Indiana State Board of Health has
issued a circular letter to all railroad officials asking them to
have ejected from their trains every man who persists in spit-
ting on the floor of the cars or stations after he has been
warned not to do so. In the circular the board explains that
the sputum contains the germs of la grippe, nasal catarrh, and
various other diseases. It also declares that "spitting is a
nasty and unnecessary habit," and explains that the Board of
Health will pass a rule against spitting which will have all the
force of law if the railroads will post it up and endeavor to
enforce it. The circular adds: "When the rule is first pub-
lished and posted up in public places this board will, of course,
be loudly abused as foolish, impracticable and idiotic. Atten-
tion thus being gained, we will publish in every county reason
for the action." Such a reform as the Indiana health officers
have undertaken is needed in every part of the United States.
Identity of Croup and Diphtheria Officially Recognized in Quebec. —
The following is a portion of an official circular over the signa-
ture of Dr. Elzear Pelletier, the Secretary of the Board of
Health of the Province of Quebec. It shows that formal action
has been taken by that board placing croup under the same
sanitary regulations as diphtheria. "Being informed that a
great number of cases of croup escape the control of sanitary
authorities, and that it is mostly due to the public being gen-
erally under the impression that croup is not a contagious dis-
ease, the Board of Health of the Province of Quebec authorizes
the publication of the following definitions : Croup is nothing
else than diphtheria, attacking more especially the respiratory
tract (larynx). The expression laryngeal diphtheria designates
better than the term croup the nature of the disease and should
be preferably employed. Distinction should always be made
between croup or laryngeal diphtheria, which is contagious,
and false croup or laryngismus stridulus, which is not conta-
gious. There are no membranes in laryngismus stridulus or
false croup. The cough of croupal form which characterizes
this disease is due only to a nervous element."
Mortality by Casualty from an Insurance Standpoint. — The Medi-
cal Examiner reviews the recent publication by the Mutual
Life Insurance Company of New York on the above subject.
The author, Dr. E. J. Marsh, is the statistical medical director
of that company. It says : "The record is very interesting,
but, after all, there is no broad principle to be deduced. So-
many died from railroad accidents, so many murdered, so many
suicided," etc. We can hardly agree with the broad statement,
of the author that "no examination can give any protection
from chance of accidental death." In all application blanks,
questions are asked regarding occupation, environment and
physical defects, which, if rigidly and correctly answered, will
give protection from chances of accidental death in some cases.
That is one reason why they are inserted. The answers to the-
questions alone will cause the company to decline, provided
the answer is such as to show an element of danger. Often
an applicant is presented who is perfectly acceptable in alt
respects, save the possible element of danger from occupation
and environments. No company, for instance, would accept a.
powder or dynamite maker, be he ever so healthy, knowing-
that any moment he may be blown to atoms, and yet no one
but the medical examiner may have conveyed the information
to the company. The examination revealed this fact, and,
therefore, is a refutation of the unqualified statement of the-
Doctor in his essay. We fail to discover anything regarding-
the apparent fact, if it is a fact, that accidents run in families,
so to speak. All underwriters have noticed that certain fami-
lies seem to be destined to die from accidents ; it may be one
particular kind of accident, or it may be simply from violence.
Why is it? Is it because there is a careless trait in the family,
or is it due to physical defects in hearing or seeing? Or is it
the old doctrine of fatality? Whatever it is, certainly accidents
do occur again and again in a family. When this is the case
it is best to investigate the applicant presenting the family
peculiarly on general principles. The pamphlet is the result
of the experience of the company represented and may not be
the experience of another. Each company presents its own
experience in this respect, and is governed by its own figures.
On Baths for Public School Children.— The Boston Medical and
Surgical Journal, July 16, advocates the above named inno-
vation, and argues in favor of the School Committee of Bos-
ton following German example, by the experimental introduc-
tion of shower baths into a school about to be built in the
most squalid and congested section of the North End. The
writer believes that, even where municipal baths are most
numerous and well devised in Europe, the policy of providing
special bathing facilities in schoolhouses for the children who
resort to them for instruction has developed rapidly in the
last decade and is now highly approved. The initial impulse
to the widespread and admirable system of municipal baths
now so common in Great Britain and on the continent is
ascribed by the Boston Herald to the success which attended
1896.]
NECROLOGY.
279
the establishment of Liverpool's first public both and wash
house in 1842. That the Boston School Committee should be
forced to consider the question of school baths before even the
site of the first of Boston's municipal bathhouses has been
determined bespeaks an enhanced and diversified interest in
school hygiene in the community. Fortunately the advocates
of school shower baths can point to the result of ten years'
experiment by school boards in Germany and Switzerland. It
would appear from the evidence cited from European experi-
ence that school shower baths have proven popular, cheap and
efficacious wherever they have been given a fair trial. They
are admitted to be very much cheaper, both in respect to orig-
inal cost and cost of maintenance, than any other form of bath.
Heing self cleansing, school shower baths have commended
themselves to sanitarians and hygienists as superior to tub
baths. If, as is claimed by Dr. Hartwell, bathing and dress-
ing-room appliances adequate for bathing 2,000 children weekly
during school hours can be placed in the Paul Revere School
at a cost of less than $3,000, we are inclined to think that the
School Board will do well to test the matter practically. It is
admitted by the education authorities that schoolhouse air in
Boston is bad. It is probably as bad in the North End as any-
where in the city. We have little doubt that the comfort,
health and efficacy of teachers and pupils in the new school
would be greatly enhanced, as a result of the purer air which
would be had if the bodies of the pupils who come from
"unplumbed" houses were occasionally subjected to a warm
shower of water during the winter months.
Health Report. —The following health reports have been
received in the office of the Supervising Surgeon-General,
Marine-Hospital Servioe :
SMALLPOX — UNITED STATES.
New Orleans, La., July 11 to 18, 3 cases.
Pensacola, July 11 to 18, 1 case.
SMALLPOX — FOREIGN.
Callao, June 14 to 28, 61 deaths.
Genoa, Italy, June 5 to 12, 1 case.
Gibraltar, June 28 to July 8, 1 case.
i luayaquil, July 3 to 10, 2 deaths.
Hamburg, July 4 to 11, 1 case.
Licata, June 27 to July 4, 3 deaths.
Madrid, June 30 to July 7, 22 deaths.
Matanzas, July 3 to 10, 1 case, 1 death.
Montevideo, June 12 to 19, 1 case.
Odessa, Russia, June 27 to July 4, 11 cases, 4 deaths.
Osaka and Hiogo, June 20 to 27, 49 cases, 20 deaths.
Prague, June 27 to July 4, 2 cases.
CHOLERA.
Yokohama, June 12 to 19, 1 case, 1 death.
YELLOW FEVER.
Matanzas, July 3 to 10, 100 cases, 46 deaths.
Sagua la Grande, July 4 to 11, 59 cases, 7 deaths.
St. Petersburg, June 27 to July 4, 14 cases, 7 deaths.
Warsaw, June 13 to July 4, 7 deaths.
San Juan, Porto Rico, May 1 to 31, 14 cases, 4 deaths ; June
1 to 30, 17 cases, 2 deaths.
NECROLOGY.
Vincent Lombard Hurlbut, M.D., died July 24, at his
home, 2342 Prairie Avenue, Chicago, 111., of Bright's disease.
Though most of his busy life had been spent in Chicago, Dr.
Hurlbut was a native of New York State, where he was born
in the town of West Mendon on June 28, 1829. His father was
Dr. Horatio N. Hurlbut, a descendant of the Puritans. As a
child he moved with his parents, first to the town of Sparin,
Crawford County, Pa., and later to Jefferson, Ashtabula
County, Ohio. Graduating from the Jefferson Academy, he
studied medicine, first under his father at home, and later in
a medical college at Cleveland. In 1851 he came to Chicago
and entered Rush Medical College, from which he graduated
the next year. During the same year he began the practice of
his profession and followed it with unflagging application.
He soon gained prominence in his profession, and for a gen-
eration had been one of the leading physicians of the city. In
1873 he was appointed surgeon of the Woman's Hospital for
the State of Illinois, and long held that position. He was a
member of the American Medical Association, of the State
Medical Society, was Vice-President of the Cook County Med-
ical Society. Dr. Hurlbut was a thirty-third degree Mason
and one of the oldest and most widely known members of that
order in the West. He entered the Blue Lodge in 1860 and
took the various degrees until he reached the highest, receiv-
ing the thirty- third in Boston in 1864. From 1863-5 he was
commander of Apollo Commandery and in 1867 he was made
Grand Commander of Illinois. In 1871 he was elected Gener-
alissimo of the order, and in 1877 was chosen Grand Com-
mander of the order at the triennial conclave at Cleveland,
Ohio. Notwithstanding his success and honors he was very
unostentatious in his manner and his acts of charity were
innumerable, ever ready to alleviate suffering and unhappiness.
Our genial colleague will also be greatly missed by former
habitues of the old Grand Pacific Hotel, to which hostelry he
was house physician for over twenty years.
Paul P. Prendergast, M.D., of Brooklyn died July 10, in
the twenty-fourth year of his age, in consequence of an attack
of pulmonary tuberculosis that made its onset about one year
ago. He was a native of Brooklyn and a graduate in 1894 of
the College of Physicians and Surgeons, New York. He was
a nephew of Dr. J. J. Prendergast and the late Peter Paul
Mahoney, M.C. He had been ailing for about eighteen months
from pulmonary symptoms, which are supposed to date back
to the time when he was in the hospital. He was very fond of
his profession and for six months after the symptoms of his
disease were discovered he continued to study in the class of
surgeons to which he was attached at St. Mary's Hospital.
He was for a time at Seney Hospital. He was also for a time
an assistant at the Sloane Maternity in New York. Before his
his illness Dr. Prendergast was in good health. He was six
feet tall and weighed nearly two hundred pounds. But his
health failed to such a degree that it was considered expedient
that he should leave the city. He went to Saranac Lake in
the Adirondacks, where he spent about a year. He returned
home early in the present year and later took a trip to Califor-
nia. While in the mountains of the Pacific coast he con-
tracted what is known as the mountain fever. His health
gradually grew worse. He realized his condition and came
home to die, a victim to hospital tuberculosis, hastened and
fostered by an over-zealous attention to clinical study.
Theron Z. Gibbs, M.D., of Fort Ann, N. Y., was killed
early in July, by being struck by a train while he was crossing
the track near his home. He was born at Shoreham, Vt., in
1826. He was graduated from the Castleton Medical School
in 1853. He practiced in New York State until the breaking
out of the war, when he entered the volunteer service as an
assistant surgeon of the Fifteenth New York Engineers,
becoming full surgeon in 1863 ; his regiment was then with the
Army of the Potomac. He was ex-President of the Washing-
ton County Medical Society and had been the health officer of
Fort Ann from 1888 to 1890, in which town he had practiced
fully thirty years. He was a member of the State Medical and
other societies. He had been twice married and is survived by
his widow and three children.
William A. Piper, M.D., of Philadelphia died July 6, aged
77 years. He was a graduate from Jefferson Medical College,
in 1844. ,
James Thomas Pettus, Jr., M.D., of New York City died
on July 13, at Reading, Pa., He was a graduate from the
College of Physicians and Surgeons, New York, of the class of
1844.
S. H. Bottomley, M.D., of Chicago July 26, from a compli-
cation of kidney troubles. Dr. Bottomley was born in Birm-
ingham, England, fifty- one years ago, and came to Chicago in
1866. He was a graduate of Lind University, and during the
Civil War served as a surgeon.
280
MISCELLANY.
[August 1,
SOCIETY NEWS.
The Central Texas Medical Association.— This association was in
session at Waco July 14 and 15. Among the papers read and
discussed were "Medical Legislation," by Dr. J. D. Law, and
"Hypnotism in Disease," by Dr. R. W. Park.
Chautauqua County (N.Y.) Medical Society.— The annual session
was held at Chautauqua July 14 with a large attendance. The
following officers were elected for the ensuing year : President,
E. S. Rich ; vice-president, Morris N. Bemus ; secretary, C. A.
Ellis.
Medical Society of the County of Clinton, N. Y.— This society
held its semi-annual meeting at Plattsburg, July 14. Dr.
Henry C. Fisher, U. S. Army, was elected an honorary member
of the society. An interesting paper, entitled "Purpura," was
read by Dr. Taylor, who also presented a clinical case in illus-
tration.
The Lexington and Fayette County (Ky.) Medical Society meeting
was held at Lexington, Ky., July 13, and the following officers
were elected for the ensuing year : President, R. L. Willis :
first vice-president, J. C. Carrick ; second vice-president, J. Y.
Oldham ; secretary, R. C. Falconer ; treasurer, Ed. Green ;
librarian, N. L. Bosworth.
Oneida County (N. Y.) Medical Society.— A meeting of the Oneida
County Medical Society was held at Utica, N. Y., July 14. Dr.
Dye presided. Dr. F. H. Peck read a paper on "Ununited
Fractures." Dr. Glass reported two cases in which the Mur-
phy button had been successfully used. Dr. A. I. Simmons
gave a sketch of the life of the late Dr. Claude Wilson of
Waterville. Dr. Smith Baker also paid tribute to the deceased.
Wyoming County (N. Y.) Medical Society.— The annual meeting
was held at Warsaw, N. Y., July 14. The following officers
were elected for the ensuing year : F. R. Barross of Attica,
president ; A. E. Ellinwood, vice-president ; A. B. Straight of
Perry, secretary. Papers were read by Prof. Floyd S. Crego
of Buffalo, "Value of Animal Extracts in the treatment of
Nervous and Mental Diseases ;" James E. Walker of Hornells-
ville, "Renal Auto-intoxication;" Cordelia E. Greene, "Lep-
rosy on the Hawaiian Islands." The next meeting will be held
in Castile the first Tuesday in October.
The XlVth Congress of Internal Medicine in Germany.— A feature
of this congress which has been much commended, was the pre-
sentation of each address in two parts, one by a physician and
the other by a surgeon, who regarded the subject from such dif-
ferent points of view. It was held at Wiesbaden in April. Nothing
of an epoch-making character was presented, although Ewald
used that term to express his appreciation of Baumann's dis-
covery of the presence of an organic compound of iodin in the thy-
roid gland, "which gave us our first real insight into its essential
elements, and cast in a new mold the application of the thy-
roid preparations to therapeutics, without contradicting our
previous knowledge." "In Baumann's thyroiodin we have
secured the long-sought exactness in the amount and strength
of doses, and as it contains all the essential elements of the
gland, it can be substituted for the fresh, the dessicated and
the extracts of the gland." Ewald administers it in very small
doses at first, gradually increasing, but always keeping within
a daily maximum of ten tablets, corresponding to 3 mgr.
iodin. The fact was established once more that the fever
of infective diseases is now considered a salutatory reaction
of the organism in its struggle with the microbes. The
revulsion of feeling in regard to the effect of alcohol in fevers
was also noticeable, and the rapid fall of temperature in
septic and puerperal fevers after the administration of large
quantities of alcohol dwelt upon. Rosenfeld announced that
urotropin and urea are efficient in the treatment of uric
diathesis, and 5 to 20 grams of urea a day produce no incon-
venience. The diet must include caseate of sodium, peptone
or aleurone, and meat, fat and sugar be excluded. Uric acid
diminished 24 to 70 per cent, under this treatment. Noorden
stated that lime combined with a phosphate is eliminat
rapidly by means of increased intestinal secretions, and
therefore much to be preferred to sodium and potassium
preventing renal concretions of uric acid and keeping
blood in a neutral state. By avoiding intestinal irritatic
the use of four grams a day of monophosphate of lime
be kept up quite a long while.
MISCELLANY.
Trained Masseurs for the French Army.— The war departmer
of France has established three schools where massage is
taught as a science to a corps appointed for the purpose. One
is at Paris, another at Lyons and the other in Algeria. The
course requires six weeks.
Training School for Nurses Wanted in Rio Janeiro.— O Brazil-
Medico is urging the establishment of a training school for
nurses of both sexes at Rio Janeiro, where the articles in the
press on the abuses in the National Insane Asylum are now
quite in vogue. Buenos Ayres already has a model establish-
ment of the kind.
Rape in Virginia.— Section 3,680 of the code of Virginia defir
ing rape, was amended in March, 1896, substituting fourteen
for twelve, as the age of the female affected thereby ; extend
ing its application to any female who is an inmate of a deaf
dumb or blind institution who is a pupil therein, and reducin
the minimum penalty of confinement in the penitentiary fron
ten to five years.
Two New French Hospitals.— The one at Clichy was erected
through the generosity of Jules Gouin, at an expense of
8240,000. It occupies a large square, one side of which
devoted to a model apartment house for working men. The
other hospital is at Auteuil, and is chiefly designed for the
training of army nurses. There are twenty-five beds, a large
garden and an open space in the rear that could be filled with
tents in time of war so as to extend the capacity of the hospita
indefinitely. It is the work of the Association des Dames
Francaises.
The "Laryngoscope."— We have received No. 1, Vol 1, of the
Laryngoscope, a journal devoted entirely to the consideration
of diseases of the nose, throat and ear. The journal intends
to fill the niche between the strictly special and the general
journals, with that class of physicians who confine themselves
entirely to the treatment of the diseases mentioned or who pay
especial attention to these troubles while maintaining a gen-
eral practice. We extend the hand of fellowship to the new
journal.
Virulence of Klebs-Loeffler Bacillus Slightly Attenuated by the
Action of Roentgen Rays — The Prov. Med. of June 27 (Lyons)
reports some experiments with cultures and diphtheria toxins
exposed for seven hours to the Roentgen ray. Cultures made
and animals inoculated afterward with them showed in each
case a slight diminution in the virulence. The bacilli did not
develop so rapidly in cultures, and the animals survived four
to nine hours longer than those inoculated with toxins that
had not been exposed to the ray. It adds that Lortet con-
siders the action of the ray beneficial in augmenting the resist-
ing powers of the animal exposed to it, rather than in impair-
ing the virulence of the microbe.
Our Mexican Exchanges.— The monthly bulletin of the Health
Department of Mexico is not the usual dry record of statistics,
but a handsome, blue-covered, 32-page pamphlet containing
several popularly written and instructive articles on hygiene
and the prophylaxis of various diseases, printed with large,
1SW.]
MISCELLANY.
281
eiear type. The statistics are also compiled in a manner that
will render great services to science in time. The publications
of the Academia Nacional de Medicina are also conducted
with great enterprise, and according to modern methods. A
ill scientific study of the plants of Mexico is now under
■a) . which is already an important contribution to science.
Another journal is conducting a special and comprehensive
ttudy of the manifestations of tuberculosis in Mexico.
Thrombus of the Labium. Dr. S. A. Goodwin reports a case
Occurring after a natural and easy confinement. He says:
The moss increased until it had acquired the size of a new-
born child's head, exceedingly painful, and extending to the
perineum. The labium was everted so that it appeared to be
covered externally by the mucous membrane. We applied
cloths wrung out of hot water and solution of acetate of lead,
and succeeded in keeping it from rupturing. The tumor
became dark in color, almost black, and very hard. In three
days the tumor was ruptured and contents removed, which
was a dark coagulation of blood. The wound healed rapidly,
and in five weeks all that remained to indicate any abnormality
was the cicatrix.— Ind. Med. Jour., July.
Injured Person's Duty.— In the personal injury case entitled
West Chicago Street Railway Co. v. Stephens,, the appellate
court of Illinois, held, July 1, 1896, certain instructions erro-
neous which required the plaintiff to show what part of his
injuries were attributable to the original cause as separated
from those due to the lack of care by him in getting cured of
them, as not stating the rule of law in regard to the duty of
one who receives an injury is under to take reasonable care
that his injuries shall not, by undue neglect, become aggra-
vated, also because such instructions failed to include the ele-
ment that the plaintiff had knowledge, or reasonable cause for
knowing, that he needed better care and attention in getting
cured than he gave or caused to be given to himself, and that
such increased care and attention were within his means and
power.
Experimental Tuberculosis Attenuated by the Roentgen Ray.
Lortet and Genoud report a series of successful experiments
with guinea pigs inoculated with tuberculosis in the inguinal
region. Three selected at random out of the eight inoculated,
were tied to a board on their backs, and the inoculated region
exposed to the Roentgen ray for one hour each day, from April
• June 18. Ganglionary abscesses developed in the control
animals, which discharged spontaneously a whitish suppura-
tion : the inguinal ganglia grew soft and could not be distin-
guished from the surrounding tissue. The animals also showed
great emaciation. On the other hand, the three animals
exposed to the Roentgen ray gained in weight ; they had no
abscesses, and their inguinal ganglia remained hard and dis-
tinct, with no tendency to suppuration. These results prove
that the Roentgen ray materially modified the acute develop-
ment of the tuberculous infection, and justify its application
to human beings, especially children, with superficial tubercu-
losis, limited to the pleura, or with tuberculous ganglia in the
mesentery. — Bulletin Midical, July 1.
New Application of the Roentgen Ray. Fluorescent Screen. — An
important advance in the application of the Roentgen ray to
medicine is described in the Semaine Mid. for July 1. Instead
of taking photographs, it is now possible to look directly into
the body and see the skeleton with our own eyes. This is
accomplished by means of a screen made by gluing a piece of
cardboard '..mm. thick, on a pane of glass. A square piece is
then cut out of the center, 10x25 cm. and the space thus left
on the glass is filled with the finely pulverized chemicals, which
we know become fluorescent under the Roentgen ray ; double
cyanid of potassium and platinum, or double cyanid of barium
and platinum. This is covered with another piece of cardboard
the same size as the first, enclosing the chemicals. If this
screen is held at the cathode end of a Crookes' tube concealed
in a pasteboard box or covered with a cloth, the part of the
frame that holds the chemicals is instantly illuminated, and a
hand interposed between the illuminated frame and the invisi-
ble Crooke's tube, becomes transparent, so that nothing but
the bones can be seen. Promising results have already been
secured by Buka, Roentgen, Salvioli, Lewy, Grunmarch, du
Bois-Reymond, etc., who have distinguished the skeleton and
organs throughout the body, and diagnosed several cases of
arterio-sclerosis, etc., with amazing accuracy. Becherof Berlin
adds the suggestion that lime water injected into the stomach
or intestines or the introduction of air prevents the passage of
the Roentgen ray.— Deutsche Med. Woch., July 2.
Bicycle Riding among Those Having Unsound Legs.— Mr. E. B.
Turner, the author of a series of special reports in the British
Medical Journal on "Cycling in Health and Disease," has not
found that this form of exercise is injurious in cases of im-
paired venous circulation. He says ordinary varix of the lower
limbs, however produced is very frequently much benefited by
regular cycling, but if the enlarged veins be of considerable
size, a stocking should be worn. Out of a very large number
of such cases the writer has never seen the slightest increase
which could be put down to riding, not even in men who raced
long distances on the road and path, while in many cases of
infiltration of the skin and varicose eczema, a perfect cure has
resulted. A suspender should always be used if the rider has
a varicocele, as a protection from injury by the saddle, when
the roads are rough and lumpy. Piles diminish and cease
from bleeding in a wonderful fashion by the time a few hun-
dred miles have been judiciously covered, and though external
masses must remain, they do not as a rule increase.
Complications and Sequelae of Diphtheria. — The complications
are those of extension to or ulceration of the respiratory tract
and involvement of other regions from toxin poisoning. Locally
there is hemorrhage, due to ulceration, from the nose, throat
and bronchi ; occasionally petechial hemorrhages under the
skin and other skin rashes, especially erythema, appear. By
extension of the process or by inhalation of particles of mem-
brane, acute bronchitis, more especially capillary bronchitis,
or broncho-pneumonia with atelectasis or gangrene, may
develop. Kidney symptoms are common, albuminuria is pres-
ent in severe attacks ; occasionally suppression of urine is
present, and rarely, dropsy develops later. Heart failure or
fatal syncope may occur at any time during the attack or after
convalescence has commenced. Of the sequelae, paralyses are
the most important. They appear usually during the second
or third week of convalescence, in from 10 to 15 per cent, of
cases. One of the most common is that of the velum palati.
Sometimes the eye is involved and strabismus, ptosis or loss of
accommodation may result. Facial paralysis sometimes occurs.
One of the limbs may be involved. Occasionally multiple
neuritis develops. — Dr. Howard Van Rensselaer in Albany
Med. Annals, July.
Subcutaneous Injections of Artificial Serum in Anemia and Septi-
cemia.— The meeting of the AcadCmie de Medecine, June 30,
was chiefly devoted to a discussion of this subject. Pe^an
closed the discussion by remarking that all were evidently
unanimous in regarding subcutaneous injections as marvelously
effective in hemorrhages and acute anemia, and as a possibly
useful adjuvant in septicemia. But as to intravenous injec-
tions the few remarkable successes announced here and there
are isolated cases, and he believes it is better to return to the
subcutaneous method. Pozzi mentioned a case of "veritable
resurrection" from death in post-operative septicemia. He
strongly advocates subcutaneous injections as effective, harm-
less and easily administered. Pinard stated that in the Bau-
delocque clinic they lost every woman in acute anemia from
hemorrhages, from 1882 to 1893. Since 1893 he has been treat-
282
MISCELLANY.
[August 1,
ing these cases with subcutaneous injections of artificial serum
and has not lost one of the seventeen presented. He has never
had occasion to inject more than 1400 grams in the twenty-four
hours. Tarnier has also seen four women revive when they
were practically dead from excessive hemorrhages. He has
never used the artificial serum in septicemia. Champonniere
deprecates the use of enormous injections, and has never found
the serum beneficial in septicemia. Porak has used the sub-
cutaneous injections to advantage in eclampsia. — Bulletin MM-
ical, July 1.
Patent Medicine Scandal at Bellevue Hospital.— The Boston
Medical and Surgical Journal for July 2 reports that
motives other than scientific have brought to pass a scan-
dal of magnitude, concerning which the medical staff of
the hospital concerned has shown a quiescence, if not acqui-
escence, that apparently merits its condemnation by the pro-
fession and the public. It may have been the "fault of
Mayor Strong," as has been said, but the staff is not obliged
to continue on duty if an outrage is committed against its most
sacred principles. The Journal says : "Considerable comment
has been caused of late by the setting apart of the Commis-
sioners of Public Charities, in spite of the protest of the medi-
cal board of the hospital, of one of the alcoholic wards of Belle-
vue Hospital for the use of a certain physician of New
York, but not connected with the institution, who is to treat
patients by means of a secret remedy which he claims to have
discovered. This physician is Dr. Isaac Oppenheimer, and the
curious part of the matter is that up to the present time he
has been a regular physician in good standing, being a grad-
uate of the College of Physicians and Surgeons (in the year
1876), a Fellow of the Academy of Medicine and a member of
the Medical Society of the County of New York. In the only case
that has thus far been made public of which Dr. Oppenheimer
had charge the patient, who had been transferred to the Bellevue
from the Harlem Hospital, died a few hours after his admission
to the ward. In this case, however, the Doctor asserts that
the man was suffering from an advanced stage of Bright' s dis-
ease, and that he made no attempt to treat him with his new
"cure."
A Medico-legal Case Affecting a Young German Practitioner. -The
Medical Press and Circular makes comment on a recent med-
ico-legal case in Germany. The central figure of this case was
a young medical practitioner of Spandau, who became quali-
fied in 1893 ; he was accused of causing bodily injury through
negligence. About a year ago a young woman, recently mar-
ried, presented symptoms of threatened abortion. She con-
sulted two medical men who agreed as to her condition. She
then placed herself under the care of the accused, who declared
that a harmless operation was necessary. This she consented
to, and the operation was performed, with the result that the
patient died of hemorrhage two and a half hours afterward.
What the operation was is not clear, but it appears to have
been a curettement of the uterus, in the course of which per-
foration of the walls of the uterus took place. As a result of
the postmortem examination the young practitioner was
accused of culpable negligence. The two principal medical
witnesses were the Kreisphysikus, Dr. Reinicke and Prof.
Landau. Whilst Dr. Reinicke laid the whole of the blame on
the accused, Prof. Landau laid it on "the present state of scien-
tific knowledge and the defective clinical training of students.
Operations such as the one in question were not taught prac-
tically to young practitioners, and they had to gain their
experience from their patients. Moreover, science followed
the fashions, and there was a widely-spread school that had
given up the plan of observation and waiting, and taught a
method of treatment that the witness must characterize as
brutal, and must, therefore, lead to brutal consequences. The
accused appeared to belong to this modern school ; the woman
was, therefore, not the victim of his negligence, but the victim
of the modern tendency of medicine. The court then requested
a written opinion on the matter from Dr. Landau, and at the
same time a control opinion, or Obergudachten, from the Royal
Medizinal Collegium. It is well to bear in mind that Prof.
Landau is not an ordinary professor of gynecology in charge in
either of the teaching clinics, but a professor extraordinary
with a privilege of private teaching."
American Tenacity. — M. Patenotre, the French Ambassador,
went crabbing the other day at Cape May. He soon caught a
crab, and not being familiar with the creature he grasped it
with his left hand. Then the crab promptly caught him.
The ambassador was evidently both pained and surprised. He
instinctively grasped it with his right hand, and the crab in
turn seized his right hand. Thereupon the captain of the
yacht went to the rescue of M. Patenotre, who remarked :
"Ze tenacity of ze creature is so very much Americaine !"
Oregon Opium Law Constitutional. — In 1887 the legislature of
Oregon passed "An act to regulate the sale and gift of opium,
morphin, eng-she or cooked opium, hydrate of chloral or
cocain." It provides that no person shall have in his or her
possession or offer for sale any of the drugs enumerated, who
has not previously obtained a license therefor, unless, as it
clearly implies, it be obtained on the prescription of some duly
qualified physician or pharmacist for medicinal purposes. The
license is to be issued only to regularly qualified physicians who
keep a stock of drugs and medicines for their own use in pre-
scription, and regularly qualified druggists. This law the
supreme court of Oregon holds constitutional, in the case of
Luckv. Sears, decided April 27, 1896. Speakingonly of opium,
it says that it is an active poison, and has no legitimate use
except for medicinal purposes, though it is frequently used to
produce a kind of intoxication by smoking or eating, a loath-
some, disgusting and degrading practice, which results not
only in pauperism and crime, but also in the serious impair-
ment of the mental and physical condition of those who
indulge in it. The sale and disposition of such a drug, it
therefore thinks, may unquestionably be regulated and con-
trolled by law, and whether its nature and character is such
that, for the protection of the public, its possession by unau-
thorized persons should be prohibited, is a question of fact and
public policy, which belongs to the legislative department to
determine. The discretion of the legislature in the employ-
ment of means which are reasonably calculated to protect the
health, morals, or safety of the public is very great, and so long
as it does not infringe upon the inherent rights of life, liberty
and property, either directly or through some limitations upon
the means of living or some material right essential to the
enjoyment of life, its determination is conclusive upon the
courts. And, while the State can not assume to be the guard-
ian of morals, it has the undoubted power to enact measures
calculated for the suppression of such form of vice as threaten
its welfare by generating disease, pauperism and crime. No
right secured by the fundamental law is interfered with or
impaired by this legislation relating to opium, because the pos-
session and use of the drug are not restrained thereby, so as to
destroy its value as a remedial agent, its only recognized legiti-
mate use. The principle maintained by some courts that the
legislature can not make it a crime to have in one's possession
intoxicating liquors, although it may regulate, or even prohibit,
the sale and disposition thereof, the court declares has no
application here.
Drill Regulations for the Hospital Corps, U. S. Army. — The new
drill regulations will probably be issued before this paragraph
is in print. The board of officers to whom the revision was
entrusted consised of Majors Hoff and Havard and Captain
Cabell. The booklet is of the same size an, " style as the last
edition. There is practically no change in the methods of falling
1896. |
MISCELLANY.
283
la the detachment, or of marching and maneuvering it without
litters: but it is to be noted that officers will not hereafter
'wear swords at drill, and hospital stewards and acting stewards
will wear tho belt but no equipment of any kind unless spe-
cially ordered. In paragraph 48, which describes the recently
adopted hand litter, is the tirst notable change from the old
regulations; and paragraph 49 which formerly read: "One
pair of regulation slings is permanently attached to each litter"
now reads : "One regulation sling is issued to each private as
part of his equipment." On this change is based the material
changes in the new drill regulations. With the slings fixed on
the handles of the litters the bearers at every command to lower
litter had to become unhitched from them and at every lift
litter they had to get into harness again and have it adjusted,
while in many of the movements the bight of the sling when
not on the shoulders of the bearer had to be looked after
specially to prevent its getting in the way. With the present
individual slings the bearers have merely to slip the loops of
tint sling on or off tho handles when they want to lift or lower
the litter, and as the bight is always on their shoulders it is
never in the way. This simplifies the drill greatly, and it is
in fact a return to the method of the Leavenworth board, pub-
lished in 1890, the fixed sling now discarded having been intro-
duced in 1893. The illustrations, with the exception of the
diagrams for the marchings, are all new. The slings on the
men, the new style of army cap and the absence of the large
sword bayonet like knife give the members of the hospital
-corps an unfamiliar appearance.
Diaphragmatic Hernia. -S. M. Fortier, M.D., reports a case in
.Y. C». Med. and Surg. Jour., July: Patient, a colored male,
aged 41 years, states that until two weeks prior to his admis-
sion in hospital, he has never been sick. At above mentioned
time he was stricken with severe abdominal pain, which neces-
sitated his abandoning work. His condition grew steadily worse,
pain more acute, constipation, distension of the abdomen
supervening, and exacerbations of vomiting were noted. Exam-
ination at the hospital : Conscious and answering questions
rationally, but intensely collapsed : abdomen much distended,
especially in left hypogastric region. Percussion revealed a
tympanitic sound, extending to the lower border of the fourth
rib on the left side. Auscultation showed an absence of the
vesicular murmur. Auscultation of the opposite lung revealed
a supplementary puerile respiration. Heart sounds normal,
although rapid and tumultuous ; apex beat displaced slightly
toward the right. Patient complained of a dull pain in the
umbilical region, followed at times by lancinating pains. Dysp-
nea marked, not persistent and progressive, but coming on in
paroxysms. Hiccough, a permanent and distressing symptom,
was accompanied, at times, by vomiting. Deglutition, although
easy, was followed by immediate vomiting. Any movement on
the patient's part would aggravate the symptoms. An enema
of soap and water was administered, high up, through the
rectal tube, but with no results. The diagnosis of intestinal
obstruction was made and the patient transferred to the oper-.
ating room. His condition was so alarming that it was deemed
inexpedient to interfere surgically. Pulse 150 ; respiration 45 ;
temperature subnormal. The patient was surrounded with
cans of hot water and stimulants given. He rallied under this
treatment, but died the next day. Autopsy : Great disten-
sion of the transverse and ascending colon and cecum was
observed. Descending colon collapsed. The obstruction was
found to be due to the passage of the colon through the dia-
phragm, to the left of the median line and behind the central
tendon. It was impossible to remove, by traction, the intes-
tines from the thorax, as a previous inflammation, following
gangrene of a portion of the strangulated gut, had firmly
agglutinated the a \icent structures. The left lung was col-
lapsed, the pleura forming a part of the hernial sac ; adhesions
were firm, especially in the fifth interspace, and pointing of
the sloughing gut was observed to have taken place in this
region. This report shows the difficulty of the diagnosis of
Diaphragmatic hernia.
Kroenleln's Surgical Experience with Carcinoma of the Stomach.—
In sixty-seven cases (patients from 27 to 66yearsof age), twenty-
six were inoperable ; in twenty-two cases he performed explor-
atory laparotomy ; in four gastroenterostomy, and in fifteen
resectio pylori. In one of the latter 13 cm. of the small and 22
cm. of tho large curvature were resected. The patient is now,
a year and a half after the operation, pursuing his usual occu-
pations in good health. Of the rest, four died and ten recov-
ered. Five still survive without a relapse ; two died from
intercurrent diseases, and four had relapses after an average of
597 days (one after 794 days). The immediate deaths were due
to collapse in two cases, in one to inflammation of the lungs,
and in another to gangrene of the lungs and peritonitis follow-
ing necrosis in the region of the suture. He recommends mor-
phium ether for the necrosis, and the strictest asepsis. The
preliminaries, emptying the stomach and bowels, are to be as
limited as possible. He remains loyal to the Billroth-Wolfler
method as superior to all others, and asserts that Kocher's
success in his operations is due to his fine technique rather
than to his method. He gives a little milk and tea the day
after the operation and abandons rectal feeding the fourth
day. In only one of the four cases of gastroenterostomy was
the result satisfactory ; the vomiting and distress passed away
for three months, when death ensued. He urges a more accu-
rate knowledge of the indications of this operation. Six of
the cases of carcinoma that seemed operable but were not
operated upon, survived an average of 209 days, the inoperable
77 days, and after exploratory laparotomy 139 days. The
article in the Beitrage zur klin. Chir., Vol. XV, No. 2, is com-
pleted with photographs of the preparations made of the
cases. — Centralbl. f. Chirurgie.
Injections of Carbolic Acid in Serocysts.— Dr. Victor H. Coffman
advocates its use in preference to the knife or irritating injec-
tions of iodin, on account of simplicity of application, efficiency
and freedom from danger. His method of treatment for hydro-
cele is as follows : By the use of' the hypodermic syringe, one
dram of 95 per cent, solution of pure carbolic acid, inserted
into the superior part of the tumor, guarding the superficial
veins of scrotum, is injected forcibly into the sac without pre-
vious evacuation of the fluid. Should the tumor be exces-
sively large, two drams will be necessary for the first treatment ;
withdraw the syringe slowly after two minutes, preventing
escape of fluid, apply a little vaselin to the surface, or mop the
parts with alcohol if any of the acid has escaped, put on a
dressing of gauze to protect from oozing, and the patient is
permitted to go about his occupation, no risk incurred or pain
endured. Within twenty-four hours a slight reaction follows,
which lasts from two to five days, and the size of the tumor
diminishes gradually. Should it not recede, then repeat the
injection, and within one month all traces of enlargement dis-
appear. For bursa of the patellar tendon, a dram of acid is
injected, and a second injection of one-half dram, five days
thereafter, is necessary in about one- third of the cases.— West-
ern Med. Review, July.
The Mauser Rifle in the Cuban Revolution.— The London Lancet
quotes an article in the Revisla de Ciencias Medicas of Havana,
written by Surgeon Enrique Pedraza of the Spanish Army, on
the effects of the Mauser projectile as seen by him in the pres-
ent war. He points out the great difference which exists be-
tween this and the older forms of projectile, as the Remington
and Freire Brul. These latter being much larger and having a
smaller initial velocity cause large openings and carry septic
materials into the wounds they make which are therefore very
difficult to render aseptic on the field and consequently when
284
MISCELLANY.
[August 1, 1896.]
they come under proper treatment in a hospital are in a condi-
tion which is very difficult to manage, especially when, as is
frequently the case, the hemorrhage has necessitated the use
of perchlorid of iron which increases the size of the wound, or
when a bone has been hit, and, as usually happens, even at a
distance af 100 or 150 yards, is shattered. The Mauser pro-
jectile as issued in the Spanish army is 3 centimeters in length
and 7 millimeters in diameter, and consists of a hard nucleus of
lead and antimony coated with steel, outside of which is a coat-
ing of nickel and copper alloy, the whole weighing 13.7 grams
and having an initial velocity of 632 meters per second, which
enables it to pierce a Krupp steel plate 10.5 millimeters in
thickness at a distance of 50 meters. Such a projectile ought,
it might be thought, to produce a clean and minute wound
with little hemorrhage, easy to close on the field and therefore
likely to heal rapidly in the hospital, more especially as the
bones would be bored rather than shattered and as there would
be little chance of foreign matter being introduced into the
wound by the projectile itself. These expectations are, however,
by no means always realized, and the first few cases of primary
wounds from a Mauser projectile which Dr. Pedraza saw at
Manzanillo very greatly surprised and disappointed him.
With longer experience, however, he learned that the benign
results he had expected to see do occur, but only when the
enemy is 150 yards or more distant. When the patient is shot
at from ten to seventy yards the destruction of the tissues is
very great, and it is this that has given rise to the suspicion
that explosive bullets were being used, especially as the orifices
of entrance and outlet are sometimes so smal! that they can
scarcely be seen. The explanation suggested is that the shock
which the enormous velocity of the projectile produces on
entering the soft parts causes them to behave as a fluid or
semi-fluid does when enclosed in a box and "shot through,"
the hydraulic pressure bursting the sides, or if an opening be
left, driving a column of the fluid through it. As to how far
any destruction of the projectile itself may be a contributing
factor he has no direct evidence, but from specimens he has
seen of the Wagner and Mi'innlicher projectiles after experi-
ments made by Dr. Cardenal, which he showed at a lecture
before the Cataluna Academy of Medicine, he thinks it prob-
able that the projectiles do become more or less disintegrated
when they hit at short distances. In striking contrast to such
wounds are those produced at 150 yards or more by the Mauser
rifle. Here the entrance and outlet are very small and there
is but little evidence of internal destruction, even bones being
tunneled through without fracture, and as aseptic treatment
is possible from the first a rapid recovery may usually be
anticipated. Thus, in one case where the projectile entered
the abdomen in the eighth intercostal space on the right side,
passing through the stomach and coming out three fingers'
breadth on the left of the sternum, though the ninth rib was
fractured and the patient suffered from vomiting, hematemesis
and fever, he very soon improved and recovered completely.
In another case the projectile entered the left frontal eminence
passing out by the right parotid region. The patient suffered
from concussion of the brain, with some difficulty of vision of
right eye, but recovered in twenty-six days. If, therefore, it
could be arranged that fighting should never occur at less than
200 yards distance the Mauser would, Dr. Pedraza thinks, be
a most humane weapon.
Hospitals.
The German Hospttal, San Francisco, Cal. — At the regu-
lar July meeting of the board of directors the following staff
of physicians was elected for the German Hospital : Visiting
physicians, J. F. Morse, H. Kreutzmann, G. Dresel, R. Baum ;
consulting physicians, Beverly MacMonagle, W. A. Martin, D.
W. Montgomery, L. Newmark, M. Regensburger, Paoli de
Vecchi, A. Wilhelm. Max Saloman retains the position held by
him for the past two years as city physician of the society.
City Hospital, Marquette, Mich. — The new city hospita)
threw open its doors to the sick of the city July 13. The fol-
lowing named physicians compose the staff : Geo. J. North-
rup, A. Desjardins, O. G. Youngquist, F. McD. Harkin, A. A.
Foster, J. H. Dawson, E. B. Patterson, C. G. Dick, H. J.
Hornbogen.
.Louisville.
Anthrax. — An epidemic of anthrax has been found raging
in the herd of milk cows owned by a dairyman in the western
portion of the city, a number of deaths having occurred among-
them. The health authorities have taken the matter in hand
and have isolated the herd, burned the carcasses and are boil-
ing and burying the milk from the rest of the herd. Thus far
the trouble has been limited to this one herd and no serious,
spread is anticipated, owing to the prompt action of the city
and State officials.
THE PUBLIC SERVICES.
Army Changes. Official List of changes In the stations and duties
of officers serving In the Medical Department, U. S. Army, from
July 18 to July 24, 1896.
Capt. Paul Clendenin, Asst. Surgeon (Ft. Warren, Mass.), Is hereby-
granted leave of absence for one month.
Capt. Edgar A. Mearns, Asst. Surgeon (Ft. Myer. Va.), Is granted leave
of absence for three months, to take effect on or about Aug. 3, 1896.
Capt. Geo. E. Bushnell, Asst. Surgeon, extension of leave of absence-
granted is further extended one month.
Navy Changes. Changes In the Medical Corps of the U. S. Navy for
the week ending July 25, 1896.
Asst. Surgeon L. Morris, detached from Indian Head proving ground,,
ordered home and granted one month's leave.
Asst. Surgeon F. C. Cook, detached from treatment at the New York
hospital and ordered to proceed home.
Medical Director G.H. Cook, detached from special duty at Philadel-
phia and ordered to take charge of hospital there.
Medical Director D. Kludleberger, detached from duty in charge of
hospital at Philadelphia, ordered home aud await orders.
Medical Inspector W. G. Farwell, ordered to special duty at Philadel-
phia attending officers.
Change of Address.
Armstrong, C. L., from La Due to Webster Grove, Mo.
Bertling, A. E., from 360 Blue Island Av. to 512 Ashland Boul., Chi-
cago, 111.
Burns, R. J., from Rockford to 101 Galena St., Freeport, 111.
Bishop, L. F.. from Morristown, N. J., to 30 W. 86th St., New York,.
N.Y.
Haberjnass, A., from 8154 Shenandoah Av. to 8317 S. 18th St., St. Louis,
Mo.
Luebbers. A., from Dallas, Texas, to 2432 Larimer St., Denver, Colo.
Makeun, G. H., from Philadelphia to Cresson, Pa. (until September 15).
Prentiss, D. W., from Aix la Chapelle, Germany, to Zurich, Switzerland..
Rockey, A. E., from The Marquam to 671 Glison St., Portland, Ore.
Rohe, Geo. H., from Catonsvllle to Sykesville, Md.
LETTERS RECEIVED
Allison, H. E., Fishkill Landing, N. Y.; Alma Sanitarium Co., Alma,
Mich., (2)
Burr. C. B., Flint, Mich.: Bittman, Chas. W., St. Louis, Mo.: Bartlett.
Edward P., Springfield, 111.: Boehrlnger, C. F. & Soehne. New York,
N. Y'.: Butin, Mary Ryerson, Madera, Cal.; Bower, J. L., Reading. Pa.;
Brodrick. J. P.. Boston, Mass.
Colvln.D., Clyde, N. Y.; Cook, G. F„ Oxford, Ohio, (2).
Dooley, A. J., Marion, lud. ; Douglass, J. C, Franklin. Kv.; De Courcy,
J. O., St. Libory, 111.; Dale, J. Y., Lemont, Pa.; Dorman, Wm. J., Phila-
delphia. Pa.
Elkhart Carriage and Harness Mfg. Co., Elkhart, Ind. ; Ellis, Griffith,
Dayton, Ohio.
Farber & McCassy (Drr.), Dayton, Ohio; Fairchild, Bros. & Foster,.
New York, N. Y.; Farrington, J. M., Binghamton, N. Y.
Gihon, A. L., New York. N. Y.
Haven, O. D., Youngstown, Ohio: Herdman, W. J., Ann Arbor, Mich.;
Hummel, A. L., Adv. Agency, New Y'ork, N. Y., (2) : Hewitt, C. N., St.
Paul, Minn.; Haruden, R. S., Waverlv, N. Y.; Holmes, Bayard, Chicago,,
111.: Huasey, E. J. & Co., New York, N. Y. ;"Holt, E. E., Portland, Me.;
Haldensteln, J., New York, N. Y.
Kenyon, Paul. Minneota, Minn.; Kiess & Owen Co., New York, X. Y.J
Kyle, De Braden. Philadelphia, Pa.. (2).
Lee. Elmer, Chicago. 111., (2): Lichty, D.. Rockford, 111., (2); Lock-
wood, E. K.. Virden. 111. ; Love. I. N.. St. Louis, Mo.
Maclean. Donald, Detroit, Mich.; Mulford, H. K. & Co., Philadelphia,
Pa.; Mackie, L. V. G.. Attleboro, Mass.
O'Gorman, James, Baltimore, Md. : Osmun, I,. C, Washington, D. C.
Paquin. Paul, St. Louis, Mo., (2) ; Press Clipping Bureau, The, Boston,
Mass.; Peterson, Reuben, Grand Rapids, Mich.; Pearse, W. M., Mt.
Vernon, Ind.
Koss. A. A.. Hochheimer, Texas.
Sutherland, J. Lue, Grand Island, Neb.; Storer, H. R.. Newport, R. I.;
Shurly, E. L., Detroit, Mich.: Stevens, B. F.. London, England; Stock-
well, Miss M. H., New Y'ork, N. Y.; Strueh, Carl, Chicago, 111.; Single,
Jacob, Portsmouth, Ohio.
Taylor, P. R., Louisville, Ky. ; Truax, Charles. Chicago, 111.; Tuasey,
A. Edgar, Philadelphia. Pa.
Vogeler. Julius, St. Louis, Mo.; Von Koerber, P. E., Loup City, Neb.
Wilbur, C. L„ Lansing, Mich., (2); Wyman. Hal. C, Detroit, Mich.;.
Woody, 8. E., Louisville, Ky.; Williams, H. L., Philadelphia, Pa.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., AUGUST 8, 1896.
No. 6.
ADDRESS.
CHAIRMAN'S ADDRESS.
red in the Section on Stat* Medicine. «t the Fortv-Seveutli Annual
Hatting ol the AniiTiiiin Medical Association at
Atlanta, lia.. May 5-8. 1S96.
BY CHARLES H. SHEPARD, M.D.
BROOKLYN, N. Y.«
FeUow Members: — It was both with diffidence and
reluctance that I accepted the honor and obligations
of the chairmanship of this Section, a place which
has been held by some of the most distinguished and
gifted members of the American Medical Associa-
tion, and for the time being I rely upon your patience
and generosity.
The amount of useful information that has been
diffused from this Section since it was first organized,
has been possible only by the indomitable energy and
self-sacrificing work of those who have labored in its
field. They have plowed and sowed, and while we
gather the fruit of their labors, it is also incumbent
upon us to do our share in the promotion of the work.
Unfortunately, outside of the medical profession,
but comparatively few minds are possessed of a prac-
tical knowledge of sanitary matters. Hence the neces-
sity of continually reiterating and disseminating what
many of us consider the most commonplace truths,
until their full acceptance shall render our land a
sanitary Eden.
The healing of disease is a most noble work and
worthy of all praise, but he who teaches how to pre-
vent disease is engaged in a higher and holier cause.
It is not a question of how far it is well to go in
destroying one's own business, for the lover of his
race realizes that his own higher interests are bound
up with the welfare of the people. We are now in
the kindergarten state of knowledge regarding many
of the most important sciences that bear upon the
prevention of disease. Far reaching as recent devel-
opments appear to be, the glory of those yet to come
will undoubtedly cast them into the shade in the not
distant future. It is a matter for which to be thank-
ful that one is able to devote a life to the advancement
of ideas that may prove of incalculable benefit to
mankind.
The ideal physician would be the State physician,
whose position and income assured, would enable him
to devote his entire time and best powers in seeking
the highest interests of the community in the preven-
tion of disease.
For ages men have sought for a panacea. New
remedies become candidates for public favor with
surprising rapidity, and are popular for a time, only
to be displaced by a new candidate. Strive as we
may, we are convinced that never will a remedy be
found to obviate the penalty sure to be exacted by
violated law. Preventive medicine will teach people
how to live, and then ignorance and panaceas will die
a natural death. This is worthy of the earnest atten-
tion of the ablest minds, and will produce most impor-
tant results. The loss of time on mere effects, instead
of the original causes of disease, is like giving atten-
tion to the branches, instead of striking at the root of
the deadly upas tree.
The first work on preventive medicine was furnished
us by Moses, the great lawgiver, nor has it yet been
surpassed by any modern discoveries. Granting all
that is claimed for antitoxins of various kinds, and
for vaccination as a preventive of smallpox, these are
but so many milestones in the progress of preventive
medicine, which shall yet lead to the cause of the
original disturbance. Diphtheria, scarlet fever, etc.,
are filth diseases, and smallpox belongs preeminently
to this class. Preventive medicine, witlf the aid of
personal hygiene, will yet enable us to avoid all filth
diseases of whatever kind.
As Rome carried civilization with her conquests, so
shall preventive medicine, and this Section, as its
representative in the American Medical Associa-
tion, continue to diffuse a saving knowledge of human
live in its all-conquering march.
It is well to look back occasionally, in order to
measure our progress. Among the subjects which
have been advocated by this Section were soil drain-
age and improved systems of sewerage, the better
housing of the poor in our cities, the registration of
vital statistics, civic cleanliness, quarantine reform
and, more recently, improved pavements and public
baths.
History tells us that sanitary measures, methodi-
cally carried out, are invariably followed by improved
public health and a decreased death rate. But for
the important sanitary measures carried out by the
rulers of Rome, the eternal city would never have
become the mistress of the world. Had it not been
thoroughly drained, a large part of it would have
been uninhabitable. The sanitary works of Rome,
introduced when she was at the acme of her glory,
have been a model for ages past, and will so continue
for ages to come. Her enormous aqueducts, particu-
larly those built by Agrippa, were virtual rivers
brought into the city to flush the streets and sewers,
and to supply all public and private requirements.
Before the streets of London were paved the inhabi-
tants were as great sufferers from periodic fevers as
are those of the most unhealthful rural districts in
our own country. It has been computed by an emi-
nent authority, Sir Lyon Playfair, that in one county
alone in England, the pecuniary burden borne by the
community in the support of removable disease and
death, amounted to the annual sum of twenty-five
millions of dollars.
After the paving of Dijon, the ancient capital of
Burgundy, in the middle of the fourteenth century,
dysentery, spotted fever and other diseases, became
of less frequent occurrence in that city.
286
CHAIRMAN'S ADDRESS.
[August 1,
The evils of a certain form of modern architecture
in our cities is a growing one that should be thought-
fully considered. The crowding together of tall
buildings, necessarily depriving the lower floors of
proper sunlight and ventilation, is one of the modern
aggressions that is not of unmixed benefit, even in a
business sense, involving the health of the occupants
of all such buildings. The deficiency of sunlight and
insufficient ventilation common to these structures,
seriously affects the eyesight of multitudes, and
the depressing effect of confinement and labor in
the vitiated atmosphere, under such circumstances,
render the occupants fit subjects of temptation in the
shape of tobacco and other narcotics to satisfy the
craving for the absence of the healthful stimuli of
fresh air and light and thus render them liable to dis-
ease in every shape. The height of buildings should
be in proportion to the width of the street. As a
prominent and conscientious architect, Ernest Flagg,
has well said in the May number of the Cosmopoli-
tan: " It is best in this matter to place a curb upon
private greed for the public good. "
The disposal of the sewage of cities is a subject
that is demanding more and more attention, for what
now goes to waste, to the pollution of rivers and
obstruction of harbors is a menace to health, besides
being a pecuniary loss to the community. Sewage
should instead be so disposed of as to be devoid of
danger, and a profit to the city.
From its noiselessness, cleanliness and consequent
comfort, the improvement of street pavements by the
use of asphalt is intimately related to the health of
the community, and this was strongly urged by Dr.
Bell, in the Sanitarian, over thirteen years ago. It is
now rapidly growing in favor, and making way for
the horseless carriage which is to banish to the
country districts the horse and his insanitary
surroundings.
It is proper here to refer to the Sanitarian, the first
journal in this country devoted to sanitary subjects,
as the source from which I have been able to glean
many facts on the progress and present status of pre-
ventive medicine in the United States, and also to the
editor who projected that periodical in the same year
that this Section was organized, and of which he was
the first chairman twenty-three ago. This publication
presents essays by the most distinguished sanitary
authorities on a great variety of subjects, and the gist
of sanitary medicine in all its phases.
Dr. Bell's activity as a sanitary reformer prevented
the yellow fever from reaching the city of Brooklyn
from Bay Ridge and Fort Hamilton in 1856. He
fought against the quarantine system as it then
obtained, and succeeded in reforming it on the basis
of the regulations which he devised and reported to the
National Sanitary Convention in Boston, in 1860.
He devised measures in detail relating to departure,
as the primary means of preventing the conveyance
of infectious diseases from one place to another, and
their introduction into new places. Moreover he
instituted and successfully practiced, under the
auspices of the National Board of Health, measures
which prevented the yellow fever from being conveyed
to other places from New Orleans, in 1879, without
restricting commerce, and with the result of raising
all the quarantines against that city within six
weeks.
In a contribution to the Report of the New York
Board of Charities for the year 1876, on the " Rela-
tion of Insanitary Conditions to Pauperism, Vice
and Crime in New York, " Dr. Bell suggested a man-
datory law requiring assessment, seizure and destruc-
tion, at public expense, of a stated few of the worst
tenement houses in the city and the conversion of
their sites into grass plots, annually, as an efficient
means of reform ; means that would not only weed out
the worst from year to year, but continually promote
the improvement of the remainder, whose proprietors
would not allow them to be destroyed, and the legis-
lature has recently conferred the power of so doing,
in a modified form, on the health authorities.
Municipal sanitation in New York and Brooklyn
on a scientific basis, began thirty years ago, under the
auspices of the Metropolitan Board of Health. The
average death rate in New York, per 1,000 of the pop-
ulation, for the ten years preceding that date was
33.39; for the first ten years following it was 29.70;
for the ten years ending December 31, 1894, it was
25.48. The death rate for 1895, according to the last
report from the State Board of Health, was 18.25. per
1,000. Surely it would be difficult to find more sig-
nificant results of practical sanitation equivalent to
saving of about eight lives per 1,000 of the population,
annually, and amounting in the aggregate, measured
by the present population and death rate, to 14,464
lives annually.
One of the most imperative necessities for preserv-
ing the public health is an ample supply of pure
water, and it is to be hoped that some better medium
than lead pipe will soon be found for conveying
drinking water through our houses. The more pure
the water the more it acts on the lead to absorb the
poison, and therefore it becomes the more dangerous.
Possibly aluminum may come in to supply this press-
ing need.
The character of the public water supply is the first
and chief concern of every intelligent sanitarian, for
in that lurks the means of transmission of all the
most virulent and fatal of the infectious diseases.
As population increases the sources of contamination
multiply and it becomes more and more difficult to
secure an abundant supply of pure water. Rain water
falling upon the earth's surface becomes more or less
contaminated from the soil, with mineral matters,
which it holds in solution, and should be used with
caution. The home of the most deadly of the micro-
scopic enemies of man is water. Many of the epidemics
that have desolated different countries have been
caused by the use of impure water. Cholera, typhoid
fever and dysentery are fostered and disseminated
almost exclusively through the medium of drinking
water.
While the use of water ranks high as a remedy for
many diseases, its greatest value is in the prevention
of disease. Never was the true theory of disease
understood until it was put forth by the advocates of
the hygienic system of treatment, otherwise called
water cure, which was very popular about the middle
of this century. While not now conspicuously promi-
nent as a separate system it has had a powerful influ-
ence in modifying the practice of all the other schools.
Disease was known only by its phenomena and medi-
cines by their effects. The true definition of disease
is remedial effort, an action to cast out impurities. It
wastes vital power, as a man would expend his strength
to eject a thief from his premises. When people
understand that disease is a vital struggle in self
defense they will cease to fear it. They will fear only
18<H5.]
CHAIRMAN'S ADDRESS.
287
its oauses and instead of trying to suppress the symp-
toms will endeavor to remove the onuses. Disease
ami the ris medicatrix nature are one and the same
thing. When in the progress of knowledge it comes
to he understood that in all relations between living
and dead matter, the dead is passive and the living
active, then the application of this truth to foods,
remedies and poisons will settle many vexed questions
and place mankind on the high road to perfect health.
It would be a' profitable investment for any city
which is suffering by reason of a polluted water sup-
ply to expend all the money that may be required for
the substitution of a wholesome supply, either by
going to new sources or by purifying the supply on
hand. This can be demonstrated easily by figures
that men of ordinary intelligence would be obliged
to accept. The loss to several cities throughout our
land from typhoid fever during the past year which
has been traced to the water supply has emphasized
this fact. A few of the cities have taken up the work
of purifying their water by filtration, and in every
ease the decrease in the death rate has been most
satisfactory and warranted all the outlay. This is a
work that should be carried out by the cities in their
corporate capacity rather than left to private enter-
prise. Where all are to be benefited all should be
interested.
It is but trite to say that the Section on State Med-
icine has a most comprehensive work on hand, includ-
ing as it does, preventive medicine, public hygiene,
public baths, street paving, together with cleanliness
of the streets, disposal of the garbage, factory inspec-
tion, cattle inspection, milk inspection, employment
of child labor, cremation, etc. I will trespass on your
time only to refer to a few facts in preventive
medicine.
The camera and the bicycle, by calling people out
into the open air, and giving them pleasant occupa-
tion and mental stimulus, is doing more to prevent
disease than all the doctors in the land. We may be
very thankful for the sudden popularity of the bicycle,
in that it has given a wonderful impetus to the ques-
tion of good roads.
The blessings of sunlight and fresh air should be
more appreciated. The sun is the godfather of us
all. The source of all light, heat, electricity, and
energy, what wonder that it was once worshipped as
the Creator. The future will recognize it not only as
the best disinfectant, an all powerful preventive of
disease, but also as a wonderful healer of disease. The
more people can be taught to live in pure air out of
doors, and bask in the rays of the sun, the less of dis-
ease there will be to prevent.
The Women's Health Protective Association of
Brooklyn, N. Y., is doing a most useful work by pre-
venting litter in the streets, by burning of garbage,
and more and above all by endeavoring to abate the
nuisance of expectoration in the public streets and
conveyances. When that is accomplished there will
be less of disease floating in the air ready to be
inhaled at every breath.
The study of the microscope is gaining new impe-
tus every year and giving us more and better informa-
tion in regard to the minutiae of life. The knowledge
of microbic life is so intensely attractive as to absorb
the whole time of many students of eminent degree,
and the wonderful results developed have many times
astounded the world, and will in many ways help to
prevent disease, by teaching us what to do in emer-
gencies, and yet what is now known may be consid-
ered as but the forerunner of what is to come. New
facts have been so rapidly developed as to dazzle the
imagination with their possibilities.
Already have the X rays, lately discovered by
Roentgen, produced a profound impression upon the
public mind. The correct view of this new radiant
energy will undoubtedly soon be formed, when new
experimental data appear. In the meantime we can
rest assurred that a new entrance to the region of the
ether phenomena has been opened, and the impor-
tance of this fact can hardly be overestimated. It
may be that the rays will be proved identical in kind
with vibrations of light, heat, or electricity, already
well known. It may be on the other hand, a new
form of energy. It is easily possible that the new
photography, when fully developed, may reveal to us
secrets of cellular growth, glandular activity, and the
like, that have hitherto proved inscrutable. The
power of looking through a man, as reported by Mr.
Edison, may yet lead to still greater discoveries in
the prevention of disease.
No more desirable work has been done by any
board of health than in looking after the adulteration
of food, as in Ohio for instance. Of all the liars in
existence, none are worse than those who advertise to
furnish food or medicine and really deal out that
which is bound to cause disease and leave ruin in its
path. If there was a soul above filthy lucre in the
patent medicine vender there would be none of this.
To protect the ignorant public is the god-like mission
of State medicine. But when we get pure food, much
of it needs cooking, and cooking schools are im-
mensely useful as a preventive of disease, not alone to
prevent the waste of valuable portions, but also to be
able to derive therefrom sound tissue for the building
up of the entire man into his most vigorous condition.
The bad work that people make in dosing them-
selves with patent medicines, without a physician's
prescription, is not unfrequently punctuated with a
sudden death from overdosing with antipyrin, sul-
phonal, or some other coal-tar preparation. Children
should not play with edge tools. The teachings of
preventive medicine will do away with such work.
Another thing in which it is most desirable that
the public should be enlightened, is the imperative
need of rest, instead of what is called stimulation;
that what are called tonics or stimulants are used only
at a ruinous expense to the vitality, and if people
would take time for recreation and recuperation, they
would obviate the necessity for their use and prevent
more disease than ever was cured.
If ever our people are to be redeemed from the
thraldom and unmitigated and unlimited curse of
tobacco using, it must come from the teachings of
preventive medicine.
There is an immense amount of ignorance abroad
in the community on the subject of health and the
proper way of living to secure the best physical con-
dition, and there is a corresponding need for instruc-
tion in such matters. That is why the charlatan has
such free play in this cbuntry. One of the most
important of all studies for old and young is that of
personal hygiene. This it is that protects from per-
sonal contagion. This do and thou shalt live! That
do and thy body shall become a fertile breeding
ground for all manner of disease! The earlier in life
this is recognized the more surely will success crown
man's daily pursuits.
288
CHAIRMAN'S ADDRESS.
[August 8,
In fact, the very best preventive of all disease is a
condition of well nourished physical purity, combined
with a mental and bodily alertness that leads to the
enjoyment of all good work. Such a one can walk
through pestilence unharmed, will live out all his
days, and, barring accidents, be gathered in when his
full time shall have come, like a shock of corn fully
ripened.
The delights of mental pursuits, in calling its
devotee out of himself to the attainment of certain
truths or facts and the vantage ground gained by
every such conquest, giving broader field and more
expansive view with intensified joys, place mental
pursuits among the more desirable means for prevent-
ing disease and prolonging life.
The multiplication of intellectual entertainments
and resources, that give the people something to think
about and occupy their minds to the exclusion of
things of a lower grade, is to be welcomed by all who
place a higher faith in prevention than in cure. We
very well know that if we can fill the minds of the
young with the good, there will be no room for the
bad.
Laugh as we may at the vagaries of the teacher of
what is called mental science, there is a germ of truth
at the foundation of it all. The mind reacts upon
the body as well as the body upon the mind. We can
magnify or minify our troubles; therefore if weak and
delicate invalids can be made to believe that they are
to get well, they are thereby in a better condition to
become well. So also with one who girds himself up
to face disease and disaster. He is by so much less
liable to the disease or disaster, and should it overtake
him he is better fitted to cope with the emergency.
The little that has been accomplished is but the
forerunner of what is to come. The time is not far
distant when the people will demand that all these
desiderata shall be taken up in a manner commensu-
rate with their importance, and then public baths will
be made as free to the people as the postoffice and the
public school. Good roads will be uniformly extended
throughout our country, and kept in proper condition.
Dwelling houses, and business houses as well, will
receive their full modicum of sunlight and ventila-
tion, pure water will abound, and excreta, along with
garbage, will be disposed of with advantage to the
community. Our public schools will be well lighted
and ventilated, the children will be taught the evils
of the indiscriminate use of narcotics of all kinds, and
the pupils will not be overworked by a too cumber-
some curriculum.
It will be a happier day for all when the people in
their representative capacity shall take charge of all
vagrancy, see that all who can labor shall have the
opportunity, and those who are disabled properly
cared for. This also is preventive medicine, and is
but cooperation, wherein the people shall demand
reforms to be carried out by the government, which
is, or should be, but the expression of the will of the
people. Thus will state medicine fulfill its highest
duties. By some this might be called socialism, but
the whole world is traveling that road. Our Ameri-
can Medical Association is but a step in coopera-
tion by liberal minded men, lifting us for the time
being out of the slough of competition, and our Sec-
tion on State Medicine is preeminently socialistic in
that it seeks the benefit of the mass through the
power derived from the people in their collective
capacity.
If ever legislation regarding public questions shall
be elevated above the plane of practical politics or
personal gain, we may obtain some results that will
help to promote the best interests of the community,
instead of, as at present, being made the foot-ball of
conflicting parties.
Let us bear in mind that we are responsible for this
condition of things, that it is every physician's duty
to take an active and intelligent part in all political
matters, and not leave them to the ignorant and
vicious. When this is thoroughly carried out, and
direct legislation comes in, a new era will be
inaugurated.
A bill has been introduced in the Senate, creating
a new cabinet officer who shall be known as Secretary
of Manufactures and Commerce, and certainly this is
of great importance to all of our industries, but of
still greater importance would be a Secretary of Pub-
lic Health, for if the health of the community is not
assured, the industries are of small account.
While State medicine has saved the world from an
immense amount of charlatanism and superstition
regarding avoidable disease, there are larger fields and
higher ground waiting for occupancy by the interested
students who are to bless the community by their new
discoveries. The range is too vast for any one depart-
ment, but all will combine in this, that their work
shall bless and lengthen the days of man, for all the
achievements of the true physician are the common
heritage of mankind, and thus is he to become one of
the most potent of all the civilizing agencies of the
future. This forward march is to go on, and blessed
are we who are permitted to take part in the work,
insignificant though that part may be.
During the past year the harvest of death has been
very great in the ranks of medical men, particularly
among the younger members, leaving gaps that will
be hard to fill. The demands of modern society are
too exacting, and the results of the pace that kills are
sometimes realized too late. From out of our own
ranks have gone Dr. Joseph Jones of New Orleans,
Dr. James E. Reeve of Chattanooga, Tenn., and Dr.
C. G. Comegys of Cincinnati, Ohio. They rest from
their labors, and we shall see them no more, but the
bright example of their noble work will remain to
bless all the land.
Gentlemen, I am proud that you have thought me
worthy to assist in your deliberations, and shall enter
upon the duties of our session with an earnest desire
to forward the good work.
Hopefully then, do I commit to your hands the
pleasant task of spreading over this vast country the
ennobling light of your wisdom and experience.
Excessive Doses of Bicarbonate of Sodium in Hyperacidity of the
Stomach. — Tournier relates a couple of cases of intense gastric
pain caused by hyperacidity, relieved by large doses of bicar-
bonate of sodium, with no accompanying inconveniences. The
amount prescribed was 20 to 30 grams a day, which the
patients increased to 60 and 65 grams, before obtaining perma-
nent relief. The male patient continued these large doses for
two to three years, securing a permanent cure, with no return
of the gastralgia in the four years since. The other case was
a young woman, who took at last 60 to 65 grams for a month,
with the result of much improved gastric conditions and again
of three kilograms in weight. She took the soda in a powder
every half hour, followed each time with a little milk, of which
she carried a small bottle with her when she left home. The
elimination of chlorid of sodium in the urine amounted to 36
grams per liter, testifying to the actual transformation of the
sodium in the organism. — Province Me'dicale, June 27.
is-. i.;. |
INTESTINAL OBSTRUCTION AFTER LAPAROTOMY.
289
ORIGINAL ARTICLES.
INTESTINAL OBSTRUCTION AFTER
LAPAROTOMY.
Head in the Section on Obstetrios and Diseases of Women at the Forty-
MVantb Annual Meeting of the American Medical Asso-
ciation, held at Atlanta, tia., Mav ,V.s, 1896.
BY HENRY O. MARCY, M.D., LL.D.
1IOSTON, MASS.
The internal hernia, so-called by the early authors,
Besses an entirely new and increased interest,
[nee intestinal obstruction occurs more frequently
'inn formerly, as a sequel to the surgical invasion of
10 abdominal cavity. I believe also that this is a
more common cause of death than usually sup-
ised, since the success attending the surgery of the
jtbdomen has emboldened many surgeons to undertake
great variety of operations, considered unwarranted
decade ago.
Before entering into any general discussion of the
(object, it has seemed instructive to give a brief report
if all the oases of intestinal obstruction following lap-
jtoiny. which have come under my observation.
Cast- 1. Mrs. C, aged 31, married, has three children.
Ipril 11, 1890, 1 removed a dermoid cyst of the left ovary
reigning eight pounds. Right ovary size of an egg, capsule
hick and friable. Peritoneum covering pedicle parted easily
under constriction of the suture. Marked nausea after ether-
ization. The stump was touched with liquid carbolic acid and
eo\ ered with iodoform. The uncovered peritoneum was scarcely
larger than a split pea. Convalescence comfortable, with pri-
mary union of the abdominal wound, which was closed without
drainage. Bowels moved the third day; kept open by saline
laxatives. On the seventeenth day symptoms of intestinal
obstruction supervened, with nausea and vomiting, slowly
becoming more pronounced. On the twenty second day it was
evident that grave danger was imminent, every effort to evac-
uate the bowels having proved futile. Assisted by the late Dr.
Trenholme of Montreal, I reopened the abdomen and found
two loops of the lower portion of the small intestine firmly
adherent to the stump of the right ovary. The adhesions were
separated with difficulty. The intestines were not very much
exposed, and yet the shock was very pronounced and for some
hours danger of death seemed imminent. Convalescence was
slow but satisfactory. The patient remains well up to the
present, entirely free from abdominal pain.
Oam ?. Mrs. L., aged 35, married, has borne children.
Genera! health fair. On July 13, 1892, I performed vaginal
hysterectomy for cancer. Operation less difficult than usual.
The broad ligaments were constricted by clamps which were
removed the second day. The third day nausea and vomiting
supervened, rapid elevation of temperature and death occurred
on the fifth day from intestinal obstruction, not clearly recog-
nized until autopsy, since it was believed that septic peritonitis
was in process of development. On examination it was found
that a loop of the lower portion of the small intestine was
adherent to the stump of the right broad ligament, but the
lymph adhesion was easily separated. The intestine above was
filled with a large quantity of dark-colored fetid fluid, and it
is believed that the symptoms of septic poisoning came from
the absorption of the products of decomposition of this fluid.
There was no peritonitis and the pelvic wound was uninfected.
The adhesions could have been easily freed by an abdominal
section.
Case 3. — Mrs. C, aged 42. General health fairly good,
although she had suffered long from pelvic troubles. Two
] Bare previous I had removed the right ovary, which was cystic,
resulting in an adherent tumor cocoanut size. Recovery was
rapid and uneventful. For six months prior to the sec-
ond operation a cystic tumor of the left ovary had developed
until it reached a point above the navel. Operation Nov. 28,
1892, Dr. James R. Chadwick present. The omentum was-
found somewhat adherent on the line of the old cicatrix. The
tumor was removed with difficulty, owing to its being bound
down by adhesions. Recovery from the operation was not
satisfactory, shock pronounced and nausea persistent from the
litst. All the symptoms became slowly more aggravated, until
at the end of the third day it was apparent that intestinal
obstruction was threatening the life of the patient. Upon
re-opening the abdomen a loop of small intentine was found
constricted by an old omental band of adhesions upon the left
side, just above the brim of the pelvis. It is very probable
that the intestine became entangled at the time of operation.
It was easily freed and the operation was completed in a short
time, but the shock following was very pronounced, the patient
never rallying from it, and death supervened in a few hours.
Ctim'4.— Mrs. G.,aged 52. General health good. She had suf-
fered severely from a rather rapidly growing multiple uterine
myoma, which was impacted in the pelvic cavity ana extended
to the umbilicus. Operation Oct. 24, 1895, assisted by Drs. H.
D. Didama, Syracuse, and D. T. Nelson, Chicago. The opera-
tion was not difficult, the most noteworthy feature being that a
small firm lobe of the tumor was so fixed to the right lower
vaginal cul-de-sac that upon removal the adjacent peritoneum,
although not bleeding, was dotted with minute red points. At
the time of operation it was remarked that such a condition of
the pelvic peritoneum would favor intestinal adhesions. The
tumor was dissected to the cervical neck, resected and the
arteries separately ligated and the peritoneum intra-folded by
a running continuous buried tendon suture which left no
abraded peritoneum other than the portion already described.
It was deemed unwise to drain the depressed portion through
the vaginal canal and for better protection it was covered freely
with sterilized aristol. There was considerable shock following
the operation, but the patient rallied well and for forty-eight
hours gave every promise of easy recovery. Nausea and vom-
iting t hen ensued with elevation of temperature and abdominal
distension. Intestinal obstruction was recognized, but the
danger was not thought sufficiently imminent to warrant
surgical interference, until suddenly the condition became too
grave to render the procedure, even as a folorn hope, advisable.
Death occurred about seventy-five hours after the operation.
Nausea and vomiting persisted to the end. Six hours before
death the temperature began to rise from about 101 degrees
until at death it had reached 107 degrees. Autopsy snowed
adhesion of the lower part of the small intestine to the punc-
tated portion of the peritoneum. It was readily separated.
The intestine about the point of adhesion was greatly distended
by a large quantity of dark-colored fluid, evidently having
undergone decomposition prior to death. The line of union
of the intra-folded peritoneum was perfect. There had been
no pelvic serous exudation and no septic infection.
Case 6. — Miss S., aged 44. Operation performed Nov. 30,
1895, for removal of a large adherent uterine myoma, assisted
by Dr. Nelson of Chicago, Dr. Cilley of Boston, and Dr.
Berrymore of St. Johns, N. B. The operation was long
and tedious, followed by pronounced shock. Rallied well
and on the second day the conditions seemed favorable
for recovery. Nausea and vomiting commenced about thirty-
six hours after the operation. Not very pronounced until
twelve hours later, when it was evident that intestinal ob-
struction had supervened. I reopened the abdomen and
found a loop of the lower part of the small intestine
involved in adhesion of the omentum, situated in the right
iliac region. The small intestines were greatly distended by
gas and fluid, and were manipulated with some difficulty. At
the time of the operation temperature was 101 ; immediately
following the operation there was a large fluid dejection.
Within an hour it was noted that she was in profound shock,
from which she never rallied, death occurring some hours
later. The most noteworthy feature was the elevation of tem-
perature, which rose steadily about a degree an hour, reach-
ing 107 degrees before death. I twice used an intravenous in-
jection of saline solution, each time introducing nearly a pint.
The flagging heart immediately responded, giving a compara-
tively slow, full, compressible pulse. The effect, however,
soon subsided, notwithstanding the use of digitalis, strychnin
and nitroglycerin, used freely hypodermically.
Case 6. — Mrs. K., aged 34, never pregnant, married eight
years, advanced cancer of the cervix from which she had suf-
fered seevrely in her general health. Vaginal hysterectomy
Dec. 7, 1895, assisted by Dr. C. E. Miles of Boston. Operation
difficult, owing to a long narrow vagina and the extent of the
disease. I sutured the broad ligaments and introduced gauze
drainage. Convalescence seemed well established the tenth
day, .when symptoms of intestinal obstruction supervened.
Upon opening the abdomen a loop of the lower portion of the
small intestine was found incarcerated by an old band of adhe-
sions which crossed the pelvis in the region of the right ovaryv
This was easily divided and the intestine freed. The abdomi-
nal wound was closed without drainage. Fecal evacuations;,
soon followed with speedy relief. The shock following the,
operation was pronounced, but the convalescence was uner
ventful. The patient is well at the time of writing.
Case 7. — Mrs. D., aged 42. Very nervous organization, but
in fair general vigor, although a severe sufferer for some years
290
INTESTINAL OBSTRUCTION AFTER LAPAROTOMY.
[August 8,
from a retroverted, adherent, enlarged uterus, cystic ovaries
and diseased tubes. The bowel had been freely evacuated,
only fluid food in small quantities often repeated given for
some days before the operation, with as large quantities of
water as could be easily taken. Operation March 18, 1896. It
was difficult, owing to the imbedding of the diseased adnexa in
the pelvic cavity. After the removal of the diseased structures,
the enlarged, retroverted uterus was brought forward and
sutured upon each side to the abdominal wall. The pelvic
peritoneum was reformed by lines of buried tendon sutures,
leaving only a small portion of the fundus of the uterus uncov-
ered, which was partially denuded of its peritoneum, owing to
old adhesions. The small intestines were covered by the omen-
tum with great care, the fundus of the uterus dusted with
sterilized aristol and a vaginal drain of iodoform gauze carried
through the posterior cul-de-sac into the vagina. Patient
rallied well from ether. The night following the operation
was comfortable. Nausea and vomiting ensued on the morning
of the 19th, with a singular weakening of the heart's action,
followed by rapid elevation of temperature, reaching before
death 107 degrees. The skin was mottled with dusky patches
some hours prior to death. These conditions were believed to
be due to intestinal obstruction. The gauze drain was with-
drawn and an effort made to examine the pelvis through the
opening, but without avail. The general condition forbade
reopening the abdomen. Regardless of every effort the patient
died about forty hours after the operation. The autopsy showed
a loop of the lower part of the small intestine attached to the
fundus of the uterus, which was separated with the greatest
ease. The intestine above was filled with several pints of a
very fetid, dark-colored fluid believed to have undergone
decomposition prior to death.
The cases reported were all operated on under the
most favorable of hospital appointments and with the
very best of attendant care.
I purpose to confine myself to the salient points
offered in a review of the cases just reported.
Anatomic Relationship. — It will be noted that
the portion of the intestine involved in the obstruc-
tion in each case was the lower part of the ileum, and
that the obstruction was caused either by an adhesion
of the intestine to an abraded peritoneal surface, or
by a constriction.
Owing to the erroneous teaching of a leading
English authority, it has been too generally accepted
that, in the normal condition, the small intestines do
not descend sufficiently to enter the pelvic basin.
Since it was found that more commonly the portion
of the intestines strangulated in inguinal hernia was
a loop of the small intestine, this author ingeniously
advanced the theory that the hernia itself was due to
the elongation of the mesentery, causing the disloca-
tion of the intestinal loops, rather than to a previous
weakness of the abdominal wall. The measurements
made by this distinguished anatomist seemed to show
that the distance from the root of the mesentery to
the intestinal loops was so short that only by drag-
ging upon them could they be pulled down sufficiently
to enter the pelvic basin. I do not doubt the cor-
rectness of his observations, but it must be remem-
bered that the postmortem rigidity and fixation of
the parts furnish conditions quite different from those
found during life. My studies of hernia early led me
to a consideration of this subject, and my observations,
based upon the examinations made in about a thou-
sand laparotomies furnish abundant proof that the
small intestines, the ileum especially, in its normal
range of motion includes a juxtaposition of the pelvic
structures and organs.
Here the intestines are less protected by the omen-
tum which intervenes between them and the abdom-
inal wall, where the omentum is interposed, and it is
a question by no means settled satisfactorily, if nor-
mally the omentum lies between the basic folds of the
small intestine and the pelvic structures. It prob-
ably does, not and so gives easy explanation why
portions of abraded pelvic peritoneum are especially
liable to offer points of attachments to the superin
cumbent intestinal folds.
A study of the large intestines shows ample rea
son why obstruction does not usually occur in thii
portion of the intestinal tract. That part within tb
pelvis, and which may be more or less involved b
surgical manipulation, is within easy range of digital
and instrumental examination, and the solution of any
complications is easily determined. Ascending above
the pelvis, the remaining portion of the large intes-
tine, because of its position, construction and rela-
tionship, only very rarely can become involved in
intestinal obstruction, and as a consequence may
usually be excluded in the differential diagnosis.
The mooring of the cecum is generally sufficiently
fixed to preserve its relationship unimpaired, but
pathologic conditions arising from the appendix are
much more common causes of intestinal obstruction
than was earlier supposed. Adhesive bands fre-
quently extend to the surrounding parts, which may
become causes of intestinal obstruction by producing
constriction of an incarcerated loop. In one instance
of intestinal obstruction, I found an abnormally long
appendix encircling the small intestine near its
junction, and fixed by inflammatory adhesions.
This had caused a slowly developing intestinal
obstruction, which had been complete for some days
ending in fecal vomiting before operation. Else-
where the intestinal canal was normal.
In three of the cases here reported, two fatal, it
will be observed that intestinal obstruction occurred
from incarceration of the lower portion of the small
intestine, caused by adhesive bands of old forma-
tion. In the two fatal cases a laparotomy had been
performed some years previous and, although both
were nonsuppurative cases, adhesions had formed,
probably caused by undue pressure of opposing
peritoneal surfaces, owing to pathologic condi-
tions. When, as in these cases, the omentum
becomes the offending structure, I know of no ana-
tomic guides that will lead us to the part involved.
Hence, the surgeon must examine carefully a wide
area, without special direction except the guidance
taught by the individual history.
Diagnosis. — The foregoing histories teach a wide
difference in the severity of symptoms from that
of intestinal obstruction as usually observed in
volvulus, or strangulation resulting from hernia.
Here, even in volvulus, in umbilical and femoral
hernia, where the symptoms are the most acute, a
considerable longer period ensues before the patient
is in extremis. In the last case reported, death
occurred before it seemed possible for a fatal issue to
follow from an arrest of the intestinal fluids, where
also the greatest care had been exercised in empty-
ing the intestinal tract, and preventing fermentation
by use of salol, etc.
In none of the fatal cases reported, was the integ-
rity of the intestine endangered, and it is not to this
we look for the cause of death, as has usually been
considered the greater danger in cases of constriction
of the bowel in hernia.
To what then are we to attribute the cause of death ?
May it not be, in the first instance, the operation
which has so lowered the vital processes, which hold
their sway over the living structures, as to. admit
changes to ensue which otherwise would not occur?
y
I
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INTESTINAL OBSTRUCTION AFTER LAPAROTOMY.
291
These vitiating processes are rapidly augmented by
the fermentative changes which occur in the superin-
cumbent intestinal contents. These fluids are not
extraneous, that is to say, only in very small part con-
sisting of the ingesta, but are made up largely of the
albuminoid secretions, vitiated products of the glands,
together with the fluids poured out by the obstructed
blood circulation. The chemic products resulting
from this decomposition are crystallin and in solu-
tion easily reenter the blood current, producing a
septic infection of the most virulent character.
Changes in the hepatic structures occur early and
the devitalization of the tissues, at first pronounced,
go on pari /xifsii in geometric ratio until the individ-
ual is destroyed by acute blood poisoning, rendered
far more rapid from its initiation having commenced
under such unfavorable circumstances. Peristalsis of
the intestine lessens at an early period because of a
reflex paralysis of the local inhibitory nerve centers
and. as a consequence the opposing peritoneal sur-
faees remain more nearly at rest, and at the point of
injury the effused lymph rapidly becomes organized.
Nausea, vomiting, diminution and arrest of peristal-
sis, abdominal distention, accompanied by general
constitutional depression, with increasing thirst
dependent upon lack of absorption are among the
earlier symptoms. Possibly local pain, which how-
ever, in my eases has been absent, may point to the
site of adhesion. A marked elevation of temperature
is relatively not an early symptom. The nervous
centers are disturbed by an indefinite anxious fore-
boding, the pulse becomes accelerated, respiration
often shallow and rapid. The latter is probably
due to an interference with the action of the dia-
phragm. These symptoms may be complicated by a
general peritonitis, and have without doubt often
been mistaken for it. However, a careful analysis of
svmptoms will generally enable the observer to make
an accurate, differential diagnosis.
Prevention. — Although in not more than one per
cent, of laparotomies, does intestinal obstruction
occur, and in my own experience the percentage is
about one-half less than this, when it does take place
the complication is so severe, and the fatality so great
that the fear of intestinal obstruction may well be
considered the nightmare of the abdominal surgeon.
Therefore it is of the utmost importance that every
precaution possible should . be taken to prevent its
occurrence. Believing that its causation depends in
a large degree on the abrasion of the peritoneal sur-
faces about the site of the operative field, one of the
first queries that arise is, how may this be lessened
or avoided? It was for this very purpose, that years
ago I introduced to the profession various methods
of plastic surgery of the intra-abdominal and pelvic
structures. These I constantly practice and enthusi-
astically advocate in order to restore all injuries of
the peritoneum.
In the removal of tumors I cover with the greatest
care, the healthy peritoneum over their pedunculated
attachments. Where, for any reason, it is necessary
to remove the uterus, for a long period I have divided
the tissues in such a way that the cervical stump can
be carefully closed over by the double intra-folding of
its peritoneal investment. This I do by the use of
the parallel running suture, the stitches taken in such
a way that when drawn upon, the suture itself is com-
pletely buried, and the peritoneum lies in easy, acciirr
ate approximation without tension. If a ureter is laid
bare, the peritoneum is covered over in the same
manner.
In the removal of the appendix, the stump is always
covered and peritoneal abrasions are intra-folded
where the integrity of the same has seemed doubtful.
In some instances I have even closed the entire peri-
toneum across the brim of the pelvis, at its basic
attachment, to the floor of the bladder, thus com-
pletely obliterating it. By these measures, in this
class of difficult cases I have found it possible to attain
another very desirable end, that of closing the' abdom-
inal wound without drainage.
■ Here also, for many years, I have taken the precau-
tion to approximate the abdominal peritoneum with
the same care, in order to prevent adhesions of the
omentum to the line of the wound, and with most
excellent results. Since 1892 there has occurred in
my experience the three cases above reported where
death has taken place from peritoneal adhesions. In
the first, a case of vaginal hysterectomy, it was
thought wise to use clamps which left uncovered the
divided peritoneum of the broad ligament. However,
in a majority of vaginal hysterectomies by careful
manipulation it is possible to suture across the everted
peritoneum. When this can not be effected, the raw
surfaces can usually be protected by gauze. It may
however, happen as in Case 5, that pathologic changes
have ensued at some previous period, leaving result-
ing inflammatory bands. I know of no way to provide
against such complications, unless it may be in
doubtful cases to open the abdomen from above also,
in order to deal intelligently with existing conditions.
In Cases 4 and 7, at the time of operation, doubts
were entertained as to the method to be selected. In
Case 4, where the pelvic peritoneum seemed scarcely
abraded, the results show that it would have been
wiser to have adopted one of two alternatives. A
vaginal opening might have been made and the parts
protected by iodoform gauze, or the depressed portion
of the peritoneum have been sutured across at its
upper part. It is probable this would have been the
better of the measures to have adopted, since it would
have added very little to the traumatism and taken
less time than the opening of the vagina and the
introduction of the vaginal drain. It was, however,
covered with a thick layer of aristol, which I can not
doubt would prove ample protection in the majority
of instances.
In Case 7, the uterus should have been removed.
The organ had long been bound down by adhesions
which were separated with difficulty. The protection,
however, seemed ample, by the free introduction of
iodoform gauze which was so packed about as to
cover the denuded peritoneum. The point of adhe-
sion was very near the fundus of the uterus where the
gauze had become displaced. I can not question the
wisdom of removing the uterus in many cases where,
until a very recent period, such a procedure would
have been considered unsurgical. It adds compara-
tively little to the difficulties or severity of the opera-
tion and permits the covering in of the pelvic peri-
toneum in an even fold, from side to side, entirely
across the pelvis.
The omentum. — Where for any reason the omentum
has been involved in the pathologic changes, it
becomes very important to examine it carefully, and
if rents have occurred to close them. This is best
effected with a continuous tendon suture. It should
then be,, replaced with the greatest care, and if any
292
INTESTINAL OBSTRUCTION AFTER LAPAROTOMY.
[August 8,
points of abrasion appear they should be well dusted
with aristol.
Cases 3 and 6 are instructive; Case 3 where it
seems very probable that a more careful observation
should have been made and the attachment of the
omentum to the anterior abdominal wall, resulting
from a former operation, should have been separated.
In Case 6, it seems as if every precaution had been
taken to prevent such an occurrence. The omentum
which had been carried up to the region of the liver
by the large myoma was somewhat changed in its
structure. The parietal peritoneum had long remained
in direct contact with the myoma and by friction was
also changed in structure. The omentum was- spread
out evenly over the intestines and brought well down
to the brim of the pelvis. There was no bleeding
from the separated points of attachment, and the
pelvic organs were carefully cared for by the plastic
repair of the peritoneum. This had been lacerated in
various directions, and the left ureter was exposed for
several inches. No points of attachment to the pelvis
were found, the effused lymph leaving them smooth
and unadherent. The abdominal peritoneum was also
intact. The constriction was well down on the right
side at the brim of the pelvis and was easily freed.
It is not supposed that any better measures for the
prevention of intestinal obstruction could have been
instituted and the resulting adhesion of the omentum
to the side forming the band was probably the more
easily induced, owing to the changed conditions
resulting from. the long pressure of the tumor.
Treatment. — The object of this paper and the anal-
ysis of this series of cases is a practical deduction as
to what may be done when this most grave of all
complications in abdominal surgery occurs. This is
the more important, since authors are singularly at
variance and apparently without definite reasons as
to the selection of the means to be employed. Unfor-
tunately, medicines, in the hands of all, fail to be of
much value, except so far as hypodermic medication
may control pain and perhaps materially aid the great
motor nerve system.
It is evident that the entire alimentary tract above
the point of constriction becomes early paralyzed and
incapacitated to do more than permit the absorption
of crystallin substances in solution.
It may be doubtful if our efforts to stimulate peris-
talsis, even if successful, do not hasten the fatal issue,
unless they are equal to the forcible separation of the
intestine at its point of occlusion. If this supervene
a happy issue will be attained and prompt relief
afforded. This is often seen in the unfolding of a
displaced intestine with the disappearance of all
untoward symptoms.
One of the most extraordinary of the conditions
which supervene in intestinal obstruction is the rapid
accumulation of fluid above the occluded part, and,
although the thirst is usually excessive, the absorp-
' tion even of water from the stomach does not take
place, and it is probably a positive detriment to add
to the rapidly accumulating fluid by even the admin-
istration of water. Vomiting certainly does harm
unless by the forcible strain the adherent parts may
be separated. This rarely happens, and in case a loop
of intestine is incarcerated must add to the mechan-
ical impedimenta.
If then we are deprived of the administration of
medicines by the stomach, and if thus given, they are
to the detriment of the patient, what remains at our
command as a means of relief? Since fecal evacua-
tion is the desired end to be accomplished, experience
in other conditions would teach that injections anc
medicamenta, applied to the lower bowel, might be of
service. The foregoing discussion of the anatomic
construction of the large bowel teaches us why we
would not expect the constriction to occur in this
part of the alimentary canal, unless, indeed, in rare
instances the pelvic portion of the canal is involved
as the result of our surgical interference. If this has
happened, rectal examination will determine the fact
and probably enable us to deal easily with the occlu-
sion. Other than this, the benefit to be derived from
large injections, even if they penetrated to the trans-
verse colon, is exceedingly doubtful. The still further
distension of the abdominal cavity is certainly to be
deprecated, the pain and discomfort of the patient
tend to weakness, and the reflexive stimulation of the
peristalsis of the small intestine thus aroused induces
nausea and vomiting, which is an injury unless it
may, in itself, be sufficient to free the obstruction.
If, as happens in a majority of cases, the portion
of the alimentary tract involved is the lower part of
the small intestine, then we may determine why our
efforts, applied to the large intestine are so utterly
futile and the result only a loss of time and exhaus-
tion of the patient.
It is the more important to consider these probabil-
ities, since one of the primary rules laid down for the
treatment of intestinal obstruction is the use of large
enemata, variously medicated. That sufficiently care-
ful consideration has not been given to this phase of
the subject, that the obstruction does not lie in the
large intestine except by the rarest of accidents, I
cite the recent experience of a prominent English
authority who, after using enemata freely without
relief, made an artificial anus above the sigmoid flex-
ure only to permit an easy escape of the injected fluid.
It is needless to remark the patient died unrelieved of
the obstruction.
If summoned to the relief of the sufferer in such
desperate cases, what shall be advised? Certainly
not to do harm if we can do no good. Assuming
that, prior to the operation, we know that the ali-
mentary canal had been properly emptied so that, at
the time of operation, the bowel was in the best pos-
sible condition to bear its necessary manipulation,
then it is clearly our duty to keep the stomach empty.
It seems to be equally important to desist from the
common practice of fretting and exhausting the
patient by large, repeated rectal enemata. It is true
that a certain amount of water may be absorbed which
the system very much needs, but that can be accomp-
lished by much less violent measures. Hypodermic
medication of morphia is of value, but this is better
given in small doses, often repeated. More recently
this valuable remedy has been decried under the belief
that it caused an interference of peristalsis, even to the
producing of intestinal paralysis. It is indeed strange
if opium which has been relied upon for generations
as the remedy of greatest value in nearly all the intes-
tinal diseases can now be considered by any as the
cause of obstruction and its administration criminal.
Its use should be minimized to the moderate relief
of pain.
Strychnia, digitalis, nitroglycerin are remedies, to
be used hypodermically, of much value in holding in
conservation the rapidly ebbing vital force. Nature's
own powers are not to be held in too light esteem,
18%.]
INTESTINAL OBSTRUCTION AFTER LAPAROTOMY.
293
since in the most desperate of conditions slic triumphs
occasionally. Of this we were never so fully aware as
at the present, since the laparotoinist is often called
upon to examine the battle ground of previous
victories, as he studies the results, where intes-
tines have been banded to each other and the neigh-
boring parts, and yet, within limitations, able to per-
form their functions for an indefinite period.
Although, as in the operation for appendicitis, it
may be in the minority of cases that the aid of the
surgeon is justly called to attempt to restore the dam-
ages incident upon his previous work, a considerable
class of these cases doubtless exist, and when to re-
operate is a question that may never be settled. When
the weight of evidence points clearly not alone to
obstruction as the impending danger, but that nature
is powerless to remedy it, there can be but one rule,
as in strangulated hernia, operate at the earliest pos-
sible moment for the relief of the incarcerated organ.
A reopening of the abdomen within two or three
days after the primal operation must ever be consid-
ered a formidable surgical measure, not alone in that
the patient is necessarily in a serious condition from
the previous operation, but that these conditions have
become greatly intensified owing to the constriction in
the alimentary canal. It is important to first wash out
the stomach by means of the stomach tube. Often a
large quantity of fluid will pour out with much advan-
tage in the subsequent result. This I have done at
times for years. Our previous knowledge of the intra-
abdominal conditions is of the greatest value. We
must keep in mind the portion of the intestine prob-
ably involved, and the location where we are likely to
find it. This usually is the small intestine, generally
the ileum, and the location the site of the surgical
operation. Since this is more commonly the pelvic
basin it is the first location to be explored. The sec-
ond is in the neighborhood of the appendix. These
having failed to furnish results, we are to examine
carefully the omentum and its relation to the small
intestine. A careful observation of these factors in
the order proposed is of the utmost value. Nothing is
more to be deprecated than the aimless searching in
the abdominal cavity, and the evisceration of the
patient by the rolling out of the distended intestine,
as is often practiced in the blind search for the
constriction.
The inflated intestines are ever protruding, but as
far as possible are to be avoided, since the infla-
tion itself teaches that this can not be the part
involved. On the contrary, a portion of the intestine
that is empty and flat is likely to lead almost at once
to the constricted part. Here as elsewhere intimate
anatomic knowledge of the abdominal cavity and its
contents is of the utmost practical importance.
Etherization should be minimized. My experience
with oxygen gas leads me to think favorably of it as
an adjunct to chloroform. The operation should be
undertaken under as favorable circumstances as pos-
sible, conducted with coolness, deliberation and dis-
patch, since the resources of the surgeon are rarely
more severely taxed than in this dilemma.
Owing to the severe shock incident to an operation
as above described, it has been recommended and
practiced to make a small opening in the abdomen
and through this withdraw the first inflated fold of
small intestine that presents, suture it to the perito-
neum and open. This gives temporary relief, per-
mitting the escape of the pent-up toxic elements and
affords time for the patient to rally from the extreme
depression incident to the obstruction. As soon after
as the general condition will permit, a third operation
is undertaken for the relief of the constriction, at
which time operative measures for the cure of the
artificial anus are also instituted. In a dilemma
of severe complications there may be conditions
that would cause such a temporary operation to be
favorably considered, and it is well for the surgeon to
keep in mind the possibility of its advantage.
In review, I am constrained to add emphasis to the
practical importance of the preparation of all patients
for laparotomy. The condition of the nervous sys-
tem is important. The lowering of the nervous ten-
sion is a very great gain. The substitution of hope
for fear, and confidence in the outcome is of much
more value than I earlier believed; and why should
not this be true, since the best definition of life itself
is the equilibrium of the vital processes in their sway
over the organic matter which they hold in control?
The intestinal canal should be earefully emptied
and peristalsis kept active at the time of operation.
It is better to employ only fluid food for some days
prior, and antiseptics, such as small doses of calomel
and salol, I believe to be of value. Time is an import-
ant factor in the operation, but this is no excuse for
undue haste or inaccuracy of work.
Intraperitoneal surgery must ever be of the high-
est order, and accuracy and completeness of detail
must go hand in hand in every process to prevent
infection. When these great surgical laws have been
complied with recovery is in direct ratio with the
minimizing of the devitalization of the patient.
These are the almost ideal results which modern sur-
gery has attained and upon their practical application
depends the marvelous success of the surgeon of
to-day.
DISCUSSION.
Dr. A. H. Cordier, Kansas City, Mo. — In the majority of
instances we will find the obstruction near the junction of the
small with the large bowel. It is impossible to locate this
dangerous condition when we are operating through the
vagina. The argument which Dr. Marcy has presented is in
favor of doing these operations through the abdominal wall.
The work then is complete. It is not the specimen alone for
which the surgeon should seek in doing abdominal operation.
He should seek to liberate adhesion and relieve the patient of
all likelihood of intestinal obstruction following the work. At
the time of operation we will find the bowel flaccid — compara-
tively speaking, empty, with adhesions. These adhesions may
not have given trouble prior to operation, but with the amount
of handling which of necessity must be done in operating,
either through the vagina or abdomen, if the adhesions are not
separated, we have following the operation great distension of
the intestines, and following that a semi-paresis. We have the
difficulty of a paralyzed bowel to contend with and inability to
force the contents of the bowel beyond the seat of obstruction.
We must separate the adhesions and liberate the bowel. I am
satisfied that many cases, reported as dying from some form
of sepsis or peritonitis, would, if a careful postmortem was
made, be found to have died from intestinal obstruction, the
sepsis and peritonitis being secondary, because the gaseous
distension can not relieve itself.
Dr. E. E. Montgomery, Philadelphia — Too much stress can
not be placed upon the early treatment of cases of intestinal
obstruction. The distension which takes place in the upper
part of the stomach may be relieved temporarily by introduc-
ing a stomach tube, washing out the stomach, allowing a large
quantity of gas to escape, removing the contents of the stom-
294
HYSTEKECTOMY.
[August 8,
ach. This takes away the pressure against the diaphragm,
relieves respiration and facilitates the heart's action. This
should be tried once or twice, and if the patient continues to
suffer from intestinal obstruction the proper plan would be to
reopen the abdomen. I must take exception to the remarks
of the last speaker, that in these cases it indicates the neces-
sity of opening through the abdomen in cases of pelvic disease.
Cases operated upon through the vagina are not more subject
to intestinal obstruction than are those operated through the
abdomen. I have not seen a single case of removal of the
uterus through the vagina for inflammatory conditions in
which the subsequent convalescence of the patient was dis-
turbed by symptoms of obstruction.
Dr. Rufus B. Hall, Cincinnati — It is a difficult matter in
any given case of intestinal obstruction to make a positive
diagnosis until the patient is practically dead, and that is why
a reopening of the abdomen in such cases gives such a high mor-
tality. The differentiation of intestinal obstruction is difficult.
Many times I have been on the point of giving the patient an
anesthetic to reopen the abdomen, and in half an hour afterward
my patient was convalescing and recovered without trouble.
If we only knew that the patient had obstruction we could
probably save them all.
Dr. Henry P. Newman, Chicago — The fact that we have
these cases of intestinal obstruction following laparotomy
should stimulate us to better, more thorough and complete
work. True, the obstruction usually occurs in desperate
cases, but if the patients are handled with care and with the
utmost thoroughness, they will frequently escape this acci-
dent, particularly if we exercise caution in covering abraded
surfaces with pertioneum and the vaginal tract with omentum.
As to the protection of abraded surfaces after laparotomy that
can not be covered with peritoneum, they may be kept apart
by the proper application of gauze or wicking.
It was my misfortune to lose a case of vaginal hysterectomy
recently from intestinal obstruction, which probably could
have been avoided if someone had been at hand to watch
the case. Unfortunately, I was called out of the city at the
time. Presumably a portion of the intestine had become
adherent and was drawn into the fold of the vagina, causing
obstruction and death.
In regard to the proper application of gauze after vaginal
hysterectomy, the gauze should not penetrate the abdominal
cavity. It should be applied in a manner to guard against
hernia and a means of drainage, but should not come in
contact with the intestine. Furthermore, it is important to
begin the use of mild catharsis to stimulate peristalsis early,
and here let me enter a protest against the use of opiates.
Morphin is sparingly used at the present time in laparotomies,
and I think it ought to be. On the other hand, use laxatives
early, beginning twenty-four hours after your operation, par-
ticularly where there is an accumulation of gas and perhaps
great distress.
Dr. J. W. Bovee, Washington, D. C. — I had the misfortune
to lose a case from intestinal obstruction following abdominal
section, the woman dying on the fifteenth day after operation.
She progressed nicely for five days, and then the bowels did
not move for one or two days. They moved again on the
seventh day. On the ninth day she was taken with consid-
erable pain in the region of the cecum. I commenced with
catharsis, but could not move the bowels, although I used
enemata and also croton oil. On the fifteenth day I opened
the abdomen and found two or three coils of the small
intestine down in the right side of the pelvis attached to the
posterior surface of the broad ligament from which I had
removed a tubo-ovarian abscess. I separated the adhesion
with scissors, closed the abdomen as quickly as possible, and
did it with scarcely any anesthesia, realizing that it was a
desperate case. I make it a point now to close raw sufaces
in the abdomen if the condition of the patient permits and
move the bowels as soon as possible. Within twenty-four
hours after the operation I commence salines.
Dr. George Wm. Reynolds, Chicago — One of the fruitful
causes of intestinal obstruction is the manner in which the
abdominal incision is closed. It is my practice not to include the
parietal peritoneum in the deep sutures. Frequently, in tying
them, where we penetrate the peritoneum, loops of intestine
are caught and obstruction follows. My practice has been to
sew the parietal peritoneum separately, including in my deep
sutures the muscles, the fascia and the external skin.
Dr. Joseph Taber Johnson, Washington, D. C. — It is alto-
gether possible that by passing the same suture down through
both sides of the abdominal incision and up through the other
side by the time the operator is ready to close the abdominal
wound, tying off one suture after another, a knuckle of intes-
tine or piece of omentum may get in between the stitches and
produce adhesions which result in intestinal obstruction. I
have known one or two cases due to this cause* There is no
doubt but that a great many cases can be prevented by perfect
operating, leaving as few raw surfaces as possible, taking great
care in separating adhesions that exist about the tumor itself,
and by the covering of all raw surfaces in the manner sug-
gested by the paper. The diet question after operation is one
of importance. I had the misfortune to lose a patient some
time ago when a difficult hysterectomy had been performed.
The patient was about ready to go home. She was exceed-
ingly anxious that evening to have some veal cutlets. She
partook of them and had an attack of indigestion shortly after
which brought on vomiting. She vomited until she died. A
postmortem was made and a twist of the small intestine was
found. The intestine below the twist not larger than a pencil,
while above it was as large as my wrist. If we had been able
to diagnose the case when the first symptoms of intestinal
obstruction came on, we doubtless could have separated the
adhesions caused by the intestinal obstruction and saved our
patient.
Dr. Marcy — Had I written upon this subject a year ago I
probably should have taken a different view of it, but during
the last year the cases which I have reported occurred. If
you will look carefully over reports of cases you will find that
intestinal obstruction following laparotomy is more frequent
than we formerly supposed. These cases point out the neces-
sity for more careful, thorough work in order to avoid this
accident. It is a question in my mind whether the pelvic-
structures are protected by the omentum, and that is the rea-
son we are so likely to have intestinal adhesions occur in the
pelvic region. The normal range of motion of the small intes-
tine, including the pelvic basin, gives emphasis to that remark.
In reference to the vaginal route, I do not exactly agree
with Dr. Montgomery. Blind surgery may be stigmatized as
bad surgery. Vaginal surgery is necessarily in large measure
blind surgery, in that the eye does not direct the hand. In
one case that I lately saved there was an old band of adhesion
which had nothing whatever to do with the carcinomatous
uterus which I had previously removed. Under this old adhe-
sion was a loop of intestine which had become incarcerated.
It was freed and the patient recovered.
In another case, twenty-two days after operation a double loop
of the small intestine was found united to the stump from
which I had removed an ovarian cystoma. In this case we
reopened the abdomen and saved the life of the patient.
HYSTEKECTOMY AS AN ACCOMPANIMENT
TO BILATERAL REMOVAL OF THE
APPENDAGES.
Read In the Section on Obstetrics and Diseases of Women, at
the Forty-seventh Annual Meeting of the American Med-
ical Association, held at Atlanta, Ga., May 5-8, 1896.
BY REUBEN PETERSON, M.D.
GRAND RAPIDS, MICH.
During the past five years decided changes have
taken place in the methods of dealing with pelvic
inflammatory diseases. Prior to 1890, it was the
established custom in America to deal with irrepara-
bly diseased appendages by removal solely through
an abdominal incision. Deliberate hysterectomy as
L896. j
HYSTERECTOMY.
295
an adjunct to ablation of the tubes and ovaries was
not practiced. Pean in 1886 removed by the vagina
the diseased uterus of a patient whom he hail failed
to oure by a previous removal of the appendages.
From this ami similar oases he sought to establish
the principle that for certain forms of pelvic inflam-
matory disease hysterectomy as well as removal of the
appendages should be performed. His work along
these lines, which was reported before the Paris
Academy of Medicine in 1S1R), seems to have at-
tracted but little attention in this country. Operators
of large experience who had carefully followed up the
history of these cases, subsequent to the operation of
bilateral ablation of the adnexa, were forced to admit
that many of their patients were not restored to health.
Many still suffered from hemorrhagic and purulent
uterine discharges and the reflex symptoms, which
had prominently figured among the indications for
the operation, persisted to a greater or less degree.
In order to do away with these unfavorable sequelae,
portions of the uterus were surgically treated. It was
Gtrged that in every case where the appendages were
to be removed for chronic inflammatory disease, the
uterus first should be thoroughly curetted and drained.
Also that the tubes should be dissected out of the
uterine cornua in order that no diseased tissue be left
behind. Although these procedures were carefully
carried out there still remained cases which presented
the old train of symptoms. Hence when Polk's
paper1 on "Hysterectomy (supra pubic) for Sal-
pingitis and Ovaritis "' appeared in the latter part of
1893 in which hysterectomy was advocaed for every
case where both appendages had been removed for
serious disease, the idea, coinciding as it did with the
clinical observations of many operators,2 was eagerly
seized upon by prominent gynecologists throughout
the country and immediately put into practice. Since
that time hysterectomies have been done by the score
in this class of cases. Is it not well to pause after
three years' work in this line and ask ourselves not
how many uteri have been removed during this period,
but how much has been learned from careful micro-
scopic and bacteriologic examinations of these re-
moved organs? In other words, do the pathologic
lesi. ins found in the ablated uteri confirm the correct-
ness of the reasoning of those who, mainly upon
clinical grounds, advocate hysterectomy in certain
inflammatory pelvic diseases. Henrotin 3 at the last
meeting of the American Gynecological Society states
that " the position of advanced, observant gynecolo-
gists who are not hampered by tradition or custom or
afraid of their own stubborn dogmatic expressions in
the past can be stated as follows: ' In every opera-
tion for septic diseases of the female generative
organs which demands the removal of the tubes and
ovaries, hysterectomy should also be performed unless
there are contraindications forbidding it.' " I con-
sider this a fair statement of the present position of
surgery upon the subject. The whole question will
turn upon the interpretation placed upon the phrase
"contraindications forbidding it." The more care-
fully the removed uteri are studied in connection with
the history of the case and the condition of the pelvis
found at the time of the operation, the nearer we will
be to determining what will constitute a contraindi-
cation. If it can be shown that certain pathologic
uterine lesions either of the mucosa or of the deeper
structures are susceptible of cure without removal of
the organ, then considerable advance has been made I
toward establishing another contraindication. On
the other hand microscopic examination of the
removed organ may show such decided morbid
changes in its structure as to render any curative
treatment short of ablation ineffectual. This line of
research may not be the easiest or most enticing.
One would far rather have a universal rule for guid-
ance, such as is laid down above, but conservative
surgery does not advance along these lines. For
example, it is much easier to adopt a universal rule to
operate for appendicitis in every case as soon as the
diagnosis is made. Yet those who advocate and
observe this rule are in the vast minority and ever
will be, so long as it can be proven that a certain
percentage of cases recover by adhering to other modes
of procedure. The technique of hysterectomy has
been so perfected that in the hands of the skilled
operator the mortality is increased but little over that
resulting from removal of the tubes and ovaries alone.
This fact, however, does not justify one in removing
the uterus in every case. While clinical experience
has shown me that a certain percentage of my cases
were not cured after their pus tubes were removed,
on the other hand it has demonstrated that certain
cases recovered after this treatment. It seems to me
it is plainly the surgeon's duty under these circum-
stances to endeavor to solve the problem why one set
of cases recovered and the other did not. The reason
must lie, other things being equal, in the condition
of the uterus at the time of the operation. How can
these different conditions be studied and definite
rules of procedure be established except it be upon
both pathologic and clinical grounds. Yet a peru-
sal of the literature emanating from our gynecologists
upon hysterectomy for inflammatory affections will
show that their conclusions have been arrived at
mainly from a clinical consideration of the subject,
That this is a dangerous mode of studying any surgi-
cal question and one liable to lead to grave errors is
demonstrated by the abuse of ovariotomy when it was
performed for symptoms and not for demonstrable
pathologic lesions. I fail to see the line of reasoning
adopted by Polk. He, the advocate, par excellence,
of conservative surgery, who would leave in an ovary
or part of one with everything else removed, advo-
cates the removal of the uterus in every case of
bilateral ablation of the appendages because some
cases fail of cure without this additional procedure.
What right has he or anyone to justify his position
by claiming that the " emasculated uterus " is a use-
less organ and hence should be sacrificed? It should
be sacrificed if it is so diseased that no known pro-
cedure can effect its cure and that should be the only
justifiable ground for its removal. One who claims
so much for thorough dilatation and curettage of the
uterus, in the way of depletion and drainage, should
surely obtain better results than are shown by his
advocacy of the proposition to perform hysterectomy
in each of these cases.
I am making a plea against the adoption of any
universal rule in regard to these cases as if it were
finally settled. I claim that the surgeon has no right
to remove the uterus after removal of the appendages
unless he is convinced that the organ is diseased
beyond the hope of cure by less radical methods.
Krug * in the discussion of Polk's paper, said he had
" never found a healthy uterus when there had been
such inflammatory disease in the tubes and ovaries as
would warrant bilateral salpingo-oOphorectomy. " It
296
HYSTERECTOMY.
[August 8,
is not a question of the uterus always being diseased
in these cases. As most inflammatory disease of the
adnexa arises from some form of intrauterine affec-
tion, it would be remarkable if the uteri were per-
fectly healthy. The question is how much are they
diseased and how can this disease be cured? I would
not underrate the work of those who were the first to
advocate hysterectomy for inflammatory disease. I
consider it a great step in advance and for certain
conditions it is the only procedure which should be
adopted. But I believe that the prediction of Baldy
made two years ago in a paper 5 on this subject, that
uteri would be removed which might safely be left, has
proven true to a far greater extent than one could
have predicted. Even if the uterus be a functionless
organ after bilateral salpingo-oophorectomy, I do not
think the most radical operator would urge its removal
for this cause alone, if he could determine in which
cases it could " safely " be left within.
The investigations of Wertheim 6 have thrown con-
siderable light upon gonorrhea of the uterus. They
would tend to show that the deeper uterine structures
are affected to a greater degree than was formerly
supposed. There is in many cases infiltration of the
muscle with hyperplasia of the vessel walls. That the
gonococci can penetrate into the muscularis is con-
sidered highly probable by Wertheim though he has
never bacteriologically demonstrated their existence. '
That a metritis with sensitiveness and general enlarge-
ment occurs in gonorrheal disease of the uterus is a
well known clinic fact, but that it is due to the gono-
coccus has never been proven because the muscular
tissues being an unfavorable soil for the germs they
either perish or pass on through the uterine wall to
the peritoneum. Madlener " asserts that he actually
demonstrated the gonococci in the muscular tissue in
one case where the uterus was removed seven weeks
after confinement.
Gonorrheal disease of the uterine deeper structures
offers then an explanation of the unsatisfactory
results obtained by treatment through the curette and
drainage. Removal of the endometrium leaves the
deeper structures still diseased and in a short time the
old symptoms will again appear. For this reason Werth'1
claims inasmuch as it is impossible clinically to
distinguish these forms of endometritis where the
deeper tissue is involved, that a thorough cauteriza-
tion after curettage should always be made. He
recommends liquor ferri and shows that after its use
a regeneration of the epithelium is delayed.
The conclusions were arrived at from a careful
microscopic examination of uteri removed after
curettage performed some days previously, and are
therefore more valuable than mere theoretic conject-
ures in the matter. In another article 10 he shows
that the endometrium is never entirely removed,
patches untouched by the curette remaining. The
cornua were most likely to be spared.
Just what percentage of cases of inflammatory dis-
ease of the adnexa are due to gonorrhea it is hard to
say. Probably 25 per cent, would be a conservative
estimate. It is generally conceded that Noeggerath's"
picture of latent gonorrhea and its frequency was
exaggerated. Yet no one can question the important
role played by the gonococcus in the production of
pyosalpinx. Apparently gonorrhea of the uterus
is especially difficult of cure, and this should have
weight in deciding whether hysterectomy should fol-
low removal of pus tubes.
Schauta 12 takes a very decided stand in this matter.
From the results of his observations he finds that only
59 per cent, of cures result when both appendages
are moved and only 23 per cent, where one side is
removed. When this lesion is due to gonorrhea, he,
like Tait, claims that when one side is removed the
other should be also together with the uterus. This
recommendation is not based, it seems to me, upon
sound scientific principles and is not advocated by
the majority of gynecologists. If this dictum be fol-
lowed then we practically concede that we are power-
less in the presence of gonorrheal disease to effect a
cure short of hysterectomy. While the investigations
referred to have shown us why frequent failures
result from our efforts to cure gonorrhea of the uterus,
still, I do not believe that every case of gonorrheal
endometritis is incurable. A certain proportion of
the 25 per cent, will no doubt fall under this category
and in time we shall be in a position to recognize
these cases and act accordingly. Much will depend
upon the wishes of the patient in cases where one
side is unaffected 13. She may demand the most
radical operation if there exists a possibility of the
other side becoming affected. On the contrary she
may be desirous of bearing children and be willing to
risk the possibility of a secondary operation from the
failure of intrauterine treatment. Schauta makes
every effort to establish the diagnosis of gonorrhea
prior to operation and during the progress of the latter
has the contents of the pyosalpinx examined for the
gonococci. If gonorrhea is found to exist both
adnexa and uterus are removed on the ground that
the gonococci work irreparable change in the uterus
while the inflammation of the appendages due to
streptococcus and staphylococcus infection is usually
one sided, the uterine lesion heals and consequently
the uterus can safely be left. As more than 50 per
cent, of the cases of inflammatory disease of the
adnexa are believed to arise from infection after
abortions or the puerperal state, it will readily be
seen that if Schauta's claims be true there are many
cases where the uterine lesions will either be cured or
amenable to treatment after the removal of the
adnexa.
More such investigations should be made and by
the collections of bacteriologic and clinical data,
rules can be formulated which will be of universal
value to the surgeon in deciding what should be done
in a given case. Whatever may be said to the con-
trary, hysterectomy is a much more radical procedure
than bilateral removal of the adnexa and should never
be performed except when demanded for the cure of
the patient.
Some advocate hysterectomy on the ground that 12
per cent, of chronically diseased adnexa requiring
removal are found to be tubercular upon microscopic
examination and that the uterus may be also affected.1*'
This position is strengthened by the observation of
Cullen, " who thinks tubercular disease of the uterus
is usually secondary to that in the tubes. But tuber-
cular uterine disease is usually demonstrable by the
examination of scrapings and hence it is possible to
have a fairly clear idea of the condition of the uterus-
prior to the operation. Where the uterus is found
to be tubercular it should always be removed, because-
of the difficulty of curing it by intrauterine treatment.
Where the microscopic appearances of the adnexa
show tubercular deposits, it would seem advisable to
remove the uterus because of the serious nature of
18W.]
HYSTERECTOMY.
297
the disease, the possibility of the uterus being affected
ami the difficulty of curing tubercular uterine disease
by the curette. If the microscope shows tubercular
disease in the appendages unsuspected before, the
uterus can be removed by a secondary operation.
At the last meeting of this Association a former
chairman of this section, Dr. Eastman, remarked in
speaking of hysterectomy for fibroids, that he was
not sure of what the after-effects of complete removal
of the uterus would prove to be, that he found vagi-
nal prolapse, cystocele and rectocele following some
eases, and that he would be obliged to suspend judg-
ment until he had operated on more cases by this
method. This was said by a man who has probably
performed as many if not more complete hysterectom-
ies khan any operator in the country. It would seem
that the lesson to be learned from the remarks of
such a man, was to be cautious in urging that the
uterus be removed. It is generally conceded that
when we are obliged to remove an organ, it is a prac-
tical acknowledgment of defeat. Starting from this
defeat however our efforts involving removal may end
in victory as regards the health of the individual.
We must continually keep before our minds the
two great classes of cases calling for bilateral removal
of the adnexa, and it is only necessary to recall our
past cases to find examples of each.
The first is where there is advanced disease, usually
chronic, involving both adnexa. The tubes and
ovaries, whether filled with or free from pus, are
bound down in the posterior cul-de-sac and to the
omentum and bowels by dense adhesions. Much
labor must be expended in enucleating these masses
and much injury may be done the uterus in separating
it from the pus sacs. Repeated infections with
resulting metritis and endometritis have also greatly
impaired its integrity. Here the indications are
clearly for removal of uterus. Its peritoneal cover-
ing may be so injured that, if left, it will be firmly
bound down by dense post-operative adhesions and
give rise to great suffering. These are the cases
where hysterectomy will give brilliant results as com-
pared with the older methods. But these are not
the usual but the severe cases and fortunately the
exceptions.
The second class is the one we are considering in
this paper. Here the recurrent attacks of pelvic
peritonitis have been fewer, hence the adhesions less.
The tubes and ovaries may be the seat of purulent
collections, or their contents may have become
changed to a cheesy material with thickening of the
walls. The fimbriated extremities of the tubes are
closed and no conservative operative procedure can be
entertained. The uterus is enlarged but fairly mov-
able. The masses on either side having been removed
without much difficulty, the operator is confronted
with the question of whether hysterectomy shall fol-
low. His decision will depend largely upon the con-
dition of the uterus and the possibility of its being
cured by treatment directed to its interior, aided by
the atrophy resulting from the removal of the append-
ages. Careful, recorded observations, both pathologic
and clinic, will result in rules which will guide the
surgeon in his choice of procedure.
602 Pythian Temple.
REFERENCES.
i Polk: Hysterectomy for Salpingitis and Ovaritis. New York
Journal Gyn. and Obs., Vol. 3, 1898. p. 1058.
2 New York Journal Gyn. and Obs., Vol. 8, 1898, p. 1088; Vol. 4, 1894,
p. 61.
3Henrotin: Conservative Surgical Treatment of Para- and Peri-
Uterine Septic Diseases. Am. Gyn. and Obs. Jour., Vol. 6, 1805, p. 769.
« New York Journal Gyn. and Obs., Vol. 4, Jan., 1894, p. 72.
SBaldy: Extirpation of tin- uterus in Disease of the Adnexa
Transactions American Gynecologic*] Society, 1894.
» Wertaeim : Centralbl. f. Gyn., 1896, No. 26.
' Wertheim : Deutsch. Med. Woeh., No. 27, July 4, 1895.
* Madlener: Centralbl. f. Gyn., Dec. 14, 1895.
« Werth : Archiv f. Gyn., Band 49, Heft 2.
10 Werth : Centralbl. f. Gyn., 1895, No. 7.
n Noeggerath: Transactions American Gynecological Society, 1876.
12 Schauta : Centralbl. f. Gyn., 1895, No. 29.
1' Noble: Certain Aspeets of Gonorrhea in Women. Transactions
American Gynecological Society, Vol. 17, 1892.
1* Williams : Johns Hopkins Hospital Reports, 1892, Vol. 8.
15 Cullen : Johns Hopkins Hospital Reports, Vol. 4, Nos. 7-8.
DISCUSSION.
Dr. Joseph Eastman, Indianapolis — I am intensely pleased
with Dr. Peterson' s paper. The gentlemen who run to extremes,
who ride hobbies to the extent that some of those engaged in this
work have done, have been severely reprimanded by the Presi-
dent of the American Medical Association, as well as the
incoming President, during this meeting, and it is encour-
aging indeed to see a young man come in here and present such
a conservative paper, in an aggressive way, that neither the
criticism of Dr. Cole nor of Dr. Senn touches him or a word he
has uttered. He did not know when he wrote this paper what
they were going to say, yet he has disarmed their criticism and
has effectually parried their stroke. From that lesson we take
warning, and the people, as well as the attending physician,
will attach importance to these words and admonish us that
the surgical pendulum has swung to the extreme, and that
uteri and ovaries have been sacrificed that might have been
saved by either medical or conservative surgical treatment. I
am pleased with the paper from beginning to end. We see
the sparkling diamonds of surgical thought crystallized and
matured. We see from beginning to end science, surgery and
sense.
Dr. Edwin Walker, Evansville— The question of diagnosis
has been hinted at, but I think our diagnosis should extend
outside of the pelvis. Many of these recurrent cases have
diseases which have nothing whatever to do with the sexual
organs, and until we clearly recognize this and properly treat
the cases we will never cure them. We all know there are a
class of neurasthenics, who are often anxious to be operated
on, and after having been treated surgically are no better than
before. Many of the cases reported as incurable are not really
pelvic diseases. The number of uteri which give trouble, after
the removal of the appendages, it seems to me, must be small.
From my own experience, I can recall but two cases, and in
both of these there was a persistent purulent discharge.
Neither of them has been operated on since. I think in both
I recommended extirpation. But because in these rare in-
stances we have such cases that are not cured, it is by no
means a just conclusion that all should be treated by total
extirpation. The point I wish particularly to make is that
before a diagnosis is made our examinations should extend
throughout the whole system, and not the pelvis alone.
Dr. Henry P. Newman, Chicago — I regret that these con-
servative remarks were not injected earlier in our proceedings.
Some sweeping statements have been made from time to time
regarding radical operations performed for the relief of inflam-
matory diseases of women, and it is certainly to be deprecated.
We are oftentimes in a position to be criticised, as we have
been at this meeting by two prominent men. For that reason
I am pleased to have heard Dr. Peterson's able and conserva-
tive paper. At the same time it is a very aggressive contribu-
tion. I like the tone of it and wish to thank the author for it
Dr. J. W. Bovee, Washington, D. C. — I do not have a
dread of the gonorrheal uterus, that the essayist has. It does
not seem possible that this condition is beyond our aid. When
a uterus is to be removed for the cure of a diseased condition,
if the gonococcus travels through the walls, how can we feel
any safer in removing the uterus for gonorrhea than in remov-
ing it for cancer? It may be, that I have had a unique experi-
ence, because it is a revelation to me that there is so much
VAGINAL VS. ABDOMINAL SECTION.
[August 8,
evil resulting from this class of work, or in following this class
of procedures. I have not had bad results following abdominal
section.
Dr. Rufus B. Hall, Cincinnati — I endorse the sentiment
and views expressed by Dr. Peterson most heartily.
Dr. Peterson — 1 am very much obliged to the members for
their complimentary remarks, but I wish the paper had been
more freely discussed and not complimented so much. We
are continually meeting with this question which we have to
solve at the operating table, and while it is easier perhaps to
adopt a universal rule, still it does not seem to me as though
along these lines our department of science will progress.
Dr. Bovee spoke about the fear of the gonorrheal uterus.
Possibly he misinterpreted some of my quotations from Schauta.
I simply said that the investigations of this man and others
have shown that where the gonococci penetrate into the mus-
cular tissue, they leave sucu a damaged condition that it is
difficult to cure the cases by curettage. By these investiga-
tions we are enabled to compare the ravages produced by the
gonococci, the streptococci and the staphylococci. The
inflammation is entirely different from cancer.
VAGINAL VERSUS ABDOMINAL SECTION
FOR SMALL TUMORS AND PUS
IN THE PELVIS.
DISCUSSION.
Dr. R. S. Sutton, Pittsburg— It is especially appropriate
that this discussion should take place in the former home of
Robert Battey, whom we all revered, and who has passed to
his final reward for the noble services which he extended to
suffering women. His first conceptions led him to remove the
ovaries by the vaginal route, and it is especially gratifying to
American surgeons that this route is still held by all as a
proper one, and by many as the better one in suitable cases.
The question of this route or the upper or abdominal route for
the removal of pus tubes is the one first before us. The
advantages of the vaginal route are multiple. The removal of
the uterus with the suppurating appendages opens the way to
perfect drainage. It also disposes of an organ which is patho-
logic and useless, and which if left may afterward become
the seat of other pathologic changes. The rate of mortality
for the removal of pus tubes by this route is exceedingly low,
probably in good hands not above 3 per cent. The objections
to an abdominal wound are removed and the convalescence of
the patients is remarkably short and free from febrile features.
The point on which many are at variance is the disposition of
the uterus. I hold that the whole question hinges upon the
pathologic condition of the uterus itself. If the uterus is a
focus of infection, loaded with pathologic germs, such as the
gonococci or bacillus tuberculosis, streptococci or staphylo-
cocci, it should be removed with the appendages, and no por-
tion of it should be left. I hold further that a uterus deprived
of the ovaries and tubes is a useless organ. That it may
become, if left, a future incubator for cancer cells, gonorrheal
or tubercular germs, and is quite as dangerous, or more so,
than the appendix vermiformis, which surgeons do not hesitate
to remove for prophylactic reasons. We have been told that
we might as well remove the penis after male castration as the
uterus after removal of the ovaries. The cases are not analog-
ous. The anatomic construction of the uterus and penis are
not alike, they are not equally liable to the same diseases, and
their position with reference to the bladder is totally different.
The uterus lies hidden in the pelvis, behind the bladder. The
penis is attached to the bladder in front, and every few hours
it is thoroughly washed out by the urine discharged from the
bladder. It is impossible that it should harbor and incubate
pathologic germs to the extent that the retained uterus may
do. It is probable that Jacobs and others are right in fixing
the causes of diseased appendages about as follows : 75 per
cent, for gonorrheal infection, 10 per cent, for tubercular, and
15 per cent, of extraneous or other causes, including cancer.
In addition to the occurrence of pus in the tubes, we may have
abscesses form in the pelvic cellular tissue, the infection enter-
ing abrasions and being conveyed by the lymphatics. By the
vaginal route, then, collections may be reached without dis-
turbing the uterus. I urge that an infected uterus should be
taken out with the appendages, and that a uterus deprived of
them is of no use and is dangerous ; that its removal adds
greater safety to the operation.
As to the question of the removal of fibroids by the vaginal
route : Large fibroids should be removed by the abdominal
route by the method laid down by Crobak, and popularized in
this country by Baer. Submucous fibroids may generally be
safely enucleated per vaginam. Pediculated fibroids, as a
rule, large or small, are better attacked by the abdominal
route. But what of the small fibroids affecting the wall of the
uterus? I do not believe that we have a right to deliberately
destroy a uterus by either route in all such cases. Such
tumors may often be shelled out and the woman afterward
bear children.
But the President reminds me that my time is up. I will
only say that the uterus bearing a small fibroid in its walls may
be exposed by anterior colpotomy, and that often the tumor
may be incised and shelled out, and the uterus safely returned
to the pelvic cavity.
Dr. W. E. B. Davis, Birmingham, Ala. — The man who has
executed much successful work through the vagina will be
loathe to change, and vice versa. Both operations have a large
field, and it is well that we have two routes by which to reach
the diseases of these important organs.
Dr. Sutton rightly emphasized the fact that the choice of
operation depends largely upon the decision as to the disposi-
tion of the uterus in bilateral diseases of the appendages.
Undoubtedly the question hinges on this point, and he very
properly devoted much of the time allowed him in its discus-
sion. I agree with him that if the uterus is to be removed,
when the bilateral operation is necessary, that the vaginal
route should be selected in a large proportion of such cases.
However, it should be the aim and pride of every surgeon to
preserve everything consistent with thorough surgical work,
and not to sacrifice important organs because it can be done
with only small mortality. He and others tell us that the
uterus has no function after the removal of the appendages,
but they have not demonstrated this, and on the contrary we
know that the sexual life of the woman is very much better
preserved by leaving the uterus, and that the mental effect is
also much better. A slow convalescence, or even a seconc
operation is preferable to its removal unless very much dis-
eased. It is a reflection on the correctness of the reports of
complete recoveries of such a large percentage of cases by many
most excellent surgeons, when the uterus was not removed, to
accept the argument now being used in favor of riysterectomy
in all these cases. I can not agree with Dr. Sutton that pus in
the tubes is due to gonorrhea in 75 per cent, of cases. I think
that puerperal infection is the cause of more than 50 per cent.
Tubercular infection is rarely the cause and is not so import-
ant as his discussion would indicate. However, the importance
which he attaches to gonorrhea is against his argument for the
removal of the uterus, as the infection from this source is not
deep, and can be removed with the curette. Because some
patients are not completely cured by the removal of the
appendages is no argument for hysterectomy in every case
where the bilateral operation is required, for nearly all these
can be relieved by a thorough curettage. Some large uteri
will require in addition to this the ligation of the uterine
arteries with a high amputation of the cervix ; only a small
number of cases will need hysterectomy.
LSW.]
VAGINAL VS. ABDOMINAL SECTION.
299
Vaginal incision for the drainage of pus in the pelvis, not
confined to the tubes, is a most valuable method of treatment,
and has been practiced for a long time with gratifying results.
A large percentage of these cases have required no further
surgery. More recently large pus tubes and ovarian abscesses
have been incised and drained through the vagina with perma-
nent recoveries in a large proportion of cases. These are the
very eases where the vaginal operation and hysterectomy have
been recommended so highly by the French surgeons. Yet a
Ittge percentage can be relieved by vaginal incision and drain-
age. If not completely relieved, the patient's condition will
be made better by getting rid of the pus, and later on an
abdominal operation can be done and the patient cured by the
removal of the appendages, and perhaps of one side only. The
uterus can nearly always be saved by this method of proced-
ure. It is not best to do a radical abdominal operation at first,
M recommended by the leader of the discussion. As to the
mortality of t he two methods it is very low in both and one
possesses nothing over the other from that standpoint. The
object of the surgeon now should be, not so much toward still
further reducing the death rate from the operation, but to
relieve these cases and preserve as far as possible organs which
have so much to do with the woman's health and happiness.
For that reason the abdominal operation is preferable, as the
aid of positive sight is given, thus affording an opportunity for
conservatism. It affords a wider field of operation and hemor-
rhage is more easily controlled. After the operation is com-
menced it can be changed to suit the conditions found, which
could not be known before the abdomen is opened. Extensive
adhesions can be much more readily dealt with. There is less
danger of intestinal, vesical and ureteral fistulas There is less
labor to the surgeon. More time is required for the patient to
be out of bed, but the additional time thus spent is beneficial to
these cases whose nervous systems have been greatly impressed
by long suffering. It may be urged against the abdominal opera-
tion that a small number of cases of ventral hernia would
follow. The scar is also an objection. In view of the great
advantages furnished by the Trendelenburg position for posi-
tive diagnosis and thorough work we must all agree that the
abdominal route has a field in pelvic surgery that can not be
supplied by the vaginal operation. Very little was said by Dr.
Sutton in regard to fibroids. I think if a fibroid is large
enough to require removal that it can be better dealt with by
the suprapubic operation.
Dr. J. \V. Bovee, Washington, said he had been operating
by both methods and had found that both are needed in this
class of cases. A great many fibroid tumors may be operated
on from below, as through the opening made in anterior col-
potomy by the incision along the anterior vaginal wall meeting
one that parallels the front wall of the cervix a growth having
a diameter of four inches may be removed. So that for small
fibroids in the anterior wall of the uterus the vaginal route is
a very good one. There are also some pus cases in which it is
absolutely necessary to take away the pus and yet not prolong
the anesthetic and the operation. These demand a vaginal
incision. They should not be classed with operations in which
organs are removed. For ordinary pus cases, fibroid tumors of
some size and nearly all intrapel vie diseases that require enter-
ing the peritoneal cavity he prefers the abdominal route because
it is much the simpler and the cosmetic objections have no
place in the work of good, clean surgeons. He does not believe
it necessary to remove the uterus in but few of the cases in
which the appendages are removed. His experience in this
may have been unique for he had cured nearly all the cases he
had operated on. He usually curetted first and then, putting the
patient in proper position did the abdominal operation. If the
patient is too weak for all this he curettes after recovery from
the section. In many women the sexual sensation is greatest
in the cervix and many of them do not feel that they are so
much different from other women if they can touch the cervix
with the finger. We can not completely ignore the ideas they
have on these subjects. At the present time he employs drain-
age very little but may be led to use it more in the future than
he has in the past. He believes that tuberculosis of the Fal-
lopian tube is rarely primary and that usually it extends from
the peritoneum to the tube and later infects the uterus. So
that tubal peritonitis does not necessarily require removal of
the uterus as Dr. Sutton would have us think. The very small
per cent, of cases in which infection of the cellular tissue to
the side of the uterus occurs need not be considered in this
connection. To continue the ovarian function he has been in
the habit of leaving at least a portion of an ovary whenever
it was possible to do so, in all abdominal cases. It at least
prevents the sudden onset of the menopause just when the
woman is endeavoring to recuperate the powers that were so
severely taxed during the progress of the disease for which the
operation was necessary.
Dr. L. S. McMurtry, of Louisville — This discussion is lim-
ited to a choice between the abdominal and vaginal route in
operating for inflammatory diseases of the uterus and its
adnexa and for uterine fibro-myomata. We should never lose
sight of the principles which should guide all operations here,
requiring the greatest preservation of organs and functions
consistent with thorough work and permanent cure. It is
indeed a crude conception of surgery which would do away
with a diseased organ or structure by amputation or complete
excision. It is a higher standard of surgical art which, while
removing diseased and disintegrated structures, preserves all
organs capable of restoration to normal structural integrity.
This is not sentiment, but a great principle of surgery which
should be generally applied. To remove the uterus for suppu-
rative disease of the uterine appendages, upon the basis that
after the ovaries and tubes have become disintegrated the
uterus is no longer useful, is a violation of this principle. I
have seen uteri exhibited to societies which had been removed
under these conditions, and which presented no evidences of
positive inflammatory lesions, while the suppurating tubes and
ovaries, with adhesions and multiple pus sacs, were left to the
chances of gauze drainage. I submit that this is not good sur-
gery, and although the patient may be symptomatically cured,
the surgical work is neither thorough nor accurate. This oper-
ation in such a case is little more than drainage from below,
which as a valuable life-saving temporary operation has been
long recognized and applied in pelvic surgery.
The advantages of the supra-pubic incision are numerous
and demonstrable. The facilities for a clean operation are
greater than by the vagina. The danger of wounding bowel
or bladder is much less. The abdominal route furnishes a field
for open work where every step may be seen, and every danger
and complication may be measured and dealt with intelligently.
Ligation of vessels can be done deliberately and securely ;
adhesions separated, and previously unrecognized complica-
tions (such as appendicitis) properly treated. More complete
and refined surgery can be done by the abdominal route
than is possible by the vaginal approach. A more judicious
operative scheme can be carried out and more careful applica-
cation of conservative principles is possible. Moreover, when
the operation is completed by abdominal section, the operator
has a clear apprehension of the condition within to guide him
throughout the subsequent management of the case. Experi-
ence of many operations and many operators, dealing with
every phase and variety of disease, has demonstrated the efft-,
cacy of the abdominal route. Skilled and experienced opera-
tors have perfected operative methods which have stood the.
test of practical application. The objection urged against,
abdominal section that a scar is left as a reminder of an oper-
ation is trivial. In my own experience I have never known a,
patient to allude to this. The danger of hernia is not great.
300
VAGINAL VS. ABDOMINAL SECTION.
[August &,
In my observation and experience the shock is not severe in
either operation ordinarily, and is about equal in the same
grade of cases. The danger of injury to the hollow viscera is
much greater by the vaginal route.
All these considerations apply with even greater force to
operations for subperitoneal and interstitial uterine fibro-myo-
mata of any size whatever requiring radical operation.
Dr. Joseph Eastman, Indianapolis, thought the question of
accurate diagnosis in these cases had been overlooked. It was
very important; we must deal with facts and not fancies.
He was surprised that Dr. Kelly advocated the partial removal
of the uterus in these cases, whether done from above or
below. If it is diseased, the whole of it should be removed and
nothing left to carry infection. The decision as to the method
to be employed must depend on the history of each individual
case. He agreed with Dr. Kelly that a diseased appendix is
frequently associated with diseased tubes, probably in 10 per
cent., and possibly 25 per cent. He was also fully in accord
with Dr. McMurtry that everything possible should be left.
The vaginal route has advantages to recommend it in individual
cases where the uterus is diseased as well as the tubes. He
wished to protest against the discharge of patients as soon as
the eighth day. He thought there is an analogy between the
opening of the pelvis by either route, and much the same pre-
cautions should be used. There is no excuse for such exten-
sive packing with gauze in the vaginal method as had been
recommended. In many cases the wound could be closed as
perfectly as in abdominal section, and that was the plan he
had adopted with great success.
Dr. I. S. Stone was surprised that attention had not been
called to the selection of cases. Where the patient is very ill,
suffering from sepsis, and can not endure the shock of an
abdominal operation, a simple incision through the vagina as
advocated by Dr. Noble was the only thing to do. He thought
there was less shock in the vaginal operation. He thought the
time would never come when the abdominal operation for
fibroids would be discontinued.
Dr. Rufus B. Hall, Cincinnati, Ohio — I am of the opinion
that the vaginal route will not be the one of election in fibroid
tumors of the uterus, larger than an orange, after the enthu-
siasm of the operation has had time to abate. I know from
practical experience that when the uterus is much enlarged
from a fibroid it is difficult if not impossible to get working
room and deliver the uterus without morcellement. The dif-
ficulties of this procedure contrasted with the ease and suc-
cess attending the removal of tumors by the abdominal route
has induced me to use the latter in all cases where hyste-
rectomy was indicated and the tumor and uterus combined
were too large to remove by the vaginal route without mor-
cellement. I believe the vaginal route gives us a new means
of operating in septic cases which are in no condition to be
subjected to section. It places them in a position to be
relieved of their septic condition by opening the abscess into
the vagina. We can occasionally save the patient's life by so
doing, and if necessary make a second operation later to
remove the diseased organs. For many reasons I do not
believe it is good practice to attack every case of suppuration
in the ovaries and tubes through the vagina in preference to
abdominal section. We must not loose sight of the fact that
in many of these old pus cases, the bowel and omental adhe-
sions need surgical attention for the relief of the patient.
This can not be given as satisfactorily through the vaginal
route as it can by the abdominal. How many times have you
liberated a coil of ileum or an omental adhesion in approaching
these pus cases by the abdominal route which needed the atten-
tion of the surgeon fully as much as the pus collection which
caused them. It is a well recognized fact now that except in
acute cases, very rarely is the pus infectious. Therefore,
there is very little risk in chronic cases of infection from that
cause and the argument used by the advocates of the vaginal
route, that it will avoid infection is not of much moment. In
all acute cases where the pus can be readily reached by the
vaginal route, I prefer that, and in those desperate cases where
we must temporize, as in those narrated by Dr. Noble yester-
day, I would incise and drain and make a second operation
later if necessary for relief.
Dr. A. H. Cordier, Kansas City, Mo. — The aim of the sur-
geon in the application of his methods is to obtain the maximum
benefit with the minimum sacrifice of structures and the least
amount of risk to life, and the saving of time and pain to the
patient. These various results are best obtained by one sur-
geon by the following of a technique to him easy and success-
ful, while another is equally successful in obtaining the same
results by a procedure differing wholly or in part. With
many surgeons the choice of operative procedure determines
his success, while others possess that rare gift of making a
success of any or all methods, and are to be congratulated and
admired by those of less dexterity. Some never make a success of
any method, and are constantly scanning the pages of foreign
literature for something new to try. In this way much harm to
surgery is wrought, and many lives lost. I would not be mis-
understood on this point, as I do not in the least desire to place
a depreciative stamp on any good and safe surgery, be it a
foreign or home procedure, but I do desire to enter a protest
in the matter of hastily accepting the revival of a class of sur-
gical procedures discarded some time ago in this country,
lately revived in part of Europe. I refer to the draining and
partial removal of the diseased appendages, and the total
removal of the uterus in cases of double tubal disease. It is
perfect surgery, or as nearly perfect surgery as is possible,
that all surgeons desire, but before accepting precepts involv-
ing human life or comfort all evidence should be brought to
bear on the topic, duly analyzed and weighed for its proper
worth. It is from this standpoint that the writer desires to
discuss the subject of vaginal hystero-salpingo-oophorectomy
as described and practiced by many of the French and a few
of our American gynecologists. Some men in other profes-
sions achieve renown by the mastership of their art ; for
instance, Paderewski, whose dexterous and delicate touch on
the ivory keys of his piano has startled and charmed the people
of two hemisphere's. However, there is but one Paderewski.
The limit and character of the pathology should form an indi-
cation as to the nature and extent of the surgical procedure.
A flaccid and pus-infiltrated uterus, with, possibly, numerous
foci, surrounded with pus-laden tubes and ovaries, should be
removed, the choice of operative procedure being the one which,
in the opinion of the surgeon, offers the most favorable condi-
tions of immediate recovery from the operation, a permanent
relief of the constitutional (septic) manifestations and the local
symptoms resulting from the presence of these structures and
the repair of the damage to surrounding organs wrought by
their presence. In an old recurring puriform disease of the
uterine adnexa, where the adhesions are well organized and
where the intestinal, bladder and omental attachments are
firm, the vaginal method would be fraught with more danger
than the abdominal. These cases have established in part a
peritonitdc immunity by a prolonged and gradual process of
auto-sero-therapy, consequently the abdominal method is not
so liable to inaugurate an acute dangerous peritonitis or septi-
cemia as is often the case in the acute or primary attacks if
operated on. Some of the advocates of the vaginal method,
only a short time ago, maintained that it was an admission of
incomplete operation to use drainage, yet they advance the
claim for good drainage by the vagina as an argument in favor
of the vaginal route.
It has long been an established and demonstrable fact that
in the majority of instances the uterus is capable of taking care
of itself, and that it does not give rise to any trouble by its pres.
I
18%.]
TREATMENT OF LARGE PELVIC ABSCESSES.
301
ence after the diseased appendages have been removed. I do
not understand why an organ with a good and free natural
drainage should not recover, and yet (as is claimed) an ovarian
abscess or parts of diseased tubes with walls as thick and
y as a cocoanut recover with only an opening into the
L.ina.
The vaginal operation is not an easy one, neither is it as
quickly performed as the suprapubic. In comparing the
relative ease with which the manipulation can be carried on
through an abdominal incision and an opening in the vaginal
vault, it must be remembered that the bony resistance met with
by the impinging of the hand against the pubes is unyielding,
differing very much from the pliant muscle of the abdomen
under anesthesia.
A small percentage of post-operative hernia is found follow-
ing in a large series of abdominal incisions, but these are dis-
ed by the patient and not by the surgeon, and are not of
such frequent occurrence as to be used as an argument against
the suprapubic incision. Time and close investigation of the
vaginal cases will reveal an equal or larger amount of vaginal
bowel protrusions.
1. The operation of vaginal salpingo-hysterectomy in many
instances is incomplete ; 2, it takes longer to perform it ; 3, there
is more danger from hemorrhage ; 4, the uterus is removed in
many instances where it should be saved.
Dr. E. E. Montgomery, Philadelphia — The object of all
surgical procedures should be conservative ; that no organ
whose function could be maintained should be sacrificed. In
dealing with pelvic disease we can not claim that any special
procedure should be followed in every case to the exclusion of
any other ; that both the abdominal and the vaginal routes
have their advantages in special cases. The vaginal procedure,
however, is a conservative one, inasmuch as it enables us fre-
quently to treat conditions without the sacrifice of the organ.
It enables us to evacuate pus collections in the broad ligament
on either side, or even in the tube, and after irrigation to pack
the cavity, so that it subsequently becomes obliterated and
the patient is relieved of the diseased condition without loss of
function. In those cases in which both tubes are involved to
such a degree as to render them functionally useless and their
retention prejudicial to the health or life of the individual,
none will question the wisdom of their removal. In such cases
the infection has begun in the uterine endometrium and
extended from it to the tubes and ovaries. The removal of the
tubes does not, consequently, remove the entire diseased tissue.
In some cases it will be found that pus extends down to and into
the uterine end of the tube, so infected tissue remains after the
removal of the tube. In all cases, the inflammation which has
existed in the uterus has given rise to plastic exudation and
enlargement of the organ, which subsequently produces dis-
tress and discomfort after the involution has been completed.
The contraction of the walls, compressing the nerve filaments
in the uterine structure, produces various hystero-neuroses of
a distressing character, so that in every case in which it is
desirable to remove both ovaries and tubes it is preferable the
uterus should accompany it. Those who do this operation
through the abdomen leave the vaginal portion of the cervix,
forgetting that this has its own lymphatics, is subject to rein-
fection and in continued irritation may develop malignant dis-
ease. Where the tubes and ovaries alone are removed, we not
unfrequently find patients suffering from hemorrhage of a
regular or irregular character, purulent discharges, so that the
patient may have to undergo a curettement in order to over-
come the symptoms.
In the removal of the pelvic organs the vaginal route affords
the preferable procedure, for the reason that through it we
can thoroughly remove the uterus, ovaries and tubes with less
interference with the abdominal viscera, than by the abdomi-
nal section. As the opening is made in the most dependent
portion the drainage is more effective ; no ligatures are used
to be subsequently infected and keep up a sinus ; convales-
cence of the patient is less uncomfortable and more rapid ; the
abdominal wound, cicatrix and sequela? are avoided. The
dangers of injuring the intestines and ureters are about equal
in the two procedures. The abdominal method, however,
affords the advantage that a better opportunity is given to
repair damage.
DRAINAGE VERSUS RADICAL OPERATION
IN THE TREATMENT OP LARGE
PELVIC ABSCESSES.
Read in the Section on Obstetrics and Diseases of Women, at the
Forty-seventh Annual Meeting of the American Medical
Association, at Atlanta, Ga.. May 6-8. 18%.
BY CHARLES P. NOBLE, M.D.
SURGEON-IN-CHIEF, KENSINGTON HOSPITAL FOR WOMEN.
PHILADELPHIA, PA.
It is my purpose in this paper to call attention to
the value of drainage in the treatment of large pelvic
abscesses, and to contrast the results which can be
secured by this method of treatment with those which
have been obtained by the more radical operation of
abdominal section, together with the removal of the
pus sacs — whether of ovarian, tubal or other origin.
It will be well, to avoid misapprehension, to point
out that only a specific class of cases is under discus-
sion. It is not my purpose to discuss the treatment
of suppuration in the pelvis in women in general.
The ordinary case of pyosalpinx or abscess of the
ovary, chronic in character, is not considered. We
are concerned to-day only with those cases of exten-
sive suppuration in which, in general, in addition to
pyosalpinx or abscess of the ovary, there exists an
intraperitoneal abscess, and in which the pelvic vis-
cera are matted together by extensive exudate; and
very frequently, at the time the patient comes under
the observation of the surgeon, active inflammatory or
septic processes are going on, which have confined the
patient to bed for weeks, so that she is greatly reduced
in strength, and unprepared to resist the shock of a
serious surgical operation.
Until May 1, 1894, 1 had never employed drainage
without abdominal section in the treatment of this
class of cases, but had always operated upon them by
abdominal section and the removal of the diseased
parts. This radical method of treatment has yielded
in my hands, as it has in those of others, many bril-
liant cures, and others which were eminently satisfac-
tory, although long continued; but, on the other
hand, the mortality following this operation has been
relatively high. Instead of a mortality of 5 per cent.,
it has been nearer 25. Every operator of experience,
with whose results I am familiar, has had in dealing
with this class of cases, similar results; hence, I
believe, it is unnecessary to further elaborate the pres-
ent status of the treatment of this class of cases by rad-
ical operation. Had we no other method of treatment
the results obtained by this would be eminently satis-
factory, as a spontaneous cure is a very rare event.
Fortunately simple drainage, intelligently applied, has
wrought a revolution in the results which can be
obtained in that treatment.
Since May 1, 1894, I have operated by simple
drainage, without a death, upon eight patients, each a
typical and very marked example of the class of cases
under consideration. Seven of these were very crit-
ically ill at the time of operation. They had been
confined to bed with septic fever from three to eigh-
302
TREATMENT OF LARGE PELVIC ABSCESSES.
[August 8,
teen weeks, and I feel certain that if operated upon
by abdominal section, at least six of the eight would
have died of shock or septic peritonitis. A short his-
tory of each case is appended:
Casel. — Mrs. X., a multipara, was seen in consultation with
Dr. Dunn, May 1, 1894. Her last child was born March 27,
1894, and in the meantime she had suffered from a mild but
persistent septic infection, which had resulted in the formation
of a true pelvic abscess. The pus had burrowed along the
inguinal canal, and was making its way to the surface of the
groin. The patient was extremely feeble from the long con-
tinued sepsis, and in bad condition for a major operation.
This case was treated by direct incision into the groin, with
evacuation of the abscess. A thoroughly satisfactory but
tedious convalescence resulted. Some months later Dr. Dunn
informed me that this patient was entirely well.
Case 2. — Mrs. M., aged 23, a nullipara, was seen June 18,
1895, in consultation with Dr. Robinson. About a week before
this her uterus had been dilated and curetted because of the
existence of an endometritis and catarrhal salpingitis, with
resulting sterility. Some days after the operation symptoms
of peritonitis manifested themselves. The peritonitis was of
moderate intensity, and it seemed not unlikely that the inflam-
mation would undergo resolution. About June 24, it became
evident that suppuration had taken place, and that pus was
collecting in Douglas' pouch. At this time the patient's con-
dition was very serious, so that a radical operation by abdom-
inal section offered very little prospect of a favorable termina-
tion. On June 26, an incision was made into Douglas' pouch,
and the abscess evacuated and washed out. A very satisfac
tory and rapid recovery followed, and since that time there
have been no unpleasant pelvic symptoms. An examination,
however, shows that the left tube is adherent.
Case 3. — Mrs. B., aged 30, 2 para, was delivered Oct. 24,
1895. The labor was tedious and instrumental. The first labor
had been easy and the delivery spontaneous. During the sec-
ond pregnancy there had been persistent and annoying pain in
the right inguinal region. About thirty-six hours after labor,
the patient had a chill, with a temperature of 103 or 104
degrees, and in spite of the treatment instituted, the tempera-
ture fluctuated between 99 and 100 degrees in the morning,
and between 103 and 104degrees in the afternoon, until Novem-
ber 12, when I saw her in consultation with Dr. Cross. At
that time a well marked mass could be made out high up in
the false pelvis and in the region of the cecum. The diagnosis
lay between an appendicitis with an abscess and an abscess of
puerperal origin. The absence of any history of foul smelling
discharge from the uterus, and the fact that on examination
the uterus and broad ligaments were not found abnormal, and
especially that no exudate could be felt even high up in the
pelvis, inclined me to accept a diagnosis of appendicitis, which
had been arrived at by Dr. Cross. Operation was advised, and
on the 13th a direct incision was made into the mass, evacuat-
ing a large amount of pus. Unfortunately the ileum was
adherent under the point of incision, and was opened for a dis-
tance of half an inch, requiring suture. This patient was so
weakened, as the result of the septic poisoning which had con
tinued for eighteen days, that it was desirable to avoid a rad-
ical operation, as the prospect of recovery from a radical pro-
cedure was very unfavorable. A steady improvement followed
the operation, but the sinus did not close, and it was evident
that either a diseased appendix or uterine appendage must be
removed in order to effect a cure. On March 2, Mrs. B. was
operated upon by abdominal section, in the Kensington Hos-
pital for Women, and the right uterine appendage was
removed. The persistence of the sinus was due to the presence
of .a small pyosalpinx. She is now rapidly recovering her
health and strength.
Case 4. — Mrs. L., aged 22, 2 para, was prematurely delivered
November 20, by a midwife, of an eight-months child, which
lived only a short time. November 28, she had a chill, and
subsequently developed an inflammation in the right inguinal
region. She was seen December 7 by Dr. Stoner, who found
her much prostrated, complaining of general abdominal pain,
most marked in the right iliac region. A small mass was
detected upon pressure in the appendix region. Her tempera-
ture was 100 degrees, and pulse 112. Under treatment the
general condition improved, but the mass in the iliac region
increased in size. On December 11, I saw her in consultation
with Dr. Stoner, and a very large mass in the appendix region
could be made out. On this day the symptoms had become
aggravated and an immediate operation was urged. Consent
to this was refused, but on the following day she was taken to
the Kensington Hospital for Women. In the meantime her
condition had become worse, her pulse was above 130, and
temperature 103 degrees. The peritonitis was evidently ex-
tending, and she was becoming decidedly septic. She was
operated upon in the night. A direct incision was made over
the mass, but adhesions had not formed between it and the
abdominal wall. The general peritoneal cavity was packed off
with gauze, the abscess cavity was opened and the pus evacu-
ated. The abscess extended well up behind the cecum. No
attempt was made to find the appendix. The abscess was
drained with gauze and rubber tube. The patient's condition
was no worse than before operation. During the night edema
of the lungs developed, and the following day when the first
urinary examination was made, it was found that acute neph-
ritis was present, and the casts found indicated that the
patient had been recovering from the nephritis of pregnancy
before operation. The patient was so ill for ten days, that it
was impossible to say whether she would rally, but she finally
made a good recovery, and is now quite well.
Case 5.— Mrs. S., age 31, 5 para, was first seen Dec. 20, 1895.
She had been in bed since September 21, and had a distinct
history of ectopic pregnancy with rupture. She was quite
feeble from the long continuance of the pelvic peritonitis, and
had lost about fifty pounds in weight. Operation was advised,
but for a time not accepted. January 1 she was admitted to
the Kensington Hospital for Women, and on examination it
was discovered that a sinus was present behind the cervix,
through which the femur bone of a fetus was removed. As
her condition improved for some days after admission, she was
not operated upon until January 14, when the sinus was dilated
and the vaginal wall incised, and a pelvic abscess in front and
to the left of the rectum was washed out. Most of the fetus
and clots had been discharged before the operation. She made
an uninterrupted recovery, and at this time is doing full work
and feeling well.
Case 6. — Mrs. K., aged 25, 1 para, was seen Jan. 28, 1896.
She gave a history of inflammatory attacks extending over
several years, and stated that she had been advised to have her
ovaries removed. She had been bleeding irregularly since
Nov. 8, 1895, and there was reason to believe that she had an
early miscarriage at that time. Inflammatory symptoms had
manifested themselves some three weeks before my visit, and
had been growing steadily worse. She had had rigors, followed
by a temperature of 105 degrees, and was decidedly septic. The
pelvis was filled up with a large mass, more especially on the
right side. Her condition grew steadily worse, and the peri-
tonitis extended from the pelvis to the abdomen. On the 31st
the pelvic abscess was incised from the vagina and a large
amount of pus evacuated, Her convalescence was very satis-
factory. She was out of bed in three weeks and has since
steadily improved. The appendages are adherent and the his-
tory of the case indicates that it will be necessary to remove
them to effect a cure.
Case 7. — Mrs. R., aged 40, 8 para, 2 miscarriages, last one
Jan. 4, 1896, at the sixth week of development. The ovum
was discharged after one day. She apparently had very little
trouble, and was out of bed on the tenth day. About two
weeks later she was seen by Dr. Walker. She had severe pain
in the hypogastrium, and later in the left groin. At no time
did she have much fever, but a persistently rapid pulse. I
saw her with Dr. Walker on February 22. Her pulse was 120
and temperature 101 degrees, and a large mass was outlined
between the uterus and bladder, extending into the left broad
ligament, and in addition there was evidence of pus formation
under the skin in the left groin, the exudate extending well up
toward the ribs. The following day I made an incision in
front of the cervix, pushed off the bladder from the uterus,
and introduced my finger into an abscess cavity, which
extended from slightly to the right of the cervix well over into
the left broad ligament. About four ounces of pus was dis-
charged. A second incision was made into the groin and a
large abscess evacuated. The pus in this location had evi-
dently burrowed along the round ligament, and was external
to the abdominal muscles. The following day the temperature
was 102 degrees, but the patient's condition was much better.
She gradually improved, and the temperature and pulse
became normal after three weeks. At this date she is entirely
well and an examination shows that the left ovary and tube
have escaped infection. Her pelvic organs are normal, with
the exception of some old lacerations.
Case «.— Mrs. B., aged 28, was delivered Dec. 18, 1895, at full
term, of her first chijd. Marked hydramnion existed and
about two gallons of liquor amnii was discharged. The patient
was delivered instrumentally by Dr. Robinson, under full anti-
septic precautions. A poorly developed child was delivered
alive, who died of convulsions after two days. Forty-five min-
utes after delivery Mrs. B. was attacked with convulsions,
which were very severe and persisted in spite of active treat-
L896. 1
TREATMENT OF LARGE PELVIC ABSCESSES.
303
meat, especially with the veratruin viride. The patient
Unproved bo far as the convulsions were concerned, but was
much dazed mentally, and soon developed decided mania. On
the tifth day there was a slight chill, and a decided one on the
twelfth day. The lochia was normal throughout. The
patient continued to be very ill physically and did not improve
mentally. The temperature in the evening ranged from 101 to
104 degrees F. For a long time there was no tenderness or
indications of inflammatory processes about the pelvis, but
after the sixteenth day the abdomen became tympanitic. On
the sixty-third da} a mass was recognized behind, above, and
left of the uterus, but there was no complaint of tender-
1 saw Mrs. I'... with Dr. Robinson, on February 21 and
advised operation, and on the 26th was able to reach the pus
sac by vaginal incision, introducing the Angers well up behind
the uterus, and puncturing the sac with scissors. A large
amount of very offensive pus was discharged. The sac and
pelvis were irrigated and a large gauze drain introduced into
the pelvis. Improvement was manifested at once; within a
week the mental condition was greatly improved, the insanity
disappeared within two weeks; the temperature became nor-
mal after rive days and remained so. The present condition
of the patient is very satisfactory. The nature of the pus sac
was not discovered.
A review of what has been accomplished in these
cases, by this simple operation, will be of interest:
Case No. '■> has had a secondary operation to remove
the pus sac. Her condition was most critical at the
time of the drainage operation and the result of sav-
ing her life is eminently satisfactory. The other
patients are feeling well and at least two of them are
permanently cured.
Two of the eases, Nos. 1 and 7, were puerperal in
origin, and the abscesses were of the broad ligament.
Drainage from the vagina or loin will permanently
cure all such eases. Heretofore I have made an
exploratory abdominal section to definitely determine
the condition of the uterine appendages. Hereafter
1 shall simply drain the abscesses when this is possi-
ble and save the patient the ventral incision.
The prospect for a permanent cure in two other
eases is excellent. Case No. -4 may have a recurrence
of appendicitis but where the abscess has been large
frequently the appendix sloughs away, or is so infil-
trated with pus that when resolution takes place it
becomes obliterated. Case No. 5 has adherent
appendages as the result of an extensive hematocele
anil exudate, due to the ruptured tubal pregnancy.
But this sac has been drained and become obliterated.
This patient feels perfectly well.
The remaining three patients feel and consider
themselves well, but it is not unlikely that the dis-
eased appendages which they have will give further
trouble and require removal.
My own experience in the use of drainage, in the
treatment of such cases, has been too limited to make
profitable an expression of opinion as to the percent-
age of permanent cures which can be obtained. My
advocacy of the operation is based upon the fact that
it is a life-saving procedure, and that in a certain per-
centage of cases a permanent cure will be effected.
By this method of treatment either a cure can be
obtained with little or no risk to the patient, or a crit-
ical and highly dangerous operation can be avoided.
At the very least, establishing drainage permits the
patient to recover from sepsis, and to have her strength
built up by judicious feeding and medication. If a
radical operation be demanded, it can then be done
when the patient is in a favorable instead of an unfav-
orable, or even a desperate condition.
DISCUSSION.
Dr. Joseph Price, Philadelphia — While Dr. Noble has
directed special attention to pelvic abscesses and desires the
exclusion of pus tubes and ovarian abscesses, at the same
time he has introduced and discussed a number of other sub-
jects. The management of abscess in cellular tissue, or in the
pelvis, in the palmar or plantar fascia, is precisely the same.
These is but one specific or radical treatment, that of incision
and drainage. They are not enucleable and never have been.
So it seems difficult to reconcile these points with many
gynecologists. There seems to be an impression that a certain
class of men have but one method of managing so-called pelvic
abscesses, and have but one pathology ; not so at all, nor has
it ever been so. I am sorry that all abscesses are not of tubal
and of ovarian nature in all parts of the body. We can not
enucleate mammary abseesse.8 in the axilla as we do pus tubes
and ovarian abscesses. The removal of abscess is ideal treat-
ment. Abscesses in cellular tissue in any part of the body
should be treated by incision and drainage, and about all cases
so treated recover. If you have an abscess in the cellular
tissue of the pelvis, with matted viscera limiting it, there is
but one treatment, and that is to free the matted viscera, and
in that much you have done something that will relieve the
condition, at the same time the result is death, for even after
incision of these abscesses obstruction follows, or the symp-
toms remain permanent, and death follows from obstruction or
advancing peritonitis, particularly in the puerperal cases. It
is common in puerperal cases to find a puddle of pus, and in
twenty-four hours the parts are covered with lymph, and a
simple incision does not always save ; but section, freeing the
adherent bowel, with a thorough toilet with drainage from
above and below, does save. You may find cases with black
congested tubes, which should not be interfered with. There
is nothing more to be done other than a thorough toilet, fol-
lowed by drainage. If in those cases you arrest sepsis you
save them. If you fail to do that, they all die. It is sepsis
pure and simple. Just in that direction copious drainage, or
free gauze drainage from above and below, or the so-called
open wound treatment has been popularized, and I fear the
profession fail u> recognize what extensive drainage from above
and below by the open treatment does. It simply arrests the
progress of sepsis. It is copious drainage, and you find some
recently reported cases of that character. I might allude to a
case recently reported by Dr. Hare, of Philadelphia. The boy
was taken ill on Friday evening. Dr. Hare saw him at half
past seven Saturday evening with well-marked trouble about
the head of the cecum. He was vomiting, had a pulse of 120
to 160, condition alarming. He was taken hurriedly to the
hospital, his abdomen opened, a gangrenous appendix removed,
and a toilet made of his whole peritoneal cavity. The patient
had all the symptoms of a severe general septic peritonitis.
His condition seemed hopeless. After a thorough toilet the
symptoms improved, and within thirty-six hours after opera-
tion the drainage tube was removed and the abdomen closed.
Symptoms again became alarming. Arrest of sepsis had pri-
marily taken place, but it was not continued by drainage.
After the removal of the drains again symptoms of sepsis
developed and the incision was reopened, drainage reestablished
sepsis arrested, and the boy recovered. None of us surely will
question the fact that this was not a case of septic peritonitis.
Drs. Keen and Hare are both abundantly capable of determin-
ing that fact. I allude to this case in order to emphasize those
points that have been brought out, because so many practi-
tioners say that cases of general purulent septic peritonitis are
not saved. I can refer them to suppurative forms of general
peritonitis where we have saved nearly all of them. We have
but little fear of pus in the pelvic cavity. I have many times
seen the peritoneal cavity deluged with pus.
Dr. W. E. B. Davis, Birmingham, Ala.— I am sure we all
appreciate the paper which has been presented by Dr. Noble,
because it emphasizes a surgical procedure that has been
adopted and resorted to for a long time. It is life-saving when
304
PHAKMACEUTIC NOTES.
[August 8,
further surgery would endanger the life of the patient, for as
Dr. Price said on a previous occasion, "It takes but a feather's
weight to depress the beam," in such cases. Usually these
cases have been confined to bed for weeks and to do anything
more than evacuate the pus and relieve the septic condition is
dangerous. And while this is an incomplete procedure and
should be so explained to the patient, and that a more thor-
ough operation will be required later, still a certain percentage
of the patients will be cured. There may be some adhesions
left behind, some trouble still in the tube, but they are prac-
tically cured. A radical operation in a large number of cases
will have to be done later. This should be borne in mind and
impressed upon tha patient.
As to the adhesions to which Dr. Price refers, in cases of
puerperal infection the adhesions to the omentum and intestine,
after the pus is evacuated, give way. I have opened the abdo-
men and found very few adhesions. In one case I opened a
large abscess of the right tube which had its origin in puerpe-
ral infection. The woman had a pulse of 140 to 150, she came
near dying from the evacuation of this pus, but recovered ; had
no more unpleasant symptoms, and was delivered of a child
some three years later.
Dr. W. G. Macdonald, Albany — The cases which have been
so clearly reported by Dr. Noble, belong to a class which may
be said to be neglected cases of accumulations of pus either in
the pelvis or about the head of the cecum. I quite agree with
him as to the benefit derived from the operation which he has
done, yet at the same time I do not believe it will cure his
patients in the majority of cases. Probably in the case of
appendicitis, where he has opened and drained these abscesses
it will be the last of the appendix, but not always so. I have
found it necessary under similar conditions to resort to sec-
ondary operations after some months to remove the stump of
the appendix. It would astonish many men if they had a large
area of induration in the right iliac fossa to find after six
months there were very few adhesions.
A number of years ago Dr. Clinton Cushing recommended a
procedure which Dr. Noble has described. He presented a
dilating trocar and referred to a method of drainage by douch-
ing. I have employed for some time that method in suitable
cases. I have put drainage tubes between the dilating trocar
and kept them in four or five weeks, and have seen cavities
evacuated. I then took out the drainage tube, and at the end
of three months there was a relapse, and I had to repeat the
operation. Finally I have been compelled to remove the
uterine appendage on that side by making a clean abdominal
section. But I do gain this advantage, in that my patient is in a
better general condition. This is not always true. Only a few
days since I had occasion to operate on a case of pelvic abscess
due to puerperal sepsis. I made an incision through the
abdominal wall just parallel with Poupart's ligament. The
abscess presented there, so that I did not include very much
of the peritoneum. The abscess had several pockets which I
evacuated and drained. The difficulties of abdominal section
in the removal of the uterine appendages are not great. I
have made a considerable number of abdominal sections in
those cases, and I have not experienced serious difficulty in
removing the damaged appendages.
Dr. E. E. Montgomery, Philadelphia — It is true, as has
been said, that this procedure does not always result in
cure of the cases, that we can not promise as much for it as
the more radical procedure, and we must necessarily subject
the patient to a more radical operation in order to effect an
absolute cure. But this method affords us a means of treating
cases which would otherwise be exceedingly dangerous to treat
by radical procedure, cases that are so depressed, in which the
condition of debility is so marked that we can not hope for a
favorable result if we proceed to a radical operation at the
time. It also affords an opportunity for curing some cases and
preventing a sacrificial operation, where if the abdominal
method were resorted to it would be necessary to remove the
organs in their entirety. Whether the abscess be in the cellular
tissue, broad ligament, or tube, and there is a large accumula-
tion, and the tube is distended at the expense of the broad
ligament, so that we can determine pus on one side of the pel-
vis, and the symptoms indicate that it is inflammatory, we are
enabled to evacuate the pus, wash out the cavity, or practically
curette or scrape it before thoroughly removing the diseased
tissue, then packing it with gauze to bring about contraction
of the abscess cavity and subsequent obliteration. A mistake
is often made in the treatment of these cases in making too
small an opening. For instance, in using a trocar and passing
through it a drainage tube. It is preferable to make a free
incision across the posterior surface of the vagina, opening into
the broad ligament and operating through it, pushing the
ureters aside, making a free opening into the sac, subsequently
packing it with gauze in order to bring about its obliteration.
I have been practicing this method for a number of years and
have seen cases recover from the operation where there were
large collections of pus, where the operation through the
abdominal cavity would have been dangerous, and very little
trouble has resulted to the patient during convalescence.
PHARMACEUTIC NOTES.
Read in the Section on Materia Medica and Pharmacy, at the Forty-
seventh Annual Meeting of the American Medical Association,
at Atlanta, Ga.. May 5-8. 1896.
BY EDGAR L. PATCH.
BOSTON, MASS.
Liquid Extract of Malt. — "What value have the
liquid extracts of malt of the market that is not pos-
sessed by the common beers, ale, lager and porter?"
This question has been frequently asked us. We
give the results of the examination of several prom-
inent market makes in comparison.
Extract. Alcohol. Converting
Per cent. Per cent. power.
No. 1, 10 3.59 none
No. 2, 10.1 5.33 none
No. 3, 14.7 2.34 none
No. 4, 10 6.45 none
No. 5, 10 4.86 none
No. 6, 7 3.47 none
No. 7, 8 3.8 none
Lager, 5 to 9 3.5 to 5 none
Ale, 6 to 10 10. to 14 none
Porter, 5 to 7 6. to 8 none
As these liquid extracts do not possess a particle of
diastasic power it is not reasonable to suppose that
they are of more value than any beer possessing the
same proportion of extract and alcohol.
The thick, non-alcoholic extracts average to contain
about 72 per cent, of solid extract and to convert from
eight to eleven times their weight of starch. A fluid
extract made from select malt by repercolation, using a
menstruum of 18 per cent, alcohol by weight will con-
tain about 13 per cent, alcohol, about 30 per cent, of
solid extract and convert fifteen times its weight of
starch.
Diluted with two parts of water it would be super-
ior to any of the liquid extracts in all qualities but
one. It would not be as agreeable in taste as the
products prepared by direct fermentation.
Solution of Nuclein. — What shall the pharmacist
dispense when this article is called for? No. 1 is
an alcoholic solution and is said to be made from
thyroid and thymus glands; dose, hypodermically,
two to five minims diluted with water, price $5 per
ounce. " Indicated to counteract a disorganized state
of the blood." Two c.c. — 0.001 residue, a little more
18%. J
PHARMACEUTIC NOTES.
305
than 5-100 of 1 per cent. Gave no ppt. or change
when diluted with water, the alcohol gently evapor-
ated and the residue tested with Mayers reagent.
No. 2. — Non-alcoholic solution made from yeast,
slight brown, odor of carbolic acid. Two c.c.--0.041
residue or 2 5-100 per cent. *Gives a slight precipi-
tate with Mayer's reagent and gives test for albumi-
noids with Biuret test. Dose ten to eighty minims
hypodermically as a non-poisonous germicide.
No. 3. — Colorless liquid, non-alcoholic. " Made
from shad's roes." Two c.c.-^-O.OOS residue, J of 1
per cent. No ppt. with Mayers reagent but gives
yellow color. Does not respond to test for albumi-
noids. Price $2.50 per ounce.
Natural Sodium Salicylate. — "There is considera-
ble variation in color, odor and taste of market pro-
ducts. What explanation can be offered?" When
the salt is made by acting on the oil of wintergreen
with solution of sodic hydroxid there is a possibility
of the contact being insufficient or the temperature too
low. In consequence a considerable quantity of sodium
methyl salicylate is produced. This is a white
powder, but neutralizing with an acid frees gaultheria
oil and salicylic acid instead of salicylate acid only.
We have seen samples that contained over 25 per
cent, of sodium methyl salicylate.
The latest investigations of oils of gaultheria and
birch by Dr. Fred. B. Power and Dr. Clemens Kleber
demonstrate that the statement of many text-books
that these oils contain 10 per cent, of a terpene C10 Hie
is an error, and must have arisen from an examination of
an oil adulterated with turpentine. Power and Kleber
conclude that the true oil of wintergreen consists of 99
per cent, of methyl salicylate with fractions of 1 per
cent, of a paraffin, an aldehyde or ketone, an apparently
secondary alcohol and an ester. When fresh it has a
left rotary power. Oil of sweet birch, commonly
offered as gaultheria oil, consists of 99.8 per cent, of
methyl salicylate, the remaining .2 per cent, being
made up of the before-mentioned paraffin, an aldehyde
or ketone and an ester, but does not contain any of the
secondary alcohol. It is always optically inactive.
The artificial oil of wintergreen is supposed to con-
sist entirely of methyl salicylate.
It is said that the statement that natural oil sepa-
rates at once in drops from water while artificial does
not, is erroneous. It is doubtful if any ordinary
observer can detect the presence of as much as 40 per
cent, of synthetic oil added to the natural and the
natural salicylate of sodium might possibly prove to
have been made largely from an artificial oil. WThy
should any natural sodium salicylate made from oil
of wintergreen completely converted possess any ad-
vantages over a pure product from any other source?
Kola Nut and Kola Wine. — Much has been written
upon kola nut. It has been stated that the fresh nut
does not contain caffein but that this alkaloid and
theobromin are produced by the decomposition of a
natural glucoside by a proteid ferment having dias-
tasic power. Kola red and glucose are said to be pro-
duced at the same time. Heckel and Schlagden-
hauff er give as the constituents of kola : Starch 33
to 37 per cent., cellulose 29 to 30 per cent., water and
inert matter 22 per cent., tannin 1% per cent., kola red
1J per cent., albuminoids 67 per cent, and caffein
1 to 2| per cent.
We have obtained from different lots of dry kola 1.2,
1.5, 1.48, 2.2, 1.48, 1.88, 1.91, 1.52, 1.32, 1.6, 1.76 per
cent, of caffein.
Fresh Jamaica kola nuts assayed .795 per cent,
caffein. They contained 61.19 per cent, of water, so
that the dried should yield 2.05 per cent, caffein. A
portion of the fresh nuts dried rapidly at 60 degrees
C. assayed, gave 2.16 per cent, caffein. ,r— ^
Three of the market kola wines assay as follows :]J |
No. 1. Twenty-ounce bottle, alcohol 13.22 per cent,
by weight; 6 per cent, of extractive and 0.036 of 1 per
cent, caffein, equivalent to 2.25 per cent, of an aver-
age kola nut.
No. 2. Seven teen-ounce bottle, alcohol 13.81 percent,
by weight; 23 per cent, extractive including glycerin
and 0.11 of 1 per cent, of caffein, equivalent to about
7 per cent, of an average kola nut.
No. 3. Sixteen-ounce bottle, alcohol 16 per cent, by
weight ; 12 per cent, of extractive and 0.198 of 1 per
cent, caffein, equivalent to 12 per cent, of an average
kola nut.
Ether. — Are the complaints frequently made con-
cerning the value of ether due, as suggested by Dr
Squibb, to different methods of use or inefficiency in
administration? The same lot that is pronounced by
several operators as superior in every respect is decried
by others as "watery," "half alcohol," "weak," etc.
We were requested to supply different grades of
ether to a skillful operator for trial, the samples to
include an ether as nearly pure as possible. The
samples were numbered and consisted of the follow-
ing products:
No. 1. Two 4-oz cans, the contents having a specific
gravity of .7420 at 25 degrees O, equivalent to 74
per cent, of absolute ether, 26 per cent, alcohol and
water.
No. 2. Two 4-oz cans of 1890 ether specific gravity
.7163 at 25 degrees C, equivalent to about 95 per cent,
absolute ether.
No. 3. A carefully distilled concentrated ether of
specific gravity 0.7150 at 25 degrees C, was shaken
repeatedly with distilled water during twenty-four
hours, separated, added to 10 per cent, of its weight
of quick lime and 10 per cent, of its weight of potassic
carbonate recently dried at 125 degrees C, shaken
frequently, decanted and fractioned by distillation,
that fraction having a gravity of 0.7110 at 25 degrees
O, and corresponding to over 98 per cent, of absolute
ether being submitted for trial.
No. 4. A second lot prepared the same as No. 3
from Squibb's ether, of specific gravity 0.7146 at 25
degrees C, (95.35 per cent.) and giving a product
testing the same as No. 3 — about 92.06 per cent,
absolute ether.
No. 5. Prepared as No. 3, using quicklime alone,
and giving a product of specific gravity 0.7109 at 25
degrees O, equivalent to about 98.13 per cent, abso-
lute ether.
No. 6. Prepared as No. 3, using dried potassic carbo-
nate alone, and giving a product of specific gravity
.7104 at 25 degrees O, equivalent to 98.51 per cent,
absolute ether.
(A small amount of yellow liquid remaining after
distilling each lot of ether, that evaporated from filter
paper, left an unpleasant odor resembling that of
cyanids or bitter almond.)
The surgeon reported: " No appreciable difference,
could be observed in the action of the different lotsv
In comparison with Squibb's ether, we were impressed
that it was somewhat more bland, i. e., seemed to have,
rather less irritating effect upon the respiratory-
mucous membrane.
306
TREATMENT OF TYPHOID FEVER.
[August 8,
"Very careful records were kept of every patient
upon whom we made the tests. I still have the feel-
ing that ether of superior quality to anything now in
the market may be produced by using chemically
pure materials to start with. If I could have a suffi-
•cent supply to carry me through a year of surgical
work, which would aggregate between two and three
hundred anesthetizations, I think I could draw con-
clusions which would be of some value."
It is interesting to note the specific gravity accepted
as correct for absolute ether at 25 degrees C. by dif-
ferent authorities:
Dumas and Boullay, 0.70737 ; Sassure and Thenard,
0.70987; Gay Lussac, 0.71190; Kopp, 0.7084; Watt
and Wurtz, 0.70891: Mendeljiff, 0.70826; Allen,
0.71000; Roscoe and Schorlemmer, 0.70750; Dr. E.
R. Squibb, 0.70842.
MODERN METHODS OF TREATMENT OF
TYPHOID FEVER CRITICALLY RE-
VIEWED, WITH SUGGESTIONS
FOR A RATIONAL
THERAPEUSIS.
BY GUSTAVUS M. BLECH, A.B., M.D.
DETROIT, MICH.
Motto: Im Erkeiinen und Heilen der Krankheiteu liegt die Auf-
gabe der Medicin. Das Erkenneu alleln ist Wlssenschaft; das Heilen
war bisher Empirie und wird es uoch lange bleiben.— Hyrtl.
There is hardly any other disease to which the
above, written by the immortal Austrian anatomist,
could be better applied than to typhoid fever. The
dignity, the value of all scientific work and research,
lies in the recognition of this malady and its pathol-
ogy— not in its therapeusis. The more there is writ-
ten to enlighten the profession in that respect, the
better for us. The devising of new formulae or new
methods of treatment can never add much to the
reputation of the prospective discoverer ( ?) Typhoid
fever patients have recovered without any treatment
whatever; others have died, and probably will die,
under the most rational and scientific therapeusis.
Infallible methods exist only in the minds of their
promoters and advocates. The number of methods,
sub-methods and modifications is as large as that of
bivalve vaginal specula which are baptized after their
modifiers, the modification often consisting only in
the different shape of an unimportant screw or handle.
In this article only those methods will be considered
which have acquired some popularity, or which have
really a scientific value.
A priori, typhoid fever does not always appear as
that dreadful constitutional disease described in text-
books; there are light forms of short duration. Indi-
viduals of regular habits will offer a good deal of
resistance, the fight between the disease and the system
being even, while others, especially alcoholic drink-
ers or those with prostrated or affected nervous sys-
tems, will succumb immediately. Again, the age, the
previous history and the present status of the patient,
all need to be considered, and will indicate the course
of treatment that should be pursued. We should not
treat diseases the same way the cook prepares a cer-
tain soup, after a receipt; we claim to be scientific
physicians, and as such will have to use our own judg-
ment in each individual case. A specific for typhoid
fever has not been discovered as yet. However, we
have made of late some advance in the knowledge of
the treatment, and can truly assert that our methods
of to-day, if properly applied, are more scientific and
more effective than the symptomatic treatment of ten
or fifteen years ago.
We will first of all consider the treatment of typhoid
fever with water.
Balneo- and Hydro-therapy. — This system, espe-
cially when carried out in the rigid manner advocated
by Brand, who gave it to the profession, influences
the entire course of the disease, reducing the mortal-
ity to a minimum, preventing complications (espe-
cially affections of the respiratory tract), and now
stands ahead of all other therapeutic measures. Hydro-,
especially balneo-therapy, has its opponents, one of
the objections being that cold bathing is cruel, and
can hardly be carried out in private practice. There
is much truth in the criticism, and many general prac-
titioners have often been compelled to let patients die
from hyperpyrexia, owing to their prejudice or pov-
erty. If the full cold baths be objected to, we can
immerse the patient in lukewarm water and let the
water gradually cool. Dr. L. E. Maire,1 of this city,
when a general practitioner, obtained good results
from full baths with hot water. Where the procedure
can not be* carried out, the wet pack will prove of
great help, although it is not as efficient as the full
bath. But in no case of typhoid fever, should regu-
lar sponging of the body be neglected. I use in my
practice a 10 to 20 per cent, aqueous solution of alco-
hol. Balneo-therapy will not only reduce the temper-
ature but influence the entire nervous system. Striim-
pell3 is right when he asserts that under balneo- thera-
peutic measures the grave "status typhosus" is much
rarer than otherwise.
The details of bathing can not be given here; in
fact, the condition of the patient and his surround-
ings will dictate to what extent and degree this
method of treatment should be employed. In mild
cases sponging of the whole body is sufficient.
The Abortive Treatment. — The theory that typhoid
fever can be aborted is not of recent date. Wunder-
lich2 believes that if at the onset of the disease a few
large doses of calomel were administered, the disease
could be aborted. His assertions, however, are very
conservative, and he is not so sure of being able to
abort every case as some modem writers are. A pri-
ori, typhoid fever aborts spontaneously in some cases,
without any interference whatever. The so-called
typhus levissimus runs a mild and short course. If
such a case came under the care of the authors
referred to, they would surely attribute the short
course of the disease to the drugs they have " fired "
into the stomach of their patient. When reviewing
the statistics of their reports, this should always be
borne in mind.
Dr. Aulde, of Philadelphia, editor of the American
Therapist, asserts that he can abort typhoid fever
with arsenite of copper. His paper was read only in
part at the last meeting of the Mississippi Valley
Medical Association. The writer has no experience
with this drug. Dr. Aulde's assertions have not been
verified by competent authorities in medical literature.
Dr. Woodbridge, of Youngstown, Ohio, has pro-
claimed himself a pioneer of the jugulant treatment of
typhoid fever, and states that if he sees a case early
he can undoubtedly abort it, and that death is a
wholly unnecessary consequence, for which the phy-
sician is to be blamed. It is natural that such asser-
tions must cause some excitement, although at the
above mentioned meeting, his theories were received
1896.]
TREATMENT OF TYPHOID FEVER.
307
In a large body of eminent physicians with disbelief
ami skepticism. He calls his system after his own
name. It consists of tablets and soft elastic capsules
containing small doses of calomel, thymol, menthol,
guaiacol, podophyllin and eucalyptol, of which he
administers one every fifteen minutes.
What is more startling is that he allows his patients
to cat what they please and to attend to their business
affairs while sick! His tablets and capsules are put
ii} > and sold by .Messrs. Parke. Davis & Co.. of Detroit,
who send reprints of his various articles to every phy-
sian free of charge and distribute them " en masse"
among students of medical colleges. Dr. Woodbridge
could never have gained so much popularity, had it
not been for the action taken by Messrs. Parke, Davis
A Co., and it is for this reason that I beg the reader's
pardon for dwelling somewhat at length on his treat-
ment. It is well for every one to send for his pam-
phlet, so as to verify the following criticisms:
Dr. Woodbridge is not the first one who has claimed
that typhoid fever could be aborted. His formulae
are nothing but a combination of antiseptics and ape-
rients which have been used singly for years by differ-
ent physicians; the combination forms no new chem-
ical. It is nothing but a "shot-gun" prescription.
Similar preparations are already on the market, the
well-known antiseptics sold under the trade names
listerin. borin, pasteurin, euthymol, etc. He is not
original. If Dr. Woodbridge expects us to accept
his statistics, he must first prove to be a man who
adheres to facts even in little things. He states in
his publication that the discussion, which took place
after his paper was read at the Mississippi Valley
Medical Association, Sept. 4, 1895, lasted three hours;
while in fact, including my own criticism, which was
also the concluding remarks for my own paper, the
discussion lasted thirty-five minutes only.
As regards the value of the formulae, as intestinal
antiseptic treatment, I fully appreciate them. There
is nothing bad about them, unless it be that it is very
unwise to prescribe his ingredients in tablet form,
owing to the pungent taste and the volatility of some
ingredients. All his formulas ought to be put up in
soft clastic capsules. To bother a typhoid fever
patient every fifteen minutes, is an outrage. Wrhy
not give usual doses every three or four hours? The
effect is the same. But Dr. Woodbridge regards rest
as unnecessary. I trust that no sane physician, for the
sake of his patients and his own reputation, will
accept this theory of the uselessness of rest and diet-
etic restriction.
Dr. Woodbridge points with pride to the reports
sent him by other physicians. Without casting any
reflections on the standing of the reporters, 1 will
merely say that, considered carefully, the reports are
inexact, unreliable and far from satisfying the scien-
tific reader.
In most cases we are compelled to accept their
statement that they treated cases of typhoid fever.
If my criticism has been harsh, I will cite two of the
reports which will amuse us:
One physician reports a case in which he observed
the usual prodromes. Highest temperature 103.4
degrees; no delirium, no eruption; cure in seven days!
0 tempora, O mores! Another physician reports a
case of two weeks' standing, after which he was called
in. He gave one tablet and the patient improved
immediately after the first dose. It must be borne in
mind that the second dose had to be administered
fifteen minutes after the first one. The abortive treat-
ment as such is valueless; the title antiseptic treat-
ment, however, is justified.
A iitixeptic Treatment. — According to modern views,
typhoid fever is considered a microbian disease, caused
probably by Eberth's bacillus typhosus. Most of
these germs gain entrance into the human system,
multiply in suitable soil and develop toxins, causing
a general infection of the entire system.
By internal administration of antiseptics and
chemicals the action of the germs is neutralized,
their powers of multiplication and toxin production
destroyed, thus giving the system an opportunity to
eliminate the noxious toxins already produced. Pathol-
ogy teaches that typhoid fever, as far as local lesions
are concerned, is principally an intestinal affection,
hence intestinal antiseptics are indicated. Bouchard6
urges us to employ general as well as intestinal anti-
sepsis.
This at best is theory only. The writer has prac-
ticed, and intends to practice, antiseptic therapeutics
in affections now generally accepted as of microbian
origin. But he frankly admits that he does so, not
from blind belief in the correctness of the above
quoted theory, but because it is the duty of every
physician to leave nothing undone that might save
the lives of his patients or prove of benefit to their
sufferings, as no harm can follow from a judicious
administration of antiseptics.
Trouessart1* complains that antisepsis has not
received general acceptance in internal medicine,
while it is indispensable in all surgical procedures.
That was so two or three years ago. To-day, chemic
antisepsis is entirely discarded by modern surgeons.
Even in septic wounds the antiseptic measures taken
are not those formerly used. Modern surgeons state
that wounds ought to be treated " aseptically." This
is not the proper term.4 Modern antisepsis in surgery
does not consist of the employment of strong and
toxic chemicals, but mild measures are used, such as
sterilization, normal salt solution, peroxid of hydro-
gen, etc. The reason for this change is that carbolic
acid, mercury, etc., in solutions usually employed,
have been found to have very little influence on the
microbes, and that wounds, even of a septic charac-
ter, heal just as rapidly and just as nicely under a less
rigorous antisepsis. If such is the case in surgery,
the present fad for killing the germs through general
counter-intoxication, will have to give place to a less
serious medication.
In looking over the list of antiseptics one is
impressed with the large number. Almost every drug,
beginning with ordinary household coffee (in infu-
sion) and ending with a saline cathartic has been
found to be a direct or indirect antiseptic. And now
the old-fashioned treatment of malaria with quinin,
rheumatism with salicylates, and syphilis with mer-
cury, has been found to be nothing but the antiseptic
treatment of those affections. What is in a name?
And now modern surgery has taught us that salicy^
late of soda has but a slight antiseptic power! If the
typhoid fever bacillus is so easily neutralized by guai-
acol carbonate, that Dr. Woodbridge, or others, have
succeeded in bringing typhoid fever patients to an
almost normal state, as far as the symptoms of a gen-
eral intoxication are concerned, in twenty-four hours,
why, I ask, does the same drug not kill the malaria
organism or the as yet undiscovered and unbaptized
but sure to exist bacillus rheumaticus?
308
TREATMENT OF TYPHOID FEVER.
[August 8,
That it does not I can testify from clinical experi-
ence. In several cases of malaria, for a few days,
various antiseptics (guaiacol carbonate, carbolic acid,
calomel, iodin) were tried with no effect. A hypo-
dermic injection of the arsenite of quinin was suffi-
cient to stop the chills.
In acute inflammatory rheumatism the salicylate of
sodium, in spite of the fact that it has but slight, if
any, antiseptic power, has proven of greater benefit
than any of the above-mentioned antiseptics. Is
rheumatism after all then a non-microbian disease?
Colchicin has proven to have no antiseptic power
whatever, and still one must be astonished to read in
French literature the results obtained from its use in
various rheumatic affections.
I have a large number of cases of chronic rheuma-
tism, deforming and non-deforming under my care,
and the administration of general antiseptics has pro-
duced no marked results within four weeks. Gener-
ally in private practice I can control chronic
rheumatism with large doses of natrium salicylicum
in about ten days.
If microbes are the cause of disease and they are
destroyed by antiseptics, then consumption will soon
be as much a curable disease as typhoid fever.
When such an eminent man as Osier, with his
unusually large opportunities for observation in one
of the largest hospitals in the world, testifies to the
inefficiency of the antiseptic treatment of typhoid
fever5 1 must defer further discussions of " cause and
treatment of microbian diseases" until further exper-
iments can be carried out. It is to become my life
study henceforth. The statement of the eminent
Chicago surgeon, Nicholas Senn, at the last meeting
of the American Medical Association that antisep-
tics fail when we mostly expect them to do the work,
ought to have awakened the dormant thinking energy
of many an intelligent practitioner.
It has been said that the antiseptic treatment influ-
ences considerably the typhoid fever curve. Most of
the antiseptics are antipyretics and vice versa, and the
fever could probably be controlled just as well by the
continuous administration of small doses of quinin or
acetanilid, which antipyretics have but slight depress-
ing action on the heart. That the fever curve is con-
siderably lowered by a systematic treatment with
water is well known.
The hygienic and dietetic treatment of typhoid
fever forms an essential part of the general manage-
ment of such cases. It would be too much risk, how-
ever, to abandon all other means of treatment and to
rely solely on the dietetic, as has been advocated
by some believers in the vis medicatrix natures.
In mild cases it may be sufficient, but who can tell
whether a given case is to remain as mild as it
appears in the beginning? Non medicamentis sed
medica mentis is a very good sophism, but I fail
to see why it should be the motto solely of doctors,
"a la Kneipp." It ought to be, and in fact is, the motto
of every drug practitioner. As regards hygienic
treatment it can be framed in four words: Rest, a
food bed, ventilation and an intelligent nurse. The
iet of typhoid fever should be light, liquid and
nutritious. Meat, ordinary bread and raw fruits, espe-
cially apples and pears are to be strictly prohibited.
The patient should drink cold, fresh water freely.
I allow my patients from ten to twenty glasses pro
die and would give them more if they so desired.
The water can be acidulated with hydrochloric acid,
lemon or pero'xid of hydrogen (or hydrozone) alter-
nately. Alcohol should be given early. I am sur-
prised that most of the latest writers restrict its use
to cases where direct stimulation only is indicated, as
it is a medicine and food at the same time.
The key note of the dietetic treatment is nutrition.
For more than a century plain cow's milk has been
used. But plain cow's milk has many disadvantages,
deranging the digestion and necessitating repeated
macroscopic and microscopic examinations of the
stools. These objections can be ovorcome by the
addition of Mellin's food. This food, although hardly
needing any further recommendation, has proven to
me of incalculable benefit not only in typhoid fever
but in a great many other acute and chronic affections
of the gastro-intestinal tract. The effects this prepa-
ration has on milk can be summed up as follows:
1. Owing to its alkalinity it acts chemically upon
the casein of the milk, converting it into soluble
albuminates.
2. The dextrin present is a powerful peptogen and
greatly increases the secretion of pepsin from the
stomach glands, by is physiologic action.
3. Clinical observation as well as chemic experi-
ments have proven beyond doubt that if the food be
added to cow's milk it is rendered more easy of diges-
tion and more nutritious.
4. If necessary Mellin's food can be given with
water instead of milk, with similar results.
Light soups, preparations of beef juices, beer and
coffee, can be given in small doses.
Suggestions for a Rational Treatment. — After con-
sidering the former methods together with my own
experience, I think I can propose a treatment, that
although far from being infallible, will recommend
itself to the thinking physician, as one that promises
the most satisfactory results.
I divide the disease, for practical purposes into
three stages : 1, the time when owing to certain symp-
toms and phenomena, the disease can be suspected
only; 2, the time from the definite diagnosis of
typhoid fever until convalescence; 3, convalescence
plus two weeks.
The treatment as long as the disease is only sus-
pected, consists of attending to the symptoms as they
appear. To produce diuresis, diaphoresis and cath-
arsis is the most rational procedure.
But as soon as a diagnosis of typhoid fever is made,
all energy should be awakened.
Hygienic and hydro-therapeutic treatment must be
outlined for the entire course of the disease and sys-
tematically commenced at once.
No matter what the condition of the bowels, the
first two days, the following prescription is given.
K. Calomel gr. iii I 18
Salolis gas. 16 |
Misce. F. pulv. No. vi. Sig. : One powder three times a
day.
Then I commence with tonics, calculated not only
to support vitality but to sustain the heart. Digitalis,
strychnin, nitroglycerin are prescribed in suitable
doses, and proper excipients administered at regular
intervals. (Steam's essence of pepsin is what I pre-
fer.) For this reason I commence early with the
administration of alcohol. French brandy (cognac)
port or sherry wine are suitable. Recently I have
obtained good results from the wine of fresh (undried)
kola nuts, "kolavin-Stearns," which is not only a
good tonic but a brain stimulant.
i
18%.]
TREATMENT OP TYPHOID FEVER.
309
But one of the drugs on which I place much
dependence is the peroxid of hydrogen. Care should
be taken to obtain the strongest and best brand, as
most of them sold in this country are poor imitations
of even what the Pharmacopeia prescribes and that is
weak enough. Hydrozone, as prepared by the New
York chemist, Charles Marchand, is at this date rec-
ognized as the best in every respect being a 30 volume
solution. It is best administered in teaspoonful doses
(to be measured with a glass spoon only) in the water
used as drink three or four times a day. I also add
some hydrozone to the water used for washing the
colon. The effects of hydrozone when administered
in typhoid fever are these:
1. It oxygenates the blood, thus keeping the brains
in activity. It is a brain tonic. If hydrozone be
given properly all cerebral disturbances, delirium,
that state of semi-unconsciousness which most of our
patients pass through will be a "rara avis." 2. It
improves digestion and checks abnormal fermentation.
3. It stimulates exertion. 4. Mechanically it cleanses
the bowels, allays the hyperemia, prevents ulceration,
and assists in "disinfecting" the contents of the gas-
trointestinal tract. 5. It is as powerful an antiseptic
as creosote and carbolic acid without possessing any
of their disadvantages.
A useful procedure is irrigation of the colon, which
should be practiced twice daily in cases of typhoid
fever, It matters little whether the fluid passes
beyond the ileo-cecal valve or not, for either through
reflex action or through the aseptic state of the rec-
TREATMENT OF TYPHOID FEVER.
BY F. M. GREENE, M.D.
LEXINGTON, XT.
Before continuing the discussion, on the disinfect-
ant and eliminative treatment of typhoid fever, which
was presented in a former paper, we wish to notice
some criticisms upon this method read at the last
meeting of the American Medical Association at
Atlanta. The distinguished chairman of the section
on general medicine, attacks rather severely, the
advocates of the new method, calling them " heretics
of the worst possible stamp, " because they do not
choose to "swim in his puddle with him." Being
himself an advocate of hydrotherapy of most enthu-
siastic stamp, he takes issue with all those who differ
from him, and triumphantly declares it " impossible
to disinfect 25 feet of intestinal canal, with such
remedies as Woodbridge recommends. " He may
find before getting through with the discussion of
this important subject that there are " more things in
heaven and earth than are dreamt of in his philosphy" ;
also that there are more than " two grains of wheat
in his two bushels of chaff." His late work on the
Practice of Medicine, lies on the table before us, and
we venture the assertion that he will not spoil the
next edition of his '"jewel" by omitting a full de-
scription of the new method of treating typhoid fever.
He may not then regard the papers which have hitherto
appeared in the Journal of the Association on the
subject, as a "heterogeneous jumble, entirely unworthy
turn, the state of the bowels is greatly improved by
the irrigation throughout the disease. It produces a
natural catharsis. Only when an emaciating diarrhea
exists (a case I never observed) I would substitute
sugar of lead and opium and then would not irrigate
but inject the fluid as a simple clysma. A stiff rectal
rubber tube attached to a fountain syringe is the best
means for irrigation. Soft rubber is not to be used
as it lodges in the mucous folds of the rectal wall and
bends over.
A metal sigmoid flexure irrigator has been devised
by Dr. Cole. It is manufactured by Messrs. Halsey
Bros, of Chicago, to whom I am indebted for the
accompanying cut, which represents about one-third
the actual size. On my suggestion they now manu-
facture smaller nozzles for children, which can be
easily screwed on the instrument. This instrument
has proved of great use in my hands, as it can be easily
introduced into the sigmoid.
This treatment is routine in my practice. Depend-
ing on circumstances it is altered in minor points.
Special symptoms call for special medication. This
article is an incomplete pen sketch rather than a
treatise on the treatment of typhoid fever. It is
intended to cause the general practitioner to think,
not to copy formulas.
LITERARY REFERENCES.
i The Physician and Surgeon. Vol. xvm. No. 4. (Discussion.)
2 Lehrbuch der speciellen Pathologle und Therapie der inneren
Krankhetteu. Leipzig : Vogel, 1889.
3 Antiseptic Therapeutics. English transl. by Dr. Ward. Detroit:
Geo. S. Davis, 1893.
« G. Blech. What is asep3is? New York Med. Journal. Vol. lxii,
No. 12.
5 Practice of Medicine. New York : D. Appleton & Co. 1894.
(■ Lectures on Autointoxication in Disease. English by Dr. Thomas
Oliver. Philadelphia: The F. A. Davis Co. 1894.
of the best traditions of the profession, and of a subject
connected with the names of Bartlett, Gerhard,
Jackson and Flint. " He might have added also the
name of George B. Wood, who first called attention
to the value of oil of turpentine in this disease. We
had the pleasure- of listening to the clinic lectures of
both Gerhard and Wood on typhoid fever, and believe
that were they with us to-day, they would be found
in the front ranks of antiseptic medicine. The latter
had discovered an intravascular disinfectant of great
value, without being able to explain its " modus
operandi."
We agree with Dr. Osier that " all wisdom is not
found in the professorial corps" and that "a good
thing may come out of Nazareth. " Professor Quine
from the chair of the section on the Practice of Medi-
cine, was more considerate of the new method and
reports " twenty-one consecutive cases, covering his
private practice during the last two years," and
which were treated antiseptically. Under the same
treatment, he gives an account of 275 cases and 6
deaths; a mortality rate of 2.2 percent. He does not
claim however that " the Woodbridge method was
employed in one of them." The plan of treatment fol-
lowed consisted in a general way of purgatives to the
extent of from two to six evacuations daily. The
antiseptics used were a mixture of guiacol carbonate,
thymol, menthol and eucalyptol — but not the Wood-
bridge formulae. He declares: "Athough no death
occurred, the results, especially in the direction of
aborting the malady, albeit, not discouraging to one
who had not expected much, were less brilliant than
those recorded by our friend from Ohio."
810
TREATMENT OF TYPHOID FEVER.
[August 8,
Again — " It is not. assured that this inconsequential
showing proves anything" ! ! Were "reasons as plenty
as blackberries" we would not ask Professor Quine to
give us "a reason upon compulsion." Finally he con-
cludes : " No one has the right to condemn the method
without proof. " We think an impartial reader of
these criticisms, might conclude that the one is highly
prejudiced against, and the other favorably inclined
toward it. The opponents of the method try to
account for its success by saying that the observations
of medical men everywhere go to show that the dis-
ease has existed in a mild form for the past two or
three years, which is about equivalent to saying that
a patient is threatened with typhoid fever. Physi-
cians of experience know that it is one of the gravest
maladies, and never threatens anyone; that in the
same endemic, in the same section, and in the same
family, the most severe and mild forms, frequently
exist together. In these mild and so-called " walking
cases" we may have grave complications, as hemorrhage
and perforation. Both the etiology and pathology of
this disease has been determined. The typhoid bacilli
having entered the alimentary canal, find lodgement in
the glands of the ileum, or are carried away in the ex-
creta from the bowels. They have doubtless commenced
their work when the physician is called, and there
already exists hyperemia and congestion of the mucosa
in this locality. Some time elapses before there is ulcer-
ation, erosion or necrosis. It is not the work of a day,
but of many days before these changes take place.
Neither are they confined to the lumen of the bowel,
but through the absorbents they enter the blood, and
are conveyed to the most distant parts of the system.
They have been found in the liver, spleen and pan-
creas. It is some time, usually about the close of the
second, or beginning of the third week, before a toxin
is formed and nervous symptoms begin to appear, such
as delirium, subsultus tendinum and picking at the
bed-clothes. Now if we see the patient early, disin-
fect the bowel as soon as possible, and at the same
time maintain free evacuation and elimination, it is
not improbable that we may prevent these secondary
symptoms, or that the disease may be aborted in its
earlier stages. This is what some of its advocates
claim, and,the result seems to bear out the assertion.
We have the testimony of many physicians that,
under it, meteorism when present rapidly subsides;
putrefactive changes are prevented, and the stools
lose their peculiar odor. The most remarkable results
are shown in fall of temperature, which sometimes
reaches normal by the tenth or twelfth day of treat-
ment. The patient now enters upon a favorable con-
valescence, asks for food, and it may be allowed much
earlier than under the old regime. The bowel at any
rate is the starting' point of the bacilli, and if they
are destroyed here, the intensity of the infection at
least is modified, and the work of the phagocytes is
lessened in proportion. It is more than probable
that the essential oils of eucalyptol, menthol, thymol
and turpentine act as intravascular disinfectants in the
various organs and tissues of the body. Dr. George
B. Wood introduced the latter many years ago, and
it has maintained its reputation up to the present
time. These remedies are absorbed before they
reached the ileum, and are not supposed to act locally
upon ulcerated surfaces.
The remedy which is perhaps the most important
of all is the carbonate of guiacol, which has been
proved to be insoluble in the stomach. After it
leaves the stomach it is broken up into guiacol
and carbonic acid. The former is the active principle
of creosot, and the odor of the latter is detected in
the various excretions. Hoelscher and Seifert of
Berlin and many other German physicians regard it as
an intestinal antiseptic of much value, and especially
useful in typhoid fever.
Creasote has gained reputation as a germicide in
phthisis and is destructive both of the typhoid
bacilli and other putrefactive bacteria which are
found so abundantly in typhoid stools. We do not
claim that it can repair damage already done or
cure ulceration already existing, but when used early,
is preventative of these, and other grave complica-
tions. Neither can the carbonate of guiacol be
regarded as an antipyretic, although rapid fall of tem-
perature follows its administration. It is therefore
the destruction of bacteria and consequent prevention
of rapid metabolism, which, if not the cause, is always
associated with the pyrexia of this disease. As the
season approaches for the prevalence of this fever,
physicians will have courage at any rate, to try the
new method and decide for themselves its real merit
or demerit.
So many new remedies have been foisted upon the
profession lately, all claiming to be specifics, and
when tried have proven worthless that it is difficult to
call the serious attention of physicians to a new method
which claims as much as this. We may undoubtedly
control the high temperature of typhoid fever by the
Brand method, but the disease is not subdued but
only held in check and we have yet to contend with
dangerous complications and sequelae. There is some
difficulty in carrying it out with hydrophobic chil-
dren, and the poorer classes, among whom the disease
is more prevalent. It is impossible for the physician
to be present during the administration of the baths
and there are required a number of intelligent assist-
ants to carry it out properly.
There are sometimes contraindications to the use
of cold baths in typhoid fever. In hemorrhage,
whether active or passive, the exertion required in
taking them is injurious, and the application of cold
to the surface produces a greater determination of
blood to the internal organs. So in hypostatic con-
gestion of the lungs and in pneumonia; though in
moderate attacks the application of cold water may
be beneficial. In very great weakness of the heart's
action, there would be danger from shock by the sud-
den immersion of the body in cold water. In country
practice and among a large class of patients in our
cities it is impracticable, unless, Diogenes-like we
carry our tub around with us.
We allude to some of the difficulties of the Brand
treatment not to influence any one against it, but to
show that the new method is better adapted to
patients of all classes and conditions.
26 North Mill Street.
THE RATIONAL TREATMENT OF TYPHOID
FEVER.
Abstract of paper read at the meetiue of the Tennessee Medical Society
in Chattanooga, April i4. 15 and 16, 1896.
BY J. A. CROOK, M.D.
JACKSON, TENN.
That the curative treatment of a disease so univer-
sally prevalent in all countries, latitudes and civiliza-
tions as typhoid fever, should engage the attention of
lovers of science and the promoters of health, is most
1896. |
TREATMENT OF TYPHOID FEVER.
311
natural and laudable. A disease whose preference is
so great for young manhood and womanhood when
active life, with its duties and pleasures is just unfold-
ing a disease whose grave character and fatal issues,
makes its consideration and the possibility of its
abortion of great importance to the profession and to
humanity, is certainly worthy of the attention of this
honorable body, devoted, as it is, to the amelioration
of suffering and the conquest of disease.
Typhoid fever is a disease, whose nature and path-
ology have long been known and often described, but
whose etiology, until recently, has been but little
understood. This has been left for late observers,
with the aid of the microscope and much experimen-
tal research, to develop and determine.
While some observers were of the opinion that
every one carried in the intestinal canal, waste pro-
ducts from the organism, material susceptible of putrid
intoxicalion and the development of typhoid fever
under favorable circumstances, later authorities, as
Koch. Eberth and others, have demonstrated the
bacillus typhosus to be the germ and cause on which
this disease depends, and its origin otherwise impos-
sible; thai the disease is not contagious and these
germs have to be introduced into the system from
without in order to produce the disease, and that this
is chiefly done through drinking water; that the
habitat of these germs is chiefly the lower portion of
the ileum and upper portion of the colon, where they
rapidly grow and multiply till sufficient irritation and
toxins are produced to develop the characteristic fever.
W'liile every form of treatment that could be devised
had been tried, none, until very recently, tended to
cut short the disease, and typhoid fever had come to
be regarded as a self-limited disease and had to run
its usual course. Flint says: " It must be admitted
that the known resources of therapeutics do not. afford
reliable means for the arrest, nor even shortening the
febrile career." Loomis, says: " After the poison has
once gained entrance into the system, no means have j
as yet been discovered by which it can be counter- '
acted or neutralized so as to prevent the development
of the disease. The duty of the physician is to guide
the disease to a favorable issue, keeping in mind that,
a certain definite time must elapse before this result
can be accomplished." Johns Hopkins Hospital re-
port, Vol. 10, No. 1, says: " No known drug shorters
by a day the fever. No method of specific treatment
or of antisepsis of the bowel has passed beyond the
stage of primary laudation."
While, until very recently, this represented the true
status of medical knowledge, yet, if the consensus of
professional opinion be true as to its cause, namely, a
specific germ whose habitat is the small intestine, any
remedy that will sterilize the entire alimentary canal,
destroy this germ and neutralize its toxins effectually,
that is not deleterious to the system, is certainly-
rational and worthy of trial.
Flint again says: " It is not an unreasonable ex-
pectation that an antidote or parasiticide as effective
in typhus and typhoid fever as quinia in malarial
fever, may hereafter be discovered, and such a discov-
ery is a proper aim for continued experimental obser-
vations."
This has been the teaching of nearly all authors.
On this idea carbolic acid and iodin, sulpho-carbolate
of zinc, salol, salicylate of ammonia, etc., have been
used as intestinal antiseptics and germicides. Not-
withstanding all these remedies, with the Brand
treatment, lessened the mortality and modified the
course of the disease in some instances, it remained
for John Eliot Woodbridge to discover and introduce
to the profession the ideal intestinal antiseptic, and
demonstrate with certainty, the success of his reme-
dies, and render typhoid fever no longer one of the
grave and much dreaded diseases.
I here report some of my cases:
Case 1. — K. McC, male, age 17. I was called to see him on
the fourth day of his sickness ; temperature 103, tongue coated,
and a feeling of malaise. I gave blue mass calomel and soda
to move bowels, also phenacetin to reduce fever, and pressed
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quinin. Next morning bowels had acted well ; he had a free
perspiration, temperature 99.4. In afternoon temperature was
102.. Morning and evening temperature next day 100.4, free
perspiration. Temperature next morning 102. Afternoon tem-
perature 100.2, when I put him on Woodbridge tablets No. 2
every hour, but kept up quinin. Temperature next morning
103, and in afternoon 103.2 : added phenacetin. Temperature
next morning 102, and in the afternoon 102.2, I added Wood-
bridge No. 3 alternated with No. 2. From this time on the
fever gradually declined, the yellow thin actions kept up from
312
THE MEMORIALS OF EDWARD JENNER.
[August 8,
bowels for a while, the nervousness grew less, and the patient's
temperature reached normal on the seventeenth day of the
disease, and the tenth day after the Woodbridge treatment
was commenced, and he rapidly recovered. I may add that
this young man was very despondent from the start, as he had
a short time before lost his cousin with the same disease.
Case 2. — H. R., age 47, married. August 26, temperature
103.6, bowels tympanitic and three or four paint-like actions
a day. I put him on Woodbridge treatment every hour, gave
nothing else. Next morning temperature 102. No other
change. I added Woodbride No. 3 alternated with No. 2. The
temperature continued as shown by the chart until the fifth
day of treatment, when it reached normal. His recovery was
uneventful except one of his legs swelled and remained swollen
for some time during convalescence.
Case 3. — L. M., age 25. September 6, the second day after
he had taken to his bed, morning temperature 100.8 ; put him
on Woodbridge No. 2 every hour ; afternoon temperature 102.2 ;
added an occasional dose of quinin to satisfy patient ; Sep-
tember 8 added Woodbridge No. 3, alternated with No. 2. The
seventh day I noticed several rose spots on his chest and abdo-
men. September 20 his temperature reached normal.
Case 4. — Miss M., a young lady. October 2, temperature
105.5, tongue coated. I thought she had bilious fever. 1
gave blue mass, calomel and soda to move the bowels and put
her on phenacetin and quinin. Next day bowels had moved
well ; she was perspiring freely but fever high. I pressed phen-
acetin and quinin. On the third day, as her fever kept up, I
put her on Woodbridge No. 2 every hour, and kept up quinin.
Next day no change. Next morning fever not so high and
patient not so nervous. About 2 o'clock same day I found that
she had had hemorrhage from the bowels three times, the
chamber nearly filled with clotted blood and she was almost
pulseless, temperature below normal. By the use of hypoder-
mics of strychnia, stimulants and astringents, I was enabled
to bring about reaction. As soon as I felt that she was suffi-
ciently safe from another hemorrhage I put her on Woodbridge
No. 3, alternated with No. 2 and kept it up.
When this hemorrrhage occurred I thought that
she had been sick longer than reported. It appeared
she had been sick for two weeks or more, but had tried
to wear the feeling off.
I might add reports of a dozen cases thus treated
with like results, but I deem these sufficient, with the
testimony other physicians who have had like results,
to establish the fact that typhoid fever can be cured.
I have used only prescriptions Nos. 2 and 8. This
I did purposely, as No. 2 contained the same amount
of everything as No. 1, and four times as much car-
bonate of guiacol and the addition of one-sixteenth
grain of thymol. I am confident that the virtue of
these perscriptions is increased, if not dependent on
one or both of these drugs; and it seems more
rational to give these at once, and get the patient
earlier under the influence of these remedies. Besides
it is contrary to my idea of treating a patient, to dis-
turb him and his stomach every fifteen minutes with
medicine.
I think that the success of this treatment is due to
one or all of the components in No. 3, and that if this
combination alone were used, with sufficient calomel
and sodium tablets to keep the bowels open, the result
would be the same as when Nos. 1 or 2, or both, are
used, according to Dr. Woodbridge's directions.
In closing will say, that from the facts here adduced,
in addition to statements published in Dr. Wood-
bridge's paper read at the meeting of the American
Medical Association in Baltimore last May, the fol-
lowing conclusions may be drawn :
1. That the treatment given by Dr. Woodbridge for
typhoid fever far surpasses in results any other treat-
ment hitherto employed.
2. That it is entirely harmless, and it, or the anti-
septics it contains, can and should be given without
hesitation by any physician to any and all patients
and under all circumstances when typhoid fever exists.
3. That if this treatment is begun early and per-
sisted in, the disease will not only be materially
shortened, but that all serious consequences and
sequelae, such as tympanites, glazed tongue, nervous
prostration and delirium, will be prevented.
4. That if any reliability can be placed in this evi-
dence, the Woodbridge treatment actually cures
typhoid fever as certainly and surely as quinin does
malaria, and that under this treatment there are but
two stages of this formidable disease, first, that of
rapid decline in temperature, and secondly, that of
convalescence.
1796-1896.
THE MEMORIALS OF EDWARD JENNER.
Address delivered at the Centennial Celebration held at Atlanta, Ga.
May, 1896.
BY HORATIO R. STORER, M.D.
HON. PEES. NEWPORT MEDICAL SOCIETY, NEWPORT, R. I.
Upon the one hundredth anniversary of Jenner's
discovery, anything connected with him becomes of
unusual interest. There exist a number of medals,
statues, busts, paintings, engravings, lithographs and
wood cuts, purporting to represent him as he ap-
peared in life.
Medals. — It was my intention to present to the
Association a list, with descriptions, not merely of
the personal medals of Jenner, but of those illustrat-
ing the history of smallpox and the physicians who
have written thereon; inoculation, and those identi-
fied with its employment; and vaccination, with those,
including Drs. N. S. Davis and J. M. Toner, who have
been prominent, since Jenner's day, in its develop-
ment. Quite a number of them were shown by me to
the Association at its Newport meeting in 1889. A
portion of the medals relating to the subject have
been given by Dr. Charles Louis Hippolyte Kluys-
kens1 of Ghent, and a larger number still by Medicinal
Rath Dr. L. Pfeiffer and Hof Rath C. Ruland2 of
Weimar. The first of these gentlemen has now
deceased. His list of medals comprised twenty-nine,
only of vaccination. To the others, Pfeiffer and Ru-
land, too much praise can not be given for their inde-
fatigable labors. In their latest publication, 1.882,
they gave twelve medals of inoculation, and fifty-four
of vaccination. That 1 have been able to materially
add to these numbers, has been only through con-
stant searching through several years, and a large
amount of correspondence with numismatists. The
list has been nearly finished, but ill health has pre-
1 Numismatique Jennerienne. This first appeared in the Revue
beige de numismatique for 1875, vol. xxxi, page 55, and was privately
reprinted.
'^ Dr. Pfeiffer, who has been a prolific writer upon smallpox and vac-
cination, has been the collector of these medals, and Mr. Kuland, the
curator of the Goethe Museum at Weimar, has been their collator. Dr.
P. first published in 1876" Die auf die Entdeckung und Ausstreitung der
Impfung geschlageu Denkmiinzen" (Deutsche Ztitschrift fur prakt. Med.,
Leipsic, 1876, pp. 516-524). There then appeared anonymously but evi-
dently from the hand of Mr. Ruland, " Beschreibendes Verzeichniss
Der zu Ehren William (sic) Jenner's und Aloysio Sacco's Sowle Auf
Die Schutzpocken-Impfung und die Blattern-Inoculation Gepriigten
Medaillen" (Archiv fur path. Anatomie, Berlin, 1877, LXXII, pp. 1-14).
This was privately reprinted. There then came, also anonymously.
" Pestilentia in Nummis. | — | Beschreibendes Verzeichniss | der auf
Epidemien von Pest, gelben Fieber, Cholera, auf Pocken — Erkrank-
uugen und Inoculationen, auf Jenner, Sacco und die Vaccination,
sowie der auf Hungersuothe und andere Calamitiiten gepriigten
Medaillen," Weimar, 1880; and finally, with the authors' names for the
first time upon tbe title page, " Pestilentia in Nummis. | Geschichte |
der Grossen Volkskrankheiten | in Numismatischen Documenten. I Ein
Beitrag zur Geschichte der Medicin und der | Cultur." Tubingen, 1882.
[Since my paper was presented at the Atlanta meeting I have
received still another and very interesting article upon the subject
from Dr. Pfeiffer, entitled "Zur Jenner feier j des 14 Mai 1S96 | Medaiilen,
Portriits und Abbildungen, | betreffend | E. Jenner. die Variolation, die
Vaccination | und die Vaccine." | Tubingen, 1896. While it lacks a num-
ber of the memorials I had cited, it gives several that were new to me.
These I shall enter, giving due credit for each with an asterisk.]
1896.]
THE MEMORIALS OF EDWARD JENNER.
313
Vented its completion, and indeed the hours of the
present session have been so wisely parceled in
advance that there would have been scant leisure for
its consideration. I shall, therefore, now offer but a
oatalogue of the personal medals of Jenner alone.
ENGLAND.
1. Obverse. Apollo presents a sailor who has been pre-
,1 by vaccination to Britannia, who holds a civic crown
hearing: jenner Legend: alba nautis Stella kefulsit.
1801.
An anchor. Above : georoio tertio rege. Be-
low : spencer duce (Viscount Althorp, First Lord of the
Admiralty and subsequently Earl Spencer.)
Gold.
Schliehtegroll, Annalen der gesammten Numismatik, I, p.
186; Rudolphi, Recentioris Aevi Numisraata de Rebus Med-
icis et Physicis Meritorum Memoriam Servantia, Berlin, 1829
(3d edition), p. 81, No. 338; Kluyskens, Des Homines Celcbrea
dans les Sciences et les Arts, et des M^dailles qui Consacrent
lour Souvenir, Ghent, 1859, II, p. 68, No. 1; ibid., Numis-
matique Jennenenne, No. 1; Duisburg, C. A. Rudolphi, etc.,
Pernio Edidit, Emendavit et Auxit C. L. D. D., Dantzic, 1862,
i,. 230, DCIX, 1; Pfeiffer and Ruland, 1882, p. 139, No. 385;
Baron, Life of Edward Jenner, London, 1838, II, p. 456;
Storer, Sanitarian, March, 1889, No. 926; ibid., American
Journal of' Numismatics, July, 1894, p. 14, No. 747. [Pfeiffer,
1896. p. 3, No. 385.]
Presented to Jenner by the surgeons of the British Navy.
Its locality is now unknown. It is not, as Pfeiffer has sup-
posed, a portrait medal of Jenner.
2. Obverse. Bust, clothed, to left. Upon truncation : [T.R.]
Poole 1809 No inscription.
Reverse. Blank.
Of pink wax upon colorless transparent glass; 82 mm.
(length of bust).
er, loc. rit., April, 1895, p. 128, No. 880. [Not given by
Pfeiffer, 1896.]
In the Library of Royal Medical and Chirurgical Society of
London. I know of it" through Dr. F. P. Weber of that city.
A gold medal was presented to Jenner by the Medical Soci-
et\ of London, at its anniversary dinner, March 4, 1804. It
bore either upon its rim or the casket that contained it:
E. Jenner M.— D. Socio suo eximio ob vaccinationem
explobatam
Biographie MeMicale, V, p. 574 : Rudolphi, p. 81, No. 339;
Kluvskens, II, p. 68, No. 2; ibid., Num. Jenn., No. 2; Duis-
burg, p. 230, DCIX, 2; P. and R., p., 139, No. 386; Storer,
sanitarian, March, 1889, No. 927; ibid., Amer. Jour, of
. July, 1894, p. 14, No. 748; Baron, loc. cit.
Though mentioned by all these writers, its true character
has remained undecided until it was lately ascertained by Dr.
F. P. Weber of London that it was the John Fothergill
medal of the society (Storer, Am. Jour, of Num., Oct., 1893,
and July, 1895, p. 6, No. 645). Its present locality is
unknown. If "the inscription were upon its casket it is possi-
ble that it is the specimen now in the British Museum, as but
one or two of these medals were struck in gold. [Pfeiffer, 1896,
p. :>. No. 386, describes its bust as that of Jenner. It was not
so, however, but of Dr. John Fothergill.]
There exists a medallion engraving, with bust in profile to
right, by J. B. Drayton, from life, and Anker Smith. Though
drawn for the purpose of a gold medal it was never struck.
\ centennial medal has just been issued at Bristol.
3. Obverse. Bust, to right. Beneath: Fenwick, Sc.F.
Birm'm. Inscription: Edward Jenner, M.D. LL.D. F.R.S.
&c. Born 17 May 1749. Died 26 Jan. 1823. Berkeley, Glostersh.
Reverse. Within laurel wreath : May 14th, 1896. In com-
memoration of the centenary of Dr. Edward Jenner' s First
& Successful Experiment in Vaccination May 14th, 1796.
Silver. 38 mm.
Brettauer, Mittheilungen des Clubs der Munz-und Medail-
kii Freunde in Wien, May, 1896, p. 55.
A medal in honor of Jenner has also been determined upon
by the Epidemiological Society of London.
HOLLAND.
4. Obverse. An allegorical group.
Reverse. Eduard Jenner, Doctor in de Geneeskunde |
Geboren den 17 Mey 1749 te Berkley in het Graaf | schap
Glocester in Engeland en Aldaar overleden J den 26 Jan-
UARIJ 1823. UlTVINDER DER KoEPOKINENTING f IN HET JaAR
1775. DOCH EERST IN 1798 DOOR HEM | BEKEND GEMAAKT.
Copper. By A. Bemme, at expense of H. Westhoff, Jr.
Dirks, Nederlandsche Penningen, 1889, I, p. 169, No. 210 ;
Storer, Am. Jour, of Num., July, 1894, p. 14, No. 749. [Not
given by Pfeiffer, 1896.]
BELGIUM.
5. Obiwse. Bust, upon an oval shield, between two females
holding over it a crown. Beneath, an elongated shield, upon
which a cow, to right.
Reverse. Blank.
Plaster of Paris. 37 mm. Unique. By Charles Wiener of
Brussels.
Alvin, Revue beige de numismatique, April, 1888, p. 243;
Storer, Sanitarian, March, 1889, p. 935; ibid., Am. Jour, of
Num., July, 1894, p. 15, No. 757. [Not given by Pfeiffer, 1896.]
Reference to Jenner is also made upon a medal of Dr.
Vrancken of Antwerp.
FRANCE.
6*. Obverse. Bust. Beneath : Barre. Inscription : Napo-
leon III. Empereur.
Reverse. Bust of Jenner, facing. At sides, a cloaked and a
nude female figure, with laurel wreath. Beneath, a cow. In-
scription : Edward Jenner. Upon rim : Comite de vac-
cine de la Seine Inf. By Hamel.
Silver. 41 mm.
Pfeiffer, 1896, p. 6, No. 415c.
7. Obverse. Bust, facing, within palm leaves. Inscription:
Edward Jenner. To left i Hamel et Lecompte Beneath,
1749 (the date of Jenner's birth).
Reverse. Between laurel branches : Medaille de Ire
Classe. Inscription : Comite central de vaccine du De-
partment du Nord.
Silver. 40 mm.
Kluyskens, Num. Jenn., No. 9; Pfeiffer and Ruland, p. 145,
No. 416; Storer, Sanitarian, March, 1889, No. 933; ibid.. Am.
Jour, of Num., July, 1894, p. 15, No. 755. [Pfeiffer, 1896, p. 7,
No. 416.]
8. Obverse. As preceding, but bust somewhat toward left,
and on pedestal, upon base of which the date.
Reverse. A laurel wreath, beneath which : Medaille de
2e Classe. Field vacant for name of recipient.
Silver. 36 mm.
Pfeiffer and Ruland, p. 146, No. 417, fig. of obv. ; Storer,
Sanitarian, March, 1889, No. 934; ibid., Am. Jour, of Num.,
July, 1894, p. 15, No. 756. [Pfeiffer, 1896, p. 7, No. 417.]
In the collection of Dr. Joseph Brettauer of Trieste.
9*. Obverse. As preceding.
Reverse. Merely the wreath.
Silver. 36 mm.
Pfeiffer, 1896, p. 7, No 417 a.
GERMANY.
10. Obverse. Beneath a rose bush and a cornucopia, an
infant with rose in its hand points to its arm. At right of
bush : L (oos) Inscription : Eduard Jenner's Wohlth/ETige
Entdeckung Exergue : Vom 14 Mai | 1796
Reverse. Zum | Andenken | an I Erhaltenen | cnd | Mit-
getheilten I Schctz | (a scroll) | Gereicht vom J Doctor
(Eduard) Bremer | in Berlin | 1803
Silver. 25 mm.
Rudolphi, p. 82, No. 340; Kluyskens, II, p. 68, No. 3; ibid.,
Num. Jenn., No. 5; Duisburg, p. 230, DCIX, 3; P. and R.,
p. 141, No. 393 ; Baron, loc. cit. ; Storer, Sanitarian, March,
1889, No. 928; ibid., Am. Jour, of Num., July, 1894, p. 14,
No. 750. [Pfeiffer, 1896, p. 4. No. 393.]
In the Brettauer collection, that of the U. S. Army Medical
Museum and my own.
11. Obverse. As preceding.
Reverse. As preceding, save that after Schutz there is :
, and after Berlin : 1811— | 8 L. 6 or.
Silver. 25 mm.
Rudolphi, p. 82, No. 340; Kluyskens, Num. Jenn., No. 6;
Duisburg, p. 230, DCIX, 3, note : Bremer, Die Kuhpocken,
Berlin, fig. ; P. and R., p. 142, No. 394; Storer, Sanitarian,
March, 1889, No. 929; ibid., Am. Jour, of Num., July, 1894,
p. 14, No. 751. [Pfeiffer, 1896, p. 4, No. 394.]
In the Brettauer collection and my own.
12. Obverse. Bust, to left. Beneath shoulder : F. Loos
Inscription: Edu ard Jenner Entdecker der Schctzimpfung
d. 14 Mai 1796
Reverse. An angel from clouds, garlanding a cow, around
which seven children are dancing. Legend : Ehre sey Gott —
in der Hohe Exergue : Und Freude | auf Erden
Silver, bronze, Berlin iron. 36 mm. Thick and thin planchets.
Rudolphi, p. 82, No. 341 ; Kluyskens, II. p. 69, No. 4, fig. ; ibid. ,
Num. Jenn., No. 7; Duisburg, p. 231, DCIX, 6; P. and R.,
p. 139, No. 387, fig. ; Wroth, Numismatic Chronicle, 3d series,
VI, 1886, p. 303 ; Storer, Sanitarian, March, 1889, No. 930 ;
ibid., Am., Jour, of Num., July, 1894, p. 14. No. 752; Weber,
English Medals by Foreign Artists, p. 50, No. 161. [Pfeiffer,
1896, p. 3, No. 387.]
314
THE MEMORIALS OF EDWARD JENNER.
[August 8,
In the Brettauer and U. S. Government collections, those of
Prof. S. Oettinger of New York, Dr. W. S. Disbrowof Newark,
N. J., and my own.
13. Obverse. As preceding, save that engraver's name is in
exergue.
Reverse. Hygieia, with serpent upon her right arm, pro-
tects, by a shield bearing a cow, an infant against a flying
demon. Legend : Triumph ! Getilget ist des Schecsals
LANGE WUTH
Silver, bronze, Berlin iron. 28 mm. With and without loop.
Rudolphi, p. 82, No. 342; Kluyskens, II, p. 69, No. 5;
ibid., Num. Jenn., No. 13; Duisburg, p. 231, DCIX, 7: P.
and R,., p. 140, No. 388; Wroth, Num. Chronicle, 3d series,
VI, 1886, p. 302 ; Storer, Sanitarian, March, 1889, No. 931 :
ibid., Am. Jour, of Num., Julv 1894, p. 15, No. 753; Weber,
loc. cit. [Pfeiffer, 1896, p. 3, No. 388.]
In the Brettauer and U. S. Government collections and my
own.
14. Obverse. A child, between a rose tree and the rising
sun, exhibits its arm; at its feet a serpent. Legend: Dank
der Gotigen Vorsehung. Exergue : Kruger.
Reverse. Within a pearled octagon : Wohl \ thatige
ENTDECKUNG ] DER | SCHUTZPOCKEN | DURCH | Ed : JENNER.
Silver. 30 mm.
Kluyskens, Num. Jenn., No. 8; Duisburg, p. 231, DCIX, 8:
P. aDd R., p. 142. No. 397; Storer, Sanitarian, March, 1889,
No. 932; ibid., Am. Jour, of Num. July, 1894, p. 15, No. 754.
[Pfeiffer, 1896, p. 4, No. 397.]
In th3 Brettauer collection.
15. A centennial medal is said to have been issued at
Berlin, of which the details have not yet reached me.
Russia.
16. There has also been a centennial medal struck at St.
Petersburg, but its description has not been received.
ITALY.
Jenner's name appears upon the two medals of Dr. Sacco of
Milan.
THE UNITE!) STATES.
A week after the meeting at Atlanta, the following medal
was issued by the Medical Society of the County of Kings
(Brooklyn, N. Y.), to commemorate its own very successful
Jenner celebration. It is to be regretted that, through inad-
vertence, the locality of the society was omitted from the medal.
17. Obverse. Bust, with queue, to left. Inscription : vac-
cination, may 14th j 1796—1896 | .Jenner.
Reverse. Within a circle, the staff of iEsculapius, upright.
Inscription : Medical Society of the County of Kings [
(Pointed rosette.) (This is a copy of the society's seal. |
Silver (but four struck), bronze. 38 mm.
Scientific American, May 30, 1896, p. 344, fig. of obverse.
In my collection, the gift of the Society.
PAINTINGS.3
I. Standing, facing and slightly to the left, leaning against
tree ; right arm upon branch, with hat, glove and cane in
dependent left hand. Milkmaid with four cows and buildings
at left.
Drawn from life. J. R. Smith, 1801. [Pfeiffer, 1896, p. 18. :
not B. M. J.]
II. Three quarter's length, in coat lined with fur, to right,
seated at table upon which his work, "An Inquiry, etc." show-
ing diagram of pustules, lies open. In background, figure of
Hygieia and cast entitled " Sacred Cow."
By James Northcote, R. A. (For the Medical Society of
Plymouth and Plymouth Dock.) [Pfeiffer, 1882; not men-
tioned by him in 1896 ; B. M. J.]
III. Older. Facing, with left forefinger upon brow.
Northcote. This is preserved in the National Portrait Gal-
lery at London.4 [P., 1896 ; not B. M. J.]
IV. In easy chair. Bust turned to left, but looking forward,
and showing portion of right hand.
Sir Thomas Lawrence, Pres't R. A. Owned by Royal Col-
lege of Physicians. [P. , 1896 ; B. M. J. ]
V. Seated. Facing, and to left. At side, MS. with ink
stand and pen. In background, reclining cow and buildings, at
left.
J. Robinson.5 [Not P., 1896; B. M. J.]
3 While this paper Is in press a list of Jenner memorials has appeared
in the British Medical Journal for May 23. I gladly take the opportunitv
to add the few that had escaped me, distinguishing them by across, and
also indicating by initials the others which were there mentioned. I
also add four references to the Revue Scientlfique for June.
* A copy of this in oil was at the Bristol (Eug'd) Industrial and Fine
Arts Exhibition in 1893, examination of the catalogue of which, corn-
rising the Mockler collection of Jenner relics, I owe to Dr. Joseph H.
'unt of Brooklyn, N. Y.
o A minature of the above, on ivory, possibly the original, was at the
Bristol Exhibition.
l'i
II
VI. Bust, to right : medallion.
Drawn from life by L. B. Drayton. [NotP., 1896 ; B. M. J.J
VII. Three-quarters length, in arm chair, with fur-collared
robe. Left elbow resting on volume lettered at back : John
HUNTER.
Win. Hobday. [Not P., 1896; B. M. J.]
VIII. t Aged, three quarters length, seated, fating and
slightly to left, with right arm resting on that of chair.
By Sir Thomas Lawrence. Owned by Mr. T. Malcolm
Watson. [Not P., 1896.]
IX.t Artist unknown. At Royal College of Surgeons o
England. [Not P., 1896.]
X.f There is said to exist an original portrait in the possession
of Mr. William Smith of Chesterfield, a photograph of which
is in the collection of the Royal Medico-Chirurgieal Society.
I have not as yet been able to identify this.
STATUES.
I. Marble statue, at west end of nave of Gloucester Cathed-
ral, near his birth place. Erected in 1826.
By Sie"vier. [P., 1896; B. M. J.]
II. Bronze statue, in London. Erected in 1858 at Trafal-
gar Square, and thence transferred in 1862 to Kensington ( lar-
dens. In gown, face resting upon left hand, and right holding
a scroll ; seated in antique chair, upon whose side the staff of
.Esculapius.
By W. C. Marshall. [P., 1896; B. M. J.]
III. Statue at Boulogne-sur-Mer. In standing position, left
hand upon a pillar, and right flexed forward with lancet. Upon
base : jenner. Upon pedestal : A eduard jenner. | la |
FRANCE RECONNAISANTE 11 SEPTEMBRE 1865.
By Eugene Paul. [P., 1896 ; not B. M. J.]
IV. Marble statuette, with rounded pedestal. Seated, and
vaccinating a nude child, upon his knee.
By Giulio Monteverde. Exhibited at the Paris Exhibition
of 1878. [P., 1896; B. M.J.]
BUSTS.
I. Looking to left and upward, draped, rounded and on
rounded pedestal.
By C. Manning. [P., 1896 ; B. M.
II. Looking forward and to right,
pedestal.
[NotP., 1896; or B. M. J.]
III. At Briinn, Moravia. Within a temple dedicated to Jenner.
Upon its pedestal : Divo Anglo | Eduardo Jenner, | LXV. I
Aetatis Ejus Anno ! Vaccinata Brunensis | MDCCCXIV.
(Baron, Life of Jenner, n, p. 214.) [Not P., 1896 ; B. M. J.,
which wrongly calls it a statue. ]
IV. By Fujite Bunzo. Exhibited at the Centennial Vacci-
nation Festival at Tokio, Japan.
ENGRAVINGS."
I. From painting No. I :
a. With the milkmaid and four cows.
1. J. R. Smith, 1801. [P., 1896 ; B. M. J.]
2. Engraved by R. Page. No other inscription. Rectangu-
lar, 95x125 millimetres. In the J. H. Hunt collection. [Not
P., 1896, or B.M.J. ]
b. As preceding, but showing only a portion of hat and
glove, and with but two cows and milkmaid.
3. D'Argent Sc, Edward Jenner (in script), M.D. F.R.S.
Rect., 73x98 mm. At library of Surgeon-General's office. [P.,
1896; not B. M. J.]
4. As preceding, but anonym, and without title. Rect.,
73x98 mm. S. G. O. ; N. Y. Academy of Medicine. [P., 1896;
notB. M. J.]
c. As preceding, but not showing hat or glove, cows or
milkmaid.
5. J. R. Smith pinxt., Londini — Dav. Weis sculps. Viennae |
Dr. Jenner (in German script) I Zu flnden in Wien bey Phil. Jos.
Schalbacher. Oval, 98x120 mm. S. G. O. ; J. H. H. [P., 1896;
notB. M.J. ]
d. As preceding, but less shown of left arm and waist.
6. Engraved by E. Scriven :- | Jenner i From aprintengraved
and coloured by J. R. Smith, in the possession of the late John
Ring, Esqr. Under the superintendence of the Society for the
Diffusion of Useful Knowledge. London. Published by Charles
Knight, Ludgate Street. (The Gallery of Portraits ; with
Memoirs, London, 1836.) Rect., 100x125 mm. S. G. O. ; J. H.
J.]
Nude, squared, without
6 I am under the greatest obligations to Deputy Surgeon-General D. L.
Huntington, U. S. A., Curator of the Army Medical Museum and Library,
who. upon my request for information concerning several of the engrav-
ings of Jenner in his care, most generously sent to me at Newport for
inspection the whole collection, over thirty in number. Dr. Joseph II.
Hunt of Brooklyn, N. Y.. with equal courtesy, forwarded to me for exam-
ination as many more, all different from the preceding, from his own
magnificent collection. I have thus been able to perfect the list to an
extent that would otherwise have been impossible.
1896. |
THE MEMORIALS OP EDWARD JENNER.
315
=
ml Redwood Library,, Newport. |Not P. 1896, or IS. M. j.i
7. .1. K. Smith pinxt E. Scrives, Set Edv\ vrd Jenner.
M.I). William Mackenzie, Glasgow, Edinburgh, London
a \u Vokk. Rect, 105x130 nun. J. H. H. IXotP 1,S')6
or II. M. .1.1
8, Mackenzie Sc. (in centre), Edward Jenner, M.D., P R S.
Bcript . Pub. July 1, 1802, by T. Hurst, Paternoster Row'
Rect, 7-Jx!»S mm. .1. 11. H. 1 1"., L882, not 1896; not B. M. .).|
;>. Mackenzie Sc. (in centre) l-'.nw iri> Jenner M D., PR 8.
,v.\ Pub. Aug. 1. 1802, by T. Hurst, Paternoster Row. Oval'
83x102 mm. J. H. H. [Not P., 1896, or B. M. J.|
Hi. Mackenzie Sc. ito right) Edward Jenner (in script) M 1)
F.R.S. Rect., 74x100 mm. J. H. H. I Not P., lS'.Hi. or B M J "l
11. P. Anderloni. |1\. 1896 ; not B. M. J.I
18. K. Page, L82a [P. 1882. not 1896: B. M. J.]
13, Engraved by G. Stodart. Jennek. Published by ,T. Ma-
son, 14. City Road, & tK>. Paternoster Row. Rect, 70x91) mm
.1. 11. II. [Not P., 1SSH5, orB. M. J.f
II. Prom bust alone of Painting 1.
14. Smith pinxt.: Rahl Set. Dr. Jenner (in script). Oval
li.">x74 mm. 8. G. O. [P., L896 : not B. M. J.]
16. H. Lips sculp. | Eduard Iknnku, M.D. | Entdecker der
Schutablattern i in script, and both upon an oblong label). Oval,
in rect. sotting. 165x1 25 mm. S. G. O. ; J. H. H. [P., 1896;
Dot li. M. J.]
It!. As preceding, but merely Eduard Ienner, M.D., Ent-
tUker der Sehuzblattern (in script, and both upon an oblong
label i. Oval, in rect Betting, 165x125mm. {Scientific American,
May 30, 1896. 1 J. H. 11. [Xot P., 1896, or B. M. J.]
17. Jacquemot sr. Jenner (in script), durch Kunst-Verlag,
\V. Creuzbauer in Carlsruhe. Open, 78x75 mm. S. G. O -J
11. II. [1*.. 1896; not B. M. J.]
18. As preceding, J. M. Pontaine i Jenner. Open, 78x75 mm.
S. Q. O. : J. H. H. [P., 1896 : not B. M. J.]
19. As preceding, but head more elongated. Dessine et
Orave par Ambroise Tardieu Eduards [sic) Jenner. Open,
B0x80mm. S. G. O. (P., 1896 : not B. M. J.]
•JO. J. K. Smith pinx. J. Hopwood sculp, j Edward Jen-
nki;. M.D. | Publish'd June 4. 1803 bv W. Bent, London. Oval
73x90 mm. J. H. H. [P., 1882, not 1896, or B. M. J.]
H. Edward Jenner. M.D. | Painted by J. R. Smith— En-
graved by Joseph Jenkins, j Published by James Robins &
Ob. lw Lane, London. Sep. 1. 1828. Open, 80x95 mm. J. H.
H. [ Not P. , 1896 ; or B. M. J. ]
III. Prom Painting I, but reversed.
a. Bust to right, with left arm on bough, and merely hat
d glove in right hand : the hat shows two-thirds ; milkmaid
id but two cows, at right.
22. est. von Hoppe Leipzig 1804 I Dr : Edward Jenner ; j
Wohlthater der Menscheit durch Erfindung | der Schutz-
pocken (all in script). Oval, 120x145 mm. S. G. O. [P., 1896;
not B. M. J.]
b. As preceding, but body is shorter and but small portion
of hat seen.
23. Anonym. Edward Jenner, M.D. F R S &c. (in script(
Engraved for the Hib. Mag. (1802.) Rect., 70x98 mm. J. H.
H. ; H. R. S. [Not P., 1896; or B. M. J.]
IV. Prom bust alone of Painting I, but reversed, to right.
24. J. R. Smith pinx. London | Edward Jenner, M.D. [
Erfinder der Schutzpoken (in script) | * | Zugeeignet
dem eifrigen Beforderer dieses grosen j Wohlthat | fiir die
Menscheit, seinem Freund (in script) Dr. Eichhorn | von Chris-
toph Wilh. Bock sen. (in script.) Oval, 72x90 mm. S. G. O.
(P.. 1896; notB. J. M.]
25. Anonym. Oval, 55x65 mm. (Knight, Popular History of
England, vn, opposite p. 475.) J. H. H. [Not P., 1896; not B.
M. J.]
26. C. Bohme sc. Dr. Edward Jenner. Above, z. f. d. J. — •
No. 8 (in script). Oval, 75x93 mm. J. H. H. [P., 1896; but
wrongly classed as lith. ; not B. M. J.]
V. Seated upon a bank in top boots, to right and facing ;
left arm upon tree with its closed hand against temple, while
right holds a scroll : behind, at left, two cows.
27. Bosiodis. F. Testadura inc. Edoardo Jenner (in script).
Rect, 115x168 mm. J. H. H. [Not P., 1896, or B. M. J.J
VI. From Painting II.
28. W. Say. Published January, 1803, by W. Say, No. 5
Quicksett Row, New Road, opposite Fitzroy Square, London,
270x275 mm.; [Not P., 1896; B. M. J.]
99. Anonym. [P., 1882, not 1896, or B. M. J.]
30. J. Northcote, Esqr., R.A. — Edw'd Finden | Edward
Jenner, M.D. F.R.S., &c. &c. | Published by John Murray,
Albemarle Street, 1830. Rect., 62x60 mm. (Lives of British
Physicians, 1&30.) S. G. O. ; J. H. H ; H. R. S. [Not P.. 1896 ;
B. M. J.]
' At the Bristol Exhibition.
VIII. Prom Painting III.
31. European Magazine (in script), (xevi, 1804, p. 163.)
Engraved by Ridley from an original Painting by Northcote.
J Kiiward Jenner M.D. | Published by J. Asperna at the
Bible, Crown and Constitution Cornhill 1 Oct 1804. Oval,
78x98 mm. J. H. H ; N. Y. Acad, cf Med. ; H. R. S. [P., 1896 ;
B. M. J.]
32. Anonym. [P., 1882; not 1896, or B. M. J.]
See also at the end of this list
IX. Prom Painting IV.
33. Sir T. Lawrence, P.R.A.—W. H. Mote | Edw. Jenner (in
facsimile script), M.D.-F.R.S. | Fisher, Son & Co. London &
Paris. 1838 (Frontispiece to Vol. i, Baron's Life of Jenner ;
Pottigrew, Medical Portrait Gallery, II.) Rect, 100x112 mm.
J. H. H. ; N. Y. Acad, of Med. [P., 1896; B. M. J.]
X. From Painting V.
34. J. Robinson pinxit — R. M. Meadows sculp. | Edward
Jenner (in script) M.D. | Published by M. Thomas, for the
Analectic Magazine. 1817. Rect, 85x110 mm. S. G. O. ; J.
H. H. : H. R. S. [Not P., 1896 ; or B. M. J.]
35. As preceding, but without the Published, etc. Rect,
85x110 mm. J. H. H. [Not P., 1896; B. M. J.]
XI. From Painting VI.
36. L. B. Drayton, ad. viv. del.— Anker Smith A.R. A., sculp.
j Edwd. Jenner, M.D. L.L.D. F.R.S. &c. Circular, 47 mm.
S. G. O. [P., 1882, not 1896, or B. M. J.)
37.t As preceding. Published February 1st, 1823, by J. B.
Drayton, Cheltenham, Gloucestershire. [Not. P., 1896.]
XII. From Painting VII.
38. Wm. Skelton, "begun by the late William Sharp." Ded-
icated to the King, George IV by permission. Engraved from
the Original, in the possession of Edward Davies. London :
Published by R. Ackerman, 101 Strand, January 2d. 1826.
325x425 mm.8 [Not P., 1896 ; B. M. J.]
XIII. Profile bust to left, seated, and with queue, arms
folded.
39. Anonym. DR- Jenner within scrolls ; above at left, Ms
C L (Meyer's Conversations Lexicon) No. 1730. Rect., 84x96
mm. S. G. O. [P., 1896; not B. M. J.]
40. As preceding. Dr. Jenner | Eioenthum & Verlag des
Bibl. Instituts in Hilburghausen Above, walhalla — No.
38. Rect, 80x96. J. H. H. [P., 1896; not B. M. J.]
XIV. Shortened bust of preceding.
41. W. Read sc. | Dr. Jenner (in script). Open, 40x50 mm.
(Profess. Anecd. or Ana of Med. Lit, London, 1825, n, p. 74.)
J. H. H. ; H. R. S. [Not P., 1896, or B. M. J.]
XV. Silhouette bust, to left, with queue.
42. Anonym. Dr. Jenner (in script). (Frontispiece to Vol.
m, Lettsom, "Hints Designed to Promote Beneficence, Tem-
perance and Med. Science," London, 1801 and 1816.) J. H. H. ;
Redwood Library. [Not P., 1896 ; B. M. J.]
43. As preceding. E. Jenner M.D., F.R.S., &c. (in script.)
J. H. H. [Not P., 1896, or B. M. J.]
XVI. Aged bust, facing.
44. W. Read sc. Edward Jenner, M.D. Open, 65x55 mm.
S. G. O. ; J. H. H. [Not P., 1896, or B. M. J.]
XVII. Bust facing, coat thrown open, shoulders truncated
obliquely.
45. Anonym. Edwd. Jenner M.D. Open, 43x42 mm. J. H.
H. [Not P. , 1896, or B. M. J. ]
XVIII. Erect, facing and slightly to left, with right arm
resting upon pedestal of a pillar.
46. Anonym. Dr. Jenner. | The Discoverer of Cow Pock
Inoculation (in script). Published by J. Robins & Co. Ivy
Lane, Paternoster Row, March 22. 1823. Open, 100x100 mm.
J. H. H. ; H. R. S. [Not P., 1896 ; or B. M. J.I
47. Anonym, jenner. Rect, 53x40 mm. J. H. H. [Not
P., 1896, or B. M. J.I
XIX. With cocked hat. (?)9
48t. Hicks sc. Published by Henry Fisher. Caxton. Lon-
don : March 1st, 1823. [Not P., 1896.]
XX.
49t. ByBranwhite. Bust. In Medley's group of the Found-
ers of the Medical Society of London. Not originally upon the
plate, but subsequently introduced. I am not as yet certain
as to its exact place in this list. [Not P., 1896.]
XXI.
50t. J. Hazlitt jun. C. Turner, sculptor. London : Pub-
lished October 20th. 1808, by J. Hazlitt, No. 109, Great Rus-
sell Street, Bloomsbury. I am also uncertain as to the exact
classification of this. [Not P., 1896. ]
XXII.
8 At the Bristol Exhibition.
9 Thut this is of Jenner is denied by Dr. Hunt, who points out that it
seems identical with that of Dr. Sims of London, in Medley's group of
the Founders of the Medical Society of that cirv.
316
THE MEMORIALS OF EDWARD JENNER.
[August 8,
51f. Head, on large scale. H. E. Shrapnell. I am not sure
as to its allotment. [Not P., 1896.]
XXIII. From Statue II (London). Front and to right.
52. Engraved by J. Moore, from a Daguerreotype by Beard.
| Dr. Jenner. Rect, 95x120 mm. S. G. O. ; J. H. H. [P., 1896 :
not B. M. J.]
XXIV. From Statue II, left side.
53. Jenner. | Engraved by J. Brown from the statue by
W. C. Marshall, R.A. Open, 130x165 mm. J. H. H. [Not
P., 1896; B. M. J.]
XXV. From bust of Statue I (Gloucester). Looking to right
and slightly downward ; draped, squared and on mounted
pedestal.
54. *Anonym. [P., 1896 ; not B. M. J.]
XXVI. From Bust I.
55. Edward Jenner, M.D. L.L.D. F.R.S. | Engraved by J.
Dadley from a Bust by C. Manning [Esq.] (in script.) Open,
65x110 mm. S. G. O. ; J. H. H. [P. 1896; not B. M. J.]
XXVII. From Bust IV. Japanese.
56. (Sei-i-Kwai Medical Journal, Tokio. )
XXVIII. There exists also an engraved portrait, of 1801, with
this inscription in Spanish :
57. Edward Jenner, English physician, to whom the world
is indebted for the discovery of vaccina, the wonderful and
only preservative from the smallpox. It is prefixed to the
dissertation upon cowpox published by the Royal Academy of
Medicine. (Baron: Life, etc., I., p. 604.) [Not P., 1896, or
B. M. J.]
In addition, there is an engraving of a cow with star above
shoulder and crescent upon side. R. Reeve sc. Above ;
Sacred Cow. Circular. S. G. O. ; J. H. H. I do not num-
ber it. It alludes to the cast represented upon Painting II,
and refers to the "Sacred Cow of India," represented upon a
medal of Dr. Guillaume Demanetof Ghent. [P. and R., 1882,
p. 421.]
One of Northcote's paintings, II or III, is reproduced in the
Practitioner for May, 1896.
LITHOGRAPHS.
I. From bust of painting I.
1. Th. Hosemann. [P., 1882 ; not 1896, or B. M. J.]
2. Anonym. Lith. de Gregorie et Deneux, a Paris. | E.
Jenner. Open, 195x190 mm. (Me'decinset Chirurgiens celfe-
bres. Paris, 1842.) J. H. H. [Not P., 1896, or B. M. J.]
3. Anonym. Lith. rue Salle au — Comte, 10. j E. Jenner.
Open, 200x190 mm. S. G. O. [Not P., 1896, or B. M. J,]
4. As preceding. E. Jenner. | Vigneron del. — Lith. de
Engelmann. Open, 200x190 mm. S. G. O. [P., 1896; B. M.J. ]
5. *As preceding. Engelmann. [P., 1896; not B. M. J.]
6. fAs preceding. Lithographed by C. de Lasteyrie, 1824.
(Asclepiad, VI, p. 250.) [Not P., 1896.]
7. *As preceding. Villani. [P., 1896; not B. M. J.]
8. As preceding. Steandrrij van H. J. Backer, Dordt.
| Edw'd Jenner (in fac-simile script). Open, 98x100 mm. S.
G. O. [P., 1896 ; not B. M. J.]
9. E. Jenner, M.D., F.R.S. &c. | Hart & Mapother, lith.
Louisville, Ky. Open, 100x110 mm. S. G. O. ; J. H. H. [Not
P., 1896, orB. M. J.]
L 10. Anonym. Dr. Edward Jenner. I Born 1749. Died 1823. |
at Berkeley, Eng., | &c. &c. Dr. H. M. Alexander & Co., &c.
Open, 40x40 mm. J. H. H. [Not P., 1896, or B. M. J.]
11. Anonym. Dr. Edw. Jenner (in script), j 1749—1823.
within cartouche, over palm leaves : Dr. H. M. Alexander&Co.,
&c, 30x40 mm. J. H. H. [Not P., 1896, or B. M. J.]
12. Anonym. Jenner. (Dr. H. M. Alexander&Co., Colum-
bian Exposition. ) Circular. Colored, 30x30 mm. J. H. H.
[Not P., 1896, or B. M. J.]
II. From bust of painting I, but reversed, to right, and with
smooth instead of wavy hair.
13. Lagrand (in script) — Lith. de Ducarme. ' E. Jenner, |
M^decin Anglais, | ler Observateur de la Vaccine, n6 en 1749,
mort en 1823 (in script). Galerie Universelle — Publiee par
Blaisot. | Place Vendome, No. 24, | No. 353. Open, 150x135
mm. S. G. O. [Not P., 1896, or B. M. J.]
III. From bust of painting I, but reversed, to right, with left
arm dependent, and right extending a MS. volume, upon cover
of which a cow.
14. Leon Noel (in script) — Lith.,deFrey j Edouard Jenner.
Open, 100x170 mm. S. G. O. ; J. H. H. [P., 1896; not B. M.J. ]
IV. From engraving XIII.
15. Anonym. Dr. Jenner (in script), j Published by R.
Phillips, No. 71, St. Paul's Churchyard, London. Open,
42x45 mm. J. H. H. [Not P., 1896, or B. M. J.]
16. Anonym. Edward Jenner,M.D., LL.D.,F.R.S., etc., etc.
Open, 45x50 mm. (Brooklyn Med. Jour., December, 1891.)
J. H. H., H.R.S. [Not P., 1896, or B. M. J.]
17. As preceding. Dr. Jenner. Open, 45x50 mm. (Ibid.
April, 1896.) J. H. H. ; H. R. S. [Not P., 1896, or B. M. J.]
18. As preceding. At sides: 1796—1896. (Jenner Centen-
nial Festival, Med. Society of County of Kings, Brooklyn,
N. Y.) Open, 45x50 mm. J. H. H. ; H. R. S. [Not P., 1896,
or B. M. J.]
V. From bust of Statue I (Gloucester).
19. Edward Jenner. M.D. | L.L.D. F.R.S., &c. &c.
Drawn from the bust by H. Corbould, and on stone by R. J.
Lane. | Printed by C. Hullmandel. | Published March, 1827, by
Henry Colburn, London. Open, 80x120 mm. (Frontispiece to>
Vol. II, Baron's Life.) S. G. O. : J. H. H. (P., 1896., B. M. J.],
20. As preceding. Edward Jenner. M.D. | L.L.D. F.R.S.
&c. &c. Open, 95x140 mm. J. H. H. [Not P., 1896, or B. M.J. ];
21. Anonym. (Variola and Vaccina. N. E. Vaccine Co.
J. H. H. [Not P., 1896, or B. M. J.]
VI. From Bust I.
22. M. Gauci, 1823. Published by N. Chaterand Co., 33:
Fleet Street, London, & Washbourn & Sons Gloucester, August
10th, 1823. 225x300 mm. J. H. H. [P., 1882; not 1896; B-M. J.]
23. Methode de Dessin ] par Vigneron. — PI. 49. | Edwd.
Jenner j Inventeur de la Vaccine. | — | d'apres une Gravure-
Anglaise (engraving No. 55 of this list), j Paris, Mon. Basset,
33, rue de Seine. Lith. de Thierry freres, Paris. Open, 294x420'
mm. S. G. O. [Not P., 1896, or B. M. J.]
VII. From Bust II.
24. Anonym. Jenner (in script). Open, 68x95 mm. S. G..
O. [Not P., 1896 ; or B. M. J.]
WOODCUTS.
I. From bust of Painting I.
1. Anonym. Edward Jenner, born May 1749, died Febru-
ary, 1823. (From an illustrated paper.) Open, 100x130 mm.
J. H. H. [Not P., 1896, or B. M. J.]
2. Anonym. (Russell, History and Heroesof Art of Medicine,.
London, 1861.) 60x65 mm. J. H. H. [Not P., 1896, or B. M J.]j
II. From bust of Painting I, but with a cow beneath.
3. Les Medecins et les Administrations Reconnaissants.
Monument | a | Jenner. | W. Brown Del. &Sc. Rect., withi
upper corners rounded ; 195x245 mm. S. G. O. [Not P., 1896 ;
orB. M. J.]
III. From bust of Painting I, but reversed, to right, with
head erect. ,
4. Anonym. (German.) Eduard Jenner. Open, 65x76.
mm. S. G. O. [Not P., 1896, or B. M. J.]
IV. As preceding, but head inclined downward.
5. Anonym. (German.) Eduard Jenner. Rect., 74x87'
mm. S. G. O. [Not P., 1896., or B. M. J.]
V. From Engraving XIII, but with large collar to coat.
6. Anonym. Dr. Jenner. Rect., 100x130 mm. J. H. H..
[Not P., 1896, orB. M. J.]
VI. From Statue II (London). Front and slightly to right.
7. D A — J A W (in script). Statue of Dr. Jenner.—
Sculptured by W. C. Marshall. — Placed in Trafalgar-
Square. Open, 115x185 mm. J. H. H. [Not P., 1896, or B.M.J. J
VII. From Statue II, looking to right.
8. Statue of Dr. Jenner to be erected in Trafalgar.
Square. Open, 135x120mm. J. H. H. [NotP., 1896, or B. M. J.]
VIII. From Statue III (Boulogne). To right and front,
with vessels, groups and buildings.
9. Anonym. Statue of Dr. Edward Jenner, recently
erected at Boulogne, France. Open, 240x165 mm. J. H. H.
[NotP, 1896; or B. M. J.]
IX. From Statuette IV.
10. Anonym. Edward Jenner. (Leipziger Illvstrirte Zei-
tung, 1885.) Open, 115x185mm. S.G. O. [P., 1896;notB. M. J.]'
11. As preceding. From the original by Monteverde. Open,
115x185 mm. J. H. H. [Not P., 1896, or B. M. J.]
12. |As preceding. Ferrier. Jenner vaccinating his own
child. From the statue by Monteverde. (British Medical'
Journal, May 23, 1896, p. 1254.) Open, 70x106 mm. [Not
P., 1896.]
PHOTOGRAVURES.
From Painting I.
1. fAnonym. From an engraving by J. R. Smith. (Britisli
Medical Journal, May 23, 1896, p. 1251; Revue Scieiitiji([ue,
June, 1896, p. 741.) Rect., 84x110 mm. [Not P., 1896.]
From Painting II.
2. fAnonym. From a painting by Northcote now in the-
National Portrait Gallery. (British Medical Journal, May 23,
1896, p. 1247; Revue Scientifique, June, 1896, p. 739.) Rect.
127x152 mm. [Not P., 1896.]
From Painting IV.
3. t Anonym. From the painting by Sir Thomas Lawrence*
in the possession of the Royal College of Physicians. (British
SEMINARY METHOD IN TEACHING SURGERY.
317
Medical Journal, May 23, 1896, p. 1246; Revue ScieiitMati*
June, 1896, p. 738.) Rect., 82x100 mm. [Not P., 189(5 \
4. As preceding. Edw. Jenner (autograph) M.l). p R S
Souvenir Jenner Centennial Celebration by American Medical
A-.h-iation, Atlanta, Ga., 1896. Rect, 94x115 mm. [Not P.
1896, or B. M. J.]
6. As preceding. Edward Jenner. ( Journal of the Vmbri-
CanMkdicai Association, June 13, 1896.) Rect., 94\115 mm
Not P., 1896. or B. M.J.J ^ mm.
From Painting VIII.
& tAnonym. {British Medical Journal, May 23 1896 p
12 U>: /urn,- Scientiftque, June, 1896, p. 743.) Rect., 125x152
mm. [Not P., 1896.]
From Kngraving 53, of Statue II, left side.
7. + Anonym. Statue in Kensington Gardens by Mr W
Calder Marshall, R. A. [British Medical Journal, May 23
1896. p. 1248.) Rect., 127x153mm. [Not P., 1896.1
From Lithqgraph 4.
8. tAnonym. From a portrait by Vigneron. (Ihid, p. 1252 ;
Revue Scientifique, June, 1896, p. 738.) Rect., 82x100 mm.
I Not P., 1896.]
There are a number of caricatures of Jenner, and engrav-
ings of vaccination, vaccine farms, etc., but I have purposely
omitted these.
During Jenner* s life, as an offset to the innumera-
ble insults and scurrilous attacks that he received,
the Royal Jennerian Society was founded in 1803. In
1 si n at his own request, it was merged in the National
Vaccine Establishment. He was given a Parliamen-
tary grant of ,£10,000 in 1802, another of £20,000 in
L807, and subsequently an additional £8,000 by
India. He was also presented a service of plate by
his country friends, and the freedom of the city of
London, in a casket set with diamonds. There is a
memorial window and tablet of him at the church in
his native Berkeley.10
THE SEMINARY METHOD IN TEACHING
SURGERY.
Read before the American Academy of Medicine, Atlanta, May 4, 1896.
BY BAYARD HOLMES, B.S., M.D.
PROFESSOR OF SURGERY
IN THE COLLEGE OF PHYSICIANS AND SURGEONS
OF CHICAGO.
I can best give an idea of this method by relating
the history of an experiment which I made in teach-
ing a few topics in surgery to a class of thirty stu-
dents. A case of osteomyelitis of the tibia came to
my clinic and was carefully studied by me with the
help of the class. The history was outlined upon the
blackboard, and the diagnosis, prognosis and indica-
tion for treatment were carefully discussed and our
conclusions written down. When this had been done
the students were instructed to bring into the class
at the next recitation hour histories of three or more
cases of osteomyelitis, which they had themselves
observed or had copied from articles in the medical
literature. The class had previously been instructed
in the method of using the medical library, and cards
had been placed in the card catalogue of the college
library guiding the students to as many articles as the
library contained bearing upon the subject of acute
osteomyelitis. During the next clinic hour this pati-
ent was operated upon in the presence of the class,
and a large sequestrum of bone removed. The invo-
lucre was so cut down so as to allow the resulting con-
cave surfaces to be covered with skin. At the next
recitation hour the students came with some original
and some copied histories of cases of osteomyelitis.
One student with a good voice and prompt address
was requested to read one of his cases aloud. This
case had been selected by me because it was typical
io They are figured in the British Medical Journal for May 23, 1896,
p. 1253.
and well recorded. As the reading progressed notes
were placed upon the blackboard indicating the age
of the patient, the predisposing causes of the disease,
the immediate cause of the onset of the disease, the
most prominent symptoms and the subsequent course
and the treatment.
Opposite the age of this typical case was set down
the age of the sixty-four other patients, whose histor-
ies were in the hands of the students in the class. In
this way we discovered that nearly all the patients
were between six and twenty-five years of age, one
student was requested to make a statement, which
would show the condition represented by the mass of
figures. After a number of trials he wrote out the
following sentence, which was accepted as expressing
the facts: " Of the sixty-four cases presented by the
class, 52 per cent, were between 5 and 20 years of
age, 20 per cent, were between 20 and 30 years of age,
and all of the remaining 28 per cent, were less than
46 years of age." In the same manner the previous
condition of the patient and the predisposing causes
of the disease were noted down upon the blackboard
and afterward expressed in short sentences, thus:
" Thirty per cent, of the sixty-five cases presented had
suffered from some acute infectious disease immedi-
ately before the onset of osteomyelitis." In the same
manner the other important points in the clinical
history, in the pathology and in the treatment of the
disease, was discussed. It required several hours for
this work, and the intervening time was spent by the
students in collecting new information and in exchang-
ing histories of cases with one another. After every
important point had been studied, the students were
directed to make an abstract of the histories of ten or
more cases, and then from these cases to prepare a
generic history of the disease. Instructions had been
given as to the size of the sheets of paper, the dis-
position of the manuscript on the page and the method
of arranging and binding. Two weeks were then
allowed for the completion of the thesis upon this
disease. Thirty very excellent and satisfactory papers
were written. One would naturally expect a great
deal of sameness in these efforts, but contrary to my
own expectation there was the greatest variety of
treatment. One student of a judicial turn of mind
numbered very carefully his cases and the pages of
his manuscript, and then in the original portion of
his thesis referred after each statement to the cases
which authorized it. One man divided his histories
up into fragments and quoted the fragments in full
corroboration of each fact or conclusion stated. A
few men copied outright from text books on surgery,
but on the whole this was a most satisfactory exercise.
Various other subjects were studied in the same
manner, all the class working upon the same subject
at the same time.. When familiarity with the method
of work had thus been secured, separate topics were
given each student, and he was directed to investigate
the literature of the subject as represented in the
college library, and then to prepare in the usual man-
ner a complete account of the disease, its pathology
and treatment, basing his remarks entirely upon the
histories of the cases, which he had either observed
himself in the clinics or on those he had abstracted
from the literature, but best of all upon both. Care
was of course taken to assign only such subjects as
were adequately represented in the college library,
and also so as to give each student one surgical dis-
ease of the head, one of the thorax, one of the abdo-
318
MALARIA
[August 8
men, and one of the extremities. At first the work
was reluctantly undertaken by the students, but after
an examination at the County Hospital had been held
in which, by chance, questions were asked involving
a knowledge of two of the subjects which had been
studied by this method, the value of this intensive
teaching was recognized, and enthusiastically under-
taken by nearly all the class ever afterward.
This method of study must be conducted in small
classes of mature students, who understand the use of
and have an adequate library at hand. It requires
about six or eight hours preparation for each recita-
tion hour, and it must be conducted by a teacher who
fully understands the resources of the students and is
wise enough to present at the start no insurmount-
able difficulties. Perhaps the ideal can only be
attained when the teacher has previously studied each
of the subjects he assigns in the library of the college
and has taken care to have such cards put in the
catalogue as will guide the student to all the litera-
ture without too much effort.
One of my students had assigned him a topic involv-
ing the repair of fractures in long bones. He took
the trouble to study the specimens in the museum,
and he also made a series of experiments on animals
in which he made microscopic demonstrations and
prepared large macroscopic sections sawed out near
the seat of fracture. In the seminary method noth-
ing should be neglected which will add to the con-
creteness and vividness of the conception of the
student. He should be placed as far as possible in
the position of an original investigator, with many of
the difficulties which ordinarily beset the investigator
removed.
This method is equally applicable to the study of
any topic in the medical curriculum, but it should
not be used to the exclusion of any other method, but
rather as supplementary to any or all of them. It is
especially adapted to students who have been trained
in independent thought in colleges and universities,
and it will be found an excellent preparation for such
students as propose to contribute to medical litera-
ture.
MALARIA.
BY ELLSWORTH D. WHITING, A.B.
AURORA, ILL.
(The L. P. C. Freer Prize Essay, Rush Medical College, 1896.) *
(Concluded from page 269. )
The increase of connective tissue is first observed
in the interlobular spaces, and later dips down into
the lobules. The atrophy of liver cells follows this
increase of interstitial connective tissue. (Plate vi.)
On gross examination the kidney is found to be
larger and heavier than normal. In consistency it is
either firm or soft and edematous, presenting a mot-
tled surface, the result of infarction. The capsule
strips readily or is thickened and adherent as in severe
cases. The Malpighian bodies are either prominent
and swollen or sunken and atrophied. These condi-
tions are often present in the same specimen. On cut
section the color of the kidney varies from the normal
to a yellowish brown, marked by opaque, dark and
minute hemorrhagic areas. The medullary rays are
pale, showing between them dark, red lines of con-
gested intertubular vessels. The cortex is generally
thick and paler than normal. It is translucent and of
yellowish appearance. (Plate iv.)
On microscopic examination the glomeruli may fill
their capsules, but they are often atrophied, the space
between the glomerulus and Bowman's capsule being
empty or filled with albumin, red corpuscles, dis-
quamated epithelial cells or leucocytes. In some
instances there seems to be a proliferation of the cells
lining the capsule. Outside the capsule, at times.
a space may be made out, filled with leucocytes and
red corpuscles. Within the capillaries of the glom-
eruli are numerous leucocytes, parasites and micro-
organisms, which may completely fill up the lumen
of the vessels. The leucocytes contain granular pig-
ment and parasites. Parasites are also present in
large numbers outside of the leucocytes. In the
glomeruli macrophages are generally few.
Turning to the convoluted tubules, these appear
dilated, the epithelial cells of which are swollen and
show evidence of degeneration. Fringing these epi-
thelial cells are small hyalin droplets. The tubules
are often plugged with granular and hyalin casts,
within the substance of which are blood corpuscles,
degenerated epithelial cells, pigmented granules and
yellowish urinary sediments or excretions. The inter-
tubular capillaries are also dilated and crowded with
the foreign materials found in the glomeruli. (Plates
iii and v. )
Plate III. Kidney —Figure shows enormous increase of connective
tissue which is infiltrated with rouud cells. macrophages, parasites and
pigment granules. Tubules are filled with hyalin caste In which ire
seen pigment granules and leucocytes. Zeiss Obj. D D, Oe. .">. Draw
tube 160 mm.
The changes in the interstitial tissue are usually
slight. Here and there may be seen areas of round-
cell infiltration, consisting of lymphocytes and large
mononuclear leucocytes. In severe cases these changes
may be great. (Plate iii.)
As a result of thrombosis extensive infarcts are
present, embracing glomeruli, tubules, blood vessels
and interstitial tissue. These infarcts are surrounded
by a strongly marked margin of deeply staining round
cells. It is in these thrombosed vessels, at the apices
and margins of the infarcts, that the greatest number
of parasites are found.
Fatty degeneration is present in the glomeruli, the
lining membrane of Bowman's capsule and muscular
coats of the arteries.
The heart on gross examination is practically nor-
mal in size and weight. The only constant patho-
logic change present is a brown pigmentation of the
myocardium and a slight thickening of the endocar-
dium. Calculus degeneration is commonly present in
the valves, associated with atheromatous degeneration
of great and coronary vessels.
On microscopic examination the only pathologic
1S5H5 )
MALARIA.
319
picture to be seen is in the muscular fibers of the
myocardium, where, at the polos of the nuclei of the
muscle cells an excess of brown pigment may be
observed.
Pathologic changes are common in the bone mar-
row. Macrophagi are present in great numbers and
show contents similar to those found in the spleen
and liver. Red corpuscles both nueleated.and degen-
erated may be seen in increased numbers, also leuco-
cytes whose nuclei are fragmented and filled with
pigment. The endothelial cells are also degenerate
and tilled with pigment.
On gross examination the lungs are either normal or
emphysematous and non-collapsing. When non-
emphysematous they are much darker than normal.
On cut section edema of dependent parts is observed.
Large and small bronchi are filled with a muco-puru-
lent secretion, showing general bronchitis. In a great
number of autopsies no lung lesions are present with
the exception of a slight general bronchitis.
Plate IV. Kidney.— Figure shows atrophy of glomerulus, Increase
of interstitial tissue, infiltration with round cells, parasites and pig-
ment granules. Kpitheliuni of uriniferous tuhules is swollen and
granular. Zeiss Obj. D D, Oc.5. Tube length 160 mm.
On microscopic examination the pleural and pul-
monary veins are seen to be dilated. Here malarial
organisms are present in great numbers, either
enclosed in the red corpuscles, free in the plasma or in
the leucocytes. Collections of pigment granules and
phagocytes may exist in sufficient quantities to plug
up the lumen of the vessels.
Pathologic changes in the brain are not numerous,
but those present are of great importance from a
clinical standpoint
On gross examination an increase in the spinal
fluid is observed. The dura is thickened and small
pigmented and hemorrhagic areas can be made out,
iciated with turgescence of blood vessels.
On microscopic examination infected corpuscles
and organisms are present in the phagocytes and
endothelium lining the capillaries. In the cerebral
tissue white infarcts with hemorrhagic margins are
quite numerous.
In the supra-renal bodies many pathologic lesions
are present which correspond closely with those
described as associated with the kidney, liver and
spleen.
Oligocythemia is always present in malarial fevers.
It is caused by the direct destruction of the red cor-
puscles by the organisms and is in inverse ratio to
the number of parasites present in the blood. A marked
reduction of red corpuscles is noted after the par-
oxysm, from which point there is a gradual increase
which continues to the beginning of the next par-
oxysm. In the mild tertian and quartan types during
the apyretic stage complete restitution of corpuscles
may be accomplished but in the severer form there
may be an actual decrease during this period. It is
quite a noticeable fact that restitution of red corpus-
cles takes place to a greater degree during the earlier
days of the disease than in the later stages. As the
disease lengthens in duration the decrease in red cor-
puscles may reach as low as one million corpuscles to
the cubic millimeter. After protracted sieges of
malaria the changes brought about in red corpuscles,
are marked. In the blood stream may be found
poikilocytes, degenerated and vacuolated red corpus-
cles, microcytes, macrocytes, normoblasts and megalo-
blasts. (Plate xvi.)
In regard to the leucocytes, their number follows
Plate V. Kidney. — Figure shows enlargement of epithelial cells
lining tubules aud increase of interstitial tissue, which is infiltrated
with round cells, macrophages aud pigment granules. Zeiss Obj. 112
oil. Oc. 8. Tube length 160 mm.
closely the changes noticed in the red corpuscles.
Directly after the paroxysm there exists a marked
leucocytolysis. At times the number may reach as
low as one thousand per cubic millimeter. From this
point ah increase is observed until during the first hour
of the paroxysm, when the count may be normal or an
actual leucocytosis exist. The degree of leucocytoly-
sis seems to depend greatly upon the size of the spleen.
The greater the size of the spleen the greater is the
leucocytolysis, a condition directly opposite to that
found in splenic leukemia.
The recuperative power of the leucocyte is much
less than that of the red corpuscle. In postmalarial
conditions the red corpuscle generally gains its nor-
mal state long before the white, but in some cases of
pernicious malaria a marked leucocytosis exists.
In regard to oligochromemia, its presence in mala-
ria, as would be naturally expected, is marked and is
generally in direct ratio to the oligocythemia. In
some cases the lack of hemoglobin is greater than can
be accounted for by the oligocythemia. No acute
infection known has such a depleting action upon the
320
MALARIA.
[August 8,
hemoglobin of the blood as malaria. Depending
upon the severity of the underlying cause this con-
dition may be brought about in a few days or be
the result of a long infection. (Plate xvi.)
As in oligocythemia and leucocytolysis, oligochro-
memia increases after the paroxysm and diminishes
gradually until the beginning of the following par-
oxysm. The rapidity and severity of the loss of
hemoglobin affords a valuable diagnostic aid in dif-
ferentiating malaria from pneumonia, typhoid fever
and enteric fever.
The relative number of phagocytes present in the
blood crresponds closely to that of the leucocytes.
The ability of the leucocyte to cope with the par-
asite seems to increase with the age of the leucocyte.
The small mononuclear leucocyte or lymphocyte which
is supposed to be the first stage in the development
of the adult form, possesses little or no phagocytic
power. The large mononuclear has some phagocytic
function, but is unable to cope with flagellate forms
of the organism. The eosinophile has never shown
any indications of phagocytic power. The greater
portions of the work done by phagocytes is therefore
accomplished by the large polynuclear leucocytes and
macrophages aided by the cells lining the blood
Plate VI. Liver. — Figure shows interlobular space with portal vein,
hepatic artery and bile duct and greatly increased connective tissue.
Pigment granules are seen in and between hepatic cells. Capillaries
are distended with many leucocytes. Connective tissue is infiltrated
with ronnd cells. Zeiss Obj. 1> D, Oc. 3. Tube length 160 mm.
vessels and endothelial cells of the liver and spleen.
As to the effect of the phagocytes upon the course
of the disease there are two theories. The first,
upheld by Grolgi, Bignami and others, goes to prove
that the spontaneous cure of malaria and the preven-
tion of the mild forms from becoming pernicious is
due to the action of the phagocytes in removing from
the body spores, adult organisms and degenerated
corpuscles. These men account for relapses by stat-
ing that when spores are contained in white corpus-
cles a struggle takes place between the two bodies, in
which the phagocyte is finally worsted. On the other
hand, Osier and others claim that phagocytes do not
play the most important part in cutting short the
course of malaria. To prove this statement these
observers call attention to the fact, that in severe par-
oxysms phagocytosis is most apparent, and that in cases
of spontaneous recovery there is no evidence of
increased phagocytosis, but rather an increase in the
number of degenerated organisms. They also call
attention to the rhythmic course which untreated
malarial fevers pursue. The paroxysms gradually
increase in severity, a period of fluctuation, then
spontaneous recovery followed in two or three weeks
by a relapse. If the checking of the course of the
disease depended upon the action of the phagocytes,
the fever would be allayed in the first part of its
course, for phagocytes are as numerous in this part
of the course as in the later stages.
The theory of these latter investigators is that
malaria is self- limiting and that at each period of seg-
mentation a toxic substance is thrown into the blood
stream, which becoming more and more virulent at
each succeeding paroxysm, eventually becomes suffi-
ciently potent to cause the death of the organisms,
only a few spores protected by degenerate phagocytes
surviving to be the source of a relapse.
Mannaberg claims that the temperature caused by
the body in reacting against the toxic irritants in the
blood, exerts also a deleterious influence upon the
half and full grown organisms.
Thus in summing up causes which may bring
about spontaneous cures we must take into considera-
tion these three factors, phagocytosis, toxic excretions
of the parasite and the temperature.
Plate VIII. Liver.— The figure shows a thrombosed vessel contain-
ing red blood corpuscles, small round cells, macrophages, parasites and
pigment granules. Pigment granules also in capillaries and in and
between hepatic cells. Capillaries are dilated and contain many
leucocytes. Zeiss Obj. D D, Oc. 8. Tube leugth 100 mm.
In consideration of malaria from a clinical stand-
point, it may be divided into the following forms: 1,
intermittent; 2, pernicious intermittent; 3, remittent;
4, pernicious remittent; 5, typho-malaria; 6, malarial
cachexia and irregular forms. The clinical manifesta-
tions of malaria may also be classified in reference to
the length of time between paroxysms: 1. Quotid-
ian, produced by the segmentation of two groups of
tertian organisms on successive days. 2. Tertian,
produced by a single group of the tertian organisms.
3. Quartan, single, double and triple, produced by the
quartan parasite. 4. Irregular or continuous, pro-
duced generally by estivo-autumnal parasites. The
first classification, as proposed by Thompson, is much
more complete and will be followed here.
Intermittent fever is caused generally by the tertian
or quartan parasite, rarely by the estivo-autumnal.
It is characterized by complete disappearance of
symptoms between paroxysms. Its course may be
divided into three distinct stages: 1, the cold stage;
2, the hot stage; 3, the sweating stage.
1896.]
MALARIA.
321
The first stage may appear suddenly or come on
gradually. It is preceded by a headache and general
malaise anil is characterized by a subjective sensation
of oold while the thermometer records a rise of inter-
nal temperature. The face is pale and pinched, the
skin cold, clammy and of the goose quill appearance.
Tin- pulse is weak and rapid and respiration shallow.
The patient complains of cold which abundant covers
will not relieve, muscular pains and headache. Asso-
ciated with the chill are often severe rigors in which
the patient shakes violently from head to foot. The
teet h chatter wildly and coherent speech is impossible.
The superficial, sub-normal temperature is caused by
the constriction of the peripheral vessels, resulting in
great internal congestion. This fact explains the
enteric, liver and splenic symptoms, evinced by fre-
quent nausea and vomiting and tenderness. The
paroxysm may be of varying duration. In some
instances it may last for but a few moments, associa-
ted with simply a chilly sensation, or feeling of weak-
ness, or it may last from two to four hours, accompa-
nied with great rigors and intense pain. In children
the chill may be replaced by a convulsion. There
seems to be no relation between the severity of the
chill ami the following hot stage.
The second stage is characterized by a gradual rise
in temperature which may reach as high as 106 F.
The face is flushed; the skin of the mouth, throat and
nasal passages hot and dry; the pulse full, rapid and
strong and frequently dicrotic. The respiration is
deeper; the headache and vomiting may continue,
but disappear with the fever. When the fever runs
exceedingly high the patient may sink into a coma-
tose or delirious state.
The third or sweating stage follows the fall in tem-
perature and is ushered in with a profuse perspiration.
This commences upon the face and forehead, but soon
the whole body is bathed in sweat, which often soaks
the bed clothes. During this stage the patient expe-
riences great relief. The headache, muscular pain,
vomiting, tender abdomen and splenic tumor disap-
pear. This is due in great part to the relaxation of
the peripheral blood vessels, which relieves the inter-
nal congestion. After the perspiration has ceased
the patient is greatly prostrated and may remain in
this condition for many hours. This stage lasts from
two to five hours and may continue from three to ten
or twelve hours. During apyrexia the temperature
is generally sub-normal.
The urine during and after the chill is increased in
solids, although there is a relative decrease in the
amount of urea excreted. Slight albuminuria and
glycosuria have been noticed during paroxysms.
Intermittent fever at times assumes a grave and
malignant aspect. It may be ushered by an ordinary
paroxysm followed by a severe one which in turn is
succeeded by a third and fatal one.
The following classification of intermittent per-
nicious fevers, based upon the most prominent symp-
toms, is given in the American Text Book of the
Theory and Practice of Medicine: 1, bilious; 2,
hemorrhagic; 3, algid; 4, asthenic; 5, comatose.
In the bilious form severe abdominal symptoms are
present. There is generally flatulency and tender-
ness of the abdomen, associated with the vomiting of
large quantities of bile, and watery discharges from
the bowels. The liver and splenic areas of dullness
are much increased. Jaundice may occur within a
few hours after the paroxysm.
The hemorrhagic form is always grave. During the
hot stage blood appears in the urine, which is
decreased in quantity and contains albumin and casts.
Soon there appear hemorrhages from the mouth,
stomach, rectum and skin. Suppression of urine
soon follows, with violent headache, delirium, coma,
Cheyne-Stokes respiration, heart failure and pulmon-
ary edema and death from uremic and malarial
poisoning.
The algid form simulates closely the algid stage of
cholera. Great prostration is present, associated with
purging, vomiting, muscular pains, superficial sub-
normal temperature and at times jaundice.
The asthenic form is accompanied by great nervous-
ness, imperfect aeration and feeble heart.
In the comatose form the patient may immediately
enter into the comatose state from which he can not
be aroused. If this first attack be survived the sec-
ond is certain to prove fatal. This form may be pres-
ent in any of the preceding types, but it is rare.
The same stages characterize the remittent forms of
malaria as the intermittent, with the exception that
the temperature rarely falls below 100 degrees F.
This form of the disease is associated especially with
the second cycle of the estivo-autumnal organism.
Remittent fevers may commence as intermittent or
they may immediately assume this form after a
severe initial paroxysm. The second stage is often
prolonged, lasting from twelve to twenty-four hours.
The third stage is not so prominent as in the inter-
mittent. During the interval between paroxysms the
patient is not as free from symptoms, complaining of
fever, nausea, vomiting and muscular pains. The
remission generally occurs during the night. The
fever may subside gradually, retaining its remitting
character or first become intermittent before
disappearing.
Penicious remittent fever is so nearly identical in
symptomatology with pernicious intermittent fever
that a separate description is not necessary.
Typho-malarial fever consists in a combination of
the symptoms of malaria and typhoid fever. It
begins with a chill followed by fever. The symp-
toms of this disorder may be most markedly those of
either of these diseases; however, the typhoid symp-
toms are generally most prominent, the malaria being
in evidence only by the variations in temperature.
Typhoid fever, when associated with malaria is not as
fatal as when existing alone.
Malarial cachexia is seen in persons who have had
many attacks of malaria or in those who have lived
for long periods in malarial districts. It is associated
with a pale, muddy complexion. Anemia and indi-
gestion are common. Circulation is poor and anasarca
may be present. There is lassitude and mental
depression. The temperature may be subnormal or
slightly elevated. There is generally an enlargement
of both liver and spleen.
Under the head of irregular forms are found many
disorders of malarial origin which may escape the diag-
nostician. It is in these that the blood examination
is of the greatest importance. In some instances the
chill may be entirely absent. This is termed "dumb
ague." In other cases the sweating stage is not pres-
ent, and again both the foregoing may be absent.
The entire paroxysm may be wanting, in the place
of which malaise is noticed, headache, diarrhea or
vomiting, with perhaps a very slight rise in tempera-
ture. Such patients are termed by the laity "bil-
322
MALARIA.
[August 8,
ious." Again the malarial paroxysm may appear in
the form of severe neuralgic pain associated with the
fifth, sciatic, brachial or intercostal nerves.
The diagnosis of pure types of intermittent fever is
readily accomplished without a blood examination,
based upon the peculiar quotidian, tertian or quartan
paroxysms and splenic tumor. These forms simulate
closely, however, the onset of pneumonia which is
later easily differentiated. Suppurative infection
should be excluded by careful examination for infec-
These forms may be confused with typhoid fever,
cholera, ulcerative endocarditis, pyemia, septicemia
and meningitis. It is in these cases that the micro-
scope is of invaluable aid to the physician and in
many cases is the only means of arriving at an accu-
rate diagnosis.
When rose-spots are absent in typhoid fever, a con-
dition which often exists, it may be simulated very
closely by the typho-malarial form of malaria. In
I yellow fever the characteristic symptoms, peculiar
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Plate XIII. Intermittent Quotidian oe Double Tertian Fever. Temperature Chart.
Plate XVI. Diagram of Blood Changes in Teetian Fever.— 1, Red Blood Corpuscles ; 2, Hemoglobin ; 3, Temperature ; 4, Leucocytes.
tion atrium and hidden foci. In these diseases the
chills and fever are irregular and no splenic tumor
«xists. When suppurative processes are present with
phthisis it is necessary to examine the sputum. Even
in cases where the symptoms are pathognomonic, cor
roborative blood examinations should be made, if
possible, in order to establish the type of organism
present.
On the other hand, when it is necessary to contend
with remittent and pernicious forms the diagnosis is
at times very difficult from a clinical standpoint,
onset, black vomit, jaundice and suppression of urine.,
are all simulated by pernicious malaria. The diag-
nosis of the algid stage of yellow fever from the algid
form of malaria is impossible without a blood exami-
nation. Ulcerative endocarditis can usually be dif-
ferentiated from malaria by a physical examination
of the heart, and pyemia by establishment of infec-
tion atrium. In differentiating uremia and menin-
gitis from comatose pernicious malaria it should be
remembered that coma comes on later in meningitis
than in malaria, and that it is accompanied with
18%.]
PRACTICAL NOTES.
323
photophobia and lowered temperature. Pernicious
malaria often merges into uremia and can be differ-
entiated only by the microscope. It is in the differ-
cntial diagnosis of malaria from the foregoing diseases
that the discovery of the organism of malaria has
worked its greatest benefit to the .medical profession.
This is especially true in the case of typhoid fever;
and it is probably a fact that to-day many nmlarial
patients are being treated for typhoid fever.
The prognosis of the milder forms of malaria is
always good. In the pernicious types it is grave, the
degree of mortality depending upon the vitality of
the patient, the promptness of treatment and accu-
racy of diagnosis.
Prophylactic treatment is very efficient. Taken in
connection with hygienic observations and pure
water, quinin will in most instances establish immun-
ity for a considerable length of time. Following this
treatment travelers have invaded the most deadly
malarial regions without serious results.
\s to the treatment of malaria, quinin is the
great panacea. Probably 95 per cent, of all cases
succumb to its effects.
Most observers agree that quinin causes the death
of the organism by direct contact when the parasite is
in the sporulating form outside the corpuscle. This
drug, when given two hours before the paroxysm,
even in fifteen grain doses, will not stop the oncoming
paroxysm but will prevent the spores from entering
new corpuscles. This fact seems to prove that the
adult segmenting organism is not affected by the
drug while the free and growing spores constantly
imbibing nourishment from the plasma of the blood
are readily destroyed. When the spores have gained
entrance into the corpuscles they are equally invul-
nerable as the adult organism. This goes to prove
that the hyalin body lives to a great extent upon the
protoplasm of the corpuscle.
As to the administration of quinin, two principal
methods are in practice at the present time. The
first consists in giving moderately large doses every
four hours until the paroxysms are overcome and then
gradually decreasing the size of the dose. The second
method is to give small doses during apyrexia with
very large doses from three to five hours before the
anticipated paroxysms. As many as thirty grains
may be given at one time. Good results follow both
these methods.
In some instances quinin can not be given on
account of individual idiosyncracies. But a few days
ago the writer saw a young girl the skin of whose
hands had completely peeled away as the results of
taking a few grains of quinin. In other cases this
drug in the minutest doses may produce distressing
symptoms of cinchonism associated with nervousness
and vomiting. In such cases the other alkaloids of
cinchona must be tried. Marburg's tincture is often
effective, and bone marrow and methylene blue have
been used with a moderate degree of success. Arsenio
is a powerful antiperiodic but is slower than quinin.
During the paroxysm palative treatment should be
used, as hot drinks and cloths during the chill and
sponging during the fever if the temperature rise
exceptionally high.
In pernicious cases quinin should be given hypo-
dermically and with great promptness and the patient
kept warm and quiet. The great object should be to
tide the patient over the first paroxysm and abort the
time of the second lest it should prove fatal. In
these cases the medicinal treatment, aside from the
administration of quinin, cathartics and diuretics,
should be largely symptomatic, and the symptoms
oonibatted as they appear.
As convalescence approaches, a nourishing and
easily digested diet should be arranged and the med-
ical treatment consist of tonics and simple bitters
with a moderate amount of healthful exercise.
BIBLIOGRAPHY.
Malarial Fevers of Baltimore. Thayer and Hewetson.
( isler's Practice of Medicine.
Lyman's Practice of Medicine.
American Text-Book of Medicine.
A Study of Some Fatal Cases of Malaria. L. F. Barker, M.B., Tor.
Centralblatt ff'ir Bakteriologie and Parasitenkunde.
(irundriss einer Klinischen Pathologic
The Leucocytes in Malarial Fever. John S. Billings.
The Malarial Disorders of Large Cities with Special Reference to
Chicago. Wm. E. Qulne. M.D.
Malaria as a Water-borne Disease. W. H. Daly, M.D.
Medical Diagnosis. J. B. Herrick, M.D.
Note.— The writer is under obligations to Dre. Bishop and Weaver
who kindly loaned him the pathologic specimens from which the
accompanying drawings were made, also Drs. Tice and RIchter of Cook
County Hospital, through whose courtesy he was able to procure the
blood specimens.
PRAGTI6AL NOTES.
Keratitis Dendritica. Dr. Prank Allport says, that from expe-
rience with the last cases under hiB care, the application of
absolute alcohol affords the most certain and rapid cure. He
soaks a bit of lint in alcohol and scrubs the surface of the cor-
nea with it. This may require to be repeated two or three
times.— Am. Jour, of Ophthalmology, July.
Loretin.— Drs. Nichols and Gee state that, loretin has been
used in the dispensary of the Medical College of Virginia for
over a year under most careful and conscientious observation
and with entire satisfaction. They have arrived at the defi-
nite conclusion that it not only equals, but surpasses, iodoform
in its favorable action upon the processes of granulation and
healing. As it is entirely odorless, it is obviously much more
pleasant than iodoform to handle.— Med. Bulletin, July.
Camphor in Strychnia Poisoning.— Dr. A. K. P. Meserve reports
the case of a child, 1% years old, who was supposed to have
taken 1-60 grain of strychnia. Characteristic symptoms of the
poisonous action of the drug soon appeared. In the absence of
a physician ten drops of tincture of camphor was given. The
effect was almost instantaneous, the spasms relaxed and when
a physician arrived, nearly an hour later, the danger seemed to
be over, tannin and a larger dose of camphor, gtt. xx were
administered, as a precautionary measure. Tbe next day the
child had fully recovered.— Journal of Med. and Science, July.
Diagnosis between Diphtheria and Tonsillitis in Children.— True
diphtherial exudation may commence at the orifices of the
crypts of the tonsil, but does not long remain limited to the
tonsils and muco-lymphoid glands of the pharynx, as does the
exudate of tonsillitis. The diphtherial membranes will extend
within twenty to twenty-four hours to the pillars, velum or
pharyngeal wall. The exudate of tonsillitis is thin and not
materially raised above the surface. It is white, translucent
and presents a living, clean aspect and no necrotic changes,
while the exudate of diphtheria protrudes from the surface, is
opaque and of a dirty yellow color. The exudate of tonsillitis
is punctated, the spots corresponding to the follicular openings,
and' two or more puncta may join each other at their borders.
In simple inflammation of the pharynx and in follicular tonsil-
litis as compared with diphtherial inflammation, the invasion
is more sudden, the temperature higher and the redness of the
throat more diffuse, and not confined to one side, as is fre-
quently the case in commencing diphtheria. In follicular ton-
sillitis the yellowish-white spots can often be removed from the
crypts which the secretion occupies, and the inflammation fre-
quently ceases in thirty-six hours, whereas in diphtheria it
324
PRACTICAL NOTES.
[August 8,
continues for a week or two. A doubtful looking layer of
mucus is often removed by having the patient gargle the throat
with some mild antiseptic or salt-water. The microscope of
course clears up the diagnosis if the Kleb-Loeffler bacilli be
present in large numbers. — Dr. Leo B. Auerbach in Denver
Med. Times, July.
Observations on Surgical Shock. — Dr. W. N. MacArtney says :
" In the human subject after crushing injuries of the limbs I
have occasionally seen the pulse very slow and strong, but
with a peculiar characteristic which should indicate to the
careful observer that shock was present. It is a pulse difficult
to describe, but which points unmistakably to a tendency to
cardiac spasm. There is a prolongation of the systole, which
encroaches upon and interferes with the diastole ; cardiac
spasm diminishing cardiac relaxation. This increase in the
length of the systole once recognized in the pulse is not easily
forgotten. This slow pulse indicates grave shock impending,
and where I have observed it, when, in spite of protests, opera-
tion was done at once on the theory that with such a pulse no
shock could be present, profound and sometimes fatal shock
followed. It is a warning not to be lightly disregarded. In
these cases do we have vaso-motor paralysis or does vasomotor
spasm precede the paralysis? The term vasomotor paralysis,
however, is so ambiguous that some uncertainty exists as to
the exact meaning. There are vasoconstrictor and vaso-dila-
tor fibers, and the term vasomotor paralysis might be con-
strued to mean either or both." — Charlotte Med. Journal,
July.
Acute Milk Infection. — Dr. W. H. Wells says : One of the most
fatal of diseases is cholera infantum. Its causes are always
the same, namely, the poisons produced by various forms of
pathogenic milk bacteria. It is always found in infants fed on
artificial foods containing milk. It seems particularly viru-
lent in infants fed continuously on condensed milk, or the
various dextrinized foods which are intended to be used with
milk. The child having once taken milk containing the germs
no amount of subsequent feeding on sterilized or Pasteurized
milk will prevent the continuation of the acute poisoning. The
point in the treatment which is of the first importance is to
take the child absolutely from a diet of milk and all substances
containing it. Tha second indication is to free the system as
quickly as possible from the milk poison with which it is
already charged. The plan generally followed is to give the
child no food at all for twenty-four hours and sometimes
longer. During this time cold sterilized water into which fif-
teen or twenty drops of good brandy or whisky have been
dropped, can be given to the child every hour. — Philadelphia
Polyclinic, July.
Suburethral Calculi in the Female.— The Rev. Int. de M. et de C,
for June 25, remarks of an article on this subject in the April
Annates des Mat. des Org. Oen.-Ur., that it fills a gap in medi-
cal literature, as there is no other study of the calculi formed
in the urethrovaginal wall. These suburethral calculi are
rare, and are different from the calculi of the urethra itself.
The pocket forms in the anterior wall of the vagina, below the
under surface of the urethra, into which it opens, one centime-
ter at least, above the meatus. The walls are usually com-
posed of the vaginal mucous membrane, a layer of muscular
tissue and of urethral mucous membrane, with a fibrous inter-
growth and enlarged veins. The contents are a scanty yellow-
ish liquid, sometimes sero-purulent, urine mixed with blood,
with the calculi, generally ovoid in shape, but always of urin-
ary origin. The symptoms are obscure ; distress when seated,
increased by walking and relieved or abolished, by reclining,
with frequent and painful mictions, each followed by an invol-
untary discharge of a few drops of urine. Hematuria may
also exist, with trouble in coitus. Investigation reveals a hard
and painful tumor in the anterior wall of the vagina, with crep-
itation if there is more than one calculus. Certainty is attained
by introducing a curved, grooved sound into the urethra, with,
the finger in the vagina. Spontaneous recovery is rare. The
urethrocele sometimes discharges its contents into the urethra-
and heals, but new calculi are apt to form or a fistula persist.
The best treatment is an urethrovaginal incision, with resec-
tion of the pocket and complete suture on two separate planes.
Strangulated Hernia.— Dr. Alexander Hugh Ferguson says,
that in a case of stranulated hernia, judicious and peristent
taxis, carried out for five minutes, is long enough to tell of its
inefficiency without an anesthetic. This being administered,
taxis may be tried for five more minutes. At the expiration of
this time, all preparations for herniotomy should be complete,
and if taxis had failed, no time would be lost before liberating
the strangulation. The dangers of prolonged taxis are : 1, ulti-
mate failure and increased injury to the hernial contents ; 2,
rupture of the bowel ; 3, the reduction of so traumatized and
gangrenous a bowel as to cause peritonitis ; 4, reduction en
masse, i.e., without liberating the bowel; 5, intraparietal
reduction and reduction into the canal ; 6, the non-detection of
a second strangulation should it be present ; 7, the rupturing
of the sac and the forcing of the gut through the rent between
the peritoneum and abdominal wall ; 8, a diseased and perfor-
ated vermiform appendix may be reduced ; 9, reduction en
bissac, i.e., the forcing of hernial contents into a congenital
pouch or diverticulum ; 10, bruising of the contents and hem-
orrhage into the sac is common. Most of these complications
are rare, but they have all been encountered. — Chicago Med.
Recorder, July.
Simple Treatment of Chronic Catarrhal Deafness. — Dr. B. Alex.
Randall says, in the majority of cases, decided improvement
will follow rational treatment, and though this may leave the
patient possessed of only a remnant of hearing, it may be
many times greater than before, and a most acceptable benefit
to him. For the attainment of this result, no elaborate meth-
ods or apparatus are needed. "The nasopharynx, from which
the affection proceeded, must first be gotten into better condi-
tion. Only a small proportion of cases will present deformities
or hypertrophies, which compel operative intervention to free
the air passages. Vigorous spraying with an alkalin fluid in
the hand atomizer, will generally suffice to cleanse the pharynx
vault, but must be supplemented by mopping the region of the
tube-mouths, and any parts to which the mucus clings, with
the bent applicator, generally charged with glycerole of tannin
or of iodin. An oil spray can usually advantageously follow, that
of menthol-camphor, 1 to 2 per cent., for most cases. This gives
a protecting coating to surfaces denuded of their usual cover-
ing of mucus, and about to be exposed to the outer air, while
it medicates the cavities with a stimulating, disinfecting vapor,
which will saturate every breath of air passing into the nose
for a considerable while. It lubricates the nose, too, for the
easy passage of the catheter." A good catheter is a very
important factor. One of 3 millimeters external, and 2 milli-
meters internal diameter, 13 centimeters long, made of silver
to secure pliability, serves in all but exceptional cases. The
auscultation tube is very necessary. Only by its aid or the
examination of the drum-head later can we determine that the
tympanum is actually reached by the inflations. With the
catheter properly placed it is easy to substitute the atomizer
with its oily spray for the air bag and spray the fluid freely up
the tube. Pure fluid petrolatum is recommended for this pur-
pose, but probably more can be accomplished by medicating it,
usually with from 1 to 2 per cent, menthol-camphor. Careful
massage with the pneumatic speculum of Siegle or similar
apparatus should complete the procedure. Without denounc-
ing the "new" and "radical" procedures which are con-
stantly being thrust into notice, better results can generally be
secured by avoiding these innovations — University Med. Mag.,
July.
1896.]
PRACTICAL NOTES.
325
Application of Qastrlc Juice la Therapeutics. Fremont an-
nounced at a recent meeting of the Acadeniie de Medecine,
that lie had been very successful in relieving and curing gastric
disturbances, such as enteritis, grippe with gastrointestinal
complications, apepsin, etc., by administering gastric juice
obtained by isolating the stomach of dogs, according to his
method previously communicated.
Treatment with Serum from Convalescents. Weisbecker has been
experimenting with serum from patients recovering from
measles, with which he injected others in the incubatory stage.
He considers the results quite satisfactory, as the incipient
disease was very much modified, and cases of measles pneu-
monia cured. He urges others to continue these experiments
with serum which nature herself has immunized, in scarlet
fever, measles, etc. — Therap. Wochenschrift, June 28, from
Zcitschr.f. A7. Med., Nos. 3, i.
Tannigen in Diarrhea. — Tannigen is a diacetyltannin, and like
tannalbin isee Journal, June 27) does not release its tannin
until it reaches the lower alkalin secretions. Bachus reports
marked success with it in seventy cases, and no unfavorable
accompaniments. In some cases the improvement was sur-
prisingly rapid. The dose for an adult was as much as could
be taken up on the point of a knife, and for children 0.25 grams,
three times a day. The only failures were in a few cases with
ulcerous or tuberculous complications. The diarrhea ceased
in two or three days in the forty -one cases of children treated.
He preceded the tannigen with three powders of calomel, at
0.008 to 0.01 gram, in severe cases (Milnch. Med. Wehnsch.
Dec. 37). Schneider calls attention to the fact that tannigen
becomes viscid at the temperature of the body when moist,
and therefore he recommends mixing some insoluble substance
with it (like silica one-half to -one-tenth part), to prevent the
adhesion of the particles of the tannigen. — Nouveaux Remedes,
June 8.
Cardiac Therapeutics. — A hypertrophied heart sometimes needs
aconite or bromids to restrain an excess of effort. If bromids
are used, that of potassium should be avoided on account of
the especially toxic action which it has on muscle. Perhaps a
conspectus of the drugs which have been commonly used to
add to the heart's force, will aid in making a rational choice.
Tonic and sedative — Digitalis, tonic, slows pulse, cumulative,
contracts arterioles, diuretic ; spartein and convallamarin,
similar, but not so powerful and not cumulative ; squill, prac-
tically digitalis plus a nauseating but stimulating expectorant :
strophanthus, digitalis minus cumulative action and with very
little action on the arterioles ; caffein, digitalis plus cerebral
stimulant and with especial diuretic action, not cumulative but
secondary depressing action liable to occur ; cactina, not well
understood. General supporter — strychnin. General regula-
tor— atropin which is stimulant to arterioles in small dose,
relaxing in large dose. Emergency class — ammonia, accelera-
tor and stimulant ; alcohol and ether, slightly accelerating and
stimulant, vascular dilators, later depressing ; amyl nitrite,
nitro-glycerin, etc., vascular dilators, scarcely stimulant to
heart muscle. — Dr. A. L. Benedict in Am. Therapist, July.
Formalin in Dental Practice. — Abraham, in Zahndrztliches
Woehenblatt is quoted in the London Therajjist, June, as fol-
lows : By the use of this substance he has been enabled to avoid
that form of secondary periostitis that so often complicates
the treatment of periodontitis. It is his belief that the vapors
of formalin have a regenerative influence upon the diseased
periodonitum and promote restitutio ad integram. The method
of formalin treatment made use of by the author more recently
is less complicated, and less likely to cause pain by the formalin
accidentally overflowing on the surrounding tissue. He makes
use of a powder, calc. sulphas., 200 ; hydrarg. bichlor. i. These
to be finely mixed, also a liquid form, acid sulphuric 32 ; for-
malin, 100; aq. destil. 100. A few drops of the liquid are rub-
bed on a glass plate together with sufficient of the powder to
form a paste, which, introduced into the previously dried root
canal, solidifies in a few minutes. The crown can be filled
with any stopping desired. The small quantity of corrosive
sublimate and sulphuric acid in the paste, does not have any
discoloring or corrosive effect on the tooth. The above propor-
tions have been found to be the best as a result of numerous
trials, and this formalin root cement may be employed safely
after cautery of the pulp, etc., and for closing the foramen pia-
cale. In a few cases, after employing this cement a slight peri-
ostitis without pain has appeared, continuing only one or two
days.
Morbus Basedow! a Neurosis.- Hoesslin questions the r61e gen-
erally attributed to the thyroid gland in the evolution of this
disease. He considers it a neurosis, and describes several
unusual features in some cases he has had under observation
for years (Milnch. Med. Woeh., No. 2). One case (6yearsi was
distinguished by the marked rhythm of the pulse ; it grew fast
in the morning and slow at night. The attacks of tachycardia
were also peculiar, beginning so suddenly that the pulse would
jump from 130 to 250 in a minute, and ending as abruptly, with
the phenomenon of a sudden violent contraction of the heart.
These attacks lasted from an hour to weeks, and were most
distressing. In another case the struma fluctuated in size,
growing smaller as the tachycardia developed, and increasing
as the latter subsided. A typical leucoplasia also formed on
the tongue, forming a "lingua geographica" with painful
cracks, as the disease reached its height, and subsiding with
it, which Hoesslin attributes to sympathetic action of the
vagus. In one case the patient ascribes his recovery to the
vegetable diet which Hoesslin enforced for three years. He
states that the attacks of tachycardia were much relieved or
prevented by several successive rectal injections of opium, 20
to 30 drops of the ordinary tincture in a mucilaginous medium.
All other treatment proved ineffectual. — Deutsch. Med. Woeh.,
June 25.
Brenz-catechuin Located in the Suprarenal Capsules. — It is
announced from the Path. Inst, at Berlin that the presence of
brenz-catechuin (pyrocatechuin) in the suprarenal capsules
has been definitely established. It has hitherto baffled inves-
tigators, as it did not respond to the usual tests, owing to its
combination with a still unknown substance, from which it
has finally been successfully separated. It is secreted in the
medullary substance, and it is an interesting fact that the part of
the medullary substance next the cortex is the deepest in color.
Brenz-catechuin is turned brown by contact with the air, and
alkalins, which explains this fact, and is also probably the
explanation of the bronze pigmentation in Addison's disease.
As it is a poison, abnormal secretions of it may not only be
responsible for the pigmentation, but also for the other symp-
toms of this disease. It has been much disputed whether it is
to be attributed to abnormal functions of the suprarenal cap-
sules or of the celiac ganglion. The present investigators con-
sider it settled that the former secrete the brenz-catechuin,
while the latter or the suprarenal plexus, neutralize its toxic
effects in normal conditions. The announcement in the
Deutsch. Med. Woeh. for June 25, is soon to be followed by a
more comprehensive report in Virchow's Archiv.
A Case of Antipyrin Eruption.— Dr. H. W. Webber of Plymouth,
reports in the London Lancet, an interesting case of the above
nature. The patient was a woman aged 53 years, who had
two months previously undergone supravaginal amputation of
the cervix uteri for cancer. "On Dec. 7, 1895, I found the
entire surface of her body covered with a copious eruption
exactly resembling in appearance that of a severe case of
measles ; the face and eyelids were also swollen. The temper-
ature was 101.4 degrees F. and the pulse 102. She had been
taking ten-grain powders of antipyrin twice daily for the pre-
vious three weeks for the relief of pain extending down the
right thigh. These had produced no ill effects, but it appeared
on the evening of December 5, she had eaten some unwhole-
326
PRACTICAL NOTES.
[August 8,
some food, the results of which no doubt interfered with the
proper elimination of the drug. Three grains of calomel and
a mixture of ammonium acetate were prescribed, and the next
morning the skin was almost free from eruption, the swelling
of the face had subsided, and the temperature had fallen to 98
degrees. The antipyrin was omitted and pills containing a
quarter of a grain of morphia were substituted. Finding,
however, that these did not relieve the pain so well as the anti-
pyrin had done, after a few days the patient recommenced tak-
ing the powders. After a second dose swelling and redness of
the face came on and she had again to leave them off. No
symptoms of cardiac depression appeared to be produced by
the drug in this case."
Codes' Fracture. — Dr. J. B. Morgan {Southern Medical Record,
July, 1896) says : "A great deal has been said and written about
the diagnosis of this typical fracture ; but two points only are
necessary to observe, in order to arrive at a correct diagnosis.
The marked displacement of the whole hand toward the radial
side of the wrist, and the relative position of the styloid
processes of the ulna and radius. In the natural condition of
the parts with the arm hanging by the side, the styloid process
of the radius is on a lower level than that of the ulna ; that is
to say, nearer the ground. After fracture, this process is on
the same or higher level than that of the ulna. The first
requirement in treatment is to effect exact reposition. The best
way to effect this is with the patient's hand in pronation, you
grasp his forearm with one hand, in such a way that while the
radius is firmly held, your thumb rests just above the line of
fracture. With the other hand, you grasp the hand of the
patient, so that your thumb presses firmly upon the back of
the lower fragment. The hand is now carried strongly back
toward the dorsal aspect of the radius in forced and extreme
dorsal flexion, until you feel by palpation that the lower frag-
ment has become unlocked, and can be pushed into place by
your thumbs, while at the same time, the patient's hand, under
strong extension, is carried into the normal position. The best
temporary and, in most cases, the best permanent dressing is
Wyeth's modification of Pilcher's. It is applied as follows:
Roll two pieces of a bandage, two inches and a half wide, into
a compress about as thick as the little finger. After reduction
is complete and the hand brought back into straight position,
place one compress along the inner aspect of the ulna, extend-
ing from the anterior margin of the carpus upward, the other
parallel with this, along the outer border of the radius, over
the styloid process. Secure them by strips of adhesive plaster,
one inch in width, wound around the wrist and arm, from the
upper to the lower end of the compresses."
Etiology and Diagnosis of Epidemic Cerebro-splnal Meningitis.. —
Heubner arnounces in the Deutsche Med. Woch. for July 2,
that he has succeeded in locating in the spinal fluids of patients
suffering from epidemic cerebrospinal meningitis, the microbe
discovered not long ago by Jaeger, in necropsies after this
disease. He has also established its pathogenic action by suc-
cessfully inoculating with it a couple of goats, after failing'
with rabbits, guinea pigs and dogs. The microbe is found
inside the pus cells, and is in the form of a diplo- or tetra-
coccus, not long nor lance shaped, but broad and arranged
side to side, recalling the gonococcus in this respect. It devel-
ops luxuriantly on agar, dirty yellow in color, but shining like
varnish. The experiments on animals showed that it is not a
virulent microbe like the pneumococcus, which corresponds to
the facts observed in epidemics of the disease. A pneumo-
coccus meningitis ends fatally in a very few days. (Netter
records sixty -one deaths in sixty-eight cases.) In epidemic
meningitis on the other hand, only a h,alf or third terminate
fatally, and they frequently last weeks and even months. This
also explains the relatively small number of cases in an epi-
meningococcus intracellulars is the factor in epidemic mening-
itis, then Quincke's "lumbar puncture" with aspiration of the
spinal fluid, will become of still greater importance, enabling
us to differentiate at once sporadic cerebrospinal meningitis
from isolated cases of epidemic cerebrospinal meningitis.
Hemostasis of the Bones with Shoe Nails. The Semaine MM. of
July 8 states that Professor Rapin of Lausanne controlled the
hemorrhage during a Kraske operation by stopping the blood
vessels in the bone with a small shoe nail which he inserted in
each. They were left in place until the suture was to be made ;
no further hemorrhage occurred after their removal. Six of
these little nails sufficed to arrest completely the hemorrhage
across the surface of the sacrum.
The American Blood Test for Cattle Tuberculosis.— Dr. Ephraim
Cutter compares the morphology of human blood in health
with that of tuberculous subjects and says that consumption
can be detected before there is any appreciable lesion in the
lungs. He states the points of similarity of kine tuberculous
blood to that of man are : White corpuscles enlarged often
more than in man ; the mycoderma aceti or vinegar yeast is
present as in man. It is on this yeast the diagnosis is made.
He summarizes the advantages of the blood morphologic
test over that of tuberculin, in cattle, as follows : 1. It is
simple, readily learned, easily applied. 2. It introduces no
diseased matter into the blood to set up efforts to expel dis-
eased tissues (not to stop causes), which efforts of expulsion
cause fever. 3. It allows the diagnosis of the pretubercular
stage and the cure of the cattle ; tuberculin is of no value
except when there is actual disease and breaking down of the
lungs, i. It does not involve the loss of the kine. 5. It is
always good so long as pre-tuberculosis or tuberculosis exists ;
and as in man, is of immense value in making negative diag-
noses when neither tuberculosis nor pre-tuberculosis exist. 6.
The amount of the yeast spores present is a sort of measure of
amount of the lesion ; the more the disease the more the yeast.
7. It can be applied often and harmlessly. 8. It is commoii
sense in principle, as it treats of causes, while tuberculin
treats only with results, not influencing causes. 9. It is the
best means of detecting tuberculosis and pre-tuberculosis in
man and kine. He says that the evidence is overwhelming
that tuberculosis comes from food, in excess and long-contin-
ued, which either before or after ingestion undergoes the acetic
acid fermentation. — New England Med. Monthly, July.
Lithium Preparations.— The New York Medical Journal gives
the following abstract, which states that the Therapeutische
Wochenschrift for April 5, mentions in a list of new remedies,
two preparations of lithium. The first is the American tartar-
lithin or lithium bitartrate. The Wochenschrift remarks that
it is much employed by American physicians in the treatment
of Riggs' disease (pyorrhea alveolaris) on the theory that that
form of suppurative gingivitis is of a gouty nature. The cal-
careous collections about the roots of the teeth are said to con-
tain, beside the ordinary calcium carbonate and phosphate, a
considerable amount of uric acid, calcium urate and sodium
urate. Dr. E. C. Kirk is cited as having found tartarlithin a
remarkably efficacious remedy in this affection, superior to any
other lithium salt. Its diuretic action is manifest in many cases,
but with some persons it acts as a laxative. Five grains may
be given three times a day, dissolved in a glass of carbonic-acid
water. The other preparation is lithium brornid, which is
described as a grayish-white granular powder, soluble in water
and in alcohol. The efficacy of this compound in gout is attrib-
uted by Mendelsohn to its diuretic effect rather than to any
action as a solvent of uric acid. Polakow has employed lithium
bromid in acute and chronic parenchymatous nephritis and
found its diuretic action accompanied by diminution of the
excretions of albumin and subsidence of edema, even when the
patients were not on a milk diet or subjected to any other reme-
dial measures. Polakow uses lithium bromid in the following
prescription : Lithium bromid, 1 to 2 parts, sodium bicarbonat
4 parts, distilled water 200 parts. Mix. Sig. : Three or four
demic. Heubner adds that when it is once accepted that this I tablespoonfuls to be taken in the course of twenty-four hours.
18%.]
EDITORIAL.
327
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SATURDAY, AUGUST 8, 1896.
THE NOMENCLATURE OF DISEASES.
The want of an authorative and uniform standard
nomenclature of diseases, for the purposes of regis-
tration, has long been felt in this country by registra-
tion officers and scarcely less by medical writers.
The confusion that long existed in the materia medica
nomenclature in the middle ages was measurably cor-
rected by Simon of Cordo, who was physician to Pope
Nicholas IV and chaplain to Pope Boniface VIII,
but no similar service was rendered the profession in
regard to the nomenclature of diseases until the pres-
ent century.
As nearly every reform in medical methods in this
country has had its origin in the American Medical
Association, so we find that as early as 1847 a system
of classification was adopted by the Association, and
in 1851 a Committee was appointed " to consider the
subject of registration of births, marriages and deaths,
and to use their influence to cause the same to be
adopted by their respective legislatures." The Com-
mittee had no general meeting, but the chairman, Dr.
Edyyakd Jarvis, of Massachusetts, reported at the
meeting held at Washington in 1858 in favor of the
nomenclature prepared by Dr. William Farr, of
London, which had been adopted by the Registrar-
General of England, and in this country by Massa-
chusetts.
The report of Dr. Jarvis was not adopted at this
meeting, but referred to a special Committee consisting
of W. L. Sutton of Kentucky, Edward Jarvis, Massa-
chusetts, Edward M. Snow, Rhode Island, Wilson
Jewell, Pennsylvania and R. W. Gibbes, of South
Carolina. The report of Dr. Sutton the following
year, signed by all the members, recommended
adherence to the nomenclature adopted by the Asso-
ciation in 1847, because many of the States had sub-
sequently adopted it and it was still in use. They
made very few alterations, but left the twelve classes
according to the original and added two, viz.: 1,
zymotics; 2, diseases of general ulceration, or unr-
ealized seat; 3, diseases of the nervous system; 4,
diseases of respiratory system; 5, diseases of the cir-
culatory system; 6, diseases of the digestive system;
7, diseases of the urinary system; 8, diseases of the
generative system; 9, diseases of the locomotive sys-
tem; 10, diseases of the integumentary system; 11,
old age; 12, from external causes; 13, from causes not
specified; 14, stillborn.
No action was taken on the report except to refer it
to a committee, and the minutes are silent as to any
further action, but the meeting in New York City in
1864, on motion of Dr. Cyrus Ramsay of New York,
passed a resolution of thanks to Dr. Appleton Howe
of Massachusetts and Dr. Johnson Gardner of
Rhode Island for having, while serving as State sena-
tors in 1842, secured the adoption of the (Parr)
nomenclature. In 1867 Dr. Christopher C. Cox
presented the Association with advance sheets of
the "Provisional" nomenclature, proposed to be
adopted by the Royal College of Physicians of
London.
At the meeting held in 1869 a Committee was
appointed "to determine what alterations, if any, are
necessary to adopt the 'Provisional' nomenclature to
general use in the United States." This committee
consisted of Francis Gurney Smith, George B.
Wood, S. H. Dickson and Alfred Stille of Phila-
delphia, S. E. Chaille of New Orleans, J. J. Wood-
ward and George A. Otis, U. S. Army, W. S. W.
Ruschenberger and Ninian Pinkney, U. S. Navy,
Alonzo Clark of New York, Edward Jarvis of
Massachusetts, Wm. M. McPheeters, of St. Louis,
L. P. Yandell of Louisville, A. B. Palmer of Ann
Arbor, Theophilus Parvin of Indianapolis, and R.
F. Michel, Alabama. Surely as strong a Committee
intellectually as was ever appointed by the Associa-
tion on any subject. This committee issued 1,000
printed copies of the English and Latin portion of
the proposed nomenclature to the members of the
Association for criticism and comment, but outside
of the membership of the Committee, but three
replies were received by the chairman; a majority
and minority report resulted. The majority favored
the adoption of the following resolution :
Resolved, That the American Medical Association be
requested to appoint a committee to prepare a nomenclature
of diseases which, on approval by the Association, shall be
328
THE LEAST ATTRACTIVE DUTY OF THE SURGEON.
[August 8,
submitted to the medical practitioners of the United States
for adoption and observance.
Dr. Austin Flint and Dr. Chaille favored the
adoption of the London nomenclature.
The Medical Society of New York sent a paper on
the subject of the nomenclature, and through Dr.
Alfred Underhill moved that it be substituted for
the report of the Committee, but the majority report
of the Committee was adopted.
In accordance therewith, at the meeting held in
Philadelphia, 1872, the Committee reported the prep-
aration of a nomenclature. They offered a system
based upon the provisional nomenclature of the Royal
College of Physicians, with some additions and modi-
fications. They gave precedence to the English over
the Latin names, an example which was followed when
the London nomenclature was finally published. The
Committee reported that they had held nearly fifty
meetings in the two years. This report also had a
majority and minority report, Drs. A. B. Palmer,
Austin Flint, J. J. Woodward and George A. Otis
asserting that they had not attended the meetings of
the Committee and had had no time to examine the
report. The Association thereupon voted the distri-
bution of the proposed nomenclature before final
adoption. At the meeting at St. Louis in 1873, the
" Philadelphia " nomenclature, as it was called by Dr.
Woodward, was reported by a majority of the Com-
mittee. Dr. Woodward, representing the minority,
asserted that the proposed nomenclature was inferior
to that of the British, and that "as it was advisable
to have some nomenclature which should be recog-
nized wherever the English language was spoken, it
would be advisable, until some definite plan was
adopted, for that of England to be used, there being
so many objections to that of Philadelphia as to render
its adoption inexpedient." He then proposed the
rejection of the majority report, and the appointment
of a committee of three whose duty it should be to
communicate with the Royal Physicians of London,
and to negotiate for representation of the American
Medical Association in the first decennial revision
of their nomenclature. This was adopted, and the
Committee consisted of Drs. Woodward, Edward
Jarvis of Massachusetts, and Alfred Stille of
Philadelphia. It was also resolved, on motion of Dr.
Toner, that the occasion of the centennial celebra-
tion at Philadelphia was opportune for the consider-
ation of plans for the adoption of an universal nomen-
clature for use by the profession throughout the world.
The action of the Association was in effect the
adoption of the London nomenclature, and in Octo-
ber, 1873, the late Dr. John M. Wood worth, the
Supervising Surgeon-General of the Marine-Hospi-
tal Service, issued formal regulations adopting the pro-
visional nomenclature of the Royal College of Physi-
cians as the official nomenclature for the use of that Ser-
vice, and in 1874 and 1878 republished the nomencla
ture and distributed them to the Medical Corps, and to
health officers generally. The American Public Healt;
Association also indorsed the nomenclature in 187;
The second edition of the nomenclature began
be considered by the Royal College in October, 1880,
and to the Committee, Dr. Chas. F. Folsom of Bos-
ton, and Dr. John S. Billings, U. S. Army, gave aid
and suggestions. The revision was completed am
the book issued late in 1885. This revision w
adopted by the U. S. Marine-Hospital Service by
circular issued Nov. 7, 1885, by Surgeon-Gener:
Hamilton.
The third edition of this nomenclature, being i
second revision, has just been issued by Her Majesty':
Stationery Office in London, and we regret to noti<
that no American representation was had in this revi-
sion. The Italian version which was included in the
former editions has been very properly omitted from
this. This revision necessarily has made man;
changes, for pathology has been greatly changed b
the discovery of the microbic cause of many diseases
and the section relating to bacteria is entirely new.
There may well be question whether more frequen
revisions are not required, for no sooner has a nomen
clature been promulgated, than the progress of dis-
covery and changes in art make portions of it behind
its time, and by the end of the decade, the whole
nomenclature is well-nigh obsolete, although, for the
essential of uniformity, it must still be used until offi-
cially changed. The general plan of former editions
has been retained in this, while many new terms have
been introduced.
to
th
:
».
)N.
so
ur-
THE LEAST ATTRACTIVE DUTY OF THE SURGEON.
The specialized surgeon of the present has
many things in his favor, as compared with the sur-
geons of fifty and a hundred years ago, that it becomes
necessary at intervals to " shake him up, " and remind
him of his full duty, a part of which is unwelcome to
the minds of some of us. It is related of the late
Professor Alfred C. Post, of New York, that his
sense of rectitude led him to unduly emphasize,
before his classes in surgery, the fatalities that
occurred in his practice. Dr. Post was a surgeon in
every sense of the word; he was actuated always and
only by the highest motives, and yet his formula,
" But, gentlemen, the patient died, " recurred so fre-
quently in his prelections that the average student
often wondered, what, after all, is the good of surgery?
Both Von Nussbaum and Sir James Paget have
recognized the less welcome side of surgery, its con-
tretemps, its disasters. We quote the British Medi-
cal Journal, May 16, in further confirmation of this
thought which is never far distant from, if never
fully formulated in, the genuine surgeon's conscious-
ness: "The ideal of the surgeon, as Plato said of
1896.]
MEDICINE OR QUACKERY .?
329
his idea] republic, is laid up in paradise for him who
will behold it and regulate his life according to it.
And the recognition of nil the slight defects of average
surgery will surely help toward a clearer sight of our
ideal. In every walk of life, the recognition of our
demerits is essential to improvement of our practical
work. An operation that is faultless is a wonder
indeed, and most operations are far from faultless;
the exquisite accuracy, fine touch, resource, insight,
swift decision which the public attribute to the sur-
geon are seldom seen in practice. But if the surgeon
will keep a daily record of his slightest faults he will
find a sure way of improving his skill. ' Live in your
own heart,' says Persius, ' and you will then find how
scanty your furniture is.' And if he desires the
advancement of surgery, let him not be. silent, or like
an ostrich hide his head in the sand of success and
think that nobody sees the tail feathers of failure. It
would be a good rule for every hospital surgeon to
point out to those round him at least one slight
defect in each operation, and seldom to publish
isolated cases; for these, as a rule, are of no great
value unless they are ahead of what other men have
done.
" Two suggestions are pertinent to him who wishes
to fill the blank left in the literature of surgery by
the want of any regular record of our faults. It is
not proposed to set apart a confessional of surgeons,
for that has been tried before, and commonly with
the result that the confessions were loaded down with
an unprofitable vicarious impleading of the faults of
others. But there is a real need of a careful and com-
plete statement of the defects of surgical work. Von
Xissisaim's essay, published in 1887, isonly a sketch
of what might be done. He begins with the dangers
of the anesthetic; next, the general risks of operation,
such as hemorrhage, septic absorption and traumatic
delirium; then he considers the mistakes made in
various operations, some of them belonging to minor
surgery, such as tenotomy, circumcision, puncture of
hydrocele, removal of tonsils; others being of a graver
character, such as tracheotomy, ovariotomy and the
operation for strangulated hernia. He gives examples
of faults in all these operations and in many others;
and indeed the ways of error in tracheotomy and
herniotomy, to take these two only, are many and
hard to avoid; each one of them might well afford a
whole chapter of accidents. But his essay is short,
incomplete and somewhat old fashioned; we want a
full, careful, fresh account of the defects of surgery.
Happily grave errors are rare; it is the trivial faults,
the slight mistakes of skill or judgment, many of
them so slight as to have the least influence on the
result of the operation, that require to be set forth.
The risks of the anesthetic, the drawbacks of this or
that antiseptic lotion or dressing, the disadvantages
that "may attend the boiling or instruments, these
might go toward the first chapters of the essay. But
the essayist would find that his chief business lay
apart from these subjects, in collecting, arranging and
criticising all the small techinal faults of operative
surgery, and thus raising the standard which we
desire to reach.
"Our second suggestion is that surgeons should
publish less often isolated cases, and more often
groups of cases, sets of consecutive operations, every
example that has come under their care. This has
been done by many surgeons — Sir Spencer Wells,
Mr. Knowsley Thornton, Mr. Herbert Allingham,
and others; the method may be studied in such
works as Bardeleben's Klinik, or in some of our
hospital reports. This is the way to advance knowl-
edge and to carry conviction; and we may be sure,
for example, that Sir Spencer Wells would have
had even greater difficulty in establishing the success
of ovariotomy if he had published only selected cases;
it was just because he published every case that he
won the field for the operation and for himself a
name that will not soon be forgotten. "
It is as Von Nussbaum says, a single reverse has
more teaching in it than ten successful cases. Students
are quick to remember every criticism that the sur-
geon makes on himself, and trust him all the more
for it; and they tend to distrust him who seems
always satisfied, or finds fault in everybody and
everything but himself. Again, the reports in the
medical press and at medical societies of isolated suc-
cesses, unless they mark some definite advance of
surgery, do not teach much to those who read or hear
them; they make us wish that the surgeon had pub-
lished other cases where the result had been less
pleasing to himself; they raise unkind doubts
whether his experience is not in inverse ratio to his
readiness to publish it. And it is certain that in the
long run we hesitate to believe in the man who
always believes in himself; and he who begins by
publishing nothing but his success may end by hav-
ing nothing to publish.
The confession and record of an imperfect work,
and the publication of consecutive rather than iso-
lated cases, are a sure way to improve the details of
operative surgery; and unless we do these things we
remain exposed to the reproach that the surgeon's art
owes its high place in the minds of man not wholly
to his own skill and insight, but in some degree also
to the fact that he practices it on a fabric more frail
and more precious than anything else in the world.
SHOULD GOVERNMENT ENCOURAGE MEDICINE,
OR QUACKERY ?
It is high time that the American medical profes-
sion should ask the American people if it is the
proper function of our Government to enact and exe-
cute laws furthering the science of medicine, and
therefore the health of the community and the prog-
ress of civilization, or whether it is much longer to
ignore these noble purposes and continue to support
downright quackery? A most striking instance of
this pernicious result of legislation has lately come
to light in the last Report of the Postmaster General,
in which he shows that the Government annually car-
ries 133,000 tons of mail matter costing at the rate of
eight cents a pound, for which there is received in
postage but one cent a pound; this results in a direct
annual loss of about eighteen and one-half millions
of dollars. It would be impossible to say what pro-
portion of this second-class mail matter thus carried
at so heavy a loss to the Government is nostrum and
330
MEDICINE OE QUACKERY?
[August 8,
" patent medicine " advertisements, but there can be
no doubt that much more than half is this execrable
trash. Hence we are deprived of one-cent postage
on letters, a thing that long ago should have been
brought about, in order that the nostrum vendors may
make fortunes. Beside their larger direct profits
wrung from the ignorant and poor, we give them an
indirect Governmental bonus of ten or fifteen million
dollars more out of the postal revenues. What insane
folly!
But this was not intended. It is an unseen con-
sequence of the mistaken policy that we should pub-
licly encourage the diffusion of printed matter by
lowering the postage upon second-class mail matter.
Now, the reading of ink-marked white paper is per se
no aid either to intelligence or to morality, and Gov-
ernment should very properly leave it to private
enterprise. It has, as we see, got itself into a box by
the mistaken aim, and a large part of the labor of the
post-office officials is now expended in trying to exclude
from the mails the filthy and injurious literature
which the law permits the greedy advertiser to put
there. We may reasonably hope for some remedial
legislation which shall undo the blunder. But physi-
cians should aid in bringing it about. It will hardly
come of itself.
A still more powerful effect of laws, and one that
is no unseen or unintended happening, is Govern-
mental protection and encouragement of quackery
by our patent or copyright laws. It may be that
some of the so-called " patent " nostrums are com-
paratively harmless when considered in their direct
effects. But, by encouraging reliance upon them
instead of upon intelligent diagnosis and treat-
ment, even these do incalculable harm. But what
physician does not know that the majority of these
vile concoctions are directly and positively injurious?
In how many ways are they not directly injuring the
poor in health and pocket, and indirectly preventing
medical progress and sanitary civilization ? If a cure-
all can repair the damages of disease, why prevent the
disease by sanitary legislation and a lowered death
rate? What imaginable reason except this and allied
facts is there for the difference between the English
and the American death rate? If we were as wise as
London in these matters, the number of our dying
would each year be very many thousands less than
it is.
How much longer are we to continue our hideous
policy of protecting the nostrum vendors by United
States laws and so-called patents ? Why has the United
Profession of Medicine had nothing to say to the
United Quacks of America about this matter? Are
we afraid of the silly gibe that we are acting simply
from selfishness and for our " monopoly " of medi-
cine? Let the answer be heard that they who unpaid
carry on the free treatment of all comers in the thou-
sands of hospitals and dispensaries, may not be>
charged with selfishness by patent medicine vendors-
and syndicates!
Why do not our Congresses of medical men and our
American Associations act to abate the disgrace?
When the " homeopaths " meet in general convoca-
tion, a big proportion of their energies and time is
spent in the consideration of public laws in their
interests and in agitation concerning their public
estimation and position. " And for that very reason
we should not do the same," do we hear? For that
very reason, we answer, we should — not do the same,
but do better. The public does not understand or
care about our technical questions, and somewhat justly
concludes that if we care nothing about our own pro-
fessional well-being and estimation, and especially
about national medical questions, we are therefore
more interested in fads and theories than in public
health. In the one exceptional instance when we
have spoken out — r& vivisection — this mistaken idea
of professional feeling on the part of the public is,
unfortunately, likely to be increased. The public are
opposed to what they call " vivisection." The " home-
opaths " are, of course, with the public and against
us. It therefore is doubly unfortunate that we are
extremely likely to find an increased hostility toward
medicine in the minds of the people and, rest assured,
especially in a democracy like ours, this hostility will
make itself disastrously felt in wretched laws and
bitter agitation. We already have enough of this
prejudice to bear in private, professional and public
life, without having any further increase of it. In
what way can we offset and neutralize it better than
by showing interest in the public welfare, and by
attempting to influence legislation on medical matters
for the public good. The ignorant and the nostrum
syndicates will for awhile roar at us all the more, but
the leaders of public opinion, and indeed the great
body of intelligent people, will be with us. Beside
all this, it is wrong to longer permit this wrong to go
on. " We must educate our masters," and if we would
only collectively and thoroughly take the matter up,
we could soon bring such influence to bear upon our
Congress at Washington as to convince even that
body that our contention is just. The copyrighting
a name as a trade-mark of a nostrum, keeping con-
stituents and method of manufacture secret, instead
of being justified by our law-makers, should be made
a crime. At present the Government stamps the
crime with its hall-mark of favor, and the poor
deluded public is encouraged in its stupidity by the
very authority that should be its protector. There is
no work, scientific or other, to which the American
Medical Association could devote a tithe of its ener-
gies better than to this of abolishing the laws at
present the very condition of quackery. Every phy-
sician should personally write his representatives in
18%.]
INSANITY
AND
=r
DIVORCE.
331
"the House and in the Senate, and petitions signed by
•every praoticer of scientific medicine in the country
.should be presented to both bodies. A committee of
leading members of the Association should also be ap-
pointed to effectualize the reform. Even the '• homeo-
paths " should be willing to join in such a movement.
INSANITY AND DIVORCE.
" Modern Barbarism " is the title given by a well-
known and well-edited New York religious weekly to
tin- recent action of the German Reichstag in making
incurable insanity a legitimate cause for divorce, and
to the commendations of this legislation by an Eng-
lish paper, the London ( 'hromcle. The latter had said,
in effect, that in making this enactment the German
legislature was in accord "with the common sense of
civilized mankind," and that the existing law of Eng-
land which does not recognize insanity as a cause for
divorce, was only "a piece of barbarian bigotry."
From an alienist's medical point of view the stand
taken by the religious journal can only be com-
mended. Insanity acquired after marriage is a misfor-
tune only comparable with other serious diseases, and
it should therefore be no more considered as a cause
for complete legal separation of husband and wife than
.should tuberculosis, organic heart disease or any other
•chronic and presumably incurable disorder. If the
marriage relation were nothing more than a mere
partnership for the purpose of keeping up the popu-
lation, sterility would be a sufficient ground for
divorce and insanity perhaps a still more valid one.
But there are many other considerations to be taken
into account, both ethical and social, and in a purely
medical point of view divorce for insanity can not be
considered justifiable. The subject was fully consid--
ered and discussed in France several years ago and the
conclusion reached was much more creditable to the
moral sense of the nation than appears to have been
the case in Germany. While most cases of long-
continued insanity are probably permanent or incur-
able, it is almost impossible to predicate this in any
particular case with absolute certainty, and unex-
pected recoveries are constantly occurring amongst the
chronic insane. The mere fact that the puerperal
■condition is one of the common causes of mental
derangement in women is enough to affect the ques-
tion ; it would be manifestly wrong to make the wife
suffer for what is partly at least the husband's doing.
The chances of and temptations to actual wrong-doing
that such a cause for divorce would afford are not to
be ignored, but this is a sociologic rather than a
purely medical consideration.
It is advisable, indeed, that the insane should not
propagate their infirmity, and a legal restriction of
the conjugal relations might be desirable. This,
Chinese Graduates in Medicine.— Two Chinese girls have been
graduated from the University of Michigan, Department of
Medicine and Surgery. They were sent to the university by
however, would apply in many conditions of mental miSB Charlotte Howe of the mission school at Kinglang, and
•disease that are not to be included under the form are to act as medical missionaries in China.
that are proposed as a cause for divorce. Insanity is,
of all disorders, the most liable to recur, and a single
acute attack, as a rule, implies a cerebral weakness or
instability that has a bad outlook as regards the
inheritance transmitted to offspring, and should from
this aspect be considered as valid a pretext for divorce
as a chronic, so-called, incurable type of the disease.
There are other points that can be made against
the admission of chronic insanity as a legal cause for
divorce, but the above are enough, from a medical
point of view, to condemn it. If incurable or trans-
missible disease of any kind is to be so considered, there
are other affections that should precede insanity; the
govemmont itself should take the initiative and no
more regard should be given to one side than the
other ; the elements of plaintiff or defendant should
not be allowed to enter into the case. Our civiliza-
tion, however, is not tending toward such a state of
affairs, and the action of the German parliament is
not in the line of progress any more in its medical
than in its moral aspect. Perhaps "modern barbar-
ism" is about as suitable a term to apply to it as any
that can be suggested.
LOCATION OF THE JOURNAL.
The following is the result of the ballot cast on the
permanent location of the Journal, as counted by
Trustees D. W. Graham and Joseph Eastman:
Chicago . . 2128
Washington 810
New York 24
Philadelphia • . . 48
St. Louis 22
Baltimore 4
Louisville 3
Cincinnati 3
Boston 2
Atlanta 2
Cleveland 1
Columbus, Ohio 1
Milwaukee 1
Salt Lake City 1
Hamilton, Ohio 1
Pittsburg 1
Elmira, N. Y . . . . 1
Sedalia, Mo 1
Little Rock 1
Indianapolis 1
San Francisco 1
Camden, N. J 1
Charleston, S. C . 1
Buffalo 1
Total votes cast 3061
Five thousand two hundred and sixty- five ballots
were issued to members, 2,204 of whom did not vote.
Several ballots were signed but no place specified,
and several were filled out but not signed; these were
necessarily thrown out.
332
CORRESPONDENCE.
[August 8,
CORRESPONDENCE.
The Michigan Medical Legislation League.
Open Letter !No. 2 to the Members of the Medi-
cal Profession (regular) in Michigan.
Detroit, Mich., Aug. 3, 1896.
In response to my brief, but earnest appeal to the adherents
of regular medicine and the friends of suffering humanity in
this State, published in the Journal of the 23d ult., two let-
ters appear in the issue of August 1, just received.
One of these letters is signed by the President of the so-
called "League," and the other by his "alter ego," J. H. Car-
stens. Simmered down to their ultimate elements, these
communications, with apparent politeness, charge me with
"illiberality" and with Phariseeism, and my attitude toward
the question at issue as lacking in patriotic duty. To all such
personal accusations the only answer that I have time or
inclination to offer is written and can be plainly read in the
quarter century record of my professional life in Michigan.
Neither do I propose to condescend to recriminations or
"tu quoque" charges of any kind. Surely if the "Catholics
and Lutherans and Presbyterians" can afford to be ranked
with or compared to the indefinite, inglorious and mercenary
sects which are so eager to grasp at any recognition by or asso-
ciation with true scientific unselfish regular medicine ; surely,
I say, if the friends of these three great branches of the Chris-
tian church can rest satisfied with the use which the president
of the League has seen fit to make of their time honored
names, it is not for a humble sinner like myself to undertake
their vindication. But will the president kindly show us
where we may be able to read and learn of the occasion when
any one branch of the Christian church or the church as a
whole ever formed or sought to form a coalition for the attain-
ment of any great ecclesiastic undertaking, and in so doing
asked its combined enemies to accept the controlling power and
assume the honors which belong to the majority? While it is
quite true that both religious and secular bodies have formed
from motives of policy coalitions with other bodies more or less
inimical to them, has the spectacle ever before been witnessed
in the history of nations, of churches, or of professions of the
party overwhelmingly in the majority, and possessing the
greater power, humbly proposing that it be graciously and
with humility accorded a position in the coalition inferior in
point of numbers (and therefore of power) to that of its com-
bined enemies?
I am not opposed to a Legislative Medical League as such,
but I am opposed to any proposition which amounts to a con-
fession of weakness on the part of the medical profession, of
which I am a humble but a loyal member.
The president of the League says, and truly, that "our
efforts at convincing the people and politicians of the wisdom
of adopting measures which we alone promulgate have repeat-
edly failed, as the history of medical legislation, not only in
this State, but in every other State in the Union, attests."
Does the president wish us to understand him to say that,
"Because well known errors and weaknesses of human nature
have in times past operated to prevent us from getting a good
law, therefore, we have no resource but to turn round and
labor for a weak, inadequate and infamous law?" "Half a
loaf better than no bread" is a good old homely adage, but if
that half is saturated with cold poison, how then? "Better
fast a little longer." Would it not, my friends, be better,
wiser, more worthy the history and traditions of our noble pro-
fession to pause and study carefully the causes on our own
part of failures in the past and wake up to a true and just
sense of their nature, their magnitude and the means of avoid-
ing and counteracting them in the future? Two or three lines
in the very characteristeric letter of my friend, Dr. Carstens,
to my mind, gives the whole case of the Michigan Medical
League dead away. They are as follows: "It will give the-
young man a chance by preventing competition;" also the-
immediately succeeding lines as follows: "It makes no differ-
ence to Dr. Maclean or myself how many or how few quacks-
there are in this State, but it does make a difference to the-
new beginner." "The public be damned!" The letter and
the spirit of these sentences are, so far as I am myself con-
cerned, absolutely repudiated. If I had the strength and the-
opportunity to do ten times the amount of my present work, I
should still take as great an interest in this legislative ques-
tion as I now do, and I should still feel grieved and humiliated
that in spite of my utmost exertions thousands of my fellow
citizens are still medically, morally and financially writhing in
the clutches of the omniverous quack.
As to the young doctor himself, his interests have ever been
a sacred and affectionate object of my most earnest considera-
tion, and it is in the defence of his best and highest prosperity,
and his good name that I protest against any such accusations-
of weakness on his part, no matter from what quarter they may
come. I should pity and despise the young doctor, ambitious,
for professional distinction and usefulness, who should be will-
ing to accept and endorse this cringing proffer of protection.
Protection from what? May I be permitted to quote here a
single sentence from my open letter No. 1. "Can it be possi-
ble that at this late date the regular profession in Michigan
feels itself so feeble and unable to maintain itself that it stands
ready to defy the public professional sentiment of this and
all other lands in the hope of obtaining a milk and water
degree of protection (for themselves rather than their
patienU), enter into a combination and unholy alliance with its
most insidious and meanest foes and place the balance of
power in the hands of the enemy?"
The president of the "League" complains of the term unholy
alliance, and perhaps I should have used some other term, and
I will leave it to the readers of the Journal who have the
instincts of honorable regular physicians to say what it shall
be. One of the members of the executive board of this "Leg-
islation League," with whom Dr. Shurly and others have
formed an alliance, is Dr. C. Edson Covey, 6 Madison Ave.,
Detroit. The following is his advertisement, which appears
daily in Detroit papers :
"Specialist in private or delicate and all chronic diseases. Confi-
dential. Call or write Dr. Covej , 0 Madison Ave,, Detroit."
When we consider the full significance of thisadvertisement,
we do not envy Dr. Shurly any glory he may get from it, even
though the profession generally do not consider it unholy.
Quackery and charlatanism is condemnable in every field of
human endeavor and in none more so than in the matter of
" Medical Legislation."
If the regular profession in Michigan and in America hopes-
ever to assume and enjoy the regal and just position freely
accorded the profession in other lands, we must study the his-
tory and emulate the example of the profession in these coun-
tries. Let us confess our manifold sins and transgressions, too
numerous and too well known to require rehearsal here. Let
us go back to fundamental principles. Let us study not merely
the letter, but the spirit of the code of ethics of our National
Association ; let us live up to its teachings and laws, using
them not as a cloak for Pharaseeism and disloyalty, but as a
true living and ennobling inspiration and guide for all the
duties and relations of professional life.
This may seem Utopian and the expression of a forlorn hope,
a vain aspiration in the direction of the unattainable. But is
it not more worthy of our vocation to persevere in our efforts
and die if necessary in our upward and onward struggle than
to sell our birthright for a mess of pottage and barter all our
hard earned power and honor for any such ficticious aid and
comfort as this alliance could possibly promise?
isw. !
CORRESPONDENCE.
333
The last two sentences of the " President's" letter charge me
with error as to the statistics of the Executive Hoard of this
["League." If so, all I have to say is that I am unable to read
and understand plain English when I see it in plain print. But
let that be as it may. Neither of these, mine, accusers have
assailed the statistics upon which my main plea is based,
namely, that the Board of registration provided for in the main
clause of the bill, is by the request of the president and all his
"League" to consist of nine members, not more than four of
whom shall be regulars, the other five to be just aliont any
thing you please to call them.
Before closing it is impossible for me to avoid calling atten-
tion to ■ most marvelous misstatement on the part of Dr. Cars-
tens as follows :
" Dr. Maclean has been at the head of the Legislative Com-
mittee of the regular State Medical Society for twenty years,
and has never accomplished anything." The facts are :
1. Dr. Maclean was chairman of that Committee for one year
and no me
2. No such thing as a Legislative Committee of the State
Medical Society has existed except during occasional years and
then by special appointment.
"■>. Dr. Maclean might have been successful in his earnest
effort to secure a just law, but for three things, namely :
1. The dignified apathy and the masterly inactivity of
the regular profession. 2. The beaverlike political activity,
the wire pulling and the perfect consolidation of the quacks of
every denomination. 3. Dr. Maclean's unalterable determina-
tion to stand true to that which he believes loyalty to the
great science and art of medicine demanded and still demands
of every individual who owes allegiance thereto. The tone and
tenor of the two letters herein reviewed, together with the gen-
eral •' facial" characteristics of the Michigan Medical Legisla-
tion League, can hardly fail to excite the dread that the signifi-
cation of the term " loyalty" as understood and interpreted by
the fathers and friends of the League is in great danger of
undergoing an unfortunate and degenerated form of metamor-
phosis, and being changed into " a something" utterly differ-
ent from that which has always been accepted and approved
by the fathers and friends of the regular profession of scien-
tific medicine in this and all other countries from the dawn of
civilization down to the date of the conception of the Michigan
Medical Legislation League.
Dr. Carstens closes his very striking letter in these words :
" I am happy to say that it is the overwhelming sentiment of
all regular practitioners, of all so-called (sic) 'homeopaths' and
of all the quacks of this State that the further influx of char-
latans and quacks should be checked."
My friends, this is a truly wonderful sentence from a man in
Dr. Carstens' position, and it will repay your careful dissection
and analysis. His right to speak authoritatively for all the so-
called "homeopaths" and quacks of this State, I have neither
the right nor the desire to question, but by the authority of
written letters and countless verbal declarations, I have not
only the right, but equally the pleasure of giving here an abso-
lute denial to the only statement contained in this never to be
forgotten sentence, worthy of our attention, namely, that which
in so wholesale a manner presumes to commit " the profession"
to this preposterous scheme of abdication and degradation and
evil association.
Finally, brethren, let me assure you that nothing could be
further from my inclination than strife and dissension. If the
accouchement of this anomalously begotten "League" should
by any chance be successfully accomplished, and if by any
chance the resulting progeny should after all prove to be a
healthy, vigorous and noble infant, and if I should live long
enough to see genuine signs and marks of "good breeding"
with a promise of a life of usefulness and honor, I will be
found ready to take my hat off to the youngster and wish
Mm, her, or it Godspeed. Not only so, but I will be found
equally ready to pay all reasonable honor and respect to its
strangely assorted progenitors and apologize for any "remarks"
I may unadvisedly have made about them at the time of their
courtship and marriage.
But if, on the other hand, to speak seriously, the effect shall
prove to be, as I fear it will, to disgust and deter desirable and
to attract undesirable persons to the ranks of the profesion in
this State, thereby leveling the profession down and the irreg-
ulars and charlatans up, I will at least, no matter how much
such a result would inevitably grieve me, have the satisfaction
of having done what little lay in my power to protect and
defend science and humanity from so great a misforune, and
I will do my best to rest satisfied with the verdict of
approval from what to the individual is the highest of all
earthly tribunals, namely, the tribunal of my own conscience.
Donald Maclean, M.D.
Was Goldsmith a Physician?
Sydney, Australia, June 29, 1896.
To the Editor: — In your issue of May 16, Dr. John Morris
publishes an extremely interesting and scholarly article under
the above heading. There is great doubt concerning the dates
of the various incidents in Goldsmith's life, and as I may be
able to throw some light upon the matter, I send you a few re-
marks on the subject of the poet's life in Trinity College, Dublin.
Dr; Morris states that Goldsmith was born at Pallas, or
Pallasmore, in 1728, that he entered Trinity College in 1745,
and took his degree of B.A. in 1750. John Forster, in his
"Life and Times of Goldsmith," gives these dates also, but
they are not in agreement with the records of Trinity College.
The Rev. Dr. Stubbs, in his "History of the University of
Dublin," published in 1889, gives in an appendix, some uni-
versity records of well-known members of the college during
the seventeenth and eighteenth centuries, from which I extract
the following passages : "It may be interesting to inquire
what the college records inform us as to the undergraduate
career of the eminent men who were educated in Trinity Col-
lege during the first two centuries of its university work. It
must be remembered that no records of terms or examinations
during the first century of the college have been preserved.
The Senior Lecturer's books, which contain an account of the
attendance of the students at the term examinations, and of
their answering, were not kept until the middle of the
eighteenth century. The old Senior Lecturers, however, filled
up in their own handwriting a series of books in which were
entered the names and the Christian names of all who were
admitted into the college as students, the names and profes-
sions of their fathers, the place of their own birth, their own
age at entrance, the date of their admission, the name of the
schoolmaster who had educated them, and of their college
tutors. The oldest of these books which remains begins in
January, 1637-8, and continues to November, 1644. The
entries then ceased, and they were not resumed until January,
1652, from which day to the present there is a continued record
of the admission of students." Then follows a list of the
most notable students of the college: "Goldsmith, Oliver,
admitted as Sizar 1744, aged 14 years ; son of the Rev. Charles
Goldsmith ; born in Westmeath ; educated by Mr. Hughes ;
college tutor, Mr. Wilder. B.A. 1750." He was the celebrated
poet, and the author of the "Vicar of Wakefield." As this
entry was made during Goldsmith's stay in the college, there
is every reason to believe that the statements it contains are
correct. Therefore, Goldsmith was born in 1730 (not 1728), at
Westmeath (not at Pallas, which is in the County Longford),
he entered Trinity College in 1744 (not 1745), and took his
degree of B.A. in 1750 (not 1749). The Catalogue of Gradu-
ates, published in 1869, gives the record, "Goldsmith, Oliver,
B.A., Vern. 1750."
334
COKKEKPONDENCE.
[August 8,
Now, Forster states that the Goldsmith family moved from
Pallasmore in 1730, "to a respectable house and farm on the
verge of the pretty little village of Lissoy, ' in the County < if
Westmeath, barony of Kilkenny West,' some six miles from
Pallasmore, and about midway between the towns of Bally-
mahon and Athlone." Prom this it would appear that the
poet was born after the removal from Pallas.
In my opinion, the dates given by Dr. Morris and other biog-
raphers of Goldsmith are not quite accurate.
Yours very truly, George Lane Mulxins, M.A., M.D.
Trin. Coll., Dublin.
Medical Grievances.
New York, July 18, 1896.
To the Editor: — I respectfully submit the prevailing griev-
ances of the profession, as near as I have been enabled to col-
lect them :
1. Medical appointments in free hospitals, dispensaries,
maternities and other medical charities, lodges, societies or
clubs, free visiting physicians of boards of health and daily
newspapers, vaccination by boards of health, drug store chari-
ties, free advice in newspapers, etc., shall be made under the
supervision of our medical associations. These associations
should appoint committees or engage persons to investigate the
financial responsibility of all recipients of charity and collect
accordingly. These sums to be applied to a general tund,
which should be devoted to the assistance of needy
practitioners.
2. The duration of medical appointments in institutions to
be so regulated that all applicants shall have equal opportuni-
ties to serve.
3. Charitable medical institutions should not have the power
to make rules prohibitive as regards the profession in general
or to employ offensive officers in their buildings.
, 4. Directors have no right to be overbearing toward attend-
ing physicians.
5. Physicians in hospitals or dispensaries, professors, lectur-
ers and instructors should avoid making derogatory state-
ments concerning other physicians.
6. There is a too prevalent disregard of our code of ethics.
If members were disciplined for slight offences, graver ones
would be avoided.
7. Many patients, who are in moderate circumstances, but
not poor, prefer the skillful attendance obtained at our mod-
ern free institutions, with their perfect appointments, to that
of the young medical beginner in private practice.
8. Hospital authorities have no right to refuse a patient
admission because the diagnosis was made by a physician not
connected with the institution. A physician does not wish his
patient's case re-diagnosed and remarked on by any but the
prospective operator or chief in the institution.
9. A physician, once given an appointment for an unlimited
period, should not have his office vacated without the acqui-
escence of our medical associations.
10. Physicians having medical appointments should not be
guilty of improper practices.
11. If a patient is temporarily in financial difficulties and
visits a charitable institution, it is not proper to say that he or
she is "nobody's patient" for that reason.
12. Physicians should not send patients to charitable insti-
tutions unnecessarily. Many operations can just as well be
done at home, with proper assistance, and had better be
accepted for a smaller fee, or referred to a neighbor who will.
13. Directors of free hospitals should be prohibited from
making store-to-store canvasses for the purpose of soliciting
members, and incidentally to laud the virtues of their institu-
tions and their members. Women should be prohibited from
making house-to-house visits for the purpose of collecting
charity for certain hospitals, and incidentally acting as solicit-
ors for the institutions and their associated physicians.
14. Midwives should be prohibited from acting in any
capacity beyond that of nurse, unlesB they have a complet
obstetric education.
15. A physician dare not prescribe for the purpose of produc
ing a criminal abortion ; yet a druggist may sell "remedies''
his heart's content. Thousands of abortions are occurring
annually.
16. Druggists sell therapeutic preparations for all ailments,
When charged with prescribing, they contend that it was only
for an emergency, which is legally allowable.
17. Patients with contagious disease are indiscriminately
brought in contact with healthy customers in drug-store
dispensaries.
18. It should be considered a breach of ethics for a physician
to prescribe or recommend patent medicines, proprietary arti-
cles or drugs which have been untried in hospital or dispen-
sary practice, or to recommend quacks or charlatans, or their
remedies.
19. Physicians should not compound their own medicines or
furnish tablets. These practices have a deteriorating influence.
20. Physicians should be discouraged from furnishing cer-
tificates of competence to midwives and nurses.
21. College appointments should be made solely for efficiency.
22. Association meetings should not be controlled by certain
groups of members, to the exclusion of the remainder. All
members should receive equal opportunities to address the
meeting.
23. Associations should not devote all their energies to some
professional offence affecting a few members, while ignoring the
grievances of the mass of the profession.
24. The adoption of polyspecialism is not fair toward the
mass of specialists. A professor on one subject should confine
himself to that specialty alone.
25. "Indirect" professional advertising has been com-
plained of.
26. The medical press should be freely accessible to the pro-
fession on all occasions and at all times.
Audi alteram partem. S. B.
The Oppenheimer Drink-cure In Bellevue Hos-
pital and Gen. O'Belrne's Letter.
To the Editor : — Herewith is given in extenso the rejoinder
of Charity Commissioner O'Beirne, in response to charges of
collusion between the board, which he represents, and the
new remedy for alcoholism.
The action of the Commissioners in this matter has been
much the subject of two virulent attacks by the Medical News
of July 18 and 24; but, after all, on cooler reflection, there
does not seem to be any substantial ground for the charges
made against the Commissioners. The medical profession
should for once and all time, cast aside prejudices, and when
a regular member of the profession, after proper testing and
experimenting, offers a remedy for trial in a public hospital,
before announcing it in general details to the profession at
large, he should be permitted the fullest liberties in this
direction. This was done in Paris, with Pasteur's attenuated
virus for hydrophobia ; with Roux's antitoxin serum in Charitg
and Koch's tuberculin in the Moabit Hospital and the Berlin
Institute, for months, before its composition was revealed to
the professional world. From what can be gathered from
reliable and impartial sources, nothing further than this is
being done at Bellevue, as the following communication from
Commissioner Jas. R. O'Beirne in the New York Herald, July
20, clearly shows :
"The statements under caption of 'No Cure for Drink,' in
your issue of to-day, are not true in point of fact. As I know
the Herald aims to present only facts, I take occasion to say,
1896.]
PUBLIC HEALTH.
335
in correction of the article in question that, so far ;is it assumes
to speak for the Board of Commissioners of Charities ;ind 'the
action they arc to take to-day,' as to a specific for the cine of
drunkenness— to 'saddle the city with several thousand dollars
extra expense'— it is unfounded and unwarranted. So also is
the cast- as to ignoring the Medical Hoard. The same is true
Hi to taking the views of 'a young practitioner and Superin-
tendent Murphy.' In making a trial of methods ascertained
to be of value by a respectable practicing physician of stand-
ing in his profession, the object sought by the Hoard is to dis-
cover, with all proper safe-guards whether suffering humanity,
in cases of misfortune and vicious habits, with apparently
irresistible appetite for liquor; may not be further assisted and
rescued in the domain of charity through the conscientious
discharge of duty by the Board of Charities of New York city.
If they can save the drunkard, the morphin fiend and the poor
unfortunate conspiring against his own safety and that of the
community, they believe it is their duty to do it, and that the
charitable public of New York will approve it and rejoice if it
shall be demonstrated a success. It is worth trying, at least,
and, believing this to be their duty, they have acted accord-
ingly, but do not think 'there is no cure for drink.' So far
encouragement to warrant a reasonable doubt, without any
expenditure of money. It is a misrepresentation to say that
the Commissioners paid certain patients to undergo the treat-
ment without expressing any opinion on the merits of the
■cure' as not one cent has been paid to any one by the Com-
missioners in connection with it, and the investigation as to
aracter and effectiveness having been assigned to me by
the Board, it becomes imperative that I should make this
denial. It will perhaps take months before a final conclusion
will be reached in this investigation, which will be thorough,
fearless and honest, but the result will be duly given to the
public. [Signed] Jas. R. O'Beirne,
Commissioner of Charities, New York.
Oeneral O'Beirne. whom I am sure you know personally,
is a high minded and scholarly gentleman, incapable of a mean
act,
Faithfully yours,
Justitia.
Test for Albumin.
Traverse City, Mich., July 28, 1896.
To the Editor:— On page 1091 of our Journal of May 30,
1896, I find a test for the detection of albumin in urine. The
reagent suggested contains sodium hypochlorite, a compound
known only in solution, and one that I believe can not be
obtained for use as indicated in the formula. If you know of
any way of preparing the reagent, will you be kind enough to
tell me how it is done? Yours very truly,
Guy L. Noyes, M.D.
Resigned bis Editorship.
Chicago, Aug. 1, 1896.
To the Editor:— Will you kindly notify your readers that in
consequence of the intrusion of nostrum advertisements by the
publishers on the Medical Standard, the attempt to convert
this journal into a write up organ for nostrums and allied per-
formances, I have severed my connection therewith after an
editorial service of nearly ten years.
Very sincerely, Jas. G. Kiernan, M.D.
We are sorry to see that our valiant colleague has been
crowded out, but we hope to have an occasional article from
his trenchant pen in our Journal. — Ed.
PUBLIC HEALTH.
Illinois State Board of Health.— Governor Altgeld has accepted
the resignation of Dr. William E. Quine of Chicago as member
of the Illinois State Board of Health, and appointed Dr. Edgar
P. Cook of Mendota to the vacancy.
Special Tuberculosis Committee.— The New York State Board of
Health at its meeting in Jamestown July 13 appointed two of
its members, the Hon. Owen Cassidy of Montour Falls and Dr.
Frederick W. Smith of Syracuse, a special tuberculosis com-
mittee
Double Entente "Mike," said the superintendent, "there is
a dead dog -reported in the alley between Illinois and Meridian
streets. 1 want you to look after its disposition." An hour
later the intelligent officer telephoned: "I have inquired
about the dog, and find that he had a very savage disposition."
— Indiaiiajtolis Journal.
Delaware County l Pa.) League of Health Boards.- The call which
has been issued for a meeting at Chester July 16, of the various
boards of health of Delaware County, was liberally responded
to. An organization was effected to promote sociality and the
interchange of views on sanitation. Dr. Isaac Crowther of
Chester was elected president, Dr. D. M. McMaster of Ridley
Park vice-president, and W. H. Flaville of Chester secretary
and treasurer.
The Monongahela Valley. — The Monongahela valley of Penn-
sylvania is a complete wreck from Pittsburg to the head waters
of the Monongahela River. All kinds of crops have been
swept away, fences and outbuildings destroyed and scores of
cattle and stock drowned. Fruit trees were blown bare and
thousands of acres of oats, corn, etc. , destroyed. To make the
matter worse the contents of vaults have been swept over the
low lands and will breed disease. Half-ripened fruit and all
kinds of vegetables line the river banks. It is reported that
the assistance of the State Board of Health will be asked to
destroy decomposing matter.
The Navy to Assist in Florida Quarantine.— Governor Mitchell
of Florida has appealed to the Navy Department for help in
protecting his State against the introduction of smallpox from
Cuba, where the disease is reported to be raging. Secretary
Herbert has accordingly telegraphed instructions to Captain
Crowninshield of the Maine, now at Key West, to aid the local
health authorities in the work of boarding steamers and
passing upon bills of health. The Maine will not long be kept
at this work, as orders have been given to the cruiser Mont-
gomery, now at Tompkinsville, S. I., detaching her from
Admiral Bunce's squadron and sending her to Key West to
take the Maine's place in looking after filibustering expedi-
tions and enforcing observance of quarantine regulations.
Ophthalmia Neonatorum in South Carolina.— In the above-named
State the following enactment was adopted and became law
on Feb. 25, 1896, and is applicable to all towns having a
population of one thousand or more : '^Be it enacted by the
General Assembly of the State of South Carolina, that should
one or both eyes of an infant become reddened or inflamed at
any time after birth, it shall be the duty of the midwife or
nurse or person having charge of said infant to report the
condition of the eyes at once to the local board of health of
the city or town in which the parents, of the infant reside ; that
the Secretary of State shall cause a sufficient number of copies
of this act to be printed, and supply the same to health officers
and health committees, whose duty it shall be to furnish a
copy to each person who is known to act as midwife or nurse
in the cities or towns for which they have been appointed ; any
failure to comply with the provisions of this act shall be pun-
ishable by a fine not to exceed $25 or imprisonment not to
exceed one month, or both."
Advice to Inmates of Public Institutions.— Dr. John Morris, one
of the Board of Managers of the Maryland Prisoners' Aid
Association, has prepared a circular of advice to the inmates of
public institutions, 3,000 copies of which have been printed
and one placed in every prisoner's cell in the State, including
reformatories male and female. The circular urges upon all
prisoners the necessity for cleanliness, moderation in diet, and,
above all, the avoidance of the practice of self-pollution. For
cure of the habit it recommends cleanliness of the body, Sim-
ple food, hard beds, abundance of fresh air and, more import-
ant than all else, occupation of mind in some elevating study
or pursuit. Directions for the prevention and cure of many
minor ailments to which persons in confinement are subject,
336
PUBLIC HEALTH.
[August 8,
are given. Attention to the advice contained in the circular
would add much to the bodily comfort and mental tranquility
of the prisoners.
Staff of the German Hospital, Chicago. — The following are
the names of the members of the new medical staff : Surgery
— Christian Fenger, William Hessert, Weller Van Hook, E. H.
Lee, Truman W. Miller consulting surgeon. Medicine — Gus-
tav Fiitterer, F. W. Rohr, J. H. Hoelscher, Otto T. Freer,
Gustav Hessert consulting physician. Gynecology — Fernand
Henrotin, William Doepp, Albert Goldspohn, Paul R. Welcker.
Ophthalmology — H. C. Welcker, F. C. Harnish, Boerne Bett-
mann consulting ophthalmologist. Laryngology and Rhinol-
ogy— Otto T. Freer. Obstetrics P. R. Welcker.
Sanitary Plumbing for Toledo, Ohio.— Steps were taken at the
special meeting of the health board July 23, which will result
in a revolution in Toledo plumbing, sewerage and ventilation.
A new board was created, which will look after all plumbing
and see that it is done in accordance with the best sanitary
precautions. A new inspectorship of plumbing was made and
will be filled at an early date. The last Legislature provided
for the creation of a board of plumbing directors, whose duty
it is to examine all plumbers engaged in business in the city.
The examination is to be conducted upon the lines of qualifi-
cation in sanitary work and house ventilation. An inspector
of plumbing is also to be appointed under the law, whose duty
is to examine all work under construction and report violations
of the plumbing ordinances to the board of health. He is
supreme in his position, and no work can be done, except in
repairs of leaks, without his permission. A penalty of from
$5 to S50 is provided for all violations of the regulations, and a
plumber's license can be revoked at any time for good cause.
Prevention and Cure of Seasickness. — Legrix has made a study
of seasickness for the last twenty-seven years and asserts that
all will be exempt if they follow his directions as given below.
First, as a preventive, take one or two % milligram pills of strych-
nin (arsenate, sulphate or hyposulphite) every fifteen minutes
for an hour before the boat starts, five to ten pills in all, and lie
down. At the slightest symptom of uneasiness take every fif-
teen minutes the following combination : One strychnin pill
as above, with two pills of J-4 milligram hyosciamin extractive
and one pill of 1 milligram morphin (hydrobromate or hydro-
iodate). Twenty doses of this triple combination can be taken
if necessary without danger. To establish the cure, take at
night three 1 centigram podophyllin pills, with the triple com-
bination above three times a day, for three or four days.
Keep the horizontal position as much as possible ; remain on
deck in the open air ; avoid pastry, acid candies and liquids.
Brucin can be substituted for the strychnin in the case of chil-
dren from 4 to 7 years, given every half hour, with no mor-
phin and the hyosciamin pills only three or four times a day.
Calomel should replace the podophyllin. — Address at the Tunis
Congress of the French A. A. S., April.
Differentiation of Pathogenic Bacteria in Suspected Waters.— Besson
states that the difficulties so often experienced in locating
pathogenic bacteria in waters supposed to contain them, are
due to the presence of other interfering bacteria, which pre-
vent their development, as the development of the cholera
bacillus is retarded by the presence of certain other bacteria
in the intestines and in cultures. In analyzing water this fact
is of supreme importance, as the preventing bacteria conceal
the presence of the pathogenic microbes. Cultures of waters
near Tunis developed constantly and exclusively a red coccus,
resembling the micrococcus prodigiosus, which produced trim-
ethylamin and was fatal to rats and guinea pigs. But perse
" vering with another medium, Metchnikoff's gelo-pepto-salt
medium, at 100 degrees, three passages resulted in pure cul-
tures of an unmistakable bacillus pyocyaneus, which never
showed at all on the plate cultures. Further investigation
disclosed the prevalence of this bacillus everywhere around
Tunis, which may explain the fact that this region has always
been exempt from cholera although hygienic conditions cer-
tainly invite it, as Kitasato and Metchnikoff have stated that
its presence retards the development of the cholera bacillus.
Besson urges the adoption of Metchnikoff's medium in the
analysis of waters ; it retards the growth of saprophytes until
the pathogenic bacteria have had time to develop. He also
commended Eisner's method of differentiating typhoid bacilli
as a valuable aid in analyzing waters. (See Journal, March 7,
page 493. ) — From address at the Tunis Congress of the French,
A. A. S.
The Health of New York State in June. The Bulletin of the
State Board of Health of New York reports the following sta-
tistics for the month of June, 1896 : The reported mortality
for the month is 200 less than that of the preceding month,
but is 600 greater than that of June, 1895. The death rate for
the month was 16.85, against 17.50 in May and 19.30 in April,
that of June 1895, having been 16.10. The customary decrease
in the mortality is less than usual, the average daily mortality
for the month being in fact greater than in May, 311 against 308,
that for June the past ten years having been 285. Of the 9,342
deaths 37.0 per cent, occurred under the age of 5 years, and
18.3 per cent, were from zymotic diseases. More than half of
the deaths of this class, and nearly 10 per cent, of the total
mortality were from diarrheal diseases. The diarrheal mor-
tality of June is very variable, some years the number being
less than 500 and others over 1,000, because of the varying
earliness of commencement of the summer increase. This
month there were 900 deaths, or about 250 more than the
average. In the Maritime district 12.5 per cent, of the total
mortality was from this cause, and in the Lake Ontario and
Western districts 9.0 per cent., but in the more rural parts of
the State it constituted but from 2.0 to 4.0 per cent, of the
total mortality. From all other zymotic diseases respectively
there were fewer deaths than in May. From consumption
there were 1,100 deaths, which is above the average for the
month. Acute respiratory diseases decreased one half from
May, a saving of 600 in the number of deaths, less than 10 per
cent, of the total mortality being from this cause against 15.5
per cent, in May. There is an increase in the reported mor-
tality from diseases of the digestive system, which always
varies with the diarrheal mortality. Deaths from all other
local diseases are less than in May. Next to November, June
is the healthiest month of the year in this State. The average
mean barometer was 29.96, the relative humidity 71 per cent,
and the average temperature for the entire State 69 degrees,
or 2 degrees above the normal ; there was an average rainfall
of 3 inches, a slight deficiency. The prevailing wind was
southwest.
Health Report. The following health reports have been
received in the office of the Supervising Surgeon-General,
Marine-Hospital Service :
SMALLPOX — FOREIGN.
Barcelona, June 1 to 30, 35 deaths.
Bombay, June 23 to 30, 13 deaths.
Buda-Pesth, July 8 to 15, 2 cases.
Calcutta, June 13 to 20, 1 case.
Callao, June 28 to July 5, 10 cases.
Genoa, July 11 to 18, 1 case.
Havanna, July 9 to 16, 23 deaths.
Licata, July 4 to 11, 4 deaths.
Madras, June 19 to 26, 3 deaths.
Odessa, July 4 to 11, 11 cases, 3 deaths.
St. Petersburg, July 4 to 11, 14 cases, 4 deaths.
Warsaw, June 27 to July 4, 2 deaths. '
Yokohama, June 19 to 26, 2 cases, 1 death.
CHOLERA.
Bombay, June 23 to 30, 19 deaths.
Calcutta, June 13 to 20, 29 deaths.
YELLOW FEVER.
Acapulco, July 11 to 18, 1 case.
Havanna, July 9 to 23, 115 cases, 46 deaths.
Matanzas, July 15 to 22, 100 cases, 54 deaths.
Sagua la Grande, July 11 to 18, 65 cases, 8 deaths.
Note.— The report of 7 deaths each in Warsaw and St.
Petersburg from yellow fever, in last week's Journal, should
read 7 deaths each from smallpox.
1896.]
MISCELLANY.
337
NECROLOGY.
SOCIETY NEWS.
Sirokon Chaki.ks S. 1). Kkssenden, United States Marine
Hospital Service died at Salem, Mass., July 23, aged 68. He
was a great grandson of the Rev. William Fessenden, and
brother of Et Secretary William Pitt Fessenden, of Maine.
He was born in Portland, Maine, Feb. 23, 1828, was graduated
from Bowdoin College in 1848, from the Brunswick medical
school |n 1S.M. and settled in Portland, where he was for three
years oit.v physician. He was appointed to the Marine Hospi-
tal Service in 1881, and served at Portland, New York, Louis-
ville and Mobile. In November 1895, he was placed on wait-
ing orders on account of physical disability. Although not a
frequent contributor to medical literature he possessed great
ability in his profession, as an able operator and a profound
scholar. He was greatly beloved by his fellow officers who
deeply regret his loss. He was for many years a member of
this Association.
Frank Whitman Him.. M.D., of New York city, died July
IT. in New Haven, Conn., at the home of his brother, Dr.
Henry Wilson Ring, where he had been ill for nearly three
months. Dr. Ring was born in Portland, Me., August 28,
LM8. He graduated from Bowdoin College in the class of 1869,
and from the Medical Department in 1878. He subsequently
continued his medical studies in Paris and London, returning
to New York city in 1883. He has since been well known as a
most proticient eye and ear specialist. At the time of his death
he was the Executive Surgeon of the Manhattan Eye and Ear
Hospital of New York city, a member of the American Ophthal-
mologieal and Otological Societies, the New York Ophthalmo-
logic^ Society, a Fellow of the New York Academy of Medi-
cine and a member of the New York County Medical Society.
He was the author of several important professional pamphlets
relative to his specialties.
A. C. Mackenzie, M.D. (Long Island College Hospital,
Brooklyn, N. Y., 1868), of Negaunee, at Marquette, Mich, July
13. N. N. Patton, M.D. (Jefferson Medical College, Phila-
delphia, 1873 1 at Monongahela City, Pa., of Bright' s disease,
July 14, aged 50 years. Phillip G. Corkins, M.D. (Rush
Medical College, Chicago, 1853) at Harwood, Mo. July 16, aged
70 years. W. B. McPheters, M.D. (Medical Department of
Western Reserve University, Columbus, 1870), at Hookstown,
Pa.. July 20, aged 45 years. G. M. Roberts, M.D. (Hospital
College of Medicine, Louisville, 1880) at Union Center, July 25.
W. W. Walters, M.D. (Pennsylvania Medical College,
Philadelphia. 1853 > at Johnstown, Pa. July 23, aged 73 years.
J. M. Benedict, M.D. (University of the City of New York
Medical Department, 1867) at Salt Lake City, Utah, July 24,
aged 52 years. John D. Dillon, M.D. (Jefferson Medical
College, Philadelphia, 1878), at Philadelphia, July 28, aged 40
years.
Wm. Rose, M.D., aged 49 years, July 26, of apoplexy, at
Columbia, 111. He was born in Germany, where he received
his early education. At the age of 17 years he came to this
country. After graduating from the College of Physicians and
Surgeons at Keokuk, Iowa, in 1878, he located in Columbia,
where he practiced up to the time of his death.
Cub. Isaacs, M.D., aged 40, a well known physician and
politician, died at his home at Flat Fork, near Saylersville,
Ky., of general debility. He had been blind for several years
and was confined to his room ; his condition not improving he
became despondent and his failure was rapid.
Simeon H. Pearce, M.D., died at Friendship, N. Y., July
16, aged 66 years. He graduated from the Medical College of
Castelton, Vt., in 1854. Has been a resident of Mt. Vernon,
Ind., and in active practice of his profession since 1859. He
was a member of the American Medical Association since
1875. Member of Indiana State Med. Association, Secretary
of the Posey County Board of Health, and member of the Pen-
sion Examining Board, and Posey County Med. Association
from its organization. He had gone East for his health.
Mississippi Valley Medical Association.— St. Louis, July 30,
1896. To the Editor:- I desire to announce that the date of
the meeting of the Mississippi Valley Medical Association has
been changed to September 15, 16, 17 and 18, in order to per-
mit the members and their families to take the opportunity
accorded by this change to make a pleasant tour through the
Yellowstone Park, so justly celebrated as the Wonderland of
America. Prominent resident members of our Association in
St. Paul and Minneapolis are formulating plans for the Spe-
cial Yellowstone Park Excursion Trip, to leave on the evening
of September 18, arriving in Mammoth Hot Springs in the
Yellowstone Park about noon on the following Sunday, and
devoting the following five days to the wonders of this remark-
able region, returning to St. Paul Sunday, September 27. The
cost of the trip, including all expenses west of St. Paul, will
be announced in due season, but we are authorized to say that
the figure will be a very favorable one, and we simply wish at
this time to make the preliminary announcement of this most ■
enjoyable feature of the St. Paul meeting, so as to give mem-
bers the opportunity of making their plans in advance to join
the party. It is desirable that there be a party of one hundred
or more, in order to obtain the benefit of the special train
service in both directions. It is urged that all members who
desire to join the party should send their names to Dr. C. A.
Wheaton, Chairman of the Committee of Arrangements, St.
Paul, at as early a date as possible. If you desire to read a
paper before the meeting, please send to me the title at once.
Very truly yours, Hanau W. Loeb, Secretary.
The Upper Peninsular (Mich.) Medical Association.— This society
held its first meeting at Marquette on July 20. Physicians
from all parts of the peninsula were present. The election of
officers held in the afternoon resulted as follows : President,
Dr. J. Vandeventer, Ishpeming; Vice-President, Dr. O'Keefe,
Menominee ; Treasurer, Dr. B. D. Harison, Sault Ste. Marie ;
Secretary, Dr. H. J. Hornbogen, Marquette ; Committee on
Organization, Drs. O. G. Youngquist, O'Keefe, Felch, Hari-
son, Crowell.
MISCELLANY.
Yale's Oldest Medical Graduate. -Dr. Chauncey Ayer of Stam-
ford, Conn., is said to be the oldest living graduate of the Yale
medical school. He was a member of the class of 1831, and
was born in 1808.
Insane Asylum Appointment.— Dr. C. T. Simpson, superintend-
ent of the lunatic asylum located in Austin, Texas, tendered
his resignation July 25, to take effect August 1 or as soon as
his successor could be appointed. The Doctor leaves to take
charge of the insane asylum of Oklahoma.
Kentucky School of Medicine.— A number of changes were
made in the faculty July 28. The chair of anatomy was
divided between C. W. Kelly and W. Ed Grant. Louis Frank
was elected to the chair of clinical and operative gynecology ;
Henry E. Tuley, professor of obstetrics and also obstetrician
to the Kentucky School of Medicine hospital ; Carl Weidner
to the chair of physiology. The chair of the practice of medi-
cine was divided by the appointment of Ewing Marshall as
professor of physical diagnosis. The chair of clinical ophthal-
mology, laryngology and otology will be filled by Thos. C.
Evans.
An Honest Newspaper.— In a recent issue of the Post, pub-
lished in Fort Dodge, Iowa, the editor of that paper declares
that its advertisement pages can not hereafter be used by trav-
eling doctors and medical fakirs. He says: "The Post,
while not holding itself responsible for its advertising columns,
338
MISCELLANY.
[August 8,
does feel this to be true, that it owes to the public who read
it a duty, especially relating to advertising traveling doctors
and medical fakirs, for the reason that no one is so liable to be
imposed upon as a person in search of health, and such a one
is deserving of the utmost good faith upon the part of every pro
f essional man who is called upon for advice or treatment. This,
we are convinced, they are not apt to receive from the hands of
traveling doctors and medical fakirs. In the future the
advertisement of no such person will appear in the Post while
it appears under its present management." — Am. Med. Surg.
Bulletin.
Dr. Henry T. Byford of Chicago has gone to Geneva, Switzer-
land, to attend the International Congress of Gynecology and
Obstetrics.
Pregnancy Following Salpingo-oophorectomy.— Dr. S. C. Gordon
reports the following case: "March, 1894, I removed both
ovaries and tubes from Mrs. R. , aged 33, and so far as I know
there were no fragments of the ovaries left ; each was much
enlarged and flabby, that on the right side being two and one-
' half inches long. She recovered promptly, but menstruated
regularly each month after two or three months. In June,
1895, she became pregnant. The period of gestation was
marked by no peculiar symptoms, and she was delivered of a
healthy child March 12, 1896. In this case there must have
been some stroma of ovarian tissue left, but the question
of interest is, by what means did the ovum reach the uterine
cavity? The only explanation is that the tube, after being
ligated, must have opened at the stump, thus allowing it to
pass through. I have seen the lumen of a varicose vein resume
its normal caliber after having been ligated with catgut-
absorption having taken place before the coats were destroyed.
I presume, the same may occur in the Fallopian tube." — Jour,
of Med. and Science, July.
Deciduoma Malignum.— The Vienna letter to the London Lancet,
July 11 contains the following note on Saenger's disease : At a
meeting of the Vienna Medical Society Dr. Neumann read a
paper on deciduoma malignum, a disease which was first de-
scribed by Saenger in 1882. As a rule it occurs after delivery,
abortion or cystic mole/and it may sometimes be observed even
in childbed. It is characterized by obstinate hemorrhage which
renders the sufferers too weak and anemic to undergo an oper-
ation. Metastatic deposits are formed in the vagina and lungs :
in the latter case there is hemoptysis which may cause death
by asphyxia. The initial symptoms are hemorrhage associated
with enlargement and softening of the uterus; the disease
may be distinguished from cystic mole by microscopic exam-
ination of portions removed by curetting. The general form
of the tumor is like that of a polypus, its tissue has a reddish-
gray color and shows hemorrhages, and in growth it resembles
sarcoma.
Lumbar Puncture of the Subarachnoid Space.— Dr. A. H. Went-
worth summarizes the results of some experimental work as
follows : 1. The normal cerebro-spinal fluid contains neither
cells nor fibrin, and is perfectly clear. 2. In cases of menin-
gitis the cerebro-spinal fluid is invariably cloudy when with-
drawn. The degree of cloudiness is to some extent propor-
tionate to the amount and character of the exudation in the
meninges. 3. The cloudiness is caused by cells. The charac
ter of these differs with the variety of the meningitis. After
withdrawal, more or less fibrin is formed in the fluid. The
presence of these cells and fibrin is pathognomonic of inflam-
mation in the meninges. 4. The cloudiness is oftentimes so
slight that close observation is necessary to detect it. 5. The
operation is not difficult to perform on infants and children.
It is not dangerous, if strict cleanliness is observed. 6. The
differential diagnosis between the various kinds of meningitis
can be made by microscopic examination of the sediment, by
cultures taken from the fluid and by inoculation experiments.
7. Inoculation experiments afford the surest means of deter-
mining tubercular meningitis. It is of value to distinguish
between the varieties of meningitis in order to determine if
tubercular meningitis is recovered from. 8. In the normal
fluid, a faint trace of albumin is usually present, about one-
fiftieth of 1 per cent., or less, by quantitative analysis. In
meningitis the amount of albumin is increased, and has varied
from one-thirtieth to one-tenth of 1 per cent. 9. In one case
a diagnosis of general infection with the staphylococcus pyo-
genes aureus was made from cultures taken from the cerebro-
spinal fluid. — Archives of Pediatrics, August, 1896.
"The Vilest of Crimes Against Dr. X."— The following is an
expurgated edition of the reportorial note in one of our daily
contemporaries : " Dr. X. announced last fall that he had
discovered a preparation which, if used in season, would in
the majority of cases prove a cure for . He has recently
discovered that the country has been flooded with spurious
preparations, not only worthless, but full of danger as com-
pared with his own. As a result of this discovery, Dr. X. has
just brought suit against two prominent individuals, placing
his damages in each case at many thousands of dollars, and
additional suits will be brought as soon as the necessary evi-
dence is obtained. ' This is not a question of money with me,'
said the proprietor of the preparation, which for convenience
may be called Assertolin, or Dogmatocin, ' for I freely pub-
lished the formula, in the hope that the use of the remedy
would receive the widest extension. Personally, I object to
the use of my name in connection with these spurious com-
pounds, the manufacture and sale of which is a crime of the
vilest kind. I shall rigorously prosecute every person I find
engaged in this infamous traffic' " If the language applied
by Dr. X. to his imitators is correctly reported, it is vigorous
and pungent, to say the least. Does he really mean that the
offense of which he writes is an "infamously vile crime?"
Such conduct is admittedly tricky and of the nature of sharp
practice, designed mainly to reduce the financial prosperity
of the person imitated. The personality of the latter is indif-
ferent to the imitators ; to them Dr. X. is an unknown quantity
and the name, whether that of Dr. A. or Dr. X., is chiefly
valuable to them in proportion to the amount of notoriety
through the press that has been previously attained.
Dry Sterilized Catgut. -Mr. Chas. Truax of Chicago has made
some experiments on the tensile strength of sterilized catgut.
He says: " I recently submitted specimens of catgut to the
following tests : Ten pieces of German catgut, No. 6, each 6.
feet in length were taken and numbered consecutively from
one to ten, each being labeled at three points ; at each end
and in the center. These pieces were then each cut into three
pieces, each 2 feet in length, resulting in three of each number.
One set of sutures, those cut from the center of each piece,
were then tested to ascertain their tensile strength by suspend-
ing with each a five gallon can and pouring water into the can
until the suture broke. The breaking tensile strength was
found to vary from 26 pounds to 32 pounds and 6 ounces, as
shown by the following table :
Raw.
Boeckmann.
Schimmelbusch.
No.
1
27 pounds
27 pounds, 12 oz.
27 pounds, 14 oz.
'*
2
26 " 6 oz.
24
26 " 12 "
3
28 " 10 '•
23 "
24 " 6 •'
"
1
32 " 6 •'
26 " 4 "
23 "
•*
5
27
27 " 4 "
23 " 12 "
"
6
31 " 10 "
29 " 4 "
26 " 6 '•
"
7
28 " 4 •'
20 ■'
23 " 6 "
41
8
26 "
22 " 12 «'
21 " 10 "
"
9
26 '• 12 "
25 " 10 "
27 "
10
80 " 13 "
23 " 12 "
24 •' 12 "
■ I 284 13-16
249 10-16
248 14-16
"The second set of pieces were then sterilized by the Schim-
melbusch process, which in brief consists in immersing the
ligatures in ether for twenty-four hours, after which they were
transferred to the following solution :
1896.]
MISCELLANY.
339
Corrosive sublimate Ill
Absolute alcohol 300
Aqua destillata 200
where they were allowed to remain twenty-four hours, after
which this solution was changed for a second lot of the same
solution, and this process repeated until the catgut had suc-
cessively passed through three like solutions, after which it was
placed in absolute alcohol for forty-eight hours. The ten sutures
wore then subjected to the same test as above mentioned and
the breaking tensile strength found to vary from 21 poundsand
10 ounces to -27 poundsand 14 ounces. The remaining ten pieces
were subjected to the Boeckmann-Benckisser system of dry
heat sterilization, after which the breaking tensile strength
was found to vary from 20 pounds to 29 pounds and 4 ounces.
It will be seen by consulting the above table that the combined
weight sustained by the ten raw sutures was 284 13-16 pounds,
or an average of about 28 6 10 pounds each. The ten steril-
ized by the Schimmelbusch process was 248 14-16 pounds, or
nearly an average of 24 9 10 pounds each, while that subjected
to the Boeckmann-Benckisser process was 249 10-16 pounds, or
nearly an average of 25 pounds each. It is evident from this
single experiment that the difference resulting from the use of
the Schimmelbusch and Boeckmann-Benckisser systems is
practically nothing, as a little variation in a single suture might
have resulted in one or the other showing a slight advantage.
It requires but little argument to demonstrate the superiority
of the dry heat system. As the sutures require no vessels or
containers in which to preserve them they can be stored or
transported in a small space. Sealed in small sterilized envel-
opes they may be kept indefinitely without danger of infection.
As no expensive chemicals are necessary either in the process
of sterilization or storage the cost of preparation is reduced to
a minimum. No expensive containers are required and no
danger of loss by breaking of containers and spilling of con-
tents is incurred in transportation. We trust that surgeons
generally may be induced to make similar tests and satisfy
themselves, for if these statements are verified by further
actual tests and laboratory experiments still continue to demon-
strate that catgut prepared by the Boeckmann-Benckisser
method is surgically sterile the surgeon will have to exempt the
catgut from blame if infection takes place."
Baltimore.
Dr. Edward N. Brush, Superintendent of the Sheppard
Asylum of this city, has been elected professor of psychiatry
in the Woman's Medical College of Baltimore.
Indianapolis.
Dr. Joseph R. Eastman of Indianapolis, the son of Dr.
Joseph Eastman, has passed the examination at Berlin Uni-
versity, Germany, and received "Magna Cum Laude."
Cincinnati.
The Health Report for the week shows 132 deaths from
all causes ; annual rate per 1000, 19.61 ; below the age of 5
years 47 : preceding week 111 ; corresponding week 1895, 114 ;
1894, 154 ; 1893, 108.
Dr. Charles A. L. Reed announces that the Mexican Cen-
tral Railroad has made a single fare for the round trip to the
Second Pan-American Medical Congress. It is expected that
the American lines will make the same rate.
The Board of Medical Examiners have rejected one-third
of the midwives who have applied for a license to practice.
They have also notified a colored man hy the name of Porter,
who has been practicing medicine, that he must leave the
State.
Dr. J. B. Barker of Piqua, Ohio, has been appointed U. S.
Pension Examiner in his district.
An advertising specialist of Cincinnati, Dr. W. I. Kelley,
has been arrested and fined $50 by the Kentucky courts upon
a warrant sworn out by Dr. J. M. Mathews of Louisville, the
President of the State Board of Health, charging him with
practicing medicine without a State license. It is alleged that
Dr. Kelley applied for a license which was refused him. The
Hon. W. C. P. Breckenridge defended him and he has given
notice of an appeal.
Mrs. Annie Florein has again appeared in the coroner's
court as a result of an alleged suspicious death occurring at
her establishment. In this instance she presents the evidence
of a young practitioner who attended the case and who denies
any grounds for suspicion regarding the infant's death. The
State Board of Examiners are somewhat handicapped in any
attempt at prosecution in this case for the reason that Mrs.
Florein claims that she does not practice medicine and there-
fore can not be governed by the Board. It is a particularly
unfortunate matter that she can call to her assistance regular
members of the profession to attend cases in which a fatal
termination is expected, and then be able to present the phy-
sician's certificate as evidence of the fact that she is not prac-
ticing medicine.
A case or unusual interest to the neurologist and pathol-
ogist developed last week through a postmortem held on a man
who had fallen out of a window and sustained a fracture of
the frontal and occipital bones. An extensive adhesion of the
dura and pia mater was found at the top of the brain and a
suit for heavy damages is anticipated, as it is claimed that the
diseased condition of the brain was responsible for the fall and
that in turn the diseased condition was the result of an injury
he received on the head some six months ago while working in
a freight car at which time a quantity of ice fell upon him, an
engine having forcibly struck the car.
Dr. E. W. Walker is again on duty after a serious illness.
Philadelphia.
Death or Infant from Accidental Administration of
Strychnia. — The danger of careless handling of medicine in
the household was illustrated by a case investigated recently
by the coroner, in which a fatal result in a colored child
of 21 months was caused by eating some tablets adminis-
tered by an older child who had taken them down from the
mantel-piece. It was ascertained that they contained strych-
nin, which had been prescribed for the child's mother. A
physician was brought in immediately, but was unable to save
the child's life.
The Jewish Maternity Association of Philadelphia has
greatly extended its usefulness by opening a Jewish seaside
home for invalids at Atlantic City, the institution being now
in its fourth season. Accommodations are also provided for
sick infants and crippled children. It is purely charitable
and no expense is borne by the patients. Dr. Boardman
Reed of Atlantic City is the consultant and Drs. A. D. Cas-
caden and L. R. Souder are the attending physicians.
Pollution of Water. — In the annual report of the State
Board of Health, Dr. Benjamin Lee. secretary, forcibly directs
attention to the importance of the prevention of the pollu-
tion of water used for drinking purposes, and the great neces-
sity of legislation upon this subject. He says :
"The fact that, during the past year, thirty-nine complaints
have been made to the board of the pollution of water sup-
plies, only serves to emphasize the misfortune to the State
of the persistent refusal of the Legislature to accede to the
request of the board to give it a special appropriation which
would have enabled it to make a thorough investigation into
the condition of the public waters of the Commonwealth. A
pure water supply is the one great desideratum for building
up a healthy, vigorous community. All other questions are
dwarfed by it. The board will probably remember that early
in the present year a communication was addressed to it by
the health officer of Louisville, Ky., calling attention to the
fact that a bill had been presented in Congress providing
for the appointment of a commission to inquire into the
pollution of such public streams as passed from one State to
another, and requesting our Board to use its influence with
the representatives of Pennsylvania in the national Legislature
340
MISCELLANY.
[August 8, 1896.]
in favor of the measure. A communication was also received
from the State Board of Health of Missouri, enclosing a reso-
lution adopted by that board endorsing the proposed law. At
the meeting of the National Conference of State Boards of
Health at Lansing, two years ago, your secretary, at the
request of the board, made a report upon the subject, calling
attention to the necessity of an investigation by the national
government in consequence of the general inertness of State
governments in dealing with this important question. A reso-
lution was adopted at that time to memorialize Congress upon
the subject, and the present movement was undoubtedly due
to the action then taken. On receipt of the communication
the board adopted a resolution approving the bill, and a copy of
the same was forwarded to each of our representatives in the
national Legislature, requesting him to give the measure his
support. Inasmuch as many important streams pass both into
and out of our territory from and to that of other States,
such an investigation pursued by the thoroughness which
characterizes work undertaken under national auspices could
not but prove of the greatest benefit to us."
A Sensational Robbery in a Hospital. — A patient who
occupied a private room in the St. Joseph's Hospital had his
trunk forced open by an attendant, who carried off jewelry
and bonds amounting to $20,000 or more. The thief was soon
afterward arrested in New York City, and with a female accom-
plice is now in custody. In such a case it might be asked
whether there was not contributory negligence in carrying
into a public institution such a large amount of valuables with
such slight protection as is afforded by a trunk.
Accident to an Ambulance — A trolley car last week struck
an ambulance that was taking a boy to the Jefferson College
Hospital to be operated upon there for appendicitis. The
rear wheel was broken and the axle bent, and the boy's father
was thrown violently upon the patient, greatly increasing the
gravity of the condition. The operation was done soon after-
ward in the hospital and the lad, who was 12 years of age, died
a few hours later. The coroner decided that the death had
been accelerated by the accident, but had not been caused
by it.
Death from Acute Indigestion. — On one of the warm days
recently a man applied for treatment at the Episcopal Hos-
pital, stating that he had eaten a great deal of cheese and
thought that might be the cause of his illness. He grew rapidly
worse and died a few hours later. He was a German, 49
years of age, and it was held that he died of heat stroke and
acute indigestion or gastritis, from eating cheese.
The Samaritan Hospital on North Broad Street, which is
under the fostering care of Grace Baptist Temple, is increas-
ing its capacity by the erection of an additional wing to be
devoted to isolation purposes.
The New Clinical Amphitheater of the Medico-Chirur-
gical Hospital is now under roof and presents a handsome
appearance.
The Medico-Chirurgical College Trustees, it is an-
nounced, have in contemplation the creation of a faculty for a
dental department as soon as the present arrangement with
the Philadelphia Dental College is dissolved, which will be
at the end of the next term. For a number of years the
association of the two institutions in the same buildings was
mutually advantageous, but the phenomenally rapid growth of
the medical school has now placed it in position to occupy the
buildings for its own purposes.
A Case of Double Personality.— At the Philadelphia
Hospital a curious case of loss of memory has excited much
interest, among the neurologists especially. The patient, a
young man, after four months' stay in the hospital has been
recognized by Dr. E. F. Robinson of the resident hospital
staff as a former college companion named Spencer. The
patient, however, did not recognize Dr. Robinson nor acknowl-
edge the name. In fact, he did not remember his name at all
and could not give any when admitted into the hospital, nor
could he remember anything about his previous life or explain
how he came to be in Philadelphia with nothing in his posses-
sion save some pawn tickets made out in the name of George
Brandt, under which name he was received into the hospital.
Dr. Daniel E. Hughes, the superintendent, took great interest
in the case and recently brought him before the Neurological
Society. Dr. Lloyd was of the opinion that the young man
might have been hypnotized. Dr. Hughes considers that it is
a case of loss of personal identity, or of double personality of
the Archibald Malmaison type. Mr. Spencer's home is in
Lawrence, Kan., where his father resides. He was last heard
of January 27 in Washington, but he can give no aecount of
his wanderings before coming to Philadelphia. From his con-
versation, however, and replies to questions, Dr. Hughes
believes that he has recently been in London and perhaps on
the continent.
College News. —The State Board of Medical Examiners
and Licensers of Pennsylvania met at Harrisburg last month,
as directed by the statute creating this board, and the results
have just been published. The examination comprised ques-
tions in anatomy, physiology, pathology, diagnosis, hygiene,
surgery, obstetrics, chemistry, materia medica, therapeutics
and practice of medicine, and requires four days to complete
it. Out of a total of 381 candidates 340, or 89.24 per cent.,
were successful in obtaining the license to practice medicine
in this State. The University of Pennsylvania sent up 48 can-
didates, all of whom passed the examination, and the 9 candi-
dates sent by the Woman's College of Philadelphia were
equally successful. Three out of 42 from the Medico-Chirur-
gical College were unable to pass, and 8 out of the 131 from
the Jefferson were unsuccessful. It is proper to state that one
of those rejected from the former college had failed to pass the
board last year and had not attended lectures in the interval.
The West Pennsylvania Medical College of Pittsburg was repre-
sented by 81 candidates, of whom 62 passed. There were 16
from the College of Physicians and Surgeons of Baltimore, of
whom only one failed to obtain the license. Among the names
of the successful candidates is that of Horation C. Wood, Jr.
THE PUBLIC SERVICES.
Army Changes. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
July 25 to July 31, 1896.
Major Henry McElderry, Surgeon (Ft. Robinson, Neb.), is granted leave
of absence for one month, to take effect on or about Aug. 3, 1896.
First Lieut. Isaac P. Ware, Asst. Surgeon (Madision Bks., N. Y.), is
granted leave of absence for three months, on surgeon's certificate
of disability.
Capt. George E. Bushnell. Asst. Surgeon, is relieved from duty at Ft.
Hamilton. N. Y., to take effect upon the expiration of his present
leave of absence, and ordered to Ft. Assiniboine, Mont., for duty at
that station, relieving Capt. Peter R. Egau, Asst. Surgeon. Capt.
Eean, upon being thus relieved, is ordered to Ft. Hamilton, X. Y.,
for duty.
« Iuiiiu <■ of Address.
Dvorak, W. J., from ISM t. . 1841 W. SSd SSt„ Chicago.
Judson, A. B., from 36 to 1 Madison Av., New York, N. Y.
KaUmheimer, G., from B10 to608 8d st.. Milwaukee, Wis.
Lawrence, O. H., from Chicago to 6 and 7 Klttredge Bldg., Denver,
Colo.
Morrall, G. W., from Barnwell to Millettville, S. C.
Martens. E. J., from St. Louis to Forsyth Junction, Mo.
Mi-Mahan. C. Agnes, from Chicago Beach Hotel to 2970 Indiana Av.,
Chicago.
Mi-Daniel, K. B., from Cove to Rooms 306 and 107 Dekum Bldg., Port-
land. Ore.
Oglesby, C. R., from l'ensacoln, Fin., to Kirkwood, Mo.
Potts, j. S.. from Los Angeles to San Jose, Cal.
Percy, J. F.. Galesburg, 111., to Mnntorville, Minn.
Syno'n, G. C, from Cedar Rapids, Iowa, to 1557 W. Harrison St., Chi-
cago, 111.
LETTERS RECEIVED.
Arters, J. D., Oil City. I'a.; Alma Sanitarium Co.. Alma, Mich.
Burr, C. B. (2), Flint, Mich.; Battle Creek Sanitarium, Battle Creek,
Mich.: Beieer Mfg. Co., The. Brooklyn, N. V..; Borck, Edward, 8t. Louis,
Mo.; BntterwortK, Alice, Chicago; Berry, H. A., Oswego, 111.; Boeh rin-
ger, C. F. &Soehne, New York, N. Y.
Caldwell. J. R.. St. Clairville, Ohio; Colvin. D., Clyde, X. Y.; Cham-
bers, J. H. & Co., St. Louis, Mo.; Uhesman, Nelson A Co., St. Louis. Mo.
Drevet Mfg. Co., New York, N. Y.; Dvorak, W. J., Chicago; Dollber-
Goodale & Co., Boston, Mass.
Gaston, J. McFadden, Jr.. Atlanta, Ga.; Guthrie, F. A„ Aledo, 111.
Ilaldenstein, I., New York, N. Y.; Hummel, A. L., Adv. Agency (5),
New fork, N. Y.
Ingals, B. F., Chicago.
Kiernan, James G., Chicago.
Lawrence, G. H- Denver. Colo.; Leresche, E. P., Chicago.
Morse, Edward E., Washington, D. C.j Macmlllan Co., Tin-, New York,
N. Y.; MaltineMfg. Co., New York, N. Y.; Mauley, Thus. 11.. New York,
N. Y.j Marcband, Unas., New York, N. Y.; McDaniel, E. D. (8), Milton.
Fla.
Rabuck, S. H., Lyle, Minn.
Small, Edward H., Pittsburg, Pa. : Stirling, A. W., Atlanta, Ga.; Smith,
W. H. C, Lincoln, 111.; Smith, H. F., New Troy, Mich.; Strong, B. F.,
Howard, Kan.
Tyree, J. S., Washington, D. C; Truax, Chas. Greene & Co., Chicago.
Von Koerber, P. E., Loup City, Neb.; Van Cleve, A. H., El Paso.
Texas.
Wathen, W. H„ Louisville, Ky.; Walsh, Ralph, Washington, D. C;
Wood, Casey A., Chicago.
1
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., AUGUST 15, 1896.
No. 7.
ORIGINAL ARTICLES.
HEREDITY AS A SOCIAL BURDEN.
Read in t!n> Section on State Medicine, at the Fortv-seventh
Annual Meeting of the American Medical Association,
held at Atlanta. Ua.. Mav 5-8, 1890.
BY A. W. WILMARTH, M.D.
FIEST A8SISTANT PHYSICIAN NORRISTOWN HOSPITAL FOR THE INSANE;
LATE ASSISTANT SUPERINTENDENT PENNSYLVANIA INSTITUTE
FOR FEEBLE MINDED CHILDREN.
NORRISTOWN, PA.
It may appear a waste of time to place before you
proofs of the existence of heredity as a large factor in
the production of those nervous diseases on which I
wish to speak briefly to-day. My reason for doing so
is two-fold. The existence of heredity as such a fac-
tor has been occasionally denied by men of such posi-
tion that their opinion must carry weight, even though
they are opposed by the majority of the thinking men
who have given this matter their attention. The
existence of heredity appears thoroughly established
by statistics which have been most carefully compiled
and verified. Moreover, the great number of these
defectives, and the vast, ever-increasing expense of
their maintenance, as well as their harmful influence
on society at large, can only be realized in this way.
The three forms of disease which are most liable to
make their victims dependent on society by rendering
self-support impossible, or their society dangerous,
are epilepsy, insanity and imbecility. In dealing
with heredity in connection with these three forms of
nervous disturbance, it is not reasonable to expect
each condition to exactly reproduce its kind. The
law of heredity is that each characteristic in the
parents tends to reproduce itself in the offspring.
Characteristics derived from one parent may be over-
come by the influence of the other, and may even
reappear a generation farther on, or be permanently
obliterated. The three above named conditions are
all simply evidence of degenerative changes of the
nervous centers, dependent for their form on the por-
tion of the brain attacked, and the age at which they
develop. Brain trouble occurring early in life occa-
sions imbecility; later, insanity; while epilepsy may
complicate either condition or, rarely, occur independ-
ently. Almost any lesion or trophic change in the
brain may occasion one or more of these manifesta-
tions of disturbed nervous action.
Let us look first at epilepsy as an inherited neuro-
sis. The statistics being more accurate than in the
other two diseases, for the reason that its symptoms
are unmistakable, and thus friends can neither deceive
themselves or others in regard to its existence. Even
in uncomplicated epilepsy, if the spasms are at all
frequent, the sufferer's power of self support is less-
ened, if not entirely destroyed, and he becomes a bur-
den on friends or the general public. Echeverria,
after ten years' careful research in tracing the off-
spring of epileptics, has published the most valuable
statistics on this subject that I have yet found.
Excluding all cases which could not be fully verified,
he found that 62 male and 74 female epileptics begot
553 children whose life histories were as follows: 22
were still born ; 195 died in infancy from spasms; 78
lived as epileptics; 18 lived as idiots; 39 lived as par-
alytics; 45 lived as hysterical; 6 had chorea; 11 were
insane; 7 had strabismus; 27 died young from other
causes than nervous disease; 105 were healthy.
Excluding the last three divisions we have 414 out of
553 who either died in utero or were affected with
nervous disease. Could a more convincing story be
told? He concludes that the marriage of epileptic
women to non-epileptic men is more liable to result in
neurotic offspring than when the conditions are
reversed. He quotes one case when two epileptics
married and out of five offspring two died of infantile
convulsions, one from hydrocephalus, one lived an
epileptic, and one was said to be bright. Of his 136
original cases 87 had parents with either insanity or
epilepsy, while in forty-six cases epilepsy had existed
through three generations. One woman had epilepsy
from puberty to her marriage, which demonstrates that
marriage may benefit epileptics, but of four children
born afterward, two were epileptic and one paralytic.
Dr. Knight of Lakeville, Conn., in an address before the
American Conferences of Charities and Correction,
quotes a case where an epileptic mother bore fifteen
children. Eight died in infancy, two were fairly
teachable imbeciles, two were epileptics and three had
sufficient intelligence to secure husbands and thus
risk the multiplication of their kind. Dr. Landon C.
Gray tells of an epileptic woman who bore nine chil-
dren, seven of which died of infantile convulsions.
I studied the records of 500 epileptics at the Elwyn
(Pennsylvania) school for the feeble minded during
my residence there as a medical officer. Of these 149
were very incomplete. In the remaining 351 I found
neurotic disease in 108 families on the father's side;
in 106 on the mother's side; in 22 instances on both
sides, or 236 families in all. In 19 other families
some neurosis existed in brothers or sisters, but was
not acknowledged farther back. From my personal
knowledge of some of the families, I am sure that
strict truth and the power to see "themselves as others
see them" would swell these figures considerably.
Insanity, imbecility and epilepsy with 56, 58 and 71
cases respectively, figure most prominently in this
array of epileptic inheritance, chorea, paralysis, etc.,
forming the remainder.
The heredity of insanity is not so evident, nor is it
so certainly transmitted to offspring, especially in
neurosis of the same form, as is epilepsy. The rea-
son for this may be looked for in the fact that many
cases of insanity are the direct result of excesses, or
other causes occurring in adult life. The transmitted
effect manifests itself more frequently in childhood
342
HEKEDITY AS A SOCIAL BURDEN.
[August 15,
or infancy, and epilepsy or imbecility results. Or
possibly we may find that incurable perversion of the
moral nature, aptly termed "moral imbecility," which
furnishes so much contention as to whether it should
be regarded and punished as depravity or treated as
a congenital absence of the faculty of moral control.
A smaller number reach mature years before coming
into their inheritance of misfortune and are classed
as insane, and occasionally reproduce the parent mal-
ady with singular exactness. Savage, the eminent
English authority, states the matter very concisely as
follows: "Heredity produces some insanity, but is
more likely to produce either mental defect or special
and unusual forms of muscular, sensory mental or
moral disorder." Nearly every systematic observer
admits heredity as an etiologic factor in insanity,
and while the most conservative statistics place the
average from 20 to 25 per cent, of the cases observed,
others place it higher and Kestevan says: "The most
influential of causative conditions is heredity, and it
is the most commonly suppressed by the friends!"
The truth of the last statement at least is indisput-
able. I wish to particularly emphasize the influence
of heredity in imbecility and idiocy for the following
reasons. They are the legitimate offspring of nearly
every form of neurotic taint. Their extent and bane-
ful influences are not realized by any one who has not
given the subject very careful study. The census
reports for 1890 and the natural increase would bring
their number to between 90,000 and 100,000. This
is far below the real number. So slow are parents to
publish their children to strangers as feeble minded,
that the late Dr. Kerlin of Elwyn, Pa., investigated
the matter. Out of 295 applications for admission to
his school in 1880, 178, or 60 per cent., could not be
found on the census enumerators list. How far this
may apply throughout the country we can only sur-
mise, but mothers are much the same everywhere, and
are not willing to publish their childrens' defects.
There are two conditions in parents which figure
largely in the production of feeble mindedness in
children, tendency to neurotic disease and inebriety.
These conditions are associated with the greatest fre-
quency. Dr. Beach of England states that drunken-
ness is found in the ancestry of 38 to 40 per cent, of
the parents of idiots (using the term idiot in its
broadest sense). The Fourth Conference for the Care
of Idiots in Germany agreed that inebriety was the
principal cause of idiocy. In this country the Asso-
ciation of Medical Officers engaged in the care of the
feeble minded agreed unanimously that a large per
cent, of imbecility is due to the transmitted effects of
alcohol and counseled, as did the German conference,
more stringent legal restriction of its sale. It is well
to bear in mind, in regard to these conclusions, that
we can not draw too close a line between the habitual
inebriate and the neurotic, for one class merges into
the other and makes the distinction between cause and
effect a difficult study. A cloud of witnesses testify
to the transmission of neurotic taint in one or more
of its many forms, to produce the multitude of imbe-
cile and idiot children whose large aggregate number
and marked increase is shown by every census. The
largest and most complete studies on this subject have
been made by Dr. Barr in this country and Drs.
Beach and Shuttleworth in England. The work of
these gentlemen is too well known to make any doubt
of the great care exercised in the preparation of their
tables, or the accuracy of their results, possible.
Barr.
Total cases 1,044
Per cent.
Insanity and imbecility.38.02
Other neuroses .... 21.55
Beach.
1,080
Per
cent.
22.71
36.85
Shuttleworth.
1,200
Per cent.
20.08
Incomplete.
Total 59.57 59.56
If we accept the aggregate totals of Barr and Beach
which are nearly alike we have nearly 60 per cent, of
the families with more than one victim of nervous dis-
ease. These figures fairly illustrate the results of other
observers. We can not go much into detailed cases,
but I would like to quote Dr. Ireland in illustrating
the persistence of this tendency to produce offspring
of low grade in some cases. He cites an instance
where four illegitimate feeble minded children were
born to one defective woman from four different
fathers. In another instance, under my own care,
was a little idiot boy with the well-formed but lax
and useless muscles in certain regions, which usually
accompany the cerebral condition known as micro-
gyria. His mother, a robust, high grade imbecile with
no apparent physical defect, came to see him. She
had married again and bore in her arms another idiot
child very similar to his half-brother. A local phy-
sician assured me that they were certainly the chil-
dren of different men, the second husband not having
come to that region until after the birth of the first
child.
Such is the evidence that tendency to nervous
degeneration or instability descends from generation
to generation, broken or interrupted perhaps by
infusion of stronger elements, reappearing a genera-
tion farther on. What is their number and to what
extent do they affect the welfare and progress of the
public? Of epileptics, Dr. Knight, who has given
their care much study, estimated that in 1892 there
were, in this country, 19,000. They almost invaria-
bly drift into imbecility, dementia or other form of
insanity, and are cared for, if cared for at all, under
these heads. Some children recover, but adults very
rarely. They are ever liable to injury, which prevents
their following many forms of employment. They
are free to marry if they can find a mate, and there
are very few who set out earnestly on that quest and
are not very particular, who do not succeed; and they
leave as a legacy to the public more epileptics.
When subject to attacks of epileptic mania no class
of the insane are more dangerously violent.
The number of the insane in the country will
hardly number less than one hundred thousand.
Probably there are more. It would be difficult to
ascertain the total cost of their support. We will
look at the approximate cost in the two largest States
which in 1890 contained about one sixth of the pop-
ulation of the country, which will furnish some guid-
ance to the possible expense in the whole country.
In Pennsylvania, in 1894, there were 8,616 insane in
institutions of all kinds, of which number 6,342 were
in the six State hospitals and the private hospitals at
West Philadelphia and Frankford. These 6.342
insane represented an expenditure of nearly one and
one-half million dollars. The care of less than one-
eighth of the State's feeble minded added $150,000 to
this large total. New York spent in 1893 for the
care of her insane in public hospitals and for a small
proportion of her imbeciles, over two and a half mil-
lions of dollars. Carry out this ratio throughout the
country and the amount would be startling. The
bulk of the insane are in asylums, for public safety
L89& ]
HEREDITY AS A SOCIAL BURDEN.
343
demands this. Where are the feeble minded, who are
found in European countries to outnumber the
insane, and probably would here if properly enum-
erated? Not one-tenth are eared for in institutions.
The remainder are in almshouses where their proper
care is, in many eases, doubtful. Many are in homes
where they monopolize their mothers' time andcare.and
elsewhere, where they are teased by children, abused
by the vicious and live a strange life among their own
people, with whom they have little in common. From
the highest grades of imbeciles are recruited the ranks
>t potty criminals, prostitutes and tramps, who marry
early and often, and who reproduce with the frequency
of animals. Officers in reformitory institutions are
becoming impressed with the idea that the majority
of the younger criminals are permanently lacking in
the higher mental traits, without which the develop-
ment of moral character is difficult if not impossible.
The growth of the burden on the industrious of sup-
porting the helpless and the worthless may be better
realized when we find that the New York State Board
of Charities and Correct ion expended nearly eight and
one-half millions of dollars in 1880 and nearly sixteen
and one-half millions in 1890, although the popula-
tion in that decade increased less than 20 per cent.
to you realize that the taxpayer may support, during
life of ordinary duration, members of three genera-
tions of these defectives? The remakable increase in
lumbers in a family line of defectives and incapables
lay be best illustrated by quoting two instances. One,
founded on the report of Miss Schuyler, President of
the New York Charity Aid Society, of "Margaret the
Mother of Criminals," and progenitor of a family of
banners, beggars, prostitutes and criminals, which
finally became a race of 700. Their family vigor was
largely preserved by intermarriage with fresh, vigor-
ous families of ruffians, and some of the women bore
at least twenty children, among which were numbered
insane, epileptic and imbecile. I would quote briefly
from Dr. Barr's exhaustive article on the influence of
heredity on idiocy, the record of the family known
as the " Tribe of Ishmael," where the descendants of
one unclean, neurotic man traced through many
years, " multiplied by consanguineous marriages into
260 families, numbering some 5,000 individuals,
whose continuous criminal record has poured over the
Northwest a flood of imbecility and crime." Nor do
these instances stand alone. It is the salvation of
society that at a certain stage of nervous retrogres-
sion nature appears to check further increase by
making the most defective sterile and short lived.
The cost of human life through the insane each
year is very large. Professor White, late of Cornell,
places the number of homicides in the country last
war at over 10,000. How many of these are due to
insanity I will not pretend to say, but almost daily we
read of suicides preceded too often by the death by
violence of one, two, or even five or six people under
circumstances which appear hardly consistent with
normal mental balance. So frequent have such affairs
become that only when some one of more than ordinary
standing becomes the victim do they excite more than
temporary local interest or arouse us to the danger
which may be very near us.
The remedy for this state of affairs is a subject
which demands earnest thought and radical measures
for relief. The evil is so wide spread, so thoroughly
grafted in the every day life of society that to think
of its immediate or entire suppression would be folly.
It is time to attack the evil in some quarter. We can
not expect relief from purely medical means. No
more hopeless disease exists among the more common
maladies than epilepsy in the adult. The relatively
small number of "recoveries" in hospitals for the
insane would be diminished if we subtracted the
number who are committed to recover from alcohol,
and other such cases who go out only to find their
way back to some hospital later. Officers of institu-
tions for imbeciles no longer look for restorations to
normal brain power in large numbers, and even in
such cases as leave the institutions there is a fear that
their places may shortly be claimed by their children.
He knows that the chief value of his work lies in the
knowledge that the high grade imbecile is safer and
the low grade and idiot more comfortable than he
could be made at home. That he has relieved other
children of association which would work harm and
no good. He has relieved the family of an expense
which deprived the other members of their due and
the mother of a burden often too great for her. More
than this, by enabling one person to:care for perhaps
five of these children, five families have been able to
turn their entire efforts to ordinary social duties
unhampered by such a burden as an imbecile child.
Moreover, defective imbecile children should become
the wards of the State until the danger of child-
bearing is past. It is not so important with males.
I need not explain why girls with strong animal
passions and low mental or moral powers need such
care.
It seems strange that our marriage laws should be
so lax. The marriage of the unfit goes on unhindered.
The epileptic may marry his kind and reproduce more
of his kind. The drunkard, from a body thoroughly
diseased, may cause any number of defective children
to become public wards to be supported by the more
self-respecting and industrious. There is no legal
preventive against the man whose father and grand-
father have been insane, and who has been, at some
time, insane himself, from marrying a woman sim-
ilarly afflicted and charging the bill to the public.
The lunacy law of Pennsylvania expressly provides
that a patient while still insane may go home for
stated periods to resume all his family relations. It
is time for a radical change in this condition of things.
The excellent example of New York should be followed
in other States and more accommodation provided for
mentally and morally incapable women and girls.
More stringent marriage laws should be enacted and
enforced. The need of some such law was most
strongly impressed upon my mind during my frequent
observations of the mothers of feeble-minded children,
so many of whom, though not feeble minded were
surely close to the line. So many had a different
name from their child's, from remarriage. Possibly
the fathers were the same, but this was not so evident.
In one winter, out of five children who died consecu-
tively, four of the mothers had contracted a second
marriage. One woman who was said to be the mother
of six microcephalic imbeciles, and had two of them
in our care, once visited us and announced her inten-
tion of contracting another marriage. It is a well-
established fact that a mother who has had a micro-
cephalic child is liable to have any successive children
similarly marked.
So long as this evil continues it is difficult to see
how we can stop the constant increase of this class.
Such marriages should be legally prohibited. While
344
HYGIENE VEKSUS DRUGS.
[August 15,
women, in every way fitted to fill the post of wife and
mother, hesitate before the responsibilities such a
position entails, these women should not be allowed
to assume such duties as they can never properly fill,
at so great a public cost, for the mere gratification of
animal instinct or a prospect of support. Such a law
would not be unjust. The right of society to control
all powers which militate against the general good
ought not to be denied, and such a law judiciously
applied would work no material hardship and inter-
fere with no one's just rights. The marriage of an
epileptic is a crime. It is almost absolutely sure to
result in the birth of human beings foreordained to a
lifetime of suffering.
On whom does the responsibility of righting these
wrongs fall more heavily than upon ourselves. No
one understands so well as we how surely the fruit
follows the seed in these matters, and no one's word
would have the same weight in molding public opin-
ion to force proper legislation to this end. The mar-
riage of the unfit should subject the perpetrator to
punishment as surely as would any other offense
against the public peace and morals. The whole
body of the intelligent public would agree with us in
this matter. The clergy would endorse such a move,
perhaps excepting a few who are entirely unworthy
of the vocation they have assumed, who disregard the
divine warning that the consequence of the father's
sins shall surely descend to the children and cheer-
fully assist, for a marriage fee, in perpetuating the
evil.
These two measures, of providing safe and comfort-
able homes for the weak and preventing in some
measure marriage among those who can only perpet-
uate and increase human suffering, poverty and crime,
fall far short of fully solving the question, but they
have the advantage of being practicable, and furnish,
so far as I can see, the only radical method of pres-
ently reducing this class to its minimum number, for
it truly attacks the evil at the root. We can not
abolish human weakness and sin, but we can deprive
it of the seal of the State and the Christian church.
HYGIENE VERSUS DRUGS.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association,
at Atlanta, Ga., May 5-8, 1896.
BY C. F. ULRICH, A.M., M.D.
WHEELING, W. VA.
The American people have been called a medicine-
taking nation. If the quantity of drugs prescribed
by physicians, the masses of patent medicines, the
barrels of so called home remedies, such as teas,
decoctions, infusions and other monstrosities, swal-
lowed by the American people, were ascertained,
collated, arranged and published in a book, it would
strike the reader dumb with astonishment. The fact
that any human body can survive the injection of
such an endless variety of vegetable, animal and min-
eral poisons as are poured into the patient and unre-
sisting stomach and thence distributed throughout
the various channels, acting upon the digestive organs,
the circulation and the nervous system, proves that
man is indeed " fearfully and wonderfully made," and
has much greater powers of resistance than we would
believe possible. v
Let us suppose that an individual has what is com-
monly called a cold, which may be catarrh of the
pharynx, the tonsils, the larynx, the trachea, the
bronchi ; it may even be an incipient pneumonia.
This person tells his or her suffering to a neighbor,
the neighbor replies: "Oh, I had that, and I took
such and such medicine." Immediately the article is
procured and taken. Another one comes in, hears the
tale of woe, and recommends something else, this also
is duly swallowed. By the time the gauntlet of the
whole neighborhood has been run, and the entire
catalogue of the domestic and the proprietary phar-
macopeia has been exhausted, the patient has either
recovered by virtue of his good constitution in spite
of the horrible dosing, or the disease has progressed
to a dangerous stage. In the former case, the wisdom
of the neighborhood gossips or the excellence of this
or that patent medicine is lauded to the skies; in the
latter case the doctor is called in and is told they have
given the patient everything that everybody recom-
mended and having failed, they now call him in to
try his skill. Thrice happy is the poor doctor if these
busybodies have left enough constitution and vitality
in their unfortunate victim to give him even a faint
prospect of working a cure. If, however, owing to
the exhaustion of the vital powers, or the general sub-
version of all the functions of the body by the heavy,
indiscriminate and absurd dosing to which the poor
sufferer has been subjected, the doctor fails to cure
him, all the vials of wrath will be poured upon his
devoted head by the would be doctresses in the
neighborhood. If he thinks the patient requires
rest from drugs and gives nothing, he is promptly
discharged and another one called in, who will come
up to their standard of excellence by ordering some
kind of medicine to be taken every hour, or oftener.
I have frequently been told when presenting a bill
that certain visits should not be charged for, because
I did not make the patient take medicine on those
days. My answer would be that it required as much
medical knowledge to determine when medicine is
unncessary as to know what remedies are required.
It has often been suggested to me by my patients, or
their families, that it is not necessary to come every
day, but to return about the time the medicine is
exhausted, in order to prescribe more. It does not
occur to these individuals that the physician's duty
is to watch the course of the disease, note its changes,
assist nature in her efforts to bring about recovery,
prescribe suitable remedies against unfavorable ten-
dencies; in short to act as a kind providence to
watch over the patient and promote recovery. They
imaging the physician's business is to pour all sorts
of drugs down the poor patient's throat and keep him
constantly saturated with medicine. While engaged
on the preparation of this paper, I visited one of my
patients in the afternoon, whose medicine was
exhausted in the morning. I found the family in
terrible trepidation because he had not been dosed
for six hours. The fever having abated, the temper-
ature normal, the pulse regular, the patient free from
pain, he was all the better for getting a little rest from
drugs; but the family had suffered agony on account
of my coming so late, and were on the point of send-
ing a messenger to my house to inquire what was to
be done. It is often necessary to prescribe a placebo
in order to retain the patient. The physician who
studies nature carefully, who makes himself thor-
oughly acquainted with the physiologic and patho-
logic processes of the human organism, acquainting
himself with all the changes that take place in the
interior of the body, both in health and disease;
1896. !
HYGIENE VERSUS DRUGS.
345
riving the proper remedy at the right time and
refraining from the administration of drugs when
mt mo is doing the work for him, will be successful
rhere success is possible; although he may some-
limes confront the prejudices or the dense ignorance
his clients, and thus lose caste with some of them;
;>ut in time, it will be better, not only for the patient,
:mi for the physician himself.
I oan call to mind very many families who had
abandoned me for some new and more complaisant
physician, who would prescribe large quantities of
igs. resort to a variety of mechanical methods, that
ie represented as new. convincing the family thereby
"tat he possessed more knowledge and skill, who
inally became disgusted with the meddlesome activity
the new man and returned to me, saying: "I like
ie old doctor best after all." Having said as much
necessary about the pernicious abuse of drugs,
let us see what we can offer as a substitute. Hygeia,
in the ancient mythology, was the goddess of health.
We call this divinity Vis Medicatrix Naturae, the heal-
ing power of nature. To the diligent student of
nature and of physiologic processes in the human
body, this divinity, Hygeia, assumes a greater impor-
tance than is generally attributed to her by the young
and inexperienced practitioner. In a paper read at
San Francisco in 1894, entitled " Cleanliness the
Chief Antiseptic." I endeavored to show that the
earnest and continued effort to prevent the develop-
ment of bacilli and their entrance into the human
organism, is of much more value in promoting health
than the effort to destroy them after they have been
introduced, or to relieve the system of the disease
caused by their presence. This is the first considera-
tion in the study of hygiene, which was fully discussed
in that paper. But, as every physiologist knows (and
every physician should be a thorough physiologist),
there is a very complete apparatus in the human sys-
tem to carry off, not only the waste material in health,
but to dispose of the results of abnormal processes
and of disease caused by the introduction of malig-
nant bacilli. This consists of the various emuncto-
ries. as the large intestine, assisted in part by the
entire alimentary tract; the urinary apparatus, i.e.,
the kidneys, the ureter, the bladder, the urethra; the
skin with its system of transpiration, i. e., the sudori-
parous glands and ducts. Now, although physicians
know all about these, the masses are ignorant of the
importance of keeping these emunctories in order,
and many physicians are inclined to be careless in
this direction. Bacteriology, antisepsis and abdom-
inal surgery have so engaged the attention and called
forth the enthusiasm of our modern practitioners,
that the good old custom of investigating the bowels,
the kidneys and the skin is often lost sight of. How
much misery and suffering might be avoided, what an
enormous quantity of patent pills and other purga-
tive drugs would be rendered useless, and the sums
of money wasted on them might be devoted to mak-
ing the family more comfortable, if proper attention
were paid to keeping the intestinal tract in good con-
dition, which could be done without taking pounds
of pills or swallowing gallons of medicine, by simply
adopting a sensible and hygienic system of diet, by
observing proper times for attending to the calls of
nature, by never allowing other avocations or a false
notion of propriety to interfere with the performance
of that most important function. How much kidney
disease might be averted by only introducing into the
stomach such liquids as contribute to the preservation
of .the proper relations between the solids and fluids
of the body. Here some one asks the question:
" Shall we live like the beasts of the fields, drinking
nothing but water? Shall we not pay some attention
to the taste which nature has bestowed upon us, and
enjoy the pleasant beverages with which the world
abounds?" I do not propose to be so severe; you
may enjoy the pleasant beverages that nature, assisted
by the art of man, furnishes you, but you must prac-
tice moderation; you must become acquainted with
the capabilities of your organization ; you must study
the effect of these beverages, and stop before the
point of deleterious influence is reached. When you
see a man suffering from that deadly malady, Bright's
disease of the kidneys, take it for granted that he has
abused that great organ, whose function it is to rid
the body of worn out and dead material. It is a very
patient and long-suffering organ, that will submit to
an immense amount of abuse; yet there is a limit to
its endurance and it must eventually succumb. The
skin, an important auxiliary to the kidney, can be
kept in a healthy condition by attending to hygienic
rules. If we promote perspiration by reasonable and
moderate exercise, and by keeping the pores open
through frequent ablutions, we will find much poison-
ous material carried off that the kidneys would fail to
dispose of. If these two organs, the kidneys and the
skin, are treated according to the rules of hygiene,
much disease will be prevented and the taking of
enormous quantities of drugs avoided. The stomach,
that great work-shop, in which the first stage of con-
verting food into tissue is accomplished, is as much
abused as the kidneys and the skin. All kinds of
incongruous, indigestible and injurious articles, under
the false name of food, are forced into the long-suffer-
ing and much-enduring stomach; indigestion or dys-
pepsia, which brings in its train so many other ills, is
the inevitable result. This was for many years the
prevailing disease of the American people, causing
them to be distinguished by their sallow complexions
and pinched features. The consequence is that the
sufferer, not knowing what is the matter with him,
resorts to all kinds of absurd medication, throwing
the entire machinery of the body out of gear, thereby
damaging the intellectual faculties and ruining the
disposition. There is not a more unfortunate creature
in existence than the chronic dyspeptic, a source of
misery to himself, to his family and to all who come
in contact with him. Now, how is this to be pre-
vented? Not by filling the stomach with drugs which,
in many cases, act as a foreign body, or even as a
poison. It can only be avoided by learning the
requirements of the system, the ability of the stomach
to dispose of the ingesta, and the peculiar character-
istics of the food to be supplied. Another thing to
be avoided is the unhealthy habit of bolting the food
to gain time for business, neglecting mastication, an
essential process in digestion, and swallowing the too
often unhealthy food with such rapidity that it forms
at first an inert mass and afterward ferments, produc-
ing gastralgia, acidity of the primae viae, with a long
train of disastrous consequences. This is perhaps the.
most important branch of hygiene, and should bA
studied by every parent and by all the children old)
enough to understand it. The hygiene of drinking-
water has been sufficiently discussed to require no,
mention here. Already intelligent housekeepers are.
filtering and boiling their drinking-water, and tha.
346
PREVENTION OF SMALLPOX.
[August 15,
remarkable absence of typhoid fever in our city shows
that this reform has borne good fruits. The hygiene
of the lungs, the heart, the liver, etc., would require
space enough for another paper; hence the examples
given must suffice.
The question may be asked: "What has all this
to do with State medicine?" The answer is plain:
Give all your working men and women, your employes
in stores, offices, factories, etc., ample time to consume
their food leisurely; let none but healthy teachers be
employed in your schools; require every teacher to be
well versed in the elements of physiology and hygiene,
and require them to teach these branches to the chil-
dren who are old enough to understand them; devote
a reasonable amount of time in the schools to physi-
cal culture; require the teachers to inculcate general
rules of health into the minds of the pupils. Another
thing I would recommend: Let schools for hygienic
cooking be established at the public expense, to ena-
ble poor people to enjoy healthy food as well as the
more prosperous. Much of this can be accomplished
by intelligent legislation. If the rules barely hinted
at in this paper be carried out by the more intelligent
part of the community, and taught by precept and
example to the masses, the unreasonable consumption
of drugs will be reduced to a minimum, and the
health, prosperity and happiness of our people will
be more than doubled in a few years.
PREVENTION OF SMALLPOX.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, held at
Atlanta, Ga., Mav 5-8. 1896.
BY ELMER LEE, A.M., M.D., Ph.B.
CHAIRMAN OK THE SECTION ON STATE MEDICINE, AMERICAN MEDICAL
ASSOCIATION, VICE-PRESIDENT AM. ACADEMY OF MEDICINE.
CHICAGO.
It is not my intention to rudely characterize the
world-wide process instituted by Jenner just one
century ago, as either inefficient or- a failure. As
there was more than one road which led to Rome, it
may be that there is other than one method by which
a given disease may be prevented. It was 100 years
ago, on the 14th day of May, that the English
physician perceived the effect of a slight accident and
gave the world the deductions by which vaccination
with cowpox, made his name forever to be remem-
bered, and rendered universal aid to the people. It
has not been in my power, personally, to inaugu-
rate experiments for determination of the cor-
rectness of conclusions concerning prophylaxis by
vaccination; indeed, it is the privilege of few physi-
cians, to know the exact facts by personal knowledge.
It is not my purpose to question the validity of the
statistics which are prepared for our guidance on
this subject. There are some physicians both in
America and Europe who have expressed a doubt
concerning the efficacy of prophylactic inoculation.
Their sincerity and privileges of investigation have
undoubtedly been equal to the majority of the phy-
sicians who may take an opposite view.
The reason that the paper on this subject was pre-
pared for this occasion, was suggested by the near at
hand centennial of our great confrere. This meeting
of the Association is, practically, a memorial to one
whom the world loves to cherish, and whom physi-
cians are willing to honor. The first thought on the
subject was to prepare an address relating to the treat-
ment of smallpox, but owing to the relationship which
exists between this Section and myself, a paper suita
ble for that Section was suggested.
The origin of smallpox is unknown, at least, it
not recorded. The first recognition which is authen
tic, of the appearance of this disease dates only
the sixth century, in Europe. Undoubtedly it pre
vailed among nations during the earlier centuries, but
owing to imperfect classification, as well as defective
records, recognition is lost. The unwritten history
of the disease is probably co-equal with the age of
our race.
Its propagation is by two methods, namely, contag
ion and inoculation. The first is the most importan
and far reaching. Of what this contagion consists.
our senses fail to grasp. The active principle by
which the attack is produced is not able to be encir-
cled by either scientific processes of detection, or the
highest development of the senses. Whether the
contagious influences are transmitted to the air pass-
ages or to some other vital organ, it is surpassing
strange that, up to the present time there is no means
of detection. We know full well the pathologic order
of the symptoms of the body which has been invaded.
Precision of the successive steps in the development
of the disease marks the course of every smallpo:
patient. It has been my privilege to note the physi-
cal expressions of variola by clinical experience. It
seems to me that there is no disease so exact in th
regular order of symptoms as the one under consider-
ation. Once having mastered the knowledge of th
diagnosis of smallpox, it is an acquirement which i
never lost. The fever and the characteristic pain in
the lumbar region, or the back of the head, with the
rapid appearance of the papules, the vesicles and pus-
tules, make it a picture never to be forgotten. This
much is certain, that smallpox is a systemic disease
and whatever process leads toward prevention is
necessarily that which best preserves the generai
economy.
Vaccination by the use of smallpox lymph creates
some alteration in the animal body which is beyond
the keenest sense of man to determine. Analysis of
the fluids and solids, by the highest scientific pro-
cesses reveals not the secret wrought. It eludes
investigation, and is analogous to and the parallel of
electric display. We do not know the condition,
only the effect. There is no perceptible difference,
except by a knowledge of the result between the
wire carrying the electric influence and the uninflu-
enced wire.
Inoculation also produces smallpox. This is a rare
form by which the disease is contracted. It is easy
to understand the relationship between the introduc-
tion of the virus into the circulating fluid, and its
effect, but it escapes our keenest perception to explain
disease from contagion. As inoculation is rarely the
actual cause in the production of smallpox, measures
of prevention against it need not occupy our consid-
eration.
Smallpox preys upon all races regardless of geo-
graphic separations, it does not spare the young or
the old. There are some individuals, however, in
whom there is some prevailing condition by which
they are rendered insusceptible to the disease.
Whether vaccinated or not, their exemption from
attack is perfect. Could we but know with scientific
accuracy the precise peculiarity and state of the powers
of resistance in such presence, it would afford data
upon which to base absolute measures of protection
e
1896.]
PREVENTION OF SMALLPOX.
347
for others. My own opinion as to what constitutes
this immunity will be explained presently. Negroes,
especially those who inhabit warm countries, are dis-
astrously affected by this disease. Generally speak-
ing, one attack of smallpox precludes a second; but
the rule is not invariable.
Vaccination, as is known to all of us, is the intro-
duction beneath the skin, of a minute portion of
lymph from the vesicle which is produced by inocu-
lation of some lower animal with the virus of small-
A disease similar to smallpox in man is natural
ttle. The origin of vaccination sprang from the
incident by which the maid who milked the cow
received into an abrasion some of the cowpox virus,
and thus became immune to the disease which rav-
aged the community. It was Dr. Jenner's part in
tins drama of life to discover the relationship between
cause and effect, and give a world-wide significance
to the incident of the milkmaid, and the humane ser-
vice which she performed. The protecting influence
aocination is regarded as acting in two ways.
The first assumption is, that to him who is inoculated,
a protection against the disease is sure to follow.
The second, that if the individual contracts smallpox,
its duration and severity are lessened. These posi-
tions are reasonable and upon the same line of thought
my plan for prevention of smallpox is now to be, for
the first time, presented for your consideration. It
is the desire at this moment to state that my prevent-
ive proposition is founded upon a process of reason-
ing from analogy. There are no cases reported by
which the position is sustained, and it may be that
there never will be; but in my own mind the convic-
tion is established that whatever measures we are able
to secure, to preserve a perfect health of the body,
are necessarily, a prevention of disease, even the dis-
ease of smallpox. My views take two directions.
First, the natural agent which is able to preserve
immunity, and second, a method whereby, the pro-
phylactic measures can be made practicable. It is
sometimes a long step between that which is useful,
and that which is able to be used. The distinction
may be the insurmountable difficulty in the present
instance, but it is certain that one step in the plan is
sure to find a sympathetic response from modern
sanitarians.
Uniform and stable health is maintained by pre-
serving the quality and parity between the solids and
fluids and between the supply of new material and
removal of the old. This is the quadrangle and
within its four sides the processes of life and health
are protected. Water is the controlling factor of the
organized human body. More than three-fourths of
all the structures are water; 80 per cent, of the blood
is water; seven-eighths of the brain and nervous
structures are water. The preservation of the integ-
rity of the soft structures depends upon water.
Insufficient water results disastrously to the cellular
tissue of the vital organs and to the physiologic func-
tion of those organs. It is a maxim of health,
that impairment must precede invasion by disease.
If it is possible by any universal agency such as
water to practically prevent impairment of the system
then it is able to say that water, when used rightly,
may be a prevention of smallpox. The knowledge
of the proper use of water is not generally understood
or employed. A brief reference to physiology teaches,
that two liters of water or its equivalent is required
to maintain physiologic equilibrium each day. There
are but few people who are aware of this requirement
and fewer still who practice it. My theoretic pre-
vention of smallpox, other than by vaccination, is
the physiologic use of water introduced into the sys-
tem through the mouth. Does it not appear as a
reasonable proposition that if water constitutes so
large a portion of the tissues and of the fluids and
solids of the body, then, according to the laws of
nature if that relationship is persistently disturbed, a
condition suitable for disease is established? Such is
my conclusion based upon over four thousand clini-
cal experiences in the use of hydriatics.
The second element of the proposition is how to
make the first practicable. It would be my sugges-
tion, first: that the United States government should
speedily enact a law creating a bureau of public
health, the commissioner of which shall be an officer
of equal rank with those of the other present existing
departments. Wise and sound measures of public
health can be authoritatively disseminated among
the people, only through a national department at
Washington. As a direct means of prevention to the
whole population, public baths for all classes and
both sexes should be provided. At these public
institutions there should be provisions made for sup-
plying pure, soft water to drink. In each establish-
ment permanently maintained printed instructions
should adorn the walls concerning the physiologic
daily uses of pure water. Circulars of information
should emanate from the national department, plainly
and in straightforward terms of simplicity, explaining
to the people the value of water drinking, also the
injury resulting from its neglect. The use of public
baihs should be included in the instructions. It is
not the fault of the masses of the common people
among whom smallpox principally prevails, that
such measures of prevention are not employed.
Recently a private patient informed me that
since his youth the average daily consumption of
water had been so small that the quantity could not
be remembered. As a result of his ignorance and
neglect, while yet about 30 years old, his appearance
resembled that of a man between 40 and 50. The
stay of a month under treatment at the hospital
revealed to him the value of the use of water inter-
nally, and gave him encouragement for improved and
prolonged life. There is a wide difference between
so-called hydropathy and true physiologic hydriatics.
In formal treatises on hydropathy reference is espec-
ially made to external use of water, whereas, the essen-
tial principle underlying the views entertained and
expressed by the author regards the internal use of
the proper amount of the proper kind of water as of
first importance. The use of the bath is a refinement
and is to be encouraged by providing public estab-
lishments throughout the whole world, and in these
public establishments may be easily and naturally
taught the higher value of the internal use of water.
At the same time the harmful and sad consequences
of the abuse of alcoholic drinks could be successfully
explained.
Finally, the prevention of smallpox, by other means
than by vaccination, is by the physiologic uses of pure,
soft water; and secondarily, the provision of a
national bureau of public health and the con-
struction of public baths for the use of the common
people. 103 State Street.
DISCUSSION.
Dr. Cochran — If a man were perfectly healthy would he bo
§48
PREVENTION OF SMALLPOX.
[August 15,
'equally resistant to the poison of scarlet fever, as the gentle-
man maintains he would be to the poison of smallpox or to the
poison of diphtheria or strychnin, arsenic or any other poisons
^that we know of? I think not. I think water may be made to
Supply a very important part in the prevention of smallpox,
but I think it is very hot water applied to the bedding and sur-
roundings of the man who is sick, and not cold water taken
internally. I expect if there is any attempt to celebrate Jen-
ner's Day, there will be ample time to discuss this question.
But I suppose from what I have heard that it is quite possible
to prevent the spread of smallpox without vaccination or inoc-
ulation. Put a man under quarantine ; smallpox does not fly
through the air like a bird and attack people at a distance.
It will not cross an ordinary street under ordinary circum-
stances, unless it is carried across. I have had large experi-
ence with smallpox. There is no doubt about the prophylactic
efficacy of vaccination. You may vaccinate a number of men
and place them in a smallpox hospital and if the vaccination is
properly done none of them will have smallpox. It is a very
curious thing, an item that went around among the papers a
few weeks ago (among others the Journal of the Associa-
tion) stating that there had been a very considerable outbreak of
smallpox in the town of Gloucester, the county town of Glou-
cestershire. It was the town in which Jenner lived and made
his experiments. He did not live in the town of Gloucester,
but in the town of Berkeley ; but it is a little strange that in
the town where he made his discoveries there is an Anti-Vacci-
nation League with a large number of members, and owing to
their systematic neglect of vaccination this disease has come
on them.
Dr. Kober — One remark might be a trifle misleading. In
my experience in treating smallpox, which has been consider-
able, I have never seen vaccination done without good effect.
I believe if taken two or three weeks, or a month, before expos-
ure one may then be exposed and not have smallpox ; but if
taken the same day of exposure, notwithstanding the fact that
it runs its course, that patient is likely to have a modified
form of smallpox.
Dr. Cochran — My experience was not similar to that. We
had an epidemic of smallpox in Mobile in 1874-5, and having
made close observation of the disease, I concede the statement
of the gentleman that the disease is checked in warm climates
is correct. Along the Gulf coast during the summers small-
pox will almost die out. When the weather turns cold in the
fall the number of cases increase and continue to increase
until the weather becomes warmer in the spring and then they
diminish. At one time it prevailed continuously for ten years,
and I made a table showing the mortality for three months ;
as the mercury fell in thermometer the smallpox increased
among the people. Black races are very much more liable to
smallpox than the white. Prior to this epidemic I speak of,
very little had been done in the way of vaccination for many
years. There were 450 cases when we took charge, and we had
to work very energetically, and use a great many agents that
had never had smallpox, nor had they been vaccinated, and
we vaccinated them at the time. The general result was that
those who were vaccinated nearly all escaped.
Dr. McDaniel — We naturally are controversial, but when
we try our best to agree it sometimes seems impossible. There
was one remark made by Dr. Lee that I can not exactly under-
stand. If I understand you, Doctor, you say that when we
are healthy, perfect health would protect from smallpox. Do
you take that stand?
Dr. Lee — Yes sir.
Dr. McDaniel — I desire to say that I appreciate his paper
very much, but I believe that smallpox is a specific disease,
and I believe that you will all agree with me. I believe that
vaccination is a specific remedy for that disease, and if it be a
specific remedy I do not see how it can confer a more perfect
health on the individual than he had before he was put under
the effect of vaccination poison. For instance, the results
from vaccin virus are sometimes very severe. There has been
a fatal case lately in our midst. In the convalescence fron
this extreme illness so produced, the patient is absolutely pro
tected from an attack of smallpox. It can not surely
because he is on a higher plane of health at that time than
before the vaccin ordeal was encountered, because of hii
debility, and in that debilitated condition is perfectly immune
from the smallpox. During the war I had charge of a Confed-
erate recruiting camp ; smallpox had been brought from
Marietta, Ga., among our men, the raw recruits. There were
127 persons that were exposed to this case of smallpox brought
from Marietta. In a few days it developed into an unmistak-
able case of smallpox ; as Dr. Lee stated, the case was so char-
acteristic that none could make a mistake after a few days. So
I found on examination. All in camp were examined. Those
who were unprotected, had no scar, were vaccinated. There
were 118 out of the 127 who had the pitted mark ; these I had
disinfected, but of the nine others one had a scar that I could
not approve ; it had some signs of vaccination, but were not
satisfactory. That man contracted varioloid, the other eight
genuine smallpox. Out of the one thousand or more that I
vaccinated, not one had smallpox.
Dr. Stoner, of Baltimore — During the past month a vessel
came into port on which was a case of smallpox. The patient
was put in quarantine on arrival at Baltimore, and everything
thoroughly disinfected ; after a few days' detention the immi-
grants were allowed to go. As an additional precaution the
health officers were disinfected, and as a result there was no
spread of the disease. The point I wish to make is simply
this, that where a case is otherwise susceptible, if that person
is vaccinated, the vaccination, if successful, would not be an
absolute protection against smallpox. It would be modified to
a very great degree, and might, in forty-nine out of fifty cases,
prevent. My experience is that vaccination modifies to such
an extent ; that smallpox is not entirely prevented every time
and varioloid occurs to a small extent. The point is that
vaccination is not a preventive against it, still it is well enough
to vaccinate to endeavor to keep a man from contracting it.
Dr. Quimbv — One word in reference to Dr. Lee's paper; it
seems to me, as long as smallpox is a filth disease, if the cau-
tion is taken to destroy and put the surroundings in a good
sanitary condition, then carrying out Dr. Lee's treatment, we
certainly would have a preventive. Then use cold water inside
and out and put everything in proper sanitary condition,
because it is an insanitary disease, and if we dispose of the
filth, we are freed from the germinating microbe that forms
the disease.
Dr. Kober — I desire to be placed on record as opposing Dr.
Lee. It seems to me, in the present state of our knowledge,
that nothing short of vaccination and severe quarantine regu-
lations can afford perfect immunity from this disease. In
proof of this I will mention an epidemic which occurred two
years ago in California, where the people enjoyed the best
hygienic surroundings, in perfect health and blessed with the
purest water and best food. The case of smallpox was intro-
duced into the community from Chicago, a distance of over
two thousand miles, and within a period of three weeks not
less than fifty cases occurred in adjoining houses. All the
hygienic conditions did not protect them from the disease, but
as soon as sufficient quarantine and vaccination were resorted
to the epidemic stopped.
Dr. Hibberd — He did not hold that the presence of pure
water prevents, and if you do not use it, it is not a prophy-
lactic.
Dr. Kober — But if they use the pure mountain water it
should be considered a prophylactic.
18%.]
REGULATION OF MARRIAGES.
349
THE WELFARE OF THE COMMUNITY DE-
MANDS THAT MARRIAGE SHOULD
BE REGULATED.
Bead In the Section on State Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlimta. Gil.. Mav 6-.S, is»f>.
BY DANIEL R. BROWER, M.D.
PROFESSOR MENTAL DISEASES AND THERAPEUTICS, Rl'SII MEDICAL COL-
LIDE; PROFESSOR MENTAL AND NERVOUS DISEASES,
WOMAN'S MEDICAL COLLEGE.
CHICAGO.
The closing hours of the nineteenth century are
full of marvelous results in science and art, and of
wonderful progress in medicine and surgery, but in
the midst of these brilliant achievements may be seen
on every side insanity, pauperism, criminality and
the degenerating effects of various vices of nutrition
so rapidly increasing that they will overwhelm the
race unless they can be arrested. These melancholy
effects are produced, at least in part, by the viola-
tion of the laws of heredity, constantly taking place
in unregulated marriages. Under our higher civi-
lization abnormal man, be he defective, dependent
or delinquent, is propagated, cultivated and pro-
tected, his feeble and crippled offspring are nursed
to manhood and sent forth to produce their kind.
Under savage and semi-civilized conditions these
abnormalities are speedily extinguished, the deformed
and the weaklings have no place in their system,
and some way or other are soon cut off.
The physicians, who have always been the advance
Board of progress, ever watchful of the welfare of
those entrusted to their care, must rise in their
might, find the remedy and apply it to these defects
of this brilliant age. The study of these defects of
our civilization develop startling revelations.
First, consider the increase of insanity in Great
Britain. In 1860 the proportion of insane to the
population was 1 to 523, in 1870 1 to 411, in 1880
1 to 360, in 1890 1 to 320. The proportion of the
insane to the population in New York to-day is 1 in
315. If this increase is to be stopped, it must be
by the earnest efforts of such distinguished members
of the profession as are gathered here.
Consider the question of crime. The census of
1890 places the criminals in prisons and reforma-
tories at 82,329. If only one-third are incarcerated
this gives a criminal population of about 250,000.
Between the years 1850 and 1890 the population
increased 170 per cent., the criminals increased 445
per cent. Between the years 1880 and 1890, the total
population increased 24.5 per cent., the criminal pop-
ulation increased 45 per cent.
The statistics of pauperism show equally startling
defects in our sociology. Dugdale, in his admirable
study of the "Juke" family, shows how from one
degenerate man, in seven generations there were
developed 1,200 criminals and paupers. McCullock,
in his history of the "Ben Ishmael" family, showed
as the offspring of this degenerate, 1,750 criminals
and paupers. Maudsley says that an idiot is not an
accident, nor an irreclaimable criminal an unaccount-
able casuality. Our mental and physical condition
is an' inheritance, an estate in trust received from
our ancestors; we make it better or we make it worse,
and we hand it down to our children. Heredity,
according to Ribot, "that biological law by which all
beings endowed with life tend to repeat themselves in
their descendants," is the great underlying factor, and
yet, while we are extremely careful to observe its
demands in the breeding of horses and cattle, we pay
but little attention to it in laying the foundation for
the physical, mental or moral condition of our
children.
The laity need to be instructed on the subject; they
should be taught that insanity, epilepsy, tuberculosis
and drunkenness are all most certainly transmissable,
and that out of them proceed pauperism and crime,
and that he or she who possesses any one of these, or
any other vice of nutrition, by marrying assumes a
terrible responsibility in the suffering and misery
they inflict upon their progeny.
Fortunately for the race these degenerates tend to
extinction, and in the third and fourth generation, if
not sooner, they have paid the penalty by annihilation,
of their violation of the laws of nature.
Some of the laity are already deeply interested in
this matter, and are seeking to find ways and means
by which they may avoid these consequences; and the
tendency to reversion furnishes us with the method
by which the milder cases of hereditary taint may pro-
duce children who will but slightly inherit the abnor-
malities. We would, of course, advise such persons to
unite in wedlock with those as far as possible removed
from the vice of constitution which they possess, and
then their progeny may be thrown back to the normal
type.
The most perplexing, as well as the most active fac-
tor in producing the defects of our civilization, is
alcoholism. The appetite for alcohol may be acquired,
but it can be transmitted to the children, and various
diseases and degenerations follow. Echeverria col-
lected the statistics of sixty-eight males and forty-
seven females who were alcoholics. The number of
children born to them was 476. Of these, 23 were
stillborn, 107 died of convulsions in infancy, 3 sui-
cided, 96 had epilepsy, 13 were idiots, 19 maniacal, 7
had general paresis, 5 had locomotor ataxia, 26 had
hysteria, 23 paralysis, 19 deformed, 9 chorea, 7 strab-
ismus, 3 were deaf, and 205 exhibited drinking tend-
encies.
Dr. Tarnavskin examined at St. Petersburg prosti-
tutes who had been inmates not less than two years,
and found eighty-two per cent had parents who were
habitual drunkards.
Boies1 makes the statement, "that the consumption
of distilled spirits, per capita, has not materially
changed even in fifty years in this country, but the
consumption of malt liquors has increased 738.1 per
cent, contemporaneously with an increase of 445 per
cent, in criminals in fifty years. These statistics
show very plainly that the temperance reformers have
not reached the masses. While the decanter is no
longer seen on the sideboard, and the consumption of
wine among the well-to-do people has diminished, yet
the saloons are multiplying on every side. Surely
we can not permit this condition of things to con-
tinue longer, and must recognize the inadequacy of
the forces that are contending with it. The physi-
cians must educate the laity, must impress them with
a knowledge of the disastrous effects of alcoholism,
and through their cooperation secure such legislation
as will remove the blot from our civilization.
The effect of marriages, in disregard of the laws of
heredity, are well shown in the following life trees.
They are taken from Dr. Strahan's admirable book on
"Marriage and Disease," and other sources.
i Prisoners and Paupers.
350
MORTALITY IN MICHIGAN.
[August 15,
J. E
M.
A suicide. Aged 5(5.
Married; no issue.
CASE I.
's Family.
-M.-
Died of cancer
of stomach.
Aged 6«.
Died in a fit.
Aged 54.
M.
Died of
cancer of
stomach.
Aged 88.
Left five
children.
M.
Died of
convul-
sions.
Aged 13
weeks.
F.
Died of
f.
k
Died of
M.
Died of Died of Healthy,
eon- con- con- has 7
sumption, sumption, sumption, children.
Married Married Aged 18.
several several
years; no years; no
M.
Epilep-
tic.
Twice
insane.
Testes
in abdo-
tssue.
issue.
men.
Married.
No issue.
CASE II.
K. S 's Family.
M.-
Epileptic.
Had sister insane.
M.
Epileptic.
Dead. No
issue.
F.
Epileptic and
insane. Dead.
No issue.
M.
Idiot.
Impotent.
k
Sane as yet.
Nine chil-
dren; some
imbecile.
i.
Insane; sui-
cidal. Incura-
ble. No
Issue.
CASE III.
Father a drunkard.
Son.
A drunkard; disgustingly drunk on his wedding day.
II
Died of convul-
sions.
Idiot at 22
years of
age.
Suicidal.
A de-
ment.
CASE IV.
M.
Died mad.
Peculiar
and irri-
table.
Repeat-
edly in-
sane.
Nervous
and de-
pressed-
M.
Imbecile.
Irritable.
I
M.
M1.
Died of brain disease.
F. Epileptic. Epileptic.
Imbecile.
1 2
I e
CASE V.
F.
A suicide.
All seven died in convulsions.
CASE VI.
M . F.
Mute.
Normal.
M.
M.
Insane.
I
F.
M.
Mute. No
issue.
Normal.
-M.
Normal.
Excitable. Dull.
Epileptic.
Imbecile.
F.
Mute.
k
Mute.
M.
M.
J.G.A-
Paternal side.
( Grandfather, a drunkard.
I Grandmother, normal.
Jst Gen. < Uncle, a drunkard.
Uncle, a drunkard.
2d Gen.
3d Gen.
Uncle, an epileptic.
Father, excitable and irri-
table.
I
Normal. I Normal.
M.
Mute.
CASE VII.
-'s Family History.
Maternal siile.
Grandmother, "odd."
Grandfather, normal.
Uncle, epileptic.
Uncle, rheumatic, total cripple;
and his daughter also.
Uncle, rheumatic.
Aunt, rheumatic.
Mother, died in an asylum.
i
r Daughter, has had rheumatism and has heart disease.
Son, now insane.
) Son, died a few days old of convulsions.
| Son, now a chronic maniac in an asylum.
Daughter, suicidal melancholiac; died in an asylum;
I issue. Family extinct.
M.-
CASE VIII.
S. H 's Family.
Asthmatic.
Somewhat weak-minded.
1 I I I I
2 8 4 5 6
I I I I I I
7 8 V 10 11 12
Healthy. * — ' Drowned. Epilep- — . — Idiot. Died in
Died in tic. Healthy. infancy
infancy in convul-
in convulsions. sions.
I
13
Healthy.
I
14
Scrofulous.
Father.
Eccentric, hypochondriac.
M.
Suicide.
Age 40.
M.
Suicide,
Age 85.
M.
Suicide.
Age 30.
M.
Suicide.
F.
Father.
Melancholia; died insane.
Normal. Suicide.
-Falert.
' Mother.
Nervous, emotional.
I
r.
Melan-
cholia.
Imbecile.
One child,
Deformed,
Imbecile.
F.
Sui-
cide.
I I
1-5 «
Die in Insane.
Infancy.
Eccen-
tric.
M.
Imbe-
cile. No
issue.
3
childen.
1. Imbecile.
2. Dies of apoplexy.
3. An artist.
I
M.
Insane.
No
issue.
A.
Insane.
One
child,
Imbecile.
8
— Doiitrcbeub.
Marry. No issue.
Father
Cancer.
Mother.
Tuberculosis.
I
I I
12 8
Died of lupus. Died of pul- Died of epi-
monary leptiform
consumption, convulsions.
Died of
diabetes.
I
5
Died of
cancer.
Dr. Richardson.
In the midst of these overwhelming exhibits, surely
the welfare of the community demands that marriage
should be regulated. It is horrible to contemplate
what will be the condition of the race in the future,
and what will become of our social and political insti-
tutions if this wholesale production of abnormalities
does not cease.
In most of the States of the Union a marriage
license is necessary before the ceremony can be per-
formed, but its requirements are insignificant. Let
us agree that in addition, proper evidence must be
furnished that both parties are in good health, that
they are not insane, criminals, paupers, alcoholic nor
narcotic inebriates, that they are not tuberculous, can-
cerous nor epileptic, and that they have not active
venereal disease.
If the members of this great profession will
unitedly advocate this great reform, they will suc-
ceed, and more than ever deserve the title of public
benefactors.
AGE AND SEX INCIDENCE OF MORTALITY
IN MICHIGAN FROM DIPHTHERIA
AND FROM CROUP DURING
TWENTY-FIVE YEARS,
1870-94; A STATIS-
TIC STUDY.
Read by title In the Section on State Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta, Ga.. May 6-8, 1896.
BY CRESS Y L. WILBUR, M.D.
DIVISION OF VITAL STATISTICS, DEPARTMENT OF STATE, LANSING, MICH.
No apology is necessary at the present time for a
statistic study bearing upon the history of diphtheria
and croup in the United States during recent years.
It is only a short time since the etiologic character-
istics of the disease, or diseases, dependent chiefly
upon the presence of the Klebs-Loffler bacillus and
associated microorganisms, have been definitely ascer-
tained, and a still briefer time has elapsed since the
antitoxin treatment, based entirely upon modern bac-
teriologic research, has promised to revolutionize
entirely the treatment, and to greatly reduce the mor-
1896.]
MORTALITY IN MICHIGAN.
351
tality of this, by fur the most fatal acute infectious
disease prevalent in this country, or at least its
northern part.
It is of especial importance, therefore, in order
that it may be known whether the claims of the new
method of treatment are substantiated by experience,
that reliable statistics of immediately preceding peri-
ods be available for comparison, and in case the
employment of the serum therapy in any given local-
ity appears to be attended with a reduction in the
death rate from diphtheria, that it be known whether
such reduction was probably caused by the special
measures employed, or whether a reduction in mor-
tality was reasonably to be expected as a consequence
of the periodic fluctuations characteristic of the his-
tory of this and most other epidemic diseases.
Usually on the introduction of a new remedy, the
appeal is primarily to the results of hospital treat-
ment. This was necessarily so in the present instance,
as the curative serum was costly and difficult to be
obtained at first by general practitioners. Later, with
increased facilities for its production and the under-
taking of its preparation by official agencies, its use
was more generally diffused, and an appeal could be
fairly made to the testimony of the mortality statis-
tics prepared by the general registry offices. Hospi-
tal statistics are notoriously unreliable, it being often
impracticable to eliminate or fully describe the selec-
tive influences that determine the characters of
patients and the results of treatment, as well as the
preliminary diagnoses upon which the statistic con-
elusions largely depend. Small numbers are also usu-
ally employed, iu themselves a frequent source of
fallacy. In the deductions drawn from general mor-
tality statistics, on the other hand, these minor sources
of error tend to neutralize one another, so that any
marked change from the usual course of a disease
may, with considerable certainty, be ascribed to some
extraneous influence.
Purpose of the present paper. — The data con-
tained in the present paper are not presented in the
interest of any particular method of restriction or
prevention of diphtheria, nor, primarily, to illustrate
the value of the antitoxin or any other method of
treatment. If the serum therapy shall prove to be of
as great usefulness as at present appears likely .valuable
evidence as to its efficacy will probably be derived
from the comparison of the incidence of mortality
by sex and periods of age, as presented in this paper,
for Michigan for the pre-antitoxin period, with cor-
responding data to be tabulated later for the " anti-
toxin era." If the antitoxin method goes the way of
the Bergeon, Koch's tuberculin and other "fads,"
nevertheless the evidence here presented may be of
special interest to the sanitarian and to all students
of State medicine, from its bearing upon the history
and success of the methods of prevention and restric-
tion of diphtheria advocated and carried out by the
Michigan State Board of Health under the able direc-
tion of Dr. Henry B. Baker. In any event it seemed
to me that an impartial account of the prevalence of
diphtheria in Michigan, and one as accurate as the
available statistics would permit, would be of service
in advancing our knowledge of this disease.
As indicated by the title, the discussion is confined
entirely to the presentation of two features, with their
inter-relations, of the mortality in Michigan from
diphtheria and croup, viz., the distribution by ages in
periods of years and by sexes of the decedents. It
will be necessary to preface the subject proper with
some general account of the history of diphtheria in
Michigan as a whole, and its relation to the recorded
mortality from this cause in other States and coun-
tries, in order that the position of Michigan in refer-
ence to the disease may be understood. Other
important features of the recorded mortality are pur-
posely excluded from the present discussion, e. g., the
geographic distribution through the State,1 relative
death rates of rural and urban populations, and
monthly and seasonal prevalence, with relations to
meteorologic conditions.
The study will chiefly show: 1. the availability of
mortality statistics known to be imperfect in certain
directions for use in certain other directions, as evi-
denced by the constancy and clearness of their testi-
mony; 2, the characteristic differences in the age and
sex incidence of diphtheria and croup, and, infer-
entially, the inexpediency of confusing their statistics
under the term "diphtheria and croup" from a statis-
tic point of view; 3, the desirability of ascertaining
the causes, and so far as practicable, of preventing
the increased relative mortality from diphtheria of
female children on reaching the age of five years and
upward.
Source and character of data. — The Registration
Reports of Michigan are utilized as the source of
information. This series of annual reports began
April 5, 1867, and is continued at the present time in
substantially the same form that it originally assumed.
The method of collection of data is imperfect, being
nearly the same as that of the United States census
in non-registration States, i. e., an enumeration of the
facts some time after their occurrence. Many deaths
fail to be registered each year, and the deaths in
months near the date of enumeration are more thor-
oughly collected than those of months more remote
from it. The result is precisely as in the case of the
United States census mortality statistics of non-regis-
tration States, that study of the monthly and seasonal
prevalence of mortality is entirely misleading, unless
a graduated "correction" be applied to the monthly
returns, something nearly or quite impossible to sat-
isfactorily accomplish ;2 and, secondly, that the abso-
lute rates for the year, both of aggregate mortality
and of individual causes, are considerably below the
truth. For the latter imperfection it has been neces-
sary to make an approximate estimate, since other-
wise we should have no means of judging of the rela-
tive mortality of the State as compared with other
States and countries. In the Registration Reports of
successive years up to the year 1890, amounts of
deficiency, different for each year, have been calcu-
lated, varying from 66.24 per cent, down to 9.92 per
cent, of the original returns, and giving an average
"correction" of about 40 per cent.8 There has been,
however, no evidence whatever to show that the accu-
racy of registration has been any greater in one year
than in another; indeed, the only condition of useful-
ness of the data presented, as employed for comparison
of mortality in successive years, involves the assump-
tion that the degree of imperfection of registration
remained substantially the same from year to year
1 For geographic distribution, see Michigan Registration Report for
1892, map opposite p. 196; the period is one of five years, 1888 to 1862, and
diphtheria and croup are taken as one disease. See also the maps of
diphtheria and croup (separately) in the Mortality and Vital Statistics
Report of the Teith Census, in which, however, percentages to total
deaths, and not death rates, are shown.
2 See Mortality and Vital Statistics of the Tenth U. S. Census, Part I,
p. xl.
3 Mich. Reg. Rep., 1891, p. 132.
352
MOKTALITY IN MICHIGAN.
[August 15,
This is the assumption under which the vital statis-
tics of successive United States censuses are com-
pared, and is, in fact, even more tenable as regards
the Michigan statistics, since they have been collected
under an unaltered law and by precisely the same
registration machinery, at least since 1869. For this
reason the writer has rejected the variable "correction"
formerly employed in the reports, and has substituted
since 1891, and employs in the present paper, an esti-
mation— a mere guess, somewhat qualified by study
of actual registered death rates of certain Michigan
cities, and knowledge of the general rate of mortality
of similar populations — that the returns of deaths in
Michigan should be increased by about 60 per cent,
to give the actual deaths that occurred. This esti-
mate is probably sufficiently low, corresponding to an
increase of the registered mortality from about 10 per
1,000 to an estimated actual mortality of about 16 per
1,000 population; is applied uniformly to successive
years, and to the subdivisions of population, by sex,
periods of age, etc. ; and is only applied when the Mich-
igan statistics are brought into relation with approxi-
mately correct rates of registration States or countries
for direct comparison. For study of the course of
mortality, the uncorrected rates, if only the assump-
tion of their substantial uniformity of inaccuracy be
granted, are as reliable as more complete ones.
Having stated the chief respects in which the Mich-
igan statistics can not be taken at their face value, viz.,
monthly and seasonal distribution of mortality and
absolute death rates, the following points upon which
the results obtained from the Michigan returns are
probably fully correct and reliable may be stated:
1, relative mortality from all causes and from special
causes of death in successive years — the latter subject
to the usual criticisms dependent upon defective
diagnosis; 2, geographic distribution of mortality
through the State; 3, proportions of deaths from
specified causes to total mortality — this, however, a
discredited ratio in vital statistics, although much
used in the United States census reports in default of
abetter; 4, incidence of mortality by sex; 5, incidence
of mortality by age. It is with the two latter features
that the present paper is specially concerned, and it
should be clearly understood that the admitted defi-
ciency of Michigan registration in certain particulars
in no wise affects the indications drawn from a large
and fully representative mass of returns in regard to
the facts of age and sex incidence of mortality from
diphtheria and croup.
Statistic nomenclature and classification of diph-
theria and croup. — The statistic study of a disease
is necessarily secondary, in point of time, to its clinical
study. It follows that uncertainty in diagnosis, con-
fusion as to the true clinical and etiologic characters
of a disease, or confusion of one disease with another,
will be reflected in the vital statistics subsequently
collected. The advances of knowledge in methods qf
exact diagnosis are shared, first, by the most progres-
sive members of the medical profession, or possibly,
by specialists in certain fields of investigation, in
whose particular lines of research the advances were
made; second, the rank and file of the profession
adopt the discovery and it becomes a part of ordinary
professional opinion; and lastly, the new knowledge
filters through medical opinion and is more or less
rapidly and thoroughly disseminated by the press
until it finally becomes a part of the common belief
of the people. It is from the people themselves, as a
rule without the immediate intervention' of profes-
sional opinion, that the data in regard to causes of
death are collected in Michigan, and the foregoing
considerations are given in explanation of the facts
that they are apt to be somewhat indefinite in char-
acter and, further, that the returns of any year do not
correspond to the latest professional knowledge of the
time. There is in this an advantage, however, that
the returns are not affected by the more transient
waves of medical thought, but only by those deeper
currents representing well-grounded changes in med-
ical belief.
The vital statistics of Michigan do not extend back,
by about ten years, to the time of the first general
recognition of diphtheria in this country. It is prob-
able that substantially the same clinical distinctions
between diphtheria and croup have existed during the
entire twenty-five-year period. The early confusion
between diphtheria and croup, prior to the recogni-
tion of the "new disease," such as appears in plain
evidence in the death rates of Chicago (Table 2),
had been outgrown, and the recent tendency to report
deaths from what would have formerly been consid-
ered "croup" or "membranous croup," as diphtheria
pure and simple, has probably not affected the statis-
tics to a very great extent, although it may be
expected to show a marked influence in the next few
years.
Bacteriologic analysis, by its proof of the Klebs-
Loffler bacillus as the cause of true diphtheria, has
laid the foundation of future exact statistics of this
and related diseases. But we should not allow our
statistic methods to outrun the actual advance of
knowledge. While on the one hand, there is
undoubted evidence that many cases of croup are
diphtheritic in character and due to the infection of
the Klebs-Loffler bacillus, it is equally positive that
a certain proportion of them are not diphtheritic.
Indeed, a certain fairly large proportion of cases of
clinical diphtheria is found to be lacking in the pres-
ence of the essential germ, under our present methods
of recognition, while in the undoubted cases of true
diphtheria the action of the Klebs-Loffler bacillus is
modified so largely by the presence of other species
of microorganisms that the tendency is undoubtedly,
at present, in the direction of a more minute analysis
of true diphtheria, rather than to the inconsiderate
consolidation of diseases possessing quite distinctive
clinical, etiologic and statistic characters. Professor
Novy of the University of Michigan well remarks,
"That which for clinical or anatomic reasons is
described as a definite disease, may in reality be far
from be an entirety. . . . What was called a dis-
ease becomes, through the study of its etiology, a
group of diseases. The old typhoid fever has passed
through such a history, and we may say in advance
that diphtheria has recently experienced a similar
development."4
In the older Farrean classification of causes of
death, as employed at present in the Massachusetts
and Rhode Island Registration Reports, and in the
Michigan Registration Reports up to the year 1892,
diphtheria and croup are placed together, but sepa-
rately, among the zymotic diseases. In the later
classification adopted by the Registrar-General of
England, and which is in use in most of the English
colonies and in certain States of this country, croup
* Etiology of Diphtheria, Trans. Mich. State Med. Soc, 1894, p. 396.
1SW.]
MORTALITY IN MICHIGAN.
353
is removed from its position in conjunction with
diphtheria, and placed among the diseases of the
respirator} system under the class of local diseases.
This was undoubtedly a mistake, although made with
the sanction of the Royal College of Physicians at the
time (1883), for recent bacteriologic evidence makes
it clear that a large proportion, perhaps at least 75
per cent., of cases o( croup is in reality diphtheritic.
The distinction made by the Italian reports5, which
place "difterite i crup difteritico ed altre forme difter-
lohe)" under the head of infectious diseases, while
"crup noii difteritico" is put under the head of dis-
of the respiratory organs, would be valuable,
were it not certain, ill the light of our present bacter-
iologic knowledge, that the practical distinction of
non-diphtheritic from diphtheritic croup must have
been quite impossible at the time this classification
was adopted. The tendency at present, as evidenced
by many European (continental) reports, and some
in this country, is to combine the mortality reported
from diphtheria and croup under one title, namely,
diphtheria and croup, orsimply diphtheria. Bertillon
says, referring to his proposed statistic nomenclature
of causes of death, which was presented to the Inter-
national Statistical Institute, Chicago, 1893:" "It is
very important for exactness of international compar-
ison that the titles "diphtheria" and 'croup* should
always be placed side by side to facilitate adding the
numbers: we prefer to combine them under a single
title." This latter preference lean not but regard as
unfortunate for the reason that such statistics of
diphtheria and croup cease to be comparable with
those of diphtheria and crouj) stated separately, as
found in all reports following the present Registrar-
General's classification. An even worse method, con-
sidered statistically, however justifiable it may be
from the present bacteriologic and from a sanitary
point of view, is the plan boldly adopted in the
Chicago report for the year 1894, of adding bodily 80
per cent, of the reported deaths from croup to diph-
theria. The rates thus changed become wholly
incomparable with those of previous years, which
should have been either changed in a similar manner,
or, better, an additional column showing the aggregate
mortality from diphtheria and supposed diphtheritic
croup might have been given. "It is not the duty of
a statistic office to interpret diagnosis (that is to
say. to guess at what has been left incomplete). It
can only register facts as they are formulated."
(Bertillon.)
In the provisional classification of causes of death
employed in the Michigan Registration Reports since
1892, I have placed the returns of diphtheria, croup
and membranous croup side by side, in order that the
summation or total deaths from diphtheria and croup,
might be readily obtained, while at the same time the
statistic integrity of each cause of death, as returned,
remained unimpaired. The aggregate number of
deaths registered during the twenty-five years from
diphtheria and croup was 28,088, of which number
there were 21,095 deaths reported as diphtheria, 5,897
as croup (otherwise unspecified) and only 1,096 as
membranous croup. The very few cases returned as
spasmodic croup are included under simple croup,
while a few returned as diphtheritic croup have been
5 Elenco syscematico delle cause dl Morte, Statistica (telle cause di
Mori: . 1X85, p. Mil.
eTranslated and appended to Report of Committee on Nomencla-
ture and Forms of Vilal Statistics made to the American Public Health
Asaociutiou, Montreal, 1894.
compiled under diphtheria. So also are included
under the latter head a few cases of "putrid sore
throat" occuring during the early years of registra-
tion.
General prevalence of diphtheria and croup in
Michigan, — Two tables are given in illustration of
this subject, which show respectively the general
importance of diphtheria as a cause of death during
recent periods of years in certain European countries,
Australasian colonies, and in the United States; and
the course of diphtheria and croup as registered year
by year in Michigan, compared with Chicago, Massa-
chusetts, England and Wales, and the colony *of
Queensland.
Tahlk 1.— Comparison of death rates per 100,000 population from diph-
theria, and from diphtheria and croup in certain countries, states and
cities during recent periods of vears.
Country, State or City.
Europe.
Austria
Belgium
England and Wales
London
Cities, 28 largest
France (cities)
Germany (cities)
Cities, 28 largest
Holland
Italy
Ireland
Prussia
Sweden
Switzerland
Australasia.
New South Wales
New Zealand
Queensland
South Australia
Tasmania
Victoria
America.
United States, registrationStates
Cities. 28 over 100,000 pop.. .
Massachusetts
Baltimore
Boston
Brooklyn
New York
Philadelphia. ...... T .
Washington
Chicago
Chicago
Detroit
Grand Rapids
Michigan, as returned. . . .
Michigan, as returned. . . .
Michigan, as estimated . . .
Michigan, as estimated . . .
Years.
1887-91
1887-91
1887-91
1897-91
1890
1887-91
1887-91
1890
1987-91
1887-91
1887-91
1887-91
18*7-91
1887-91
1878-87
1878-87
1878-87
1878-87
1878-87
1878-87
1890
1890
1886-90
1885-90
1885-90
1885-90
1885-90
1885-90
1885-90
1885-89
189C-94
1890-94
1890-94
1885-89
1890-94
1885-89
1890-94
Rate per 100,000 population.
Diphtheria.
17.4
32.8
14.5
80.8
7.6
63.0
61.6
119.9
72.7
47.4
45.6
75.8
78.0
Diphtheria
and Croup.
182.0
57.7
29.1
21.9
102.1
92.0
86.6
70.5
23.7
141.7
52.0
85.3
47.7
24.2
47.5
69.3
44.6
41.7
95.4
116.6
85.0
80.1
124.5
164.4
181.6
98.8
69.6
170.7
100.3
164.0
100.3
67.8
59.8
108.5
94.9
Note.— The data for Europe are from the Statistica delle Cause di Morti
Rome, 1894. and have been kindly revised by Prof. Richmond Mayo-
Smith of Columbia College, from whose work, Statistics and Sociology,
they were taken. The rates for Australasia are as given in the Victorian
Year Book, 1894. The rates for the American cities during the six-year
period, 1885-90, are from the special investigations of the Eleventh u. S.
Census. The rates from diphtheria for Chicago are the means of the
rates stated for the five-year periods in the valuable "Chronological
Summary of Chicago Mortality, 1851-1894," forming a part of the Annual
Report oj the Department of Health for the year 1894. In obtaining the
rates for croup from this Summary the writer nearly fell into error
from the fact that the column in the statistics of this disease (p. 250)
corresponding in position to the column of death rates per 10,000 popu-
lation in all of the other tables, does not contain death rates, as stated
by the general heading, but instead contains "percentages of total
deaths;" it was necessary to calculate all of the rates given for croup in
Table 2, and from these annual rates the means given above were
obtained. For the Michigan cities, Detroit and Grand Rapids, reference
was madeto the table in the Michigan Registration Report, 1893, p. 248, the
rates in which were based upon the deaths actually registered by the
city health officers, and recorded in their monthly or annual reports.
Table 1 indicates the world-wide extension and
universal importance of diphtheria as a cause of
death.7 Incidentally it shows the inconvenience in
'Cape Colony has only just adopted a general registration system
(Act of 13th July, 1894), so that data representative of Africa are not
available. It may be noted, however, for certain cities and towns of
Cape Colony the death rates from "diphtheria and croup" in 1894 were
extremely high: Cape Town, 80.4: King William's Town. 88.0; Worces-
ter. 92.5; Malmesbury, 162.5; Beaufort West, 179.1; Murraysburg, 382.8-
Aberdeen, 898.4, all rates per 100,000 population. The antitoxin treatment
has come Into general use, serum being supplied to medical men free of
cost.— Cape of Good Hope Reports on the Public Health, 1894, p. xxiv.
354
MORTALITY IN MICHICAlN.
[August 15,
making comparisons arising from the fact that for some
countries and cities rates for diphtheria only, in others
for diphtheria and croup only, could be obtained. We
notice that England and Wales, Ireland, Holland and
Switzerland, show a low mortality as compared with
other countries of Europe, that the prevalence in
Australasia is light compared with Europe and Amer-
ica, and that the mortality in America is very high as
a rule. The rates for the twenty-eight largest cities of
the United States, Germany and England, are from
the report made to the Eighth International Congress
of Hygiene and Demography, Budapest, 1894, by the
American Committee on Diphtheria, whose chairman
was Dr. J. S. Billings, ex-Deputy Surgeon-General
U. S. Army, editor of the "Vital Statistics Reports of
the Tenth and Eleventh U. S. Censuses," and the
foremost American authority on the subject.
Table 2.— Course of mortality from diphtheria and from croup — annual
rates per 100,000 population— In Michigan, compared with Chicago.
Massachusetts, England and Wales, and Queensland.
Michigan
Massachu-
England
Queens-
as returned.
setts.
and Wales.
land.
Year.
a
03
P
o
a
i
£
08
a
o>
■
0>
•a
&2
A
a
ft
&
a
A
a
Ji
a.
SB
a
a
3
a
a
J3
a
a
a
a.
O
a.
o
a
o
o.
o
ft
OS
6
ft
O
ft
w
ft
o
ft
a
1865 . .
60.9
2.0
23.9
1856 . .
84.6
3.2
27.7
1857 . .
184.9
8.2
27.7
1858. .
208.6
l
42
33.9
81.9
1859 . .
1.1
170.6
2
44
61.7
28.6
1860 . .
140.9
114.3
21
47
26.1
22.0
1861 . .
93.8
102.8
52
87
22.5
21.9
1862. .
54.0
78.0
58
89
24.1
27.8
186S. .
91.3
117.4
113
69
31.5
23.7
1864. .
67.9
106.1
98
61
26.1
32.4
1865 . .
94.7
154.1
58
40
19.6
28.0
1866. .
67.0
80.8
81
83
14.0
24.1
1867 . .
84.7
44.8
19
26
12.0
20.2
1868. .
84.5
45.0
22
35
13.7
20.4
1869 . .
46.4
49.7
21
38
11.7
20.2
1870 . .
10.2
.8
10.5
53.4
81.4
17
29
12.0
18.1
1871 . .
9.9
.6
12.0
29.0
41.5
18
32
11.1
19.1
1872 . .
15.6
.8
12.1
40.3
55.8
18
81
9.3
15.7
27.8
30.2
1873 . .
16.9
.5
12.8
24.2
85.0
19
28
10.8
18.8
52.1
48.5
1874 . .
16.2
.7
9.9
19.7
22.3
81
25
15.0
21.1
80.8
36.5
1875 . .
15.4
.8
11.8
31.2
84.5
78
41
14.2
18.9
86.0
38.9
1876 . .
22.8
1.5
10.9
111.8
67.5
158
41
12.9
17.2
29.3
40.2
1877. .
40.1
1.8
9.8
77.4
54.9
158
33
11.1
15.8
22.6
43.6
1878. .
57.9
2.4
13.0
67.3
51.1
116
84
14.0
16.2
8.2
80.6
1879. .
98.3
2.8
14.7
122.9
78.9
101
38
12.0
14.1
11.7
21.0
1880. .
94.2
4.0
15.7
184.8
105.8
99
36
10.9
13.8
18.5
25.7
1881. .
122.0
3.8
18.7
112.8
73.7
94
32
12.1
13.8
12.7
89.8
1882 . .
81.1
2.6
17.4
94.8
41.3
69
26
15.2
17.5
12.2
80.8
1883. .
56.0
2.9
15. 8
102.1
21.5
58
28
15.8
17.2
14.6
40.3
1884. .
57.5
2.2
15. 4
103.0
40.6
56
29
18.6
17.6
13.7
31.5
1885. .
55.7
2.4
15.4
106.2
46.0
51
27
16.4
15.6
27.3
38.0
1886. .
57.8
5.4
15.8
134.1
50.9
58
26
14.9
13.4
29.5
80.7
1887. .
47.4
5.9
14.8
131.8
52.9
55
26
16.0
14.3
26.5
18.3
1888. .
35.9
4.5
19. 1
106.8
54.6
65
24
17.1
12.9
22.8
18.6
1889. .
41.3
2.2
17.4
120.4
50.0
80
22
18.9
11.4
22.7
18.9
1890. .
60.5
27
19. 8
72.8
81.8
55
17
17.9
10.9
39.1
16.9
1891 . .
49.7
1.6
11. 9
76.7
32.0
17.8
9.1
88.8
11.9
1892. .
47.1
8-7
97
70.5
87.0
22.2
7.6
25.7
16.6
1898. .
48.5
19
9.8
60.9
30.6
81.8
7.1
1894. .
28.6
2.0
6.1
82.4
7.3
29.2
5.8
In Table 2 the fluctuations, but not the absolute
rates, of the mortality in Michigan from diphtheria
and croup may be compared with corresponding rates
for Chicago, Massachusetts, England and Wales, and
Queensland for successive years. These comparative
data are chosen for their special significance. The
course of the disease in Chicago, from its geographic
proximity, may be taken as corresponding fairly
closely to that in Michigan, but it extends over a
longer series of years, in fact from beyond the first
recognition of the disease diphtheria as such during
the present period of prevalence. The high death
rate from "croup" in 1858 and 1859, during which
years practically no "diphtheria" was reported, to-
gether with the high death rate from diphtheria in
1860 attended with some decline of the rate from
croup, are indicative of the confusion between these
diseases which was present at its first outbreak. Until
about 1875 croup had caused a larger annual mortality
in Chicago than diphtheria as a rule, but since that
time diphtheria has been the more fatal. It should
be remembered that for 1894 the compiler of the
Chicago statistics has taken 80 per cent, of the regis-
tered mortality from croup and added it to diphtheria,
thus disturbing the true relations of these causes of
death as returned.
Massachusetts was selected as a State fairly repre-
sentative of the East, and because her system of
registration is the oldest and probably the most perfect
of any in this country. The data are from the Regis-
tration Report of 1890, the rates having unfortunately
not been continued in later reports.
Besides the rates given for England and Wales as
representative of European statistics of diphtheria, it
would have been desirable to present a corresponding
series for Germany or some other continental country,
in which the disease is far more prevalent, as a rule,
than in England. Unfortunately statistics were not
at hand for this comparison, so that the general rela-
tions indicated in Table 1 can only be referred to as
illustrative of the general European mortality from
this disease.
The data for Queensland, which colony was taken
as fairly representative of Australasian experience, do
not extend back as far as would be desirable in order
to show the early development of diphtheria as a
cause of death in the Southern Hemisphere. They
were, however, the longest series of death rates access-
ible to the writer, and have been taken directly from
the annual reports of the Registrar-General of that
colony. A complete file of the annual reports of
New South Wales, beginning with the year 1857,
completely covers the history of the disease, but,
unfortunately, for the early years of registration the
zymotic diseases are all grouped together, without
stating separately the number of deaths due to each
cause. The first mention of diphtheria occurs in the
Report for the year 1864, but the disease had occurred
to some extent during previous years, and had been
tabulated as quinsy. An interesting table is given in
the 9th Annual Report for 1865 showing the deaths
annually registered from certain diseases during pre-
vious years, part of which is here given :
Deaths registered in New South Wales, 1856-64.
Year.
1856.
1857.
1858.
1859.
1860.
1861.
1862.
1868.
1864.
Scarlatina.
Quinsy.
81
4
38
4
166
6
120
50
89
115
70
158
108
309
95
51
350
82
Diphtheria. Croup
289
162
61
38
69
85
52
74
85
142
85
General age and sex incidence of diphtheria and
croup in Michigan during the twenty-five-year period,
1870-94. — In Table 3 are given the condensed results
of registration for twenty-five years as regards these
particulars. About 85 per cent, of all decedents from
croup were under five years of age, and about 13 per
cent, were aged from 5 to 9 years. The propor-
tions at more advanced age periods were insignificant.
From diphtheria a smaller percentage of deaths
occurred under 5 years of age (46.3 per cent, for
males, 42.1 per cent, for females), about one-third of
the total deaths was at the period of 5 to 9 years,
1896.]
MORTALITY IN MICHIGAN.
355
chile
the period 10 to 14 showed about the same
proportion of deaths from diphtheria as the preceding
quinquennial period did from croup. Nearly 8 per
cent, of all deaths from diphtheria were of persona
over L5 years of age.
The death rates per 100,000 mean population from-
Group are much less than those from diphtheria at
every period of age except the first (0-4); the greater
concentration of deaths from croup into this period
raises the rate of mortality from croup to over 50 per
oent. of that from diphtheria.
As regards sex, the marked distinction will be noted
that croup causes more deaths of males, diphtheria
more deaths of females. Comparing the death rates
at each age period by sex (and thus eliminating the
unequal distribution of the sexes in the population,
which would affect the results if the numbers of
deaths of each sex were only compared), we find that
the proportion of death rates of males is higher than
that of females for croup at all ages and during the
quinquennial age periods, 0-4, 5-9, 15-19. For the
period 10 to 14 a lower rate appears for males, while
for ages over 20 years the rates are equal. There
were only 102 deaths returned from croup over 10
years of age, so that the proportions above the first
two periods of age should probably be rejected from
insufficiency of data. Except for the first five-year
period, during which the death rates of each sex are
nearly the same, with a slight excess of males, diph-
theria shows a markedly greater fatality among
females. From 5 to 9 years of age about eighteen
males die for every twenty females; from 10 to 19
about seventeen males to every twenty females, and
above 20 years of age the disproportion is still greater,
being at the rate of only about thirteen males to
twenty females.
In both age and sex incidence, membranous croup
is seen to occupy an intermediate position between
croup, returned only as such, and diphtheria. Con-
trary to what might have been expected, the propor-
tions, both by sex and age, appear to stand in some-
what closer relation to those of croup than to those
recorded for diphtheria. It is therefore obvious that
in the statistic treatment of deaths returned from
"membranous croup," consolidation with croup is
more desirable than consolidation with diphtheria,
pn »vided the apparent distinction between these two
latter forms of return is to be maintained. This posi-
tion leaves open the question as to whether all deaths
from croup are not largely diphtheritic, the peculiar
age and sex incidence of the former being due to
clinical distinctions not borne out by bacteriologic
criteria.
In any case, from the small number of deaths
reported from membranous croup, we shall be justi-
fied in neglecting this item, and referring chiefly to
the deaths reported as croup and diphtheria in the
following comparisons. Also, for convenience, the
series of five consecutive quinquennial periods from
1870 to 1894 is generally employed rather than single
years. Rates of the average deaths in each period,
carefully computed from the mean population, are
used, not the means of the annual rates. Since only
.4 per cent, of decedents from croup were over 20
years of age, and only about 3.5 per cent, of those
from diphtheria exceeded 20 years, we shall be justi-
fied in grouping all decedents aged 20 years or over
together, analysis by quinquennial periods of age
being confined to decedents under 20 years of age.
We accordingly have four consecutive five-year peri-
ods, viz., 0-4, 5-9, 10-14, and 15-19, the study of which
is practically exhaustive for the causes of death under
consideration. Indeed, it will be found that so few
deaths are reported for croup above the age of 10
years, that only the data referring to the first two
quinquennial periods are of value in the discussion of
this disease.
Table 8.— Showing, for the twenty-five-year period, 1870-94, in Michigan :
1, the percentage of deaths, by sex, at certain periods of age, as returned
from croup, membranous eroupand diphtheria; 2. the death rates per
100,000 population of same age and sex from each disease; 3. the ratios
of death rates of males to death rates of females at each period of age
Periods of age of decedents.
Causes of
death as
returned
1S70-94.
Sex.
All
ages.
Under 5
years.
10 to 14.
"H""?.
Per cent, of total deaths from each cause at known ages.
Croup
Croup, mem
branous. .
Diphtheria .
j Males. .
100.0
83.7
12.7
1.0
.2
1 Females.
100.0
84.9
13.2
1.4
.2
J j Males. .
100.0
72.2
25.3
2.0
.2
1 - Females.
100.0
73.3
20.7
4.3
.2
1 1 Males. .
100.0
46.3
38.4
13.0
4.1
I ( Females.
100.0
42.1
34.9
14.4
4.7
Rates per 100,000 population of same age and sex.
Croup. . . .
Croup, mem
branous. .
Diphtheria .
\ Males. .
14.6
103.3
16.2
1.4
.3
( Females.
12.7
83.8
18.7
1.7
.2
J Males. .
2.7
16.1
6.0
.5
1 Females.
2.4
13.5
4.0
.9
1 Males. .
45.8
175.3
184.2
56.4
19.7
1 Females.
52.2
171.4
149.3
67.1
28.3
Percent, of death rates of males to death rates of females.
Croup. . .
Croup, mem-
branous.
Diphtheria
115.0
123.3
I 118.2
82.4
112.5
119.8
1 150.0
55.6
87.7
102.8
I 89.9
84.1
150.0
84.5
.4
.4
.3
1.4
8.1
4.0
.1
.1
.1
2.6
3.8
100.0
65.8
Sex incidence of diphtheria and of croup by years
and quinquennial periods. — Sex incidence at all ages
is shown in Table 4 for diphtheria, croup and mem-
branous croup. Individual years are given as well as
the results for quinquennial periods. With the
exception of a single year, 1873, the death rates of
males from diphtheria are lower than those of females;
with five exceptions, 1874, 1884, 1889, 1893 and 1894,
the contrary is true for croup. From the small num-
bers involved, the relations of the mortality of the
sexes from membranous croup may be expected to
present less uniformity, but on the whole the death
rates of males are greater, as with croup reported
without further specification.
In the last two columns of this table the ratios of
death rates of males to death rates of females from
diphtheria and from croup are stated, the death rates
of the females being taken as a basis (100.0 per cent.)
in each case. This form of expression, which elimi-
nates the error incident to comparison of deaths of
males and deaths of females as returned without
allowance for relative numbers of each sex in the
population, will also be used in Table 5 for comparing
the relative mortality of the sexes from each disease
at the different age periods. It will be called, for
convenience of reference, the relative male mortality.
(See upper part of diagram.)
The relative male mortality from croup was slightly
higher during the last quinquennial period than dur-
ing the first; it rose rapidly from 1870-74 to 1875-79,
declined nearly as quickly as it rose for the next two
periods, and rose again from 1885-89 to 1890-94. The
relative male mortality from diphtheria fell slightly
from 1870-74 to 1875-79, but has risen since that time,
It must be remembered that these statements refer-
solely to the quinquennial periods as a whole; within,
these periods are many minor oscillations in the oppo»
site direction to that of the general tendency of the
ratios.
356
MOKTALITY IN MICHIGAN.
[August 15,
By age periods, it will be noted that the curve of
croup, 0-4, corresponds very closely to the relative
male mortality of croup at all ages, as should evi-
dently be the case, since about 85 per cent, of all
decedents from croup were under 5 years of age. The
relative male mortality of decedents from croup aged
5-9 may be said to exaggerate the variations of the
group 0-5, rising and sinking more rapidly than the
latter, but moving in the same general direction.
The relative male mortality of diphtheria for the
two periods, 5-9, 10-14, corresponds closely to the
relative male mortality of diphtheria at all ages.
That of decedents under 5 years of age moves in the
opposite direction to that of the two following peri-
ods, but on the whole shows little variation. The age
period, 15-19, as is generally the case when the aggre-
gate number of deaths is becoming too small for reli-
able inferences, shows the most violent changes.
The relative male mortality from diphtheria between
the ages of 15 and 19, during the period 1885-89,
exceeded the relative male mortality from croup at
any age, something quite the reverse of the usual
experience.
Table 4. — Death rates by sex, from diphtheria, membranous croup and
croup, as returned in Michigan for each of the years, 1870-94; with
rates for the quinquennial periods included, and for the twenty-flve-
ye»r period. Also per cent, of death rates of males from diphtheria
and from croup to corresponding death rates of females.
Death rates per 100,000 population, by sex.
Years
j i, i n ,.; Membranous
andpe-| Diphtheria. Croup.
riods. ! —
Males,
1870.
1871 .
1872 .
1873.
1874.
1875 .
1876.
1877.
1878.
1879.
1880.
1881.
1882.
1888.
1884 .
1885 .
1886 .
1887.
1888.
1889. .
1890. .
1891 . .
1892 . .
1898 . .
1894 . .
1870-74.
1876-78.
1880-84.
1885-89.
1890-94.
8.1
8.8
13.4
17.1
15.5
15.0
21.4
38.5
49.8
85.8
86.3
115.8
78.1
52.8
51.5
50.6
54.6
45.9
35.4
40.1
57.1
49 1
46.6
39.5
27.1
Fe-
males.
Males.
12.8
48.2
75.1
45.2
47.8
1870-9-1. 45.8
11.5
11.6
18.0
16.6
17.0
15.8
24.8
41.8
67.4
101.6
103.0
128.9
90.1
59.4
64.0
61.2
61.3
49.0
36.4
42.7
64.2
50.6
47.5
47.8
15.0
51.6
88.2
49.9
48.7
52.2
.3
.8
.9
.9
.9
1.2
1.2
1.8
2.5
2.2
4.1
4.4
8.2
2.9
2.5
2.8
5.6
6.6
4.4
1.8
8.5
1.6
8.7
1.9
2.1
1.7
8.4
4.2
2.6
2.7
Fe-
unit's.
1.8
1.8
1.8
2.8
3.6
8.9
3.1
2.1
2.9
1.8
2.0
5.1
5.2
4.6
2.8
1.8
1.7
8.6
1.9
1.8
.4
1.9
2.7
3.9
2.2
Croup.
Males.
11.5
12.2
18.1
14.2
9.6
12.8
12.8
10.9
11.1
17.7
17.2
21.3
19.9
16.3
14.6
15.8
15.8
15.4
20.3
16.1
22.8
12.0
11.4
9.7
6.8
Fe-
males.
12.1
13.7
17.8
16.6
12.1
9.4
11.6
11.0
11.3
10.2
9.5
8.9
8.5
11.7
11.8
14.1
15.7
14.5
15.2
16.3
14.9
15.3
13.1
17.7
18.7
17.1
11.7
8.0
10.0
6.4
10.7
10.0
15.2
16.0
10.6
14.6 i 12.7
Per cent, of
death rates of
males to death
rates of females.
Diph-
theria.
Croup.
79.1
122.3
71.6
105.2
74.4
119.1
103,0
136.7
91.2
94.1
94.9
134.7
88.1
143.8
92.1
128.2
78.1
120.6
84.4
156.6
83.8
122.0
89.8
135.7
81.1
137.2
88.9
107.2
80.5
89.6
82.7
106.0
89.1
100.0
88.7
117.6
97.3
114.7
98.9
86.1
88.9
130 4
97.2
102.6
98.1
142.5
82.6
97.0
89.4
90.6
85.3
88.7
85.1
90.6
91.4
87.7
118.1
137.0
117.1
108.8
115.2
115.0
Age incidence of diphtheria and of croup by (/niii-
quennial periods. — In the first part of Table 5 the
ratios of deaths by sex, to total deaths at all ages from
diphtheria and from croup are shown, for each of the
quinquennial age periods studied, at each of the five-
year periods of registration lying between 1870 and
1894. (See second part of diagram.) It will be observed
that the lines representing the sexes are nearly paral-
lel, thus showing that the influence exerted by the
factor of sex at each age period is very nearly con-
stant. The only exceptions to this rule are croup,
0-4, for the period 1875-79, and diphtheria, 5-9, dur-
ing the last quinquennial period of registration,
1890-94.
The ratio of mortality from croup under 5 years of
age to total mortality from croup at all ages is nearly
double that from diphtheria at the same or at any
other age period. Its course is nearly uniform, and
averages about 85 per cent, for both sexes.
The curves representing the proportional mortality
from diphtheria at the periods 5-9 and 10-14 are
nearly parallel, and show a slight increase between the
two most recent quinquennial periods. Both rose
from 1870-74 to 1875-79, continued nearly stationary
from 1875-79 to 1880-84, and declined together from
1880-84 to 1885-89. It is evident that the curve rep-
resenting the proportional mortality from diphtheria
in children under 5 years of age must exhibit changes
of a compensatory character, that is to say, as appears
after examination of the figures, the ratio of decedents
from diphtheria aged 0-4 fell from 1870-74 to 1875-79,
remained nearly stationary from 1875-79 to 1880-84,
rose from 1880-84 to 1885-89, and fell again from
1885-89 to 1890-94.
Table 5.— Showing, by sex, the proportional deaths, death rates per
100.000 like population and ratios of death rates of males to death rates
of females, at ceriain periods of age, from diphtheria and from croup,
according to the returns in Michigan during five quinquennial
periods, 1870-94.
Five-
year
periods.
Causes of death
as returned.
Sex.
Periods of age of decedents.
Under
5
years.
20
and
over.
Percent, of total deaths from each cause at known ages.
1870-74.
1X75-79.
1880-84.
18S5-89.
1890-94.
1870-74.
1875-79. .
1890-94.
I
1870-74.
1875-79.
1880-84.
1885-89.
1890-94.
j Males.
( Females.
\ Males. .
( Females.
. Males. .
( Females.
< Males. .
( Females.
j Males. .
i Females.
< Males. . !
) Females.
i Males. . i
( Females,
j Males. .
( Females.
j Males. .
( Females.
j Males. .
( Females.1
Rates per 100,000 population of the same age and sex.
79.2 , 10.7
C Croup. . . .
( Diphtheria .
( Croup. . . .
( Diphtheria .
( Croup. . . .
( Diphtheria .
( Croup. . . .
( Diphtheria .
( Croup. . . .
( Diphtheria .
88.1
86.8
56.4
49.8
88.5
85.2
46.5
39.9
86.0
82.3
46.3
41.0
85.5
85.4
47.8
44.9
86.1
85.7
43.0
41.1
10.9
.8
11.9
.«
.3
28.3
7.6
2.6
38.5
10.9
2.7
13.9
1.9
12.2
2.0
88.fi
13.6
2.9
:i.-».7
15. ft
4.5
12.7
.7
.1
16.2
1.4
83.2
11.1
:;.!)
35.6
15.4
12.9
1.1
.2
12.9
1.1
32.-1
11.3
5.2
::::. 7
12.7
4.6
12.4
.9
.4
U.6
2.0
.6
:;.-,.::
13.8
4.5
34.5
14.4
4.2
J Croup. . J SSJfaiei.
(Diphtheria ) Females.
i
! Diphtheria .
65.1
53.9
52.4
, Males. . I 89.9
crouP j Females. 81.8
Males. . 166.4
Females. 150.9
„ ; < Males. . I 126.8
0rouP (Females.! 96.2
„. ... ,. ( Males. . ! 287.4
Diphtheria. . . . j Femaiea. -j7,v,n
,„ * Males. . 12:: 8
(CrouP (Females. 112.6
) m_>.»h<.*<. » Males. . 188.0
(Diphtheria. . . . J Females. i,x:;.<;
._ „„„ (Males. . 91.2
Croup (Females. 78.0
Males. . 164.9
9.9
80.8
38.]
16.4
9.8
123.8
146.1
I 19.8
20.0
8.5
23.5
2.3
1.7
88.1
69.2
1.3
2.0
ai8.« ioi.i
266.3 121.-1
( Diphtheria .
' Females.: 165.4
19.1
17.2
130.4
189 ::
18.7
I 10.5
140.9
1-11.8
17
1.8
49.6
57.7
1.1
3.0
59.2
64.3
.8
3.4
3.8
13.0
21.8
.2
30.8
44.7
.4
24.6
22.1
.6
.6
20.6
19.7
Per cent, of death rates of males to death rates of females.
i Croup [ 121.7
Diphtheria 102.9
\ Croup
( Diphtheria
Croup. . .
( Diphtheria
\ Croup. . .
( Diphtheria
t Croup ! 1200
( Diphtheria
143.6
103.6
381.8
103.1
lf'9.8
102.4
110.1
133.8
.0
77.5
68.0
89.6
107.3
186.8
84.4
77.0
59.6
99.0
05.0
85.6
89 :;
68.8
111.0
94.4
93.6
86.0
111.8
130.6
66.0
100.0
99.4
92.1
104.6
.3
.8
5.0
3.1
.8
.6
8.4
4.8
.5
2.5
2.7
.2
.6
3.3
4.0
.1
.2
3.4
5-7
.1
.1
1.8
.9
.2
.1
2.6
4.1
.2
3.3
4.5
.1
.2
2.6
3.7
2.5
4.9
100. 0
183.8
200.0
68.4
78.8
60.0
70.3
51.0
Relations of age and sex incidence of diphtheria
and croup to their epidemic prevalence in Michigan.
— Having considered separately the principal features
of the changes in age incidence and sex incidence of
diphtheria and of croup as manifested in the stastistics
of successive quinquennial periods of years, it will be
18%.]
MORTALITY IN MICHIGAN.
357
GRAPHIC ANALYSIS OF MORTALITY IN MICHIGAN AS BETURNED FROM DIPHTHERIA AND FROM CROUP, BY
QUINQUENNIAL PERIODS, 1870 91, WITH REFERENCE TO AGE AND SEX INCIDENCE.
£
l«L
i }'
->-*-
-*-«-
JU.
I 0
ate
FIVE-YEA4 FIVE-YEAR RVE-YEAH
PERIOD, PERIOD, PERIOD,
1870-74 1875-7!) 180094
Vfct\_VUVX
*\M_E.
10-1<+-
TVOHNL
0-4
5-9-
10-1H- — t
FIVE-YEAR
PERIOD,
1385-89
FIVE-YEAR
PERIOD,
ltCO-84
DIPHTHERIA
TVOV\ ot'snya^. KC*.
DIPHTHERIA
5-9
and females by broken line, ,
aged under 5 ; 0+ represents
Note. — Males are indicated by a continuous line,
in all cases. Ages are both inclusive : thus 0-1 represents the five-year group
all ages, etc. Beginning at the lower part of the diagram (1), death rates at alf ages per 100,000 population
are shown for each cause of death. These rates are further analyzed by age-periods in the part above (3), and
the relations indicated in this portion of the diagram are more clearly shown with reference to sex and periods
of age in parts 1 and 2 respectively. In part 1 the basis of comparison is female mortality (death-rate) taken
as 100 per cent.
of interest to see what relations these changes bear to
the variations in the death rates. For this purpose
the death rates from diphtheria and from croup at
the most important periods of age, and from diph-
theria, croup, and membranous croup at all ages, are
represented in the diagram, by sex, and may be
directly compared with the curves showing relative
male mortality from each disease at specified age-
periods, and with the curves showing the per cents of
deaths at each period of age.
The death rates per 100,000 population according
to the returns are, of course, too low in their absolute
values for purposes of comparison with corresponding
statistics of States or countries having accurate sys-
tems of registration; for this reason a supplementary
scale making an estimated correction (addition) of 60
per cent, might properly have been added to the dia-
gram on the hypothesis that the percentage of defi-
ciency for these diseases, and for the several age
periods included in them, is substantially the same as
the estimated percentage of deficiency in the returns
of deaths from all causes and at all ages. So far as
the variations in mortality are concerned, ratios of
the sexes, etc., the figures represented in the diagram
are probably perfectly comparable among themselves,
without correction. A constant error in statistic
358
MORTALITY IN MICHIGAN.
[August 15,
data, affecting various elements uniformly, may be
entirely disregarded for purposes of intrinsic com-
parison.
A characteristic feature of the curves representing
the death rates from diphtheria is the high mortality
for the period 1880-84. In the statement by single
years (Table 2) it will be seen that the maximum
year was 1881, the great epidemic year for diphtheria
in Michigan, for which year the number of deaths
registered from this cause (2,063) was greater than
from any other cause of death, even consumption
(1,954) being exceeded. The rise from the first
period of registration, 1870-74, to the period 1875-79,
and from the latter the period of maximum preva-
lence, 1880-84, was very rapid, being especially so for
children at the age periods 0-4, 5-9. From 1880-84
the death rate as a whole declined, somewhat faster
than it rose, to the next period, 1885-89, and contin-
ued nearly stationary from that to the present time.
The ages 5-9 and 10-14 showed a somewhat more
rapid decline from 1880-84 to 1885-89 than other ages,
and have somewhat increased since 1885-89.
In marked contrast with diphtheria is the uniform
and moderate course of croup. A slight amount of
variation may, however, be noted, which is mostly in
the same direction as the variations of diphtheria for
the same time. Taking the age period 0-4 as espec-
ially characteristic, we see that croup increased very
slightly from 1870-74 to 1875-79; somewhat more
rapidly, but not at all approaching the virulence of
diphtheria at this period, from 1875-79 to 1880-84;
and, instead of rapidly declining like diphtheria,
remained nearly stationary from 1880-84 to 1885-89.
From 1885-89 to 1890-94 the death rate from croup
has diminished.
The relative male mortality from croup appears to
sustain a somewhat inverse relation to the general
movement of the mortality from that disease. Tak-
ing the period 0-4 years of age as typical, the relative
male mortality rose noticeably from 1870-74 to 1875-
79 while the death rate increased in less degree; from
1875-79 to 1880-84 and 1885-89, the relative male
mortality decreased while the death rate increased;
from 1885-89 to 1890-94, the relative male mortality
again rose while the death rate fell to about the same
extent. Nothing very definite appears in regard to
the proportional deaths from croup at this age, since
the curves representing the ratios of male and female
decedents move in opposite directions, and nearly
neutralize each other.
The regular and nearly uniform rise of the relative
male mortality of diphtheria at all ages, especially at
the ages 5-9, 10-14, and the slight decline in the rela-
tive male mortality of decedents under 5 years of
age, when compared with the very similar mortality
curves at all of these ages would seem to indicate that
sex has not been an appreciable factor in the epi-
demic history of the disease; that is to say, variations
in the extension and fatality of diphtheria have not
been attended with simultaneous special increase of
mortality in one sex. The change in sex incidence
seems to be a general one, advancing throughout the
entire history of the disease, as included in the
quarter century of statistics, in a determinate direc-
tion, and perhaps dependent upon some general
social change or development in the treatment of
male or female children.
Age incidence, unlike sex incidence, appears to
sustain a certain relation to the degree of epidemic
prevalence of diphtheria. This relation is direct for
the age periods 5-9, 10-14, and inverse for the period
0-4. That is to say, when an increase in the general
mortality from diphtheria and croup occurs, there is
an increased percentage of deaths of children over 5
years of age and a decreased percentage of deaths of
children under 5 years of age, as compared with the
total mortality.
Dr. H. B. Baker, in a report to the Michigan State
Board of Health on " The Present Comparative Immu-
nity of Adults from Diphtheria," found that " when
the reported deaths from diphtheria are over five-
tenths of one death per thousand inhabitants, the
average per cent, of diphtheria decedents over ten
years of age is 22.55, and when the reported deaths
from diphtheria are less than five-tenths of one death
per thousand inhabitants, the average per cent, of
diphtheria decedents over ten years of age is 19.27."
This observation covered the statistics of Michigan
during twenty-one years, 1868-88, for which period
the mean per cent, of diphtheria decedents aged over
ten years was 20.68."
Mr. Arthur Shirley, President of the Epidemio-
logical Society, makes the following statements in
regard to the changes in age incidence in England
and Wales:10
" There has been throughout England and Wales
relating to the diphtheria mortality at all ages a con-
siderably augmented incidence of the disease upon
the population aged above 3 and under 10 years in
the decennium 1871-80, ojompared with that in the
decennium immediately preceding. And in the case
of England and Wales as a whole, that increase has
been maintained throughout the succeeding decen-
nium 1881-90.
"When croup and diphtheria are taken together it
is found that in both the periods 1871-80 and 1881-90
there was a relative increase of the disease at school
ages (3 to 10) as compared with 1861-70."
Diphtheria declined in England and Wales from
1861-70 to 1871-80, and rose from 1871-80 to 1881-90.
Between the two latter periods, therefore, the varia-
tion agrees with the tendency in Michigan, but the
increased age incidence at older ages from 1861-70 to
1871-80, with a decreasing death rate, differs from the
observation in this State. It is possible that the dif-
ference in the exact age periods taken may in part
cause this decrepancy; and that it may be due, in part,
to the increased proportion of children exposed at
school in England under the Education act, which
went into operation in 1870.
General conclusions. — It may be well to summarize
the principal indications, statistic and otherwise,
which may be drawn from the study of these statistics
and which are clearly shown in the accompanying
diagram. It is understood that such general conclu-
sions have reference entirely to the history of the
disease in Michigan, and are of wider application only
so far as confirmed by the study of the statistics of
other States and countries. As there are no other
statistics, however, for any State west of New England
embracing the time included in the Michigan statis-
tics, together with statements of ages of decedents
from individual causes of deaths, the results presented
9 Rep. Mich. State Board of Health, 1891. p. «.'
10 Quoted by Edward Seaton. M.D., In a " Report on the Present State
of Knowledge Respecting the Etiology and Prevention of Diphtheria."
presented on behalf of the English Committee at the Eighth Interna-
tional Congress of Hygiene and Demography, Budapest, 1894. British
Medical Journal, Sept. 15, 1894.
1SW.1
MORTALITY IN MICHIGAN.
359
in the Michigan Registration Reports will ever remain
the only exaol history of the course of diphtheria
over any State area in the Western part of the United
States during the onset and most fatal period of pre-
valence of the great epidemic, and as such are deserv-
ing of special study.
1. Statistically, the line of demarcation between
diphtheria and croup is clearly defined. Their age
incidence, their sex incidence, and, I might add,
although the subject has not been studied in the
present paper, their monthly and seasonal prevalence
are distinct. This statistic difference is the expres-
sion of an equally well-marked clinical distinction.
Even though bacteriology should decide with more
certain voice than at present, that diphtheria and
(nearly all) croup are identical, would it not still be
advisable to keep separate the statistics of such a
definitely distinguished portion of the diphtheria re-
turns as are the deaths from " croup? " And if not the
mere presence, but the predominance, of the Klebs-
Loffier bacillus shall come in future to be the dis-
tinguishing characteristic of true diphtheria, statisti-
cians may awake to the fact that a great mistake has
been comitted in confusing the statistics of two
disc;;
'2. If the statistic distinction between diphtheria
and croup be maintained, the return of " membranous
croup. " providing it be not given a separate place as
in the Michigan reports, belongs rather to croup than
to diphtheria.
8. The fact that the death rates are higher for males
under 5 years of age from diphtheria, and that after
that age the mortality of females from this disease is
greater, is of interest, and accords with English
observation. From this change in the relative mor-
talities, it would seem possible to derive therapeutic
or prophylactic suggestions of value. What is there
in the conditions attending the development of girls
after the fifth year that is more favorable to fatality
from diphtheria? They start out with a relative
immunity, the death rate of female children under 5
years being markedly lower than that of male chil-
dren at that age. Why does not this relation persist,
and what causes the disease to bear more heavily
upon girls than boys at the usual school age?
This question is discussed by Dr. T. W. Thompson
in the article on " The Natural History of Infectious
Diseases, " Stevenson and Murphy's Hygiene, vol. ii.
p. 298, but the reasons given are not intended to be
considered conclusive. As embodying further the
opinions of Dr. Downes and Dr. Thorne Thorne, I
present his remarks in full:
" The excess of female mortality, at certain ages, at
least, is no doubt largely due to greater exposure to
infection — that is, to the closer and more continuous
contact with the sick to which females are exposed as
compared with males; but Dr. Arthur Downes has
pointed to the very early ages at which the excess of
female mortality is discernible as perhaps indicating
that some further explanation is required. As regards
this, Dr. Thorne remarks that ' the excess of diphthe-
ria death which attaches to females over males from
3 to 15 years of age, increases precisely as the age
advances which fits them more and more to take some
share in the care of home, and of relations during the
periods of sickness. ' And he further remarks that
' something may depend upon the full significance of
the term ' domesticity, ' and upon its taking account
of those acts of affection and tenderness which, in
their relation to the sick characterize females during
the period of girlhood, as well as in mature woman-
hood. ' Both these considerations are deserving of
considerable weight, especially as regards a disease
such as diphtheria, in the dissemination of which
close contact is known to play a conspicuous part;
but it still appears to remain doubtful whether
increased exposure to infection can be regarded as
entirely accounting for the excess of female mortality,
especially in the very early years of life. "
It is probable that the greater docility, affectionate-
ness and domesticity of girls render their share of the
mortality from diphtheria greater than that of boys.
A larger proportion of girls may be found in regular
school attendance, owing to less temptation to truancy
and less liability to employment during school age.
Among children girls tend, as a rule, to come into
more intimate personal contact with one another.
Boys naturally isolate themselves after an early age,
and repulse kisses, embraces and other demonstrations
of affection, as unbecoming the manly character.
Besides boys indulge much more persistently in out-
door sports and occupations, and thus " toughen "
themselves to resist the initial lesions of the mucous
membranes, resulting, perhaps, from atmospheric
irritation, which often afford a point of entrance for
the diphtheria germ. Speaking of croup, but with
equal application to diphtheria, Hirsch remarks:9
" Something wrong in the upbringing of the family,
particularly in the way of too much tenderness and
coddling, has been the real cause of the family liabil-
ity. The susceptibility which predisposes to this
disease would seem to be bred in those children who
are kept most from the effects of the weather, sheltered
from every wind, and during the cold season anxiously
detained whole days and even weeks indoors, and
that too, in heated and not always well- ventilated
nurseries. "
Whatever the cause of the greater relative female
mortality from diphtheria above the age of five years,
it is a cause that has been undergoing progressive
amelioration during nearly the whole history of the
disease in Michigan. Should the change continue at
approximately the same rate, the relative death rates
of the sexes will become nearly the same after the
lapse of a few years. Does this indicate that the
" new woman " of the future is already foreshadowed
in a more masculine type of education for girlhood?
At least, then, one favorable result will have to be
placed to the credit of the female renaissance, if it
tends to prevent diphtheria.
4. The increased proportion of mortality at ages
over five years coincident with a general increased
prevalence of diphtheria, has already been sufficiently
pointed out. Pacts of this class have an important
bearing upon our knowledge of immunity, and the
self-limitation of infectious diseases, but the limits of
the present paper preclude any special reference to
this subject.
5. Incidentally the importance of stating death
rates from diphtheria and from croup in the terms of
the susceptible population has been suggested. It is
only in this way that the real prevalence of these dis-
eases in countries or States with various age-distribu-
tions of population can be accurately compared. For
diphtheria the number of inhabitants under 15 years
of age, or if this basis were not generally obtainable,
' Handbook of Geographical and Historical Pathology, 111, 65.
360
PREVENTIVE MEDICINE IN APOPLEXY.
[August 15,
the number under the age of 21 years, would give
fairly accurate results; for croup, the rates should bo
based on the population under five years of age. In
the same way that the standard distribution of ages
suggested by Korosi has been adopted by the Inter-
national Statistical Institute for the computation of
mortality indices, instead of the unreliable death rates,
for international comparisons, so should certain
standard ages be selected as bases for stating all mor-
tality rates of children's diseases; and whenever a
higher mortality is shown to belong to either sex, the
standard population should be stated by sex.
6. Lastly, if this paper has any predominant pur-
pose, it is to emphasize the necessity of statistic study
of diseases, and to maintain that clear-cut statistic
distinctions are equally cogent with clinical or bacte-
riologic arguments in determining nosologic classifi-
cations. Statistics may be likened to the brake that
serves to restrain the plunges of the wild horses of
medical theorizing, and prevent their dragging the
car of true medical science through devious ways,
and to final wreck amidst a chaos of unsupported
opinions. It may not be the noblest office, but it is a
necessary one; and a knowledge of statistic tech-
nique should be regarded as a fundamental part of
the equipment of the medical reasoner just as fully
as equipment in chemic, bacteriologic, pathologic and
clinical methods is deemed essential at present. Vital
statistics is historically and practically the basis of
an enlightened sanitary science. The statistic pic-
tures are to be considered, in their place, equally with
the clinical pictures in making up our concepts of
diseases; yet from the paucity of data, especially in
this country, this is very seldom done. There are
very few medical colleges in the United States that
give any systematic instruction in the treatment of
medical statistics. The hope for the improvement of
this condition lies in the spreading of a higher opin-
ion of the services of the medical statistician among
the ranks of the profession at large, and through the
profession to the people. As a result of such enlight-
enment, accurate systems of registration will gradually
come into existence in this country in all of the states
whose density of population and advanced civilization
may warrant them; medical schools will adequately
treat the subject in their curricula, and health officers,
graduated therefrom, will be able to make intelligent
practical use of registration data in limiting and pre-
venting the spread of disease; finally a vast body
of the most essential facts concerning the constitution
and destiny of our people will be accumulated, whose
full import, vast, social significance, and practical
beneficence can not be estimated in advance, but,
judging from the triumphs of sanitary science based
upon an exact knowledge of vital statistics in the past,
will prove a potent factor in the elevation of the
human race.
PREVENTIVE MEDICINE IN APOPLEXY.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga.. Mav 5-8, 1896.
BY EPHRAIM CUTTER, LL.D., M.D.
HARVARD, 1850; UNIVERSITY OF PENNSYLVANIA, 1857.
NEW YORK.
Presuming that the Section I have the honor to
address is a board of medical police whose business it
is to detect the pre-stages of diseases and to procure
their prevention, if not their birth, the subject is then
legitimately up for thought and has an ever-present
living importance. The press rarely appears without
some reference to apoplexy. To-day it is Baron
de Hirsch's death cabled across the Atlantic in thou-
sands of words and eagerly read by the public who
love and appreciate such wealthy nature's noblemen.
The press also, with the confidence conferred by its
position, affirms that champagne freely drank caused
his apoplexy within a few hours. But it must have
had pre-stages longer than these few hours. This idea
was expressed by the late Dr. F. A. Sawyer, Vice-
President Massachusetts Medical Society, who told
his son that his death would be from apoplexy, as it
was. My cousin, the late Dr. Calvin Cutter, author
of Cutter's Physiologies, after he had experienced
apoplexy accurately predicted to his son. Dr. J.
Clarence Cutter, the two succeeding "strokes" he
should sustain and that he would die from the third
and last, which he did. If I am correctly informed,
Prof. Joseph Jones, M.D., LL.D., late member of our
Association, and one of the brightest medical lights
of the South, if not of the age, died from apoplexy.
So also died Job S. Crane of New Jersey, another
A. M. A. member whose character was like pure gold,
and whose presence in our meetings has added the
charms of delightful friendship and genial person-
ality in the past. If they do these things in a green
tree what shall be done in the dry ? If such medical
men are destroyed what will be done with the laity?
The high esteem of these distinguished gentlemen
impels me to tell what I know personally about their
disease as a grateful tribute to the lovableness and
glory of their characters.
What is Apoplexy Clinically and Conventionally?
— It means "sudden loss or diminution of sensation
and power of voluntary motion, usually resulting from
inter-cranial hemorrhage." Simple or nervous apoplexy
is where no lesion is discovered. Reference is here
confined to apoplexy from clot or serum pressure on
or in the cerebral substance or ventricles. The chief
agency lies in the rupture of an artery, usually the
basilar. No rupture, no apoplexy. A normal artery
will not rupture with ordinary or extraordinary heart
pressure. It must be weakened beforehand. Or, in
other words, there is a weakening of the artery before
it ruptures.
This weakening is not due to violence of puncture
by a weapon; we are not considering traumatic cases.
For years it has been taught and it has been found
true that this weakening comes from a substitution of
the circular muscular fibers of the arteries and of the
fibrous coats of capillaries, sometimes by fats or fat
acids, as oil, cholesterin, lardacein, stearin and mar-
gerin, with gravelly matters as atheroma, etc. The fats
have not the tensile strength of muscular and fibrous
tissues and hence the damage comes the moment the
artery is not strong enough to resist the arterial pres-
sure, normal or abnormal. Indeed, the artery
becomes fragile like a worn-out rubber hose, which
gives out where the interstitial molecular changes of
the mechanical mixture of rubber and sulphur are
most rapid.
The Clinical Lesion is the Fatty Degeneration. —
The results of the clot pressure vary from instant
death to protracted paralysis more or less complete as
the site of hemorrhage is nearer to or more remote
from vital nerve centers. Hemorrhagic apoplexy,
then, is merely a masquerade and local manifesta-
tion of fatty degeneration in the cerebral arteries and
1896.]
PREVENTIVE MEDICINE IN APOPLEXY.
361
this is the line on which our medical police have to
work.
Clues Macroscopic, i.e., with Unaided Observation.
— 1, 50 years of age and over, though apoplexy
sometimes comes in younger persons from severe sick-
ness or bodily abuse by food, drink and otherwise; 2,
arens senilis; 3, cataract; 4, amaurosis; 5, apoplexy
of retina; 6, obesity, though strictly speaking it is not
a tatty degeneration; it is an abnormal accumulation
in normal localities; T, waxy ami lardaceous counte-
nance; S, edema or thickening of eyelids; 9, hebe-
tude; 10, neuralgia sometimes; tic douloureux; 11,
muscular weakness; VI, rlabbiness of tissues; 13,
atheromatous radial and temporal arteries; 14, senile
gangrene; 15, defective vision; 16, the urine shows
albumin, often necessary to examine seven specimens
from voidings of seven successive days; 17, glaucoma.
Clues Microscopic— 1, casts of kidney, tubes; 2,
fatty epithelia; 3, amyloid bodies in blood and urine;
4. free oil in blood and urine; 5, pigments blue
bronze, anilin blue, emerald green in urine and blood.
6, fat globules in leucocytes; 7, cholesterin in blood
( credit should be given Dr. Jas. H. Salisbury for first
noting 3. 4. 6 and 7 in his writings); 8, protoplasmic,
filamentous or Indian club catarrh, one or all alter-
nating with albumin, casts and fatty epithelia. This
catarrh is very common in neurasthenia and should
not be overlooked. A recent case under my son's
care had been diagnosticated gout because of painful
shoulder by another physician. Use on urine work
for above clues, first, a good inch objective. All clues
are not present in every case.
Causes General, — 1, impeded or retarded languid
functions; 2, fat food in excess; 3, carbohydrate foods
in excess, producing paralyzing gasses by fermenta-
tion in alimentary canal; 4, want of exercise; 5, old
age; 6, disuse of organs; 7, lack of motions and emo-
tions; 8, abnormal metabolism or transformation
(Dunglison); 9, loss of vital force or dynamos by
work or pleasure, etc.
The general prophylactic treatment is to stop
causes, restore normal metabolism, fully sustain nature
and then she will restore healthy in place of fattily
degenerated tissues.
Particular Treatment. — 1, restore languid, impeded
or retarded function by removing all mechanical,
physiologic, chemic or pathologic restraints; 2, avoid
fat foods; 3, avoid carbohydrates including alcohol
entirely till signs are gone, and thus stop the gases
which paralyze parts near and remote, thereby imped-
ing the functions of life. Dr. Joseph Jones, in 1856,
reported through the Smithsonian Institute that car-
nivorous turtles fed on parsley had fatty degeneration.
Sir B. W. Richardson of London and S. Weir Mitchell
of Philadelphia produced cataracts in ten minutes by
injecting under the skin of a guinea pig or a frog 1
dram of a saturated watery solution of sugar. 4, exer-
cise in some labor that has the psychologic stimulus of
doing good to others; work is healthy. 5, avoid prema-
ture old age. Obliteration of the caliber of arteries,
more or less complete, by peripheral deposits usually
of a calcareous, atheromatous character, blocks in the
aged the circulation of blood, osmosis, secretion, etc.
But there is no reason for having old age come prema-
turely and people should live longer than they do now.
In olden times there were some 900 years old, showing
what the human race is capable of! 6, organs should be
used as far as possible consistent with common sense.
Unused horses, overfed, fattily degenerate in muscles.
7, when the list of motions and emotions that the lim-
ited knowledge of the writer can trace in normal human
life reaches forty-three in number, it is plain that life
is made up of motions and that it is important these
motions should be normal. If they are languid one
indication is to quicken them by forms of motion
biologically penetrating. Music is one such form of
harmonious motion now proved by Dogiel of Kazan,
Russia, to dilate the capillaries, increase the flow of
blood, remove congestions, calm the nervous system
revive memory, promote excretion of carbonic acid
from the lungs, promote digestion and confer vital
force. Hence music means much good to those pre-
disposed to apoplexy and should be had by them
either as listeners or performers. The Hon. J. Gr.
Blaine, in his final fatty ills, is said to have allowed
hand-organ music under his windows. The late Czar
of Russia, it is said, in his last illness had the trom-
bone played at midnight. There was good reason for
this. Electricity (specially the galvanic, as Althaus
says that the induced will of itself produce fatty
degeneration of the muscles) is an effective form of
motion, biologically penetrating. Hence the favora-
ble use of galvanism in fibroids — the writer has seen
cases standing cured for twenty-one years. Fibroids,
probably, are caused by impeded or hindered func-
tions as fatty ills are. On this principle galvanic
electricity is useful in the pre-apoplectic. Trolley
car rides do good also, by the induced electricity.
8. Normal transformation or the laying down and
taking up of tissues all the time going on — or
metabolism, if the Greek word is preferred, is aided
greatly by drinking distilled hot water one hour before
meals and on going to bed. It may be taken cold,
not iced, as there is no easier way of retarding or
impeding functions than by a temperature below
32 degrees F. One argument is, as there must
be from 100,000 miles or more of capillaries in
an average human adult, it follows that in normal
conditions there must be considerable force expended
to maintain the blood circulation and all the functions
dependent upon normal circulations. Now, if this
capillary circulation is impeded by lack of water in
the system (which is too generally the case) the way
to relieve it is to supply more water. Spring waters
heavily charged with salts are interdicted. They pro-
duce evil by blocking. Again, the drinking of hot
water washes out the stomach of slime and yeast, pro-
motes peristalsis, carries off undigested and unfer-
mented foods and thus removes the gases which are
causes of apoplexy. In this clinical light, flatulence,
which is tabooed by society ethics everywhere, is a
means of relief. Pre-apoplectics would, there is evi-
dence to believe, prolong their lives by allowing flatu-
lence to have free evacuations. Hot water and
sometimes cold wonderfully promotes beneficial flatu-
lence by causing the unstriped muscular fibers to
contract. The proper treatment to stop flatulence is
by cutting off foods that ferment. Hot water also
washes out the liver, kidneys, skin, keeping the
primse via? clear of gas, wonderfully quickening
retarded and impeded functions and promoting normal
metabolism.
9. Loss of dynamos by work, worry or pleasure. Life*
is very much a question of expenditure of vital force-
It takes a certain amount to " run, " so to speak, the
body systemic and the reserve should be used for
work, worry or pleasure. If one has no reserve he is
like Sam Small's steamboat that every time it blew its
362
A NEW TREATMENT OF PHTHISIS.
[August 15,
whistle it stopped! Of course this is overdrawn, as
stopping the body means death, immediate; but
many pre-apoplectics are using so much steam to
blow their whistle in work, worry or pleasure, there
is not steam enough left to run the body healthily ;
hence a retardation and impeding of function, and
hence follow fatty ills we are considering. Allow an
illustration. A woman of 65 years with an enlarged
and fatty heart showed signs of pre-apoplexy. Under
treatment on these principles the signs had nearly
disappeared on a certain visit. The next day the free
oil in the blood and the fat in the white corpuscles
were greatly increased. The cause lay in a sudden
removal from one room to another in her boarding
house, the patient being mentally worried and tired
out by the discharge of womanly duties which she
would not entrust to others. On resting these signs
soon diminished but did not entirely disappear. Rest
is a remedy approved by all practitioners of medicine,
and cures are due to rest that sometimes are credited
to schools of medicine and medicinal measures. Other
ways of treating loss of force are by ptenty of fresh
air (air is food) by a diet for pre-apoplexy of two-
thirds animal to one-third vegetable food, or better
by beef, mutton, lamb, whites of eggs, all suit-
ably cooked, not raw, for animal food; wheat, rye,
potatoes, sage, hominy, tapioca (celery as a relish),
choosing not all but few of these foods at a meal, and
watching their digestion and assimilation by the con-
dition of the blood, feces and urine, not depending
upon the patient's feelings or opinions. Force is also
to be conferred in massage or the imposition of hands.
The masseur must not be tired; I have known such
to deplete patients of strength given them by resting
and food. Massage is an old measure dating, it is
said, 2,600 B. C. The blind have been masseurs from
time immemorial in Japan. Force can be conferred
by contact with horses riding, driving and handling.
Force may be conferred by the stimulus of ideas, of
well-deserved praise, by trust in God, by calmness,
moderation and temperance, by not pulling oneself
up by the roots daily to observe progress, by crush-
ing out all envy, malice, hatred, by following out the
golden rule; force may then be saved by not wasting
what one has. These are little things. David Cop-
perfield said when his wife was dying, " Life is the
sum of little things." The successful prevention of
pre-apoplexy means the intelligent study of little
things, and nothing that touches the patient is too
small; these are the days when the medical heavens
are illuminated (?) by the lights of pathologic ex-
perts, that is, dead men's doctors. Would it not be
just as well to practice medicine for the living? Text
books of medicine are silent on this great subject of
pre-apoplexy.
The result to be expected is that nature will restore
to health the diseased cerebral arteries; space does
not permit the adding of the clinical evidence of cases
on which this communication is based.
A NEW TREATMENT OF PHTHISIS.
Bead in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8, 1896.
BY HUBBARD WINSLOW MITCHELL, M.D.
NEW YORK.
Pulmonary phthisis or pulmonary tuberculosis is
perhaps one of the most widespread diseases to which
mankind is subject. It occurs in persons of all ages
and in every country, and in all conditions of life.
While tuberculosis occurs in nearly every organ of
the body, the scope of this paper is confined to that
form of the disease which attacks the lungs, and that
form also which is known as acute tuberculosis.
Cause. — The cause of phthisis pulmonalis is due
to the introduction into the lungs of the microor-
ganism known as the tubercle bacillus. The existence
of this bacillus was suspected by many, but it was
left for Koch to demonstrate its existence, and its
invariable association with this special disease.
The tubercle bacillus is a short, fine rod, slightly
bent or curved, and hence the name often applied to
it of the " bent rod." Its average length is from one-
half to one diameter of a red blood globule. When
stained with carbolic fuchsin it assumes a bright red
color and presents under the microscope a well-defined
body which contains from two to five vacuoles. These
vacuoles give it a sort of beaded appearance, and some
observer has attributed this appearance to the presence
of spores, but it is probable that these vacuoles are
the nuclei of new bacilli which are formed by the
fission and subdivision of the parent bacillus. It is
undoubtedly the case that these bacilli multiply by
a rapid subdivision of themselves.
When the bacillus is treated with anilin dye or
carbolic fuchsin it stains slowly of a bright red color,
and retains this color permanently after treatment
with acids, and this characterizes it from all other
known forms of bacteria, with possibly the exception
of the bacillus of leprosy. It can be cultivated in
blood serum and on the potato, most readily in the
former, and the cultures must be kept at blood heat.
They grow slowly and appear about the end of the
second week. The colonies of bacilli form thin
grayish-white masses on the surface of the culture
medium, and but little is known yet of the chemic
composition of the tubercle bacillus. They are found
in all tubercular lesions throughout the body, and in
every organ where tuberculous disease is present, but,
as above stated, they will be studied solely in connec-
tion with pulmonary tuberculosis.
The bacilli multiply with great rapidity in lung
tissue, and a patient suffering with pulmonary con-
sumption discharges them in the sputum in consider-
able numbers. When they are so expectorated, if
great care is not taken to destroy their virulence, they
become a focus of danger to others wherever they are
discharged, and this shows the great danger associ-
ated with the sputum of phthisis unless it is most
carefully disposed of.
In the dust collected from the walls and bedsteads
of hospital wards, in asylums and prisons, bacilli have
been found, sometimes in great numbers, showing
that in these places the sputum was carelessly distri-
buted and new foci of infection were thus formed.
The tubercle bacillus is thus a widespread and dan-
gerous organism in all places frequented by patients
suffering from phthisis.
Mode of infection. — It is not altogether satisfactory
to say that phthisis is hereditary. Life insurance
companies reject applicants for insurance whose
parents or brothers or sisters have died of phthisis,
even when the applicant himself was in perfect health.
How far the theory of heredity is true is a disputed
question, but from my own observation and studies,
I believe that the ancestors of such persons did not
confer a taint sufficient to warrant his rejection.
If a woman suffering with phthisis becomes preg-
18%.]
A NEW TREATMENT OF PHTHISIS.
363
mint it is not true, certainly in many cases, that she
confers a phthisical taint upon her child, and the
same may be said of a man suffering with phthisis,
the woman whom he impregnates can not, through the
venereal act, contract the disease, so that heredity is
of less value to-day. in the line of modern researches,
than it formerly was.
Contagiousness of phthisis— It we accept the the-
ory thai phthisis pulmonalis depends for its existence
upon the introduction into the lung of the tubercle
bacillus, then that microbe must be introduced from
without, and from some source where the bacillus has
retained its activity and virulence, and when we
remember that the sputum from phthisis patients
contains vast numbers of these bacilli, which are dis-
tributed widely through dust and carelessness with
which the sputum is voided, it will be seen that the
danger from contagion is very evident, and the acquire-
ment of this disease by contagion directly from a
patient, or indirectly through his dried sputum which
is inhaled elsewhere, forms the most common source
from which this disease is acquired.
It has been very justly remarked by many obser-
vers that it is important to draw a line always between
hereditary and accidental tuberculosis, for cases pre-
sent themselves to the practitioner that have a very
incomplete history, although by careful examination
a conclusion can be reached upon which we can base
our opinion as to its source.'
~es have been noted where phthisis has been
acquired through inoculation, as from persons wash-
ing the clothes of phthisis patients, or the bite of
a tuberculous person, or inoculation from a cut or
abrasion where the sputum has been brought in con-
tact with this traumatism. The expired air from the
tonga of a tuberculous patient does not convey the
disease, and a person coming in close contact with the
patient will not necessarily acquire the disease from
his breath, but kissing a tuberculous patient will
undoubtedly produce the disease in some cases.
Infection by milk, by meat, and by water and food
need not be touched upon here. The danger from
these sources exists and must not be lost sight of, but
space prevents my speaking of them in detail.
Influence of age. — Tuberculosis occurs at all peri-
ods of life. It is met with in the nursing infant, as
well as in those tottering upon the edge of the grave.
No age is immune from the disease. In the young
we find the lymphatic glands very frequently affected,
while in the old, the lungs seem to be especially prone
to the disease.
In my judgment, soil and locality play an unimpor-
tant part, and the association of other diseases is to
me of less importance than has been ascribed to
them.
It is interesting to note the changes produced in
the pulmonary tissue from the introduction of the
tubercle bacillus. When a bacillus enters the tissue
of the lung, it is believed to cause in the first
place a proliferation of epithelioid and giant cells,
followed by an inflammatory reaction and the for-
mation of masses which are termed tubercle, and
when these tubercle masses are once formed they
quickly undergo caseation. This caseation, which is
undoubtedly caused by the bacillus, is a process of
coagulation going op. in the cells, which lose their
outline, become irregular, and are finally converted
into a structureless substance. The tubercle may
gradually be converted into a yellowish-gray pus in
which the bacilli are abundant, and when this matter
infiltrates the inflamed lung tissue it is loosened more
or less by inspired air, escapes into the smaller bron-
chi, and finally is coughed up by the patient in the
form of a thick yellowish or grayish sputum contain-
ing the bacilli in greater or less numbers.
When the bacilli are introduced into the lungs two
processes may go on, the first, caseation and ulcera-
tion which is destructive and dangerous, the other,
sclerosis, which is conservative and healing, and the
ultimate result in a given case depends upon the
capabilities of the body to restore the tissues, and
limit the growth of the bacillus, or to permit the pro-
cess to go on to a dangerous and finally fatal termi-
nation.
There are some cases where the bacilli are intro-
duced into the pulmonary tissue and are for some
reason destroyed at once, and in these we say sclero-
sis has taken place. The bacilli have gained a lodg-
ment and have done some damage, but finally the
victory is with the conservative forces of the body.
In other cases the bacilli grow luxuriantly, caseation
and softening occur, and victory is with the invading
bacilli and a fatal result follows.
Symptoms of pulmonary phthisis. — After the bacil-
lus has invaded the lung tissue, the symptoms are
very soon manifest. The patient develops a cough
which at first seems to be of a broncho-pneumonic
type, and is marked with expectoration of a muco-
purulent character. Dyspnea is a striking feature and
is more or less severe. The respiration rises from
twenty to fifty per minute and there is frequently
cyanosis of the lips and finger-tips. The early phys-
ical signs are those of bronchitis.
Percussion teaches us but little in the early stages.
On the contrary, auscultation is of the utmost impor-
tance. Rales are nearly always heard, either sibilant
or sonorous, or they may be crepitant. We may,
rarely, have crepitation from the presence of tubercle
on the pleura. As the disease advances the rales
become larger and more mucous in character, and we
have a fine or coarse bubbling rale according to the
intensity and extent of the disease. As the disease
advances cavities may form in the lung tissue.
When the disease is confined to one lung the physical
signs just described are present more or less, and the
opposite lung is very frequently congested, and aus-
cultation on that side reveals a harsh, rasping respi-
ration.
The temperature rises sometimes as high as 103
degrees and is always a symptom of severity. The
pulse is rapid and feeble in proportion to the extent
and severity of the disease.
I will not touch upon the symptoms caused by the
invasion of other organs by this disease. It is suffi-
cient for this paper to deal only with the pulmonary
type.
Duration, of the disease.— Cases have been noted
where the disease ran a rapid course and caused death
in a few weeks. I have not myself met with cases
terminating in so short a time. It is usually of a
slower development and continues for a much longer
period. In my own experience many months elapse
before death takes place, and under the treatment
which will be described later in this paper, no deaths
have occurred up to this time, so that it is impossible
to tell the exact duration of the disease. But without
treatment of any kind the disease will terminate
fatally in from four to twelve months.
364
A NEW TREATMENT OF PHTHISIS.
[August 15,
Diagnosis. — The diagnosis of pulmonary phthisis
is not difficult. The presence of cough, emaciation,
night sweats, diarrhea, anorexia, thirst and general
anemia, are nearly always present and point to the
nature of the difficulty. But the unfailing test in
the diagnosis is the presence of the bacillus in the
;sputum. As it is believed that this microorganism is
the direct cause of phthisis, its presence is proof
positive that the disease is pulmonary tuberculosis.
If the sputum contains no bacilli, then the disease is
hot pulmonary tuberculosis per se.
It is not necessary here to touch upon the morbid
anatomy of the disease, nor of the many lesser symp-
toms which are present in any given case, nor is it
necessary to divide the disease into clinical groups, as
some writers have done. This paper deals with pul-
monary phthisis induced by the bacilli reaching the
lung through the bronchi, termed by some writers
" inhalation tuberculosis," the ulcerative tuberculosis
which we are now considering.
Prognosis. — The prognosis of pulmonary phthisis,
when not modified by treatment, is extremely fatal.
Various percentages of death are given, and while
these percentages differ with many writers, and per-
haps no accurate percentage can be given, it is true,
as every practitioner will testify, that the death rate
is extremely high.
The mode of death may be by asthenia, or gradual
failing of strength. Here the end is usually peaceful
and quiet, disturbed perhaps by cough, but rarely by
pain, and consciousness often is retained until near the
end. Or by asphyxia. This occurs in the acute cases
which run a rapid course, but rarely in the chronic,
even of great severity. Syncope is also a mode of
death, but not common. It occurs when patients in
a very advanced stage of the disease insist upon going
about, and if organic cardiac disease be present, as it
often is, then syncope may occur.
Hemorrhage also may be a mode of death in chronic
phthisis, and is due to the erosion and rupture of a
large blood vessel or of an aneurysm in a pulmonary
cavity. Coma may occur,- due to meningitis, but this
I believe is rare.
The most common mode of death is by asthe-
nia, where the vital powers slowly succumb to the
onslaughts of the disease.
Treatment. — The treatment of pulmonary phthisis
is the special point to which I desire to call attention.
About three years ago I began to experiment in my
private laboratory with a group of chemic salts known
as the halogen group, and I found that these salts,
when combined in definite proportions, formed a
fluid having remarkable antiseptic powers. To this
group I subsequently added the hypochlorites of
sodium and potassium, as will be seen in the formula
below. The resultant fluid was a chemic combination
of the above named salts, and for want of a better
name has been called after me, namely, " Mitchell's
Fluid." It is with some diffidence that I use this
name, but no better one appears to be available, and
I will in this paper term it " fluid."
I first used the " fluid " in a large number of cases
of ulcerative and suppurative processes occurring
upon the external surface of the body, and through
the courtesy of Drs. Taylor, Sturgis, Phelps, MeGuire,
Burchard, and the very able house staff at Charity
Hospital, in the wards of which I was allowed to
experiment freely, I obtained satisfactory results in
ulcers of a syphilitic, traumatic and varicose nature,
and in many of the lesions of syphilis and chancroid,
the sores were healed in a very short time.
I conducted these experiments through a period of
two years, treating 375 cases. I also used the " fluid "
extensively in my own private practice, but up to
this point it had been used externally only.
It occurred to me that if the " fluid " acted so well
upon the outside of the body, it might be that it would
act well upon phthisis, which is an ulcerative process
in the lung tissue due to the presence of the tubercle
bacilli, if the "fluid" could be brought in contact
with the lung tissue, and I reasoned thus:
As the gastric juice is of hydrochloric acid reaction,
and this " fluid" being of the same reaction, I thought
if it could be introduced into the stomach when that
organ was perfectly empty, it might be carried by the
blood into the lung and there modify the course of
the disease, and perhaps destroy the bacillus. This
reasoning was acted upon immediately and with flat-
tering success.
My first case was that of a young man 21 years old,
who had a cavity in his right lung. He had had hem-
orrhages weekly of considerable severity, and when I
first saw him he raised blood at each effort of cough-
ing. His sputum contained pus cells and the charac-
teristic bacilli. He had night sweats, anorexia, loss
of flesh, and began to show the signs of phthisis
cachexia.
I gave him the "fluid" in 2 dram doses, always on
an empty stomach, that is, half an hour before each
meal, and at bed time. The " fluid " was given full
strength; no other remedy was employed. His diet
was ordered to be rich and nutritious. Treatment was
begun on June 1, 1894. On the third day his night
sweats ceased, he stopped spitting blood and immedi-
ately his cough began to lessen. The treatment was
continued steadily, and on July 31 his sputum con-
tained few bacilli and few pus cells, and his general
symptoms were much improved. On October 1, aus-
cultation showed the lung had healed, and the sputum
was free from bacilli and pus cells. He was com-
pletely cured.
I immediately selected eight cases, all women and
all having the typical symptoms of phthisis pulmon-
alis. The treatment was the same as in the first case,
and in periods varying from four to seven months
they all recovered.
At this time I have in my private practice 130 cases
of true phthisis pulmonalis. In every case there are
present all the characteristic symptoms. Forty of
these are now practically well, and this opinion is
based upon the fact that the sputum is entirely free
from bacilli and pus cells. Thirty of the above 130
cases are absolutely hopeless. The destruction of
the lung tissue is too extensive to be restored, yet
severe as they are, all of the symptoms are consider-
ably modified. The diarrhea which so often accom-
panies severe cases is quickly checked, the night
sweats cease, and very soon the respiration becomes
more normal, and a degree of comfort given which
was not hoped for, and when death comes, it will come
largely robbed of its terrors through an amelioration
of these distressing symptoms.
The remaining sixty cases, while they are all severe,
1 have every reason to believe that most of them will
ultimately recover.
Treatment in detail. — I give the " fluid " in from
2 to 3 dram doses, clear, four times daily, always upon
an empty stomach. This is absolutely a sine qua non.
18%.]
SERO-THERAPY IN TUBERCULOSIS.
365
I use a glass to measure the fluid, not a metal spoon.
In all eases whisky is given, 1 to 2 ounces at a dose,
two to three times per day.
The cou^h is somewhat lessened by adding essence
ot peppermint to the whisky in the proportion of half
a dram to each dose. The diet must lie nutritious
and liberal.
In every case of phthisis in my practice the sputum
is examined once in ten days or two weeks. These
examinations are made by Dr. John Hoch of this
city. His method of examining the sputum is as
follows:
llv stains the fresh sputum with carbolic fuchsin
and methylene blue; the former stains the bacilli of
a bright red, while the pus cells and other ingredients
of the sputum are stained blue by the methylene.
The sputum thus stained is mounted on glass slides,
and a permanent record made of each case and of
each examination, so that they can be referred to at
any time.
Dr. Hoch uses a one-twelfth inch objective oil
immersion lens, which gives a diameter of 925 times.
This high power makes it possible to count every
bacillus in each specimen of sputum, so that errors
are absolutely eliminated. As the treatment pro-
gresses these microscopic examinations are made at
short intervals, and the diminution in the number of
bacilli are accurately observed. '!T?".^_^_4;
When a case of phthisis presents itself for treat-
ment I make a complete and careful examination of
the patient, keeping a permanent record of each case
with the history of all symptoms noted, and this with
the record of the sputum made by Dr. Hoch, places
the treatment of phthisis upon a firm, careful and
scientitie basis. This, so far as I am aware, is the
first attempt made in this country to treat the disease
in this scientific and methodic manner, and the results
obtained have shown that it is of the highest possible
value.
In addition to the above I enjoin every patient to
keep as quiet as possible, remaining in bed and in
doors when necessary, and I rely upon rest as an
important adjunct of the treatment.
In the severe cases, where the cough is incessant
and distressing and the fever high, I often give a pill
at night, containing 3 grains of sulphate of quinin
and | grain of powdered opium, omitting it as soon
as possible for fear of disturbing the stomach.
The composition of the "fluid" is as follows:
Sodic hypochlorite 7 grams.
Potassic hypochlorite 7 "
Magnesic chlorid 1.5 "
Calcic chlorid 2
Hydric chlorid 2
Chlorin 5
Potassic sulphate 1.5 "
Magnesic sulphate .5 "
Aquae 1,000
Sodic carbonate, potassic carbonate, equal parts added in
sufficient quantity to bring the solution to the proper degree
of acidity.
Hemorrhage into the Poos and Opium Poisoning. — A special inter-
est is attached to the symptomatology of hemorrhage into the
pons Varolii, because lesions here sometimes very closely simu-
late narcotic poisoning. The slowing of respiration, the pin-
point contraction of the pupils, the unconsciousness, all give
to some cases of pons hemorrhage a similarity to opium poison-
ing, and mistakes in diagnosis have been made even by men of
large experience.— Dr. Dana in Post-Cfraduate, July.
THE EXPERIENCE OP SEVERAL PHYSI-
CIANS WITH SERO-THERAPY
IN TUBERCULOSIS.
Read Id the Section on Practice of Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association held at
Atlanta. Ga., May 5-8, 1890.
BY PAUL PAQUIN, M.D.
ST. LOUIS, MO.
One year ago, I was honored by the courtesy of
this Association when I presented the results of my
humble laboratory and clinical work in the domain of
sero-therapy, as applied to tuberculosis. I had had
then only six months of experience in the application
of immunized horse blood serum in man. Preceding
work had been in animals. Notwithstanding the
many decided improvements I then reported and the
apparent recoveries, it was yet too early to arrive at a
reliable conclusion as to the merits of this form of
treatment and the remedy itself. Since then, I have
enlisted the aid of many physicians throughout the
country, and will take pleasure to-day in reporting, in
part, the results of their work, and my own, in proper
cases, as well as indicate the failures, unavoidable in
many instances by any and all forms of treatment.
Many of these physicians have been persistent even
in desperate cases of their tests of anti-tubercle serum,
and some have been rewarded with results unlooked for.
Although I shall have the pleasure to present
another paper on this serum to this Association, i.e.,
before the Section of Pharmacy and Therapeutics, a
preface to this report, by way of explanation of certain
disputed questions concerning the rationale and util-
ity of serum in tuberculosis will not be amiss.
I am facing some who have failed in treating con-
sumption with serum ; physicians who have doubts as
to its value in therapeutics except as may be due to
inherent conditions dependent on the relative immu-
nity of the horse against tuberculosis; doctors who
doubt the qualifications of private laboratories and
their delvers and of a general practitioner's ability,
opportunities and time to investigate, experiment
scientifically, safely and successfully.
Since presenting my report last year Maragliano, of
Genoa, reported recoveries of consumption by the use of
the serum of the ass, to the British Medical Society, Be-
hring, Winternitch, Foa, Roux and others write on the
efficiency of immunized serum produced by themselves,
either on experiment animals or man. Their labors are
in the line of my own, and possibly some of their work
antedated mine, although my researches on tuberculo-
sis and its general treatment, which led to the produc-
tion of serum and its application in medicine in 1894,
date back many years, when I was connected with the
State University of Missouri. While these foreign
scientists of world repute, used serum from various
animals, particularly the ass, the horse blood serum
was immunized first in this country by myself.
The anti-tubercle serum, like the anti-toxin for
diphtheria, rests on the biologic laws governing the
defensive forces of an organism to oppose the encroach-
ment of microbes and their products on the tissues
and blood. Tuberculous individuals sometimes re-
cover without remedy. This is due to nature's own
efforts, viz.: exalted phagocytosis, with all that this
interesting physiologic phenomenon implies. A com-
plex being, such as man or the horse, is a republic of
small animated subjects, the cells, with distinctive
individual properties and obligated to co-operative
functions for the sustenance of the whole. The brain
366
SERO-THERAPY IN TUBERCULOSIS.
[August 15,
and nerve cells constitute the governing power; the
phagocytes constitute the soldiers of the country.
Their arms consist of their individual annihilating
power in a physical sense and the antitoxin elements
they produce, capable (probably by a digestive or
diastatic property) of neutralizing the poisons thrown
amidst them by the armies of microbes constantly
attacking the wonderful aggregations which they
defend. What occurs in a case of consumption
cured by nature occurs in a horse properly sub-
jected to the influence of the consumption poison.
Either a natural antidote is increased in power,
or a new one created, and this is what exists in
the serum I use in man. Man suffering from tuber-
culosis is under the influence of a certain amount of
tuberculin, a poison, and nature produces in his sys-
tem an antitoxin to counteract this nocive agent. But
usually the army of invaders win the fight after a
more or less prolonged and painful conflict. What
the laboratory is expected to do is, to supply man
with this defensive force, the antitoxin, produced
at the expense of the horse's system rather than
his own.
One must not be too sanguine. Little hope can be
offered to the unfortunate who suffers from advanced
tuberculosis, with extensive destruction of tissue;
general tuberoulous intoxication; general debility;
pronounced dyspepsia, deficient assimilation and dis-
similation, difficult and perverted secretions and excre-
tions, and the hopelessness of such cases is empha-
sized, more or less, according to the more or less pro-
nounced microbic complications which may exist.
These complications are influenced only secondarily,
by virtue of nature having recovered some strength
after the bacilli of tuberculosis are arrested in their
development and devastation. I have confidence that
early cases of tuberculosis can nearly all be arrested
by serum administered under proper conditions, and
that were it the policy of the laity to submit to con-
stant observations and repeated analysis the moment a
lung or bronchial irritation manifests itself, the diag-
nosis of incipient phthisis would be made early
enough to diminish the death rate due to consumption
90 per cent, by the action of serum.
While I would take pleasure in quoting from all the
reports of more than sixty physicians, who have used
the serum, more or less successfully, the time at my
command will not permit it. Consequently, I will
limit myself to cases that have not yet been reported,
or reported in the past to a limited degree, and are
now in a different or more improved condition.
I shall call attention first to a case of J. R. Lemen,
M.D., St. Louis (reported in the New York Medical
Journal for Sept. 21, 1895) in which the Doctor
claims to have effected the recovery of an acute case
of tuberculosis, in the person of R. C. G., a real estate
agent; age 60. I am personally acquainted with the
patient and saw him when he was prostrated in bed,
weighing less than 160 pounds. The symptoms were
clearly those of acute tuberculous pneumonia. The
bacilli were present in profusion. He has now recov-
ered and to-day attends to his business as usual and
weighs 224 pounds.
Case under care of Geo. W. Cale, M.D., St. Louis,
Mo.: B. McGr., age 18 years, 2 months, has been suf-
fering with joint and bone tuberculosis for seven years
and had had ten operations performed on different
parts of his body to open abscesses and to remove
necrosed bones. The seat of the primary trouble was
the right hip joint but it was giving him trouble in
every limb. The left tibia was much involved, having
at one time eight openings, discharging a tubercular
pus. The hip had three openings that would heal and
open alternately and one that was open continually for
seven years. He had an abscess on each arm, one of the
sternum, one of the index finger of the right hand, a
tubercular nodule in the scrotum, an abscess near the
apex of the left scapula and two on the lower jaw.
The patient says that after the continued efforts of Dr.
J., of Waverly, Ky., who had four consultants, Drs. H,
of Henderson, Ky., and A. J., of Sturgis, Ky., had
failed to cure the patient; it was decided to let nature
take its course. He was without medical aid for two
years. In the fall of 1894, he was put in charge of
Dr. Broome, St. Louis, who performed an operation
to remove necrosed bone from thigh and tibia, think-
ing that these openings would heal. This having
failed, he decided to try the serum treatment and the
case was taken in charge by Dr. Cale. He began the
treatment in March, 1895, at which time he had four
abscesses discharging a characteristic tuberculous pus
and two others that afterward opened. He had daily
injections of 20 to 30 ms., and at the close of six
months treatment, five of these abscesses had healed,
he had gained ten pounds and temperature was nor-
mal. He is working steadily and is still gaining in
weight. The last and only opening, a very slight one,
is in the thigh, and dead bone has been located which
is the cause of it remaining open. Up to the present
date he has gained sixteen pounds, and is enjoying
good health.
Dr. L. L. Shropshire, of San Antonia, Texas, reports
in the New York Medical Journal, of January, 1896,
the case of a brakeman 25 years old, who had had hem-
orrhage of the left lung, followed by fever, purulent
expectoration, loss of weight, and generally declining
health. The physical examination had revealed dull-
ness over upper lobe of the left lung, moist rales and a
gurgling sound; violent cough; abnormal temperature
reached as high as 103 F. Had had night sweats ; could
retain but little food, losing flesh rapidly, weighing at
the time 125 pounds. Microscopic examination re-
vealed bacilli of tuberculosis. After two or three weeks
of daily injections of serum, night sweats grew less,
appetite returned and digestion improved. Four
months after the beginning of treatment he is practi-
cally well, and to-day, about seven months after the
beginning of the treatment, he is reported as recovered
and attending to his duties as a brakeman.
He reports another case, a shoemaker, age 51, who
had contracted tuberculosis. The diagnosis was
made from physical signs and microscopic analysis.
He had declined in health and strength very rapidly,
weighing at the time 131 pounds. At the time of
the report, he had returned to work and had gained
18 pounds, and to-day he is reported as having
recovered.
He reports two other cases with positive improve-
ment and gain in flesh and mentions twenty-five
cases, treated up to that time with improvement in
all of them.
A. M. Hayden, M.D., Surgeon, St. Mary's Hospital,
Evansville, Ind., reports cases as follows (In the
Journal of the American Medical Association):
My first case was one with large cavities in left lung, hepati-
zation of the lower portion of right lung ; had a great many
hemorrhages ; sputum contained large quantities of bacilli ;
weight 120 pounds. Treatment commenced May 10, 1895. In
1896.]
SERO-THERAPY IN TUBERCULOSIS.
367
three months tubercular bncilli disappeared from sputum
entirely, and it has remained free from them ever since. The
cavities in left lung healed up, with great contraction of the
left chest, three or four inches. It has remained so. The
patient ceased to expectorate heavy sputum, and now expec-
torates a light frothy sputum. Has had no hemorrhages since
treatment began : he lias weighed 140 pounds for the last six
months; ridden a bicycle; eats well, and commences his duties
as assessor to-morrow. After the first three months, I gave
him one to t w o ounces only at intervals of one and two months.
1 am satisfied that he would have been dead long before this
had he not had the serum.
Case .'. A young man, 25 years old. Family history was
that of tuberculosis. His sputum contained quantities of
tubercular bacilli : weighed 110 pounds ; had been west without
benefit ; had night sweats, fever and all symptoms of the dread
disease. 1 commenced his treatment September 8, 1895. I
gave aim 66 daily injections of 35 ms. each. Tubercular bacilli
disappeared from sputum ; gained 10 pounds. January 20 I
commenced and gave him 16 more injections, during which
time he gained live pounds, which is more than he ever weighed
in his life. He is still in splendid health and says he is feeling
better than he ever did in his life. To-day I advised him to
take another ounce of serum to guard against relapse.
Que 3. A young man with long standing hip-joint disease.
I gave him an ounce in January, 1896, during which time he
gained sixteen jiounds in flesh and general health much im-
proved. He then stopped two weeks, during which time he
ceased to gain flesh. Ho then commenced again and took one
ounce more and gained ten pounds. His health has been much
Improved since.
Cam I- A man aged 40 years. Several brothers had died of
tuberculosis : was taken sick in November with a cough, night
Sweats atnl fever. His family physician treated him until Jan-
ua.y. 1896, when I was called. He was much emaciated, no
appetite, night sweats, fever, etc. While he coughed almost
incessantly, he did not expectorate. I failed to find any lesions
of the lungs in physical examination. His liver failed to act
i chalky evacuation, etc. ) His family physician had treated him
faithfully without results, and he was satisfied that patient
was Buffering with tuberculosis of liver and other glands. I
advised him to use serum, stating to patient that if his trouble
was tuberculosis he would be benefited, if not cured. Hecon-
sented and started the treatment. The improvement com-
menced at once In sixteen days he gained sufficient to get
up and walk a square to a grocery and get weighed, and found
that he weighed his usual weight, 150 pounds. We then
stopped the treatment for ten days. Patient requested me to
begin again, saying that his appetite was not so good and that
he was having night sweats again. I ordered another ounce ;
had him weighed, and found he weighed 150 pounds still. I
gave him one more ounce, which covered sixteen days, and
again had him weighed, and found he weighed 170 pounds, a
gain of twenty pounds in sixteen days. He is now at work and
says the serum saved his life, and will not hear to anything
else. After I commenced the treatment I stopped all other
medication.
I have a case of laryngeal tuberculosis that has just finished
her second ounce, of thirty- two days' treatment, and she has
gained one pound ; has a better color and says she feels much
better ; and Dr. Lehardy, a throat specialist, who has been
examining her throat, says the ulcers on vocal cords are
improved.
I have one lady patient with acute tuberculosis of lungs that
has taken two ounces, thirty-two days' treatment ; was bene-
fited during the first two weeks, since which time she has lost,
and at present her condition is not any better than when she
commenced her treatment. However, she has a mixed infection.
I am also treating another lady that has pulmonary tubercu-
losis. She has taken 1% ounces, twenty -four days' treatment.
She is improving very rapidly, and I am satisfied that she will
recover. All my cases have been diagnosed by presence of
tubercular bacilli in the sputum, as well as by physical exam-
ination, except the one with tuberculosis of the liver. Diag-
nosis in that case was based on family history and physical
signs, together with the fact that he went from bad to worse
in spite of the best medical treatment.
Dr. J. A. Dunwoody, Cripple Creek, Colo., April 23,
1895, reports: I will begin first with my own case.
Case l.—J. A. D., male, white, age 30. On July 26, 1895,
upon physical examination, the upper two thirds of the left
lung was found to be infiltrated ; numerous moist rules could
be heard throughout this portion. Expectoration of a muco-
purulent character ; about two ounces during the twenty-four
hours. Weight 125 pounds. Microscopic examination showed
tubercle bacilli. Range of temperature was from 99 to 100
degrees in afternoon, which continued until August 2, when
I was attacked with acute pleurisy on the left side, which con-
fined me to bed ten days. The temperature ranging then from
100 to 102.5 degrees for a week, after which time it fell to 99 to
100 degrees; until September 18, when it became 98.5 degrees.
The injection of serum was begun July 26, 1895, with 10 m.
and rapidly increased to 45 m. ; then went back to 30 m. , which
was maintained continuously, notwithstanding the attack of
pleurisy, until Dec. 24, 1895, at which time there was a small
abscess produced, through want of proper care of the physi-
cian giving the injection. Weight at the time (December 24)
had increased to 143 pounds ; expectoration had ceased, not
being able to collect enough for microscopical examination.
Physical examination revealed the absence of all rales ; clear
vesicular respiration throughout the affected portion of the lung,
though somewhat weak in character. Right lung not affected
at all. March 24 was attacked with la grippe, during which
time weight was reduced to 134 pounds, and cough returned
for a short time, loss of appetite, etc. April 13, I resumed the
daily injection of 30 ms. of serum with an increase in weight of
two pounds, and cessation of cough. Have used no other
treatment at all, the ingestion of serum alone. This point in
my case proves conclusively the great mistake of stopping the
serum before the lung tissue has been restored to its full
strength and vitality.
Case 2. — H. H., white, female age 4. Weight 27 pounds.
Date of examination Jan. 3, 1896. Left lung almost completely
consolidated ; no vesicular respiration, bronchophony quite
distinct, cough quite distressing at times ; range of tempera-
ture 99 to 100 degrees in the afternoon. Began the use of serum
Jan. 3, 1896, with a dose of 4 ms. and rapidly increased to 12
ms. daily. Right lung no lesion. During the first six week ;
of serotherapy patient increased in weight four and one-half
pounds and has maintained this weight (31 }£ pounds) until the
present time. Upon physical examination, April 8, find that
there is some vesicular respiration throughout the affected lung ;
cough has almost entirely ceased. During the last three weeks
the injections have been somewhat irregular as the little patient
was in another city two miles distant from my office, having
had a mild attack of scarlet fever.
Case 3. — Mr. S., white, male, age 46; weight 135 pounds.
Date of examination March 16, 1896. Left lung almost com-
pletely consolidated ; no vesicular respiration ; quite dull and
flat upon percussion ; small tubercular ulcer upon the epiglottis
and vocal chord, affecting the voice. Expectoration about
four ounces daily. Patient states that he was first affected
with tuberculosis in October, 1894. Daily injections of 30 m.
were begun on date of examination. There was considerable
erythemia in this case which gradually disappeared, though
the serum was given daily. Examination, April 21, find that
there has been wonderful improvement in the condition of the
lungs. There is already some slight vesicular respiration
throughout the lung. Expectoration has diminished about one-
half. Has increased four pounds in weight. When this
patient commenced the daily injections of serum, he could only
walk a very short distance without extreme fatigue ; now he
can walk at least half a mile, without any discomfort at all.
Case 4. — J. B., male, white, age 21 years. Date of examina-
tion Feb. 15, 1896. Patient states that he has had tuberculosis
since the spring of 1893. His normal weight was formerly 143
pounds. Left lung at time of examination was in the same con-
dition as the preceeding case ; no vesicular respiration ; dull
and flat upon percussion. Present weight 115 pounds ; very
much emaciated. Patient difficult to control and comes at
irregular intervals for the injections. There is evidence that
this patient practices the disgusting habit of masturbation.
Upon examination April 21, can find little or no improvement
and there is little hope of his ever being relieved.
Dr. A. D Mclntyre, Union Grove, Wis., reports hav-
ing used the serum, with very flattering results, in a case
of ovarian tuberculosis, the history of which I failed
to receive in time to embody in this paper, but which
will be published.
Dr. William Miller, Boerne, Texas, reports a case
of pulmonary tuberculosis in the second stage abso-
lutely recovered. I had an opportunity to examine this
case about a month ago and there existed then no
physical signs of tuberculosis, nor in the expector-
ation by microscopic analysis. After several months
of treatment, on March 19, 1896, Dr Miller reports as
follows concerning this case: "Examination of Mr.
368
SERO-THERAPY IN TUBERCULOSIS.
[August 15,
Malloy, at Boerne, Texas, March 19, 1896: Pulse, 72,
full and strong; respiration 18; temperature 98V,
weight 152 pounds. This gentleman has gained 20
pounds since he came under treatment. Chest meas-
ure: expiration, 35|; inspiration, 37|. Respiratory
murmur clear and distinct over both lungs; no cough
or expectoration."
Dr. Miller claims " specific improvement in 40 per
cent, of the cases treated; 30 per cent, received some
benefit, and 20 per cent, did not improve." In his expla-
nation of the failures he says : "Nearly all the cases I
have treated were in the third stage, and 30 per cent,
of these at the end of their rope."
Dr. Hoell Tyler, Mentone, Cal., himself a tubercu-
lous patient, states that he took the serum for five
months through the kindness of Dr. C. C. Browning,
Highlands, Cal., and that he had on Jan. 2, 1896, no
symptoms of the disease in his lungs, and to-day he is
attending to his usual duties as a physician.
Dr. J. L.Wiggins, East St. Louis, 111., had the fol-
lowing case in June, 1895:
Miss V. Z., East St. Louis, 111.— Had been ill several months
and prostrated in bed with a complete history of acute, pul-
monary tuberculosis for some weeks. Temperature 103 to 104
degrees F. almost continually ; microscopical analysis demon-
strated the bacilli of tuberculosis. Three physicians consulted
and diagnosed acute tuberculous pneumonia. Every ordinary
method of treatment was pursued, and the fever remained at
104 P., even reached 105 F., with symptoms of delirium, etc.
The lungs were both largely involved, consolidation nearly com-
plete in one. Dispnea excessively pronounced, weakness
extreme; prognosis fatal. Everything having failed, the
serum which I produce was tried. The treatment began early
in June, 1895. Doses ranged between 20 and 40 ms. daily, and
were continued some six weeks more or less regularly. The
result was that the temperature decreased gradually and
steadily after the first seven days' treatment to normal tem-
perature, which was reached on the 22 of June, or thirteen
days after the first injection. Injections were continued until
the end of July. The patient gradually gained strength and
flesh and is again at work. She weighs 132 lbs ; was emaciated
to at least 80 lbs before treatment. The germs of tuberculosis
have disappeared entirely and all previous symptoms of lung
disease are absent. Case recovered. The diagnosis of this
case, which seemed clear to all the physicians, was questioned
by one man because recovery had occurred, and here is the
reply of Dr. Wiggins: "In answer to your query, 'Did you
consider the case of Miss V. Z. acute tuberculosis,' I will
answer unqualifiedly, yes. At the time of treatment with serum
I had no hopes that the case would recover, either with or
without serum. But as the temperature began to fall, diar-
rhea, which was before uncontrollable by medication, was con-
trolled without medication, and the cough and hemorrhage
became lessened and gradually disappeared. I concluded that
these marks of improvement were more than a mere coinci
dence. The diagnosis was clear, outside of microscopic analy
sis. This in the beginning was clouded. I would have filled
out a death certificate, had she died, as being the result of
tuberculosis."
Among my own cases I may report :
Mr. E. D., St. Louis, Mo., age 36 years; occupation, ship-
ping clerk. History of glandular tuberculosis, dating back
about eleven years. Had pneumonia four years previous to
examination in my office, May 16, 1895 ; had been declining six
months ; had night sweats and fever ; pain in left lung, back
and front. Pulse at 108 degrees at the time of examination ;
abnormal temperature ranged from 99 3-5 to 101 degrees;
cough chiefly in the morning ; expectorated a yellowish mat-
ter. Bacilli present. Slept fairly well on the right side but
could not sleep on the left ; was too weak to attend to his
duties properly. Dullness in the left lower lobe and crepitus
of the left apex over a lateral area of four inches, extending
about three inches downward; interrupted breathing both
sides. All these symptoms disappeared in four months of
treatment consisting of 15 to 30 ms. of serum a day. Several
examinations of sputum made since revealed no bacilli. Mr.
D. is at work from twelve to fifteen hours a day, Sundays
included, and feels strong and in good health. He did not
bear the injection of serum well, but he was persistent and
recovered.
Mrs. H. R., St. Louis, Mo., consulted me in February, 1895.
Had been ill for two years. Had had slight hemorrhages ; was
coughing very severely and expectorated a yellowish, muco-
purulent material, occasionally tinged with blood. The sputum
was full of bacilli of tuberculosis and largely loaded with dif-
ferent forms of pus germs. There was infiltration in the apex
of the right lung between the third and fifth rib, covering an
area of about four inches, laterally, and penetrating the lung
more or less. There were mucous rales about the middle of
this area, very pronounced, and interrupted breathing on both
sides. The circulation was exceedingly rapid and the fever
ranged from 99 to 101 degrees F. ; it rarely went above that.
Patient had lost much flesh, being reduced from 130 to 90
pounds. At the regular dose of 30 ms. three days for four
months and then irregular treatment three or four times a
week, and with a loss of three weeks at one time, the whole
treatment covering a period of six months, Mrs. R. increased
in weight to 132 pounds, and became strong accordingly;
developed a splendid appetite, and for the last three months
the sputum was exceedingly scarce and comes now only when
she is affected by cold. It exhibits no bacilli of tuberculosis.
She suffered a miscarriage and six weeks' illness recently, but
her lungs remained apparently sound. The consumption
symptoms which existed at the beginning have disappeared.
Mr. F. S., St. Louis, Mo., was examined in February, 1895.
He weighed about 145 pouuds at the time. He had had very
profuse hemorrhages at Hot Springs, and was sent home con-
sidered hopeless; had lost about fifty-five pounds from his
regular weight which was above the normal for his size;
coughed a great deal at night and day ; expectorated a thick,
yellowish matter loaded with the bacilli of tuberculosis and
other microbes and was gradually losing ground. He was
unable to perform his duties as a groceryman. Physical con-
dition evidenced tuberculous affection in both lungs, particu-
larly in the right, over the whole of which interrupted breath-
ing was very marked. The lower half of the lung exhibited
moist rales and softening. Symptoms after seven months of
more or less regular treatment, which consisted of 20 ms. daily
in the beginning, and was increased to 40, and once in a while
to 60 ms., almost entirely disappeared, with the exception of a
slight interrupted breathing. Flesh was regained to the amount
of 170 pounds, and now strength is as good as ever. Mr. S.
has been for four months without treatment, attending to his
usual duties, working hard every day. He expresses the opin-
ion that he is free from disease. The bacilli are now absent,
but there is still a slight catarrhal condition of the bronchi, with
micrococci. His condition of health is continually improving.
Active tuberculosis, at least, has been arrested by the serum.
Mr. G. N. F., St. Louis, Mo., was examined April 29, 1895.
Age, 45 years; occupation, bookbinder. Had had a dry,
hacking cough two years ; had had pneumonia at the age of
18, congestion of the lungs, so-called, two years previous to his
examination. February 7, 1895, he had severe hemorrhages,
and at the beginning of treatment he weighed 130 pounds.
Expectoration thick and yellowish. Bacilli of tuberculosis
numerous. Temperature increased at times : infiltration of
the left apex below the second rib, about three inches
downward and four inches across, evidenced both anteriorly
and posteriorly, dullness over same region; crepitus over
some of the area, and rslles and crackling on deep inspira-
tion extending below left breast, anteriorly. Mr. F. was
treated with tubercle antitoxin from the beginning of May
until October, almost every day, at the dose of 30 to 40 ms.
Since then several examinations have been made and no germs
of consumption are to be found. Physical symptoms have now
disappeared and the patient is at his work, feeling strong and
well and considers himself cured. He weighs 143 pounds,
which is more than his normal weight before his illness.
Mr. F. B. M., St. Louis, Mo., age 20: occupation, railroad
clerk working at night. He had bronchitis at the 'age of 14 ;
had suffered from night emissions of early puberty ; previous
health feeble ; cough slight ; pain in the lower lobe of the left
lung ; temperature 99 to 100 F. Physical examination evi
denced dullness of the lower left lobe, beginning at a line
drawn below the nipple and extending toward the base. Micro-
scopic examination revealed the bacilli of tuberculosis ; not in
large numbers. Mr. M. was treated from May 27, 1895, to the
middle of September, practically four months. All physical
symptoms and evidences of tuberculosis have disappeared. He
is now at work as before in good health. No bacilli have been
found in examinations made since September.
Miss Q. A., St. Louis, Mo., age 19 years: occupation, music
and vocal student; had influenza in Memphis six years before;
dry cough for a year ; weighed 123 pounds. Hemorrhages four
years previous toexamination Sept. 26, 1895, larynx infiltrated ;
temperature from 99.5 to 101 ; coughing much and expectora-
18%.]
SERO-THERAPY IN TUBERCULOSIS.
369
lion in the morning of a yellowish matter. Bacilli of tuber-
culosis quite numerous. Heart disease evidenced regurgitation.
Treatment began the last day of September, 1895; injected
very small doses on account of her heart condition, that is, 10
to •-'■"> ins. daily. At this time Miss A. weighs 130 pounds ; the
bacilli of tuberculosis arc now absent and for two months
there has been but one or two in the field of bi-monthly exam-
ination. Cough has almost entirely disappeared. Strength
has been regained and appetite is splendid, and the patient is
considered as having almost, if not quite, recovered, as there
. no longer the physical signs of infiltration nor any
of breaking down. There is still expectoration with
cocci.
Miss S.. Nashville, Tenn., began treatment in May, 1895,
ami remained under ite influence for some three months. She
eame with a written diagnosis of pulmonary tuberculosis
from her family physician, which was substantiated by micro-
scopic and physical examination. The bacilli of tuberculosis
were found in large numbers and the patient was rapidly losing
Round both in weight and strength; coughing considerably,
particularly at night; expectorated occasionally a yellow
greenish matter. Night sweats had existed and fever ranged
at times from W to 102 F. She was treated with serum at
doses ranging from 20 to 30 ms. daily. After three months she
gained ten pounds. She then removed to Las Vegas,
N. M~. where she resumed the treatment and her improve-
ment continued. She had first lost flesh, but again increased
in weight and every symptom seems to have disappeared, if I
mav judge from the reports sent me. Bacilli have not been
present for two months.
Mrs. A. C, age 26 years, married, has had three chddren
and two miscarriages, one recently. At the age of 14 she
received a blow in the chest, at which point pain appeared fre-
quently whenever the patient contracted cold. On examina-
tion infiltration was discovered, covering an area of about three
inches in diameter, on the right side below the breast; also a
dullness in the left lung between the second and third ribs,
extending about two inches downward and two inches later-
ally. She had had various symptoms of tuberculosis for some
Tears and dated the accidental incipiency of it fourteen years
previously when she had received the injury mentioned. She
ad several hemorrhages. The active development of the
disease dated three years before my examination, which
occurred June 7. 1895. " At that time she weighed 115 pounds.
To dav she weighs 135 pounds. She had dyspnea ; expector-
ated a" great deal ; coughed very much and had a poor appe-
tite. Now all these symptoms have disappeared and her
strength has increasd so that she is able to perform her duties ;
conies to my office daily and expresses herself as improving
continually. The physical signs above mentioned have disap-
peared almost completely. A few bacilli were found in the
last three months.
Mr. V. ^employed at our institution) a patient under the
charge of Dr. Hanau W. Loeb, had laryngeal and pulmonary
tuberculosis. His condition had been declared hopeless by a
number of specialists in St. Louis. He has been treated under
the special care of Dr. L. and myself, occasionally, for a period
of about ten months, having received from 30 to 120 ms. daily.
\t the beginning of his treatment there existed infiltrations of
the larynx and other lesions. He had lost his voice, weight
and strength. He was in a hospital, unable to perform any
work. He was, at the writing of this report, assisting in the
care of some twenty-two horses, working many hours every
day in water and dust. His appetite had improved and his
strength good. " He is susceptible to colds, but under the
treatment with serum he had gained a condition which permits
him to do all the menial labor that can be asked of any man.
Rarely have we found the bacilli in the scant expectoration of
the last four months. I report him because he was incident-
ally and indirectly under my supervision some months, and
the injections were done by my assistants or myself. The case
is surely under control at present. Some physicians pronounce
him practically cured.
John H. , aged 48. Pulmonary tuberculosis two years ; pros-
trated in bed at city hospital ; cavity, contracted lung, bacilli
numerous ; mother died of phthisis ; cough aggravating. Injec-
tions 30 ms. daily, begun Dec. 1. 1894 : continued for three
months regularly. Weight increased 6>3 pounds first two
months. Has since been under treatment irregularly. Has
been at work for over a year, grooming from twelve to twenty
horses, ploughing and farming generally part of the time.
Bacilli absent.
Miss Y., age 18 : pulmonary tuberculosis, first stage. .Lost
ten pounds; infiltration in and dullness over area of three
inches in diameter between second and sixth ribs, in right
lung ; cough persistent at night and expectoration profuse in
morning; bacilli present.
months almost daily, at a dose of 30 ms. hypodermically.
To-day she has more than gained her normal weight, is abso-
lutely free from cough, and the last symptom of pulmonary
tuberculosis has disappeared ; bacilli absent.
Miss Y. was treated over four
Dr. S. B. Hall, Rock Island. 111., reports as follows,
April 28, 1896:
Case i.— Age 27 ; has been coughingsince January, 1895 ; nor-
mal weight, 160 pounds. Weight at commencement of treat-
ment (Dec. 20, 1895) 132 pounds ; present weight 136 pounds.
Average dose 25 to 30 ms. Have had to suspend treatment
several times. Coughs and raises very little at present ; sleeps
well ; has a good appetite, has moist rales in upper lobe of left
lung. Right lung normal. Have suspended treatment for a
while. This was a charity case ; lived in a poor damp house
and had barely the necessaries of life. I think he has made a
wonderful improvement.
Case 2.— Male, age 40 ; sick one year, given up by several
doctors, is a carpenter by trade ; was confined to bed three
months prior to the beginning of treatment June 25, 1890 ; no
cavities, but the upper lobe of the left lung and the middle
lobe of the right lung were the most affected. Cough was
incessant — coughed two-thirds of the night. Maximum dose
45 m. average 30 m. Cough is markedly diminished and he
sleeps and eats fairly well. His greatest trouble now is a
soreness in the trachea and bronchial tubes. He says they
seem raw. Both of these patients refused any additional
treatment and they have both improved wonderfully.
Dr. C. E. Bauer, St. Louis, Mo., writes on April
28, 1896:
Case 7.— Age 40 years ; weight 140 pounds ; height 5 feet 10
inches. I was called the latter part of October, 1895, while he
had a hemorrhage. I was told that he had two hemorrhages
before this last one, about three or four months apart. He
coughed a great deal and expectorated a thick greenish sputum.
On percussion I found a dullness of the left side extending
from the supraclavicular space to three or four inches below
clavicle. On auscultation, I could hear nothing but a blowing
murmur ; after coughing, moist rfiles. Very profuse perspira-
tion at night. Temperature in the morning 99 ; in the evening
100 and 101. I commenced with injections of 10 ms. of serum
and gradually increased to 50 ms. daily. After injecting about
two months, I had to reduce the amount to 30 or 35 ms. on
account of sudden rise in temperature. I have used the serum
in this case from Nov. 2, 1895, until April 1. Since then I am
only making two injections a week. The patient has increased
in weight from 140 to 156 pounds. He coughs very little and
there is not any sputum at present. The sputum before treat-
ment showed a great number of tubercle bacilli and strepto-
cocci. Night sweats have ceased entirely. On auscultation, I
hear a blowing murmur, but no moist rales. He has returned
to his occupation as fruit peddler.
Case 2.— Miss L., age 22 years; height 5 feet, 4 inches;
weight 110 pounds before treatment. Had a cough for some
months and was losing flesh, expectorating a great deal ; res-
piration increased to about 35 ; temperature in the morning
99 ; in the evening 102 and sometimes 103 degrees ; perspires
considerably when sleeping; face becomes flushed toward
evening. Sputum was examined before treatment and showed
a great number of tubercle bacilli, also streptococci. On per-
cussion I found dullness on the right side from the clavicle
down about four inches, also over suprascapular space ; on aus-
culation, I could hear moist rales. I have been injecting
serum in this case since November 3, daily, up to two weeks
ago, and intend to continue. This case did not get along very
well but we have been rewarded at last. The temperature
does not go above 99 ; she coughs and expectorates very little.
I do not hear moist rales on ausculation. Her weight has
increased from 110 to 118 pounds; respiration is not so fre-
quent and she does not perspire at night. When she came to
me she could not speak above a whisper. I examined the lar-
ynx and found the vocal cords red. On the left cord was a
small ulcer ; since the treatment with serum her voice has been
entirely restored ; the ulcer cicatrized. I have treated this
case with Paquin's anti-tubercle serum, commencing with 10
and increasing to 50 ms., but had to reduce it to 25 ms., on
account of palpitation of the heart. I think it very advisable
to discontinue the injections for about two weeks in cases
where patients have been injected daily for three or four
months.
Dr. Elizabeth McLaughry, New Castle, Pa., in one
of her recent reports states:
Patient, a young woman, age 32, had been ill for two years,
370
UTERINE FIBRO-MYOMATA.
[August 15,
gradually growing weaker. When I first called, found her
prostrated with a temperature of 104, pulse 120. Cavity in
• left lung and dullness in apex of right, dyspnea, huskiness of
voice, night sweats, cough, which prevented her from sleeping ;
sputum, mucopurulent, often streaked with blood. No appe-
tite, throwing up what food she did take, and diarrhea.
Weight 84 pounds. Bacilli very abundant in sputum. Began
treatment by injecting five minims of serum — increasing to
thirty daily. She began to improve at once ; temperature
gradually went down to normal in less than two weeks, night
sweats ceased, coughed much less, slept soundly all night,
appetite became good and diarrhea ceased. Now after two
months treatment, she has grown quite strong ; gained four
pounds.
Dr. Richard Fricke, Fort Wayne, Ind., April 28,
1896:
Case 1. — Mr. S., a man 37 years of age, was taken sick Jan-
uary 4 with typhoid malaria. About the beginning of Feb-
ruary the fever had disappeared, and there were no symptoms,
except weakness. But after about one week's time a hacking
cough set in, with but little expectoration, and at the same
time, he began to get asthmatic, losing flesh and having night
sweats. I learned that several members of the family had
died of consumption. By examination, I find the apices dull
and contracted. The microscopic examination was negative.
March 4 I began to inject the Paul Paquin anti-tubercle
serum. After about one week's treatment he began to feel
better, his appetite improved, his night sweats grew less and
at the end of the second week he had gained four pounds. From
that time he improved rapidly in every respect and gained an
average or three pounds a week. He lost his night sweats,
his asthma, got strong and robust and is now at work again.
During the treatment he did not take any medicine except the
injections of serum.
Ed. W., St. Louis, Mo. Examined July 9, 1895, complained
of sore lungs, both sides for two years. Dullness in left apex ;
cough slight ; expectorated, thick yellow sputum, containing
bacilli of tuberculosis. Dyspeptic. Bowels irregular : had
lost seven pounds in preceding three months. Was treated
with an average dose of 30 ms. almost daily since examination,
and to day is absolutely free from tuberculous phenomena,
although he has a slight catarrhal discharge with micrococci.
He has regained lost strength and weight.
It is useless to say that the improvements in eases
in very advanced disorganization and prostration have
not been of long duration. Nothing will restitute a
lost tissue to its former condition, nor will anything
cure moribunds.
DISCUSSION.
Replying to the interrogatories by Dr. William Dougal, and
others, Dr. Paquin said the serum would not kill germs outside
the body as a chemic germicide ; that the horse from which it
was obtained was treated with tuberculin, or the toxins of the
germs of tuberculosis, in a manner similar to that followed in
producing diphtheria antitoxin. The horses were first kept
under observation three or four weeks, and if there were the least
indication of illness they were not used. The tuberculin injec-
tions in the animals were continued as long as they produced any
reaction. It was usually three months before reaction ceased.
The subsequent steps taken insured a very clear serum. The
living germs of tuberculosis were not injected into the horse.
Moreover, the horse Was naturally relatively immune to tuber-
culosis, for out of many attempts to infect the animal he had
succeeded only twice in producing even local tuberculosis, and
this failed to become generalized. The immunized horse serum
injected into tuberculous man did not kill the germs of tuber-
culosis, but, as with diphtheria antitoxin, simply stimulated
the forces within us to neutralize their products. In diphtheria
we found germs three or four weeks after the use of antitoxin.
It was not at all due to chemic action.
Dr. A. M. Hayden of Indiana — I have obtained the very best
results in eight cases out of ten. The question most impor-
tant to settle at the present time is, what cases will be bene-
fited, and under what circumstances, and how to distinguish
between cases which will be benefited and those which will
not, I have been unable at the commencement to decide. A
case in mind was that of a patient having an immense cavity
in the left lung. Apparently he got no benefit from the treat-
ment the first three weeks, but had the flushed face, disturb-
ance of circulation, and seemed to lose ground for a month.
But on examining the sputum we found the tubercle bacilli
were diminishing. After thirty days the tubercle bacilli were
very much diminished in the sputum, and he began to gain in
strength, appetite, flesh, etc. In three months the tubercle
bacilli had disappeared from the sputum, although they had
been very numerous on the microscopic slide at the first. He
had had hundreds of hemorrhages, and could not go out of the
house alone. The other lung has cleared up, the chest wall
has contracted over the cavity, he is at work and enjoying life.
In one or two other cases there was improvement the first two
or three weeks. Then it ceased and they lost ground. In 80 per
cent, of my cases the results obtained have been better than
those I have ever succeeded in getting from any other thera-
peutic agent. I discontinued all other treatment in these
cases in order to give the serum a fair trial. One man whose
condition was regarded as hopeless would take no other treat-
ment, and the result was so favorable that I abandoned all
other measures while using the serum. The man whose his-
tory was sent Dr. Paquin, and who had tuberculosis of the
glandular system, coughed, was emaciated, had swollen feet,
pulse 140, night sweats and insomnia. Everything else was
stopped and he was given the serum. At the end of sixteen
days he had improved sufficiently to get out of bed and had
gained a number of pounds. The treatment was discontinued
ten days or two weeks ; he began to feel badly again, and
another ounce of serum was sent for ; soon afterward his weight
increased to 170 pounds, and since then he has gained five
pounds more, being heavier than he had ever weighed before.
One of my patients who did not improve had mixed infection,
and I believe it will be found that such cases are less likely to
be benefited than those with purely tubercular infection. The
other case which apparently improved at first, but relapsed
afterward, was one of laryngeal tuberculosis. It is a peculiar
fact that most of the cases in which I got good results did not
seem to improve at first, whereas the two which at first showed
improvement of appetite and some gain in flesh, afterward
relapsed.
Dr. Richards and Dr. Webster of Illinois, inquired
wfiether the serum had been used in local tuberculoeis by
injection.
Dr. Paquin knew of only one case of lupus in which it was
used, the report coming from the State of Washington. The
physician stated that the disease had disappeared.
Dr. William Dougal of Illinois — It seems to me that by
this treatment we are stimulating the natural forces within us
to throw off and annihilate tuberculosis within the system.
THE SURGICAL TREATMENT OF. UTERINE
FIBRO-MYOMATA.
Read before the Minnesota State Medical Society, June 18, 1896.
BY E. C. DUDLEY, M.D.
PROFESSOR OF GYNECOLOGY, NORTHWESTERN UNIVERSITY
MEDICAL SCHOOL.
CHICAGO.
The object of this paper is not to enlarge upon a
great variety of procedures which have become or
seem destined to become obsolete, but rather to pre-
sent briefly the more useful operations for the treat-
ment of fibro-myomata of the uterus. The subject
will be divided as follows: 1, palliative operations.
2, radical vaginal operations. 3, radical abdominal
operations.
I. PALLIATIVE OPERATIONS.
The palliative operations are, a, curettage, b, elec-
trolysis, c, ligature of the uterine arteries and broad
ligaments, d, removal of the uterine appendages.
18%.]
UTERINE FIBRO-MYOMATA.
371
a. Curettage. — The irritating presence of the
tumor often gives rise to hemorrhagic endometritis
Curettage is therefore indicated precisely as it would
be in hemorrhagic endometritis from any other cause.
The operation is generally followed by a degree of
relief from the monorrhagia, is seldom permanent in
its results and must usually therefore be repeated
again and again. It is especially useful in connection
with intrauterine gauze tamponade to control hem-
orrhage until an exhausted patient can gain blood
and strength for a more radical operation, or in cases
of small tumors until the menopause has passed.
Curettage of the myomatous uterus gives increased
danger of sepsis, hence the necessity for great anti-
septic and aseptic care.
h. Electrolysis, especially electro-puncture, must
lx> taken as a surgical procedure ; even the simple
intrauterine electrode is powerfully caustic and
therefore Burgical. Undoubtedly this agent may in a
limited number of selected cases be capable of pro-
ducing a more or less permanent symptomatic cure,
and may occasionally result in the disappearance or
reduction of the tumor. The earlier promise of its
enthusiastic supporters however has not been fulfilled.
Its immediate dangers also are considerable. The sur-
vival of this method depends chiefly upon the patient's
ignorance of its inadequacy and dangers, upon her
worship of the mysterious, upon an unreasoning dread
of operative measures and upon a desire to grasp any
other promising means of relief.
c. Ligature of the Uterine Arteries and Broad
Ligaments. — The purpose of these measures is to shut
off the blood supply to the uterus and by this means
to induce atrophy of the growth. Gottschalk of
Berlin reports cases of multiple myoma in which he
he ligatured the uterine arteries with good results.
Martin ligatures the whole base of the broad ligament
so as to include not only the uterine artery but its
branches and certain uterine nerves. He even goes so
far in desperate cases as to ligature also the ovarian
artery on one side. Robinson reports successful
oases in which he has ligatured the Fallopian tubes
and broad ligaments, including the ovarian and
uterine arteries on both sides. The method has hitherto
failed to elicit much discussion. Even its authors
of late preserve on this subject an ominous silence.
d. Removal of the Uterine Appendages. — This
procedure, which suggests the names of Battey, Hegar
and Tait, when properly carried out — i. e., when the
ligatures are placed close to the uterus so as to include
a large part of the broad ligament — usually stops the
hemorrhage and reduces the tumor, sometimes even
causes it to disappear. Its dangers however, are
nearly if not quite as great as those of the more radi-
cal operations. This is especially true since the
technique of the latter has been perfected. Removal
of the uterine appendages for fibro-myomata is be-
coming an obsolete operation. At least it will be
done only in rare cases of small tumors in which for
some special reason the hysterectomy and myomec-
tomy are unadvisable.
II. RADICAL VAGINAL OPERATIONS.
The vaginal operation is preferable when the tumor
can be readily reached by that route. All cervical
fibroids, all intrauterine pedunculated fibroids and
some of the more accessible submucous fibroids have
usually been removed by the vagina. In their removal
the ecraseur and galvano-cautery so often used for
hemostasis are unnecessary, because hemorrhage is
either not feared or can be readily controlled by the
uterine gauze tampon. This route has usually been
reserved for the smaller tumors of a size not larger than
the capacity of the small pelvis. Latterly however the
vaginal method has been often and successfully used
by certain French surgeons for the removal of much
larger tumors. Their removal is accomplished by
repeatedly seizing the presenting part of the tumor
with vulcellum forceps and cutting away as large a
piece as possible with the scissors, one piece after
another, until the whole tumor has been removed. I
refer to the operation by traction and morcellement.
This method, although generally supposed to be of
more recent origin, was really described by Dr. T. A.
Emmet more than thirty years ago and has been con-
stantly advocated and practiced by him ever since.
It is applicable to those cases in which the tumor is
accessible through the vagina but too large to be
enucleated and delivered entire.
The operation of traction and morcellation when
its technique is more generally understood and its
advantages more appreciated will undoubtedly become
more and more a procedure of election in place of
hysterectomy. Many large submucous or mural tumors
for which the abdomen is now opened and the uterus
sacrificed may be rapidly, safely and effectually man-
aged by this method. One strong contraindication
to the vaginal route for large tumors must always be,
however, the constant possibility of pus tubes or
ovarian abcesses, so often unrecognized or unrecog-
nizable when they occur in connection with large
irregular fibro-myomata. Many a fatal result has
followed the rupture of an unsuspected small pus
tube caused by most careful enucleation or morcel-
lation through the vagina. The vaginal route then
should be avoided if there be any reason to suspect
purulent disease of the uterine appendages. The
tumor is usually made more accessible and its enuclea-
tion or morcellation is facilitated either by dilatation
or more frequently by deep lateral incisions of the cer-
vix even to the internal os. These incisions having
been made, the anterior and posterior lips of the cer-
vix are drawn well down to the vulva and held widely
apart by means of strong double-tooth forceps in the
hands of an assistant. The operator then seizes the
presenting part of the tumor with strong tooth
forceps and removes it, either by enucleation or by
morcellation. If the tumor be of mural origin it may
be necessary to divide the mucous membrane and
submucous muscular tissue before commencing the
enucleation. This incision should be parallel to the
uterine canal.
I now propose a possible improvement upon the
two lateral incisions. It is a simple median incision
through the anterior wall of the uterus, as follows:
1. Make a circular incision in front of the uterus
which shall separate the vaginal wall from the cervix
at the utero-vaginal attachment in the line CD,
Figure 1.
2. Incise the anterior vaginal wall from the point
at the middle of the first incision for a distance of
one-half to three-fourths of an inch, line AB, Figure
1, taking care not to invade the bladder and to avoid
the ureters on either side.
3. Separate the bladder from the uterus by means
of the finger or some other blunt instrument, keeping
close to the uterus until the peritoneum is reached
but not divided. Then expose with retractors the
anterior wall of the uterus. (Figure 2.)
372
UTERINE FIBRO-MYOMATA.
[August 15,
4. Divide the anterior wall of the uterus longitud-
inally in the median line by means of scissors to
whatever extent may be necessary to render the tumor
accessible. (Figure 2.) If necessary, the peritoneum
may be opened and the incision carried high up into
the corpus uteri.
This simple anterior incision would permit wide
separation of the lateral fragments of the anterior
uterine wall and thereby expose the endometrium and
in selected cases would render accessible a myoma in
any part of the uterine wall. It would probably have
the following advantages over the lateral incisions:
1. Less traumatisms, one incision instead of two.
2. The parametria are not opened and exposed to
possible sepsis.
Figure l.
3. The tumor would be more accessible because the
anterior uterine wall would be out of the way instead
of being between the operator and his field of
operation.
4. A much longer incision may be made if neces-
sary, because the broad ligaments are not involved.
5. Less hemorrhage.
6. The pelvic cavity may be easily reached for any
accessory operation on the uterine appendages or
peritoneum. Even a small pedunculated or subperi-
toneal tumor could be removed.
III. — RADICAL ABDOMINAL OPERATIONS.
The radical abdominal operation includes the fol-
lowing subjects:
1. The extraperitoneal versus the intraperitoneal
treatment of the stump, i. e., the clamp versus the
ligature.
2. The removal of the tumor together with the
whole or a part of the uterus and its appendages.
3. The removal of the tumor, leaving the uterus
and its appendages intact, so as to preserve their
reproductive functions.
The question of intraperitoneal versus extraperi-
toneal hemostasis recalls the old contest between the
clamp and the intraperitoneal ligature in the treat-
ment of the pedicle in ovariotomy, a contest which
resulted in a complete victory for the ligature and
necessarily established the general principle that the
extraperitoneal method is relatively dangerous and
consequently, whenever perfect hemostasis by the
intraperitoneal method is practicable, should be
avoided. Undoubtedly this general principle should
apply with some force to the removal of other abdom-
FlGURE 2.
inal tumors. Nevertheless the earlier statistics in
myomectomy and hysterectomy show that the dan-
gers which necessarily belonged to the clamp were
more than balanced by the insufficiency of any means
then known of intraperitoneal hemostasis. The
advocates of the clamp based their objections to the
ligature upon the supposition that the moist soft
uterine stump when ligatured and returned to the
abdomen would at once become a source of danger
from hemorrhage and decomposition, with consequent
peritonitis and sepsis. However tightly the ligature
was drawn around the uterine stump, however care-
fully the flaps of the stump were stitched together,
however perfect the hemostasis may have appeared
upon the completion of the operation, the fact
1896.]
UTERINE PIBRO-MYOMATA.
373
remained that shrinkage of the stump within a few
hours with consequent loosening of the ligatures
almost invariably occurred from the escape of scrum,
and fatal hemorrhage or sepsis often followed. The
extraperitoneal treatment therefore became for a time
almost universal, and with improved technique gave
promise of becoming the established method. In the
hands of Keith and a few other extraordinary sur-
geons it gave a singular freedom from mortality; but
in the hands of the average operator the mortality was
unfortunately too great. This was so because of the
extreme difficulty in keeping the 'stump aseptic. It
would suppurate in many cases and become the
medium of deep peritoneal infection.
In myomectomy the history of ovariotomy has
repeated itself — first, the intraperitoneal treatment of
the stamp; second, the extraperitoneal treatment, ren-
dered necessary on account of the difficulty of intra-
peritoneal hemostasis. Now, finally, the intraperi-
toneal treatment has become the established method
in myomectomy.
The great condition hitherto wanting is now sup-
plied by ligaturing the uterine and ovarian vessels,
thereby shutting off the blood supply from the field
of operation. This not only renders the operation
bloodless, but prevents secondary hemorrhage. It
now seems extraordinary that the very first men who
ever attempted myomectomy did not realize the sur-
gical necessity of first shutting off the blood current
by ligaturing these vessels. Instead of using this
simple, direct, natural procedure, we have been for a
quarter of a century, groping about in the dark,
searching in out of the way places for a method by
which we could secure intraperitoneal hemostasis.
Just as soon as Baer and others began to ligature
these vessels the whole procedure became simple. It
is the old story of Columbus and the egg over again.
It would be unprofitable here to continue the dis-
cussion of the clamp against the ligature in the sur-
gical treatment of uterine fibroids. The subject is
rapidly passing out of the field of discussion and
becoming a matter of history. There is, however, a
limited class of cases in which the very much con-
stricted stump may readily be brought into the abdom-
inal wound, and fixed there by means of the clamp,
in a much shorter time than would be required to
secure hemostasis by ligature of the uterine and ova-
rian vessels, and to complete the operation by the
intraperitoneal method. In such a case, if the condi-
tion of the patient is precarious, the clamp will always
be useful, because it will enable the surgeon to com-
plete the removal of the tumor with the minimum of
operating. It will then fulfill a most important indi-
cation— the saving of time.
Nearly eight years ago I reported to the Chicago
Gynecological Society a case' operated upon in St.
Luke"s Hospital, in which the abdomen was opened,
the tumor enucleated, and the cavity from which the
tumor had been taken stitched into the abdominal
wound by means of catgut sutures. By this means
the uterine wound made by enucleating the tumor
was rendered extraperitoneal. The tumor cavity was
then tightly packed with a continuous strip of gauze
to control hemmorrhage and to drain through the
abdominal wound.
This operation differs from the so-called " perito-
neal cuff operation " recently introduced by Dr. Senn
I Reported before the Chicago Gynecological Society. May, 1889, and
published in the Am. Jour, of Obstetrics, September, 1889.
somewhat in detail, but not at all in principle. I have
recently, however, learned that Dr. Polk, of New York,
described substantially the same operation before the
New York Obstetrical Society in January, 1888, thus
anticipating me by a few months, but he soon aban-
doned it for hysterectomy. When I first described
this operation I regarded it, for selected cases, as a
great advance in the surgical treatment of uterine
myomata, because it saved the reproductive organs.
In about fifty cases it gave me a mortality of only 2
or 3 per cent. Now, however, I would usually prefer
one of the modern intraperitoneal operations soon to
be outlined.
The grounds upon which the extraperitoneal
method, whether by clamp, elastic ligature or suture,
should for the most part be discarded, may be given
as follows:
1. No greater safety in the extraperitoneal method.
2. Fixation of the whole or a part of the uterus to
the anterior abdominal wall is objectionable from an
anatomic standpoint, and often gives the patient great
inconvenience from traction and from other mechan-
ical causes.
3. Extraperitoneal hemostasis in any form is apt to
cause unnecessary adhesions. It usually makes a
longer and more tedious convalescence.
4. Greater danger from ventral hernia.
OPERATIONS WITH INTRAPERITONEAL HEMOSTASIS.
To illustrate the various operations which may be
performed with intraperitoneal hemostasis, I will
briefly present from my note books the histories of
three operations performed at St. Luke's Hospital on
three consecutive days, Nov. 4, 5 and 6, 1895.
Case 1 was of many years' standing. Electrolysis— electro-
puncture — had been repeatedly used. This treatment had
been followed by extensive, almost fatal pelvic peritonitis,
There had been so much inflammation of the tumor itself that
it could not be easily shelled out of its capsule. On account
of extensive adhesions to the abdominal viscera, the inacces-
sibility of the field of operation and the bad condition of the
patient, the operation presented unusual difficulties. After
figating the uterine and ovarian vessels, the tumor, weighing
about ten pounds, and the entire uterus with its diseased
appendages, was removed. The operation necessitated great
traumatism in the pelvis, and large surfaces were left uncov-
ered by peritoneum. The pelvic cavity was therefore packed
with gauze. This gauze was continued into the vagina and
left as a capillary drain. The abdominal wound was closed
without abdominal drainage.
Case 2. — The next case was very much like the preceding
one, but the tumor was somewhat smaller and there were no
adhesions. Both tubes were distended with fluid. Each
ovary was as large as the double fist. The tumor, the entire
uterus and its appendages were removed, as in Case 1. The
broad ligament stumps were drawn down into the vagina and
held there by sutures. The vaginal and abdominal wounds
were both completely closed, the latter with catgut sutures.
No drainage.
Case 3. — On the following day the third case presented itself,
with a perfectly round, globular tumor as large as the double
fist springing from the anterior wall of the uterus. This tumipr
was removed by an incision through the corpus uteri, precisely
such as would be made in a Caesarean section. Temporary
hemostasis was secured by a rubber ligature. This was
removed before closing the abdominal wound. The tumor
having been enucleated, the cervix dilated and the granula-
tions curetted out of the endometrium, the cavity of the
uterus, which communicated with the uterine wound, and the
vagina were packed with a gauze drain. The uterine wound
from which the tumor had been enucleated was then closed.
As in CtEsarean section, the entire uterus was dropped back
into the pelvic cavity and the abdominal wound closed without
drainage. The Fallopian tubes and ovaries were preserved
intact.
The method adopted in this last case is undoubt-
edly applicable to the treatment of a much larger
374
NOTES ON TAKA-DIASTASE.
[August 15,
number of tumors than is generally supposed. I desire
to emphasize the statement that any surgeon who is
constantly alert to enucleate the tumor and preserve
the reproductive organs will be surprised at the num-
ber of cases in which this is entirely feasible. The
mutilating operation of hysterectomy for fibro-myoma
is often necessary, but not so often as the statistics of
the present time would indicate. In the vast majority
of cases the uterine appendages will be found normal,
and in a large proportion of this majority the tumor
may be enucleated from the uterus and the wound
successfully closed precisely as would be required for
the removal of such a tumor in any other part of the
body. Cases of very large tumors and cases in which
many small tumors are scattered through the uterine
wall may require hysterectomy. The conservative
operation of simple enucleation will apply in many
cases when the tumor is even larger than the fetal
head, and in cases of multiple myomata when there
are not too many tumors.
If the tumor is subperitoneal, and especially if
pedunculated, the uterine traumatism is superficial
and easily treated with catgut sutures. In mural
tumors large numbers of buried catgut sutures may
be used in bringing the surfaces of the uterine wound
together, and then some modification of the Lembert
suture may be used in closing the peritoneal margins.
If the tumor is submucous and the uterine cavity is
invaded in its removal, the same method of buried
suture applies. In these cases it is well to tampon
the uterine canal and vagina for drainge with a con-
tinuous strip of sterilized gauze. The question has
been raised whether the wound made by enucleation
of a mural tumor without entering the endometrium
should be simply closed with buried catgut sutures
and left without drainage into the uterine canal, or
whether an opening should be made into the endome-
trium for that purpose. I have operated several times
in both ways, and always with success. I recall one
case, however, of large tumor, the enucleation of which
made a very large wound in the uterine wall. This
was closed with buried catgut sutures without estab-
lishing any drainage into the uterine cavity. The
patient recovered, but only after a period of high
temperature and rapid pulse which lasted for about
two weeks. During this time the uterus was enor-
mously swollen and I feared suppuration in the ute-
rine wound. Nothing, however, was done in the way
of a secondary operation for drainage. The experi-
ence of this case indicates that drainage into the
uterine cavity is desirable for large uterine wounds.
In the introduction of the gauze tampon I always
dilate the uterine canal from the abdominal side, the
temporary elastic ligature being in place around the
cervix, and then force a continuous strip of gauze
three or four inches wide down into the vagina, pack-
ing the vagina first and then the uterine cavity. All
of the gauze may be removed in forty-eight hours by
traction from the vagina. If not removed within two
or three days it is apt to produce high temperature
and rapid pulse, which usually subside promptly upon
its removal.
I have presented these three cases, all of which
recovered, to illustrate the fact that there can be no
stereotyped operation for uterine myoma. Each case
must furnish its own indications for the particular
operation which applies to it. Sometimes the entire
uterus and its appendages must be sacrificed; often
they may all be preserved and their functions restored ; I
sometimes the cervix uteri alone may be left, after the
method of Baer. Often, as in Case 1, the injury to
the pelvic peritoneum is so great that gauze packing
is necessary for drainage and hemostasis. In other
cases the injury is so slight that when the ligated
stumps are drawn down into the vagina and the vagi-
nal and abdominal wounds are closed there is no peri-
toneal traumatism save the united wounds, and there-
fore no need for gauze packing. The modern tendency
is properly on the side of the vaginal drain as against
drainage through the abdominal wound. When no
opening has been made into the vagina in the course
of the operation proper, and drainage is necessary, I
would favor as a general proposition that such an
opening be made there, posterior to the cervix, for the
purpose of drainage. The advantages of this are, 1,
better drainage ; 2, complete closure of the abdominal
wound; 3, consequent rapid convalescence; 4, mini-
mum risk of ventral hernia.
In myomectomy the uterus should, if possible, be
saved when the tubes and ovaries are healthy. When
the appendages have to be removed, the uterus may
as well go with them, especially if its removal facili-
tates drainage or in any way renders the operation
more simple. I do not, however, share a certain
modern prejudice against the uterus, which would
prompt one to remove it simply for the purpose of
getting it out of the way.
1617 Indiana Avenue.
NOTES ON TAKA-DIASTASE.
BY T. H. ALLEN, M.D.
NEW YORK.
I have been using taka-diastase recently in a large
number of cases, my attention having been called to
it some time since by a physician whom I met in
consultation.
It has been efficacious in such cases of amylaceous
indigestion as are so frequently met with in gyneco-
logic practice, and which seem dependent on irritation
of the sympathetic governing digestion. The follow-
ing case best illustrates its effect:
Mrs. H., aged 38, had chronic ovaritis with intense
pain in left inguinal region, flatulency, headache,
colic occasionally. The ovaritis had been treated in
the usual way, but the intestinal pains depending
upon the flatulency and headache, resisted all reme-
dies until I administered the taka-diastase in three
grain doses after each meal. The result was remark-
able in its promptness; at the end of three days the
tympanites and pain had completely disappeared. I
continued to use the remedy during two weeks, after
which time there was no return of the symptoms.
The ovaritis is yet being treated.
Instead of giving in detail a report of the cases in
which I have seen so much benefit derived from the
use of taka-diastase, I will only mention one other
case. Mrs. X., aged 26; fibroid of the uterus. Owing
to the continued loss of blood she was very anemic
and very much run down generally. She suffered
from flatulence and digested starchy foods poorly.
The relief of her intestinal symptoms and increase in
weight was marked soon after she began to take the
remedy.
In treating cases of this kind, where there is an
abnormal degree of acidity in the stomach, I have in
some cases given a dose of bi-carbonate of soda or
lithia immediately before eating, thinking that by
1896. 1
SOCIETY PROCEEDINGS.
375
lessening the degree of acidity the digestive proper-
ties of the diastase were less apt to be interfered
with.
I consider taka-diastase a valuable addition to our
newer remedies and do not hesitate to recommend it
most cordially for the various forms of amylaceous
imligest ion. I might add that a very large proportion
perhaps more than half, of the cases of indigestion
we meet with are of the amylaceous variety, and the
ii why we are so often disappointed in the use of
pepsin is that we give it in cases needing a ferment
to aid in the digestion of starches and not proteids.
52 West Forty-fifth Street.
SOCIETY PROCEEDINGS.
British Medical Association.
Si.rty-fourth Annual Meeting held at Carlisle, Eng., July
:, 1896, under the Presidency of William Barnes,
M.D., F.R.C.S., J.P., of Carlisle.
[Reported for the Journal of the American Medical Association.]
The proceedings began with a meeting of the Council, and
was followed by a general meeting in the new Public Hall.
Subsequently a special service was held in the Cathedral, it
being attended by a considerable number of medical men and
their friends. The Bishop's sermon was appropriate to the
occasion.
At the second general session the report of the Council was
presented and adopted. It showed the Association to be in a
satisfactory condition, both as to its finances and membership.
Last year the number of members on the books was 15,669.
During the past year 1,240 had been elected, 145 had died and
ii. had resigned, leaving on the books 16,332.
Reports of various committees were also presented and
adopted.
Dr. Charles Parsons of Dover was elected Treasurer of
the Association.
A resolution was introduced and adopted, requesting the
Ethical Committee to draw up a Code of Professional Ethics to
be submitted to the Association for discussion and ratification.
President Barnes then delivered his address, an abstract
of which we give herewith :
THE PRESIDENT'S ADDRESS.
He selected for his subject "The Medical History of Car-
lisle." At the outset he stated that it was assuredly a dis-
tinction of no common kind to be elected President of the Brit-
ish Medical Association, the largest and most powerful
medical association which the world has ever known. Having
its origin in a small provincial city sixty-four years ago, it had
grown and prospered, and now numbered among its members
all that was most distinguished and eminent in the profession.
When he looked back to the long list of distinguished men
who had preceded him in this position, his mind was filled
with misgivings, for the list included names of men distin-
guished alike for their high literary and professional attain-
ments. The only claim which he could advance was that he
had worked for the Association for nearly thirty years.
After a brief sketch of the general history of Carlisle, the
speaker passed on to matters of medical interest and impor-
tance. He spoke of those eminent Cumbrians who had con-
tributed to the advance of medical science, and of the condi-
tions of life which existed at various periods. The question
as to whether the Roman armies were provided with medical
officers was one which had not received much attention from
archeologists. In many of the works on Roman antiquities
there was no allusion whatever to it. The practice of medicine
was not much encouraged in the early days of Roman power,
and its professors were not held in high esteem. The surgical
treatment of disabled Greek warriors was minutely described
in many parts of the Iliad, and in Xenophon and other Greek
writers reference was made to the services rendered by surgeons
in times of warfare. But neither in the Roman classics nor
among the writings of the Greek physicians who practiced in
Rome are there any direct notices relating to the medical and
surgical care of the numerous and scattered armies employed
by Rome in different parts of the world. Celsus, it is true,
lays down very distinct and practical precepts for the extrac-
tion of war weapons from the bodies of the wounded ; but
neither he nor PaulusiEgineta makeany allusion to the appoint-
ment of physicians and surgeons as a part of the regular army.
Bitter military experience, however, proved in ancient times, as
it has often done in modern times, the necessity of having an
efficient medical staff in connection with the armies in the field,
and in no part of the world was this more clearly shown than in
this part of Britain. Some modern discoveries in this part of
Great Britain and elsewhere have demonstrated that in the
time of the Empire, at all events, the armies of Rome were
provided with a medical staff. Among the many monumental
tablets which have been discovered along the course of the
great Roman wall there is surely none more interesting than
one which was discovered a few years ago at Houseteads.
The inscription shows that it was erected by the first cohort of
the Tungrians to the memory of their " medicus ordinarius."
This cohort distinguished itself under Agricola at the battte
of Mons Grampius, and was afterward engaged in the erection
of a portion of the more northern Roman wall of Antoninus.
Another point in connection with the early history of Carlisle
is deserving of notice. One of the earliest institutions estab-
lished for the reception of cases of leprosy in this country was
placed just outside the city walls. It is not quite certain at
what period leprosy was first introduced into England, but it
must have been fairly common before the date of the Norman
conquest, as he finds it the subject of legislation in the codes
of a Welsh king, Hoela Dha, or Hoel the good, who died about
the year 950. In the laws relating to married women, it is
enacted that a wife may leave her husband without losing her
dower if the husband become a leper. It is reported that
Lanfranc, Bishop of Canterbury, who died in 1080, founded
two hospitals at Canterbury, one for general diseases and one
for leprosy. Some years ago the speaker investigated the
records of the leper hospitals connected with the counties of
Cumberland and Westmoreland. These were three in number,
but the Hospital of St. Nicholas at Carlisle was the wealthiest
and most important. The earliest records of which he could find
any notice date back to the year 1180. There is a general concur-
rence of opinion that it had a royal foundation, and some his-
torians believe that it was founded by William Rufus. If this
be so, it was one of the earliest institutions of the kind in this
country. Leprosy seems to have been a fairly common disease
in this part of England, there being several hospitals for lepers
in the adjoining counties of Cumberland, Westmoreland and
Northumberland, three of which provided accommodation for
ninety-one lepers.
At the close of the thirteenth and in the early part of the
fourteenth centuries the city of Carlisle was the scene of many
events in the history of England. Here within our walls three
parliaments were summoned by Edward I, the father of parlia-
ments. Here, in this remote corner of the English kingdom,
probably for the first time in the world's history, the question
of river pollution was brought under the consideration of a
parliament. The Earl of Lincoln came to the Carlisle Parlia-
ment to seek redress for the restriction of the channel of the
river Thames and its general condition, being so restricted by
filth and refuse. The Earl prayed that "the Mayor, Sherifs
and discreet Aldermen of London may inspect the river Thames,
and restore it to its former condition." The matter having
been considerered, orders were given by Parliament that imped-
iments to the course of the river caused by filth and the refuse
of barnyards be removed. This early recognition of the evils
of river pollution by a parliament met to consider the general
business of the country is a striking testimony to the value
attached to sanitary legislation by our ancestors, and the prompt
action which was taken contrasts strongly with the tardy legis-
lation of modern times.
During the dark period of the Middle Ages there is little
medical progress to record in connection with the history of
the district. In common with other parts of the country medi-
cine was here under a cloud, and we find abundant evidence of
the faith in charms, witchcraft and the miraculous gift of heal-
ing supposed to be the special attribute of the reigning mon-
arch. Several persons suffering from the king's evil were cer-
tified by the clergy and church wardens, or by the local justices,
and sent to obtain the royal touch in order that they might
obtain that restoration to health which the physicians of the
day were powerless to give. Much of. the ordinary medical
practice was in the hands bf irregular practitioners, and appar-
ently a good deal of domestic doctoring was done by the heads
of families. A few extracts from the account books of Sir
Daniel Fleming of Rydal, shows the value which attached to
376
SOCIETY PROCEEDINGS.
[August 15,
the services of regular and irregular practitioners. Under date
of Aug. 10, 1658, there is an entry, " Given unto George Brown
of Troutbeck, a bonesetter, when Will was hurt, 00 02 06.
August 11. Given unto William Story of Seadgewicke, neare
Sighser, bonesetter, for lookeing at Will's thigh, 00 07 06.
August 12. Given unto John Rawling, a bonesetter for Will,
00 010." The services of these three irregular practitioners
do not seem to have been of much avail, for the account book
shows that a certain Dr. Dykes obtained " for comeiug and
laying plasters unto Will, 00 10 0 ;" and at a later date, "for
his plaisters and paines contributed towards the cure of Will,
the sum of 05 00 00." The same account books also show the
value of the services of a midwife Under date July 30, 1659,
there is this entry : "Given unto Daniel Harrison's wife for
being my wife's midwife, 00 05 00."
In the eventful history of Carlisle the visitations of the
plague have at times caused serious calamities ; occasionally
the disease has swept away such multitudes that the living
were scarcely sufficient to bury the dead. One of the most
notable epidemics was the great plague of 1598, which is alleged
to have caused a mortality of 2,260 at Penrith, 2,500 at Kendal,
2,200 at Richmond and 1,196 at Carlisle. These figures, which
are taken from an inscription on a stone in the chancel of Pen-
rith Church, have given rise to considerable controversy. The
Carlisle parish registers do not go so far back, and the Penrith
registers only record the deaths of 583 persons from plague at
this period. It is therefore now believed that the numbers
refer to the mortality in the rural deaneries bearing the above-
mentioned names. Another great plague occurred in many
parts of the country in 1623, and a third occurred in 1646. Of the
former we find evidence in many local parish registers, but of
the latter we have few particulars. The historic MSS. of the
mayor and corporation of Carlisle, under date 1649, contain
the following reference : "It is ordered that John Diffecke,
bellman, shall have forthwith paid to him . . . the sume of
forty shillings in consideration of his labour and paines during
the time the heavy judgement of Plague continued in this place
in the year 1646." The circumstances of the town about this
period were such as to make an outbreak of the plague exceed-
ingly probable. The citizens had suffered much from wars for
a series of years. In July, 1644, it was seized by Royalists,
and was besieged by Lesley in October, the siege lasting many
months. It had a garrison of about 700. About the end of
February all the corn was seized to be served out on short
allowance. On June 5 " hempseed, dogs and rats were eaten."
All Cumberland was in such a state of destitution that Parlia-
ment ordered a collection for its relief; numbers of the poor
are said to have died in the highways, and 30,000 families were
in want of bread.
In the evolution of its sanitary administration, progress has
been somewhat slow in Carlisle. During the Middle Ages, the
government of the town was first vested in the free merchants'
guild, which in later times became the town council. The
Governor or Dormont Book, which bears the date of 1651, con-
tains a code of by-laws for the government of the city, and
among them are manv useful sanitary edicts. It is ordained
that, "If any person or persons hereafter caste any manner of
corruption as deyd dogs, catts, nolt homes, or any other thinge
corrupte in any of the common wells of the city, or do place
any midden or dunghill towards any of the said wells or within
twelve feet thereof, he is to be fined for every offence 6s. 8d. to
be levied of his goods, or else to be extremely punished by the
Mayr as of the pillorie or otherwise." Swine are not allowed
on the common streets ; for the first offence the penalty is 6d.,
for the second 12d., and for the third the swine are to be for-
feit to the "Mayr and balif." Penalties are also ordained
against inhabitants who fail to keep the forefront clean to the
middle of the pavement, and middens and dunghills are to be
cleared away within eight days.
The Chamberlain's accounts of the city contain several items
of expenditure for cleaning the town dykes, removing dead
animals, etc., and during times of pestilence special precau-
tions were taken to prevent the introduction of the disease.
The following is the heading of one of the accounts: "Dis-
bursements in attending the gaittes in the time of the seakness
being at Newcastle beginning the iii of August, 1603."
In 1874, however, voluntary agencies were superseded and a
regular sanitary administration established. A medical officer
of health was appointed, who has since published annual
reports of the health of the city. From these reports it is pos-
sible to judge of the results to some extent of sanitary admin-
istration by comparing them with previous periods. The ear-
liest data upon which any reliance can be placed are the bills
of mortality drawn up by Dr. Heysham. In the eight years
between 1779 and 1787 there were 1,615 deaths, being at the
rate of 24.9 per 1,000. In 1788 to 1795 the rate rose to 26 per
1,000, while from 1796 to 1800 it was only 23.3. In the ten
years from 1800 to 1810 with the average population at 12,660,
the death rate was again 23.3 per 1,000. It was upon these
tables that the Carlisle tables of mortality were founded, which
afterward became so much used by life insurance offices. The
complete tables of the first period are the only ones to which
he had access. The most fatal disease in the list is smallpox,
which caused 238 deaths. Consumption was the cause of 214
deaths, 204 deaths were due to the weakness of infancy, and
226 are set down to the decay of old age. There were 193
deaths due to what we should now classify as zymotic diseases.
Between 1842 and 1848, with an average population of 24,000,
the death rate varied from 24.25 to 43.92 per 1,000. Since the
publication of the reports of the medical officer of health there
has been a steady fall in the death rate. In 1874 it was 32.6 ;
in 1875 it was 29.2 ; and in 1889 it had fallen to 18.1. In 1874
the zymotic rate was 11.3 ; last year it was only 0.8.
Dr. Barnes closes by saying that the question of the improve-
ment, training and restriction of midwives was one to which
much attention had been devoted, and it was one which called
for a speedy settlement on a satisfactory basis as much in the
interest of the public as of the medical profession.
The present unsatisfactory state of the law relating to Cer-
tificates of death and Coroner's Inquests had often been under
consideration and steps must soon be taken for its amendment.
The compulsory registration of stillbirths was another mat-
ter of urgent necessity. These were all matters in which the
public was as much, or even more concerned, than the profes-
sion. Free discussion in meetings like the present would lead
to more definite views of public and professional requirements,
and he concluded with the hope that the deliberations at this
meeting would help to further a settlement of some of these
questions.
Sir Dyce Duckworth, M.D., LL.D., F^R.C.P., delivered
THE ADDRESS IN MEDICINE.
He selected for his subject "The Importance of Prognosis of
Disease." The first part of the address was largely historic.
In recent times the literature relating to prognostics had been
far to seek, and the speaker knew of no work purely relating to
the subject which had been published in this century. He
dwelt at length upon acute specific diseases, after which he
discussed chronic infectious diseases.
The prognostics respecting syphilis relate largely to individ-
ual peculiarities, habits and environment, to the adequacy of
treatment, and the degree and virulence of primary impregna-
tion. It is certain that the greater number of persons so
infected ultimately recover satisfactorily if they have been
properly treated from the outset. It is equally certain that
the character of the primary lesion does not enable us to prog-
nosticate the ultimate evolution of the malady.
Pyemia and septicemia. — If organisms be present in the
blood of the patient, and capable of cultivation from it, the
prognosis, according to Kanthack, is bad.
Prognosis in relation to tuberculosis is a large question.
The factors on which determination has to be made vary greatly
with the individual and his environment. Without doubt the
prognosis of all disorders of a tuberculous nature admits of a
more hopeful view than formerly.
Cancer of the stomach commonly proves fatal within a year
from the time a certain diagnosis is made. Those cases last
longest and have less suffering in which neither orifice is
involved.
In cirrhosis of the liver, if signs of toxemia set in, life will
not be prolonged many days. Tapping of ascitic fluid may
aggravate the nervous symptoms of such toxemia. If a free
collateral circulation is gradually established between the
portal and systemic veins, life may be prolonged for some
years. A recurrence of either copious hematemesis or melena
is generally fatal.
Cancer of the liver is usually fatal within twelve or fifteen
months, but rapidly growing tumors sometimes in a few weeks.
Cancerous growths of the peritoneum commonly kill within a
year.
Gallstones. — The prognosis of cases in which gallstones are
believed or proved to exist in the gall bladder is always uncer-
tain. Many may be present for years and give rise to no or few
symptoms ; or a few may be present and cause serious attacks
of biliary colic. Continued irritation from them may induce
cancer of the gall duct, the gall bladder and the liver. Obstruc-
tion of the small intestine, commonly the ileum, is sometimes
a grave complication due to plugging by a biliary calculus. A
calculus may be removed from the bowel and the gall bladder
emptied of calculi with complete relief of all untoward symp-
toms. Although unaware of any treatment by diet or by drugs
which can cause removal of calculi already formed, their
L896.]
SOCIETY PROCEEDINGS.
377
further formation can certainly be prevented by appropriate
medical procedures.
Typhlitis. Many cases recover under judicious medical
treatment. Perityphlitic abscess, if opened carefully about
the ninth or tenth day, and the peritoneal cavity escape con-
tamination with its contents, may generally heal favorably.
Earlier surgical interference is very apt to lead to a fatal issue
bj toxic peritonitis. A gangrenous state of the vermiform
appendix, if diagnosticated, demands an early operation.
In diseases of the heart the outlook is generally better than
it was half a century ago. Pericarditis of rheumatic nature
is nry rarely fatal per se. In Hright's disease pericarditis is
OOtnmonly fatal, and septic pericarditis is uniformly so. With
the practice of aseptic surgery purulent pericarditis is no
necessarily fatal. Tuberculous pericarditis may be
•ather protracted, lint is beyond recovery. Pneumo pericar-
dium is commonly fatal within two days. Rupture of the
heart is generally promptly fatal, whether from injury or as a
result of muscular degeneration. Tachycardia demands a very
cautious prognosis. The outlook in Grave's disease is uncer-
tain. Due case in three may recover. In the viable class of
congenital malformed heart life is rarely prolonged over
puberty. A better prognosis for longevity attaches to lesions
of the aortic orifice, which are however rarely encountered.
Life may he prolonged to the third decade in these cases.
Ulcerative endocarditis is almost always fatal.
Aortic aneurysm. Xo certain prognostics can be laid down
in cases of this disease. Sacculated aneurysms of the ascend-
irt of the thoracic arch, pressing forward, are commonly
very chronic and cause least interference with vital structures,
but they may vary in the direction they take. In aneurysm of
the abdominal aorta the prognosis is always grave.
A reus senilis is perhaps more generally recognized as a diag-
nostic than as a prognostic sign of a degenerated vascular
system.
Diseases of the blood and ductless glands. — Simple anemia
in young women is apt to recur, but most cases will recover if
vigorously treated at intervals for three years. Pernicious
anemia admits now of less grave prognosis than formerly owing
It) treatment with arsenic and marrow. Examination of the
blood may help us in prognosis. Kanthack considers a steady
diminution of leucocytes a bad sign and no less grave is an
increase of the nucleated red corpuscles with a progressive
diminution of hemoglobin. Leukemia generally proves fatal
within two or three years. The pure lymphatic form is the
gravest Hemorrhagic tendency is of evil augury. In Hodg-
kin's disease recovery is rare, most patients die within two
years. A fatal result is usual in Addison's disease within two
or three years, but life may be prolonged for six or eight years.
Diseases of the kidneys. — Anuria of the obstructive variety,
unless relieved by surgical measures, generally proves fatal
within two weeks. The prognosis in respect of albuminuria is
only to be framed by full consideration of all the features of
each case. Chyluria of the non-parasitic variety may last for
many years without disturbance of health. Chronic nephritis,
tubal, interstitial or tubulo-interstitial often runs a protracted
course. Prognosis can be framed only by a consideration of
all the personal and diathetic factors in each case.
Diseases of the nervous system. — Taking the whole group of
conditions due to neuritis, we may affirm that our prognosis is
guided by consideration of the etiology and personal factors in
each case. Early recognition of the nature of the disorder and
of the peccant matter which has induced it is no less important
than early treatment. The cases often last for years, but
the results are quite remarkable if treatment be persisted in.
The prognosis in Meniere's disease is always uncertain.
Recovery may occur, but deafness is the most frequent result.
The symptoms may persist through life. In torticollis com-
plete recovery is rare. In essential paralysis of children the
outlook is certainly less grave than formerly if assiduous elec-
tric treatment be long carried out from the outset. In loco-
motor ataxia no absolute cure is to be expected. Cases setting
in violently are often devoid of the characteristic later symp-
toms, and an arrest of the disease may ensue. This is espe-
cially noted after the occurrence of early optic atrophy. In
aphasia the prognosis is only hopeful in the young, who may
be educated again in the right cerebral hemisphere.
Cerebral apoplexy. — Prognosis in this condition chiefly
relates to the particular locality involved and the size of the
blood clot. Pontine hemorrhage is uniformly fatal, generally
within a few hours, and so is that into the ventricles. The
gravest indications are deepening coma, rising temperature
two days after the hemorrhage and Cheyne-Stokes respiration.
Chorea. — Cases of this disease admit of a generally favora-
ble prognosis at any age below puberty. At that period, and
after, the outlook is much more grave. Chorea insaniens is
a very dangerous form. The average duration of the disease is
ten weeks and three days.
Epilepsy. — The truth of Hippocrates' aphorism respecting
this malady is still attested: "Epilepsy supervening before
puberty may undergo a change, those cases arising after the
age of 25 for the most part terminate in death."
Roderick Maclaren, M.D., of Carlisle, delivered
THE ADDRESS IN SURGERY.
His subject was "Preventive Surgery." He claimed that it
was a product of modern times, the outcome of recent advances
in the knowledge of the intimate causes of disease, of the intro-
duction of anesthetics, and of perfected methods of wound
treatment.
The conditions which render preventive operations justifiable
were next considered at some length. Passing on to anesthetics,
the speaker said that surgeons no longer inflicted pain during
any operation. This had been a solved question for fifty years ;
and in this, the jubilee year of anesthesia, he thought it not
inappropriate to call attention to a development of surgery
which hangs entirely on its use. There are still, however,
longings after the perfect anesthetic, which should be as port-
able, manageable and pleasant to take as chloroform ; as capa-
ble of long use as either chloroform or ether, and yet as safe
and free from after-effects as nitrous oxid.
For miminizing after- pain, much rests with the individual sur-
geon. If he avoids by direction of incisions all unnecessary inj ury
tonerves, if he manipulates as gently as possible, if he leaves his
wound free from tension either by tight sutures or contained
blood-clot, secures the most restful position, and ensures for his
wounds a normal healing, he may do extensive operations with
exceedingly little after-pain.
A large amount of preventive operative surgery has a casual
connection with the throat and nasopharynx— diseased condi-
tions, to which are given different names, branch in various
directions from this locality as a common center. They are
conditioned by the various tissues and localities they subse-
quently affect, by their rate of spread and by their surround-
ings, and they give rise to appearances entirely different and
which often seem to be separate diseases till we go back to
their essential nature and cause. Under ordinary circum-
stances the inspired air entering the body is free from organ-
isms by the time it reaches the back of the nose. But when
highly charged with impurities this is altered, and as the air
there turns at angle and meets with a moist surface organisms
and their spores are deposited. There are crypts, gland open-
ings, and channels in which they find a home ; if their nature
be infective only a delicate and easily injured epithelium sep-
arates them from lymphatics and veins, ready to carry them to
new fields. Even if this region remains their home they may
cause tissue growth in the form of enlarged tonsils and
adenoids.
The inflammatory swelling set up by organisms may hinder
the exit of natural secretions from cavities, as, for instance,
from the Eustachian tubes, giving rise to their distension with
fluid and admirably fitting them to promote the further growth
of microorganisms. These start a chain of changes which has
often grave consequences. With the preventive surgery of this
region there is no small risk of overlooking the original cause.
Hypertrophied tonsils, adenoid growths, suppurating ears and
glands are all so obvious that further investigation is apt to
stop, leaving out of consideration the behind cause, though it
should be removed as well as the visible lesions attended to.
Enlarged tonsils and adenoid growths produce some slight
local discomfort, but the chief evil they do is in checking
growth and nutrition. Children who are affected with them
are generally small for their age, anemic, and ill-developed ;
their chests contracted and drawn in along the line of the rib
cartilages. It is often striking to see the growth and develop-
ment which follow the removal of large tonsils and the scrap-
ing away of adenoids. The guillotine operation for tonsils is
wanting in precision, and very given to miss the lower portion
of the tonsil, which may be much hypertrophied just out of
sight. It fails moreover in those cases in which the enlarged
tonsil is contained and hidden between the pillars of the fauces.
The imperfect results which it so often gives have brought the
operation into a certain degree of undeserved discredit from
the frequency with which the portion left increases again. It
is much more satisfactory to give the patient a deep anesthetic
and deliberately cut out— or, still better, with a blunt director
teaze out— the whole structure, doing an operation of pre-
cision.
Adenoid growths in the nasopharynx produce similar
remote effects to those of enlarged tonsils ; their nature is pre-
sumably the same, and most commonly they exist together.
So, generally speaking, the removal of tonsils is not a com-
378
SELECTIONS.
[August 15,
plete operation without a scraping away of all growths. Few
operations give so good results with so little trouble. In the
throat is the common starting point of another set of condi-
tions in which preventive surgery has given assured and bril-
liant results. From diseased and swollen mucous membrane,
from secretions bottled up and cultivating organisms powerful
for evil, a train of sequences is set up which may ultimately re-
sult in brain abscess or purulent meningitis. The middle ear
may be converted by the blocking of the Eustachian tube
into a full cavity with complicated recesses and chambers.
These become the dwelling of many organisms, which set up
suppuration and destruction of tissue, the ear drum gives way
and opens a new channel of contamination, or it may be that
an independent opening to the surface is formed behind the
ear, and pus escapes there. Every case of suppurating ear
should not be made the subject of operation, for many are
amenable to treatment and are permanently cured. With
many, however, treatment fails, and everybody who has a
chronic suppurating ear goes about in deadly peril. It should
be a rule to operate on every discharging ear which does not
get right by treatment. The mastoid cavities should be laid open
and converted into hollow cones ; all diseased bone should be
removed, all unwholesome structures scraped away and every-
thing made suitable for speedy healing, not for the sake of the
ear as an organ, not even for the sole purpose of removing the
local trouble, but for the avoidance of the grave secondary
risks which are always present.
He believed the view generally held by surgeons was that
so long as hernia could be steadily kept up by a truss, which
does not much incommode nor prevent the patient following
his occupation, there was no necessity for operative interfer-
ence. But if trusses fail for any reason to keep up the gut,
if the truss is painful to bear and excites repeated inflamma-
tions of the sac, or if the patient's occupation requires excep-
tional activity, the time has come to operate. Perfect results
can be got from almost all the present so-called operations.
Whatever secures good closure of the rings effects a cure. The
peritoneum is of hardly any value in aiding the integrity of the
abdominal wall. If left in the ring it is undoubtedly a source
of weakness by keeping open a channel and preventing a union
of the stronger structures, but in itself it is a mere slack dis-
tensile membrane with little resistant capacity. It is on the
union of the aponeurotic and tendinous structures, and oblique
that we rely for real strength, and the more thoroughly we
get these together, and the more they form a uniform sheet
the less likely is the rupture to recur.
Among the miseries which may make long life a burden to
its possessor there are none greater than those resulting from
an enlarged prostate. It is much better to advise early opera-
tion than to wait for a desperate state of matters. We have a
certain latitude of choice in operations. Supra-pubic cys-
totomy may be combined with perineal removal of portions of
the prostate, or with perineal drainage, and finally we have
castration.
Suprapubic cystotomy with removal of enlarged prostate,
whether central or lateral, and the establishment of a clean
low-level canal into the urethra, is at present the operation to
be first considered, though every surgeon should be prepared
to deviate from it should local circumstances show that this
would be of advantage. The resulting mortality is small, per-
haps not more than 1 in 10, and it must be kept in mind that
the condition itself is a very fatal one. The mechanic result is
that in at least 40 per cent, the bladder recovers its function,
and in the remainder suprapubic drainage establishes a state
of greatly increased comfort. Within the last three years a
new operation has been introduced for enlarged prostate.
Relying on the observed fact that atrophy of the organ follows
removal of the testes, surgeons have performed castration.
The operation is too new and the cases too few to allow of any
decided opinion of its merits ; the results, however, have been
sufficiently good to justify its further employment. Cases in
which the urine was offensive and loaded with mucus and
requiring removal at frequent intervals are reported as, after
operation, passing a healthy urine spontaneously, and as having
no detectable enlargement of the prostate. In other cases,
though complete cure has not followed, a large improvement
has. From one or other method we have the possibility of pre-
venting one of the most prominent terrors of old age.
Twenty or thirty years ago a physician or surgeon attending
a patient with an acute condition of distended tympanitic and
painful abdomen, a quick and small pulse, and drawn-up legs
thought that he had fulfilled the whole duty of man when he
had diagnosed peritonitis and excluded perforation of the
stomach and obstruction. Who is content with such a diag-
nosis now? It has gradually become apparent to our minds
that peritonitis has almost always its cause in some other lesion
and that our investigation is not complete till we have localized
that cause. We know also that the origin is very often indeed
situated in the appendix vermiformis, that this tube is Bubject
to several morbid states ; it may be strictured, and the part
distant from the bowel may distend with septic contents ; it
may ulcerate through ; it may be the seat of tuberculous dis-
ease ; foreign bodies may lie in it or concretions form ; the
whole thing may go gangrenous. As consequences of these we
may have at one end of the scale a mere local disturbance passing
away after a few days' discomfort or at the other a general
rapid peritonitis followed by death. Between these extremes
we find many degrees of severity of attack. Thus if a slow
perforation occurs we have an abscess in the peritoneum, but
shut off from the general cavity by adhesions. We probably
hardly yet know the whole pathology of the appendix, but we
know enough to form a good clinical idea in most cases of the
essential state of matters.
A general peritonitis following perforation or a local abscess
round the appendix demands immediate surgical interference ;
the stage is past when prevention can come in. The class of
cases which falls within the domain of preventive surgery is
that in which the appendix has not perforated, but in which it
is subject to repeated attacks of distension, in which it inflames
from retained concretions ; indeed, when from any cause it is
the subject of one or more inflammatory attacks of a severity
short of immediate danger to life. Three views of surgical
duty prevail. Some surgeons hold that the appendix should
never be removed ; that the probability of a putrid infection
of the peritoneum during the necessary manipulations makes
it an operation of unjustifiable risk, and that the prospect of
natural cure is a more hopeful outlook. He believes this view
is held by an ever-narrowing circle.
Another opinion strongly held both here and in America by
men whose surgical work entitles their views to the highest
possible respect, is that every appendix which has given rise
to morbid symptoms should be cut down on and removed when
in a quiescent state. The third view is that only after a
repeated appendicitis and the failure of careful dieting does
there exist the necessity for a preventive operation. The fol-
lowing arguments are adduced in favor of this view : The
great majority of attacks are not repeated, after one all clears
up, and no further disturbance occurs. Most instances of per-
foration are first attacks ; an evidence that one seizure does
not increase the probability of perforation in the case of recur-
rence and, lastly, that a milk and farinaceous diet and mild
aperients are often successful in preventing return.
Another disease holds out the prospect of a wide field for
tne extension of the preventive principle, namely, carcinoma.
There is much to learn about its nature. In the absence of
knowledge we may use our reasoning faculties and make some
effort to infer the unknown from the known. In cancer of the
lip and in Paget' s nipple are two instances in which the life-
history is well made out.
Let us investigate the small and early changes. If we can
find out the antecedent or even the first symptoms of carci-
noma, we may then know how to prevent it. The recent devel-
opments of surgery in cancer have been in the direction of
extensive operations and wide-reaching removal of tissue —
wider than we dreamed of some years ago, for we are now
aware that the visible disease is but a fraction of the total, and
if we have far-spreading disease we must have sweeping
removal. He thinks and hopes that there is in the future a
preventive surgery founded on fuller knowledge, which will
anticipate these great operations by small ones or, it may be,
by such preventive measures as will do for cancer what we are
steadily doing for so many other diseases — compress it within
narrowing limits.
(To be continued.)
SELECTIONS.
Chloroform and Ether In Parturition. — Bukoemsky, of St. Peters-
burg, in Monatschrift fur Geburtshillfe und Gynekologie,
March, has given comparative research to the use of ether and
chloroform in normal labor. He remarks that while many
observers have studied the action of chloroform, but com-
paratively little has been done for ether. Bukoemsky carried
out a series of experiments to determine whether ether or
chloroform render labor painless and why they do so ; what
effect they have upon the contractile power of the uterus, upon
the strength and frequency of the pains and the interval
between them, upon the dilation of the os, and the abdominal
1896.]
SELECTIONS.
379
pressure. He looked also for the irritative symptoms due to
ether and chloroform, examining their action upon the kid-
neys, respiratory function, pulse, temperature and general
condition. In the puerperal period he examined the loss of
Mood, the involution of the uterus, the lochia and the secre-
tion of milk, and finally noted the effects on the child and the
frequency and degree of icterus neonatorum. The following
conclusions are drawn : 1. Ether undoubtedly diminishes the
painfulness of uterine contractions in all cases and generally
makes painless the actual birth of the child. Its anesthetic
effect is most marked during the expulsion period, if the
patient has been already partially under its influence. It does
not prolong labor, but on the contrary seems to shorten it about
one hour in primipane. It increases the force of the uterine
contractions as shown by the toko-dynamometer. It does not
lessen the length of the pains, but shorten the intervals
between. " In respect of the secretion of milk, its effects were
not unfavorable ; in some cases the quantity seemed to be
increased. Even in larger doses ether had no unfavorable
effect on the fetus, which was in no case dull or narcotized
when born. Icterus was less common and severe and the loss
of weight was less during the first week. The best time for
the administration of ether seemed to be when the os was
dilated to the width of three finger-breadths ; it seemed to
have no effect upon the early dilation of the os. 2. Chloroform
in small doses do not diminish the contractile power of the
uterus. In the majority of cases examined the pains were
shortened eight seconds, but in a few they were lengthened
eight seconds. The intervals between the pains were gener-
ally lengthened 13 to 49 seconds. Although chloroform gen-
erally protects labor somewhat, it seems to have no ill effecton
the mother when given in small doses. It is pleasanter than
ether, but in a few cases slight irritative symptoms were
noticed at the commencement of chloroform narcosis. It had
no unfavorable effect upon the puerperal period, and in no case
did hemorrhage occur when it was used in small doses. The
children seemed unaffected by it, and a mild icterus occurred
in about half the cases. The best time for administration is
the same as for ether. In comparing the action of ether and
chloroform it seems that ether is generally preferable, because
it has less toxic effect upon the organism and does not pro-
duce such ill effects as chloroform if it has to be given in a
relatively large quantity or for a length of time. Moreover, it
shortens labor and has a more favorable effect upon the puer-
peral period and upon the fetus. As most of these patients
were delivered at night, and a common coal-oil lamp was used
in the room, there need be no fear of ether taking fire or
exploding if ordinary precautions are used. From these obser-
vations it seems clear that either anesthetic may be used in
ordinary cases of labor, if given carefully and in small doses,
without injuring mother or child and without causing hemor-
rhage during the puerperal period. It is equally certain that
chloroform may predispose to hemorrhage and injure both
mother and child if given in too large doses or for too long a
time. Chloroform should be selected when complete relaxation
of the soft parts is required or when there is much spasm to
overcome. Ether is preferable when deep anesthesia has to be
maintained for sometime, or when there is severe cardiac
trouble, or when some operation has to be done after the con-
clusion of labor, such as the repair of perineal laceration or
the removal of an adherent placenta. When chloroform has
been given for some length of time during labor, the child is
apt to be lethargic when born and does not begin to cry without
considerable stimulation."
The Strychnia Cure of Alcoholism and Opium Habit. — A certain
proportion of the submerged 4,000 who pass yearly through the
alcohol wards of Bellevue Hospital distinctly and seriously
wish to have a treatment given them which will take away
their tendency to periodical sprees. Consequently the use of
strychnia and the solanaceae, with certain adjuvant tonics and
moral influences, is employed in these cases. The technique
of the treatment as arranged by myself has been carried out
most skillfully and improved in its details by my house physi-
cian in charge of the alcohol cells, Dr. J. D. Brown. I am
greatly indebted to him for the intelligence and faithfulness
shown in his work among this class. The drugs selected for
use in this "cure" are those which the experience of ten
years in the care of these cases has shown me to be most use-
ful. The suggestive and moral influences thrown about the
"cure" are borrowed, I freely admit, from the Keeley and
other alcohol cures of the country. Selected patients, after
having passed through an attack of acute alcoholism, and
are convalescent, are allowed to remain two days and take
the "cure." The wards of the hospital are not large enough
to permit of a longer stay. Only persons who have reason-
able intelligence and who show. real evidence of sincerity are
chosen. The following solutions are used :
I. B . Strychnia nitrat gr. 1-15.
Atropise sulph gr. 1-300.
Aquae distilled m. x.
Misce. Sig. Inject ti.d., first day injection.
II. R . Strychnia nitrat gr. 1-20.
Atropiae sulph gr. 1-200.
Aquaa gx.
Misce. Sig. Inject t.i.d., second day injection.
III. R . Tinct. cinchon. comp . . . . m. xv.
" capsici m. ^ to m i.
" solan, carolineus. . . m. ii.
Vini ferri amari ad 3i.
Misce. Sig. Mistur. stomachic, 3i t.i.d. Shake.
III. Order : ^ to 1 glass of milk (hot or peptonized),
alternating with hot beef tea or broth, every
two hours.
IV. First and second nights, if needed.
R. Potas. bromid gr. xxxii.
Chloral hydrat gr.xvi.
Tinct. valerian gi.
Aquae ad giv.
Misce. Sig. 3' dose, repeated once, if needed.
Shake. Mistur. sedativ.
The patients are given the injections I. and II. and "stom-
achic," III., three times a day, with abundant nourishment,
washing out the stomach if necessary, to help any catarrhal
disturbance. The patient, during the treatment, is made to
understand distinctly that he is taking a "cure" with all that
that implies, but no mystery is made of its character or of the
means used. After the second day he is perforce discharged.
In most cases his craving is gone, but this generally occurs
after a debauch. In fact, the natural history of many cases
of periodic alcoholism is that craving ceases after the spree
for from one to nine months. On being discharged, the patient
is given :
IV. R. Tinct. columbo gi.
" capsici m. xv.
" nucis vomic gi to giss.
Apomorphinae gr. \i,
Tinct. cinchon. co ad giv.
Misce. Sig. 5* ti.d. in water after meals.
The patient is told to take this and report weekly. After a
month he reports monthly, and is kept supplied with the bottle,
which he is told to take the minute any craving develops, and
report at once. By the application of this method to alco-
holics, we are able to send out many patients with hope in the
future, confidence in themselves, and a staff upon which to
lean in this weakness. The same treatment, when applied to
patients with the morphin habit, has to be given much longer,
and sometimes must be modified by adding bromids or gradu-
ally reducing the morphin. Dr. Brown was able in one case
to stop imediately the use of morphin taken to the extent of
30 grains a day. The patient did not suffer in the least. —
Charles L. Dana, M.D., in Post-Oraduate, July, 1896.
380
PRACTICAL NOTES.
[August 15,
Operative Treatment of Entropion and Trichiasis. — The lid is split
in the ordinary manner along the whole border of the eyelid,
or only a short distance if the incurving of the lashes is but
partial. The incision is placed well behind the roots of the
cilia and is carried up into the substance of the lid a distance
of from 4 to 6 mm. A second incision is then made through
the skin on the outer surface of the lid, at a distance of from
2 to 4 mm. from the point of emergence of the lashes. This
incision is continued parallel with the edge of the lid so far as
the in-curving extends and carried down to meet the other, so
that the edge of the lid from which the lashes are growing is
then completely detached, except at its ends. But the incision
is not taken horizontally backward ; it is carried upward and
backward, so that it joins the other at an acute angle. We
have, then, the portion of lid containing the lashes attached
only at its ends, but with its upper margin wedge-shaped. The
next step consists in the rotation of this piece so that the edge
from which the lashes spring is applied to the upper lip of the
skin incision, the lower lip being pushed backward into the
wound. This rotation can easily be effected by sutures passed
from the lower margin of the detached portion to the upper
margin of the skin incision. The sutures are tied and the
operation is complete.— James W. Barrelt, M.D., F.R.C.S., in
Ophthalmic Review, May.
Injections of Gray Oil in the Treatment of Syphilis.- Dr. James
Galloway writes in the Practitioner that a much greater
measure of success has followed the renewed trial of this treat-
ment since an improved technique has been adopted. The
preparations made use of are the gray oil and a suspension of
calomel, as before ; but it has been found advantageous to use
vaselin oil in the manufacture of the fluids, in preference to
other vehicles. (The gray oil formula? are mercury, 3 ; lano-
lin, 3; olive oil, 4; or, mercury 39; mercurial ointment, 2;
vaselin oil, 59. Martindale and Westcott.) But preferably
Milliet and Thibierge's formula (Vide Annal. de Derm, et de
Syphil., 1894, p. 943, which is itself a modification of that
employed by Professor Neisser). Three and a half drops of
the gray oil and 1 gram of the calomel oil, containing 0.05
gram of the pure salt, are the doses now used instead of the
much larger doses formerly employed. The injections are
given weekly over periods of six or eight weeks, or at longer
intervals as circumstances direct, and between each course of
treatment is a period of repose, according to the rules formu-
lated by Professor Fournier. The fluid is injected deeply into
the muscles of the buttock, taking care to avoid the vessels
and nerves of this region, and, in order to secure that the
injection shall be placed at a sufficient depth, the syringe is
armed with a needle of from 5 to 6 centimeters in length.
Great care must also be taken to prevent any of the fluid from
coming in contact with the skin or subcutaneous tissue of the
part. A rigid antisepsis of the fluid, of the apparatus and of
the skin is essential. With these precautions, the painful
swellings, the abscesses, the severe mercurialism, which for-
merly gave the treatment "a black eye" are evaded. The
advantages claimed for the method are : 1, the certainty and
convenience of the treatment, so that, as a rule, the patient's
occupation is in no way interfered with. The patient comes
once a week for his injection, nothing interferes with his dose,
and then he goes about his daily occupation, whether of pleas-
ure or of business. 2. The secrecy which is characteristic of
the treatment is much appreciated by patients, and can not be
obtained so completely by any other means. 3. Its non-inter-
ference with the digestive apparatus and the liver— an impor-
tant consideration when one recollects the evidence showing
that structural alterations are produced not infrequently in
the mucous membranes of the stomach and intestine, and in
the liver by courses of mercury administered by the mouth.
4. The inability of certain patients to take mercury, owing to
the immediate irritation .caused in the alimentary tract. 5.
Its powerful effect and rapid action when compared with the
other methods of administration — a fact of the utmost moment
when syphilitic lesions of vital organs have to be treated.
The efficacy of the method has never been in doubt, and now
many cases are on record of inveterate syphilis treated and
completely cured by these injections, after having resisted all
other forms of treatment. We will quote one only, given by
M. Thibierge, which has the additional authority of Professor
Fournier himself. The patient was a cachectic and chronic
syphilitic of eighteen years' standing, and suffered from severe
headache associated with the formation of exostoses from the
cranial bones. Very little result had been obtained by Four-
nier with the ordinary methods of treatment, and the patient
was sent to Aix-la-Chapelle, where he was subjected to courses
of inunction, which had given much pain and inconvenience,
but did no good. He then had the good fortune, as Fournier
puts it, to consult Thibierge, and was treated by injections of
the gray oil ; he rapidly lost the headache, and at the same
time the exostoses diminished in size, while his health rapidly
improved.
As to the relative merits of the gray oil and calomel, it
appears that the effect produced by the calomel is more rapid
and powerful, while the gray oil acts somewhat more slowly,
but causes little or none of the characteristic pain ; so that, as
Thibierge remarks, in the case of calomel we have a remedy
producing its effect cito, while the gray oil has the advantage
of acting tuto et jucunde. The only inconvenience is the pain
which seems to be so often the result of the injection. At the
actual time of the injection nothing is complained of, but
on the third or fourth day a certain amount of pain resembling
that caused by a bruise is felt at the spot where the operation
has been performed ; it reaches its maximum on the fifth or
sixth, and subsides by the eighth day. In the majority of
cases the pain is not severe, in many it is altogether absent,
but in a small proportion it is so acute as to render the method
intolerable. Even in the last group of cases the pain does not
always occur, and thus it is suggested that the very severe
pain is an accidental circumstance, and may in the future be
eliminated.
PRACTICAL NOTES.
Cause and Treatment of a Volvulus. — Prioleau states that a fre-
quent cause of volvulus is defecation deferred when the desire
is imperious, on account of the conflict between the peristaltic
and antiperistaltic movements. Mucous enteritis and sigmoid-
itis may also produce the same result. The most important
diagnostic indications are the absence or tardy appearance of
vomiting and a sharp localized pain accompanied by local
meteorism. Treatment recommended : Forced injections of
3, 4, or 5 liters, administered with an Esmarch douche, and
glycerined water at 100 per cent. ; supplemented by puncture
of the distended intestine and abdominal massage. — Bulletin
M6d., April 26.
Efficacy of Thyroid Treatment for Fibroma of the Uterus. — It was
by accident that Jouin discovered the value of this treatment.
He had a patient with a voluminous fibroma, and as she was
painfully obese he administered thyroid extract to relieve her
of her obesity, when he found that the fibroma shrank rapidly
to one-quarter of its former size. He reported at the Tunis
Congress that he had used it since in twenty -four cases, find-
ing that thyroid medication certainly reduces the fibroid
growth, and has also a most favorable effect on the attendant
symptoms, local neuralgias, debility and depression, but it is
especially valuable for its power to arrest the tendency to hem-
orrhage. It is very effective in uterine hemorrhages due to the
menopause, with or without fibroid growths. He suggested
1896. ]
PRACTICAL NOTES.
381
that as the fibroma is really only a sarcoma in a certain stage,
thyroid medication may yet be found useful as a preventive.
He suggested also a possible connection between the atrophy
Of the thyroid gland with increasing adult age, and the atro-
phy of the genital organs at the menopause, generalizing that
f function may perhaps be the cause of the tendency of
the tissues to return to their original embryonic fibroid state,
of which the fibroma is an extreme instance.
Low Temperature Pasteurization of Milk. Dr. Rowland G.
Freeman recommends the Pasteurization at a temperature
between 65 and 70 degrees C, for the following reasons: It
destroys almost all the ordinary air bacteria which occur in
milk. It destroys the bacillus tuberculosis, the bacillus
typhosus, the bacillus diphtheria and many other pathogenic
bacteria. It causes no change in the taste of tho milk and
avoids those chemical changes which are produced by higher
temperatures. Arehirrs of Pedriatrics, August.
Results from Antldiphtherial Serum at Edinburgh — In the Olas-
;/..»■ Medical Journal, Dr. Ernest L. Marsh publishes a care-
fully prepared set statistic tobies showing the influence of the
antitoxin treatment on the cases of diphtheria admitted to the
Heh idere Fever Hospital during 1895. The admissions num-
bered 179, and of these 137 were treated by antidiphtherial
serum, the remaining 42 cases were not brought under the
treatment, as being mild and not requiring it, or as being mor-
ibund on admission. Of the mild cases, the number was 38,
and of the moribund there were 4 cases. The fatal cases num-
bered 25, giving on the admissions a percentage of 14 deaths.
In the five years previous to 1895 the cases of diphtheria had
never given a less percentage than 35.5 deaths in any one year,
so that the improvement is a very impressive one. Of the 179
patients in 1895 tracheotomy was needed in 29, and of these 10
died, giving a mortality of 34.5 per cent. The author draws
special attention to these cases and contrasts the low death
rate with the high mortality of the tracheotomy cases in pre-
vious years, viz., 76.2 per cent. (42 cases) in 1893 and 86.9 per
cent. (23 cases) in 1894.
Diphtheritic Laryngeal Stenosis " Cured " with Behrlng's Serum.—
The Diutscli. Med. Woch. for July 9 describes a severe case of
diphtheritic stenosis in which the parents refused to allow
tracheotomy, as they had lost another child previously where it
had been performed (non serum treatment). The physician
considered the case hopeless, but still administered a dose of
Behring's serum (1,000 immunity units) with the usual local
treatment. The case continued growing worse for thirty hours,
when a sudden change for the better became apparent, and
rapid improvement and recovery ensued. Bornemann adds
that if other cases confirm this experience, that serum treat-
ment promptly administered will cure diphtheria in spite of
laryngeal stenosis (if it is of short duration and the heart still
vigorous), new fame will accrue to its inventor and many chil-
dren now considered past hope will be saved. All of which, to
use use an old phrase, " is important if true."
Tuberculosis of the Lungs in its Incipiency. The microscope,
when it demonstrates the existence of tubercle, confirms the
diagnosis of tuberculosis, but its failure to demonstrate their
presence does not imply that the disease does not exist, because
the germs of consumption appear in the sputum only when the
tubercles open and the germs are liberated and this occurs not
in the incipiency of the development but in the second, third
and fourth stages. Pulmonary tuberculosis may present at
first the slightest pigmented catarrhal secretion, which gradu-
ally changes to a more yellowish substance, and finally becomes
thicker and more profuse. The first discharge may contain no
bacilli. This seems to be the result of limited inflammation,
provoked by the development of tubercle foci, and not until
some of the foci rupture do we find pus in its true nature and
germs of consumption. Catarrhal conditions of the lungs then
should always be considered suspicious, and only good can
result from a treatment based on this ground.— Dr. Paul
J?AQum in Medical Herald, July.
Tic Douloureux. Dr. Danas's method of treatment consists in
tho following procedures : 1. Strychnia is given in single daily
doses, hypodermically. He usually begins withgr. 1-30, and this
is very slowly increased until by the fifteenth or twentieth day
gr. 1-6 to 1-4 is given. Most patients can not take over gr. 1-5,
an excess being shown by stiffness in jaws and legs, trembling
and nervousness. Sometimes the largest doses are not well
borne and are not advisable, but this is rare. After receiving
the maximum dose it should be continued for a week or ten
days and then gradually reduced, so that by the end of five to
six weeks the beginning dose is reached. The drug is then
stopped and is replaced by others. 2. The patient is now placed
on potas. iodid, gr. v, ter in die increased to gr. xx ; and
tincture of iron m. v, increased, if possible, m. xxx, and well
diluted. In some cases salicylate of potassium replaces the
iodid, or nitroglycerin is added to the iodid or iron. 3. Rest
in bed, with light diet and diuretics. — The Post-Graduate,
July.
Thyroid Medication In Goitre. - Pharm. Institute of Budapest,
has been making a special study of this subject. The investi-
gations are described in detail in the Deutsch. Med. Woch. for
July 9. The results briefly stated are : 1. The goitre in every
case decreased in size. 2. The patients lost in weight, some as
much as one to two kilograms. 3. The amount of urine
increased. 4. The elimination of nitrogen, especially, in the
urine, increased. 5. Increased elimination of CINa and of
P205. 6. The amount of uric acid execreted was much
increased, especially in the first days of the treatment. We
know that the amount of uric acid excreted increases with
increased numbers of leucocytes. The latest researches have
established the fact that thyroid medication increases the num-
ber of leucocytes, which accounts for the increased amount of
uric acid. Until we are better acquainted with the chemic
structure of the thyriod gland, it is not sufficient to explain this
increase in the amount of uric acid by the assumption that
it corresponds to the amount of deterioration of the nuclein
bases (xanthin, hypoxanthin) in the thyroid gland. It is inter-
esting to note that Baumann does not consider it settled that
the thyroiodin he discovered may not be some product of a
nuclein acid.
Operation for Appendicitis.— Dr. A. J. Bloch describes his
method of operation, in acute and gangrenous forms, as
follows: "An incision four inches long was made in the right
linea semilunaris, and the cecum exposed. This was drawn
into the abdominal incision and the appendix located. The
appendix was detached from the abdominal viscera, to which
it was adherent and brought out at the wound, the cavity of
the abdomen being shut off with sterilized gauze. With two
pairs of long forceps I seized the appendix, placing one pair
three-fourths of an inch from the cecum and the other a little
nearer the distal end, dividing the appendix between them.
Cleansing the surface, two long straight needles threaded
with fine silk, were passed, one into the anterior, the other into
the posterior lip of the remaining appendix, tied and given to
an assistant to hold, the needles and sutures being left in place.
The forceps were now removed, a small uterine dilator passed
through the lumen of the divided appendix into the cecum, and
both dilated to the extent of from one half to three-fourths of
an inch. The needles were then both together passed through
the dilated lumen of the appendix and cecum, into and out of
the cecum at its posterior surface, making but one puncture.
Pulling now upon the sutures the appendix became invaginated
into the cecum, and healthy tissue approximated, three rows
of Lembert sutures were then passed through the cecum, com-
pletely closing off the invaginated appendix, the traction sutures
382
PRACTICAL NOTES.
[August 15,
cut and allowed to drop into the bowel, and needle puncture
closed by one or two sutures. The abdominal wound was
closed with silkworm gut without drainage and sterilized dress-
ings applied. — New Orleans Med. and Surg. Jour., August.
The Technique of Suprapubic Puncture. — In the Wiener klin.
Wochenschrift, Dr. Von Dittel state that he has tapped the
bladder above the pubes considerably more than one hundred
times. He washes it out by means of a two-way cannula, and
and then introduces a Jacques catheter (No, 8), the caoutchouc
of which has the property of swelling up and so effectually pre-
venting any escape of urine. The catheter must be changed
at least once in eight days ; its stopper is to be removed when-
ever the necessity for micturition is felt, once at least every
four or five hours. When introduced in this way the foreign
body seems much less likely to induce vesical catarrh than if
inserted per vias naturales ; this is probably due to the absence
of the bacteria of the urethra. The puncture has a great
tendency to spontaneous closure, which is a manifest advant-
age when the indications for its employment have been obvi-
ated. Von Dittel has always operated in the mid line, but of
late Schopf has conceived the ingenious notion of a lateral
puncture, whereby the rectus or pyramidalis is used as sphinc-
ter and the permanent catheter done away with. One disad-
vantage of this method is that the puncture requires keeping
open by the nightly passage of a sound or drain. Furthermore,
Von Dittel has shown that the depth of the peritoneal pouches
inclosed by the urachus, obliterated hypogastric arteries and
the epigastric arteries is very variable, so that in some cases
but a very small portion of the anterior wall of the bladder is
free from peritoneum. In such instances lateral puncture may
lead to perforative peritonitis, and of this he records one fatal
case. He has therefore abandoned Schopf s procedure, and
reverted to his own former method. He has found, however, that
the poorness in vessels of the linea alba sometimes leads to
necrotic changes round the puncture, and therefore now adopts
the plan, particularly in old people, the operating just at the
edge of this tendon.
Improper Performance of Caesarean Section. — We are indebted
to the New York Medical Journal for an analysis of a discus-
sion of the above named operation, that has appeared in the
Centralblatt fur Gyndkologie. It appears that Dr. J. Esser
reported a case of that operation, the sole indication of which
was an enlarged fetal trunk (the head had been detached by
the use of forceps) ; this distension was later found to be due
to the presence of a large quantity of clear fluid in both chest
and abdomen. He reported his case in the Centralblatt for
March 21, defending his employment of Caesarean section
rather than embryotomy. The woman made a good recovery.
In the same journal for April 4, however, Dr. F. Ahlfeld
criticises Dr. Esser' s course very severely. "It may happen, he
says, that in the conduct of a case harrowing to both mind and
body, in which one resource after another fails, an obstetrician
at last loses his head and subjects both mother and child to dan-
ger by resorting to a wholly unsuitable procedure, and under
the circumstances he may be pardoned, or at least the circum-
stances may be pleaded in extenuation. But in the whole his-
tory of obstetrics it has not been recorded before that a prac-
titioner calling himself ' Frauenarzt, and having a ' Klinik,'
presumably, therefore, having served for some time as assistant
in a hospital, when called to a well-built woman in labor in the
sixth month, has applied and reapplied the forceps, then
explored the interior of the uterus up to the fundus on the
right and on the left, whereby he has ascertained that the
obstacle to delivery lay in abnormal distension of the child's
body, and finally sent the woman into his ' Klinik ' and per-
formed the Cesarean operation on her. The climax is capped
when Herr Esser has the heart to publish such a case and main-
tain that his conduct of it was proper. Dr. Ahlfeld goes on to
declare that, if Dr. Esser had followed the precepts laid down
in the text-books, his course would have been as follows :
When an hour or two had elapsed after full dilatation of the
os uteri, and the little head, lying deep in the roomy pelvis,
failed to advance, he would have suspected at once that the
trouble was due to immense distension of the fetal trunk. An
examination with four fingers, or at all events with the whole
hand, would easily have cleared up the point, and then he
would have simply opened the distended trunk with the per-
forator, after which the child would soon have been expelled
without further medical intervention. Dr. Esser has no ground
for alleging that his case possessed extraordinary features ; on
the contrary, that particular cause of dystocia is a typical one,
occurs over and over again, and is always to be met in the same
way. Ludwig's case, which Esser unjustly adduces, showed
real difficulties ; the child was gigantic, and a young physician
might well have been perplexed as to his choice of resource.
But even in this case the Caesarean operation was unnecessary.
Neither case can be regarded as legitimately extending the
field of usefulness of the Caesarean section ; on the contrary,
each of them should serve as a warning to young physicians."
New Method of Diagnosing Typhoid Fever with Serum from Patient.
— Recent investigations by Pfeiffer, Koll and Gruber have
shown that the serum of persons convalescing from typhoid
fever, the same as the serum of animals immunized against
typhoid infection, will produce a distinct and specific Reac-
tion when added to a culture of Eberth's '.bacillus in vitro.
They found the same phenomena with the cholera spiril-
lum and Escherisch's bacillus. The process is so clearly defined
that it promptly differentiates the disease, while it is so sim- •
pie that it requires nothing but a tube culture of Eberth's
bacillus (which keeps for weeks) and a drop of blood to com-
plete it. If a few drops of immunized serum are added to a
culture of the coli bacillus they produce a noticeable cloudi-
ness, with decided motility of the microbes. The effect is
entirely different if they are added to a tube culture of Eberth's
bacillus. There is no cloudiness, but the reverse ; the microbes
cluster in masses, forming agglomerations and a precipitate at
the bottom of the tube, with limpidity instead of cloudiness.
This agglutination is the point in differentiating, and the
higher the serum is immunized, the more rapid the effect,
sometimes occurring as rapidly as a chemic process. Widal
announces that he has been testing the serum from patients
in various stages of the disease, and has found the reaction
unmistakable in each. He drew the blood from the vein in
the bend of the elbow, with a syringe, after antiseptic precau-
tions, or from the hand of the patient, hanging over the edge
of the bed, after slightly massaging the finger from the root
to the point, when a prick with the lancet will draw enough
blood (}4 to 2 c.c), which should be caught in a thimble or
test tube first passed through a flame. After corking and
waiting a few minutes for the serum to separate, add one drop of
the serum to ten drops bouillon culture of Eberth' s bacillus, and
in a very short time the agglomeration commences, if it is a case
of typhoid. Between the characteristic agglutinations a few
scattered and motile microbes are still to be seen, growing less
in number until, in a few hours, they have all been absorbed
into the clustered masses. The drop of blood can be drawn
directly into the culture, but no time is gained, as the serum
has still to separate. Widal also made the test with serum
from normal persons and also from numerous patients suffering
from different diseases, as well as from persons who had recov-
ered from typhoid fever from one to fourteen years previously.
In each of these cases there was none of the specific typhoid
reaction, the agglomeration, but the Eberth bacillus kept on
the even tenor of its way, isolated and motile. — Bulletin Med-
ical, June 28.
L896. |
EDITOEIAL.
383
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SATURDAY, AUGUST 15, 1896.
THE WICKED HOUSE FLY.
I'll hide my master from the flies as deep as these poor pick-
axes can dig. — Cymbelene.
At the August season when the summer dog-days
are with us, the mighty insect Diptera, of the noble
family muscidce, particularly the musca domestica or
the musca harpya, commonly mentioned in the ver-
nacular as the house fly, makes his presence seen and
felt. From the earliest times, the ancestors of this
species were known to be most malicious, and at the
same time as a plague most unacountable.
When the Lord threatened Pharaoh that he would
send " swarms of flies upon him," Pharaoh was prob-
ably not aware that the mere presence of the fly,
insured the planting of plenty of pathogenic microbes,
and it is probable that the corruption of the land by
reason of the swarm of flies (Psalms cxv. 21), had a
great deal to do with the death of the first-born in the
plague next succeeding.
" Dead flies cause the ointment of the apothecary to
give forth a stinking savor," says the good book
(Eccles. x, 1) and it is morally certain that in these
bacteriologic days, not only dead flies, but flies of all
kinds are known to be carriers of contagion.
" The proboscis of the house fly" says one of our
popular encyclopedias " is a very interesting object,"
a remark almost paralleled by that attributed to the
late Artemus Ward concerning the kangaroo. " The
kangaroo" remarked Artemus reflectively, is an
" amoosin cuss." " The proboscis of the fly is the
greatly developed 'tonguelet' or lingula, the upper part
of the under lip, but with these are combined lancets
formed of the metamorphosed maxilla?" (Chambers).
Not only may this weapon infect the tiny wound
made in the skin, but bacteria themselves develop in
the intestinal canal of the insect, and are ejected on
every accessible object of food or furniture. This is
the well known " fly speck " abhorrent to the good
housewife. But the measure of the iniquity of the
house fly does not end here. As he has a decided pre-
ference for a diet of decaying garbage, putrid sores or
rotten carcasses he alights upon them and without stop-
ping to sterilize his feet afterward he flies to madame's
kitchen where he dips his feet jauntily into the iced
tea, deposits a " speck" or two on cut bread just as it
goes to the table, or annoys madame herself by
maliciously alighting near the corner of her eye.
It needs no philosopher, no Pasteur or Tyndall to
show the infinite capability of the fly as a carrier of
infection. Bacteriologists have traced the infection
carried by flies until there is no longer any question
of the fact (see this Journal, June 25, 1892, Vol.
xviii, p. 8 18 ) . Lucien Howe remarked the frequency
with which the fly is the most probable source of con-
tagion in the Egyptian ophthalmias. When flies walk
over a gelatin culture, bacteria develop in their tracks
(see this Journal Sept. 22, 1894, Vol. xxxiii, p. 479).
It is proper to say that the constant irritation of the
lid produced by fine particles of sand, predisposes to
the development of the bacteria when once deposited.
The observation of Dr. Howe, however, is not new,
for M. Sonnini, years ago in speaking of Egypt, said:
" Of insects there the most troublesome are the flies.
Both man and beast are cruelly tormented with them.
No idea can be formed of their obstinate rapacity
when they wish to fix upon some part of the body.
It is in vain to drive them away; they return again in
the self-same moment, and their perseverance wears out
the most patient spirit. They like to fasten themselves
in preference on the corners of the eyes and on the edge
of the eyelid. . . . The Egyptians paid a supersti-
tious worship to several sorts of flies and insects. If
then such was the superstitious homage of this people,
nothing could be more determinate than the judgment
brought upon them by Moses. They were punished by
the very things they revered, and though they boasted
of spells and charms, yet they could not ward off the
evil. How intolerable a plague of flies can prove
is evident from the fact that whole districts have been
laid waste by them. Such was the fate of Myuns in
Ionia and of Alarnae. The inhabitants were forced
to quit these cities, not being able to stand against the
flies and gnats with which they were pestered. Tra-
jan was obliged to raise the siege of a city in Arabia,
being driven away by the swarms of flies. Hence
different peoples had deities whose office it was to
384
BICYCLING— PRO AND CON.
[August 15,
defend them against flies. Among these may be
reckoned Baalzebub, the fly-god of Ekron, Hercules
Muscarum Abactor, and hence Jupiter had the
titles of apomnios, muigros, muiochoros, because he
was supposed to expel flies and especially to clear his
temples of these insects." '
The Hebrews also had the same superstition as
appears from Josephus, who narrates that "Ahaziah,
as he was coming down from the top of his house,
fell down from it, and in his sickness sent to the Fly,
which was the god of Ekron, for that was this god's
name, to inquire about his recovery." 2 A footnote
states that the "God of flies seems to have been so
called, as was the like god among the Greeks, from
his supposed power over flies in driving them away
from the flesh of their sacrifices, which otherwise
would have been very troublesome to them." In liter-
ature the fly has been execrated from time immemo-
rial. Persons who forced themselves into other men's
entertainments were called flies, as a term of reproach,
and "in Plautus an entertainment free from unwel-
come guests is called hospitium sine muscis, an enter-
tainment without flies; and in another place of the same
author, an inquisitive and busy man, who pries and
insinuates himself into the secrets of others, is termed
musca. We are likewise informed by Horus Apollo
that in Egypt a fly was the hieroglyphic of an impu-
dent man, because that insect being beaten away still
returns again; on which account it is made by Homer
an emblem of courage." 3
But the wicked fly notwithstanding his demoniac
doings has had his defenders, some from pure benev-
olence, as Tristram Shandy's Uncle Toby: "So,"
says he, one day at dinner, to an overgrown one
which had buzzed about his nose and tormented him
cruelly all dinner-time, and which, after indefinite
attempts, he caught at last, as it flew by him, " I'll
not hurt thee," says my Uncle Toby, rising from his
chair and going across the room with the fly in his
hand, "I'll not hurt a hair of thy head; go! " says he,
lifting up the sash and opening his hand as he spoke,
to let it escape. " Go, poor devil, get thee gone, why
should I hurt thee? This world, surely, is wide
enough to hold both thee and me."*
Another defender was Oldys, whose two stanzas,
according to D'Israeli,5 were occasioned by a fly
drinking from a cup of ale, the favorite potion of
poor Oldys :
Busy, curious, thirsty fly !
Drink with me, and drink as I.
Freely welcome to my cup
Couldst thou sip and sip it up ;
Make the most of life you may,
Life is short and wears away.
Both alike are mine and thine,
Hastening quick to their decline,
Thine' s a summer. Mine no more,
Though repeated to three score !
Three score summers when they're gone
Will appear as shortas one.
i Edwards' Encyclopedia of Religious Knowledge, 1852.
2 Josephus' Antiquities of the Jews. Book IX, Chap. 11.
3 Potter on the Miscellany Customs of Greece.
i Sterne: Tristram Shandy, Vol. II, Chap. 12.
s Curiosities of Literature.
But however sweet and delicate the strain of Oldys,
we can not forget that this is not the age of senti-
ment, and we must therefore insist in the interest of
public health and suffering humanity, that the fly must
be excluded from our houses by every possible bar-
rier; he must be kept away from our food supplies by
every possible means, and if he persist he must be
destroyed with no less sterness than is displayed by
Boys pursuing summer butterflies
Or butchers killing flies. Coriolancs.
BICYCLING— PRO AND CON.
If every smoothly paved thoroughfare, crowded,
especially at night, with men, women and children
bestriding a bar suspended between two wheels, were
not alone evidence of a furor populi, the facts that
large establishments exclusively devoted to the supply
of bicycles and their numerous appurtenances have
sprung into existence in every quarter, that piano
stores include among their offerings for sale more
varieties of the silent wheel than musical instruments,
and that even little narrow " holes in the wall," where
thread and needles or candies and newspapers once
modestly bid for buyers, now exhibit their half dozen
apparatus, betoken a craze that has possessed the peo-
ple wilder than the magnetic syrup or any other fad
of forty years ago or the silver folie of to-day.
It is, perhaps, injudiciously soon to cry " halt " to
the maddened crowd of riders, and so many physi-
cians, themselves victims, have sanctioned the prac-
tice by precept and example, that the criticising
medical men, who do not ride, are sought to be dis-
credited because they have not ridden. As for the
clerical advocates who have hastened into print with
their indorsement of this new sanitary device for
developing the muscles and at the same time encour-
aging innocent diversion at the expense of roof -gar-
dens and rum-shops, Mrs. Charlotte Smith has
spiked their guns by suggesting that the grateful
recognition of an acceptable gift has unfitted them
for unprejudiced judgment.
If medical men and medical journals ought to inter-
est themselves in the every-day affairs of life, there is
good reason why they should give most serious con-
sideration to this bicycle question, which has grown
to such incredible proportions within so short a time.
Its only parallel is the jinriksha of Japan (the two-
wheeled buggy with a man between the shafts),
which wholly unknown thirty years ago, has now
almost completely supplanted all other modes of
travel. Inasmuch as no inconsiderable number of the
members of the profession themselves bestride the
double wheel, the case so far as they are- concerned
has been prejudged, and it may be assumed that
others, whose families and friends have acquired the
habit, are in the same category.
Enthusiasts do not kindly brook criticism. If you
18%. !
BICYCLING— PRO AND CON.
385
have not eaten raw fish with the Japanese or limacjons
with the French, you are apt to be challenged with :
" What do you know about a diet of uncooked salmon
■or slimy slugs anyhow?" Admitting the palatability
of the dish, it is still possible for the looker-on to
argue its wholesomeness. A moment of impartial
inquiry, therefore, may be permitted the physician,
who is seriously concerned with the welfare of the
people among whom he lives.
At the first view, it seems plausible that anything
which impels individuals to pass so many hours a day
at exercise in the open air should be beneficial, and
undoubtedly the abstract statement is incontroverti-
ble. One startling revelation for which the bicycle is
responsible is the amazing number of spindle-shanks
among the feminine part of the population. Not-
withstanding the aid of leather leggins and worsted
stockings, the cruel fact is evident to the on-looker
that Mary Ann and Eliza Jane, as well as Birdie
and Rosie, Maud, Ginevra and plain Susan have
unsubstantial understandings that bespeak lack of
exercise and poor nutrition, and the pedaling action
required to propel the machine ought, prima facie,
be the indicated means of repairing attenuated calves.
It is true that the same amount of exercise afoot
would be equally salutary, but the inducements to
walk are so much less that the outdoor recreation is
not obtained. The mere purpose of improving the
health has never been sufficient to impel either young
or old to do anything that will accomplish this end,
as the admitted fact of downright harmfulness has
never deterred even the intelligent, wise and cultured
from some gratifying indulgence. The novelty of
the bicycle, the delusion that one is sitting down and
gliding without personal effort, the element of fash-
ion, the contagiousness of example influence all
classes to mount and away, when the suggestion or
advice or invitation or command to " put on your hat
and take a brisk walk" is resolutely ignored or defiantly
• opposed.
Granted then, that the congregation of men, women
and children in the open air, on broad avenues, upon
country roads, in park-ways and by river-banks
rather than sitting in crowded, ill-ventilated theaters,
saloons, billiard-rooms and beer-gardens is a sanitary
gain, shall it be denied that this alone commends the
practice '? Not — were this the whole truth and nothing
but the truth.
Watching the swiftly moving throng on a city
boulevard the observer notes the fact that the posture
of the majority of male riders involves a curious con-
tortion of the body, by which the head is lowered and
the face lifted, thus curving the neck anteriorly, while
the back and shoulders are elevated into a hump, the
chest and abdomen forming a hollow corresponding
to the dorsal convexity. The legs are bent at an acute
angle upon the trunk, the whole weight of this being
thrown upon that portion of the body which in the
normal act of walking is absolutely free from strain
and pressure. Medical bicyclists admit that the pos-
ture of most wheelmen causes injurious pressure upon
the parts around the neck of the bladder, developing
irritability of the latter, increased desire to urinate,
congestion and hypertrophy of the prostate, narrow-
ing of the canal of the membranous and prostatic
urethra, and ultimately atrophy of the testes. The
last might not be an unmitigated evil in the condi-
tions of modern civilization. The others are sure to
enlarge the clientele of the genito-urinary specialists
of a few years hence. It is fair to say that a minimum
only of bicyclists, including, of course, all medical men,
sit upright, as upon a horse and are content to amble
along with gentle effort. In their case, the ischial
tuberosities support the body, provided the saddle is
broad and without the anterior horn (pommel), reliev-
ing the genital region of the pressure inevitable in
the hideous hump-backed caricatures which profes-
sional wheelmen and their multitudes of imitators
make of themselves.
Great as the physical injury to men, it is small
beside that suffered by young women. Surmounted
upon the edge of a wedge, their very erect posture
forces this wedge up between the tuberosities, the
yielding soft parts of the perineum resting upon the
narrow rigid fulcrum. The tendency consequently is
to diminish the outlet of the plastic pelvis by approxi-
mating the ischial extremities instead of spreading
them apart as in the normal exercise of walking, when
the weight of the body is borne upon the widely sep-
arated heads of the femurs. It is a sorry sight to
watch the young girl enamoured of her wheel, devot-
ing every hour she can spare to the novel, exhilarating
occupation, obtuse to the soreness and pain so many of
them experience, bruised and excoriated by the pro-
longed friction, weary and worn, but with the deter-
mination of the ballroom belle who dances when
ready to fall from fatigue and blistered feet. There
are hygienic seats, in two parts, fitted to receive the
tuberosities, but they are not in common use, and the
majority bestride the narrow saddle with its promi-
nent anterior horn, which presses into the vulva in
resisting the tendency to slide forward, especially in
ascents.
The esthetics and morality of bicycling do not
come within the professional ken of the physician.
A costume and posture which make ninety women in
a hundred absurd spectacles, will not long be popular
with the thousands and tens of thousands of the fair
sex as to-day. Slim legs operating like a steamer's
walking-beam, and generous buttocks, whose contour
is alarmingly delineated, are not pleasing displays; and
we leave to the philanthropic lady who is President of
the Women's Rescue League to show that the promis-
cuous commingling of respectable young women on the
386
ROENTGEN RAYS IN DIAGNOSIS.
[August 15,
same roads with the coootte class, for whom the wheel
has such fascination that all ride who can borrow the
money to hire a vehicle, and that the accentuation of
the leg as the feature of the girl who has learned to
swagger in bloomers or short skirts into crowded public
restaurants for the much needed refreshment, can only
have a demoralizing effect. It is enough for us to
declare that a woman, especially an adolescent girl, can
not be suspended on the summit of a wedge without
injury to the structures above, and deformation of the
pelvis; and that the bruising of the flesh, which some
riders unwillingly admit, and the craving for stimulants
after a fatiguing ride, ought to restrain the prevailing
indiscriminate and intemperate use of the vehicle.
If exercise be the object, we commend a pair of sturdy
human legs as a motor of unsurpassed fitness for
every sanitary purpose. Assuredly, the pedestrian's
features will not wear that intently anxious expression,
which has already been given the designation of the
" bicycle face."
ROENTGEN RAYS IN DIAGNOSIS.
The surgical utility of the Roentgen rays is now
a well-established fact, and every day adds to the
evidence in its favor. Their therapeutic value is. on
the other hand, a dubious quantity and, as yet, only a
few enthusiasts, mostly outside of the ranks of the
regular profession, have seriously expressed their
faith in it. Experiments conducted under scientific
conditions have so far led at best to only unsatisfactory
results.
There is, however, in the latest developments of skia-
graphy more or less suggestiveness of possible extra-
surgical uses of these rays, and it does not seem
altogether unreasonable to look forward to their
future employment in medical as well as in surgical
diagnosis. The methods have already improved to
such an extent that it appears even probable that
before long we may be able to detect diseased condi-
tions in the viscera by the fluoroscope and thus throw a
light also on various pathologic questions. There
is a whole field of research in determining the perme-
ability of the various organic and inorganic com-
pounds in these rays, which has thus far only just
been touched upon, here and there, in medical litera-
ture, notwithstanding its suggestiveness from a medi-
cal point of view.
In the latest issue received in this country of the
Deutsche medicinische Woehenschrift, that of July
23, there is an important paper by Dr. E. Sehrwald
of Freiburg i. B., on the action of the halogens,
chlorin, bromin and iodin, on the Roentgen rays. He
finds them in a pure state to give an almost complete
shadow, and in chemic combination producing a
shadow proportional to the percentage of the element
contained. Solutions and compounds that are almost
or absolutely transparent, like hydrochloric acid and
bromoform and chloroform, show this peculiarity
very plainly, as they give a shadow as dense as that
of the metals. The transparency to these rays of organic
substances generally is due to the fact that the four
chief component elements, carbon, hydrogen, oxygen
and nitrogen, present to them very little, if any,
obstruction. The shadows that are cast in a skiagraph
by the soft parts of the organism are due to the pro-
portion of iron in the blood and the alkalin metals,
but especially to the chlorin contained in the tissues.
Such facts as these and others that will undoubt-
edly be developed along these lines, will suggestively
supplement our existing data in regard to the physio-
logic and pathologic chemistry of the animal tissues.
Their practical value will, of course, remain to be
determined by future investigations.
A REGRETTABLE OVERSIGHT.
National medical associations are becoming so numer-
ous that it requires considerable watchfulness to avoid
conflict of their several dates of meeting. This has
led bodies like the American Academy of Medicine,
the Medical College Association, the Association of
Medical Examining and Licensing Boards and others,
to assemble coincidently with the American Medical
Association, that as many as possible might be able
to attend two or more. The circular issued on July
20 by the Secretary of the Mississippi Valley Medical
Association, announcing the change of date of the an-
nual meeting of that body from October 20-23 to Sep-
tember 15-18, is in probably unintentional, but very
regrettable, conflict with the date of the next meeting
of the Amercan Public Health Association, which long
ago announced its forthcoming annual session at Buf-
falo, N. Y., on these very days. While the latter is
not technically a medical body, since any one who is
interested in public sanitation may belong to it, its
membership is so largely composed of prominent
medical men, that it has a quasi-professional charac-
ter, and the enthusiastic devotion of its members to
their work, which has made it the leading sanitary
body in the world, is so great that its claims to con-
sideration can not justly be ignored.
While it will be difficult for such as are earnest
members of both organizations to decide which to
sacrifice, a very little forethought would have obvi-
ated any necessity for it. Giving the right of priority
to the American Public Health Association, not only
on account of its longer existence and greater mem-
bership, but because of its antecedent selection of the
date, considerations which have operated in the case
of the American Medical Association and its attend-
ant correlated bodies, the Mississippi Valley Medical
Association might readily select the week following
the adjournment of the older and larger organization,
for its own re-amended date of meeting and we earnestly
hope that the president, Dr. H. O. Walker of Detroit,
L««.]
CORRESPONDENCE,
387
in deference to the wishes and convenience of those
who belong to both bodies, may authorize this
change.
THE BRITISH MEDICAL ASSOCIATION.
The very complete abstract of the annual meeting
of the British Medical Association, which we have
received from our special correspondent, is too vol-
uminous (o publish entire this week. We are sure that
our members will be pleased to know that the Jour-
nal representative received great courtesy at the hands
of Mr. Ernest Hart, the editor of the British Med-
ical Journal, anil every facility was afforded our cor-
respondent for the accurate abstract of the papers
read at the meeting, which we shall present in this
and succeeding issues. It will be noticed that the
next meeting will lie held in Montreal.
CORRESPONDENCE.
The Michigan Medical Legislation League.
Detroit, Mich., Aug. 10, 1896.
To the Editor:—! hope you will permit me to occupy a little
more space in the Journal for a few remarks concerning the
Michigan Medical Legislation League. Of course, there is no
use of continuing a controversy upon a subject when the par-
ticipants are so widely apart in their premises ; but I can not
see wherein the "Regular" members of the League merit any
censure ! On the contrary, they deserve commendation for
their patriotism and liberality of spirit in putting aside, for
the moment, special ethical scruples for a .broader code of
human ethics which embraces the welfare, not only of the
craft, but of all their fellow human beings. As already pointed
out, the Michigan Medical Legislation League is merely a
political organization. This controversy illustrates curiously
the romance of history. Twenty years ago Dr. Donald Mac-
lean and his colleagues of the Faculty of the Medical Depart-
ment of Michigan University were arraigned before the State
Medical Society and, later, before the American Medical
Association, for associating with, and assisting in the teach-
ing of, the "despised" "homeopath." At that time, I am
ashamed to say, I was one of the multitude who shouted at
them epithets of derision. They were accused, as this League
is now by Dr. Maclean, of degrading our noble profession,
assisting in the prostitution of medical science, bringing the
quack and the fraud (for as such homeopathists were then
denounced) up to the level of honorable recognition with scien-
tific medicine. They were called feeble, cowardly, treacherous !
Such was our bigotry, then, that even the eloquence of Mac-
lean, Prothingham and Dunster could not broaden our narrow
disposition, and we persisted in persecuting the Ann Arbor
Faculty with a spirit of intolerance for some time. Their
position, however, in the light of a broader intelligence, was
right ! although we were honest in allowing our action to be
governed by a belief born of tradition, instead of reason and
benevolence. I am sorry that one of those defenders of right-
eous expediency and equity, has changed so that to-day he is
attacking the principles which he formerly assisted to defend !
It is a pity that Dr. Maclean did not bring his objections for-
ward at the meeting which adopted the constitution, and for-
mally organized "The League." He was present at that
meeting and took an active part in its proceedings, and if he
had thus voiced his sentiments, the regular profession might
have been spared the appearance (so ludicrous in the eyes of
the laity) of dissension and lack of public spirit on matters of
public interest. Personally, I would be glad to turn over the
"glory " of my office as President of the League to Dr. Mac-
lean, for I do not enjoy the unpleasant duties of official life,
while he unquestionably does. However, I feel that the League
is engaged in a highly beneficent undertaking, and hope that
its members, one and all, may display a courage and fortitude
in the coming battle for humanity, which may equal in glory
and results the magnificent campaign against bigotry and intol-
erance which the Ann Arbor Faculty of 1876 achieved.
Regarding my statement pertaining to the composition of
the Executive Committee of the League, I should have
explained, had I not supposed that Dr. Maclean was aware of
the fact, that the Executive Committee included the officers of
the League. E. L. Shurly, M.D.
Congress of Leprologlsts.
New York, Aug. 4, 1896.
To the Editor:— It has seemed desirable to publish all over
the world the fact that the government of Norway will next
year probably convoke a congress of leprologists, and delegates
from all civilized countries, especially from those which, by
the suffering of their own people, are especially interested in
the question of leprosy. Hansen, the discoverer of the bacil-
lus, suggested that this congress should be held at Bergen,
Norway, and out of compliment to him we suppose that there
will be no opposition to this proposition. Dr. Goldschmidt,
a Paris physician who has practiced among lepers during twenty-
six years in Madeira, has originated the scheme. You will
find inclosed my correspondence with this eminent leprologist
which I hereby authorize you to publish. The American,
Mexican, Japanese and Chinese governments, also all the
Republics of South America, who are evidently and consider-
ably interested in the question of the! suppression and preven-
tion of leprosy, have been appealed to, to join their efforts in
this philanthropic undertaking. Norway and Hawaii have
already expressed their willingness to send their delegates.
The American, English and French governments will assur-
edly support the movement. The delegates of the different
governments will form an international committee, to be per-
manently active. Funds will be raised by that committee in
all civilized countries, and applied to the support of leper asy-
lums in those countries where either the willingness or the
capacity to help those institutions is wanting or insufficient.
All problems concerning leprosy will be submitted to that inter-
national committee.
It is hoped that by this common and universal effort against
the dreadful scourge it may, in a comparatively short time, be
wiped off from the surface of the world. It is certainly
worth the while to fight some years for such a tremendous
result. Mankind certainly at no time of history has fought for
a greater object. Such a momentous matter can not help to
appeal to the sympathies of so important a medical journal as
yours, published in a country which suffers more than even
China from the terror, against which we mean to begin this
fight.
May we hope that you will use the influence of your paper
to obtain an expression of opinion from the principal leprolo-
gists of India as to this matter. Should some of them, as we
fervently hope, be willing to join our congress, will you ask
them to communicate their intentions to me, as now and for a
little time to come I shall have the foreign correspondence on
my hands. Yours respectfully,
Albert S. Ashmead, M.D.
A Crusade of Education.
Burlington, Iowa, Aug 10, 1896.
To the Editor: The controversy now going on in the Jour-
nal between Dr. Maclean and the Michigan Medical Legisla
388
PUBLIC HEALTH.
[August 15,
tive League reminds some of us of the struggle some years ago
to get a medical law in Iowa ; and some of us perhaps sympa-
thize with Dr. Maclean even if we have such a law and the
Regulars have a majority on the Board.
Specialists in general, and eye and ear men in particular,
have not infrequently been accused of tendencies to lax
methods in practice ; and the specific charge commonly made
is that of consulting or desiring to consult with homeopaths,
etc. Some of our brethren in New York (and they are not all
specialists), on account of their liberal declaration on this sub-
ject have been denied fellowship in the American Medical
Association.
But here in Iowa (and it may have been so in other States)
we had the spectacle of a "joint legislative committee," com-
posed of committees from the regular, homeopathic and eclec-
tic State Medical Societies, who consulted together, moved
unitedly upon our legislature, and secured the law we now
have.
To some of us I fear that the consultation with a homeopath
or eclectic for the welfare of the individual, and a consultation
with the same for the welfare of the State, is a distinction
without a difference ; and we must be pardoned for holding to
the belief that the end no more justifies the means in one case
than in the other.
No wonder that, under these circumstances the public dis-
regards our denials that medical legislation is intended to
benefit the profession more than the public. The public only
sees what it esteems factions, always warring against each
other on everything else, but all in harmony on just this one
point ; and the conclusion is inevitable. So what sort of a law
on the average, do we get? Is it really worth the time and labor
spent upon it by the profession?
The Iowa law does not prevent quackery in Iowa. It makes
a great show, but the quack who is not ingenious enough to
dodge its provisions is too dull to be dangerous ; and the dan-
gerous fellows continue to dodge it successfully — as the records
will show.
It may be considered rank heresy to entertain such a thought,
but after as complete a survey of the situation as I am capable
of making, the question arises — is law a proper remedy in the
physicians' armamentarium? In other words, would it not be
better to wait until public sentiment crystallizes into a demand
for a medical practice law, the profession confining itself mean-
while to a crusade of education in this direction? Let no phy-
sician degrade his time honored title by appearing as a lobbyist.
Truly yours, H. B. Young, M.D.
PUBLIC HEALTH.
Examination of Milk Cows.— Secretary Briggs of the Scranton
(Pa.) Board of Health has sent out a circular to wholesale
milk dealers requesting them to have their cattle examined for
tuberculosis.
Epidemic of Sore Eyes Among Boys at Newark, N. J. — A number
of physicians have complained that sore eyes were epidemic
among the small boys who bathe at one of the public baths, and
it was thought the contamination was carried through the water.
A number of the cases have been reported to the board of health
by the physicians connected with the eye and ear department
of St. Michael's Hospital. Measures for disinfection were
taken.
New Jersey Law as to Bread and Bakeries. — Chapter 178 of New
Jersey Laws, session of 1896, is an act to regulate the sale of
bread, which will take effect Aug. 1, 1896. It provides that
bread shall be sold by weight, and that all bread sold shall be
free from all impure or foreign substances or any material
injurious to health. Chapter 181 is to regulate the manufacture
of flour and meal food products. It provides how biscuit, bread
or cake bakeries shall be drained, plumbed and ventilated ;
how rooms for manufacture are to be constructed and what to
contain ; how flour is to be kept ; that there shall be washrooms,
and that closets and sleeping places shall be kept separate from
the work and storage rooms.
To Prevent Illegal Practice in New York City.— At the request of
the New York County Medical Society, Chief of Police Conlin
ordered every policeman to take the census of the physicians
- not including surgeons — found on his post July 29. The
Medical Society has inaugurated a war upon bogus doctors,
and the enumeration of the medical men is the first step tend-
ing toward a vigorous ousting out of practice of all who are not
regularly and legally entitled to recognition.
A Sanitary Examination In England.— Some questions and queer
answers are reported as having lately been exchanged at a test-
examination lately held in England for itinerary inspectors. A
question having been asked about the wilful exposure of a per-
son suffering from an infectious disease, the examinee promptly
answered: "He must not ride in any conveyance except a
hearse without first informing the driver," while another
answered : " A person dying of an infectious disease must give
notice to the local authority within twenty-four hours."
Another candidate said : "Members of a family where small-
pox has broken out must be sent to the hospital and well boiled ;' '
while still another said that milk is the best food for children,
because it does not require any chewing ; and his notion that
food builds up the " waist" of the body would seem an error
in spelling rather than in idea.
Consumption and Typhoid Fever. — Prof. V. C. Vaughan lectured
to the summer school students at Ann Arbor, Mich., July 28*.
He talked for the most part on typhoid fever and consumption.
Dr. Vaughan ventured the assertion that one out of every seven
of those present would die of consumption, that 3,000 die of it
every year in Michigan, and that 50,000 people annually die of
typhoid fever. Both diseases, he said, were easily prevented.
He claims that the medical profession of to-day is fully a cen-
tury ahead of the politicians and others who are in control
over municipalities. In Berlin and Hamburg people are com-
pelled to disinfect their sputa, thus retarding the spread of tu-
berculosis. The death rate in those cities has decreased rapidly.
He believes that in time cities will be held responsible for
typhoid fever outbreaks as much as they are for defectiveside-
walks. To prevent typhoid fever, he says, boil your water.
To prevent consumption use a cheap paper cuspidor and burn
it twice a day.
Danger of Leprosy from Russian Immigrants. — According to.
reports from Germany the commissioners of immigration and
quarantine physicians of this country should be especially vigi-
lant in the examination of Russians who come to the United!
States. The famous Berlin physician, Prof, von Bergmann,.
who was recently consulted by the officials of the German
health department, declares that a large number of the-
Russians who enter Germany with the intention of pro-
ceeding to America are afflicted with leprosy. The increase of
the loathsome malady in the western provinces of Russia has-
become so alarming that the German government has ordered
the immediate establishment of lazarettos at various points-
along the Russian frontier.
New Jersey Backs Up Health Codes as to Sewers.— A law was-
passed in New Jersey in May, 1896, providing that in all cities,
townships and other municipalities of that State, wherein,
there are now or hereafter may be sewers constructed for the-
purpose of carrying off the sewage of such cities, towns, town-
ships and other municipalities, or in streets or sections of such
cities, towns, townships and other municipalities, the owners
of property along the line of any such sewers shall be compelled
to connect their houses and other buildings therewith, in com-
pliance with the ordinances, rules and regulations of any local
1896.]
PUBLIC HEALTH.
389
board of health now or hereafter to be made for that purpose.
The provisions of this act shall be enforced by the local boards
of health, by a fine of $25 against any delinquent who shall
not comply with the terms of any such ordinance, bylaw or
regulation within thirty days after notification to make the
prescribed connection or connections by the proper officer of
the local boards of health, and an additional fine of $10 for
each and every day after such thirty days in which the provi-
sions of this act and of such notice shall not be complied with.
New Departures in the Massachusetts State Board of Health Id
Diphtheria and Tuberculosis — The State Board of Health of
Massachusetts has recently issued circulars stilting that it is
prepared to examine cultures taken from the throat for the
bacilli of diphtheria, sending out the necessary tubes and
swabs, am! reporting to the physicians or local boards of health
who may send cultures for examination. The circulars explain
in detail the proper methods of taking cultures, and explain
their value both in the diagnosis of doubtful cases and in deter-
mining the length of time the isolation of convalescent cases
shall be continued. This circular is accompanied by another
which explains in detail the methods of administering the anti-
toxin furnished by the State Board of Health, and of caring
for the syringe, etc. The Board also offers to make examina-
tions of sputum for tubercle bacilli, the object being, as stated
in their circular, not so much to enable the physician to make
an early diagnosis as to protect the public from manifestly
infective sputum. Examinations of cover-glass preparations
of blood for the malarial organism will also be made by the
Board. The opportunities offered by the Board to physicians
and local boards of health for having such examinations made
without charge can not fail to be of great value to the promo-
tion of public health by the prevention of infectious diseases,
especially in our smaller communities, where absolutely no
facilities for having this work done have existed. The State
Board of Health furnishes an example well worthy of imitation
by other boards in Massachusetts et al., or elsewhere, in the
thoroughness and efficiency which they have shown in making
available to all who may need them, the best modern scientific
methods in the diagnosis, prevention and cure of infectious
disease.
Havoc by Measles in London. — The London Lancet for July 18
sounds the alarm regarding measles as a form of child murder.
It says that the mortality for measles has proportions that call
for more attention from sanitary authorities than it receives.
There is this most significant difference between this mortality
in different classes of the community ; in the better sort of
practice the mortality from measles is almost nil. "Some prac-
titioners with well-to-do patients have possibly never seen a
fatal case of measles in their practice, though the disease is
. often highly pyrexial. But the number of deaths from it now
in the large towns of England and Wales and of Scotland
exceed greatly the number from scarlet fever or diphtheria, or
from both of these put together. This mortality has been
described lately by writers in the nineteenth century as a form
of murder. It is sufficiently illustrated in our issue of last
week. Our monthly analysis of London sickness and mortal-
ity gives a mortality in June from scarlet fever of 67 and
from diphtheria 173, and from both of 240, whereas the
mortality from measles was 412. In thirty-three of the largest
English towns during the week ending July 4, of 720
deaths due to the principal zymotic diseases, 175 were
from measles and 100 from scarlet fever (36> and diph-
theria (64) combined. The case of Scotland is not much
better. Of 548 deaths in eight Scotch towns, 109 were
caused by the principal zymotic diseases ; of these, 38 were
referred to measles. Glasgow — whose physicians, notably Dr.
Gairdner and Dr. Russell, have directed attention to this
infanticidal disease— has a bad preeminence in this respect, and
measles is resposible for 33 of the 38 zymotic deaths." Such
havoc of infant life can not be much longer continued without
scandal and discredit to sanitary authorities. The remedy is
not so easy as in the case of the other two diseases, as the infec-
tiousness is greater and has time to act before quite declaring
itself. Nevertheless, ways must be found for improving the
hygienic environment of the little patients and for anticipating
the diagnosis under suspicious circumstances.
New Regulations in New York City Concerning Garbage Collection.
— After August 1, the householders of that city will be obliged,
under penalty of a fine of $50, to observe the new regulations
of the health department directing the separation of kitchen
garbage. They can not allege, however, that they have not
had timely notice, for on Juno 23 the Mayor issued a proclama-
tion and the health department sent out these notices : Please
take notice that section 95 of the sanitary code, which requires
that a suitable and sufficient receptacle be provided on every
premises for receiving and holding garbage without leakage,
and that a separate receptacle, made of or lined with some
suitable metal, shall be provided for ashes, and that ashes
and garbage shall not be placed and kept in the same recep-
tacle, will be enforced by the board of health on and after
Aug. 1, 1896. The department of street cleaning will collect
ashes and garbage in separate carts on and after Aug. 1, 1896,
at each house. It has also been decided that householders
shall provide a third receptacle for refuse of such a character
as would come under the head of broken furniture, bottles,
rags, old shoes, clothing, etc. The street cleaning department
is not obliged to remove articles of that description from
houses, as they do not properly come under the head of gar-
bage, but it does so as a matter of convenience to the house-
holder, and also with a view to the preservation of the public
health. The third receptacle may be a basket, box or a simi-
lar article. The occupants of flat houses may in some cases
seek to avoid complying with the order. In such cases the
owner of the building will be held responsible. The police
department has been instructed to cooperate with the health
and street cleaning departments to secure a thorough enforce-
ment of the law. Twenty-two policemen were detailed by
Acting Chief Cortright to assist in the work. Only one col-
lection of garbage will be made daily, and that in the fore-
noon. The city has entered into a contract with the New York
Sanitary Utilization Company, which has established a large
plant at Barren Island for the purpose of disposing of garbage.
All garbage except ashes will be taken charge of by the com-
pany after it has been delivered by the street cleaning depart-
ment at the dump. The city is considering the advisability of
entering into a contract with a contractor who is willing to buy
the ashes and use them for filling purposes.
Health Report. — The following reports of mortality from small-
pox, yellow fever and cholera have been received in the office
of the Supervising Surgeon-General U. S. Marine-Hospital
Service :
SMALLPOX — UNITED STATES.
Ohio : Dayton, July 1 to 31, 1 death.
Louisiana : New Orleans, July 25 to August 1, 4 cases, 1 death.
Florida : Key West, August 3, 3 cases, 1 death.
Tennessee : July 1 to 31, Tipton County, 8 cases ; Shelby
County, 5 cases, 2 deaths.
SMALLPOX — FOREIGN.
St. Petersburg, July 11 to 18, 2 cases, 6 deaths
Gibraltar, July 12 to 19, 1 case.
Licata, July 11 to 18, 2 deaths.
Konigsberg, July 18 to 25, 1 case.
Osaka and Hiogo, June 28 to July 4, 45 cases, 12 deaths.
Kanagawa, July 3 to 10, 3 cases.
Madras, July 18 to 25, 1 death.
Odessa, July 11 to 18, 13 cases, 1 death.
Calcutta, June 20 to 27, 3 deaths.
London, July 18 to 25, 37 cases.
Cairo, May 28 to June 3, 7 deaths.
390
NECROLOGY.
[August 15,
Alexandria, May 28 to June 3, 4 deaths.
Warsaw, July 11 to 18, 4 deaths.
Bologna, July 18 to 25, 2 cases.
CHOLERA.
India : Calcutta, June 10 to 27, 38 deaths.
Egypt : Cairo, May 28 to June 3, 175 deaths ; Alexandria,
May 28 to June 3, 54 deaths.
Japan : July 2 to 11, Tokio Tu, 12 cases, 1 death ; Cheba
Ken, 1 case ; Tuknoka Ken, 8 cases ; Hiogo Ken, 2 cases ;
Iboraki Ken, 2 cases, 1 death ; Kagawa Ken, 1 case ; Kana-
gawa Ken, 2 cases ; Migayaki Ken, 1 case, 1 death ; Okayama
Ken, 3 cases ; Shidsuoka Ken, 1 case, 1 death ; Tochigi Ken,
1 case ; Taraanashi Ken, 2 cases ; Jehime Ken, 1 case.
YELLOW FEVER.
Vera Cruz, July 23 to 30, 3 cases.
Matanzas, July 22 to 29, 35 deaths.
Santiago, July 25 to August 1, 21 deaths.
Havana, July 23 to 30, 90 cases, 40 deaths.
NECROLOGY.
Dr. Joseph Meredith Toner, of Washington, D. C, died
at Cresson Springs, Pa., August 1. He had practiced medi-
cine in that city over forty years, and his death will be keenly
felt in medical and scientific circles. He took an active inter-
Joseph Meredith Toner, m.Ii.
est in all public-spirited and charitable institutions and socie-
ties for scientific investigation. In 1871 he founded the Toner
Lectures by placing the sum of 83,000 in the hands of trustees
charged with the duty of securing two lectures annually on
some original research. The interest of the fund with the
exception of 10 per cent., is paid to the authors of the lectures.
The balance is added to the regular fund which has thus been
increased to $5,000. In 1875, and for three subsequent years,
he offered the Toner medal at Jefferson Medical College for the
best thesis on the results of original investigation. In 1882 he
gave his library, consisting of 28,000 books and 18,000 pam-
phlets, to the Congressional Library and this collection is kept
separate from the other books. This collection is specially rich
in American medical writings prior to 1800. Dr. Toner possessed
a large collection of the writings of Washington, which is also
deposited in the Congressional Library and will be of great his-
toric value. He was born in Pittsburg, April 30, 1825, and
received his academic education at the Western University and
the Mount St. Mary's College. His medical studies were pur-
sued at the Vermont Academy of Medicine and at the Jeffer-
son Medical College, from which he was graduated in 1853.
He practiced in Summit and Pittsburg, Pa., and Harper's
Ferry, Va., and established himself in the city of Washington in
1855. He was president of the American Medical Association
in 1853, and was subsequently a member of the Board of Trus-
tees. He was a member of the Medical Association and Medical
Society of the District of Columbia, and at various times filled
leading offices in both organizations ; of the American Public
Health Association ; a delegate to, and one of the vice-presi-
dents of the International Medical Congress at Philadelphia in
1876 ; an honorary member of the New York and California
State Medical Societies, of the Boston Gynecological Society,
He was the founder of the " Rocky Mountain Medical Society,"
an organization composed of members of the American Medi-
cal Association that attended the meeting at San Francisco, in
1871. Among his many writings may be mentioned : "Abortion
in a Medical and Moral Aspect," in 1861 ; "Arrest of Devel-
opment of the Cranial Bones; Epilepsy," in 1861; "Maternal
Instinct or Love," 1864; "Propriety and Necessity on Com-
pelling Vaccination," 1865; " Anniversary Oration before the
Medical Society of the District of Columbia," 1866 ; "The Port-
ability of Cholera and Necessity of Quarantine," 1866, joint
paper with Charles A. Lee, M.D. ; "History of Inoculation in
Massachusetts," 1867; "Medical Register of the District of
Columbia," 1867; "Address at the Dedication of Medical Hall,
Washington," 1869: "Statistics of Representation in the Ameri-
can MedicalAssociation," 1870; "Necrology of the Physicians
of the Late War," 1870; Prepared "Medical Register of the
United States," 1871; "Sketch of the Life of Dr. Charles A.
Lee," 1872: "Statistics of the Board of Health in the United
States," 1873; "Free Parks or Camping Grounds, or Sanita-
riums for Sick Children of the Poor in Cities," 1873; "Facts
of Vital Statistics in the United States, with Diagrams," 1872:
"Statistic Sketch of the Medical Profession of the United
States," 1873: "Statistics of the Medical Associations and
Hospitals of the United States, 1873; "Address as President
before the American Medical Association," 1874; "Diction-
ary of Elevations and Climatic Register," 1874; "Annals of
Medical Progress and Education in America," 1874; "Contri-
butions to the Study of Yellow Fever in the United States :
Its Distribution, with Weather Maps," 1874; "Annual Ora-
tion before the Medical and Chirurgical Faculty of Maryland,"
1875; "Biographic Sketch of Dr. John D. Jackson," 1876;
"Medical Men of the Revolution; an Address before the
Alumni of Jefferson Medical College," 1876; "Sketch of the
Life of Dr. T. M. Logan," 1876; "Biography of Dr. John
Morgan of Philadelphia," 1876; "Address on Biograjihy
before the International Medical Congress," 1876; "Water
Supply of Cities; Public Health Association," 1876; "Notes
on the Burning of Theaters and Public Halls," 1876 ; etc.
During his whole life he was one of the most industrious mem-
bers of the profession, and as he always verified every quota-
tion, he liked to be known as the "fact hunter." His card
indexes were prepared mostly by himself. Socially, Dr. Toner
was more prominent than any other member of his profession
in Washington, and his influence in shaping scientific and
medico-political matters at the capital was very great. His hand-
some, genial countenance will be greatly missed, and he will
have no more sincere mourners than those of his colleagues
who have met him at the annual meetings for over a third of
a century, and who will remember his fraternal hand grasp and
his kindly smile with deep regret at the loss of a faithful
friend and colleague.
William Morris Holt, M.D., of Anchorage, Ky., died at
1896.]
MISCELLANY.
391
the St. Joseph Infirmary, Louisville, Ky., of appendicitis, on
the 4th inst. He was operated on the day before he died, but
the abscess was general and the operation was too late. Dr.
Holt was born fifty six years ago in Henderson, Ky., and grad-
uated at the Louisville Medical College, beginning practice
soon after at Lebanon, Ky., where he remained until about
Bfteen years ago, when he removed to Anchorage where he
enjoyed a large and lucrative practice up to the time of his
death. He was of a kind and jovial disposition and his death
is a great loss, not only to the profession, but to the commu-
nity in which he lived.
I, wvKKNiK C. Cortelyou, M.D. (Bellevue Hospital Medical
College, New York City, 1864) at New York, August 5, aged
SO rears.
SOCIETY NEWS.
American Public Health Association. The Twenty-fourth
Annual Meeting of the American Public Health Association
will be held at Buffalo, N. Y., Sept, 15-18, 1896. The Execu-
tive Committee have selected the following topics for consid-
eration : "The Pollution of Water-Supplies;" "The Disposal
of Garbage and Refuse ;" "Animal Diseases and Animal Pood ;"
"The Nomenclature of Diseases and Forms of Statistics ;"
"Protective Inoculations in Infectious Diseases;" "National
Health Legislation ;" "The Cause and Prevention of Diph-
theria;" Causes and Prevention of Infant Mortality;" "Car
Sanitation ;" "The Prevention of the Spread of Yellow Fever ;"
"Steamship and Steamboat Sanitation ;" "The Transportation
and Disposal of the Dead;" "The Use of Alcoholic Drinks
from a Sanitary Standpoint;" "The Centennial of Vaccina-
tion;" "The Relation of Forestry to Public Health ;" "Trans-
portation of Diseased Tissues by Mail ;" "River Conservancy
Boards of Supervision." Upon all the above subjects special
committees have been appointed. Papers will be received upon
other sanitary and hygienic subjects.
Officers, 1895 96 : — President, Dr. Eduardo Licgaga, Mexico,
Mex. ; first vice-president, Lieut. -Col. Alfred A. Woodhull,
Medical Dept., U. S. A., Denver, Col. ; second vice-president,
Dr. Henry Sewall, Denver, Col. ; secretary, Dr. Irving A. Wat-
son. Concord, N. H. ; treasurer, Dr. Henry D. Holton, Brat-
tleboro, Vt.
The Canadian Medical Association. — This Association will hold
its twenty-ninth annual meeting at Montreal, Aug. 26-28, 1896.
The following papers will be read : ' ' Hemorrhagic Pancrea-
titis," A. McPhedran, Toronto ; Title to be announced,
Wm. Osier, Baltimore; "100 cases of Retroversion of the
Uterus, treated by Ventrofixation and Alexander's Operation,
with subsequent results," A. Lapthorn Smith, Montreal : "The
Influence of Mitral Lesions on the Existence of Pulmonary
Tuberculosis," J. E. Graham, Toronto; "A Note on Amputa-
tion at the Hip Joint in Tubercular Disease," A. Primrose,
Toronto; "Tetanus following Scarlatina," J. B. McConnell,
Montreal ; "Etiology and Treatment of Acne Vulgaris," A. R.
Robinson, New York ; "The Foot, its Architecture and Cloth-
ing," B. E. McKenzie, Toronto ; "Ophthalmia Neonatorum,"
R. Ferguson, London ; " Observations on the Relation between
Leuchemia and Pseudo-leuchemia," C. F. Martin, G. H. Mat-
thewson, Montreal ; "Thyroidectomy," D. Marcil, St. Eustace,
Q. ; " Some Observations on the Heredity of Carcinoma," T.
T. S. Harrison, Selkirk : " Some Applications of Entomology
in Legal Medicine," Wyatt Johnston, George Villeneuve,
Montreal; " Physiologic Demonstrations of Interest to Medi-
cal Men," Wesley Mills, Montreal : "The Theory of the Elim-
inative Treatment of Typhoid Fever," W. B. Thistle, Toronto ;
"Oral Surgery," G. Lenox Curtis, New York ; " Vaginal Fix-
ation of the round Ligaments for Backward Displacements of
the Uterus," Hiram N. Tineberg, New York; "Clergyman's
Sore Throat(?)," J. Price-Brown, Toronto; "Non-malignant
Tumors of the Tonsil, with report of a case," H. D. Hamilton,
Montreal ; " Sinus Thrombosis, associated with acute Suppur-
ative Otitis Media, occurring during Scarlet Fever," J. W.
Sterling, Montreal; "(a) Exhibition of an Artificial Nose-
bridge, (b) Some cases of Foreign Bodies in the Eye, in which
the Electro- magnet was used successfully," F. Buller, Mon-
treal : " Remarks on Cold Air in the Treatment of Pulmonary
Tuberculosis," Edward Playter, Ottawa; "Hereditary Cere-
bellar Ataxia (with patient), D. Campbell Myers, Toronto; "A
report of three cases of Abdominal Section for Conditions Com-
paratively Rare," H. Meek, London ; "Early Atrophy of Mus-
cles in Cerebral Disease," Frederick G. Finley, Montreal ;
Title to be announced, F. J. Shepherd, Montreal; "Electric
Baths and Dyspepsia," A. L. de Martigny, Montreal ; Title to
be announced, J. C. Webster, Edinburgh; " Militia Medical
Reorganization," W. Tobin, Halifax;
MISCELLANY.
Name of South Carolina Asylum Changed.— The South Carolina
institution formerly known as the " State Lunatic Asylum"
has had its name changed by law to the more euphonious one
of " State Hospital for the Insane."
Appropriation for Vaccin and Antitoxin. — The Chicago city
council has appropriated $25,000 for the purchase of vaccin,
antitoxin and the employment of physicians to prevent the
spread of smallpox and diphtheria.
Date of Meeting of South Carolina Examiners. — The general assem-
bly of South Carolina has changed the date of the regular
meeting of the State board of medical examiners, at Columbia,
S. C, from the fourth Tuesday in April to the third Tuesday
in May, each year.
Medical Heroes.-~A hall has been established in the Val de
Grace Hospital in Paris, where the names of French medical
men who died in the performance of their duty are inscribed
on marble tablets. A list of 143 practitioners has just been
placed on its walls, all of whom perished in the yellow fever
epidemic in San Domingo, 1801-1803.
The Old "Faculte de Medecine." — This structure has been bought
by the city of Paris as a historic monument. There is great
rejoicing in medical circles that the municipality has pur-
chased this superb specimen of fifteenth and eighteenth cen-
tury architecture, around which cluster so many memories,
as the "cradle of medicine." It will probably be devoted to
a scientific museum.
Age of Consent Advanced in South Carolina. — Section 2460 of the
general statutes of South Carolina of 1882, defining the crime
of having carnal knowledge of a woman child has been amended
by changing the age from ten to fourteen years, and providing
that where the woman or child is over ten years of age the jury
may recommend mercy and the penalty shall be reduced to
imprisonment for a term not exceeding fourteen years.
Fees for Examinations for Life Insurance. — The Equitable Life
Insurance Company of New York has issued the following cir-
cular to medical examiners: "Please take notice that for
medical examinations for new insurance in this society made
in the United States, the Canadian provinces and Newfound-
land on and after July 1, 1896, compensation will be by the
uniform fee of $5 for each case of a completed examination
report and opinion of the risk, rendered according to the
society's standard blank form for a medical examination
report. The cost of an examination for the restoration of a
lapsed policy is to be borne by the subject, and not by the
society. The fee in such cases is accordingly a matter of pri-
vate arrangement between the examiner and the examinee." —
Med. Exam., July.
Vacancies in South Carolina Boards of Health.— The South Caro-
lina statute approved Jan. 5, 1895, entitled "An act to estab-
lish local boards of health in the cities and incorporated towns
of the State and to define the powers thereof," has been
amended, by act of 1896, providing that in all cases of vacan-
cies on said board occurring from any cause at any time, said
392
MISCELLANY.
[August 15,
vacancies shall be filled by appointment for the unexpired
term or terms. The city as well as town council is also now
expressly authorized to impose or collect the 825 fine provided
for failure of any member after accepting and being duly
elected, to qualify and serve on the board.
Medical Service at the Paris Exposition of 1900. — It is amusing to
note in the discussions of this subject that the medical service
at our Columbian Exposition seems to be regarded by the
Parisians as an unattainable ideal, absolutely beyond realiza-
tion. Baudouin of the Progres Mid. remarks that he actually
had to lie down on one of the beds in the hospital inside the
grounds at Chicago, to convince himself that he was not
dreaming.
To prevent Adulteration of South Carolina Candy.— A law was
passed at the recent session of the general assembly of South
Carolina prohibiting, under penalty of not less than 850 nor
more than 100, the manufacture for sale, knowingly selling, or
offering for sale, of any candy adulterated by the admixture of
terra alba, barytes, talc, or any other mineral substance, or by
poisonous colors or flavors or other ingredients deleterious or
detrimental to health. The candy so adulterated shall be for-
feited and destroyed under direction of the court.
The " American Suture" the Invention of Chassaignac— The intra-
dermic suture was much admired by Pozzi as he saw it em-
ployed at the Johns Hopkins Hospital in Baltimore on his visit
to this country. He introduced it into France, where it has
been quite generally adopted, and called the "American
suture." It has now been found that it was originally the
invention of Chassaignac, and is described by him in full in
the Bulletin de therapeutique in 1852. Hereafter the French
will call it the Chassaignac suture. As the little knots to hold
the thread are hard to make, some surgeons use a small piece
of lead for the purpose, and others a small roll of iodoform
gauze, which is always ready and requires no further steriliza-
tion.— Union Mid., July 11.
The Silver Craze.— As a foretaste of what may be a common
occurrence, we print the following from one of our advertisers,
a very shrewd business man, who writes us a follows : "Refer-
ring to the way of advertising which you suggest, I already
submitted to our board a proposition of this kind, which you
made to me, at the time I had the pleasure of seeing you in
Chicago, but they don't like to advertise in this way, and just
now, they requested me to limit the advertising expenses as
much as possible, because we don't know how the anarchists of
the Windy City will turn out in November, at the time of the
elections. You will understand quite well, that if we have to
pay for our goods in gold and get 53 cents in silver for $1.00 of
gold, we will be in such a bad fix that we will have to reduce
still more our advertising expenses in order to meet all emer-
gencies. I don't believe that we will do anything new in the
way of advertising between now and the end of this year. We
are cautious people and we never do anything which we are
not sure we can carry out."
Cessation of a Medical Journal in Havana.— The Revista de
Ciencias Medicas, of Havana, closes its eleventh and last year
with the June number. The farewell editorial pathetically
states that the management is compelled to this decision by
" the circumstances through which the country is passing, the
general scarcity of resources, the dispersion of the noble medi-
cal family . . . the absence of beloved friends whose coop-
eration has been so valuable to us, but especially as the imme-
diate cause, by the assessment levied upon a periodical devoted
exclusively to the publication of scientific matters. . . .
" Stronger and more solid structures have fallen, men of prom-
inence have been overwhelmed, familyafter family ruined, and
happy hearths deserted ; the disappearance of the Revista is
merely an incident in the general ruin and desolation on all
sides."
Fees for Postmortem Examinations in South Carolina.— By law
passed in 1896, physicians in South Carolina shall be paid the
following fees for postmortem examinations and testifying at
coroner's inquests : For a postmortem examination and testify-
ing, when no dissection is required 85; when dissection
is necessary and the body not interred, if requested, by
the coroner's jury, $10; for same after interment for three
days or more, $15 ; for chemic analysis, a sum not exceed-
ing $40 and expenses for such analysis; and when chemic
analysis has been made the chemist who makes it must
furnish to the county board of commissioners, with his account
a full statement of the analysis. The clerk of the county board
of commissioners shall verify and file with the clerk of court of
general sessions a copy of such statement of analysis and
account. Provided, that nothing contained in this act shall
apply to counties of Barnwell and Williamsburg. The account
of claim for the services herein named shall be certified to by
the coroner, and if dissection is made it shall be certified that
it was done at the request of the jury.
Progress in the Preventive Treatment of Cholera.— The May num-
ber of Annates Pasteur, reports another forward stride in our
knowledge of cholera, and the methods of preventing it. Roux,
Metchnikoff and Taurelli announce that they have estab-
lished the fact that cholera is an intoxication, and to combat
it an antitoxic serum is required and not an antimicrobian as
Pfeiffer asserts. This serum they have succeeded in produc-
ing for experimental purposes. Animals injected with it before
they are inoculated with the comma bacilli, resist the action
of the latter in most cases, while animals inoculated without it
almost all succumb. The same favorable results are obtained
if the serum is administered simultaneously with the bacilli cul-
ture. But the results are negative if it is administered after
the inoculation. The serum therefore is not curative, but it
is preventive, which is, however a great advance. The exper-
imenters hope to secure better results when they have obtained
a stronger serum.— Annates de la Soc. MM. Chir. de Liige,
June.
Liquid Salol in Surgery.— Salol becomes liquid at a temperature
of 108 degrees and remains fluid for fifteen to twenty minutes.
In this state it is slightly syrupy, but much less than glycerin
and will pass through a Pravaz syringe without the slightest
difficulty. While fluid, different antiseptics can be mixed with
it, and as it solidifies the two substances become intimately
blended. Salol thus combined with iodoform or aristol has
many uses in surgery, especially in cases of osseous cavities
from tuberculosis, osteomyelitis, etc. After trephining it can
be used in the place of iodoform gauze, with the advantage
that the suture can be made directly on the injection, and
union by first intention thus secured. It can be prepared at a
moment's notice at the bedside, by heating the salol and the
other substances together in a test tube over a lamp. It has
also proved very effective in tuberculous adenitis. Two or
three drops of the iodoform-salol injected into the tumor will
either abort it or else render it much more benign in its devel-
opment.— Reynier in the Jour, de M. et de C. Prat. Quoted
by the Annates de la Soc. Mid. -Chir. de Liige, June.
Sudden Death after Puncture of a Hydatic Cyst.— Chauffard
reports a case of almost immediate death with symptoms of
a triple reaction, cutaneous, cerebrospinal and myocardiac,
following a simple exploratory puncture with a Pravaz syringe,
of the anterior surface of the liver, below the ribs. Ten centi-
meters of a characteristic limpid fluid were withdrawn, con-
firming the diagnosis of hydatic cyst. The subject was a vig-
orous man, 38, with traces of old benign syphilis, malarial
attacks in 1887,at which time he was drinking absinthe to excess,
but not since. The necropsy showed marked compensation in
the liver ; the sound lobe weighing 1,205 grams, and the other
1,245. The liver with the cyst weighed 6,500 grams. The
18%.]
MISCELLANY.
393
Other organs were apparently normal ; death occurred in sys-
tole. ;ind the heart was found empty. The hydatic fluid was
tested both chemically and by inoculating guinea pigs, with
negative results. Xo alkaloids were discovered in it, but there
were traces of an albuminoid, apparently belonging to the
niuein group. Chauffard attributes the fatal result to the
■escape of some of the hydatic fluid into the peritoneum, as the
puncture had been completed several minutes before the dis-
turbanees began. The intense toxic effect can only be due to
some individual reaction or idiosyncrasy, "to use the old term
which expresses in so many instances, the limits of the know-
able." lie adds the warning that owing to the possibility of
such an idiosyncrasy, which it is impossible to foresee, this
operation is ono to be approached with caution in cases of
hydatic cyst. His report includes a review of the literature on
the subject. S maim Mtdicoie, July 8.
Retirement of Dr. I. N. Love from Marion-Sims College, St. Louis.—
Dr. Love, who hits been for many years connected with medical
-college circles of St. Louis, has tendered his resignation, owing
to the fact that his private practice and his Medical Mirror
work require his undivided attention. The Alienist and
Xe urologist of St. Louie for July says : "The resignation of
Dr. I. N. Love from the chair of Clinical Medicine and Diseases
•of Children in Marion-Sims College of Medicine leaves a void
in the faculty of this institution that will not be easily filled.
Love's lectures are fluent and instructive, and so entertaining
as to always hold his class in rapt attention while he speaks, a
•desideratum in the teaching corps of a medical college too
often overlooked. In many medical schools no style of speak-
ing and teaching is considered too dry for the medical student,
-a plain-speaking knowledge of the English language not
always being regarded as requisite. Love taught the science
of his chair in entertaining phrase and never made a student
tired to listen to him." Dr. Love's large acquaintance and
great popularity in the medical profession of America as well
as abroad, together with his ability as a teacher, should make
his place hard to fill in any college. A special committee
appointed by the faculty, composed of Drs. B. M. Hypes, R. C.
Atkinson and C. Borck, expressed full appreciation for past
services of Dr. Love and kindliest hopes for future pleasure
and profit in all his relations.
The Etiology of Appendicitis.— There has been much discussion
of Dieulafoy's statement that appendicitis is invariably caused
by a calculus or some accumulation of fecal or foreign matters,
which obstruct the appendix and transform it into a closed
-cavity. It is confirmed by Klecki and Roger, who have proved
that the bacilli circulating harmlessly through the intestines,
acquire extreme virulence when arrested and forced to stagnate
in a closed cavity. In this virulent state they soon find their
■way through the enclosing walls and produce infection, even
before there is actual perforation. Dieulafoy ascribes the
-obstruction of the appendix in many cases to the formation of
-a calculus and states that the appendix makes a trio with the
renal and biliary systems in the formation of calculi. He
classes appendicitis with the arthritic family, in which the
French include all forms of rheumatism and rheumatic neu-
ralgia, gout, obesity, and the tendency to the formation of bil-
iary and renal calculi, as also asthma and migraine. These
diseases are not contagious, but they are all hereditary, that is
they can be transmitted from parent to offspring, either
directly or by the inheritance of the tendency, so that although
the offspring may not inherit the same disease, he is liable to
any one of the group, as they are chronic conditions of imper-
fect chemic or organic transformations in the organism. The
Germans are not so fond of grouping diseases as the French,
and the arthritic tendency is neither so frequent nor so pro-
nounced with them as in the countries farther west, conse-
quently Dieulafoy's classification has not been accepted in
Germany.— Deutsche Med. Woch., July 2.
Etiology of Hysteria. -An article with this title by Sigm.
Freud has just been concluded in the Wien. Klin. Rundsch.,
Nos. 22 to 26. He makes the grave assertion that hysteria,
hysteric parasthesia or paraplegia, hysteric sensations, etc.,
and probably also paranoia, "compulsory ideas" and various
psychoses, are all traceable to one cause, viz., conscious or
unconscious memories of sexual occurrences in early childhood,
and that the character of the neurosis is directly determined
by the character of the sexual actions. The hysteria com-
mences with an effort of the will to throw off some haunting
idea ; this idea is connected either logically or by association
with some unconscious memory ; this unconscious memory is
invariably of one or more sexual occurrences dating perhaps
from the earliest childhood. The hysteria usually develops
after puberty, but in the severest cases it commences with
unfailing regularity at the eighth year. The sexual events that
preceded it date therefore, from a still earlier age, in some
cases from the fourth, third or even the second year. In the
eighth year, the period following the second dentition, the sex-
ual system probably passes into another stage of development,
as the same sexual events commencing or continuing after this
period, have none of this pathogenic effect. Freud believes
that the original instigation always proceeds from an adult.
His statements are based on extensive clinical experience, and
scrupulously careful investigations. He expects to meet with
opposition and incredulity, until the pathogenic power of
unconscious memories is more fully recognized than at present.
On the Indecency of Patent Medicine Announcements.— The Medi-
cal and Surgical Reporter commends the conductors of the
Ladies' Home Journal for their avoidance of those advertise-
ments, so largely addressed to suffering mankind, and for tak-
ing the ground that as the better portion of the medical pro-
fession will not advertise, they the conductors of the Journal
will not cater to those not in good standing in their profession
and yet willing to publish their wares. It further says : "The
patent medicine monger has recently awakened to the fact
that young girls have not been sufficiently instructed in the
psychic and physical phenomena of puberty and menstruation.
Here, as in modern fiction, the worst sinners are women who
first catch the eye of the victim with some such complaint as
that "only a woman can understand woman's woes." Fre-
quently we encounter the picture of a miss of 18 writhing with
dysmenorrhea, and the latest abomination is a novelette in
which some phase of female weakness stands between the
heroine and marital bliss, and in which sexual restoration, a
vegetable compound, and marriage bells are artistically ming-
led. The purpose of such advertisements is manifestly to
direct the attention of the young woman to her sexual organs,
to exaggerate the importance of trifling abnormalities incident
to civilized life, to awaken the sexual instinct, and at the same
time to arouse forebodings as to the existence of some physical
obstacle to marriage and reproduction, so that a sale of reme-
dies may be effected. Although actual indecency of phrase-
ology is studiously avoided, the moral and mental tendencies
of such literature are decidedly injurious. We grant that the
ideal of the last generation of ignorance as innocence was not
a wise one, and that the girl should be instructed in the phy-
siology and hygiene of the pelvic organs. But the instructor
should be the mother, teacher, or some other intimate and
mature female friend, and we would prefer ignorance to the
obtaining of knowlege from a mercenary charlatan, while false
modesty is better than no modesty at all.
The climax of indecency is reached with the proclamation of
the abortifacient nostrum. Pennyroyal seems to be the favor-
ite catch- word, and women are informed that the pill or powder
in question is prompt, sure and safe, and this statement is
often coupled with the sly intimation that it should not be
taken by women who are pregnant, since it will produce abor-
tion. In many, if not most cases, the women who buy these
394
MISCELLANY.
[August 15,
nostrums desire the discharge of something more than
blood from the uterus, and the advertiser, without direct
allusion to criminal therapeutics, is calculating not on the pat-
ronage of women already in trouble, but on those who will
yield more readily to temptation if the danger of pregnancy is
eliminated."
A Sneer from Merck's " American Medico-Surgical Bulletin."— The
shrinking modesty characteristic of a trade organ, believed to
be operated by and for an importing branch of a foreign drug
house in New York city, induces it to print the following ill-
mannered slur. This is the sheet that has heretofore omitted
no opportunity to print unkind and discourteous words of the
Association and its membership :
"The Journal of the American Medical Association. —
Our most esteemed friend in spirit, the Journal or the Ameri-
can Medical Association, appears to be having a wofully hard
time in selecting a permanent abode. The atmosphere of Chica-
go does not appear to agree with it.and it thinks a little of testing
the National capital. So far no voice seems to have been raised
in favor of New York,and yet, since this is the center of medicine,
whyshould it not come to our welcoming arms — Journal, Edi-
tor, Code and all. It can fight our very much esteemed con-
temporary, the Medical Record, to better advantage here than
from a distance, and we can assure it that it will find the edi-
tor of the Record a much better and milder and every way
more acceptable individual than he appears to be from a dis-
tance. We think it might sleep in the same bed with equa-
nimity as that which another great friend of ours occupies —
the New York Medical Journal ; and we are satisfied from
personal contact that the News (late of Philadelphia and now
of New York) is overflowing with the spirit of brotherly love.
As for ourselves it would please us greatly to look at this great
organ from close quarters, and we may without loss of mod-
esty say that we think we could teach it something along the line
of fearless, independent, scientific journalism. Further still,
personal contact would make the Journal love the Bulletin a
little more and a little long, so that from every point of view
we trust that our suggestion will prove acceptable, and that
New York may become still more the headquarters of peace
and good will in medical journalism."
The Proof of Insanity.— In the April number of the Physician
and Surgeon, Professor Frank T. Lodge of the Michigan Col-
lege of Medicine, contributes a paper on insanity in its relations
to crimes, contracts and wills, inclusive of the spirit of the
laws of his State as to the proof of mental alienation. On the
latter branch of his subject he writes, "In nearly every case
where insanity is set up, physicians are called as witnesses.
The law does not recognize expert testimony in these cases as
being of any greater value than that of ordinary persons. The
credibility of each person's testimony, be it laymen or doctor,
is to be weighed and determined by the jury. Nevertheless,
if the testimony of a physician, called as an expert witness, is
properly given, it must and should have great weight with the
jury. As a rule, the physician will be called to testify with
reference to the particular person whose sanity is under con-
sideration. His testimony should be based upon a previous
examination. The subtle essence of the mind can not be sub-
jected to ocular and visual examination. Its quality must be
determined from close observation of the acts and conversation
of its owner. Most physicians testify from a short conversa-
tion with the person, and we all know how unsatisfactory such
an examination is. Nervous persons of perfectly sound mind
may appear almost insane under certain conditions, while the
wildest lunatic frequently converses for hours rationally and
intelligently. In many cases it is only when his particular
hobby happens to be touched upon that he manifests his men-
tal bias, and in the absence of previous knowledge, how can
the examiner know toward what point to direct his inquiry?
In my opinion, the sanity of no person should be decided until
he has been under close observation by competent physicians
for a considerable period, say from one to two months, under
;ill the circumstances most favorable to the examination. The
examiner should be furnished with the life history of the patient,
the history of his family for the preceding two or three gener-
ations, the mental condition of his ancestors with relation to
possible hereditary taints, and the many other details which
will readily occur to all of you. Without this opportunity for
a careful and thorough examination, there will always be
abundant opportunity for punishing innocent persons for crime,
for setting clever and unscrupulous scoundrels at large and for
depriving imbecile and incapable persons of large property
interests by the clever machinations of designing villains."
Birch Agaric in Cancerous and Non-cancerous Gastro Intestinal
Disturbances. — The belief is current in Russia that the polyporus
betulinus will cure cancer. Smirnow has been testing it and
finds that it is highly efficacious in chronic gastro- intestinal
troubles accompanying cancer and other inflammatory condi-
tions of the stomach and intestines. The cancer itself con-
tinues its course, but great relief is experienced even in a
couple of days after imbibing the strong decoction. The pain
subsides ; the food can be retained and the inflammation heals,
if not cancerous. — Semaine Midicale, July 8.
A Powerful Emetic. — A foreign contemporay states that Dr.
Kraus, privat-docent in the Medical University of Berlin, hav-
ing been called upon by the faculty to explain why his name
appeared in a testimonial of the alleged virtues of a certain
soap, "declined to do so, or even to express regret, and when
the faculty, justly indignant, inflicted upon him the severest
reprimand at its disposal, he threw up his appointment."
Notes on the British Medical Association Meeting. — At a general
meeting of the second day, Dr. Robert Saundby of Birming-
ham, was elected President of the Council for the next three
years, and on motion it was resolved to accept an invitation of
the Montreal Branch to visit Canada next year and hold the
annual meeting at Montreal in August. An amendment in
favor of Portsmouth was lost. Professor Roddick, President
of the Montreal Branch of the British Medical Association,
was appointed President elect. The business part of next
year's meeting will be transacted in London, and only the sci-
entific meetings will be held in the Dominion. The British
Association will hold its annual meeting in Toronto next year,
and it is hoped that arrangements may be made so that mem-
bers may attend both.
The Council of the Association decided to present a gold
medal to Captain Whitchurch for gallantry in connection with
the Chitral expedition, and it was presented by Dr. Barnes, the
President. This medal is rarely given, and is consequently
greatly prized by those who may be considered worthy of it.
The same medal was presented to Dr. Ormrod of Workington,
who distinguished himself in connection with the St. Helene
colliery explosion.
At the meeting of the Association last year, held in London,
there were 3,000 members in attendance ; at Bristol the year
before 897 members were present, while at Carlisle this year,
up to Wednesday evening, the second day of the meeting, only
600 had registered, showing a very small attendance in view
of the fact that the Association now has a membership of
16,332.
The scientific work of the Association is divided into nine
Sections, as follows : Medicine, Surgery, Obstetrics and Gyne-
cology, Public Medicine, Psychology, Pathology and Bacteri-
ology, Ophthalmology, Diseases of Children, and Ethics.
Speeches at the general sessions are limited to ten minutes.
At the sectional meetings no paper is allowed to exceed fifteen
minutes, and participators in discussions are allowedten min-
utes each.
1896.]
MISCELLANY.
395
The discussions in the various Sections are not reported
stenographically, but each speaker is furnished with a writing
pad at the close of his remarks and asked to write them for
publication. Neither are the remarks on motions in the gen-
oral meetings reported in e.itenso. The members of the Asso-
ciation are beginning to see the absolute necessity and impor-
tance of having their proceedings taken dawn by an expert
shorthand writer, because there is a movement on foot to the
effect that a volume of Transactions be published as soon as
possible after each annual meeting, giving full or well-con-
densed reports of all papers prepared for the meeting, with the
discussions that followed, and also verbatim reports of the
general meetings.
Duty to Sick Passengers A girl of 18 was the only passenger
on a certain street car. While there, she became sick and,
going to the door, she told the conductor that she was sick,
and asked him to stop the car, so that she might get off. He
told her to sit down, and she would feel better after a while.
She sat down, but felt worse all the time. Presently the con-
ductor passed through the car, and she again appealed to him
to stop ; but he looked at her, smiled, went to the front of the
car, and began talking to the motorman. She then felt dizzy
and sick at the stomach, became frightened and dazed, got up
from her seat, and staggered toward the rear door for the pur-
pose, she said, of seeing whether she could not get some one
on the street to stop the car, and fell unconscious through the
door, remaining unconscious for several weeks. The car had
then 670 feet to go before reaching the end of the electric route,
at which point the girl was to be transferred to a horse car for
carriage about a mile further, to her destination. An action
was brought against the street car company for damages.
June 15, 1896, the court of errors and appeals of New Jersey
affirmed a judgment for the plaintiff. McCann v. Newark
A S. O. Ry. Co. The court says that in view of the plaintiff's
youth, her illness, and her mental disorder, it can not say, as
matter of law, that she was bound to exercise the same degree
of care and forethought as persons of mature years in the full
possession of their faculties would ordinarily exercise; and
that it was for the jury to determine whether, under the pecu-
liar conditions then existing, she had used such prudence as
it was reasonable to require. The court also holds that it was
lawful for the jury to find that, when the plaintiff made
her second appeal to the conductor, he was apprised of her
serious illness, or, at least, should have inquired further as to
her condition. The jury also had the right, the court says, to
conclude that, on perceiving or informing himself of the extent
of her sickness, it became his duty either to stop the car, so
that she might alight as she requested, or else to afford her
such reasonable attention as would save her from harm in the
moving vehicle. He did none of these things, but passed her
by heedlessly, and left her utterly uncared for, when there was
no other person at hand to render her assistance. Such conduct
would not fulfill the duty of the defendant as a carrier of pas-
sengers. It is but a corollary from the principle which enjoins
upon these carriers reasonable care for the security of their
passengers that when, through sudden illness, a passenger
becomes less able to look after his own safety, and that fact is
made known to the proper agent of the carrier, the latter must
exercise toward the passenger a greater degree of care than is
demanded in ordinary circumstances.
Louisville.
Pure Water. — The filter tests, a reference to which was
made in these columns some time ago, have at last been com-
pleted and the reports of the experts will be made to the Water
Company in the near future. A year ago the Louisville Water
Company invited all representatives of water filters in the
country to compete in a test of efficiency, making very liberal
propositions in regard to the conduct of the tests. The result
was that four companies erected filters on the ground at the
pumping station, the water and steam power being furnished
by the water company from the pumps at work. The contest
has attracted not only local interest but has attracted the
attention of the scientific world, and the success of the test
means the adoption of the filter by all the principle towns of
the Ohio and Mississippi Valley. The question of a whole-
some water supply has agitated the minds of the people of this
community for some time, for with every freshet and flood the
Ohio becomes a rushing stream of mud, carrying along the
drainage from five States at least. The public has not as yet
benefited by these tests, for the water pumped into the filters
has been allowed to run back at once to the river, but we live
in hopes that there will be at least one of the filters represented
accepted. The water company had as its representative in the
laboratory specially erected, Mr. George W. Puller, from the
Lawrence Experimental Station in Massachusetts, a man of
ability and experience. Throughout the test the character of
the water from the river, filtered and unfiltered, and the action
of the filters had to be carefully recorded and the report is a
most thorough and exhaustive one. Three of the filters use
alum and the fourth is an electric one. The company has been
unusually fortunate in having such a protracted muddy spell
as they have had while the tests were in progress, for it has
not been equaled since 1875.
Smallpox. — Seven cases of smallpox have developed near
Paducah, supposed to have been contracted from the pest-
house, which is located near one of the most frequented pikes
near the city. There has already been a lawsuit in regard to
this building, which is regarded as a menace to the commun-
ity on account of its location.
Medico-Literary Notes.
Guy's Hospital Gazette. — The editors of this journal have,
with that energy and acumen which characterizes them, issued
a special Festival Number. It gives a full account of the great
festival dinner and an interesting sketch of the history of the
hospital.
In a recent work published in Paris by the SocUU d' Edi-
tions Scientifiques, Dr. A. Calmette gives in epitome the result
of his investigations into the nature of snake poison and the
best way of treating envenomed bites. The only drugs he has
found beneficial are the hypochlorite of lime and the chlorid of
gold, the use of the latter having been recommended by him in
1892 ; but he maintains that in the serum of immunized horses
there exists a perfect antidote against snake poison. The
serum is now prepared in a bulk at the Pasteur Institute in
Lille, of which Dr. Calmette is the director. The price of the
the book is 3 francs.
A Medical Man's Experience at Sedan. — Dr. Charles E.
Ryan, now of Glenlara, Ireland, has written quite an elaborate
account of his services with an ambulance during the Franco-
German War, and his personal experiences and adventures
with both of the opposing armies in 1870-1871. This book may
be best described as a series of photographs of the tragic side
of a most tragic war. A simple record of what the author or
his comrades saw, it constitutes nevertheless an impressive
word-painting, and affords a painful view of the ghastly scenes
which form the background of the romance of battle. Dr.
Ryan was a member of an Anglo-American ambulance in the
Franco-German War, and by force of circumstances was
brought into close contact with both French and Germans.
He does not conceal the fact that he felt great enthusiasm for
France at the first, and that his sympathies were throughout
with her. Yet he is an honest and just man, and did not fail
to note the shortcomings of the French and to recognize the
merits of the Germans.
The Standard Biography of Dr. O. W. Holmes, "the
genial Autocrat," has appeared in admirable form under the
title of "Life and Letters of Oliver Wendell Holmes." The
396
MISCELLANY.
[August 15, 1896.]
Book News, June, contained the following points of informa-
tion interesting to the medical profession: "We have before
us one of the most delightful biographies ever produced in the
United States, in these two volumes. The author, Mr. John
T. Morse, Jr., has every qualification for his task, including
that of relationship, as he was a nephew of the subject of the
book. All the material obtainable in the form of letters and
autobiographic notes has been placed at his disposal, but
these are less copious than may have been expected. It appears
that letter writing was irksome to Dr. Holmes, and conse-
quently his letters were comparatively few. A report has been
current that Dr. Holmes for some time before his death was
engaged upon an autobiography. It turns out, however, that
he left only some disjointed memoranda in which he had not
advanced beyond the period of youth, and had not even cov-
ered that period consecutively and thoroughly. Instead of
weaving these notes into his text, the biographer has thought
it better to print most of them collectively in a separate
chapter.
Medical Journal Enterprise in Paris. — The publishers
of one of the medical papers of Paris, it is said, have hired a
large shop almost opposite the School of Medicine on the
Boulevard St. Germain, and transformed it into a reading room,
free to all the physicians and medical students of Paris, to each
of whom a card of admission was sent. The front part of the
establishment opens directly on the street, and on one side
contains notices of anything which may be interesting from a
medical point of view, such as courses of lectures, etc. ; the
other side is devoted to the latest reports from various news
agencies. In the rear of the establishment are found numer-
ous desks, paper and ink, and a case containing several hun-
dred medical papers from various parts of the world. The
reading room opens into a small garden where the visitor may
smoke. — Boston Med. Journal.
A Cholera Tract from India. — A most useful little pam-
phlet on "The Cause and Prevention of Cholera" has been
written by Mr. E. H. Hankin, chemical examiner and bacte-
riologist to the Northwest Provinces and Oudh. It is intended
for the people of India, showing how they can easily mitigate
the prevalence of cholera by strict attention to the purity of
their water supply. Mr. Hankin says that twenty-four cholera
epidemics, of which he knows, were stopped on the disinfection
of the wells with permanganate. He advises that the perman-
ganate should be added at sunset, so that it may have all the
night to settle. In this way the sediment has time to fall to
the bottom, and on the following morning the water is fit to
drink. The theory being that the permanganate removes
the organic matter, consequently the microbes cease to thrive.
THE PUBLIC SERVICES.
Army Changes. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Aug. t to Aug. 7. 1896.
Capt. William D. Crosby, Asst. Surgeon (Ft. Missoula, Mont.), is granted
leave of absence for one month.
Major James C. Worthington, Surgeon, leave of absence granted on
account of sickness is further extended one month on account of
sickness.
Navy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending Aug. 8, 1896.
P. A. Surgeon G. H. Barber, detached from the " New York," ordered
home and granted two months' leave.
P. A. Surgeon v. C. B. Means, detached from the " Maine " and ordered
to the " New York."
Marine-Hospital Changes. Official list of changes of station, and
duties of Medical Officers of the U.S. Marine-Hospital Service, for
the sixteen days ended July Si, 1896.
Surgeon H. E. Carter, directed to inspect Marine-Hospital Service at
Tampa, Fla.. July 28. 1896.
P. A. Surgeon. C. T. Peckham, directed to report to Surgeon Godfrey,
chairman of board for physical examination, July 24, 1896.
P. A. Surgeon B. W. Brown, granted leave of absence for six days, July
23. 1896.
P. A. SuTgeon W. J. S. Stewart, granted leave of absence for four days,
July 17, 1896.
Asst. Surgeon C. E. Decker, to proceed from Battle Creek, Mich., to St.
Louis, Mo., for duty, July 21. 1896.
Asst. Surgeon Emil Proehazka, granted leave of abseuce for twenty days.
July 23, 1896.
BOARD CONVENED.
Board convened to meet at Port Townsend, Wash., for the physical
examination of P. A. Surgeon C. T. Peckham; Surgeon John God-
frey, chairman ; W. G. Stimpson, recorder, July 21, 1896.
PROMOTION.
P. A. Surgeon C. E. Banks, commissioned as Surgeon, July 27, 1896.
DEATH.
Surgeon C. S. D. Fessenden, died at Salem, Mass., July 23, 1896.
Circular Letter.
Treasury Department,
Office of the Supervising surgeon-General M.-H. Service,
Washington, D. C, July 81, 1896.
Tn the Medical Officer/! of the U. S. Marine-Hospital Service:— It is with
regret that I have to annouuce to the medical officers of the Service the
death, on the 23d iust., from a complication of heurt and kidney affec-
tions, of Surgeon Charles Stewart Daveis Fessenden. Surgeon Fessen-
den was the senior surgeon of the corps, having served since April I,
1861 — a period of more than thirty-rive years. He was born in Portland,
Maine. Feb. 23. 1828, and was of a family noted in the annals of his native
State and the nation. His father, General Samuel Fessenden, was for
many years a leader at the bar of Maine, and his eldest brother, William
Pitt Fessenden, was the distinguished senator of that State, and during
the administration of President Lincoln became Secretary of the
Treasury. Two nephews of Surgeon Fessenden rose to the rank of
Brigadier General duriug the Civil War, and others have been promi-
neut iu private life, two of them in the profession of medicine.
Surgeon Fessenden was fitted for college at Portland Academy, and?
in 1844 entered Harvard University, where he pursued his studies for
one year; leaving Harvard he became a student at Bowddin College,
from whence he was graduated in 1848.
He studied medicine under Charles W. Thomas, M.D., of Portland,
Maine, and attending medical lectures at the Medical School of Maine
and also in New York, was graduated In 1851 from the Medical School1
of Maine. From 1833 to 1856 he was physician in charge of the Portland
City Hospital, alter which date he became a private practitioner until
his appointment as surgeon in the Marine-Hospital Service in 1861.
During the period of his membership in the corps, he served as com-
manding officer at the ports of Portland, Maine, New York, N. Y., St.
Louis, Mo., Norfolk, Va., Louisville, Ky., and Mobile, Ala. Duriug this
period he was also a member of three boards of medical officers con-
vened for the examination of applicants for (he Service, and of eight
boards convened for the physical examination of candidates for admis-
sion to the revenue cutter service, beside serving on various special
details as inspector.
On account of the failure of his health in the fall of 1895, he was
ordered to appear before a board of medical officers for physical exam-
ination, and in accordance with the report of the board was placed on
waitiug orders Nov. 22, 1895.
During the few months which intervened between this date and his
demise, Surgeon Fessenden resided at Silem, Mass., at which place his
death occurred. Respectfully yours, Walter Wy.man.
Supervising Surgeon-General, M.-H. S.
Change of Address.
Dunne, A. J., from Springfield to Pittsfieid, Mass.
Johnson, C. W.. Litchfield, 111,, to 625 Locust Street, St. Louis, Mo.
Kober. G. M., Washington, D. C, to Box 277 Winchester, Va., (care of
Mr. Spangler) ; Klebs, E., from 422 Center Street, to Hotel Majestic
Chicago.
Stanley, F. A., from Mobile, Ala., to Julien Hotel, cor. 68d street and
Stewart Avenue, Chicago, 111.
LKTTERN KKI'KIVKl)
Allen, B. Ci., Robblns, Teun.; Ammonia] Chem. Co., New York, N. Y. ;
Asdale, W. J.. Pittsburg. Pa.
Brothers, Samuel, New York, N. Y.; Benjamin, D., Camden. N. J.;
Battle Creek Sanitarium (2), Battle Creek, Mich.: Burr, C. B., (2) Flint,
Mich.; Buehler, Jacob, Indianapolis, Ind. ; Blakely, T. J., Avalon, Mo. ;
Brophy, Truman W., Chicago, III.
Cokenower, J. W., Des Moines, Iowa; Coffman, W. H., Georgetown,
Ky.
De Courcy, J. O , St. Libory, 111.
Elliott, J. L., Duluth, Minn.
Fehr, Julius, Hoboken, N. J.; Fairchild Bros., & Foster, New York.
Gihon. A. L., New York, N. Y. ; Gundrnm, F., 8acramento, Cal.
Howe, Lucien, Buffalo, N. Y.; Henley, A., Fairmount, Ind.: Hodges,
J. Allison, Richmond, Va.: Hayne, H. W.. (2) Lawrence, Kan. ; Hassard,
J. G. & Co., New York, N. Y.
Kiernan, Jas. G.. Chicago, 111. ; Kearsley, M. J., Austin, 111.
Loewy, Arthur, Elgin, 111.
McAlester, Alex.. Camden, N. J.; Marchand, Charles, New York, N. Y.;
Miller, Irving, Baltimore, Md.: Mclntire. Chas., Easton, Pa.; Moore, J.
N.. Atlantic Mine, Mich.; Mullen, T. R., Marcus, Iowa.
Newell, Mary E., Altoona. Pa.
Prevatt, J. B„ Levyville. Fla.
Reed, R.. Harvey. Columbus, Ohio: Resinol Chemical Co., Baltimore.
Sattler, Robert, Cincinnati, Ohio ; Strueh, Carl, Chicago, 111. ; Stengel,
Alfred, Philadelphia, Pa.; Sander, Enno M. W., Co.. St. Louis. Mo.;
ScheringA Glatz, New York, N. Y.; Starkey, Horace M., Chicago, 111.;
Smith, H. F.. New Troy. Mich.
Tuley, Henrv E., Louisville, K».
Walker, W. K., Philadelphia Pa.; Walker, A. B., Canton, Ohio; Will-
ard, Wm. G., Chicago.Ill.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL, AUGUST 22, 1896.
No. 8.
ORIGINAL ARTICLES.
AHSCKSS OF THE LUNG, WITH REPORT
OF SEVEN CASES.
Read before the Detroit Medical and Library Association and the
Cook County Hospital Alumni Association,
January and Juue, 1896. .
BY E. FLETCHER INGALS, M.D.
CHICAGO.
The subject to which I invite your attention is one
of peculiar interest on account of the difficulties sur-
rounding its diagnosis and the brilliant results that not
infrequently follow its proper treatment. Abscesses
of this variety are either primary or secondary, pri-
mary when the direct result of injury or exposure, as
for example the entrance of foreign bodies into the
air passages or such exposures as often eventuate in
pneumonia-, secondary when the direct result of some
antecedent disease, asforexample tuberculosis, pyemia
or embolism.
An abscess of the lung may be described as a cir-
cumscribed collection of pus within the pulmonary
parenohyma. It is usually characterized by pain at
times very severe, by chills and fever, and later by
the expectoration of a small amount of blood, followed
shortly afterward by a considerable quantity of pus
which usually escapes within a few hours. As a
result of the inflammation a small or a considerable
mass of lung tissue may be destroyed, but usually in
the primary abscess the tissues are crowded before
the collection of pus, and only a limited part becomes
necrotic. Primary abscesses (in which we are chiefly
interested), are comparatively rare, but secondary
pulmonary abscesses, especially those of tubercular
origin, are very frequent; the latter, however, I do
not wish to consider at this time, because the symp-
toms and signs which they produce are quite different
from those produced by the primary affection and
also because the treatment and the results of treatment
are not like those of the primary disease.
Etiology. — Primary abscesses usually result from
exposure, from the entrance of foreign bodies into
the air passages, from injury and for our present
purpose I will say from pneumonia. Secondary
abscesses result from pyemia, embolism, syphilis, the
pressure of tumors upon the bronchi, suppuration of
bronchial glands, and from perforating abscesses
below the diaphragm, or within the mediastinum.
Although my remarks apply to the secondary abscesses
that are not tubercular, and to a limited extent even
to the latter, they are mainly applicable to primary
abscess and to abscesses resulting from acute pneu-
monia which present the same symptoms and demand
similar treatment.
Symptomatology. — The primary pulmonary abscess
usually speedily follows some exposure or accident
which causes acute inflammation of the lung, the
inception being marked by a chill and fever, very
similar to that of croupous pneumonia, though com-
monly neither are quite so severe as in the latter dis-
ease; however, the abscess may not occur until some-
time after the acute stage of the pneumonia has
subsided. In either case the formation of pus is
attended by repeated rigors followed by hectic fever
similar to the symptoms indicative of suppuration in
other parts of the body. Pain, sometimes very severe,
is usually present in the beginning of the disease.
The temperature fluctuates two or three degrees dur-
ing the day corresponding to the irregular chills and
fever. In the milder cases although the pulse is
rapid the fever is not pronounced; but in most
instances the constitutional symptoms are very like
these of croupous pneumonia, and they are apt to con-
tinue for two or three weeks. In favorable cases
spontaneous opening of the abscess and convalescence
may be expected within twenty or thirty days and in
most of them the pus will escape within ten or twenty
days. The abscess may open into the bronchi, medi-
astinum, pericardium or pleura, or through interven-
ing adhesions may discharge its pus into the abdomi-
nal cavity or externally . The discharge of the contents
of the abscess is usually preceded by a few drops of
blood or bloody pus which is followed by the expect-
oration of from a few ounces to a pint or more of
yellowish or greenish pus. The pus is apt to be
brownish when there is considerable necrosis of lung
tissue. The contents will escape freely for a short
time, or possibly for several hours, until the abscess
is emptied, when the opening is liable to close for
two or three days; it may then be reopened and give
vent to a copious discharge. ,The pus is not usually
offensive except when it has been long retained or
gangrene has occurred. The sputum generally con-
tains small yellowish or dark pieces of lung tissue
visible to the naked eye that upon microscopic exam-
ination are found to consist of elastic lung tissue.
The essential signs of the disease are: dullness
with feebleness of respiration or absence of the respi-
ratory murmur over the abscess combined with indis-
stinct rales in the lung tissues immediately about it and
sometimes with bronchial breathing. After escape
of the pus the well-known signs of a cavity may be
present for a short time, though in the primary affec-
tion the lung is apt to contract speedily so that cav-
ernous respiration is present for only a few hours ;
or refilling of the cavity with pus may prevent the
respiratory and vocal sounds common over a vomica.
Diagnosis. — The affection is liable to be mistaken
for bronchitis, pneumonia and acute or chronic
pleurisy. The most important features in the diag-
nosis are the occurrence of symptoms similar to those
of acute croupous pneumonia, but followed by irregu-
lar chills and hectic fever indicative of the formation
of pus and dullness more or less circumscribed that
is apt to be more distinct over a small region than
that of pneumonia but less distinct than in pleurisy.
398
ABSCESS OF TQE LUNG.
[August 22,
Atypic respiratory and vocal signs unlike those we
expect to find either in pneumonia, pleurisy or bron-
chitis, are a most important element in the diagnosis
and finally the sudden expectoration of a considerable
quantity of pus containing elastic lung fiber reveals
the true nature of the disease.
Bronchitis. — Bronchitis is to be distinguished
from pulmonary abscess by absence of the irregular
chills and fever common in the latter disease, by the
comparatively slight fever in bronchitis; absence of
dullness on percussion and the presence of bilateral
mucous rales; by frothy and subsequently muco-
purulent expectoration instead of the purulent expec-
toration of abscess, and by the quantity and time of
occurrence of this expectoration. The sputum in
bronchitis is at first frothy and subsequently gradually
becomes muco-purulent; whereas in abscess of the
lung there is usually little or no expectoration at first,
but finally a large quantity of pus preceded by a few
drops or drams of blood.
Pneumonia. — In pneumonia the symptoms and
signs are much like those of pulmonary abscess,
indeed this disease is very liable to obscure the signs
of abscess, but a careful review of the symptoms and
signs will generally enable us to make a correct diag-
nosis, except in cases where the abscess results from a
primary croupous inflammation. In the beginning
of pneumonia we have a severe chill instead of the
irregular chills and fever indicating suppuration; yet
abscess of the lung may have- been preceded for a
few days by all the symptoms of pneumonia. In
pneumonia there is usually more or less distinct dull-
ness over the greater portion of one lobe or more, of
one lung, slight in the beginning but well marked
later on. In abscess of the lung the dullness is
apt to be circumscribed at the middle or upper part
of the lower lobe and the area smaller than in croup-
ous pneumonia. The dullness may be more pronounced
than in pneumonia, when the abscess is close to the
surface, or scarcely discernible when the collection of
pus is deeply seated and a considerable quantity of
healthy lung tissue intervenes between it and the
chest wall ; but in most cases of abscess the dullness
eventually becomes pronounced and distinctly circum-
scribed and it is liable to be surrounded in every direc-
tion by fair pulmonary resonance.
Upon auscultation in pneumonia, distinct crepitant
rales are heard in the beginning, distinct bronchial
breathing later on and still later the subcrepitant
rales of resolution ; but in pulmonary abscess the respi-
ratory sounds are atypic and commonly very confusing.
At first over the abscess there may be no sign excepting
a feeble respiratory murmur, though if the abscess is
near the surface there may be entire absence of respi-
ratory sounds due to occlusion of the air vesicles and
smaller bronchi, by compression. Usually, however,
there are a few subcrepitant and larger bronchial rales
in a zone two or three inches wide about the abscess
and there may also be a few crepitant rales; but these
signs are much less numerous and less distinct than
in typical pneumonia. It will be readily understood
that location of the abscess near the surface, or deeply
seated would necessarily change the character of the
respiratory sounds over it.
To me the most important elements in the diagnosis
of this affection consist of the indistinctness of the
respiratory murmur and the irregularity and confusing
character of the rales all of which are very different
from the typical signs of pneumonia or pleurisy.
The signs are such that the physician, even though
an expert, after having made a thorough physical
examination is inclined to admit (to himself at least)
that he does not know what is the matter. A careful
consideration of the history of such a case including
all predisposing and exciting causes together with a
study of the early symptoms, taken in connection
with the atypic signs will generally lead to a correct
diagnosis.
Acute Pleurisy. — In pleurisy as in abscess of the
lungs there are apt to be irregular chills and fever,
but the chills and fever of pleurisy occur in the begin-
ning and are not followed after three or four days by
rigors, and hectic indicative of suppuration. In
pleurisy the discovery of friction sounds and fremitus
in the beginning is important in differentiating it from
abscess, but frequently these signs are not very dif-
ferent from the irregular rales which are heard in the
latter disease. After, the effusion of fluid in an acute
pleurisy the dullness necessarily extends to the lower
limit of the pleura and becomes more pronounced
than in an abscess. There is also a change in the
level of the fluid on changes in the patient's position,
and absence of vocal fremitus when the patient
speaks; signs which do not occur in abscess. Con-
trary to the usual teaching, the respiratory and vocal
signs though feeble, are not entirely lost over the
upper part of a pleuritic effusion, but they are usually
less distinct than over an abscess. In acute pleurisy
the fever commonly subsides from the third to the
fifth day and after this time we do not have irregular
chills and hectic fever such as indicate the formation
of pus. In pleurisy the displacement of the heart
to the opposite side is an important sign which does
not occur in the abscess of the lung. In acute pleurisy
we do not get the expectoration characteristic of the
disease under consideration.
Chronic Pleurisy. — In this disease we are apt to
find a very different history from that of pulmonary
abscess. Empyema, when involving a large part of
the pleural cavity may be easily distinguished from
abscess of the lung by the well-known signs of a
pleuritic effusion, but when circumscribed the signs
are not characteristic. In a case coming to us several
weeks after the inception of the disease a physical
examination may reveal only a limited area of dis-
tinctly circumscribed dullness; the cavity may have
opened into a bronchus and the patient may be raising
large quantities of pus so that neither by the physical
signs nor symptoms could we distinguish between
the two affections with accuracy. In such cases a
microscopic examination of the pus may reveal the
true nature of the disease by discovering elastic pul-
monary fiber in the case of abscess, but none in
empyema.
Prognosis. — Pulmonary abscess may prove fatal
within four or five days, but usually even fatal cases
extend over two or three weeks or sometimes many
months. When an abscess opens spontaneously it
usually does so within three weeks. In unfavorable
cases, especially of secondary abscesses, many of the
patients die of exhaustion or as the result of infection
of some other part, and others succumbed to repeated
inflammation of the lung tissue about the pus cavity.
Abscesses of the lung resulting from pyemia, gangrene,
tuberculosis, embolism or the infectious diseases are
necessarily very grave. Those that we have classed
as primary are much more likely to recover.
Treatment. — The treatment of abscess of the lungs
1896.]
ABSCESS OF THE LUNG.
399
when of secondary origin must be that appropriate
for the primary disease with such tonics and stimu-
lants as appear necessary and ample nourishment.
The early treatment of primary pulmonary abscess is
very similar to that of lobar pneumonia. In practi-
cally all cases the expectant form of treatment is the
best in the beginning, but when an abscess can be
distinctly located, especially if near the chest wall,
the question of surgical interference must be consid-
ered. Remembering the natural tendency of this
disease and the possible dangers of an operation, I
believe that the greatest good to by far the greatest
number of patients will be obtained by pursuing the
expectant plan for at least three or four weeks. I
know that some cases may be shortened by an earlier
opening, but 1 am satisfied that some lives would be
lost by this procedure which might be saved by wait-
ing. After three or four weeks if the abscess does
not open spontaneously and an accurate diagnosis can
be made surgical measures should be adopted. The
comparative safety with which surgical operations
may be made under antiseptic precautions and the
glamour surrounding extensive and showy operations
strongly tempt the surgeon to cut down at once,
resect one or more ribs and perforate the lung to
allow the escape of pus. That this operation is
proper and desirable, in certain cases we do not deny
but that it should be held as a dernier ressort seems to
me to have been demonstrated by common experi-
ence and by the records of a few cases in my own
practice, brief histories of which I will presently
give.
Aspiration alone is competent to effect a cure in
many oases where necrosis of lung tissue is small,
even though the collection of pus may be large.
Aspiration combined with washing out of the cavity
by disinfectant solutions would be effective in others,
but where there is a considerable necrosis of lung tis-
sue or where aspiration has been tried and failed, the
more radical operation of cutting down and resecting
a rib and then perforating the lung by the thermo-
cautery should be adopted. When we have decided
that an abscess of the lung is present, or when after
a thorough examination by a competent diagnosti-
tian we are led to believe that one exists, exploration
to discover the pus should be made, in several places
if necessary, with a fine clean needle at least three
inches in length. Having in this way located the
abscess, aspiration may be done by any of the com-
mon instruments and a comparatively large needle.
It has always been my custom to disinfect the aspi-
rator needle by dipping it into a solution of equal
parts of carbolic acid and olive oil or oil of almonds,
and it has seemed to me that this strong solution is
especially beneficial in cauterizing the tract of the
wound and thus preventing absorption of purulent
matter. The pus cavity should be emptied by the
aspirator and the operation repeated at the end of
five or ten days if it refills, and again and again if
necessary. The question of washing out the abscess
will have to be determined by the indididual opera-
tor; but usually it is not best unless the pus is very
offensive, when there is reason for believing that a
considerable mass of gangrenous lung tissue is pres-
ent within the abscess cavity.
When an abscess results from gangrene or from
any other cause that leads us to believe free drainage
necessary, and after aspiration has been tried and
failed we should resect a rib in the ordinary method.
If the pulmonary pleura is found adherent to the
costal pleura we may at once open the lung with the
thermo-cautery ; if not, the two should be stitched
together and fifteen or twenty-four hours allowed for
adhesion to take place before the lung is opened, in
order to prevent the escape of pus into the pleural
sac. Preliminary aspirations as already recommended
will usually excite adhesive inflammation if the latter
has not already occurred in the natural course of the
disease so that the stitching will be unnecessary.
Having made a free opening and secured adhesion of
the two pleural surfaces it only remains to open
through the lung tissue and introduce a large sized
drainage tube, or tubes, after which it is managed in
the same manner as other large abscess cavities, the
patient being supported by tonics and nutritious diet.
In illustration, I have to record briefly a few cases
that have come under my own observation in private
practice. Of the first case I have no notes, of the
second a brief record, of the third case I have com-
plete notes regarding the laryngeal condition, but
only a very concise history of the pulmonary abscess
though it occurred so recently, that I have the features
of the case clearly in my mind. Of the fourth case I
have no notes, of the last three I have good records.
Case 1. — About ten years ago I was called to see a physician
between 50 and 60 years of age, who had been hunting a few
days previously and returned with the symptoms of acute
pneumonia. Upon examination of the chest I found signs
suggestive of pulmonary abscess, but a positive diagnosis was
not made until a few days later when the abscess opened spon-
taneously and the pus was evacuated. In this case the cavity
rapidly contracted and the man made a speedy recovery ; the
whole duration of the disease probably not occupying more
than four weeks.
Case 2.— Mrs. D. F., aged about 40. This patient I first
saw in July, 1894. She presented obscure symptoms pointing
to inflammation in the region of the diaphragm involving the
liver and later apparently involving the pleura and lung. She
had suffered from the disease for many months when I first
saw her, and was in a low condition when she came under my
constant care a few weeks later. It was impossible to make a
positive diagnosis, but about six weeks later I became satisfied
there was an abscess in the lower .outer corner of the right
mammary region ; this I aspirated and withdrew a few ounces
of pus ; subsequently it refilled, and eventually a small quan-
tity of pus continually escaped from the wound made by the
needle. She had been expectorating purulent material at
times, and every few days had been evacuating several drams
of pus from the bowels. Early in November, I resected por-
tions of two ribs, and penetrating about half an inch of lung
tissue came upon a pulmonary abscess which communicated
through the diaphragm with an abscess cavity of the liver, and
by an obscure opening with the bronchial tubes. Large drain-
age tubes were inserted and the wound treated in the most
approved manner ; but she failed more rapidly after the opera-
tion and died in about three weeks. What the result in this
case would have been if the operation had been made sooner
can never be known, but from the patient's history and symp-
toms I believe that had the abscess been opened earlier death
would have been correspondingly early.
Case 3. —Mrs. W. G., aged 28, came under my care March
17, 1894, suffering from stenosis of the larynx. She had great
difficulty in breathing and was much emaciated. The history
and appearance of the larynx convinced me that the obstruc-
tion was due to the contraction of syphilitic cicatrices. The
cords were adherent nearly to their posterior extremities
and the caliber of the glottis was reduced 80 per cent. I
opened the glottis with Whistler's cutting dilator and subse-
quently kept it dilated with O'Dwyer's large tubes until heal-
ing had occurred. The patient improved greatly in flesh and
general condition, and was about to be discharged when I was
sent for to visit her at her lodgings. I found her suffering
with severe pain in the right side and dyspnea, with all the
symptoms of a sharp attack of acute pleurisy. The room was
cold and conditions were such that a careful examination of
the chest could not be made without too much exposure,
therefore I contented myself with a diagnosis of acute pleu.
risy and prescribed accordingly. The pain was relieved by
400
ABSCESS
3 OF T]
HE LUNG.
[August 22,
anodynes ; but four days later the abscess ruptured and the
patient expectorated large quantities of offensive pus with a
little blood. The pus was also aspirated into the surrounding
bronchi and greatly increased the dyspnea ; secondary infection
and inflammation speedily followed so that she rapidly failed
and succumbed to the disease about thirty-six hours after the
opening of the abscess. This case illustrates a syphilitic
origin and a rapidly fatal course.
Case 4. — Mr. X., about 22 years of age, was seen by me in
consultation some three years ago. I found him with what
might be called typical signs of pulmonary abscess, because
they were so much like, yet not typical of, pneumonia or pleu-
risy. There was dullness on percussion, and a feeble respira-
tory murmur with indeterminate rales over and about the
abscess. I found a valvular lesion of the heart that explained
the origin of the disease. The history showed that the
inflammation had come on suddenly and that after a few days
the pus had escaped, but the abscess cavity had subsequently
closed to reopen again in about forty-eight hours. This open-
ing and closing continued for some days, but the man eventu-
ally died. This case illustrates the origin, course and termi-
nation of embolic abscesses.
Case 5. — S. J., aged 36, cameundermy carejan. 8, 1884. He
stated that eight months previously he had an acute attack of
inflammation in the left lung and that thirteen days later he
had expectorated about a quart of offensive matter. With the
attack he was confined to his bed about four months, since that
time he had been expectorating pus at irregular intervals. He
had formerly weighed 168, but had lost 44 pounds. At the
time of my first examination the pulse was 110 and irregular,
but the temperature normal ; the appetite was poor and the
digestion imperfect. He suffered very much from dyspnea
upon exertion, had a spasmodic morning and evening cough
and said that he expectorated about a pint of purulent offen-
sive matter daily. About ten weeks previously on two occasions
after a particularly hard coughing spell he had expectorated
a few drops of blood. A careful physical examination revealed
a little flatness in the left infra clavicular region. The left
side measured sixteen and one-half inches, the right sixteen
and three-fourths to seventeen and one-half just below the
nipple. The heart was in its normal position. The respiratory
sounds were feeble at the upper part of the left lung and lost
below, but there was slight vocal fremitus. The right side
was normal. I introduced an aspirator needle between the
seventh and eighth ribs near the angle and drew off four ounces
of very offensive pus ; as the last of it came away he felt like
coughing and the pus became bloody. That night he slept all
night which was the first time since the beginning of his illness.
Six days later it was noted that he had coughed about as much
the preceding night as before the aspiration. Another aspira-
tion was made, but at this time only about one ounce of pus
escaped followed by blood. Fourteen days later the aspirator
needle was again introduced but no pus was obtained. He
was given tonics consisting of iron, quinin and strychnia and
also the chlorid of calcium. One month after the first opera-
tion he had gained eleven pounds, and ten days later it was
noted that he weighed twenty-five pounds more than at the
first operation. He continued to improve rapidly in weight
though he was still annoyed by a cough for several weeks. The
dullness over the lung subsided slowly, and I did not consider
him perfectly well until about four months after he first visited
me. He is still living ingood health and has had no recurrence
of the pulmonary trouble or any indication of tuberculosis.
Case 6. — Mr. W. W. G., aged 19, came under my care first in
Sept. 1888, complaining of cough and loss of strength. Four
months previously he had suffered from an attack of what
appeared to be pneumonia from which he had recovered except
that the lung did not fully clear up. About four weeks before
1 saw him he began to feel ill again, having slight chills and
fever which continued for about twenty days. He had been
better for some ten days just before I saw him, and the fever
had mostly disappeared, but the cough was very trouble-
some. Physical examination revealed circumscribed dullness
over the lower part of the right lung. I aspirated and with-
drew twelve ounces of pus which was not offensive in odor.
Five days later I aspirated again and withdrew ten ounces of pus
when it became necessary to desist because of cough and pain.
About a week later I again aspirated and withdrew a smaller
quantity of pus. Three weeks later the dullness over the
lung continuing, I thought it would be necessary to introduce
drainage tubes, but making explorations in several places no
pus was discovered. The young man continued to improve
and shortly after went to Colorado where he has remained
since. About a year later, happening in Colorado Springs, I
made a careful examination of his lungs and found them in
perfect condition except a scar from the old disease. He still
continues in perfect health. In this instance there was appar-
ently abscess of the lung as a sequel to pneumonia. There
was at first some question as to the diagonsis in this case, but
the pus was so distinctly circumscribed and so deeply seated,
and the respiratory murmur in other portions of the lung wa
so distinct that after aspirating I felt confident that it was
abscess though I did not make microscopic examination.
Case 7. — C. A., aged 16, came to me in July, 1895. Hii
history showed that the previous April he had suffered fron
inflammation of the lung and that subsequently he had fre
quent chills and fevers, with cough and free expectoration <
pus. The boy was pale and sallow, and had lost considerable
flesh, but he had no fever at the time I first saw him, although
his pulse was 132 per minute. Physical examination showed
the heart in normal position and revealed considerable dullness
at the lower part of the right lung, more pronounced over a
limited area a little below the spine of the right scapula. A
feeble respiratory murmur could be heard about this spot,
vocal resonance was diminished and vocal fremitus absent over
some parts of the lung in the vicinity, but the signs could not
be satisfactorily accounted for by the hypothesis of either
pneumonia or pleurisy. This case was first examined by my
associate, Dr. John Edwin Rhodes, who pronounced it empyema.
He introduced a hypodermic needle in the region indicated
just below the angle of the right scapula, and withdrew a
small quantity of pus, and sent the patient to me for opera-
tion. When the boy came to me I could easily see the point
of puncture that had been made with the hypodermic needle.
Having Dr. Rhodes' letter before me, without careful exami-
nation, I introduced the aspirator needle at the same point
and withdrew about twelve ounces of pus. The boy was sent
to his home, a few miles distant, and a few days later I saw
him again in consultation with his former physician. At this
time I explored the chest in two or three places about an inch
from the former point of puncture, but was unable to find pus.
I found also that the respiratory and vocal sounds were dis-
tinct over portions of the lung, above, below and laterally of
the area of dullness. Finally, upon entering my needle at the
site of the old puncture and passing it in about an inch and a
half, I again found the abscess and withdrew ten or twelve
ounces of bloody pus. At the first operation I supposed I had
to deal with a circumscribed empyema, but after obtaining a
more definite history of the boy's case from the physician who
had him first in charge, and after my explorations and deep
aspiration, I became convinced that it was an abscess of the
lung following pneumonia. I left word with the doctor that
in case the cavity refilled it should be again aspirated, but a
recent letter from him informs me that the boy continues to
improve and has gained twenty pounds in weight. The cough
did not return and the abscess did not refill.
These last three cases all resulted from pneumonia,
they were all deep seated and chronic in character.
In each there were distinct signs of a collection of
fluid and a preliminary diagnosis of empyema, but in
every case the pus was so sharply circumscribed and
deeply seated that I feel sure of the diagnosis, even
though I did not use the microscope to detect elastic
lung fiber. These last cases are of special interest in
showing what may be accomplished by simple aspira-
tion in chronic, deeply seated abscesses of , simple
inflammatory origin.
36 Washington Street, Chicago.
DISCUSSION.
Dr. McArthur — In reviewing the literature of the subject
I have been greatly surprised that men of such wide-spread
experience and acuteness of observation as Trousseau or
Chomel had in twenty-five years experience seen but two cases
each of pulmonary abscess. It has been my fortune to see at
least ten or a dozen, most of which have been operated upon.
The large proportion of cases occurring subsequent to a pneu-
monia, is striking and worthy of emphasis. In these cases the
consolidation instead of liquefying and being absorbed or
expectorated, breaks down into pus, together with the pulmon-
ary tissues involved. This frequently does so at the time when
termination of the pneumonia should occur, but does not. A
diagnosis of pulmonary abscess being made (and in addition to
the physical and microscopic examination we might recall with
advantage the fact that the pus being expectorated from a
189H.J
ABSCESS OP THE LUNG.
401
jui Imonary abscess if shaken up with water will separate, on
■tending, into three layers: the upper mucous, middle water,
|DW«r pus, as in purulent urine), I believe the general plan a
good one to empty them surgically ; though Dr. Ingals has
had such good results by the conservative treatment in
selected cases. Dr. Fenger has emphasized : 1, the point that
if we desire to determine the presence or absence of adhesions,
that this ran best be done by inserting a hypodermic needle
deeply, when if the surface of the lung be not adherent the
needle will move with each respiration ; 2, that thickened, dis-
eased lung tissues bear surgical interferences very well, and do
not retract as do the healthy lungs. In the absence of adhe-
sions in the lower portion of the pleural cavity (three hepatic
abscess cases I 1 have been able to protect the pleura against a
septic pleurisy by simply packing off with iodoform gauze
strips the small area necessary for perforation of the diaphragm,
and since in this situation it was possible in one very putrid
BOhinococcus cyst. I have no doubt the same means might be
employed to advantage in pulmonary abscess without adhe-
sions, thus obviating the extremely difficult though some-
times successful suture of parietal and pulmonary peuraj.
Dr. Frank Hillings— I agree fully with Drs. Ingals and
McAithur, that the mostcommon cause of abscess of the lung
is croupous pneumonia. Of the cases I have seen, pneumonia
preceded the abscess in all but three. In one case, an ordinary
copper cent lodged in the right bronchus and caused abscess
of the lung near the foreign body. A postmortem revealed
the abscess and the cause. In two cases, stricture of the
esophagus was the cause ; in both carcinoma of the esophagus
near the eardia, with consequent dilatation and perforation of
the esophagus above the stricture, allowed infection of the tis-
sues and abscess of the lung. Postmortem examination was made
in these cases also. In one cases of chronic abscess of the right
lung which was successfully operated upon at Mercy Hospital
there was a history of pneumonia, which occurred two years
before. Cough continued after the pneumonia, with the
expectoration of decomposing pus. The abscess cavity was
reached by resection of a piece of rib just below the scapula,
and after a needle exploration, by cutting through the lung
and pleural adhesions, the operation was made simple. Thor-
ough drainage resulted in a cure. This case returned to the
hospital a month ago, more than a year after the operation,
suffering with cerebral syphilis. A full history of syphilitic
infection several years before the occurrence of the pneumonia
was obtained. It is therefore possible that syphilis had some
causative relation to the abscess of the lung in this case. In
my experience, abscess of the lung following pneumonia,
occurs most often in the lower lobes, contrary to what the
books state. In abscess following pneumonia the crisis may
occur and the temperature fall to normal. If the temperature
falls it will rise again in what seems a prolonged convalescence.
Hectic usually occurs. The physical signs of consolida-
tion of a part of the lung remain with, however, as
a rule, diminished respiratory sounds. I think it is not
possible to make a positive diagnosis until the presence
of pus is shown by aspiration or by spontaneous rup-
ture of the abscess into a bronchus or other outlet. The
differentiation of circumscribed or encysted empyema from
abscess of lung would be difficult without the discovery of
lung tissue in the pus aspirated or discharged. From an
empyema involving the whole pleural cavity, the usual signs of
fluid in a pleural cavity and especially the displacement, by
pressure, of neighboring organs would make a diagnosis easy.
The diagnosis, therefore, in abscess of lung must depend, I
think, upon the visible presence of pus, usually containing
formed elements from the lung. The clinical history and
physical signs furnish rational or presumptive evidence only.
The treatment resolves itself into palliative, expectant medical
treatment and curative surgical measures. If in an acute case,
the patient is anemic and emaciated as a result of pneumonia
or other causative disease, operative interference should be
postponed until the patient may be strengthened by restorative
iron and other tonics, good food, etc. One may cause a cavity
to drain by placing the patient in a position to allow the pus
to run into a communicating bronchus. I have had patients
hung, head downward, over the bed for a few minuteB at a
time, a few times a day, or in certain cases a recumbent pos-
ture, on ons side, or the back or face, for a time. A cavity
may be so drained that recovery will take place without sur-
gical interference. In acute cases, when drainage by posture
can not be obtained, and in all chronic abscesses, chronic
because drainage has not been good, surgical interference is
indicated.
Dr. Shurly— It is often exceedingly difficult to make out
abscesses of the lung when deeply seated. This seems to be
one of the things over which we fail. A great many of these
cases presenting obscure physical signs are abscess of the lung
following pleuro-pneumonia. Some of them, however, present
so little constitutional disturbance that we are apt toletnature
alone. Others present such constitutional symptoms that our
attention and aid are required at once. I have had three
cases in which inflammation of the brain came on after the
development of abscess in the lung and chest. I might have
saved these patients perhaps if I had operated early. Even in
cases of ordinary empyema it is not uncommon, whether they
have been operated upon or not, for an attack of meningitis to
follow, the exact cause of which we are unable to determine
even under our modern doctrines. I think many cases where
only the pleura seems to be involved are really cases of abscess
of the lung thus presenting the most complex features to us,
and requiring the most careful treatment. If the contents of
the cavity be so imprisoned by fibrous walls that there be little
absorption we may have little or no temperature or other con-
stitutional disturbance ; but if these barriers break away a
sudden infection of surrounding pulmonary tissues takes place
and we have septicemia, which may end life in a few days.
Some of the most virulent cases of septicemia follow upon
abscess of the lung. Sometimes making an openieg will not
avert it ; for in the cases I opened, the abscess of the lung all
died of septicemia. It was probably because I opened two
inches of lung to reach the abscess. I am not surprised at the
result, for I thus exposed a field of capillaries and lymph
spaces such as does not exist anywhere else in the body outside
of the generative organs. It is a wonder that one does not
observe septicemia in every case. I have thus been warned
from sad experience to refrain from cutting into lung abscesses
which are deep seated, unless I can see some sign of invasion
of some other part of the body, and if the cases seem to be
improving ever so little I content myself with waiting. I have
two cases on hand now which are recovering slowly of abscess
of the lung, in which I did not feel warranted in attempting
any operation. We should be extremely cautious if we can
not positively distinguish the location of the abscess. A few
years ago I had a case of abscess of the lung, following croup-
ous pneumonia, sent to me for operation. The man was in a
very low condition, his temperature fluctuating between 105
and 97 degrees. I thought the operation must be done at
once and advised the man accordingly, but a brother tele-
graphed requesting that nothing should be done until his
arrival. As he persistently refused to have it done we were
forced to wait and when the brother came the man was some-
what better. Later in consultation with his physicians we,
concluded that we would be justified in continued waiting, and:
the result was that the man finally recoved without an opera-
tion. If I had operated he might have died.
Dr. Samson — I have had the opportunity within the last,
twenty-four hours of seeing one of the most interesting cases of
abscess of the lung in existence at the present time. The
402
PUKE WATER.
[August 22,
patient six years ago swallowed a boring of maple. He began
to suffer in health and was sent to Denver and other health
resorts. Specialists tried to reach the abscess by passing a
trocar in some distance below the scapula. They did not find
any pus. Just now the case is a typical one of abscess of the
lung, coughing up fully a pint of pus every day. Very much
can be done in a surgical way for the relief of this trouble, and
I believe we should operate in all cases where we are able to
make a correct diagnosis.
Dr. Flinterman — 1 would like to inquire of author if where
there was a pulmonary abscess was there not sometimes a pleu-
ritic effusion in the pleural cavity?
Dr. Ingals — I have not seen the condition referred to by the
last speaker. I was much interested in the statement made
by Dr. Shurly, that inflammation of the brain was a common
occurrence with abscess of the lung. Dr. Shurly's experience
seems to correspond with my impression, viz., that as a rule
the earlier we operate the sooner the funeral. The early evac-
uation of a pulmonary abscess does not seem to me as safe as
tentative treatment, at least for a few weeks.
PURE WATER.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 6-8, 1896.
BY FRANK W. EPLEY, M.D.
NEW RICHMOND, WIS.
In the beginning God created the Heavens and the
Earth, and he filled the Earth with pure water and
surrounded it with pure air.
Then he made man and put him on the earth.
And for a time he also was pure. Then he began to
be restless and to invent. He has sought out many
inventions.
The Allwise Creator provided means whereby all
filth should be purified and resolved into its ultimate
elements. Man has sought out many cunning devices
for defeating God's plan of purification. The most
potent purifying agents are heat, light and air. The
most potent factors in the development of poisonous
ferms and gases are warmth, moisture and darkness,
'he offal of all living things except man is deposited
upon the surface of the earth. The bird deposits his
while flying through the air; the ox and horse upon
the dry grass, or in the dry dust. The dog is wont to
place his upon the top of a stump or stone, and all are
left in the best possible condition for the action of
nature's disintegrating elements heat, light, air, etc.
Man alone, whom God made upright and in the image
of Himself, has invented a hole. Two holes in the
earth; nearly always close together, at least rela-
tively, so that both shall be convenient. One he
makes comparatively shallow but deep enough to
accommodate himself and family for many years. In
this he deposits his offal both liquid and solid and
says, "Soul take thine ease," in this hole thou shalt
lay up much goods for many years, "eat, drink and be
merry," and if thou hast any other unclean thing
which offends thy sight or smell, cast that also into
this hole and it shall sink away into the earth out of
our sight. Even so the rain falls upon the surface of
the earth and sinks away out of sight, finding its way
into the other hole which man has invented, and
from this he supplies his family with pure (?) water.
If he, this Lord of creation, lives in a modern city
which is embellished with all the improvements of
our advanced civilization (?) he has a much handier
method. He has a bottomless bowl, or one having
one side wanting and with a small quantity of water
in the bottom into which his offal is deposited and which
is washed away by a dash of water; mostoi it, out of
his sight and into a tube which leads down into a
subterranean passage, this passage communicating
with a like tube from his neighbor's bath room and
receiving the contents of tubes leading to thousands
of other bath rooms until the filth of the whole city
is coursing through it and is finally deposited into a
pond of pure ( ?) water just without the city; or what
is more likely, within the city.
I said most of the offal was washed off the smooth
polished surface of the bowl in his bath room; some
small quantity, however, frequently requires a vigor-
ous rub to be displaced. When it reaches the inner
surface of the tube below, it does not get this vigor-
ous rub and remains stuck to the sides until the whole
tube is, many times, full. From this a gas is found
to arise finding its way in six out of ten cases directly
into the living apartments, and when it has any odor,
is very frequently termed the "smell of aristocracy."
But pardon this digression, we were to speak of
pure (?) water. However, we were very close to it
when we left the end of the tube leading down from
the bath rooms into the pond. We have now only to
go a short distance further out into this pond to obtain
an abundance of pure (?) water. Then we lay another
tube along side of the first one, which leads up to the
kitchen faucet. Will any one attempt to give us the
chemic formula for the water obtained from this fau-
cet? It is H2 off ah contemplation. Can we reason-
ably expect to obtain pure water to drink from our
abundant natural resources when we resort to such
civilized ( ?), shall we say such outrageous, systematic
methods of wholesale pollution. Can we while we do
this lay any reasonable claims to rationality ? I say
" no."
Gentlemen of the American Medical Association :
We are the logical keepers of the public health. We
all know these two systems of disposal of filth are
abominable. Shall we sit quietly down, fold our
white clean hands, and say, this is too dirty a subject
to handle? They are wrong, but they are old estab-
lished customs and it is too great a task to undertake
such a revolution. For shame! There is no task too
great for Saxons to undertake.
There is no wrong, however grievous, too great for
Americans to try at least to rectify.
The death knell of our American vault and sewage
systems should be sounded, and it is incumbent upon
this Association to hurl the fatal shaft.
DISCUSSION.
Dr. Hibberd— I desire only to call attention to the inference
that I think might be drawn from the verbiage of the paper —
that man made all that is bad on the earth in spite of the
Beneficent Providence, which created it pure and good in the
early arrangement of the universe. All I want to say is, so far
as my knowledge concerns, everything of the kind takes place in
the world as precisely according to the laws of the Creator, as
though they were made in the beginning ; therefore, man did
not invent them, and if they are not salutary in their effect, it
is simply because there is a lack of observation of what is good,
as the Creator intended. I think God is good, and that He has
made the world good. I think the laws by which we grow, and
progress are all good, and if we fail in recognizing what we should
do to maintain the operation of these laws in a sanitary direc-
tion it is a failure, but not on the part of the Creator. All I
want to do is to raise the idea that God is Supreme and has
made everything good primarily ; and that if we do not obey
L896.]
PURE WATER.
403
His laws and receive the benefits which He intended us to
derive, then we are at fault and should not throw the blame
00 Him.
Dr. McIntyre— Of course we can not all see the value of
the paper and appreciate the ideas brought forth therein
regarding pure water ; and while there may be mistakes con-
tained in it I will simply speak on the line suggested by the
author, rather than suggest any corrections. It seems hard to
■Uggest anything that will take the place of our present sew-
age system, or exactly meet the requirements ; but will the
correction of the evil be found in purification? I think that is
being done. I think the demands of modern civilization
require two things: First, thorough purification of sewage
before it contaminates the streams and lakes, and secondly,
thorough purification of the water itself before it is pumped
into the mains to be distributed into the city. The manner in
which this is done at Lawrence, Mass., has demonstrated that
as the solution of the difficulty. The experiments tried in the
last cholera epidemic at Hamburg show the difference between
filtered and untiltered water. These experiments all show that
this can lie done and at the same time that the sewage of the
city can be cared for in the convenient manner in which it is
generally disposed of. And then, by proper ventilation, there
is no odor in the house, and the water in the house is kept
clean.
Dr. Jerome Cochran, Montgomery, Ala. — Having some-
thing to do with practical sanitation, I am naturally interested
in it. Filth, doubtless, is a very undesirable thing to have
about a place, and it is especially undesirable to have it in
the water supply ; but I would like to emphasize that there is
a great deal of filth that is offensive to the senses that is not
detrimental to health. I would insist that that filth which is
detrimental is a sort that is not offensive to the sight or taste.
The things which produce diseases in water supplies are bac-
teria. We have disclosed the filth so far without reference to
its organism. The fecal matter in itself, when it is not filled
with the bacilli of typhoid fever, is perfectly innocuous to health.
1 think the remedy is to purify the sewage before it enters the
waters, and purify the water after it is taken away from the
lakes ; fortunately for us nature has shown us how to purify
water. The great method of purification is by filtration. That
is the way nature purifies water, but there are practical diffi-
culties in the way of getting rid of those pyogenic organisms
that do not seem to have attracted the attention of sanitarians.
The city of Lawrence, Mass., has made a study of the filtration
of water, but you find that all the bacteria are not eliminated
in that way nor all the organic matter. It is this matter going
to any water — these pyogenic bacteria already taken out of it
that will soon multiply again» You can not thoroughly purify
by filtration. It is in a very much better condition than
before so that if you want to get water that is practically free
from bacteria there is only one way, and that is to re-filter it.
Dr. Epley — I only hinted at the subject to call attention to
the disposition of filth and the obtaining of what is termed
"pure water."
We have all of us recognized the difficulty in the disposition
of human offal. As I said, man has invented a hole, and for
that reason I have for many years been endeavoring to create
a disposition among people where they have no sewerage to dis-
pose of offal in a dry condition. But they say "I have dug a
vault, and it will last me a great many years. I shall never
have any more trouble." I have for years advocated the
keeping the human offal dry and letting the water fall off on
the top of the ground. It is very easy to do that when a sys-
tem of closets are used. I have seen them used for eighteen
years without any trouble at all. I have encouraged their use
in the community where I live, where they had no sewerage. In
fact I have encouraged it where they have sewerage. The sew-
erage system has many faults, and it must sometime be cor-
rected. We have no right as intelligent beings to deposit our
offal in all conditions, whether benign in its character or filled
with diseased germs, into running water, our pure sources of
running water that we must have for our sustenance. So far
as the purification of water before it reaches our streams is
concerned, I am not conversant with any system which prom-
ises anything substantial or reliable in this line that can
purify water that is one-third or one-fourth or 10 per cent., or
5 per cent, fecal matter, while it is still in the sewer and before
it reaches the water course. It seems to me to be an imprac-
ticable plan. I do not understand how it can be done.
Dr. McIntyre— It is done by filtration at sewage farms, by
the use of the lime and iron process.
Dr. Epley — It is purified, but at what expense? The dispo-
sition of it as a fertilizer is right, and should be used, but at
the same time it is truly impracticable to attempt to dispose of
offal in the current of water and have so much more to destroy ;
it is much harder to destroy a quantity of water that is one-
half or a very large percentage solid matter, than it is to have
the solid matter and the water separate. But this process
would not exclude sewer gas ; and if I understand the gentle-
man who spoke of sewer gas correctly, he said proper ventila-
tion would prevent it from entering the house. I was investi-
gating this matter in Milwaukee a few days ago, and I asked
an inspector, who was testing for sewer gas (and his test
responded beautifully, in a large percentage of houses in Mil-
waukee, a well ventilated and well sewered city) what per-
centage of houses would respond to that test, and he said nine
out of ten. The gas was entirely without smell, but it was
deletrious in its effect upon the inmates of the household.
The method of filtration is satisfactory, if it is executed as it
should be ; but what I state is that to keep the solid matter
separate from the liquid matter is much easier and can be done
with much less expense than purifying the whole mass after it
has become thoroughly mixed.
Dr. Kober — 1 would like to ask how he considers it feasible
in a large city. The plan he speaks of is very applicable to
small communities and is, perhaps, the best method of dispo-
sition ; but the dry earth system is scarcely applicable to a
town of over twenty-five thousand inhabitants. Indeed, it has
been considered quite expensive in every way, and if he has any
data on the subject I would be glad to hear it read.
Dr. Epley — I have not a thoroughly matured plan, indeed,
I do not profess to be an inventor or civil engineer; but I
believe that it is an evil to which our inventors and civil engin-
eers should turn their attention, and I have no doubt but
that a system can be provided whereby this solid matter can
be kept from the lake by a system of dry closets, or keeping
the offal dry in some way.
Dr. McIntyre — I think, in parts of Birmingham and Glas-
gow there is no sewage system. There are places where the
pail system prevails. My impression is that the cost per capita
of removing the pails in this way is larger than the system of
purification. It is in small towns where it has been used on a
small scale.
Dr. Epley — You have not disposed of the sewer gas.
Dr. McIntyre — I refer you to the report of the committee
appointed by the London Commissioners of General Works on
the air of sewers, where it is shown that the air of the sewer is
better than the outside air.
New Jersey County Hospital Law Amendment.— The law passed in
New Jersey in 1886, entitled "An act to enable counties which
have no free county hospital to assist in maintaining hospitals
located in such county," was amended in May, 1896, making
it lawful for the board of chosen freeholders of any such
county to make an appropriation therefor of a sum not exceed-
ing $8,000 a year, instead of 81,000 as heretofore, and provid-
ing that the act shall not apply to counties of the first class.
404
EVIL RESULTS OF OVERSTUDY.
[August 22,
EVIL RESULTS OF OVERSTUDY IN THE
YOUNG.
«ead in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association at Atlanta.
Ga., May 6-8, 1896.
BY W. THORNTON PARKER, M.D.
MEMBER OF THE MASSACHUSETTS MEDICAL SOCIETY,
AMERICAN MEDICAL ASSOCIATION.
GROVELAND, MASS.
IEMBER OF THE
In the early days of our Republic, it was the unwrit-
ten law that the youth must work first, and study
afterward.
The children of the wealthy could be sent to school
or college, but for the average American book learning
formed a small part of life.
The picture of Abraham Lincoln lying on his
stomach, in front of the open fire, with a piece of char-
coal ciphering on a broad wooden shovel, represents
the man who afterward became President of the
United States. This is not an extraordinary picture
in early American life. Garfield, as well as hundreds
of other prominent men, won his education by a
struggle. And up to the present moment, there are
countless young men throughout our country who are
earning their way through college, just as there are
many other young men who are squandering their
way through. These two classes suffer from the evil
effects of overstudy; the former being obliged to
work with the mind when the body is weary, the latter
recklessly wasting time in pleasure and dissipation,
struggle in the process of cramming to make up for
lost time in order that they may retain their class
membership.
The American public school has been the pride and
glory of American institutions, not because the stand-
ard of learning is any higher, but because it repre-
sents liberty, equality, fraternity. In this nation of
ours, the humblest can, if he will, acquire a good edu-
cation. We are inclined as a nation to have a rather
exalted opinion of ourselves in everyway. Our water-
falls are the biggest, and everything else is in notice-
able proportion. The recent rumors of war illustrate
the fact that we are becoming rather reckless. The
victory of the American athletes in the recent Olym-
pian games, is likely to create a popular idea that our
students are the strongest in the world, and that our
educational system is therefore all right.
A recent paper by T. S. Waters, D.D.S., in the
Journal of the American Medical Association,
concerning " The Public School, and its Defects in
Relation to Health," is particularly instructive in this
connection. The writer being a dentist emphasizes
the fact that inferior teeth demonstrate the existence
of abnormal constitutional conditions. He says:
" School crowding and cramming impairs the health
and lessens the appetite, which causes imperfect
nutrition, bad assimilation of food and of ideas. This
therefore lessens appropriations of good amounts of
food which should consist of a proper amount of phos-
phates, with lime salts for the growing child, the very
want of which retards and impairs the development of
the second growth of teeth, of hair, nails and bones."
This is the sum and substance of the matter in a nut-
shell. The overtaxed student immediately suffers
from physical as well as mental harm. We often hear
it said that some young cripple possesses an extraor-
dinary amount of brain to compensate for the weak-
ness of body. I believe that physiologists are quite
agreed that during our sleeping hours there is less
blood in the brain than during our waking moments.
It is unreasonable to suppose that because a man's
circulatory fluid is diminished in quantity, he will be
able to compete mentally with a man whose mental
and physical vigor is as near normal as possible. But
it is reasonable to suppose that the student who is
mentally and physically overworked, and who does
not receive suitable nourishment, who is deprived of
needed rest and sleep, and whose circulatory fluid is
below par, is not in a fit condition for physical or
mental work. He is unable to stand the pressure.
Unusual mental activity is apt to result in speedy
bodily derangement amounting to more or less serious
illness. The illness may be so profound that the ner-
vous system is permanently disabled, and this injury
may range all the way from simple nervousness to
hopeless insanity.
I will quote from a paper which I have published
in the March number of the Dietetic and Hygienic
Gazette: "The nervous strain laid upon our young
students is inexcusably wrong. Generally speaking
they are too young to understand the full meaning of
the condition which this . youthful rush, miscalled
energy, inflicts upon them. Later on in adult life, if
they survive the terrible strain, they recognize the
injury they have sustained when it is practically too
late to undo the harm which has resulted. The strain
of study and the effort to acquire a high standing in
the class is encouraged by the teachers and directors.
The tension of modern schooling must necessarily
create nervous disorders, of which heart disease is one
of the most easily recognized manifestations. The
trouble is present in the rudimentary errors of modern
life, which we can see all about us, and which to the
onlooker appear very much like morbid restlessness.
The loads we place upon the shoulders of .our children
should shame us. We would never place physical
loads in proportion to the mental burdens we force
them to assume, because if we did public justice
would cry out against us. The physical burdens are
not so injurious or far reaching in harmful influence
as the mental strain. Our children go to school and
labor mentally to please us, as well as to gratify their
own ambition. We stand by and witness this outrage
on our own flesh and blood without making any active
effort to save them."
It is not intended that these remarks shall apply to
our young men only ; unfortunately the outlook for
our young women in this respect is even more serious.
Dr. Waters, and other writers, have called attention
to the nervous injuries which overstudy inflicts upon
our girls. "Neurasthenia saps the nervous energy
that should be devoted toward fitting her for mother-
hood within the next few years, when her greatest
development in mind and body should be perfected.
Hysteria is the most prolific source of domestic infe-
licity."
The new woman craze endeavors to teach the
daughters of Eve that they can study as well as men,
and can accomplish as much if they endeavor to do so.
There is a partial confession that, although physi-
cally inferior in strength and not suited for war, agri-
culture, or mining, in every other respect they are
man's equal, and it is essential that the girl of thir-
teen should go to school with the boy of the same age
and continue her studies by his side. The fact that
she is about to ripen into young womanhood, that
every twenty-eight days she should menstruate regu-
larly, seems to suggest no mitigation of the amount of
toil which is placed upon her. She bravely attends to
L896. ]
PREVENTION OF INFECTIOUS DISEASES.
405
household duties at homo, hurries off to school whether
head or back aches or whether she should bo in bed,
and trios to keep up in the unequal contest with the
boys. That she appears to win and graduates with
higher honors, gives us little idea of what the strug-
gle lias eosl her, and of what the sum and substance
of the struggles of all these girls will cost our nation
later on. These little misses ought to be at home
(earning from their mothers, if their mothers know
enough to teach them, lessons in domesticity. The.
noble women who had so much to do in shaping the
fortunes of this Republic in its early days would be
disappointed in their descendants, in spite of the
incongruous cap and gown, of this fin-de-siecle age.
This interesting, artificial young creature so unlike
the women of a century ago, abnormal in her bodily
functions and very much given to neurasthenia and
hysteria, intends to marry some day; but many of
them do not intend to have children if they can pre-
vent it. and if they survive the birth of one child, it is
doubtful if they could properly nourish it. When a
little school girl, clothing was given her irrationally
made; it mattered not if it pressed on the breasts and
retarded their growth, or if its pressure on the pelvic
organs pushed them out of their natural position until
pelvic disease was almost a certainty. The object of
her existence seemed to be that she hold her own with
the hoys of her age; that would be her glory! The
fact that such artificial women are likely to know
something of divorce laws later on makes no differ-
ence, she must be educated no matter what happens.
The result of all this is most excellently shown in an
editorial in the Journal of the American Medical
Assoc nation of April 25. "The Despised Office of
Motherhood.".
The fault therefore in American student life is to
be charged to the educators and to the parents of
children, rather than to the youths themselves. In
an article published in the December number of the
Dietetic and Hygienic Gazette: "Most parents think
that the studies of their sons and daughters at high
school are altogether too numerous and too severe. We
are apt to suppose that it is the particular high school
to which our young people go that is at fault; but a
little inquiry shows that our neighboring academies
are just as bad, or even worse, in this respect. Who
are to blame for this? Certainly not the parents?
The teachers disclaim the responsibility, and many
of them even regret it. Therefore in our municipality
at least, we are forced to conclude that it must be
either the supervisors or else that august body of irre-
sponsible, tyrannical solons called the school com-
mittee. We desire no worse punishment for such
supervisors and committees than that they should be
obliged to swallow the mental food which they have
prescribed for the young people. This would give
them a mental dyspepsia for the remainder of their
days that would surely keep them from doing any
more harm of this kind."
Dr. Dujardin-Beaumetz has also called attention to
these evil effects of overstudy. He says: "These
students are badly developed, pale blooded, exhibiting
an excitability of the nervous system which results
from mental overwork depriving them of sleep."
Insufficient sleep is one of the most noticeable evils
of modern civilization; the nervous system, as well as
the brain, suffers severely from this want of sleep.
Both mind and body are seriously and oftentimes per-
manently injured. Mental exhaustion, irritability,
and brain fag are the result, the sleeplessness causing
neurasthenia. So many of our students are ignorant
concerning the requirements of health, or if not igno-
rant, are forced to continue their studies far into the
night, reserving only four or five hours for sleep when
they should have eight or nine. These hours of
repose should be passed in rooms where the best san-
itary conditions obtain, and this is what almost never
happens. One of the most frequent causes of heart
disease, is the want of proper rest. There are many
influences provocative of heart disease in the young,
which we can readily understand if we give the mat-
ter attention.
With the bars of our ancient puritanic austerity
thrown down, in an age of the sharpest competition,
and when great things are expected in every depart-
ment of life, it is no wonder that the sands are strewn
with many a noble wreck. In the rush of student life,
the meals are eaten with too much haste, the quality is
apt to be inferior, mastication improperly performed,
and indigestion the invariable result. These diseases
of the nervous system, of the heart and the digestive
apparatus, are the exciting cause of melancholia. Our
daily papers chronicle from time to time the extraor-
dinary suicides of our youths. This fact alone should
call for a radical reform in our educational system.
A very grave responsibility rests upon the managers
of our institutions of learning. They desire to satisfy
the public as to their faithfulness; the public demands
that these educators shall exhibit a good showing for
the large sums of money invested; and all this
great burden rests at last upon the shoulders of our
children. The manly vigor of the Republic is robbed
of its strength for the sake of creating an artificial
condition which does not contain the elements of
future national prosperity.
THE PREVENTION OF INFECTIOUS
DISEASES.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association held at
Atlanta. Ga., May 5-8, 18%.
BY J. M. G. CARTER, M.D., Sc.D., Ph.D.
Professor Preventive and Clinical Medicine. College of Physicians and
Surgeons, Chicago; Fellow of the American Academy of Medi-
cine, the American Association for the Advancement
of Science, the American Academy of Polit-
ical and Social Science. Etc.
WAUKEGAN, ILL.
Perhaps no branch of medicine occupies so much
of the thought of the medical profession to-day as
infectious diseases. The manner of dealing with
these has undergone great changes during the last
few years.
The treatment is more satisfactory, and the prophy-
lactic and preventive phases of treatment are most
prominent. Since Jenner discovered the importance
of vaccination as a preventive measure against small-
pox the belief has prevailed in many minds, and hope
in all, that some means might be discovered to reduce
the terrors if not prevent the prevalence of all the
diseases commonly known as infectious. Under
improved hygienic precautions and more scientific
methods of treatment this hope is beginning to be
realized. Typhoid and malarial fevers are almost
conquered, the specters of tuberculosis and diphthe-
ria are beginning to pale and show evidences of van-
ishing, the terrible cases of scarlet fever are not so
frequent, measles et al. are not so frightful.
The object of this paper is to offer some sugges-
406
PREVENTION OF INFECTIOUS DISEASES.
[August 22,
tions upon certain points in this field of medicine,
but a full discussion can not be undertaken in the
brief time allowed to this subject.
The most successful methods in bringing about
these results in the past are the means which should
be pushed under wise supervision in the future until
they assist us in conquering all these diseases or dis-
cover better methods which will help us to attain
this end. The principles upon which these methods
as practiced at present are based may be given as:
1. Systematic cleanliness. 2. Prevention of individ-
ual contact. 3. Fortifying the system against an
invasion of the disease.
1. Systematic cleanliness is of the utmost importance
and includes the whole field of asepsis and antisepsis,
a subject which can nat be discussed in this paper.
2. The prevention of individual contact with per-
sons who have an infectious disease, or who have
been exposed to one, has been attempted ever since
the infectious and contagious nature of certain affec-
tions was discovered. These attempts have been con-
ducted in various ways, however, and frequently with
very meager knowledge of what is required to make
them efficacious.
Without stopping to explain the terms infectious
and contagion I will observe that the only difference
between them is one of degree, not of kind; that all
bacterial diseases are conveyed from one person to
another chiefly through the medium of the atmos-
phere, or water and other liquids; that those cases
occurring from the immediate application of the poi-
son, as in instances where particles of diphtheritic
membrane have been coughed into the mouth or
eyes of attendants, or scarlet fever has been carried
by fomites, are not exceptions to this statement. The
virulency of the poison depends upon its degree of
attenuation. A few of the bacteria which produce a
given disease may not infect a person while an inva-
sion by a large number may be irresistible. The
atmosphere and water (liquids) while serving as
media for the conveyance of these disease germs, at
the same time cause an attenuation of the poison by
dilution. There is a difference in resisting force to
this dilution manifested by different bacteria which
helps some to remain concentrated while others are
rapidly separated. This enables us to explain the
well-known fact that whooping-cough, diphtheria,
measles, etc., are conveyed only by an immediate or
almost an immediate contact usually ; as soon as the
germs reach the atmosphere they are in most instan-
ces widely and rapidly diffused, concentration is
quickly overcome, and their virulence soon destroyed.
The bacteria of scarlet fever and typhoid are more
resistant to diffusion, perhaps their poison is more
malignant or possibly they are more tenacious of life;
hence these bacteria may be conveyed through air or
water (liquids) to a greater distance. Still other dis-
eases, like influenza and cholera, are caused by bacilli
which are not so much affected by separation in the
atmosphere, in fact frequently seem to have greater
opportunities for growth by such diffusion under cer-
tain favorable conditions of moisture and temperature.
In all these cases, however, sufficient attenuation of
the poison by atmospheric dilution will destroy the
virulency of the bacteria and put an end to the spread
of the disease. This principle is the basis of judi-
cious efforts at isolation, segregation and quarantine;
but it will also convince us that these means alone
may prove futile in many instances.
It is well known that bacteria inhabit the soil n
large numbers, non-pathogenic in the superficial and
pathogenic in the lower layers. More air is found ir
the superficial than in the lower layers; so that the
principle of atmospheric attenuation seems to apply
here also. Water which filters through the soil and
enters a well may poison the water with pathogenic
bacteria. In like manner ground water which enter
a cellar may fill the space with the germs of some in-
fectious disease. It is to the latter point that I desire
to direct especial attention. In order to avoid some
of the dangers and prevent the occurrence of infec-
tious diseases in houses otherwise in good hygienic
condition it is necessary to have good ventilation of
the cellar or basement. Where this precaution is not
taken even in homes otherwise above reproach, fre-
quently ravaging outbreaks of measles, scarlatina,
diphtheria and the like are held to be mysterious
dealings of an inscrutable Providence, when it is but
the misdoings or shortcomings of unwise men, and
one of the least mysterious matters in preventive
medicine. If such disastrous results may be expe-
rienced in houses of the well-to-do and of the rich,
what shall we say of those farm, village and city
houses of the poor where, to keep out the cold, the
entire foundation is banked with dirt or manure, thus
preventing any access of fresh air under the floor
during a long winter? The effect of such exclusion
of the air is to make a favorable culture medium for
the bacteria of diphtheria and scarlatina, and it is the
experience of many practitioners that their most
frightful cases are met under such circumstances.
Architects and officials should direct especial atten-
tion to this matter and prevent the erection of build-
ings which can not be easily and thoroughly ventil-
ated from cellar to garret.
3. Fortifying the system against the invasion of
these diseases is a legitimate undertaking and
although some of the methods which have been
adopted may be of doubtful efficacy, every earnest
effort in this line should be encouraged. Vaccina-
tion and inoculation have been resorted to with such
satisfactory results that in smallpox and hydrophobia
they may be said to have passed beyond the stage of
discussion. Serum therapy has promised brilliant
results and the most hopeful have great confidence in
this new form of attempting to strengthen the cells of
the body to enable them to destroy, or at least resist,
the evil influences of pathogenic bacteria.
The condition of immunity which is said to be
established by these antitoxins is subject to variations
in the time limit, and in some instances the influence
seems to be negative. A friend and neighboring
practitioner who had immunized many cases told me
lately that of the cases in which he had given the
injections of Behring's serum for immunizing pur-
poses some of the patients had suffered from diph-
theria in three or four days after exposure to the dis-
ease and the administration of the immunizing agent.
The time limit of immunity varies after vaccination
also, but the virus has a more prolonged effect than
the serum upon the human system. It must be
remembered, however, that the serum treatment is
scarcely fully understood yet, while the value of vac-
cination has been firmly established. We may
ardently hope that this new method may lead to dis-
coveries of means which will enable us to rescue
humanity from the blight of infectious diseases.
While we are waiting for the realization of this hope
1896.]
PHYSICIANS AS PAUPERIZING AGENTS.
407
many will still prescribe belladonna to prevent scarlet
fever and iron to ward off diphtheria; but I wish to
emphasize what I consider a more rational process,
particularly with diphtheria, typhoid fever and othei
exhausting diseases. It is known as a physiologic
f,ui that certain fluids of the body, as blood, serum
and the gastric juice, when in a normal condition are
germicides. They kill bacteria. For our present
purpose it does not matter how they accomplish this
result. Such being the case, whatever helps to keep
those fluids in a healthy condition will serve to fortify
the system against the bacterial or infectious diseases.
In view of the fact that the human body has the
power within itself to battle with these enemies it may
be suggested that most if not all cases of infectious
diseases are results of neglect of some hygienic law or
of the transgression of some other. The individual
should not reduce his vitality or derange his diges-
tion by eating too much or too little, or by submitting
to fear or excitement, or any other condition which
will diminish the normal resisting power. He should
not permit work, pleasure nor social relations to inter-
fere with his physical well being. He should be well
clothed as well as properly fed and comfortably
housed. This opens up a question which is too broad
»for just consideration in this paper, a social and
political question. It is our duty, however, to call suf-
ficient attention to this phase of our subject to make
it a matter of thought. It is a cardinal fact that
infectious diseases are prone to prey upon if not to
originate among the poorer classes of society. To
avoid this occurrence, to prevent these diseases from
arising thus, requires that the poor should be well
housed, well clothed, well fed, well bathed and prop-
erly exercised. How is this to be done? I do not
discuss the method, I only desire to suggest whose
duty it is to remove the condition. The poor can
not do it. No man so thoroughly realizes as the phy-
sician that he is to a degree his brother's keeper. If
a man has no right to do anything which may bring
disaster to his neighbor, he has no right to go dirty,
to live slovenly, to breed disease. If children are
unable to accomplish results, to perform duties, which
the rights of men lay upon them, the father's duty to
aid them is paramount. We, and the poor with us,
are but children of the State. The question then
remains with us, how shall we as physicians, humani-
tarians, socialists, politicians, statesmen, provide the
unfortunate with proper food, proper clothing, com-
fortable houses, opportunities for bathing and suffi-
cient work to help them keep the grim monster from
threatening our doors by invading the homes of the
poor in the form of an infectious disease? Until
something can be done in this direction, infectious
diseases will still dwell in our land, although improved
prophylactic or preventive agents may reduce their
mortality.
Believing that the plan of supporting the ultimate
tissues of the body by general hygienic procedures
and proper feeding is the best means given to us for
preventing the group of infectious diseases, it may be
admitted that some good may be accomplished by the
administration of certain drugs. If belladonna is of
any value as a preventive of scarlet fever, it must be
so because it has some modifying effect upon the cells
of the body, not because it produces a rash. So far
as I am aware no experiments have determined this
point. Still I use this remedy for the purpose here
suggested and in many instances have thought it
seemed to have some virtues as a preventive. The
use of iron to prevent diphtheria is in direct accord
with the ideas advanced in this paper, and without
doubt serves an excellent purpose. Hydralactin, pro-
tonuclein and other proprietary preparations like the
antitoxins have not enough reliable evidence in their
favor to make their use as preventives general, but we
are encouraged to hope that further reports and im-
proved methods of production and administration will
justify the high expectations which have been excited
by the introduction of these agents, especially the
antitoxins. A remarkable claim has lately been made
for a specific action for jaborandi or its alkaloid, pilo-
carpin, upon the white blood cells. It is said to
increase their phagocytic power or function. If this
should be confirmed pilocarpin will be of great value
in the treatment, as well as in the prevention, of all
bacterial diseases. In two cases of tuberculosis in the
earlier stages I have observed a favorable modification
of the symptoms when administering this remedy and
in several cases of chronic bronchitis the improve-
ment has been marked. I shall conclude this paper
with the following resum 6:
1. Systematic cleanliness should be practiced, (a)
by thorough disinfection of the patient, the sick
room, all instruments, vessels, and other apparatus or
clothing in use; (b) by allowing no unclean or infected
fabric or vessel to be taken from the room until ren-
dered aseptic.
2. Prevent individual contact (a) by isolation,
segregation or quarantine; (b) by prohibiting com-
munication between the infected and uninfected
except under strict surveillance of the physician or
in accordance with his explicit directions.
3. Provide thorough and systematic ventilation of
cellars and basements as well as all other rooms in
houses used for dwellings, and give free access of air
under floors of houses which have no cellars or base-
ments, and supply complete drainage.
4. Fortify the system against pathogenic bacteria
(a) by abundant and suitable nourishment; (b) by
insisting upon the observance of the laws of hygiene
relating to clothing, eating, exercise and bathing; (c)
by the administration of certain drugs, among which
belladonna, iron and pilocarpine are prominent; (d)
by the conservative use of vaccination, inoculation,
the serums or antitoxins and perhaps protonuclein.
5. The State or city should see that the poor have
work, food, clothing, good shelter, public baths and
fresh air.
6. Health inspection officers should keep their
wards in good sanitary condition, and see that the
water and food supplies are uncontaminated.
PHYSICIANS AS PAUPERIZING AGENTS.
Read in the Section on State Medicine at the Forty-seventh
Annual Meeting of the American Medical Association,
at Atlanta, Ga., May 5-8. 1896.
BY DOUGLAS H. STEWABT, M.D.
NEW YOKK.
The writer has no desire to indorse any doctrine of
socialism, communism or the like, but he wishes to
call attention to two axioms which, though trite in
themselves, are ever new in their application and
abuses: 1, capital requires labor; 2, competition
compels capital to lower wages. Without labor, cap-
ital may neither be accumulated nor maintained.
Any sum of money must be dissipated eventually
unless it brings interest, and interest, directly or indi-
408
PHYSICIANS AS PAUPERIZING AGENTS.
[August 22,
rectly, means the earnings of hand workers. The
fundamental laws of progress, and of animal life itself,
seem to begin at toil with the hand or its substitute.
Thus we see large communities of brainless beings,
and the descending scale brings us to the jelly-fish
which presents only a stomach and tentacles — a per-
fect type of absorption and acoumulation. The brain
may be essential to civilization, but without the hand
existence would be impossible.
Lower wages may be obtained by reduction, regard-
less of employes or their needs. Business is without
sentiment, and this direct method has been tried and
has called forth the denunciations of organized unions
from Maine to Calfornia. United labor has become
capable of such independence and reckless readiness
in asserting real or fancied rights that capital is cau-
tious of unnecessarily antagonizing it. Constant
attempts at making the hire unworthy the laborer
arouse feelings quite different from the plaintive pro-
tests of a few individual sufferers, and if persisted in
could only end in a chaotic condition of society. The
Government Reports for the last seven years show a
total loss to the community from strikes of $64,000,-
000; fully 25 per cent, being due solely to attempted
reduction of wages. Another method of decreasing
compensation would be the importation of men under
contract for a remuneration which may seem fair in
Italy but, owing to the radical difference in the pur-
chasing power of money, is starvation's limit here.
Hordes of such immigrants would glut the market
and force the American to compete with foreigners
who can and do exist on food found in the garbage
barrels. This danger was dissipated by labor's vot-
ing power and its effect on the legislative bodies.
Laws were passed cutting off the contract- labor sup-
ply from too economical employers, and the capital-
ist is now between two fires — the stubborn resistance
of labor and keen competition, with a possible removal
of protective duties. From a business standpoint he
can not be condemned for managing any industrial
investment with the sole idea of "product as low and
market as high" as circumstances will permit. Eco-
nomical machinery has enabled one man to do the
work of ten, and quality is made secondary to quan-
tity. But despite all this, the element of expense in
the cultivation, collection and conversion of raw
material remains the price of labor.
The laborer will not adopt a cheaper mode of life
without a protracted struggle; therefore, if his earn-
ings are to be lessened, his living expenses must be
cut down and his money made to go farther. The
leading items of his disbursements are rent, clothing,
food and professional services. Overcrowding will
lower the value of rent and clothes, but labor is united
on the plan of : "One for all, all for one," and the
packed tenement and the "sweaters' " pittance press
hardest on the poor toiler. This objection, backed by
solid votes, has caused a law to be passed forbidding
the " double-decker" house and the erection of any
structure occupying more than 65 per cent, of the lot.
The present "sweat-shop" investigation is presuma-
bly only preliminary to prohibitory legislation.
Food, mostly farm products, can go no lower.
Many farmers are now abandoning the farms and
seeking a livelihood in the city. Those who do
remain in the country are organizing for protection
from ruin.
Professional services are rendered by the lawyer,
the clergyman and the physician. The lawyer may
be called perhaps but once in a lifetime. He does no
public charity work and all attempts at starting legal
dispensaries have come to naught. He can be a help
if employed or a hindrance if opposed. He is in
command of the legal machinery from the White
House to the " Tombs " prison. He and his profes-
sional brethren are so united in their interests that
malpractice suit against him must fail for lack of
expert testimony. Capital can not reduce his fees,
for he is a most dangerous adversary when attacked
through the pocket.
The sums paid to church and clergy may be great
or small, but an attempt to diminish them would
cause such an upheaval as has not been since the
Crusaders. The owners of wealth are growing old.
The grave and the chances of a leveling process
beyond make awkward thoughts for quiet hours.
Capital sleeps lightly and if a millionaire is timid a
multi-millionaire is often hysterical. Conscience
does make cowards and the man of the cloth is let
alone. He even receives "offerings" instead of fees,
but he uses his influence for what he mistakenly
believes is a good cause, and has collections in his
church for charity falsely so called.
The doctor is an urgent necessity to the working-
man. Exposure incident to toil, low vitality from
lack of sunshine and from malaria and other diseases
consequent upon meagre air space and indifferent
plumbing — all these make the physician a frequent
visitor upon the tenement families. The doctor's
charity toward laymen is unlimited, but toward his
colleagues he holds the simple faith of "Holy Willie"
in Robert Burn's satire: "God bless me and damn
my neighbors."
The farmer and the physician are ground very
fine — but with this difference, the farmer is organ-
izing but the physician is disorganizing. The work-
man does not yet realize that the cheapening process
means lower wages later on. It is not sufficient to
give the work people free medical attendance, but
everyone must be furnished as well, so that the shop-
keeper can decrease the pay of his employes, as the
banker can his bookkeeper's salary. To lower the
cost of living everybody but the very rich must
become paupers — so far as the medical man is
concerned.
What must we think of any citizen quietly sub-
mitting to such imposition and becoming part of a
great wedge which is to split up the manhood and
self-esteem of our whole community? Is any one
willing to inculcate the doctrine of non-payment for
value received? Is this not the very teaching most
opposed to all political economy, and the plan of
action which makes the counterfeiter the most dan-
gerous foe to the Government? There is such a man.
He comes to the city a student, advertised for and
welcomed by the medical colleges. They extend
promises, either real or implied, of a livelihood after
his diploma is secured. The demand and depend upon
high fees and have many extras. The advertised
multitude of patients available for teaching purposes
is a very tempting bait. The victim does not appre-
ciate the fact that if one institution attends 10 per
cent, of the whole population there are, within a mile,
ten other dispensaries all depending on a portion of
the remaining 90 per cent. He may at this stage of
his life have fine ideas of elevating the poor and of
the dignity of charity, and has not yet learned that
pauperizing processes are not conducive to high
1896.]
PHYSICIANS AS PAUPERIZING AGENTS.
409
Handedness and that charity is not the " benevolence
business." He goes through his whole course, sup-
ported by hope and a fund contributed by the self-
denial of his whole family, till he gives his graduation
f,v of $30, and exits from college life in a blaze of
iid glory. He becomes a practitioner, puts up
his Bign and finds himself penniless. He discovers
that lie has been deceived — that his most pitiless
enemy is the alma mater who received him so smil-
ingly and relieved him of his last $110 with the ease
and grace of a confidence queen. He realizes now
that of the 10 per cent, of the population wrongfully
under tree treatment, two out of three individuals
might pay him a small fee and one in three could
recompense him handsomely. This year he learns
that the clinic is to attend all the students of Columbia
University in their own homes. Some of these pupils
are the sons of wealthy parents and neither deserve
nor need alms. The question of deserving poor or
alms-receiving rich does not enter into the plans of
the dispensary. The whole population must be able
s e at the expense of the doctor in order that
labor shall be cheap. So the young man becomes a
member of the dispensary staff in order that he may
obtain a few dollars by clandestinely sending patients
from the ■•free'' classes to his office — thus, by his aid
in perpetuating the evil, the medical profession finds
its charities, the viper warmed in its bosom which is
stinging it again and again. The charitable and the
taxpayer pay the expense. No medical union, on the
plan of the laborers is contemplated. Personal jeal-
ousies are fostered by interested outsiders — the very
governing boards actually think they do a physician
a great service by allowing him to work for nothing.
No position of trust is open to him; even the office
of president of the health board is closed by law. He
il wanted as a commissioner of charity, yet the
whole public service must cease without his gratuit-
ous services in the hospitals. Membership upon the
trustee boards of both hospital and the dispensary is
denied him. The trustees themselves endeavor to
arouse enmity between the specialist and general
practitioner and are primarily responsible for the fact
that worthless patients so crowd the institution that,
for lack of time, the worthy can not receive proper
attention. They promulgate the doctrine that the
specialist has created the hospital and dispensary
because he must have material to study and experi-
ment upon. This is plausible reasoning, but its casu-
istry is made evident by the fact that any man can
learn more from ten cases carefully mastered than from
a hundred cases crowded in so fast that the most super-
ficial diagnosis is all that is possible. The woeful
daily mistakes resulting from such snap-shot methods
is a significant proof of this.
The large sums spent out of public taxes for private
institutions are wasteful and unnecessary. One-half
this expenditure placed in the hands of a powerful
charity organization society, could do all the work
required and perhaps leave a surplus, simply by the
exclusion of unworthy objects of charity, which deplete
the treasury and burden the taxpayer. All private
contributions for medical charity are superfluous if
the thronging of public and private clinics by
would-be paupers was stopped. At present the city
is giving $1,500,000 per annum to establishments not
under its control, and private persons in mistaken
kindness are donating a great deal more. Including
the excise fund of more than $60,000 a month and
the four and a half millions requested by the Charity
Commissioners, the city of New York, at a rough esti-
mate, expends $5 per capita per year for charity
alone.
What is the local effect of promiscuous beneficence?
"a prostituting charity." John Stuart Mill expresses
the idea thus: "A charity which makes twenty beggars
while pretending to relieve one is a condition of affairs
which makes it possible for some one to grow rich by
administering the funds for the poor." We all know
a neighborhood where the people were thrifty and
contented before a medical college and its appurte-
nances appeared on the scene and initiated free treat-
ment for all comers. The laborers, especially the
younger ones, have become idlers; policy shops and
loan offices have been opened; gamblers, dissolute
women and opium "fiends" have appeared in such
numbers that the locality is now named the "New
Tenderloin." I have asked those addicted to morphin
and loose women why they congregated near the dis-
pensary, and their answers are appalling. The first
say they can always "procure a jab" (hypodermic)
when out of money. The second reply, "the female
department is so crowded and the gynecologist so
rushed that they can fool him and 'get a free abortion
on tap." " The speaker claimed personal experience;
whether this be true or false, it is evident that the
self-respect of the entire community has been under-
mined and the decent element is moving elsewhere.
Post hoc if not propter hoc. The druggists know
the status of the people and every apothecary can
name many who are shameless in their abuses of
charity. All classes are drifting to the dispensary,
even the agricultural population. The country doc-
tors inform me that only their richest patients can
afford the time and money to take the journey to the
city and stop at a hotel while obtaining free advice
at the clinic. Surely the efforts at pauper-making
may be said to be very successful.
The two parties most to blame are the millionaire
and the medical man. The first enters the benevo-
lence business for what it is worth to him ; he may
even think his contributions are doing good, though
the smallest investigation by disinterested parties
would prove the incalculable harm he is working to
the very class he believes himself relieving. The
medical attendants are only flies in the spider's web.
They are engaged without salary and discharged with-
out a hearing. On the first of November the visiting
boards of six or eight hospitals were removed with-
out any charges being preferred, and "reorganized"
by a man who was "not impressed" by maggots in
the patients' food.
You can not compel the capitalist to cease his
donations, you can not obtain his ear against those
who flatter his soul and place his name in the pros-
pectus; the only remedy lies in the profession. That
should demand that the poor should be treated like
men and not like "clinical material."
In the public mind the doctors are all "good fel-
lows," who are to give much and to get what they
can. This is characteristic, as there is no human
being lower in the social scale than the good fellow.
The good fellow of the saloon "treats the crowd" and
spends money for liquor that should buy his children's
clothing, while his whole family depends in sickness
upon the dispensary. The good fellow is the prey of the
gambler and blackmailer. Goodness and weakness
seem to be synonymous, and the final end of all good
410
PHYSICIANS AS PAUPERIZING AGENTS
[August 22,
fellows is they are cast into outer darkness after giving
their best to the bad fellows; their course and termi-
nation is the same with the saloon hero, the Wall
Street lamb, the card sharper's prey, and the physi-
cian at the hands of the trustee boards of the dispen-
sary and of the commissioner of charity. The saloon,
the gambling hell and the hospital can get plenty more
good fellows to fill the places of those who now attend.
The people who formerly went to a consultant's
office, now have a plain dispensary dress and consult
him at a charitable institution. I have myself sent
patients to well-known men and have received an
opinion written on a dispensary blank — the gratuitous
advice having been obtained by deception. A certain
specialist charges $10 for an office fee; sometimes the
patient demurs and is sent at once to the dispensary,
regardless of the fact that many a younger man in
the same line, and possibly a more careful worker,
would be glad to obtain $5 for the same case.
The public can not believe that the profession is
so imbecile as to seek positions which pay nothing,
and consider that the places are sought for advertis-
ing purposes and for self-protection.
The fees for the specialist come, in most instances,
from the general practitioner, but the practitioner is
fast becoming an all-round specialist. Thus, through
unquestioning charity, the specialist crushes the gen-
eral man and he retaliates by sending cases to the
dispensary rather than have a consultation. In the
Manhattan Eye and Ear Hospital this is a common
occurrence, and if an outrageous case is turned away,
he proceeds immediately to the Vanderbilt, where no
question as to length of pocket-book appears to be
asked.
There is honor even among thieves — but the spe-
cialist and the practitioner, by suicidal and foolish bick-
erings, seem determined to prove that honor has fled
from the grandest profession that ever shed luster on
humanity. The medical "pirate" and the dishonest
consultant appear with the lofty brow and amiable
mien of the true philosopher, while they do deeds
and participate in actions that even a bunco steerer
would blush to contemplate toward his pals. The
code is no longer the "Golden Rule," it has become
the commandment of the Golden Calf. It is not "do
as you would be done by," but "do or you will be
done." Is it not evident that the whole profession is
a most applicable tool, when pauperization is the
work?
What is the remedy? The present condition is
unjust to the tax-payer, and if the physician is a
decent citizen he will stop enlarging our tramp class.
In London I found many who would not work,
because physicans and the charitable had made it
easier for the pauper than for the laborer. Is it
wonderful that the unemployed exceed a million in
that city? In New York the dispensaries make it
comfortable for those who wish to save the doctor's
fee and spend it in the grog shop. I am now study-
ing the transformation of men from clerks to rum
soakers and then to tramps and I know that some of
these men took their first step in pauperism in the
clinics. I am convinced that some might be good
citizens to-day had they not known the influence
of such a family physician as came to my father's
house when I was a lad. The institution crowds
are maddening and confusing; they are only "clinical
material" to the attendant, who becomes a doctor
of medicine and not of humanity. He may say
hastily to some miserable wreck, "you are a bum"
or some equally helpful remark, but the words are
very different in effect from a man-to-man state-
ment, "your heart is damaged; if you do not stop
whisky you are a dead man." All physicians know
that the hospital builders are no friends to the poor,
that the service as now conducted is no more charity
than stone is bread. If the money required to found
these great places was meant for the benefit of the
laborer it would have been spent for better homes
and hygienic tenement houses and then the working-
man's medical requirements would have been very
few.
Let the physicians resolve not to attend undeserv-
ing dispensary cases, the trustees will ask for resig-
nation, let the outside members of the profession
refuse to fill vacancies produced by removals with-
out cause; the matter will be remedied. To the
honor of Philadelphia be it spoken that a position
vacated by such a condition of affairs was not filled,
and the trustees became humble. In New York a
whole hospital staff was dismissed without a notifica-
tion of charges or discharges. The nominating com-
mittees of three medical colleges, the Mayor and the
Commissioners were written to and a hearing requested
by a committee representing 1,000 physicians; not
one of those written to had the courtesy to reply.
This is mentioned to show how little the authorities
care for any stand the medical profession may take,
short of a point-blank refusal to fill the vacancies.
Boston has adopted a system of cards which requires
some investigation into the qualifications of each
applicant for free treatment. Some physicians have
started their own dispensaries under the hope that
they can reduce the material of the teaching clinics,
so as to bring them to reason and give the physician
a chance to say who shall or shall not be paupers.
Some of the brightest young minds in the profession
are seriously contemplating entering on an advertis-
ing career, arguing that the hospital attendants only
hold their positions for advertising purposes, and
printers' ink is much quicker. The physicians of
New York can have all the institutions put under the
care of the Charity Organization Society; they could
have the powers of that body enlarged to those of the
"Gerry" and "Berg" corporations, and make the
sine qua nan of free service that every dispensary
should be under the supervision of a capable and dis-
interested investigating body. A committee sent to
the Legislature with a petition signed by the majority
of those practicing under the laws of the State of
New York could obtain all the power necessary.
The profession has a duty to the public of our city,
and as no medical man has ever been deaf to the cry
of "Give, give," let him not stop his ears to the demand
of "Withhold." Let him always help "God's poor
and the poor devils," but let him stop making or
unmaking the " devil's poor." And let him ever set his
face against any and all means used for increasing the
awful burden of pauperism which our city is already
called upon to bear.
POINTS BROUGHT OUT IN DISCUSSION.
The writer of the essay has not suffered by the
action of the Commissioners and colleges and is sim-
ply interested as anyone might be in an act of con-
temptible injustice toward the profession of which he
is a member.
The Commissioners pretend to have consulted only
1896. |
THE TURKISH BATH IN MENTAL DISORDERS.
411
tho interests of patients; if so why did they not secure
the best physicians by making the hospitals over to
the Civil Service Board and till vacancies by compet-
itive examinations?
Were t he Commissioners legally justified in turning
public hospitals over to three close corporations. /. c,
the colleges?
Is the medical profession at large "riff raff,'* in con-
tradistinction to about one hundred men connected
with the teaching faculties?
Had there been a medical union as firm in resisting
injustice as the Hod-Carriers' Assembly, would the
Commissioners have dared to ignore its request for
a hearing?
Why were homeopaths not molested? For political
reasons and pull?
Was not the whole so-called " hospital deal" a trans-
action by which an ex-commissioner was to be re-ap-
pointed by the influenoe of certain men, to whom he
turned over all the hospitals of the department of
Public Charities of New York City ?
THE TURKISH BATH IN MENTAL
DISORDERS.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting ot the American Medical Association, held at
Atlanta. Ga., Mav 5-8. 1896.
BY L. FORBES WINSLOW,
M.B. CAMB., M.B.C.P. LONDON, D.C.L. OXON.
Senior Physician to the British Hospital for Mental Disorders, London
i'hvfU'iMi to the Mount Vernon Hospital. Loudon. Late Lecturer
on Psychologic Medicine at Charing Cross Hospital Medical
School, London; and Physician tothe Hospital for Epi-
lepsy and Paralysis, London.
The treatment of disease at the present day is not
based on "guesses" or "surmises" whatever might
have been the case many years ago. This is the lan-
guage of the empiric, not that of the man of science.
There are intelligent men in our profession at the
present time, who are now able to diagnose with
extraordinary accuracy the pathologic changes going
on in the brain, so wonderful has this knowledge
1 ieec nne that it is not to be wondered at that we should
gradually, but surely progress in the investigation of
the treatment of those complaints. We learn from
our experience that by opening the flood-gates of the
skin from time to time, and submitting ourselves to
the manipulation of the shampooer, in the oriental
fashion, we may attain unblemished health under cer-
tain circumstances, both in mental and bodily com-
plaints. During a long experience in diseases of the
brain and nervous system I have had frequently to
resort to the use of the Turkish bath as a remedial
agent. I allude especially to cases of what is known
as "brain fag." Where the victim to that complaint is
reduced to a very low degree of vitality, I have found
that after a systematic course of Turkish baths, that
in many instances the mind recovers its wonted con-
ditions and the brain exhaustion from which the
patient suffers has diminished, if not entirely disap-
peared. The use of cold shower baths in the treat-
ment of mental disorders has been known to the pro-
fession for a great many years. I have also found the
Turkish bath beneficial in the treatment of some cases
of acute mania. A patient is brought to the asylum
in a state verging on cerebritis, and exhibiting all the
well-recognized symptoms of sanguinous congestion
of the brain. He is wildly delirious, the scalp burning
hot, the skin dry and parched, the conjunctivae injec-
ted, the pulse rapid; it has been found in such a case
that material improvement has taken place, even after
the first Turkish bath has been used; but in such a
case I would not advise a prolonged one, but of short
duration, each alternate bath to be of increasing length
in gradations. In the treatment of acute brain dis-
ease I would suggest that the whole process should
not exceed half an hour for the first bath.
" Without principles," says the great Dr. Cullen,
"deduced from analytical reasoning, experience is a
useless and a blind guide." Appreciating the truth of
this dictum we are naturally led to ask ourselves the
question as to the rationale of this treatment in acute
brain diseases; the answer plainly is the gradual and
general lowering of the vital powers causing a certain
nervous prostration, by means of which the cerebral
vessels become relieved, and the system calm and
quieted. In insanity, the vis vitce is often reduced
to the lowest possible condition. In the great mass of
acute cases of disordered mind which the physician is
called upon to treat, particularly in our public insti-
tutions, the nervous system is in a state of positive
exhaustion and debility.
The furor, the violence, the maniacal excitement;
the muscular resistance, so often associated with
insanity, are generally symptomatic of profound ner-
vous and vascular depression. The excitement of the
insane is an excitement without power, and it must be
left to the discretion and experience of the physician
versed in the practical use of the Turkish bath to
discriminate as to in what acute cases it may be used
beneficially, for we must recognize this important
pathologic fact that in some cases it is our duty to
conserve and husband the flagging and ebbing vital-
ity of the patient until the mind recovers its equili-
brium. If in the treatment of acute brain diseases
the Turkish bath is prolonged in the first instance
fatal results may follow; of this there is abundance of
proof; therefore in its use, in such acute diseases,
much discretion must be used. Insanity does not
result from active inflammation of the brain, and if
such were its origin no physician would be justified
in attempting to prostrate the system of those men-
tally disordered. In cases of profound cerebral excite-
ment, the patient often recovers under the combined
influence of a tonic and stimulant treatment. I have
known violent mental perturbation considerably miti-
gated and often cured by the administration of stim-
ulants combined with iron and quinin. Here is an
instance where it would not do to prostrate the patient
but to stimulate him; so in dealing with the use] of
the Turkish bath in such cases it becomes the imper-
ative duty to consult one versed in its use. I wish seri-
ously to draw your attention to what I have just stated,
and also to further say than an excited patient may
be made manageable and docile for the time being,
but it will be quietness and docility gained at the
expense of his reason and perhaps of his life, if the
inexperienced in its use allow its adoption to be pro-
longed in such mental cases as I have just described.
Treatment of insanity by baths of various descrip-
tion has long been in vogue in various countries.
Esquirol, the first to find fault with and denounce
many of the abuses found in the treatment of the
insane, freely used the cold douche shower bath in the
treatment of insanity and to the use of which he,
attributed the cure of many of his patients. In his*
"Maladies Mentales" he records cases where the cold,
affusion was followed by tranquility in the first,
instance and a repetition of it by a complete recovery,.
A second case is mentioned where the use of the bath
412
THE TURKISH BATH IN MENTAL DISORDERS
[August 22,
was followed by shivering, and a slow weak pulse and
ultimately by sleep. The latter lasted for four hours
during which period copious sweating took place but
on awakening the delirium had passed away and rea-
son had returned. Esquirol concludes from his exper-
iments. "That the douche on the head has a sedative
physical action, on account of the cold and a moral
action as a means of repression. The generality of
convalescents declare that they have experienced ben-
efit from its use and some patients ask for it; il nefaut
fas en abuser."
The danger, however, of too frequent use of the
cold shower bath came to be recognized, and to pre-
vent a misuse of it, the Commissioners of Lunacy in
England framed a series of laws to regulate its use. It
is now but rarely made use of except in neurasthenia
and in hysteric subjects, in both of which cases it
exercises good beneficial results, especially when it
has been preserved in, and in some cases of melan-
cholia the duration of the bath lasting from fifteen
seconds to half a minute. The warm bath is a won-
derful remedial agent in tranquilizing the nervous
system and acts frequently as a powerful soporific and
allays mental irritation.
The Turkish bath has also been used in alcoholic
cravings, and with a certain amount of success. The
functions of the skin are two-fold, that of secretion
and absorption; by it we perspire and by it we may be
said to breathe. It is a well known physiologic fact
that the oxygen absorbed by the skin through its
seven millions of pores has the same effect as that
taken in by the lungs, the purification of the blood,
and the supply of caloric to the body. The Turkish
bath causing profuse perspiration, and so opening
and cleaning the seven millions of pores renders them
permeable in an increased degree to the oxygen which
burns off the effete matter left by the stimulants;
increased vigor and vitality are thus given to the sys-
tem and the alcoholic craving is diminished.
The Turkish bath may be used beneficially in cer-
tain cases of melancholia of a recent nature, without
any possible risk ensuing; it often calms the nervous
system and often reduces the mental depression. Also
in cases of threatened recurrent mania, it sometimes
cuts short the attack if used immediately the symptoms
are returning. At one epoch in medical science
depletion was freely used in cases of insanity; this
then for a time disappeared altogether but it is now
coming into use again with some physicians. The
idea used to be that the depressing, lowering and
overpowering plan of treatment of the insane was
most disastrous in its results. It was then considered
by all practical and sagacious psychologists experi-
enced in the care of the insane that in the morbid affec-
tions of the mind a condition of brain existed which
would not tolerate a depressing and prostrating mode
of treatment. There is a vast difference between the
use of the cold shower bath in the treatment of insanity
and the use of the Turkish bath. In the former there
is an immediate depression and prestation of all the
vital energies and the effects sometimes prove rapidly
fatal. Consider for one moment what would be the
effect of using a prolonged shower bath in the treat-
ment of delirium tremens, or in a case of puerperal
mania, or the insanity following such a condition. In
this class of cases we often witness extreme excitement
and violence associated with profound vascular and
nervous depression. How dangerous then must be
the cold shower bath in such a condition, entirely
overlooking the pathologic state of the patient. If
the treatment of the insane be a rapid reduction of
the physical and mental powers of the patient to the
minimum standard; if it be all important to make a
noisy, excited, destructive lunatic tractable and quiet
so as to preclude the necessity for the use of mechan-
ical restraint, then continue the shower bath ; but if it
be the intention to carry out a proper curative mode
of treatment by some form of ablution then the Turk-
ish bath has proved itself to be the remedy needed in
such a case. I have known many instances of death
resulting from the unwise use of the prolonged cold
shower bath in the treatment of mental disorders, but
I know of no instance where such has resulted from
the Turkish bath.
Let us ask ourselves what would be the result on a
patient suffering from a depressing and exhausting
disease, and insanity is especially of this type, on
whose head was allowed to fall a continuous volume
of cold water for a period varying from a quarter to
half an hour, as was formerly practiced in some large
asylums. He emerges from such a bath with the
powers of life reduced to the minimum. I have rec-
ords of thirty-two cases of acute insanity treated by
the prolonged use of the cold shower bath, with the
following results : Fourteen recoveries, one death, the
others remaining in the asylum. I might mention
that in these cases it was used periodically, as occa-
sion required, and was prolonged for the time I have
previously mentioned. It is specially fatal in the
earliest stage of acute mania and may be called an
heroic treatment. In many cases it was apparently
made use of in instances of insubordination as a
means of quieting the patient and with effect. The
plunge bath was formerly and sometimes is now sub-
stituted for the cold shower bath. But this appears
to me to be the old story of Scylla and Charybdis.
I do not know whether any of my audience can realize
exactly what I mean by a plunge bath in the sense I
am now using it. A violent and excited patient is
forcibly taken by his legs and plunged head foremost
into an ordinary swimming bath. He is not per-
mitted the use of his limbs when in the water, but is
detained there, or taken out and plunged again into
the bath, until the required effect of tranquility is
produced.
Quietness, submission to authority, docility and
freedom from excitement and violence are the natu-
ral consequences of this gentle soothing treatment. I
say most emphatically that both the prolonged cold
shower bath and the cold plunge bath, if used at all,
are generally made use of for obstructive patients,
and not as a remedial agency. In cases of neurasth-
enia or hysteria such a treatment is often very bene-
ficial, but not in dealing with insanity pure and sim-
ple, especially in chrcnic violent cases.
Now the Turkish bath is used entirely as a reme-
dial agency, not a means of unwarrantably controlling
the individual. Its use has been generally adopted
in England since 1861, when it was first introduced
into my country and used extensively but Dr. Lock-
hart Robertson, the late Lord Chancellor's Visitor of
Lunatics in England, and Dr. Power of Cork, were the
two first to introduce the Turkish bath into the treat-
ment of insanity. The first asylum for lunatics where
a Turkish bath ,vas constructed, was the Devon
County Asylum. It was here found useful in certain
cases of melancholia, where the skin was hard and
dry, and in some tases of dementia. At the time of
1896
•1
THERAPEUTIC ACTION OF THE TURKISH BATH.
413
which I speak the use of it was in its infancy. I was
requested at the opening of the second series of
Turkish liaths in London to preside as chairman; this
was about twenty-five years ago. While in your
oountry last year I derived much pleasure from a visit
t, Dr. Shepard's Turkish baths at Brooklyn; I found
them in every way perfect and quite up to date in
every possible requirement. When the Turkish bath
first introduced into my own country it was said
:>y some that so long as we diligently and regularly
uul resource to the Oriental bath neither malaria nor
miasma nor infection nor the poison of fever could find
lodgment in us. All that was hurtful would be
swept away in the health-giving, health-preserving
rspiration which streams forth. The mind and the
man, nay the whole of the nervous system, central and
aripheral, would hold their own against the deterior-
iting influences which haunt our daily life. Man
lay indeed confront the world, armed in proof at all
lints against every danger which may assail his
une. whether wholly or in detail, from morbific
agencies, if he can only be persuaded to habituate
himself to the use of the Turkish bath. Its chief
action is depuration by the skin, but it also acts by
diuresis and its effects as a narcotic and tonic are
well known. It may be considered, in fact, to be a
complete materia medica in itself. I think that all
those physicians who have advocated its use in the
treatment of disease and especially of insanity, will
never regret so doing. It has been left, however, to
the wisdom of the nineteenth century to unveil the
therapeutic use of the Turkish bath, and I trust that
the few remarks I have to-day made may further its
continous use for the benefit of humanity in general.
THE THERAPEUTIC ACTION OF THE TURK-
ISH BATH.
Read In the Section on State Medicine at the Forty-seventh Annual
Meeting of the American Medical Association, at Atlanta, Ga.,
May 5-8, 1896.
BY VICTOR JAGIELSKI, M.D. (Berlin), M.R.C.P. (Lou.)
Consulting Physician to the Royal York Bath, London, N. W. Physi-
cian in Ordinary to Infirmary for Diseases of Consumption.
Diseases of" the Chest and Throat, London, W., etc.
LONDON, ESC.
My long experience with the Turkish bath prompts
me as most essential, before going into the therapeu-
tic aspect of the question, to make you first acquainted
with the tools with which you have to work in order
to obtain good results. All Turkish baths do not cor-
respond to the requirements of modern science and
vary so greatly in this respect that many of them now
in existence should cease to exist on this ground.
We doctors try to do the best we can for the public
and ought to direct the patients only to baths which
we have ourselves examined so that we can recom-
mend them conscientiously for curative purposes.
But, alas, how many bathers do consult doctors, and
how many doctors have taken the trouble of studying
balneologic details; hence bathers go to any Turkish
bath they hear of without any previous or proper
instruction. From my experience of the Turkish
bath, I must greatly impress upon your consciences
as doctors the necessity of going and examining per-
sonally each Turkish bath and better still to have per-
sonal experience of the bath before advising your
patient. I acquired this knowledge theoretically and
practically when I rebuilt in 1883, with my good friend
Mr. Thomas Duarans, the eminent architect in Lon-
don, the Turkish bath at the Royal York Bath, York
Terrace, London, N. W. We studied together the
subject of building a Turkish bath according to the
requirements of modern scientific principles. When
we considered the architectural plans, we based them
first on sanitary principles, and adopted the beautiful
Moorish architecture for secondary reasons ; but the
drainage system and the ventilation claimed our first
attention. We gave the drainage a good fall for the
rapid off-flow of the water and erected the plunge
bath that holds over 5,()00 gallons of water at the end
of the whole drainage system, so that a thorough
washing out of all the pipes is obtained by giving the
necessary speed and power to the stream and there-
fore cleanliness and freedom from all dirt and bad
smells. A fall of 1 foot in 15 feet within the length
of 120 feet between the plunge and the sewers was
adopted. The diameter of pipes six inches. Equi-
distant manholes enable us to open the entire system
for the inspection at any time with convenience and
to brush the pipes out in case of stoppage by acci-
dent and to observe if the sediment pass down. This
is essential. At the deepest manhole, and that near-
est to the sewers in the street, an air-shaft is built to
admit the fresh air which is drawn through the pipes
by means of exhaust shafts at the top end of the
drains. Thus, the air flows in the reverse direction
to that of the water. The waste pipes from the
bath and the rain pipes are separated from the main
pipe-drains discharging into a side inlet gulley which
has an open gridiron top for the admission of fresh
air and passage of the cleansing brushes or rods.
The next point was the ventilation of the suite of
rooms of the Turkish bath. This was attained by
building a tunnel 75 feet in length, 5 feet in width
and 7 feet in height tapering toward the furthest end
where the furnace is situated beneath the hottest
room. In this way the fresh outside air is forced
toward and into the space around the convoluted iron
furnace, and with such a velocity that the draught on
the candle flame visibly indicates the constant cur-
rent of fresh air to be heated and finally enters the
hottest room above through the open grating. In
this room which is a vault of glazed white bricks with
an ornamental colored skylight in the roof, a tem-
perature of 250 to 300 degrees Fahrenheit can be
obtained as required, but 230 or even 210 degrees are
sufficient to produce perspiration with ease in the short-
est time possible in the habitual bather. The second
hot room is between 170 and 180 deg. F., and the com-
municating first hot room is about 130 F., and the next
communicating shampooing room is 110 F., and the
douche room 90 F. and so on. The plunge room and the
cooling room are about 65 F. All these rooms have
large colored skylights to admit sunshine or daylight,
and when dark gas-burners within large white and orna-
mental globes of 20 inches diameter, are arranged so
that the products of combustion do not mix with the
air of the rooms. At the bottom of the seats around
the rooms are " hit and miss " exhaust grates by
which the vitiated air, from perspiration and exhala-
tion being heavier in specific gravity and accumula-
ting nearest the floor, is drawn off through upcast
shafts outside the roof. This principle of ventilation
ensures a constant stream of hot air through all the
rooms, and so great is its effect on the Mosaic floor,
through the created friction caused by its uninter-
rupted flow from above downward and out through
the upcast shafts, that the floor appears to a new-comer
414
THERAPEUTIC ACTION OF THE TURKISH BATH.
[August 22,
to be heated from underneath; slippers are required
when walking on the floor, and sheets when lying
down on the marble plates around the walls. I need
not describe the shampooing methods, nor need I
speak of the shampooers who work according to my
system, and make use of the soap and brush, showers,
needle-bath, douches, etc.; but this description I
think will show you sufficiently in an abstract way,
that the first essentials of a good Turkish bath are a
free circulation of pure air with plenty of oxygen,
sufficient heat and good light. The dryness of the air
in the hot rooms is most strikingly proved in a foggy
London day, when the bather enjoys this beautiful
change of pure air, free of mist, and feels contented
in this clear, hot atmosphere within the Turkish bath
as nowhere else. It is evident that this artificial dry,
hot air is a happy imitation and substitution for the
natural hot dry climatic resorts where patients are
sent to by their medical advisers, like Madeira, Egypt,
Algeria, Australia, India, etc., especially for lung
and kidney complaints. Under certain conditions and
circumstances many patients are unable to leave their
homes and are bound to remain in this country and
do the best they can for their health. For these the
Turkish bath proves a great boon, and you will under-
stand with what safety you can recommend your
patients to avail themselves of what constitutes a good
sanitary Turkish bath. Oxygen is the great want in
a hot air bath, particularly for weak people or weak
lungs. It is true we have also in England excellent
places for consumptives at the South Sea Coast and
the Channel Islands; but when patients have to
return to their homes in sooty, foggy towns, it is
frequently the case, that their improvement vanishes,
the air being too polluted ; for these the Turkish
baths are a delightful change. Advanced cases, to be
sure, ought not to be sent away to distant countries,
which deprives them of the comforts of their home,
their friends, their relatives, their native language.
I have made it my principle not to send patients away
unless they are wealthy enough to procure for them-
selves the utmost comforts possible, and when they
have improved in health I do not allow them to leave
the security of their new homes for the risks they run
in a wet and cold climate.
The literature on the Turkish bath is not very great,
particularly by men of science and learning. On the
physiology of these baths we find besides Urquart
and Sir Erasmus Wilson only exceptional papers like
those of Dr. Bucknill in the Lancet of 1876, of Dr.
Cameron in 1877 and of Dr. W. J. Fleming, Lecturer
on Physiology, Glasgow, 1879; the latter investigated
the effects of immersion in hot dry air, and his con-
clusions are:
1. That a very large quantity of material can be
eliminated from the body in a comparatively short
time and, although the greater part of this is water,
still solids are present in quantity sufficient to render
this a valuable emunctory process.
2. The temperature of the body and 3, the pulse
rate are markedly raised.
4. The respiration falls at first but afterward is less
influenced.
5. The urine is increased in density and deprived
of a large portion of its chlorids, while, if anything,
an increase in the amount of urea is produced.
6. The sweat was found to have an average specific
gravity of 1006.3; faintly alkalin, or neutral; the col-
lection of the sweat, its determination and analysis
require further experiments.
7. The principal effect upon the arterial tension
seems to be an increase produced by the greater
rapidity of the heart's action combined with a dilated,
we may almost say, gorged condition of the capillary
circulation.
Dr. Fleming's deductions from these conclusions as
to the use of the Turkish bath in medicine are : Its
most important effect is the stimulation of the emunc-
tory action of the skin. By this means we are enabled
to wash, as it were, the solid and fluid tissues, and
especially the blood and skin by passing water
through them from within outward. Hence, in prac-
tice, one of the most essential requisites is copious
drinking of water during the sweating. Persons of
sedentary habit or suffering from disease interfering
with fluid excretion will, therefore, benefit very
greatly by the use of these baths which produce such
a reaction of the skin, and by its means considerable
elimination of morbid matter may also be brought
about. On this point there is but one opinion of all
the writers, who also agree that sweating in these
baths relieves the internal congestion on the same
principle and with much greater certainty than the
usual diaphoretics; besides it softens the skin, relaxes
the muscles and permits more readily of passive move-
ments called rubbing or shampooing, which follows
systematically and enhances the process of perspira-
tion during the manipulations. The shampooers who
work so many hours a day in this hot air perspire
very freely and enjoy the best of health, although
they constantly pass from hot into cold and vice
versa. So every one can harden his skin and accus-
tom it to these changes by taking a Turkish bath
twice a week; it will then be difficult for people to
"catch a cold." Should a shampooer get one he will
cure it by the next following copious perspiration fol-
lowed by a shower of cold water or a cold douche.
This may appear alarming to the inexperienced, but
in practice it proves grateful to the sensations and is
wholly free from even a shadow of danger. In fact,
immunity from colds is thus acquired by persevering
in Turkish bathing ; the triple faculty of preservation
of health, of prevention of disease and of curing the
same is thus exercised by the action of the skin, which
repels the depressing effects of cold by its intrinsic
power of generating heat, and it also expels mias-
matic poisons by its emunctory power. The malaria
is eliminated from the body in this simple way; the
chill passes into heat and the hot fit is transformed
into perspiration. Gouty and rheumatic poison in the
form of uric acid and urea is constantly eliminated by
perspiration in the Turkish bath, and a man who has
taken too much alcohol can with proper care expel it
rapidly by the lungs and skin during the stay in the
bath. What is eliminated by the Turkish bath is the
excess of effete matter, which the weak body or degen-
erate organs can not excrete and which if retained by
the inefficient action of the skin, liver and kidneys,
is the prime cause of chronic disease. It is, however,
not only the action of dry heat in the bath, but of
hot, dry oxygenated air in the internal organs through
the lungs and circulation, as well as on the skin
which is so beneficial. The bath not only cleanses
the skin, but purifies the whole circulation and blood,
effecting a thorough cleansing of the system. A defi-
ciency of oxygen and an excess of carbonic acid gas
is the first cause of bad health, whatever form the
symptoms may take. Ignorant people, and I am
sorry to say many medical men, have an idea that the
18%.]
THERAPEUTIC ACTION OF THE TURKISH BATH.
-
Turkish bath is weakening or that its only immediate
effect is •• to bring down fat." Sweating, it is true,
under abnormal conditions — in the fetid workshop or
crowded assembly rooms for instance — is weakening,
but it is far different when perspiration is naturally
and beneficially induced in and by a thermo-oxygon-
ated atmosphere. Here the life-giving oxygen
replaces during the action of the bath the impurities
of the blood. People who suffer from eruptions of
the skin which indicate the too rich or too poor
blood, or in fact, an impurity of the blood, by appear-
ing on the surface of the skin in the form of pimples,
i, carbuncles and abscesses, eczema, herpes, etc.,
Bee those unpleasant and painful manifestations dis-
appear after the. first Turkish bath. They may expect
if they persistently use this purifying process twice
or three times a week that they will never see these
complaints return again. In the Turkish bath we
learn to distinguish by the eye and the touch the weak
and the strong, the healthy and the unhealthy skin.
In the bath there are no wrinkles and no decrepid
age: the skin becomes firm and elastic, recovers color
and smoothness and even upon the scalp of the bald,
I have seen the hair return. The skin may have a
deficient and imperfect circulation of the blood and a
deteriorated sensibility, a defective cell-formation and
Becretion, and exhausted tone and vigor, but you may
take it for granted that the habit of the bath will
reverse these unnatural conditions. I remember how
greatly it impressed me when taking my first Turkish
bath. I placed my quickly heated hand on any part
of my skin and felt a sensation of coldness; soon,
however, the whole skin became warm and dry, then
moist and soft, and finally I saw the pores opening,
the humidity on the chest and arms gathering into
drops like the dew on flowers or grass when garnished
with crystal beads; the beads running into little rills,
and the rills trickling down in small streams so that
the whole body admitted of being washed by means of
the water that issues from the blood.
Believe me, the bath is a preservative of health, a
prevention of disease, and it will cure most chronic
diseases when persevered with. How many cases
could I describe from my practice that have lost their
chronic bronchitis, their asthma, their inclination to
catching cold in the nose, the pharynx, the Eustach-
ian tubes, their larynx and vocal cords, who had
crackling in their joints when moving them, even in
the jaw joints so that bystanders could hear the mas-
ticating movements. All this rheumatic, gouty,
scrofulous and other constitutional dyscrasias which so
easily cause local deposits, show their evil existence
and manifestation of sufferings in headache, earaches,
neuralgias, giddiness, deafness, singing in the ears,
etc.; all these inherited or acquired weaknesses of
constitution and illness are curable and preventable,
but the baths must be persevered with during the
time you are apparently free from disease. I mean
you must not only take the baths when you are ill or
suffering but during the intervals when you are seem-
ingly well and healthy; then you will preserve your
health and prevent any development of a cold, because
it is the first cold that has the tendency to localize
somewhere and produce mischief of longer duration.
Shampooers always enjoy remarkable health because
they at once cure their cold. If you want to know what
regular perspiration in a Turkish bath can do, you
must watch others and watch yourself most scrupu-
lously and you will soon learn how true it is that per-
415
spiration in hot and well oxygenated air with all the
manipulations of the Turkish bath will prevent con-
gestion of the internal organs like the brain, spine
and nerves as well as the organs lying in the thoracic
and abdominal cavities. These congestions and
inflammations from colds in certain constitutions
with proclivities and inclinations of localizing in the
periosteum, the muscles, the fibers, mucous, serous
and all other tissues of our body may become very
serious and dangerous, but the perspiration drives the
blood from the internal parts to the peripheries or
skin and frees the internal organs. When cold has
chilled the skin, driven the blood inwardly producing
shivering, headaches, etc., a weak spot exists locus
minoris resistentice, To drive it out again you must
fo to the Turkish bath at once and get rid of the
rst attack; then you prevent disease and cure it at
once at its start. It represents the whole principle of
balneology and should be had recourse to by every-
one, immediately he is seized with disease whenever
and wherever possible. 'It is useless merely to treat
a cold when it appears; the proper and effectual way
is to persevere with the bath, even when in apparent
health. It is very curious to hear how often you
find the Turkish bath praised, by doctors, for its
effect in reducing the bulk of fat people, and how
difficult it is to bring them to acknowledge how
wonderful Turkish baths are in restoring, for instance,
a weak heart and circulation to strength. The heart
is naturally a very powerful muscle which does an
enormous amount of work in twenty-four hours, in
order to pump the blood by each pulsation into all
the arteries of the body. The innervation of the
heart is frequently disturbed and its muscular power
impeded so that the blood vessels of the skin do not
sufficiently dilate and keep the circulation free. Most
nervous complaints produce palpitations, but indi-
gestion is frequently the first cause. Through over-
feeding fatty degeneration is induced as well as
through alcoholic intemperance. I advise abstinence,
regular walking exercise and a Turkish bath in such
cases with excellent results. They stimulate the skin,
depurate the blood, relieve internal organs of conges-
tion, relax spasms, improve digestion and assimila-
tion and restore vigor to the body even when exhausted
by bodily or mental labor. The hot-air bath has a
quieting effect on the heart, especially, as all shock is
avoided in undergoing the sweating process. Patients
suffering from disease of the heart obtain instant
relief in the bath, although the number of pulsations
is increased. The more the pores are opened and the
perspiration enhanced, the greater is the relief and
the gradual improvement in the health of the patient.
Cool ablutions and drinking of pure water must not
be neglected. Persons can avail themselves of the
benefits of the Turkish bath with less risk than
attends ordinary medicinal treatment in nearly all
forms of heart disease, because the skin becomes very
inactive in heart disease, and the oppression in breath-
ing increases; immediately, however, the skin be-
comes moist and active, the oppression subsides and
the patient is relieved. A hot drink before entering
the bath, and deep quiet breathing when extended on
the back, or reclining in the chair accelerates perspi-
ration and soothes nervous irritability, giving a happy
feeling of relief. Directly the skin is active the inter-
nal conditions are relieved and the improved condi-
tion of the circulation through the body is reestab-
lished. It is simply marvelous how in this way the
416
THERAPEUTIC ACTION OF THE TURKISH BATH
L
[August 22,
action of heat affects beneficially all organic com-
plaints not only of the heart, but also of the liver, the
lungs, etc., immediately the skin acts. Thus, even in
incurable complaints, the Turkish bath proves a
source of comfort when all other means have failed,
as in dropsy, anasarca, edema, etc.; the intelligent
administration of the Turkish bath is the great desid-
eratum if it is to be used as a medicinal or curative
agent and not merely for nettoyage. The compe-
tency of the people who have the direction of the
Turkish bath establishment is a conditio sine qu& non
and doctors should sometimes take the first bath or
two together with their patients to give them confi-
dence; but notwithstanding all the blundering man-
agements in Turkish baths without doctors, there
have been fewer accidents and more good results from
their use than one would reasonably expect under such
conditions. People with hypertrophy of the heart and
a very powerful pulse have to be careful in taking the
Turkish bath and must follow special advice, particu-
larly if giddiness and headaches complicate the com-
plaint; but people of what we call an "apoplectic" build
will do well to take the Turkish bath regularly, and
to accustom themselves to the change of hot air and
cold ablutions. In very hot summers when apoplectic
fits are frequent, habitual Turkish bathers will not be
likely to stand in fear of these but will find a great
advantage and comfort when leaving the bath to find
that 80 degrees F. in the shade feels agreeable. We
never hear of a death from syncope in a Turkish bath.
Sunstroke never occurs in people who perspire copi-
ously from the head and neck. Cold hands and feet,
biliousness, stitches in the sides, lumbago, sciaticas
and neuralgias of all kinds are indications for habitual
Turkish bathing. Predisposition to fainting, palpita-
tion, sinking feeling give way entirely to the gradual
use of the Turkish bath. People who can endure a
heat of 200 degrees F. with comfort and afterward
take a plunge of 60 degrees F. or less are sure to
remain in a strong and good condition of health,
unless they commit excesses in eating and drinking,
or contract influenza or malaria, etc.
I know bathers who have been living now comfort-
ably for over twenty years with symptoms of soften-
ing of the brain, chronic alcoholic poisoning or
nervous tremor, and constantly speaking of themselves
as improving, and others who complained of restless-
ness and sleeplessness at night were entirely cured and
slept as well as ever after every Turkish bath. The
supposed danger of a Turkish bath to elderly people
i& quite a fallacy. Physiologically, pure air and
exercise are as necessary in old people to keep up
health as in young ones. Indeed, they want these
more to restore a certain amount of lost vitality. In
fact, the bath is of great value in prolonging life
in the aged as well as in the diseased, and I know
many old gentlemen between 65 and 85 who keep in
vigor by taking their Turkish bath regularly once a
week.
As to our brains and nerves, the close connection and
reaction between the mind and body are indisputable
proofs that the right action of the mind greatly depends
upon the health of the body and consequently of the
senses, for they are inseparable in life while the nerves
are capable of their functions. If we possess pure blood
disease is baffled, blood being the material out of
which all the organs repair themselves its deficiency
in quality and quantity lessens the energy of the
brain's functions. A stimulant — be it alcohol, tea or
coffee — accelerates the circulation and increases the
vascular supply. I always recommend a stimulant in
a weak heart before the bath for weak persons until
they can do without. I never recommend it after the
bath; rest and a good meal must take its place after
the Turkish bath. One writer fears the bad reaction
of the stimulant; I have never observed it in practice;
but I always try as soon as the patient is accustomed
to the Turkish bathing to recommend cold water in
place of the stimulants in the bath. Another writer uses
stimulants and says people require a stimulant before
they feel "fit," I suppose, for brainwork. Now, before
I used the Turkish bath for sleeplessness I always
had a good result from a stimulant for sleeplessness
in people with a weak circulation and with mental
worry and over-fatigue, and the dose must be a full
one, for a small dose would produce mental excite-
ment. To excite rapidity and intensity of thought
one writer recommends the Turkish bath, "If," he
says, "I require to think out a knotty point, I take a
Turkish bath ; my mind is clear, my judgment more
keen and my loftiest and purest thoughts come to me
during the process of blood arterialization."
There is not the slightest doubt that for the brain,
the spine and the nerves the Turkish bath is excellent,
and even noises in the ears and head may be cured or
mitigated; but should the- complaint want additional
help in order to rectify and bring it to normal condi-
tions of health, I always give the preference to the
natural means of treatment, among which massage
and electricity form the principal ones.
I have cured several cases of deafness which were
given up as incurable by specialists. One of them,
Mr. R. A., had to retire and take his pension — half-
pay — at the Trinity House, when nine years later I
unexpectedly restored his hearing by massage and
Turkish and electric baths. "What a pity," the patient
then said, "had I known of you before I spent all my
money with specialists on the continent and in Eng-
land, I would still have been in office to-day with full
pay." However, let us hope that others will profit
by this experience. He is now 74 and takes his Turk-
ish bath frequently, being mentally very active, and,
I am happy to say, useful to his family and to
society.
I have not said anything about febrile diseases
with high temperature, nor have I given opinions
about treatment of hydrophobia by Turkish and
vapor baths, the paper being already too long, but I
repeat my warning, that a Turkish bath establishment
which does not invite the doctors and the public to
inspect their drainage and ventilation systems, or
which refuses to show these must be looked upon with
great diffidence and had better be avoided; there can
be no mystery-pleading in these things, and the pub-
lic has a right to see all. Therefore, allow me to
impress, let the public constitute themselves their
own inspectors and fearlessly demand of each Turk-
ish bath proprietor a display of the ventilating
arrangements before entering the bath.
Military Hospitals Thrown Open to the Civilian.— The German
authorities have decided that civilians residing near military
hospitals can be received and tended in them whenever the
physician considers that transport to another hospital might
be injurious. A decree in France also opens the military hos-
pital in places without hotel accomodations, to civilians who
apply to the chief of the department. The prices are to be the
same in both countries as for the lower military ranks. The
Bulletin MM. July 12, strongly deprecates this transformation
of the little hospitals in the colonies into boarding houses.
1896.]
PUBLIC TURKISH BATHS NEEDED.
417
PUBLIC TURKISH BATHS NEEDED.
Read tn the Section on State Medicine, at the fortysevontli Annual
Meeting of the American Medical Association, held at
Atlanta. Ga„ May 6-8, 1886.
BY CHAS. H. SHEPARD, M.D.
BROOKLYN, N. Y.
The action of the New York Board of Health in
appropriating $30,000 for applying the discovery of
antitoxin in the treatment of diphtheria, encourages
the hope that in the near future the public, mind may
be quickened to recognize its opportunities and its
necessities in other and broader fields. It is time to
appreciate the fact that we are our "brother's keeper,"
and that whatever works harm to him reacts upon
ourselves. This action of the Health Board also indi-
cates a growth in public sentiment that will encour-
age and sustain important measures for the public
welfare. It is a moral duty as well as a principle of
public polity, in all civilized countries, to protect the
people from the invasion of infectious disease, and it
would be very short-sighted to stop at mere infection.
The use of antitoxin is only to supply a temporary
exigency. It does not purify the homes of the people
or teach them to take better care of their bodies or
sanitary surroundings. We need something to uproot
the cause of the disease, and when this is secured, it will
be found that many other diseases have disappeared.
The Romans understood and perfected public sani-
tary works on a most stupendous scale, as is witnessed,
among other things, by their aqueducts for bringing
pure water to the city of Rome. Magnificent ruins
of many of them are standing to-day, and some of
them are in use at the present time.
It is known that in India, the home of cholera, the
city of Calcutta is now protected from epidemics of
that fearful scourge by the supply of comparatively
pure water that has recently been furnished the city.
When the community can be assured of pure water
to drink and pure food to eat, with proper bathing
facilities, the enjoyment of life will be much enhanced
and its length prolonged.
In a recent report of the Committee on National
Quarantine of the New York Academy of Medicine,
it was stated that " the most certain protection of this
or any other country against the ravages of infectious
disease, lay in the practice of internal sanitation."
What is true of the State is also true of the individual.
The more cleanly a man's habits, and the purer his
food and drink, the less liable he is to disease, because
his body is thereby rendered naturally immune to
disease. Whatever our theories as to prophylactic
measures in the prevention of disease, the production
of a barren soil for the growth and development of
pathogenic germs is of greater importance than the
destruction of the germs themselves, though efforts
should be made in every direction for the elimination
of all diseases. Various theories have been offered
by different authorities concerning the processes and
changes that take place in the body in consequence
of artificial immunization, but the scientific contro-
versy regarding it has not yet been settled. Suffice
it to say, that the more pure and active the fluids of
the normal living body, the more powerful are the
bactericidal properties thereof.
There is at present a revival of a favorite practice
of the ancients, and that is their system of bathing.
The old Roman baths, which are identical with the
Turkish baths of the present day, were prominent
features of the daily life of the Romans and were
counted among their choicest privileges, and so con-
tinued during the period of their greatest prosperity.
They were then carried to a scale of perfection never
surpassed. The baths of Diocletian, which were the
largest ever built in the world, were capable of accom-
modating 18,000 bathers at one time.
We have heretofore maintained, and would reiterate,
that as one of the great sanitary necessities of the day,
it is most desirable that large public Turkish baths, as
a preventive of disease, should be established through-
out our cities at public expense, placed under medical
supervision, with admission at nominal rates, so that
the poorest individual could partake of their advan-
tages with a feeling of self-respect in paying some-
thing for the help and comfort to be derived there-
from. They should be made attractive, and thus draw
people from demoralizing enjoyments. This would
react on the social life of the community, and by
purifying the people would purify their homes.
We support public schools, and compel our children
to attend them. With more propriety could we fur-
nish public Turkish baths, and insist upon every man,
woman and child availing themselves of their luxuries
at least once a week. The physical is of greater
importance than the mental; indeed, it is of the first
importance to the State.
Herein would wealth have a royal opportunity to
consecrate itself to the service of mankind. The
endowment of public baths was among the most noble
actions of the Roman Emperors. Eight hundred of
those institutions adorned the capital of the empire,
and they supplied, during many eventful years, almost
the only medicine to a people distinguished for their
corporeal and mental vigor.
Among the important results that are brought about
by the use of the Turkish bath maybe mentioned: 1,
a perfect cleansing of the external body, and relief
from any undesirable odor, replacing therefor the
beauty and fragrance of health; 2, a purification of
the blood by the elimination of its impurities through
the surface of the body; 3, an equalization of the cir-
culation and perfect distribution to and through every
organ and tissue of the body, however remote; 4, the
speedy elimination of blood poison, laying the founda-
tion for; 5, increased nutritive changes throughout
the whole body ; 6, a relaxation by heat of the tissues
of the body, and thereby relief of congestion, whether
located in the lungs, bowels or other organs of the
body, or in the muscular tissues, as shown in the
relief from rheumatism, malaria, etc.; 7, absorption
of exudates and inflammatory products; 8, better
ventilation of the lungs, and the placing of climatic
treatment on a scientific basis; 9, greater activity of
the secretions and excretions; 10, the prevention and
the eradication of the predisposition to disease; 11,
strengthening of every vital organ, and therefore an
increase of vital capacity.
The arguments in favor of public Turkish baths are
both manifold and important. To enumerate but a
few of them:
They would be comparatively inexpensive.
They would lessen the cost of medication.
They would prevent the spread of epidemics.
They would render extinct many classes of diseases^
They would lessen the demand for stimulants of"
every kind and render the police force less necessary.
They would be more powerful than any law of pro-
hibition, because they would be more attractive than
the saloons.
418
MASSAGE IN APPENDICITIS
SI
[August 22,
They would reduce the expenses of hospitals and
asylums.
They would shorten the time necessary for patients
to remain in such institutions.
They would reduce the demand for hospitals, so
that what are already built would be sufficient for a
generation to come.
They would help toward the refinement of the com-
munity.
They would vastly prolong the average of the life
of the people.
They would add to the enjoyment of life, by mak-
ing everybody healthier and happier.
They would tend to render the cities that adopted
the bath preeminent among all the cities of the world,
and be an example for all other cities to follow.
They would redound to the honor, and conduce to
the growth of such cities, and continually increase
the numbers of the better elements of their citizens.
They would uplift the community and tend to
develop a superior race of mankind, as handsome as
were the Greek models, and as powerful as ever were
the Romans.
To the individual the Turkish bath is the perfec-
tion of sanitary science, and to the nation it is the
coming blessing.
These few reasons but imperfectly state the great
need and many advantages that would accrue to the
community adopting the practice of public Turkish
baths.
DISCUSSION.
Dr. Kellogg — This subject is one of very great importance.
I am sure that there is nothing so valuable, as a health meas-
ure, as public baths. In different parts of Europe I have
noticed that where there are public baths the cities possess a
superior class of people. On the streets of Stockholm I saw
some very fine looking men, stalwart and ruddy-faced. There
you can get a public bath for five cents. There are several in
the city ; for twenty-five to fifty cents you can get a better
bath. There are different grades, so that all classes are accom-
modated. Connected with these baths are laundries also, so
that poor women can wash their clothing.
Three years ago I attempted some missionary work in the
way of establishing free baths in Chicago. I wanted to find
the wickedest men in the city. For this purpose I consulted
the chief of police, who told me which was the worst place in
the city. There I put in fourteen free baths. There was a
gospel mission next door. I asked the superintendent of the
mission what he thought of the idea. He did not think it
amounted to much, but I nevertheless determined to proceed
with it. There was but one place where a man could get a
bath without paying for it, and that was by falling into the lake,
and there was a law against that. Two or three weeks after-
ward this same gentleman came to me and said that he wanted
to shake my hand ; that the baths had changed the complexion
of many of the people as well as of the community. The
baths were patronized by men who were so black you could
not tell to what race they belonged. I was astonished to see
how anxious the lower classes were to be clean. I spent Sun-
day there until within the last three years ; I found one Decem-
ber morning, when the temperature was a little below zero,
180 men in line, the nearest one against the door, waiting to
wash their bodies and clothes. There was not a man who had
an overcoat or gloves. Their collars were turned up and they
were shivering in the cold. They had been there since 6
o'clock in the morning. It was really a pathetic sight. It is
the rule to find a line like that there now every morning.
Sometimes 200 men come and wait their turn in line. I was
glad to see that the city authorities, two years later, estab-
lished as a memorial of the Mayor, Mr. Harrison, their own
free baths.
The Chairman — Were your baths entirely free?
Dr. Kellogg — Yes sir, entirely free ; we are still carrying it
on. We find the men are still ever ready to patronize these
baths. I think it is a means of free grace that is better than
preaching.
Another thing I have noticed, in studying this question, is
that those people who give attention to public cleanliness, are
the most advanced in civilization. To illustrate that, I remem-
ber an anecdote that I heard at the expense of Spain. An
Englishman was traveling in Spain some time ago. He went
to a hotel and called for a bath. The proprietor was aston-
ished, and could not fully understand what was wanted. Fin-
ally the traveler learned that his host did not possess such a
thing as a tub. After considerable delay he brought two large
butcher's trays, and the traveler was enabled to take his bath,
presenting the appearance of a miniature Colossus of Rhodes.
The result was that the water leaked through the floor upon
the people below, which caused the traveler considerable
trouble.
I think what is called bogus Christianity is chargeable with
the degeneration of the baths. One of the first things the
Christians did in Rome was to try to tear down the baths and
convert them into unnecessary churches. You will find in
Rome at the present time scarcely such a thing as a public
bath, only two or three floating arrangements, but several
hundred unnecessary churches. They have been built almost
entirely from unused public baths. The baths have been torn
down and to day serve as churches or convents.
I was reading regarding one of the early fathers who was
supposed to be very eminent in piety and canonized because of
his little regard of appearances. He was filthy and had three
hundred patches on his pantaloons, and was canonized because
it was believed that the purest souls were found in the dirtiest
bodies. What this country needs is the promulgation of the
gospel of life, and I do not know of anything more conducive
to pure minds than ample facilities for personal cleanliness.
The Turkish bath is one of the best ways by which it can be
promulgated.
A celebrated doctor in Vienna called attention to the fact
that a hot, followed by a cold, shower bath caused the blood
corpuscles to be increased in number from 35 to nearly 50 per
cent. That seems unreasonable, but I have repeated his
experiments, and while I have found no instance in which the
increase was so great as 50 per cent., I have frequently found
an increase of from 10 to 20 per cent. But that is consider-
able when we have an area of nearly two thousand square
yards in the body.
I think we must consider this bath as one of great value.
It is not that the corpuscles are originated, but simply brought
out of their lurking places. They accumulate in the spleen,
viscera and liver, whereas by the circulation they are brought
into the stream of the blood, whereas before they were stag-
nating. So that the Turkish bath becomes the means of
increasing the general vitality, and at the same time preserves
the corpuscles from destruction. I do not think anything can
be of greater benefit than the Turkish bath.
MASSAGE IN CASE OF APPENDICITIS.
Read before the Scandinavian Society of Teachers of Gymnastics,
Stockholm.!
BY ASLEY LEVIN, M.D.
All authors on internal medicine whom I have
studied on this subject (Niemeyer, Eichhorst,
Strumpell, Kunze, etc.) regard it unanimously to be
the first rule in the treatment of appendicitis, to let
i Translated by Hugo Olden borg, Central Music Hall, Chicago.
1896.]
MASSAGE IN APPENDICITIS.
419
the patient have complete immobility, not even
allowing examination with palpation. In all the
papers on gymnastics which I have perused. 1 have
not found a single word mentioning tin- benefit or
oven the possibility of a gymnastic treatment for
the disease in question. As far as I know, the only
publication on the subject to be found is in the
report from the Swedish Medical Congress in Norr-
kdping, 1SST. where Dr. A. Wide reports about four
eases which he has treated. During the last years
some masseurs have made use of massage in this dis-
ease, regarding the treatment as often very service-
able, although always more or less dangerous. I wish
to present my experience on the subject. It may
first be necessary to distinguish the meaning of the
word appendicitis.
Authors on medicine speak of three different dis-
8, all of which may be included under the name
of appendicitis. They are typhlitis, perityphlitis,
and paratyphlitis. Typhlitis is an inflammation of
the intestinal wall; perityphlitis of its serous mem-
brane, and paratyphlitis means an inflammation of
the porous connective tissue behind the appendix,
between that and the rear abdominal wall. The dif-
ference between these three is often difficult to deter-
mine, especially as they often pass into each other
ami may he found simultaneously.
The disease usually commences as a typhlitis or a
perityphlitis and may remain in this stage, or later
on develop into paratyphlitis. During the course of
the disease we can plainly distinguish two stages.
The tirst stage, the acute, is characterized by fever,
pain and great soreness. The second begins when
the fever has subsided, the pain decreased and the
bowels moved. The most marked symptom is sore-
ness, localized in a circumscribed place. It is
observed when the patient makes a stronger contrac-
tion of the muscles of the abdomen or of the lower
extremities. It is also felt on pressure.
The treatment is quite different during the differ-
ent stages. In the acute stage complete immobility,
ice. opium, etc., are prescribed, and only in the sec-
ond stage of the disease has massage, as far as I know,
been applied by some masseurs.
In the manual method of treatment the rule is, and
in some respects even more than when treating the
disease by medicines, tentare licet (hasten slowly).
Without trying something new, without testing the
adaptability of the method on new regions of the
body, we would here, no more than elsewhere, not be
able to make any progress. Furthermore, with the
means which one has, literally speaking, in one's own
hand, there is less danger attached to experimentation
than with many other methods. All of us have been
happy to witness how the therapeutic gymnastics
continually enlarges its field of work and takes posses-
sion of additional diseases for treatment. May I then
be permitted to describe the method I have followed,
and which may be an example of many other methods
that are pursued by other masseurs.
Case 1. — A man, 40 years of age, who was treated by me in
1884. Seven years previously he had suffered from appendi-
citis, having had fourteen relapses, several of which were
quite serious. Seven or eight months have intervened since
the last attack. The patient consulted me for a stubborn con-
stipation, which had followed as a result of the disease, and
probably the constipation was the cause of the many relapses.
There was also a moderate soreness in the fossa ileo-cecalis.
I started the treatment with much cautiousness and a feeling
of respect for the dreaded disease. The treatment consisted
of bowel-massage, given in the beginning with great precau-
tion, on the right side ; but as the soreness gradually disap-
peared the strength of the treatment was increased, and finally
all tho soreness having gone, this side was especially worked
upon. The stools became more and more regular, and there
was no need of any more treatment. The patient had then
been treated during four or five months. Perhaps the func-
tion of the intestines varied after that and occasionally
required repeated treatment, but in the mean time there has
been an absence of relapses. The last effect of the treatment
was, so to say, added to the bargain, because it was not
expected from the beginning, as I could hardly have hoped to
obtain such a result.
Case ^.—Encouraged by the result secured in the first case,
I eagerly started in with my second case m 1885. Mrs. K., of
20 and some years, was taken ill with appendicitis (typhlitis,
peri- and paratyphlitis) after a cold. She was attended by a
colleague here, and after consultation with him I commenced
the treatment about five weeks after the disease had set in,
and three weeks after the patient had left the bed. There
still remained a rather considerable resistancy along the cecum
with moderate soreness, except on one single spot, the size of
a finger tip, located about the middle between the navel and
the right anterior superior spine of the ilium, which point was
very sore. The treatment now consisted of gentle massage of
the resistant part, avoiding the tender spot. After a couple
of months there was nothing to be found of the resistancy.
The circumscribed soreness, however, still remained, although
it had somewhat decreased in severity. The stools were
always normal.
These two cases are to be regarded only as results
from the appendicitis, or, at least, as such cases in
which the acute stage has already passed. All of the
cases treated by other masseurs have been similar.
Case 3. — Contemporary with the above mentioned case, I
received a third one for treatment. The patient was a man,
37 years old, who accidentally slipped down on his right leg
from the last step of a staircase, and landed on the heel with
straight knee. He felt a sudden pain in the right side of his
abdomen, and eight days later noticed soreness in the side. On
the eleventh or twelfth day I was called and found the patient
suffering from pains and great soreness over the lower part of
the right side of the abdomen. Constipation had been present
for three days, and there was slight fever. The usual treat-
ment was carried out, immobility, ice and opium. The pains
soon subsided ; the soreness disappeared, and the temperature
became normal. On the ninth day I tried to effect evacuation
by means of an injection, but did not succeed. I ordered
another injection for the evening and returned the following
day in company with a colleague. No stools. Two great
injections did not have any effect, but as there was no soreness
I gave a common bowel-kneeding, beginning with great care,
but by and by, as no pain was felt and gases began to leave
the patient, a matter that had not occurred before, I increased
the vigor of the treatment. The patient soon felt an inclina-
tion to move the bowels, and a small injection had the desired
effect. As the patient lived some six miles distant from me
out in the country, I was only able to treat him irregularly
with massage during one month. The soreness in his right
side disappeared, however, entirely during this time ; the
stools became normal, and since then he has had no reiapses.
In this case the treatment was begun nearer the
acute stage; but all fever having disappeared and the
soreness already much reduced, we considered the
acute stage as being passed, although the patient had
not yet had any stools, when the treatment was started.
During the winter 1887 I spent a month in London
in order to pursue at the very place the so much
spoken of "method" of Mr. G. H. Kellgren. In my
opinion it does not decidedly differ from the method
of Ling, upon which method it was admitted to have
been based ; but in some cases it was carried out quite
differently. For instance, a couple of manipulations
were used, already mentioned by Ling, and also in
our gymnastic institutes. Kellgren, however, prac-
ticed them a good deal more and had technically
improved them. These were nerve-friction (our
nerve pressure) and vibration (a very slight and fine
shaking or trembling motion). Beside that, the
whole gymnastic treatment was given during a much
420
MASSAGE IN APPENDICITIS
,
[August 22,
longer time and with more energy than is generally
the case here.
The above mentioned manipulations were also used
in several acute diseases, such as fevers, etc., which
generally have been regarded as unsuitable for
mechano-therapeutics. I am sorry to say I had not the
opportunity of following up such a case, but judging
by from what I heard and regarding the splendid
technique that was displayed and which I also tried
to practically learn, I decided to try this kind of
treatment as soon as an opportunity presented itself.
I thought especially of the appendicitis which Kell-
gren said he had treated during the acute stage and
with good results.
Case 4. — It was not before 1888 that I had an opportunity of
trying the method on a more acute case. It was when the
same lady whom I had treated before (Case 2) had a relapse.
I started treatment on the fourth day, while there was still a
great deal of soreness and fever (38 to 39 degrees C.) existed.
It consisted then of extremely fine vibrations j ust over the most
sore place. I argued like this : Here is a stasis ; if I were now
able to produce a motion which on one side is strong enough
to cause an excitation of the debilitated tissues, especially in
the vessels, but, on the other hand, is not so vigorous as to
tear possibly existing adhesions, the effects must be beneficial.
I regarded the vibrations to be. such movements, if they were
carried out, that the trembling of the arm and hand is trans-
ferred to the underlying parts without so great a motion being
produced, that no rubbing or dislodgment of adjacent tissues
could take place. I would not, even now, begin the very first
day. The treatment with ice and opium was resorted to as
before. The exceedingly sore abdomen could not only stand
my treatment, but the patient felt relieved ; it had even a
soothing effect upon her. The first day the treatment only
lasted for five minutes ; the second it was increased to fifteen
and it then relieved the pain and decreased the pressure in the
abdomen by causing gases to escape for the first time. So
also the following day and when on the seventh the fever had
disappeared and an injection of water was given with good
result, the attack was over. Massage and vibrations were
then continued. One week later all resistancy was gone, but
the old sore point still remained.
Case 5. — In the summer of the same year, 1888, there came
to the watering place of Bie, a 17 year girl. Miss A. In the
spring of 1887 she had a slight attack in the ileocecal region,
which, however, by her physician was not regarded as a real
inflammation, until the patient in the spring of 1888 had a
strongly marked appendicitis, leaving a soreness in a small
place, also the one localized about midway between the navel
and spine of the ilium, anterior superior dextra. There were
also found so-called cellulites (infiltrations) in the subcuta-
neous connective tissues of the abdomen, which possibly
started after the long lasting cold compressions that were used
during the attack in the spring. There was no resistancy to
be observed except in the sore spot, the size of a finger tip.
The treatment consisted of general abdominal massage,
directed partly against the subcutaneous infiltrations, partly
against the slowly acting intestines, and especially against the
sore point. The patient was getting along all right, when one
day I saw her in a running race down a long steep hill.
Being below, I immediately stopped her, but it was too late.
The following morning I received notice that she had been
taken ill during the night with pains in the right side and very
much increased soreness, slight aching, but no fever. The
patient, as well as her mother, who was along with her, were
convinced that it was a relapse, because the previous attack
had begun under the very same circumstances and with the
same symptoms. Treatment was immediately commenced,
and as the usual massage could by no means be endured, 1
resorted to vibrations during half an hour and repeated this
treatment twice the same day with a constant diminution of
the pain. There was slight fever in the evening. The follow-
ing morning no fever was present ; the pain had nearly disap-
peared, and the soreness decreased. After the first treatment
this day the patient felt entirely well and wanted to leave the
bed. She remained in bed that day, however, received one
more treatment, and felt completely well the next day. The
massage treatment was continued with the result that the
patient did not feel anything but a little soreness on pressure
at the above mentioned point.
In December of the same year she came back again in
order to get this soreness, which had now somewhat increased,
worked away. I had hardly treated the patient a week before
she happened to slip on the floor and fell, and, as she expressed
it, sprained her right side. She immediately felt pain again
in the old place. The pain and soreness increased, so that at
my visit the following day they were pretty severe and did not
permit of the usual kind of massage. I took up the vibrations
at once and after half an hour of treatment the pain disap-
peared, and the soreness was not worse than before. The fol-
lowing day the condition was as usual. After that, I treated
the patient occasionally without being able to entirely remove
the soreness in the above mentioned point.
Case 6. — The same year I had at the Central Gymnastic
Institute another patient with recurrent appendicitis. Miss
T. was 19 years of age. She suffered in February, 1886, from
appendicitis. In May, the same year she had a relapse after
an improvement. Since that time she has had soreness in the
ileo cecal region, which later spread over the groin and the
whole hip, with pain in the small of the back and the whole
right leg, attended with increased difficulty in walking. Nov.
22, 1888, she came to me for treatment at the Central Gymnas-
tic Institute. During the first month her condition was
unchanged, with considerable pain in the small of her back,
right hip and groin, and a great deal of hardship in walking.
Great soreness in the ileocecal region, with the resistancy
spreading in the right side of the abdomen. During the stop
at Christmas time the patient had a relapse without known
cause, Jan. 9, 1889. I was called the 10th, when the patient had
pain in her right side which had considerably increased in
severity, accompanied with soreness and slight fever (38 to
39 degrees C). I immediately gave the treatment with vibra-
tions and afterward ordered ice and morphin. The treatment
was repeated two or three times this day, also the following
day for from fifteen to twenty minutes each time. As the
patient felt greatly relieved and pain and soreness had mate-
rially decreased after every treatment, ice, as well as morphin,
was discontinued after the second day. On the 15th the tem-
perature was normal ; an injection was given with the desired
result. A couple of days later she was up, and after a fort-
night more she appeared again at the Institute, to which place
she had quite a distance to walk. This case showed what a
different effect the treatment has when the vibrations are
properly given. As my time in the beginning of the term was
so much occupied that I could not possibly visit the patient
more than once a day, I desired to let some of the pupils from
the Institute (now in their second year) try the treatment in
such a delicate case. Consequently I let the pupil which had
previously treated the patient at the Institute, who had given
very good movements, and when giving the abdominal massage
to the patient (which she had done for a month previously)
displayed marked ability in moderating the strength of the
movements, again accompany me and give treatment with
vibrations. The patient, however, had marked soreness dur-
ing the whole treatment which lasted quite a while after the
treatment was discontinued. Treatment was again tried, but
with the same result. My own treatment gave, as before,
relief. I did not dare let this pupil continue the treatment,
but took another, whom I had found previously to give the
best vibrations, although she had not before treated this
patient, and had not even had a case resembling it. Her
treatment was tolerated very well from the start and afforded
relief. I might remark here that the patient did not like to
change the masseuse she once had become accustomed to.
When she returned to the Institute she was treated once
daily with massage and light passive movements. As the
soreness passed away the strength of the movements was
increased, with the result that when the patient stopped May
15, the soreness was very nearly gone, and the resistancy could
hardly be felt. She could walk without any trouble, and her
bowels moved regularly, daily. Since that time she has had
no relapse.
Case 7. — Mrs. D., 33 years of age, came April 1, 1889, to the
Central Gymnastic Institute. She had had perityphlitis
December, 1883, a relapse during the summer, 1884, since
which time there was soreness in the right side. The patient
felt "tired and weak" ; the slightest exertion produced addi-
tional soreness and even pain for a couple of days. She suffered
from another relapse in January, 1889. During the last two
weeks she has been treated with massage by a colleague in this
city and has improved. Now she gave evidence of slight pain,
a great deal of soreness on pressure in the cecal region, espe-
cially at a point a little below the middle between the navel and
the right superior spine of the ilium ; pain in the sore region
when bending or turning the trunk ; also in case of longer and
more rapid walks. Stools fairly regular. , After a month of
treatment with massage and light movements, her strength
was considerably increased ; there was no pain experienced
1896.]
MASSAGE IN APPENDICITIS.
421
while walking or in moving the body. The soreness on pres-
sure remained, though very slight. Her bowles moved
regularly.
Cases. - -In April, 1889, Mrs. Y. (See eases 2 and i) had
another relapse. This time, as before, she suddenly com-
plained of pain and great soreness which came on at once;
later a high fever developed (38.3 to 40.1 C). The same col-
league was called who treated her before and the treatment con-
sisted of ice, morphin and opium. I began the following day
to jive vibrations and my colleague, who had been very doubt-
ful as to the benefit of this treatment, had to acknowledge its
good effect. It gave more relief than the ice. The treatment
ven twice a day, and at the end of seven days the attack
subsided. The after-treatment, which was continued forsome
time, could not even now remove the soreness in the old place.
'. In October of the same year another relapse
Occurred in t lie same patient, which was just as sudden and
se\ere. This time I had the opportunity of giving two treat-
ments the first day, which afforded so much relief that neither
ice nor opium was used. The temperature ranged from 38 to
X'rees C.
A brother of Director Kellgren in London, Dr.
Arvid Kellgren (also from London), who happened to
bo in the city, was kind enough, at my request, to
accompany me the following day and give the treat-
ment, which in manner was the same as I had pre-
viously given, but in execution undoubtedly much
bettor, as his technique was exceptionally good.
After his first treatment, which was kept up for half
an hour, the pain decreased very much. We then
both continued the treatment for half an hour each
daily until the fifth day, when the patient was able
to leave the bed. After that I gave a long after
treatment, following which she felt less of her sore
spot than ever after the first attack. But the sore-
ness did not disappear entirely. This lady was preg-
nant in 1887 and 1888 which condition normally
progressed without any influence upon the soreness
in her right side. During none of the relapses was
there any soreness to be found in the pelvic regions,
which were always examined.
My opinion as to the use of therapeutic gymnastics
in the treatment of the above-mentioned disease,
judging from the experience I have had, and what I
have found out from other masseurs, is that the indi-
cations are quite different in different stages of the
disease. My opinion is decided about the later stage,
the so-called "after stage," which, as above men-
tioned, has hitherto been the only stage where
mechano-therapeutics have been used. I regard the
treatment in this stage, as a rule, both useful and
beneficial. The anatomic alterations consist in most
cases of effects that are left after the inflammation
has subsided. These effects consist sometimes of
adhesion between the cecum and the surrounding tis-
sues, as the abdominal wall, other intestines, etc.,
resulting from the inflammation of the serous mem-
brane of the intestine. It is very natural that in pro-
portion to the degree that these adhesions are short
and broad, they will obstruct and limit the peristaltic
action and to the same degree, when they are length-
ened, this hindrance will decrease. A strong bowel
kneading which will make the intestines move about
each other, helps to extend and lengthen those adhe-
sions, without tearing the intestinal walls, because of
the now well organized condition of the results of the
inflammation. Such a movement must consequently
be very beneficial and there is no reason to suspect
.any danger.
Another effect depending upon the inflammatory
process in the intestinal wall is a remaining edema,
which renders the intestinal wall thicker, its muscles
less powerful, and consequently the whole action of
the intestine is lessened. From this there results an
inclination for constipation, and the constipation on
its side is generally the cause of the relapse. It is,
of course, analogous to the effect of the kneading
upon any other part of the body, that the direct
kneading of the intestine will promote the circulation,
remove the products of the disease, and consequently
bring the tissues back to their normal stage. If there
are no other changes in the intestinal wall we can not
suppose that such a kneading would be of any danger.
Had there been paratyphlitis, that is, an exudation of
pus behind the cecum, the amount of pus would regu-
late our action. If the amount is rather limited, an
infiltration, it is often absorbed without any interfer-
ence from the outside. Careful massage or, perhaps
better, vibrations will then increase the tissues' power
of resorption, distribute the pus, and prevent it from
accumulating and forming an abscess. If, on the
other hand, the amount of pus is so great that an
abscess really exists there, it is very doubtful if any
kind of manual treatment would be beneficial. It
might be a source of danger in producing a rupture
and, above all, we can sometimes do more harm than
good by this kind of treatment, by deferring what in
such a case would be more beneficial — a surgical
operation.
In still other cases (cases of real typhlitis) a sore
may be developed in the intestinal wall and perfora-
tion thus threatened. Such cases are frequent when
the disease begins in the vermiform appendix. In
most cases such a perforation is prevented by a pre-
viously circumscribed peritonitis which solders the
threatened place together with the adjacent part of
the peritoneum. In this way an adhesion will be
developed, which will always be in great danger of
breaking before the intestinal wall has healed up
again.
All manual treatment during this stage is, of course,
dangerous and as the benefit it might produce in pro-
moting resorption does not exceed the danger to which
we subject the patient, we must say that this kind of
treatment under such circumstances is decidedly con-
traindicated. If pus is encapsulated somewhere we
must think of the possibility that by manipulating the
same we might cause an acute inflammation, which
will be followed by perforation.
With reference to the acute stage, our experience as
yet is so little regarding the treatment, that we would
hardly dare pronounce an opinion. So much might
be said, however, that the treatment seems to give the
patient relief without causing any annoyance or dan-
ger; so consequently we are justified in continuing
the experiments, observing the greatest caution and
possessing as complete a knowledge as possible about
the case. It is not advisable for any masseur to try
such treatment without being closely controlled by a
physician.
In case of relapse I regard it of great benefit to im-
mediately make use of the treatment, because we
might be able to abort the attacks in some cases,
a matter which, will always be difficult to prove.
Finally, I would again call attention to the fact that
the manner in which the movement is given is of the
greatest importance, and should be given in such a
manner that the hand of the masseur will not injure,
but rather have a decidedly beneficial effect. Any
other movement would really do harm. Only a good
operator in consultation with an expert diagnostician
ought to try the manual method of treatment. In
422
ENCHONDROSIS.
[August 22,
the same degree as more practitioners try this method,
our experience will be proportionately increased, and
then I hg*pe better methods will be devised and more
decided' indications given.
ENCHONDROSIS.
Read byTHle in the Section on Surgery at the Forty-seventh Annual
Meeting of the American Medical Association held at
Atlanta, Ga., May 5-8, 1896.
BY MERRILL RICKETTS, Ph.B., M.D.
CINCINNATI, OHIO.
While this disease is one of the rarest affecting the
human skeleton, it has many interesting features and
causes. The literature pertaining to it is indeed
scarce, but few cases being reported, and those by
Berg of Stockholm within the last year.
The principal causes assigned in the twenty-one
cases referred to were syphilis, tuberculosis, typhoid
/ '
/
fcv
Figure l.—H. McK. Aged 37 years. Injured June 29, 1865. Abscesa
spon. Opening Sept. 29, 1895. October 19, curetted. November 1, removed
two inches seventh cartilage. December 1 curetted sternum and removed
part of cartilage of seventh, eighth and ninth. Ktbruary 4, removed
part of cartilage of seventh, eighth and ninth cartilage. March 11, 1896,
removed cartilage and three-quarters of an inch of bone of the sixth,
ceventh, eighth, ninth and tenth; also curetted sternum and removed
double pedunculated flap from left side to cover entire granulating sur-
face. Recovery. "Traumatic chondritis."
fever and trauma. When once the cartilage becomes
diseased there seems to be no remedy but complete
removal and also a portion of its bony attachment.
The accompanying report of a case of traumatic
enchondrosis illustrates the amount of destruction
which may result from an injury to the perichondrium :
H. M., age 37, white, American, received an injury to
the right seventh costal cartilage on June 7, 1895. An
indurated mass appeared about one and a half inches
to the right of the median line over the seventh costal
cartilage. An abscess appeared which was opened on
the 20th day of September following; this continued
to discharge pus until October 19, when he was
brought to my office by Dr. J. K. Brammer, his
attending physician. Cocain was injected and an
incision made about two and a half inches long. It
was found that the cartilage was diseased, necessita-
ting a thorough curetting. He returned November
1, no improvement having taken place. Two inches
of the seventh cartilage was removed at this time.
On December 1 the sternum was thoroughly curetted
and a portion of the seventh, eighth and ninth carti-
lages removed. Still there was no improvement, the
disease gradually extending. Feb. 4, 1896, another
portion of the seventh, eighth and ninth cartilages on
the left side, allowing the space from which it was
taken to granulate. A drainage tube was passed
beneath the entire flap. He made a rapid and unin-
terrupted recovery and is now able to perform work
of any kind.
In conclusion I would offer the following sug-
gestions:
Figure 2.
1. None but the most radical operations should be
made at the onset of the disease.
2. At least one half inch of the bony attachment of
the cartilages should be removed.
3. Great care should be exercised to prevent punc-
turing the pleura.
4. Surgical anesthesia should always be resorted to,
as it is difficult to determine the extent of the disease
before operating.
5. If the sternum be diseased a portion of the nor-
mal should be removed with the diseased tissue.
6. Unless bone is removed with the cartilages, the
wound should be allowed to heal by granulation and
not by flaps, as fistulas indicate the diseased tissue.
7. Flaps should be resorted to when possible.
8. There is no evidence that medication is of any
avail.
The Trinidad, 415 Broadway.
ISM. l
INTUBATION OF THE LARYNX.
423
REPORT OF FIVE HUNDRED CASES OF
INTUBATION OF THE LARYNX
Kouil before the Colorado State Medical Society, Jane 17, 1899,
BY F. E. WAXHAM, M.D.
PROFESSOR or DISEASES or tub chest, laryngology and riiinoloot,
COLLEGE : ATTENDING PHYSICIAN N08E, THUOAT
AND CHEST DEPARTMENT, ST. JOSEPH'S HOSPITAL.
DENVER, COLO.
It has been my pleasure to have reported, on a pre-
vious occasion, 466 cases of intubation. To this
number I can now add 37, making a total of 503. Of
these thirty-seven cases there were seventeen recov-
eries, or 16.64 per cent. Many of these cases were
beyond all hope when the operation was performed.
Several were complicated with scarlet fever and some
with measles, and in these cases the operation was
simply performed for euthanasia, much to the detri-
ment of a good record. In nine eases antitoxin was
administered with six recoveries, or 66.66 per cent.
In order to complete the record I desire to publish the
following rases:
( 'ase 4t!7. -Diphtheria of pharynx and larynx ; age 6 years.
Wore tube seven days ; complete recovery.
Caae 168, Diphtheria of nasal cavities, pharynx and larynx ;
;><ze IS months : patient died within thirty-six hours.
Case (69. A case of malignant diphtheria with larynx
involved. Great relief from dyspnea afforded by the opera-
tion, but patient died within twenty-four hours from exhaus-
tion : age 7 years.
Case 170. Semi-malignant diphtheria of nasal cavities,
pharynx and larynx : patient died three days after the opera-
tion from exhaustion; age 3 years.
Case 471. — The case was considered to be one of membranous
croup, as no membrane was visible in nasal cavities or pharynx.
Patient wore tube nine days, making a good recovery ; age 3
: other children in the family developed pharyngeal
diphtheria.
Caae 472, Patient died on third day after operation from
extension of membrane to the finer bronchi ; age 4 years.
Case J7:i. — Diphtheria of nasal cavities, pharynx and larynx ;
wore tube ten days ; complete recovery ; age 16 months.
Case 474.- Patient dying from suffocation when operation
was performed ; wore the tube four days; perfect recovery ;
age "JO months.
Case 11'k A ease of laryngeal obstruction complicating
measles. Operation gave relief to the urgent dyspnea, but
patient died from exhaustion within twenty-four hours ; age
20 months.
Case 476. — A case of laryngeal diphtheria. Operation gave
relief for twenty-four hours, when obstruction occurred below
the tube which could not be expelled on removal of the tube.
Tracheotomy was done and a membranous cast of trachea and
larger bronchial tubes was removed. Patient died forty-eight
hours later from bronchial obstruction due to the reformation
and extension of the membrane. Age 13 years.
Case 477. — Diphtheria of pharynx and larynx ; wore tube
four days ; uneventful recovery ; age 3 years.
Case 478. — A bad case of diphtheria involving the larynx ;
wore the tube ten days before it could be dispensed with.
General paralysis occurred, involving muscles of throat ; neces-
sary to feed through stomach tube ; slow but complete recov-
ery ; age 3 years.
Case 479. — Operation gave relief, but patient died twenty-
four hours later from extension of membrane. Age 5 years.
Case 480. — Operation gave relief for forty-eight hours, when
obstruction occurred below the tube. The tube was removed,
but the patient was unable to expel the offending membrane
and immediately became asphyxiated. Tracheotomy was
quickly done after respiration had ceased and the patient
resuscitated. A membranous cast of trachea and bronchial
tubes was removed. The case did well for thirty-six hours,
when reformation and extension of the membrane occurred and
the patient died ; age 5 years.
Case 481. — A case of malignant diphtheria terminating
fatally twenty-four hours after operation ; age 3 years.
Case 482. — A sister of the previous case ; malignant and
fatal within twenty-four hours ; age 4 years.
Case 483. — Diphtheritic case ; wore tube four days ; recov-
ery ; age 4 years.
Case 484. — Wore tube five days ; recovery ; age 3 years.
Case 485. — Diphtheritic; died three days after operation
from extension of membrane to the finer bronchi ; age 11 mos.
Case 486. —Wore tube rive days; uneventful recovery; age
8 years.
Case 487. -A diphtheritic case ; prompt relief was given, but
case terminated fatally within thirty-six hours from extension
of membrane ; age 12 years.
Case 488.— The case was one of edema of the larynx associ-
ated with very severe form of scarlet fever. The patient died
from edema of the lungs within twenty-four hours after the
operation ; age 17 years.
Case 489.— A case of scarlet fever attended with laryngeal
obstruction. The case was hopeless when operated upon and
died within twenty-four hours ; age 3 years.
Case 490.— Wore the tube six days; uneventful recovery;
age 5 years.
Case 491. —Wore tube six days; antitoxin administered;
good recovery, although slow ; a secondary attack of pharyn-
geal diphtheria occurring within three weeks ; age 3 years.
Case 492. — Wore the tube nine days, making a good recovery ;
age 7 years.
Case 493.— Patient very low with scarlet fever accompanied
with laryngeal obstruction. There was but little relief from
the operation and the child died within a few hours ; age 2%
years.
Case 494. — The patient was very feeble and died within
thirty-six hours ; age 3 years.
Case 495. — Antitoxin used : patient nearly moribund from
asphyxiation ; wore the tube four days ; recovery.
Case 496.— Patient died within twenty-four hours after the
operation ; age 3 years.
Case 497.- -Diphtheritic case; patient greatly exhausted
from difficulty of respiration ; antitoxin employed ; wore tube
five days ; good recovery ; age 2 years.
Case 498. — Wore tube nine days before it could be dispensed
with ; antitoxin used ; recovery ; age 3 years.
Case 499. —A very bad diphtheritic case ; patient nearly dead
and lower trachea and bronchial tubes already invaded ; intu-
bation gave no relief on account of obstruction in trachea and
bronchial tubes which could not be expelled ; tracheotomy
performed and patient died within twenty-four hours ; age 2
years.
Case 500.— A bad diphtheritic case, nose, throat and larynx
being involved ; four other bad cases of diphtheria in the
family ; antitoxin used ; wore tube five days ; recovery ; age 2
years.
Case 501. — A case of pharyngeal and laryngeal diphtheria
and patient greatly exhausted from long continued dyspnea ;
antitoxin used ; wore tube five days ; recovery ; age 3 years.
Case 502. — A case of laryngeal diphtheria, no membrane
being visible in pharynx ; child suffering from intense dyspnea ;
case terminated fatally within thirty-six hours from extension
of membrane : age 7 years.
Case 503.— The patient did well for four days, when the tube
was removed. Within a few hours the stenosis returned and
before reaching the patient death had occurred from suffoca-
tion ; antitoxin used ; age 3 years.
In conclusion, arranging my cases in series of 100
consecutive cases the record to date is as follows:
First One Hundred Cases.
Age.
Under 1 year .
1 vear .
2 ' •'
3 " .
4 "
5 •' .
6 " .
7 " .
»
H)
Total .
No. Cases. Recoveries. Percentage,
5
13
22
17
15
9
5
8
4
1
1
100
20.00
15.38
18.18
17.76
46.6B
83.83
40.00
25.00
75.00
100.00
00.00
27.00
Second One Hundred Cases.
424
OUR PATENT AND COPYRIGHT LAWS.
L
[August 22,
Third One Hundred Cases.
5
11
18
19
22
10
7
6
2
2
1
1
1
100
2
2
5
11
9
5
1
3
0
0
1
0
1
■ID
40.00
18.18
88.46
57.72
40.90
5 "
50.00
6 "
14.28
50.00
00
00
100.00
00
100.00
40.00
Fourth One Hundred Cases.
Under 1 year . .
1 year . .
2 years .
3
4 "
5 "
6 "
7
8 " .
10 "
11 "
60 " .
Total .
Last One Hundred and Three Cases.
Under 1 year .
1 year .
2 years
8 "
4 "
5 "
6 "
7
10
12
13
17
36
Total .
Total Number of Cases.
Under 1
1
2
8
4
5
6
7
8
9
10
11
12
18
14
17
20
86
48
60
year .
year .
years
Total .
60.00
27.27
35.00
52 68
85.00
36.36
20.00
20.00
66.66
50. (X)
100.00
00
38.00
26.66
21.05
86.08
87.89
89.42
42.00
28.57
80.55
64.70
87.50
33.33
100 00
00
.00
00
00
00
100.00
00
00
I can not close this paper without emphasizing the
importance of the use of antitoxin in cases of laryn-
geal diphtheria. I am fully convinced that antitoxin
limits the extension of diphtheritic exudation as does
no other remedy that we possess and as the danger
lies chiefly in the extension of this membrane it is
apparent that the remedy should be employed early
before the membrane has extended to the lower trachea
and to the bronchial tubes. In a case of diphtheria, the
very moment that it is evident from the slightly em-
barrassed respiration and croupy cough, that the lar-
ynx has become invaded the remedy should be used.
By the early use of antitoxin in these cases not only
will many operations be avoided but many cases
requiring operation will be saved that would other-
wise perish. In corroboration of this statement I
would say that since the general use of this remedy
in Denver I have been called much less frequently by
my confreres to operate than formerly, and in those
cases operated upon a much larger percentage have
been saved.
THE EMINENTLY SCIENTIFIC NATURE
OP OUR PATENT AND COPY-
RIGHT LAWS.
THE KLEBS ANTIPHTHISIN CASE.
BY F. E. STEWART, M.D., PH.G.
DETROIT, MICH.
For the purpose of promoting progress in science
and the useful arts the Constitution of the United
States gives Congress the power to grant to authors
and inventors for limited times the exclusive use of
their respective writings and discoveries. On the
clause in the Constitution referred to, our patent and
copyright laws are based. The question at issue is
the right to copy. The copy right law refers to the
right to copy the writings of others; while the
patent laws refer to the right to copy the inventions
of others. Now I propose to show that it is just as
equitable for the medical profession to endorse the
patent as applied to medicine, as it is to endorse the
copyright as applied to literature. At the same time
I hope to make it clear that so-called " Patent " medi-
cine business is a misnomer; and I hope to show that
what is generally known as the " Proprietary " medi-
cine business possesses no property in medicines
whatever, and is a misnomer likewise.
All will admit that the promotion of science and
the useful arts is of great benefit to society at large,
and any fair minded man will agree that capital in-
vested in business should be properly protected. If,
therefore, there is a law which will protect both
science and commerce at the same time such a law
must be truly beneficent. Such exists in our patent
law, which, if properly applied is capable of effecting
that most desirable end.
" A patent is a contract between the inventor and
the government representing the public at large.
The consideration moving from the inventor is the
production of a new and useful thing, and the giving
to the public a full knowledge thereof by means of a
proper application for a patent, whereby the public is
enabled to practice the invention when the patent
expires. The consideration moving from the govern-
ment is the grant of an exclusive right for a limited
time, and this grant the government protects and
enforces through its courts." Simond's Manual of
Patent Law, p. 11.
The patent office at Washington is a great bureau
of archives representing progress in science and the
arts in the United States. Any one who wishes to
post himself in regard to inventions in any special
line of work can obtain full knowledge of everything
patented in that line by applying at the patent office.
Models, drawings, descriptions, working formulas, are
all there for inspection; and he can secure, at small
cost, copies if he so desire.
Many useful arts of the ancients have been lost to
the world for lack of publication which would have
been preserved if patent laws similar to those devised
by our law makers had been in force. The necessity
of securing the publication of the art of manufacture
of every medicine must be apparent to every one. In
case of & patented medicine such publication is secured.
Moreover, the inventor, to whom the world is in-
debted for the discovery of a new and useful thing
receives well merited reward for his labor.
The patent law provides " That any person who
has invented or discovered any new and useful art,
18
698.]
OUR PATENT AND COPYRIGHT LAWS.
425
machine, manufacture, or composition of matter, or
any new and useful improvement thereof, not known
or used by others in this country, and not patented
or described in any printed publication in this or any
foreign country, before his invention or discovery
(thereof, and not in public use or on sale for more
than two years prior to his application, unless the
same is proved to have been abandoned, may upon
payment of the duty required by law. and other due
proceedings had. obtain a patent therefor." Sect, 24,
Act of -Inly S. 1870.
It may be observed, first, that an invention for
which a patent is sought must be original with the
applicant; second.it must be new and useful; third,
full knowledge of it must be filed at the patent office;
fourth, the grant is limited to a term of years at the
end of which the monoply ceases, and the invention
becomes common property.
If all these requirements are not complied with the
tent is invalid, even if granted, and the courts owe
t to the public not to protect inventions when the
demands of the patent law are ignored. Now I con-
tend that the enforcement of these demands, when
patents for medicines are applied for, would do much
to correct the abuses which are throwing our laws into
disrepute in their relation to medicinal preparations.
The inventions specified as patentable are:
1. An art or an improvement of an art.
2. A machine or an improvement of a machine.
3. A manufacture or an improvement of a manu-
facture.
4. A composition of matter or an improvement
thereof.
To define what constitutes a new art, machine or
manufacture, or an improvement thereof is sometimes
a difficult task. But it is far more difficult for courts
to define what constitutes new and useful composi-
tions of matter or compositions thereof. The law
requires that an invention to be patentable, must be
" new and useful." To define what are new and use-
ful compositions of matter may require the most pro-
» found knowledge of chemistry; and when referred to
therapeutic inventions, a score of expert physicians
and chemists might be required to settle it. Yet
patents have been granted without any attempt being
made worthy of the name to ascertain whether the
alleged inventions conformed to the demands of the
patent law or not. More care should be taken to
carry out the wise provisions of the Constitution in
this connection, so that the patent law shall promote
and not hinder progress in the science of therapy and
pharmacy. Surely no patents should be granted for
» medical compounds unless the applications are first
submitted to a commission of physicians and chemists
to pass thereon; and the courts should not attempt to
decide questions of infringement without first con-
sulting such a commission.
Another point of great importance in the applica-
tion of patent law to medicine is the question of
naming new compositions of matter. Mistaking the
nature of the patent privilege some inventors have
registered the names of their inventions as trade-
marks for the purpose of continuing the monopoly
after the patents expire, and thereby defeating the
patent law. Now it is cerainly true that if the only
name by which a compound is known may be legally
used as a trade mark, it is equally true. that its use as
a trade mark may be continued indefinitely after the
patent has expired, so that the trade mark law may
render the patent law ineffective so far as pro-
moting progress in science and the arts is con-
cerned. But when the patent expires the article,
according to the contract between the inventor and
the government, becomes common property. Surely,
under the contract, it is not fair to permit the inventor
to exercise a perpetual control over the name of the
article and thus exclude the public from an equal
chance in its manufacture and sale. Moreover, the
name by use becomes descriptive of the article, and
it is an axiom of law that a descriptive name can not
be made a trade mark.
Mr. George H. Lothrop of Detroit, one of the most
eminent patent lawyers in America, in a conversation
recently used an illustration which seems to make
clear the absurdity of claiming the only name of an
article as a trade mark. He said: "When a baby is
born into the world, a name is given it. Does the
name of the baby belong to the baby or to the one
who gave the baby its name?" Every new thing
born into the world must have a name ; and that name
belongs to the thing, not to the one who named it.
While the patent is in force the use of the name is
restricted to the patentee along with the invention,
but when the patent expires both should, and I hold
that they do, become common property.
Now, as we have no law in this country granting
the exclusive use of articles of trade to individuals
except the patent law, and as every article not patented
in which the world is trading is free to the public to
manufacture and sell, it follows that there is no prop-
erty in a medicine unless it is patented. The major-
ity of medicinal compounds on the market are not
patented. The reasons for this are various. First,
only a few of them are patentable, being mere aggre-
gations of old and well-known drugs. Next, the
manufacturers had rather rely on secrecy and semi-
secrecy for protection than expose their trade secrets
by an application for a patent. Then the monopoly
permitted by the patent law is limited, and it is
possible to monopolize a medicinal compound indefi-
nitely by secrecy as to its true or working formula.
But it is hardly a correct definition to call these
unpatented compounds proprietary medicines, for it
inculcates the idea that there is property in them
(which there is not), and that any one except the intro-
ducer who may desire to manufacture and sell them is
guilty of piracy. As well might every manufacturer of
pens, ink, paper, silk and woolen goods, and of every
article of commerce not patented be called a pirate.
Competition is the life of trade, and it is this mistaken
idea that every manufacturer of unpatented articles
except the introducers are pirates, imitators and infring-
ers of the rights of others that is throttling the entire
manufacturing interests of the United States as far as
medicine is concerned.
If the medical profession and the pharmacists of
this country would combine on this one thing and
demand that every medicinal composition shall be
published and provided with a name under which it
may be manufactured and sold by all, it would do
more than anything else to blot out that great mis-
nomer, the so-called "patent medicine" business. It
is a wise and just policy that rewards the inventor of
a new and useful composition of matter with a patent.
But let no patents be granted for medicines unless
there are reasonable grounds for believing that they are
new and useful inventions, and then see to it that
the scientific and beneficent ends of the patent law
426
OUR PATENT AND COPYRIGHT LAWS
PYI
[August 22,
are carried into practice. The protection of labels'
trade marks and packages is indispensable to the exis-
tence of trade and a great protection to the public,
but let it be known that there is no legal warrant in
the use of the only name of an article as a trade mark.
Such a use of it creates a perpetual monopoly, pro-
tects secrecy, kills all competition and is an open door
to fraud.
Another very important point in this connection is
the right possessed by the government representing
the public at large to refuse a patent to an inventor
when public policy demands it. The granting of a
patent that will hinder progress in science and use-
ful arts is contrary to the policy of the patent law.
" The policy of the patent law is, primarily, a sel-
fish one on the part of the public, and only second-
arily intended for the benefit of inventors, and then
as a means to an end only." Simond's Manual.
The same author states that the United States
Supreme Court has, twice at least, decided that a
principle can not be patented, " and this in one in-
stance when one of the most important of all inven-
tions of all ages was under consideration — that of the
electric telegraph." The Government thought that by
giving the inventor a monopoly it would delay the
development of that most useful discovery, and so re-
fused the application. In the same manner the gov-
ernment has a right to refuse a patent upon a chemical,
such as phenacetin, for example. A patent on a pro-
cess or machinery for making the chemical might
not be objectionable, but the granting of a patent
upon the chemical itself, and thus cutting off all
opportunity for developing new and improved meth-
ods for its production does not seem wise public
policy and compatible with the end in view, viz., the
promotion of progress in science and the arts. Espe-
cially does the policy seem a foolish one when the
manufacture of the chemical is conducted in Ger-
many, and results in the enrichment of a foreign cor-
poration. Still more foolish does it seem when it is
considered that Germany will grant no such privi-
leges to American inventors manufacturing in this
country and exporting to Germany. But the height
of unfairness is reached when our laws are so con-
strued that phenacetin is protected in this country so
that it costs at wholesale $1(5 a pound, when, accord-
ing to the Chemist and Druggist, it can be purchased
under its chemical name ( paraacetphenetidin ) in
England for about $1.25 per pound.
Now for the practical application of all this to the
"Antiphthisin " case. Dr. C. P. Ambler, Associate
Medical Director and Laryngologist, Winyah Sani-
tarium, Ashville, N. C, an institution where that
preparation is being exploited, asked the privilege of
reading a paper on the subject of " Antiphthisin "
before the Section on Materia Medica, Pharmacy and
Therapeutics of the American Medical Association.
As chairman of the Section I gave my consent. This
I was justified in doing, as " Antiphthisin " is the
invention of the famous scientist, Klebs, of Klebs-
Loffler bacillus fame, and Prof. Klebs was present in
person to discuss the subject. In the discussion it
developed that the product known as "Antiphthisin "
is patented in Germany and a patent applied for it in
this country. The name "Antiphthisin " is also reg-
istered as a trade mark in the Patent Office at Wash-
ington. "Antiphthisin " will not be made in this
country, but will bear a stamp " Made in Germany."
As the Code of Ethics of the American Medical
Association forbids physicians prescribing patented
medicines it is not surprising that there were mem-
bers present who seriously objected to permitting Dr.
Ambler's paper to go unchallenged. Accordingly a
resolution was passed and referred to the Business
Committee of the Association in condemnation of
"Antiphthisin." The Business Committee is com-
posed of conservative gentlemen who will doubtless
decide the question on its merits, yet it would be a
very unfair thing to affix any serious penalty on Dr.
Ambler for reading his paper, or to take any action
under the circumstances that might injure the good
name and reputation of Dr. Klebs.
When it is considered that probably 25 per cent, of
the medicines prescribed by the members of the
American Medical Association are claimed as pro-
prietary by their manufacturers is it any wonder that
Dr. Klebs considered the rule against proprietary
medicines of no binding force, even if he knew of its
existence? Was it any more objectionable for Dr.
Ambler to read a paper before the Section on "Anti-
phthisin " than it would have been if he had made the
subject "The Comparative Merits of Phenacetin, Anti-
pyrin and Salol"? All these substances are pat-
ented, and their names are registered as trade marks.
Now is the time for the American Medical Associ-
ation to take definite action in relation to the subject
of patented medicines. Something must be done.
The Association will not be satisfied with any com-
promise measures. The patenting of medicines is
right or it is wrong. Personally I believe it is right
if the scientific demands of the patent law are com-
plied with. Now that the matter is brought clearly
before the Association by the Klebs case let the mat-
ter be carefully considered, and acted on in a manner
fair to all concerned. If the Code is to be sustained
in this instance then let it be enforced all along the
line and dismiss every member of the Association
who prescribes phenacetin, antipyrin and salol.
The Code can not be enforced in this matter. What
then shall we do? Shall we indorse the use of pat-
ented medicines without qualification, and thereby
indorse the nostrum trade in toto, to the utter ruin of
scientific pharmacy? Shall we repudiate those man-
ufacturing houses who have sacrificed many oppor-
tunities of making money by standing by the profes-
sion and throw our influence in favor of those who
leave no stone unturned to throw the profession into
disrepute by advertising to cure incurable diseases
and jeering at the medical profession because of its
admitted impotence in such cases? These are seri-
ous questions that demand an answer and the nostrum
trade will not be slow to seize the opportunity to use
it for the advancement of the nostrum business unless
we answer these questions in such a manner that it .
will leave no doubt in the minds of the public in
regard to our true position. We can not afford to
fight the patent law, founded as it is on the Constitu-
tion of the United States, as it is eminently scientific
and just, but we can demand that it shall be so
enforced as to promote progress in the science of
medicine and the useful arts of pharmacy and therapy,
and not be a hinderance to all progress by patenting
principles, protecting secrecy, killing competition
and throttling trade under the guise of law.
Ichthyol in Orchitis. — Dr. Leedom Sharp recommends envel-
oping the inflamed testicle and cord in a 30 per cent, ichthyol
ointment. — Univ. Med. Mag., August.
1896. i
SUPPURATING MASTOIDITIS.
427
A CASE OF SUPP1 HATING MASTOIDITIS
CURED WITHOUT CHISELING.
::;
mi
SI
Wi
ex
mi
BY ALFRED HINDE, M.D.
tiKSlOK Sl'RciEON KYIt AND EAR DEPARTMENT, CENTRAL KRRE DISPENSARY ;
OPHTHALMOLOGIST TO THE NEUROLOGIC CLINIC IN BUSH
MEDICAL COLLEGE.
CHICAGO, ILL.
N. McG., a robust Irish girl aged 17, about ten days
the I'nited States, applied on May 8, 1891, for
atment on account of a severe earache of the right
t-ur that had commenced twenty-four hours before
and had become progressively worse since its onset.
She gave a history of "catching cold" about three
Weeks previously, adding to it during the voyage
as the* Atlantic and on the cars to Chicago. On
examination marked tenderness was elicited on pres-
ure over the tragus and downward behind the ramus
far as the angle of the inferior maxilla. The drum
membrane was intensely reddened, thickened, and its
landmarks buried. The adjacent soft parts of the
external auditory canal were swollen and injected,
especially those of upper posterior wall. The mucous
membrane of the nasal cavities was hypertrophic, and
it and that of the naso-pharynx was still inflamed and
discharging. The Eustachian openings were red and
swollen. The ear disease was evidently an extension
of the naso-pharyngeal catarrh, and the grade of the
inflammation was such that an accumulation of pus
was expected in the tympanum as soon as sufficient
time had elapsed for its formation. The symptomatic
treatment consisted in syringing with hot boric acid
solution in large amount, and in a continuous stream
into the external auditory canal; hot fomentations of
■the same solution applied to the region of the affected
■ear. In the absence of leeches, a fly blister was
applied over the tragus. Saline derivatives to move the
bowels were advised, and for the usually increased
nocturnal pain pills of camphor and opium were
ordered to be taken one every four hours as needed.
Nasal cleansing with warm salt solution was ordered.
The nose and naso-pharynx were daily sprayed with
Dobell's solution and an eucalyptol-menthol-vaselin
mixture. Beside every second day, after cleansing
the naso-pharynx, a dram solution of nitrate of silver
to the ounce was applied. Gentle inflation of the
Eustachian tube was resorted to after a few days.
Ear pain continued, deafness increased, and a pro-
fuse serum-like discharge appeared at the external
meatus; then the sufferings ceased. The discharge
became muco-purulent and lastly purulent and lessened
in amount under the above treatment, and the perfor-
ation of the drum-membrane decreased in size. The
membrana flaccida was now seen to be bulging and of
yellowish-red color and on this, the thirteenth day of
the disease, it was freely opened under cocain, but the
pain produced by its incision was so severe that the
patient did not return for treatment for sixteen days
following. During the latter time no treatment was
had. She returned, however, with a complete relapse
of all the inflammatory ear symptoms and a slight ear
discharge. Beside, there was some headache on the
right side, and slight tenderness on firm pressure over
the right mastoid.
A free incision of the membrana tympani was
advised, and a crucial incision was made in its poste-
rior half and much sanguinous pus was evacuated,
and a thorough cleansing, with the peroxid of hydro-
gen and the other solutions, was resorted to. At this
period of the disease the Eustachian tube could not
be opened by any means whatever. The urgent symp-
toms decreased rapidly and the case did well for eight
days, when another relapse occurred.
The patient became pale and looked sick, the ear
discharge continued, the headache and mastoid ten-
derness returned and increased. A slight edema and
redness of the soft parts over the mastoid appeared
and a Wilde's incision was suggested but objected to,
so that the foregoing treatment was continued. The
symptoms increased in severity. The mastoid tissues
became more swollen and painful and pyrexia (101
degrees F.) supervened, upon which latter quinin had
little effect. She sickened still further and was
unable to attend to her domestic duties. During two
days she vomited at intervals and was nauseated all
the time, and could not eat or sleep. An incision of
the mastoid process was urged, but permission was
only given to cut through the soft tissues and this
was done freely, close to the pinna, through the peri-
osteum, and an inch in length. A small amount of
thick, creamy pus was evacuated from beneath the
edematous tissues, the wound was irrigated, and the
bone was found to be sound and without any opening
into it, and permission to open it was positively
refused by the patient and her friends. The drum
membrane was again incised and the parts thoroughly
irrigated. After this the symptoms rapidly decreased
and the patient was quite comfortable again for a
week. The mastoid swelling and tenderness disap-
peared so long as the wound remained open, but
when it had almost closed she again became ill with a
complete recurrence of all the ear, mastoid, head and
stomach symptoms and fever. An opening into the
affected mastoid was urgently advised but more pos-
itively refused. A second incision through the soft
tissues over the mastoid was done and a slight amount
of pus again let out. The bone was not osteo-porotic
but perfectly healthy. No sinus was visible in the
exposed field, but after a protracted search in all pos-
sible directions with a No. 6 Bowman's probe the
latter sunk into the bone through a normal canal to
the depth of three-quarters of an inch, and in the
upper posterior part of the mastoid process. The
incision through the soft parts was now made to
expose this opening into the bone. The bone was laid
bare and found to be perfectly normal, and undoubt-
edly the passage-way was a physiologic canal giving
exit most probably to an emissary mastoidal vein (the
emissarium mastoideum of Santorini). The mem-
brana tympani was again freely incised. Into the
newly found opening in the mastoid was inserted the
tip of a finely-pointed, tightly-tied medicine dropper
whose point diameter was one-sixteenth of an inch.
It snugly fitted the entrance and through it was
injected a dropper full of sterilized water — the drum
perforation being watched at the same time — and pus
was seen to ooze from the tympanum into the external
auditory canal as the water disappeared from the
large bulb of the medicine dropper under extreme
pressure into the mastoid cavity.
This was repeated until the external auditory canal
was filled with a watery pus and the patient felt fluid
running into the throat and coughed it out. An open
way was thus demonstrated between the mastoid pro-
cess and the tympanum and through the Eustachian
tube, and seeing that we had no choice, we decided to
try and drain the abscess through existent openings.
Irrigation was continued until clear water escaped
from the ear. The relief of symptoms was almost
428
LEPERS OF COLOMBIA.
L
©1
[August 22,
immediate and the patient slept well the first night
and next day was much improved in appearance, and
said she felt almost well — the head and stomach
symptoms were all gone. The ear was discharging
freely, and we injected a solution of peroxid of hydro-
gen and watched the bubbles escape through the per-
forated drum membrame, and the entire external canal
became filled with the same, and the patient coughed
the froth out of her throat and blew it out of her nose.
Afterward a one-half per cent, warm solution of car-
bolic acid was injected and last of all an alcoholic
solution of boric acid was used and the latter caused
considerable temporary pain. The mastoid wound
was dressed in the usual way and the nose and throat
treatment was continued. So rapid and marked an
improvement resulted from the daily treatments that
at the end of four days the ear discharge had almost
ceased and what little was still present was thin, pale
and watery, and seen only in the neighborhood of
the perforation in the drum membrane. At the end
of one week from the initial injection of the mastoid
a mere speck of watery moisture at the site of the
drum perforation was mopped up on cotton, and on
examination, per microscope, was seen to consist of
detritus, with a few granular, breaking down, and
fissured pus cells. Ear treatment was now discon-
tinued. A plug of cotton was kept in the external
auditory canal, and the mastoidal wound was allowed
to close. In another week the tympanic perforation
and the wound of the mastoid had healed and the case
was dismissed with the request that the nasal douch-
ings be continued. The cure was complete, and it
proved to be permanent as no relapse has since
occurred. One year later the hearing distance for the
watch was 11-40, whereas for the left ear it was 40-40,
and the tuning fork was heard in all positions, better
in the right ear. In all, the diseased process had
lasted about fifty- eight days in the right ear, but a
complete and thorough drainage and antisepsis of the
infected cavities had been instituted for only four to
seven days before a perfect and permanent cure
resulted. This is the indication in all suppurative
processes, but it is notably difficult to accomplish in
aural surgery without opening up freely the suppur-
ating cavities. This case shows, however, that, even
as dangerous as conservative surgery is in such omin-
ous cases, very occasionally a cure may result from
simple methods.
16 Laflin Street, Chicago, 111.
THE CHURCH OF ROME AND THE LEPERS
OF COLOMBIA.
BY ALBERT S. ASHMEAD, M.D.
NEW YORK.
I send you an appeal of the order of St. Lazarus
for help to the unfortunate lepers of Colombia. For-
merly the grand master of this order had to be a
leper himself. His Grace, the Archbishop of New
York, informs me that this manner of qualification
for the grandmastership was abolished by the Holy See
in 1253.
LECTURE.
Lecture given by the Reverend Father (Salesian) Evasio
Rabagliati, in the Solemn Session of the Society of St. Lazarus
(Bogota, Colombia) on July 7,1895. (Exordio— Et occurrerunt
ei decern viri leprosi, qui steterunt a longe et levaiverunt vocem
suam dicentes : Jesu preceptor, miserere nostri— and there
met him ten men that were lepers, which stood afar off ; and
they lifted up their voice and said: "Jesus, Master, have
mercy on us.")1
The first thing we should observe in this story is
the great and exquisite kindness of Jesus, etc. . .
Brethren, not far from here, not one, not ten, lepers
lift their voices, there are many more. In Agua de
Dios there are 850, in Contratacion (San fancier) I left,
a few months ago, 700 and more; and all these lift their
voices, in order that you may hear them. And what
do they say? What is their plea? The same as that of
the gospel, miserere nostri, have pity on us. . . .
Until to-day, according to data gathered in a private
manner, I believed that the number of lepers of Colom-
bia did not exceed 15,000 or 16,000. Now, I see that
I was mistaken. Before I ascended this pulpit one
of our physicians, Dr. Carlos E. Putnam, member of
the Academy of Medicine, Bogota, assured me that I
was; for he, after asking from all the departments the
precise number of the patients, obtained this result :
That the number of lepers in the whole Republic of
Colombia on July 6, 1895, amounts to 27,250! Is
there an error in this account? Who knows? For
my part, I will admit an exaggeration; I will suppose
that there is an error in the figures; I will try to
believe that the number does not reach 20,000, even
less; that there are not more than 15,000. Do you
think that if we can abate a few thousands of the offi-
cial account, this is an argument that ought to quiet
us? Even thus, do you not believe that the calamity
is great, and that the consequences for the future
would be serious and baneful
During fifteen years which I passed in the Argen-
tine Republic, in Uruguay and in Chili, I did not see
one leper. If anyone should take the time and
patience to gather precise data on this subject, "Lep-
rosy in the World," the result would be, that the
Republic of Colombia alone has more people attacked
by leprosy in its different manifestations than all the
other nations of the universe. Really such a thing
is amazing and terrible. . . . Let us ask the men
of science, the physicians; they all, unanimously, will
tell us that the principal causes of this disease are
heredity and contagion. As to heredity, there is
not the least doubt; the Lazarinos themselves
acknowledge that either the children or the grand-
children inherit the disease; the germ remains. Who
is able to say what enormous proportions the disease
must assume through this cause? As to the conta-
giousness, not being competent I shall give no opin-
ion. All the Lazarinos say that the disease is not
contagious. Almost all the physicians say that it is;
and I have said almost all because in the medical
congress held at Bogota about two years ago, of more
than one hundred physicians called upon to give an
opinion on the matter, only two said, No. All the
others answered in the affirmative. Who was mis-
taken? The two or the ninety-eight? But I give my
opinion, whatever its value. I believe there are
climates unfavorable to the disease, and that others
favor it. In the first place there will be no contagion,
or it will be very slight; in the other case there will
i And it came to pass, as he went to Jerusalem, that he passed
through the midst of Samaria and Galilee. And as he entered into a
certain village, there met him ten men that were lepers, which s ood
afar off. And they lifted up their voices and said : ''Jesus, Master, have
mercy on us." Aud when he saw them, he said unto them : "Go show
yourselves unto the priests." And it came to pass that as they went they
were cleansed. Aud one of them when he saw that he was healed
turued back, and with a loud voice glorified God. And fell down on his
face at his feet, giving him thanks; and he was aSamaritan. And Jesus
answering, said: "Were there not ten cleansed, but where are the
nine? There are not found that returned to give glory to God save this
stranger." And he said unto him: "Arise, go thy way, thy faith hath
made thee whole." St. Lnke, xvii : 11-10.
ISM.]
LEPERS OF COLOMBIA.
429
be contagion and it will manifest itself rapidly and
energetically
One fact most evident is that the evil increases every
year. In the year 1888, according to the statistics of
theLazarinos of the Department of Santander, which
were made conscientiously by one of the most distin-
guished physicians of that Department, the number
of patients in that year did not reach 1,500; in Octo-
ber of the next year, I think, I met from 5,000 to
ti.lXH); I have since heard from persons of competent
authority that I had been very much mistaken, for
in the department in question there are not less than
10,000 lepers. There is another fact which is evident.
A few years ago this disease was totally unknown in
Antioquia; now it is frequently seen there. In the
Oauoa we hear the same story, the number of the
Lepers can not be very small, when we consider that
the authorities of that department have decided to
establish a lazaretto for their exclusive use. . . .
Allow me to speak with entire frankness. The public
in general believe that isolation exists, because we
have a large lazaretto a few leagues from the capital,
in Ago* de Dios, and another lazaretto in Santander.
That is true; but these lazarettos have only the name
of a hospital, and I may say without the least exag-
geration there might be written over the entrance of
both, "Fabrication of Lazarines." I can tell you, even
now, that in both these leper houses the healthy are
much more numerous than the diseased; two healthy
ones to one sick ; this is the proportion of the popula-
tion of the lazarettos. But what are the healthy
people doing there? Some, the smaller number,
probably attend to the patients; it is the healthy
daughter who accompanies and attends her mother,
or rice versa ; it is a brother, some relative who does
not want to forsake a sick brother or relative; to that
there is nothing to say, it is a laudable act of charity
which these healthy persons are performing, and God
will not leave this work of love without reward. But,
on the other hand, there are other healthy persons,
the greater number, probably, who are there for other
reasons. Some for the purpose of doing business,
others with the infamous object of exploiting the
poor lepers. On this subject, I have been told in the
Lazaretto of Contratacion of incidents that were really
scandalous. Moreover, in both lazarettos he enters who
will, and remains as long as he likes; he may even
establish his residence there if the whim takes him
to do so, without anyone having the right to inter-
fere. . . . The attendants are generally healthy
persons, who have to live in intimate contact with the
diseased, eat at the same table, perhaps from the same
plate, sleep under the same roof, use the same gar-
ments
And now, tell me frankly your opinion, are these
lazarettos just as we see them, places of danger, or
are they not? You must consider, that from these
houses the lepers may go to other places and establish
themselves in the villages with the greatest facility.
Any pretext is good ; if there is none, one is invented.
It is not the President of the Republic who gives
these permissions, not even the alcalde of Tocaima,
which is the nearest place to the lazaretto. They
may be given simply by the administrator or a person
delegated for that purpose
We recognize the necessity for a large and unique
lazaretto; but where? The prospect of the island of
Coiba, in the Pacific ocean, as a place of isolation has
entirely failed for many reasons; and the most forcible
of these, in my opinion, was the obstinate resistance
of the lepers. They have told me over and over again,
on all occasions, "We shall flee to the woods, Father,
we shall hide in the mountain oaves, we prefer starv-
ing here; but to the island we shall not go." I have
consulted reliable persons on this matter, and they
have pointed out to me the plains of Casanare, or of
San Martin. The idea of taking Casanare could not
be considered, because it is a region very little adapted;
1, because these plains have a large population; 2,
because the inundations are frequent during many
months of the year. In San Martin it is very differ-
ent; the rivers are not so numerous nor so rapid; we
can find with exceptionably favorable conditions, a
great plain, surrounded by the Meta and Nare Rivers,
which form a very beautiful peninsula several leagues
in extent, the elevation rendering flooding impossible,
however rainy the winter may be; and it has other
advantages not necessary to enumerate here. As to
population we may say it has none; it is a desert pure
and simple
The successor of Don Bosco, the present superior
of the Salesian order, Don Miguel Rua, long ago
solemnly promised the representative of Colombia in
Rome, the most excellent Dr. D. Joaquin Velez, to
send as many monks to Colombia as was necessary to
execute this project. In one of his last letters, dated
from Bogota, he approved and blessed it and encour-
aged us to begin to execute that great idea. The friend
and father of the Lazarines, Father Miguel Unia,
also approved the project, and thinks it feasible ; he,
who is speaking to you, has received from his supe-
riors of Turin all the means necessary to consecrate
himslf exclusively to this mission, and after the feasts
of Our Lady of Carmen he will be entirely at the
disposition of the public. He will fulfill his promise
and begin his journey from place to place through
the whole extent of the republic to ask for the mite
of Colombian charity; if this shall be the decision of
this conference. I wish before starting, to speak to
you again; in order to further elucidate these ideas,
and answer the objections which may be made. In
the meanwhile, to the intelligent, distinguished and
charitable people of the capital, I intrust the project.
To all, without distinction of opinion, either religious
or political, I recommend it most seriously; study it,
discuss it, amend it also, if you see fit. What is
important to all is to arrive at satisfactory and feasi-
ble solution. Especially do I intrust it to you, men
of science and of arts, to the physicians and publicists;
adopt this project, make it your own, and let your
valuable opinion be spread to the last confines of the
republic, in order to fill with hope the heart of all
lepers, and with charity and generosity the hearts of
all Colombians.
My last word is for you, virtuous and devoted Sis-
ters of the Society of San Lazaro. May God bless
you for all the good you have done during the four
years of existence of your beloved society. Forward,
with perseverance, you have done much; but there
remains immeasurably more to do; enlarge the sphere
of your activity, increase your ranks; every Colom-
bian whose heart beats with love of religion and
fatherland must enter them. Your work is a work of
redemption above all others. Do not be discouraged
by the difficulties which you will meet; remember
that every great and holy work must bear the seal
divine, the seal of contradiction and struggle. Once
passed through the crucible, the work will prosper
430
CONGENITAL ABSENCE OF THE ESOPHAGUS.
and triumph. God certainly has blessed and is bless-
ing us now, for his Vicar on earth, the Sovereign
Pontiff Leo XIII, has blessed you and blesses you
now. You find the proof of that in the treasure of
indulgences, partial and plenary, which he sent you
last year. Be ye all enthusiastic propagandists for
the project which I have announced; and with your
fervent and constant prayers help the work which we
undertake.
In the name of God, in the name of your wards, the
lepers of Agua de Dios, in the name of religion and
fatherland, I send you the most sincere thanks. And
for all you have done, and all you may do in the
future, all the glory will be solely for God and the
salvation of souls.
Ad Majorem Dei Gloriam. I have said.
PASTORAL.
We, Bernardo Herrera Restrepo, by the grace of
God and of the Holy Apostolic See, Archbishop of
Bogota, to the clergy and to the faithful of the Arch-
diocese:
All the good sons of Colombia who are animated
with Christian charity toward their fellow men, are
deeply concerned by the sad situation in which are
placed so many of our brethren, who suffer this terri-
ble disease of leprosy and its painful and inevitable
consequences of isolation and perhaps of abandon-
ment and utter want.
The church could not do less than take part in that
general solicitude; and, therefore, if in other times
and in similar circumstances, men especially called to
help the poor diseased arose from among her minis-
ters, now, too, by means of the sons of Don Bosco,*
she gives examples of love for the unfortunate lepers.
They with the spirit of sacrifice which is above all
praise, live among these unfortunates, nursing them
as a father would, and offering them in life and death
the consolations of religion.
Now the great work of the founding of the national
lazaretto having been begun with the object of insur-
ing to the lepers habitation and means of subsistence
to make their lives less bitter and of opposing the
spread of the contagion, the Salesian Fathers will
announce and propagate this grand work in the whole
republic. With that object, the Reverend Father
Evasio Rabagliati prepares to journey about in the
republic in order to persuade all to cooperate accord-
ing to their means and to contribute with their alms
and voluntary donations.
It is our duty to support this holy and charitable
enterprise; and for that purpose, we appeal to the
clergy and to the people of the republic, and espe-
cially of the city of the archdiocese entrusted to us,
and we request everyone to give a hearing to the
Christian sentiments of his heart, and to contribute as
largely as he can to the founding of the national laza-
retto, delivering into the hands of the Rev. Father D.
Evasio Rabagliati the alms which he destines for
that purpose.
Our Lord, God, will reward all those who help in
this work of Christian love which we recommend;
they will return an hundred-fold to the giver the
goods which will be offered for the relief of those who
cry like Job:3 "Have pity upon me, have pity upon
me, O ye, my friends; for the hand of God hath
touched me."
±
[August 22,
This pastoral shall be read twice in all the churches
in the archdiocese. Given in Bogota, Aug. 4, 1895.
Bernardo,
Salustiano G6mez Riano, Archbishop of Bogota.
Canonical Secretary.
CONGENITAL ABSENCE OF THE
ESOPHAGUS.
BY DANIEL LICHTY, M.D.
MEMBER OF THE AMERICAN MEDICAL ASSOCIATION.
ROCKFORD, ILL.
A writer in a late issue of the Journal, in an article
on a subject remote from this, made the statement
that '"malformations of the internal organs of the
fetus are still more rare than the various orthopedic
lesions of the exterior body." In confirmation of this,
a case of the above title came to my notice, whose
rarity then impressed me, and it is here given to add
to the peculiarities and mysteries of tissue growth in
pre-natal life. If those who have the Index Medicus
can find similar cases recorded in it, it would be inter-
esting to know of them.
There was born in Rockford Hospital July 24, 1895,
after a quite natural and easy labor, of a healthy
Swedish mother aged 25, her third child, a male
weighing six and three-fourths pounds, well formed
and fully developed in all its external parts. After
birth there was some of the obstructive mucous respi-
ration often observed, which usually passes away after
wiping the mouth, a drink of water, inverting the
child and such like procedure. In this case, however,
it persisted from day to day ; it could nurse and seem-
ingly swallow. There was nasal regurgitation, though
the hard and soft palate and pharynx were perfectly
normal; the gurgling respiration continued in spite
of all efforts to relieve it, and on the eighth day the
child died of inanition.
The privilege of a postmortem examination was
obtained from the grieved but sensible parents.
Exploration began by removing the sternum, dissect-
ing through the thyroid isthmus, exposing and inspect-
ing the larynx and trachea, which were each found
normal except being filled with the ingested milk; a
soft catheter was passed into the pharynx and esopha-
gus which met obstruction that resisted further
advance. Deeper dissection brought to light the
esophagus ending in a distinct cul-de-sac, in which
the tip of the catheter was engaged at the second
dorsal vertebra. The lumen of the gullet was nor-
mal to this abrupt terminal, being about one centi-
meter in diameter, easily admitting a No. 12 catheter.
Two centimeters below this and a little to the left, as
would follow the normal course of the esophagus, began
a fibrous impermeable cord one millimeter in diameter,
very gradually increasing in size, in its passage through
the diaphragm, until the natural dilatation of the
stomach was attained, where its permeability was
reestablished, and the remainder of the alimentary
tract was of normal form and function throughout.
No other malformation was discovered.
a Brothers of the Whit* Frock.
3 Jobxix, 21.
Minnesota Coroner's Fees. — Where the coroner on the same
day makes two separate examinations of two different dead
bodies, or holds an inquest on one body and makes an examina-
tion of the other, the supreme court of Minnesota holds, in
Kistler vs. Board of Commissioners of Hennepin County,
decided June 24, 1896, that, under section 5554, General
Statutes 1894, he is not entitled to a fee of five dollars for each
examination and each inquest, or to anything more than five
dollars per day "for the time actually spent."
lSl'f,. i
SOCIETY PROCEEDINGS.
431
SOCIETY PROCEEDINGS.
British Medical Association.
Sixty-fourth Annual Meeting held at Carlisle, Eng., July
1,1896, under the Presidency of William Banns,
M.D., F.R.C.S., J.P., of Carlisle.
(Continued from page 37S.)
ted for the Journal ok the American Medical Association.]
Dr. \V. P. Robertson, of Edinburgh, gave in the Section on
Psychology, a microscopic demonstration upon the pathology of
hematoma auris. The sections illustrated the various stages of
t he degenerated lesion in the ear cartilage, which, as had already
been contended by Fischer, Pareidt and others, prepared the
IU for the occurrence of the hemorrhage. Typically this
Ux>k place from new vessels in the wall of an intra-cartilaginous
cyst. It was shown that these vessels were specially prone to a
degenerative change, which must render them liable to rup-
ture from slight violence, or even spontaneously. The blood
was slowly effused into the cyst, which tended gradually to
enlarge by separation of the perichondrium.
In the same section, Dr. A. Robertson of Glasgow read a
paper on " The Treatment of Mental and Nervous Diseases by
Animal Extracts." He first drew attention to other special
methods of treatment which he had used in his practice, before
considering the group of therapeutic agents which were the
subject of the paper. These special methods were :
1. Heat and cold to the head at graduated temperatures. In
some cases of insanity recovery was at least largely due to this
mode of treatment.
•J. Mechanical stimulation of the brain and membranes by
percussion of the skull. This has conduced to the recovery of
some patients.
3. By electrization of the brain through the medulla. One
electrode passed along the floor of the nostril, rests on the
cervical spine, the other is moved slowly over the convexity of
the head. He had not yet used it in the insane, but is now
recording a case of diabetes insipidus cured under this mode
of application.
1. Psychical, combined emotion and suggestion. The rapid
recovery of a patient after mental shock is referred to, and the
fact that it has been tried by the writer as a mode of treatment
is mentioned.
5. Hypnotism should not be discarded. Its power over the
nervous system is illustrated by the intermediate and confirmed
recovery of a patient recently in the Royal Infirmary suffering
from hemianesthesia, after other treatment had failed.
He then proceeded to record his experience with organic
extracts, and also his impressions of their value. He had made
observations on the effects of the following preparations : The
fresh brain of the sheep ; cerebrinin, an extract of the cortex ;
thyroid extract ; Brown-Sequard's testicular liquid ; the thymus
gland. These preparations were then discussed in their order.
The author closed with the remark, that in the thyroid and
cerebral extracts, as well as the other special methods of treat-
ment referred to at the outset, we have additional remedial
measures, and it is the duty of the physician in charge of the
insane to have recourse to them in suitable cases.
Dr. Rutherford Macphail made some remarks on
POST-INFLCENZA INSANITY.
In which he presented an analysis of twenty cases admitted
under his care into the Derby Borough Asylum in the five
years ending Dec. 31, 1895. He included only cases among the
recent admissions whose insanity was attributed to influenza,
or who were reported to have had an attack of influenza a few
months previously. This represented 4.8 per cent, of the
admissions.
Of the twenty cases, nine were men and eleven women. The
youngest patient was a lad aged 18, the oldest a man aged 71.
The average ages were, for men, 37.6; for women 39.2. The
largest number of cases (eight) occurred in the fifth decade.
Hereditary predisposition to insanity was admitted in six of
the twenty cases. In all except two the attack of insanity was
an initial one. As to the form of mental disease, melancholia
occurred in the cases of three men and seven women, mania in
five men and four women, and one man was a general paralytic.
Fifty per cent, of the cases were therefore melancholies, a larger
proportion of melancholia than usual, for the records of the
asylum during the five years in question show only a percent-
age of twenty melancholies to all admissions. The type of
melancholia varied from simple depression to the acute forms,
with well-marked delusions. The delusions most common in
the maniacal cases were those of suspicion and of poisoning.
Four of the cases were actively suicidal and had made
attempts on their lives at home.
Tho results were as follows : Among the men, four recov-
ered, two were relieved, one died and two are still under treat-
ment and are chronic. Of the women, eight recovered, one
died and two have become chronic. All the melancholies
recovered except one woman who died. The average residence
in the asylum of those who recovered was three months for
men and four months for women. These numbers are too
small to permit of any definite conclusions, and accordingly
no attempt was made to dogmatize. It was, however, worthy
of note that in the cases under review the average percentage
of recoveries to the total admissions was higher than usually
obtains in public asylums, while the average period of asylum
residence was considerably lower.
In the section on public medicine Mr. Gordon Sharp, of
Leeds, contributed a paper entitled :
THE SOILIN RELATION TO DIPHTHERIA AND ITS ORGANISM.
He drew the following conclusions :
1. Diphtheria would appear to be endemic in certain dis-
tricts. Soils organically laden are dangerous, but much may
depend on the nature of the subsoil. Where the subsoil is
porous a neighborhood may be free. Where the subsoil is
impervious the surface at certain seasons of the year may be a
favorable breeding ground.
2. I think I am justified in deducing that soils which would
otherwise be sources of the spread of diphtheria are rendered
innocuous by deep drainage.
3. The presence of a large quantity of air in the surface soil
appears to be salutary and the contrary holds. However, this
may be an accidental circumstance.
The close connection between enteric fever, scarlatina and
diphtheria has often been remarked, and Bond has especially
called attention to the close relationship between scarlatina
and diphtheria, and formerly the connection seems to have
been even more marked. Thome has called attention to the
fact that as authorities have improved their water supply,
enteric fever has declined in frequency, while under the same
conditions and with improved sewerage systems diphtheria has
increased. Immersion in water for a short time seems fatal to
the microbe of diphtheria, while the contrary holds with regard
to the organism of enteric fever ; both seem to live in sewage.
A moist rather than a water-laden soil seems to be the home of
the organism of diphtheria.
Mr. James Niven, of Manchester, followed with a contribu-
tion entitled :
THE PUBLIC HEALTH ASPECTS OF TUBERCULOUS DISEASES.
He said that preventive action in this affection should take
something like the following shape :
1. Information as to the precautions needed to be taken
should be distributed to every home from time to time, until a
sufficient body of opinion was created on the subject.
2. Tuberculosis, attended with discharge, should be made a
notifiable disease. This would entail additions to the sanitary
staff, including probably a qualified medical assistant. The
objects of notification would be : (1) To gather precise clinical
knowledge as to the various conditions under which individuals
contract tuberculosis. During such an inquiry in Oldham in
1889 I found that more than half the deaths from tuberculosis
investigated were of people who had previously been in inti-
mate and prolonged intercourse with previous cases. (2) To
ascertain and remove insanitary conditions about the house as
speedily as possible, so as to give a chance to the patient of
recovery, and so as to diminish the risk to the other members
of the household. (3) To distribute printed information on the
preventive measures required, and to bring about an under-
standing with medical practitioners as to their giving systematic
personal instruction to the patient and attendant.
3. Hospitals for consumptives are at present foci whence a
practical knowledge of preventive measures radiates. It may
be doubted whether the time is rife for the establishment of
such hospitals at the public expense. If this becomes possible,
such hospitals would greatly aid in reducing the amount of
infective material in circulation.
4. To prevent the milk from tuberculous cows remaining the
source of danger which it now is we require a systematic exam-
ination of in all cowsheds by competent veterinary inspectors.
Two assistant veterinary surgeons have recently been appointed
in Manchester for this purpose, and already five cows have been
slaughtered as tuberculous and found to be so. This appoint-
ment is one which I have had much at heart. The milk of
suspected cows will also be examined bacteriologically where
the grounds for condemnation are otherwise not perfectly clear.
The veterinary surgeon is now authorized by the corporation
to examine suspicious cows with tuberculin. Under new reg-
432
SOCIETY PROCEEDINGS
E]
[August 22,
illations an effort will be made to bring the cowsheds into a
tolerably sanitary condition— at least those which can be so
amended. If the cowsheds are cleansed with water twice a
day and the cows kept clean, and if in addition the cowsheds
are kept well lighted and well ventilated, then there will not
be much risk of infection between cows and human beings or
from cow to cow.
5. All meat and pork should be thoroughly examined ; hence
no meat should be taken direct from a private slaughterhouse
for sale. The presence of tuberculous glands in meat or pork
should suffice to condemn it. In the case of animals killed at
the public abattoir this criterion is not required. It is the
more necessary that it should be rigorously applied in other
cases.
6. Cats certainly, and fowls possibly, are a serious source of
danger. More attention should be given to the diseases of
which cats have died — and, indeed, the cause of death of all
our domestic animals should be fully investigated.
Dr. F. A. Dixey of Oxford, read an interesting paper on
VITAL STATISTICS OF DIPHTHERIA IN LONDON.
The most interesting question in the paper was that of the
effect of the antitoxin treatment of this affection. On this
point the general conclusion reached by the author in a former
paper was fully maintained, and he asserted that the diphtheria
mortality of the metropolis had received a considerable check
which it was difficult to attribute to any other cause than the
introduction of the serum treatment. We quote verbatim
from the paper the following :
"Comparing together the average weekly number of deaths
for the last five years, we find that after rising from 26.2 in
1891 to 36.2 in 1892 and 62.8 in 1893, it fell to 51.4 in 1894 and
44.5 in 1895. It is true that the opening months of 1895 prom-
ised a greater diminution than that exhibited by the figures
for the whole year, and that the intensity of the rise last
autumn seems to show that some other factor than the anti-
toxin treatment must have been concerned in the diminished
mortality at the end of 1894 ; but notwithstanding these facts,
which are freely admitted, it would seem that the general run
even of these figures suggests a conclusion favorable to the
efficacy of the treatment. This conclusion becomes strength-
ened if, in place of the actual number of deaths, we consider
what is of course a truer test of the matter at issue — namely,
the case mortality, or relation of deaths to notifications. Under
this head the main facts are as follows : The number of cases
notified during 1893 was 13,694 ; of deaths during the same
year 3,264 ; giving a case mortality of 23.8 per cent. In 1894
the corresponding figures were 11,190 and 2,674 ; the case mor-
tality stood, therefore, at 23.9. In 1895, however, while the
notifications rose to 11,229, the number of fatal cases fell to
2,289, and the case mortality was therefore only 20.4 per cent.,
the lowest rate for the whole year yet recorded. The numbers
for the first half of the present year are respectively 6,193 cases
notified, and 1,239 deaths, which work out to a case mortality
of 20.2 per cent. In view of the fact that quite irrespective of
the number of cases, the case mortality of the last half of the
year is invariably below that of the first, it may fairly be anti-
cipated that by the end of 1896 the year's case mortality will
for the first time on record have sunk below 20 per cent. This
diminution in case mortality, which appears to be still in prog-
ress, represents the annual saving of some hundreds of lives,
and I may be allowed, in conclusion, once more to repeat that
it is difficult to see what cause can have been at work during
the last two years in producing so marked a result, unless it be
the treatment by antitoxin."
Dr. A. Sheridan Delepine of Manchester, in his opening
address as chairman of the Section of Pathology, dwelt on the
place of pathology in medical education, saying that it formed
such an important part of medical science that any question
touching medical education necessarily concerns teachers of
pathology, who should do their utmost to make their sub-
ject useful and not a stumbling block to the medical student.
This is all the more important as pathology has only of late
been recognized in our universities or colleges as a subject
worthy of a special chair.
To quote Professor Hamilton's words: "It will, I think,
be granted that the pathology of to-day is not delimitable
merely as a matter of pure morbid anatomy, pathologic histol-
ogy, pathologic physiology, pathologic chemistry or clinical
medicine, but that these are simply the members of a great
body, and that they are indissolubly bound together."
He first considered how the subject is taught in schools thus :
1. Under the name of clinical medicine, that part of pathol-
ogy which deals with symptoms, diagnosis, prognosis, is taught
at the bedside with applied therapeutics.
2. The same subjects are also usually dealt with in system-
atic lectures on medicine and surgery, lectures which are also
very often made to cover a considerable portion of other
branches of pathology.
3. Pathologic anatomy is taught in systematic lectures and
demonstrations, and practically in the postmortem room.
4. Pathologic chemistry and histology are taught by means
of lectures and demonstrations, and of practical classes.
5. Etiology and pathogenesis are taught by means of lec-
tures, which are sometimes complemented by a practical course
in bacteriology.
6. Experimental pathology is reserved for advanced students,
and does not form a regular part of any curriculum.
If all these subjects were taught by the same man, he would
certainly not require to say in systematic lectures what he had
already clearly explained at the bedside or in the postmortem
room, or in the laboratory ; he would as much as possible try
to save his own time as well as that of his pupils by not
repeating himself. He would reserve for lectures those sub-
jects that can not be easily and better taught by actual
demonstration.
Is it possible for three or four men teaching the various
branches of the same subject so to combine their efforts as to
give students the benefit of advantages which they would
derive from being taught by a single man? He believes that,
within certain limits, such a thing is possible on condition that
the following principles be kept in mind by all teachers :
1. Every fact capable of simple actual demonstration should
be taught by means of demonstration whenever this method
does not involve excessive loss of time, considerable expense,
wanton cruelty or a knowledge of methods unknown to the
student.
2. In each department the teacher should, as much as is
compatible with clearness, confine his teaching to the demon-
stration and exposition of those facts which fall within the
natural sphere and the actual work of his department.
3. It seemed to him also important that the time devoted
to the study of each branch of medicine should be propor-
tional to the relative importance of the facts and principles
taught, rather than to the number of details which have erro-
neously been thought to be necessary elements of certain
studies. And in determining the relative value of scientific
courses from an educational point of view, he would feel
inclined to give the preference to those in which it is possible
to make the student see and judge for himself. Lectures
should be reduced to the smallest number compatible with a
clear exposition of those principles which would otherwise
have to be constantly repeated in the course of practical
demonstrations, or to those subjects which are not capable of
demonstration at all.
In order to give a more concrete form to his ideas, he asked
the members to suppose that they follow a student desirous
of gaining personal knowledge in his study of cases, medical or
surgical.
1. In the wards of the hospital he is shown how to recognize
the presence of certain symptoms, and from this to establish a
diagnosis ; he then sees various modes of treatment, sur-
gical or medical, applied, and is made to note the course of
events that follow, being thus initiated to the art of prognosis.
Here the only means he has to test the accuracy of the views
expressed to him by his teachers are the effects of treatment
and the correctness of the prognosis.
2. In the postmortem room he has an opportunity to see for
himself what gross lesions correspond to some of the symptoms
to which his attention has been attracted during life. The
meaning of the appearances due to alteration of size, shape,
color, etc., have to be explained to him as far as it is safe to do
so from a naked-eye examination. The teaching in the post-
mortem room can not go further, and is necessarily frag-
mentary.
3. It must therefore be supplemented by demonstrations of
museum specimens by which complete series of lesions, some
of which occur rarely in the postmortem room can be made to
illustrate the coarse anatomic changes produced in the body
by disease. Such specimens being provided with short clinic
histories, there should be as little room for speculation as
possible regarding the nature of the symptoms associated with
the lesions. This general study of morbid anatomy is specially
useful in directing the mind to the parts of the body which are
most generally affected by disease, and to the way in which
certain symptoms are mechanically produced. Naked-eye
anatomy, however, gives very little information regarding the
nature of the reactions of the organism to morbific agents ; it
seldom gives the means of finding the actual cause of diseases,
and it must be admitted that many of the naked-eye appear-
ances are so ambiguous that even an experienced morbid
1896.]
SOCIETY PROCEEDINGS.
433
anatomist is often mistaken as to the meaning of lesions
observed in the postmortem room or in the museum.
i. In the histologic laboratory the student sees the changes
of structure which give rise to the appearances observed in
the postmortem room, and here he begins to be on firmer
■sound and better able to acquire a knowledge which will
depend less on an extensive practical experience than on well-
trained powers of observation. The reasons for this are : 1,
that all the organs of the body are composed of a few elemen-
tary tissues ; •_!. that these tissues are composed of cells which
have many properties in common: 3, that the morphologic
changes indicating the reaction of these cells to pathogenic
9 are ver\ comparatively few. It is, therefore, possiblo for
a teacher to impart within a limited space of time and by means
of actual demonstrations a tolerably complete and accurate
notion of the anatomic changes produced in the organism by
disease. It is to these advantages and not to any special
fancy for microscopic work that pathologic histology has taken
such a leading part in the study of disease.
.">. We now come to the most difficult part of pathology. So
far, we have had to deal only with the objective parts of the sub-
ject, with facts which necessitated chiefly powers of accurate
observation, and which could all be easily demonstrated. When
we come to deal with causes of disease and with the way in
which lesions are produced we must necessarily introduce into
our work induction, deduction and experimentation. When a
number of facts seem to indicate that two or more phenomena
are correlated and due to the action of a certain cause, we feel
generally, when dealing with biologic problems, that we may
have overlooked many factors, and therefore we have to test
our views by experimentation. Experimentation is not, how-
ever, always guided by direct observation, for it often happens
that the causation of certain lesions is inferred from what we
know of the causation of other more or less analogous lesions.
The conclusion which the speaker drew from the above con-
siderations was that students could obtain a more useful
knowledge of medicine if they had fewer lectures and more
practical courses. They should be made to attend thorough
practical courses on: 1, pathologic anatomy, histology and
chemistry : 2, bacteriology as applied to the study of infectious
diseases ; 3, general clinical medicine and surgery, with special
courses in special branches of clinical work, such as diseases of
women and obstetrics, diseases of children, infectious diseases,
mental diseases, diseases of the eye, of the ear, of the throat,
etc.
Systematic lectures should be confined to courses on : 1, eti-
ology of disease and pathogenesis ; 2, general considerations
regarding the practice of medicine and surgery. These courses
should be as short as is compatible with a clear exposition of
those principles which but very few students would be able
to formulate for themselves from the study of facts.
Sir Joseph Ewart of Brighton in opening the public medi-
cal section, delivered an address upon the lowering of the
general death rate. He said that in time typhoid fever,
consumption, scarlet fever and many other diseases would
come to be prevented with as much success as had attended
the warfare against scurvy, the plague, leprosy, cholera, etc.,
and to assist in securing that end our scientific machinery
should be perfected.
One of the subjects discussed in the section was vaccination
and revaccination, and a resolution was passed that it is
desirable that calf lymph should be made universally available
by the State.
The section on ethics discussed the abuse of the out-patient
system in hospitals. Mr. Loch, secretary of the Charity
Organization Society, read a paper in which he said, that
while there were 87,000 in-patients in London hospitals, there
were over a million and a quarter out-patients. Millions of
out-patients at hospitals must mean large numbers of patients
withdrawn from the general practitioner. He suggested that
the number of out-patients should be limited to as many as
could be fully and fairly dealt with in the allotted time, and
that there should be a well-trained almoner at a hospital able
to make proper inquiry or insure its being made.
Dr. Nelson Hardy challenged anyone to say that the out-
patient departments were carried on by assistant physicians
out of charity and benevolence. The appointments were
accepted by them with a view to their own advancement and
ultimate profit.
Dr. G. H. Broadbent of Manchester read a paper on "Prov-
ident Dispensaries," cautioning medical men against such
institutions.
Dr. Major Greenwood of London said the cheapening of
medical services through the outdoor departments of hospitals
was doing an appalling amount of mischief to the medical pro-
fession, and the time had come to secure radical reform. Other
members spoke on the same line.
Dr. Alex. Ooston of Aberdeen presided over the Section
of Surgery.
An interesting discussion on
prostatic hypertrophy
was opened by Dr. David MacEwen of Dundee, who said that
as long ago as 1856 Mercier had suggested the operative treat-
ment of an enlarged prostate which was causing obstruction
to the outflow of urine. The method proposed was to remove
part of the enlarged gland through the urethra— in other words,
to perform urethral prostatectomy. Following Mercier, Sir
Henry Thompson and Reginald Harrison had urged perineal
section and drainage. Later, Dr. Wm. T. Belfield of Chicago
employed the "combined method," as did also Dr. Nicoll of
Glasgow and Dr. Alexander of New York. But whatever form
of prostatectomy was employed, the mortalitv was still high,
and even now reached 20 per cent. In 1893, Dr. J. W. White
of Philadelphia suggested that the testes had an influence on
the nutrition of the prostate similar to that exercised by the
ovaries on the uterus, and that just as oophorectomy leads to
a diminution in size of the fibroids of the uterus, so would
castration lead to atrophy of an hypertrophied prostate. In
May, 1895, White reported the results of 111 cases in which
orchectomy had been performed for the purpose of causing
atrophy of an hypertrophied prostate. Of this number, in 82
per cent, rapid atrophy is said to have taken place, in 52 per
cent, cystitis had either disappeared or had been materially
lessened, in 66 per cent, there was a return of vesical contrac-
tility, in 83 per cent, there was marked amelioration of trouble-
some symptoms, and in 46.4 per cent, there was a return to
the normal conditions. Dr. MacEwen said he had collected
fifty-two cases of orchectomy operated on since White read his
paper ; of these forty two were said to have resulted more or
less successfully ; of the ten unsuccessful cases, in four there
was no improvement, and six died. The speaker had himself
operated in five cases. Of these, three were treated by double
orchectomy, and two by resection of the vas deferens. Orch-
ectomy is sometimes followed by marked mental disturbance,
but this is never seen when the testis is removed for disease.
The essayist had had no experience with unilateral orchectomy.
The results of resection of the vas deferens are divergent. He
had done it twice. The first patient died within a week from
uremia. The second case was 65 years of age and for seven
years had been troubled with micturition. Dr. MacEwen drew
the following conclusions :
1. In many cases castration causes more or less atrophy of
the prostate.
2. Atrophy occurs most commonly when the prostate is soft.
3. It is of most value when the enlargement is general.
4. Cystitis may be relieved or cured.
5. In marked cystitis drainage is better.
6. It may do away with the necessity of the use of the
catheter.
7. Or the catheter may be required less frequently.
8. Resection of the vas deferens acts more slowly, but the
effect is similar.
Mr. Reginald Harrison of London, read a paper on
vasectomy, or division of the vas deferens for prostatic
hypertrophy.
He stated that cases of vasectomy could be divided into two
groups : 1, where only one vas has been divided ; and 2, where
both have been operated upon. He had performed unilateral
vasectomy in twelve cases. Of these seven obtained permanent
benefit, and in five negative results were secured or the patient
could not be traced.
One patient was 69 years old. He had a large prostate.
Micturition occurred hourly, but no catheter was necessary.
The right lobe was distinctly larger than the left. The right
vas was divided, the patient was able to retain urine much
longer, and the right lobe atrophied. In the second group of
cases there were ten ; of these, five were much benefited. In
two cases there was no improvement, two disappeared, and
one is too recent to be considered a success. This case was
that of a man 70 years of age, who had a suprapubic fistula
after lithotomy. Micturition was attended with considerable
difficulty. Double vasectomy was performed, and he was able
to abandon the use of the catheter. In the five successful
cases the points gained were diminished frequency of urination,
improved condition of urine and less suffering from vesical
spasm. No fatal cases, and no cases with mental disturbance.
Lastly, both by castration and by resection much good could
be done. It should be remembered, however, that some cases
were not benefited by either method.
Mu. C. Mansell Moullin, of London, looked upon statistics
as almost valueless, and said he relied on his individual expe-
rience. He would include prostatectomy as one of the methods
434
SELECTION*
[August 22,
of treatment of enlargement of the prostate ; while the mor-
tality was very high, it had of late been materially reduced.
For instance, of eleven cases reported by Mayo Robson, there
was only one death, and Mr. Moullin himself had operated on
five cases with no deaths. He urged the importance of ope-
rating on cases before the urine was ammoniacal and before
cystitis and pyelonephritis had supervened. The operations of
castration and vasectomy should be reserved for cases unsuited
for prostatectomy. In eleven cases he had done bilateral
orchectomy, but he did not think any benefit would follow
from the unilateral operation. Of the eleven cases, three
died. In six of the eight cases which survived the relief was
great.
Prof. John Chiene of Edinburgh, held that castration
should only be performed when all other means had failed to
afford relief in prostatic enlargement. Suprapubic cystotomy
should be first tried in cases in which an operation was needed,
and then if there was enlargement of the third lobe, and if the
urine was aseptic, the third lobe might be removed. In case
the urine was septic, the surgeon should wait for six weeks, if
no relief occurred even then perineal drainage should be tried,
and a tube inserted, which might be worn with comfort for
years.
Mb. F. A. Southam of Manchester, took the ground that
an operation was required in only a limited number of cases.
He urged the early use of the catheter. If the urine is septic,
the bladder should be washed out and antiseptics, such as
salol given by the mouth. These failing, suprapubic cysto-
tomy should be done. In some cases in which he had resorted
to double orchectomy, a complete cure had resulted.
Mr. C. A. Morton of Bristol, had done double orchectomy
in one case, the man being 70 years of age, who had much
enlargement of the prostate, and frequent micturition. Atrophy
followed gradually, but the patient had improved.
Professor I. H. Cameron of Toronto, had done double
orchectomy in twenty cases, with one death from suppression
of urine.
Dr. MacEwen, in closing, said he did not wish to be under-
stood as implying in his previous remarks that orchectomy
should sepersede prostatectomy. He should try resection of
the vas deferens, after listening to the remarks of Mr. Reginald
Harrison. Intravesical growths should be treated by pros-
tatectomy, but that general enlargement of the prostate requires
orchectomy. Drainage was simply palliative and may be used
in very weak or aged patients.
THE GENERAL MEDICAL COUNCIL.
The probability of an animated discussion in reference to
the General Medical Council— which, as is well known, is a
Government institution created by the medical act of 1858—
attracted an unusually large number of medical men to the
section of Ethics. Nor were they disappointed for the discus-
sion, though one sided, was certainly vigorous. The attack
was lead by Dr. A. G. Welsford, who opened with a very
outspoken criticism of the General Medical Council. "The
history of the Council," said Dr. Welsford, "is one long story
of wasted opportunities and neglected duties. Although by
pressure from without it has been forced into a semblance of
activity, the work has been done unwillingly, and when possi-
ble, difficulties have been created. The Council is a great
stumbling block to reform. Its failure is mainly due to its
non-representative character, which places it beyond the con-
trol of the medical profession. The Council is mainly com-
posed of nominees of universities and colleges, and the net
result is that whether the Council originally was intended to
protect the public or the profession, it actually is concerned
only with the interests of these bodies. The General Medi-
cal Council is an anachronism. It is out of date in the nine-
teenth century. Its very constitution embodies the opposite
of the principle 'No taxation without representation.' The
medical profession has to pay for a governing council which it
does not elect, over which it has no control, but which has
arbitary and absolute power of legislation upon matters affect-
ing general practice of which the members of the Council are
profoundly ignorant. A new spirit has appeared in our pro-
fession. We long ago lost respect for the impotent and vacil-
lating coterie of university and corporation nominees, called
the General Medical Council.
"We recognize its callous indifference to all other interests
than its own, and we object to contiuue to pay for the main-
tenance of this nineteenth century medievalism. When we
obtain a new medical act, as we shall succeed in doing by union
and organization, a new council will be created, and this coun-
cil must be one representative of the profession. Combined
attack is being made on all sides upon institutions which main-
tain and protect vested interests, and the Council will not
escape deserved censure. Apologists may assert that the
Council is the best possible in this best of all possible worlds,
may whittle down these duties to vanishing point, and then
claim that the Council performs these duties most ably, but the
medical profession can not any longer be hoodwinked as to the
real nature of the General Medical Council and will with united
voice demand reform."
Prof. Victor Horsley of London pointed out the great
danger to which the profession is liable in consequence of
the standing orders of the General Medical Council in regard
to "condemnation of infamous conduct" and "the protection
of the honest practitioner from exploitations of quackery."
He complained, among other things, that the president of the
council was endowed with a degree of autocracy which was
dangerous to the safety, honor and welfare of the members
of the profession. The profession ought to memorialize the
Council to appoint a president who was capable and scrupu-
lous, and to actively urge reform upon its very imperfect
procedure.
Dr. Lovell Drage of London agreed that the great fault of
the General Medical Council was that the president had
absolute power under the standing orders, which should be
radically reformed. The medical profession, he said, was
given over to the hands of its enemies, and it was exceedingly
difficult for the five direct representatives to use moral suasion.
What could five votes do against twenty-five when those
twenty-five were the votes of men who had common interests
and common monopolies to defend? The cornerstone of the
whole edifice of reform must be an increase in the direct rep-
resentation.
It happened that a member of the General Medical Council
was present in the Section. Dr. Glover of London, who is a
"direct representative" on the censured body, but is not a
member of the British Medical Association, was invited to say
a word in defense of the General Medical Council. Dr.
Glover admitted that there was great force in the complaints
that had been made as to the way in which the disciplinary
work of the Council had been carried on and as to the powers
of the Penal Committee. At the last meeting of the Medical
Council there was a strong feeling that a change was necessary
in the conduct of penal cases and in the way in which evidence
was to be laid before the Committee and the Council, and he
thought he could encourage them to believe that in the future
the investigations and the evidence would be much more com-
plete than it had been in the past. He hoped this Association
would not lend its sanction to the idea of relieving the quali-
fying bodies of their disciplinary functions, for it was explic-
itly stated in their charters that they should not only qualify
men but take note of their conduct.
Dr. W. Douglas (Leamington Spa) considered that Dr.
Glover had only confirmed the very unfavorable view enter-
tained with regard to the General Medical Council. It was
difficult to move that Council, and he suggested that instead
of going to them they present a petition to Parliament,
showing how inefficiently the Council peformed their duty,
keeping neither the spirit nor the letter of the laws which they
had to administer. If by that means they did not get a new
Act which would give better representation to the profession
on the General Medical Council, they would, at least, bring
such pressure to bear on the Council as would compel them to
act in the interests of the profession.
Much merriment was provoked by the suggestion of Dr.
Broadbent of Manchester that a new element in "moral sua-
sion" might be introduced by appointing on the General Med-
ical Council a lady doctor, who might have some power over
the gentlemen in that body.
Dr. James Myrtle of Harrogate believed the root of the
whole difficulty was that the Council was an antique and
insufficient body. He agreed that if they could put pressure
upon their representatives in Parliament they would secure an
alteration of the Council and a greater share of direct
representation.
SELECTIONS.
The Curative Serum of Hydrotherapy. — It is a fact long since
known that the pathogenic microorganisms and their products
possess poisonous properties. Experiments and observations
have taught us that the system reacts against these poisons by
producing antipoisons and other preventatives which are only
known to us to a minor degree. From the endeavor to antago-
nize the poisonous products of infection by their antipoisons,
serum therapy has emanated. Like every other organic func-
1896. |
SELECTIONS.
i:;r,
Hod the resisting power which the system possesses in order to
keep off injurious influences, can be strengthened by methodic
rote. As we can gradually make ourselves unsusceptible to
mineral and vegetable poisons, like arsenic and morphin, we can
also to those poisons produced by microorganisms.
Upon such a systematic strengthening of the natural resist-
ing powers of the system against a certain poison immuniza-
tion seems to be based. It is now said that the blood serum of
the immunized animal contains those antitoxins which, when
injected into a person who is afflicted with the same injection
are able to assist the patient in overcoming the disease.
As. however, the sovereign antitoxin for any and every injec-
tion has not yet been discovered, a certain serum must be pre-
pared for every species of disease. After the readily prepared
antitoxins have been injected into the blood, they must be con-
verted by the system in such a way as the healing process
requires.
Yet it is doubtful, if the serum injected is equivalent to the
one produced by the diseased system itself; itisalso doubtful,
if the entire process of reaction against the disease consists
exclusively in the serum and the antitoxins. It is more likely
that the whole system and all its functions participate in the
process of reaction, that in the cells themselves and their
assimilation, in the nervous system, etc., auxiliary powers are
put in motion. We must also consider that the injection of
the blood serum of one animal into the blood of another species
undoubtedly involves dangers. Serum therapy tends to sub-
stitute in an artificial way a substance which the system is
unable to produce, at least not to a sufficient amount. It may
not be timely to criticize the new treatment, still we must ad-
mit that we know but very little of the biology of so-called
internal secretion and that the substitution of living or morbid
tissue or serum can not at all be held for an actual substitu-
tion of the missing or imperfect function. The various physio-
logic and pathologic proceedings can be explained by physic
and chemic laws only partially, which is the reason diseases can
not always be treated in the same way and why equally compe-
tent physicians often disagree entirely as to the same remedy.
From quite a different standpoint I believe in antitoxic powers
of the living organism and in the more or less complete substi-
tution of a missing function by the system itself, or in other
words, I believe in an " autoserum" and " autoorgano-therapy"
and in the possibility to improve this "autotreatment" by
physic agents. It is no longer doubtful that numerous infec-
tious diseases, often the most severe and dangerous types, con-
valesce without any medical aid whatever. If, therefore, the
power of the system to overcome the infection, intoxication or
autointoxication, consists in the blood and its serum, as is sup-
posed to-day, the system itself must produce the antitoxins
required to defeat the infection. " Gradually," says Buchner,
"we have come to the conclusion, and this has since been proven
by experimental investigations, that the system is possessed of
natural auxiliaries against the producers of disease." I have
occasionally controverted the belief that this conclusion is of a
late date. Since Hippocrates and since there are medical
schools, the physicians were forced to come to this conclusion
from the observation of the undisturbed course of various
diseases.
Could we now prove that there are agents by which we are able
to improve or even call in action the natural powers of the sys-
tem to resist the producers of disease, or in other words, to
assist the system in its fight against the injurious influences,
we would have to call this treatment a rational and physiologic
one. And we would have to consider, if such a treatment which
is based upon the action and functions of the system, was not
less dangerous, and yet, not less efficacious than any other arti-
ficial treatment. It would lead me too far to prove this for the
effects of all physic agents. This has been done repeatedly by
numerous investigators, also by myself, and it has been shown
that there is no function of any organ or any system of organs
which can not be altered, invigorated or labefied by thermic
and mechanic agents. As to hydrotherapy, I only want to say
that it is first of all a therapy of oxidation, as is shown by Pos-
pichil's and my own investigations on respiration, and by
Strasser's and others' investigations on the chemism under
thermic influences ; it is a therapy which increases internal
oxidation, leucocytosis and the alkalescence of the blood. We
not only command the distribution and circulation of the blood
by thermic agents, but also its morphologic and chemic compo-
sition, as I have shown years ago. In the first place, I found,
at the same time as Rovighi did — that upon the employmentof
cold, leucocytosis sets in, a fact which is of fundamental impor-
tance for the explanation of the effects of thermic applications
in infectious diseases. I knew long ago, and have mentioned
this repeatedly, that the decrease of temperature could only
partially explain the favorable effects of the water treatment
in infectious diseases. We have long been familiar with the
favorable symptomatic effects which an improvement of iner-
vation, circulation and tonus of blood vessels and tissue caused
by the water treatment has upon the feverish process. But
we could not explain how the treatment could affect the path-
ogenic microorganisms and their toxins. If, however, the leu-
cocytes are the real phagocytes in the meaning of Metschnikoff
and, as Buchner says, the transporters of the alexins, the
destroyers of the toxins, we understand why we can affect the
infection by means of hydriatics which enable us to produce
leucocytosis at any time we desire. Further investigations
taught us that under the cold water treatment, also the red
blood corpuscles, the specific weight of the blood and the
amount of hemoglobin increase considerably. If we further
consider that we can stimulate or modify the circulation in the
whole body and the locus morbi by hydriatics, we have a good
explanation for the value of the water treatment in infectious
diseases.
Further we must consider that numerous secretions and excre-
tions can be affected considerably by hydriatics. I called atten-
tion to their diuretic effect in infectious diseases long ago, a fact
of great value in regard to prognosis. Rogue and Weil saw the
urotoxic coefficient of the urin increase in typhoid fever under
the hydriatic treatment, and proved that under this treatment
six to eight times as many toxins were eliminated as under any
other treatment. Thus we know also that the elimination of
the noxse and their products by the kidneys, the skin, the
bowels, the salivary glands and probably most of the excretions
belong to the reaction of the system against the infection, which
reaction can be greatly invigorated by hydrotherapy.
Even the chemic composition of the blood can be changed by
cold applications, as has been shown by Strasser's investiga-
tions. The alkalin blood is of great importance not only as a
vehicle of the phagocytes, but also because of its chemic condi-
tion. Numerous investigators observed that the alkalin reac-
tion of the blood decreased considerably in infectious diseases.
Tassinari found from experiments on rabbits, that upon a sep-
tic infection the index of alkalinity decreased from 3.6 to 1.58
within two days. It could hardly be doubted any more that
the intensity of the bactericide power of the blood and, proba-
bly also the neutralization of various acid products of the
microorganisms, depend upon the degree of the alkalescence of
the blood. Strasser by his investigations has made this pre-
sumption a certainty, and has shown that cold baths increase
the alkalinity of the blood. This fact forms an exact basis for
Buchner' s presumption that "the cold water treatment very
probably acts as a direct destroyer of the producers of
infection."
Thus we can call the hydriatric treatment a true autoserum,
and autoorgano-therapy by which the blood and its serum obtain
a stronger bactericide power and by which we have a perfect
control of the circulation of the blood in the whole system, at
436
PRACTICAL NOTES.
7
[August 22,
large, and in the locus morbi, in special. It is a treatment by
which the functions of all organs and also the internal oxida-
tions are increased and improved considerably, and which is a
natural stimulus to vital energy. — Prof. W. Winternitz,
Vienna. Translated by Dr. Carl Strueh, Chicago.
Organ Extract Therapeutics of Female Genital Organs.— The
Therap. Woch. of July 12 contains an article by Bell of Glas-
gow, describing his success in the treatment of carcinomas,
fibromas, etc., of the female genital organs with extracts of
the thyroid, parotid and lacteal glands. The parotid gland
seems to have an important effect on ovarian troubles, and the
lacteal on uterine. He describes fourteen cases taken at ran-
dom. The patients applied to have the neoplasms extirpated,
but this soon became unnecessary after taking a teaspoonful
three times a day of one of these extracts, with ichthyol or iodo-
phenol tampons applied locally. The neoplasm rapidly dimin-
ished in size, while the general health improved, and the
patients were dismissed practically cured, with no further
pains or discomforts, and in some cases no trace left of the
Deoplasm after a few months of this treatment. Knauer has
succeeded in implanting an ovary in the uterus of four rabbits,
which became incorporated with the tissues and resumed their
functions, reproduction of ova. Mainzer reports various
climacteric troubles cured by two 5 gram pastilles a day
of freshly dried ovarian tissue, increasing the dose to three
pastilles a day, returning to a smaller dose as the troubles dis-
appeared. In two cases menstruation was produced in women
who had never menstruated before. The most favorable
results were obtained in troubles of a vasomotor nature ; next
came primary or secondary amenorrhea, while purely nervous
or hysteric patients were not affected by it except suggestively.
These facts may be found useful in differentiating. Jayle has
successfully treated the troubles consequent to castration with
dry ovarian extract or an ovarian fluid prepared in the same
way as the Brown-S&juard extracts. He considers himself
justified in advocating ovarian therapy in amenorrhea or dys-
menorrhea caused by ovarian disorders, as it may render cas-
tration unnecessary.
Gymnastics in Heart Disease.— The Boston Medical and Surgi-
cal Journal, June 18, contains an elaborate report of the dis-
cussion, before the Society for Medical Improvement, of the
above subject. Some interesting observations by Dr. Polsom
were the following :
"When I was in Munich in 1879 I had considerable talk
with Ziemssen about the treatment of organic heart disease
by muscular exercise, to which Oertel had called the attention
of the profession several years before. Ziemssen was using it
pretty generally in his practice, and I asked him to see an
American gentleman who had seen a number of specialists in
this country and in London and had been advised not to take
vigorous exercise. Ziemssen immediately put him on Oertel's
treatment, and that very afternoon this gentlemen walked a
number of miles over the hills in the vicinity of Munich. He
has kept up that treatment, more or less, under suitable
guidance. He now walks, rows, walks over hills, rides horse-
back and has absolutely no symptoms so far as his heart is
concerned. The valvular murmur is pronounced and the heart
is larger than it was then. The compensation is perfect, and
itseemed to me an extremely good result. It was not one of
the cases to which allusion has been made, of 'beef-eating, beer-
drinking Englishmen. He was very temperate in all respects,
and did not materially change his course of life. Five or six
years ago a highly accomplished Swedish medical gymnast
came to this country. She had a large practice after gradua-
tion, and was so proficient in her work that she had been the
assistant of the professor in charge in Stockholm, She came
into the wards in my service at the City Hospital and did some
work to show me what she could do. Since then I have used
gymnastic exercise very largely in my practice. . . . There
were three things with regard to the Swedish medical gymnas-
tics which struck me : In the first place, the very complicated
system ; secondly, their apparent simplicity, and thirdly, their
great power for good or for evil according to the judgment and
skill of the operator. I think in the whole system which Ling
introduced there are something like one thousand different
movements. I was also struck with the extreme simplicity of
them. One would hardly think their physiologic effect would
amount to so much. As regards the very great power of
these movements, the movements to correct slight scoliosis
may defer menstruation one, two, three or four weeks. On
the other hand, in the absence of menstruation it can be
brought on with great rapidity. It is the most efficient means
of correcting metrorrhagia without organic trouble that I have
seen. I have had a number of cases of organic disease of the
heart treated in this way. I have four at present. One is a
lady who five years ago had valvular disease of the heart,
dilated heart, weak, irregular, intermittent pulse, and had had
complete hemiplegia of one side, including the face. She has
continued that treatment more or less all this time, and it has
constituted one of the chief means of treatment. The pulse
is regular, a little above seventy. She considers herself in
perfect health. Another is a lady with a marked arterio scler-
osis and dilated heart. She has been under my care about,
two years, and that has been the chief method of treatment.
The benefit in that case has been striking. . . . My belief
is that the best way of using physical exercise, if the person
is able to do it, is some out-of-door, regular, general exercise.
Of course a very large number of patients can not do that, and
the medical gymnastics which would be required in valvular
disease of the heart where there is compensation or hyper-
trophy, would be entirely different from the movements which
would be required in a dilated heart where the walls are weak,
and especially where there is arteriosclerosis. It seems to me
that while there are people in this community who are suffi-
ciently accomplished and can be trusted in these cases, and
who have demonstrated the very great value of this treatment,
there is also a large number who call themselves Swedish med-
ical gymnasts who have certificates or diplomas of varying
value, and whose knowledge is so imperfect that they are dan-
gerous persons to set to work on any important or difficult
PRACTICAL NOTES.
Eliminatlve Treatment of Typhoid Fever. — M. Gottman, M.D.,
gives the following synopsis of the treatment : 1. Eliminate
the poison by the free use of salin cathartics, as they are best
and safest. 2. Give baths of ten or twenty minutes' duration,
beginning with the temperature of the patient, for their tonic
and sedative effect, as well as their eliminative action. 3.
Dilute the poison freely by imbibing largely of good, cold
water, i. Avoid food, unless peptonized (and sometimes even
this will not agree), until you know it can be digested, and this
applies especially to milk and lime water. The mental and
physical condition of the patient is the best index to the exhi-
bition of food. — Memphis Med Mo., August.
Bekarewitsch Treatment of Varicose Ulcers.— After the spot is
thoroughly disinfected, a piece of gauze smeared with a 10 per
cent, boric vaselin is laid over it, through which it is delicately
massaged for five to ten minutes, and then more energetically.
It is then dried and dusted with iodoform and wrapped in an
antiseptic bandage covered with the following : Zinc oxid and
gelatin equal parts ; glycerin and dist. water, four times the
quantity, equal parts. The whole is then enclosed in a starch
bandage and left undisturbed for two or three days, during
which time the patient can go about and do light work. — Therap.
Woch., July 12 from Wratsch, No. 1.
Improved Method of Narcosis. — Grafe has found that the sensi-
tiveness of the nasal membrane is of far more importance in
terminating narcosis than is generally supposed, owing to its
reflex action on the vagus region. If the nose can be kept
closed, the narcosis proceeds far more readily and rapidly, and
lasts much longer, with less of the anesthetic required. He
has therefore invented a light spring pad with which he stops
the nostrils before the operation, and does not remove it until
the patient is completely aroused. (Schiitz, Leipsic, Wind-
muhlenstrasse, 30.) It has rendered surprising service in the
narcosis of persons with pronounced heart troubles, with the
minimum of after effects. — Cbl. f. Chir., July 18.
8%.]
PRACTICAL NOTES.
437
Somatose Increases the Lacteal Secretions and Improves the Blood.
Drews reports from his experience in twenty-five cases that
somatose has a direct specific effect on the lacteal glands,
promptly and efficiently increasing their secretions. Ho urges
its use in all cases of deficient or decreasing lacteal supply,
(•commending one teaspoonful three to four times a day, in a
cup of warm milk, soup„cocoa, etc. Owing to its tastelessness,
the use of it can be kept up indefinitely as long as it may be
Deeded [Cbl. f. inn. Med. No. 23). Sconamiglio has been tnak-
-;tudy of the blood of patients taking it with no other
medication. He found that the erythroblasts gradually
Increased in number, while the microcytes and poikylocytes
iltvreased. The amount of hemoglobin was increased from
B.9 per cent to normal, 13.5 to 14.5 per cent— Therap. Woch.,
July 12.
Chronic Otorrhea Permanently Cured with Trichloracetic Acid.
Hulas/, confirms Okuneff's announcement of the value of this
treatment, and recommends the following modus operandi : As
the pain is severe, five to eight drops of a 10 per cent, solution
Of cocain should be held in the ear for three minutes. During
this time a syringe of tepid water should be used to melt the
crystals of the acid on the specially constructed sound. The
inner ear is then lighted and the sound introduced into the
middle ear through a rubber ear speculum. Every spot to be
cauterized should then be touched lightly but effectively with
the acid, especially the edges of the perforation and the
mucous membrane of the middle ear. The ear should then
be rapidly rinsed out with one or two syringes of water and
after it is dry, dusted with aristol or powdered borax blown in.
The operation should be rapid and repeated once or twice a
week, when the otorrhea soon disappears, the perforation in
the drum closes, and the hearing is completely restored. —
Therap. Woeh. July 1 from Orvosi Hetil. No. 17.
Sodium Hyposulphite Antidote for Malonic Nitrite.— Heymans of
Ghent reports that "nitrite malonique" (dinitrite malonique,
CN, CHt, CN) is fatal at a dose of .006 milligram per kilo-
gram (rabbit i, with symptoms resembling intoxication by
hydrocyanic acid. Animal succumbing to this intoxication
can be recalled to life at any moment, even when in convul-
sions, by an intravenous injection of sodium hyposulphite, and
if the latter is injected at the same time as the nitrite there
are no toxic accidents. The interesting point is that the anti-
dote follows and neutralizes the poison in the inmost nerve
cells, instead of its action being restricted to the poison in the
blood or the alimentary canal. — Bulletin de V Acadhnie de M6d.,
July 22.
Lewaschew Method of Substituting Salt Solution for the Effusion
in Pleurisy. — Requests have been received by the Journal for
further information in regard to this method. We refer those
interested to the Deutsche Med. Wochenschrift, No. 52, 1890
(G. Thieme, Leipsic, Seeburgstrasse, 31), and to the Therap.
Woch. of June 28 (Vienna, xix, Doblinger Haupstrasse 36).
Lewaschew states in the former : "I first, with extreme care
and very slowly, withdraw a certain amount of the effusion
from the pleural cavity, stopping at the first indication of pain.
Then with a syringe I very carefully introduce the same amount
or a trifle less of the 7 to 10 per cent, sterilized chlorinated
soda solution, warmed to about 86 degrees. Again I with-
draw the effusion from the cavity until slight pain is experi-
enced, when I stop and again introduce a corresponding
amount of the salt solution. I repeat this procedure from two
to six times as may be necessary, which depends upon the |
character of the effusion and the peculiarites of individual I
cases." (See this Journal, page 214, July 25.)
Early and Intensive Method of Curing Syphilis. — Manino reports
the highly successful results of eight years' experience with
this treatment (Giorn. It. delle Mai. Veil., p. 50). Instead of
Wiiiting for the usual symptoms to appear, the initial chancre
is excised or thermo-cauterized and calomel injected every
fortnight for ten to twelve months (10 centigrams calomel to 1
gram glycerin and one drop water). After this the injections
are made every twenty days for three or four months ; then one
in sixty days for two months more, when potassium iodid is
administered for two months ; then two months more of mercury
injections, this time the sublimate. The patient then rests for
a couple of months, when the iodid is recommenced for a while,
followed by a protoiodid, which is kept up till the end of the
second year. The initial chancre soon subsides, and no sec-
ondary or tertiary phenomena have appeared in any of the cases
treated during the eight years. The inconveniences of this treat-
ment, the painful injections, the temporary loss of appetite and
weight, are far more than compensated by the victory over the
disease, which is arrested before it becomes constitutional. —
Bulletin Mid., July 22.
The New Celluloid Mull Bandage.— It has been found that cel-
luloid will dissolve in acetone into a thick gelatin, which can
be used for casts, as it hardens sufficiently in an hour and a
half, and becomes absolutely solid in three to four hours. The
sheet of celluloid is cut with a pair of scissors into scraps and
placed in a wide-mouthed bottle, filling it a quarter full. The
rest of the bottle is then filled with the acetone and the con-
tents stirred with a stick occasionally. When rubbed on the
mull bandage it forms the cleanest, hardest, and by far the
lightest substance known for this purpose, while it is not
.affected by the secretions of the body. It has been used at
Strasburg with great suceess, and is warmly recommended as
a most valuable bandage on account of its cheapness, durability,
solidity and elasticity, especially for use in policlinics. It is
not necessary to have as many layers of the bandage as with
other substances, and the celluloid rubbed in for the outer
layer forms a handsome finish. As it is very sticky and can
only be dissolved with acetone, it is best to wear leather gloves
while handling it. It is especially adapted for permanent
removable casts, with or without splints. In some cases a cast
or model of the limb or part has to be made, and the celluloid
cast modelled on this. — Cbl. f. Chir. July 18.
Oxycyanid of Mercury; Ophthalmia Neonatorum. Von Sicherer,
in the Milnchener Med. Wochenschrift, recommends the use
of mercury in the treatment of ophthalmia neonatorum. The
advantages of this drug were first brought to the atten-
tion of ophthalmologists by Schlosser in 1893, at the meeting
of the Ophthalmological Society in Heidelberg. Schlosser
demonstrated that this preparation presented antiseptic prop-
erties equal to those of the bichlorid of mercury, but caused
much less local irritation and much less power of coagulating
the albumin than the corrosive sublimate. Generally in acute
affections of the conjunctiva 1 or 2 per cent, solutions were
used. In ophthalmia neonatorum a solution of 1 to 500 has
proved most effectual, and has been used exclusively in this
affection in the University clinic for several years past. The
application is extremely simple : After eversion of the lids they
are rinsed thoroughly with this solution, and in such a manner
that every fold of the conjunctiva is freed from the secretions.
This should be done daily. Instruction should be given for the
constant use of ice compresses. The nurse should be cautioned
against removing the secretion, for, unless the greatest care is
exercised, injury is done to the superficial layers of the cornea
with subsequent ulceration. If the cornea is not already
affected when this treatment is begun, a favorable ter-
mination can be absolutely guaranteed, which is by no means
the case with other methods of treatment. Even when
slight infiltrations of the cornea exist, by this meanB they can
usually be made to subside, and it is only in extensive ulcera-
tions and in prolapsus of the iris that this and other means of
438
PKACTICAL NOTES.
[August 22,
treatment are of no avail. If the results of the ordinary
method of treating this affection — namely, brushing with a 2
per cent, solution of nitrate of silver and neutralizing with a
solution of sodium chlorid — be compared with those obtained
by simply rinsing with the oxycyanid, the preference would be
unhesitatingly given to the latter method. An efficient rem-
edy for combating a disease which causes 41 per cent, of the
cases of total blindness should be welcomed by all.
Delayed Paralysis after the Use of the Antidiphthcritic Serum.—
Filiatre in the Gazette Hebdomadaire de Med. et de Chir.,
June 4, has reported the case of a child 3 years old, presenting
symptoms of laryngeal obstruction which proved on bacterio-
logic examination to be of diphtheritic origin. An injection
of 15 c.c. of antitoxic serum was at once made into the right
flank, and forty-eight hours later a second injection of 10 c.c.
into the left flank. In the course of twelve hours the false
membrane had completely disappeared, the child breathed
easier, the pulse was normal, the fever had disappeared, and
only the submaxillary adenopathy remained. The child con-
tinued well for more than a month, when it was observed to
speak through the nose. A day later speech was almost unin-
telligible, and saliva dribbled from the mouth. In the course
of several days more, the head could not be held up, the chin
falling upon the chest. Deglutition also became difficult. The
knee-jerks, as well as the pupillary reflexes, were preserved.
Sensibility was intact. The muscles especially enfeebled were
the extensors of the neck, the rotators of the head, excepting
the sterno-mastoid, the supraspinous and the elevators and
abductors of the scapulae. The fascial muscles also were
largely affected, as well as the recti abdominis. Under elec-
tric treatment, improvement rapidly set in, and soon proceeded
to final recovery.
Herpes Zoster. — Dr. A. H. Ohmann-Dumesnil recommends
the following in treatment :
R Acidi arseniosi , .- 003
Pulv. piperis nigris 16
Extract gentian q. s.
Misce. Fiat pilula No. 1. Sig. To be taken thrice daily
after meals.
Externally, campho-phenique powder liberally sprinkled
upon absorbent cotton and applied to the eruption, or the fol-
lowing :
R Pulv. camphorse 8.0
Bismuthi subnitrat 16.0
Cretae preparat 32.0
Misce. Sig. Apply twice a day.
— St. Louis Med. and Surg. Journal, August.
Local Applications in Pharyngitis.— The following combination is
an antiseptic stimulant and protective :
R Oil Scotch pine 2.0
Oil eucalyptus 4.0
Oil cassia 2.0
Menthol 1.3
Ext. balmgilead, fld. q. s., ad 128.0
Sig. Spray on pharynx.
One of the best combinations to be used as a spray in the
simple acute form of the disease is the following :
R Cocain 0.5
Oil cassia 2.0
Menthol,
Gum Camphor aa 4.0
Albolene, q. s., ad 128.0
—Dr. Lewis M. Somers, in the Laryngoscope, August.
Chrobak's Use of Ovarian Extract.— A post-operation treatment
in ovarian cases has been adopted by Professor Chrobak in
order to obviate, if possible, the symptoms that often annoy
the surgeon ; and also to mitigate the disturbances peculiar to
the menopause, and is recorded by him in the Centralblatt fur
Gyndkologie. He was led to administer ovarian tissue and to
practice ovarian grafting. He accordingly had prepared an
extract of the ovaries of sexually active and healthy cows, and
had undertaken experiments to determine the practicability of
ovarian grafting. The extract was employed in six cases in
which the ovaries had been removed and in one of which, with
perfectly normal genitalia, the climacteric molimina were
severe. In three of the cases of the first group, in which tbe
treatment had covered a period sufficiently long as well as in
the remaining case, distinct improvement followed. The
results of the transplantation experiments are detailed by
Knauer. It was found that not only did ovaries grafted
between folds of the peritoneum, or between fascia and muscle
retain for a time at least, their integrity, but that they also
continue to exercise their functional activity, as indicated by
the maturation ovisacs.
Palliative Treatment of Uterine Cancer with Chlorate of Sodium. —
This treatment, recommended by Brissaud for cancer of the
stomach, has been found very effectual in arresting the pains,
hemorrhages and discharges in cancer of the uterus, improving
the appetite and digestion and the health of the patient in
general and prolonging life, although it fails to stop the final
progress of the disease. One patient treated by Boucher lived
three years a "very supportable existence," although the
inoperable cancer in the uterus and vagina was accompanied
by a cancerous lesion of the stomach. He administers it inter-
nally in two to eight teaspoonfuls a day of the following mix-
ture : Chlor. sod., 20 grams; orange flower syrup, 30 grams;
acq. dest., 100 grams. It is also applied on a tampon to the
neck of the uterus in a powder composed of equal parts of
chlorate of sodium and subnitrate of bismuth with half the
quantity of iodoform. If the latter produces symptoms of
intoxication, viz., a coated tongue, bad taste in the mouth and
the iodoform reaction in the saliva with calomel, it can be
replaced by a tampon of salolized cotton dipped in a 20 per
cent, solution of chlor. sod. In addition, a daily vaginal injec-
tion of 10 grams in a liter of boiled water is also given. —
Semaine Mid., July 15.
Pruritus Ani. — Dr. Charles G. Cumston says that patients suf-
fering from pruritus ani are usually either arthritic or nervous.
For local application the following are recommended :
R Menthol 4.0
Alcholis 30.0
Aq. dest 60.0
Acid acetic, dil 150.0
Misce. S. For external use only.
R Acid, carbolic 5.0
Kalii hydrat .2.0
Ol. lini sem 30.0
01. bergamot 9.5
Misce. S. Apply at bedtime.
In very severe cases deep cauterization of the parts with
nitrate of silver or the thermocautery had been employed.
Section of the nerves gave good results in pruritus of the anus,
vulva and scrotum when the affection was very intense. — Am.
Gyn. and Ped., August.
Prolapsus Ani. — Dr. Piatt resorted to the following procedure
in the case of a child operated on in vain by other methods :
At the junction of the skin and mucous membrane, just beneath
the latter, a curved needle is inserted in the median line below,
and a silk thread is carried half way around the anus and out
again, in the median line above, reinserted in the same opening
and brought out at the first puncture, making a purse-string
suture. The little finger is then put in the anus and the string
tied snugly around it. Apparently this would cause suppura-
tion, and possibly a fistula. It does nothing of the kind, nor
does it cause any pain afterward. The child has his stools in
the recumbent position. If the feces are at all hard, injections
are given to soften them. After three weeks the suture is with-
drawn when it heals immediately with no return of the prolap-
sus. By this method the bowel is kept in, place long enough to
contract adhesions. — Johns Hopkins Hospital Bulletin, July.
I
1896. 1
EDITORIAL.
439
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SATURDAY, AUGUST 22, 1896.
"MEDICAL DEFENSE."
It seems that of thirty-eight local branches of the Bri-
tish Medical Association, twenty-seven have written in
favor of such alterations in law and practice as shall
make the Association capable of acting in its corporate
capacity for the defense of its members in case of law-
suits, etc. The meeting at Birmingham has adopted a
resolution that may be considered as the preliminary
step of the plan. This naturally brings into view certain
criticisms — especially of those not unduly loving the
Association or its managers — that the Association
will find itself incapable of acting in this capacity,
that it will prove expensive, that it is too huge and
unweildy a body to act promptly and justly, etc., and
lastly that it will lessen the respect of the general lay-
world for the profession, and lead to a reversal of the
esteem in which it has heretofore been held as a body
of men not bent on self-aggrandizement or defense,
but solely determined to alleviate the sufferings of
humanity without thought of self.
To all of which criticism we would humbly answer,
bosh! The esteem of the public for the profession
may be most aptly synonymized by the word disesteem.
And this disesteem is very largely due to the fact that
the profession has heretofore shown little or no esprit
dc corps, and has been inexcusably weak in permitting
the contempt of the world to stand as a confession of
just judgment. By no means would we adopt the
creed of ethics of the world, an eye for an eye, etc., I
but just as little should we longer hold our cheeks out
for unjust and indiscriminate smiting. Self-defense
is the first law of nature and when consciousness
reaches anything like adult development it instinc-
tively guards itself against injustice and unauthorized
dictation. More than this the cause of the medical
profession taken in its best sense is the cause of
society and humanity. If they but knew it no one is
more interested in encouraging the feeling of self-
respect and honor among medical men than non-
medical men. The evils of quackery exist because
we are not united in crushing them out of existence,
and in the estimation of the public our failure to do
this is due to the fact that we are half-quacks our-
selves, with but a faint-hearted belief in the thera-
peutic value or scientific quality of our own "science."
It is one of the strangest facts of modern sociology
that so large a body of men as we have no professional
unity, that we present no united front to the enemies
of our guild or to the public influences prejudicial to
public health. Every other calling or occupation
bands itself together and seeks to influence legislation
or popular feeling by a hundred instrumentalities
while we are content not only to do little or nothing and
what little we do sporadically and by individual imita-
tion and energy, but we allow our thousand enemies to
deride us and " walk over us " by their unanimous
and organized opposition. We trust the British
Association may not listen to its critics so much as to
prevent it from entering upon the proposed work, and
that its success may inspire the American profession
to undertake functions furthering our professional
honor and importance, and the work we all have at
heart.
MEDICAL CHARITY ABUSE IN ENGLAND— AND
ELSEWHERE.
At last the British lay public is becoming aroused
to the existence of what an editorial writer in The
Saturday Review justly calls "an intolerable national
scandal" — namely, the abuse of medical charities, and
such being the case, we may hope for some abatement
of the evil. From or through the medical profession
we may apparently hope little or nothing at all.
There are a hundred reasons for this, many of which
have often enough been iterated and reiterated, and
the fact is deplorable — but fact it is. It is true that
there is a' committee of the British Medical Associa-
tion on medical charities, and the last report of its
subcommittee through its chairman, Mr. Thomas
Bridgwater, concerning certain London hospitals
(Brit. Med. Jour., July 18, 1896, p. 139) is interest-
ing reading — interesting from the positive proof it
gives of the failure of " Keform within the Party,"
and also from the indirect evidence of the huge sin of
omission left untouched by this or any other commit-
tee. The hospitals visited by the subcommittee were
as follows: Charing Cross, Guy's, King's College,
440
/
MEDICAL CHARITY ABUSE IN ENGLAND.
[August 22,
London, Middlesex, Soho, Westminster, Westminster
Ophthalmic, St. George's, St. Mary's, University,
West London, Chelsea for Women. In six of these
no attempt is evidently made to exclude those able to
pay for medical attendance, and the notices to patients
(that the institution is intended for those unable)
recommended to be displayed in the waiting rooms,
were not to be found. In only two or three was any
thorough-going system of inquiry and exclusion in
operation. The committee give examples of abuse
they found, of people of property and even of wealth
using the "charity" instituted for the poor. The
report adds: " The painful fact is revealed that the
wider the inquiry, the broader 'and deeper are the evi-
dences of abuse of charity, not only in the metropo-
lis, but through the country generally."
In his presidential address at the annual meeting
of the Birmingham and Midland Counties Branch of
the British Medical Association held last June, Mr.
Messiter devoted a portion of his time to this im-
portant question. The population of Birmingham is
in round numbers 500,000. In 1885, in five hospitals
there were treated 127,852 patients, and in 1895 the
number had risen to 167,160.' "Can anybody pre-
tend," said the lecturer, "that this system does not
pauperize the public at the expense of the profession?"
"How is to be remedied?" he asks. Acknowledging
that the responsibility lies largely or entirely with
medical men, he argues that the cure must come from
them, but cites only two elements of relief— the
return to " their own medical attendants" of first-aid
cases after one treatment and the establishment of
provident dispensaries, to relieve the hospitals, and
where some small fee, tax or cooperative support shall
be carried out. The cure is certainly homeopathic in
"the thirtieth," or even a higher "potency"; Hahne-
mann might think it sufficiently high to suit him, and
denominate it a cure by " olfaction."
The Saturday Review commends the recommen-
dation of the 1890 Special Committee — a Central Hos-
pital Board "empowered to receive and publish hos-
pital accounts, to advise upon new schemes and to act
generally as the authorized representatives of the
public in the way of observing, appreciating and crit-
icising hospital management and work," but also
strikes at the heart of the matter in further urging
outright governmental control. We suppose the
writer to mean by this the local and not the supreme
or central government. But whether local or general,
we believe at least for England (if we as foreigners
may hazard such an opinion) that there will be no
adequate remedy found except in this way. The
abuse has become so deep seated, the habit so invete-
rate that only by this means can thorough reform be
brought about. As illustrating the extent to which
1 In 1890 in the London hospitals there were treated gratuitously
3,429,219 out-patients, while in 1894 the number had risen to 4,108,089.
this "craze" has gone, it may be mentioned that in a
number of cases some hospitals spend as much as 25
per cent., 50 per cent., and even more, of what they
receive in contributions and subscriptions in advertis-
ing and appeals. Is it possible to have a more perfect
and flagrant reductio ad absurdum than this? Let it
increase only a little more and longer and the adver-
tisements for patients and contributions will equal in
cost the income, and then perhaps there will come
some attempt at separation of the sheep and the goats,
and exclusion of the unworthy. This is, perhaps, a
method of "reform" not intended or expected. And
if it should come about, can any one doubt that it
will be precisely the very poorest, those most needing
the charity, and those ex hypothesi for whom it
exists, who will be the excluded? Because — and this
is the essence of the whole trouble — every person now
treated gratuitously who is at all able to pay some
fee (insufficient or not, matters not) by the very fact
itself, excludes the worthy poor from receiving the aid
intended for them and not for the hypocrites. Many
hospitals and dispensaries now are compelled to limit
the number presenting to a certain maximum in order
that the work may be got through with at all by the
overworked staff. And when one thinks of one or
two men attempting to scientifically diagnose and
correctly treat in one hour or so the diseases of this
maximum the absurdity grows to disgust. In such a
mess has the profession got itself! Financially and
therapeutically stultifying itself and committing the
double suicide with its eyes wide open and suppos-
edly in its right mind!
Are we in the United States any better off? By
only so much as we are a younger people and that
our institutions have not yet crystallized their abuses
into such set systems and inveterate habits. Per-
haps also there is not the same hypocritic desire to
deceive on the part of the lay public. But we can teach
them to be hypocrites fast enough, and beyond all doubt
we are hard at the job. It would be interesting to know
the proportion of subscriptions for treating the poor
spent by American hospitals in riotously profuse illus-
trations and pictures of the hospitals thus advertising
for money and patients. Every room is photographed,
the water-closets, views, grounds, etc., and one won-
ders whence in all the world come the hothouse plants,
the evidences of luxury everywhere displayed with
confident and exulting pride. We have seen street-
car and poster advertisements of hospitals, their
advantages, number of beds — and, in big "caps," the
names of all their visiting and consulting physicians.
We strongly suspect that this latter display as much
as the desire for patients (to treat gratuitously) was
the hidden motive that begat the device.
One indirect result of all this unseemly rivalry, but
one of the most important, one moreover confirmatory
of our maxim, is the fact of the influence it has on the
1896.]
MALPRACTICE CASE.
441
oharaoter of the over-worked members of the staff, and
on the kind of treatment the patients receive. When
there is a lively competition for patients, then, like
Over-affable storekeepers, there is over-treatment of
tin- few patients in order to attract more — "I was
most beautifully treated there, the doctor was so
agreeable and nice. etc. — go there!" But this soon
becomes tiresome and useless, and at least at the
§Dgorged and popular places the very reverse plan
ecomes operative. Are hospital manners improving
r not': Besides this, it is positively known to us
iat in those hospitals in which no inquiry into the
patient's financial ability or social standing is per-
mitted (and from one reason or another this is very
frequently so. though usually adroitly hidden) cer-
»tain of the assistants or of the staff, feeling the shame
of treating gratis those with better incomes than
themselves, deliberately mistreat such with the
(laudable?) intention of driving them finally to the
private office. We mean by the word, that in minor
ailments a painstaking diagnosis is consciously
shirked, and slipshod treatment and placebos or what-
not instituted. Are we as a profession equally with
our British confreres unable to cope with the dis-
grace': Surely we are fast going the same road to
the same institutionalism and habitualization of abuse
that they have reached. Shall we proceed recklessly
without any attempt to haul up? It is not only a
question of "where we are at," but where we shall be
at in a few years if, at the present rate, we continue
our facilis deoensus.
A MALPRACTICE CASE OF EXTRAORDINARY AND
UNUSUAL CHARACTER.
That is the way Richards v. Willard, which was
decided July 15, 1896, struck the supreme court of
Pennsylvania, and it did not hesitate to say so. The
plaintiff claimed damages against the defendant for
negligent surgical treatment for an injury to his leg.
He alleged that he had sustained a fracture of both
bones of his leg at a short distance above the ankle
joint, and was treated, not for a fracture but for a
sprain, and was thereby greatly injured. If there
were no fracture the plaintiff had no case, for he did not
contend that the treatment he received was improper
treatment for a sprain. The defendant denied most
positively that there was a fracture.
The singularity of the case arose upon the character
of the testimony, and the conflict developed as to the
great leading fact. Two surgical witnesses testifying
from actual examination, declared that there was an
actual compound fracture, one of both bones of the leg,
and the other of the tibia. Against this, three surgical
witnesses for the defendant testifying also, from an
earlier and more complete and thorough examination,
several times repeated, declared most positively and
emphatically that there was no fracture whatever of
either bone. Then, two experts, who examined the
leg a year or more later, testified that, in their opinion,
there had been a fracture. And again, on the other
hand, nine experts who also made examinations at a
later date, declared that, in their opinion, there was
not and never had been a fracture.
A verdict for the plaintiff for $12,000 was returned
by the jury. After a painstaking, careful and minute
study of the testimony the supreme court felt con-
strained to say that it regarded that verdict as an out-
rage upon the administration of justice. Coupled with
this is the suggestion that it must not be overlooked
that the medical and surgical service rendered by the
defendant to the plaintiff was entirely gratuitous. For
many years he had been rendering such service to the
hospital to which the plaintiff was brought, after
receiving his injury. If such gentlemen are to be
harassed with actions for damages when they do not
happen to cure a patient, and are to incur the hazard
of having their estates swept away from them by the
verdicts of irresponsible juries, who, caring nothing
for law, nothing for evidence, nothing for' justice,
nothing for the plain teachings of common sense,
choose to gratify their prejudices or their passions by
plundering their fellow citizens in the forms of law,
the court rightly further states that it may well be
doubted whether our hospitals and other charitable
institutions will be able to obtain the gratuitous and
valuable service of, as it calls them, these unselfish
and charitable men.
The trial judge showed his appreciation of the
verdict by promptly striking down two-thirds of its
amount, but the supreme court says that he might
with still greater propriety have set the verdict aside
altogether, because of its being against the law and
the evidence, and grossly excessive in amount.
The plain truth, adds the supreme court, is that
the plaintiff was probably afflicted with a tendency
to tuberculosis, and when he received his injury
that tendency became developed in the bones of his
leg, and the disease called "tuberculosis of the bone"
fastened upon him at the seat of the injury.
For these reasons, and on account of certain other
errors in the trial, the supreme court reversed the
judgment for $4,000 that was entered for the plaintiff.
Of the points of law of special interest estab-
lished by this decision, it is to be noted that the
supreme court holds that as the fate of the case in
the hands of the jury depended upon the surgical
testimony, there should have been, which there were
not, instructions as to how the jury should reconcile
the contradictions if they could, or, if they could not,
then how they should regard it, or act in relation to
it. They should also have been told just what the
issue was, or the matter of fact upon which the case
turned, as that it was whether there was a fracture or
not, and whether the treatment administered was in
442
NO FULL DRESS UNIFORM.
[August 22,
accordance with the usual and ordinary treatment
practiced by competent surgeons in such cases.
As the actual fracture was not seen, it was only a
matter of opinion whether it existed at all, and conse-
quently the value of the particular testimony, the
court holds, depended upon the competency of the
witness to form a reliable opinion, upon the extent
and character of the examination he made, upon the
reasons given by him in support of his opinion, and
upon the judgment of the jury as to the weight and
character of the testimony submitted on both sides in
support of the respective contentions, all of which
should have been explained to the jury, with suit-
able comments.
Furthermore, it seemed probable that if the plain-
tiff had been content to remain at the hospital a week
or two longer, he would have been cured of his hurt,
and because he would not submit to such a reason-
able detention, but chose to take the risk of leaving,
which apparently brought upon him all his subse-
quent sufferings, the court says that he must take the
consequences himself. And it being impossible to
know what would have been the result of the treat-
ment if the plaintiff had remained at the hospital,
and this impossibility resulting from his own action,
the court holds it would not be proper to attempt to
separate the consequences of alleged negligent treat-
ment prior to his leaving from the ulterior conse-
quences resulting from his contributory negligence,
after he left, in traveling and omitting to have medi-
cal treatment.
NO FULL DRESS UNIFORM.
It has been decided by the military authorities of
the country, including Surgeon-General Sternberg,
at whose suggestion the action was taken, that there
shall be no full dress uniform for the members of the
hospital corps. The pomp and pride and panoply of
war, the nodding plumes of grand parades and glitter-
ing military pageants are not for them. Although they
may be in these parades and pageants hereafter, they
will not be of them. When they are there they are
there not for show but for business — in their fatigue
suits, with their hand litters handy and their hospital
corps pouches ready to furnish whatever is needful for
the emergency. The process of trimming to fit their
equipment to their duty has been going on gradually,
and the present administration of the medical depart-
ment is to be commended for the common sense which
has dictated these changes. A cut was made in the
right direction, when the useless sword was cut from
the side of the hospital steward, and it was an equally
good cut which relieved the men from the weight of
the huge knife which they wore so long on their left
side, and which was useful, so far as the ordinary
observer could see, only in demonstrating how itself
and its sheath could be utilized as extemporized
splints for a broken humerus during some fancy drill
for the popularization of " first aid.-' The hospital
corps man may be considered now to be in full dress
when he has his sling on his shoulders, his pouch by
his side and his litter at the " carry." This is a great
improvement. He has one less suit of clothes to pur-
chase out of his allowance for clothing and to keep
from getting moth-eaten during his enlistment; and
as his clothing allowance has not been cut down cor-
respondingly, he can now provide himself with white
suits for hospital wear without having to invest some
part of his small monthly stipend on this account.
And this leads us to consider what is and what
ought to be the full dress uniform of the soldier. The
medical department has solved this question for itself
as regards the sanitary soldier. May we be permitted,
from our professional standpoint, to suggest that the
military authorities might profit by the example. Is
the full dress uniform of the soldier that in which he
is ready for any duty that may be required of him, or
that which his care keeps from getting moth-eaten so
that it may be on hand for special occasions of cere-
mony? Is it the uniform best suited to show off the
mobility, gracefulness and power of the human figure?
The officer who can not bring his hand to the salute
without risk of dislodging his shoulder knot, can
hardly say so, nor can the soldier who, from heat
exhaustion or sunstroke, sinks, before the parade is
half over, into the hands of the hospital corps to have
his full dress coat unbuttoned as the first step of the
first aid they have been taught in such cases. Mili-
tary officers recognize the rigidity of the helmet, the
stiffness of the padded coat and the general unsuit-
ability of the full dress uniform to the active duties
of the soldier; but they fear that in abandoning it
there would be a risk of developing in the carriage of
the men, we will not say a tendency to slouchiness,
but some loss of that dignity or stateliness which is
usually considered to be a visible manifestation of the
reserve power of the individual. But this is a poor
argument against a desirable reform. Troops that
require to be splinted into a military set-up are not
those that will win the battles of the future. The
erect figure and martial bearing of the soldier should
be the development of graded gymnastics and athletic
games, and should ask nothing from the uniform
except freedom of movement for every muscle in the
well-developed physique.
The soldier's leathern stock died hard more than a
generation ago. Is it not time to consider and reject
what remains of the stiffness of antiquity about the
full dress uniform ? This may not be a consideration
of national importance as concerns the uniform of
our small regular army, but it becomes so when we
consider the larger number of our State troops and
the tendencies manifested in uniforming the various
schools, public and private, of the oountry.
1896.]
CORRESPONDENCE,
443
CORRESPONDENCE.
The MU-liljraii Legislation League.
Letter No. 3, to the Members ok the Medical Pro-
fession (Reuular) in Michigan.
Detroit, Mich., Aug. 10, 1896.
tin- Profession in Michigan:
Tin- letter of Dr. Shurly in the Journal of last week is
inly a most astonishing document. He begins by saying
luu " of course there is no use of continuing a controversy"
td then he proceeds to " continue." In so doing the writer
lunges head foremost intoancient history and appears to revel
oonfeaaiiig the iniquities and follies committed by himself
nd friends in former times. In that respect we are perfectly
•coord with every word. The confessions have our sincere
ml cordial endorsement. But when Dr. Shurly presumes to
Mouse nie and my friends of the crime of emulating the horri-
ble example set by him and his friends twenty years ago, I
have no choice but to charge Dr. Shurly with a degree of
inaccuracy utterly unworthy of the man who occupies the
exalted position of President of the Michigan Medical Legisla-
tion League !
Twenty years ago the medical faculty of the Michigan Uni-
versity found themselves face to face with a most trying
dilemma. We had to choose whether we would stand by reg-
ular medicine and defend its good name against all comers and
protect the university from the evils of sectarianism in medical
teaching, or whether we would accept peace and popularity for
ourselves by handing over the whole institution to the enemies
of science and honest medicine. Dr. Shurly and his friends,
by his own confession, cruelly and bitterly urged the latter
alternative, but we preferred the former, and the time soon
came when the profession and the public, with wonderful
unanimity, applauded our course. The eloquence sneered at
by Dr. Shurly certainly proved effective with the profession
and the public although he admits that so far as he and his
friends were concerned it was "pearls before swine." In
other and perhaps plainer terms I hereby solemnly declare that
Dr. Shurly and his friends, in the emergency to which he refers
to proclaimed with intense bitterness their ambition to secure
the engrafting of homeopathy on to the great State institution
of Michigan in the hope that thereby the University Medical
School, with all its honorable record, might be crushed and
disgraced and the embryo weakling, the Detroit College of
Medicine built up on its ruins. At that time the scheme was
to deliver the university into the power of irregulars. The
scheme now is to hand over the whole profession of the State
into the same hands !
Through all that painful and discreditable controversy, Dr.
Shurly and everyone else knows full well that I and my asso-
ciates in the faculty and in the profession never for a moment
entered into any association or compromise with the homeo-
pathic sect. On the contrary, in the medical societies and in
the medical journals, in season and out of season, we consist-
ently and persistently denounced them and all their pretentious
claims to respect and public recognition as unfounded and
fraudulent. We never justified or approved the graduation of
a single homeopathic doctor. We never signed a single homeo-
pathic diploma. Our utmost efforts were used at all times to
convince everyone of the folly and iniquity of that peculiar
form of mental and moral aberration called "homeopathy."
We opposed by all the means in our power, the crime of intro-
ducing sectarianism into the medical department. With calm,
cool dignity we stood entirely aloof from the homeopathic
department in the university, never condescending to contend
with or notice them in any way, except when grossly attacked
to defend ourselves. Consequently we enjoyed the privilege of
fleeing their institution pass through one long interrupted series
of internal squabbles and scandals and failures until now it has
got to be a by-word and a reproach among the educational
institutions of the State and the nation, repudiated even by its
own followers.
When Dr. Shurly ventures to draw a parallel between the
admittedly shameful conduct and policy of himself and friends
in that old controversy and our attitude toward his Michigan
Medical Legislation League, he is as illogical and ridiculous as
he would be if he propounded the following problem: "If a
barrel of pork cost SS10, how much would a gold mine in
Nevada cost."
Even Dr. Shurly justifies now our course in the old homeo-
pathic controversy, but I defy him and all his league to justify
or defend their associations with the whole army of quacks
and imposters for the purpose of obtaining legislative action,
the aim and object of which, by their own published avowal,
is to "protect the new beginner by limiting competition."
From the best information which we have been able to obtain,
there would seem to be well-founded expectations that the
"Michigan Medical Legislation League" is causing painful
apprehensions as to its "viability." Its nearest and dearest
friends, as we are informed, are seriously alarmed for it, and
the hopeless term "stillborn" seems quite likely to sum up its
whole unfortunate and discreditable career, suggesting the oft-
quoted and pathetic couplet: "If I am so soon done for, I
wonder what I was begun for." It seems pretty certain that
the "League" is, to say the least, a "dead issue." In these
circumstances it seems to be incumbent upon all right think-
ing members of the profession to bestir themselves and in the
true spirit of professsional honor and wisdom endeavor to
evolve some plan by which the best interests of humanity and
of science may be sufficiently provided for in the matter of
medical legislation in the State of Michigan. It is inconceiv-
able that this must of necessity prove to be a hopeless task.
If approached in a proper spirit it ought to be, if not an easy,
still a practicable, undertaking, to construct a policy and per-
fect a program by which, while granting reasonable and just
recognition to all parties and pathies outside the pale of regular
medicine, the honor and the good name of the latter shall still
be preserved safe from charges or insinuations of weakness,
evil association and cowardice. If it should ultimately appear
that the time is not yet ripe for the accomplishment of such a
program surely the regular profession is the one party which is
strong enough to maintain itself unaided in the future, as it has
in the past, and while regretting for the sake of the sick and
the suffering the unfortunate condition of affairs in Michigan,
we as a school, or party, can best afford to go steadily forward
in our honest endeavors to promote the interests of science
and humanity. We of all others can afford to wait and hope
for the time to come when the clouds of ignorance and quack-
ery shall pass away and justice be done to science and
humanity so far as the practice of medicine in our State is
concerned. We take this opportunity to suggest to those who
may feel an interest in the subject a careful study of the med-
ical law of the State of Pennsylvania.
Without being in any degree prejudiced in favor of any indi-
vidual law at present in operation, and while we stand ready
now and always to do all in our power to secure a sound and
satisfactory solution of this problem, no matter what source or
quarter the idea may spring from, we feel free to say the Penn-
sylvania law would seem to contain many valuable and prac-
tical features. But in any event we are more than willing to
cooperate with any man or set of men (so long as they are fit
for gentlemen to recognize and associate with) for the purpose
of accomplishing or in any way advancing the matter of medical
legislation for the suppression of quackery with all its distressing
accompaniments of cruelty and robbery, and at the same time
'conferring increased honor and power upon all those who are
honestly and sincerely devoting their lives and labors to the
444
CORRESPONDENCE.
[August 22,
relief of suffering and the extension of science and art in med-
ical practice.
We will be glad to communicate with all persons whose views
are in accord with those set forth in these "open letters," or
to listen respectfully to those who differ with them, if any such
there be.
In conclusion, I am perfectly willing to accept and endorse
the suggestion of Dr. H. B. Young of Burlington, Iowa, in his
letter to our Journal this week. There seems to me to be
something of a professional wisdom and dignity in his plan
which is a great deal more than anyone can claim on behalf of
the avowed policy of the Michigan Medical Legislation League.
Here must end this correspondence so far as 1 am concerned.
Donald Maclean, M.D.
Professor Klebs Repudiates an Attempt to Place
Him in a False Light.
Chicago, 111., Aug. 14, 1896.
To the Editor: — The enclosed is a copy of a letter which I
have this day sent to the President and Secretary of the Har-
vard Evening Medical College and Hospital of Chicago.
1 never authorized the use of my name in any capacity, in
connection with said institution, and their using it in an
Announcement, is entirely without a shadow of right.
Respectfully yours, Edwin Klebs, M.D.
"Chicago, III., Aug. 14, 1896.
"A. H. Tagert, M.D., President, and Walter M. Pitch, M.D.,
Secretary, Harvard Evening Medical College and Hospital,
Chicago, 111. :
" Qentlemen: — I have received a copy of your Announce-
ment for the session of 1896 and 1897, and have to express my
astonishment that you put me down as ' Professor of Morbid
Anatomy, Bacteriology and Original Research ' in your insti-
tution.
"I never consented to accept any such position in your
school, and you are hereby notified that, unless you immedi-
ately suppress these Announcements, I will be compelled to
tak« legal measures to compel you to do so. I have also made
public announcement of the fact that I have no connection
whatever with your school.
"Respectfully yours, Edwin Klebs, M.D."
It was Pernicious Fever.
New Haven, Conn., Aug. 13, 1896.
To the Editor : — Replying to yours of the 11th inst., would
say, the case you allude to was probably one of malarial poison-
ing in a severe form, but the symptoms taken in connection
with a recent visit to New York, Brooklyn and Newark, fully
justified the suspicion of yellow fever. Her first symptoms
were great lassitude and supra-orbital pain. She had a very
severe chill lasting several hours, which was followed by high
fever and nausea and vomiting. Temperature 106 degrees,
followed by collapse. At one time the vomit was blackish. She
had only one paroxysm terminating in collapse and death. An
intense and rapidly developed jaundice, shortly before death.
Some uterine hemorrhage.
The New York health authorities say however, that no source
of infection is known to exist in that vicinity, either now or
recently. No autopsy was made. The present opinion is that
the case was one of pernicious or congestive fever.
Respectfully yours, C. A. Lindsley,
Secretary, Connecticut State Board of Health.
(a
I
Another Diploma Mill In Wisconsin.
Madison, Wis., August, 17, 1896.
The Attorney-General of the State of Wisconsin, Hon. W.
H. Mylrea, has filed the following petition. Any of our readers
having circulars or letters relating to this institution will con-
fer a favor by sending them to this office.
In the matter of the application of the Attorney General for leave to
bring sun to dissolve the corporation known under the name of the
Milwaukee University (Medical and Dental College), to the Supreme
Court of the State of Wisconsin.
The Attorney General of the tetate of Wisconsin respectfully shows:
That on or about the 24th day of February, 1890, there whs formally
organized uuder the laws of this State, by Dr. Samuel bhorer, Dr. Theo-
dore Walther aud Dr. Oscar Abert, a corporation to be known uudt-r the
style and name of the Milwaukee University. That said corporation
was formed without capital stock "for the purpose of teaching students
the science of medicine and dental surgery, and preparing and educating
them to practice as physicians and dentists, and conferring upon them,
upon examination, and they having succeeded in passing such exam-
ination as to their knowledge of such sciences, the Degree of Doctor ol
Medicine or Doctor of Dental Surgery, or such other degree which may-
be proper, according to their knowledgeexhibitedon such examination.
Your petitioner further shows that heretofore he has been credibly
informed that said corporation in bteach of its trust has knowingly and
wilfully abused the powers conferred upon it by its articles of associa-
tion and certificate of incorporation, and also has knowingly failed to
exercise its powers so * onferred, and still wilfully neglects to exercise
its powers and trusts as provided by law.
That after receiving said information and within a few days last past,
your petitioner visited the city of Milwaukee, being the city iu which
said corporation is located, and visited its alleged college, located at the
corner of Eighth and Chestnut streets, iu said city and tetate. That your
petitioner there met and interviewed said Dr. Oscar Abert. who claimed
to be the secretary and treasurer of said corporation, as well as the
dean of the dental faculty thereof. That at sai< timeaud place said Dr.
Oscar Abert admitted that so far as he knew no records bad been kept
of the meetings of the board of directors, and thMt no by-laws had been
adopted, or any means whatever taken to preserve the records of any of
the acts or doings of said corporation, contrary to the statutes in such
case made and provided. Said Dr. Abert stated to your petitioner that
possibly such records had been made by the president thereof or by the
dean of the medical faculty, Dr. Theodore Walther, but that no such
records were kept in the University. That your petitioner visited the
alleged office of said Dr. Theodore Walther and found that he was
absent from the city of Milwaukee, and State of Wisconsin, and that no
definite information as to his return could be obtained. That the office
of said Dr. Theodore Walther was in a small building, the lower part of
which was occupied as a saloon. That the keeper thereof informed your
petitioner that said Dr. Theodore Walther might return to the city of
Milwaukee on the following day and might not forsome time. That the
buildiug of said college was formerly a residence, and later a small
private hospital, and as your petitioner is informed, is not owned by
said corporation. That the said Dr. Oscar Abert further admitted to
your petitioner that all the college library in use in said building was
two small bound volumes, printed iu the German language, ana a few
pamphlets. That the said Milwaukee University does not own or i
the necessary appliances for the successful teaching of medicine, surgery
and dentistry. That the University owns and possesses only one skull
and a few bones of the human skeleton, aud is not supplied with any of
the ordinary paraphenalla used in teaching the sciences before men-
tioned.
Your petitioner further alleges upon information and belief that
said college was formed without capital stock and that it does not even
possess sufficient medical and surgical instruments as would be used by
an ordinary member of the profession in every day practice. That no
salaries have ever been paid to any teachers. That the only resident of
the college building or person in charge thereof is said Dr. Oecar Abert.
That said Milwaukee University publishes a prospectus from which
it appears that one Dr. Shorer is president thereof. That said Dr. Shorer
Is a resident at No. 571 Mitchell Street, Milwaukee, Wisconsin, and is
engaged in the private practice of medicine. That one Dr. Carl Wagner
is also a director of said corporation and resides at the city of Chicago,
and that be has never vifited or given any instruction in said college.
That the vice-president of said college is one Dr. E. Schoene, a resident
of Fredonia station, Washington County. Wisconsin.
That your petitioner has been informed and verily believes It to be
true that said Milwaukee University has issued a large number of
diplomas conferring the degree of Doctorof Medicineor Doctorof Dental
Surgery upon persons who have never even visited the city of Milwaukee.
That said Dr. Oacar Abert admitted to your petitioner that quite a large
number of such diplomas had been issued to parties residing in Ger-
many, and that the sum received for each diploma issued was two hun-
dred dollars ($200.00). and in addition the notary fees necessary to furnish
the party with a certified copy of the articles of association mid certifi-
cate of incorporation. That said diplomas, as your petitioner is informed
and verily believe .were fraudulently issued to persons utterly unqual-
ified to practice medicine, and who had never pursued a proper course
of study, and who fraudulently intended to procure these diplomas for
the purpose of enabling them* to practice medicine and surgery, the
same as the graduates of the best medical schools of the land. That
said Dr. Oscar Abert further admitted to your petitioner That he was not
a graduate of any medical college and had never received any authority
to practice medicine, and that the only diploma he had ever received
was that of Doctor of Dental Surgery. That he was unable to exhibit to
your petitioner said diploma, but in lieu thereof exhibited to your peti-
tioner what purported to be a liceuse issued by the Board of Dental
Examiners of the State of Illinois.
Y'our petitioner further alleges on information and belief that the
said Milwaukee University was never organized or formed for the pur-
poseoi teaching students the science of medicine and dental surgery,
and that said Milwaukee University has never prepared or educated, or
intended to prepare or educate any person or persons for the purpose of
enabling them to practice as reputable physicians or dentists, or for the
purpose of conferring upon them, after due study and examination, the
degree of Doctor of Medicine or any other degree, according to their
knowledge as exhibited on such examinations. Your petitioner further
shows upon information and belief that said corporation was not organ-
ized in good faith, but was knowingly and wilfully organized for the
purpose of issuing diplomas in order to enable unfit and unskilled per-
sons to secure authority to practice medicine and to enable the organ-
izers and promoters of said Milwaukee University to secure large sums
of money for false and fraudulent diplomas, not only from the innocent
and unsuspecting, but from ignorant and corrupt persons who desired
the pretended authority to practice medicine for their own selfish
purposes.
That your petitioner is informed and verily believes that said Mil-
waukee University has caused large numbers of advertisements to be
18%. |
BOOK NOTICES.
445
Inserted In newspapers throughout the different states of the Union
soliciting such persons as are above described to apply to it ford intoning
and licenses ■inch as would permit them to practice' medicine in this
and other st.d s v ttbont being qualified or prepared forsuch profession.
That said corporation has Issued a great many diplomas to persons'
who have made no preparation or study of the science of medicine or
dentistry, (hat said Milwaukee University sends out a large numherof
to different persons throughout the United States and foreign
rles for the purpose ol Soliciting applications to purchase the
fraudulent and bogus diplomas .hereinbefore mentioned. That said
ration is In no wise a bona jUtc corporation, or organized for the
fiurpose of ad\ anclng science, or for the maintenance and use of a col-
ir the study of medicine and dentistry, or for anv other lawful
purpose whatever, hut for the purpose of falsely ami fraudulently
Obtaining mouey from the innocent and vicious.
Your petitioner further alleges on Information and belief that to
permit tins corporation to carry on its alleged business is detrimental
to public policy and good morals and contrary to the interests of the
State of Wisconsin, »s well as to the advancement of the science of
medicine and dental surgery.
your petitioner asks leave to bring an action In the name
of the people of the State of Wisconsin for the purpose of vacating the
charter arid annulling the existence of said corporation.
w. 11. MTUH4, Attorney General.
State of Wisconsin. (
Dane County, i B '
w. 11. Mylrea, being duly sworn on oath, says that he is the duly
elected and qualified attorney general of the State of Wisconsin, and
acting as such, that he has read the foregoing petition and knows the
co ntents thereof, and that the same is true of his own knowledge, except
as to [hose matters therein stated on information and belief, and as to
matters lie believes it to be true. W. II. Mylrea.
Subscribed and sworn to before me this 11th day of August. 1896.
John Prick, Jr., Notary Public, Dane County. Wisconsin.
NEW INSTRUMENTS.
A NEW MIDDLE EAR, MASTOID AND LACHRYMAL
SYRINGE.
BY ALFRED HINDE, M.D.
CHICAGO.
In suppurative inflammations of the middle ear, both acute
and chronic, and of both atrium and attic and also in the
extensions of the same pathologic process into the mastoid
antrum the difficulties of removal of exudate, 'drainage, irriga-
tion and disinfection of the infected parts are almost insuper-
able. For some years past I have had made and used drawn
out and bent glass syringes, not unlike medicine droppers with
elongated bent points. These, though exceedingly valuable for
the purposes required have now been relegated to the curiosity
shelf and the following syringe, modeled on their plan but
indestructible and of greater capacity and power has taken
their place in my practice and has been found a most useful
and satisfactory instrument for the purposes required.
The syringe has four hollow tips, each seven centimeters long ;
the diameter of the ear end of each tiD is one millimeter and
that of the outer end three millimeters. One tip (B) is straight
and the other three have a bend of four millimeters at right
angles to the shaft. One of the bent tips (C) has an end opening
at the ear end, one has an opening (E) on the right side at the
tip, the other (D) has an opening on the left side at the tip ; the
two latter have closed ends. These tips fit on to a plain metal
slip- joint on the other part of the syringe, which is as follows :
From the extremity of the joint one centimeter, the shaft is
bent at about an angle of 70 degrees and continues for a dis-
tance of four and a half centimeters, enlarging in caliber as it
proceeds. At the widest end it fits upon a screw, the enlarged end
of which is within a rubber ball. Between the screw and the
rubber bulb is a metal cup into which the rubber ball fits.
This cup covers one- third of the outer circumference of the
rubber ball. The joint between the shaft and the ball being
a screw requires a washer to render it water tight. The syringe
when filled with fluid has an emptying capacity of two drams
as at present made, but larger rubber bulbs can be attached
as desired, or a connection with an irrigating vessel be used.
The metal parts are of German silver. The instrument can be
readily taken apart and sterilized. The straight tip can be
used and an excellent lachrymal ' syringe improvised. Also
the bent tip with the opening at its end can be used for irri-
gating the antrum of Highmore. For ear purposes the straight
tip is used for emptying, disinfecting and irrigating the
atrium. The bent tips are used in the attic. The one with the
end opening is merely for injecting the attic cavity after the latter
has been emptied of its necrotic ossicles and suppurating con-
tents. The two bent tips with the lateral openings placed pos-
teriorly when in use are for injecting and disinfecting the
mastoid antrum through its opening into the attic after the
latter has been cleared, and in those cases where every means
of cure is resorted to before chiseling the mastoid, and where
the latter operation is positively refused by our patient.
Messrs. Sharp & Smith have made the instrument for me and to
Mr. Cotter of that firm I must extend my thanks for aid in
getting it out.
BOOK NOTICES.
A System of Surgery. By Frederic S. Dennis, M.D. , assisted
by John S.Billings, M.D. Vol. IV. Tumors; Hernia;
Surgery of the Alimentary Canal ; Appendicitis ; Surgery of
the Liver and Biliary Passages ; Of the Uterus ; Of the
Ovaries and Tubes ; Gynecologic Surgery ; Symphysiotomy ;
Surgery of the Thyroid ; Surgical Peculiarities of the Negro ;
Surgery of the Female Breast ; Use of the Roentgen Rays
in Surgery. Profusely Illustrated. 8o, cl., pp. 970. New
York and Philadelphia : Lea Bros. & Co. 1896.
This volume completes the most extensive system of surgery
exclusively American yet published in this country. We
must accord it a very high rank among the surgical works of
the period. Indeed, it is not too much to say that the work, as
a whole, is a fair reflex of American surgery of to-day as prac-
ticed in New York city.
Liberal use without credit is made of Prof. Nicholas Senn's
scholarly article on enterorrhaphy, first published in this
Journal Aug. 12, 1893, Vol. xxi, p. 215. Of the forty-four
illustrations in the chapter illustrating the methods of intes-
tinal suture, nearly one-half of them may be seen in the arti-
cle on enterorrhaphy. Nor is this all. It is impossible to
resist the conclusion, on a fair comparison of the two, that the
Senn article furnished the basis for this portion of the chap-
ter, as almost without exception every author quoted appears
in the Senn article, in which, indeed, are many not quoted
in the book. The language descriptive of these sutures bears
l Since wrltlngthe above I have had a conical tip (A) one and a half
centimeters long and with the small end of a diameter of one millimeter,
and the latter diameter extending from the point for two millimeters
distance. This conical tip fits on to the slip joint of the shaft as do the
others, and is used for lachrymal syringing.
446
SOCIETY NEWS.
[August 22,
a very close resemblance to the Senn article, as may be seen
on comparison.
In the article on hypertrophy of the breast two cases are
mentioned, presumably on account of their exceptional size,
neither of which approached in size the case reported by
Professor Hamilton in this Journal March 9, 1895, Vol. xxiv,
p. 358, in which the glands after removal weighed respectively
27^ and 24V£ pounds. Before removal, one of these breasts
measured 42 inches in circumference at the nipple and the
other 39 inches. The quotation from Williams also appears
in Hamilton's article, but in the book there is a grammatic
error in copying.
We notice in the excellent article on surgery of the thyroid
gland, p. 830, that the old director of Kocher is figured. The
one at present used by that distinguished operator has a fen-
estra near the end.
The chapter on the surgery of the alimentary canal from the
ileo-cecal valve to the anus, by Dr. Lewis S. Pilcher, is one of
the most satisfactory in the book.
The last chapter, by Prof. W. W. Keen of Philadelphia, "On
the Use of the Roentgen X Rays in Surgery," presents in a con
densed form the salient points of the subject, and gives this
book the credit of being the first work on surgery in the
English language to contain any reference to it. We can not
close this notice without complimenting the editor on the
happy conclusion of his arduous task, and the publishers on
having produced a work with such uniformly excellent illus-
trations, and such splendid appearance. No general surgeon
or general practitioner can consider his library complete with-
out a copy of Dennis' System.
Treatise on Appendicitis. By John B. Deaver, M.D. Contain-
ing 32 full-page plates and other Illustrations. 8o, cl. Phil-
adelphia : P. Blakiston, Son & Co. 1896. Chicago : W. T.
Keener & Co.
This monograph contains an account of the history, anat-
omy, etiology, pathology, symptoms, diagnosis, differential
diagnosis, prognosis, treatment, complications and sequelae
and after-treatment of appendicitis.
Dr. Deaver' s work will be found in all respects satisfactory,
the illustrations are accurate and clear and the author's advice
is sound.
SOCIETY NEWS.
Alabama, Georgia and Tennessee Meeting. — The Tri-State Medi-
cal Society of Alabama, Georgia and Tennessee will hold its
eighth annual meeting at Chattanooga, Tenn., October 13-15.
The prospects are favorable for a large attendance.
Lehigh Valley Medical Association. — The sixteenth annual meet-
ing of this association took place in Wilkesbarre, Pa., August
6. Dr. George M. Gould, by request, read a paper on "Some
Curiosities of Medical and Surgical Practice," in which he
cited a number of instances of children having been born at
railway stations, theaters and in street cars, and gave an
explanation of the cause of the incidents that came under his
practice within the past few years. The following officers were
elected for the ensuing year : President, Dr. J. R. Bucher,
Lebanon ; vice-presidents, Dr. Mary Greenwalt, Stroudsburg ;
Dr. G. T. Fox, Allentown ; Dr. O. F. Harvey, Wilkesbarre ;
Dr. C. J. Leaver, Reading ; secretary, Dr. Charles Mclntyre ;
assistant secretary, Dr. W. S. Stewart, Wilkesbarre ; treas-
urer, Dr. A. Stout, Bethlehem.
The American lilectro. Therapeutic Association.— The sixth annual
meeting of the American Electro-Therapeutic Association will
be held Sept. 29-30, and Oct. 1, 1896, in Boston, Mass. Prof.
A. E. Dolbear, Tufts' College, Mass., is the Chairman of the
Committee of Arrangements. Dr. W. H. White, 222 Marlbor-
ough Street, Boston, Mass., is the Vice-Chairman of the Com-
mittee of Arrangements. Dr. Frederick H. Morse, Melrose,
Mass., is the Chairman of the Committee of Exhibition.
The next annual meeting promises to be a greater success
than any former one. Great interest is shown in all quarters ;
a large attendance is promised. Many candidates of national
reputation are proposed for membership, so that the amend-
ment to increase the limit of members becomes a necessity
The best talent has already announced papers, a larger num-
ber than ever before, at this early date ; material almost suffi-
cient to make a program for the session of unusual interest.
There will be two discussions of importance in electro-thera-
peutics, interesting reports of all standing committees, several
scientific lectures on the first evening, with demonstrations
and stereoscopic views (including Roentgen X Rays, , and elec-
tric principles in the treatment of diseases), given by eminent
talent. The Committee of Arrangements has surprises in
store for the social element in receptions and excursions. The
exhibition promises to be a good feature and of more than
usual interest. The fifth annual volume of the Transactions
of the American Electro-Therapeutic Association is now on
press, and will be ready for delivery about the end of July, 1896 ;
illustratedj cloth bound, gilt lettering, octavo, about three
hundred pages. Emil Heuel, M.D., Secretary.
The American Academy of Railway Surgeons. — The third annual
meeting of this Association will be held in Chicago, Sept. 23-
25, 1896. The officers are: President, John E. Owens, M.D.,
Chicago; first vice-president, L. E. Lemen, M.D., Denver,
Colo. ; second vice-president, F. L. Peck, M.D., Clinton, N. Y. ;
secretary, Webb J. Kelly, M.D., Galion, Ohio; treasurer,
C. B. Kibler, M.D., Corry, Pa. ; editor, R. Harvey Reed, M.D.,
Columbus, Ohio.
The following papers will be presented and discussed :
President's Address, J. E. Owens, M.D., Chicago.
' Use and Abuse of Expert Testimony, with some Recommen-
dations for its Improvement. An Attorney.
Diseases of Railway Men, caused by their Occupation. J. F.
Pritchard, M.D., Manitowoc, Wis.
The Personal Equation among Train-men ; its Importance
Equal or Greater than the Color Sense. Illustrated by an
automatic machine which records both. Robert Tilley, M.D.,
Chicago.
Penetrating Wounds of the Eye Ball. Archibald G. Thomp-
son, M.D., Philadelphia, Pa.
Penetrating Wounds of the Eye Ball. G. A. Wall, M.D.
Topeka, Kan.
Penetrating Wounds of the Eye Ball. T. J. Redelings,
M.D., Marinette, Wis.
Penetrating Wounds of the Eye Ball, with Special Refer-
ence to Differential Diagnosis. D. C. Bryant, M.D., Omaha,
Neb.
Remote Effects of Bone Trauma. D. S. Fairchild, M.D.,
Clinton, Iowa.
Medico-Legal Aspects of Floating Kidney. R. Harvey Reed,
M.D., Columbus, Ohio.
Railway Surgery. Jessie Hawes, M.D., Greeley, Colo.
Emergency Surgical Practice. C. K. Cole, M.D., Helena,
Mont.
First Aid in Railway Emergencies. James E. Pilcher, M.D.,
Columbus, Ohio.
Experimental Research into Shock in Abdominal Operations
and Injuries. Geo. W. Crile, M.D., Cleveland, Ohio.
Shock and Collapse, with Special Reference to Amputations.
Webb J. Kelly, M.D., Galion, Ohio.
The Delirium of Shock. R. S. Harnden, M.D., Waverly, N. Y.
Injuries of the Hands and Fingers. John McLean, M.D.,
Pullman, 111.
An Experimental Study of Colles' and Pott's Fractures on
the Cadaver. A. D. Bevan, M.D., Chicago.
The Cause and Mechanical Treatment of Subluxation of the
Knee-joint. S. L. McCurdy, M.D., Pittsburg, Pa.
Compound Comminuted Fractures at the Knee, with
Report of a Case. W. A. Ward, M.D., Conneaut, Ohio.
Relation of Tuberculosis of the Knee to Injuries of said
Joint. H. Reineking, M.D., Sheboygan, Wis.
Fractures of the Femur. E. M. Dooley, M.D., Buffalo, N. Y.
Past and Present Obstacles to the Radical Cure of Hernia.
E. Wyllys Andrews, M.D., Chicago.
Treatment of Tramps and Trespassers. H. J. Williams,
M.D., Macon, Ga.
Roentgen Ray Demonstration.
I
1896.]
PUBLIC HEALTH.
447
PUBLIC HEALTH.
wen
diar
The
Rochester Death Report. The Health Hoard of Rochester,
\ ST., report the number of deaths for the month of July as
2ti2 : 108 were under I year of age, 23 over 60, and 22 over 80
a's ol age. Four of the decedents were 90 years old.
Chicago Death Rate tor July. -During July the total number of
in the city was 2,457. One hundred and twenty two
were due to violence, 58 were from typhoid fever, 367 infantile
rhea, 385 acute intestinal trouble, and 107 heart disease.
■ death rate for the month was 1.52 per 1,000.
Sanitary Rules for Mothers. The Board of Health of the city
Macon, tia., has issued a little pamphlet for the benefit of
titers who have young children, and who need advice and
warning in order to guard the health of their offspring from
the diseases incident to hot weather.
Necessary Precautions.— Dr. Alvah H. Doty, Health Officer of
the Port ol New York, sailed August 8 for Cuba, where he
will remain ten days collecting information for use in prevent-
ing the outbreak of yellow fever and smallpox among passen-
gen in route to this port from Havana. The principal object
of Dr. Doty's visit is to select and appoint a resident physi-
cian in Cuba upon whom he can call at any time for such work
and information as might help him in the purposes of his own
work here.
New Orleans Free from Smallpox. — New Orleans has practically
■tamped out the smallpox, which has been epidemic in that
eity for some time past. It made its appearance in 1895 and
increased in the number of cases until in March of this year
there were 334 eases and 83 deaths. Up to July 31 there had
been 828 cases and 235 deaths this year. The methods adopted
were general vaccination and strict quarantining. It is
claimed that no such energetic campaign against the smallpox
was ever conducted before. The climatic conditions and the
nature of the population of New Orleans made this necessary.
Health in Michigan, July, 1896.— Reports to the State Board of
Health. Lansing, by observers in different parts of the State,
show that, compared with the preceding month, cholera
infantum, dysentery, cholera morbus and diarrhea increased
in area of prevalence : compared with the average for July in
the ten years, 1886-1895, consumption, intermittent fever,
remittent fever and cholera infantum were less than usually
prevalent. Consumption was reported present in Michigan in
the month of July at 213 places ; typhoid fever at 82 ; measles
at 66 : scarlet fever at 44 ; whooping-cough at 40 and diphthe-
ria at 27 places.
Inefficiency of Filters and Sterilizing Processes for Drinking
Water. ■- -A couple of years ago the Paris authorities offered a
prize for the best process of purifying and sterilizing large
quantities of water. The committee in charge report now that
no such process exists, that every attempt thus far has proved
a failure, and that the only means to secure suitable drinking
water is to procure it from unpolluted sources. The nearest
approach to this is the sand filter, with or without chemicals,
but enough filters must be provided so thatthey can be changed
and used in turn, and they must be under the incessant and
scrupulous care of experts. The only process for separate
establishments, schools, barracks, etc., is to boil the water
and keep it exposed to the air while protected from dust. No
known filter, large or small, will supply permanently suitable
drinking water, as they all require care and supervison beyond
the possibility of realization. — Semaine Mid, July 22.
Formalin as an Official Disinfectant. — According to Hygienische
Rundschau, the above substance can be applied to the disin-
fection of rooms and goods such as is practiced by sanitary
officials. An inquiry taken up at the Stockholm Hygienic
Institute by Nils Englund into the best and most practical
method among the many proposed for the disinfection of rooms
and buildings, has demonstrated that the original recommen-
dations of spraying with a dilute formalin solution, or the sus-
jionBion of clothes saturated with formalin solution in the
space to be disinfected are after all the best. Both these
methods proved most efficient in the destruction of bacteria in
rooms: 1. The spray method. Walls, furniture, etc., were
thoroughly sprayed with a 2 per cent, formic aldehyde solution
and the room closed for twenty four hours ; 60 to 70 c.c. of the
above solution sufficed for each square meter of surface. 2.
Evaporation of solutions. Clothes were saturated with one
pint of formalin solution in which half a pound of calcium chlo-
rid was dissolved. The clothes were then hung in the room
which was closed for twanty-four hours. For furs and books
especially this method of disinfection with formalin proved spe-
cially useful. For dwelling-houses generally the spray method
is exceedingly cheap. While working with it the eyes should
bo protected with spectacles and the mouth and nose with cot-
ton-wool masks ; the hands may be covered with vaselin or
gloves.
Violent Deaths In Great Britain.— During 1895, 820 persons lost
their lives in railway accidents, while 1,054 were killed in acci-
dents to vehicles ; 253 were run over by trains and 372 by
vehicles. Other causes of accidental death were : Lightning,
15 ; cold, 91 ; football 16 ; cricket, 3, and cold baths, 2,172.
Suicides, 2,052 men and 677 women.— Prog. Mid., July 25.
Improved New Sanitary Prisons for Paris.— The new hygienic
prisons at Fresnes, which are to take the place of the old ones
inside the city limits are said to be models in every respect.
The new Montesson school will receive the children until
recently incarcerated in cells at the Petite Roquette, and teach
them some useful trade amid beautiful, healthy surroundings.
The men and the children are thus provided for, but the dis-
graceful old prison of St. Lazare for the women has not yet
been superseded.
Preliminary Medical Examinations In Pennsylvania.— The State
Medical Council having adopted a rule that all who expect to
practice medicine in the State must submit to a preliminary
examination. It will be conducted at the following places by
the examiners named : Altoona, Prof. D. S. Keith ; Easton,
William W. Cottingham ; Erie, H. C. Missimer ; Harrisburg,
L. O. Foose ; Philadelphia, James F. C. Sickel ; Pittsburg,
George J. Luckey ; Reading, E. Mackey ; Scranton, George
Howell ; Williamsport, Charles Lose. The scope of the exam-
ination includes arithmetic, grammar, orthography, American
history and English composition.
Inspection of New York State Charities.— We note with pleasure
in the Medical News, August 1, an announcement that the
veteran sanitarian and philanthropist, Dr. Stephen Smith of
New York City, has been invited to assist in the reforming of
certain of the charities of his State institutions that are said to
receive more than $20,000,000 annually. Dr. Stoddard, of
Rochester, the associate of Dr. Smith, although ten years or
more his junior, is not new in the sanitary field. Dr. Stephen
Smith and Dr. E. V. Stoddard, are members of a newly
appointed committee of inspection of charities, under the New
York State Board of Charities. Their duties relate largely to
the economic expenditure of moneys, bestowed by the State
upon hospitals, dispensaries, and other charitable institutions.
Under the new State constitution, supplemented by laws
passed last winter, it is provided that the State board of char-
ities "shall visit, inspect and maintain a general supervision of
all institutions, societies, or associations which are of charita-
ble, eleemosynary, correctional or reformatory character,
whether State or municipal, incorporated or not incorporated,
which are made subject to its supervision by the constitution
or by law." The committee of inspection will investigate all
charities in Brooklyn and New York, both public and private,
448
NECROLOGY.
[August 22,
and will organize a system of direct supervision over all char-
itable work. The State has approprieted $10,000 for this year's
work. The charitable donations last year in New York State,
public and private, amounted to the immense sum of $23,000,-
000. No other State spends nearly as much. It is to provide
for the wisest distribution of this money that the present
supervision has been provided.
Wide Dissemination of Typhoid Fever in North Carolina.— Acc6rd-
ing to the Bulletin of the Board of Health for July, not less
than fifty-two counties in the "Old North State," out of ninety-
six, reported from one to twelve cases of fever in the month
of June. In Alamance County a physician lost his life by
that disease. In some counties the health officers report
rather vaguely, "typhoid fever in nearly all parts." The Sec-
retary, Dr. R. H. Lewis, again demands that the water supply
shall be watched in these fever stricken communities. The
Bulletin gives the following explanation of the policy of the
State Board : In order to assist in locating the origin of
typhoid fever and checking its further spread when occurring
in more or less epidemic form (the means at the disposal of the
board would not permit it in sporadic cases), arrangements
have been made with Drs. Albert Anderson of Wilson and W.
T. Pate of Gibson Station for bacteriologic examination of
suspected drinking water. On the back of the permit for this
analysis the following appears : "Parties desiring a bacterio-
logic examination of drinking water must first apply to the
Superintendent of Health of his county (or to the medical
health officer of his city or town if it have one), who will, if in
his opinion there be just cause to suspect said drinking water
as the source of disease, write to the Secretary of the State
Board of Health, giving his reason for such suspicion. Should
they be satisfactory to the latter he will forward this permit
either to said superintendent or such other physician as he
may designate. The sample must be taken and packed by a
physician, in strict accordance with the following directions :
The fact that nearly twice as many counties reported typhoid
fever this month as did last suggests the advisability of calling
attention again to the importance on the part of both physi-
cians and householders of carefully looking after the means of
preventing its spread. When it is remembered that 50,000
p»ople die annually in the United States from this disease, of
which North Carolina's quota would be about 1,000, to say
nothing of the constitutions shattered, of the suffering, anxi-
ety, expense and loss of time, the gravity of the subject is appa-
rent and no excuse for repeatedly directing the attention of
both the profession and the people to their duty in relation
thereto is necessary. Enteric fever is by long odds the most
fatal of all the preventable diseases which occur within our
borders. And it is undoubtedly preventable, in large meas-
ure certainly, and, too, by very simple and inexpensive
methods. That the drinking water is the medium of trans-
mission in an immense majority of the cases, and that the
water is contaminated by the undisinfected bowel discharges
of another case is practically demonstrated. So that the pre-
ventive measures necessary may be summed up in an immedi-
ate change to a water supply clearly beyond the risk of
contamination, or boiling the home supply, and in promptly
and thoroughly disinfecting the bowel discharges and the
soiled linen."
Health Report. — The following reports of mortality from small-
pox, yellow fever and cholera have been received in the office
of the Supervising Surgeon-General U. S. Marine-Hospital
Service :
SMALLPOX — UNITED STATES.
New Orleans, August 1 to 8, 1 death.
SMALLPOX — FOREIGN.
Birmingham, Eng., July 25 to August 1, 1 case.
Bombay, India, July 7 to 21, 12 deaths.
Calcutta, India, June 27 to July 11, 3 deaths.
Callao, Peru, July 5 to 19, 36 deaths.
Genoa, Italy, July 24 to August 1, 3 cases, 1 death.
Havana, Cuba, J uly 23 to August 7, 39 deaths.
Licata, Italy, July 18 to 25, 2 deaths.
Madrid, Spain, July 7 to 28, 58 deaths.
Naples, Italy, July 18 to August 1, 15 cases, 6 deaths.
Odessa, Russia, July 18 to 25, 5 cases, 4 deaths.
Prague, Bohemia, July 4 to 25, 6 cases.
Rio de Janeiro, Brazil, June 27 to July 18, 21 cases, 6 deaths.
St. Petersburg, Russia, July 18 to 25, 10 cases, 1 death.
Tuxpan, Mexico, July 18 to 25, 1 death.
Warsaw, Russia, July 18 to 25, 2 deaths.
J CHOLERA.
India : Bombay, July 7 to 21, 29 deaths ; Calcutta, June 27
to July 11, 54 deaths ; Madras, July 4 to 17, 3 deaths.
Japan : July 13 to 21, Kisto Tu, 1 case, 1 death ; Osaka Tu,
1 case ; Tokio Tu, 10 cases, 4 deaths ; Fuknoka Ken, 5 cases ;
Ibaraki Ken, 2 cases, 1 death ; Kagawa Ken, 1 case ; Kana-
gawa Ken, 2 cases ; Okayama Ken, 1 case ; Saitama Ken, 1
case ; Sidzuoka Ken, 1 case ; Wakayama Ken, 2 cases, 1 death
Yehime Ken, 2 cases.
Egypt, July 14 to 20 : Cairo, 16 deaths ; Alexandria,
deaths.
During this period, July 14 to 20, there were 1,540 deat
from cholera throughout Egypt, exclusive of those occurring
in Cairo and Alexandria. Total since beginning of cholera
epidemic 13,343 cases and 11,099 deaths.
YELLOW FEVER.
Havana, Cuba, July 23 to August 6, 210 cases, 95 deaths.
Rio de Janeiro, Brazil, June 27 to July 18, 20 cases, 13 deaths.
Sagua la Grande, Cuba, July 18 to August 1, 166 cases, 16
deaths. Vera Cruz, Mexico, July 30 to August 6, 3 cases.
According to reports of the Spanish Army Sanitary Corps
in Cuba for the first twenty days of July, 1896, there were
during that period 1,835 new cases of yellow fever admitted to
the hospitals in Cuba. There were also during the same per-
iod 497 deaths among the yellow fever hospital patients.
1
.
hs
NECROLOGY.
Jerome Cochran, M.D., Montgomery, Ala., died after a
lingering illness August 17. He was the descendant of a
jekome cochran, m.d.
Portrait from Watson's Physicians and Surgeons op America.
Scotch-Irish family, and was born at Moscow, Tenn., Dec. 4,
1831. Having received a common school education, afterward
supplemented by a course of private study, embracing biology,
theology, metaphysics, and the foreign languages, he entered
the medical department of the University of Nashville, and
was graduated from that institution in 1861. During the Civi
War he served as surgeon in the Confederate Army. In June,
1865, he established himself in Mobile, where he resided
for some years. For the past fifteen years he resided in Mont-
gomery. Of his writings may be mentioned : "Administration
of Chloroform by Deglutition," "History of the Yellow Fever
Epidemic of 1873," "The White Blood Corpuscle; its Physi-
ology and Pathology," "History of the Smallpox Epidemic of
1874-75 in the City of Mobile."
1S%.]
MISCELLANY.
Il'.i
As ■ sanitarian he was one of the foremost and through his
■Aorta many acts of the Alabama legislature relating to State
medicine were passed by that body. He drafted the "Act to
Establish Boards of Health in the State of Alabama" (passed
by the legislature in 1875), constituting the State Medical As-
■OOiation, the State Board of Health, and the County Medical
Societies ; drew the "Health Ordinance of the City of Mobile,"
ipted in IST'J, and revised in 1875: and drew the "Act to
Regulate the Practice of Medicine in the State of Alabama"
(passed in 1877), requiring satisfactory examination of all per-
sons desiring to practice medicine in the State. He had been
an ardent advocate of this measure since 1871. Since 1873 he
had been chairman of the committee on public health of the
State Medical Association, a position equivalent to that of
health officer of the State. From 1868 to 1873 he was Pro-
fessor of Chemistry in the Medical College of Alabama, and
since that time he has been Professor of Public Hygiene and
Medical Jurisprudence in the same institution.
He was associated with the late Surgeon-General Woodworth
of the Marine Hospital Service, and the late Dr. S. M. Bemiss
of New Orleans on the Yellow Fever Commission, which inves-
tigated the yellow fever epidemic of 1878, and collected the
history of each single case that was obtainable. This report
was remarkable for the vast amount of painstaking labor
expended upon it. The traveling expenses of Drs. Cochran
and Bemiss were defrayed by the late Elizabeth Thompson of
New York and the MS. was turned over to the National Board
of Health by Dr. Hamilton, who succeeded Dr. Woodworth.
We believe that this report was never printed, although
extracts were from time to time printed. Dr. Cochran was
one of the most active health officers in the United States, and
a man of phenomenal energy. His sanitary work at Decatur,
Ala., in 188S was intelligent and thorough. As a man his
character was that of one devoted to sanitary science, of great
learning and unwearied industry. His long and faithful ser-
vice to his State is such that it can not be overrated or
excluded from the history of its progress. He had his "quips
and oddities," what genius has not? But take him all in all,
we shall not see his like. His friends, his State, his country
and our Association have suffered a great loss.
W. H. Ross, M.D., atPensacola, Fla., August8. He gradu-
ated from the College of Physicians and Surgeons, New York,
in 1868, and was a member of the Florida State Medical Asso-
ciation. He had formerly been house physician in the Char-
ity Hospital, New York, professor of anatomy in the Medical
College of Alabama at Mobile, assistant State health officer of
Florida, etc.
John H. Norris, M.D. (College of Physicians and Surgeons,
Keokuk, Iowa, 1870), at Metropolis, 111., August 13, aged 66
years. He was ex-mayor of the city and prominent among the
medical fraternities of Southern Illinois and Southwestern
Kentucky. He was captain of Company M, Thirteenth Illi-
nois Cavalry, served with distinction throughout the late war,
and was breveted major.
Wm. H. Matlack, M.D., of Downingstown, Pa., died there
July 12, aged 59 years. He was of the class of 1859, Jefferson
Medical College.
Dayton E. Decker, M.D., of Woodbridge, N. J., died at
Princeton, N. J., July 20. He was the only son of the late Dr.
Dayton Decker and a graduate of the Long Island College
Hospital, class 1874.
John H. McGivern, M.D., died at Plympton, Nova Scotia,
July 21. His remains were interred at St. John, N. B., the
place of his birth. He was a graduate of the New York Uni-
versity Medical College in 1883, and soon after began practice
in the Harlem portion of New York city, where he became
somewhat prominent in the cause of municipal reform.
Wm. A. Rothacker, M.D., Cincinnati, aged 42, died after a
prolonged illness. Dr. Rothacker was compelled to retire from
active practice a number of years ago by reason of poor health,
but up to that time he had occupied a prominent position in
the local profession. He was at one time demonstrator of
anatomy in the Medical College of Ohio, and edited a well-
known work on anatomy. He graduated from the Cincinnati
College of Medicine and Surgery in 1877.
Simon M. Curtwell, M.D., of Maysvillo, Ky., aged 78
years, died August 4. He was surgeon of the Sixteenth Ken-
tucky Regiment during the war and was the oldest practitioner
in his county.
S. T. Anderson, M.D. (Rush Medical College, Chicago, 111.,
1881), at Bloomington, 111., of apoplexy, August 10, aged 52
years. He was a prominent member of the State Medical
Association. Horatio H. Johnson, M.D. (Harvard Univer-
sity Medical School, Boston, Mass., 1869), at Belfast, Me.,
August 4, aged 51 years. He was a member of the Maine
Medical Association and formerly secretary of the Board of
Medical Examiners of Waldo County. J. L. Henot, M.D.
(University of Vermont Medical Department, 1888), atWinsted,
Conn., July 26, aged 38 years. James Dunlap, M.D. (Col-
lege of Physician and Surgeons, New York, 1850), at North-
ampton, Mass., August 3, aged 77 years. Fred C. A.
Kellam, M.D. (University of Maryland School of Medicine,
Baltimore, Md., 1866), at Pringoteague, Va., August 6, aged
83 years. Edwin T. Morrison, M.D. (University of Mary-
laud School of Medicine, Baltimore, Md., 1887), at Baltimore,
Md., August 7, aged 47 years. Charles H. Weinholtz, M.D.
(University of the City of New York, Medical Department,
1883), at New York city, August 7, aged 45 years. C. C.
Chaffee, M.D. (Vermont Medical College, Woodstock, Vt,
1835), at Springfield, Mass., August 8, aged 85 years. James
Northrop, M.D. (Geneva Medical College, Geneva, N. Y., 1857),
at Woodstock, 111., August 9, aged 71 years. Daniel H.
Brennan, M.D. (University of Buffalo, Medical Department,
Buffalo, N. Y. 1885), of Albion, N. Y., at Buffalo, N. Y., of
appendicitis, August 11. Clarence O. Arey, M.D. (Depart-
ment of Medicine of the University of Pennsylvania, Philadel-
phia, Pa., 1894), at Cleveland, Ohio, August 11. Curran C.
Smith, M. D. (University of Louisville, Medical Department,
Louisville, Ky., 1850), at Richmond, Ky., August 13. Will-
iam Joseph Morton, M.D. (Louisville Medical College, Louis
ville, Ky.), at Racine, Wis., August 14, aged 89 years,
feasor Kekule, at the University of Bonn, noted
important works on organic chemistry.
-Pro-
for his
MISCELLANY.
Preliminary Question for the Court.— The preliminary question
whether a witness offered as an expert has the necessary quali-
fications, the supreme court of Minnesota says, in Sneda v,
Libera, decided June 29, 1896, is for the court, and is largely
within its discretion.
A Good Showing for an American Medical College.— We are
informed that by some flaw or omission in the return of pre-
liminary qualification of the Barnes Medical College of St.
Louis to the Missouri State Board of Health, the unprece-
dented number of 101 matriculates were notified to appear
before the said board to show cause why they should not be
debarred from matriculation, all of whom responding to the
summons, after a rigid personal examination and searching
scrutiny of their credentials, were found by the board to be
fully qualified by first grade teacher's certificate or academic
or high school degree, many of them showing exceptionally
high qualifications.
Speculative Evidence. — It is no more speculative to say that
hernia causes pain, and might terminate fatally, so the appel-
late division of the supreme court of New York holds, in the
case of Stever v. N. Y. C. & H. R. R. Co., decided June 17,
1896, than it is to say the same of appendicitis or peritonitis.
450
MISCELLANY.
[August 22,
Consequently, the court holds that it was not incompetent to
ask a physician, who had testified to a party having what he
termed "direct hernia," whether "a breach of that kind at
any time becomes dangerous to life, or becomes dangerous or
painful in any way." The answer here was : "I think it dan-
gerous," and then the witness added, without any further
question, "It may come out and become strangulated so it is
impossible to return it without an operation." This reference
to strangulation it is intimated was open to criticism as being
speculative.
Thyroids in Catalepsy. — After giving detailed histories of cases
treated by thyroid medication, Dr. Joseph G. Rogers makes
the following deductions : 1. That in conditions marked by
inhibition of sensory, motor,, and mental activity, without
gross organic lesion, such as obtain in katatonia and in certain
types of stuporous insanity and melancholia, we may expect
benefit from thyroid medication, judiciously used. 2. That
the effects of thyroids in full dose bear a striking resemblance
to many of the symptoms of Graves' disease, namely, orbicular
weakness, consecutive conjunctivitis, skin eruptions, and tem-
porary bronzing, without icterus of eyes, profuse local fetid
sweats, subjective sense of heat and thirst, excessive metabol-
ism, decided tachycardia, and the absence of any fixed relation
between pulse rate, respiration, and temperature. 3. That, in
so far, the theory of Mobius, that Graves' disease is due to
hyperactivity of the thyroid gland, is strongly supported. — Am.
Jour, of Insanity, July.
Foreign Graduates in French Medical Schools.— Important modi-
fications have been made in the regulations for the admission
of foreign students to the medical schools of France, and for
granting them permission to practice their profession in that
country. Heretofore, American medical students who went to
Paris with the view of graduating from one of the medical
schools were allowed certain facilities. When they were grad-
uates of well-known American colleges, or held a diploma of
doctor of medicine issued by a reputable foreign scientific
institution, they were permitted, upon application being made
through the American embassy, to follow the regular courses
of the French medical schools, the same as French students
who had graduated from the French faculties, and if successful
in the final examination, were awarded the same diploma as
those to Frenchmen, which carried with it the privilege of
practicing in France. The number of foreign students having
considerably increased in numbers and the proportion of those
who remain in Paris to practice their profession having also
become much larger, the French government has adopted a
stricter rule for the admission of foreigners to the French med-
ical schools. In the future foreigners desirous of obtaining the
same diploma of doctor of medicine as that awarded to French-
men will have to submit to the same conditions imposed upon
French students, that is, the diploma they may have obtained
abroad or in any private institution will not be considered, and
before being allowed to register at any of the French medical
schools they will have to produce a French state diploma of
Bachelier de V enseignement classique, and the Certificat de
sciences physiques, ehimiqueset naturelles. To foreign students
who do not intend to practice medicine in France the facilities
usually extended to them will be continued and even enlarged.
But they will only be entitled to a special diploma granting no
rights to practice in France. These regulations were issued
on the 21st ultimo, and are not applicable to foreign students
already registered.
Cure of Sarcoma in Algeria by Native Doctors. — Legrain describes
several cases of sarcoma which he had removed and examined
histologically. These had been treated by native doctors, who
applied a tar obtained from certain bushes in the Sahara dis-
trict, among them juniper. In each case the sarcoma was
entirely and permanently cured. The question arises whether
the supposed sarcoma may not have been a tuberculous affec-
tion, as tar1 is especially efficacious in them, while it has no
effect on sarcoma, and it is not always easy to distinguish a
sarcomatous from a tuberculous tumor. Legrain adds that
epitheliomata are unknown in Algeria except as they appear
on a European. This may possibly be due to the vegetarian
diet without meat, and absolutely without pork. Verneuil and
Reclus asserted long ago that the herbivorous animals were
much less liable to cancer than the carnivora, and they ascribe
the six-fold increase in the number of cancers at their hospit
during the last forty years, to the increased consumption of
meat by the laboring classes. — Bulletin de VAeadimie deMM.,
July 21.
New Method of Anastomosis Without Opening Organs.— Souligoux
unites the stomach to the intestines, or one part of the intes-
tines to another, or the gall bladder to the intestines, with-
out opening into the organs, by creating artificially a process
similar to the pathologic process in tuberculosis or cancer
when a communication is established between organs. This is
accomplished by seizing and squeezing a piece of the intestine
in a clamp forceps ; when released, this piece is reduced to a
thin transparent membrane no thicker than a piece of cigar-
ette paper, about 4 cm. long by 2 to 3 wide. A similar piece
of the other organ is crushed to correspond, and the two
bruised portions are then united and one long edge sutured.
The crushed surfaces are then lightly cauterized with potassa,
the assistant instantly sponging off any liquid that exudes.
The rest of the suture is then completed, and if any of the
black produced by the caustic shows, a separate suture is made
to enclose it. The bruised walls give way very soon, in forty-
eight hours at farthest, and communication is established,
with the formation of adherences that strengthen the suture.
Some of the Paris surgeons are enthusiastic in their praise of
this new "easy, certain and elegant" method of anastomosis,
by which all the dangers of opening into vital organs are obvi-
ated. One necropsy showed perfect union with only a small
fragment of the bruised tissue still adhering. Reclus advises
cocain instead of ether in these operations. Chaput has been
experimenting with the thermocautery which he prefers to the
cold forceps for this purpose, and makes a row of separate
sutures around the eschar. He also proposes a circular union
on this principle, by thermo-cauterizing the bunch formed by
ligating the intestine, and then making a circular suture en-
closing it. He has had perfect success on dogs. Raynier very
sensibly doubts whether this will prove practicable, as it
totally closes the intestines until the bruised portion breaks
away. — Bulletin MM., July 19, and Sem. MM., July 22.
Gleanings. — Vaccination made compulsory in Peru and vac-
cine institute established at Lima. (Crouica MM., May 31.)
Diphtheritic toxins exposed to a weak electric current for
three or four days become transformed into effective antitoxins-
(Gaz. d. Osp. e d. Clin., July 19.) The International Insti-
tute of Bibliography founded last September (Brussels) to
collect in one catalogue all the scientific, artistic, literary and
intellectual publications of the world, advocates the general
adoption of the American Dewey decimal system. (Progres
Mid., July 18.) Bequest of $20,000 to the Paris Academie
de M&Jecine from Mme. D'Ernesti, and twice this sum
bequeathed by M. Marelleau to the society that aids tubercu-
lous children. (Union Mid., July 18.) International Con-
gress of Applied Chemistry met at Paris, July 27, with more
than fourteen hundred members. Monument erected at Dijon
to Woicikowsky, who performed the first successful ovariotomy
in France. Red Cross corps of Scotch collies trained to carry
all that is needed for first aid to the wounded and seek them
out as they fall. In readiness for the autumn maneuvers of
the German army. (Progress MM., July 18.) Menstruation
of healthy child at 46 months. (Marseille MM., No. 9.)-- —
lSUC.j
MISCELLANY.
451
Case of akinesia algera, nineteen years in reclining posture,
lower extremities spastic, atrophic and powerless : cured by
suggestion. (Wien. Klin. Rundsek., July 16.) Epidemic of
icterus in children, eighteen cases. (Deutsche Med. tt'och.
.Inly 16.) Honorary title of M.D. conferred upon Bismarck
by the University of Jena. Dermatitis and alopecia caused by
exposure to the Roentgen ray during a month of experimenta-
tion with the fluorescent screen. {Deut. Med. H'oc/i., July 23. |
Apparently healthy child of healthy mother gives syphilis to
wet nurse and her family, who sue for damages. Court of
appeals Poitiers, France) decides for the defendants, as no
fault could be proved. [Journ. de Mid. de Paris, July 19.)
— Twenty-nine cases of abdominal typhus treated with
guaiaeol salicylate with negative results. (Polnit. Gas. Both:,
No. 8. | Successful extirpation of wandering spleen and left
ovary, both much degenerated, without interference with
pregnancy. Average annual consumption of alcohol in Russia
from IS'JT to 1863 I1., liters per capita ; since been decreasing,
until in IS1>:>, it was only half this amount, which is less than
in any other country, Norway excepted. {St. Peters. Med.
M"i >(/(.. July 18.) Recent case of infection emphasizes impor-
tance of sound teeth in a wet nurse. Gelatin found efficacious
in arresting hemorrhages, 5 to 10 per cent, solution, at 95
degrees. Death follows enema containing 40 grams of boric
acid. One-fifth to one gram boric acid fatal to guinea pigs.
Barth reports two severe cases of pneumonia cured by digitalis,
daily doses, 2 gr. pulv. digitalis leaves in an alcoholic infusion
with syrup of orange peel. (Semaine Mt'd., July 15.) -Sea-
sickness prevented by suggestion. (Semaine MM., July 22.)
Pasteur Monument Committee of the United States. — The follow-
ing circular has been issued :
It has been decided to erect in one of the squares of Paris a
monument to the memory of M. Pasteur. Statues or bust will
also no doubt be located at his birthplace and in other cities.
The Paris committee has, however, wisely determined that the
statue obtained through international effort shall be located at
Paris, where it will be seen by the greatest number of his coun-
trymen and also by the greatest number of his admirers from
other lands. The Paris committee has for honorary members
the President of the Republic and his cabinet, together with
about one hundred and sixty of the most prominent officials,
scientists and other distinguished citizens of Prance. The
active members of the committee are J. Bertrand, President,
member of the French Academy, Perpetual Secretary of the
Academy of Sciences. J. Simon, Vice-president, member of
the French Academy, Perpetual Secretary of the Academy of
Moral and Political Science. Grancher, Secretary, member of
the Academy of Medicine, Professor in the Faculty of Med-
icine. Bruardel, member of the Academy and of the Academy
of Medicine, Dean of the Faculty of Medicine. A. Christophle,
Honorary Governor of the Credit Foncier, Deputy from l'Orne.
Count Delaborde, Perpetual Secretary of the Academy of Fine
Arts. Duclaux, member of the Academy of Science and of
the Academy of Medicine. Magnin, Governor of the Bank of
France, Vice President of the Senate. Baron A. de Rothschild,
banker. Roux, Assistant Director of the Pasteur Institute.
Wallon, Perpetual Secretary of the Academy of Inscriptions
and Belles-Lettres. The Paris committee has kindly extended
the opportunity to the people of the United States to assist in
this tribute of appreciation and love and have authorized the
organization of the Pasteur Monument Committee of the United
States. The members of this committee gladly accept the
privilege of organizing the subscription, and of receiving and
transmitting the funds which are raised. We believe it is
unnecessary to urge any one to subscribe. The contributions
of Pasteur to science and to the cause of humanity were so
extraordinary, and are so well-known and so thoroughly appre-
ciated in America that our people only need the opportunity in
order to demonstrate their deep interest. All can unite in
honoring Pasteur. He was such an enthusiastic investigator,
so simple, so modest, so lovable, and yet so earnest, so great,
so successful — his ideals were so high and his efforts to amelior-
ate the condition of humanity were so untiring that we antici-
pate an enthusiastic response from the whole civilized world.
The United States will vie with the foremost of nations in this
tribute. Chemists, zoologists, physicians and all others inter-
ested in science will wish to be represented. No one is expected
to subscribe an amount so large that it will detract in the least
from the pleasure of giving. A large number of small sub-
scriptions freely contributed and showing the popular appre-
ciation of this eminent Frenchman is what we most desire.
This committee supplies subscription blanks, which should be
returned in the accompanying envelope, together with a money
order, check or draft covering the amount subscribed. All
checks, etc., should bo made payable to "Treasurer Pasteur
Monument Committee," and when received by the secretary a
numbered receipt will be forwarded to the sender. The origi-
nal subscription papers will be forwarded to the Paris commit-
tee for preservation. It is our purpose to do our work as
largely as possible through societies or other organizations.
We prefer to have each organization appoint one of its mem-
bers as an associate member of this committee with authoriza-
tion to collect and forward the subscriptions. The amounts
thus far subscribed by individuals vary from fifty (50) cents to
ten (10) dollars. It is hoped that no one who is interested will
hesitate to place his name upon the list because he can not give
the maximum amount. Please let this receive your early atten-
tion and in that way assist Our committee which must conduct
correspondence with the societies of the entire country. The
committee consists of Dr. D. E. Salmon, Chairman, Chief of
the Bureau of Animal Industry ; Dr. E. A. de Schweinitz, Sec-
retary, President of and representing the Chemical Society of
Washington, Chief Chemist Biochemic Laboratory ; Dr. Geo.
M. Sternberg, Surgeon-General U. S. Army; Dr. J. Rufus
Tryon, Surgeon-General U. S. Navy ; Dr. Walter Wyman, Sur-
geon-General U. S. M. H. S. ; Prof. S. F. Emmons, U. S. Geo-
logical Survey, representing the Geological Society ; Prof. Les-
ter F. Ward, President of and representing the Anthropologi-
cal Society of Washington ; Dr. G. Brown Goode, Treasurer,
Assistant Secretary of the Smithsonian Institution ; Dr. Wm!
B. French, Representing the Medical Society of the District of
Columbia ; Hon. Gardiner G. Hubbard, President of and rep-
resenting the National Geographical Society ; Mr. C. L. Mar-
latt, Assistant Entomologist U. S. Department of Agriculture,
representing the Entomological Society ; Dr. Ch. Wardell
Stiles, Zoologist U. S. Bureau of Animal Industry, represent-
ing the Biological Society of Washington.
The Journal will be pleased to forward any subscriptions
received for this purpose.
Cincinnati.
The mortality report for the week gives : Zymotic diseases
20 ; constitutional, 30 ; local, 50 ; developmental, 6 ; violence,
6 ; under 5 years, 32 : total, 112. Annual rate per 1000, 16.49 ;
corresponding week, 1895, 104 ; 1894, 115 ; 1893, 95.
At the meeting of the State Board of Charities held at
Longview Asylum the reports from the different institutions
show them to be all full and in many instances it has been
necessary to refuse admittance on account of the over-crowded
condition. Superintendent Ratliff of the Dayton Hospital said
that he thought insanity was increasing but that the old pre-
judice against institutions for its treatment was dying out.
The new hospital at Massillon which is being built at a cost of
over $700,000, will accommodate 2,000 patients and is expected
to give relief to the other institutions. Much of the session was
spent in discussing the cost of supplies at the various hospitals,
and suggesting methods to equalize prices. At Cleveland cereal
foods for each inmate for the past six months cost $2.09, while
at Longview they cost $3.23.
Dr. Van Der Veer Taylor, a recent graduate of this city,
has been appointed Medical Director of the Cincinnati Young
Men's Christian Association. Dr. Taylor will act in conjunc-
tion with Physical Director Fisher and will also deliver a course
of lectures during the winter on anatomy and physiology before
the class in preparatory medicine.
A Cincinnati physician has been arrested upon the charge
of violating the U. S. Postal laws in sending through the mails
a threatening postal card. The card was sent to a man whom
the doctor claims owed him $106, and whom he threatened to
put to trouble if the account was not paid by a certain time.
Owensboro, Ky., and vicinity is suffering from an invasion
of typhoid. There is hardly a farm house along the banks of
Mud River, for twenty miles, in which there is not at least one
case. Berea, Ky., is also suffering from a typhoid epidemic.
The contracts for the Massillon insane asylum have been
452
MISCELLANY.
[August 22, 1896.]
made to the extent of $265,000, a portion of which it is claimed
will have to be annulled by reason of the fact that the amount
is in excess of the appropriations made by the last Legisla-
ture, although that body authorized the trustees to expend
$50,000 in excess of the appropriations. Attorney-General
Monnett and State Auditor Guilberthave decided that this is
unconstitutional.
The Miami Medical College have completed the organiza-
tion of their new dispensary and announce the following staff :
Chas. H. Castle, clinical director ; G. L. Bailey, assistant
clinical director ; Robt. Suttler, ophthalmology ; Chas. E.
Caldwell, surgery and andrology ; C. R. Holmes, ophthalmol-
ogy ; J. A. Thompson, laryngology ; E. W. Mitchell, medi-
cine ; R. B. Hall, gynecology ; W. McMillan, surgery ; Julius
H. Eichberg, medicine ; E. H. Shields, surgery and andrology ;
George Sudhoff, medicine ; F. W. Langdon, neurology ; H. W.
Bettman, medicine ; R. H. Ingrato and H. K. Dunham, medi-
cal assistants ; W. E. Schenck, neurological assistant ; Ernest
Jacob, pharmacist.
James T. Scott, M.D., of Greentown, committed suicide
August 10. Dr. Scott was mentally deranged as the result of
a kick from a horse received forty years ago.
Thomas Freeland, M.D., of Boston, Ind., was shot by a
patient named Philip Cochran on the 11th of this month.
Lioulsvllle.
Kentucky Institute foe the Education op the Blind. —
An address has just been issued by the trustees of this insti-
tution, which contains much of interest to the profession as
well as to those who have under their care children who are
so afflicted. Kentucky established her school for the blind in
1842, the eighth school of its kind in the country, last year
there being 132 inmates of the Kentucky school out of a total
of 3,757 blind children educated in thirty-five such schools.
The purpose of the State in founding such a school was to give
to the child with defective sight as good an education as is
offered to the seeing child and, in addition, to give it instruc-
tion in manual training. In 1884 the general assembly passed
an act providing for the addition of a department in a separate
building for the care of the colored blind children of the State.
The board has provided that the children under their control
have the best teachers, faithful and devoted servants, improved
educational appliances, and have also provided that the chil-
dren shall be properly and kindly cared for as regards their
clothing, food, shelter and health, all free of cost to blind
children of the State. Notwithstanding this, about 70 per
cent, of all the blind children of the State between the teach-
able age of 6 to 16 years are allowed to grow up in ignorance,
without any share in the advantages so freely offered by the
State. The American idea of a school for the blind is as far
removed from its being an asylum on the one hand, as it is
from its being a hospital for treatment of diseases of the eye
on the '-ther. Its work is strictly educational. A blind child
should be sent to school as soon as it can get along without a
nurse, say at 6 or 7 years of age. Every year's delay after that
renders the task of its education difficult and incomplete. From
the moment it reaches the school the sense of touch has to be
persistently trained. The kindergarten i9 of inestimable value
for this purpose, and the work done in this department excites
the admiration of every visitor. After the kindergarten the
child studies things and models of things, and in its study of
geography, models in sand and clay the surface of the State
and country and the grand divisions of the globe. He is taught
to read and write and cipher, studies grammar, history, natu-
ral philosophy and all the branches of a good education. If
he has any musical ability it is scientifically and sedulously
cultivated, for it is in the practice of the art of music that he
can compete with his seeing comrades on more equal terms
than in any other occupation. He is also given a course in the
workshop, where he learns to cane chairs, make brooms and
practice simple upholstery, such as the repair of lounges and
mattresses. Piano-tuning is also taught to those who are
capable of learning it. The girls are taught the use of the
needle, and learn as they progress how to patch and darn and
mend, how to knit and use the sewing machine, how to cut
out, fit and make their own garments. In this course of study
and development, extending over eight or ten years, the blind
child gains a confidence in his own powers that enables him to
overcome, to a great extent, the natural awkwardness of his
blindness. He is to a considerable extent enabled to earn a
livelihood for himself. The school term is from September to
June, and at its close the children are returned to their homes,
as it is the desire of the trustees to maintain as far as possible
the home ties of the child.
THE PUBLIC SERVICES.
General Order Xo. 37.
The following is a copy of the order discontinuing full dress uni-
form for the Hospital Corps of the U. S. Army :
Hdqrs. of the Army, Adjutant General's Office,
Washington, Aug. 13, 18%.
* * * * * #
II. By direction of the Secretary of War. from and after this date,
the issue of the full dress uniform to hospital stewards, acting hospital
stewards and privates of the Hospital Corps, U. S. Army, will be discon-
tinued, and an equivalent allowance in money value of white cotton
duck clothing will be made instead.
By command of General Miles.
Samuel Brkck. Acting Adjutant General.
Army Chanfres. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Aug. 8 to Aug. 14, 18%.
First Lieut. Henry A. Shaw, Asst. Surgeon, will proceed to Ft. Brady,
Mich., without delay, and report for temporary duty at that post.
Lieut. -Col. Alfred A. Woodhull, Deputy Surgeon-Gi neral, and Major
Charles Smart, Burgeon , are detailed to represent the Medical Depart-
ment of the Army at the twenty-fourth annual meeting of the
American Public Health Association, to be held at Buffalo, N. Y.,
Sept. 15, 18%.
Major Clarence Ewen, Surgeon, extension of leave of absence granted
on account of disability is further extended oue month on account
of disability.
First Lieut. Benjamin Brooke, Asst. Surgeon, so much of S. O. 09, A. G.
O., March 23. 18%, as directs him to report to the president of the
examining board appointed to meet at San Francisco, Cal. April 14,
18%, for examination by the board, is revoked.
Navy ChnnjreM. Changes in the Medical Corps of the U. S. Navy for
the week ending Aug. 15, 18%.
Asst. Surgeon M. K. Johnson, detached from the U. S. S. " New York."
and to the coast survey steamer " Bache."
P. A. Surgeon G. A. Lung, ordered to the receiving ship " Vermont."
P. A. Surgeon E. R. Stitt, detached from the receiving ship " Vermont "
and ordered home on waiting orders.
Cnanire of Address.
Furay, Chas. E., from Omaha to Chadron, Dawes Co., Neb.
Galbraith, T. S., from Norman, O. T., to Seymour, Ind.
Gedge, D. M., from Honolulu. H. I., to 108 Stockton St., San Francisco,
Cal.
Houston, Jas., from Ingersoll, Ont. to Swartz Creek, Mich.
Kuhlman, F. E., from 2245 Mulphauy St. to 2323 Cass Ave., St. Louis,
Mo.
Kneedler. W. L., from Barracks to 2003 D St., San Diego, Cal.
Pain£, H. M., from Atlanta, Ga. to West Newton, Mass.
II I I I Its RECEIVED
Apolllnari8 Company Limited. The, London. England; Alderson, Jas.,
Benton, Wis.; American Sports Publishing Co., New York, N. Y.
Breakey, W. F., Ann Arbor, Mich.; Benson. John A., Chicago, 111.;
Bell, A. N., Brooklyn, N. Y.; Burr, C. B., Flint. Mich.
Castle, Chas. H., (2) Cincinnati, Ohio; Cobleigh, E. A., (2) Chattanooga,
Teim.; Chattertou, A. L. & Co., New York, N. Y.
Dunham, W. R.. Keene, N. H.; Daland, Judson, Philadelphia, Pa,:
DeSchweinitz.E. A., (2) Washington, D. C; Dlbrell, J. A., Jr., (2) Little
Rock. Ark. ; Doliber-Goodaie & Co., Boston, Mass.; Davis, N. S., Jr.,
Chicago, 111.; Davis, F. A., Chicago, 111.
Edes, Robert T., Jamaica Plain, Mass.; Earp, S. E., Indianapolis, Ind.
French, l'inckuey, St. Louis, Mo.; Flint, Austin, New York. N. Y.
Gihon, A. L., New York, N. Y.; Gillette, Wm. I.. Toledo, Ohio.
Hughes, C. H., St. Louis, Mo.; Hervey, E. V., Indianapolis, Ind.;
Haldemau, F.D..Ord, Neb.; Hodges, J. Allison, (2) Richmond, Va. ; Hynd-
man, J. G., Cincinnati, Ohio; Hummel, A. L. Advertising Agency, New
York, N. Y. ; Hurdy, J. N., Indianapolis, Ind.
Imperial Granum Co., (2) New Haven, Conn.
Jennings, J. Ellis, St. Louis, Mo.
Kercher, J., Chicago, 111.; Krelder, Geo. N., Springfield, 111.
Laughlin Pen Co., New Haven, Ind.
Millard, Perry, H., St. Paul, Minn.: Manley.Thos. H., New York, N. Y\ ;
Mylrea, W. H., Madison. Wis.; Murphy, Francis E.,(2) Kansas City. Mo.;
Moreuius, M., Chicago, 111.; Macrae, D., Chicago, 111. ; Mettler, L. Harri-
son, Chicago, 111.: Montgomery, L. H., Chicago, 111.; McBride, M. A.,
Leesville, Tex.; Middleton, W. D., (2) Davenport, Iowa.
Newman, Henry P.. Chicago, 111.
Ott, Isaac, (2) Philadelphia, Pa.
Parker, F. L., Charleston, S. C.
Raymond. W., Roston, Mass. ; Reed, R. Harvey, Columbus, Ohio.
Shurly, E. L., Detroit, Mich.; Sharpe, N. W., St. Louis, Mo.; Smith,
Frank Trester, Chattanooga, Tenn. ; Scribner & Hilliary, Boouton, N. J. ;
Schooler, Lewis. Des Moines, Iowa; Steele, A. J., St. Louis, Mo.
Thornton, Wm. M., Charlottesville, Va. ; Tnley, Henry E., Louis-
ville, Kv.
West, C. I., Washington, D. C; Woods, T. J., Batesville. Ark.; Wilbur,
C. L., (2) Lansing Mich.; Wlngate, U. O. B.. Milwaukee, Wis. ; Whitford,
Wm.. Carlisle, England: Weaver, W. H., Chicago, III.; Woodward, A. P.,
San Francisco. Cal.; Whamond, A. A., Chicago, 111.: Withrow, J. M.,
Chicago. 111. ; Westmoreland, C. W., San Luis Patosi, Mexico.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., AUGUST 29, 1896.
No. 9.
ORIGINAL ARTICLES.
THE PREVENTION OF WAR AND THE PRO-
MOTION OF PEACE, IN RELATION
TO STATE MEDICINE.
Kt>a.i in the Section on State Medicine, at the Forty-seventh Annual
Miitiug of the American Medical Association, held at
Atlanta, Ga., May 5-8, 1896.
BY E. D. McDANIEL, A.M., M.D., LL.D.
MOBILE, ALA.
The oommon saying that every question has two
sides is generally true. But it is also true that the
reasons in favor of one side are more numerous and
stronger than those in favor of the other. It is fortu-
nate that this is so. Persons of a fair degree of intel-
ligence, by laying aside selfishness, passion and preju-
dices and by honestly using proper available helps,
can reach such proofs as render truth plain and duty
clear. One of the greatest questions that can arise in
the course of human affairs happens to be before the
nations as the question of the hour. It is the ques-
tion of "war or peace." Two strongly antagonistic
tendencies are in energetic action over nearly all the
civilized world. The tendency toward war is mani-
fested by the popular masses and their legislative
representatives in our own and many foreign coun-
tries by an unusual restlessness, a want of forbear-
ance, a spirit of aggressiveness, of pugnacity and a
loud clamor for hasty and extreme action. On the
other hand, the tendency toward peace is equally pro-
nounced. It is heard in a strong, clear, solemn, im-
-ive voice that comes in great earnestness, spon-
taneity and harmony from the consciences and
convictions of the foremost, the best and the most
intellectual men of the times — the great leaders in
education, science, statesmanship, economics, ethics,
beneficence and industry. Especially comes this
voice from the two great English speaking centers of
Christendom — Great Britain and the United States.
It demands that a system of international arbitration
be adopted for the impartial and authoritative settle-
ment of international disputes and wrongs, without
resort to war. The 'question is open and urgent.
Prompt decision must be had. Even if complete
unanimity of opinion be unattainable, no neutrality
in action is practicable. All influential persons and
all potent agencies must act with one of the parties or
with the other. The present occasion furnishes a
fit. time and place for discussing and deciding what
part State medicine, as the proper representative of
all the coordinate departments of medicine and of all
the men who make up the medical profession, is to
act in the great cosmopolitan drama that is being
planned. To invite this discussion and to have the
opinions and actions that may be elicited properly
set forth is the motive of this paper.
In a subject so momentous in magnitude and scope
as the one before us, many things that are more or
less important must be passed without mention.
The limited time allotted imposes this necessity.
Moreover, the thorough knowledge and agreement
known to exist in many pertinent matters would make
it equally a waste of time and an abuse of patience to
attempt to prove what is already believed and to gain
assent to what is already granted. Let us not be
understood as ignoring the matters that are omitted
or as underrating or disparaging such as may seem to
be too little elaborated, or insufficiently emphasized.
Let us try to get a correct conception of State medi-
cine, of war and of peace, respectively, then let us
view the three in close juxtaposition, that we may
better see their just relationship.
State medicine has for its function to formulate,
apply and enforce rules for the protection and im-
provement of health and for the prevention and man-
agement of disease in organized communities. Its
great and final aim is, therefore, the preservation, pro-
tection and improvement of human life. Its impor-
tance must be estimated by the value of human life.
But how may this value be ascertained and if possi-
ble standardized? Only by one, or two, or all of three
methods: 1. Sacred and human tradition confirmed
by the common agreement of mankind. 2. By con-
sciousness and ratiocination. 3. By observation of
the work that can be done by man.
Let us look, as in a dictionary, for the value of
human life — meaning by life, the living human being
— as indicated by tradition and fixed by the common
estimate of our race, and we find it among the fore-
most, if not the very foremost of all precious and
sacred earthly things. The first uttered injunction to
the primal human pair was this: "Be fruitful, and
multiply and replenish the earth and subdue it." The
first penal verdict was a sentence pronounced upon a
shedder of human blood. Subsequently the com-
mand was given: "Thou shalt commit no murder."
Old Testament writings abound ini^evidences that the
care of life is the first duty of law. %iIn the enumera-
tions of rights and in the preambles and drafts of
forms for organic laws submitted to men of various
countries, races and times, preparatory to the forma-
tion of governments, constitutions and laws, the pro-
vision for the protection of life has been a leading
requirement and by being ratified has become a sol-
emn pledge of the race. That life is a foremost, if
not the foremost and greatest of values, is plainly
implied by the fact that prophecy, history, poetry,
philosophy and philanthropy voicing the concurrent
sense of our race, deplore wars, famines, pestilences,
earthquakes, floods, poverty and oppression as among
the greatest of human evils, because of their destruc-
tiveness to human life and, on the other hand, extol
peace, plenty, security, wealth, domestic repose and
abounding health as among the greatest of public
blessings because of their benign influences upon the
life-interests of the world. That the greatest of these
454
THE PKEVENTION OF WAR.
[August 29,
evils is war, and the greatest of these blessings is
peace, are conclusions based upon the clearly implied
predicate that life is the greatest and most sacred of
human interests and values.
Let us next appeal to the tribunal of consciousness
and ratiocinaction. In doing so let us clothe our-
selves in devout humility. Let us remember that we
are nearing the dark border of the spirit land, and let
us take heed that we put not unholy footprints
beyond the proper boundary of human territory. Let
us exclude all physical, metaphysical and theologic
methods, doctrines and dogmas — efforts to understand
or demonstrate the essence, origin or eternity of life,
as not at all pertinent to our present purpose. Let
us also leave out all evolutionary questions as to what
may have been the forms and capacities of man in
periods of duration that have long vanished into the
remote past, or what may be his possibilities in a
future period that lies beyond the reach of all reason-
able and practical speculation. Thus we will find
ourselves at home, as it were, among beings of like
size and born with ourselves — face to face with incar-
nate life — life with bodily limitations and instrumen-
talities, with consciousness, sensation, power of motion,
reason, conscience, speech, knowledge of good and evil
and tendencies to both. This is plain, practical, unde-
niable, tangible, personated life — rather it is living man,
the man of our past, present and future — the typical
man of our planet and our era. What value do his
conscious superiority, and his capacious attributes and
his regular courses of action, assent and maintain, as
due to his life ? Obviously the highest that can attach
to any earthly interest, and beyond all fixable estimate.
All else that man has, will he give for his life; and, as
a rule, all else that he has, he does give for his life
when its redemption is required.
In the Declaration of American Independence life
is held to be an "inalienable right." In accurate defi-
nition life is not an inalienable right, nor, indeed, a
right at all. The life of a living being is an attribute,
an endowment, a possession of that being, and like
other endowments, possessions or trusts, it is condi-
tioned, forfeitable and alienable in case of both indi-
viduals and communities. It can not be maintained
that human life is an absolute, persistent, fundamental
good; it is only a fundamental possibility for good,
and this even alone makes it a thing of priceless
value.
The third and only remaining method of ascertain-
ing the value of human life is the plain and easy one
of judging a tree by its fruit. What work, then, and
how much of it, both on the side of good and of evil,
is man able to do, so far as we can judge from what
he has already done, what he is now doing, and what
he is evidently proceeding to do?
Thousands of times he has desolated the earth by
his resistless blows in war, and thousands of times he
has restored it to prosperity, by his all-conquering
perseverance in peace. In schemes for wreaking his
vengeance on the one hand and of extending the field
of his blissful beneficence on the other, he defies all
dangers and disregards all costs. He compasses both
sea and land, sending his ships and his cables through
the one and his telegraphs and cars over the other.
He scales the loftiest mountains and fathoms the
deepest oceans. He marches through clouds of dust
and seas of blood. He enters as a missionary the far
off abodes of horrid cruelty in the face of all priva-
tions and perils. He treads under foot the slow mov-
ing glacier and the never melting snow. He traverses
Alaska by voyage and Sahara by caravan, and explores
and develops the resources of both. He tames the
massive elephant into a kneeling beast of burden.
He drags from the rivers, the shores and the seas
their monster crocodiles, alligators, sturgeons, sharks
and whales, and converts them into food and mer-
chandise. He plays with the manes of the strongest
lions of Africa and with the teeth of the fiercest tigers
of Bengal. He sinks quarries and mines for sand-
stone, freestone, limestone, granite and coal, the use-
ful and precious metals, thus furnishing employment
to the idle, indispensable necessaries to the poor,
comforts to such as can afford them, desirable luxu-
ries to the affluent and rich. Many valuable commod-
ities to commerce; many appropriate materials to
manufacturers, artists and artisans; many avenues to
varied employment; to trade a widened domain and
to finance an available standard of value. In pasture,
forest, farms, fields and fishery, he provides the great
ruling contributions to clothing and food for the
human family. He opens wide and deep channels
through everglades, pocosons and lakes at once mak-
ing waterways for trade and reclaiming for cultivation
millions of acres of valuable land. He sinks artesian
tubes through the thick, dense strata of many vast
unwatered areas and brings up copious unfailing
streams to fructify the soil and soften the air, and thus
causes the desert to blossom as the rose and waste
places to teem with population and wealth. He bores
deep into the earth's crust and taps great long-sealed
reservoirs of gas and oil and brings up the contents to
furnish mechanical illuminating and various other
materials that give diffusion to human progress and
well-being. He spans great rivers and straits with
bridges and ferries. He has already or will shortly
have, his sleepless sentinels on watch, in hailing dis-
tance of each other, all over the continents and islands
to give timely notice of storm centers that may form
or threaten to form, and to warn all men to provide
against blighting blizzards, desolating tornadoes,
wrecking ocean forces, or inundating cloud bursts.
In Byron's day, it was only in the transporting frenzy
of poesy and when live lightning leaped from cliff to
cliff and the loud thunder shook the far off air that
"Jura answered back to Alps;" now in words of sober-
ness and in stormless calm, the Himalayas can talk
with the Rockies and the Urals with the Andes.
Orders of the President, issued with gentle but con-
siderate firmness in Washington, are instantly heard
throughout most of the States and territories of the
Union. Victoria speaks in London and her words of
love and authority are promptly heard by dwellers in
Great Britain and Ireland, in India, Australia and
New Guinea, in the Ea*t and West Indies, in the
Dominion of the Canadas, in provinces in South
America, and in various other far off possessions.
Nearly two thousand years ago the Great Galilean
told his Apostles that they should do greater works
than even he was then doing, and, by the instrumen-
tality of railroads, telegraphs, telephones and phono-
graphs. Talmage and other evangelists are now
enjoying the promise and fulfilling the prediction by
preaching in New York or Washington and being
heard the same day, to the ends of the earth.
Cleveland touched a button, and instantly the ma-
chinery from all the world went into motion in far dis-
tant Chicago. He touched a button and every spindle,
lever and engine in Atlanta responded to the touch.
1896.]
THE J'KEVENTION OF WAR.
455
In travel, the day's journey of antiquity is now
accomplished in less than an hour. We lie down to
Bleep when we start for a distant destination and
when we awaken we are there. The hours of darkest
night are now as valuable for travel and many other
purposes as those of brightest day, and rest is as
teetive as the most energetic toil. In midst of dens-
irkness men can cause radiant light to shine —
iot by the slow word of command, but with thequick-
if thought. In all the departments of applied
intheinaties man displays his wonderful works of
erseveranee and capacity. He gives to navigation
.11 her maps of the stars and constellations, her charts
jf the oceans and seas, her compasses, barometers,
chronometers and quadrant. He marks the bounda-
ies and calculates the areas of states, nations and
mt incuts, and the altitudes of their various parts;
Dates routes and estimates costs for railroads and
kland water ways for travel and transportation and
ijusts the gradings of railroads for thousands of
dies. In the department of bookkeeping he is the
ooountant without whom no census could be taken,
no tax levied, assessed or collected, no financial suits
ettled in law. and by whom it could, without egotism
boasting be said: "By me kings reign and princes
Hive justice.'' In statuary, painting, poetry and
itory man has opened in the hearts of his fellows
iew fountains of justice, pity, tenderness, sympathy,
compassion, forgiveness and of love. But it is in
astronomy, geology, cosmology, physics, chemistry,
biology and medicine that in the more recent times
man's achievements have become the most transcend-
ent ly glorious, marvelous, beneficent and financially
important. He has analyzed the earth, separated,
differentiated and classified its elements and their
combinations; has measured and weighed the earth
and the moon and ascertained their orbits, distances
and revolutions; has done the like for the other plan-
ets and satellites of our system; has discovered and
explained the causes and laws of the tides and pre-
dicted the times of their coming for all the points of
the coasts of the world. Away back in the millen-
iums of time much was undoubtedly known about the
conditions of health. Thirty-five hundred years ago
the great Hebrew lawgiver wisely recognized cleanli-
as essential to health, and enjoined morality, iso-
lation and purification as safeguards of the life of
individuals and communities. But disregard of this
wise enactment was followed by outrage and war and
these by famine, poverty, filth and discouragements.
These conditions brought on many horrid and loath-
some pestilential epidemics that ravaged and some-
times almost depopulated medieval nations and cities.
One hundred years ago, there lived in Gloucester,
Kngland (the place just now under an epidemic of
smallpox) a humane physician of very studious turn
and threat aptitude for scientific research. His name
was Edward -Tenner. His acumen, patience and per-
severance were all taxed to the utmost for a time
longer than the average man lives, but finally accom-
plished the wonderful and beneficent discovery of a
preventive of smallpox. The discovery was so valu-
able in itself, so hard to account for, and so suggestive
of some great underlying principle that it excited the
curiosity of scientists all over the world. These
scientists by careful, persevering and protracted
study, observation and experiment, have discov-
ered many disease germs and germicides, and much
about the sources and laws of action of these, and have
already obtained such control over some of the
dreaded epidemic diseases of animals, plants and
man as to effect an annual saving of thousands of
human lives and of countless millions of property
values in animals and crops.
In the above feeble attempt to place in view man's
working power, not as much as a tithe of all that
invites consideration has been said or even alluded
to. But surely enough has been said to show that
man is, in reality, the lord of earth's present era, that
he is discharging the commission of subduing the
earth, with a prospect and promise of final success,
that his life is, therefore, the leading object of human
care, and that everything that either directly or
remotely affects it, for better or for worse, lies within
the domain of state medicine.
We come next to consider how war and peace stand
related to human life.
It is admitted that war deserves the credit of hav-
ing done much good, of having sometimes carried the
blessings of civilization to benighted barbarians, of
having aroused activity where energy was dormant,
of having forced hostile and disunited tribes to dwell
together and form states and nations, of having im-
proved its votaries in enterprise, courage, patriotism,
magnanimity, gallantry and chivalry. It may also be
admitted that peace has its proneness to certain evils,
such as supineness, slothfulness, effeminacy, enerva-
tion, gluttony. It is believed to be fair to let these
opposite influences offset each other and that our pur-
pose will be most quickly and fairly subserved by plac-
ing the conceded effects of war and those of peace side
by side and letting the spectator impartially judge
for himself.
It has been shown already that by the traditions
and common consent of the human race, the fact is
admitted that war is the arch enemy of human life
and peace its best friend. To some it may seem that
our whole case might rest here. But others may
think that proofs are so numerous, obvious and avail-
able and the cause so momentous that something
more should be added.
Especially formidable would be an array of the sta-
tistics of war and of peace. But for this there is no
time available here. We must refer to histories,
official reports, and compilations of census returns for
figures to show how vastly and palpably peace pro-
tects life and war destroys, how peace increases popu-
lation and war diminishes it, how peace establishes
law and order and war brings anarchy and chaos.
Peace clears land, fences it, plants seeds, raises crops,
builds homes and farm houses, rears domestic ani-
mals for food, clothing and profit, drains and reclaims
swamps, fens and bogs, thus converting sources of
pestilence into fountains of health, wealth and life.
War burns or razes these homes, kills or otherwise
destroys the inmates, consumes the flocks and herds,
leaves fields that were ripe for harvest a naked surface
on which victims of famine must drop down and die.
How peace by long periods of patient toil, steady
perseverance and unselfish economy, builds highways
and factories, villages, towns and cities; and how war
rapidly reduces all these to ashes and ruins. How
peace covers continents and islands with happy trav-
elers and merchants, with depots and stores of food
and clothing and other human comforts and luxuries;
war with armories and magazines for destruction and
death. How peace checkers the oceans and rivers
with merchantmen, happy voyagers and hopeful trad-
456
HEALTH BOARDS AS DISTURBERS OF PEACE.
[August 29,
ers, that as they pass each other exchange smiles and
wave friendly greetings; war with privateers and bat-
tleships commissioned to rob, kill and destroy. How
peace, by encouraging thought, industry, invention,
discovery, enterprise, science and art among the mil-
lions of earth's inhabitants, stores up billions upon
billions of accumulated value — crystallized profit-
coined capital — thus furnishing means for additional
strides in the path of upward progress. How war,
both by paralyzing the agencies of peace and by a
wholesale process of consumption and waste, by enor-
mous reduction of income and extravagant expendi-
tures, exhausts the treasuries of states, of nations,
and often of the entire civilized world; then resorts
to promissory paper and accumulates public debts to
amounts of billions upon billions, tempting following
generations of children to repudiation, or subjecting
them to endless oppressive, impoverishing, vexatious,
demoralizing taxation for the payment of claims
which they did not contract and did not approve.
How peace, for all the countless and boundless bene-
fits it creates and bequeaths, expects, and, as a rule,
receives no state appropriations for its veterans and
dependents, leaves no public debt and imposes no tax.
Ben Franklin sent heavenward an ardent invocation.
His prayer mounted up to a dark cloud that was
flashing with lightning. From the midst of the
cloud there descended a great angel agent and filled a
vial with blessings to be poured out upon the inhab-
itants of the earth-blessings that now fill not only all
lands but also all seas. They are blessings, the fruits
of peace, priceless but costless. Franklin's compen-
sation is the halo of glory that encircles his name. The
like is true of Galvani, Faraday, Morse, Roentgen, and of
the great host of scientists whose gratuitous but inval-
uable achievements can be accomplished only in the
quiet retreats of peace. From the same beneficent
retreats, in our own days, came the discovery of anes-
thesia, all without cost. A great phantom-like appa-
rition that made its first earthly advent, that Eve
might be born from Adam's painless side, and its sec-
ond in the fullness of time for the fulfillment of the
prediction: "There shall be no more pain." Long,
Wells, Jackson and Morton received no compensation
or pension. Military and naval academies, navy
yards, veterans and their families cost the world bil-
lions upon billions of dollars annually, necessitating
oppressive taxation, this taxation causing poverty, and
poverty bringing exposure, disease and death.
But the industrious work of many lives and the vast
volumes of many libraries would not suffice for the
endless detail of the stunning contrasts between war
and peace, and the opposite tendencies of their respec-
tive works as shown in the gross and obvious facts
that are presented in ordinary statistics. Even if this
overwhelming task were accomplished only a few
pages of the momentous history would be written.
Nature has vast regions that lie beyond the domain
of statistics. The greatest and dearest of human
interests are of things for which there is no commer-
cial unit and no possible place in mathematics. Dur-
ing one of the fierce battles of our recent war it is
estimated that ten thousand men were killed in not
more than ten minutes, but the value of these men in
all directions and the cost to the aggregate interest of
the world of their horrible slaughter can never be esti-
mated until death sighs can be painted and family
agonic analyzed, family bereavement measured and
the suppressed possibilities of themselves and of their
prevented offspring can be understood. It is a saying
that more men are lost in war by disease than by the
enemy. It is probable, on due reflection, that the
damage caused by the remote, long-lasting, unre-
corded and ramifying influences of war far transcend
its direct, obvious and loud-crying evils. These
remote and recondite influences contribute in num-
berless ways, in various degrees and for indefinite
periods, to reduce human vitality and to increase the
mortality of disease. They are solid realities in cast-
ing shadows on the face of the world and in darken-
ing the homes and the highways of men. They are
not visible to man's eye, nor audible to man's ear, nor
enumerable in man's figures, but, nevertheless, they
are potent agencies in drying up fountains of life
that otherwise would have fed perennial streams , of
hope, faith, love and happiness.
Here this humble thesis must end. The conclu-
sion reached is: That human life is man's para-
mount earthly interest and the foundation of his tem-
poral happiness; that war and its effects are great
destroyers of life; that peace and its fruits are great
conservators of life; and, therefore, that the prevention
of war and the promotion of peace are not only legiti-
mate but imperative works of State medicine.
Hoping that the medical brotherhood of this coun-
try may desire to place itself properly on record on
the question above presented, and that some prac-
tical action may be inaugurated and expedited, I beg
to submit to the Section on State Medicine, anc
through it to the American Medical Association,
the following resolutions:
Resolved, That the American Medical Association is in
favor of the movement now in agitation for the establishment
of an international system of arbitration for the settlement of
international disputes and wrongs without resort to war.
Resolved, That the said Association constitute the Sur-
geon Generals of the U. S. Army, U. S. Navy and U. S. Marine
Hospital Service its representatives to act with the great organ-
ization already at work in favor of said arbitration.
HEALTH BOARDS
THE
AS DISTURBERS OF
PEACE.
Read in the Section on State Medicine, at the Forty-seventh Annun)
Meeting of the American Medical Association, at
Atlanta. Ga., May 5-8, IMS,
BY CHARLES McINTIRE, A.M., M.D.
KASTON, PA.
LECTURER ON SANITARY SCIENCE, LAFAYETTE COLLEGE, ETC.
With a title as sensational as the one that I have
ventured to announce for this paper, it may not be
amiss to hasten the statement that no violent attack
upon boards of health is contemplated. The great
good accomplished through the official supervision of
these boards, whether municipal or State, is so patent
that he would be foolish, who, at this late day, would
asseverate the contrary. It is not necessary to attempt
to enumerate the good accomplished nor to chronicle
the unselfish labors of the men to whom all honor
should be given, and by whom these things have been
brought about. But, acknowledging the good, and
wishing them greater usefulness and power, it may
not be amiss to have some of their acts pass in review
for kindly inspection, and to criticize, in a friendly
manner, should errors or failings appear.
You are all familiar with the Oriental fable, where
the Cholera on his way to Bagdad, informs a dervish
in the desert, of his intention of killing 10,000 people
with his plague. And on returning from his mission,
is met by the same dervish who accuses him of a much
1896.]
HEALTH BOARDS AS DISTURBERS OF PEACE.
457
higher death rate. The Cholera replied that he had
lupt himself well within his bounds, the excess was
due to fear. Doubtless, if you have not read, you
have all looked at that volume of goodly size by
Daniel Hack Tuke, entitled "Illustrations of the
[nfluence of the Mind upon the Body in Health and
Disease." With the thought suggested by these
illustrations in mind, may not a doubt arise that some-
times our health authorities in their efforts to warn,
really alarm: wishing to awaken, they really affright;
desiring to preserve peace, they really disturb it.
I have known in a case of diphtheria, where
neither an appeal to gratitude for past favors bestowed,
nor to greed for a present reward offered, was able to
seeure any one to perform the household duties for
the well, in a house where the proper isolation could
be maintained in the apartments assigned to the ill.
Of a husband who was not able to be with his wife at
the deathbed of their son; she must bear the strain
alone, or he would be so quarantined that, not being
subjects tor public support, the proper supplies could
not be brought to the imprisoned household. Of an
arrangement by which the death of a child would be
announced to a neighbor after the manner of the tele-
graphy devised by the political prisoners in Russian
fortresses, as described by Mr. George Kennan,
because no one ventured beyond the door, on which
the dread placard was placed, to do a neighborly deed.
Making an inspection for our state board of health in
an outbreak of diphtheria, I inquired as to possible
carelessness in isolation, and was told that the simple
announcement of the presence of the disease was
enough to keep every one away, regardless of what
might be the ability of the family to properly care for
the suffering.
I might multiply examples, but these are enough
for my purpose. And I ask you that if this is the
outcome of the teachings of our health boards, is it
not a fair inference that one result of these teachings
is to disturb the public peace?
You all remember the scare attendant upon the last
visit of cholera in New- York Harbor. Of the meet-
ings of the health boards, their preparations and pro-
nunciamenta, for inspection of trains, detention of
the suspected, etc. One effect of that effort on the
part of the state boards was to unceremoniously, let
us hope not uncharitably, take a man from his com-
fortable bed-room in a certain Pennsylvania hostelry,
to a covered porch, because he was attacked with
vomiting and purging. The fear that the man might
be attacked with the dread disease, and the business
of his house ruined because of its contagious nature
conquered every other feeling in the heart of the
landlord. Fortunately the night was a warm one, and
no serious result followed.
These are trivial incidents, no doubt, and some of
you may be inclined to quote:
"Diseases, desperate grown,
By desperate appliance are relieved
Or not at all."
And some to point to the fact, of which we are all
proud, of the restricting the disease to the harbor
whence it came and to the communities bordering on
it: or to the wonderfully encouraging statistics that
demonstrate the decrease of communicable diseases
through the employment of such agencies as are here
criticized. Still others may deny the' conclusion and
assert that these incidents are not an outcome of any
action of the health authorities.
To the former objections, permit me to make clear
that the contention is not for a disregard of precau-
tions, but the unnecessary alarm to defend against a
danger that does not exist: the exciting a dread of a
hygienic bugaboo. The latter objection is a fair one.
If such incidents as I have described are not fairly
the results of the teachings of the boards of health, it
is not only unfair, but unkind as well to even associ>
ate the two in the same paragraph.
As I examine soim of the pamphlets prepared by
our State boards for popular reading, I am reminded
of a habit in dress of the worthy burghers of New
Amsterdam as chronicled by that most careful his-
torian, Diedrich Knickerbocker. These worthy heroes,
you will remember, were wont to wear a half score
pair of breeches at one time. Whether these indis-
pensable nether garments were placed one over the
other at one time, or whether a period of time elapsed
for one pair to become somewhat threadbare before
another pair covered the sturdy limbs, the historian is
not careful to state. If the latter supposition be the
correct one, the resemblance suggested by the pam-
phlets is closer. At some time in the past the medi-
cal world was using an hypothesis as to the method
of communication of a disease, and the sanitarian
arranged his precautions accordingly. The world
wears out the hypothesis and there is need for a
change of procedure. There remains, however, the
doubt of conservatism. May it not be possible, under
some circumstances, no matter how remote, that the
older attempts to express the methods of communica-
tion may still be true? What a risk Tnay be run if
every possible precaution be not taken. The old gar-
ment is not discarded although the new one is added,
and some of the circulars are almost worthy the name
of "Tenbroek." Does this seem to be an exaggera-
tion? I quote a few paragraphs, first from some of
these circulars prepared by our boards of health for
the instruction of the citizen ; secondly, from certain
named physicians who have written for the profession.
I use but a very few of the possible citations from the
former, and only enough from the latter to demon-
strate that I have not restricted myself to the opin-
ions of the few. I will then leave it to you to deter-
mine if my illustration is an apt one.
"Most of the so-called 'contagious' diseases are
usually spread by means of atmospheric dnst of
which the germs of these diseases sometimes consti-
tute a part. Consumption, diphtheria, pneumonia,
influenza, scarlet fever, measles, whooping cough and
smallpox are usually spread in this manner."
"Diphtheria is spread by the sputa, saliva and
whatever comes from the throat and mouth of the
patient, and by the dust which results from the dry-
ing of such saliva. "
"Diphtheria poison has great vitality and may lie dor-
mant in clothing, blankets, paper and houses for weeks
and even months. It seems to be able to travel in the
air of sewers, and thus to pass from house to bouse;
also to rise from the emanation of putrid privies and
cess-pools. "
" Close attention should be paid to the sources of
water and food supplies. If possible, only the purest
water should be used. If there is any doubt about
the purity of the water, boil it thoroughly before using
it." (From a pamphlet on diphtheria.)
"A general rule applicable to all persons sick or
well, is that the handkerchief should be looked upon
458
HEALTH BOARDS AS DISTURBERS OF PEACE.
[August 29,
with suspicion. They should not be used after any
secretion from the uo* has been permitted to dry
upon them. After being used they should be put
into a paper bag which may then have its top twisted
shut, there to remain until put into boiling water. "
These are enough for our purpose, and it is not
necessary to give the source of the quotations: they
were selected hap-hazard from various pamphlets:
had the circulars of other boards been used, essenti-
ally the same language would have been found. Nor
is it asserted that everything quoted is open to adverse
criticism; the general excellence of the suggestions
makes the harmful portions all the more dangerous.
The only arrangement attempted was to group
several statements regarding diphtheria for the con-
venience of brevity in the discussion.
Permit me now to bring several quotations to your
notice apropos to the extracts already read.
" The relation between imperfect drainage and the
diphtheria poison has not yet been satisfactorily
determined. Perhaps as Thorne suggests, the faulty
conditions produce sore throat of a benign character,
which, as in scarlet fever, affords a soil suitable for
inoculation of the diphtheria germ, when present in
the air. Drains, too, he thinks may retain the virus
received through the sputa and dejecta of the sick.
This author states that no prevalence of diphtheria
has ever been definitely traced to polluted water." '
" Diphtheria is a highly contagious disease, readily
communicated from person to person. The poison is
given off in the pharyngeal secretion and in the saliva,
but not in the breath. . . The virus attaches itself to
the clothing, the bedding and the room in which the
patient has lived and has, in many cases, displayed
great vitality. The disease may be transmitted by
inoculation. The contagion does not seem to be
widely diffused in the neighborhood of the patient.
At the Montreal General Hospital we rarely had cases
develop in the wards adjacent to those in which there
were diphtheria patients, in bed." 2
"There is no evidence that the disease (diphtheria)
can be disseminated by the air for more than a few
feet; it is usually necessary to come in actual contact
with the bacillus at its lodging place in order to
become infected, and unless it is propelled from the
patient for some little distance by the patient in
coughing, it is rarely taken through the medium of
the atmosphere." 3
The New York Medical Journal quotes Flugge in
Ztschr.f. Hyg. u. Infectionskrankh., for July 1894,
as saying that the bacilli causative of diphtheria
perish when dried and converted into fine air-borne
dust. . Accordingly the danger of the infection being
carried through the air is minimal. It is by direct
contact that most harm results. Inanimate objects
keep the contagion alive. In moist climates it sur-
vives better than in dry regions. If soiled clothes are
kept in closed containers or in cellars, the germs there
have a good chance to live and do harm.
Overcrowding and lack of personal cleanliness
assist in spreading the disease. Common use of the
same unclean spoons, dishes, etc., Decomposing filth
piles (as such) and sewer gas are not causes. Houses
where it has occurred are not so much to be feared as
are the people who are unclean and careless.
•'Wright and Emerson examined the dust upon the
floor of tr diphtheria pavilion of the Boston City
l Osier: Practice of Mediciue, First Edition. -'Ibid.
J U.O! B. Wingate, Journal American Medical Association, Nov.
21, 1864. In a paper read before this Section at San Francisco.
Hospital and upon the clothing and persons of the
attendants, to determine if the bacilli were present.
Four cultures were made from the floor sweepings,
and in only one did the examination reveal the pres-
ence of the Lofner bacillus, although other bacteria
were present. In four examinations of the dust
adherent to the shoes of the attendants, three showed
the presence of the Loffler bacillus with other bac-
teria. Cultures were made from the hair of the
attendants in four cases, with positive results in one.
Examination of the margins of the dresses of the
attendants, of the bed-clothes, shirts and finger nails
of the patients were negative as regards bacilli, as
was also the examination of the air of the pavilion.
In two of the five examinations in which bacilli were
found their virulence was slight,'"
"The inhalation of sewer-gas wherever diphtheria
prevails has been regarded as a common cause of this
disease. For this reason the following investigations
relating to the nature of sewer gas are instructive and
important. J. Parry Laws presented to the main
drainage committee of the London County Council
the results of his investigations on the composition
of sewer gas. His examination as well as those pre-
viously made by Carnelly and Haldane, showed that
the air of sewers was much better than might have
been expected. . . The number of microorganisms
was less in the sewer air than in the outside air at the
same time. . . Moreover, the sewer air contained a
much smaller number of microorganisms than the air
examined in domiciles. Laws found that the micro-
organisms of sewer air are related to the microorgan-
isms of the air outside, and not to those in the sew-
age. . . He also found that a considerable increase
in the velocity of the air currents did not increase the
number of microorganisms found in the sewer air, and
that the results of experiments were the same in
small as in large sewers, and led to the belief that all
microorganisms in sewage air are nonpathogenic.""
It is not necessary to unduly lengthen this paper
with additional quotations. Admit that they are
selected with the purpose of an advocate to further
his plea and that other opinons are suppressed;
enougb is given to show some physicians of good
repute, when addressing the profession, do not posi-
tively state that diphtheria is usually spread by means
of atmospheric dust and should be classed in this
respect, as an air- borne disease, with smallpox; that
it seems to arise from emanations in putrid privies
and cess-pools; or that it is a water-borne disease.
And to the degree that such things are asserted beyond
the proven knowledge and in an opposite direction to
the trend of investigation, by so much is a needless
dread aroused and the public peace disturbed.
One can easily see why this is done and suggest
excuses for it. The burden of responsibility placed
upon the health officer who has any fellow feeling for
mankind is so great that he naturally prefers to take
ten needless precautions than to run the risk of
omitting to take one that is necessary. He fears that
the teaching of the biologist and clinician may not
include the whole truth and, while he makes use of
their teachings, he does not, on that account, entirely
neglect other sources of information and adds, it may
be, that other knowledge whose fountain is said to lie
with elderly ladies; for fear he may make a mistake.
In much of this, I fear, he brings sanitation into dis-
repute and prevents the public support that it would
* Sajous Annual. 1895, vol. I, p. 4. = Ibid, p. 6.
1896.]
DUTY OF THE PHYSICIAN TO THE PUBLIC.
459
otherwise receive, and fails to produce in the public
mind that confidence which should always manifest
itself.
Sanitarians are not alone among physicians in their
methods of mingling science and sentiment. The
history of medicine displays a grand march of hob-
hies and hobby riders. Just now our steeds are
agriculturally inclined; we are in the midst of a time
of weed -killing. The farmers in the region about my
home have their fields at times invaded by sorrel
(oxalis strieta), but they never think of entering
opon a campaign of pulling them out root and branch.
No! they sprinkle the ground thoroughly with air
slaked lime and change the character of the soil;
then the weed can not grow. In our anxiety to kill
the weeds we suggest, in effect, that every one of us
who may sutler from a slight coryza should carry a
a bale of pocket-handkerchiefs and a package of paper
bags (preferably of waxed-paper) and, presumably, a
grip-sack; for even the capacity of a small boy's
pockets won Id not be equal to the emergency were
the cold a brisk one. If you have ever had any
experience with "hay-fever" you will be able to tes-
tify of the added burden that this would be to those
already heavily laden. At the same time, so little
attention is paid to the soil factor, with suggestions
along the line of hope and not despair. I am glad
to note that a paper on this side of the subject was
presented at the last meeting of the American Public
Health Association; may it be the harbinger of a
renaissance.
But, shall we cry "peace, peace, when there is no
peace':" Assuredly not! Let our efforts not be for
calming into false security but rather into that state
of mind that prevents a panic. Let us be scientific
in all our processes, and it is scientific to admit a
lack of knowledge when such lack exists. If we have
become convinced of the truth of any supposed fact
in medicine, let us act honestly by its teachings, lay-
ing aside all that is contrary. If we are convinced
that typhoid fever is a water borne disease, and
rarely, if at all communicated by contact, why insist
that the dead be wrapped in a bichlorid sheet or
object to the transportation by rail for burial? Our
train robbers and train wreckers, however vicious and
debased, are not cannibals; and the risk of an accident
whereby the body will be precipitated into a source
of water supply of any community is so remote that
the most painstaking need not consider it. Let us be
honest in our presentation of sanitary statements.
President Lincoln's suggestion about the ability and
inability of fooling the people is so trite that it need
' not be quoted; but it is true.
Let us be more vigilant than ever; pressing reform,
acknowledging error, seeking to educate, striving to
prevent. But science, not dogma ; deductions not
presumptions nor assumptions, only should pass
current. Not only safety but peace of mind should
be our aim. Let us strive rather to increase our effi-
ciency, and in striving remember that efficiency is
never measured by the manifest exertion or parade
in its execution.
DISCUSSION.
Dr. Cochran — I think the health authorities in various cit-
ies have put themselves to much useless trouble to instruct
the people by the leaflets and circulars they send around. In
Alabama we do not try to teach our people hygiene. We do
not send them leaflets about how to avoid diseases. We would
send them pamphlets about treatment of disease. We tell
them to send for a doctor, and when they want sanitary work
done to send for a sanitarian. We do not try to make every
man his own health officer. I have been struck with the
extremes to which these health officers go.
The Poctor related an instance of three cases appearing at
Stone's Bank, Ala. The physicians vaccinated the people,
and there was never another case, but the people at a town
fifty miles below went to the unnecessary trouble of (juaran-
tining against them, and invoking the aid of the service, after
the danger is over.
DUTY OF THE PHYSICIAN TO THE PUBLIC.
Read by Title in the Section on State Medicine', lit the Fortv- seventh
Annual Meeting of the American Medical Association, held at
Atlanta, Ga., May 5-8, 1896.
BY JAMES W. COKENOWER, M.D.
M VKKTARV IOWA STATK MEDICAL SOCIETY, AND PROFESSOR ORTHO-
PEDIC .SURGERY, COLLEGE PHYSICIANS AND SURGEONS,
DE8 MOINES, IOWA.
The tendency among modern medical writers has
been to present a subject pertaining to some special
branch of medical and surgical science and, especially,
to ride some "hobby" or pet theme, wholly ignoring
the more practical thoughts which come before us in
everyday life.
It is the purpose of this paper to point out briefly
some of these errors, and it will make no. pretense to
science, but endeavor to present such thoughts as
come under the writer's observation almost daily,
while engaged in a general practice. And, it seems to
me, they are of sufficient importance to invite the
attention of the entire medical fraternity. It is true
that science, and advanced theories of medicine and
surgery have done much, and no doubt will do more,
and are not to be disparaged, but they have in the
past, it seems to me, been prosecuted to the detriment
of the more common and practical things. I have
observed, daily, in the families, where I am called to
practice, the amount of good which the physician
might accomplish in teaching them how to live, how
to ventilate their homes, and such other hygienic meas-
ures as would advance their physical, as well as men-
tal and moral interests. And, not only this, but the
ravages of hereditary diseases, which are annually
apparently increasing in our land, seem to impera-
tively call for legislation with regard to the intermar-
riage of such people as are known to have such hered-
itary taints. However, since there are none, and since
it does not appear to be practical, that a law can be
made prohibiting the intermarriage of such persons,
it occurs to me to be the duty or the physician to
counsel and advise those who are under his observa-
tion of the dangers that lurk unseen within them, and,
thereby if possible, cut short and limit the number
of such cases.
Again, while there are laws prohibiting the physi-
cian from producing abortion, and which, I regret, is
not as fully carried out as it should be, yet, perhaps,
as nearly so as most of the laws not wholly a dead let-
ter on our statute books, the writer's observation has
been directed to another class of people aside from the
physicians, and that is the women themselves. These
counsel with no physician, or any one else, but do the
work themselves and, if everything passes off smoothly,
the physician is never consulted, but, in case they fear
trouble, the physician is invited in to assist and, thus,
bear the blame for whatever injury may have resulted.
And, so I might go on enumerating things wherein
the physician, in his greed for science, wholly ignores
the more practical things, thereby causing grief
460
HEALTH DEPAKTMENTS OF LARGE CITIES.
[August 29,
throughout our land. It seems to me if the physi-
cians would unite upon some means of extending their
influence in the proper directions with regard to these
facts, they could wield a great force, mold public
opinion, and so instruct their patrons, which means
the entire public, as to bring about a change that
would be effective in the end and would be, in fact,
more practical than any legislation upon the subject.
I have been endeavoring, in a quiet way, to mani-
fest my influence in this direction with those whom I
come in contact, and it is my opinion that a vast
amount of good can be done in this way. And, when-
ever physicians unite in this one cause, and cease to
ignore simple things, things apparently of not suffi-
cient value to give heed to: whenever they cease
to ride their hobbies, and look at such a thing
as the writer has endeavored to point out, then,
and not till then, will the time come when there will
be that change wrought upon the public that will im-
. prove and advance the physical condition of the com-
munity in which this influence may have been exerted,
and prove to the unsuspecting public that there is no
class of men who have more to do with the confidence,
and are better able to mold public opinion than the
physicians, when they work in harmony and manifest
their influence.
ON HEALTH DEPARTMENTS OF LARGE
. CITIES AND THEIR ORGANIZATION.
Read by title in the Section on State Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta. Ga.. May 5-8. 1896.
BY JOHN B. HAMILTON, M.D., LL.D.
CHICAGO.
SURGEON. FORMERLY SUPERVISING SURGEON-GENERAL O. S MARINE-
HOSPITAL service: membre honoraire socikik D'HYGIKNE,
PARIS. FRANCE: MEMBER AMERICAN Pl'BLIC HEALTH ASSO-
CIATION; CONSULTING HYGIENI3T CITV OF CHICAGO.
The progress of sanitary science, and the increase
of knowledge among sanitarians, is one thing; the put-
ting in practice of that information, is another. All
science is concerned with the former; the State, the
Government and the people, with the latter.
Our cities have grown so fast that the problems
which confront them of civic administration, have
not been dealt with as if they had come gradually on
a community prepared by long years of dwelling
together, to meet them; and so in our great cities we
find great advances in certain directions, and we find
ourselves very far behind the age in others.
Among the unsettled problems in large cities is
that of. the best means of securing a perfect sanitary
organization, and in the securing of that result, we
are more or less hampered by the laws which have
been enacted in the village before it became a town,
and the ordinances of the town before it became a
city, all of them more or less changed by acts of the
State Legislature in which the city is situated. It
therefore follows that in most cases, it is better to
create these sanitary organizations of our large cities
by legislative enactments rather than by municipal
ordinances, because in many cases the city charter
will be infringed upon or violated in some of its pro-
visions by the adoption of certain salutary regulations,
or prevent their adoption.
I recently had occasion to make a report to the
Mayor of the City of Chicago, providing for a sani-
tary organization which would meet the exigencies
of the existing law of that place, and at the same
time create a new department on a basis that would
provide for proper scientific work, in the interest as
well of promoting sanitary science generally as in
that of the health of the people of that city alone; in
other words, to draft a plan for the organization of a
model Health Department.
In drafting this organization, I was struck by the
fact that in this country there can be only two sys-
tems of sanitary administration, and these systems
are radically different; the one is an enlargement of
the old town meeting plan, whereby the select men
of a town meet at stated intervals and adopt regula-
tions in which there is no individual responsibility
either on the part of the select men themselves, or the
person who has to execute them. The other system
is the military one, in which every person is held
responsible, from the commanding officer down to the
private; each for the division of labor assigned to
him. When responsibility is thus fixed, we insure
better administration, because the results are always
apparent. A person responsible for a bad result can
be properly dealt with and removed from his position,
to enable his place to be supplied by some one judged
more competent.
In the city mentioned, the occupancy of a position
of health officer by a layman, without knowledge of
chemistry, engineering, sanitary science, or any part
of medical education, made it necessary to provide for
his retention in the act; although in my judgment,
such positions can not be filled with credit to the
incumbent, or with safety to the public, by any per-
son, however able he may be, until after some train-
ing in the fundamental branches of the education of
a health officer, and I feel obliged to say to the Section
that, in my opinion, whatever measure of success has
since been achieved by the health department named.
it has been done by reason of the advice of the Board
of Health, and the advice and experience of the trained
Assistant Commissioner of Health, our colleague, Dr.
Frank W. Reilly, who, during the present administra-
tion has guided the sanitary affairs of the department,
practically unhampered by his titular lay chief. I do
not doubt that any layman by close application to
study and honest attention to his duties, may in time
become thoroughly informed in hygienic matters, but
in such case the education is acquired at the expense
of the city, and without adequate compensation to the
public.
I herewith present to the Section a revised draft of
an ordinance, which in my judgment, is best adapted
to meet the requirements of a health department of a
large city:
AN ORDINANCE TO REORGANIZE THE DEPARTMENT OK HEALTH.
Be it ordained by the City Council of the ( ity of
There is hereby established in the municipal government of
the city of an executive department to be known as the
Department of Health.
Appointments — General Provision.
Section 1. No person shall be appointed to any office or posi-
tion in the said Department, until proper inquiry shall be made
by examination, or otherwise, into the ability and fitness of
such person to perform the duty that may be required of him,
should he be appointed.
Removals — General Provision.
Sec. 2. No officer or employe of this Department shall be
removed except for cause and no person shall be appointed,
promoted or removed for any political reason. Any officer or
employe may bo removed for crime, malfeasance, habitual
neglect of duty, willful misconduct, insubordination, dis-
obedience of orders, incompetence o» insanity, and for no
other cause.
Officers and Employes shall not accept Gifts or Bribes.
Sec. 3. Any officer, inspector or member of the Sanitary or
1896. J
HEALTH DEPARTMENTS OF LARGE CITIES.
461
Ambulance Corps who shall accept any gift of money or other
valuable thing for reporting or not reporting the existence of
any nuisance or case of contagious or infectious disease, shall
upon proof thereof be dismissed by the Sanitary Director, and
shall in addition be subject to such other penalty as the ordi-
nance may prescribe.
Enumeration of Officers and Employes.
I. The 1 >epartment of Health shall hereafter consist of
the following officers and employes to-wit: a Sanitary Direc-
tor : an Assistant Sanitary Director; a City Physician ; Chief
Clerk: a Sanitary Captain; a City Chemist: Medical Inspec-
a Sanitary Corps; Clerks and Interpreter.
Sanitary Director General Qualifications.
Sko. 5. The Sanitary Director shall be a physician of not
less than ten years' practice and shall be skilled in sanitary
Kience. He shall lie appointed by the Mayor, by and with
the advice and consent of the Council. He shall hold his
office until his successor shall have been appointed and
qualified.
Duties of' Sanitary Director.
t>. The Sanitary Director shall supervise all matters con-
nected with the sanitary interests of the city, and shall perform
such specific duties as may be de6ned in this ordinance, and
he shall have authority over all officers and employes in said
Department. Ami when at any time it shall become necessary
t.i establish sea. lake or land quarantine, he shall have com-
mand of such quarantine. He shall according tocircumstances
and season, issue such circulars of popular instruction as shall
lead to the preservation of the public health.
Assistant sanitary Director Qualifications.
7. The Assistant Sanitary Director shall be a physician
of not less than ten years' practice, and shall be skilled in san-
itarv science. He shall upon recommendation of the Sanitary
Director, lie appointed by the Mayor, by and with the advice
and consent of the Council, and shall hold the office until his
successor shall have been qualified and confirmed.
Duties.
He shall perform such duties as may be assigned him by the
Sanitary Director. In case of the sickness, disability or pro-
1. >ns,'ed absence of the Sanitary Director, he shall by direction
of the Mayor, act in the stead and perform the duties of the
Sanitary Director.
City Physician — Qualifications.
Si c 8. The City Physician shall be a physician of not less
than ten years' practice in the State of , of which not
less than the shall have been in the City of . He shall
be appointed by the Mayor, by and with the advice and con-
sent of the Council. He shall appoint a physician as City
Pathologist, who shall, under his direction, make such post-
mortem examinations of animals or men as may be required
by the Sanitary Director, to whom his report must be sent by
the said City Physician.
Duties.
He shall supervise the administration of the hospitals estab-
lished by the city, including hospitals for contagious diseases,
excepting quarantine hospitals. He shall prepare regulations
for the government of police surgeons, ambulance physicians,
resident physicians and superintendentsof the city hospitals and
the pathologist in the performance of their duties and shall have
immediate supervision of the city ambulance service, when estab-
lished. He shall attend or cause an assistant to attend the sick
in the city workhouse, calaboose, watchhouse, police stations or
houses of correction, and shall attend such meetings as may
be held by the Department of Health, and in case of epidemic,
he shall render such assistance and cooperation, and perform
such duties in connection therewith as the Sanitary Director
may require.
Chief Clerk.
Sec. 9. The Chief Clerk of the Health Department shall be
skilled in business affairs and statistics and shall be appointed
by the Mayor, by and with the advice and consent of the
Council.
Duties.
He shall have supervision over all clerks of the Department
except as hereinafter provided ; and shall have charge of all
accounts. He shall keep an accurate record of all receipts and
expenditures and shall be responsible for all fees received.
He shall keep the records of births, marriages and deaths, and
issue burial permits under regulations to be made by the San-
itary Director. He shall disburse all monies, pay all officers
and employes, make all purchases of supplies, and execute all
contracts and bonds, but he shall make no purchase of sanitary
or special appliances without the approval of the Sanitary
Director.
Sanitary Captain.
Skc. 10. The Sanitary Captain shall be a person accustomed
to superintendence of workmen, and qualified to keep records.
He shall be appointed by the Mayor on the recommendation
of the Sanitary Director, and shall have the rank and pay of a
Captain of Police.
Duties.
He shall be the custodian, and have charge of the storehouse
of the Department with all property belonging thereto, includ- '
ing horses, wagons, carts, ambulances, fumigating apparatus
and sanitary appliances of every kind belonging to the Depart-
ment, and shall make a semi-annual return thereof to the Chief
Clerk. The return shall show from whom the property was
purchased or received, to whom issued, and the present con-
dition thereof. No property of any kind shall be issued to any
person except upon requisition duly approved by the Sanitary
Director, Assistant Sanitary Director, City Physician or
Chemist as may be required. He shall have charge of the
Sanitary Corps, and under the department regulations, super-
vise the work.
Chemist — Qualifications.
Sec. 11. The Chemist shall be a graduate in medicine, skilled
in chemistry, pharmacy and bacteriology. He shall be appointed
by the Mayor on the recommendation of the Sanitary Director.
He shall have an assistant, who shall be City Bacteriologist,
and who shall be nominated by the Sanitary Director and
appointed by the Mayor.
Duties.
His duties shall be to have charge of the laboratory, and to
direct the conduct of such chemic and bacteriologic investiga-
tions as he may from time to time be instructed to make by the
Sanitary Director, to make test investigations of food products,
milk, water, ice, beverages and drugs, and to make report thereof
to the Sanitary Director.
Medical Inspectors.
Sec. 12. The Medical Inspectors shall be appointed by the
Mayor on the recommendation of the Sanitary Director, but
no person will be appointed Medical Inspector until after such
examination as shall satisfy the Sanitary Director that the
applicant is fully informed in the principles of sanitary science.
Qualifications.
Physicians holding the collegiate degree of Doctor in State
Medicine, or its equivalent, will not be required to pass such
examination.
Chief Inspector.
One of the said Medical Inspectors shall be specially skilled
in the diagnosis of the exanthematous and contagious diseases,
and shall be designated as Chief Medical Inspector.
Sec. 13. Medical inspectors, except the Chief Medical
Inspector, will perform such service as may be required of
them from time to time, and they shall be paid according to
the service actually performed, on a schedule of pay to be pre-
pared by the Sanitary Director and approved by the Mayor.
Sanitary Corps.
Sec. 14. The Sanitary Corps will consist of three divisions,
viz., first, those employed in the division of the City Physician
as litter bearers, ambulance drivers and hospital attendants ;
second, milk, meat, food and other inspectors employed in the
chemist's division; third, plumbing inspectors, fumigators,
and persons employed in the work of placarding infected prem-
ises, and disinfection of the same, acting under the Sanitary
Captain.
Uniform to be Worn.
Sec. 15. All members of the Sanitary Corps shall wear the
uniform of their grade, and shall receive such monthly com-
pensation as the Mayor may by order promulgate, as equitable
for the services respectively performed by each class.
Clerks and Interpreter.
Sec. 16. There shall be employed in the Department of
Health. clerks, who shall be appointed after due exam-
ination into their fitness for such position, and they shall be
assigned to such duty as the Sanitary Director may designate,
and the Sanitary Director is hereby authorized to employ one
person as stenographer and clerk to serve under his immediate
direction, and one person as interpreter and translator. No
person shall be employed as translator who can not read cor-
rectly and converse in five modern languages to be designated
by the Sanitary Director.
Repeal Provisions.
Sec. 17. So much of any and all previous ordinances as conflict
462
METHODS OF DRAINAGE.
[August 29,
with or in any way impair the operation of this ordinance are
hereby repealed, and all provisions of law and ordinances relating
to the Department of Health, the Commissioner of Health, the
City Physician, the inspection of food, milk, ice and drugs,
and miscellaneous ordinances relating to health, shall, so far
as they may be applicable, remain of full force and effect.
I will now take the bill up by sections for the pur-
pose of explanation. Sections 1, 2 and 3 are, in my
opinion, necessary to secure the perfect working of
the officers and employes of the department. Indeed
it will be found impossible to secure the appointment
of proper persons unless the tenure of office be made
more secure than has been the case under previous
ordinances. . Moreover, it is such as to bring the
department in line with the civil service laws of the
State and of the United States. I had charge of a
Bureau of the Treasury Department when the present
civil service law was enacted, and I am entirely
familiar with its operations. Some passages in this
ordinance will be recognized as quoted directly from
that law.
Sections 4, 5, 6 and 7 are self-explanatory, and
relate to the different classes of officers, and especially
to the qualifications and appointments of the Sanitary
Director and Assistant Sanitary Director.
Section 8, relating to the City Physician, after giv-
ing the qualifications, makes specific mention of his
duties.
Section 10, providing for a Sanitary Captain, is
self-explanatory. It must be obvious that some one
must be had to account for the property owned by
the Department, to have charge of the same, and to
superintend and to direct the outdoor work. This
section is not only calculated to protect the interests
of the city, but to prevent misuse or misapplication
of any property or appliance belonging to the
Department.
Sections 11 and 12 relate to the appointment of a
City Chemist and a Medical Inspector, which are
self-explanatory, except that definite qualifications
are provided for. The system of examination of
medical inspectors, as preliminary to appointment, as
proposed in this ordinance, should by all means be
adopted at the earliest possible moment, as the
appointment of persons through motives of friendship
or political association fails to secure that standard of
professional qualification that a great city should
always be able to command.
The adoption of an ordinance or law like this pro-
vides the skeleton organization; as will be seen, it
provides for indefinite expansion by increasing the
number of persons employed, when the necessity for
so doing may arise; it provides for extraordinary pow-
ers in case of epidemic; and more than all, a unity of
system is provided and responsibility fixed.
As all cities have an Engineer Department, City
Engineer or Department of Public Works, it is not
deemed necessary to provide specifically for that coop-
eration which may be always secured by the comity
necessarily existing between different departments of
the same administration. Should that fail the Mayor
as chief executive can always settle the matter by
special order.
The details of executive work, the regulations gov-
erning the special office and the Department, are by
this organic act left to be framed by the Sanitary
Director to suit the particular city. But in no case
need they conflict with the organic law, which, as will
be seen, is sufficiently broad to allow the framing of
all necessary regulations.
Note. — The essential features of this draft were commented
upon with approval by the distinguished editor of the Journal
d'Hygihie of\ , Paris, and a translation formally presented to
the Soctete' d Hygfene.
THE METHODS OF DRAINAGE NOW PRE-
VAILING IN SOME OF OUR EASTERN
SEABOARD MUNICIPALITIES, TEND-
ING TO THE PRODUCTION AND
DISSEMINATION OF DISEASE.
Rend in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, held at
Atlanta. Ua.. May 5-8. 1896.
BY AUGUSTUS P. CLARKE, A.M., M.D.
CAMBRIDGE. MASS.
Crudely constructed latrines and cesspools, without
connections with regularly laid drains, were the
devices which often obtained among the early inhab-
itants of the country; they were places for receiving
the waste water and the dejecta of occupants of
houses and other buildings, and were for the most-
part recommended merely for the convenience they
afforded. The method which these contrivances fur-
nished for disposing of refuse liquids and excrementi-
tious elements worked no serious manifest injury unless
some of the more deleterious products had gained, by
percolating through the surrounding soil, admission
into a well or other source of water to be used for
domestic purposes. Among the more dangerous
products of this class have been those derived from
the albuminoids and the nitrates, and from carriers of
some of the forms of bacteria that were capable of
giving rise to diseases that have been regarded as of
a zymotic character. The development of morbid
conditions from such sources in sparsely inhabited
districts has not been of common occurrence, from
the fact that the free ventilation which takes place
through the open vaults, and also the diluting action
of water from the frequent storms, have had a coun-
teracting effect upon the potency of the bacterial
agents, and have thus rendered immunity to persons
not particularly susceptible to influences of such dis-
ease factors.
As these places became more densely populated,
there were also built, in connection with the recep-
tacles, different forms of drains, into which the fluid
and the less solid portions of the waste matter were
discharged. Beyond this measure of dealing no very
definite plan at first for the disposing of sewage was
maintained, and so the contents of the drain were
disembogued into a stream or water-course that per-
chance could be found in the vicinity. When the
discharge was made into rivers whose courses had a
steep and rapid descent, very little seemingly ill
effects were experienced by those who dwelt above
the point of the inlet. Those who dwelt along the
river banks or in the valleys below were not always so
fortunate, especially when they found it necessary to
take from the river in that vicinity their water supply.
Water of large streams, if charged with deleterious
products, will not after flowing several miles become
wholly innocuous and be safe for drinking purposes.
The tenacity of life possessed by certain bacterial ele-
ments will not be overcome by such an inadequate
exposure. In this connection it is but just to remark
that it is not so much the negative testimony of the
chemist and the microscopist that insures safety in
the choice of the drinking water, as it is that there
exist no possible sources of contamination.
1896.]
METHODS OF DKAINAGE.
463
Many of our larger cities have already inaugurated
measures for taking water where the unhealthful
influences have been reduced to the minimum. Unfor-
tunately, however, this freedom from contamination
duos not prevail in the majority of municipalities.
Among the more prominent objectionable features of
the present methods of drainage for municipalities is
that of discharging large quantities of refuse matter
into sewers which are connected, either directly or
indirectly, with rivers that receive tide- water. The
people dwelling in the less densely populated portions
of a city or town where a good-sized sewer has its
outlet into the river through a gate that opens and
closes with the ebb and flow of the tide may not,
perhaps, sutler to any great extent in availing them-
selves of the use of such a drain. A long open drain,
however, connecting at one end with residences and
at the other with tide gates to allow its vile contents
to be discharged so as to be exposed to the rays of a
summer's sun. and to have its evaporations wafted
hack through the long conduit by the counter-currents
of air set up, and drawn back to the homes of the
occupants, presents features that are far from being
conducive to health.
A still more dangerous factor results even after the
closure of the gates from the oncoming tide, by the
rapid rilling up of the sewer from the numberless
drain pipes that are directly connected with the gov-
ernment drain; this arrangement tends to displace the
air laden with poison or pathogenic organisms, and
force it hack toward the house connections with the
sewer. When the pressure that produces this reflux is
moderate, the effect may be overcome by the water in
the closet traps, hut during the time when there is much
storm water to be carried off the pressure becomes
inordinate, and thus forces not only the mephitic air,
but causes a reflux of the filthy water; this may pass
through the traps that are lower down, and in some
instances also through those placed as high as the
street level. This has been particularly noticed when
great storms have been raging. The numerous con-
ductors extending from the many high buildings in
the neighborhood to these sewers tend to force, in
accordance with a well-known law in physics, the
water up through the house drains above the normal
level, and thus to flood the basements and cellars with
water and sewage that have been collecting in the
drain during the storms and while the tide gates were
closed.
This unhealthful condition of things has gradually
increased since the custom of building large apart-
ment houses and of other high structures has obtained.
To show the inadequacy of the sewers or the drain
traps employed for preventing the reflux when the
sewer is being filled by the accumulation of storm
water flowing from the conductors of high buildings
and from the street catch basins during the closure of
a tide gate, a drain pipe connected with a sewer lead-
ing to a house whose basement had been flooded by
a regurgitation of storm water through the bowls,
on being opened to determine its condition, a jet of
water like a geyser spouted up several feet into the
air, and continued thus to flow until the drains had
been relieved of their excessive pressure.
The objectionable features arising from such a
defective method of drainage have been sought to be
overcome by the construction, at an enormous
expense, of what has been designated as the " metro-
politan sewer," for the accommodation of the inhab-
itants of Boston and of other municipalities within
a certain radius. The benefits to be derived by the
laying of this drain are not altogether what was gen-
erally anticipated, for the reason that the sewer is not
of sufficient capacity for receiving and carrying off in
a proper manner the storm water, in addition to the
sewage it has to take in. The sewer has been built
out some distance into Boston harbor, where the con-
tents are discharged by means of large pumps into
the deep water, that they may be borne out with the
tide into the sea.
The object of the expedients adopted or suggested
by the engineers of the cities that have been inter-
ested in the construction of the work, is that the storm
water entering the great sewer may by an automatic
device escape into the local sewers, and so pass into
the Charles River or other water-courses with which
they may be connected. It requires but little reflec-
tion for any one to comprehend the fact that more or
less actual sewage will still be carried along with the
storm waters into the river, and that the cessation of
contamination of our natural water-courses by the
carrying into them of drainage material will only be
accomplished theoretically and not in real practice.
Again, the storm water can be discharged by the
devices above mentioned from the local sewers into
the rivers only at ebb tide and while the gates are
open. At other times the entering waters coming
from the heavy rains will not all pass on, and when
the sewers become overcharged will take a backward
flow into the estates embraced within the lower sec-
tions of the district, as has so often occurred by the
operation of the old system of drainage, with this
difference, perhaps, that the new method, as the sec-
tions become more crowded, will nevertheless give
rise to a greater reflux of the sewer contents.
It should be stated that some twenty years ago or
more, statutes by the State government were passed,
requiring certain lands below thirteen feet above mean
low water mark to be raised to grade. The difficulties
that are now being experienced are not, however, con-
fined to such districts that have been filled, but are
met with to some extent in places that are of a
higher grade. It is too bad that after the enormous
outlay of money that has been made by the inhabi-
tants, and the annoyances and vexations experienced,
beside the expenditure for the construction of sewers,
so little of real permanent value has been achieved.
This result is not dissimilar to the experiences of
other State governments when they have attempted
to accomplish any great, new and lasting benefit.
In order to overcome the unhealthful features inci-
dent to the working of the present system of drainage,
special sewers for carrying off the storm water should
be laid. Into these should pass all the water from
roofs, gutters or conductors upon buildings, and the
storm water of the streets after it has been well fil-
tered through catch basins to deprive it of its more
solid portions. These water conduits should be laid
so deep that the water in the cellar and foundation
wall trenches for some inches below the deepest por-
tion of a cellar bottom may readily flow into them, to
be carried off to the rivers or other depths of natural
water channels.
In cases of tidal rivers there should be for the most
part no tide gates; deep basins should be constructed
for receiving such waters, that, after being filtered,
could be discharged, by means of a pumping station,
into the river. For times of great drought these
464
A DEPARTMENT OR BUREAU OF HEALTH: WHICH?
[August 29,
waters could be stored in receiving basins and could
be used for the extinguishing of fires and for other
purposes in cases of emergency.
The State Board of Health has already recom-
mended that some independent system of sewerage
should be employed for the disposition of storm
waters. For one particular part of our city our mayor
has given some encouragement that he would mani-
fest his official influence for the construction of a
sewer for the greater relief of water coming during
the heavy storms. No definite experiments as yet
have been instituted for determining the feasibility of
carrying out the plan here proposed, but it is evident
that something more radical than what has heretofore
been attempted will have to be undertaken for the
insuring of permanent relief and healthfulness in our
municipalities.
Until there are adopted plans for drainage founded
on more scientific principles than those still prevail-
ing, we can not expect to achieve any great results in
diminishing the occurrence of many forms of disease.
We may raise the standard of our medical colleges
and our universities, may improve our methods in
pharmacy, extend the list of articles and remedial
agents in our materia medica, and develop to the high-
est degree our surgical technique, but these promising
helps will still be found capable of relieving only a
mere moiety of the sum total of the suffering from
disease, so long as occupants of dwellings continue
to be exposed to the increasing dangers of over-
crowding that is everywhere now taking place.
A DEPARTMENT OF HEALTH, OR A
BUREAU: WHICH?
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association at
Atlanta, Georgia, May 5-8, 1896.
BY S. S. HERRICK, M.D.
SAN FRANCISCO.
It is assumed that the American Medical Associa-
tion substantially agree that the time has come for
some permanent branch of our national government
to promote and administer the interests of public
health. There is, however, a variety of plans of
organization, each of which has its merits and defects,
the most prominent of which may be designated a
board of health, a department, a bureau, and the con-
tinuance of the present method as administered by the
Marine-Hospital Service.
The plan of a board of health has been tried, with
such want of success that, in my opinion, it would
be unwise to experiment again. It is needless now to
consider where the fault chiefly lay, and there are
too many yet living and active, who participated in
the controversy, safely to risk the danger of its
revival. The plan most favored by the American
Medical Association has been to create a depart-
ment of public health, presided over by a secretary
holding a seat in the President's Cabinet. Its con-
spicuous aim is to magnify the importance of public
health and extract a large appropriation from the
treasury. Without detracting from the value of health
as one of the enjoyments of life, we must not overlook
the fact that other great interests are clamoring for
recognition and an appropriation. The agricultur-
ists, who now number approximately 9,000,000 of our
population, have recently secured a separate depart-
ment. It may be expected that those engaged in
manufacturing and mining (about 5,000,000) will
soon demahd like consideration, and that they will be
followed in due time by the trade and transportation
interest (numbering about 2,500,000). The two
latter are already anticijmted by the sanitary interest,
which may be represented by about 100,000. Roughly
speaking, this number is now classed in the medical
ranks (regular, irregular and defective), and I think
it would be fair to deduct, as not being interested in
sanitation, quite as many as should be added to those
so interested from the laity. Teachers and scientists
(representing the educational interest) now number
approximately 300,000, or three times as many as the
sanitarians. In 1867, the Bureau of Education was
created by act of Congress, and it has done excellent
work ever since. So far as I have learned, both the
public and educators are satisfied with their modest
organization, though, doubtless, they would like more
money.
In 1885 the present writer, recognizing the excel-
lent work done by the Bureau of Education, being
deeply impressed with the need of a national sanitary
service and at the same time warned by the troubles
which had befallen the National Board of Health,
formulated a plan for a bureau of health, which was
approved by the American Public Health Associa-
tion. Under its auspices a bill for this purpose was
framed and introduced in Congress. It would serve
no useful purpose here to dwell upon the reasons of
its failure. In substance the proposed functions of
the bureau were the following:
1. To gather information upon the state of the
public health and the existence of contagious disease
in foreign countries through the consulates of the
United States government; to digest and communi-
cate the same to all government posts and health
authorities of our country ; through medical officers
attached to the consulates, when requested by the mas-
ters of vessels destined for ports of the United States,
to inspect the vessels, cargoes, crews and passengers
(including their personal effects), to use measures for
cleansing and disinfection, and to vaccinate those
requiring vaccination (all at the expense of the ves-
sel), to furnish bills of health relative to the port of
departure and full dealing with the vessel, or to notify
the bureau by telegraph of neglect or refusal to accept
such service.
2. To serve as a medium of intelligence in sanitary
matters, including vital statistics, between health
authorities throughout the United States, by means
of a weekly publication, which would contain also
foreign intelligence.
3. To inspect the various quarantine stations of the
United States from time to time; to investigate out-
breaks of pestilential disease in any part of the Union ;
to report such inspections and investigations; to recom-
mend to local health authorities needed preventive
and suppressive measures.
4. To conduct chemic, physiologic and pathologic
investigations in the interest of sanitation.
5. To publish and distribute documents relative to
public health.
It was contemplated to authorize the bureau to
require the detail of suitable medical officers from the
Army, Navy and Marine-Hospital Service for carry-
ing out its functions at home and abroad. This
would be a measure of economy and also a safeguard
against political intermeddling. At that time it was
not thought wise to give the bureau powers in quar-
antine matters, but it is now probable that there
1896.]
A DEPAKTMENT OF PUBLIC HEALTH.
4G5
would be little or no opposition to some exercise of
authority, when needed, in international or inter-
state quarantine. 1 am satisfied that a bureau organ-
ized on some such plan would fully meet all require-
ments of sanitation and could he enlarged so as to
keep pace with the growth of the country quite as well
as the Bureau of Education. Those who believe that
the right way to gain the earth is to go for the whole
solar system, may naturally suppose that the best way
to obtain from Congress a bureau is to ask for a depart-
ment. This is a matter of opinion, which I forbear
to discuss. There is. however, a choice between a
department and a bureau which, to my mind, vitally
oonoerns the utility of the service. The secretary of
public health would he a political officer, appointed
for four years, and his subordinates would also belong
to the same party. The one important qualification
for office would he partisan services rendered during
the preceding campaign. Those who are conversant
with the customary methods of securing positions in
State and municipal sanitary service in our country
need no explanation of what might be expected.
Now. the question is: Does the American Medical
ASSOCIATION, claiming to represent the most numer-
ous body of scientific men in our country, stand ready
to commit the interests of preventive medicine to that
class of adventurers who have control, for the time
being, of the national political machine? If such be
its deliberate choice, then I beg to recall jEsop's
fable of the frogs who asked Jupiter for a king. At
first he gave them a log (likened to a national board
of health ). which they sat upon in scorn, until it sunk
out of sight; then they asked for another, and he sent
them a stork (likened to a cabinet officer), which
devoured them without mercy.
On the other hand, if the choice be some plan
which will put our health interests out of politics, then
I advise a bureau of health modeled after the Bureau
of Education, in which a commissioner may hold
office under successive administrations. Let his
subordinates be drawn, as far as practicable, from the
three national bodies of medical offices, detailed for
the special qualifications which they have shown by
their works. Already the Surgeon-General of the
Army has organized a school, in which medical officers
receive special instruction in hygiene, and the Navy
and .Marine-Hospital Services will not long delay in
following the example. Perhaps in time State and
municipal boards of health may be authorized and
feel disposed to ask the detail of officers from these
corps to serve as experts in sanitary work, and thus
the whole country may see their health interests
emancipated from politics.
The last proposition, that of leaving national sanita-
tion with the Marine-Hospital Service, seems not to
meet the wishes of the medical profession at large,
though, to my knowledge, the reason has not been
openly declared. The most obvious explanation is,
that this plan does not satisfy the aspirations of an
army of patriots anxious to serve their country. If
we must choose between a department of health and
the present system, in my judgment, the change would
involve great additional expense with a strong proba-
bility of poorer service. On the whole, I find no valid
■ n to change the views held on this subject
since 1885.
Let us have a Department of Public Health!
ARGUMENTS FAVORING A DEPARTMENT
OF PUBLIC HEALTH.
Read in the 8ection ou State Medicine, at the Forty-seventh
Annual MeetinR of the American Medical Association,
held at Atlanta, Ga., May 5-8, 1896.
BY LISTON H. MONTGOMERY, M.D.
' CHICAGO, ILL.
Some of you perhaps may have views and ideas that
are not entirely in accord with those of the writer. It
is natural to suppose that some of us have hobbies or
fads in medicine in general, the science of hygiene, or
upon some branch of scientic study or research.
Emerson said, " Science surpasses the old miracles
of mythology." It is with pardonable pride therefore
that I offer this contribution and venture to briefly
discuss this important subject, which as it appears to
me, is one of the most pressing need* of legislation
thai confront* us and which our government can
bestow and by so doing promote the welfare of the
people of the United States.
It is a well known fact that by the acts of our Na-
tional legislators during the past few years hundreds
of thousands of dollars have been appropriated and
expended for agricultural pursuits including that of
saving the cattle and other stock products that belong
especially and distinctively to the farming interests of
our country, and which we as sanitarians most heartily
commend. But have you considered the proposition
that during the professional career of thousands of
members in our profession, not one dime has been
appropriated for public health matters, to save or pro-
long the lives of human beings, and while our Marine
Hospital Service has its duties to perform, it is never-
theless very circumscribed in character, and can ren-
der very little public service to the people inland,
when cholera for instance, or any other disease from a
foreign country invades our shores, as was the case
when this dreaded malady threatened New York city
during the summer of 1892 and the year following.
The disease was stamped out, or more properly speak-
ing, what was supposed to be cholera was prevented
from making inroads to the interior by the State's
laws.
But we are reminded that New York State, and the
City of New York has facilities for caring for an epi-
demic which very few other States possess.
That the United States is constantly exposed to the
importation of disease from foreign countries, and
subject because of the facility and rapidity of inter-
state transit to the rapid spread of infection and deadly
germ infection of almost any city or town, is to the
writer's mind something that ought not longer be
tolerated by the patient people of this country.
While Philadelphia, Baltimore, Boston. New
Orleans, Portland, San Francisco and our sister city
Quebec, may be sufficiently provided for in this respect,
there are numerous other cities on the Atlantic, Gulf,
and Pacific sea boards that are not as fortunate nor
properly protected and equipped to bar out disease
that has been imported should it gain a foothold.
I think this is particularly the case with our South-
ern sea board cities. That they are not sufficiently
prepared to combat the ravages of pestilential diseases
that may invade them from some foreign country is a
well-known fact to the practical sanitarian everywhere.
This fact, lamentable as it is, has, to say the least, one
specific cause, the absence of a department of public
health. On the other hand we are well aware that
the efficient health officer of the city of Charleston,
466
A DEPARTMENT OF PUBLIC HEALTH.
[August 29,
S. C, and of other cities along the southeast Atlantic
and Gulf coasts are as alert and equally efficient as
health officials can be, but oftentimes they are ham-
pered in doing thorough painstaking work toward
suppressing a threatened endemic or epidemic.
Wliat has our government done for the medical pro-
fession? Congress should do all in its power to advance
the scientific interests of the medical profession and
promote the welfare of the people of this country. Has
this been done? Governmental aid in this respect is
not lacking in several other countries with which we
are in daily commercial intercourse. I believe the
time has fully matured, and the importance to the
public welfare in the matter of sanitation and health
laws has arrived for our people to require, yea de-
mand, that we are entitled to another branch of the
Federal Government and portfolio to be known as the
Department of Public Health with a medical secretary
at its head, to be on the same plane or parity or dig-
nity as is accorded to the other departments in the
general administration of public affairs.
The consensus of opinion in this respect is wide-
spread as will be noted by the following illustrations.
This subject, to quote as near as I can recall them the
words of the late Prof. C. G. Comegys, " Is not for the
promotion, welfare, or aggrandizement of the medical
profession," but for the welfare of the people of a
united country, the fairest the sun has ever shown
upon, and to quote further from our late associate and
worthy teacher, " Who is there that is more capable
of judging of the welfare of our people, scientifically
speaking, and I will add socially and morally than we
who comprise the membership of this noble Associa-
tion, representing as it does the hundred and twenty
odd thousand physicians in the United States?
Why need our government wait for a threatened
invasion or approach from Europe or other foreign
land of some specific form of deadly germ or disease
infection?
Why wait for the advent of smallpox from Mexico,
or yellow fever from the Spanish colony or States of
South America, or the arrival on our border of some
poor indigent immigrant sick nigh unto death with
some form of pestilential disease, or until the germs of
an infectious or contagious character have already
made their appearance?
But some wiseacre (not a member of our profession)
will say : Oh well, these cases will be quarantined or
the maritime quarantine system will take care of them,
etc. Scarcely two weeks ago the utter failure of this
method was demonstrated at the city of Baltimore,
Md., when there arrived several hundred immigrants
at that port who had been exposed to smallpox or
varioloid on board the steamship that brought them.
The poor sick immigrant was detained, but the balance
were allowed to pass through and take up their abode
at their place of destination, many of them within
three days arriving at Chicago, 111.
While the maritime quarantine service does very
well indeed and is a most useful system so far as it
goes, yet it has no control in the inland and its power
of authority is limited. Its system does not include
all the ways and means of carrying into effect efficient
prophylactic measures on a thoroughly scientific basis
as should be done by scientific preventive medicine
and thorough bacteriologic investigation beyond the
few cities enumerated above. This system has no
authority to carry out the enforcement where neces-
sary of sanitary regulations tending to prevent or
abate the spread of epidemic or pestilential diseases
beyond the\seaport places it has found lodgment and
where it may be equipped for this purpose.
At the Pan American Medical Congress, the first
congress of this kind ever held in the United States,
which convened in the city of Washington, D. C, ir
September 1893 under the auspices of our Government,
this subject was critically and thoroughly discussed in
all its phases, heartily concurred in, and reported ir
favor of such a Department, with a cabinet minister
at its head.
The Chicago Medical Society having a membershij
now of upward of 750 members as early as the summer
of 1884 at the instance of the writer had a committee
appointed consisting of seven of the most able, sanita-
rians of that city, including the Commissioner of
Health to devise and formulate a plan to urge the
importance of National legislation upon this subject.
The committee submitted its report in September
following and it was unanimously adopted.
The American Public Health Association at several
of its annual meetings has heartily and unanimously
concurred in this measure, and has appointed its spe-
cial committee to confer with a similar committee of
this Association to devise the best ways and means
toward establishing this sine qua non, and much is
hoped for in this direction from this influential
body at its coming meeting at Buffalo, N. Y., next
September.
Various State, county, and municipal medical socie-
ties in a numbr of portions of the Union have within
the past two or three years unanimously approved and
adopted resolutions to this effect, and have heart Un-
approved the bill now before Congress prepared by
the special committee of this Association, to estab-
lish a department of public health.
STATE RIGHTS AND INTERFERENCE WITH STATE LAWS.
The possibility of interference with inter-state
authority I think is a subject too mythical indeed to
require discussion.
Section 2 of our bill provides for the cooperation of
State and municipal health authorities, hence no
obstacle can supervene in the matter of inter-state or
municipal boards of health and all will be of the most
harmonious advisory nature and unanimity in charac-
ter, with the one main object in view, the advancement
and improvement in the welfare of the American peo-
ple, the prolongation of human life, the physical
and mental development of our citizens, and I might
go farther by saying, the evolution of the human race
by the diffusion and promulgation of scientific facts
and treatises compiled from the best literature pre-
pared by the most thorough scientific painstaking san-
itarians of our country, thus promoting the physical
health of our people and a correspondingly cultured
intellectuality.
The following questions hove doubtless been pro-
posed to some qf you already : Is there a degenera-
tive tendency in our advancing civilization, in these
days of the new woman, hypnotism, bicycles, church
affairs, etc., or is there a tendency for the rich of our
Nation attaining a premature old age? Is insomnia,
hypochondria, hysteria, dipsomania, suicide, insanity
and cognate diseases including diseases of a tubercu-
lar nature on the increase?
I would answer in a general way. In certain geo-
logic sections of our Union and among a certain
class, most certainly this is true. We may ask our-
1896.]
A DEPARTMENT OF PUBLIC HEALTH.
4(57
solves i lion, what is the cause of this vital or mental
change?
The miscellaneous statistics on these and kindred
subjects to which 1 have had access, imperfectly as
they are collated, unmistakably prove this.
It' the government could see its way to rise to the
dignity of having a department of public health and a
medical secretary a man of well known scientific
attainments, as other nations have, statistics on this
jHiint could be made more reliable and valuable sci-
entific accurate investigation could be carried on in a
methodic manner from tlie center or fountain head.
In these days of specialism, the surgeon and the
specialist receive for their professional services a fee
which to my mind is greater and out of all proportion
compared to that which the sanitarian or general
practicing physician usually receives, or which he is
justly entitled to.
While many of the ailments suffered by man are due
to germs, morbid or toxic products or agents entering
the system whether from food in any form, drinking
water of polluted wells, rivers, lakes, etc., or germs of
contagious nature, that enter the human economy
through a wound, whether there be syphilitic, puerp-
eral, tubercular, or sepsis due to other causes. The
sanitarians of the medical profession in renewing their
endeavors toward bringing about what this paper has
(or its object again manifest their unselfishness in
exerting their influence in the matter of a department
of public health.
What we do ask after this proposed branch of our
government has been established, is that it shall have
equal dignity and rank with other branches of the
government, and the secretary be a member of the
Cabinet. In order to carry out our undertaking to a
successful conclusion we must do so intelligently.
We must be public spirited and with earnest zeal
enlist with renewed effort the united profession of
our country.
The reports of the special committee appointed by
the Association in 1891 has submitted its report
annually since, viz., at Detroit in 1892, Milwaukee in
ls<.i:i. San Francisco in 1894, one year ago at Balti-
more. Each year its deliberations have been unani-
mously approved and adopted, all of which is very
gratifying to the committee and tends to show that
the committee is not, nor at any time has it been
remiss in the performance of its duties.
But our Association7 and our profession must do
something more than adopt resolutions, all of which
are good enough in their way. We must encourage
the profession everywhere, and by concerted action
urge upon Congress the necessity of this measure.
That the matter has been successfully carried on thus
far I think no one will deny. But the profession
must not become apathetic. If our Eastern con-
freres should hold different views, let us persuade
them to unite with us, for, I am convinced after care-
ful observation and study, that practically the entire
western, middle and southern members of our profes-
sion are a unit and endorse the bill now before Con-
gress which was prepared by the committee of the
American Medical Association having this matter
in charge.
With this strong force united, and our eastern pro-
fessional friends with us, with renewed efforts on our
part and the combined support of the medical jour-
nals and newspapers, shall we not be able to convince
our friends in both branches of Congress of the neces-
sity of this urgent and needed legislation, for cer-
tainly our opinions on this topic are equally as valu-
able to public welfare, hygeia, and health as are those
who have views upon finance, the tariff, the judiciary,
theologio and ecclesiastic affairs, etc. The profession
is too modest to claim more than this.
In reviewing the Constitution of our country, sub-
mitted Sept. 17, 1787, and which went into effect in
1788, 1 find in the first or opening sentence the follow-
ing lines :
"We, the people of the United States, in order to
form a more perfect Union, establish justice, insure
domestic tranquillity, provide for the common defense,
promote the general welfare and secure the blessings
of liberty to ourselves and our posterity, do ordain
and establish this constitution for the United States
of America," etc.
Mark the words in the above clause — "establish
justice," "promote the general welfare," "secure the
blessings of liberty to ourselves and our posterity."
Is not this a sufficiently meritorious reason as pro-
vided in our Constitution to secure that which will
prove to be a blessing to ourselves and posterity?
And if so, are we not several years behind the times
in the matter of this proposed department?
Is not the well known and oft-quoted maxim which
I will paraphrase, "Solus populi suprema est lex." a
sufficient reason? Is it not sufficient to know that,
for instance, where an epidemic of smallpox prevails,
accurate information can not be obtained by neigh-
boring States or municipal boards of health from the
medical officer in charge, or commissioner of health
regarding said epidemic by his refusal to promulgate
information desired when requested to do so?
All the foregoing illustrations are facts and matters
of history, and not hypothetical queries, specific
instances of which can be furnished if needed. All
of which prove that Congress is in duty bound to pro-
vide this additional department.
IT SHOULD BE AN IDEAL DEPARTMENT.
To have this proposed department an ideal and
efficient one, it should be under the direct and per-
sonal supervision of the medical secretary, who should
not only be a graduate of a medical school, and a man
of letters, but a thorough sanitarian in all that this
word implies, as well as possess an acquaintance with
the requirements and heeds of our own beloved
country as well as those of foreign lands.
Genuine civil service reform should prevail in said
department. The obliteration of the spoils system
will mean a higher order of men. A spirit of entente
cordiale will exist between all branches and schools of
medicine and an esprit dti corps will prevail also
between the department, its secretary, and State and
municipal boards of health everywhere.
This department should have control over the poor
and unfortunate immigrants that land upon our
shores. An instance which came under my observa-
tion recently may aptly serve as an illustration.
During the first and second weeks in April about
17,000 Italian immigrants arrived in New York. On
April 17 five of these unhappy and unfortunate peo-
ple were arrested by the police of Chicago and placed,
in the police station, charged with vagrancy and begi
ging on the streets. These poor unfortunate aliens
had left their native country scarcely four weeks pre-
viously. This is but a single instance out of scorea
of analogous cases that came under my personal
468
STATE MEDICINE IN PENNSYLVANIA.
[August 2'.),
observation during the past winter and spring months
as an attache of the Chicago Health Department. So
that well may we ask what kind of citizens are we
importing now? I am thoroughly convinced that a
certain class of the illiterate and poorer classes of
immigrants should be prohibited from landing on our
shores — only to become a burden to us instead of a
benefit to our nation.
NATIONAL VACCINE FARM, BACTEEIOLOGIC
LABORATORY, ETC.
Regarding this, and what might be regarded as kin-
dred subdivisions of my topic, in the projection of
sanitary improvements, etc., I will not attempt to
discuss nor more than mention that they should be
under the scientific observation of this department.
In concluding this imperfectly prepared paper, per-
mit me to request of you to urge upon your repre-
sentatives in Congress, your governors and others, in
justice to the welfare of the people, in the name of
science and humanity, the necessities and needs of
our claim: That the medical profession and State
medicine is broad and philanthropic and has made
great strides and progress within recent years; that
our medical representative or secretary will be a man
of culture and intellect and bon camaraderie, thus
assuring the profession and the world that our claim
was not of the ignis falints kind; that at some future
time the United States will have an ideal department
of health with influence that shall be unsurpassed,
will be our reward, for which posterity will bless us is
my firm and sincere belief.
STATE MEDICINE IN PENNSYLVANIA AND
HOW WE MAY INCREASE ITS
EFFICIENCY.
Read iu the Section on State Medicine, at the Forty-seventh Annual
Meeting of the Americau Medical Association held at
Atlanta. Ga., May 5-8, 1890.
BY EUGENE O. BARDWELL, A.M., M.D.
Health Officer of Emporium, Pa.. County Medical Inspector to the State
Board of Health of Pennsylvania, Fellow of the American
Academy of Medicine', Vice-President of the West
Branch Medical Association, etc.
emporium, pa. t
The State Board of Health and Vital Statistics of
Pennsylvania was organized in June, 1885, so that its
existence covers a period of a little less than eleven
years. The appropriation made for it on its natal day
called for $5,000 per year, and the appropriation made
ten years later was for $6,000 per year, so you may
easily judge that there has been no great development
of cerebral matter in the legislature of our good
Keystone State during the past ten years. Out of
this enormous sum $2,000 is paid to the secretary
and executive officer of the board. I understand that
the clerk of the board receives $1,500 per year, and
this leaves the munificent sum of $2,500, which accord-
ing to the terms of the act is to be expended, or so
much of it as may be necessary, for postage, tele-
grams, express charges, rent, incidental office ex-
penses, traveling and other necessary expenses of the
members and secretary of the board, and for sanitary
inspections, analyses and protection of water supplies,
and for scientific investigations. Think of it, $2,500!
Sanitary inspections, protection of water supplies,
analyses, scientific investigations; and be sure to
return an unexpended balance!
Pennsylvania in point of population is the second
State in the Union. One of the oldest States. The
Keystone? \ Notwithstanding the parsimoniousness of
our legislature in regard to appropriations for the
protection orthe public health, I am happy to be able
to say that we have, as far as they go, as good legis-
lative enactments for the control of contagious and in-
fectious diseasesand the regulation of health boards and
all matters pertaining to the public health as could well
be devised. In that respect nearly every session since
1885 has seen some improvement, chiefly through the
efforts of one man, Benjamin Lee, M.D., to whose
able and untiring work as secretary and executive
officer of the State Board of Health, we primarily owe
all our laws for the intelligent supervision and pro-
tection of the public health. To Dr. Benjamin Lee
the State of Pennsylvania owes a debt she can never
repay. But the people do not appear to appreciate
the fact that to this one man all credit is due that the
great State of Pennsylvania has, in sanitary matters,
emerged from a condition akin to barbarism. Eter-
nal vigilance, however, is necessary to prevent the
repeal of our health laws. At every session of our
legislature some learned member from Squeedunck,
Daguscahonda or elsewhere will arise in his place
with the air of a Solon, pull the fringe of whisker
under his chin meditatively, and present a bill which,
if passed, would destroy the result of the labor of
years; labor, too, which has been done gratuitously
without hope of reward, except such as comes t hr< lUgh
a man's inner consciousness of duty done. We have
a large number of boards of health in small towns or
boroughs, and the effectiveness of these boards is
slowly increasing each year. The public is very
slowly awakening to a knowledge of the utility of
health boards and their work, but we are still wofully
behind the times in many portions of the State.
We have no boards of health in townships, although
there is a total of 1,511 townships in the State. Now,
such a state of affairs is a great drawback, and renders
nugatory, to a certain extent, much of the effort put
forth in towns and boroughs. In order to secure
the best results every township should have its board
of health and health officers; but our sapient legis-
lature, having several times refused to legalize such
boards, our State Board has, as a make-shift, ap-
pointed deputy inspectors who receive no pay, except
when ordered by the State Board to investigate nui-
sances. One such inspector is appointed in each
county, and when we consider the fact that many
counties contain thirty, forty or more townships, it
is easy to comprehend that such officer, serving with-
out compensation, will not be able to exercise a very
close or valuable supervision over sanitary affairs,
the more so as the people are likely to look upon him
as an outsider and give him no aid whatever. The
cause of the apathy of the people in the matter is not
general ignorance; it is ignorance on this one subject.
The public control of matters pertaining to the health
of communities is an idea comparatively new, and
when it runs against that fetich of the American peo-
ple, "personal liberty,^ it experiences a severe shock.
Now how can we give an impetus to the dissemination
of knowledge of this subject? To my mind the
answer is easy and the result certain. Compel the
State to pay for the service. It is entirely too much
to ask men to serve on health boards for love of the
people who abuse them. It has been my experience
in the practice of medicine, that the people who pay
promptly are my best friends in other ways. Nine
times out of ten when a physician is stabbed in the
1896. i
STATE MEDICINE IN PENNSYLVANIA.
469
hack it is ilono by sumo one to whom the physician
has rendered services, either without fee or at a
reduced rate.
Physicians who are supposed to act as health
officers in most places, are surely the last people who
should be expected to serve the State without foe.
Physicians who give to individual members of the
Stale from one-fourth to one-half of their total lal)or
should not be expected to do more than that much
for the public. In this State health officers receive
all the way from nothing, in many cases, to $100 per
month, in very few instances, in towns of the same
size: and where the salary is largest, there is the officer
most appreciated and there is the intelligence of the
people in sanitary matters the most marked. The
increased knowledge of the people is partly the cause
and partly the effect of the high salary of the health
officer. Where a health officer receives no salary,
the people very naturally think his services are
worth just what he gets. Aside from the fact that
the health officer gets no credit for philanthropy,
which is a small thing, his work is thereby rendered
of little value to the people and to the State, which is
a very important thing. Even ministers of the gospel,
followers of the meek and lowly Savior, do not labor
for nothing, and I most earnestly protest against
physicians serving the State free of charge. I have
just noticed in a recent medical journal that a well-
known surgeon of Philadelphia has declined to serve
as consulting surgeon to a State hospital for the rea-
son t hat he thinks physicians ought not to serve the
State gratuitously. All honor to Dr. John B. Deavor,
and may his example be widely followed. It is a
small thing to ask doctors to make reports of conta-
gious or infectious diseases for the benefit of a com-
munity, and very few physicians object to making
such reports free of charge; at the same time it is
rank imposition to frame laws making such services
compulsory, and the supreme court of Illinois has
recently decided that doctors can not be compelled to
make such reports without compensation. In Penn-
sylvania the State prescribes the duties of health
officers, and imposes the pains and penalties attaching
to non-performance of those duties; such being the
case, it is clearly the duty of the State to fix the sal-
aries of these officers and see that they are paid; and
this same plan should extend to townships. Every
township in the State should have a board of health,
or at least a health officer, and the State should fix
the salary and in case of a board, of the secretary as
well. The salaries should be small, but even in small
townships, where a salary of not more than $25 or $50
a year would be paid, it would be easy to find good
men willing to serve who would do their duty faith-
fully and well.
So long as the old plan is followed of no pay but
curses, it will be found almost if not quite impossible
to get men, especially in townships, to take any inter-
est in public health problems, or to give such matters
any efficient support. Large cities may be trusted to
attend to the administration of health laws, but out-
side of cities the State should control and should fix
the salary of every health officer and inspector and every
secretary of a board of health, at a rate proportioned
to the number of inhabitants in the territory covered
by such official.
In the State of Pennsylvania a few years ago the
State authorities printed, by order of the legislature,
a bird book which was of no use to man, woman or
child, at an expense of about $40,000. Every session
the Stale votes hundreds of thousands of dollars to
city hospitals, sufficient, one would think in some
cases, to pay all legitimate expenses of the hospitals
which pay, in most instances, nothing for medical
services, yet a patient from outside the city can not
be accommodated in any of them for a sum less than
is amply sufficient to pay all expenses incident to the
care of such patient while in the hospital. Why does
money flow so easily for such purposes? The
answer in each case is the same. The publisher or
editor of the bird book and the managers of the hos-
pitals each have a "pull."
Shall we not take a hint from this state of affairs?
We have talked and reasoned with our legislators, we
have explained the benefits to be derived by the peo-
ple from a more liberal expenditure in the public health
department, we have treated our lawmakers as gentle-
men, and we get $2,500 per year for expenses, scientific
investigation, protection of water supplies, etc.
Now, in the writer's opinion, it is time to adopt a
different plan. If we must adopt the methods of the
politician in order to obtain anything from the State,
then let us even do so and "fight the devil with fire." We
all have friends who help make the laws; let us say
nothing to them about benefits for the people, let us
not appeal to reason or say anything concerning moral
obligation. Let us say: "I am a friend of yours; I
have voted the straight party ticket, lo, these many
years; I supported you for school director and also
for the Assembly. I carried a torch in the illustrated
parade; I howled and hooted and yelled when the news
came that you were elected, but now times have
changed; I intend to fight your nomination in the
caucus, or, if you should be nominated, to work
against you at the polls, and get all the friends I can
influence to do the same thing, unless you will prom-
ise to favor honestly and heartily an appropriation
large enough to pay all health officers, inspectors and
secretaries of health boards in the State, and also to
pay for physicians' reports and to carry on scientific
investigations as may be thought necessary or desira-
ble by the State Board of Health, unless you show
something like the liberality in providing means for
preventing disease that you show in supporting hos-
pitals and publishing bird books. If you promise to
do this I will work for you in season and out of sea-
son ; but it will not be enough for you to introduce a
bill of this nature, or get some one else to introduce
it, and then lay it under the table; you must work for
the bill and work hard." Such a course is not a pleas-
ant one to follow, but I confess I can see no other
way that offers any reasonable hope of success. I am
positive that we can never hope to have health boards
in every township until we pay for the service rendered,
and I am equally positive that were it possible to have
a health officer in every township serving gratuit-
ously, the benefits derived from such service would be
infinitesimal as compared with that which would be
received in case each health officer received a salary.
Salaries should be made small enough to keep the
office out of politics where it is possible to do so, but
even a nominal salary tends to preserve the officer's
self-respect and enhance his importance in the eyes
of the public. That physicians will labor solely for
love of humanity, work against their own interests to
prevent sickness and do it without remuneration, the
public will not believe, and such services are, in the
end, of questionable utility.
/
470
HOSPITALS FOE THE TUBERCULOUS POOR.
[August 29,
life and a certain percentage regain their former
health by a residence in a suitable climate, or they
may undergo treatment at their homes without endan-
gering the public health; but there is a large class in
every community without means, and with bad
hygienic surroundings; this dependent class should
be provided by the State with proper treatment, and
the public protected by having the tuberculous poor
conveyed to a hospital for consumptives, because it
is this class of patients that spread the disease in all
directions.
In the rural sections of the country these depend-
ents frequently occupy hovels, while in cities they are
the denizens of tenement houses, cellars and garrets,
which are usually almost destitute of light and air,
deluged in filth, and surrounded by abject poverty.
In this position tuberculous patients are the dissemina-
tors of the bacilli, sowing the seed in the well prepared
soil which has been so richly fertilized by their insan-
itary surroundings. In the condition above described
it is impossible for them to secure the treatment that
humanity dictates, for temporary aid is almost value-
less, principally from the fact that the disease is
essentially chronic. The alternating hopes and fears
of a dependent family constantly come under our
observation; frequently a father with a half dozen
children depending upon him, a mother or son, the
only support of a family, is stricken down with this
inveterate disease, which is so graphically described
in the following lines by the pen of Dickens in the
death of Smike:
"There is a dread disease which so prepares its vic-
tims, as it were, for death; which so refines it of its
grosser aspect, and throws around familiar looks
unearthly indications of the coming change — a dread
disease, in which the struggle between soul and body
is so gradual, quiet and solemn, and the result so sure,
that day by day and grain by grain the mortal part
wastes and withers away so that the spirit grows light
and sanguine with its lightling load, and feeling
immortality at hand, deems it but a new term of
mortal life; a disease in which death and life are
so strangely blended that death takes the glow of
life and life the gaunt and grizzly form of death."
From the shores of the Great Lakes to the Gulf of
Mexico, and from the Atlantic to the Pacific Ocean,
wherever towns and cities are built, there will be
found special or general hospitals, and even the few
lepers within this wide domain are either segregated,
or are carefully provided with lazarettos, but for the
"great white plague," consumption, which carries off
one-seventh of the human race, scarcely a beginning
has been made in the way of building and maintain-
ing hospitals for their accommodation.
Our country is far behind England and Germany
in providing hospitals for the treatment of consump-
tives, and it will be well for us to look over the field,
in order to ascertain what has been done abroad and
what may be done at home to stamp out a disease
which is more destructive to the youth of our land
than war itself; and when we place a commercial
value on human life the aggregate annual loss would
amount to many millions of dollars.
Over a century ago England began building hospi-
tals for consumptives, and at present there are eigh-
teen hospitals containing over seven thousand free
beds for tuberculous patients, the result of which has
been to materially lessen the death rate from pul-
monary tuberculosis in that country.
It is the duty of every good citizen to preserve,
order and to suppress rioting or any public violation
of the laws of the commonwealth, but such action is
invariably left to the executive officers of the munici-
pality or government, who are paid for performing
those functions. I have looked the matter over care-
fully and I fail to find the slightest justification, the
faintest shadow of a reason why the physician should
serve the State gratuitously in any capacity. There
is no class of men who give so much to the worthy
poor ungrudgingly, there is no class who are so im-
posed upon and defrauded of their just dues as phy-
sicians, and it is time we refused to allow the State to
add anything whatever to the sum total of the impo-
sitions we already suffer from individuals. In the
way of public sanitation the Legislature of Pennsyl-
vania has next to nothing to be proud of; but in com-
ing generations, when our bones are dust, when the
people understand fully the value, the immense bene-
fits accruing to the State from public sanitary con-
trol and all that pertains to the functions of a State
Board of Health; when our Christian civilization,
so-called, shall present fewer elements of barbarism,
when the true spirit of Christ is abroad in the land,
and men who save lives are considered the heroes,
then will the name of one physician stand high on
the roll of honor as a public benefactor, as the founder
and father of the State Board of Health of Penn-
sylvania, and the letters of that name, when written
in order, will spell Benjamin Lee.
In preparing a paper on this subject to be read
before this body, I have not thought it desirable to
take up your time with an exposition of the reasons
for advocating the establishment of health boards in
townships, reasons which are patent to you all.
We ought to be and we are heartily ashamed of the
position our State occupies on this question. Still, it
is sometimes a good plan to air one's dirty linen in
public, to the end that when the housewife learns that
such a condition has become a matter of public noto-
riety, she may perchance reform.
SHOULD THE STATE PROVIDE HOSPITALS
FOR THE TUBERCULOUS POOR?
Read In the Section on State Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta, Ga.. Mav 5-8. 18%.
BY J. F. JENKINS, M.D.
TECUMSEH, MICH.
Tuberculosis prevails in almost every region of the
habitable globe. It is the most destructive of all the
contagious diseases, requiring no new proofs at the
present to establish the fact of its contagious charac-
ter. To control the spread of tuberculosis, which
stealthily enters into so many housholds in every com-
munity, is a problem which our profession is called
upon for solution.
Pulmonary tuberculosis is so insidious in its nature,
so slow in its evolution, so chronic in its course, fre-
quently requiring months for its development, while
its duration may extend over many years. From its
incipiency to its termination the tuberculous patient
is a menace to society, and although the subject of
the disease neither excites public attention nor alarm,
still he is more dangerous to the community than the
leper, whom society abhors, or Asiatic cholera, which
is feared by mankind everywhere.
We are well aware of the fact that many wealthy
patients, or those of moderate means, may prolong
1896. 1
IS. MARINE-HOSPITAL SERVICE.
471
The Progrte Medical in a recent issue makes a
statement relative to tuberculosis in France and Eng-
land which clearly demonstrates the results accom-
plished by special hospitals for consumptives. That
journal states: ''That there are three times as many
deaths in Paris as in Great Britain, and that in 1870
the mortality in England and Wales was 2,410 for
each l.lXHUXX) inhabitants, hut since consumptives
have been treated in special hospitals this number
has fallen to l.lliS. in L893. In Paris there were 4,158
deaths from tuberculosis during 1894, or almost three
times as many as across the Channel." If the fore-
going statement is correct, England saves the lives of
2tUXH) of her inhabitants yearly by wise sanitary
measures in maintaining special hospitals for her
dependent class of consumptives; on the other hand,
Paris loses several thousand of her citizens yearly
from detective sanitary laws and deficient hospital
accommodations for her indigent class of tuberculous
patients. The city of Paris has recently built a hos-
pital at Agincourt, some fifty miles from the city,
with a capacity of one hundred beds, for her depend-
ent class of tuberculous patients, and there are some
half dozen more located in different parts of France.
Many of the larger cities of Germany have recently
built special hospitals for consumptives, as Berlin,
Cologne, Hanover. Breslau, Dresden, Frankfort-on-
Main. Worms. Wilrzburg and Bremen, besides there
are two institutions located in the Hartz Mountains,
and one in the Black Forest. German statistics have
shown a marked decrease in the death rate from tuber-
culosis within the past few years. They are building
an institution near Vienna for the tuberculous indi-
gent, and even the ''unspeakable Turk" has built a
consumptive hospital for children on the banks of the
Bosphorus.
The success attending the treatment of tuberculous
patients in private hospitals is certainly an encour-
agement for States and municipalities to build and
support hospitals for the dependent class. At Gor-
I orf in Silesia a private sanitarium was built in
1854 which in the course of eighteen years has had
under treatment about 958 consumptive patients, of
which 20 per cent were permanently cured; and in the
private institutions located in the Alpine regions
there have been reported cures in 40 per cent, of
tuberculous cases. The city of Bale, Switzerland,
has lately pledged herself to build and maintain a
sanitarium for her tuberculous poor.
In our own country a number of private hospitals
have been built by philanthropic persons and socie-
ties, and it becomes necessary to mention them, and
the success attending them, in order to ascertain in a
measure what may be accomplished by public institu-
tions built for the treatment of the tuberculous poor.
One of the most widely known is the Cottage Hos-
pital, situated in the Adirondacks, which will accom-
modate eighty-four patients. This hospital during
the past ten years of its existence reports a cure in
from 20 to 25 per cent, of their cases. In the Adiron-
dack Mountains, about 1800 feet above the sea, a hos-
pital for consumptives is being built named the Sani-
tarium Gabriels.
The Sanitarium at Ashville, N. C, has an accom-
modation for 100 patients, and reports that of 600
patients treated in that institution 45 per cent, have
ered. The Home for Consumptives located
near Philadelphia, it is stated, discharge each year
about 30 per cent of their patients cured, and in that
city is the Rush hospital for consumptives; both of
these are institutions of small capacity. In the
vicinity of Boston is a small institution called the
Sharan Sanitarium, and in Colorado there are three
private sanitariums for tuberculous patients.
In all these institutions above named there are only
about two hundred free beds, while England has over
seven thousand free beds for her tuberculous poor.
Massachusetts probably has the largest death rate
from tuberculosis of any State in the Union, but she
has recently adopted measures which will doubtless
lessen the death rate from this disease, her legisla-
ture having appropriated $150,000 for building a hos-
pital for her tuberculous poor. Dr. F. I. Knight, who
was before the Finance Committee of the Massachu-
setts Legislature, states that the question was asked
him: "Have the medical societies of the country
made any formal declaration which has been put on
record, in regard to the establishment of such hospi-
tals?" Fortunately he could reply that "Some socie-
ties had made such a record." "I was astonished to
see how readily these men — most of them politicians
— favored the hospital idea, not only showing sympa-
thy with the homeless patients, but with the idea of
preventing the spread of a disease which is commu-
nicable. To our surprise on our first effort, both
houses passed an appropriation of $150,000, which
was signed by the Governor, for the establishment of
a hospital for the consumptive poor."
The above is a brief sketch of the first successful
effort to build a State hospital for this purpose. A
question was asked by the Massachusetts Legislature
which would undoubtedly be the question propounded
by State legislatures everywhere when requested to
build hospitals for the consumptive: Have the medical
societies of the country placed themselves on record
relative to building these hospitals? Finally, has the
American Medical Association made a formal
declaration relative to States and municipalities
building and and maintaining hospitals for the con-
sumptive poor?
REMARKS RELATIVE TO THE UNITED
STATES MARINE-HOSPITAL SERVICE.
Delivered in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, held at Atlanta,
Ga., Mav 5-8. 189B.
BY WALTER WYMAN, M.D.
SUPERVISING SURGEON-GENERAL U. S. MARINE-HOSPITAL SERVICE.
WASHINGTON, D. C.
I had hoped that I could prepare a paper in response
to the invitation of the Chairman, but was uncertain
whether I could attend this meeting, and was too hur-
ried to prepare a formal essay. However, the day before
I left Washington I received from the Public Printer
the Annual Report of the Marine-Hospital Service,
1895, which had been in his hands four or five months,
and as the material therein is new, I thought it might
be of interest to bring it with me, and explain to this
Section that portion of the report which relates to the
public health service.
If you will turn to page 249 you will see a resume
of the operations of the service in the interest of pub-
lic health during the last year. Referring to the pre-
ceding portion of the report I may say it deals
directly with the operations of the Marine-Hospital
Service in its care of the sick and disabled seamen
of the merchant marine, about 53,000 being treated
annually. It seems to me that any service in behalf
472
SERUM THERAPY IN DISEASE.
[August 29,
of the seamen of the merchant marine, is public health
service in the broader sense. But returning to this
section, you will find in this resum6 an account of
the danger of the introduction of yellow fever from
Cuba, and operations to prevent the same.
You will find also an account of the threatened
introduction of smallpox by the return to the United
States of some four hundred negro colonists who had
been to Mexico, where a colony had been attempted
and failed, there being 178 cases of smallpox among
them. The bureau took charge of these colonists,
established a camp, fed and held them under observa-
tion until the last case disappeared, when their cloth-
ing was either disinfected or burned and replaced
with fresh clothing and they were allowed to go on
their way.
While these operations were in progress reports
came from Japan, China and the Sandwich Islands
with regard to cholera that created considerable alarm.
The special measures adopted to meet the unusual
danger are detailed in the following pages.
The national quarantine stations are described on
pages 252-304 inclusive. I will not go into details
as they are fully set forth in the reports of the medi-
cal officers.
An account of the division of sanitary reports
and statistics is given on pages 305-310 inclusive. I
will call your attention to a table prepared in this
division, showing the yearly mortality of 199 cities in
the United States.
The operations of the hygienic laboratory are found
on pages 311-343 inclusive. In this report of the
medical officer in charge of the laboratory will be
found a complete discussion of the serum therapy of
diphtheria. There will be found also an interesting
account of some experiments which have been made in
the serum therapy of variola. Also, an account of the
examination of drinking water in the District of
Columbia, and reference to experiments made with a
view to practical disinfection of mails and school and
library books.
The sanitary inspection service you will find
described on page 344, showing results and giving a
description of the inspections which were instituted
by the bureau for the purpose of keeping out epi-
demic diseases.
I will not take your time by attempting to summa-
rize the pages on cholera, smallpox and yellow fever,
but I believe you will find them very interesting.
Since the date of this report I have prepared a cir-
cular letter addressed to the mayors of the cities and
towns of the United States making inquiries relative
to the water supply of the several cities, and the dis-
position also of the sewage. We have sent out these
circulars to a few cities at first, but we propose to
send them to all the cities in the United States, collect
the information and publish it in a condensed form.
The blank form which I have here has place for
answers to the several questions relating to the source
of water, its storage, purification, distribution, control
and its disposition. The blank also relates to sewage
and garbage disposition. In addition to the above
the bureau has recently enlarged the scope of the
health reports and improved the records pertain-
ing to diseases of all classes throughout the United
States.
DISCUSSION.
Dr. Valentine — It seems to me one matter has been entirely
overlooked. I refer to the disease which kills 80 per cent, of
the women, which destroys the health of 80 per cent, of the
children who are born healthy. I will not speak of the partic-
ular cases directly due to gonorrhea. I am not speaking of it
as a disease, but as a sequel ; but I desire to ask whether th
disease is not one of importance, and whether it does no
merit closer consideration and some active measures for the
prevention of its spread. In many cities an effort is made
requiring the prostitutes to be registered. In the city of Ber-
lin there are more than twenty thousand registered. Without
adequate methods of inspection the efforts are almost unavail-
ing, and the disease is being propagated at from six cents up.
This matter naturally belongs in this Section, but I think the
Department which has rendered such signal service in the
matter of public health should take it up also. It is my hope
to show on Friday the manner in which 60 per cent, of the
cases of gonorrhea are curable in ten days, 30 per cent, within
one or two weeks at the utmost, and 5 per cent, within two
weeks, leaving 5 per cent, as yet without the reach of the new
method. Why should not the Marine-Hospital Service adopt
the method which requires no expense, obviates all danger of
contagion and numerous other things which could be prevented.
Dr. Kellogg — I just want to enter a protest against this
country adopting any such method for the supposed preven-
tion of the disease named as that described in Europe. A
recent investigation made in Berlin, even, shows that not on
in ten of these diseases are discovered ; and this metho
while it gives a sense of security to every cautious man, at th
same time really promotes the disease which it intends
prevent.
SERUM THERAPY IN DISEASE.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga.. May 5-8, 1896.
BY GEORGE TULLY VAUGHAN, M.D.
PASSED ASSISTANT SURGEON IN COMMAND U. S. MARINE-HOSPITAL SERVICE
PHILADELPHIA, PA.
From the time of Jenner's discovery that the drie
serum of cowpox prevented or modified smallpox when
introduced into the human system, has existed the
hope that remedies would be discovered somewhat of
the same character which would cure or prevent all
diseases.
But this bud of promise was slow in developing,
and the bright expectations thus aroused were doomed
to wait a century before they were even partially real-
ized. As the ovum of the cicada septemdecem requires
seventeen years to bring forth the mature insect, so
the germ of Jenner's discovery after an incubation of
one hundred years has blossomed into the science of
bacteriology, which, through the labors of Pasteur,
Koch, Behring and others, has already brought forth
a wonderful harvest of relief from suffering and dis-
ease, and the day seems now at hand when, with a cure
or preventive for every disease, cholera, yellow fever,
diphtheria, leprosy, syphilis, and tuberculosis will be
as rare as smallpox now is among those who are prop-
erly vaccinated. The ideal treatment of disease is to
prevent it.
The fact that certain animals are immune from cer-
tain diseases, e.g., that the lower animals do not have
syphilis, has long since excited curiosity as to the rea-
son, but nothing satisfactory was offered until the
bacteriologists had established the existence of toxins
and antitoxins, and that immunity can be induced or
acquired by the proper use of the specific entity, its
products, or effects, which causes the disease.
The theory of natural immunity now most in favor
is that the blood serum contains in solution a germi-
cidal proteid, alexin or nuclein, whose source is the
1896.]
SERUM THEEAPY IN DISEASE.
473
leucocytes, soluble only in an nlkalin fluid, and that
phagocytosis (the phenomenon discovered by Stern-
berg and developed by Metsehnikoff) plays a subsi-
diary pari. Nucleins are thus defined by Victor C.
Yaughan: " Physiologically, nucleins may be said to
form the chief chemic constituent of the living part
of rolls. Speaking broadly, we may say that nuclein
is thai constituent of the cell by virtue of which this
histologic unit grows, develops and reproduces itself.
It is tlie function of the nuclein of the cell to utilize
the pabulum within its reach. It must be evident
that those tissues most abounding in cellular elements
contain relatively the largest amount of nuclein. It
must also be seen that it is by virtue of their nuclein
that the cells of various organs and organisms possess
and manifest their individual peculiarities.
"Wo should therefore expect to find that the nuclein
of the yeast cell is not identical with that of the
bacillus tuberculosis, and that the nuclein of the
spleen differs from that of the thyroid gland.
The number of kinds of nuclein is limited only by the
variety of cells. Nuclein is the chemic basis of that
part of the cell designated by the histologist as the
nucleus, sometimes called chromatin on account of the
readiness with which it absorbs and holds coloring
agents. It is the nuclein of the bacterium which takes
up and retains the stains, and it is on account of the
fact that the nuclein of the bacillus tuberculosis dif-
fers from that of other bacilli that we are able to dis-
tinguish the former from the latter by its tinctorial
properties. DitVerences in reaction with staining
reagents, so plainly seen under the microscope, are
only outward manifestations of less apparent and more
important differences in chemic composition. Chem-
ically the nucleins are complex proteid bodies, char-
acterized especially by the large amount of phosphorus
which they contain. The phosphorus exists in the
form of nuoleinic acid, which is combined with a
highly complex basic substance. So far as we know
at present, the nucleinic acid of all nucleins is the
same, yet the basic part differs in the various nucleins.
This basic substance yields, as decomposition products,
one or more of the so-called xanthin bodies, adenin,
guanin. sarkin and xanthin. Some nucleins yield
only adenin and these may be designated as adenyl
nucleinic acids. Those which furnish xanthin most
abundantly may be called xanthyl nucleinic acids.
Generally speaking, the nucleins are insoluble in dilute
acids and soluble in dilute alkalies. They resist pep-
tic digestion and in this way may be separated from
most other proteid bodies."
According to Buehner natural immunity can not,
as a rule, be transmitted to the body of another animal
by means of the blood.
Acquired or artificial immunity is of the greatest im-
portance as it affords the physician the means of pre-
ventingdisease. To Pasteur belongs the credit of having
taken up the thread where Jenner left off and he was the
second to show, by his experiments on chicken cholera
in 1888, that infectious diseases may be prevented by
inoculation with "attenuated virus." Immunity may
be acquired: 1. By having the disease. One attack of
certain diseases as yellow fever, smallpox, measles,
scarlet fever, etc., usually assuring future immunity.
Of course this may be induced by inoculation with
the microorganism of any particular disease. 2. By
inoculation with attenuated cultures. 3. By inocula-
tion with filtered cultures which are free from bacteria,
or with sterile cultures which contain dead bacilli.
Filtered cultures contain the toxins, while sterile cul-
tures contain in addition some special property in the
dead bacteria. The latter were used by Loftier and
Abel in their experiments for immunizing against
typhoid fever with the best results. This protective
power afforded by one attack of a disease against
other attacks of the same disease or by inoculation
with bacterial cultures, is generally supposed to be
due to the existence of antitoxins and something else
(enzymes) in the blood serum. The antitoxins were
discovered in 1890 by Ogata and Jasuhara of Tokio,
when they found that the blood of an animal immune
against anthrax contained something which neutral-
ized the toxic products of the anthrax bacillus.
Experiments have shown that in some cases the
blood serum of immune animals has no antitoxic
power but acts as a germicide, and as a rule antitoxins
have no such power. In such cases the immune ani-
mal may still be susceptible to the action of the toxins
though unaffected by the bacillus. Brieger and Ehr-
lich had proved that antitoxin is contained in the milk
of a goat which had been immunized against tetanus,
by conferring immunity to the same disease on a mouse
by injections of the milk. The modus operandi of
the antitoxins is involved in considerable doubt.
According to Buehner, the action of the antitoxins
does not depend on destruction of the bacterial poisons
by contact with them but upon their action through
the medium of the tissues of the body. The presence
of the antitoxins produces a lower degree of suscepti-
bility to the toxins of the bacteria, in the living cells
of the body, thereby rendering it more resistant to the
action of the specific toxin.
Sternberg says: " We must admit that the exact
source and method of production of the antitoxins in
the animal body, and their mode of action, are still
undetermined; and for the present, we must be satis-
fied with the knowledge that, in some way, these so-
called antitoxins, which have been proved to be pres-
ent in the blood serum of immune animals, protect
them from infection by pathogenic bacteria, And
that when transferred to susceptible animals they con-
fer upon them a temporary immunity; or if introduced
after infection, may neutralize the pathogenic action
of the toxins produced by specific disease germs."
The following are the known differences between
alexins and antitoxins. Alexins are germicidal and
globulicidal, destroying both red and white corpus-
cles of animals belonging to different species from
that whence they were obtained; they are coagulable
and unstable, destroyed by sunlight and by a temper-
ature of 50 to 55 degrees C. Antitoxins are not germ-
icidal or globulicidal; they resist the action of sun-
light and require a temperature of 70 or 80 degrees C.
for destruction.
Failing to prevent disease the next best thing
is to cure it, and the successful use of blood serum
in accomplishing this result first seems to have first
been made by the Japanese bacteriologists already men-
tioned, Ogata and Jasuhara, although their experi-
ments failed of confirmation by others, when, in 1890,
they announced that mice which had received a small
amount of dog's, rat's or frog's blood (animals immune,
to anthrax) two or three days before, or a few hours..
(5) after, the injection of anthrax bacilli, all recovered
from otherwise fatal doses of anthrax bacilli and
proved afterward to be immune. No doubt the first
step in this direction was made when in 1888, Nuttali
demonstrated the power possessed by blood serum of
474
ABUSE OF ALCOHOLIC DRINKS.
[August 29,
antagonizing the products of bacterial growth, while
to Behring and Kitasato belong the credit of having,
in 1891, established its use as a practical measure in
the treatment of disease.
Blood serum has been used in the treatment of the
following diseases with more or less success: Diph-
theria, cholera, tuberculosis, leprosy, syphilis, tetanus,
typhoid fever, pneumonia and others. Beyond ques-
tion its greatest triumph and most convincing effect
for good has been obtained in the treatment of diph-
theria. I had the pleasure of seeing many cases
treated by Dr. Kossel in Koch's Institute for Infec-
tious Diseases in the winter of 1894-95. It is as
unreasonable to doubt the efficacy of antitoxin in
diphtheria as it is to doubt the power of vaccination
to prevent smallpox or to modify its virulence.
Syphilis has been treated with the blood serum of
one who has just passed through an attack of the dis-
ease by Dr. Edward Cotterell of England, in eighteen
cases extending over a period of six months with the
following results: 1. In the early stages with only a
sore and glandular enlargement, injections of this
serum caused the sore to heal rapidly. The adenitis
in the groin became intensely marked, while the skin
and throat symptoms were absent or slightly marked.
2. When the treatment was not begun before the rash
and throat symptoms had developed, the skin erup-
tion faded more rapidly than under mercurial treat-
ment, but the throat symptoms disappeared rather
slowly. 3. The general health improved. 4. Serum
from a person with secondary symptoms appeared to
be more active than that obtained from one with ter-
tiary symptoms. 5. Dose of the serum from one-half
to five cubic centimeters.
The importance of finding a remedy for the treatment
of leprosy is evident when the rapid increase in the
number of sufferers from this disease in certain coun-
tries is considered. The United States Minister to the
United States of Colombia reports the number of
lepers in that country to have increased in forty years
from four hundred to twenty-seven thousand. Dr.
Carrasquilla of Bogota reports fifteen cases of tuber-
culous leprosy treated with blood serum and four
cured in less than a month, except for the scars caused
by the ulceration. Dr. Putnam of the same place
reports a case treated with serum with great improve-
ment which promised ultimate recovery.
He prepares the serum by making a culture of the
bacillus lepra? in the blood in the vessels of a living
animal instead of in an artificial apparatus, thus: He
takes blood from the leprous patient, allows it to
stand four hours in order to separate the serum which
is then injected into asses or goats.
After the proper time the serum of the asses' or
goats' blood is used as a remedy on the patient from
whom the serum was originally obtained or on any
case of leprosy. Dr. Putnam admits that he obtained
ideas as to the treatment of leprosy from Dr. Carras-
quilla. Dr. W. Impey, Medical Superintendent of
the Leper Settlement at Robbens' Island, Table Bay,
where 600 lepers live, says he has noticed that when-
ever a leprous patient is attacked by any inflamma-
tory skin disease as measles, smallpox, or erysipelas,
the part affected is invariably cured of leprosy, and
the patient either entirely recovers from leprosy or
his life is prolonged beyond the normal period of
eight years. Dr. Impey advocates the induction of
erysipelas within three or four years after the disease
begins and believes that by this means leprosy may
be eventually stamped out.
Kinyoun: (1895) reports two cases of smallpox
treated by injection of serum from a vaccinated or
immunized heifer, beginning with 15 c.c. with encour-
aging results. The treatment was commenced during
the pustular stage.
More recently Beclere reports a case of smallpox
treated by the injection, in the course of one hour,
of 1500 c.c. of the same kind of serum on the third
day of the disease, with rapid recovery.
Before ending this paper I will refer briefly to the
use of serum in tuberculosis as recommended and
practiced by Dr. Paul Paquin of St. Louis. He uses
serum from the horse which has been rendered
strongly antagonistic or antitoxic by the use of grad-
ually increasing doses of tubercle bacilli toxins. It
takes three months to prepare a horse and the method
is similar to that used to prepare him for producing
the antitoxin of diphtheria. Dr. Paquin reports the
results of one hundred cases of pulmonary tubercu-
losis treated from three to eight months as follows:
In the first stage, recovered 14; in the second stage,
improved, 26; disappeared from observation in all
stages 35; died, treatment begun in second stage, 5;
died, treatment begun in third and fourth stages, 20.
BIBLIOGRAPHY.
Sternberg: Immunity and Serum-Therapy, 1866.
Journal American Medical association.
American Journal Medical Sciences.
New York Medical Journal.
Virginia Medical Monthly.
Abstract Sanitary Reports, M. H. S.
THE ABUSE OF ALCOHOLIC DRINKS, ITS
RELATION TO PUBLIC HEALTH
AND ITS PREVENTION.
Read in the Section on State Medicine, at the Forty seventh Annual
Meeting of the American Medical Association, held at
Atlanta. Ga.. May &-8.
BY W. BAYARD, M.D., Edin.
ST. JOHNS, NEW BRUNSWICK.
I have selected for discussion the abuse of alcoholic
drinks, its relation to public health and its preven-
tion. I emphasize the abuse as I am unwilling to
believe that the moderate and proper use of them has
relation to public health.
It will not be disputed that the abuse of them,
with its attendant consequences, disease, insanity,
crime, poverty and premature death, is the greatest
evil of the age, and that it calls loudly for remedial
measures. What those measures shall be has exer-
cised the minds of many.
The subject has been discussed in the pulpit and
on the platform, some claiming that nothing but
coercive and restrictive measures will remedy the evil,
while others declare that such measures will aggra-
vate it, both wishing to arrive at the same goal, but
differing as to the road; in their enthusiasm, too
often ignoring all rights, appealing to passions and
prejudices, claiming more than can be accomplished,
and deliriously denouncing those who differ from
them, thereby injuring a good cause. The subject is
of such vast importance that it should be approached
calmly and reasonably, appealing to the mind from a
moral and sanitary standpoint.
Our professional education teaches us the physio-
logic action of alcohol, the base of all intoxicating
drinks, upon the human system; when it shall be
abstained from and when it can be taken with advant-
age. It teaches us that when taken into the stomach
in a concentrated form a chemic action takes place in
consequence of the strong affinity it possesses for
1896. ]
ABUSE OF ALCOHOLIC DRINKS.
475
water, seizing that fluid contained in the tissue, pro-
ducing a coagulation, rendering it hard and dense and
destroying for a time the absorbing power of that
organ, which will only be renewed when the alcohol
tnes sufficiently diluted with the water in the
tissue. It may be observed that pure brandy, which
usually contains equal parts of alcohol and water, is
sufficiently strong to produce this coagulation, and
when diluted is absorbed into the circulation with
marvelous rapidity, as proved by the experiments of
Dr. Percy, who found that when death took place in
two minutes after it was injected into the stomach of
the animal, that organ was found almost void of it,
while it was found in the blood and in considerable
quantity in the substance of the brain. It appears
to seek out and fasten itself upon the nervous matter.
affecting in the first stage of intoxication the intellec-
tual faculties through the cerebrum. In the second
. a disturbed function of the sensory ganglia, as
indicated by want of control over the muscular move-
ments which are guided by sensation. And in the
third stage, when the functions of the cerebrum and
sensory ganglia are suspended and those of the medulla
oblongata and spinal cord now begin to be affected,
as shown by tlie difficulty of respiration, strabismus,
dilated pupils and tetanic spasms.
According to Richardson the man who swallows
eight ounces of alcohol in twenty-four hours increases
the number of the beats of his heart from 100,000 to
124.0 16 during that period, at the same time alter-
ing the shape and quality of the red globules of the
blood.
Observation teaches us that alcohol is partly elimi-
nated from the system by the lungs, bowels, kidneys
ami skin. But the amount thus eliminated is so
small that it does not account for all that disappears.
Carpenter thinks that a combustive process takes
[dace in the blood, at the expense of the oxygen it
contains; while the experiments of E. Smith and
others go to show there is no increase of carbonic
add produced. Anstie and Thudicnm contend that
it is consumed in some way in the economy, though
how they do not say. It is urged by Beale and Bing
that alcohol possesses the property of restraining the
rapid growth of young cells and, like quinin, of
checking the increase of the white corpuscles of the
the blood.
While alcohol is one of the means of keeping up
animal heat through the increased action of the heart,
it can not be classed as fuel-food. Animal heat is
maintained by the combination of the carbon and
hydrogen contained in the blood, with the oxygen
taken in by the lungs. Fats and sugars in the blood
yield the carbon and hydrogen, and while alcohol
furnishes the same elements of combustion, it is not
certain that it plays the same part in the body.
Alcohol does not contain any of the constituents
3sary for the growth and regeneration of the
muscular system.
Our professional experience, too often, teaches us
the baneful effects, morally and physically, upon the
individual who indulges in the use of alcoholic
drinks to excess. While the justice is daily and
hourly brought face to face with the "moral evil,"
the physician is as often called upon to combat the
inroads upon the constitution produced by the abuse
of them.
Laudable efforts have been made to stay the prog-
res8 of intemperance. Societies have been formed,
laws enacted and persuasive and eoersive measures
adopted. Yet according to investigations of the
Harveian Society, it appears that in London one-
seventh of all adult deaths (male and female) [is
directly or indirectly due to the consequences of
alcoholic excess. >*',M*'TI
The statesman requires the aid of all enlightened
minds to assist him in framing such laws as will
meet the difficulty. And the people at large require
to be taught that the abuse and oftentimes the con-
tinued use of alcoholic drinks leads to results dread-
ful to contemplate. They must be made to believe
that they are swallowing a poison, which, if taken at
improper times, in improper quantities, will sooner or
later, inevitably create disease of the body and mind.
Who can educate them so well on these points as the
physician? It is our duty as custodians of the public
health and as well-wishers of our race, by precept and
by example, to exercise that influence which each and
every one of us can command toward this end.
A certain amount of self-control is implanted in
the mind of every individual; he knows that danger
attends many of his acts; he commits the act and
avoids the danger. So with the alcoholic drinks, the
danger lies not in the use of them but in the improper
use of them. His daily experience teaches that many,
very many, become victims to the abuse. He thinks
he possesses sufficient self-control to avoid the danger,
and so he does, up to a certain period; but let him
continue to indulge at improper times and in im-
proper quantities, that self-control is lost and can only
be regained by continued total abstinence; one glass
will rekindle the appetite, when the tire will continue
to burn until disease and death follow.
If an individual is so weak minded and so much the
creature of impulse and selfish desire that having
experienced the pleasurable effects of intoxicating
drinks he will voluntary surrender that power given
him by Providence for his safety and throw aside the
reins of self-government, he is to be pitied; can claim
no respect and is a fit subject for restrictive laws and
punishment. He should know that the highest attri-
bute of a well-regulated mind is the power of self-
control, that the act of self-government is noble,
when exercised in the face of temptation, and nothing
without it. He who will not restrain an injurious
appetite degrades himself to the level of the brute
creation.
The individual under the influence of alcoholic
liquors feels an exhilaration of spirits, a sensation of
gaiety, is pleased with himself and others, his ideas
flow rapidly and he pours forth his thoughts with
force of expression and richness of conception. But
as the candle burning brilliantly in an atmosphere of
oxygen soon burns itself out, so the over-stimulated
brain becomes exhausted and demands rest, upon the
well-known principle that undue mental excitement,
from any cause, is invariably followed by depression
and languor.
The fact that alcohol when taken into the circula-
tion augments the force and rapidity of the heart's
action, increases the excitability of the nervous sys-
tem and supplies one of the means of keeping up
animal heat commends it to the physician when other
means of obtaining these effects are defective. Our
practical experience teaches us that when adminis-
tered with caution and discrimination it is a valuable
remedy in various forms of disease and one for which
no proper substitute has yet been found. As to its mode
476
ABUSE OF ALCOHOLIC DRINKS.
[August 29,
of action in the cure of disease we can not speak with
certainty. Dr. Berdon Sanderson's theory seems to
be accepted, that in certain diseases the tissues waste,
first the fat, then the muscles, and that the alcohol
prevents their waste at a time when the patient's
stomach is too weak to receive nutritious food. He
says the cause of the waste of tissues is that they are
used or burned in the process of respiration, alcohol
takes their place and supports respiration when the
stomach is too weak to prepare and assimilate any
other food for the purpose. The practical applica-
tion*^ them must be left to the judgment of the phy-
sician, no two cases being exactly alike, each differ-
ing in constitution, intensity and temperament. But
he should be careful to avoid bringing the system
into a habit of dependence upon the stimulus, for it
can not be doubted that over-indulgence has com-
menced with the therapeutic use of it. Hence he
should be ever on his guard.
Those who value good health and wish to enjoy the
effects of alcoholic drinks socially will naturally ask
at what time and in what quantity can they be used
with impunity ? We may answer that except in sick-
ness alcohol in any of its forms should never be taken
without food, and preferably at dinner. I wish to
impress this precept as strongly as words can express
it upon the minds of all who hear me, believing as I
do, that food is the great antidote to its injurious
effects, and that if this rule were adopted we should
not see one inebriate for every hundred we see under
the present pernicious custom of drinking at all hours
of the day and upon an empty stomach.
A man meets a friend to whom he wishes to be
"civil;" he asks him to have a drink; the friend is not
thirsty, but he does not wish to be "uncivil," and they
have their glass. They meet other friends in the shop,
who also want to be "civil." The result is that many
glasses are taken upon an empty stomach which can not
at the time bear with impunity one glass. This is not
the use; it is the abuse, and he who so indulges will
sooner or later pay the penalty. Happily this "treat-
ing habit" is decreasing.
As to the quantity, it is difficult to lay down any
rule; what would be enough for one would be too
much for another. The quantity usually taken at a
dinner party, if habitually taken, would prove injuri-
ous. From one to three glasses of port, sherry or
claret should be the limit. Light wines are prefer-
able, the stronger liquors should never be taken in
larger quantities than from one to two ounces, and
then largely diluted.
Before a remedy is applied to an evil its cause
should be studied. The fondness for stimulants of
some kind is almost universal, every nation exhibiting
more or less of it since the time of Noah, who "drank
wine and was drunken." And I may add that the
most civilized, the most powerful nations are the most
drunken. Does not this fondness for alcoholics orig-
inate in the "beneficent instinct" implanted in man,-'
which prompts him to seak pleasure and avoid pain,
bodily or mental? I think it does.
While the history of intemperance teaches us the
evil is less than it has been at any time since the first
century, still the existing evil is of such magnitude
that it urgently demands remedial measures.
There are four that present themselves to a reflective
mind, namely, sanitation, education, legislative regu-
lation and prohibition.
Sanitation. There is abundant evidence to prove
that insanitary surroundings are the cause of more or
less bodily arid mental languor, often accompanied by
lowness of spirits. The man returns from his daily
work to a cheerless home, with few comforts, fatigued
in body and worried in mind; he takes a glass; his
cares assume a pleasanter aspect and, according to
Solomon, "his heart grows lighter." Here lies the
danger; continue the habit and this use is soon fol-
lowed by the abuse. Give him a bright, cheerful,
healthy and happy home and you remove a iarge cause
of intemperance.
Education, I contend, is the most potent combat-
ant against inebriety. Appeal to the man's fears and
to his understanding. Teach him that alcoholic
drinks do not assist his muscular power, that they do
not enable him to withstand the effects of heat or
cold, that they do not contain the necessary ingredi-
ents for his well being and that he is much better
without them. Teach him that if he will take them,
from one to two ounces of brandy or whisky should
be the limit. Teach him that under no circum-
stances— in health — should they be taken on an
empty stomach or without food. Forbid the use of
any form except as medicine to the young. Teach
him that the exhilarating effects of alcoholic drink is
evanescent and that the effect is bound to be fol-
lowed by a corresponding depression; that if he con-
tinues to take them in quantity or at improper times a
dangerous craving and dependence upon them is pro-
duced which sooner or later will obtain control of
him. No man intends or expects to arrive at this
stage. He will say to you that this one or that one
has taken them as he does, with impunity. True,
but this is the exception to the rule and many are
ruined by such exceptions. Teach him that they act
injuriously upon every organ of the body and that the
injury is not confined to himself, but extends to his
offspring, entailing upon them insanity, idiocy and
inebriety, a catalogue that should alarm any sane
mind. Plutarch says that one "drunkard begets
another," and Aristotle that "drunken women bring
forth children like unto themselves." He may tell
you that he will reduce his allowance. Impress upon
him that he can not do this with safety; one glass will
surely kindle the appetite. Total abstinence will
alone protect him.
Temperance and total abstinence societies have
done and are doing much good. While I do not
altogether agree with their mode of education, inas-
much as they ignore the power of self-control in man
and say to him : We will not trust you, we must have
a pledge. Still, • acknowledging the good they have
done, I strongly advise all those who fear to trust
themselves to take the pledge, but as men are more
easily led than driven, I feel that temperance enthu-
siasts will accomplish more for their cause by claim-
ing less and refraining from denouncing those who
do not see eye to eye with them, as holding the cup
to their neighbor's lip. Lectures should be given
pointing out the evil, and it should be daily im-
pressed upon the mind of every child in our public
schools; through the child the erring parent may be
educated.
Legislative regulation. From the year 1551 to the
present date, laws have been enacted, canons, decrees,
and anathemas made against the abuse of alcoholic
drinking, and it may be asked, what have they accom-
plished? The Committee of the House of Lords in
England declared in their report (1879) that "recent
L896.]
ABUSE OF ALCOHOLIC DRINKS.
477
legislation has had a benefioial effect throughout the
country by producing good order in the streets, by
abolishing the worst class of beer houses aud by
improving the character of licensed houses generally.
It is not. however, proved that it has diminished the
amount of drunkenness." " In certain localities drunk-
enness has increased among women, but as a rule the
respectable class of artisans (both male and female)
are becoming more sober and the apprehensions for
drunkenness are becoming more and more confined to
the poorer classes of the community."
Laws upon the statute book are useless unless
enforced. To accomplish this object the laws require
to have the approval of a large majority of the com-
munity, who must feel that he who breaks or evades
them degrades himself. This belief does not exist
owing to the fact that a large majority of those who
purchase and consume liquor, use it in moderation,
are never intoxicated and do not feel that they are
injured by it. They claim that a majority of ninety
should not be coerced by a minority of ten, who are
too selfish to obey the restraining power Providence
has given them.
The object of all laws regarding alcholics is to con-
trol and lessen the use of them. As you increase the
cost and the difficulty of obtaining them so you lessen
their consumption. To do this the price of the license
to sell should range from $500 to $1,000 per year, and
in number should not exceed one in every five hun-
dred inhabitants. Happily individuals, as a rule, are
ashamed to be seen in or going into a barroom, enter
bv a side door and drink behind a screen. I would
foster this shame by making it imperative that the
barroom shall face the street, have but one entrance,
without blinds or shutters to the windows, enabling
passers in the street to see those in the room. Bar-
rooms should not be allowed in hotels, the boarder
should be required to treat his friend in his room,
and they should be prohibited in grocery shops.
The present licensing system is defective in every
particular, inasmuch as the number exceeds the
demand, creating such competition that the "publi-
can'' can not afford to refuse credit and must please
his customer by giving him liquor at all hours. The
hours of opening are too early. For I hold that under
no possible circumstances is it necessary or beneficial
for a healthy person to drink liquor before his dinner
hour; on the contrary, when the appetite craves the
stimulus in the morning the subject is on the road to
ruin.
At the risk of being considered "Utopian" I do not
hesitate to urge that no liquor should be sold for con-
sumption on the premises at an earlier hour than 2
o'clock in the day, and then preferably with food. I
might go further and urge that it be not sold for con-
sumption on the premises at any time without food.
It may be urged that the purchaser would pay for the
food but not eat it. True, but the expense of the
performance would have its influence upon the
amount of liquor consumed by him. Legislation
should encourage the use of light wines and beer as
coutaining less alcohol.
The Gothenburg system commends itself to the rate
payers, as all the profit accruing from the public-house
sale of liquor is appropriated toward paying the debts
of the municipality. It is recommended strongly by
the committee before referred to, composed of seven-
teen of the leading men in England. It directs that
no individual, either as proprietor or manager, shall
derive any private gain by the sale of spirits. That
the whole public-house traffic be transferred to a lim-
ited liability company, who shall undertake by their
charter to conduct the business solely in the interest
of temperance and morality, and to pay to the town
treasury the whole profit beyond the ordinary inter-
est on the paid up capital. The capital annually
expended was between $30,000 and $40,000, and the
profits amounted to nearly $120,000. The number of
licenses issued by the new company was reduced from
119 to 56. The company had the power of fixing the
hours of closing and prohibited all "bar" business
from 6 p.m. on Saturday to 8 a.m. on Monday. The
experiment appears to have worked well, for almost
every town in Sweden has adopted it. The reduction
in the taxation makes it to the interest of every man
to see the law enforced.
Prohibition. As I have already said, temperance
enthusiasts claim more than can be accomplished,
indeed they are following a shadow. But legislators
wishing to gain or retain power, may yield to com-
bined pressure and place a prohibitory law upon the
statute book. Prohibition failed in the Garden of
Eden; it has failed in every instance when it has been
placed upon the statute book; and it must continue to
fail until the ninety out of the hundred adults who
use alcoholic drinks without abusing them are edu-
cated to the belief that they are committing a sin.
This belief does not exist and can not be enforced by
prohibition, upon the principle : take from a man
against his will his freedom of action, he chafes under
it and considers it a hardship. It may be asked, will
any reasoning mind believe that — with the existing
appetite for stimulants — a prohibitory law would or
could be forced, and would not the endeavor lead to
disrespect for the law, smuggling, illicit distillation
and the use' of other stimulants and narcotics with all
their injurious consequences?
Again, if such a law existed, would it not pave the
way to others equally obnoxious? The sanitarian
finds it difficult to administer laws where an injurious
appetite is not involved, and where the benefit applies
to all. It is claimed that a prohibitory law would
lessen crime and consequent expense. This is more
than doubtful, for the expense of enforcing prohibi-
tion would be necessarily large.
The next question for consideration is: What
shall be done with the inebriate ? Medical treatment
has little influence upon him while he has the ability
to indulge his appetite; entreaty is useless, the tears
of a fond wife are of no avail, the finer qualities of
his nature are destroyed, the terrible craving for stim-
ulants has in a great measure taken possession of his
will and he pursues his course to degradation and
death regardless of consequences. How the law shall
deal with him is a question of great difficulty. The
liberty of the subject must be guarded and the com-
munity justly claim protection from the violence of
his acts.
There are two classes of inebriates; those who vol-
untarily get drunk, possessing the power to resist,
and those who are so far lost that their voluntary
power is destroyed. The first should be treated as
misdemeanants, the power of the elective franchise
withdrawn from them, after the second conviction,
and in other ways degraded.
The involuntary drunkard, if I may so term him,
should be treated as a lunatic and kept in restraint
for a period sufficiently long to cure his malady; how
478
NON-ALCOHOLIC TREATMENT OF CONSUMPTION.
[August 29,
long that should be must depend upon those in
charge of him; and when that restraint is enforced
for a suitable time it is often surprising to witness
the recovery of mind and body under it. It is true
that the inebriate is not in the strict sense of the term
a lunatic. Tbe church looks upon him as a sinner,
the state as a criminal, while the observing physician
knows that he has lost his power of self-control, is
ruining his health, shortening his life, squandering
his property, and oftentimes in his delirium commits
acts of violence against those most dear to him. It
may be said that the disease was caused by his own
act. True, but that does not absolve the State from
responsibility. Is he dangerous to himself and others?
He certainly is, and therefore he deserves the same
care as a lunatic.
While restraint is necessary I deem it highly im-
proper that the inebriate should be associated with
lunatics. The government receiving a very large
income from the material causing the evil should be
forced to supply and support hospitals for the cure of
the disease — such hospitals stand upon a different
footing from others, and it is obviously unfair for the
private individual to be taxed for the support of
them, beyond that which he willingly pays consequent
upon the tax upon the material producing the disease.
Such hospitals should be established in a pleasant
district in the country, built in cottage form, so as to
receive the different classes and sexes, and so fenced
as to prevent escape. Those who can not pay should
be compelled to work at fixed wages, the proceeds of
which — deducting the amount for their board — should
be paid to those dependent upon them.
The present practice of imposing a heavy fine upon
the inebriate is cruel in the extreme, inasmuch as it
does not fall upon the offender but upon the unfortu-
nate wife and family, already beggared by the selfish
creature's act. Again, the imprisonment imposed has
the effect of recouping him for another debauch.
Dr. Norman Kerr claims that 40,000 die yearly
from inebriety in London and that one-third of those
could be cured by proper isolation and treatment. I
take it for granted that a like proportion die in the
larger towns of America. If such is the case, the
wonder is that legislators hesitate about applying the
remedy. Recently those in authority are becoming
better educated to the necessity for spending money
for sanitary purposes; surely this sanitation should
appeal to the sympathy and the judgment of all.
Voluntary isolation is valueless. The inebriate, as
a rule, will not enter, and when he does it is for a
short period and to exercise his own judgment about
leaving. In a large majority of cases a year or more
is required before the individual can be pronounced
well.
I have been unable to learn the laws of your coun-
try regarding inebriety. But in the Provinces of the
Dominion of Canada the friends of the inebriate are
empowered by law to cite him before a judge of the
supreme court who, upon sufficient evidence, may
incarcerate him for a year in an inebriate asylum.
The judge may also appoint a committee to take
charge of his estate. This is as it should be. But
each province is obliged to furnish and maintain its
own asylum. While the large revenue received from
the importation and manufacture of the material
causing the evil is appropriated by the Federal Gov-
ernment, the law is only enforced in those provinces
where asylums exist.
Believing as I do that education and hospital iso-
lation are thepost practical remedial measures for the
gigantic evil of intemperance, I appeal to the mem-
bers of our noble profession, who are ever foremost
in philanthropic work, to exercise the power which
each and every one of them may possess toward this
end. If any thing that has fallen from me has the
effect of enlisting their interest in this good cause I
shall feel that I have not spoken in vain.
II
NON-ALCOHOLIC TREATMENT OF CON-
SUMPTION.
Read in the Section on State Medicine at the Forty seventh Annua)
Meeting of the American Medical Association
at Atlanta, Georgia, May 5-8, 3896.
BY O. G. PLACE, M.D.
BOULDER, COLO.
That consumption is a disease of lowered vitality,
I think, is not to-day questioned. While the tubercle
bacilli is the active agent in this disease, yet observa-
tion shows us that while the body tissues are well
nourished and the general vitality good, tissue cells
have the power of repelling these germs, even though
they may be quite plentiful in the body, but lowered
vitality predisposes to tuberculosis.
Alcohol lowers the vitality of body tissue. On this
point Dr. N. S. Davis says: "Alcohol is a poison and
when taken into the system is not assimilated, and
while passing through the body disturbs every physi-
ologic process and is finally thrown off through the
organs of excretion unchanged. Hence, if not assim-
ilated it can not be a food, and as it disturbs every
physiologic process it can not be a medicine. There-
fore, if alcohol is not nutritious and serves no purpose
as a therapeutic agent, then mankind should be so
instructed and its promiscuous use abandoned. This
work can alone be done by the medical profession."
Also the following from Dr. J. W. Squires is worthy
of note: "Numerous scientific investigations by
various distinguished authorities bear me out in the
statement that alcohol is not a stimulant but a
depressant; is not a tonic, but an anesthetic; is not a
food, for it is not digestible nor assimilative; it
impairs the senses, and that, too, in exact proportion
to the quantity consumed."
A strong man in perfect health and strong mind
will degenerate physically and mentally by a liberal
use of alcohol in any form. It is true that in many
cases alcohol increases the production of adipose tissue,
but it is just as true that it decreases the amount of
muscle. But in this case we are to choose between
fat and muscle. What is the change in fatty degen-
eration of the heart? If adipose tissue is more valu-
able than muscle, why is our anxiety aroused and our
advice so positive when we decide that the muscle
fibers of the heart are gradually being degenerated
and globules of oil are taking their place? Alcohol
may and does, without question, often increase fat.
Bodily inactivity will often do the same; but is a fat
man stronger than a muscular man? Is a fat man
more able to resist disease than a man who has less
fat and more muscle? The cause of lowered vitality
suggests the remedy.
That there is in all cases of consumption an unnat-
ural and more or less rapid disintegration of bodily tis-
sue is not questioned. Tuberculosis is a most treacher-
ous disease and the germs are only waiting at the win-
dows of our bodies to stealthily creep in and spoil the
house as soon as by intemperance in any form, the body
L896.]
NON-ALCOHOLIC TREATMENT OF CONSUMPTION.
479
1ms been rendered so dormant as not to repel the
intrusion. In presenting the above, the point we
wish to make before speaking of treatment, is that fat
does not necessarily mean vitality; that adipose tissue
is of a lower order than muscle; that weight and
Btrength are not synonymous.
Hundreds of patients to-day are coming to Colo-
rado with this advice: "Drink plenty of good whisky
and keep in the sunshine and you will soon build up."
The climate of Colorado does stand as the best refuge
known to us for those infected with this disease. The
sunshine helps to make this climate what it is, but
the man who comes here with little vitality, low by
disease ami still lower by alcohol, and sits in the hot
sun. will go down like an ieiele in the streets of Cal-
cutta in midsummer.
In the treatment of this disease better vitality is
the one thing essential: oxidization brings better
vitality -.cold, not heat, promotes oxidization and gives
tone to the body tissue. Patients must avoid the
extreme heat of any country. The Rocky Mountain
region is recognized as having a dry climate abound-
ing in sunshine. It fully sustains this reputation;
yet in some sections of this State, especially in the
southern portion as well as other points along the
foot hills south of latitude 40, there is not that cool,
bracing air which is found extending farther north
even into southern Wyoming.
Although there has not been discovered any specific
preparation which taken internally or externally will
destroy the germ, yet we believe that by proper care,
combined with climatic advantages, a much larger
percentage of complete recoveries may be obtained.
We are convinced that tubercular patients need
equally as regular management, advice and treatment
as patients suffering from other protracted fevers.
The following outline of treatment and general man-
agement during the past two years has seemed to
bring gratifying results, and a few cases are cited
below to illustrate conditions of patients and results
obtained from the change of climate combined with
careful treatment. The general treatment pursued
has been substantially the following: All patientsare
kept in bed for a few days after arriving to prevent too
much reaction. When there is much fever the
patient is kept quiet until the temperature shows a
decided drop, and remains down. The most nutri-
tious foods are given which can be assimilated by the
digestive system, paying attention to frequent change
and good variety ; but at the same time caution against
"stuffing." When the temperature rises above 100.5
F. we have employed the moist compress, enveloping
the whole chest and so adjusted as not to allow the
air to pass under it. This is held firmly in place by
another dry covering made of cheese cloth, which
is wrapped about the chest and over the shoulders,
completely covering the moist one and holding the
same close about the chest. When this compress is
removed in the morning, unless the patient is liable to
chill, a cool, wet hand-rub is given by a skilled attend-
ant, who follows it by a light, medium or thorough
massage, according to the patient's condition and the
prescription given in each case. In this way the cir-
culation is well started just at the time when the
temperature is generally the lowest.
The object of this treatment is two-fold, for its
tonic effect on nutrition and its antiperiodic effect on
the nervous system. For it is well known that in any
fever if the periodicity can be broken or modified by
anticipating the chilly stage by a thorough warming
of the body the chill is markedly decreased, and the
fever is in like proportion lessened. The patient is
especially protected and kept warm in the morning,
but allowed to be out much in the cool air a little
before time for the temperature to rise. When there
is a tendency to night sweats a hot vinegar or salt
sponge will usually control this and so quiet the
patient as to induce sleep. From 5 to 30 drops of
creosote by enema is also given in an emulsion of oil
of sweet almonds and the yolk of eggs three times a
week. General treatment by an attendant is given,
such as light massage, electricity, dry or wet hand-
rubs or sponges, according to the strength and reactive
powers of the patient.
In cases where there is thickening or much accu-
mulation of secretion in the smaller tubes or air cells,
we have used quite liberal inhalations of ozonized
oxygen, which serves to loosen up and clear out such
exudate more satisfactorily than perhaps any other one
measure. This gas acts upon the pus and exudate ina
similar manner as dioxid of hydrogen would, but in a
very mild manner; the results can be governed at will
by regulating the quantity of gas inhaled. Ozone can
be produced quite readily by whipping pure oxygen
in the static flame generated from a large coil attached
to a dynamo producing the direct current. Any coil
which is strong enough to throw a ten-inch spark
will produce a liberal amount of ozone by using the
silent discharge, but not the spark.
In cases where the bowels are especially involved
and there is much pain and looseness, we have been
able to control both quite readily by the moist abdom-
inal girdle, protected as for the chest, the use of hot
applications over the bowels and hot starch enemas.
In jnild cases, usually the girdle will relieve in a few
hours; in more severe cases, each or all of the above
measures may be required. We find it necessary to
keep patients quiet while the temperature is high.
The following cases taken from our book of records
without selection, and including all tuberculous
patients who entered during twelve weeks ending
September 31, will give an average result from the
employment of the above outlined treatment:
Case 1. — July 3, Miss F. B., aged 20 ; home, West Virginia ;
heredity, tuberculosis. Patient has been failing for a year,
cough for past three months. When received had a very dis-
tressing cough, raising heavy yellow sputum ; test showed
tubercle bacilli : temperature 101.5 degrees. Quite extensive
thickening in right lung and rales in both apices. Treatment
as indicated above. Result, : Patient began regular work as a
nurse in one month, in three months all indications of thicken-
ing had disappeared and the temperature was normal. She
had gained eighteen pounds in flesh and no return of any
symptoms to date, and yet regular work has been continued
since the first month.
Cage 2. — P. T. J., aged 21, Iowa. Grandfather and grand
mother died of consumption. Patient never very strong. Con-
dition at examination : Left lung, lower lobe, solidified ; upper
lobe much thickened, with rales quite general; temperature 101
to 103 degrees, with chills. Patient gained during the first
three months fifteen pounds. Temperature normal, but lower
lobe did not entirely clear up. Was quite well until he took
cold about three months ago, which again caused much thick-
ening in the left lung. Patient at present has some fever, but
is making a slow but steady gain. Temperature now about
100 degrees.
Case a.- Mrs. J., aged 19, sister of above patient. Large
cavity in upper lobe of right lung, lower lobe consolidated ;
left lung slightly thickened; not able to walk; temperaturo
102 to 103 ; chills, no appetite, bowels tender and loose, pro-
fuse night sweats. Patient made a steady gain for five months.
Left lung gave no signs of further infection; right lung still
slightly thickened but no rftles ; temperature normal; cavity
contracted. March 1 patient was discharged from treatment,
480
MANAGEMENT OF GLAUCOMA.
[August 29,
but advised to remain in Colorado. Five days later took a
severe cold from exposure, contracted pneumonia of the left
lung and died the following week.
— Case 4. — Capt. B., aged 60, Iowa. Grandfather died of
consumption. Patient suffered since the war with stomach
and bowel trouble. Pneumonia two years ago, involving the
left lung ; marked pleuritic effusion. Physical examination
showed left lung to be practically consolidated, with breaking
down near the apex, forming a small cavity. Examination of
sputum showed tubercular bacilli in large numbers. Had
three severe hemorrhages. Temperature on entering 100 to
101.5. Has had two quite severe hemorrhages while under
treatment, but is now gaining in flesh and strength..
Temperature now normal both morning and evening. Especial
attention has been given in this case to the digestive system
as well as to the lungs.
Case 5. —Aug. 20, 1895; Miss C, Michigan, aged 26. His-
tory, always delicate, troubled with enlargement of the glands
of the neck for fourteen years ; have been removed twice ; was
sent to Colorado by physician two years ago after having two
hemorrhages. Made a very satisfactory gain for several
months when she had what she termed "grippe." In my judg-
ment, many of the so-called cases of "grippe" are simply an
acute attack of tubercular invasion ; that is, in these cases
which later develop tuberculosis. Examination on entering
our institution showed the left lung thickened, especially in
the lower lobe, with only fine crepitant rales and little, if any,
normal vesicular sounds. The upper lobe showed decided
signs of softening near the apex, and either dilated tubes or a
small cavity. The temperature varied from 101 to 103.6 during
the first week. The ozonized gas was used carefully, and the
exudate was quite readily cleared out of the lower lobe, but the
indications of a cavity still remained near the apex. Patient
has gained and lost at times, but on the whole is at present
about as when we first examined her, except that the lung
has cleared up almost entirely. Is still under observation but
not treatment.
Case 6.— September 1, Miss E., aged 24, Michigan. Patient
never strong ; had two hemorrhages about eight years ago ;
began to decline about one year ago ; sputum tested and the
bacilli found ; sent to Boulder by her physician. Physical
examination showed marked thickening near apex of left lung
with moist rales. Temperature varying from 100 to 101 ; no
night sweats ; annoying cough. Treatment pursued as given
above and patient after two months showed no evidence of the
thickening ; temperature normal ; no cough ; had gained
twelve pounds in flesh and has since worked continuously and
no indications of return of the disease.
Case 7.-— Mrs. W., aged 34, New York. Father died of con-
sumption. Patient well up to about five years ago, then had
pneumonia ; has had seven hemorrhages ; coughed most of the
time for the past five years ; has been failing for the past two
years ; shortness of breath, very nervous and appetite poor.
Physical examination revealed general thickening and moist
rales throughout both lungs with friction rales on right side.
Temperature varied from 99 to 100 during the first week.
Especial attention was given to diet and treatment. She was
kept absolutely at rest for one month, after which she took
some exercise, and for the past three months has been work-
ing from six to ten hours per day and her temperature has been
normal for over two months. Much of the thickening has been
cleared out and the rales have nearly disappeared. The patient
was discharged about one month ago, but advised to stay in
Colorado the remainder of her life.
Case 8.— September 10, Miss M., Indiana, aged 32. Heredity
good ; had what she called la grippe four years ago, since
which time has had two hemorrhages with cough. For past
year has had a persistent cough and throat remains irritable
and husky. Physical examination showed general thickening
of the right lung with mucous rales in upper lobe. The ozon-
ized gas was used quite freely in her case with other treatment,
and November 28 she was discharged with only slight indica-
tion of thickening in the back part of the middle lobe of right
lung. Temperature had been normal for several weeks.
Case .9.— Sept. 12, 1895, Mr. T. M., aged 20, Iowa. One
sister died of consumption. Patient in fairly "good health up
to about one year ago, when he "took a severe cold;" had
pain in lungs and after the "cold" was relieved noticed a
shortness of breath with cough. Sputum was examined and
tubercular bacilli found. His physician advised him to go to
Colorado by wagon ; the trip was very tiresome and patient
lost much strength and flesh while on the road. He was put
under treatment at our institution September 12. Physical
examination showed the upper lobe of the left lung softened
and the whole lung thickened, with crepitant rales in lower lobe.
Temperature first week varied from 101 to 103.6, with chill daily.
Patient was kept absolutely quiet, the cool compress kept con-
stantly about the chest. The ozonized oxygen was freely used,
about ten gallons twice daily. Later took careful exercise and
spent much time on the verandas and in the sun when not too
warm. The appetite was very poor, bowels tender and the
patient much emaciated. Patient was discharged from treat-
ment Dec. 10, 1895, after having gained twenty-two pounds.
Appetite good, and but slight thickening in upper portion of
left lung.
Case 10. — Mr. W., aged 23, New York. One sister died of
consumption. Had been running down for about a year ;
slight, dry cough at first, gradually grew more troublesome.
Physical examination revealed marked thickening of upper lobe
in right lung and some considerable infiltration into the small
tubes of the lower lobe. Chills daily in the morning, with a
rise of four degrees of temperature by 2:30 p.m. Tubercle
bacilli found on examination ; considerable expectoration.
Temperature gradually lessened under treatment and patient
was discharged December 1, to all appearances well, but
advised to remain in Colorado for one year at least. Two
months later he passed an examination for life insurance, and
has, to the present time, shown no indications of any return of
the trouble.
The above ten cases are taken without selection, in
the order in which they entered our institution. We
are convinced, after watching a large number of
patients in Colorado, that tuberculosis is curable in
a large percentage of cases and without alcohol, pro-
vided the same study and care is employed with these
cases as with other patients suffering with infectious
fevers.
REMARKS ON THE MANAGEMENT OF
GLAUCOMA.
Read before the Michigan State Medical Society,
BY LEARTUS CONNOR, A.M., M.D.
DETROIT, MICH.
The literature of glaucoma is honeycombed with
doubt and contradiction. If a writer advances a
theory of its causation, others demonstrate its inade-
quacy ; if one presents a pathology, another proves it
incomplete; if one proposes a plan of treatment,
others shortly affirm that they have tried the plan
and found it wanting. One cures his cases by iridec-
tomy, another by sclerotomy posterior; another by
sclerotomy anterior; another by internal division of
the sclerotic at the angle of the anterior chamber;
another by division of the ciliary body; another by
corneal punctures; another by myotics; others make
a selection from these several modes of treatment
according to the case in hand. This is a rational
method, but as no two make the same selection the
seeker for practical directions in treating a case of
glaucoma must sift his own data and follow his indi-
vidual judgment.
If the eye could be taken apart and studied during
the very early manifestations of the disease, we should
more directly attain that knowledge which shall unite
all discords into one consistent tune. As a fact, we
are compelled to wait till the eye is blind or the
patient dies from some intercurrent disease, for a
chance to study the actual changes in the eye made
by glaucoma. Experiments upon the eyes of lower
animals are utilized to fill this gap in our knowledge,
but these are always discounted by the doubt as to the
extent to which they represent the reactions occurring
in the human eye during the progress of a case of
glaucoma. Then cases of glaucoma are rare, so that
an individual observer has relatively few with which
to pursue his practical studies. Worse still, of the
cases he does see, few are within his observation
during the entire course of the disease. In spite
18%.]
MANAGEMENT OF GLAUCOMA.
481
of those and many other obstacles, the management
of glaucoma is progressively more satisfactory; what
pan be, is more definitely separated from what can
not be done and a clearer light illumines the entire
subject.
On one point all agree — normal ocular tension
should be restored at the earliest possible moment,
beoause an increase of intra-ocalar tension is to the con-
tents of the eyeball what a strangulation is to the intes-
tine in a case of hernia. Von Graefe first proved that
iridectomy would cure someattacksof glaucoma, a dis-
covery of inestimable value. Added experience has
shown that an iridectomy will not cure all attacks of
glauooma, or all stages of any one attack; that it is use-
less to stay the progress of some, and absolutely hastens
the destruction of the eye in other cases. Yet with all
its limitations it remains ihe remedy for attacks of
glaucoma with increased tension. The cause of this
increased tension has been the occasion of a vast
amount of research. Present facts seem to support
the following as the chain of events leading to an
attack of glauooma:
Normally the fluids secreted in the posterior cham-
ber of the eyeball escape through the cribriform disc
of the optic nerve and the suspensory ligament. From
the anterior chamber the outflow is by the anterior
angle through Fontana's spaces and the canal of
Schlemm. thence through the sclerotic to Tenon's cap-
sule. The spaces through which this outflow occurs
are in connective tissue and devoid of epithelium.
Hence the fluid has a constant contact with the con-
nective tissue fibers of the suspensory ligament, optic
nerve and angle of the anterior chamber. If this fluid
becomes abnormal and remains so during long
periods, the connective tissues through which it flows
must undergo changes. If the fluid be defective
in nutritive materials and loaded with irritative
elements it is clear that ultimately the connective
tissues through which it passes must undergo degen-
eration. Such changes in the secreted fluid of the
post erior chamber may be expected when the blood con-
stantly supplied to the chamber be what is known as
"dirty" blood. Such blood is found in numerous
diseases, as gout, rheumatic gout, syphilis, imperfect
digestion from either bad food, or good food taken in
excessive amounts. After a time the degenerative
process in the connective tissue outflow spaces of the
posterior chamber becomes so advanced, as to no
longer suffice for the free transmission of the fluid
secreted in the posterior chamber. If now this fluid be
changed by a disturbance of the secreting vessels,
through the nervous, muscular or digestive systems,
we may have the outflow spaces absolutely closed,
and an acute attack of glaucoma. Dr. Richey has
especially emphasized the origin of glaucoma through
the operation of "dirty" blood.
Knies has experimentally shown that the composi-
tion of the fluid in the posterior chamber may be so
altered as to effectually clog the outflow spaces, both
anterior and posterior, when the connective tissues
are perfectly normal. Much more will such changed
secretion clog the spaces when they are diminished
in size anil altered in character by degenerative
processes. Thus glaucoma is a chronic constitutional
disease, with occasional local outbursts in the eye due
to obstruction of the outflow spaces. Generally oph-
thalmologists have called the local outburst glaucoma,
and devoted their exclusive attention to its manage-
ment. Evidence is accumulating to indicate that it
is a part of wisdom to treat the general constitutional
dyscrasia that produced the local outburst, in the
expectation that the local treatment will prove more
satisfactory and future outbursts prevented.
Simple glaucoma has little to distinguish its pres-
ence in many cases, other than diminished visual
field and excavation of the optic nerve. Under the
operation of the constitutional dyscrasia the connec-
tive tissue of the optic nerve loses its power to hold
these fibers in place, so that with the central retinal
vessels they drop into the hole. The peculiar appear-
ance of the blood vessels at the sides of this hole
make it quite easy to recognize with the ophthal-
moscope this excavation. If the anterior connective
tissue spaces have escaped the ravages of the dys-
crasia no other symptom may attend the case from
beginning to end. But if the anterior spaces become
involved, other symptoms of more or less gravity will
appear. Without these latter the management of such
a case is wholly constitutional, as there is no reason
to suppose that either operation or medical treat-
ment, locally applied, will avail. To secure such
habits of life as will insure an abundant supply of
pure blood to every portion of the body, including
the eyeballs, will afford the patient the best chance
of retaining vision for the longest period. It is
surmised that some of the cases in which iridectomy
was followed by an immediate reduction of vision
belonged to this class. But most cases of simple
glaucoma, at some time in their course, present
other symptoms, as increased tension, diminished
field of vision, dilated pupil, pain, etc. These call
for local treatment, surgical or medical, or both.
Typical of the first is iridectomy; of the second
eserin.
As to the value of iridectomy in chronic simple
glaucoma, the studies of Dr. C. S. Bull (Trans.
Amer. Oph. Society, 1889) are very conclusive. He
gives the history of ninety cases treated during a
period of seventeen years, all of which he was able to
study for a considerable period after operation.
Vision was temporarily improved in two cases in both
eyes, in six cases in one eye; but in all the eight cases
a steady loss of vision and a narrowing of the visual
field set in and continued progressively so long as
the patients remained under observation. The vision
remained unchanged in eight cases in both eyes; and
in twenty cases in one eye. Vision grew steadily
worse in forty cases in both eyes, and in forty cases
in one eye. Vision grew rapidly worse after opera-
tion in two cases in both eyes, and in one eye in eight
cases. Of the one hundred and eighty eyes, only ten
eyes were at all improved by the iridectomy, and these
steadily grew worse. In thirty-six eyes the vision
was unchanged for a year after the iridectomy. In
one hundred and twenty eyes, vision grew steadily
worse after iridectomy, while in twelve eyes vision
grew rapidly worse after iridectomy. It is thus
clear that in chronic simple glaucoma iridectomy is
far from a brilliant success.
Of the comparative value of eserin and iridectomy in
simple glaucoma, an excellent study is given by Drs.
Zentmayer and Posey (Will's Eye Hospital Reports,
Vol. 1). One hundred and sixty-seven cases are
reported from the service of Drs. Norris and Oliver.
Sulphate of eserin was used in all cases when well
borne and was continued for years. At first the doses
were small, being increased or diminished according
to results. The cases irritated by its use were treated
482
MANAGEMENT OF GLAUCOMA.
[August 29,
by iridectomy. When well borne it improved central
visual acuity in 62.16 per cent, of cases, while it
retained vision unaltered in 21.62 per cent.; in 16.21
per cent, it was powerless to prevent decrease of vis-
ion. In 85 per cent, of the cases it diminished intra-
ocular tension. The visual field improved in 50 per
cent, of the cases; remained stationary in 18.75 per
cent., and steadily diminished in 31.25 per cent.
When well borne, eserin kept the fields improved
ten months, and vision fifteen months. In cases not
improved fields remained stationary for three months;
vision for thirteen months.
Iridectomy improved 60 per cent, of cases; did not
change 20 per cent.; failed to prevent loss of visual
acuity in 20 per cent.; diminished it in 10 per cent.
Tension improved in 90 per cent, of cases. The
improved visual field lasted on an average eighteen
months; the degree of visual acuity twenty months
after iridectomy.
The facts show that it is advisable to employ eserin,
when well borne, for a month; if the field of vision
has diminished nothing further can be hoped for from
eserin, and an iridectomy must be done. If there be
an improvement of the visual field, eserin should be
continued, as there is reason to expect a beneficial
action for ten months upon the extent of the visual
field, and fifteen months upon the visual acuity. In
half the cases we may expect iridectomy will check
the course of the disease for eighteen months. Ten per
cent, of the cases will not be benefited by either eserin
or iridectomy, or both. Both successfully reduce
intraocular tension. Thus in simple glaucoma we
have the following elements of management:
1. In every case make the nutrition of the entire
body as perfect as possible, by removing defects of
excretion or secretion; disturbances of digestion; con-
stitutional dyscrasias, as gout, rheumatic gout, syphi-
lis, etc. Medicines avail much, but wise regulation of
diet, exercise, sleep, bathing, etc., will generally be
most efficient.
2. Place the affected eye under the influence of
eserin, if well borne, and keep it there so long as it
controls the tension and prevents a diminution of the
field of vision. This failing,
3. Do a large upward iridectomy, and follow with
eserin, if well borne, while any manifestations of the
attack continue. This failing,- a sclerotomy anterior
may be done.
4. Correct and keep correct all defects of refraction
and muscular balance.
Acute inflammatory glaucoma presents a remarkable
likeness to acute inflammatory gout, just as simple
chronic glaucoma resembles rheumatic gout. The
following is given because the attack could be studied
from inception to close.
On March 29, 1880, Dr. Fletcher placed in my care
a boy, aged 15, suffering from an injury to his left
eye by an exploded gun-cap. The eye was operated
upon and the wound treated at a hotel under the care
of his father, a man 45 years old, of unusual intelli-
gence. Aside from a history of sub-acute rheuma-
tism, this man's general health had always been good.
His eyes were astigmatic, hyperopic and presbyopic,
though he wore a simple spherical glass to correct the
same, selected by a jeweler. While watching his suf-
fering child, he read much in a poor light. On the
morning of April 3, five days after coming to Detroit,
he complained of slight discomfort in his left eye,
and thought that at times his vision was dulled. A
careful study, of the eye revealed a slight intra- and
extra-ocular congestion, with a trifling increase of
tension. A saline cathartic was administered; a
soothing lotion applied hot to the eye at short inter-
vals; the eye protected from bright light and small
doses of quinin administered internally. On the fol-
lowing day the eye was worse in all respects ; the pain
in and about it had become intense; the pupil dilated
and very sluggish; the tension plus 2; the field of
vision contracted; the cornea insensitive; the ante-
rior chamber very shallow; the iris crowded into the
anterior angle which was filled from behind with the
ciliary body; the anterior ciliary vessels much dilated
and the entire circumcorneal margin of the sclerotic
covered with engorged blood vessels; the fundus oculi
was engorged, the optic papilla? being considerably
swollen; the retinal arteries pulsated on the slightest
pressure of the eyeball. Patient could not count fin-
gers and complained of flashes of light, when the lid
was closed, and rings about the light when the lid
was open. Thus we had a case of typical acute glau-
coma. To reduce the intense congestion, several
ounces of blood were at once abstracted by an artificial
leech from the temple, relieving the pain and reduc-
ing the tension. A drop of a two grain solution of
eserin was placed in the eye every hour while the
pupil remained dilated. Previous to each dose the
eye was soaked in hot water for five minutes. These
measures so modified the attack that the patient was
more comfortable on the following day, but the ten-
sion was still above normal; the fundus could not be
seen with the ophthalmoscope, and the eserin had
failed to keep the pupil contracted. Iridectomy was
now urged, but rejected. Local abstraction of blood
was repeated, a saline cathartic given, and the other
treatment continued, but with less effect than on the
X>revious day. Iridectomy was urged at each visit,
but rejected till the sixth day. Then vision was
reduced to a mere perception of light; the media
cloudy; pupil widely dilated; iris immovable; ante-
rior chamber very shallow; cornea steamy and insen-
sitive; great circumcorneal injection and very severe
pain. Because of the shallow anterior chamber a
Von Graefe"s cataract knife was used to make the cor-
neal incision, which was done upwards so as to admit
the removal of a full third of the iris. This was
drawn out of the wound by the iris forceps, till it was
placed upon the stretch and then divided by Wecker's
scissors, close to the sclerotic. The angles of the
wound being freed from the remaining iris the lid was
closed and protected from injury by a light bandage.
The '"little aqueous which escaped had a straw-like
color. The pain immediately disappeared never to
return; the wound healed kindly, the vision gradually
improved until it equals that in the other eye, and
the entire eye resumed its former condition, aside
from the mutilated iris. The cure of the attack was
complete.
To prevent future attacks the following measures
were adopted : His defects of refraction were fully
corrected and the correction glasses ordered worn con-
stantly. He was placed upon a diet and habit of
life, such as would tend to eliminate the arthritic
taint, and appropriate remedial agents were ordered.
There was no recurrence of the attack in the left eye,
nor did one develop in the right eye. The case
remained cured during many years till his death.
In this case we have an arthritic disorder existing
long anterior to the acute attack of glaucoma, in a
1896. i
MANAGEMENT OF GLAUCOMA.
483
changes
man who had reached middle life, suddenly subjected
to intense mental worry and marked eye strain.
Without the last two factors he might have escaped
the attack, but with them the secretion of the vitreous
was so modified as to clog the connective tissues of
the suspensory ligamenl and optic disc. This was
followed by an accumulation of secretion and enlarged
blood vessels in the posterior chamber which pushed
forward the ciliary body, the lens and iris, and forced
the aqueous out of the anterior chamber. An iridec-
tomy removed this obstruction to such a degree as to
admit of the normal circulation of the intra-ocular
fluids. No doubt the sudden change in the tone of
the intraocular blood vessels modified the
described.
The management of acute inflammatory glaucoma
by constitutional remedies, eserin and iridectomy, is
satisfactory to patient and surgeon if it can be applied
promply at the onset of the attack. Sub-acute glau-
coma differs mainly in degree from the acute. We
find moderate degrees of vascular obstruction and
some sharp pain; an enlarged and sluggish pupil;
increased tension: shallow anterior chamber; hazy
vitreous; pitted optic disc, in varying degree. The
following abstract of a case places it fairly before us.
Mrs. V.. age 70. seen first Oct. 22, 1885, a large
fleshy person of Hebrew extraction, and for many
years a more or less constant sufferer from rheumatic
gout, but otherwise perfectly healthy. At a period
prior to her visit to me she had noticed occasiona
obscuration of vision, a little redness of the eyes;
rings about lights; and some pain. At first the
attacks were infrequent, but of late they occurred
almost daily, and vision of right eye was 10-200, of
the left 6-200; pupils widely dilated and almost
immovable: aqueous cloudy: tension of right eye 2
and left eye 1; fields of vision greatly contracted;
much eireumcorneal injection and enlargement of the
anterior ciliary vessels.
She was given a mercurial cathartic followed by
full doses of salicylate of soda; her diet regulated so
as to secure the best possible digestion; her skin and
bowels were also so stimulated as to enable them to
perform their normal functions. Locally, eserin, one
grain to the ounce, was dropped into each eye every
hour till the pupil contracted, and then as frequently
as was needed to keep it moderately contracted.
Before using the eserin the eyes were bathed in hot
water for five minutes each. On the following day
all symptoms were improved and in two weeks the
eyes had become nearly normal in appearance, aside
from the cupping of the optic discs. On correcting
the hyperopia astigmatism and presbyopia her vision
was right eye 20-40, left eye 20-50 and she could
read Jaeger number 2 with each eye.
On recovering from the attack she was directed to
wear the correction glasses for her ametropia con-
stantly: to continue her anti-gouty diet and mode of
life, and to use a weak solution of eserin once daily,
if the eye seemed at all uncomfortable. She has been
faithful in following directions, and ten years later
reported no return of the disease, and fairly good
sight.
I have met many cases from syphilis, that were suc-
cessfully managed by the use, in a vigorous manner
of antisyphilitic in addition to the local treatment.
But in other cases such treatment fails and resort
must be had to iridectomy. If the cases can be kept
under close observation, and the fields of vision do not
diminish, and other symptoms improve it is safe to
wait till eserin and constitutional agents are clearly
futile, ere doing an iridectomy. But if the case can
not be carefully watched the iridectomy should be
done without delay — except in case of a degenerated
iris, when the operation is disastrous.
Absolute glaucoma presents a notable picture: eye-
ball of stony hardness; devoid of all expression ; blind-
ness complete; pupils widely dilated and immovable;
pupillary space filled with the glistening opaque lens;
sclerotic of marble whiteness streaked with the tortu-
ous and enlarged ciliary vessels; the glaucomatous
process has done its worst. No treatment remains
except such as will render the patient more comforta-
ble, which may necessitate a sclerotomy or an iridec-
tomy or enucleation.
We can not speak of glaucoma which is secondary
to other local diseases or injuries in the eye; each of
which must be managed according to its specific indi-
cation, the object in each case being the restoration
of a normal circulation through the chambers of the
eyeball. Pertinent to the management of glaucoma,
is a brief note on the technique of the operations for
its relief. In glaucoma the iridectomy differs materi-
ally from that done for optical purposes in that it needs
to be as large as possible, and the iris removed close to
its scleral attachment. Owing to the shallowness of
the anterior chamber, great care is needed in making
the corneal section, to avoid wounding the lens; other-
wise grave consequences follow. I have found the use
of Von Graefe's cataract knife most suitable for this
purpose, as by it one can skirt the angle of the ante-
rior chamber, keeping in the sclerotic, and make a sec-
tion as large as desired. The incision should always
be made in the sclera.
When the anterior chamber is nearly normal, the
lance shaped knife may be employed, or the Graefe
knife, used as in making the incision for cataract
extraction. It is desirable to make the withdrawal of
the knife so slow as to avoid the sudden freeing of the
tension of the posterior chamber. On completion of
the section, the iris is seized by the forceps and drawn
till it is fully without the eyeball, then divided close
to the sclera. Especial attention is given to the edges
of the wound that they do not retain any of the
remaining iris. Formerly a general anesthetic was
required but now cocain suffices if the patient be con-
trollable.
Anterior sclerotomy is possible only when the pupil
is contracted and the anterior chamber of nearly nor-
mal depth. A Von Graefe's cataract knife is intro-
duced about two millimeters above the horizontal
margin of the eye and a counter puncture made
directly opposite. By gentle movement the blade of
the knife is made to cut its way, till it has nearly
reached the surface, when its withdrawal completes
the operation. This operation is called for in cases
threatening hemorrhage, or after iridectomy has failed.
Posterior sclerotomy is done by opening the sclerotic
between the lower and external recti muscles, and pos-
sterior to the ciliary processes. The blade of a Von
Graefe's cataract knife having been entered horizon-
tally through the sclerotitis turned at right angles and
slowly withdrawn. Some fluid or vitreous may follow
this operation, and the tension of the eyeball reduced
so as to admit of an iridectomy which otherwise could
not be correctly done. Numerous other operations
have been done for the relief of glaucoma ; thus a large
portion of the sclerotic at the anterior angle has been
484
HYGIENE OF THE EYE.
[August 29,
divided from within and good results reported; th
ciliary body has been divided; the cornea has been
punctured at each end of the vertical and horizontal
meridians; the supratrochlear nerve hasbeenstretched.
But after all iridectomy furnishes in the ordinary
case the largest hope of relief.
Lately Dr. Gould has proposed the use of massage
of the eyeball for the purpose of freeing the outflow
spaces of the debris clogging their meshes. He reports
one case in which the results at date of writing were
satisfactory. To a certain extent all the operations
mentioned, exert a massage at the point of greatest
obstruction, and doubtless, in this way produce their
effects.
Dr. Pilgrim lately advocated with much show of
reason the local use of the galvanic current placing
the negative pole over the affected eye and the posi-
tive at the nape of the neck. In three cases of acute
inflammatory glaucoma he reports the happiest
results. He thinks that the current modifies favora-
bly the obstructing fluid, and the obstructive connec-
tive tissue at the outflow spaces.
My own experience supports the claim of Dr.
Sutphen, that salicylate of soda often relieves the sev-
erer pain of glaucoma, and accords with the funda-
mental idea of this paper, that the foundation of glau-
coma is' a constitutional dyscrasia, which should be
sought out in every case and removed so far as
possible'
CONCLUSIONS.
In the management of glaucoma, such attention
should be given the bowels, skin and kidneys as to
secure the most prompt and complete elimination of
the effete tissue metamorphosis. The diet should be
so regulated as to admit only such articles and in
such quantities, as can be perfectly digested. The
liberal use of water internally and externally greatly
assist in restoring the fluids of the body to a state of
reasonable purity. The continuance of such diet and
mode of life affords the largest hope of preventing
future glaucomatous attacks.
Such medicines should be employed as are called
for to remove the constitutional dyscrasia found in
each case, as arthritic, gouty, syphilitic, etc.
In simple glaucoma with no increase of tension such
treatment may suffice; but should there develop
increased tension, diminished visual field, pain,
shallowed anterior chamber, myotics should be first
employed (if they can be constantly watched) and if
they keep the symptoms under control, nothing far-
ther is called for. But if they are not well borne, or
if at the end of a month, the visual field has dimin-
ished, then an iridectomy should be done. If the
tension still persists, a sclerotomy should be performed
and myotics again employed.
In acute inflammatory glaucoma, the tension must
be promptly reduced by general treatment and myo-
tics if possible, but if these do not act immediately in
reducing the ocular tension and in keeping it reduced,
an iridectomy must be promptly done.
Sub-acute glaucoma is managed along the same
lines as the acute except that operative action may be
delayed a longer time, though the rule should not be
deviated from which demands an iridectomy in all
cases that grow worse under general management and
myotics.
Chronic glaucoma is managed in the same manner
as the sub-acute except that iridectomy is contraindi-
cated in cases of degeneration of the iris, the results
of the operation in such cases being unfavorable.
Absolute glaucoma is treated only to relieve pain,
if salicylate of soda fails, the treatment is exclusively
surgical, sclerotomy, iridectomy and enucleation.
Hemorrhagic glaucoma is rarely benefited by any
operation, owing to the weakened condition of the
blood vessels within the eyeball. Hence if genera-
and local medication fail, and pain persists, enucleal
tion is the only resource.
Secondary glaucoma calls for specific treatment
according to the condition inducing it. If it be an
intraocular tumor, enucleate the eye; if it be lens
swollen from discission, extract the same and so through
the list.
Finally, he who would do the most for a case of
glaucoma, must not only be able to quickly detect the
disease in the form of its acute exacerbation ; to apply
the local remedies or do the operation which will
quickest and surest restore the normal intraocular cur-
rents; but he must be able to recognize the constitu-
tional dyscrasia, underlying such acute attack and put
in operation the wisest measures for its mitigation or
removal.
103 Cass Street.
HYGIENE OF THE EYE.
Read before the Medical Society of the District of Columbia.
BY CLARENCE R. DUFOUR, Phar.D. M.D.
Physician in Charge of Eye Department. Eastern Dispensary : Ophthal-
mologist and Otologist to Sibley Memorial Hospital; Assistant
in Eye and Ear Department of Central Dispensary and
Emergency Hospital, and Instructor in Ophthalmol-
ogy and Otology, Georgetown Medical College.
WASHINGTON, D. C.
The many cases seen in private and hospital work,
which earlier could have been more effectively treated,
if not entirely cured or corrected, and the earnest desire
to obtain the cooperation of the general physician is my
only excuse for bringing this subject before this
society. As a rule, healthy parents beget healthy off-
spring; therefore, that the eyes may be free from dis-
ease and have perfect vision, the parents should live
such lives as will conduce to health, that their chil-
dren may be perfect physically and mentally; there
should be legislation preventing marriage and inter-
marriage between those suffering from disease that
may be transmitted to their children. The disastrous
effect upon the eyes by syphilitic heredity is well
known, also that of consanguinous marriages; in the
first class we find various inflammatory conditions of
retina, choroid and cornea; in the latter class we fre-
quently find retinitis pigmentosa and sequela;. One
disease that is responsible for a large percentage of
blindness and which costs the government millions of
dollars annually for support of the blind, is ophthal-
mia neonatrum, but owing to the unceasing efforts of
physicians this disease is becoming rare. Several
States have laws making it a penal offense for nurses
or midwives to neglect reporting a case of sore eyes in
infants which they alone have attended at birth. I
have seen the gradual decrease of this disease in the
clinics with which I am connected. It is the class of
persons who, from their mode of living and lack of
hygienic surroundings, and often want of medical
attendance, whose infants are more liable to this and
other ocular diseases. These people still need educat-
ing as to the necessity of applying early relief in all
eye inflammations and affections. As a rule, when
they seek advice much damage has been done, which
is almost, if not entirely, irreparable; as a result of
18%.]
HYGIENE OF THE EYE.
485
this we find many cases with all sizes and shapes of
opaoities of the cornea, disfiguring it and interfering
more or less with vision; there is not a day that we
do not meel men and women with eye affections which
could have been remedied by early treatment. Chil-
dren have been allowed to grow up with affections of
the eye which handicap them in their studies. The
failure of those having the children in charge to have
all ocular troubles treated in their incipiency is due
either to ignorance or indifference.
By the adoption of the Orede method of dropping a
■2 per cent, solution of nitrate of silver into each eye
of the newly born infant and by the adoption of
scrupulous cleanliness to avoid reinfection, ophthal-
mia neonatorum con be prevented. So it is possible to
prevent the disastrous effects of purulent ophthalmia,
of iritis, keratitis and other ocular diseases by early
and prompt treatment.
It is no uncommon experience of the ophthalmolo-
gist to have patients brought to him who are past the
period when treatment will be of benefit. Recently I
have had two such cases brought to my service at the
Eastern Dispensary, one a colored youth who had
cyclitis of both eyes, which developed into a panoph-
thalmitis, with total destruction of both of them.
This case was seen by one of our general practitioners
during the period of intense inflammation, and who
instructed him to apply at the dispensary, but he
refused to go. -He will always be a charge upon his
friends or the community, perhaps both. I shall not
be surprised at any time to see him among the many
who are daily soliciting alms on our thoroughfares.
The other case was one of purulent ophthalmia, which
was treated at home by his people; the result was
total destruction of the affected eye. Neglect of the
eyes in infancy or at an early age is often the cause of
poor eyesight; they are more sensitive to light than
at mature age; children are often taken out of doors
with their faces unprotected from the bright sunlight,
or are allowed at night to stare at the gas or lamp-
light for hours; this is all wrong; the child's eyes
should be protected from the glare of light of any
kind; also from dust and other irritating substances
and from atmospheric changes. Should this be
neglected an impairment of vision may result. As
they arrive at the age of 6 years, the age at which
they begin school, their eye work should be regulated
by their physical development; it would be better to
educate them by the kindergarten method and by
object teaching until they are about 10 years of age;
their eyes would be in better condition to stand the
work to be put upon them in the future. In a report
of the public schools of one of our cities I found for
the year 1893 that of the total attendance, 69.63 per
cent, were in the primary grade; the ages of this
grade ranged from 5 to 10 years ; 26.06 per cent, were
in the grammar grades, and only 4.31 per cent, were
in the high school. By these figures it was seen that
a little over 50 per cent, failed to enter the grammar
grades; the average age at that time was 10 years; at
the termination of the grammar grades 71.68 per cent.,
more than three-fourths, failed to enter the high
school; the total loss between primary and high school
was about 96 per cent.
The question naturally arises as to what is the
cause of this loss and why so few enter the high
grade. Removals, sickness and death are factors in
causing these results, but are they the sole causes?
Many may be taken from school because tneir parents
think that it is necessary that they receive only suffi-
cient education to enable them to read and write and
perhaps have a slight knowledge of arithmetic. Still,
if this be so, there are others who fail to enter the
higher grades because of their inability to keep up
their studies. Many of them are not in full vigor of
health, are weak and poorly nourished, have bad
hygienic surroundings, and their whole aspect is one
of lack of nutrition. These children, as a rule, also
suffer from defective vision. Not only from this
class are those who drop out of school or keep up
in their studies with difficulty, but we find them
among the healthy and well nourished; the reason of
this is that having some visual defect they can not do
their work without such physical discomfort that they
finally yield and leave school. The children at our
public schools are kept too continuously at work, long
lessons are assigned them for memorizing, and the
general curriculum, especially of the grammar grades,
is one liable to produce eye strain and mental fatigue.
I think we should have some legislation compelling
an examination of the eyes of all children at the time
of their entrance to school, and as they progress and
reach the higher grades there should be some method
whereby a supervision of their eyes could be main-
tained. Their studies should be regulated so that the
hours for home study would not be too long. The
lessons given in the eighth grade and high school
in this city are, in my opinion, too long; the bright-
est and best scholars are compelled to begin their
studies in the early evening and continue them until
10 and 11 o'clock in order to complete and memorize
them; the effect upon their eyes is bad, and not only
upon them, but upon their general health. It is no
uncommon experience to be told by parents that their
children's eyes and health began to fail after their
entrance into the grammar grades of our schools. We
need more physicians on our school boards who will take
an active interest in all matters pertaining to the educa-
tion of our children, such as the amount of work to be
done daily, the arrangement of desks, light, ventilation,
etc. They are better qualified to regulate such matters
than any other class of persons, and I think that the
country at large would be better served had we more
physicians to represent us in the different legislative
bodies of the United States. The city of Washing-
ton is fortunate in having so many of its prominent
physicians actively engaged in endeavoring to secure
such legislation as will be of great benefit to the city and
its entire population. Poor light is a factor in produc-
ing eye strain, therefore, particular attention should
be paid to the manner of allowing the light to enter
the school room, it should not be allowed to shine
directly in the faces of the scholars, but, if possible,
from behind them. The walls of the school room
should be painted some neutral tint, thus doing away
with the white walls, the glare from which further
contracts the pupil, already contracted by the effort
of accommodation. When we remember that the
contents of the eye is really a liquid, and that we
have six muscles attached to it externally, we can
readily see that a strain of this character together
with the effect of poor light and the dependent posi-
tion of the head usually assumed in studying, will
tend to produce myopia, which will, as a rule, increase
as the child advances in its studies and keeps pace
with the higher education of universities and colleges.
The effects of a high degree of myopia are sometimes
very grave, complete blindness of one or both eyes
486
HYGIENE OP THE EY
L
[August 29,
ensuing from detached retina, stretching of the per-
cipient elements of the eye, etc. Divergent strabis-
mus is mostly associated with myopia, and if not
early corrected by glasses and an operation, if neces-
sary, the sight of the diverging eye may become
permanently impaired. Parents and others having
children under their care have a great responsibility
upon them; these children are to be the bread win-
ners of the coming generation and everything should
be done that they may enter their respective vocations
of life in as perfect physical and mental condition as
possible. We need the cooperation of the family
physician in this, as he is usually the one from whom
advice is first sought, and it is he also who is to
advise the parents to have all abnormal conditions of
the eyes promptly treated.
Another condition from which children and adults
suffer is hyperopia, so-called far-sightedness. This I
believe to be the normal condition of the human eye.
Prof. Jaeger of Vienna examined the eyes of a large
number of new-born children and found nearly all of
them hyperopic. This condition is due to the shape
of the globe, it being too short antero-posteriorly,
the rays of light that enter the eyes do not focus
upon the retina, but behind it, so that in order to
sharpen the vision the ciliary muscle is called into
action, to make the lens more convex, thus practi-
cally elongating the globe, that the rays may focus
upon the proper place, the macula. This constant
effort of the ciliary muscle, which should only be
brought into action for near vision, will cause head-
aches, pain in the eyes and other distressing symp-
toms, and often affects the entire nervous system and
general health; the nervous system is kept under con-
stant strain by the effort of the eye muscle endeavor-
ing to secure perfect vision ; general character and
disposition are frequently affected by imperfect sight.
Children often appear dull and stupid from this cause,
if they are compelled to use their eyes for long and
close work, in the glare of too much light or insuffi-
cient illumination. As long as they have out-door
work and their physical condition is good, they suffer
little if at all. Children with hyperopia will find that
by squinting they can see more distinctly, they will
not squint constantly at first, but only when looking
at near objects, and sometimes when looking at a
distance ; this is periodic squint and manifests itself
about the fourth or fifth year, when they are learning
to spell. Convergent strabismus is mostly associated
with hyperopia, and unless promptly corrected the
vision of that eye may become permanently impaired.
Both of these conditions may be corrected by prop-
erly adjusted glasses, an operation, or both; as a rule
the glasses are always needed by the patient. It is
the hyperope as a rule who suffers most from his
eyes, is prone to headache both temporal and occipi-
tal, and nervous symptoms; these latter are more
aggravated when associated with muscular imbalance.
Cases are on record where chorea and epilepsy have
been cured by the correction of the refraction error
and the heterophoria. The usual train of objective
symptoms due to the eye strain are impaired vision to
a greater or less degree, winking the eyelids, con-
stantly inflamed conjunctiva, scales and crust in and
among the cilia?, crops of styes, strabismus divergent
and convergent, etc. The subjective symptoms are
inability to use the eye for any length of time on
account of pain and blurring of the image; the run-
ning together of the type, or lines or both; sensation
as of grit between the lids, etc. The ophthalmolo-
gists have of recent years devoted considerable atten-
tion to the prevention of disease and have achieved
considerable success. I believe with earnest efforts
in this direction that further good can be accomp-
lished. It is a well-known fact that the older text
books on ophthalmology contain much in regard to
pathology and treatment, but very little in regard to
refraction; true we have works which treat theoreti-
cally of refraction, such as Donders and Landolt,
which can not be improved upon, but they do not
treat of heterophoria or state that errors of refraction
are a causative factor in certain diseases and that
their correction cures them. We now know that
many of our ocular diseases, such as conjunctivitis,
chalazions, styes, blepharitis, etc., which were once
believed to be local in their origin, are largely due to
eye strain, that when they are corrected by a properly
adjusted glass, the cause being removed a cure is
effected. It is the belief of the writer that refraction
errors can produce not only the above-mentioned dis-
eases, but that it is capable of producing more seri-
ous eye troubles as well as constitutional ones.
Lately I read a paper before this society on " The
Relation of General Disease to the Formation of Cat-
aract." I would state that I believe also, that there
is a relation of eye strain to the formation of cataract
and to the causation of glaucoma; the etiology of the
latter disease is yet open to doubt; it is generally
conceded that its secondary cause is the closure of the
filtration angles; the canal of Schlemm and the spaces
of Fontana. These spaces become closed from in-
creased ocular pressure, the reason for the increased
ocular pressure can not be so easily explained. In
this connection a paper written by Dr. Swindell may
be quoted.
In twenty-five cases of glaucoma seen by him nine-
teen had errors of refraction, the other six he could
not test satisfactorily; all of those tested had hyper-
opic astigmatism. The ill effects of hyperopia and
hyperopic astigmatism have already been mentioned,
therefore, who can deny that these nineteen cases of
glaucoma were not due to eye strain? We have now
in a general way mentioned the ill effects of errors of
refraction. We kaow also that they as a rule are cor-
rected by properly adjusted glasses; the question nat-
urally arises as to who should make these examina-
tions and prescribe. I unhesitatingly say that no one
but a graduate of medicine and one who has had sev-
eral years' practical experience in that line should do
so. Theory without practical experience is of little
avail; all of the leading medical colleges of this coun-
try recognize this fact and give their students the
practical as well as theoretic instruction. The great
physicians and surgeons of our age became such
through practical experience gained in the hospitals
and clinics. It is there they put their theory into
practice, there the surgeon gained his operative skill
and physician's eye, ear and touch become educated.
The pharmacist who has only theory at his command
would not be a desirable one to compound a complex
prescription ; the chemist, the bacteriologist and
others could never become expert and accurate in
their work without practical experience; so it is
impossible for one to examine the eyes (one of the
most delicate organs of the human economy), meas-
ure the refraction error and correct it, without having
had practical experience in doing so. It is the pre-
vailing opinion of the public that fitting glasses is an
L896. ]
MEDICAL PARIS.
487
easy mat tor, that anyone who chooses may do so for
their financial benefit, notwithstanding the fact that
they have never received a medical education nor any
special preparation or experience in this line. This
rave error, the correction of which will be of
great benefit to the welfare of the public and ophthal-
mology in general. We have in this city a class of
men who have none of the above requirements, but
who advertise to tit all eyes with glasses. They are
to be found in many of the jewelry stores; there is
not a day the oculists of this city do not correct some
of the errors of these men. The glasses they furnish
are injurious to the eyes of those wearing them; they
think that all eyes having defective vision need glasses.
therefore, prescribe them when the visual defect is
due to choroidal or retinal inflammation, beginning
cataract, optic neuritis, etc. One of the first and
most important methods of examining an eye to
determine whether an error of refraction or disease
exists is by means of the ophthalmoscope; in many
instances photographs, as it were, of many diseases
which have their origin in remote parts of the body
ean be seen, patients who have applied to the oculist
for glasses have learned for the first time that they
are the victims of some incurable disease; we see
such photographs in albuminuria diabetes, cerebral
tumors, locomotor ataxia, etc. In such cases the
oculist instead of trying to remedy the lack of
visual acuity by glasses refers the patient to the fam-
ily physician for general treatment. Have we not here
an object lesson: Who can say how many diseases
have gained headway and progressed beyond being
remedied, among those in whom the first symptoms
became manifest by the lack of visual acuity and who
applied to the optician for aid and were furnished
with glasses, the true condition not having been dis-
covered until in despair they consulted an oculist.
The assurance of these men is appalling and they
are a menace to the welfare of the public, against the
perpetuation of such iniquitous optical practices as
described; in this city we are powerless at present to
do more than protest. Ohio has taken the initiative
step to correct this evil. " The regulation about to
become operative under the 'medical regulation law,'
recently passed by the Legislature, will materially
reduce the evils of refracting opticians by making a
portion of the work done by them a penal
offense. Other States must follow suit; the future is
encouraging; all that is needed is determination and
action!" We have now, through the united and
untiring efforts of our physicians, a medical bill,
which a few amendments will make an ideal one, and
we hope that in the near future, the same champions
of our cause will secure such changes as will make it
perfect in all its requirements, and we sincerely hope
that a clause will be inserted making it a penal
offense for any but a graduate of medicine and one
win ) can pass a satisfactory examination in practical
refraction to examine, prescribe or fit glasses to the
eyes of the public: for it is the belief of the writer
that, with better correction of refraction errors by
skilful ophthalmologists who have kept abreast of the
times and who are thoroughly equipped with the best
of modern paraphernalia, great and lasting benefit
will result to the eyes of the present and coming gen-
erations, preventing and curing many serious ocular
diseases, as better methods of sanitation and hygiene
have been effective in preventing the ravages of such
diseases as cholera, typhoid fever, yellow fever, etc.
1016 I Street.
MEDICAL PARIS.
NOTES FROM MY SKETCH-BOOK
BY L. HARRISON METTLER, A.M., M.D.
CHICAGO, ILL.
To have seen Paris is to have seen the world; few
are the tourists, however, that ever see Paris. A
room in a hotel near the Opera and a few buildings
viewed from an open barouche is not Paris. Once I
met a traveler who had sauntered about the "city of
delights" some three long months, and yet had not
observed that the Notre Dame cathedral was upon an
island. Except Rome, probably no city in the world
has been so much written about or has played so pic-
turesque a rQle in history as Paris. It is so full of
novel attractions, historical relics and romantic remi-
niscences, so adorned with all the beauties of art and
architecture, so enriched with the most modern scien-
tific and sanitary improvements, so systematized in
government and municipal management, that an
American physician might well be excused for forget-
ting that medical Paris is equally as full of historic
anecdote and modern achievement. Ah! no, be not
deceived; medical Paris can not be seen in a three-
days' sojourn, with an occasional call at the Pasteur
Institute or the Hotel Dieu Hospital. When Vienna
was little else than a Roman fortress, when Berlin
was still a little group of huts and drying fish-nets,
when Munich was only a monastery and when even
London was little more than a Saxon hamlet, Paris
was a royal city, the seat of government and the site
of a university. In the sixth century Clovis chose it
as his residence, and in the tenth century Hugh Capet
encouraged its learning so as to lay at that early day
the foundation of the future reputation of its great
schools.
The actual beginning of the University of Paris
was in 1253 under Robert Sorbonne. One of its
earliest and most flourishing departments was that of
medicine. To-day there are six medical schools in
France, namely, Paris, Montpellier, Nancy, Lille, Lyons
and Bordeaux. The great reputation of Paris as a
medical center began about the middle of the fifteenth
century. In 1618 the first amphitheater for anatomic
demonstrations was erected. This was rebuilt in
1744 and was soon discovered to be inadequate.
Lamartiniere, Surgeon to Louis XV, obtained the
ground of the College of Bourgogne in the Rue des Cor-
deliers and began the construction of the present vast
assemblage of buildings known as the Ecole de M6d-
ecine. They were not completed until 1785 and on
account of their architectural beauty they made the
reputation of their designer, Gondouin. They were
opened for use Aug. 31, 1776. There is a main build-
ing, flanked by two wings, joined by an open gallery.
In a word, there are four buildings surrounding a
court-yard, sixty- six feet in depth and ninety-six in
breadth. The main frontage upon the street extends
a distance of 198 feet. The open gallery, consisting
of a double row of Ionic columns, is surmounted by a
second story. The anatomic museum and library are
found on the first floor. The amphitheater at the
bottom of the court is capable of holding 1,200 per-
sons. In the wings are spacious halls for various
demonstrations. Over the main portal is a bas-relief
of Louis XV, between the allegoric figures of Wisdom,
little of which he seems to have possessed, and
Benevolence, too much of which he exhibited for his
own good. In front of the entrance stands the bronze
488
MEDICAL PARIS.
[August 29,
statue of Bichat, the anatomist. In fact, all about the
buildings are memorials of various eminent medical
men, such as Broca, Petit, Marechal, Pare, Pitard and
Peyronnie. During the latter years many additions
have been made to the old Nicole de MMecine, espe-
cially the magnificent facade upon the boule-
vard St. Germain. To the casual tourist of a medi-
cal turn of mind, however, the most interesting
of all this assemblage of batiments is the ancient
structure, which looks from the outside like a church.
It is the ancient refectory of a Franciscan monastery,
but is now used as a pathologic museum and known
as the Musee Dupuytren. How many names, now
famous in the history of medicine, did I see on the
specimens in this quaint old museum! As I saw upon
this bottle or that skull, the names of Par£, Velpeau,
Quarter is and why it is so called, the tourist can not do
better than read Victor Hugo's "Notre Dame," wherein
a certain chapter is set apart for a bril liant description of
the origin and development of Paris. Originally Paris
was confined to an island in the middle of the Seine
River. To-day this part of the capital is known as
La Cit6, and contains among many notable build-
ings the Notre Dame Cathedral, in the shadow of
which nestles the historic old Hotel Dieu Hospital, of
which I will have something to say later on. As the
city grew, its extension beyond the limits of the
island away to the north, or right bank of the river
became known as La Ville, and contains the palaces,
municipal buildings, art galleries and residences of the
aristocracy. On the south, or left bank of the river
stood the University in all its pride, independence
ECOLE DE MEDECINE, PARIS.
Larrey, Nelaton, Broussais, Dupuytren and others, it
seemed to me as though I were reading a history, not
only of medicine but of Paris as well; and memories
of the early kings of France and their wars, of Napo-
leon and of the French revolution poured in upon me.
The applicants for admission to any of the medical
schools of France must possess the "diplomede bach-
elier 68 lettres," or the "diplSme de bachelier es
sciences restreint," equivalent to the B. A. of London
University, with considerable knowledge of chemis-
try, zoology, botany, geology and astronomy.
The Ecole de M6decine is in the heart of the Latin
Quarter of Paris, whither one must go, if, as Thack-
eray says, "he is to study the humanities or the pleasant
art of amputation." Now to learn where the Latin
and scholarship, and its immediate vicinity, so dear to
the heart of the student, ere long became known as Le
Quartier Latin. I am unable to say why this partic-
ular part of Paris should be called the Latin Quarter,
unless because here are most of the great schools and
here the scholars congregate in their crowded lodgings,
conferring upon the neighborhood the general air of
Latinity that usually surrounds student life. As it
is also one of the oldest sections of the city, that, too,
may have a little to do with its pagan appellation. To
know the Latin Quarter is to know Paris, and to
dwell therein awhile is to observe student life such as
it will be seen in no other city in the world. Space
forbids my description of it here, but the reader who
wishes to revive memories of his days in the good old
1896. ]
MEDICAL PARIS.
489
Latin Quarter, will do well to read a few' chapters of
Ohnet's story of " Dr. Rameau."
One day shortly after my arrival in Paris I found
myself in the great courtyard of the Ecole do Mede-
oine. Groups of students standing about or seated
upon the doorsteps of the main entrance were vehe-
mently discussing the "exainens." It was a rare sight,
these fiery, excitable, gesticulating French lads — or
rather men 1 might say — chattering and bobbing to
one another in a most tremendous fashion, about the
soul-harrowing examinations which they were to
undergo or had just escaped. They could not talk
fast enough (a Frenchman never can) and each indi-
vidual that emerged from the doorway was pounced
upon as wolves pounce upon a helpless lamb and was
all but annihilated with questions and gesticulations.
Then> were others who stood silently apart and in
rather a comical manner kept their lips moving while
their eyes were riveted upon mysterious looking little
hits of paper which they kept stored away somewhere
in the depths of their capacious pockets. All at once
there was a profound stir among the various groups.
The mysterious papers disappeared, the mutterings
changed to mute reverence, ears were less strained,
the noisy chatter and wild gesticulations ceased, some
of the fellows moved off in a kind of nonchalant man-
ner, others seated on the doorsteps leaped up and
started off or stood near where they had been sitting
in an attitude of almost oriental obeisance, while ail
acted as if royalty itself were approaching. Their
majesties consisted, however, of only a few members
of the faculty including the late Professor Charcot.
When this sect ion of the faculty had vanished beneath
the shadow of the doorway, the chatter and gesticula-
tions, as only Frenchmen are capable of, began again
with tenfold energy. 1 saw many of the students fol-
lowing the professors and did likewise. In one of
the upper corridors the professors scattered and dis-
appeared in various small apartments. In and out of
these rooms strolled the students as though they were
merely visiting some anteroom of the Louvre or Lux-
embourg. I did the same and this is what I saw: At
one end of the room, behind a railing was placed a
green-covered table, behind which sat the examiner,
the referee and perhaps an additional member or two
of the faculty or subfaculty. Outside of the railing,
huddled as closely to one another as possible, were
fifteen or twenty students, one of whom at the time
was undergoing an oral examination, causing him
untold miseries. He would blush like the setting
sun, his knees and hands would tremble like the sun-
beams on a ruffled lake, and his tongue would scarcely
realize whether it were talking sense or nonsense. He
felt ill at ease, to be sure, but he was not in the least
ashamed, for he knew he had the hearty sympathy of
the fellows about him. Their turn was yet to come.
Thus are the examinations conducted at the great
medical school of Paris; open to all and before
several witnesses and referees. It is a severe test, but
one has the consciousness of knowing that it is fair
and equal to all alike. The questions were plain,
direct, and practical. They were not in the least
framed merely to trip the student on some rare and
abstruse item. Scholars whose homes were in most
distant parts of the world were undergoing the ordeal.
In the vicinity of the medical school are many
book stores, some of them devoted exclusively to
medical literature. They are patronized freely by the
pupils and in some respects resemble small public
libraries, in that every one is welcome to enter and
thumb over the books. Paris publishes quite a
number of excellent medical journals, notably La
Semavne MSdicale, La France M4dicale, a small but
sprightly sheet which appears three times a week, Le
Journal de Mtidecine, which is Dr. Luteaud's organ,
and a vigorous one it is, too, and many others of lesser
importance. There are quarterly publications with
the clinics of the Salpetriere and special reports of
the French Academy of Medicine. I can not say,
however, that the French journals compare favorably
with the great English weeklies; in style and general
typographic appearance, however, they maintain the
proverbial French reputation for this particular kind
of work.
The history of the management of the public char-
ities, and especially of the hospitals of Paris, forms
an interesting chapter in itself. In the earliest times
the convents and monasteries, both of the city and its
suburbs, offered a retreat not only to pilgrims, but
also to the sick and insane. Gradually these estab-
lishments erected special buildings for the sick within
their domains, and while the monks administered the
treatment, the sisters attended to the nursing. In
816 Charlemagne decreed that at each See one of the
canons should always govern the hospital or hospice;
and that these institutions should always be in close
proximity to the cathedral. This explains the near
association of hospitals and great churches in many
parts of Europe to-day, as, for instance, Notre Dame
and the Hotel Dieu of Paris. The control of the
hospitals by the clergy continued until the beginning
of the sixteenth century. After that date governors
were selected partly from the laity, though the religious
orders continued to bear an important share in their
management. As the charitable institutions developed,
as they were more and more assisted by the state and
private benefactions, the transfer of their government
from the church to the state became more and more
complete.
The Assistance Publique forms one of the admin-
istrative departments to-day of the Prefecture of the
Seine. Its revenues exceed forty million francs,
obtained by a tax on the receipts of theaters and other
places of amusement, on burials and on the Monts de
Pieie. or government pawning offices, of which there
are twenty-five. Among other charities it has under
its supervision some twenty-two civil, general and
special hospitals, nineteen public hospices, twenty-
seven asylums and almshouses and three military
hospitals.
The largest as well as the most famous of the Paris
hospitals are the Hotel Dieu and the Salpetriere. As
a student for a number of weeks at the Salpetriere, I
enjoyed the opportunity of watching some of the work
at both institutions and in another paper will have
something to relate of their history and clinics. I
would that space allowed me to do more than merely
refer to some of the others, for a visit to the Charite"
with its 504 beds, its history running back to Marie
de Medicis in 1602, its founder, and its interesting
chapel constructed at the end of the last century and
now used for the meetings of the Academy of Medi-
cine, or a morning call at the modern and elegant
Lariboisiere, with its 636 beds and the magnificent
tomb of Madame Lariboisiere, its benefactress, in the
chapel, is something to carry long in one's memory.
The H6pital du Midi was in 1613 an old convent, but
is now a hospital with 336 beds. Was it not here
490
SELECTIONS.
[August 29,
that Ricord, the famous Frenchified American doc-
tor came and first established his own school after his
rupture with the great Dupuytren! And was it not
here that he made those marvelous pathologic studies
in regard to certain unmentionable diseases, which
ran counter to and overthrew all previously conceived
notions! Certainly, and the American physician who
is interested in les hommes atteints de maladies
v^neriennes, will be sure to visit Le Midi. As that
same American physician is singularly interested in
les maladies de la peau, he will go direct from the
Midi to the Saint Louis, which was founded in 1607
by Henry IV. and contains 823 beds. I would like to
be able to sketch this quaint old hospital for skin
diseases as I saw it, its low creaking doors, its musty,
close little rooms, its pleasant, quiet little courtyard
with gravel walks and ancient trees, its energetic,
loquacious old porter, and its remarkably rich clinic,
presided over by the distinguished Fournier, but I
must hasten on.
A clinical lecture at the new and artistic Clinique
d Accouchement by the great Tarnier is a revelation to
an American. The manner and method of it is some-
thing to be envied by all teachers of obstetrics. But
I must forbear and close by simply mentioning the
Hdpital Beaujon, with its 422 beds, the Cochin Hos-
pital, with its 201 beds, the Hopital Laennec, dating
back to 1634 and containing 811 beds, the Necker
Hospital, with 418 beds, the Hopital Saint Antoine,
with 594 beds, the Hopital Tenon, with 635 beds, and
such other special hospitals as the Lourcine, with its
276 beds, for women afflicted with venereal disease,
the Maternite, with its 316 beds, the H6pital des En-
fants Malades, with its 518 beds for the little folks,
and the H6pital Broussais, with its 260 beds. These
are not all by any means, and most of the hospices
and asylums which are of particular interest I have
not even attempted to mention.
4544 Lake Avenue.
SELECTIONS.
Abnormal Mobility of the Liver. Mr. John Morris, in the Prac-
titioner, discusses some cases of this morbid condition that
have lately been recorded, inclusive of one by Dr. J. E. Gra-
ham of Montreal. "Dr. Graham published his case with a fac-
simile of a woodcut showing a displaced liver, published by
Heister in the year 1754. No fewer than seventy cases were
tabulated, excluding all in which the displacement was due to
causes above the diaphragm, and also those in which it was
due to tumors or abscesses between the liver and the dia-
phragm. Of course the diagnosis was not certain in all the
cases. A large majority occurred in women who had pendu-
lous bellies after frequent child-bearing. In the only well-
marked case that I have seen, the luxation followed the rapid
disappearance of a large fibroid tumor at the menopause. The
abdominal wall was thin, and the liver edge could be easily
defined by palpation at the level of the anterior and superior
iliac spines. The organ could be pushed into its proper posi-
tion, and an abdominal belt gave considerable relief. Abdom-
inal section has been performed (sometimes on a mistaken
diagnosis), and the liver has been fixed to the abdominal wall ;
but I have not observed a record of any such case when suffi-
cient time had elapsed to enable us to know whether real bene-
fit resulted.
"Cases of undue mobility of a portion Of the liver have been
recorded. Bastianelli (II Policlinico, 1895) has detailed a case
in which he diagnosed a cancerous right kidney. An abdom-
inal section having been performed, the tumor was found to be
a portion of live* attached to the main mass of the gland by a
band of hepatic ' tissue. The pedunculate mass contained
growths which were afterward found to be gummata. It was
removed with the gall bladder, which lay on its under surface,
and the patient was seen thirteen months later in good health,
and seven months pregnant. I have seen a case in which a similar
diagnosis of kidney tumor was made, and on operating, a portion
of the right lobe of the liver was found to be bent on the main
mass, the line of flexion being very thin, and permitting free
movement. At a recent meeting of the MedicoChirurgical Soci-
ety, Mr. Mayo Robson related a case in which he cut down on
a gall-bladder and found that it was the seat of malignant
disease, there being also a nodule in the liver close to the
growth in the gall bladder. The liver was somewhat displaced
downward, and it was found possible to draw the affected por-
tion of the gland and the gall-bladder out of the abdomen,
and to make an artificial constriction of the liver substance
behind the disease by means of an India-rubber tube. The
constricted portion was transfixed by two knitting needles and
secured outside the abdominal wound after the plan commonly
adopted in performing hysterectomy, the distal part being cut
away. A small growth, in which no malignant elements were
found, was removed from the abdominal wall of this patient
some three months later and ten days before the reporting of
the case. Recovery followed, but sufficient time had not
elapsed to allow of the permanent effect of the operation being
recorded. Bastianelli (he. cit.) attributed floating liver lobes
to malformation, acquired deformity, as from pressure, and the
traction of new growths."
Acute Peritonitis Produced by the Pneumococcus. The three
last numbers of the Archives Clin, de Bordeaux (3, 4 and 5) are
almost entirely devoted to a critical study of this comparatively
rare disease : Acute peritonitis caused by the presence of
virulent pneumococci in the peritoneal cavity. As the disease
usually terminates fatally, without prompt and sufficient sur-
gical intervention, ;t is of the utmost importance to be able to
diagnose it at once. The author, Professor Cassaet, first proves
its existence as a pathologic entity, and its essential element,
the virulent pneumococcus. It develops at all ages, without
distinction as to sex or season, but preferably where there has
been some former lesion in the abdomen or when the resisting
powers of the organism are diminished from any cause. The
infecting agent penetrates into the serous membrane without
assistance from any other pathogenic or saprophytic agent,
either through the skin or intestine after traumatism or from
inflammations, tumors, etc., in the genital region or elsewhere,
or conveyed by the blood or lymphatics. Colonizing there it
produces its specific lesions, the same as in the lungs, with the
same effusion and tendency to wall in the purulent collec-
tions. Cassaet suggests that one reason why the lungs are so
much more frequently the seat of the disease than the abdo-
men may be that the microorganisms are so easily inhaled
and remained unchanged in the lungs, while it is a much more
difficult matter to reach the peritoneal cavity and run the
gauntlet of the secretions of the alimentary canal. Primary
pneumococcus peritonitis is distinguished by an absolute
absence of prodromes, by its abrupt debut, commencing sud-
denly, like a thunderclap, in the midst of apparent health or
following some other disease. The principal manifestations are
sudden, intense pain, vomiting of bile, profuse diarrhea, occa-
sionally a few chills. In the secondary stage the fever rises,
the pulse grows more rapid, respiration labored, the urine
decreases and contains albumin, and the entire organism is
gravely affected. There is no tympanitic resonance, although
the abdomen is enormously distended ; it offers a certain soft
resistance to the finger, changing to an undulation, slight at
first, becoming an actual fluctuation, amounting at last to the
II
I
1896. 1
SELECTIONS.
491
neurit ion of a vast accumulation of fluid inside'. The meteor-
ism does not appear until a day or so after the pain period.
As the meteorism gradually increases the fever declines and
thi' pain subides;an important indication differentiation. The
terminal period is short if the infection is severe; death fol-
lows without much change from the preceding conditions. It
lasts longer if the body has had strength enough to survive
till the purulent period, when the symptoms are those of true
septicemia, subsiding to those of a circumscribed abscess,
when tlio encysting process has been accomplished. Compar-
ing it with the other forms of peritonitis, it is distinguished
from puerperal peritonitis by its absolutely sudden beginning
and the absence of repeated chills and fetid discharges. It
resembles appendicular peritonitis, but as the treatment is
the same lor both, differentiation is not imperative. It can be
distinguished from the peritonitis following perforation, as the
fever in the latter is higher from the start, with subsequent
hypothermia: the dysuria is more complete, the meteorism
more sudden, the dulness more immediate and the evolution
more rapid. The history of the case may also proclaim the
probability of perforation. Careful study of all the cases on
record ami others proves that laparotomy is the only means
of cure : and it must be prompt and effectual so as to open and
clear every infected focus. It must be median laparotomy,
extensive enough to insure a minute exploration of the flanks
and hypochondriac region. Several cases reported, which were
doing well after laparotomy, succumbed later and the necropsy
disclosed unsuspected purulent collections behind the liver or
elsewhere which had escaped notice. The percentage of recov-
eries in the cases on record which were treated in an effective
manner amounts to 80 per cent., but the mortality is 75 per
cent, in the general average of cases. We add the author's
summary of the various pneumococcus infections which may
follow or appear independently of pneumonia: Bronchitis,
broncho pneumonia, pleurisy, pericarditis, endocarditis, spo-
radic- and epidemic meningitis, arthritis, amygdalitis, pseudo-
membranous angina, enteritis, nephritis, metritus, inflamma-
tions of the nasal cavities and sinus, otitis of the middle ear,
osteo periostitis, abscesses and inflammations of the connective
tissue.
The 'Curatel" Treatment of Inebriates in Austria.— The treat-
ment of habitual alcoholics in Austria is attended with diffi-
culty, the laws having been so framed as to leave that class
virtually without direct constraint. Drunkards, in that
country, come under the same class as idiots or spendthrifts.
A special report on this subject in the London Lancet for June
6 further states that the process of "curatel," whereby the
court appoints a curator or administrator for persons who do
not look after their own affairs and who are unable to defend
their rights, is made applicable not only to children, luna-
tics and idiots, but also to those who having been declared
"spendthrifts" by a magistrate, have been deprived of the
administration of their property. A man may be judicially
termed a spendthrift if it appears on examination of the
charge that he is running through his property in a senseless
way and that he is exposing his family to future destitution
by contracting loans under reckless or ruinous conditions. In
some kingdoms, as in Galicia and Lodomeria, there is a special
law for the prevention of drunkenness, and one section pro-
vides that on being convicted of drunkenness three times in
one year the district authorities may forbid the offender to
visit public-houses or liquor shops in the neighborhood of his
domicile for the period of one year, under pain of fine or
imprisonment. "The inadvisability of mixing mere drunkards
with the insane in asylums is fully recognized by the Austrian
authorities. Last year a bill for the erection of public asylums
or establishments for the cure and reform of drunkards was
brought into the Reichsrath by the Minister of Justice. These
institutions are intended for the reception of 1, those who
havo been judicially punished for drunkenness three times in
the course of one year ; 2, those mentally affected owing to
habitual or periodical abuse of alcohol who have been admitted
into hospitals or lunatic asylums, and who, although they have
recovered their sanity, have not sufficient self-command to
resist the temptation to drink ; and 3, those who, owing to
habitual or periodical abuse of alcohol, endanger the moral,
physical or financial security of themselves or their relations.
Provision is also made for the compulsory retention of patients
for a period which may not exceed two years, and placing the
police and judicial authorities at the disposal of the administra-
tion of the asylum in order to recover fugitives from the same.
Consideration is given to the proper safeguarding of the indi-
vidual from the illegal and undue application of the various
processes upon which detention in an asylum may be carried
out."
Dress Reform for Women Rendered Probable by the Bicycle Cos-
tume.— A female medical practitioner who has ridden the wheel
since 1888, has expressed herself as sanguine that a healthful
and comfortable dress will be the outcome of the extension of
the bicycle habit among females. She states that she has
modeled one for her own use, which satisfies her as preferable,
on a variety of occasions, to the dirt-collecting long skirt. " I
frequently shop in my bicycle costume," she said, "and,
while much staring and often audible comment greet me, yet I
think if the costume were universally adopted it would soon
cease to be noticeable. As to its merits there can be no doubt,
and no woman who has experienced the freedom and comfort
of the short, light skirt will willingly return to the long, heav-
ily lined skirt which fashion now prescribes. Women are
slaves of fashion, and it will be a difficult matter to bring the
most approved style or short skirt in vogue, for it is detrimen-
tal to the interests of the mercantile trade. Many furbelows
would follow the long skirt if it were discarded and in its stead
a modification of the bicycle costume adopted, for the latter
only lends itself to the severest adornment. I object to
bloomers," she continued, "because they create unfavorable
comment and are often immodest. I think it is a great mis-
take for women to walk around and sweep up the dirt with
their skirts, and I am in hearty sympathy with any movement
to get rid of them for a more sensible style of dress. I do not
wear corsets, and I have used my pen and voice equally to per-
suade other women to discard them. In some cases I have
been successful, but in nine cases out of ten a woman clings to
her corset as the drowning man clings to a straw. The long
skirt is equally reprehensible, and there is no garment so
ungraceful, so suggestive of untidiness as a long, rain or dirt
bedraggled skirt. Especially is this the case in stormy weather,
when woman requires all her strength and the free use of both
hands and limbs to battle with the elements, and is generally
so encumbered with umbrella, bag and parcels, that her skirts
are allowed to trail unnoticed through wet streets. Any
dress which it will not be necessary to hold up and will be com-
fortable and useful, will be welcomed by all sensible women.
The bicycle costume, when the skirts are a graceful length,
and not too light about the hips, seems an ideal costume for a
rainy day, and adaptable to walking and outing generally. I
shall be most happy to advocate its use. A learned gentleman
once told me that women would never attain the same power
intellectually and physically as men until they freed themselves
from hampering clothes. Men will not submit to uncomforta-
ble fashions in clothing, and consequently do not suffer from
the nervous disorders that are produced by the unhygienic and
irritating clothes that are worn by women."
A Mild Epidemic of Scarlet Fever at Louisville. -In the Ameri-
can Practitioner and News, June 27, Dr. John Larrabee
depicts the differences that present themselves in two epidem-
492
PRACTICAL NOTES.
[August 29,
ics of fever, just twenty years apart, in the same town. The
epidemic of 1876 was grave and distressful, while that of 1896
is designated as "benign" ; and some of the physicians go so
far as to disregard the isolation of the well. In the discus-
sion of the subject before the Medico-Chirurgical Society of
that city he went so far as to say that the type of the epidemic
fever was so mild that he would not insist on quarantine
because it was a good chance for the unprotected children to
obtain immunization at a low risk. Other members expressed
the like opinion. To those of us who have never yet encoun-
tered a benign epidemic of scarlet fever, an avowed neglect of
isolation is "a hard saying," but these gentlemen of Louisville
are open-eyed and humane practitioners, so that we know that
the apparently "thin ice" they are testing will be abandoned
so soon as they discover that their course is hazardous.
Dr. Larrabee opens his paper with a historic reference that
illustrates in an admirable way the capricious behavior of
scarlatina. He says : "It is well to remember that scarlet
fever was differentiated from measles about two centuries ago.
Its history for upward of two hundred years, the period in
which it has been known, is peculiarly interesting. None of
the exanthemata is subject to such variations. Thus the
description given by Sydenham of the first great London epi-
demic, contrary to what should be expected, was that of a light
and trivial disease, only dangerous by the officiousness of the
doctors : 'Vix novem morbi merebantur.' And it was he who
first differentiated scarlet fever from measles, an older and more
prevalent disease. This is certainly a strange contrast with
the observations of more recent periods both in Europe and
America. Its prevalence in the eighteenth and nineteenth
centuries warrants the conclusion that it has steadily increased
in potency until it has come to be considered one of the most
treacherous as well as fatal diseases of childhood. Loschner,
fifty years ago, wrote that he had never seen a benign epidemic.
Thirteen per cent, of all cases became dropsical, and 38 per
cent of all dropsical cases died. Epidemics of scarlet fever
vary not only in severity but also in complications. Some
have been largely anginose, others noted for rheumatic com-
plications. The mortality has ranged from 13 to 40 per cent,
and then again as low as 3 to 4 per cent. Kostlen wrote that
scarlet fever disappeared entirely from his practice for fifteen
years, and that there was not a case in Stuttgart from 1830 to
1846, at which time an epidemic occurred in which there were
no fatal cases. Those who have had experience with the pres-
ent prevalence of scarlet fever will, I think, agree with me that
in point of severity cases are in strange contrast with those
which we have been accustomed to see in former epidemics.
The word epidemic is not strictly proper to apply to the pres-
ent prevalence as to the number of cases, and still the disease
is so widespread as to be out of consideration as an endemic. If
epidemic, it must certainly be considered benign.
Regarding first epidemics we are taught to believe in their
severity, and such was the case with measles in the Phillipine
Islands several years ago. In scarlet fever we have a disease
in which the first epidemic known was as mild as at present.
A point that has not been discussed sufficiently was the pro-
oortion of complications in different epidemics. It was my
privilege to see the epidemic of 1876. I saw in my own prac-
tice thirteen deaths. In two cases the temperature ran up to
110 degrees F. before the eruption appeared, the other case
being typical scarlet fever. In regard to middle ear troubles,
the point I insist upon is that cleansing the throat should be
made a routine practice whether the throat is sore or not, and
in all cases of the disease however mild. In regard to the point
of contagiousness the remarks have been surprising. Nega-
tives never prove anything. The fact that a child does not
contract the disease when exposed does not prove anything ;
but a child getting the disease when exposed proves the whole
question. I have always looked upon scarlet fever as the high-
est and most persistent type of contagion with which we have
to deal. In regard to the rheumatic complications of the dis-
ease and the discussion upon that point, I desire to be under-
stood that this is a true rheumatism and that the conditions of
metabolism are as perfect to produce it as could be. The
rheumatism complicating scarlet fever yields at once to salicy-
lates, which of course we all employ.
A Bishop Upholds Vivisection.— Bishop Lawrence, at the last
annual meeting of the Massachusetts Medical Society, June,
1896, gave a pointed rebuke to the antivivkectionists of his
State, which was wise and timely. The remarks given below
contain the Bishop's reference to that subject and also a recog-
nition of the debt the Commonwealth owes to the altruistic
ranks of medicine :
"Speaking not only for myself, but also for the great reli-
gious sentiment of this Commonwealth, I can say that wher-
ever one finds any representative member of this Society, one
is impressed, he is humbled, by the devotion of the doctors to
their work, by their instinctive love of their profession, by
their interest in the scientific lines of their work, and by the
service they devote unweariedly to their fellow men. The
public spirit of the physicians throughout this State, in rela-
tion to their hospitals, to sanitary movements, and to all other
civic movements which bear upon their profession, is recog-
nized ; but I can not quite believe that they are sufficiently
recognized by the people. They are doing untold work in all
those lines. The readiness with which the physicians of Massa-
chusetts and of this Society respond to calls, without asking
questions as to whether they are to receive money in return or
not— and they are sometimes imposed upon — is remarkable.
The work is done cheerfully and willingly, and is the best form
of charity. I can not. therefore, understand how it can be
that a great body of people in this Commonwealth can so far
distrust the great body of these physicians— can so far distrust
their tenderness, their humanity, their sensitiveness to pain —
as to bring any unwise, unreasonable restrictions to bear upon
scientific study as expressed in vivisection. The people of this
Commonwealth have tender hearts, and though they may be
New Englanders externally, they are desirous of seeing that
no hurt shall come to the animals. At the same time, it seems
to me that into no hands can the welfare of lower forms of
creation and the question of vivisection be more confidently
placed, than into the hands of the recognized medical frater-
nity of this Commonwealth. In reviewing in my mind the
character of the good physician and his value to the community
in which he lives, I can not help thinking of another medical
man whom, like your president-elect, I have known as a friend
and neighbor for many years, and to whose sympathy and help
in time of need so many in Cambridge can testify ; I mean Dr.
Morrill Wyman. He comes of a family in which are united
the love of pure science and the love of humanity. I need not
remind you of the scientific work of his brother, Jeffries
Wyman. Dr. Morrill Wyman unites the qualities of an enthu-
siastic, earnest, progressive student of the medical sciences, and
a most skillful and devoted practitioner of his art. I remem-
ber his telling me of the remark of an old lady, a patient of
his, upon whom he had just performed a very delicate opera-
tion, which illustrates the regard which is felt for such men by
their patients. After the operation was over she said to him,
rather to his chagrin, ' After all, physicians are but instru-
ments in the hands of God.' But she soon set him at ease
by adding, ' But there is a great deal of choice in the
instrument.' If each physician learns, as I hope he does, to
regard himself as an instrument in the hands of God. to be
more fully developed for His honor and the welfare of human-
ity, he has within him untold possibilities of usefulness."
PRACTICAL NOTES.
Chronic Pharyngitis. -Iodum .5 gm., potass, iodid 1.0 gm.,
menthol and glycerin aii q. s. ad 5.0 gms. Apply two or three
times daily. — Pac. Med. Jour., August.
Loeffler's Solution. -Alcohol 60 parts, toluol 37 parts, liq. ferri
perchlorid 4 parts. Swab the affected parts with this every
two or four hours. — Pac. Med. Jour., August.
Camphor Dressing for the Sores left after Furunculosis.— Castellan
states that the best dressing for this purpose for sailors and
laborers is pulverized camphor sifted on the sore and covered
18%.]
PRACTICAL NOTES.
493
th
with an aseptic linen cloth, which is to be kept constantly wet
with a boric solution or camphorated alcohol. — Semaine Mid.,
July 29.
An Anthelmintic. Tape worm is said to be best treated with
ten drop doses in water, three times a day, of a mixture con-
sisting of hydriodate of potash, 3 gms. ; iodin, 1 gin., and water
lOc.c. Med. Sentinel, August.
Effects of Elevated Attitudes on the Constituents of the Blood. —
Recent experiments confirm the announcement that the num-
ber of red blood corpuscles increases in mountain air, and
gradually returns to the usual number after return to a lower
level. It is also established that the increase is an absolute
formation of new corpuscles. IVien. Klin. Rund., July 19.
A Point in Differentiating Obturator Hernia.— Landerer describes
a rare case of acute osteomyelitis of the bony frame of the obtu-
rator canal, which had every indication of an obturator hernia,
with pus formation, even after exploratory laparotomy and
drainage. Two months elapsed before the discharge of a piece of
the pubis with pus. followed by recovery. ( 'bl. f. Chit: July 11.
Treatment of Tetanus with Carbolic Injections; Baccelli's Method.
A man of 88 arrested the How of blood from a crushed finger
with manure, and in six days tetanus followed. It was treated
with seven to eight injections a day of 0.01 to 0.02 g. acidum
carbolicum after the wound had been disinfected with subli-
mate and iodoform, and hourly tepid baths after the fourth
day of treatment. The patient was dismissed in ten days
entirely recovered, (.'a;, degli Osp. e delle Clin., June 27.
Early Diagnosis of Pregnancy: Hegar's Sign. Hegar's sign sel-
dom fails to diagnose pregnancy as early as the sixth or tenth
week. It consists in a change in the body of the uterus, which
s spheroidal in shape and soft to the touch, while the
neck retains its tenacity and shape until much later. The
uterus is thus palpated as a round, yielding body mounted on
the straight cylinder of the neck. In connection with the ces-
sation of the menses, disturbances in the digestion, ptyalism,
changes in the breasts, slaty appearance of the vagina and
vulva in a primipara and varicose appearances around the
external genital organs and on the lower limbs, the diagnosis
of pregnancy is certain in the great majority of cases. — Lyon
M,SI.. So. :>.
Treatment of Vitreous Hemorrhage by Sodium lodid. — Dr. De
Schweinitz states that in vitreous hemorrhage, if not other-
wise contraindieated, the internal administration of frequently
repeated small doses of sodium iodid materially aids in the
absorption of the effused blood. This is particularly true of
myopic eyes which are predisposed to hemorrhages of this
character by reason of changes in the choroidal and ciliary
vessels. In place of the sodium iodid, or sometimes alternat-
ing with it, he is accustomed to give the fluid extract of
jaborandi in doses just short of its diaphoretic action, or small
doses, for example a tenth of a grain, of pilocarpin hydro-
chlorate. Weir's Index, June 15.
Catheterization of the Pylorus Through the Mouth.— Kuhn of
(iiessen has invented a sound which can be passed through
the mouth into the stomach and through the pylorus into the
intestines, even as far as the iliac fossa. It consists of a long
metal spiral spring enclosed in a rubber tube. It is so flexi-
ble that it makes its way through the most winding passages
with a vermiform motion, when carefully twisted. A small
rubber bag at the end can be blown up through the tube at any
time. This can be palpated and the course of the sound fol-
lowed. It promises to render great services in the treatment
of strictures of the pylorus and intestines, in administering
medicine directly into the intestines, sparing the stomach, and
in radiography, etc. — Semaine Mid., July 29.
Action of Alkalies on Carbohydrates.- If some alkali is added to
the solutions of certain carbohydrates, the transforming
power is altered, and in such a way that one sugar is trans-
formed into another. Glucose, fructose and mannose are thus
transformed and it is immaterial which one is used to start
with. There is also, at least for the substance thus formed, a
certain equilibrium reaction, which is prevented from becom-
ing absolute equilibrium by another reaction occurring at the
same time, the formation of acid. In all probability the fruc-
tose is the immediate link in the transformation of glucose into
mannose, and of the mannose into glucose. The process itself
may be the work of some of the hydroxyl group. A similar
process may occur in plants, which would explain the produc-
tion of cane-sugar out of glucose.— Cbl. f. Phys., July 11, from
Ber. d. d. chem. Oes. page 3078.
Treatment of Pertussis.— Dr. Charles Gilmore Kerley reports
relative to treatment as follows: "Antipyrin, bromids and
belladonna were each used in several groups of twenty. The
ages of the cases treated varied from 6 weeks to 5 years.
They were of every condition of bodily strength and weakness.
The duration of an attack was not shortened in a single
instance. Antipyrin gave the best results. Under its use the
number and severity of the paroxysms subsided. A combina-
tion of the bromids of soda, potash and ammonia came next.
The much vaunted belladonna appeared to exert little or no
influence. It was given to the point of physiologic effect.
Alum gave practically negative results. Dilute nitric acid and
fluid extract of horse chestnut leaves were utter failures. The
results in a few cases in which antipyrin was used were not-
ably good. The number of paroxysms diminished one-half in
some, one-third in others. — N. Y. Polyclinic, August.
Hypertrophy of Prostate Treated by Castration. — The Medical
News, July 25, has an analysis of twelve cases of this nature,
as reported by Dr. C. W. Mansell Moullin, the well-known
author and surgeon to the London Hospital, before the Har-
veian Society, which were attended with gratifying results.
"In two cases, both under his own care, death had taken
place five and nine days respectively after operation ; one
death was due to cerebral hemorrhage, the other from fatty
degeneration of the heart. In two cases, both of which ulti-
mately recovered, traumatic delirium in severe form came on
very soon after the operation. In all twelve cases, even inclu-
sive of that which was fatal on the fifth day, there was reported
a distinct improvement as to obstruction, and in those cases
which remained under observation a sufficient long time to
enable the surgeon to measure the size of the prostates, there
was found an appreciable diminution in size, as measured both
by urethral and rectal examinations. One case, less success-
ful than others, was that of a patient, 80 years or age, the
diminution in size when measured by the finger in the rectum
was not very great, and voluntary control was not regained.
But as a soft catheter passed easily, whereas before only a
metal one or a bougie could be used, and that with difficulty,
and as the stranguary, which had resisted all previous treat-
ment, entirely disappeared, Dr. Mansell Moullin thought the
case could not be considered a failure. It was never suggested
that removing an obstruction at the neck of the bladder would
be able to regenerate the muscular coat, if this had been
destroyed by catheterism and previous cystitis. In another
case the inflammation of the bladder persisted, but this again
was not the fault of the operation, for the walls contained
numerous sacculi, which could not be kept empty. Respect-
ing the traumatic delirium in two cases, already referred to,
Dr. Moullin avers that it is not due to the orchotomy, but to
that tendency to delirium that obtains in elderly people after
severe injuries, and may even follow the administration of an
anesthetic."
•'Molding" Treatment of Club Foot.— This method takes its name
from the gentle, gradual way in which the soft parts of the
foot are molded into the correct shape, stretching, pulling and
/
494
PRACTICAL NOTES.
[August 29,
cutting where necessary, until a touch of the finger will turn
the foot into the normal position. Not until this is attained
is the cast applied, thus preventing gangrene from pressure.
It is the exact opposite of Wolff's forcing method, which
applies the cast and just as it hardens, the foot is forced into
the correct position. Another advantage of Lorenz's method
is that the various defects are corrected in turn, although at
one sitting. Adduction and inversion are first altered into
abduction and eversion ; the tendon of Achilles is then cut,
with care that the tuberosity of the calcaneum is brought down
into place. Then supination is changed into pronation, and
not until the foot is thus altered without force into a caleaneo-
valgus, is the cast applied ; split down the center to allow for
slight swelling. It is left for six weeks, and the later bandage
for two to three months. The treatment concludes with mas-
sage and active exercise of the muscles, especially the prona-
tors. Lorenz has invented an instrument to assist in molding
the feet of adults, as this requires more strength than a child's
club foot. The method is described and illustrated in full in
the Wien. Klinik, Nos. 11 and 122.— Cbl. f. Chir., July 5.
Pellotio, a New Hypnotic. — According to the London Lancet,
June 20, Dr. Jolly of Berlin, has made considerable progress in
the study of a new hypnotic, called pellotin, which is not pre-
pared by chemic synthesis, like the other sleep-producing med-
icaments of the present day, but is an alkaloid discovered in a
species of Mexican cactus called anhalonium. The natives of
Mexico are reported to swallow slices of this plant, to which
they give the name of "pellote," and Dr. Hefter of Leipsig,
has now succeeded in isolating its soporific alkaloid. Pellotin
itself is not soluble in water, but its hydrochlorate is extremely
soluble. Its physiologic action was first tried on frogs and
then on mammals, which very soon became unable to stand or
perform spontaneous movements, and shortly afterward an
increase of the reflexes was observed, followed by tetanic con-
vulsions. This action of the drug on animals was not identical
with that which Dr. Heftner observed in himself, for after
taking five centigrams (three-quarters of a grain), he became
very drowsy and ultimately fell asleep. The drug was then
given by Professor Jolly to a number of patients in the neuro-
logic wards of the Charite' Hospital in Berlin. The first case
was that of a man suffering from alcoholic neuritis, who, after
an injection of four centigrams, became very drowsy, and one
hour afterward he fell into a sleep which lasted for four hours.
Dr. Hefter had observed in himself a diminished pulse rate,
and the same symptoms were perceptible in this patient, dur-
ing the first hour of whose sleep the pulse fell to 56 per min-
ute, rising again to 76 before the man awoke. Another
patient with multiple sclerosis took five centigrams during the
afternoon, and after half an hour he slept soundly for several
hours. Similar results were obtained in a series of other cases.
Some patients complained of giddiness and declined to take
the medicine, but the greater number did not suffer in this
respect. The cost, at present, of the article is about fifty
cents per grain, but the chemists, Boehringer and Soehne pre-
dict that they will presently be able to bring down this high
cost as the demand for the drug increases.
Diagnosis of Calculus by the New Photography. The Bulletin de
VAcadimie de Mideeine, June 2, records Dr. D' Arsonval's opin-
ion that a great diagnostic advantage will soon be reaped, in
regard to renal and vesical calculi, by the Roentgen photog-
raphy. The latest pictures obtained by Chappuis and Chanel,
have an especial value, since they show that it will soon be
possible to diagnose calculi in the urinary passages with abso-
lute exactness. They not only show the existence of a calculus
in the bladder, kidney or ureter, but it is possible to distin-
guish the substances of which it is composed, whether it is
homogeneous or formed of different layers, whether the kernel
is small or large and of what it is composed. The most inter-
3d
so
3d
I
ed
esting photograph from this point of view showed : 1, the sil
houette cast by a calculus of pure uric acid ; 2, that of a calcu
lus the same size as the first, but composed exclusively ol
phosphate of ammonia and magnesia ; 3, that of a calculus
much larger than the others, formed of several distinct layers
of uric acid in the center, with an outer layer, 4 mm. thick,
entirely different in color, and composed exclusively of the
triple phosphate ; 4, the silhouette of a bone 1 cm. thick, and
another of the index finger of one of the experimenters. Thi
differences in the depth of shadow in this photograph are s
marked that it is impossible to mistake the characteristics and
kinds of the calculi. The tiny kernel of uric acid is distinct!
visible, while the outer layers of the large calculus are repre
sented by clearly defined rings. A second photograph showei
another calculus with a kernel formed of soda urate, inclosei
in an outer layer of the triple phosphate, both very clearly defined
in the photograph. , A third represented a number of uric acid
calculi lodged in the pirenchymaof the kidney, one-half of which
was 5 cm. thick. The rays passed through this thick layer of
tough tissue and the calculi alone showed in the photograph.
It will be a simple matter, therefore, preliminary to an opera-
tion, to take the photograph of similar calculi, and then com
pare them with the results of photographs taken through the
patient.
Cod Gall for Cod-liver Oil.— Dr. Clarence Wright*, in London
Lancet, July 11, writes on the above subject. He says that
while the claim of cod-liver oil as a powerful alterative in dis-
eases of the respiratory tract has long been recognized, yet.
owing to its unpalatability and the nausea oftentimes attend-
ant on its administration, it is the common experience of all
that the cases which on theoretic grounds are selected as most
suitable often prove least amenable to such treatment. These
are for the most part cases characterized by a general wasting
of the body and failure of its nutritive functions. How insu-
perably difficult it is to overcome this inherent propensity of
the oil may be remarked when we notice how the ingenuity
and art of the pharmacist have been strained to the utmost i
devising ways and methods whereby it may be disguised if not
destroyed. Its combination with malt, the hypophosphites,
etc., are so well known that allusion to them would be super-
fluous. It would likewise x^rove a useless reiteration to enu-
merate the many oils and fats that have been proposed as sub-
stitutes for it. However feasible such substitution as a theory
may seem, yet in practice their use has not been attended by
any marked success. Cod-liver oil has been proved by French
investigators to owe its activity, not to any peculiarity in the
nature and constitution of its oleaginous constituents, but to
certain definite antemortem products of liver action, which not
only promote the absorption of the oil, but also materially
assist digestion and exert the well-known alterative action. It
has likewise been proved by examination of frozen and pre-
pared sections of a fresh liver that these physiologically active
constituents of cod-liver oil are of biliary origin, for their dis-
tribution in sections so made bears a definite relation to the
ramification of biliary radicles, and not to the fat cells of the
liver. " I was induced thereby to utilize that biliary product
of unchallengeable antemortem liver action cod gall as a sub-
stitute for cod-liver oil, and I can now after a trial of eighteen
months, say that I have every reason to believe it an efficient,
active and palatable substitute for cod-liver oil, and one that
deserves a trial. My usual method of employing it is by mak-
ing a wine of cod gall (vinum gadeo-morrhuine) by adding one
ounce of fresh gall, along with two and a half drams of
extract of pancreas, to a pint of wine (sherry or port option-
ally), and after ten days filtering it through some cotton.
I administer the wine so made in doses of one to four teaspoon-
fuls at or after meals four times a day."
IS'Xv i
EDITORIAL.
495
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SATURDAY, AUGUST 29, 1896.
A NEW MEDICO-LEGAL QUESTION.
The highest criminal court of the city and district
of Magdeburg, Germany, in May last, decided a case
that is entirely new in medical jurisprudence.
The defendant. Dr. Hirschfeld, treated a case of
serous inflammation of the cellular tissue of the arm
which resulted in septicemia and death, without any
spirits or supporting wines. When the case became
serious it was sent to the hospital and death followed.
Dr. Boehm. a member of the medical council and
hospital, accused Dr. Hirschfeld of neglect of
proper treatment in keeping the patient on what he
called •" a cold liquid diet, " rather than the strongest
wines, and most nourishing foods. The court charge
was acceleration of death, or homicide by negligence,
in not using spirits freely. Dr. Hirschfeld was
permitted to present a scientific defense of his treat-
ment of the case. He asserted that in his long experi-
ence he had never used any form of alcohol. He
considered it very mischievous, and that it never
added strength, but always detracted from the power
and vigor of the case. A series of statements were
offered by Prof. Bins of Bonn, Prof. Strumpell, of
Erlangen, Prof. Harnack, of Halle, Dr. Smithe, presi-
dent of the German Msdical Society; also the medical
council of Saxony, consisting of five physicians with
the president, all confirming the following general
facts: " The idea that alcohol gives strength is decep-
tion, while any form of alcohol may produce an
apparent form of stimulation, there is always a reaction
in a profoundly marked diminution of energy. The
special paralyzing action of alcohol on the brain and
spinal cord is no longer a theory, but a fact that can
be measured and proved. We are confident that
experience will fully sustain our beliefs that no single
human life, which would have fallen a prey to death
without alcohol, has ever been saved by alcohol."
These general facts were supported by voluminous
statements and clinical experience. The court ad-
journed twice in order to secure a great variety of
authoritative opinions, and Dr. Boehm, the prosecutor,
seemed to rely on the statement of text-book authori-
ties; finally the following discussion was presented by
the court: After stating the legal aspect, the judge
remarks: " It appears from the authorities offered,
that in regard to the diet of fever patients strong
soups and wines have in a comparatively recent period,
been abandoned as increasing the fever. Prof. Bins
has reported an instance where the medical man was
arrested for treating a case of fever with alcohol
alone. It is clear that opinions in regard to the value
of alcohol have materially changed, inasmuch as its
stimulating effect on the heart is regarded by many
as valuable, and some maintain that it is always capable
of lowering the temperature. Notwithstanding among
the most eminent practitioners at the present day,
there is a large number of opponents of this remedy.
Some declare with emphasis that they have better
success in their hospital and private practice without
the use of a drop of alcohol than otherwise. It
appears quite certain that alcohol in large doses exerts
a paralyzing influence, increases the decomposition of
albumin in the organism and is thus capable of influ-
encing the course of the disease unfavorably. There-
fore, without giving any definite judgment on this
difficult question, we shall adhere to the principle
that it is entirely inadmissible to lay down any limits
to the exercise of the individual judgment of the
physician in such matters. " The defendant was
accordingly acquitted. It would appear that consid-
erable personal feelings were combined with this case,
and a strong disposition exists to hold prominent
medical men responsible for any new innovations of
treatment where alcohol is supposed to be the remedy.
It is also noteworthy that the opponents to the use
of alcohol as a remedy are very formidable in culture
and scientific reputation, and defend their theories
with great emphasis and spirit. This case is also of
great interest, from the eminence of the parties in the
contest, both of them being teachers of medicine and
eminent practitioners. It would appear that no ques-
tion of this nature could ever come into court in this
country, because the use of alcohol therapeutically is
becoming more and more unsettled every year, and
while there is only an occasional paper in the medical
journals, relating to this question, there is a wide-
496
THE AUGUST HEAT.
[August 29,
spread distrust and skepticism of the value of alcohol
as a medicine.
It is a curious fact that alcohol as a beverage is not
much disputed, but when given as medicine its value
is questioned at once, especially in continental Europe.
Evidently a great revolution of theories concerning
this drug has begun.
THE AUGUST HEAT.
The month of August was ushered in by a torrid
temperature causing a reign of terror throughout the
central and eastern sections of the country which
equaled, if not surpassed, all previous records of
lives destroyed by climatic causes. Day by day a
stationary high thermometer swelled the long list of
victims and the humid nights furnished no relief to
the perspiring and exhausted multitudes. Even
Chicago, "The Windy City," discarding her sobriquet,
missed the invigorating breezes from Lake Michigan,
and for a period of ten days the atmosphere was
tainted by the odor of hundreds of putrefying animals
lying in the streets, which the city authorities were
powerless to expeditiously remove.
We are indebted to Acting Commissioner of Health,
Frank W. Keilly, M.D., of Chicago, for the mor-
tality statistics of the various cities. The death rate
in Chicago for the week ended was 697, making the
annual death rate 22.38 per 1,000, as against 579
deaths during the preceding week with a rate of 18.62.
There were 148 deaths from sunstroke during the
week ended August 15. The following shows the
mortality of four Eastern cities: New York, heated
term began August 4; total deaths 2,429; maximum
temperature August 9, 98; previous record July 24-
30, 1892, total deaths 1,615, mean temperature 83,
maximum temperature 97. Philadelphia, heated
term began August 2; total deaths 1,328; mean
82.7; maximum, August 11, 98; pre-
June 30 to July 13, total deaths 1,649,
mean temperature 86. Washington, heated term
began August 1; total deaths 39; mean temperature
81; maximum temperature August 6, 98; previous
record July 1 to August 3, total deaths 66, mean
temperature 84.9, maximum 97. Baltimore, heated
term began August 4; total deaths 344; mean tem-
perature 84.2; maximum 98.
The deaths from sunstroke in Chicago amounted
to 165. It is estimated that more than 800 horses
fell victims to the heat. These statistics must cause
some inquiry as to the diet and mode of life of the
victims. As is well-known, alcohol continues to fur-
nish a large proportion of the cases. But unfortu-
nately the statistics are silent on that point.
Prof. Stanford E. Chaille has well summarized
the points to be remembered concerning hot- weather
diet. In a recent letter to the Editor he says:
1. Nature's first lesson— a prolific production of edible and
appetizing vegetables and fruits.
2. Nature's second lesson — a decrease of appetite, especially
for fats and meats, and its greater gratification with vegetables
and fruits. \
3. The greater needs of the body for temperance in eating
and in alcoholic indulgence.
4. The more abundant growth of microbes, and hence the
greater need for cleanliness of food.
5. This greater need of microbic cleanliness most urgently
requisite in the diet of infancy and childhood, and especially
as to milk.
This last point is one to which too much attention
is not likely to be given. For the benefit of those inter-
ested in these matters we reprint below an item which
appeared in this Journal December 29, 1894.1
It will be seen that while 1896 has contributed
liberally to the heat statistics of the world, the season
we have just passed through was by no means
phenomenal. A London periodical in a recent article
touching man's power to endure heat says:
temperature
vious record
I
To begin with, the difference between the highest and lowest
limits is estimated at 250° Fahrenheit. French troops in
Algiers must frequently march and maneuver at a heat of
122° above zero. A French professor has, during a stay in the
Sahara with a tribe of Tuaregs, observed a heat of 153°.
Attendants in Turkish bath establishments work ten hours
a day in rooms where the air is artificially heated to 155, 175,
and even to 195° Fahrenheit. A scientific gentleman in Paris
not long ago spent fifteen minutes in a hot air room of the
Paris Hammam, in which the dry air had been heated by his
order until the thermometer registered 250° Fahrenheit. Issu-
ing from this room, he plunged immediately into a bath filled
with water of about 53°, a difference of 200° Fahrenheit which
his body passed through in less than a minute.
On the other hand, man will stand greater cold than any of
the other mammals. For instance, during the journey of
Prince Henry of Orleans through the Central Asiatic high-
lands the party frequently had to withstand a temperature of
40 degrees below zero. The quicksilver in the thermometers
had frozen solidly at this temperature, and even the alcohol
in the alcohol thermometers became thick. Horses and camels
died from exposure, while none of the men in the party suffered
in the least.
In North America intense cold is frequent. A Captain Burn
once measured at Fort Reliance a temperature, of 70° below
zero, while Captain Dowron, at Fort Rae, saw the thermome-
ter down to 88° below zero in the month of April. The lowest
temperatures known, however, have occurred in Siberia,
where a temperature of 50° below zero is not uncommon,
while at Werchojansk a temperature of 93° below zero has
been observed. It appears, therefore, that men can stand a
cold of 90° below zero, while a heat of 160° and even 180°
Fahrenheit appears to be the extreme limit in the opposite
direction. No animal is known which is able .to resist such
changes of temperature.
It must be remembered, however that power to
resist extremes, to resist great changes in tempera-
ture, does not insure power of resistance for long
i Phenomenally Hot Years. — The recent mild winter weather in
this couutrv somewhat breaks the force for us of Che contrast which the
Journal d' Hygihu endeavors to make in furnishing a list of phenorm-n-
ally hot years as " agreeable reading now that cold weather is at hand."
Among the most remarkable of these torrid years, all of which had
serious effects on the public health, may be mentioned A.D. 788 when
the heat was so great throughout Europe and especially in France, (hut
nearly all the springs dried tip and thousands perished of thirst, in ^79
reapers who staid in the fields after midday fell dead in great numbers.
In 990 nearly all fruits dried up, occasioning a great fitmine and an
enormous mortality. In the year 1000. amidst panic fears about the end
of the world, the river sources dried up and vast numbt rs of fish putre-
fied, giviug rise to a general epidemic; it was widely believed that the
end of the world by fire was at hand. In 1182 rivers and springs again
dried up and the bed of the Rhine became a d'y sandy road In 1189 the
sand was so heated that eggs were cooked In it in a few minutes.
The Seine. Loire. Rhine and Danube could be pa sed over dry-shod in
1808. All fruits wiihered and animals dropped dead from the exuepsive
heat of 1893. Four years of great heat and continuous dryness, from
15¥8 to 1641, caused many rivers to disappear entirely, crops were fail-
ures and famine and sickness carried off large numbers. There were
fifty-eight consecutive days of extraordinary heat in 1646. There was
no rain from April to October in 1710: the Reaumur thermometer marked
over 3ri degree*; in gardens which could be irrigated fruit ripened
twice. In 1818 the theatres of Paris were closed for a month on account
of the heat; the thermometer marked over 88 degrees R. During June
and July, 1830. the centigrade thermometers registered over 38 degree- in
Paris in the afternoons.
1896. ]
THE AMERICAN ACADEMY OF MEDICINE.
497
continued heat. It is the long-drawn-out "hot spell"
thai tests the permanent resistant property of the
human frame.
CHE EXCELLENT WORK OF THE AMERICAN
ACADEMY OF MEDICINE.
The now fields which the American Academy of
Medicine have elected to till, and the noteworthy
oops at present being gleaned deserve the most
tespectful consideration of the profession. More than
this, its attempt and success in reclaiming waste and
abandoned lands and making them yield rich harvests
for professional and sociologic good demand the sym-
pathetic interest of every physician who looks upon
his work as something more than bread- winning.
For many years, about eighteen, the Academy lab-
ored with a singleness of purpose to raise the standards
of medical education, anil it should not be forgotten
that the seed sown by it has been widely distributed by
its members anil their publications, and has been a
highly important means of bringing about the remark-
able changes in this respect by public legislation, and
.. spontaneously chosen standards by medical colleges,
iow proving and still more to prove of incalculable
enetit to all concerned.
But the singleness of aim with which the Academy
iiborcd. beeame( sometimes and to not a few) somewhat
uonotonous; this fact coupled with the very patent
soeiate factor that the work of the Academy was
.id remains genuine missionary work, offering no
ort of reward, political or financial to its fellows, had
erved to make the function and even the existence of
the organization altogether too little recognized and
unsupported.
But all this is now. we are led to believe, a thing of
the past, and with its new ground and methods of
husbandry, the Academy is attracting the earnest
attention not only of the medical world but of that
reater world of which we form a part. Briefly stated,
the last two or three years the Academy has under-
taken the tillage of the " Bad Lands " of Medical
Sociology, not only as pertains to the profession con-
sidered in itself, but also as relates to the community
at large. It might at first sight appear that this was
bolj the old question of Public Health, but a glance
at the last dozen numbers of the Bulletin of the
Academy in which the papers and proceedings of its
meetings have been published will show that without
any desire or attempt to infringe upon the territorial
rights of the organizations and agencies working
these farms, the Academy has found vast domains
wherein to exercise its energies. Two years ago the
meeting of the Academy was largely given over to
the subjects of the relations of the profession to the
dependent classes, and the inter-relations of both to
the community. Instead of exhausting even the
most general of these subjects, it was evident that
here was an extremely rich soil, well-repaying years
of study and tillage. The reports of this meeting,
and the papers read there, as republished in the
Bulletin, at once gained the attention of medical
editors and of the lay-public, and were extensively
quoted and bespoken both in this country and in
Europe. The general subject then introduced has in
subsequent meetings continued to arouse interest, and
in future a not inconsiderable proportion of the time
and attention of the Academy will doubtless be dedi-
cated to it. At the meeting of last year besides due
consideration of this aspect, the question of hospitals,
their management and abuses was uppermost in the
minds of the attendants. At Atlanta this year, one
day's sessions were devoted to medical education
again, and the number of the Bulletin just at hand
(Vol. II No. 8) contains the able papers of many
distinguished teachers upon its protean aspects. The
" President of the Academy, Dr. Henry M. Hurd of
Baltimore, presented a valuable contribution upon
" Laboratories and Hospital Work."
Drs. Osler, Parsons, Gerrish, Roberts, Smith,
Wright, Edgar, Wilson, Taylor, Holmes, Park
and others dwelt upon the best methods in education
as regards the preliminary requirements, and each of
the special branches of the medical curriculum. In
reading these papers one finds himself in a new atmos-
phere, even a new world from that of but a very few
years ago. " Everyone who is interested in practical
education and the new ideals and methods now ripen-
ing into certain near harvests will not neglect the
reading of these articles.
The meeting of 1897 is to be held in Philadelphia
and is noteworthy as being the 21st. The celebration
of the attainment of its majority should be an excep-
tional and memorable gathering and the members are
already at work to make it so, and to arouse a proper
recognition on the part of the general profession to
the vital issues of the time. The words of that ideal
secretary, Dr. McIntire, concerning the Philadel-
phia meeting are as follows:
" It has been suggested that next year another
phase of the life of the physician and his environ-
ment be mada the subject of investigation. Probably
the theme can be expressed by the phrase. 'The
Associated Duties of the Physician, ' as by any other,
although a more precise wording may be thought out
later. There are certain duties to one's fellows that
pertain to the profession; unless these are clearly
understood and properly defined there is the danger
of imposing on the benevolence of the physician on
the one hand or an undue selfishness on the other.
In either event harm is wrought. These associated
duties may be crudely classified as his 1, with his
fellow-physicians; 2, with his fellow citizens (as a
physician of course); and 3, with the body-politic.
The first of these divisions treats of medical societies,
their history, use, proper method of conducting, etc.;
the associations of physicians having insurance or
financial relief in view; indeed of any question
involving the united effort of several or many physi-
cians to accomplish. The second division relates to
498
THYROID THERAPEUTICS.
[August 29,
those problems involving medicine so frequently met
with by us all in our private capacity, and in the
solution of which we must be associated with our
fellow citizens. Questions relating to the sanitary
condition of the community, or the physical side of
child-life in the public schools; the freely giving of
our professional services to those who can not pay at
the suggestion of others who, possibly, ought to be
asked to share in the giving. While the third division
includes the discussion of all questions involving the
services of physicians as incumbents of public posi-
tions, whether merely of honor, or of honor and some
profit. This outline serves to illustrate how extensive
a field is included in the topic, and the purpose of
this notice is to invite the promise of contributions
from the Fellows of the Academy in order to ascertain
if it will be practicable to arrange for a day's discus-
sion along these lines. Those who may desire to
contribute a paper are asked to write to the secretary
stating their purpose and giving the title of the pro-
posed paper. At the same time none of the themes
of the previous years have been exhausted, so addi-
tional contributions along these lines are still
acceptable."
THYROID THERAPEUTICS.
Thyroid therapeutics is an acquisition of the last
six years, and one that better than perhaps any other
illustrates the close relations between physiologic
research and the rational treatment of disease. It is
not very long since that the thyroid, like other duct-
less glands, was a physiologic puzzle, and the theories
as to its utility in the organism varied from that of
its being a merely esthetic appendage to round off
the contour of the throat to the attributing to it an
important action in mechanically regulating, as a
diverticulum, the blood supply of the brain. The
recognition of the connection of the cretinoid condi-
tion described by Gull with atrophy of this gland by
Ord in 1877, and the subsequent experimental studies
of Schiff and his assistants and of Horsley in Eng-
land, and others, led directly to the theory of the
chemico-vital function of the thyroid and to the sug-
gestion of its utility in the therapeutics of myxedema.
While the suggestion and the demonstration by
experiment on animals of the efficiency of the extract
of the thyroid is due largely to Vassale and GIley,
the first successful application in a human subject of
this treatment was made in England by Murray in
1891, the method by hypodermic injections of a gly-
cerin extract having been employed. A little later,
in 1892, the more convenient plan of administration
by the mouth was substituted for the hypodermic
method and has become the general practice. Tbe
various preparations in the market seem all, or nearly
all, more or less effective, and in some of them at least
we seem to possess all the active principles of the
gland itself so far as its specific action on the disor-
der is concerned. While myxedematous conditions
are not extremely common, they are, like other newly
described affections, becoming daily more and more
recognized, 'and the experience of the profession has
already demonstrated sufficiently the practical value of
the findings of physiologic experimentation. In an
disorder which, like myxedema, seems to depend upo:
or be connected with deficient functioning of th
thyroid gland, the use or, at least, the trial of thyroid
extract is indicated and justifiable. Thus there appears
to be a certain relation between the thyroid and the
pituitary gland, and in acromegaly both are likely to
be disordered. In those cases where the thyroid is
atrophied, thyroid extract is probably indicated; where
it is hypertrophied its utility is very questionable
The possibility of a vicarious functioning of the two
organs, the thyroid and the hypophysis, suggested by
Rogowitsch, seems to be disproven by the experi-
ments of Vassale and of Oliver and Sghafer, and
the therapeutic experience is not especially in its
favor. The results of the use of pituitary extract
have not yet been so extensive as to enable us to affirm
that its value is at all comparable to that of the thy-
roid, in the cases where it is theoretically indicated,
and the treatment of acromegaly is therefore still i
problem for the future.
In exophthalmic goitre the use of thyroid is gener
ally condemned, and yet there have been cases in
which it is reported to have been of benefit. While
we may admit that as a general rule the theory of
Moebius, viz., of hyperthyroidization, best explains
the pathology of the affection, there are possibilities
of other conditions existing, and the cases where it
tends to pass into myxedema (Putnam, Joffroy) are
very suggestive of a possible utility of thyroid extract
in some stages of the disorder.
Aside from myxedema, the principal affection for
which this medication seems likely to be of most
value, is obesity. It is abundantly demonstrated by
experience that it produces a most remarkable and
rapid reduction of body weight, probably on account
of its stimulating the fat consumption in the organism
and increasing the urinary excretion. The fact that
no change of diet is necessary and the comparative
safety, so far as known, of the treatment, makes this
property a very valuable acquisition to our medical
resources, notwithstanding the often, or even gener
ally, transitory duration of the effects after the dis
continuance of the treatment.
The value of thyroid medication in true goitre must
depend on the degree of functional inactivity of the
organ. If the disease is, as is probably generally the
case in its incipiency, a compensatory hypertrophy,
the most we can reasonably expect of thyroid ingestion
is that it may supplement an enlarged but perhaps
still overtasked organ. It may indeed relieve the
hypertrophy in some instances, but it is hardly in the
order of things to consider it as yet a specific for this
affection. In sclerodermy it has been reported as
useful, and this is in accordance with some researches
1896. 1
CORRESPONDENCE,
499
that indicate a causal nexus between this condition
and functional disturbances of the thyroid gland. In
»ther skin affections and in syphilis it has also been
ied, but in > very positive evidences of its general
value have as yet been given.
We are not yet able to say that the whole physi-
ology of the thyroid is known, and therefore may in the
future find other functions that will furnish indication
for rational therapeutics. It is occasionally deranged
we know in a large number of disorders, and when-
ever its secretory function is hindered or abolished
it is reasonable to try thyroid medication. But
beside this, this latter has in all cases a decided
effect on the general nutrition, stimulating, it would
appear, the metabolic changes, and in this way its
effects may be valuable. Thus, in many cases of
insanity where it has been tried empirically and
because of the mental improvement it causes in
myxedema, it has been found of benefit. Unless in
these eases there was direct thyroid derangement.
which it must be admitted may have sometimes
existed unobserved, we can best attribute the bene-
ficial effects, in the present state of our knowledge, to
this general systemic action producing the change
that was required in possibly a critical stage of the
disorder, or perhaps we should better say that the
stimulation of the systemic metabolism caused the
carrying off of toxic substances poisoning and derang-
ing the brain. As a general alterative of this kind
thyroid medication may have a decided usefulness in
certain cases, apart from its direct specific action in
thyroid deficiency. There is possibly more than one
active principle secreted by the gland ; the thyroidin
of Baumanx alone will suffice to account for the
specific effects, as shown very recently by Magnus-
Levy, while he states that thyro-antitoxin presents a
series of interesting peculiarities that will form the
subject of a future publication.
The comparative innocuousness of the extract has
been already noted. The inconvenient or excessive
action of the remedy in a few cases is probably due
to idiosyncrasy, though the possibility of imperfec-
tions in the manufacture and of impurities as sug-
gested by LANZ, should not be neglected. In certain
cardiac cases it ought certainly to be only employed
with caution and the state of the urine and other
secretions should always be watched during its admin-
istration. But, given with proper judgment and
care, it is as safe as any remedy with equal physio-
logic effects and far safer than many of them. With-
in its range of usefulness, the limits of which are
not yet fully determined, it seems to be one of the
most important of recent medical acquisitions.
CORRESPONDENCE.
Sunday Rest for Druggists. —The drug stores of Soissons, Prance,
close now at noon, Sundays, all except one, and the address of
this one is placarded on the door of each. They take turns in
remaining open this way on Sundays.
A L.etter from Professor Edwin Klebs.
Chicago, Aug. 23, 1896.
To the Wdttor:— The paper of Dr. F. E. Stewart, "The
Scientific Nature of our Patent and Copyright Laws," in the
recent number of the Journal, brings forward facts in the
"Klebs Antiphthisin Case" which are entirely new to me,
and which induce me to clear up my personal position in the
matter.
Though the contents of the paper of Dr. C. P. Ambler, read
before the American Medical Association, as well as the
following discussion, are entirely unknown to me, as I was not
present when the paper was read, 1 learn through the paper
of Dr. Stewart some details in the matter which demand
explanation of my standpoint on the question.
When I came the first time to this country in the fall of 1894,
induced by Dr. Karl von Ruck of Asheville, N. C, to visit his
institution, I was in every respect an entire stranger. Dr. v.
Ruck made me the proposition to accept a position as director
of a laboratory for experimental research and consulting phy-
sician to his institution. As the great advantage of an insti-
tution with the facilities for scientific research, and at the
same time for the practical perfection of my more theoretically
developed ideas, seemed evident to me, I accepted the offer,
with the greatest expectations in a final solution of all these
problems.
By the contract I entered with the Winyah Sanitarium and
Hotel Company, whose medical director and president Dr. von
Ruck was, I obliged myself to accept the mentioned position
in the laboratory of the sanitarium at an annual salary and as
well to interest myself financially in the institution, leaving to
Dr. von Ruck entirely the management of the medical and
business part of the institution, as well as the exploitation of
substances prepared in the laboratory. I therefore did not see
any harm in the application for a legal protection of Anti-
phthisin, as this lay entirely in the hands of Dr. von Ruck,
whom I would expect to be familiar with the systems and
ethics of the medical profession in this matter. In Germany
nostrums are not patented at all, and scientific preparations
only are patented. These scientific patents are frequently held
by members of the medical profession, and I was not aware
that there was a difference in the ethic practice of the two
countries.
The application for the patent as not complying with the
requirements of the office was refused, and Dr. von Ruck
therefore tried to induce me to undertake certain experiments
to fulfil these requirements. Declaring myself unable to do
this and for other reasons, which I explained to the company,
I left the institution early this year.
I was met in my efforts for a cancellation of the then existing
contract by Dr. von Ruck at the end of May, by his proposi-
tion of a new contract. Both parties in this contract agree to
cease the manufacture of Antiphthisin in this country. I
agree to furnish the preparation from Germany, leaving to Dr.
von Ruck the right to sell it here. One- third of my invest-
ment in the company was paid me, for the other two-thirds I
had to accept notes. I have never received any payment of
dividends from the company, only a small compensation for
Antiphthisin furnished from my German laboratory, in whose
management Dr. von Ruck and myself had equal shares at
this time.
Being now more familiar with the customs of this country
and better acquainted with the medical profession, I can only
regret that ever an attempt was made to protect Antiphthisin
by patent, and I am satisfied that this question will not need
any further consideration. I consider the rule of the Ameri-
can Medical Association against proprietary medicines of
500
CORRESPONDENCE.
[August 29,
binding force, though its existence was not known to me at the acter. It occurred at a final oral examination. The members
time, and though I agree with Dr. Stewart, that a qualification
of these medicines would be very desirable, which would not
indorse the whole unscientific nostrum trade. The question
has gained in importance since the introduction of bacterio-
logic products into therapeutics, as a protection by law of their
methods of preparation, not in the interest of individuals, but
as a guarantee for their purity and efficiency and as a protec-
tion against the production of such remedies by untrained
hands.
Hoping that Dr. Stewart's paper will find the well merited
consideration by the profession, to the benefit of science
and further therapeutic efforts and to the strict exclusion of
the entirely unscientific nostrums, I am yours very respect-
fully, Edwin Klebs, M.D.
Herman W. Mudgett alias H. II. Holmes.
Milwaukee, Wis., Aug. 20, 1896.
The article of Dr. Eugene S. Talbot in our Journal for
August 1, reminds me that I may say something about Holmes
which may be of interest to members of the medical profession.
Holmes was a member of my class, which graduated in 1884,
and he received his degree of Doctor of Medicine with the
other successful members. A few failed in their examinations
but Holmes was not among them. I was not intimately
acquainted with him but knew him as well as I did any mem-
ber of the class, excepting my immediate associates. What
manner of man he was I remember distinctly and as distinctly
recall several conversations I had with him.
Holmes was a mild-mannered young man, with a diffident
air, possessing no characteristics in any direction which would
attract attention. He evidently had not much in the way of
pecuniary means, for he dressed plainly, almost shabbily, and
he eked out his expenses by "doing chores" about the prem-
ises of Prof. Edward S. Dunster, who died several years ago.
As a student he was below the average of the class, decidedly,
both in ability to acquire knowledge and in readiness to
express what he knew. I distinctly remember his halting,
uncertain manner when called upon to answer a question at a
"quiz," and I also remember a "scoring" which that earnest,
conscientious old man, Professor Palmer, gave him on an occa-
sion because he was remiss in answering a question in physical
diagnosis. Indeed, a single circumstance indicating acuteness
in any direction on the part of Holmes, can not now be
recalled.
Holmes attended the meetings of the Y. M. C. A. Whether
he was a member in good standing I do not know. He once
told me that he intended to go to New Zealand as a medical
missionary after graduation. At another time, when a clerical
member of the class took exception to a eulogy of Thomas
Paine, given incidentally by one of the professors, he had a
supporter and sympathizer in the person of Holmes, when he
(the clerical member) took the matter to the president of the
University.
He seemed to take a good deal of pleasure in the uncanny
things of the dissecting room. One afternoon's conversation
with him I remember distinctly. He talked a great deal about
what he had done in the dissecting room with,- what appeared
to me at the time, unnecessary gusto, and told me that the
professor of anatomy was to permit him to take the body of an
infant home with him for dissection during the spring vacation,
which was to begin on the following day. I asked where he
would find a place in which to carry on his work without
offending his neighbors, and he replied with something to the
effect that he "would find a place."
There can not be much doubt that even at this time Holmes
would lie when it was to his advantage to do so. On one occa-
sion I was directly concerned in his lying, the circumstances of
which may be of interest as throwing some light on his char-
of the class were called in alphabetical order, one by one, and
I was surprised to find Mudgett present himself in front of me.
I called his attention to the fact that his name came after
mine and asked for an explanation. He said that L., men-
tioning the name of a student, had gone out of town and that
he (L.) had given him his place. I asked him when he saw L.,
and he said "this morning." Now, I knew asamatter of fact,
that L. had left the city the night before, and, moreover, that
he had been dismissed from the University in disgrace for
attempted cheating in an examination. Feeling a little sur
prised at Mudgett's mendacity, I told him that I knew he was
lying and I told him how I knew it, and that I would not permit
him to go in for his examination ahead of me. He received my
decision with very ill grace, but made no physical resistance.
When I came out I found him in tears, relating the matter to
a classmate, and he whined that it was "a damn mean trick"
to deprive him of the place given him. This is the last con
versation I remember having had with him.
While at the University I can not recall any direct evidence
of his fondness for women. On one occasion, the latter part of
his last year at the school, he spoke of his wife, and I was sur-
prised to hear that he was married, as, up to that time, I sup-
posed he was a single man. There must, however, have been
some story current, connecting Holmes with women during hi
University life. I have a hazy remembrance of his bein
charged with some irregular conduct of the kind, and of hii
making a stout denial. Turning to the "Class Phrophecy"
which was written at the close of last year at school, I fin
that 1 wrote of Mudgett as follows :
"Herman W. Mudgett, unlike George Washington, n<
widow shall find favor in his eyes. After being charged with
innumerable Don Juan escapades for which he is not respon
sible, he will retire to write a book on the 'Oppression of Man.'
This book will make women very unpopular." This was, no
doubt written apropos some affair with the other sex which
was discussed by his fellows.
The stigmata of degeneration discussed by Dr. Talbot, no
doubt existed at this time ; but they did not attract enough
attention to cause any remark that I ever heard, except on pos-
sibly one occasion. Following a custom which then existed,
the members of the senior class ordered silk hats and a repre-
sentative of a Detroit firm came to Ann Arbor to take the boys'
measures. In doing this the usual periphery was sketched on
paper. As is well known some startling irregularities are some-
times disclosed by this proceeding. A friend and myself took
a good deal of interest in these outlines and Mudgett's was
inspected among the rest ; but I am unable to say what the
irregularities were in his case, or how valuable they were if
they existed. The outline may still be in the hands of Walter
Buhl of Detroit.
It is not the purpose of this article to discuss Holmes as a.
probable degenerate. I simply write the facts concerning him,
as far as I know them, while he was a student in the Univer-
sity of Michigan. On the whole the impression I had of him
before he became notorious as a criminal, was that of a liar and
sneak without ability or courage to do great deeds in any
direction. John Madden, M.D.
Concerning? Dispensaries.
NEW York, Aug. 20, 1896.
To the Editor: — A circular of information wanted, is being
sent to the various dispensaries of New York City by the State
Board of Charities. I presume that it is sent to all dispensa-
ries alike, both large and small. Among the questions to be
answered are the following :
6, If connected with a medical college, hospital, or any other
institution, state the name thereof.
189(5.]
CORRESPONDENCE.
501
7. The name of the governing board of the dispensary.
8. The stilted times of meeting of said board.
>i. The average attendance at meetings.
10. How often have the members examined the work of the
dispensary ?
13. What forms of records are kept?
14. What means are employed to determine that each patient
is unable to pay for medical or for surgical treatment?
l.Y What charge, if any, is made to patients for treatment?
W>. What chart;!', if any, is made to patients for medicine?
17. If any members of the medical staff are paid for their
services, state for what service, and at what rate?
■10. How are the medical men selected, and by whom?
21. Are any physicians or officers appointed after competi-
tive examination?
•J'J. l>o the physicians ever treat the patients as their own
private patients, and if so, give the particular rule under which
the charge is made?
_S. Is there a class of physicians assigned to the treatment
of patients at their homes?
29. What pay d<> they receive, and from what source?
31. How many of the patients were non-residents of the county
in which the dispensary is located?
38. Is a collector employed to solicit contributions?
.'51'. If so, at what rate of compensation?
S. F. B.
Audi alteram partem.
A Defense of the Bicycle.
Birmingham, Ala., Aug. 21, 1896.
To the Editor: Will you kindly allow me space to comment
briefly on an editorial in the Journal of the 15th inst. entitled
•Bicycling Pro and Con."
I would like to ask how many cases of deformity of the
female pelvis from this cause have been noted? Also, how
many patients have applied for treatment for vesical and pros-
tatic irritation caused by the bicycle saddle?
To place the bicycle in its proper place as a machine for good
or evil, it would seem to be necessary to compare all such dam-
ne with the good it has accomplished. The great advan-
tage which the wheel has over all other modes of exercise is
the pleasure it affords. The therapeutic value of fun is, I
think, undisputed. It combines fun with plenty of fresh air
and exercise, and if there is any better combination from a
health standpoint it is yet to be reported. The tired drudge
of a clerk or book keeper, after being on his feet all day, does
not relish such a prescription for his dyspepsia as a "long
walk," but he can ride a wheel and enjoy it, and at the same
time promptly cure his dyspepsia.
The reason for the wide extent of "the craze" is just this
combination of exercise, pleasure and fresh air, which reaches
all classes. And the good it accomplishes I think far out-
weighs the occasional harm it may do to a young girl or an
old man.
WThere little girls once spent all their idle time cramped up
in a corner of a nursery, with their dolls or inane amusements,
pale faced, dull eyed and constipated, or strolled languidly
along the street in groups, anemic, round shouldered and
spindle shanked, they now ride wheels and are animated,
strong limbed and healthy. No doubt the morals of a few
older girls suffer, but they are far fewer than was the case
under the old style of buggy driving and entertaining their
men friends in dark corners.
Idleness and erotic thoughts always go together. There are
no such safeguards anywhere against bad habits as active
mental and physical exercise. The reproductive instinct, the
sexual appetite, is the result of a surplus of energy left after
the body heat and growth, and the menial and physical expen-
ditures, have been supplied.
There is no evidence, so far as I know, to substantiate the
theory that the bicycle will deform the pelvis, and there is no
moro reason for it than to suppose that sitting on a chair will
do it. On the other hand, it develops all the pelvic muscles,
and must, by the general good health it induces, make the girl
stronger in every way.
The bicycle costumes and contours are shocking to conserva-
tive eyes just as the modern bathing suits are shocking to the
eyes of our Uncle Reubens and A unt Marias, while others would
feel it infinitely more shocking to see a bathing skirt which
reached down to the heels. But the bicycle girl, like the sum-
mer girl, has cut her clothes for convenience, and will likewise
probably leave the Uncle Reubens and Aunt Marias to get over
it as best they may.
The bicycle has too many advantages pointing to its perma-
nency to be called a fad. The people who first took advantage
of comfortable railway coaches were, no doubt, called faddists
by their philozoic contemporaries, and no doubt a great cry was
raised about the harm to come to the morals and the hem-
orrhoidal veins of the nation from the slothful and luxurious
habit of sitting all day on the soft and warm cushions. But
the railway was more than a fad, and anything like a just rec-
ognition of its merits must show that the bicycle has also come
to stay.
Book keepers, salesmen and others, whose lives were once
one round of drudgery, bad air, no exercise and dyspepsia, now
live two or three miles out in the country where their families
can be healthy and they themselves can live on something more
nourishing than tea, toast and pepsin.
Finally, the bicycle takes young men away from the saloons
and those other places the natural allies of the saloons, the
frequenting of which probably gives rise to a thousand cases
of prostatic and vesical irritation where the bicycle saddle
causes one. ,
The writer does not ride a wheel, consequently has no per-
sonal experience of vesical or prostatic irritation to report. He
can readily see, however, that a busy practitioner forced to
an explanation of a vesical irritation in his own person, by a
recently developed monomania for urinals would be unfortu-
nate indeed if he did not have a wheel to charge it to.
2220 1st Ave. George S. Brown, M.D.
Practice In Africa.
Milwaukee, Wis., Aug. 20, 1896.
To the Editor: — Will you please inform me if our American
diploma is accepted to practice medicine and surgery in any
and all parts of Africa, and if not what procedure I will have
to undergo to begin practice in that country. I was under the
impression that anyone could practice in that country who was
a regular graduate. Will you please be kind enough to give me
the desired information I ask and oblige yours fraternally,
W. C. Arons, M.D.
211 Grand Ave.
Answer : — Each country having provinces in Africa, has a
different regulation. The independent states also have special
regulations. A letter to the colonial governor in the case of
the provinces would give you the desired information.
Albinism.
New York, Aug. 22, 1896.
To the Editor: — As bearing on the subject of racial degen-
eracy, I report the following cases :
1. Mrs. B.. an ultra-blonde, native of county Wexford, Ire-
land (limestone region), recently died of aortic stenosis and
cerebral embolism, leaving as surviving family : a sister, con-
genitally hunchbacked, a deaf and dumb son, and two daugh-
ters, one unusually tall, who is goitrous, the other a full albino.
2. Miss C. , aged 28, whose parents both were deaf mutes,
502
BOOK NOTICE.
[August 29,
has a streak of perfectly white hair an inch in width, extend-
ing from occiput to forehead ; this was congenital.
I ask the question therefore, is not albinism like deaf-
mutism, goiter, dwarfing, etc., evidence of racial degeneracy?
Certainly there exists some relation between vitiligo and lep-
rosy, and the latter is found only in degenerate classes.
Albert S. Ashmead, M.D.
Civil Service Commission.
Chicago, Aug. 24, 1896.
To the Editor: The Chicago Civil Service Commission will
hold an examination for the position of medical inspector of
the City Health Department (salary §75), September 3, at 2
p.m., in the Council Chamber. Applications must be filed at
the offices of the Civil Service Commission on or before Sep-
tember 1. Candidates must present evidence of recognition
by the State Board of Health of Illinois to practice medicine
in this State before application will be received.
Examining Board : Drs. Wm. Cuthbertson, Maurice L.
Goodkind, S. C. Plummer, Arthur R. Edwards, Jos. R.
Hawley. Respectfully, E. J. Phelps, Secretary.
BOOK NOTICE.
The Journal of Experimental Medicine. Edited by William H.
Welsh, M.D., Baltimore. Vol I, No. III. New York : D.
Appleton & Co. 1896.
A stately volume of more than 200 pages, showing in its
various contents how timely and successful appears the gather-
ing of American experimental work in one organ. This will
excite more and more the emulation of the investigators and of
the institutions dedicated to this work.
If it is practical to bring about also pathologic and anatomic
labors, I am not sure. But the division of the two lines of
scientific investigation can be made later, if it seems to be
needed.
We can give here but very short indications of the rich con-
tents, hoping that they shall provoke the reading of the original.
1. On the pigment of the negro's skin and hair, by John T.
Abel and Walter T. Davis, from the pharmaceutic laboratory
of the Johns Hopkins University.
A fine chemic work, showing that the pigment of the negro's
skin and hair forms, as is known, cylindric or rod-like granules,
contained in epithelial cells. The authors show that the pig-
ment can be made soluble by treating the granular part by
diluted hydrochloric acid, then by diluted alkalies. A very
skillful use of acetic acid, ammonia and precipitation with
alcohol ether (6 to 1) grants a high degree of purification.
The brownish powder gives a markedly acid reaction. The
first high percentage of salts can be reduced from 0.8 to 1.2
per cent. The quantity of pigment in the epidermis (3.08 to
3.78 per cent.), is greater than in the hair (1.9 per cent.).
The acid is probably identic with the hippomelaninic acid, pre-
pared by Berdez and Nencki from melanotic tumors of the horse.
The non-colored ground substance seems to be derived from
keratin, giving pyrrol and hydrocyanic acid in dry distillation.
The substance has a very high percentage of sulphur (3.6
per cent.) and is nearly free from iron, a fact which correctly
brings the authors to the conclusion that the hemoglobin, con-
taining but a little more than .05 per cent, sulphur, can not be
regarded as the mother substance of the melanin. That the
melanin probably must be derived, as is suggested by the
author, from proteids of the parenchymatous juices, coincides
very well with the anatomic facts proved in melanotic tumors
and the suprarenal melanosis (morbus Addisonii).
2. W. J. Bradley brings an anatomic description of hemor-
rhagic cysts of the thyroid gland, and thinks to have found a
new form of goitre. So far as the writer can see, it is no other
than a secondary degeneration in glandular and colloid struma.
3. A. C. Abbott has found in the Schuylkill River in Phila-
delphia a vibrio, very similar to V. Metschnikovii, and studies
its cultural, biologic and morphologic properties in a very
intensive and careful manner. The discovery of such a suspi-
cious vibrio, of near relationship to the vibrio of cholera Asi-
atica, in a place that was free from cholera since 1873, is of a
great practical and theoretic interest.
4. The same brings experimental investigations over the inrlu
ence of alcoholism upon the susceptibility against certain
pathogenic organisms. As control-animals suppported infec-
tions that killed the alcoholized animals there can not be a
doubt that the very high alcohol doses used in rabbits (10 to
15 c.c.) must heavily depress the normal faculty of resistance.
5. I. Adler and S. J. Meltzer (New York), have worked on
the question of " the path by which fluids are carried from the
peritoneal cavity into the circulation." By tying in rabbits the
innominate veins, the authors searched to exclude the lymphat-
ics ; afterward they observed the quantities of fluid reabsorbed
in a certain time (mostly forty minutes) from the peritoneum.
Injecting small quantities of potassium ferrocyanid, they found
only a retardation of the excretion in the urine, marked by the
Prussian-blue reaction, showing that by excluding the lym-
phatic circulation thus indirect penetration of the peritoneal
fluid into the blood vessels takes place, but after a longer time.
After injecting larger quantities of fluids into the peritoneum,
much more complicated processes must be expected, depending
upon the quantity influencing the circulation, and upon the com-
position of the injected fluid, influencing the osmotic process.
The exclusion of the lymphatic ducts effects also in this
order a retardation in the process of resorption, but the excep-
tions from the rule are greater and the differences not so strik-
ing as after injecting small quantities. Finally, they find the
greatest resorption from the peritoneum in dead animals, dem-
onstrating the swelling of tissues (Quellung) effected by the
osmotic process. Also filtration was effected in these experi-
ments by the gaseous distension of the intestines. The path
in which, under these circumstances, the fluids are carried
from the peritoneum, is shown by the edematous infiltration of
the surrounding tissues.
In the explanation of these phenomena the authors find diffi-
culties which they, as it seems to me, can not wholly resolve
(pp. 518 and 519). They state a marked difference between
lymph and tissue fluid, but they can not detect the forces that
direct the movements of these fluids ; forces that they do not
like to name "vital forces." Certainly, if the entrance of
fluids from the peritoneum into the tissues occurs also in life,
as in death, there must be some forces that will cease with life.
That is, what physicists may name -'vital forces" so long as the
physic of the living body is not more recognized as yet. The
problem will absorb much labor before the truth is declared,
but there is made by the authors a good step toward this end.
6. S. J. Meltzer reports very curious experiments on gastric
resorption. Strychnia solutions are not reabsorbed and will
not kill the animal, if the introduction into the intestine is hin-
dered by ligature of the pylorus. Hydrocyanic acid, on the
contrary, results fatally injected in the ligated stomach, as the
author suggests, possibly by its volatility. It would have been
interesting to see a statement of the action of the soluble salts
of the same acid.
7, 8. B. Meade Bolton brings some studies over the modern
theme of antitoxin, the first with Herbert D. Pease on the
production of antitoxin by the passage of electricity through
diphtheritic cultures, the other on antitoxin in normal horse
blood.
The authors use in contrast to the last observers (D'Arsonval
and Charrin, Bonomi u. Viola, Centralbl../. Bact., xix, 22, 23)
constant currents of 110 volts (of the Edison light) working on
diphtheria cultures in H-shaped tubes for dividing the products
formed at the two poles. The products at the positive pole
1896.]
NECROLOGY.
503
had decided antitoxic effects, if mixed to efficient toxin in the
proportion of 1 to ."> c.c. The product of the negative pole was
inefficient.
Probably the toxins are destroyed by the current and the
antitoxic effect depends upon the healing substance contained
in every culture of diphtheria.
in found antitoxic properties in the serum of some horses.
The immunization of these animals is going on with very slight
reaction. But reaching doses of more than 100 c.c. toxin, there
more difference in reaction.
9, Henry C. Beyer gives the results of regular exercises on
the growth and weight of naval cadets from 16 to 21 years of
Che increase in height reaches to nearly one inch, of
weight to 25 kilos, over the increase in untrained young men
of the same age. The lung capacity had gained in the five
years 1,722 c.c. more in the trained than in the untrained.
10. Simon Flexner Johns Hopkins University) reports in a
highly interesting treatise the results of bacteriologic studies
made regularly in the postmortems of the pathologic depart-
ment i H. Welsh i. We can not reproduce here the details, but
it is clear that, if in 255 cases 213 or 83.5 per cent., give posi-
tive results, we have an important death-promoting factor not
yet estimated. It is also shown by plate cultures that in
eases of patients with bad prognosis, the bactericide power of
serum is highly diminished, a fact in apparent connection with
the origin of these "terminal infections."
NECROLOGY.
William C. Benedict, M.D., well known to the medical fra-
ternity in Brooklyn. N. Y., for the last fifty-two years, died
August 17. The cause of death was heart failure, brought on
by the intense heat of the previous week. Dr. Benedict had
been suffering from heart disease for a number of years. He
became seriously ill on Thursday evening, but it was not
expected that the attack would prove fatal. Dr. Benedict was
born in Schenectady on April 19, 1820. He graduated from
Union College in 1840 and from the Medical Department of
the University of Pennsylvania in 1844. After his graduation
he became connected with the Blockley Hospital for the Insane
Philadelphia, where he rose to the position of chief physi-
in. and remained two years. He then became one of the
aanagers of the Insane Asylum at Poughkeepsie, which place
! filled for about a year. He moved to Brooklyn and became
ominent during the cholera plague. He is said to have treated
tie tirst cholera victim and was successful in saving his
itient's life. He served as physician at the Raymond Street
\il for a number of years. Altogether, Dr. Benedict prac-
ticed for forty-rive years, retiring in 1877, after which he made
, tour of Europe.
Lewis McKnight, M.D., medical director, at Milwaukee,
Tis. . August 21, of neuralgia. He was 71 years of age and a
ative of Xew Jersey. He graduated from the Medical Depart-
ment of the University of Pennsylvania, Philadelphia Pa.,
! 1841.
William C. Parker, M.D., at Santa Cruz, Cal., August 11,
after a lingering illness, aged 73 years. Dr. Parker was a
native of Xew York and had just graduated with high honors
in medicine and surgery when he received his appointment as
surgeon in Colonel Stevenson's famous regiment, which was
dispatched from his native State to California in 1846. At the
close of his military service a few years later he settled in San
Francisco, where he was prominent in professional and busi-
ness circles for over thirty years.
Andrew J. Pierce, M.D. (Jefferson Medical College, Phila-
delphia, 1856), at Kansas City, Mo., August 13, aged 64 years.
John H. Callender, M.D., at Nashville, Tenn., August 7,
aged 64 years. He graduated from the Department of Medi-
cine of the University of Pennsylvania, Philadelphia, in 1855,
since which time he has been in general practice in Nashville,
except from October, 1861, to February, 1862, when he served
as Surgeon in the Confederate Army. From 1855 to 1857 he was
editor of the Nashville Patriot, and from 1866 to 1869 editor of
the Union and American. In 1858 he was appointed profes-
sor of materia modica and therapeutics in the Shelby Medical
College ; in 1868 professor in the same chair in the Medical
Department of the University of Nashville, and in 1870 profes-
sor of diseases of the brain and nervous system in the Vander-
bilt University and the Medical Department of the University
of Nashville. In 1809 he was appointed medical superintendent
of the Tennessee Hospital for the Insane. He was a member
of the American Medical Association, American Medico-
Psychological Association and Tennesse State Medical Society.
J. A. S. Grant Bey, M.D. Our readers will regret to learn
of the death of Dr. J. A. S. Grant Bey of Cairo, Egypt, which
occurred July 28. He was well known in this country, having
attended the Ninth International Medical Congress at Wash-
ington in 1887, and the Columbian Exposition of 1893 in Chi-
cago. No foreign visitor made more friends in the short trips
made to America than the subject of this notice.
Robert Fleet Speir, M.D., of Brooklyn, and brother of the
late Dr. S. Fleet Speir, died August 13, at his home, of valvu-
lar disease of the heart with dropsy and some intercurrent
renal impairment. He had been ill about six months. His
early training was obtained at the Polytechnic Institute of
Brooklyn, and he was a graduate from the University of Ver-
mont, just thirty years ago. He had not been in active prac-
tice for many years.
Martin C. McCarthy, M.D., of Brooklyn, died August 12,
aged 30 years. He was a graduate of the New York University
Medical School in 1891. Dr. McCarthy had a large practice in
the eastern district of the city. The numerous cases of sudden
illness caused by the heat overtaxed his strength. Dr.
McCarthy came to Brooklyn from North Adams, Mass., five
years ago, and obtained rapidly a profitable practice. He was
married three years ago to Miss Rose McKeever, of Pittsfield,
Mass. The cause of his death was certified as being acute
renal disease, with a duration of less than three weeks.
Normand Smith, M.D., of Yonkers, died at Keene Valley,
N. Y., July 30, from apoplexy. He was a graduate of Yale,
1858 ; obtained the degree of M.D. from Columbia in 1861, and
subsequently studied at Berlin and Vienna. He practiced
medicine in New York for many years, and up to the time of
his death was a member of the Century Club. Dr. Smith suf-
fered from his first attack last January. The second was
some time during last month, from which there was a tempo-
rary recovery. He leaves a widow with five children.
Joseph Augustus Monell, M.D., a general practitioner in
New York city for about forty-five years, died at his home
August 12. He was born at Middletown, New York, on Sept.
25, 1826, and was an alumnus of the College of Physicians and
Surgeons, New York, 1850 ; a fellow of the American Medical
Association and of the New York Academy of Medicine, as
well as of other leading local societies.
George R. Henderson, M.D., of Brooklyn, N. Y., who died
July 28, was a colored practitioner of good position. He was
45 years of age and a graduate from Yale University in the
class of 1876. He had been eight years a resident of Brooklyn.
His death took place at St. Catharine's Hospital, whither he
was taken for treatment on account of an overdose of morphin
accidentally taken, for the relief of pain.
Algernon Sidney Roberts, Jr., M.D., of Philadelphia, died
August 17 at Halidon Hill, R. I., near Newport. He was a
graduate of the University of Pennsylvania, 1877. He made a
promising professional opening, but social and other oppor-
tunities led him to retire from active practice several years
since.
Woodman W. Royal, M.D. (Medical School, Maine, 1863),
died at his home in Portland, Ore., July 22, aged 61 years.
James W. Green, M.D. (Rush Medical Collego, Chicago, 1856),
a member of the American Medical Association, and at one
time president of the Shelby County Medical Society, died at
Shelby ville, Ind., July 26, aged 72. James Hanghey, M.D.
(University of Louisville, Ky., 1846), died at Scooba, Kemper
County, Miss., in his 79th year, July 26. Richard (J. Whar-
ton, M.D. (University of Pennsylvania, 1837), died at Port
Gibson, Miss., July 30, aged 82 years. Elias S. Boatner,
M.D. (Tulane University Medical Department, New Orleans,
1891), died at his home in Victoria, Texas, August 1.
504
PUBLIC HEALTH.
[August 29,
PUBLIC HEALTH.
Mortality Report There were sixty deaths in Louisville dur-
ing the past week ; none from typhoid fever though there is a
great deal of it in the city. Seven cases of diphtheria were
placarded and two cases of scarlet fever.
Vital Statistics of Cape of Good Hope.— A preliminary report
issued by the registrar of births and deaths contains an
account of the working of the new registration law of 1894.
For the year 1895 there were registered 45,642 births, 31,467
deaths, and 7,358 marriages. Exclusive of the native terri-
tories, and taking the population in 1895 at 1,143,846, the birth
rate amounted to 32.8 per 1,000 population and the death rate
was 21.7 per 1,000. These figures will be somewhat increased
in the final report owing to the addition of delayed returns.
New Respirator for Factory-Workers.— A valuable prize has
recently been awarded by the French "Society for the Preven-
tion of Accidents in Industrial Pursuits," for the best form of
respirator produced, to Dr. Detourbe, whose design has now
been adopted in quite a number of the most important work-
shops in northern France. The arrangement in question is
described as a mask so shaped as to fit the lower half of the
face closely, but not so as to interfere with the wearer's vision ;
a chamber in the middle, through which the air is filtered,
which projects only a slight distance from the rest of the mask,
contains a layer of asbestos and also one of cotton or wool,
arranged between small plates of aluminum gauze. The mask
is of copper, and a strip of elastic felt runs around the inner
surface near the edge, thus insuring the necessary contact all
around, and the device is held on with light elastic bands
encircling the head, one being on a level with the forehead,
and the other about opposite the lower lip. The orifice is of
such a size, and the lining of the chamber so loosely packed,
that the wearer of the appliance is enabled not only to breathe,
but to talk without difficulty, these two points constituting
the great advantages of the invention.
Dangerous Water Tanks of City Buildings.— Sundry are the
improvements that the fertile minds of architects and builders
have pressed upon the modern top-lofty city structures.
Divers are the perils that attend these same devices in the
case of accident or derangement. Fire Chief Bonner of New
York City has said that in that city there are not less than
5,000 unsafe water tanks upon house tops. These are likely to
destroy property by leakage at any time, and in case of fire
they constitute a serious danger to the firemen of falling
through the building when the lofts and roofs are burned
away. But if there are 5,000 unsafe tanks, how many foul ones
are there. Every such reservoir, furnishing as it does, water
for drinking, washing, cooking, etc., should be cleansed every
month or oftener, and it is not probable that one in a hundred
receives this attention. Perhaps some of the most pretentious
dwellings and the most famous hotels have the filthiest water.
Too much care can not be addressed to this source of disease
by those intrusted with the charge of public health; verily
conveniences many and menaces many go hand in hand in our
ways of civic life.
Health Officer Doty's Return from Cuba.— Dr. A. H. Doty,
Health Officer of the port of New York, returned from Cuba
August 17. The object of his adventurous midsummer visit
was to arrange with the Spanish authorities for the lessening
of the danger from yellow fever. His trip was partly successful.
He appointed health officers at Havana, Cienfuegos and San-
tiago to represent the interests of New York harbor and the
country at large. They will inspect all persons bound for New
York and prevent those undesirable from a sanitary point of view
from embarking. Dr. Doty is reported as saying that Havana
is a most unhealthy place. There seem to be no methods of
sanitation there at all. Many of the vessels in the harbor
are anchored near docks out of which the sewage flows, and
thus bring infection away with them. He intended to visit!
the south side of the island, but he could not do so because
the insurgents had practically blocked railroad traffic in that
direction. He could not find the health officer or the health
office in Havana. "Within the last two weeks preceding my
departure," Dr. Doty said, ''there were 300 cases of yellow
fever there. No attempt has been made to sewer the city
properly. By simply cutting through a narrow strip of land
and dredging a channel the city's refuse might be carried into
the gulf stream and far out to sea. With proper sanitary pre-
cautions Havana would be a remarkably fine city. The Spanish
soldiers get sick on their way to Havana in the transports.
When they land some of them are half dead from the effects of
the fever."
Culture Work in Diphtheria for the Buffalo Board of Health. Dr.
W. G. Bissell, in the Buffalo Medical Journal, reports upon
the bacteriologic work done at the laboratory of the Depart-
ment of Health in 1895. He says that although a considerable
amount of work relating to the diagnosis of diphtheria was car-
ried on in the laboratory prior to January, 1895, it was at that
time that the work was begun in a systematic manner. Out of
1,535 cultural inoculations made by the physicians in Buffalo
since the inauguration of municipal bacteriologic examination,
only eighty-three were found to be imperfect. Occasionally a cul-
ture was so neatly contaminated with various bacterial growths
that it was impossible to recognize the Klebs-Loeffler bacillus,
when the latter was present in small numbers. The smallest
amount of certain germicidal fluids, especially the solutions of
the bichlorid of mercury, in the throat of a patient at the time
of the culture-taking will frequently prevent growth on the
culture media. Of the 1,040 cultures which did not reveal the
Klebs-Loeffler bacillus, the organisms found, named in order
of the frequency of their occurrence, were as follows : Staphy-
lococci, the most numerous being the aureus ; cocci without
any definite arrangement ; streptococci ; bacilli other than the
Klebs Loefner and deserving of special mention, a very large
strepto-bacillus was of frequent occurrence; the thrush
fungus ; diplococci. The greatest mortality in cases of diph-
theria appears to be produced by a mixed infection ; that is,
the specific germ is usually associated with either the strepto-
coccus or the staphylococcus. It seems also to be a fact that
when both the staphylococcus and the streptococcus are asso-
ciated in the same culture with the diphtheria bacillus, that
the case is a mild one. From this latter point it would cer-
tainly appear as if there was a certain antagonism between the
combined cocci and the diphtheria bacillus, and this latter
point seems well worthy of consideration and experiment.
Many experienced physicians still find difficulty in believing
that cases in which the exudate or pseudo-membrane is entirely
absent from the pharynx and tonsils are those of true diph-
theria, and it is also difficult to impress upon parents that a
case is diphtheria and capable of transmitting the infection,
although the person infected is hardly in a condition to be
called ill.
Health Report.— The following reports of mortality from small-
pox, yellow fever and cholera have been received in the office
of the Supervising Surgeon-General U. S. Marine-Hospital
Service :
SMALLPOX— UNITED STATES.
New Orleans, August 8 to 15, 1 case.
SMALLPOX — FOREIGN.
Alexandria, Egypt, June 4 to 10, 1 death.
Buenos Ayres, May 1 to 31, 15 deaths.
Cairo, Egypt, June 4 to 10, 4 deaths.
Callao, Peru, July 19 to 26, 12 deaths.
Corunna, Spain, July 11 to August 1, 3 deaths.
Dublin, Ireland, July 1 to 31, 1 death.
Guayaquil, Ecuador, August 1 to 7, 1 death.
Hong Kong, July 11 to 18, 2 deaths.
L896. 1
MISCELLANY.
505
l.eitli. Scotland, August 1 to 8, 1 ct\se.
Licata, Italy, July 25 I
> to August 1, 1 death.
London, England, August 1 to 8, 22 cases.
Madrid. Spain, July 28 to August -1. 26 deaths.
Montevideo, Uruguay, July 11 to 18, 3 cases, 1 death.
o\v, Kusi.ia, July •_'."> to August 1, 1 case.
Odessa, Russia, July •_!."> to August 1, 5 caBes, 3 deaths.
Osako and Hiogo, Japan, July 4 to 11, 47 cases, 21 deaths.
Prague, Bohemia, July "."> to August 1, 1 case.
St. Petersburg, Russia, July 25 to Aug. 1, 3 cases, 3 deaths.
Warsaw, Russia, July 25 to August 1, 2 deaths.
CHOLERA.
Egj nt : Alexandria, June 4 to 10, 23 deaths; Egypt, June 4
I), 133 deaths.
YELLOW FEVER.
Matanzas, Cuba, August 5 to 12, 28 deaths.
ua la Grande, Cuba, August 1 to 8, 99 cases, 10 deaths.
Santiago, Cuba. August 8 to 15, 27 deaths.
Quantanamo, Cuba. July 1 to 31, 13 deaths.
Havana. Cuba. August 6 to 13, 160 cases, 52 deaths.
Vera Cruz, .Mexico. August 6 to 13, 3 cases.
SOCIETY NEWS.
Mississippi Valley Medical Association. The time of the twenty-
ond annual meeting of this Association at St. Paul, Minn.,
has been changed to Sept. 15 18, 1896. \
« American Dermatologlcal Association.— This Association will
ild its twentieth annual meeting at Hot Sulphur Springs,
i.. Sept. 8 10, 1896. The following papers will be read:
V Pathologic and Clinical Classification of the Diseases of the
tin." L. A. Duhring: "Erythema Multiformis," with a
report of two cases, W. T. Corlett; "A Peculiar Affection of
the Mucous Membrane of the Lips and Mouth," with colored
drawings and photographs, J. A. Fordyce ; "A Favus like Erup-
n of the Oral Mucous Membrane Caused by the Aspegillus
Niger," J. MacF. Wintield : "What Effect do Diet and Alcohol
have upon the Causation and Course of the Eczematous Affec-
tions and Psoriasis," discussion opened by J. C.White; "Cases
of Mycosis Fungoides and Sarcomatosis," J. T. Bowen ; "Xan-
thoma Diabeticorum," A. R. Robinson : "Some Olycosuric Der-
matoses."C. W. Allen : "The Relation of DermatitisHeptiformis
to certain other Diseases," L. A. Duhring; "Bath Pruritus,"
H. W. Stelwagon ; "Eruption from the Local Use of Iodoform
| with colored drawings)," J. A. Fordyce ; "Impetigo Contagiosa
Universalis," C. W. Allen.
Pan-American Medical Congress. Dr. C. H. Hughes, honorary
president of the Section of Neurology, Psychiatry and Medical
Jurisprudence of the Pan-American Medical Congress, is send-
ing out the following invitation to the alienists, neurologists
and medico-jurists of the United States :
My Dear Doctor: — Can the Section rely upon you for a paper
or subject of discussion for the Pan-American Medical Con-
gress to be held at the City of Mexico, November 16, 17, 18
and 19 proximo?
I have just been informed, rather tardily I think, of my
selection as honorary president of the Section of Neurology,
Psychiatry and Medical Jurisprudence for the United States.
The meeting promises to be an exceedingly profitable and
agreeable one socially and scientifically. We should make
the best showing we can for American psychiatry, neurology
and forensic medicine. You can materially help in this lauda-
ble direction. Will you promise a paper and your presence on
this interesting occasion? If so, please indicate on the enclosed
your intention to be present. Address Dr. E. Liceaga, Secre-
tary, Republic of Mexico, Calle de San Andres No 4, Mexico
City. Yours very truly, C. H. Hughes, M.D.,
St. Louis. Mo., Aug. 14, 1896. Honorary President.
Accompanying each enclosure is the following announcement
and request from Dr. Liceaga. Secretary-General of the Con-
gress :
I have the honor to request your presence in the Second Pan-
American Medical Congress, which will meet in the City of
Mexico on November 16, 17, 18 and 19 of the present year,
sending you separately the respective rules.
I beg of you to answer if you come, and how many persons
will accompany you. The invitation is also for ladies, and we
hope to obtain a considerable reduction on the round trip rates,
but for such reduction the railroad companies must know three
months before the meeting the number of passengers and the
places they come from.
Please send as soon as you can the answering card, filling
the spaces marked for names and addresses.
Dr. Eduardo Liceaga, Sec'y 2d P. -A. M. C.
Mexico City, January, 1896.
Dr. Hughes requests his neurologic friends who contemplate
attending the Congress and taking part in the work of this
Section to accept in his name the foregoing request from Pres-
ident Liceaga and to answer direct to him the questions Dr.
Liceaga propounds.
MISCELLANY.
New Edition of Cray's Anatomy.— Lea Brothers & Co., of Phila-
delphia and New York, announce a new edition of Gray's
Anatomy. The few errors of previous editions have been cor-
rected, and many additions made.
Honorary Chairman.— Dr. N. C. Morse, of Eldora, Iowa, has
been elected, on behalf of the United States, honorary chairman
of the Section on General Medicine of the second Pan-Amer-
ican Medical Congress.
Professor Bebring's Resignation. — Professor Behring is about
to resign his chair (hygiene) at the University of Marburg, in
order to devote himself exclusively to scientific research. Wer-
nicke will probably succeed him.
The Vienna Medical Association. — Dr. Adamkiewicz has been
dropped from the list of members on account of his having
advertised his cancer cure in the daily press. The inefficacy of
the cure was fully established by Professor Albert and others
after careful trial.
Serum Treatment of Leprosy.— Carrasquilla's success with
fifteen cases of leprosy treated with serum from horses inocu-
lated with the disease, has already been mentioned in this
Journal, page 943. A copy of his report to the Bogota Acad-
emia de Medicina (Republic of Colombia) has been received.
His methods are similar to those generally practiced in sero-
therapeutics, but until we read a detailed description like this
few realize the infinite devotion and courage required in this
branch of science.
Evidence Required to Prove Intoxication. Evidence of intoxica-
tion which unfits one for his duties is competent in some cases
in investigating whether his acts are negligent or not. But
the supreme court of Missouri holds, in Culbertson v. Metro-
politan Street Railway Company, decided June 30, 1896, that
the mere habit of taking an occasional drink can not be
regarded as any evidence of intoxication in the practical admin-
istration of justice, whatever abstract theories physiologists
may advance on this subject. The evidence should and must
go further, and show that the liquor affects the particular
individual in such a way as to incapacitate him to some extent
to attend to his duties.
Too Speculative Opinion Evidence.— The opinion of a medical
witness as to the mental condition of a person at a certain time,
based upon a physical examination made eighteen months
afterward, where such witness is not informed as to the mental
condition at the time when the mental capacity was in ques-
tion, the supreme court of Kansas holds, in Missouri Pacific
Railway Company v. Lovelace, decided July 11, 1896, is largely
conjectural, and is too uncertain and speculative to be valuable
or admissible. Opinion evidence, the court says, is only
admitted from necessity, and then only when it is likely to be
of some value.
Does Not Believe In " Fortune Telling." The supreme court of
Michigan affirmed, May 26, 1896, in the case of People v. Elmer,
a conviction of "a modern day seer," "clairvoyant," "trance
medium," and "healer" as a disorderly person. The court
506
MISCELLANY.
[August 29,
■quotes with approval the language used in the English case of
Penny v. Hanson, which was, in effect, that no person who
was not a lunatic could believe that the person referred to
possessed such power as he advertised, his advertisement and
circular amounting to pretending and profession to tell for-
tunes. And it is idle, says the court, to attempt to draw dis-
tinctions between professing to possess a power and pretending
to exercise that power.
Detection of Formol Added to Milk.— Some of the milk sold as
sterilized in the market has merely had formol added to pre-
serve it, which is certainly not a benefit to infants. It can be
detected promptly and rapidly by Deniges' method described
in the Bull, dela Soc. de Phar. de Bordeaux for July. Boil
two to three cubic centimeters of the suspected milk, add 10
to 15 drops of the following f uchsin reagent ; then add one
c.c. of pure hydrochloric acid. If the milk contains formol,
the resulting mixture will be a violet blue, but if there is no
formol it will be white like pure milk. The fuchsin reagent
is prepared as follows : One-half per cent, solution of fuchsin,
40 c.c. ; acq. dest., 250 c.c. ; add 40 per cent, bisulphite of
sodium, 10 c.c, and pure sulphuric acid, 10 c.c.
The Bertillon Method io Brooklyn.— At the Kings County Peni-
tentiary, this system has been taken up with unusual thor-
oughness. A medical man, Dr. Stumpf, the assistant physi-
cian for the penitentiary, has been placed in charge of its early
stages, and he is to have an exclusive cabinet or building
wherein to conduct his examinations, and where the photo-
graphs and measurements can be made. This building, 20 by
18 feet, will have a north light, an abundant skylight roof and
a photographic chamber.
A Characteristic Anecdote of Pasteur.— Once when Pasteur was
dining with his daughter and her family at her home in Bur-
gundy, he took care to dip in a glass of water the cherries that
were served for dessert and then to wipe them carefully with
his napkin before putting them in his mouth. His fastidious-
ness amused the people at the table, but the scientist rebuked
them for their levity and discoursed at length on the dangers
in microbes and animalcula. A few moments later, in a fit of
abstraction, he suddenly seized the glass in which he had
washed the cherries and drank the water, microbes and all, at
a single draught
Atomizer Decision — May 21, 1896, the United States circuit
court of appeals affirmed the decision of the circuit court in
the case of Codman v. Amia, holding claims 1 and 2 of the
Shurtleff patent, No. 447,064, for an improvement in atomizers,
void for want of patentable novelty. This patent, the court
says, simply describes a compact form of atomizer, which is
better adapted than some others for nasal purposes. The spe-
cific improvement set out in the first claim consists in having
the nozzle "secured directly to" the "cap or stopper, and
adapted to be applied in the nostrils, and in open communica-
tion with the interior" of the vial ; and in the second claim it
consists of a cap or stopper having "its top formed with a
seat for the nozzle." An examination of certain other patents
mentioned, the court declares shows clearly that there was no
invention in these improvements.
Care Required of the Blind.— The blind have as much right,
says the supreme court of Florida in the case of the Florida
Central and P. R. Co. v. Williams, decided April 14, 1896, to
frequent railroad depots, public crossings and other places of
danger, as any other of the general public. But, when they
do so, due care dictates that they must provide themselves
with such surroundings while there as are reasonably neces-
sary to avoid upon their part all the known dangers that
encompass the place. It is gross negligence in a blind man to
expose himself alone and unattended in any situation where he
knows that tne faculty of sight is absolutely necessary to the
safety of life and limb.
Proper Testimony as to Probability.— In an action for personal
injuries the plaintiff's mother testified that since the wound i
question had apparently healed it had broken out, and dis
charged blood and matter ; that the wound was very tender
that she called no physician, but cared for it herself. A phy
sician testified as to the cause of its breaking out, and that
from the fact that the wound had once broken out, it was lia
ble to do so again. He was then asked: "What do you say
as to whether that result is probable and likely to occur?"
This question was objected to ; but no objection was made as
to want of knowledge by the witness of the facts, or that the
form of the question should have been hypothetic, and the
appellate division of the supreme court of New York holds, in
Penny v. Rochester Ry. Co., decided June 17, 1896, that the
question was proper as calling for what was probable and likely
to occur.
Physiologic Action of Airol.— The Gaz. degli Osp. e delle Clin.
of July 5 contains the results of a careful study of the effects
of airol made in Mosso's laboratory at Genoa. It was found
that it slightly accelerates the coagulation of the albuminoids,
and that in cold-blooded animals it retards the cardiac action.
In warm-blooded animals the effect differed with the amount
administered and the method of administration. There wa
no toxic action when injections were made hypodermically
into the ear, but symptoms of intoxication followed injection
into the peritoneal cavity with renal inflammation. With
these toxic doses there were noticeable alterations in the crasii
of the blood, due to the special action of the iodin on th
hemoglobin. Used externally airol proved a good antiseptic
by no means inferior to iodoform.
The New York Skin and Cancer Hospital.— The old structures
this institution that have been in use for fifteen years are
being torn down to give room to a more commodious hospital.
The new building will be of four stories and basement, the
material to be brick with white limestone dressing. The build-
ing will be substantial, pleasingly simple, with all modern
sanitary features, with accommodations for forty-two patients
and an outside department that can care for 100 patients on
ordinary occasions. It will cost 880,000. The basement will
contain a complete system of Russian and medicated baths, so
necessary in the treatment of skin diseases. The first floor
will contain the dispensary, waiting rooms for eighty patients
and the officers' rooms. On the second floor will be the ward
for treating skin diseases, with the necessary operating rooms
and nurses' quarters adjoining. On the third floor will be
the wards for cancer patients. Then on the top floor will be
private rooms for pay patients, operating room and quarters
for attendants. Throughout, the building will be plainly and
substantially furnished in brick and tile, that the utmost clean-
liness may be observed.
Enzymes. — Fischer and Lindner have found that Frohberg
and Saaz's bottom yeast contains an enzyme that is capable of
splitting melitose into hexose, a power entirely lacking in
invertin. No. substance containing an enzyme that had any
power to split cane sugar or maltose, could be extracted from
the monilia Candida, and the yeast itself works in this way
only in the presence of toluene. They therefore conclude that
the enzyme of this yeast is an insoluble substance, which is
gradually disintegrated by the toluene. No enzyme that would
invert cane sugar could be derived from the saccharomyces
apiculatus. (From the CM. f. Phys., for July 11, which also
reviews Arthus's study of the various theories in regard to the
nature of exzymes. ) According to one theory they are albumo-
ses, as although they do not have the same proportions in their
composition as the albumoses, they possess the same proper-
ties. Others take an exactly opposite view, and still others
believe that the enzymes are carbohydrates or gummy sub-
stances. Arthus concludes by stating his own theory, which
is that the enzymes are not material substances, but only prop-
erties of material substances, like the physical forces.
18%.]
MISCELLANY.
507
Experimental Suturing of Tendons. HaUlassari has succeeded
in securing complete regeneration of tendons in animals after
cutting out a piece and making a tubular suture. In one or
two months there was no apparent difference in shape, size or
strength between the sutured tendons and the normal (rab-
bits). -Qaz. d. Osp. e d. Clin., June 27.
An Unfortunate Appointment. The appointment by Governor
AltgeM of Mr. \V. P, Boyd to the vacancy in the Illinois Board
of Pharmacy, occasioned by the tragic death of President
Coffee, while perhaps above criticism so far as concerns the
qualifications and merits of Mr. Boyd, was nevertheless in
deliberate defiance of wise precedents and of the manifest
intent of the State pharmacy law, which contains a specific
provision as to the manner of appointment, as sanctioned by
the druggists of the State. The law provides that the State
association shall annually recommend to the governor the
names of persona deemed most worthy for appointment on the
board. This provision applies in principle as forcibly to
vacancies resulting from accidents or resignations as from
term expirations. Governor Altgeld, in once before defying
this wise provision, and now again exercising his prerogative
in contemptuous disregard of the recommendations of the
Illinois Pharmaceutical Association proves himself a lover of
the very form of tyranny in himself which he affects to despise
so heartily in others. The appointment of Mr. Boyd was
clearly made for purposes of political profit for the governor in
the pending campaign. Whether the outrage perpetrated
upon the expressed sentiment of the druggists of the State
will make the appointment one of net profit remains to be seen.
Wastern Druggist, August.
Experimental Thyroidectomy.^The Cbl. f. Chir. of July 25
contains a contribution to our knowledge of the effects of
extirpation of the thyroid gland, with some curious facts col-
lected by Lanz in his extensive investigations. He finds that
removal of the thyroid gland and the absence of its secretions
can be fully made up to the organism by transplanting other
glands and even by subcutaneous injections or internal adminis-
tration of the extracts, but it is necessary to commence the treat-
ment the very day of the extirpation (dogs). A hen whose thyroid
gland had been removed, only laid one egg, one-tenth of the
usual weight during the four months after the operation, while,
on the other hand, a normal hen fed with thyroid extracts, laid
three times as many eggs during the month as any one of the
eight control fowls. Lanz also extirpated the gland in fishes.
Forty-four operations on the common shark prove that this
gland performs a vital function in cold-blooded beings also.
Death followed in from twelve to forty days, after a slow,
gradual development of the chronic symptoms usually follow-
ing thyroidectomy.
Philadelphia.
Midsummer Mortality. — During the week ending August
15, the number of deaths from suntroke and heat exhaustion
were 173. There were also 106 deaths from cholera infantum,
the total mortality of the week among children under five years
of age being 315. Probably a large proportion of these cases
was caused indirectly by the exceptionally high temperature
which prevailed from the 5th to the 14th inclusive. The total
number of deaths was 838, which was 47 less than that of the
memorable week ending July 13, 1872, during which the mor-
tality from cholera infantum was frightful. Although recently
the weather has been exceptionally severe and prolonged, yet the
mortality has not been so much increased by the heat as might
have been anticipated from the experience of former years. This
may be attributable to several causes, among which may be prom-
inently noted the improved paving of all the large streets and
particularly of the alleys and small streets, which has been accom-
plished after several years work. The small streets are fre-
quently flushed with water and great attention is given to the
daily collection of garbage and the abolishing of nuisances.
Backyards and cellars are inspected and cleaned. Unwhole-
some and spoiled food is condemned and destroyed and street
peddlers are fined for selling articles that are injurious or pre-
judicial to health. Special attention has been given to the
inspection of milk, and vendors of adulterated or watered milk
are prosecuted. In addition to these hygienic precautions, the
city has six free bathing houses in different parts of the poorer
districts, which are largely patronized. The city has recently
established a number of small parks in the congested districts
and the schoolyards have been thrown open, as well as some of
the piers on the river front, for play grounds and breathing
places, especially for the younger children. It is also believed
that the open trolly cars have had a very decided influence in
improving the public health by taking people out into the
suburbs, where they can breathe purer air than in the heated
streets. It has been stated that the business of the saloons
has fallen off during the hot spell, which, if true, indicates
that the public has learned the lesson of the special dangers
from intemperance during such weather, and the close rela-
tion existing between alcoholism and sunstroke. It is also
very probable that the deceased mortality may be attributed
to modern therapeutic measures, especially in our large hos-
pitals.
Treatment of Insolation atthe Pennsylvania Hospital. —
The method of treating thermic fever by the external applica-
tion of ice and ice water, combined with friction, originated at
the Pennsylvania Hospital some thirty years ago, during the
term of service of the late Dr. James Levick, and its usefulness
has been so fully demonstrated that now it may be regarded as
the accepted treatment of hyperpyrexia following exposure to
the sun. At this institution, temporary wards in tents have
been established for the season on the lawn, under the shade
of the trees, and the heat has recently been so great, that
during the middle of the day the hose was played on the out-
side of the tents to reduce the temperature. The woman's
insolation tent is smaller than the men's, and is in a remote
portion of the enclosure. The management of a case is gener-
ally as follows : As soon as the patient is brought in by the
ambulance, he is stripped and his temperature taken. If it is
a case of high temperature, he is put into the bath to which
pieces of ice are added and he is vigorously rubbed by the
hands of attendants, or he is placed upon a couch and rubbed
with pieces of ice, and an ice cap is applied to his head, until
the temperature is reduced to the normal or under. If the
pulse is weak, hypodermic injections of nitroglycerin (gr. 1-100)
with whisky (m. xx) are repeated at intervals of an hour or two ;
hypodermics of atropin (gr. 1-60) or of strychnin (gr. 1-30) are
substituted later, if the heart is weak. In one case hypoder-
mic injections of tincture of digitalis (m. xv) given every hour
for four hours, was apparently effective in saving life. Small
doses of morphin (gr. 1-8 to 1-6) were also used, where great rest-
lessness or muscular twitching was present. Where there was
great fulness of the vessels of the head and neck with symp-
toms of central congestion, leeching at the occipital region,
followed by the ice cap, gave good results. In one patient Dr.
Starbuck, in order to relieve convulsive symptoms in an appar-
ently moribund patient, took a pint of blood from the arm and
a pint of normal salt solution with immediate good results.
After the bodily temperature of the patient has been reduced
to somewhere near the normal, he is removed to the medical
wards, and there treated with cardiac tonics and a restricted
diet, the amount of nourishment or stimulants being regulated
by the condition of the patient. After a few days rest in bed, if
the fever returns and the temperature of the ward is excessive,
the patient is returned to the tent in the open air, and given
cold baths, or the cold applications may be used in the ward.
In cases attended by hyperthermia, the extraction of excess of
bodily heat, and the sustaining of the heart's action are the prin-
508
MISCELLANY.
[August 29, 1896.]
the jackstone through the cardiac orifice by entangling it in
the meshes of a skein of Silk. This is the second case of this 1
kind occurring recently at the Hospital of the University of
Pennsylvania, the former operation having been performed by
Prof. J. Wm. White. The condition of the bones of the foot
in the condition known as metatarsalgia, or Morton's painful
affection of the foot, was well shown in some radio-photo-
graphs exhibited by Dr. Thos. G. Morton, president of the
Academy of Surgery, at the last meeting of this society.
cipal objects sought to be attained by the treatment. In heat
exhaustion, where the temperature is not greatly increased or
remains about normal, the patient is placed in a bed in the
open tent, and nitroglycerin or atropin given in moderate doses,
followed by strichnin or digitalis during convalescence. The
success of this treatment is shown by the fact that out of a
total of over sixty cases (of which only four were women) there
were only two deaths during the ten days of hot weather. One
case at the autopsy was found to have advanced degeneration
of the kidneys, and the other had been taken ill on a train and
it was several hours before he was brought into the hospital,
when he was in a hopeless condition, dying shortly after
admission.
A Case of Mixed Intoxication. — A man 43 years of age,
after a prolonged indulgence in alcohol, being suicidally,
inclined, swallowed, it is said, ten ounces of laudanum and, in
order to take the taste out of his mouth, immediately washed
it down hy a draught of two ounces of lead water. He was
taken to the German Hospital, where the stomach pump was
used with the result of bringing to light the lead water and
laudanum mixture so familiar to a former generation of sur-
geons. The patient recovered promptly without any symp-
toms of narcotism, and may live to prove the truth of his asser-
tion that his life was not worth saving.
Appendicitis Operations. — Operations for removal of the
appendix vermiformis nowadays are of such common occurrence
as scarcely to require comment. It is, however, noteworthy
that the operation has been successfully performed upon a
dozen or more of the physicians of this city, especially those
who are rising into prominence in various specialties. Dr.
Joseph Price, who has operated upon several physicians, is
very positive that the tendency to suppurative inflammation of
the appendix, which has recently occurred with so much fre-
quency as almost to assume the proportions of an epidemic, is
in reality one of the evil consequences of the grippe. He
claims that physicians and surgeons of ten or twenty years ago
were not so ignorant or unobservant as not to be able to recog-
nize inflammation of the appendix, which every tyro can diag-
nosticate to day, and the only explanation possible is that the
cases did not occur, and in fact were extremely rare. The
wide extension of the influenza epidemics and the well known
tendency to mucous membrane inflammation, gastrointestinal
as well as pulmonary, affords, in Dr. Price's opinion, an efficient
cause for the present prevalence of appendicitis. Certainly
medical men are not fond of surgical operations upon their
own bodies, and the fact that they have taken the risks and
submitted to the surgeon's knife, demonstrates very clearly
that the condition is a real one and not a figment of the imag-
ination of the abdominal surgeon ; nor does the frequency of
operation argue the existence of an operative mania on his part.
The City Bacteriologic Laboratory and Disinfecting
Plant.— In the basement of city hall, Dr. J. M. Bolton and
his assistant. Dr. Wm. G. Gillespie, have installed a plant for
manufacturing a disinfectant solution out of sea water by
means of electrolysis. The product is termed "electrozone"
in the report just made by Dr. Gillespie of the result of his
recent experiments, which proved the solution to be a power-
ful germicide. He stated that it kills anthrax spores in five
minutes or less, and it is superior to corrosive sublimate, since
it does not form an inert insoluble precipitate with all albumin-
ous substances as the latter does, thereby diminishing its
power and efficiency as a germicide. It is further commended
for its cheapness and the facility of its manufacture in largo
quantity. It is considered an ideal agent for the purpose and
as a municipal germicide and disinfectant ; according to Dr.
Gillespie, it can not be surpassed. As it is so easily manu-
factured it would seem obligatory upon health authorities to
largely avail themselves of this cheap disinfectant.
The Roentgen Rays in Surgical Diagnosis. — In the recent
case of a child, 4 years of age, who swallowed an iron toy "jack-
stone," which was lodged in the esophagus, it was found that
the patient was too restless to permit the ordinary exposure to
the X rays required to obtain a negative, and accordingly the
fluorescent screen was substituted and the foreign body loca-
ted between the clavicle and the second rib. Dr. A. C. Wood
opened the child's stomach and succeeded in bringing down
THE PUBLIC SERVICES.
Army Changes. Official List of changes Id the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Aug. 14 to Aug. 21,1896.
Major Henry McElderry, Surgeon (Ft. Robinson, Neb.), leave of absence
granted is extended two months.
Navy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending Aug. 22, 1896.
P. A. Surgeon A. M. D. McCormick, detached from the " Bancroft" and
ordered to the naval academy.
P. A. Surgeon E. M. Sbipp, detached from the " Monongahela" and
ordered to the "Bancroft."
Marine-Hospital i 'hanges. Official list of changes of station, and
duties of Medical Officers of the U.S. Marine-Hospital Service, for
the fifteen days ended Aug. 15, 1896.
Surgeon \V. H. H. Hutton. granted leave of absence for thirty days from
Aug. 25, 1896, Aug. 1:1, 1896.
Surgeon H. W. Sawtelle, grauted leave of absence for twenty days from
Aug. 25. 1896, Aug. 13, 1896.
Surgeon C. E. Banks, to assume temporary command of the Service at
Vineyard Haven, Mass., for thirty days, Aug. 13, 1896.
P. A. Surgeou S. D. Brooke, to assume temporary command of the Service
at Cleveland, Ohio. Aug. 8, 1896.
P. A. Surgeon R. M. Woodward, granted leave of absence lor thirty day*
from Aug. 13,1896,Aug. It, 18911
Asst. Surgeou Jos. B. Greeue, granted leave of absence for twenty-three
days from Sept. 14, 1896. Aug. 13, 1896.
Change of Address.
Brassell.T. C. from Stroman to Leesville.Tex.
Greeno, H. S., from Masonic; Temple to 70 State St., Chicago.
Lacy, Hattie E.. from 1461 Jacksou Boul. to 820 N. Park Av., Chicago.
Murrull, T. K., from Santa Fe.N. M., to 2"j0.) Colfax Av., Denver, Colo.
Renn.T. H.. from 1241 Milwaukee Av. to 227 Townsend St., Chicago, 11).
Smith, O. E., from Grand and Caroline Sts. to 3509 Liudull A.V., St.
Louis, Mo.
Seacat, G. M.,from Kinsley to Cherry Vale, Kan.
Seagley, J. B.. from Chicago, 111., to Scott, Ind.
Tasche, J. C, from Sheboygan to Howard. Wis.
White. J. W.. from 64th and Grace Av. to 754 69th PI., Chicago, 111.
Walker, Robt. S., from Beacon. Mich., to Toledo, Ohio.
LETTERS RECEIVED
American Endoscopic Company, Providence, R. I.; American Thera-
peutic Co., New York N. Y.; AuheuserBusch Brewing Co.. St. Louis,
Mo.; Atkinson, W. B., Philadelphia, Pa.i American Sports Publishing
Co., New York. N. Y.
Bishop. S. S.. Chicago. 111.: Borland, E. B., Pittsburg, Pa.; Boger.
Frederick, New York. N. Y.; Bernd, Henry A: Co. St. Louis, Mo.; Byrd,
W. H.. Salem, Ore; Brown Warren. Tacoma, Wash. ; Benson, John A..
Chicago, 111: Bryant. D. C. Omaha, Neb.; Bovinine, The. Co., New
York. N. Y,; Beri-tain. David, Baltimore, Md.
Cone, Andrew, New York, N. Y.; Chapman. Jas. J., Washington,
D. C: Cain. J. S..Sewauee, Teun.; Christison. J. S., Chicago, 111.; (mi-
nor, Leartus. Detroit. Mich. ; Chaille, 8. E.. New Orleans, La.
Dufour.C. R., Washington, D. C.j Dry Extract Co., Janesville, Wis. ;
Dunham, W. R.Keeue, N. H.: Davis, N. S.. Chicago, 111.; DeCourcv,
J. O., St. Libory, 111.; DeLee. J. B., Chicago, III.
Flint, Austin, New York, N. Y.; Fite, C. C, New York.N. Y. ; Fisher,
John C, Lyttou Springs, Cal.
Gihon, A. L.. New York, N. Y.; Gratigny, L. H„Cinciunati,Ohio; Gnu-
drum, F., Sacramento, Cal.; Gilpin, Langdon & Co., Baltimore, Md.;
Gardner. R. \V., New York, N. Y. : Gould. J. B.. Minneapolis, Minn.
Haldensteiu. J.. (2) New York, N. Y.: Hugus. H. P., (2) Ravenna, Ohio:
Haruden, R. S, Waverly, N. Y. ; Hughes, C. H., St. Louis. Mo.: Hum-
mel. A. L., Adv. Agency, New Y'ork, N. Y.; Henkle, C. K., Moscow,
Idaho
Josephi, S. E.. Portland. Ore.; Jones, Louis, H., Atlanta, Ga. ; Jones,
H. Webster, London. England.
Kane. Evan O'Neill, Kane, Pa.. Kneipp Malt Food Company, Manito-
woc. Wis.: Kreider, Geo. N.. Springfield, III.
Lofton. Lucien, (2) Atlanta, Ga.; Lewis, Denalow, Chicago, 111. ; Lewis,
W. C, Boston. Mass.
Meserve, Chas. F., Raleigh, N. C; Murphy. Garrett. Garden City,
Minu. ; Munroe, J. P., Davidson. N. C; Medical Era, The, Chicago, 111.;
Meany. Wm. B., St. Louis, Mo.; Martins, E. J., Forsyth Junction, Mo.;
MacLean, Donald. Detroit, Mich.
Nash, Alfred. Joliet. III.
Opie, Thos.. Baltimore. Md.: Oxford Publishing Co., Chicago. 111.
Pershing, Howell T., Denver, Colo.; Parker, Francis L., Charleston.
8. C; Page, C. E., Boston, Mass.: Purvis, C. B., Washington, D. C. ;
Peeples, D. L.. Navasota, Tex.: Playter, Edward, Ottawa. Canada; Par-
mele, C. R.. (2) New York. N. Y.
Ross. Geo. M., Chicago. 111. ; Rockey, A. E., Portland. Ore.
Stern, Max J.. Philadelphia. Pa. ; Steele, D. A. K., Chicago, III. : Sto-
ver, G. H., Eaton. Colo. : Sharp & Smith. Chicago. 111.; Schroeder, ,t
Hinkle, Columbia, Pa.: Stuigis. E. M., New York, N. Y.; Strueh. Carl,
Chicago, III.; Simmons, Geo. H., Lincoln, Neb.; Stallman & Fulton,
New York, N. Y. : Stearns, F. & Co., Detroit, Mich.
Tucker. Willis G., Albany. N. Y'.; Travis. B. P., Chattanooga, Tenn.;
Tavlor, J. J., Philadelphia. Pa.; Thomas, F. S., Council Bluffs, Iowa.;
Trout. E. H., Oak Park. III.
Wilber, M. R., Neenah, Wis.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL, SEPTEMBER 5, 1896.
No. 10.
ADDRESS.
Till. MUTUAL RELATIONS OF THE MEDI-
GAL PROFESSION AND THE
. PUBLIC.
President's \ddress Forty-sixth Annual Meeting of the Illinois State
il Society, delivered before the Members of the Society
and the citizens of Ottawa, evening of May 19. 1896.
BY DAVID W. GRAHAM, A.M., M.D.
CHICAGO.
The Illinois State Medical Society requires of its
presiding officer each year an address on some subject
of his own choosing, the members of the Society for
the most pari constituting the audience. But to
some extent the nature of the subject and the charac-
ter of the audience for this evening have been deter-
mined by the circumstances under which this
meeting is held, and the plans of the committee of
arrangements.
The reciprocal relations and duties of the medical
profession and the community is, as a theme, like an
old jewel which requires an occasional resetting to
bring it into harmony with the changes of time and
circumstance.
While some of these relations and duties are always
and everywhere the same, the subject still requires
frequent restatement, both because of its perennial
interest to the profession and the public at large, and
also because in the progressive community the mutual
relations of the various interests, occupations and
component parts of that community are constantly
undergoing change and requiring readjustment.
In a limited sense each individual member of the
modern industrial community is pursuing that course
and conduct of life which he chooses for himself so
far as he is not prevented from doing so by the natu-
ral limitations of his own powers of mind and body,
by his environment, and by the presence and plans of
others. Every individual thus becomes a competitor
or antagonist of every other within his own sphere of
action in the struggle for existence and advantage.
The rivalry of individuals is also a prominent charac-
istic in the uncivilized state of society. But division
of labor with cooperation and mutual interchange of
the benefits and products of effort is the law of civil-
ized life. Without these no community can become
civilized or maintain the civilized state. In such a
community no one can be for himself alone. Every
one must both give something to, and receive some-
thing from, others. Likewise a group of individuals
which stands for a particular interest, or represents a
given line of activities, is dependent upon, and
accountable to, every other group of the same
community.
There is a certain analogy between the human body
as an organism and the civilized community, and the
more highly developed the latter, the more perfect is
the analogy.
The body is an aggregation of organs, as the hands,
the feet, the eyes, the ears, the lungs, the nerve cen-
ters and so on. Each organ has a function to perform
both with respect to itself, and also in its relations to
the organism as a whole. The principles of division
of labor and cooperation, with mutual interdepend-
ence, are perfectly exemplified. The civilized com-
munity is likewise an organism separable into, or
composed of, individuals or groups of individuals,
each unit or group corresponding in some sense to an
organ of the human body. There is the hewer of
wood and the drawer of water, the farmer, the mer-
chant, the manufacturer, the teacher, the preacher,
the lawyer, the physician and so on, the organs of the
body politic; each having a place for itself and a
duty to perform for all the others. No one interest
can suffer without detriment to the whole. The more
harmonious and symmetrical the development of the
various component parts, the more perfect the devel-
opment of the whole. The more perfectly and clearly
the true relations and the relative duties and functions
of the several factors to each other are recognized and
kept in view, the greater will be progress in all that
goes to make up the civilized life.
The medical profession as one of the constituent
parts of the community has intimate relations to every
other interest and to every other part of that com-
munity. Its work and the principles which it repre-
sents, are in their importance to organized society
second to no other.
If, as a modern philosopher declares with respect
to the moral quality of human actions, "the highest
conduct is that which conduces to the greatest length,
breadth and completeness of life," then the medical
calling must take high rank if not the highest of all
others; for the genius and the end of this calling are
to secure that length, breadth and completeness of
life for all mankind.
Not many centuries ago medical knowledge and
medical practice were concerned with little more than
the giving of crude drugs and caring for the more
common accidents of life. Diagnosis was almost
purely a mental process, with only a slender basis in
the observation of the most superficial manifestations
of disease. Causation was mythical speculation based
on superstition. Prevention of disease was counted
a sacrilege rather than as belonging to the science and
art of medicine.
But medical science has outgrown the narrow
limits of the past, and the history of its growth from
the primitive state to its present position is a part of
the history of civilization. It stands for the physical
perfection of the individual not only, but also for
the improvement and perfection of the human
race. Though it deals first and chiefly with the dis-
eases and imperfections of the individual, it extends its,
dominion over aggregate life in all its combinations
and ramifications, and inasmuch as it discovers and
510
THE MEDICAL PROFESSION AND THE PUBLIC.
[September 5,
demonstrates the laws and influences of heredity,
over transmitted life as well.
While its most evident functions are to treat dis-
ease and manage the sick, yet it is not less concerned
with the prevention of disease and the discovery of
its causes.
It is the source of modern psychology which dic-
tates modern methods of education. It is the center
of all that knowledge of the defective and dependent
classes, as the insane, the idiotic, the deaf and dumb,
the pauper, the inebriate and the criminal — which has
led up to their humane management and rational
treatment.
It puts every branch of science under tribute; as
biology, of which it is now itself recognized as a part,
which demonstrates that the diseases which afflict
mankind are largely the result of conflict between the
lower and the higher forms of life; and the whole
range of the physical sciences whose wonderful devel-
opment has been such a conspicuous feature of recent
time, and whose contributions have added immeasur-
ably to the powers and scope of medical knowledge in
the way of diagnosis, treatment, prevention and the
discovery of the causes of disease. Medical science
thus includes all knowledge of whatsoever kind, or from
whatsoever source that tends to prolong life and ameli-
orate its conditions. This is the high conception
of the nature and the purpose of the science and the
art of medicine for which we would plead.
Through medical science the medical profession has
a twofold relation to the community at large. First,
that in which the physician lives for himself, and
second, that in which as a benefactor he contributes
to the welfare of others, in which he is the exponent
of all that medical science means to men.
By it and through it he earns his living as a citizen.
He thus discharges his first duty to himself and others
both in point of time and importance. It is the field
in which he toils as a man, that sowing and tilling he
may reap from it the rewards of the labor of his life.
The medical calling considered purely as a calling
in which the physician manifests the selfish side of
his life, selfish in the sense and to the extent that he
lives for himself as distinguished from others, stands
on the same footing and sustains the same relation to
the community and the State as any other calling.
Physicians are not entitled to any special privileges
and should receive none on their own account. If they
sometimes ask for them on this ground, it is through
ignorance and mistaken notions of their rights and
privileges. There is a widely prevalent notion in the
minds of the public that the laws and customs of
society " hedge about" the medical calling in such a
way as to favor the physician as compared with those
of other occupations. A presumably learned judge of
our own State, within the last year, has given public
utterance in his official capacity to this erroneous
interpretation of the laws and customs of society as
they relate to the medical calling, in a case which has
become somewhat celebrated on account of the ruling
of the court and the arguments used to sustain his
position. A physician was called as an expert witness
by the city of Springfield, as defendant in a personal
injury damage suit. The physican refused to testify
unless a reasonable fee should be guaranteed him as
an expert witness. The presiding judge in arguing
against the position assumed by the witness, said
among other things that, " so far as the witness is able
to respond to proper questions propounded to him on
the trial of a cause, while he is upon the witness stand,
without previously making special preparation or
examination to enable him to answer that particular
question, I think it is his duty to answer. Especially
the court holds is that true of jmysicians. Physicians
in this State are favored children of the State; a
department of the State government is maintained
very largely for their benefit; they hold a license to
practice their profession and practice by grace as well
as by right, and are so hedged about and protected by
the laws of the State, and by public opinion and con-
fidence, that in five minutes of a time a doctor may
earn more than an ordinary laborer could earn in a
day, and may continue to earn such fees all day long,
even on a day he may be required to attend court,
except the hour or so devoted to attending on the
court. Very much of that is because of the laws of
the State which nurse their profession, and by grace
which the State and society extends to them in regard
to their profession."
If the department of the State government here
alluded to, viz., the State board of health, is main-
tained largely and principally for the benefit of phy-
sicians, then it ought to be wiped out of existence,
and would be as soon as it were put to the test. If the
State board of health has any reason for existence at
all, it is because it is supposed to protect the lives and
health of the people at large. And to the extent that
these objects are secured, just to that extent is the phy-
sician in the pursuit of his calling, as it relates to him-
self, interfered with, rather than benefited. Perhaps
the learned judge could tell us how the prevention of
disease and the preservation of health by the State
inures to the benefit of physicians, as a class, for it is
not evident on the surface.
If the laws of the State " nurse the profession,"
and foster medical science, it is that the community
as a whole may be benefited, and not the physicians
as a class. If a law of the State exempts the physi-
cian from jury duty and other duties of the citizen, it
is not because he himself has any claims to such
exemption. If a city government gives the physician
right of way in a crowded street, or allows him to
break through a procession, it is not that he may
thereby add to his comfort or his income, but because
he is supposed to be on an errand of mercy and
humanity for others.
" They hold a license to practice their profession,
and practice by grace as well as by right," says our
expounder of the law. If the practice of medicine is
a legitimate calling, a useful calling, then the physi-
cian would seem to have the same right to pMrsue
that calling as any other citizen has to pursue any
legitimate calling. If so, then it is not in any degree
by grace. The license of the physician like the
license of the lawyer or that of the locomotive engin-
eer is generally counted as an evidence of technical
qualifications and a restriction or limitation. It has
reference to the rights and. safety of the community,
rather than to the individual holding it. It tells the
public that he is a physician in fact, not a pretender.
It confers no benefit on the individual physician, but
it does protect the interest of those with whom he
deals, and is for their benefit, not his. Whatever
benefits come to the physician by reason of the laws
of the State, or customs of society bearing on the
medical calling or the medical profession, are purely
incidental to their primary object of conferring benefits
on the community at large.
1896.]
THE MEDICAL PROFESSION AND THE PUBLIC.
511
In this relation also the physician is entitled to the
rewards of his labors. No loss than others is ho worthy
of his hire. While he is treading out the corn like the
ox. he should not be muzzled. If he tread the wine press
ho should share in the vintage. That every individual
sluudd receive all the rewards which his ability, his
industry, and his opportunities can secure for him in
n legitimate calling honestly pursued, isa self-evident
proposition which admits of no exceptions. That
community in which this fundamental principle is the
most clearly recognized, and the most perfectly applied
will be the besi community, the most highly civilized,
and the most perfectly adjusted in all its parts. If
any one class or constituent part of a community is
deprived of the legitimate reward of its labors, that
class will lose something in its quality and in its power,
and the society of which it is a part will suffer
directly or remotely as a consequence. As when one
member of the body deteriorates, the whole organism
Buffers loss.
Most physicians can be trusted as a rule to claim
their own in the matter of pecuniary rewards for ser-
vices rendered and they are not generally backward in
asserting those claims. But as aclass, physicians are
inadequately paid if remuneration should bear direct
Klation to benefits conferred; and of all classes they
B the most grudgingly paid.
The genius and the traditions of the medical pro-
!i require the physician to give his services when-
ever and wherever medical knowledge and medical
skill are demanded for the relief of the sick and the
afflicted, conscientiously to the rich and the poor alike,
and with equal fidelity, and primarily without thought
of reward. Thereby the medical calling becomes a
profession as distinguished from a trade. By this
token may we know the true, the ideal physician. But
this conception of the professional aspects of the
physician's life pertain to his obligation to his calling
and his class, and does not carry with it the idea of
unrequited toil. Neither does it absolve the individ-
ual or the community receiving those professional
! vices from pecuniary obligations. While the phy-
sician is thus under obligations, by the very nature of
his calling, to the poor around him, common equity
would forbid that this obligation should be perverted
by the community or any class of the community for
its own benefit.
< >ne of the most beneficent institutions of our day
in theory and practice is the modern hospital, but
there is a growing tendency to pervert and abuse it
1 iy certain classes of the community for the promotion
of their own interest. The work of a large public
hospital supported by general taxation, as for instance,
the Cook County Hospital, is to a large and increas-
ing degree taken up with the care of the sick and
injured employes of the great corporations and the
wealthy commercial establishments.
If such an employe can get free care and free med-
ical attendance when sick or injured, he does not need
and does not get as high wages as he otherwise would.
There is, hence, more profit and larger dividends for
the employer. If the multimillionaire corporation,
half of whose capital is the value of the public fran-
chise it possesses, and whose annual profits are so
large that an occasional watering of its stock must be
resorted to in order to keep the percentage rate of
dividends within a reasonable limit in the eyes of the
public, can require the medical profession and the
public to treat and care for its sick and injured
employes free, in order that the profits of the concern
may be larger on account of low wages of the
employes; then why may not the public and other
interests be compelled to furnish said employes with
such other necessities as food, clothing and house
rent. The sophistry and process of reasoning that
would make one appear right and respectable can be
used to justify the other also.
There are rewards other than pecuniary which are
due the physician from the community, and of which
he is sometimes deprived. It is due to the dignity of
his calling, and in the interests of the highest useful-
ness of the profession to the public, that all positions
of honor, profit, or trust, whose chief functions per-
tain to medical matters and require medical knowledge
for their administration, should be held by physicians.
The law expressly forbids that the president of the
Board of Health of New York City shall be a physi-
cian, though a physician living in that city is eligible
for the office of President of the United States, for that
of Governor of his State or mayor of his city. Just
why this prohibition exists is not explained, but it may
be surmised that it is because it is the one position in
the department which carries with it a high salary. In
the chief city of our own State, the only medical office
in the city government with a respectable salary is held
by a layman, who never was suspected of having any
knowledge of, or interest in, sanitary matters. The
knowledge necessary for conducting the Department of
Health is supplied by some ten or twelve physicians in
subordinate positions, whose combined salaries amount
to but little more than the salary of the layman who is
at the head of the department. A company of West
Point graduates going into battle commanded by a
green recruit, would not be more anomalous. In our
own State, as in most of the other States, the law
provides for the office of coroner for each county. It is
the chief duty of this officer to ascertain the cause of
death in certain cases. The office is held in all the
larger counties, that is, where there is any con-
siderable remuneration attached to the office, by a
man who possesses no medical knowledge whatever.
He is ably assisted in his quest by six other laymen
as jurors, who, in the large cities, are generally tramps.
In our own State it is still allowable for six men,
also mostly tramps in the large cities, to make a
diagnosis of insanity in the name of the State.
There is another evil under the sun which pertains to
the practitioner and the question of the rewards of his
labors. A confusion of values in the minds of the
public, and to some extent in the minds of the pro-
fession, has arisen in these latter days with respect to
remuneration. This is partly due to the exuberant
specialism which characterizes modern medicine. It
is also partly due to the greater advance and wider
scope of operative surgery, and in part to the rela-
tively unimportant role which the internal treatment
of disease by drugs has assumed in comparison with
former times. There never was a time when the
drug treatment of disease could accomplish more than
to-day, when internal medication was more definite in
its purpose, though its limitations are better recog-
nized than before. While in former times it out-
ranked in importance all other means and methods,
to-day preventive medicine and operative surgery
have outstripped it in the general advance in demon-
strable results. But the physician who clearly saves
a life by internal medication ought to have the same
recognition from his fellow practitioners, and to
512
THE MEDICAL PROFESSION AND THE PUBLIC.
[September 5,
receive the same rewards from the public as he who
does a life-saving surgical operation. If a practi-
tioner prevents sickness which might or might not
prove fatal, by timely advice to the family and neigh-
bors who rely on him in times of thickness, as by
preventing the spread of typhoid fever, diphtheria
and other contagious diseases, he renders a service
upon which an adequate money value can not be
placed, and yet he rarely receives any pecuniary or
other reward for such a service. Even the average
educated, prosperous citizen would resent the effort
to collect more than a nominal consideration.
The family physician who stands by his trust and
faithfully guards and guides a whole generation from
birth through childhood and adolescence to manhood
and womanhood, directs their education, training and
growth, and blazes the way against the pitfalls of
hereditary tendency to disease of body and mind, and
in all these periods and relations gives the best
resources of the whole range of the science and art
of medicine to his charge, outranks in point of service
to the individual and humanity all other classes of
practitioners. It is to the detriment of the medical
profession and the community that he does not
receive greater rewards, both honorary and substan-
tial, for his work. As compared with the specialist and
the surgeon he gets scant measure of either, and yet
he outranks them all.
The medical profession has a standing grievance
against the community in that the pretender, the unscru-
pulous and the ignorant so often receive the encourage-
ment and the rewards which by right belong to the qual-
ified, conscientious, educated physician. It is partly
true, as the poet says, " 'tis understood that the good
are half bad and the bad are half good," and in the gen-
eral mixture of motive and conduct who is competent
to draw the line, and who shall furnish the standard
of measurement? It ought not to be difficult, how-
ever, for those who desire to do so, to discriminate
between the true physician who pursues his course
animated always by the professional spirit which
requires that his own interests be secondary and sub-
ordinate to those whom he serves, whose whole trend
of life is right, whose attitude is in the right direc-
tion, and him on the other hand whose whole conduct
and attitude are wrong. Two men may stand very
close together and yet face in opposite directions.
The charlatan is not only the ignorant pretender. He
may be highly educated and skilful. He may have
high social standing. He may not only be in evi-
dence in the advertising columns of the newspaper,
but be the special pet of the editorial chair. His
chief and distinguishing characteristic everywhere
and always is that he uses the public and his patients
for his own aggrandizement. He considers always
that his patient is made for him and not he for the
patient. His attitude to the public is that of the
tradesman, and he is animated by the spirit of the
tradesman. He makes merchandise of his calling.
He takes advantage of the foibles and weaknesses of
humanity to add to his own fame, power and pelf.
In his most perfect and typical form he is essentially
a parasite on the profession. He assumes the color
and the garb of his host, living on his vitality, receiv-
ing everything and giving nothing in return. He
lives the life of the parasite and should receive the
treatment of the parasite. Many of the best of men
may be weak enough to yield to temptation of special
influence or other causes to show some of these char-
r
acteristics in a greater or less degree some time or
many times in their professional life, but wherever
found, whether in the members or officers of our own
medical societies, whether in the professors of col-
leges or in others, to the extent and in the degree tha
they are manifested, they become the acts and the
methods of the charlatan and the unscrupulous. If
the one attitude is right the other is wrong. Which
course, followed to its logical conclusion, will prove
beneficent and which destructive?
It ought to be better understood and more con-
stantly kept in view that medical science is a field
without metes and bounds, is one and indivisible, and
all inclusive. There are no schools of medical sci-
ence any more than there are schools of the science of
chemistry or astronomy or law. Even the so-called
"schools" or "systems" of medical practice are a men-
tal abstraction, consisting more of traditional and
and rhetorical phrases expressive of a subjective men-
tal state than an objective reality. Such a conception
was more or less excusable and suitable, perhaps, in
the pre-scientific era of the middle ages when meta-
physical abstractions and dogma were the stock in
trade of the schoolman, the transcendentalist and the
doctrinaire, but it is a crime against the light of these
latter days of the nineteenth century.
It is not the belief of the medical man or the doc-
trine which he holds; it is not what he does nor ho
he practices; it is not what society he is a member of,
nor what written code of morals he professes to
guided by, that is the test of his right relation t
medical science and the public. Here again it is hi
attitude by which he is to be judged.
No doubt there are many well informed people 1:
this audience, well informed in other respects, ai
there are in every community, who persist in believ-
ing that this and similar societies require their mem-
bers to subscribe to and be governed by a code of
ethics which is more or less artificial in character and
inapplicable in other walks of life. There is no such
artificial code. What we have is but the amplifica-
tion of the golden rule and the sermon on the mount,
set to phrase suited to the medical relation. We
teach through our code what is taught as good mor-
als and good manners by every teacher of morals from
the forum and the pulpit to mankind, from the cradle
to the grave — this and nothing more. Whether it
should be used for disciplinary purposes and to what
extent, or whether it should remain as a formulary of
precepts as its language would seem to imply was the
original intention, are the only questions that can be
or ever have been raised regarding the code of medi-
cal ethics.
No doubt also the belief is just as prevalent that
we and all similar organizations require our mem-
bers to subscribe to some set of doctrines, or a con-
fession of faith, and to conform to certain modes
of giving drugs. We know of no such doctrines or
rules, except as they are sometimes put into our
mouths through others. We hold that no truth is
final, and that no man should limit his studies
or his practice by any confession. We hold that
every proposition of doctrine or of practice must
stand or fall to the mind of every individual without
let or hindrance, and that there are no limitations on
what any man may do in the way of practice or hold in
the way of belief except such as are due to himself —
his own powers and disposition. More than this we
could not do. Less than this would change our atti-
1896.]
THE MEDICAL PROFESSION AND THE PUBLIC.
513
tude to medical science, to other medical men and to
the public, and place us in the ranks of the sectarian
physician. This attitude of mind in the physician
in hi* relation to medical science and the public is
in a limited way akin to that of the banker in rela-
tion to the coin of his customer. Every coin
offered him lie must accept or reject by his own
mental process on the evidence obtainable. He
scans it. handles it, turns it over, tests it ring, weighs
it. and receives it for what it seems to him to be
worth. It' it is counterfeit, it is rejected at once and
absolutely. It' it is a debased or clipped coin, he
ascertains its value and acts accordingly. If the man
science recognizes the falsity or counterfeit char-
acter of some supposed new science, new method or
new proposition, and rejects it as peremptorily as the
banker docs the counterfeit coin, or after examining
all its claims to being genuine, still rejects it or
receives it only for what it is worth, he is likely to be
called a bigot or to be charged with intellectual
intolerance to a degree which only medical men are
supposed to be guilty of.
Indeed intellectual intolerance is a charge which is
too often laid at the door of the medical man when he
turns away from the sciolist and declines to share
with the psuedo-scientist.
An episode in the life of Israel's king, Solomon,
affords a lesson and an answer. He proposed with
his sword to divide the living child which was in dis-
pute, in order to determine which was the real
mother and which was the pretended mother. The
latter counted it a liberal proposition, but the real
mother surrendered rather than to submit to such a
compromise. There are some things which can not be
shared and are insusceptible of division.
Medical science appeals for help and wider recog-
nition from the public and the State. It could easily
be shown that the greatest discoveries in this field
have through all the past and in recent times con-
ferred much greater proportional benefits on every
class of the community than on physicians as a class.
It could equally be shown that almost all the valua-
able discoveries and resources for prolonging life,
relieving suffering and preventing disease have been
due to the individual efforts of those devoted to
' medical science with little or no aid from the State
and the non-medical public. A few notable and hon-
orable exceptions there may be.
Moreover it is not generally appreciated that
almost every one of the epoch-making discoveries
have contracted the field for the practitioner and cur-
tailed his resources for earning a living. It ought
not therefore to be expected that the medical profes-
sion be wholly responsible for the future progress of
that science which adds so much to the public welfare
and at the same time works to the detriment of the
medical calling as a calling. It is unreasonable not
to expect that some of the increasing wealth of pri-
vate citizens and the fostering care of the State should
share in the work of discovery and application and
bear the burdens thereof.
One thing the situation demands: A better educa-
tion of the citizen; not of the present generation
already in the field of active pursuits, for that is
practically hopeless; but better education of the pres-
ent and future youth of the country — that all educa-
tional institutions from the lowest to the highest
shall take cognizance of the new fields of knowledge
and the new methods of thought and investigation
which have come into view in the last quarter of the
century.
A recent writer on higher education says: "Men
may be educated in literature and philosophy and yet
only half educated or uneducated in scienoe and thus
liable to terrible mistakes because they are color
blind as to the half of human knowledge. Some of
our greatest orators and most popular writers are
simpletons as to scientific methods and arguments."
To which sentiment we all say, amen!
And another thing the situation demands, viz. :
That the United States Government which professedly
represents the most civilized, the most enlightened,
the most progressive, the most peaceable and the
wealthiest in resources of all the nations of the earth,
shall nominally and actively recognize the claims of
medical science as a science and in its beneficent
relations to the people, and shall serve as a channel
through which the energies and the wealth of the
people shall be directed to these ends.
A peaceable government which spends eighty mill-
ions of money a year on its army and navy in times
of peace, one hundred and fifty millions in pensions,
sixty millions on its inland rivers and harbors, and
many millions more to promote commerce and other
material interests of its people, ought to spend more
than one or two hundred thousand dollars a year in the
interests and in the name of the health of all the people.
This small pittance which is now expended in this
direction is spent in the name and for the sake of
trade and commerce by the Marine-Hospital Service
for the purpose of quarantine, one of the subordinate
functions of this department, which is itself a subor-
dinate department of the executive branch of the gov-
ernment. We read of some of the minor employes
of the government having charge of the inspection of
meats and other food products; but we also learn that
this is carried on wholly in the interests of our trade
relations with other countries and not for the sake of
the health of the consumer or producer. How many
of even the best informed citizens of this country are
aware of the fact that if smallpox existed as it did one
hundred years ago, that if cholera and yellow fever
could not be controlled better to-day than they were
twenty-five years ago, to say nothing of other forms of
contagion, pestilence and plague — with the increased
means and rapidity of travel and with the hundredfold
increase of running to and fro upon the earth, I say
who and how many know that with these conditions,
the towering industries would be brought low, the
mighty channels of commerce would be closed, great
cities wiped out, the whole population decimated
every decade, and if we believe the testimony of the
older days, those of the people who remain would nearly
all be defaced with pock marks.
The militant type of government was proper enough
in earlier history and is well enough now in some of
the nations of the world, perhaps, but our govern-
ment at least must be readjusted to the industrial
peace type which our conditions require. The heads
of the army and navy departments, now so prominent
in the councils of the government, must give way to
those who represent the arts of peace, industry and
humanity. In this adjustment, we propose to take
part and to be a part with the permission and co-
operation of the intelligent people. Hygeia will rise
step by step until she strikes hands with Ceres and
have an equal voice in the councils of the nation.
Then we shall see tuberculosis, the remaining
514
TRUE CLINICAL EXPERIENCE.
[September 5,
greatest scourge of the race, which is now accredited
with one quarter of the mortality of our time, shorn
of its power and controlled.
To quote from a recent address of President Eliot:
"The public does not use its imagination sufficiently with
regard to the future of preventive medicine. Leprosy and
smallpox have been measurably conquered ; it has proved
possible to exclude cholera and yellow fever ; and yet the
public is not impatient for the conquest of every other infec-
tious and contagious disease, and often not willing to provide
the necessary means of deliverance from these evils. Some
of the most intelligent communities refuse to establish public
disinfecting stations. Bacteriological laboratories are few and
far between, when they should be everywhere accessible.
Pure water supplies have diminished typhoid fever in urban
populations, but the rural populations, through ignorance, still
suffer disproportionately from this preventable scourge. The
faith and hope of the medical profession should arouse the
public from this lethargy, and redeem it from this destructive
ignorance and incredulity."
In our own State as well as in the general govern-
ment, we are not living up to our requirements nor
our opportunities. We are lagging behind less
favored communities in the matter of legislation,
looking to the best things in medical science relating
to the control of disease and the promotion of health.
We have many laws and fragments of laws which
seem to have or to have had at some time, beneficent
aims in this direction, but they were mostly enacted
from and when enforced at all, are enforced from the
standpoint of commerce and the good of some local
material interest.
We have nominally a State Board of Health, but
it has made little impression on the affairs of the
State in the name of health, largely from lack of suf-
ficient appropriations, and from lack of the moral
support of the community and the medical profession.
More of the intelligent and influential members of
the profession should be willing to make some sacri-
fice of their own interest, and take part either directly
or indirectly in legislative affairs.
An over-view in the presence of our legislature
when in session, is both instructive and discouraging,
but by this I mean no disrespect to the mass of well-
meaning men who are there. A veteran in legislative
halls summarized his experience epigram matically by
saying that the less one knows of how law is made,
the more he will respect the product. Of the sev-
eral hundred bills introduced into our last legisla-
ture, aside from general appropriation bills for cur-
rent expenditures, nine-tenths of them were for the
promotion of some local or special interest. A bill
looking to the general welfare is generally crowded
out or defeated. It has come to be more and more
that a legislature is made up of representatives of
interests rather than of representatives of a certain
number of people. A sprinkling of intelligent medi-
cal men to represent the medical interests and to see
that medical questions receive respectful and a due
share of consideration, might improve a legislature
and its work. It could not affect it seriously otherwise.
When medical men are willing to take part in pub-
lic affairs instead of staying at home and grumbling,
and writing jeremiads, medical questions may be
better treated in legislative assemblies and by the
public generally.
To quote again from President Eliot:
"The medical profession has before it an entrancing prospect
of usefulness and honor. Jt offers to young men the largest
opportunities for disinterested, devoted and heroic service.
The times are passed when men had to go war to give evidence
of endurance, or courage, or capacity to think quickly and
well under pressure of responsibility and danger. The fields
open to the physician and surgeon now give ample scope for
these lofty qualities.
" The times are past when the church alone asked men to
devote themselves patiently, disinterestedly, and bravely to the
service of their fellowmen. The medical profession now exhibits
in highest degree these virtues. Our nation sometimes seen
tempted to seek in war— that stupid and horrible savagery !-
for other greatness than can come from vast natural resources,
prosperous industries and expanding commerce. The pursuits
of peace seem to pall for lack of risk and adventure. Would
it might turn its energies and its longing for patriotic and
heroic emotion into the immense fields of beneficent activity
which sanitation, preventive medicine, and comparative medi-
cine offer it ! There are spiritual and physical triumphs to be
won in these fields infinitely higher than any which war can
offer ; for they will be triumphs of construction and preserva-
tion, not of destruction and ruin. They will be triumphs of
good over evil, and of happiness over misery."
ORIGINAL ARTICLES.
WHAT CONSTITUTES TRUE CLINICAL
EXPERIENCE IN MEDICAL PRAC-
TICE AND ITS RELATIONS TO
THE PUBLIC HEALTH?
Read in the Section on State Medicine, at the Forty-seventh Annua
Meeting of the American Medical Association, at
Atlanta. Ga., May 5-8. 1896.
BY N. S. DAVIS, M.D.
CHICAGO, ILL.
Clinical experience is to be regarded as the knowl-
edge gained by a direct study of diseases or morbid
processes, including their causes, symptoms, progress,
natural tendencies and results, and the actual influ-
ence of remedies in arresting, modifying them or
shortening their duration. If this is cornet, it must
be obvious that the value or reliability of our clinica"
experience will depend directly upon the extent am
accuracy of knowledge of the nature and modes of
action of the causes of disease, the natural tendencies
and results of each disease or group of morbid pro-
cesses, and the actual mode of action of each remedy
used in the treatment of such processes. In other
words, the clinical experience of members of the pro-
fession will be reliable, just in proportion to their
knowledge of etiology, pathology and therapeutics.
It was not until the last fifty or seventy-five years
that organic and physiologic chemistry and micros-
copy had attained such a degree of development that
many of the exciting or efficient causes of disease
could be identified and their mode of action in the
living body determined. Patient, persistent observa-
tion through the preceding centuries had led the pro-
fession to believe that all acute general diseases were
caused by specific causes to which the names of mala-
ria, miasms and contagiums were given. But their
identification had, in far the greater number of instan-
ces, eluded the powers of simple observation; and
consequently, neither their mode of development nor
their mode of action on the functions or structures of
the body could be traced with accuracy. The same
remarks are applicable to our clinical knowledge of t In-
action of remedies. Without the aid of the more
recent improvements in chemic and microscopic meth-
ods of research it was not possible, in the first place,
to separate the active agents from the crude materials
of the drugs, and then so closely follow the active
agents when administered as to see what changes, if
any, they undergo, what changes they effect in any of
1896. j
TRUE CLINICAL EXPERIENCE.
515
the functions or structures of the body, and through
what channels they are finally eliminated.
So too, in the study of diseases by direct observa-
tions at the bedside. Only the knowledge of the nian-
syniptoms presented during the successive stages
in the progress of disease, the greater or less amount
•ret ions, and the duration of each stage could be
determined. And if postmortems were made, they
revealed only the result* of the morbid actions that
had been taking place, and not the philosophy of the
actions themselves.
It is true that our predecessors, while thus limited
almost exclusively to observation, or the use of their
own senses, in the study of disease, gave us more
minute, painstaking and complete symptomatologic
descriptions of the more acute diseases, than can be
found in the medical literature of the present day.
But as they could neither see nor determine the actual
morbid processes or the modus operandi of their
causes, they were compelled to define diseases by
groups of associated symptoms, as fevers, inflamma-
tions, etc.. and their causes by names that conveyed
no real knowledge of their nature or origin, as miasms,
septic poison, foul air. hereditary, meteorologic and
epidemic influences. They logically assumed that
every disease or group of associated symptoms must
have a cause. It' careful observation proved that a
certain group of symptoms originated mostly near
marshes or on rich alluvial districts of country, it was
assumed that some causative agent was developed to
which they gave the hypothetic name of malaria or
marsh miasm. If another associated group was found
prevailing principally in densely populated districts
with crowded and ill- ventilated tenements, dirty streets
and impure water, it was assumed that from these
conditions another hypothetic poison was evolved, to
which was given the name of idio-miasm.
With neither an exact knowledge of the nature and
node of action of the supposed causes of disease, nor
of the morbid processes constituting disease, the
selection and administration of remedies could not
be otherwise than empiric or else aimed at the relief
of particular symptoms. And this again necessitated
the classification of drugs in the materia medica on a
symptomatic basis, as emetics, cathartics, diuretics,
diaphoretics, narcotics, stimulants, sedatives, tonics
and alteratives, according as they increased evacua-
tions from the stomach, intestines, kidneys or skin,
allayed pain and induced sleep, increased the frequency
of the heart's action with a sense of exhilaration or
excitement, or the reverse: a feeling of increased
strength or endurance; or such changes in metabolism
as resulted in the removal of adventitious tissues and
morbid growths.
It was during this long period of dependence upon
simple observation, with very limited means for
obtaining more complete and exact knowledge con-
cerning the actual changes taking place in the living
structures under either morbific or remedial influ-
ences, that all our literature relating to the depart-
ments of etiology, therapeutics and practical medicine
was developed. And much the larger part of the
hypothetic names and words, and phrases of ill-
defined meaning, which they necessarily embodied,
are retained not only in our text-books, but still more
in all the secular literature of the present day, thereby
causing an unlimited amount of confusion in both
the public and professional mind.
Thus, while dependent on simple observation and our
sensations for judging of the action of remedies, we
classed all agents that, when taken, induced increased
frequency of the pulse, with sensations of warmth in
the stomach and general feelings of excitement or
exhilaration, as stimulants or restoratives. And as
moderate doses of nearly all the narcotic and anes-
thetic drugs produced just these effects, they were
made to constitute the greater part of the class of
stimulants, with alcohol in the forms of fermented
and distilled drinks at their head. Hence a resort to
the latter for relief from weakness, weariness, cold-
ness, faintness, depression, shock, or even apprehen-
sion of exhaustion, became almost universal both by
the profession and the public. And it is still this
underlying fundamental idea of their power to stim-
ulate, restore and sustain, that leads to and perpetu-
ates their use not only in the treatment of all diseases
of supposed debility, but also in enormous quantities
by nearly all classes of people, to relieve every depres-
sion of feeling or apprehended evil, mental or physi-
cal. Arid all this is easily traceable for its support
to the simple alleged clinical experience of the pro-
fession as found in our standard works.
Thus, in one of the recognized standard works on
the nature and action of remedies, we read that alco-
hol " taken internally, in small quantities appropriately
diluted, excites a sense of warmth in the stomach and,
if the person is very susceptible, an almost instanta-
neous glow throughout the body, with increased fre-
quency and force of the heart and pulse, a livelier
flow of ideas which are, according to the temperament
of the individual, gay or gloomy, and actions which,
in like manner, may be playful or malevolent." This,
you will perceive, is a simple transcript of the sensa-
tions and actions of the individual under the influ-
ence of the drug. And the same high authority adds:
" The use of alcohol in every age, and by every nation
in the world, demonstrates that it satisfies a natural
instinct, that it literally refreshes the system exhausted
by physical or mental labor, and that it not only
quickens the appetite for food and aids in its diges-
tion, but that it spares the digestive organs by limit-
ing the amount of solid food which would otherwise
be required." ' This, the author seems to say, is the
actual clinical experience of the whole world in regard
to the use of alcohol in appropriate doses, and yet it
all rests on the sensations of the user, without any
accurate knowledge of the actual changes produced
by the alcohol on the constituents of the blood, the
sensibility of the cerebral hemispheres, the cardiac
and respiratory nerve centers, or on the metabolism
of the tissues and organs of secretion.
The " natural instinct " spoken of by the author,
and often repeated in popular literature, can be
nothing more than the desire of a sentient or intelli-
gent being to be relieved of any or all uncomfortable
feelings, whether mental or physical. And as alcohol
in moderate doses, like all other anesthetics, relieves,
at least temporarily, all uncomfortable feelings,
whether of grief, despondency, weariness, weakness,
cold, heat or pain, it is that which constitutes the
"literally refreshing" influence it is supposed to
exert on the human race; and in that way only does
it satisfy any " natural instinct " in the human family.
It is clearly apparent, therefore, that all the past
and present uses of alcohol in the forms of fermented
and distilled liquors, both as medicines and beverages,
originated from, and still depends for support upon,
1 See National Dispensatory, pp. 12S-4.
516
TRUE CLINICAL EXPERIENCE.
[September 5,
the supposed clinical demonstration that in moderate
doses it warms, stimulates, refreshes, strengthens and
exhilarates all the functions of body and mind.
Could there be a more striking illustration of the
direct connection between the alleged clinical experi-
ence of the medical profession and the interests of
public health and morals?
As has been already stated, however, all this clini-
cal experience is based on the sensations, movements
and opinions of the patient or person under the influ-
ence of the alcohol. He swallows a moderate dose,
and its contact with the gastric mucous membrane
produces a sensation of increased heat and he says it
warms him. Being rapidly absorbed and carried to
every tissue in his body, its contact with the nerve struc-
tures directly diminishes the sensibility of the sentient
nerve cells, and therefore he feels less conscious of
weariness, weakness, restlessness or pain, and conse-
quently he thinks it refreshes, strengthens and com-
forts him. But the same lessening of nerve sensibil-
ity extends to the nerve cells connected with both
mental and cardiac inhibition, and hence he believes
he can think and talk faster, and do more, and the
heart beats a little faster. Hence both he and his
friends say it stimulates him.
Yet, when we apply the tests of philosophic instru-
ments for accurate measurements, and thereby obtain
results independent of the sensations of the indivi-
dual, just when he thinks a moderate dose of alcohol
is warming, strengthening and refreshing him, and
enabling him to work and think or talk faster, we find
his temperature diminishing, his nerve sensibility
less [acute, its transmission of impression slower, his
mental processes tardy and less accurate, his muscu-
lar strength and endurance less, less oxygen and more
carbon dioxid in the blood, and diminished metabolic
changes generally. And when his period of this kind
of refreshment has passed, instead of being invigor-
ated and ready for active work, either mental or physi-
cal, he is pervaded by a feeling of dullness and depres-
sion that makes him think another dose of the same
refreshing liquid necessary.
In other words, we have the complete demonstration
that the so-called refreshing and strengthening effect
of alcohol depends entirely on its anesthetic proper-
ties, by which it diminishes the sensibility of the
nerve cells of the brain, the material seat of conscious-
ness, and thereby diminishes the consciousness of all
impressions, whether of heat, cold, weariness, weak-
ness or pain, and at the same time lessens every
physiologic process taking place in the blood, tissues
and organs of the body, thus showing the entire fal-
lacy of all the clinical experience founded upon the
patient's feelings or conscious impressions, and ena-
bling us to see clearly how alcohol or any other cere-
bral anesthetic may cause patients to think they are
stronger and better, when in truth all the vital or
physiologic processes are diminished. And if the
use of the agent is repeated from day to day, even in
the most moderate doses, we see how the user is
induced to think he is being refreshed or sustained,
while all the metabolic processes are being retarded, his
power to resist or eliminate toxic agents diminished
and molecular degeneration of tissues encouraged.
Then why continue to call an agent a stimulant or
tonic, that simply diminishes the patient's conscious-
ness of weakness without adding anything whatever
of strength or tissue repair, but really impairs both
in direct proportion to the quantity used?
However, it is not solely in regard to the use of
anesthetic and narcotic agents capable of diminishing |
the sensibility of our seat of conscious impression,
that our clinical experience has proved fallacious.
Only a few years since, the profession were taught to
regard the degree of pyrexia or heat as the chief ele-
ment of danger in all the acute general diseases.
Consequently, to control the pyrexia became the
leading object of treatment; and whatever would do
this promptly, and at the same time allay pain and
promote rest, found favor at the bedside of the patient.
It was soon ascertained that antipyrin, antifebrin,
phenacetin and other analogous products, if given in
sufficient doses, would reduce the pyrexia and allay
the pains with great certainty and promptness, not
only in continued fevers, but also in rheumatism,
influenza or la grippe, etc., and their use soon became
popular both with the profession and public. No one
undertook to first ascertain by strictly scientific appli-
ances the actual pathologic processes causing the
pyrexia in each form of disease, or even to determine
whether, in any given case, the increased heat was Ih
result of increased heat production or diminished hea
dissipation. Neither were any of the remedies su
jected to such experimental investigation as to deter
mine their influence on the elements of the bloo"
the internal distribution of oxygen, the metabolisi
of the tissues, or on the activity of the eliminations
Consequently, their exhibition was wholly empirica
and the one that subdued the pyrexia most promptl
was given the preference.
Yet we all know that the pyrexia invariably returns
as soon as the effects of each dose were exhausted
and in a few years the results showed that while the
antipyretics served to keep down the pyrexia, and give
each case the appearance of doing well, the average
duration of the cases and their mortality were both
increased. Step by step experimental therapeutic
investigations have proved that the whole class of
coal tar antipyretics reduce animal heat by impairinL
the capacity of the hemoglobin and corpuscular ele
ments of the blood to receive and distribute frei
oxygen, and thereby reduce temperature by dimin
ishing heat production, nerve sensibility and tissu
metabolism. Therefore, while each dose temporarily
reduced the pyrexia, it retarded the most important
physiologic processes on which the living system
depends for resisting the effects of toxic agents,
namely, oxidation and elimination. This not only
encouraged the retention of toxic agents and natural
excretory materials by which specific fevers were pro-
tracted, but it greatly increased the number of cases
of pneumonia complicating the epidemic influenza or
la grippe as it has occurred since 1888-89. And it
contributed still more to the production of that remark-
able cardiac, vaso-motor and respiratory debility that
has followed very many of the cases of the disease
just mentioned.
I might cite other cases occurring both in the pres-
ent and past history of the profession, showing the
entirely fallacious character of the clinical experience
founded on simple empirical observation, and the inju-
rious effects of such alleged experience on the public
health. But the illustrations already given are suffi-
cient for my present purpose, namely, to urge the
necessity of a much more thorough experimental study
of the nature and action in the living body, of the
toxic agents constituting etiologic factors; the nature,
tendencies and results of morbid processes constituting
1896.]
STATE SUPPRESSION OF INEBRIETY.
517
diseases, and the actual modus operandi of the medi-
cines \\v use in their treatment. The facilities for
pooh study afforded by our chemic, physiologic, path-
ologic and therapeutic laboratories and instruments
of precision, should bo so utilized as to speedily impart
to the clinical experience of the profession a degree
of reliability that, in its reflex upon the public, would
greatly improve the public health, both mental and
physical.
STATE SUPPRESSION OF INEBRIETY AND
CURE OF INEBRIATES.
Bead in the Section on State Medicine, at tho Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga.. May 5-8, 1S86.
BY O. EVERTS, M.D.
COLLEGE HIM.. OHIO.
Much attention has been given in this country and
elsewhere, within the last fifty years, to the subjects
of inebriety and the cure of inebriates. Many schemes
for the suppression of inebriety and the cure, or
reformation, of drunkards have been suggested,
adopted and tested experimentally with — notwith-
standing much good accomplished — unsatisfactory
results. These schemes have consisted mostly of so-
called temperance societies, on becoming members of
which persons pledged themselves by signature.or oath,
to totally abstain from intoxicating drinks; political
party organizations, seeking by legislation to pro-
hibit the manufacture or sale of intoxicants within
the State: public and private asylums for inebriates;
and last, if not least, innumerable gokLcures and
other quack pretensions for the regeneration of
drunkards.
Promising as some of these schemes were in their
inception, that they have all failed to accomplish the
desired end is not now a mystery to the more observ-
ing and thoughtful.
Such being the fact respecting schemes heretofore
tested, it may be rationally affirmed that inebriety is
not suppressible to any great degree by social influ-
ences, moral suasion, oath-bound obligations, or per-
sonal pledges; nor are inebriates, as a class, curable
by medication, general or specific, secret or open, if
not otherwise restrained; and that "prohibition does
not prohibit/' But as philanthropists, social scien-
tists and physicians we can not accept this verdict as
the end of contention and effort for a "consumation
devoutly to be wished."
What further effort then shall be made for the sup-
pression of inebriety and the cure of inebriates?
After many years' observation and experience in the
treatment of this class of persons, and careful study
of the causes of failure already affirmed, it is evident
to me that there are but two methods which give
promise of much greater attainment than did those
already tried and found wanting.
One of these methods contemplates absolute prohi-
bition, or putting all intoxicants out of the reach of
inebriates; and the other contemplates putting the
drunkard under such (bearable) restraint that he can
not reach intoxicants; methods, neither of which can
be successfully administered by other than the author-
ity of a State. The question then arises: Can or
should the State interest itself in such matters?
It may be again rationally affirmed that the State,
t being simply the mechanism through which popular
energy emanating from the people is transmuted into
governmental energy, having in view "the greatest
good to the greatest number," should be interested
and exercise authority for the suppression of inebriety,
because inebriety is offensive to society and beneficial
to nobody; and in the cure of inebriates, because
inebriates are citizens of a defective class, disqualified
for the functions of good citizenship and dangerous
to themselves and others, by reason of disease that is
not amenable to ordinary, or other, medical treatment.
The first of the foregoing propositions likely to be
challenged is that which affirms the incurability of
inebriates by moral or medical means. It is rational
indeed for persons who see only the factor of vice in
the problem of inebriety, to believe in the efficacy of
moral suasion, or correction, for its suppression, or the
cure of the inebriate. One may be rational, however,
and yet very much mistaken. Reason finds in accord-
ance with whatever testimony is before it, and is as
facile in confirmation of error as of truth. The ignor-
ant— at all times a comparative term including the
greater portion of mankind — and some doctors of
medicine — regard all phenomena as supernatural and
occult. They ascribe the phenomena of evil to a
supreme spiritual embodiment of evil immanent in
the universe, between which and a supreme spiritual
embodiment of good, also immanent, if less active, poor
man is forever being attracted or repelled, as by the
poles of a gigantic spiritual magnet, though boasting
still of freedom. Inebriety being regarded as a vice,
what could be more rational than the supposition that
all that is required for its suppression is a renunciation
of evil and submission to good? Regarding inebriety
as a manifestation of disease, believing disease to be
instigated by, or in some way related to supernatural
influences, and ascribing the curative virtues of drugs
to supernatural qualities, with the blind faith or
fetishism of ignorance, what more rational than to
suppose the inebriate can be cured by medicine? A
wider range of testimony, however, discredits and
renders irrational both theory and practice. If the
testimony of a single century against these assump-
tions is not sufficient, the facts of human history
stand arrayed in solid columns ready to confirm it.
Nor should the more enlightened be impatient
because of the credulity and delusions of the ignor-
ant, as out of the same root-conditions they have
grown into higher light and broader perceptions.
Knowledge of the constitutional history of a man —
biologic science, indeed — is a revelation of to-day.
The physiologic effects of medicines, as related to
constructive and destructive processes effected by
them when ingested by living beings, are of too recent
recognition to have become generally understood, or
accepted as valuable knowledge. No physician of
education and experience, however, will pretend that
other than exceptional persons suffering genuine
pathologic inebriety, have ever been cured by any
social or moral influences that could be brought to
bear upon them, or by the administration of drugs of
any kind. By cure I mean restoration to primary
conditions and normal appetites, the establishment
of physiologic protection against almost immediate
relapse.
Objection to State interference with inebriates,
other than punitive, will be made by a class of pious
or fanatic religionists, who fear that by consenting
to any measures for the suppression of inebriety, or
cure of inebriates, that do not express their ideas of
sin and reclamation by fear of punishment, they will
in some way commit themselves to toleration, if not
518
STATE SUPPRESSION OF INEBRIETY.
[September b,
approval, of vice and thus become accessory to crime.
A class conscientiously opposed to any legal enact-
ments contemplating an amelioration of the condi-
tions of the sinful, or the protection of the innocent,
by "regulating" social vices that can not be eradicated
under immediate circumstances, because of mistaken
notions respecting the relation of vice to material
conditions, and the relation of government to social
circumstances. Persons incapable of reflection, be-
cause void of facts or inconsiderate of their signifi-
cance, who feel that their whole duty has been done
toward their fellow men when they have notified them
of their sinfulness, warned them of consequences, and
pointed out a narrow way of escape, saying to them-
selves: "Let them do as bidden, or be damned! If
society suffers let society suffer! or join with us and
make short work of this iniquity." In close practical
alliance with these pious people are the makers and
venders of intoxicants, and all of the vicious classes
of society which blindly antagonize the authority of
State on general principles. Still another class of
citizens, pseudo-philosophic politicians, who main-
tain the rights of individuals as superior to the rights
of society, and resent the interference of government
in matters so personal as eating and drinking, or the
observance of holy days, or any exercise of "paternal-
ism" as a function of State; maintaining the right of
a man to get drunk and suffer the consequences, if he
so elects, oblivious to the fact seemingly that while the
individual alone gets drunk, society is the principal
sufferer of consequences. The affirmation that inebri-
ates belong to a defective class of society, correlatable
with the insane and criminal, may also be challenged.
That they do constitute a defective class so correla-
table may be inferred from the fact that, while the
appetite for brain-stimulants, or sedatives, is common
to mankind, and universally indulged by the use of
some natural or artificial product, alcohol, opium, tea,
coffee, cocoa, kola, tobacco, and others, but a small
proportional number become inebriates, or patholog-
ical habitues of such intoxicants, showing that the
potentiality of inebriety is as definitely referable to
organic peculiarities as is the potentiality of insanity,
about which there is no longer room for disputation.
Were no distinction of this kind to be made, indeed,
were the liability to become insane or inebriate the
same for all persons under the same conditions of
provocation, but few persons instead of the many,
would escape lunacy or inebriety. A few drinks of
whisky may determine the fate of a man of neu-
rotic instability of nerve organization; while many
others, not so constituted, may drink occasionally or
frequently, for years, without danger of becoming
inebriates. That inebriates are correlatable with the
insane constitutionally may be inferred from the
facts that an intemperate use of alcohol is regarded as
an efficient exciting cause of insanity, and inebriety is
recognized as the manifestation of cerebral disease by
which mental capabilities are impaired and disordered
temporarily or permanently. So parallel indeed are
the psychic phenomena of insanity and inebriety
even experts have sometimes to differentiate one from
the other by physical signs and commemorative
circumstances. What are the psychical characteristics
of simple, typical lunacy?
1. Well marked departure from ordinary habits of
thinking and acting on the part of the lunatic.
2. Loss of self-control, partial or entire.
3. Deterioration of moral perceptions, inveracity,
immorality of conduct and depraved appetites.
4. Deterioration of general intellectual capabilities,
disorderly imagination and defective reasoning, stu-
pidity, insensibility, death.
Are these not also characteristics of inebriety?
How close the resemblance of periodic mania and
periodic inebriety, commonly called dipsomania?
Are not the accessions of these two conditions as
irresistible as the explosion of epilepsy, and indica-
tive of correlatable neuroses? Was epilepsy ever
cured by moral suasion ? Did any other than a mer-
cenary quack ever pretend to cure an epileptic by
specific medication, who did not, sooner or later, dis-
cover the error of his pretension?
The affirmations that inebriety is a manifestation of
morbid physical conditions effected by the interaction
of intoxicants with the activities of defective struc-
tures, practicably irremediable by moral or medicinal
treatment, and that the State is justifiable in admin-
istering all needful authority for its suppression, and
the cure of its victims, because of its offensiveness
and their helplessness, being admitted, the only ques-
tion left for discussion is: By what method can the
State accomplish the desired end most effectually and
satisfactorily ?
Of the two methods already alluded to, namely,
putting intoxicants out of reach of inebriates, and its
alternative, putting inebriates out of reach of intoxi-
cants, the latter seems to me much more promising
than the former.
Prohibitory liquor laws have failed of complete
success because they can not be executed with the
hearty good will of the people and are therefore
imperfectly enforced. They are objectionable to
many persons who have no need of protection from
them, because of their own infirmities, for the reason
that they require a large majority of citizens to forego
certain privileges held in high esteem as pertaining to
the rights and dignity of freemen, for the benefit of
the few who have by viciousness or weakness for-
feited such privileges. Furthermore, unless such
laws could be made National, State lines are too thin
to protect the citizens of one State from the liberality
of the laws of adjoining States.
Inhibition of inebriates from intoxicants is less
objectionable and more practicable, because laws pro-
viding for such restriction could be executed with the
full approval of nearly all citizens, as they would
deprive no one of liberty that had not forfeited some
of the privileges of citizenship, or who would not be
personally benefited thereby.
This method of suppressing inebriety, and curing
inebriates, contemplates something more than the
establishment of asylums, or recruiting stations,
where inebriates can recuperate sufficiently to go out
and enjoy another season of debauch ; it contemplates
a colonization, so to speak, by voluntary and involun-
tary settlement, or admission, of all inebriates within
a given district of the State, where not only hospital
accommodations and appliances for the treatment of
the infirm will be provided, but such a variety of
industries, under intelligent supervision, as will
enable all persons so far restored as to be able to work
to not only earn their own living, but accumulate
something to the credit of themselves or dependent
families. It contemplates a more or less protracted
residence in such colonies of persons committed, and
an unremitting supervision of colonists on parole,
authorizing immediate return, for increasingly longer
terms, on violation of conditions constituting the
1896. )
NON-ALCOHOLIC TREATMENT OF DISEASE.
519
basis of privileges granted, so long as the colonist
remains within the jurisdiction of the State:
As neither time nor inclination permits a more
elaborate presentation of such State provision for the
suppression of inebriety, and cure of inebriates, as I
bare mentally evolved from materials of observation,
memory and reflection, I will content myself with the
suggestion that such provision should not be re-
garded as punitive in any sense, but benevolent and
Beneficent in every feature.
It will require, perhaps, more than one "campaign
of education" to interest "statesmen" in such a
scheme, but once tested I have no doubt of its suc-
cess, and that the end will have compensated the
labor.
TWENTY-ONE YEARS' EXPERIENCE IN
THE NON-ALCOHOLIC TREATMENT
OF DISEASE.
Read In the Section on State Medicine, at the Forty-Seventh Annual
K»«tlBg of the American Medical Association at
Atlanta. «a„ May 5-8. 1896.
BY J. H. KELLOGG, M.D.
BATTLE CKKKK, MICH.
( >n becoming connected with the Battle Creek San-
itarium, an institution of which I have had charge for
the last twenty years, and having been connected with
the institution for a year or two previous, I established
a rule that alcohol should not be relied upon as a thera-
peutic agent in the treatment of curable cases; that,
if used at all. it should be only in those cases which
were utterly hopeless, and in which it would conse-
quently be useless to withhold any agent which would
afford even temporary relief to the patient's sufferings.
These cases have been so exceedingly rare that it may
be said that alcohol has been absolutely discarded as
a therapeutic agent under any and all circumstances,
in this institution, although it had been previously
used, sparingly.
The total number of patients treated during this
time, of which careful records have been kept, is
16,869. In addition to this, a considerable number
of cases who have not been inmates of the institution
have been treated by myself and my colleagues in
the city and surrounding country, and in dispensary
practice in connection with our medical mission in
( thicago, of which less complete records have been kept.
The majority of cases treated have been persons
suffering from chronic diseases. As the larger pro-
portion have been sent to the institution by their
attending physicians, it is scarcely necessary to state
that they have been cases of more than ordinary
gravity, requiring advantages which they could not
receive at home.
A city of nearly twenty thousand inhabitants, in
which the sanitarium is located, affords opportunity
for a limited observation of acute disease. In the
twenty-one years I have been connected with the
institution, however, myself and my colleagues have
treated 333 cases of typhoid fever in persons of all ages,
with nine deaths, or a mortality of 2.7 per cent. Within
the same time we treated eighty-two cases of pneu-
monia, with four deaths, or a mortality of 4.9 percent.
When we recall the fact that under the alcohol treat-
ment of pneumonia and typhoid fever, the mortality
rate has been 30 and 20 per cent, respectively, I think
it will be conceded that our patients have in no wise
suffered in consequence of the disuse of this drug.
Alcohol is much less used in the treatment of
chronic maladies at the present time than formerly,
but many physicians still cling to the idea that alco-
hol is a stimulant, a nutrient, or in some way a sup-
porter of vitality, and hence prescribe it in a variety
of morbid conditions which are more or less chronic
in character. I have demonstrated to my satisfaction
the absolute inutility of alcohol for the accomplish-
ment of any useful purpose in the treatment of either
chronic or acute maladies.
One purpose of this paper is to call attention to
other measures which may be used in the place of alco-
hol as a means of meeting the therapeutic indications
which alcohol has been supposed to meet, but which
experiments made by Dr. N. S. Davis long ago, and
in recent years confirmed by numerous investigators,
have shown it to be entirely incapable of meeting.
ALCOHOL AS A CARDIAC STIMULANT.
I have never found alcohol necessary in any case as a
2
M
cardiac stimulant, and all recent physiologic experi-
ments respecting the effect of alcohol upon the heart
go to show that it lessens its force rather than
increases it; or, in other words, is a depressing agent
rather than a tonic or stimulant. The cold shower
bath is one of the most powerful of all means of stim-
ulating cardiac activity. The application of cold water
to the surface of the body produces an immediate
increase in the strength of the pulse. This is very
clearly shown by the sphygmograph, with which I have
made a considerable number of tracings for the pur-
pose of demonstrating the influence of peripheral ap-
plications of cold upon the heart and circulation. The
cold shower bath, however, is by no means applicable
in every case, neither is it always convenient. Cold
may be applied to the skin in many other ways, as by
the cool sponge bath or the short cold full bath; and
the force of the application can be graduated to a nicety
by varying the temperature of the water employed,
520
NON-ALCOHOLIC TREATMENT OF DISEASE.
[September 5,
the length of the application, and the extent of sur-
face to which the application is made.
The application of cold to the surface produces its
effect upon the heart, both through its influence upon
the peripheral blood vessels, and by means of a reflex
action through the afferent vasomotor nerves and the
sympathetic system. The effect of these peripheral
applications upon the heart being almost instanta-
neous, it is very easy to graduate the dose to suit every
possible case in which increased heart vigor is
required.
The accompanying reproduction of sphygmographic
tracings taken by my friend and colleague, Dr. W. H.
Riley, very well show the influence of the peripheral
application of cold as a cardiac tonic.
Alternate hot and cold sponging of the surface, or
hot and cold sponging of the spine, short applications
of dry heat over the heart, are also measures of value
suited to particular cases. One would not apply cold
to the general surface with the skin in a cyanotic con-
dition or wet with perspiration. In such cases,
vigorous hot and cold applications to the spine, hot
fomentations over the heart, or general hot sponging
immediately followed by a brief cold application,
would be more appropriate. Drinking of hot water,
the hot enema, and the alternate hot and cold foot
bath, even the placing of the hands alternately in hot
and cold water, are measures which operate power-
fully in increasing the vigor of the heart. The value
of applications of this sort in reviving the energies of
the flagging heart are more clearly seen in cases of
syncope, threatened death from chloroform, ether,
cocain, opium, and other narcotic drugs, including
alcohol.
I shall never forget the impression made upon my
mind by a case of opium poisoning to which I was
called some twenty years ago. Half a dozen physi-
cians who were in the room had been applying various
remedies, all without avail. I was sent for to bring
galvanic and faradic batteries. I found the patient
with respiration four a minute, pulse rate twenty, but
very irregular. The breathing was labored. The
patient had doubtless been unconscious for eight or ten
hours. The electric applications slightly improved
the pulse and respiration for a short time, but the
patient quickly relapsed, and I then resorted to hot and
cold applications, applying fomentations the whole
length of the spine for one minute, then removing
the hot cloths and rubbing the bare skin from occi-
put to sacrum with ice for ten or fifteen seconds,
then reapplying the fomentations. In less than three
minutes a change in the patient was noticeable. Per-
spiration appeared, respiration was increased to six-
teen per minute, pulse rate to fifty, the patient moved
about in bed, and even uttered a few words, to the
astonishment of every person in the room. Although
in this case the patient ultimately died, the wonder-
fully stimulating effect of the revulsive applications
to the spine in arousing the activity of the cardiac
and respiratory centers was apparent to all present.
I believe I have saved the lives of a number of per-
sons under similar circumstances, by the use of this
simple but wonderfully powerful measure.
The most powerful of all means of stimulating the
heart is the alternate hot and cold spray or shower
bath, applied to the whole surface of the body. In
cases of chronic cardiac weakness, applications of this
sort must be used with care. In some cases only the
gentlest hydrotherapeutic measures should be em-
ployed; centripetal friction and carefully graduated
joint movements should be depended upon as the
most efficient means of gradually developing cardiac
vigor.
I have, by the careful use of massage and the
Swedish movements, frequently succeeded in bring-
ing a patient suffering from cardiac insufficiency,
from what seemed to be the very brink of the grave,
to a condition of comparative health and vigor.
ALCOHOL AS A STOMACH TONIC.
In cases of chronic dyspepsia, the use of alcohol
seems to be particularly deleterious, although not in-
frequently prescribed, if not in the form of alcohol or
ordinary alcoholic liquors, in the form of some so-called
"bitter," "elixir" or "cordial." Nothing could be far-
ther removed from the truth than the popular notion
that alcohol, at least in the form of certain wines, is
helpful to digestion. Roberts showed, years ago, that
alcohol, even in small doses, diminishes the activity
of the stomach in the digestion of proteids. Glu-
zinski1 showed, ten years ago, that alcohol causes an
arrest in the secretion of pepsin, and also of its action
upon food. Wolff2 showed that the habitual use of
alcohol produces disorder of the stomach to such a
degree as to render it incapable of responding to the
normal excitation of the food. Hugounencq3 found
that all wines, without exception, prevent the action
of pepsin upon proteids. The most harmful are those
which contain large quantities of alcohol, cream of
tartar, or coloring matter. Wines often contain col-
oring matters which at once completely arrest diges-
tion, such as methylin blue and fuchsin.
A few years ago I made a series of experiments in
which I administered alcohol in various forms with a
test meal, noting the effect upon the stomach fluid as
determined by the accurate chemic examination of
the method of Hayem and Winter. The result of
these experiments I reported at the 1893 meeting of
the American Medical Temperance Association. The
subject of experiment was a healthy young man whose
stomach was doing a slight excess of work, the
amount of combined chlorin being nearly 50 per cent,
above normal, although the amount of free hydrochloric
acid was normal in quantity. Four ounces of claret with
the ordinary test meal reduced the free hydrochloric
acid from 28 milligrams per 100 c.c. of stomach fluid
to zero, and the combined chlorin from .270 to .125.
In the same case the administration of two ounces of
brandy with the ordinary test meal reduced the com-
bined chlorin to .035, scarcely more than one-eighth
of the original amount, the free hydrochloric acid
remaining at zero. Thus it appears that four ounces
of claret produced marked hypopepsia in a case of
moderate hyperpepsia, whereas two ounces of brandy
produced practically apepsia.
There would seem to be no further proof needed
that alcohol is of no use in the treatment of disorders
of digestion. Indeed, Dr. Roberts asserts that alcohol
is useful only as a means of hindering digestion, which
he considers a very important function in it, owing to
the tendency of excessive alimentation, especially in
the excessive use of meats. Dr. Roberts' recommen-
dation is perfectly consistent with the results of this-
investigation, so far as the effects of alcohol are con-
cerned, although it would seem to be more sensible to
suppress the excess of nitrogenous foods, or the total
1 Arch. f. Klin. Med.. 1886.
2 Zeitschrlft f. Cliu. Med., 1889.
3 Lyon Med., 1891.
1896.]
ALCOHOL IN THERAPEUTICS.
521
amount of food taken, rather than to indulge in the
use of a drug to act as a disturbance and hindrance to
the digestive process. The disorders of digestion are
easily managed by the rational employment of diet-
etics in connection with a careful investigation of the
stomach fluid by the exact chemic and baeteriologie
lothods with which we arc now acquainted.
Roberts has also shown, and the writer's experi-
uents verify his conclusions, that wines, beers and
imilar liquors, in even comparatively small doses,
event the salivary digestion of starch in the stomach.
Thus it appears that stomach digestion is altogether
iterfered with, and inhibited by alcohol in any
inn.
LLOOHOL AS A TONIC OR STIMULANT.
Nothing could bo more absurd than the use of alco-
10I or alcoholic preparations in the production of
-called tonic effects. Far from being a tonic, alco-
10I is not even a stimulant. Recent investigations
iow clearly that the drug is a narcotic and a seda-
tive rather than a stimulant. In a paper presented
tiore the American Medical Temperance Associa-
ion three years ago. 1 gave the results of psychologic
sts made upon a number of persons before and after
iking alcohol, by which I showed that the reaction
>r the tactile and the temperature sense were both
liminishetl more than 100 per cent., while the muscu-
strength was diminished more than BO per cent,
lleohol benumbs nerve structures of every sort, and
ps not in the slightest degree increase either mental
nerve activity. Nothing could be more absurd
urn the common prescription of alcohol or of such
dxtures as Vin Mariana, when tonic effects are
sired. These drugs are simply nerve foolers. They
mi nerve sensibility and thereby diminish the
ise of fatigue, exhaustion, weakness, or whatever
liscomfort may exist.
ALCOHOL AS A NUTRIENT.
It has long been known that the use of alcohol
diminishes the elimination of proteid substances in
the excretions. This was thought to be an evidence
that, if it were not an actual food, it was at least a
means whereby tissue degeneration might be lessened
and thereby the bodily waste diminished. Careful
investigation of this matter shows, however, that alco-
hol does not actually diminish the amount of the pro-
ducts of tissue activity, but that it prevents their
elimination, so that they remain in the tissues.
It is only recently, since the subject of leucomains,
ptomains, and toxins has come to be appreciated
from a practical standpoint, that the full significance
of the diminution of tissue waste under the influence
of alcohol could be understood. Instead of being an
evidence of tissue preservation, this lessening of the
elimination of tissue waste is simply an evidence of
the accumulation of waste and poisonous substances
within the body, through the lessened efficiency of
the liver and the kidneys.
In an experiment made a year or two ago, I found the
coefficient of urinary toxicity to be diminished 50 per
cent, in the case of a vigorous young man, by the
injection of two ounces of brandy. As I argued in a
paper presented at the last meeting of the American
Medical Temperance Association, this fact is one of
profound significance in relation to the use of alcohol
in such infectious maladies as typhoid fever, diph-
theria, pneumonia, and similar disorders. In these
diseases the system is struggling under the influence
of poisons, which the liver endeavors to destroy and
the kidneys to eliminate. By lessening the efficiency
of the kidneys as eliminating organs, and the liver as a
disinfecting organ, it is evident that the risk of death
must be considerably increased; hence the use of
alcohol in cases of this sort must be condemned.
When we remember that in the majority of chronic
cases, as well as most acute maladies, the system is
suffering from more or less pronounced toxemia,
through the failure of the liver, kidneys, lungs, skin,
and other eliminative organs to do their full duty, it
becomes apparent that the use of alcohol must be not
only detrimental, but in many cases even absolutely
dangerous.
The patient suffering from dilatation of the stom-
ach is continually in a state of toxemia, through the
development of ptomains, as the result of too long
retention of food substances in the stomach, and the
consequent action of germs of various sorts upon the
food elements. As a rule, a patient suffering from
an acute disease requires simply good nursing and such
treatment as will aid nature in the elimination of
poisons to which the most active symptoms are due.
In the treatment of chronic disease, the patient
requires not only increased elimination of poisons,
but the adoption of such measures as will suppress
the development of these poisons, such as careful reg-
ulation of dietary, and maintenance of an aseptic or
germ-free condition of the stomach. The system of
the invalid needs to be generally reconstructed. This
requires tissue renovation and regeneration. The use
of alcohol in such cases, then, must be evil, and only
evil.
I should not omit to mention the Turkish bath and
similar therapeutic means, as one of the most effec-
tual means of accomplishing the tissue reconstruction
necessary for the cure of various chronic disorders,
and particularly that class in which alcohol is so freely
prescribed, and most of all in cases of alcohol addic-
tion, in its various forms.
SOME NOTES ON ALCOHOL IN
THERAPEUTICS.
Read in the Section on State Medicine, at the Forty -seventh Annual
Meeting of the American Medical Association, held at
Atlanta, Ga., May 5-8, 1896.
BY T. D. CROTHERS, M.D.
SUPERINTENDENT WALNUT LODGE HOSPITAL, ETC., ETC.
HARTFORD, CONN.
Some very strange conceptions of alcohol as a med-
icine exist, and are repeated in really excellent text-
books of medicine. Evidently they are the repetitions
of assertions of authors which have been accepted
without question.
One of these precepts is to increase the amount of
spirits if the smaller doses do not seem to have the
effect desired.
In a given case one ounce of brandy every four
hours is increased to the same amount every two
hours. Spirits are said to be indicated and the dose
and frequency is the measure of its power.
Recent text-books urge that spirits be given freely
in certain cases and prescriptions containing large
quantities of spirits are presented as guides. In some
cases cautions concerning the dose and its frequency
are given, but the fact is assumed that large doses
have certain definite effects that can be studied and
understood. These counsels are not in accord with
the observed facts, and in some cases diametrically
522
ALCOHOL IN THERAPEUTICS.
[September 5,
opposite. Thus the effects of eight ounces of spirits
a day is not double that of four ounces. Where spirits
are taken as a beverage the man who drinks a pint of
any kind of spirits does not manifest symptoms of
double the intensity to one who uses half a pint.
Observation seems to be conclusive that a point of
toleration is reached beyond which there is no appre-
ciable effects from spirits. In a case of diphtheria an
ounce of spirits was given every two hours; this was
increased to every hour without showing any altera-
tion in the heart's action except a temporary flutter-
ing. The skin seemed to be intensely stimulated and
was bathed in perspiration and 'the kidneys were
active, the exhalations from the lungs were increased,
collapse and death followed, and the physician was
sure that the poison of diphtheria had overwhelmed
the nervous centers causing death. The spirits taken
for two days before the end had not been absorbed
but had gone on saturating the tissues and forming
ptomains which were literally poison centers of
greater magnitude than the diphtheria germs.
In a case of pneumonia the consulting physician
urged spirits ad libitum as much as could be swal-
lowed, for the reason that if the heart's action could
be sustained he would recover. Of course the patient
died. A quart of brandy was given daily. The skin,
lungs and kidneys made a great effort to eliminate the
poison of alcohol, but failed.
The real facts were, the process of inflammation
which would have been self-limited, was supplanted
by paralysis and the presence of a new source of poi-
soning of greater magnitude than the primary disease.
Beyond a certain point not clearly recognized ala-
coholic saturation begins and the effects of spirits
after this time is not apparent except in general pro-
gressive depression and enfeeblement. At times this
point of saturation is manifest in vomiting with
excessive stomach and brain irritation. This may go
on to what is termed delirium tremens and various
manias, marked by cell and nerve exhaustion, with
explosions of nerve force.
There can be no doubt of the cumulative action of
alcohol in health, even when used in small doses and
for long intervals. In disease of any form there are
no reasons for believing that this effect is prevented
or neutralized. The assumption that the anesthetic
action of alcohol increases in proportion to the size
and frequency of the dose or that any action it may
have on the organism likewise increases, beyond a
certain point, lacks clinical proof. In my opinion
alcohol and its ptomains accumulate in the tissues,
and are gradually eliminated beyond the danger point
by purely natural processes. This process of elimin-
ation has a limit, which varies widely in different per-
sons and is unknown. In disease it is feebler and is
reached sooner than in health. The supposed tonic ef-
fect of alcohol is no doubt a poison of extreme fatality
after a certain period. The point of saturation is
reached in which the direct irritant and paralyzing
action of alcohol, has reached an extreme limit. Be-
yond this spirits become a pure chemic poison. The
center of new combinations of foreign products, that
are not eliminated, but held in obeyance, until some
unknown condition expells them, or draws them into
the circulation. The clinic experience of the sudden
death of persons who are using as a beverage or taking
as a medicine large quanties of spirits seem to confirm
this view of the sudden absorption of alcoholic pro-
ducts beyond the power of resistance.
A strong man suffering from acute pneumonia had
been taking over a pint of brandy daily for eight days.
He was given a warm bath and an enema to clear out
his bowels. An hour after he died suddenly. In my
opinion the bath and enema had roused the absorb-
ent to activity, and the accumulated alcoholic poisons
had been absorbed to fatality. Before this the general
palsy of the tissues had prevented the absorption of
the poisons. Had all the alcohol been withdrawn and
the process of eliminating been slowly stimulated this
result would have been averted.
In the cases under my care alcoholic paralysis is
treated with hot showers and hot air baths accom-
panied with saline drinks. In most cases this is fol-
lowed by sharp reaction; a few hours after generally
stupor and prolonged semi-partial coma. This I
assume to be the absorption of the alcoholic products
which have been accumulating in the past. The rem-
edy for which is increased hot showers and hot air
baths. This reaction is in some cases sudden delir-
ium and hallucinations or strange morbid impulses.
The alcoholic ether odors continue for days after the
spirits are withdrawn, which seems additional evidence
of this condition. I think the process of gradual
reduction of alcohol either in medicine or the treat-
ment of inebriates in direct opposition to experience
and rational theory.
On whatever theory spirits may be given as a med-
icine, to gradually diminish the size of the dose and
increase the interval of time of giving it. is without
reason or judgment. Whatever special effect of alco-
hol may be desired, the attempt to reduce this down
to a minimum in decreasing doses, is purely fictitious.
In a case of typhoid fever where large quantities of
spirits had been given and recovery began, great stress
was insisted to discontinue the spirits in decreas-
ing doses. Death followed and no intestinal lesion
could be found, hence the diagnosis heart failure. In
my opinion it was alcoholic poison, with sudden
absorption of accumulated products directly due to
spirits. Some of the facts I wish to emphasize are
first, anesthesia of spirits has a limit, beyond this
there is saturation and accumulation of unknown
chemic poisons, of great fatality. The toleration and
fatality of excessive doses of alcohol in both health and
disease, point to some unknown conserving force
and capacity of elimination of great power. The sud-
den deaths which follow in these cases are additional
evidence. The practical fact confirmed in many ways
is that whatever the physiologic action of spirits may
be, its action is limited, and does not increase beyond
a certain point, that the effects on the body are
cumulative, principally chemic products that are not
readily eliminated.
These and other effects from alcohol seem to
check elimination beyond a certain point, and become
very dangerous. The exhaling of alcoholic ethers from
the lungs is significant of saturation and crossing the
danger line that should be heeded. In my opinion
there is no remedy known of such uncertainty, and
physiologic danger as alcohol. The need to-day is a
new critical analytic study of the entire subject of
alcohol in therapeutics.
Enormous Sac of Pus in Abdomen.— Eleven liters of thick, green,
sterile pus were removed from an enclosed sac in the abdomen
of a young female by Maydl of Prague, in which the uterus and
annexes had been floating. Complete afebrile recovery. — II 7cm.
Klin. Riaidscli. August 2.
ij
TEACHING TEMPERANCE IN PUBLIC SCHOOLS.
523
TK ACHING TEMPERANCE IN PUBLIC
SCHOOLS.
Rem! in the Section on State Medicine, at the Forty-seventh Annual
Meeting Of the American Medical Association, at Atlanta,
Ga.. May 5-8. 18%.
BY CHAS. H. SHEPARD, M.D.
BROOKLYN, N. T.
That tin- temperance problem is fraught with immi-
nent oonsequences both to the present and future
generations, none can deny. The educational method
of dealing with the subject commands itself to all,
for if it is studied from a purely scientific standpoint,
then whatever advance is made will be permanent,
and leave no room for an emotional reaction.
The use of narcotics lias become such an over-
shadowing calamity that it behooves all to make dili-
gent inquiry if perchance there may be some way of
escape for our people. Not those who give way to
such indulgences are to become the permanent inhab-
itants of our land, for such conditions do but bring
about an inferiority and degeneration that eventually
and surely leads to extinction. We also well know
that by studying and obeying the laws of life and
health, the term is lengthened and its enjoyment
enhanced.
This is a subject that comes home to every man of
family. All right-minded parents desire to give their
children the best opportunities for the struggle of life,
and even the most besotted are frequently known to
make a great effort to have their children shielded
from the effects of their misdoing. It is rarely that
a father who uses tobacco desires his son to do the
same. The young man who is to join in the struggle
of a boat race, or foot-ball game, knows that it is
incumlxmt on him to conserve all his powers and not
waste them on tobacco or alcohol, and he willingly
denies himself to any extent for that purpose while in
training, but when it concerns the race of his life, he
too often becomes prodigal of his vital energies and
makes fearful havoc of what he would give thousands
to l»e possessed of in later years, simply because he is
not conscious of the injury he is doing to himself.
For this reason it is that the school years are the
most important season of the child's life, the forma-
tive period, and if at that time basic truths can be
inculcated, he will be more likely to avoid many
errors and grow up to a more vigorous and useful
manhood.
We know that every great emergency brings a man
to fill the gap. In this case it was a woman, Mrs.
Mary B. Hunt, who has made it her life work to for-
ward this object, traveling over a large part of the
United States in its advocacy. Associated with her
as an advisory board, are some of the noblest and
ablest minds in the land. Through her persevering
and unselfish efforts, all but five of the States in the
Union have enacted laws requiring scientific temper-
ance to be taught all the pupils in their public schools.
Canada has also listened to her voice, and enacted
similar laws, and her influence has extended to several
of the European governments, notably France, Eng-
land and Russia.
The saloon element in the cities of New York and
Brooklyn is so dominating that it was not strange
that a strong opposition was developed, and in some
of the daily papers, ridicule was thrown upon the
work. But no sane man will maintain that there is
anything preposterous about the study of physiology.
On the contrary, after mastering the "three Rs"
there is no more important study in the curriculum,
and the reporters who attempted to ridicule this study
were never more mistaken, for it is a well-meant and
well-digested plan, and has the sanction and support
of some of the best and most self-sacrificing people
in the land. It is as surely bound to succeed as the
right is to come uppermost in the not very remote
future. It is undoubtedly true that the temperance
movement is to be promoted more thoroughly and
rapidly by an educational course than in a prohibitive
way, and it will be like "kicking against the pricks"
to oppose the instruction of our children in the action
of alcohol and other narcotics.
If a child can be made to understand that the pur-
pose of the stomach is the digestion of his food, and
that by its thorough digestion, impeded by no irri-
tating or debilitating element, the vigor of the system
can only be maintained, and if it is shown that the
use of alcohol impairs all the functions of the stomach
and predisposes to disease, he will as much hesitate to
use stimulants as he would to use arsenic or any other
poison.
Let any unprejudiced man who loves his race
observe what a vast amount of effort is given to the
production and use of alcoholic drinks; how it per-
meates every class of society. So, also, the use of
tobacco and other narcotics. Are we, as a people or
nation, benefited by them, or are they a hindrance to
our progress and development? The frequent death
of a victim of the cigarette habit would argue that
our children could easily find a more profitable field
of effort. Many of the parents may be astonished
when the children come home from school and tell
what they have learned about the effects of the mod-
erate use of alcohol and tobacco, but if it be true, we
have not found it out any too soon. The books that
have been compiled for use in the schools have had
the revision of some of the ablest physicians in our
land, and they will stand the test of scientific exam-
ination. Dr. Crothers, the eminent specialist in ine-
briety, says, " I have spent some time on the school
books mentioned, and I have not found errors or
extravagant statements."
If the facts contained in these books are not adapted
to the comprehension of the children who are taught,
it shows that the teacher - has mistaken his calling.
The question of the use of alcohol and other narcotics
is one that is sure to come up for discussion more and
more, and will never be quieted until it is settled
rightly. If it is well for physicians to prescribe nar-
cotics, then should the manufacture and sale be
encouraged in every legitimate way. On the contrary,
if their use is evil, and evil only, as some scientists
claim, then all should know it, that they may avoid
the pitfalls, and in no more holy ground can this
knowledge be placed than in the minds of our children.
It would not be possible for the race to continue
many generations longer in the free and increasing
use of narcotics, for it would produce degeneration
and wide-spread disaster. The light of science, which
is simply increasing knowledge, will dissipate the
clouds that now hang over us, and usher in the new
era to a regenerated mankind. For these and many
other reasons, we are satisfied that the law directing
this study by the school children is a most laudable
one, and should be encouraged by every right-minded
person. It can be opposed only by the saloon ele-
ment, and its strongest supporter, the moderate
drinker, who can not too soon become aware of the
524
DISCUSSION.
[September 5,
error of his ways. He needs education, not prohibi-
tion. If he is past learning anything new, his chil-
dren are not.
The impressions made in our childhood being the
more permanent, lead up to the fact that if our chil-
dren can be taught the truths about alcohol and other
narcotics, the time will eventually and surely come
when their daily use will be abandoned.
DISCUSSION ON PAPERS OF DRS. EVERTS, KELLOGG, CROTHERS
AND SHEPARD.
Dr. Grosvenor — If alcohol is not a stimulant, then why do
we observe the flushed face, the increased intellectual activity,
the elevation of temperature, the increased muscular power
and the general feeling of well-being which persons, especially
the weak and feeble, experience while under the influence of
alcohol?
Dr. Kellogg— Alcohol may be very aptly termed a " nerve-
fooler." Its effects are in a high degree deceptive. It makes
a man who is cold feel warm, while the thermometer shows
that his temperature is actually lower under the influence of the
drug ; it makes the weary man feel rested, and the weak man
strong, whereas the muscular strength is actually less under
the influence of the drug than before.
In experiments which I reported at a meeting of the Ameri-
can Medical Temperance Association held in Milwaukee two
years ago, I showed that the man whose total strength as reg-
istered by the dynamometer while in his normal condition was
4,800 pounds, fell to 3,300 pounds under the influence of two
ounces of whisky ; the depreciation of nearly 30 per cent,
makes a man imagine that he is stronger than ever before.
Careful psychologic tests which I have made with various
instruments of adaptability to the purpose, demonstrate how
the tactile, the temperature sense, the sense of weight, etc.,
are all diminished from 30 to 50 per cent, under the influence
of alcohol. A man is more talkative than when in his normal
condition, but he uses less discretion in the selection of words.
There is an evident lack of intellectual |balance.
Under the influence of alcohol the face is flushed, because of
the paralyzing and depressing influence upon the vasomotor
sense, causing the laceration of the small blood vessels. Prof.
Ayres' remarks, that if this were not proven, the surface should
be red with blood after death instead of pale, is most [absurd,
for the reason that every physiologist knows that in death the
heart ceases its action before that of the vessel, so that the
blood is impelled on into the veins, and the arterial [system is
completely emptied. This surface cyanosis does not appear
until the blood has passed on into the larger veins.
Professor Bunge and most of the authorities pronounce
alcohol to be a depressor. Professor Reichert's experiments
upon a frog's heart show alcohol to be a depressor. This ques-
tion is scarcely at all discussed among physiologists, for the
reason that recent experiments have been conclusive in estab-
lishing the fact that alcohol is a depressing agent, and in no
sense a stimulant. It is true, that when first introduced into
the body, whether by the stomach or hypodermically, alcohol
seems to act as a stimulant. This is due to its irritant effect
upon the nerves, whereby a reflex stimulating influence is pro-
duced, the same as would be produced by a plaster, a caustic,
a hot iron, or any other irritating agent; but as soon as the
drug enters the circulation and comes in contact with the
nerve centers, its true physiologic effects appear, and there can
be no question that these effects are those of a depressing
agent, and not those of a stimulant.
Dr. Grosvenor— I have observed the different classes of
drinkers, and I have noted the character of the drink which
they take and I have never been able to tell by the coloring of
the countenance of the drinking man whether he was a beer
drinker or a strong drinker.
Dr. Kellogg — I think the temper has very much to do with
this. Beer drinkers are thick skinned. So are certain classes
of people that are pale while embarrassed, while there are
classes who are flushed while embarrassed. There are some
who turn pale while still flushing. I am told that is one rea-
son why beer drinkers are more likely to be florid than pale,
because the attack is upon the nerve centers, while in the strong
drinker there is a reflex action so that the vessels are con-
tracted.
The Chairman — I merely wish to add the evidence of what
little experiment I have made. I have found that the white
corpuscles in some were vastly increased by the use of alcohol.
If you put them under the microscope you will find that the
red have been supplanted by the white, which was due to the
toxin poison, which accounts for the difference in the pale and
florid faces.
Dr. Kellogg — Speaking on this subject, I have been disap-
pointed in the results of experiments, more than of the blood
in strong drinkers. I have been connected with a missionary
movement in Chicago, in which we had 450. We have a little
church in the center of the city, and use it for a lodging house,
and to catch drunkards in. Most of the men who come there
are drinking men. We have a penny lunch counter, free baths
and a laundry, and I made last year a careful study of 100
drunkards, 100 hard cases. I am very sorry to be obliged to
report the fact that I found very little difference between their
blood and the blood of normal character. There was some
tendency, of course, to white blood corpuscles, but that was in
cases of persons addicted to drinking beer, in which cases the
blood is somewhat diluted. I think, too, there must be some
other change in the blood than the change of corpuscles. We
had no doubts, however, of the red corpuscles. But upon cor-
puscles of this kind we had small proofs, for the blood has
peculiar resisting power against alcohol. Being sent directly
into the blood, if not for the great resisting power we would
be able to see an ill result at any time. And proba-
bly alcohol taken into the stomach is simply absorbed. The
blood is itself stored up in the liver and passes out into the intes-
tines and is absorbed and goes through the kidneys.
Dr. Garber I object very much to the use, in Dr. Crothers'
paper, of the word stimulant. The author states that in a
case of diphtheria it was given freely, and as a result the child
urinated more freely and averted trouble. I claim this action
of the alcohol was not one of stimulation but one of paralysis.
It so paralyzes the nerve centers that the vessels become
dilated, if it is the increase of urination.
Dr. Crothers (Hartford, Conn.) In Prussia, Austria and
in Germany, provisions have been made for drinking people
the same as for the insane and the time is very near when we
shall in this country be obliged in self defense to take care of
those unfortunates and put them in asylums. This is a ques-
tion we can discuss more thoroughly than the question of res-
piration, for on the question of respiration we shall differ and
put into it our personal experiences : but when we come to
great subjects like the care of these unfortunates we can but
agree. This is a subject that will be pressed and carried home.
What to do with these people who are near to each home
circle is a subject upon which too much stress can not
be laid. I think Dr. Everts will find long before his work is
accomplished that he has undertaken a great work.
Dr. Quimby— As long as the State institutions, the saloons
are State institutions so to speak, if the State cultivates the
people in habits of inebriety and establishes schools of drunk-
enness, which the saloons are, tempting the weak, the young
and the foolish into habits of inebriety by her license system,
just how long shall it continue to debauch a large percentage
of them. If the State is particeps criminis through the laws
established by it, she ought to take care of her feeble alcoholic
patients. They are all feeble if they drink to excess, and if a
man drinks at all he drinks to excess. He has defective quali-
ties and should be taken care of. The law has made him drink
or assisted in making him become an inebriate.
Dr. Kellogg— Regarding the paper on the non-alcoholic
treatment of diseases, I want to say that the proposition of the
paper was to show that there are sufficient means for accom-
plishing what alcohol is supposed to accomplish. In a great
im\ ]
AN APPEAL TO THE PROFESSION.
525
many thousand cases it has been found entirely successful to
treat thi'in without using alcohol.
Thk Chairman 1 can add to Dr. Kellogg's statement, that
for twenty live years 1 have practiced on the non-alcoholic plan
and 1 have been more than gratified with my success, even in
the hospital.
Dk. Work 1 have not used it for the last ten years except
in the preparation of medicine, but not in the way of brandy or
whisky or anything of the kind then. I have not prescribed
whisky or beer or anything of the kind.
Dr. ( ! kRBi R 1 once treated a case of rattlesnake bite with-
out the use of whisky. I was called two miles in the country to
see a laity who had been bitten by a rattlesnake. They had sent
for whisky, hut by the time the whisky came it was impossible
for her to retain anything on the stomach, not even the whisky.
It was about two hours after the bite, they told me, when I
was called in. I used mix vomica and a ligation and cleansed
the wound and extracted the blood. 1 injected a solution
into the region of the wound and left the ligature on six hours.
In ten days she was out of danger and is living today. Not
one drop of alcohol was used in that case. I would treat a cop-
perhead bite just as a rattlesnake bite. I learned at school that
alcohol was good for most everything. We are taught that in
the books, and one of our authors has made a great speech
during this session in which he says that 70 per cent, of the
cases of typhoid fever will get well without any medicine if
treated with alcohol. 1 failed to see the use of alcohol in those
cases. Until our professors teach differently in the class rooms
and the authors teach differentlyin their works, it is going to
be a hard matter to institute a reform.
TBS Chairman I had one case come under my observa-
tion in the New York hospital, of a man bitten by a species of
snake. I think the cobra. He was treated in the most scientific
manner and was kept constantly filled with alcohol. They con-
tinued that forty-eight hours, when the man died. It has
always been a question in my mind as to whether the man died
rom the snake bite or from alcohol.
AN APPEAL TO THE FELLOWS OF THE
AMERICAN MEDICAL ASSOCIATION IN
BEHALF OF DISABLED PHYSICIANS
AND WIDOWS AND ORPHANS OF
PHYSICIANS, MEMBERS OF
THE ASSOCIATION.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, held at
Atlanta. Ga., Mav 5-8. 1896.
BY FREDERICK- HORNER, M.D.
P. A. SURGEON (RETIRED), U.S. NAVY.
The total number of the fellows of the American
Medical Association in 1884 according to the Jour-
nal, was 4,108. In 1890 the number was 3,779, and
in 1894 it was 4,095. From the three groups of fig-
ures given embracing a period of ten years, we learn
that the growth of this representative body of the
American medical profession has been almost at a
standstill, though the number of physicians in the
United States is about seventy thousand. According
to the figures above presented there was a decrease of
the Association's membership of 329, due perhaps,
in part, that during this period have been created the
Gynecological and Surgical, the Military Surgeons,
and the American Public Health Associations, all of
which, like the British Medical Association, with its
sixty-one branches in England, Scotland, Ireland and
abroad are offshoots or branches of the parent asso-
ciation. And yet, such a statement does not allow us
to reach the true explanation (as we believe) why the
American Medical Association has not a larger
membership, now that the organization is so complete
with its eleven Sections of Practical Medicine, Ob-
stetrics and Diseases of Women, Surgery and Anat-
omy, State Medicine, Ophthalmology, Diseases of
Children, Dental and Oral Surgery, Medical Juris-
prudence and Neurology, Dermatology and Syphilis,
Laryngology and Otology, and Materia Medica, Phar-
macy and Chemistry, and a journal which is the
organ now of the medical profession of the United
States. If membership with the Association has
attained only a minimum number and the majority of
physicians have raised .the question as to the "cm"
bono" to them individually and to their families, is
not the conclusion logical that if membership only
involves them in expense during their absence from
their spheres of practice, and to some may be an occa-
sion of temptation, a large number of this class
decline to enter the Association. Now, our medical
brethren in England have wisely incorporated in their
organization a section of benevolence, as long ago as
1835-36, a period even prior to the birth of our Asso-
ciation, the members of which have raised thousands
of pounds sterling, designated as the British Medical
Benevolent Fund. The British Medical Association
has since trebled its membership and now has sixteen
thousand members; wherefore should not the Ameri-
can Medical Association have its 'American Med-
ical Benevolent Fund?" Clericals and laymen have
theirs, the widows and orphans of deceased clergymen
of the Protestant Episcopal Church have had in all
a fund of $81,000 for their relief. The operative
classes, railroad men, commercial travelers, brewers
and distillers, apart from the benefit some may derive
from insurance companies, have their own mutual
assessment fund; why may not the fellows of the
American Medical Association? Bishop O. W.
Whitaker, in his address at a late meeting of the
Mutual Aid Society of Philadelphia said: "A pro-
fessional man is taught to look after the interests of
others before he looks to his own; that is the profes-
sional idea and the medical profession has lived up to
that idea from the very beginning. As the captain
of a ship looks to the safety of his passengers before
his own, as the captain of a company of soldiers is
willing to die for his country, as the engineer on the
engine faces death to save those in his charge, so the
true physician is at all times willing to sacrifice him-
self. A medical aid society has claims for support on
the whole community and these claims should be rec-
ognized. Finally this recognition of the claims of the
widowed and orphaned comes from the Son of God, who
by a miracle raised from the dead the widow's son, and
commended His own widowed mother to the care of
the beloved disciple. Throughout heathendom there
is no such sentiment. Jesus Christ taught the world
the worth of a child as a child, of a man 'as a man,
and of a woman as a woman. Outside of Christen-
dom, there is no such recognition." In the scriptures
as in the records of mankind, are mentioned the
wrongs done to the widow and fatherless, evils that
we by timely help may contribute to avert. If we
fail in such duty, recognized now as a matter of priv-
ilege by all classes, the social, industrial and pro-
fessional, there is One who will not. God, with the
force of a commandment in His word says: Leave
your fatherless children unto me, and let your widows
put their trust in me and in the sweet strains of ten-
derest melody, comes the assurance "He relieveth the
fatherless and widow," but, as Christian physicians
let no one fail to remember vital union with the Be-
stower of life in time and eternity demands of us to re-
cognize as the instruments to provide for the needy ,viz.,
disabled physicians and the widows and the orphans of
physicians. The writer could cite any number of exam-
ples of worthy physicians who stood bravely at the post
526
AN APPEAL TO THE PROFESSION.
[September 5,
of duty and died, as some did, at Norfolk, Va., in 1855,
when the plague of yellow fever decimated the popu-
lation there, and at the Norfolk Navy Yard and Ports-
mouth. How common the record is for some faithful
physician to be killed by accident — a fall from his
buggy, run over by the cars, or as in country practice,
drowned in the vain effort to cross a swollen stream
and thus injured or perishing leaves a helpless family,
if not otherwise destitute, with no accident or life
insurance policy, and no stipend contributed by a
medical aid society, save in one or two States as in
Massachusetts, New York and Pennsylvania, though
they may be Fellows of the State and American
Medical Associations, and physicians of high social
and professional rank leaving behind the memories
of spotless lives and
"Footprints, that perhaps another
Sailing o'er life's solemn main
A forlorn and shipwrecked brother
Seeing, shall take heart again."
Dr. H. Tuck, Treasurer of the New York Society
for the Relief of Widows and Orphans of Medical
Men is correct in the opinion that every medical
society in the union should have its medical benevo-
lent fund, as well as our National Association, with a
united purpose to carry on a systematic method of
benevolence annually, however small the stock in
hand may be at first. As an example of success may
be cited the work of the Royal Infirmary of Edin-
burgh, Scotland, which shows from the last report that
even shilling contributions were accepted among the
larger benefactions of the rich, making a total of
£4,228, to which were added other sums from public
works and establishments, churches, donations, lega-
cies from the counties and cities of Scotland, England,
Wales, Ireland and abroad, summing up £9,388,
details gleaned to prove how the laity and unprofes-
sional do not fail to make annually a generous and
munificent provision for the needy, it may be the
insane, and the inebriate. The founders of the Massa-
chusetts Medical Benevolent Society in 1857 can not
be too much commended in the declaration that they
endeavor to help worthy members of the profession,
reduced in circumstances and also their families,
should they need assistance and of such other medical
members of the society and profession or their fami-
lies as may be deemed by the society suitable objects
of its beneficence, a broad platform on which to do
good and worthy of adoption by the Fellows of the
American Medical Association. But the absolute
proof of the trial of an experiment to raise money as
a fund for so good a cause, is furnished to the physi-
cians of America by our medical brethren of England
as presented by the late annual report of the British
Medical Benevolent Fund for 1894-95. The most em-
inent, noble and titled physicians of Great Britain con-
stitute the officers in charge of this fund: Sir James
Paget, Bart., F.R.S., president; Sir William Jenner,
Bart., F.R.C.P., Sir Richard Quain, Bart., vice-presi-
dents; trustees, Sir H. Acland, Sir James Paget and
Sir Edward Sieveking, Barts. ; treasurer. Sir William
Broadbent, Bart., M.D., 1884. Bankers, Bank of
England.
Honorary local secretaries number seventy-nine,
and are located in all the principal cities, towns and
counties of England and Scotland and border counties.
This fund the report states is "for the relief of
medical men in temporary difficulty or distress and
for their widows and orphans, and also, for granting
annuities to those who are quite incapable of provid-
ing for themselves after sixty years of age. This
fund has been in the form of annuities to the aged
and of grants of money to urgent cases which required
immediate help; such recipients must be members of
the medical profession, or their widows and daughters
and not less than 60 years of age. The annuities are
£20 each, but may be increased to £26 a year, i.e., ten
shillings a week; the annuities are paid from the
annual income of invested property. Of late years
such have been greatly increased by legacies, so that
in 1883 the annuities were 51 ; are now 104. There
are special funds, one of £15 for two widows of med-
ical men, and the other £36, to a physician's widow
having children to educate. The grants like the
annuities are given in monthly installments. Sub-
scriptions for 1894 amounted to £1,083, 14s., 5d., and
the donations to £707, 8s., 4d. Grants in sums from
£2 to £25, were distributed to 169 applicants. Dona-
tions were received from Bath, from the Southeast
Branch, British Medical Association of Bristol, the
Society of Apothecaries and the Salters' Company;
one of the legacies of £500, was from the late Mr.
T. M. Stone, Librarian of the Royal College of Sur-
geons, and the wardrobe, besides £100, was left by
will to the Fund. The committee consider the posi-
tion of the annuity fund safe; a number of applicants
could not be relieved because safe investments could
not be found, and owing to the falling rate of inter-
est of all trust securities and the low dividend on
bank stock; it would lessen the difficulties of col-
lecting the grant's fund for regular subscribers to pay
through the bank for which a banker's form of order
is given with the report. The collector may be the
secretary of the association. The committee appoints
medical local secretaries, e. g., Bath, Brighton, North-
ampton, and in other cities to represent the fund, to
collect the subscriptions and to distribute the grants
in their respective localities, numbering in all forty-
five and including the British Medical Association,
Southwestern Branch and South Midland Branch,
and great cities — Liverpool being the largest contrib-
utor; Edinburgh, Hull, Manchester, Plymouth, Perth,
Cambridge and Oxford, Glasgow, Leamington and
others. The committee urge that an appeal shall be
earnestly made to all interested to make the existence
of the fund more widely known and to urge its claims
not only upon the members of the medical profession
but also, upon others who have the cause of true
charity at heart."
In a brief conclusion of this appeal to the Fellows
of the Association, we would respectfully claim that
an experiment of the kind by the profession in Amer-
ica can not be esteemed an impracticable one in the
presence of the facts above presented by the reports
of the Massachusetts Medical Benevolent Society, the
New York Society for the Relief of Widows and
Orphans of Medical Men; the Mutual Aid Society of
Philadelphia County Medical Society and of the
British Medical Fund Society of England. On the
contrary, we claim that now, after a half century's
existence of the American Medical Association, we
firmly believe that to ensure a larger membership with
the Divine blessing and to promote a common and
widespread fraternity, and to perfect the glorious work
of its founders, Drs. N. S. Davis, Chapman, Stevens,
John C. Warren, Mussey, Moultrie, Wellford, Gross
and others on the occasion of the birth of our glorious
Association in 1846, that the capstone needed is the
1896.]
TUBERCULOSIS INFECTION FROM FOOD.
527
(•nation of a section of Medical Benevolence — to be
styled by Federal Statute law "The American .Med
ieal Benevolent Fund." to be judiciously dispensed
for the benefit of disabled physicians and of the
widows and orphans of physicians in fellowship with
the Association — as donors of the fund, annual con-
tributors or by legacies.
TUBERCULOSIS INFECTION FROM FOOD.
In the Section on State Medicine, at the Forty-seventh Annual
HMtlngOi il»' American Medical Association, at
Atlanta, (ia., May 5-s. ism;.
l'.Y CHARLES E. WINSLOW, M.D.
LOS ANGELES, CAI..
Preventive medicine to-day, like a gigantic signal
light, sends its piercing rays into all the world, guid-
ing medical men upward to a plain above their fore-
fathers which gives advantages unknown before. Old
theories have developed into facts, prophecies of the
past are now being fulfilled, and hygiene has been
clothed in new garments of interest. There is more
earnest thought along this line than ever before. We
have the benefit of the most advanced laboratory
investigations, giving us an understanding of the
causes of disease hitherto unknown. With this
glowing enlightenment conies a greater responsibility
and a more argent need of earnest labor in preventive
medicine. Science, as she turns the pages of this
new book of knowledge, calls for pure food, pure
drink, pure air and better protection from disease and
death.
Man seems prone to disease, and of all the ills he is
heir to, the most appalling in its dire results is tuber-
culosis. Like a great octopus it reaches out its tenta-
cles after the human race, blighting all who come
within its grasp, sapping the very life blood, making
a wreck of noble manhood and bringing misery and
despair to its victims. Having a death rate in the
United States of over one hundred and seventy-five
thousand a year, with one-seventh of all deaths in the
world from this dread disease (Harsch), leaving in its
wake seeds that will bring care, sorrow and death to
thousands more, it becomes a hideous menace to
humanity.
There is an increasing anxiety among the thinking
medical profession due to the resistance of this dis-
ease to the advanced curative remedies, for at present
all have come far short in checking the progress of
this most formidable of all diseases. Although in
respect to curative medicine we are still groping in
darkness, the light of progress has illuminated the
path of preventive medicine, showing that the enemy
must be met and vanquished under its banner.
Comparatively a few years ago a majority of the
medical men did not believe in the communicable
nature of tuberculosis, but scientific research has
proved it beyond a doubt, and the cloud of heredity
that has hovered as a pronounced doom over hun-
dreds of lives, shutting out every ray of hope, has
been dispelled. Many with the predisposition to con-
sumption have accepted this bow of promise, and by
changing conditions have conquered the inherited
tendency to the disease, becoming healthy and useful
men and women.
That the colonization of Koch's bacilli in the ani-
mal tissue causes the disease is the belief of the most
advanced investigators. If this be true, beside prov-
ing that the disease is infectious, it gives grounds
u] »>n which we can work out our own salvation by
controlling the spread of the disease. The two great
mediums through which it reaches the human system
are air and food. While the inhalation of bacilli-
laden air affects the lungs more largely, tubercular
food usually causes the infection through the bowels.
The food of a people is its strength; a poorly fed will
be a demoralized people. The more wholesome the
diet the stronger is the nation. Among the food
products none take the place of milk. There are pro-
duced in the United States nearly five and a half bil-
lion gallons of milk, more than one billion pounds of
butter, and nearly nineteen millions pounds of cheese.
How important that an article which forms such a
large proportion of the food of the people of this
country should be pure and wholesome. Tuberculo-
sis is disseminated more largely through its agency
than that of any other food.
The most common disease of the cow is tuberculo-
sis. Thel'cTose relation that exists between the cow.
and the human family render it possible for the spread
of this frightful disease, and for man's best friend to
become his worst enemy. Some writers have claimed
that the only nations in the world free from tubercu-
losis are those that have not domesticated the cow,
and that this disease is perpetuated by the domestic
cattle. That this is no imaginary danger, but real
and menacing has been repeatedly proved by experi-
ment and research.
Human beings and the lower animals, living upon
the milk from tuberculous cows, have contracted the
disease. In one experiment seven out of twelve calves,
and two out of five guinea pigs, fed with diseased
cow's milk, developed tuberculosis, while the milk
from seven cows infected seventeen animals out of
eighty-seven inoculated. Obermuller found that out
of forty guinea pigs, into which milk bought from
dealers was injected, three became affected and died.
In his experiments, using centrifugalized milk mixed
with the cream of the same milk, ten out of sixty
guinea pigs were infected. Roth and Broferro in-
fected guinea pigs from butter made from the milk of
tuberculous cows. In 55 per cent, of the experiments
the milk from cows having tuberculosis has conveyed
the disease to the lower animals. (Ballinger.)
Numerous cases have been reported before the
societies where physicians have directly traced the
disease from the cow to the human being. It exists
to an alarming extent in our large dairies. Very lit-
tle milk reaches our cities free from mixture with
milk from tuberculous animals. (Bush.)
From 5 to 10 per cent, of the slaughtered animals
have tuberculosis. The cooking of the meat used for
food lessens the danger of infection from that source.
The bacilli introduced into the system may migrate
to different parts of the body, forming here and there
little colonies, the lungs being most often the seat of
attack, the digestive tract next. The infection of the
intestinal tract by tuberculosis is more common
among children than adults. The increasing cases of
tuberculous joints, meningitis and infected bowels
and glands in childhood can be largely accounted for
by the use of diseased milk.
The majority of people are not predisposed to tuber-
culosis; the immature child and the invalid are most
susceptible to the disease. The bacilli rarely find a
home in a healthy human organism. Anything that
depletes the system leaves it in a condition to become
infected; therefore an impure diet of any kind tends
toward tuberculosis, while good, wholesome food will
528
MODERN RESPIRATORY ADVANTAGES.
[September 5,
aid in throwing off the disease. The food of a human
being may be full of the bacilli and still the system
be so nourished that it will not retain the germs.
While this may be true, still if the bacilli can not
gain entrance into the organism there will be no dan-
ger of infection.
Tuberculosis is not so contagious as many diseases,
but it holds its victims more firmly in its grasp than
almost any other enemy of mankind. And yet this
curse of the human race can be prevented. To accom-
plish this there must be strict sanitation. More and
more attention is being given to the subject, not only
by the physicians but by the people at large. To-day
the hygiene of our cities is one of the great questions
which municipalities have to deal. The sale of food
that is infected with disease should be restricted and
the punishment made so severe that the dealer will
fear to sell such food. Each community should have
an inspector, whose duty shall be to carefully examine
all food sold. Some of our cities have greatly im-
proved the quality of their milk supply by so doing.
Sterilizing milk lessens the danger.
Milk containing tubercle bacilli is a diseased
product. Wherever there is this microorganism there
is tuberculosis. No tuberculous animal can give pure
milk, the disease must affect all the organs of the
body. Every cow, private or dairy, should be exam-
ined for tuberculosis and other diseases by an expert,
and the milk of every new cow entering a herd tested
before a drop of it is used. The inspection should be
periodical, and carefully and systematically made.
There should be a physical examination and the tuber-
culin test should be used, for it has been proved that
milk from cows, which give no physical signs, is often
infectious. Although Koch's tuberculin has not been
a success as a thereapeutic agent, it has proved a use-
ful aid in the diagnosis of tuberculosis, and no herd
can be thoroughly inspected without its use. The
healthy cows should be marked, and all tuberculous
animals, no matter how slightly affected, destroyed.
It is a serious matter to go into a man's herd and kill
his cattle, but it is pernicious to let such animals live,
a menace to a community.
Not only should the cow be inspected but its treat-
ment and surroundings. The animal from which
milk is taken should have the best of care, be fed
wholesome food and have stables and surroundings
neat and comfortable. The utensils used for holding
milk, making butter and cheese should be clean and
free from dust. No person suffering with tubercu-
losis should be employed about a dairy, creamery or
where food is prepared or sold.
Only milk and its products from inspected dairies
should be placed on the market. There should be
abattoirs where the slaughtered animals could be
examined by competent experts, and no market should
be allowed to sell meat which does not have the
inspector's tag.
AH articles of diet should be kept from contamin-
ating dust. Even the wrapping paper may infect
healthy food. Eating utensils used by consumptives
should be disinfected.
Inspection is a necessity. To make it a success
the inspectors should be educated men and their deci-
sions enforced by law.
The cost of sickness is great, so immense that we
fail to grasp its magnitude, nor can we form a proper
conception of the annual financial loss to the nation
from this king of terrors. Every life has a financial
value, every life saved is so much gained for the com-
munity. The child who dies before he is able to be
a wage earner, is a loss of just so much as has been
expended on him and what he could have earned had
he lived. When a man dies of this disease it is not
alone the expense of his sickness and the value of his
wages that are lost to the world, but the time of those
who cared for him, and the expense of the expanding
influence of the disease he has left behind him.
With the wonderful development of our country
comes increasing danger of infection from the foreign
element which, absorbed by our people, by its lack of
ordinary sanitary precautions aid in spreading dis-
ease. There is a demand for better means of pro-
tection.
Every charitable institution in this land is an
unconscious recognition by the people of the impor-
tance of sanitation and teaches that man should not
live for himself alone, but for humanity. It is our
duty as physicians to devise means for the ameliora-
tion of the human race.
Progress in preventive medicine has given us facts
that prove the danger and has shown us a logical
means of prevention. With this light' to aid us we
must impress the truths, upon our fellow men.
The people are thinking about these things and are
increasing in knowledge; public opinion in all its
unmeasured power is slowly progressing.
Education and a wise use of education will do much,
but an educated people can not do all. There must
be a willing government to enforce. The growth of
sanitary science calls for advancement in controlling
sanitation. State and local authorities can not shirk
the responsibility ; they are bound to protect life from
the danger of death by disease, as from rapine and
murder, no matter how great the expense. For a
municipality to pay no attention -to the sanitary con-
dition of the community is to become the abetter of
crime. Some of the States have taken up the subject
and their health officers have done noble work in
checking the advance of disease, but in order to do
the greatest good to the greatest number there must
be more legislation in favor of sanitation. There
must be intelligent men at the outposts, guarding
hamlet and city, a united action along the line, with
a master mind at Washington advising and control-
ling the entire force.
When advancing civilization shall recognize justice
to humanity and give place among our Presidential
advisers to a man of science who will guard the com-
mon safety and welfare of our nation, lessening sick-
ness and want, sorrow and suffering, wasting and
death, then may we hope to see science triumph over
disease.
MODERN RESPIRATORY ADVANTAGES.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association, held at
Atlanta, Ga., May 5-8, 189fi.
BY W. T. ENGLISH, A.M., M.D.
PROFESSOR OF PHYSICAL DIAGNOSIS IN MEDICAL DEPARTMENT OF WF.S-
TERN UNIVERSITY OF PENNSYLVANIA. AND CONSULTANT IN
CHEST DISEASES IN THE SOUTH SIDE H08PITAL.
PITTSBURG, PA.
The worker in the domain of preventive medicine
often has occasion to feel that there are excuses for
becoming pessimistic and for regarding his efforts as
unprofitable. After some acute outbreak of disease,
his heart is wrung with disappointment and his mind
is distracted. A good remedy for such hypochondri-
MODERN RESPIRATORY ADVANTAGES.
529
asis is to rehearse for himself, or have another review
for him, some of the modern respiratory advantages,
ami trace them to their source. All men are not alike
possessed of the "vision and faculty divine." but that
man must be indeed prosaic whose soul is not inspired
with gratitude and whose heart is not uplifted with
hopefulness as he beholds the human body rapidly
and surely raised from the abnormalities of life, sub-
limated, refined and saered through the avails of
modern respiratory advantages. The individual who
labors in the realm of preventive medicine is habitu-
ated to a life amid the vapors of melancholy and dis-
ease, and if no sudden or colossal change dispels
those vapors, his mental visualizing is rarely illumi-
nated. However, his efforts are continuously trans,
tanning the gruesome abiding places of disease into
palaces of good cheer, and he is creating an improved
state of existence for himself and his generation. The
influence ceases not. but it steeps in splendor the dis-
tant human prospect and reaches out its long arms
like a benediction toward the ages that are yet to be.
The solicitude with which he guards the youth
from the moment he leaves the nursery is like to the
fabled spirit of good that keeps from all evil. So
unremittingly has he demonstrated the ill influences
of bad air and advocated the benefits of good respira-
tion that the school curriculum has been extended to
include a study of the laws which govern the respira-
tory organs, with those which govern other material
things. By the intelligent application of the laws of
respiration, winch the schoolboy is thus taught to
understand, there is not only a continuous develop-
ment of the breathing apparatus, but an extension
and versatility of its functions. The schoolboy of
to-day knows better how to breathe than does his
grandsire. In him is awakened an appreciation of
the fact that the respiratory organs were never intended
to act as involuntary parts of the body, and it becomes
a portion of his daily care to observe that a fair pro-
portion of the 25,000 respiratory cycles are voluntary
and forcible acts. This age, so self-conscious in
many things, is thus to be secured against lethargic,
indifferent and unconscious respiration, which has
been the cause of much of the pulmonary weakness of
the past. The most casual observer will note that it
is not our boys and girls who need reformation from
respiratory delinquencies, but the fathers and mothers.
It is only the children who have learned from their
teachers how to use their respiratory organs who
really know how to breathe. The large majority of
those in adult life have never yet learned how to take
a full inspiration or execute a forced expiration.
They are totally ignorant of what is meant by a
voluntary respiration. In consequence of this the
average adult never employs the lungs beyond that
which is essential to existence, and to those engaged
in sedentary pursuits this need is exceedingly small.
On the other hand, every child, disciplined to-day in
the accepted respiratory school, is capable of taking
in twice as many cubic inches of air as his parent,
and habitually uses his breathing organs with propor-
tionately greater freedom and scope. In comparison
with the school children of to-day the parents are a
race of pulmonary pigmies.
This constant oversight of the lungs brings with it
respiratory fulness with perfect oxygenation that in
turn develops material out of which energy pro-
ceeds. The augmented lungs and extended respira-
tory action begets an increased desire for air, and
these promote a condition of mind that is emulous of
bright surroundings. There is nothing that secures
appreciation of hygienic conditions like a personal
experience of their benefits. To one thus endowed
there is a delicious sense of pleasure in the pressure
of the lungs against their confines, and it is not easy
to deprive him of his powers to battle with bad air.
These methods of cultivation secure an esthetic and
cultured respiratory demeanor and at the same time
create a longing for complete and repeated changes of
air, much as the cultivated taste of the epicure
delights in changes of viands. How young, whole-
some lungs do yearn for some new brand of alveola-
titillating atmosphere! Moreover the highly edu-
cated breathing apparatus has analytical capabilities
so that it may appreciate that a molecule of oxygen
is an impact of two atoms of the element while it
recognizes a molecule of ozone as a combination of
three. Furthermore, the lungs feel the corroding
energy of the triplet to be many times greater than
that of the twin, and the influence it exerts upon the
breathing apparatus exemplifies a higher intelligence
than mere automatism. An educated pair of lungs
observes that the air is not imponderable and notes
the thermometric and the barometric rise and fall.
The mind and the lungs together grow familiar with
the physical character of the air, its invisible inhab-
itants, the microbes and their potencies for good or
ill, as well as the general and specific qualities of the
air dust.
If it is true, as is calculated, that in the air of the
city a man breathes 37,000,000 spores every ten hours
it is not from aerial purity that any of the city denizens
continue to live and move and have their being. It
is also well known that in the atmosphere everywhere
there is an opulence of oxygen and the greatest need
is a capacious and intelligently controlled breathing
apparatus to utilize it, and at the same time to suc-
cessfully conduct the hygienic chemistry of the per-
fect function. The educated and sensitive lungs will
isolate the deleterious ingredients more rapidly than
the microscopist or the chemist; and those objects
entrapped upon the microscopic slide, which appear
so interesting and beautiful to the visual sense are
altogether unlovable to the breathing apparatus when
they gain access within their sacred precincts. This
ever-increasing discriminating capacity of the human
lungs enables men to remain for a season amid dele-
terious influences with comparative safety.
It was assumed many years ago that the coefficient
of oxygen needful and belonging to animals was fixed
by the animal's intelligence. Thus, a dog required
more oxygen than did a hare of equal weight; the
chimpanzee, the nearest animal to man in point
of anatomic resemblance, needed less than man.
Whether these estimates were considered fanciful or
not, it is certain that to breathe well to-day is the
most modern method of demonstrating advancing
intelligence.
Falling in line with this display of wisdom in the
exercise and development of the lungs are the efforts
that are everywhere made to reduce the aerial threat-
enings and improve the quality of the air we breathe.
But for these efforts the vitiated city atmosphere
would be most deplorable in its consequences to those
compelled to remain within the urban limits. How-
ever, it is only amid such surroundings that we can
discover how apparently insensible some persons are
to the subtle influence of vicious atmosphere, and
530
MODERN RESPIRATORY ADVANTAGES.
[Septembek O,
observe the variety of means which contribute to
counteract the bad air and unhygienic conditions.
The elaborate and perfect system of interchange
that has been going on since the world began between
the earth, the vegetable and the animal kingdom, with
no waste of material, still continues to command the
admiration and thanks of every grateful creature.
This is also supplemented by a process of sanitary
chemistry — more flexible and variable — by which the
actions and reactions of materials and the affinities
and aversions of the silent and unseen forces are
made to conform in the main to the best interests of
human kind through the provisions of the vis medi-
oatrix natures.
To reinforce these natural efforts at sanitation,
every city to-day has in its employ a capable corps of
workers whose business it is to look after the various
impurities. It is the custom in several municipalities
to gather a measure of the atmosphere from different
portions of the city and force it through materials in
which are entrapped the impurities, and these are
carefully isolated and estimated, and the result
announced. To afford all who desire to acquaint
themselves with the relative impurities existing in
different localities a record is made at intervals not
exceeding one week.
The use of the microscope and other instruments of
investigation has become popular amusement, and
there is an individual as well as public surveillance of
the atmosphere. Through thousands of channels of
observation the intelligent layman is accumulating
experience that enables him to trace facts and infer-
ences to their logical conclusions, and the good
results are constantly multiplying. Knowing that
evils exist he seeks to prevent their influences in
himself and others, and though his supremest need
demands his presence for a season amid the unwhole-
someness, he provides himself with a home beyond
its contaminations, where he can retire after his
daily duties are over, and render his lungs clean again
ere he starts them upon their fresh career of defile-
ment. His household is continuously kept amid the
respiratory advantages.
Toward the attainment of these possibilities every
recent invention seems to felicitously trend. The
proper thing is ever more and more becoming the
popular thing. In modern street paving there are
some remarkable advantages secured to the respiratory
apparatus. The myriad crevices favoring the accu-
mulation of dust and offal in the cobble-stone pave-
ments are replaced by the smoother surfaces of the
granite and asphalt. These pavements in the streets
of the present city make the dust obvious to the
street cleaner, and spontaneous removal by rainfalls
is facilitated. The frequent use of the sprinkling
cart has a salutary effect in lessening the contamina-
tion of the respirable air. We have recently bade
adieu to the lumbering horse cars and the thousands
of horses which contributed to the filth of every city.
The dust, the offal, exhalations, effluvia, gas and
odors innumerable incident upon the vast herd of
horses upon the streets are no longer with us. By
the electric and cable cars thousands of horses in
addition to those formerly employed by the horse-
car companies are rendered unnecessary. The com-
modious and wholesome rapid-transit cars are a desir-
able means of conveyance and the great celerity of
travel yields additional advantages by expediting
business, social and pleasure trips. By the reduction
of evil long prevalent, and the substitution of the
most royal good, they contribute to modern respira-
tory advantages beyond computation.
The more recent methods of city illumination baa
done much that is favorable to wholesome activity ir
the breathing apparatus. The old-time fishtail gas
jet, capable of consuming as much oxygen as several
persons, is substituted by the electric light. This is
especially noticeable in assembly rooms. By the us
of electric light there is no oxygen waste and no pro-
ducts of imperfect combustion. Its universal employ-
ment would cause an oxygen saving to every city
sufficient to supply twice the number of its inhab-
itants with good wholesome air.
In the matter of heating, the respiratory organs arc
considered. The air is not permitted to become
gloomy with smoke and other evidences of imperfect
combustion, and the smoke-consumer is voluntarily
or legally adopted. In the homes we can have our
apartments warmed by the moist or dry methods and
can so arrange that there will be an equable contin-
uous dry atmosphere, free from dust. Again, we may
imitate the barometric rise and fall to suit our fancy
or gratify our wish. In the districts where natural gas
abounds the air can be kept free from smoke by its
employment as a fuel and without even the annoy-
ance of dust from ashes. Some of the more recent
methods of supplying air and heat to modern build-
ings embrace advantages that are destined to lift us
out of the empire of death from aerial impurity.
The air is drawn by fans through closely woven silk
screens or forced through baths which wash and ren-
der it aseptic. The shafts into which the atmosphere
is drawn are extended to a high altitude to avoid the
dust and contamination. After gaining admittance to
the basement it receives the desired barometric and
thermometric qualities before it is delivered through-
out the building. In each room is placed an indicator
with a movable needle by the least motion of which
the temperature of the apartment can be changed.
This adjustment resembles that portion of our time-
pieces which enables us to regulate its speed. Hun-
dreds of other aids and means of protection to the
developing breathing apparatus can be observed in
modern city building.
How eminently fitting that an age which protects
and fosters its respiratory good should form a remark-
ably close alliance between its pastime and its busi-
ness. Wherever we go on a Saturday afternoon we
find the city denizens hastening, by every avenue,
from the crowd and tumult into the more rural sur-
roundings. The old dead roadways, that a few years
ago were overgrown with weeds and grasses, teem
with cyclers, and the little town along the way lifts
up its head again as if possessed of a new life. The
glorious half-holiday rescues many a failing respira-
tion from the thraldom of disease. To take a stroll
or join in some of these methods of oxygen hunting,
or spend the Sabbath amid nature's wholesomeness.
is to serve God. A half century ago this would have
seemed sacrilege and the Saturday half holidays
would have been regarded by our grandsires as sinful
and profligate. But this is the end of the nineteenth
century and the world is growing young again
through its modern respiratory advantages.
Cricket, football, baseball, tennis, golf, fishing and
athletics generally are familiar to every place and are
regarded as suitable pastimes for all young Americans.
How they have aided in the resuscitation of some of
L896.]
DISCUSSION.
531
the yielding respiratory organs! It is not the school-
hoy, neither the idle men of means who are interest-
ing themselves in these sports and pastimes, hut the
masses. The countless excursions by rail or water
are daily inviting a willing humanity to bathe their
bodies in the sunlight and purify their lungs in the
aerial change. Whatever morsel of air or quality of
atmosphere one desires may be secured by applica-
ion to the numerous competing land or waterways,
iind he will comfortably, cheaply and with great celerity
be transported to the Eldorado of his desire. With
these new experiences and ever-changing quality of
the respired air the lungs not only develop their vital
capacity but acquire a versatility in their methods
of accommodating themselves to the aerial circum-
stances. There is undoubtedly a remarkable adapta-
bility by which the lungs may adjust themselves to the
conditions. And this serves their possessor in good
stead when it is impossible to select the environ-
ments, because the respiratory versatility enables him
to breathe the disease-ladened air with comparative
impunity. Man is to-day capable, for the most part,
of educating and subjugating nature, and when the
surroundings are at fault he makes or modifies them;
failing in this, he can rely upon the discriminating
oare acquired by his lungs to render the atmospheric
foes inert.
Through all the avenues of hygienic information
the truth is being ever more and more impressed
that pure air and exercise are equal forces acting in
the same direction. The contaminations from dis-
ease germs and terrestial impurities are to be met by
an equable antagonism vouchsafed through the intel-
ligent employment of the functions of respiration.
Meanwhile most of us agree with Lord Beaconsfield
that 'the atmosphere has more to do with human hap-
piness than all the accidents of fortune and all the
acts of government."
The adjustment of the respiratory possibilities to
the needs of each individual is largely a matter of his
own choosing. There are some who have tarried too
long under the lethal influences of indifferent respi-
ration, and have in consequence bartered their birth-
right. Some again there are whose lungs, like the
Scotch farms of which we read, are '"poor by nature
and ruined by cultivation." There may be no regal
duty for such to perform but even these can hold from
future human struggle the burden of preventable
suffering by negatively remaining away from the
current of human life that is to-day flowing so directly
toward the goal of physical completeness.
DISCUSSION.
Dr. Kellogg— In a certain school there was considerable
difficulty in persuading the Indians to attend. I thought they
would be glad to avail themselves of the opportunity. They
were still in a primitive state and were running about in the
forest absolutely nude. There was a lot of Indians who
thought it unhealthy to be in the house, and took their chil-
dren away on that account. It was instructive to me to see
that they were so solicitous about their children's health.
He said we did not know how to breathe unless we learned
it at school. It is not even known in school. I found the best
teacher for breathing was a baby. The good Lord told them
how to breathe and they breathe just right. I have told many
ladies that the best of their breathing powers were tied up ;
and that if they wanted to learn how to breathe to take a baby
and lay it on a bed, and notice how it breathes. I say breathe
with the whole trunk. When he breathes the whole trunk
will be inflated.
Women breathe with the upper and men with the lower
gart of the body. What all need is full respiration of the
entire chest. I havo two little boys and I frequently make
them run up and down stairs once or twice to make them
breathe properly.
I formerly practiced voluntary respiration, but I am con-
vinced it is not a success. Simply breathing or exercising for
t he sake of it is tiresome. I have not been able to breathe
voluntarily more than two or three minutes at a time. The
muscles very soon get tired. But if you will compel yourself
to breathe by bicycle riding, jumping up and down, room exer-
cising, or anything else that will create a demand for pure air
you will And that it is not so tiresome. The lungs will act in
the most vigorous and voluntary manner. For the last seven
years I have used gymnasiums for my patients with excellent
results.
Dr. , in some experiments made in the Dangerfleld
Academy, showed that after six months exercise in the gym-
nasium he found that the involuntary activity of the lungs was
doubled. It became twice as great while the students slept,
showing that the effects of gymnasium work are continuous
during sleeping as well as waking hours.
There is another point : The position assumed in sitting. A
lady said, "I want to talk to you about my lungs. My mother
thinks I am to have consumption because I have no chest."
I made her stand up and she stood with shoulders and chest
contracted. A ruler laid on the chest would have touched the
shoulders on either side. I made her bend and look upward,
and found she had a well developed chest, but was carrying it
all behind instead of in front. The lungs had not been prop-
erly expanded. In making her stand straight I entirely cor-
rected the deformity. It is becoming a very common defor-
mity. I think it is largely caused by sitting on the back
instead of on the thighs, and it results in people becoming
round-shouldered. The body is held in this mold for so long
a time that it finally acquires a certain degree of permanency.
The doctors ought to be continuously calling attention to
standing straight and raising the chest. While standing
straight the lungs are expanded,' and the abdominal viscera
trained up. Walking, boxing, bicycling are agreeable and
exhilarating, and accomplish these beneficial results. They
render proper breathing more natural.
Dr. Garber — I have had considerable practice with men
who were engaged in blowing window glass, and it has been my
experience, that forced exercise will cause great development
of the chest. In 500 glass blowers I can not remember a single
case of lung trouble. I used a respirometer on some of these
men, and found they can inhale 300 cubic inches of air, and I
frequently found a difference of five and sometimes six inches
between inspiration and expiration. Some people whom I
regarded as consumptives have since become well, and lungs
predisposed to disease of that kind became strong. I am very
much in favor of gymnasium exercise of some kind for all.
Dr. Kellogg— The atmosphere is as important to us as the
water that we drink, or the light that shines upon us. I want
to ask a question in regard to the consumption of this oxygen ;
I want to ask the author if he thinks that it would materially
affect the health of the city to change to electric lights on
account of more consumption of oxygen by gas jets than by
the electric lights. 4
Dr. English — I made, some time ago, an investigation as to
the consumption of oxygen by the ordinary gaslight jet, and
it showed that one gas jet consumed as much oxygen as would
supply three ordinary persons. Assuming, then, that we have
100 lights in the assembly room, and 300 persons. We would
have consumed by the lights as much oxygen as would have
been consumed by the individuals in that room.
When we build a room the area is usually estimated to ac-
commodate a certain number of people, and a building of
532
SURGERY OF THE KIDNEY.
[September 5,
Wholesale emporiums is usually conducted upon the principle
that so many cubic inches of air must be supplied to every
individual. When we use the electric light, especially the
incandescent, we consume no oxygen. The incandescence of
the carbon must be considered the source of light. It burns
in a vacuum, with no possible oxygen waste. In every city we
have a certain proportion of people living in one room. Esti-
mate the number of rooms in the city, and in that way we can
estimate approximately the amount of oxygen we are consum-
ing by the use of these burners. Then there is another point ;
just estimate the amount of contaminations, the smoke, gas,
odors, and the various emanations which are contributed to
the oxygen by these fish-tail gas jets, and the heat that the gas
produces, whereas, with electric incandescent lights burning
in a vacuum, we have a brilliant light that is satisfactory,
comfortable to the eyes, do not have these contaminations, and
we have a minimum amount of heat. The consequence is that
we do not vitiate the atmosphere. With arc burners on the
streets and in the rooms we would have a much larger result,
for one arc burner was estimated to be equivalent to sixteen
times the power of the ordinary burner, I believe. The com-
parison is between the two different kinds of light. The arc
burner is exposed to the atmosphere, and consumes a large
quantity of oxygen ; but there is no comparison that would
demonstrate the advantage that would be accorded the electric
light. When we go back to oil lamps and candles and such
devices for lighting purposes, they are often worse, because
their contributions to the atmosphere are vastly in excess.
It is a fact that we do not in the schools to-day teach the
children how to breathe. We should impress upon them that
there are vital organs in the human body and that it is within
the capacity of our volition to control these organs, these
lungs. We may breathe fast or slow as we choose, and take in
as much or as little air. We may suspend respiration, but we
can not suspend the action of the mind enough to prevent the
use of our lungs. I think Nature has demonstrated by placing
these organs within our body it is our duty to use them, or
they are indeed not vital organs. By that means Nature
secures for us perfect respiration, good sound lungs and a
wholesome body.
Dr. Kellogg — I just want to mention three disadvantages :
gas stoves, kerosene stoves and gas grates as heaters. A doc-
tor put a kerosene stove in a room and the next day the patient
was dead. He told me he was satisfied the patient was suffo-
cated by the odors arising from the stove. The gas stove pro-
duces ten times as much impurity as an ordinary gas burner,
and a gas grate gives out at least twenty times as much im-
purity as a gas burner. It seems to me a very dangerous
thing.
Dr. English — I would like to ask the gentleman what gas
he has reference to — artificial, natural, illuminating or what?
Dr. Kellogg — It is coal gas. That is a hurtful gas. In
natural gas heaters as well as in grates, the opening for the
escape of the gases is in some scarcely ^8 of an inch in width,
so when the door was opened it was certain to drive all the
foul gases out into the room, so that I think it applies to both
natural and artificial gas.
The Chairman — I think the general fashion of ladies'
dresses is wrong, and that the weight instead of hanging from
the hips, as is now the case, should hang from the shoulders.
I think until that is done they will never have perfect respira-
tion, and that if Dr. English will start a crusade on this line
it will result in much better health in every respect, and espec-
ially there will be less falling of membranes which the women
complain of so much and which gives the gynecologists so much
work. They should also have their dresses made so that two
or three inches additional would be allowed for expansion of
the chest.
Dr. English — I think that the efforts of such reformers as
Jenness-Miller have influenced the women, and in my expe-
rience— and I have had rather large experience in respiratory
difficulties because my special realm is the treatment of dis-
eases of the chest — I find that women are disposed to lay aside
their pains and corsets and take up more life and health. I
really think if I incorporated that subject in my paper I should
have illustrated the women of the future. They are growing
sensible as well as the men.
Dr. Drayton — This Jenness-Miller reform is simply a depart-
ure from the strict lines of fashion. It is simply an attempt
to adapt certain principles of hygiene to fashionable dress.
You may get some benefit from it, but it appears to me that
the attempt will not be more beneficial than the attempts
already made on that line. The new woman will make some
difference in this matter of fashionable costume. The new
woman likes the bicycle and the woman who rides finds it nec-
essary to adopt a bicycle costume. She finds it is not only
good to make muscle in the arms but also in the abdominal
region, and after a little practice she would prefer to put her
finger in the face of fashion than to give up the wheel. So I
think we shall have a great improvement from this cause. I
have advised the use of the wheel to a great many ladies. I
have studied it and its advantages and I am satisfied its gen-
eral use will be of great benefit.
Dr. J. A. Work, Indiana — The wheel is not available to all.
We should give our women more employment that will have
the effect of developing what is claimed for the wheel, which
is for amusement, but as a vocation I believe general house-
work, such as our mothers and grandmothers used to do, would
be better for them. I have found that the German servant
girls who have not followed fashion have very good breathing
apparatus and very good lungs. They stand erect and they
have employment that compels them to do it. They have to
breathe right and they have to clothe themselves right or not
do the work required of them. Two young Swedish ladies came
to my office for treatment. One wanted to know what was the
matter with her side. I put my hand on the side of the chest
and told her to take a long breath and her chest shoved up
under her chin. She could not expand it around the base of
the lungs one-half inch. Under the armpits above the breast
she expanded three inches. I said : "That is the trouble
with your side : takeoff your corset and you will breathe well."
Let us give them employment that will make them breathe.
Dr. H. E. Garrison, Illinois — I believe I am the only
woman doctor present. I have practiced for twenty years and
I can ride and walk as readily with as without a corset. Mrs.
J. S. Lane has a book upon the subject and if the gentlemen
will read it they will know why we have worn corsets and will
continue to wear them as long as we live.
SURGERY OF THE KIDNEY.
BEING A STUDY OF A SERIES OF CASES IN WHICH METHODS
OF DIAGNOSIS AND TREATMENT ARE ILLUSTRATE").
BY BAYARD HOLMES, B.S., M.D.
PROFESSOR OF PRINCIPLES OF SURGERY IN THE COLLEGE OF PHYSICIANS
AND SURGEONS OF CHICAGO.
TUBERCULOSIS OF THE KIDNEY.
In this series of cases two appear to have been
tubercular, although in neither case was an absolute
diagnosis made before operation, and in the second
case doubt still remains as to the real cause of the
disease. In both cases, however, all the means of
diagnosis known, except inoculation experiments, were
made, and every step was guided by positive indica-
tions for treatment. In the first case, Mrs. S., neph-
rectomy was contraindicated by the desperate condi-
tion of the other kidney, determined by catheterizing
the ureters. In the second case, Miss C, unusual
1896.]
SURGERY OF THE KIDNEY.
533
difficulties presented themselves and they were over-
come, one by one. The treatment of this patient was
most conservative and careful. The full report of
those cases it is believed will be useful and suggestive.
( 'as,' /. Synopsis ; Sudden obstruction of right ureter three
years ago; pyonephrosis; aspiration, drainage: occasional
discharge of calculi through the wound; continued fever and
chills with cystitis ; catheterization of both ureters showing
advanced disease of left kidney : removal of calculus and evt-
dement: itcath in five months from uremia.
Mrs. S.. aged 34, mother of three children, con-
sulted me in August. 1894, and gave the following
history: Three years ago, and some years after the
birth of her lust child, she was taken with chills, fever
and puin in the right side. The chills continued for
three weeks, when a large tumor appeared in the right
side. This tumor fluctuated and was aspirated repeat-
edly by the attending physician, and a large quantity
of pus withdrawn. The puncture was at last enlarged
ami a tube inserted in the loin for permanent drain-
age. The temperature became normal and the patient
gradually gained in health and strength, but she was
continually troubled by the closing of the sinus and
the recurrence of the chills. There was considerable
irritation of the bladder and almost constant night
sweats. Many small pieces of stone were discharged
from the sinus, indicating the presence of other cal-
culi. The patient was a thin, slight woman, of a
nervous temperament and a quick, intelligent look, a
bright, quick eye and expressive, nervous features.
She had a well-formed thorax with no show of tuber-
cular disease in either lung, no enlarged lymph glands
in the neck or axilla? and no indication of general
tuberculosis. The heart had a free, normal and regu-
lar pulsation which was rapid, 96, and violent. The
apex was farther removed from the median line than
is normal. The arteries were soft and flexible. The
abdomen presented no abnormality except a tumor
three inches in diameter in the right side, which was
connected with a sinus opening through the skin half-
way between the crest of the ilium and the border of
the ribs. This tumor was painful on pressure and
was evidently the enlarged displaced kidney. Exam-
ination of the urine showed a normal quantity con-
taining from six to eight points of albumin measured
by the Eshbach albuminometer, some casts and a
large quantity of pus and mucus. Examination of
the sediment for tubercle bacilli was made by me
without result, though many other bacilli were found.
In a vaginal and rectal examination the right ureter
was found to be about 1 cm. in diameter, hard and
painful to pressure. The left ureter was smaller and
softer, but very easily recognized and somewhat sen-
sitive. Still I hoped that the left kidney might be
found sound and well. Although the patient's condi-
tion was not good, I determined to make an effort to
remove the calculus from the right kidney and per-
haps close the sinus, and at the same time make a
positive diagnosis of the condition of the left kidney.
With the assistance of Dr. George Nesbitt and Dr.
Harry Wilder the patient was prepared and anesthe-
tized with chloroform, the urethra was dilated and the
ureteral sounds passed by touch into the two ureters.
From the right ureter a thick pus a few drops at a
time passed on pressure above the brim of the pelvis.
From the left ureter an average quantity of turbid
urine passed in intermittent jets of four or five drops,
but the quantity was not measured. This urine con-
tained considerable albumin and was very turbid. It
was immediately examined under the microscope.
The quantity of pus and its character seemed to indi-
cate an advanced condition of disease in the left kid-
ney and contraindicated any extensive operation upon
the remnant of the right kidney. The patient was
again brought fully under the anesthetic and the sinus
enlarged sufficiently to remove the calculus in the
pelvis of the degenerated right kidney. This calcu-
lus was 1£ inches long and nearly 1 inch in diameter.
The pelvis and ureter of the right kidney were care-
fully examined with the finger and no other stones
were found. Nephrectomy seemed to be contraindi-
indieated by the condition of the remaining kidney;
the granulation tissue, which was evidently tubercu-
lar, was therefore scraped away and the wound packed
with iodoform gauze. The patient was put to bed in
good condition and rallied promptly. The wound
was dressed upon the fifth day and daily afterward by
Dr. Nesbitt. The temperature, which had been about
100 degrees at night before the operation, gradually
fell to normal, but the quantity of albumin in the
urine increased for two weeks and then, with a milk
and kumyss diet, it gradually fell to a mere trace.
The wound healed slowly. The urine, however, began
to be scanty three months after the operation, and the
patient died in uremic convulsions two months later
and five months after the operation. No postmortem
was made.
In this case nephrectomy and ureterectomy would
certainly have been made, in spite of the thickening
of the left ureter, had not catheterization of the ure-
ter demonstrated the advanced disease of the left kid-
ney. Had this operation been done the danger to the
patient's life would have been much greater, and the
benefit to be expected no more than by the simpler
procedure.
Case 2. — Typhoid at 12 years followed by cystitis, bloody
urine, pain in side, strangury; slow improvement ; after ten
years, drainage of the bladder for nine months with slight
improvement; catheterization of the ureters demonstrates a
healthy and competent right kidney and degenerated and sup-
purating left kidney; nephrectomy; partial ureterotomy;
implantation of vesical endof ureter into the vagina ; recovery.
Miss C, aged 40, consulted me in December, 1895,
for a pain which she constantly felt in her left side in
the region of the left ovary, and for frequent painful
urination and occasional attacks of chills and fever.
She gave a family history of the best kind. Her
ancestors were of healthy German stock and she was
herself well until her eleventh or twelfth year, when
she had a very severe attack of typhoid fever from
which she made an imperfect recovery. Following
typhoid fever there was painful and frequent mictu-
rition, which at last became so desperate that her
clothes became offensive from ammoniacal urine, and
it was impossible on this account for her to get any
position to work. During this time there was great
pain in the side which was relieved by lying down.
Occasionally there would be a discharge of bloody
urine and at all times, as appears from the history, a
considerable quantity of pus at irregular intervals.
The symptoms, however, somewhat subsided after two
or three years, and the patient was able to go about
in spite of frequent attacks of pain and painful urina-
tion. Many physicians were consulted without avail,
and at last fourteen years ago , the bladder was
examined by Dr. E. C. Dudley, who made some oper-
ation upon it resulting in drainage of the bladder.
This drainage was continued for nine months when
534
SURGERY OF THE KIDNEY.
[September 5,
the opening was closed up and the patient had some
relief. She frequently rose to urinate nevertheless as
many as nineteen times in the night as she discov-
ered by an ingenious method. Every time she rose
she took a match from her match box, laid it on the
table and counted the matches in the morning.
About once in two or three months during the past
ten years she had attacks of " pain in the side " of a very
severe character. During these attacks there was a
high temperature and rapid pulse. She used the
thermometer and frequently found the temperature
105 degrees F. Vomiting often" accompanied these
attacks, and they usually passed off after two or three
days with a discharge of urine containing half or two-
thirds its bulk of pus. She could give accurate infor-
mation upon this point from the fact that she collected
the urine in a wide-mouthed bottle, and allowed it to
stand long enough to see the amount of sediment.
During the past five or six months the attacks have
been more painful and more frequent than heretofore.
They had appeared as often as once in three weeks.
When I first saw her she had just recovered from
an attack of this kind. The specimen of urine which
she gave me at the time had only a small sediment of
pus, and contained only a small amount of albumin,
there were no casts or other evidence of nephritis.
The patient was large and covered with a thick layer
of fat making examination difficult. The lungs were
perfectly healthy, and the heart free from murmurs
but enlarged considerably, so that the apex beat lay
3£ inches from the median line. The spleen and
liver could not be palpated, and the area of hepatic
dullness seemed to be less rather than more than nor-
mal. There was no tumor to be felt in the abdomen,
but there was a region of very marked tenderness
commencing at the edge of the left short ribs and
extending downward into the left pelvis. The points
of greatest tenderness seem to be at the upper and
lower extremity of this line. The region of the blad-
der was also distinctly tender upon pressure. The
vagina was found to be normal and very small,
and the infantile uterus was found lying in its nor-
mal position and perfectly movable. In the pelvis
there could be easily palpated a distinct tumor upon
the left side which seemed to be quite hard, appar-
ently cystic and excessively tender to pressure. The
meatus urinarius was red and on pressure a small
amount of pus could be forced out of the numerous
folds of the mucous membrane. The patient's tem-
perature at this time was normal and her pulse 72.
There were 1200 c.c. of urine passed in 24 hours and
this urine was alkalin and had a specific gravity of
1.011 and contained 28 gramms of urea; there was a
considerable quantity of pus present but no casts.
On February 15, the patient was put in the knee
chest position, the urethra dilated, the bladder cocain-
ized and inflated and the silver ureteral catheter suc-
cessfully passed into the right ureter. She passed 6.5
c.c. of urine through this catheter in fifteen minutes.
This urine contained absolutely no pus, no epithelium,
no albumin and it registered 40 milligrams of urea to
the c.c. It was of acid reaction but the quantity was
not sufficient to allow me to take the specific gravity.
It was not perfectly clear, but was slightly turbid
with a sediment of amorphous urates and phosphates.
At this time it was impossible to find the left ureter
and the patient was so much exhausted that no farther
examination was made. The bladder appeared per-
fectly normal except for a rather pale and anemic
patch where the left ureter would naturally be looked
for. A day or two afterward a second attempt was
made to find the left ureter but without avail. The
right ureter was catheterized again with practically
the same result. For nearly two weeks attempts were
made on each succeeding day to find the left ureter,
but no trace of it could be made out, although at each
sitting the orifice of the right ureter was plainly vis-
ible. Search was made for an abnormally placed
ureteral orifice in the urethra also. Various positions
were tried and various methods of catheterization were
equally unsuccessful.
Although a diagnosis of suppurative disease of the
left ureter and kidney had been made it seemed nec-
essary to make this diagnosis positive before so grave
an operation as nephrotomy or nephrectomy should
be undertaken. There was indubitable evidence of a
painful tumor in the left side of the pelvis about
where the ureter ought to be found, and this was also
the location of occasional spasmodic pains accom-
panied by a desire to urinate. The possibility of a
calculus in this portion of the ureter was kept in
mind and on March 11 the patient was prepared for
an anesthetic. On March 12 after a comfortable
night, during which about three pints of distilled
water had been taken by the mouth, and after the
colon had been flushed with very hot water, the patient
was anesthetized with chloroform and with the assist-
ance of Dr. Fletcher, Dr. D. H. Galloway and Dr.
Mary Bates the bladder opened along the line of the
old sutures by an incision long enough to allow the
finger to be passed into the bladder. The location of
the right ureter could not be felt. The orifice of the
left ureter was recognized by a hard mass in contact
with the wall of the bladder and by the resistance of
a line of scar tissue which extended about an inch
upward from the normal location of the orifice of the
left ureter to this hard mass. By means of a small
probe passed into the bladder under the point of the
finger the end of the scar was recognized as the con-
tracted orifice of the ureter into which the probe passed
with difficulty. The sound was withdrawn and a silver
ureteral catheter passed in its place. Three ounces of a
clear, watery fluid with a few shreds of pus then
passed out the catheter with considerable force. Two
ounces of this fluid were first secured for examination
and then the region of the kidney and ureter was
kneaded and one ounce of almost pure pus was forced
out by manipulation. A long flexible ureteral catheter
2 mm. in diameter and fifty centimeters long was
then passed in the place of the silver catheter and
pressed forward until it was believed to be in the
pelvis of the kidney and until it met a distinct resist-
ance. Through this catheter three ounces of warm
sterilized water was easily carried by gravity into the
pelvis of the kidney and then allowed to run out.
This was repeated several times. The catheter met
with no obstruction in its course through the ureter.
It was decided to leave this catheter in the ureter and
wash out the kidney for a day or two, hoping in this
way to save the kidney. This catheter and the irriga-
tion produced no pain.
The patient was put to bed in good condition.
The two ounces of fluid removed from the distended
ureter at this operation contained a considerable
amount of pus, a trace of albumin and some carbon-
ates and less than one-seventh the amount of urea
which normal urine contains. This pus was labori-
ously examined for tubercle bacilli by methods that
18%.]
SURGERY OF THE KIDNEY.
535
moved adequate with sputa, but none could be
found. This examination seemed to me to indicate a
nearly oomplete destruction of the left kidney. For
the tiist time 1 had in my possession the information
necessary to warrant the complete removal of this
kidney and its ureter. During the succeeding week
the patient's temperature never rose above 99.3 F.
and her pulse varied between 82 and 96 as shown in
the accompanying chart. (Fig. 1). She slept well.
The kidney was washed three or four times a day
with sterilized water or with a solution of permanga-
nate of potash. During all this time a thick green
pus poured oul of the catheter at the rate of about
one and one-half ounces per day but no urine escaped.
After trying this irrigation for a week without any
diminution in the amount of pus the catheter was
carefully removed. The urine and the antiseptics
which had been used had produced a hardening of
the catheter so that it was no longer flexible but con-
tinued to keep the shape it had been in during the
week. This made a very interesting cast of the ureter
and showed that the kidney was displaced forward
and thai the ureter made quite a sharp turn about
one and one-half inches from the end of the catheter
Fig. 1. Miss C.
and that it maintained during the rest of its course to
the bladder a rather broader excursion from the spine
than is normal. A drawing of this catheter on a
reduced scale with the supposed position of the kid-
ney and bladder is given below. (Fig. 2). While in
bed with the catheter in place an attempt was made
to take a skyagraphic picture of the region of the
kidney, hoping to demonstrate the presence or absence
of a calculus, but this experiment was without result.
The patient went home for a rest and was put on a
full diet with one quart of milk and a quart or more
of lithiated water each day.
On the first day of April the patient returned to
my care in St. Luke's Hospital for the removal of the
kidney. Examination at this time showed that 82
ounces, 2,624 cubic centimeters, of pale alkalin urine
with a specific gravity of 1.004 and no albumin, no
sugar and only a trace of pus and bladder epithelium,
were passed in twenty-four hours. This urine con-
tained 22.5 grams in twenty-four hours. The total
solids for twenty-four hours was 44 grams.
Her temperature on the night before the oper-
ation was 98.8 degrees F. and her pulse 82 to 94 and
her respiration 24 per minute. Several small doses
of calomel were given during the afternoon followed
by castor oil and in the morning an enema. The
patient was anesthetized with chloroform and an
oblique incision was made below the margin of the
last rib in the lumbar region and curved forward over
the crest of the ilium and then downward. The
muscles and fascia were divided down to the kidneys.
The kidney was carefully separated from its surround-
ings by breaking up the adhesion and drawn up into the
wound. During this manipulation the wall of the
kidney was ruptured and a considerable amount of
clear fluid apparently containing pus escaped into
the wound. A clamp was placed upon the very small
renal vessels and the kidney with the ureter attached
was separated and drawn forward. The ureter was
dissected out as low down into the pelvis as possible,
where it was found about the size of the patient's
middle finger, thin walled and at least 15 mm. in
diameter. The ureter was grasped with forceps, cut
off and its edges caught with catgut sutures and
turned in and the raw edges brought together with
sutures and tied. The end of the ureter was then
dropt into the pelvis. The patient stood the operation
very well but took the chloroform with some difficulty.
Fig. 2. Showing supposed position of catheter.
The temperature record during the succeeding four
weeks is given in the accompanying chart. ( Fig. 3 ) . The
wound healed up rapidly but there was a tender and
painful spot in the pelvis which was supposed to be
the end of the suppurating ureter and another opera-
tion was undertaken for the purpose of implanting it
in the vagina if it was found impossible to remove it.
This operation was done April 27. After the ordinary
preparation the day before, the patient was anesthe-
tized and an incision was made in the left cul-de-sac
of the vagina and the finger pressed in. A catheter
was again with great difficulty passed into the greatly
contracted orifice of the left ureter and distinctly felt
by the finger in the vault of the vagina. With the
finger-nail and a dissecting forceps the ureter was
loosened up as high as possible, but it was found to
be impossible to remove the upper end of the ureter
from its attachments. An artery forceps was passed
into the opening in the vault of the vagina by the
side of the finger until near the bladder it was felt to
grasp the ureter with the ureteral sound in it. The
sound was then removed, the artery forceps clamped
and the ureter cut off on the bladder side of the
536
SURGERY OF THE KIDNEY.
[September 5,
A
''''I'l'i'
<0
•?
I t 1 1 I I 1 1 I
•J
forceps. By means of several sutures the end of the
ureter was pulled down and fastened into the vagina.
The contracted orifice of the left ureter in the bladder
seemed to promise closure without any manipulation
and it was let alone. The incision in the bladder
through which the left ureter had been catheterized
was then partially closed up and a catheter was left
in the urethra for drainage.
The patient again suffered a great deal from the
anesthetic, but otherwise did well. The temperature
chart shows her condition after this operation as long
as she remained in the hospital. The ureter remained
firmly attached in the vagina and no urine passed
from the bladder into the wound and there is every
reason to believe that the left ureteral orifice in the
bladder is closed up. The suture of the bladder, how-
ever, was not successful and it all opened in three
or four days. After so many examinations and so much
operative procedure the patient lost spirit and strength
and she was sent home to recuperate. The urine has
Fig. 4. Diagram of Kidney and Ureter. 1, 2, S, Cysts not connected
with ureter; 4, slightly dilated pelvis; 5, partially functionating rem-
nant of kidney; 6, encysted fatty degenerated material; 7, greatly
thickened ureter ; 8, masses of fat and connective tissue ; 9, the relative
size and thickness of dilated ureter.
been examined several times since the operation and
it is entirely free from abnormal constituents.
The accompanying sketch (Fig. 4), gives a fair
idea of the cystic condition of the kidney. The
upper two- thirds of the kidney were entirely destroyed
and the place of the normal elements of the kidney
was filled with eight or ten cysts, some of them, at
least, did not open into the pelvis of the kidney at
all. One cyst contained a white cheesy substance
which was insoluble in either cold or boiling hydro-
chloric acid or in dilute hydrochloric acid cold or boil-
ing, or in cold or boiling nitro-hydrochloric acid, but
turned yellow in the latter, or in cold or boiling
water; or in cold or boiling alcohol; or in cold or
boiling carbon disulphid. It was disintegrated and
partly soluble in 5 per cent, solution of caustic pot-
ash. Its color was not changed by iodin. Under the
microscope it was granular, but on pressure of the
18%.]
SURGERY OF THE KIDNEY,
537
■cover glass it beoame homogenous like lard. Tubercle
bacilli oould not be found in the cyst contents. In
the lower part of the kidney there was a mass of fatty
•degenerated substance and close to it, marked 5,5,
two bits of functionating kidney substance. No
valve formation could be demonstrated in the case of
the single cyst which opened into the pelvis of the
kidney and the other cysts were certainly entirely
separated from the pelvis and from each other. The
ureter as it left the pelvis of the kidney had a diame-
ter of 1 centimeter and a caliber of less than 1 milli-
meter. Three inches lower down the walls of the
ureter were 1 millimeter only in thickness and the
diameter of the ureter was 1)5 millimeters. A seg-
ment of this ureter near the pelvis of the kidney is
shown in (Fig. 5). In the section of the ureter, the
plications of the mucosa occupy a little more than half
the thickness of the tube. The mucous membrane is
Fig. 5. Segment of the ureter an inch trom the pelvis of the kidney
drawn with the camera lueida and half-inch objective. This drawing
shows two defects in the mucosa and adjacent inflammatorv areas,
reachiug out beyond the muscular layer. Atheromatous arteries are
also shown and lymph spaces filled with leucocytes.
intact for the most part and is covered by a regular
layer of cylindrical epithelium overlaid by a fold of
elastic connective tissue. This is surrounded by a
double layer of muscular tissue in which are blood
vessels and lymph channels. The pathology of this
ureter seems to consist in increase in all the tissues
beyond the cylindrical epithelium, in defects in the
mucous membrane in places, and in masses of inflam-
matory tissue containing lymphoid cells which have
infiltrated the muscular tissue outward from these
defects in the mucosa. The active cells seem to pene-
trate between the bunches of muscle fibers and fill
the intermuscular spaces. The blood vessels in places
show advanced endarteritis and they are surrounded
by inflammatory tissue, the cells of which take on a
strong stain. Even outside of the outer layer of
muscles are masses of leucocytes grouped about
defects or openings in the bundles of muscular tissue.
"Of the 63,000,000 persons living to-day in the
United States 9,000,000 or more will die of tubercu-
losis. This would mean about 150,000 deaths from
this disease each year." (Victor C. Vaughan). It is
probable that one out of every sixty of the inhabi-
tants of this country or of the world is in the process
of dying of this disease. The number of persons
actually infected is much greater. Probably one-half
or three-fourths of the inhabitants of cities are tuber-
cular. It is not a wonder therefore that renal tuber-
culosis is a common disease. Dickinson ' gives the
result of the examination of 600 consecutive post-
mortems in two London hospitals, 300 were individu-
als over 12 years of age and 300 under 12 years of age;
180 of these individuals were tubercular, 126 under
12 and 54 over 12; 66 had renal tuberculosis, 49 under
12 and 17 over 12. In the young, males and females
are attacked by renal tuberculosis with equal fre-
quency. Among adults men are much more frequently
attacked than women. Dickinson saw 44 cases in
men and 23 women. Emil Palet2says that of 100
cases of renal tuberculosis studied by him only 16
proved to involve both kidneys, while in another series
of 42 fatal cases operated upon, all were onesided
except 12. Two thousand two hundred and thirty-
one cases were treated in St. Thomas's Hospital :i dur-
ing the year ending Dec. 31, 1890, among which
were the following:
Sarcoma of the kidney, 1; tubercular disease of
the bladder, 2; hematuria, 4; pyuria, 2; renal calcu-
lus, 1; tubercular kidney, 1; pyonephrosis, 4; renal
sinus (tubercular?) 1.
During the six months ending July 1, 1890, there
were 3,860 patients treated in the Cook County Hos-
pital, * among which were the following:
Perinephritic abscess, 1; movable kidney, nephror-
rhaphy, 4; cirrhosis of kidney, 4; acute nephritis, 8;
chronic nephritis, 34; pyelitis, 1.
During the six months ending December 31, 1890,
3,823 cases were treated, among which were the fol-
lowing :
Movable kidney, 3; perinephritic cellulitis, 3; rup-
ture of the kidney, 4; cirrhosis of the kidney, 1;
acute nephritis, 7: chronic nephritis, 56; pyonephro-
sis, 3; renal abscess, 1; renal colic, 1; tuberculosis of
kidney, 1.
This disease begins as a metastatic focus in the
kidney usually after an injury or at a time when the
vital resistance is reduced by some intercurrent dis-
ease, or it arises from an extension upward of a tuber-
culosis from the epididymis or seminal vesicles through
the prostate, bladder and ureter in the male, and from
the urethra through bladder and ureter in the female.
The greater number of cases are of renal orgin. There
may be some doubt of the secondary metastatic nature
in some cases, but the frequency of a preceding
injury, a preceding infectious disease and a latent
tuberculosis elsewhere speaks strongly for the metas-
tatic origin.
Much has been written of gonorrhea and tubercu-
losis acquired at the same time. There is reason to
look with some suspicion on these observations on
account of the difficulty of distinguishing the tubercle
bacillus from the smegma bacillus.
I Dickinson, W. H. : On renal and urinary affections N.Y. Wm. Wood
& Co. 8 p. 87.
' Palet, Emil:Des resultatsimmediatset eloignesde la nephreetomte
dans la tuberculose renale. These, Lyons, 1893. .
3 Hadden and Anderson : St. Thomas Hospital Report, Vol. 20, 18M2
538
SURGERY OF THE KIDNEY.
[September 5,
The clinical history of these cases is illustrated in
my cases and in those which- every physician will
revive from the memory of his own practice or from
his reading. The beginning is insidious. There is
usually a slight rise of temperature and some discom-
fort, sideache, backache, dragging or burning pains in
the abdomen; but in other cases these symptoms are
entirely wanting and the first symptoms are cystitis
and pus in the urine. The diagnosis of renal tuber-
culosis presents the greatest difficulties and until very
recently its absolute accomplishment has been declared
by nearly all authors impossible in its early stages.
Since the ureteral catheters of Pawlik and Casper
have come into use an absolute diagnosis is certainly
possible in many cases and in all cases the diseased
condition of the tubercular organ can be detected and
the healthy and competent condition of the opposite
kidney can be established. This method is illustrated
in my cases. On men it is necessary to use Casper's
instrument.
The symptoms of renal tuberculosis are easily rec-
ognized, the fever, the pain, heaviness or tenderness,
the cystitis, the pus in the urine and the granulating
or inflamed condition of that portion of the bladder
into which the ureter from the infected kidney opens.
Fir,. 8. Renal vessels divided and ureter freed down to brim of
the pelvis.
The urine should be allowed to settle and the sedi-
ment precipitated by the centrifugal machine. The
precipitate should be examined for tubercle bacilli.
They may be found and then may be overlooked. If
they are found it must not be forgotten that some of
the best observers have mistaken the smegma bacillus
for the tubercle bacillus. Mendlesohn ' lately dem-
onstrated a kidney removed a few days previously
from a patient with the following interesting history.
She had noticed that there had been some pus in
the urine for months. There was some pain but no
tenderness. The urine was found full of pus, fatty
acid crystals, red blood corpuscles and oxalate of lime
crystals. The Casper cystoscope was used and the
normal rhythmic flow of urine from the right ureter
was observed, while from the left ureter there passed
out a steady stream of thick greenish pus that settled
down into the bottom of the bladder. The ureters
were catheterized and the urine from the right ureter
found to be normal, clear and abundant, while pus
alone was secured from the left kidney. Tubercle
bacilli could not be discovered in this pus though
* Mitchell. Louis J.: Medical and Surgical Keports, Cook County Hos-
pital, Vol. 1, 1890; Vol. 2. 1891.
t Mendlesohn : Berlin klinische Wochenschrift, April 27, 1896.
they had been found in the urine before catheteriza-
tion of the ureters. The diagnosis was, however, con-
sidered absolute, namely a tuberculosis of the left
kidney with complete destruction of its function and
a healthy and competent right kidney. The left kid-
ney was extirpated and the kidney substance found
almost completely destroyed. Two stones were found
in the pelvis.
Professor Leyden in discussing this case called
attention to the great difficulty of making a positive
diagnosis of renal tuberculosis by examining the excre-
tions from the kidney and finding the tubercle bacil-
lus on account of the almost omnipresence of the
smegma bacillus in pyelitis and the great similarity
of this organism to that of tuberculosis. It is true
there are differences; the smegma bacillus is more
delicate and does not exhibit the granular divisions
that the tubercle bacillus does, but the staining reac-
tions are the same. Leyden thinks that the only
reliable method of identifying the tubercle bacillus in
such cases is by inoculation of animals. Senator and
Konig agreed with Leyden.
Casper6 gives an account of an interesting case
illustrating the proper method of making an accurate
and absolute diagnosis and as it brings out some new
points it may be well to briefly abstract it here.
The patient was a woman 42 years old who had been
well until six months before. At that time she took
cold and had a catarrh of the bladder with painful
urination and turbid urine. Then followed pain in the
right side, with a sensation of tension. Irrigation of
the bladder was tried without avail and at last through
palpation some disease of the right kidney was diag-
nosed. When Casper first examined the patient he
found her an undersized, delicate but apparently well-
nourished and sound woman. She complained of pain
m the abdomen, especially on the right side. The
pain, she says, comes on with exercise and motion,
and she is free from pain when resting in bed. Turn-
ing in bed, however, brings on the pain. Sometimes
she is entirely free from pain whatever she does. She
urinates oftener than formerly, during the day every
three hours and two or three times at night.
The urine removed from the bladder with a catheter
was slightly turbid, acid, specific gravity 1.018. It
contained many pus corpuscles, some caudate epithe-
lium, but neither red blood corpuscles nor casts.
Albumin was present in considerable quantities.
Tubercular bacilli were found in the sediment thrown
down by the centrifugal machine. Palpation disclosed
nothing abnormal. The kidneys could not be pal-
pated. Neither the kidneys nor the region of the
bladder were tender on pressure. The genital appar-
atus was apparently sound.
Casper's cystoscope was used to introduce 200 cubic
centimeters of boracic acid solution into the bladder.
This solution by irrigation quickly became clear and
the surface of the bladder, except in the neighborhood
of the right ureter, was seen to be perfectly smooth,
whitish-yellow and glistening. Under the mucosa,
the blood vessels could be seen as usual. In the
locality where the right ureter ought to have been
found, however, there was a granulating mass and the
mouth of the ureter could not be seen. The mouth of
the left ureter could be easily observed giving out
every few seconds a spurt of clear urine. In the
neighborhood of the granulation tumor around the
» Casper, I..: Die friihe und exude Diagnose der Tnberculose des
HarnlractU8, Berlin, klluische Wochenschrift, April 27, 1890.
1896. ]
SURGERY OF THE KIDNEY.
539
in. mill of tlic right ureter occasional whirls of fluid
■could be seen as if the ureter was discharging there.
On the following day the left ureter was easily
oatheterized and a clear normal urine removed. The
righl ureter was also oatheterized by manipulation)
though the mouth of the ureter could not he seen.
Turbid urine containing pus and albumin was with-
drawn, but tubercle bacilli could not he found in this
.specimen. Three days later the right ureter was again
oatheterized and the urine found to contain tubercle
bacilli and a larger proportion of urea than the bladder
urine. A diagnosis of tuberculosis of the right kid-
ney and circumscribed tuberculosis of the bladder was
made This patient was operated upon afterward and
the right kidney removed. It was covered with tuber-
Fn;. 7. Opening of vaginal vault to bring the extremity of ureter
into vagina. The assistant's hand and scissors in vagina, operator's
hand in lumbar wound after removal of kidney and abdominal portion
of ureter.
oles and two cheesy foci were found in the parenchyma.
The patient recovered and is well. The pain is gone
and the urine clear.
When an absolute diagnosis of tuberculosis of one
kidney has been made and when an equally positive
demonstration of the healthy condition of the oppo-
site kidney is at hand, then alone are the indications
positive and absolute for the removal of the diseased
kidney and ureter. This diagnosis may be tabulated
as follows:
a. Tuberculosis of one kidney (absolute) secreting
little or no urine.
b. Healthy condition of the other kidney secreting
a normal amount of urine containing average amount
of normal constituents.
0. Bladder only slightly involved near the ureter of
sick kidney, patient otherwise in good condition.
i Indications. Prompt removal of diseased kidney
and ureter.
It may be asked on what data these indications
depend; this study is of sufficient clinical interest to
go into it more fully. The following questions will
be asked and answered:
1. What is the course and duration of primary
tuberculosis of one kidney if left to itself or treated
medically ?
Dickinson says all his cases terminated in death
within four years after the onset of the disease. Bel-
field ' says the disease always tends to a fatal termin-
ation; this end may, however, be delayed several years
and cases are known in which the disease lasted ten,
fifteen and seventeen years.
Tuberculosis elsewhere in the body is a progressive
and destructive disease. It begins in the parenchyma
of the kidney and advances through the ureter into
Fig. 8. Removal of the lower end of the ureter through the vagina
distended with three retractors. The entire remnant of the ureter to
be removed through incision in vault of vagina marked by dotted lines.
the bladder. Then it advances up the other side, but
before this is accomplished the peri-renal tissues are
invaded by the lymph channels, or the toxemia of sec-
ondary infection of the tubercular urinary tracts comes
on together with temporary renal insufficiency and
the exhaustion of cystitis.
2. What is the prognosis under nephrectomy ? Very
little statistic material is at hand. Palet (1. c.)
records eight cases of death from general tuberculosis
during the first six years after operation out of a total
136 cases operated upon, but the methods of diagnosis
in those cases were imperfect as is shown by the fact
that in seventeen cases nephrectomy was done with
7 Belfleld, W. T. : Diseases of the urinary and male sexual organs,
N. Y., 1881, p. 254.
540
SURGERY OF THE KIDNEY.
[September 5,
the other kidney so diseased that death from anuria
followed immediately. In twelve of these seventeen
cases the disease of the other kidney was tubercular.
There is an analogy which may be useful in this
connection. The removal of local tubercular disease
elsewhere in the body gives very good results. Tuber-
cular foci in bones, tubercular lymph-glands and
tubercular disease of the skin and mucous membranes
can show a very large percentage of permanent recov-
eries after local mechanical removal.
Since there is only a small chance of life and that a
very painful and miserable life, if the disease is let
alone, and since the removal of the diseased kidney
promises both theoretically and practically a great
increase in the length of life and a greater improve-
ment in its quality through relief from pain and the
toxemia of secondary infection, therefore in descend-
ing tuberculosis of one kidney with a competent kid-
ney on the other side ■nephrectomy should be 'promptly
performed.
The 136 cases reported by Palet had so high a death
rate that one would be slow to undertake the opera-
tion even on the above indications. When we come
to analyze the deaths a different conclusion may be
reached. Of the fifty-one deaths, seventeen died of
anuria through disease and resulting incompetency of
the other kidney. All of these cases could have been
eliminated by the use of the ureteral catheters. Shock
was the cause of death in eleven cases and usually in
abdominal nephrectomy. The statistics are all against
this method, which was used twenty-two times in
Palet's series. In four cases death was due to unfore-
seen accidents, and in seven cases no postmortem was
made.
In fifteen of Palet's cases fistula remained a long
time, due, he thinks, to the tubercular stump of the
ureter. On account of this unpleasant sequela and
the danger which the tubercular stump might be,
Howard Kelley's method of removing the ureter
through the vagina should be used in all cases of
nephrectomy for tuberculosis of the kidney in women.8
This is done by following the ureter down with the
fingers after tying of the renal vessels and bringing
out the kidney. The stages of this operation are
beautifully described and illustrated by Dr. Kelley.
A reproduction of sketches of these pictures and a
synopsis of one case will best give an idea of this
exquisite procedure.
The patient was an unmarried woman, 23 years of
age. As a child she began to complain of pain and
weakness in the back, which compelled her at 9 years
of age to remain in bed six weeks. She suffered from
frequent urination, which was markedly worse after an
attack of scarlet fever when she was six years old.
For four years she has urinated so frequently that she
could pass but a few drops at a time with great pain.
A year ago she had an attack of spasmodic pain in the
region of the left kidney, accompanied by vomiting
and followed by pain in the bladder. These attacks
have been frequent since, some time occurring as often
as once a week. The attacks lasted from one to three
hours.
Repeated examination of the urine showed it to be
always acid, amber colored, containing albumin, pus,
hyalin and granular casts, and had a specific gravity
varying between 1.015 and 1.020. By vaginal palpa-
tion the left ureter was found transformed into a cord
« Kelley. H. A. : Nephro-urecerectomy. extirpation of the kidney and
ureter simultaneously. Johns Hopkins Hospital Bulletin, 18»i, p. 81.
three times the normal size. On the right side the
ureter was not sensitive and not enlarged. The left
kidney could not be palpated. The left ureteral orifice
was found by cystoscopic examination deeply injected
and surrounded by an area of granulation tissue two
centimeters in diameter and extremely sensitive to
touch and bleeding easily. The ureteral catheter
was passed into the right ureter and normal urine
obtained, but it was found impossible to catheterize
the left ureter, either by sight or touch. No tubercle
bacilli could be found.
In view of all these facts it was nevertheless decided,
to remove the kidney and ureter and that portion of
the bladder that seemed to be infected with the tuber-
cular disease. The operation was performed Dec. 18,
1895. The incision commenced just in front of the
vertical muscles of the back at the costal margin and
downward toward the middle of the ilium crest, and,
then in a gentle curve around the anterior spine and
two centimeters from it and from this point in an
oblique line downward to the lower terminus of the
left semi-lunar line an inch above the symphysis pubis.
The upper third of the wound was first made, the kid-
ney detached, the renal vessels tied, the kidney
removed and the ureter separated down to the pelvis.
The lower portion of the incision was then made, the-
ureter freed with the fingers,the round ligament pushed
aside, the uterine artery and veins ligated and divided,,
and the ureter clamped and tied two centimeters from
the bladder. The kidney with ureter 23 centimeters-
long was then removed. The assistant then punc-
tured the vault of the vagina and the lower end of the
ureter was brought into the vagina as shown in Figs.
7 and 8. No ligatures were used except those on the
renal vessels and the uterine artery and vein.
The pathologic examination demonstrated advanced
tuberculosis of the kidney, but tubercle bacilli could
not be demonstrated in the caseous material nor in
the milky fluid in which it was suspended. The
healthier portions were filled with many small white
tubercles. The upper portion of the ureter showed a
slight infiltration with leucocytes near slight defects
in the mucous membrane.
There are reasons enough to make the following
summary :
1. Tuberculosis of the kidney is a relatively com-
mon disease.
2. It usually begins in the kidney itself, descends-
through the ureter to the bladder and ascends to the-
opposite kidney.
3. It is, therefore, for a long time a unilateral dis-
ease.
4. It is a progressive and destructive disease not
subject to improvement through medication, offering-
an unfavorable prognosis as to life and comfort and
subject to extension downward by the urinary tract
and outward through the peri-renal lymphatics.
5. Diagnosis can be made through the symptoms-
of cystitis, with a low temperature, rapid pulse, dilata-
tion of the heart, the detection of tubercle bacilli in
the urine, tuberculosis of the bladder about the orifice-
of the ureter of the diseased kidney, pus or blood
with tubercle bacilli and diminished normal constitu-
ents in the urine from the diseased kidney; normal
urine in increased quantity from opposite kidney;
sometimes tenderness, pain and tumor in situ of dis-
eased kidney and ureter.
6. The indications in case of an absolute diagnosis-
of tuberculosis of one kidney and healthy opposite
18%.]
SYNOVITIS OF THE SHOULDER JOINT.
541
kidney are immediate removal of the diseased kidney
and its ureter; in case of disease in both kidneys, no
operation should be performed.
7. Tln> oompetenoy of the healthy kidney should
be proved by repeated catheterization of the ureters
before nephrectomy and the removal of all toxic ele-
ments from t lie blood should be secured by a liquid
diet, irrigation of the eolon and hydration of the whole
Bj stem for some days before the removal of the kidney.
S. Lumbar, extraperitoneal nephrectomy is the
safer operation.
9. In women the removal of the ureter should be
completed through the vagina.
10. Any remaining tuberculosis of the bladder should
be treated locally by curetting or cauterization.
11. Catheterization of the ureter is not a dangerous
procedure and it may easily be accomplished in women
with the simple evstoscope of Simon, Pawlik or
Kellev. and in men with the more complicated instru-
ment of Casper.
A
FEW REMARKS ON THE PATHOLOGY
OF SYNOVITIS HYPERPLASTICA
GRANULOSA OF THE
SHOULDER JOINT.
BY E. J. SENN, M.D.
Instructor in Surgery and Assistant to the chair of Practice of
Surgery, Rush Medical College.
CHICAGO.
Tuberculosis, which has such great predilection for
bones and joints, appears to prove the rule by its
exception as regards the shoulder joint. Its compar-
ative infrequency is shown from the fact that in the
surgical clinic of Gottingen from the years 1875 to
1891, there were only sixty instances of shoulder joint
tuberculosis; while during the period from 1875 to 1882
there were 174 cases of tuberculosis of the knee. In
the great majority of cases of tuberculosis of the shoul-
der joint, caries sicca, that peculiar manifestation of
this disease which was first so accurately described by
Volkmann, is almost invariably found. Caries sicca
is a very mild form of tuberculosis, consisting of
molecular decay with a consequent cicatrization, and
very frequently terminating in a spontaneous recov-
ery. Synovitis hyperplastica granulosa was called by
Billroth fungous synovitis. The tuberculous nature
of this affection was determined by Koster in 1869.
While it is very frequently found in the knee joint,
and is characterized externally by the white spindle-
shaped swelling, the well-known tumor albus of the
old authors; on the other hand, it is extremely rare in
the shoulder joint. The shoulder joint is a peculiarly
constructed joint. It differs from the other enarthro-
dial joints in that it has numerous bursse, which may
communicate with the joint proper, or if the communi-
cation is not complete, they form points of least resis-
tance for the dissemination of disease, the three most
important of which are the bursa synovialis subscapu-
laris, bursa synovialis intertubercularis and the suba-
cromial bursa. The capsular ligament is of considera-
ble laxity and admits of great distension. It is com-
posed of closely interwoven fibers, and is fixed to the
scapula above by being attached to the margin of the
glenoid cavity and the root of the coracoid process. Pos-
teriorly it is attached to the rough surface of the glenoid
process. Below the glenoid fossa, the capsule blends
with the origin of the long head of the triceps. Below
it is fixed to the anatomic neck of the humerus. The
capsule is strengthened materially by the tendons of
the shoulder muscles which pass over the capsule
from the dorsal and ventral surfaces of the scapula,
and are inserted into the tuberosities of the humerus.
With a brief review of the anatomy of the region, it
is more comprehensible to understand the emigration
of the tubercle bacillus into surrounding structures.
Fungous synovitis of this joint is found in adult life,
as a rule. The primary focus may be in the epiphy-
seal line of the head of the humerus, and secondarily
cause a synovitis fungosa of the joint cavity and its
adnexa. Osteal tuberculosis of this joint is almost
without exception found in early life, when the embry-
onic tissues of the epiphyseal line are undergoing
great transformation. The blood vessels are then
immature and favor localization of the specific microbe;
but even if the primary focus be of osteal origin, fun-
gous synovitis following is the exception, as osteal
tuberculosis of this joint is very prone to be of the
caries sicca type. On the other hand, synovial tuber-
culosis irrespective of location manifests itself during
adult life, and synovitis hyperplastica granulosa of
the shoulder joint is no exception. The primary focus
is in the innermost layer of the capsular ligament or
of one of the bursa?. The disease is inaugurated by
a slight hydrops, due to a pathologic secretion by
reason of microbic irritation. This catarrhal stage
does not last long before here and there the continu-
ity of the membrane becomes studded with minute
tubercles, the catarrhal synovitis now having merged
into a synovitis hyperplastica, s. pannosa. The mem-
brane becomes very thick and hyperemic, and in due
course of time the minute tubercles undergo casea-
542
ANTISTREPTOCOCCUS SERUM IN CONSUMPTION.
[September 5,
tion. If this pathologic process is not interfered with,
the endothelial cells assume great proliferative power,
and as a result the capsule becomes filled with tuber-
cular granulations; the evolution from a catarrhal
synovitis into the pannus type, and lastly into the
synovitis hyperplastica granulosa. The granulation
masses do not only extend into the joint cavity itself,
but also infiltrate into the subsynovial layer; especially
is this the case where the subsynovial fat is abundant.
The para-capsular tissues become edematous. If any
of the bursas have direct communication with the joint
there is immediate extension of the disease, while if
there are delicate septa intervening, they give away
to the pathologic pressure. As a consequence, the
whole shoulder region becomes immensely swollen,
the normal contour being entirely lost. If the sub-
acromial bursa is concerned, the prominences of the
acromion and coracoid can be elicited only with great
difficulty. The consistency of the swelling is vari-
able. It may be quite tense, reminding one of the
tumor albus of the knee joint; or it may be fluctu-
ating, manual palpation giving the hand the sense of
a cavity containing fluid. This is not true fluctua-
tion, but pseudo fluctuation caused by intra- and
extra-capsular granulation masses. Upon exploratory
puncture with a trocar, there can be forced out of the
canula a few granulations, fibrin and detritus inter-
mingled with synovial fluid, if a portion of the syno-
vial membrane remains intact. Akido-peirastic gives
information as regards the density of the swelling.
The supra-clavicular and axillary glands in the course
of time become hyperplastic. There is often great
pain in the region of the brachial plexus due either to
a neuritis or pressure. The swelling in this region
should not be confounded with sarcoma of the epi-
physis of the humerus, a very rare disease indeed.
Here the capsule is also filled with effusion. After
the capsular ligament and the bursje become destroyed,
the cartilages and even- the bone itself become impli-
cated.
The case illustrated is a patient who was in my care
a few months ago. It is typical of this disease and
is especially interesting in that both shoulders were
affected. The swelling and edema were enormous on
the right side, the disease being in its incipiency on
the left. The principal bursa? were involved, also
the para-articular structures, especially those poste-
rior to the joint.
ANTISTREPTOCOCCUS SERUM IN THE
TREATMENT OF CONSUMPTION.
BY W. H. WEAVER, M.D.
CHICAGO.
For the past decade and more the tubercle bacillus
has been studied and discussed to such an extent that
the presence and activity of other germs as factors in
the pathologic processes occurring in consumption
were entirely disregarded. That the tubercle bacillus
is present and determines the general character of
the disease by initiating the inflammatory action is
admitted. Tuberculosis of itself is not a suppurative
process, hence the appearance of pus in the sputum
must be considered as the beginning of a secondary
infection which is more rapidly destructive. I believe
that a simple tuberculosis of the lung is a mild dis-
ease and easily cured if proper antiseptic and hygienic
measures are pursued. But it is sel'dom that a case
of simple tubercular phthisis in the earlier stage comes
to the physician. It is only after the complications
begin that the patient feels sick enough to consult his
medical adviser. It is a question just when the strepto-
coccus complication occurs in any particular case; but
with the onset of fever and purulent expectoration may
be found the streptococcus in the sputum. Dr. Prudden
last year showed that the rapid inflammatory symp-
toms with cavity formation were due to the pyogenic
action of the streptococcus. . These destructive pro-
cesses are slow or rapid according to the activity of
these pyogenic germs. This germ activity must be
checked and if possible abolished if the physician is
of any assistance to his patient.
When the streptococcus infection accompanies the
tubercular process from the beginning with high
temperature and active germ life the invasion and
destruction of lung tissue is rapid, and the case is one
of rapid phthisis. Just why this germ activity is
greater in one case than another, is a matter for
future determination.
Now, antistreptococcus serum as prepared by Mar-
morek has the property of killing the streptococcus-
in the blood and the tissues while it is absolutely
harmless to the patient. It can be used in conjunc-
tion with any other treatment, and gives immediate
results. It may be expected from the administration
that by the following day the temperature will be
greatly reduced; also there will be a considerable
reduction in the amount of expectoration. By the
end of two weeks the expectoration will be reduced
from 50 to 75 per cent, less offensive and less puru-
lent. The cough will also be less harassing and
frequent and the patient improved in every way.
These results must be the more permanent when
the serum is used early in the case. The cases in
which I used it were all necessarily fatal cases, one
having intestinal tuberculosis and the other two far
advanced, with large cavities, and great emaciation.
Case 1. — Mrs. N. D., age 28, a case of rapid phthisis with
extensive cavity formation in the right lung and consolidation
of the left upper lobe. Temperature range of 7° F. and pulse
120 in the morning to 150 in the afternoon. Examination
showed the sputum to be almost a pure culture of tubercle
bacilli. June 25th, antistreptococcus serum was given and
repeated every second day for three doses. After this the tem-
perature remained below 100 for two weeks and the expectora-
tion and cough was greatly reduced. The patient's general
condition was greatly improved by the use of serum.
Case 2. — H. C, age 20, has had consumption for about six
years, with a large cavity formation in the right lung, constant
cough and expectoration, emaciation and loss of appetite.
There occurred in this case a peculiar form of septic absorp-
tion which resulted in multiple inflammatory foci about the
face, scalp and neck, which would certainly have resulted in
abscesses but for the use of antistreptococcus serum. After a
single dose of the serum the deposits disappeared, the temper-
ature which was above 101 F. reduced to below 100 F. Expec-
toration was greatly diminished and considerable general
improvement established.
Case 3. — Mr. E. E. , age 22, had consumption for about one
year, tuberculosis affecting the right upper lobe. For over one
month has had tubercular diarrhea. The use of the serum in
this case reduced the cough and expectoration about one-half
and gave great relief, which continued up to the day of his
death, two weeks later.
It will be observed from the nature of the disease
under consideration and the remedy itself that it is
not proposed as a cure for consumption in the sense
of a specific, but as a valuable remedy for some of
the most terrible complications which occur in the
course of the disease. I am thoroughly convinced
that by the intelligent use of this serum together
with other appropriate treatment the ulcerative com-
plications as well as the disease itself may be robbed
1896.]
RESECTION OF HUMERUS.
543
of at least some of their terrors and disastrous results.
Willi this serum as with serum therapy in general
the earlier it is used the bettor the results attained.
l-.v, State Street
RESECTION OF TWO INCHES OF THE
111 Ml m IS AND WIRING, WITH A
REPORT OF A CASE OF WIRING
OF THE CLAVICLE FOR UN-
UNITED FRACTURE.
BY STEWART L. McCUKDY, A.M., M.D.
Orthopedic Surgeon to Presbyterian Hospital, Member American Ortho-
pedic. American Medical, and Allegheny County Medical Socie-
ties; Protestor Anatomy and Oral Surgery, Pittsburg
Pental College, etc.
PITTSBURG, PA.
It is a matter of selection, after excision of joints or
resection of bones, whether nails are selected to secure
the bones, or whether wire is used.
Possibly I am stating the facts, when the statement
is made that the majority of surgeons prefer spikes to
wire. Especially is this true for excisions of the
knee.
It is not the adaptation of bones after excisions for
chronic tubercular disease, I desire to consider, but
rather the use of wire for the treatment of compound
and irreducible fractures.
Ft*. I
That it is possible for me to secure a more perfect
adaptation of bones by the use of wire goes without
further discussion. That other operators can not get
as perfect results with wire and use spikes instead,
also goes with saying. Whether these men have tried
wiring and discarded it for the nails, I am unable to
say. To attempt to do a bone wiring without the
proper instruments would be as difficult as to do a
vaginal hysterectomy without an equipment.
To Dr. Win, F. Fluhrer of New York, must be
given the credit for perfecting instruments for bone
wiring. In order that bone wiring might be speedily
done it is necessary to use a notched drill. It is an
easy matter to pass a drill through a bone, but it is
not such an easy matter to keep the drill hole pervi-
ous or reenter again after the drill has once been
withdrawn.
As will be observed the drill is notched near the
point. After it passes through the bone a silk thread
is thrown around the point and allowed to engage in
the notch, after which it is withdrawn. The drill
hole once loaded with silk, the wire is attached and
drawn through either way as desired.
Case 1. — Mr. P. P., aged 35, was thrown from a carriage and
received a dislocation of the left shoulder and fracture of the
left clavicle. After reduction of the dislocation the shoulder
recovered promptly. The displacements of the fragments in
the fractured clavicle were so great that no effort was made by
nature to repair the injury. About six months after the orig-
inal injury he was again injured and the shoulder was dis-
located. The ununited fracture of the clavicle was more 'bT
less disturbed.
The fracture was painful at all times when the arm or
shoulder was moved. The internal end of the external frag-
ment appeared to be sharp and the patient, if he had had the
fr'%«2.
.ilr jj., , r^ftfr ,u_^> r*ss
power in the arm, could not work on account of the pain caused
by the motion.
A study of the anatomy of the parts (Fig. 3) shows that the
free eDd of the under fragment was pushed down on the tissues
overlying the subclavical artery and brachial plexus, when
even the arm was elevated. Operative interference was advised
for two reasons : 1, that union of the bones might be
544
SELECTIONS.
[September 5,
secured ; 2, that the pain caused by the projecting end of the
bone might be relieved.
Operation : Free longitudinal incision was made along the
clavicle and the ends were dissected out. The ends were
sawed off by the use of a chain saw. The bones were drilled
and brought together with silver wire.
Result : Union was perfect, and the wound healed without
suppuration. The arm is practically as good as before the
injury. The wire was subsequently removed.
Case 2. — H. B., aged 30, brakeman, received an injury of his
left thumb while making a coupling. The muscles of the
palmar surface of the thumb were squeezed through the skin,
and the bone was broken ; the thumb was practically torn off.
Preparation was made to amputate. While my assistant was
Fig 4.
anesthetizing the patient, it occurred to me that wiring might
save the thumb, and the latter operation was done. In six
weeks the wound had entirely healed and in three months the
thumb was as well as before the accident, save some limita-
tion in extension as a result of the extensive laceration of the
muscles. This was my first wiring and was done in June, 1885.
Figurk 5.
Case 3. — D. W. C, aged 37 years. The contents of a shot-
gun had passed through the arm internally to the thickest por-
tion of the biceps and making its exit near the insertion of the
deltoid. The humerus was entirely torn off ; the patient
favored amputation at my first visit, but we concluded to
adjust fracture and wait for results.
The bones showed no signs of union, and the case was com-
plicated by a severe hemorrhage three weeks after the injury,
and at this time the patient insisted upon amputation. I
assured him that amputation was not demanded, but instead
I would advise excision and wiring, which operation was done,
three weeks after the injury.
Two inches of bone were removed (Fig. i), and the bone
adjusted the wire. The ends of the bone were ragged and
showed no evidence of repair.
The case from the date of wiring did not have an
unfavorable symptom, and in six weeks was entirely
healed.
The man is a farmer and has made a full hand at
every kind of work ever since. The two inches of
shortening did not interfere with this in the least.
(See Fig. 5.)
Description of cuts: Fig. 1 shows notched drill, the
wire and silk and the method of attaching them.
Fig. 2 shows, diagrammatically, the method of loading
the drill hole with the wire as the drill is withdrawn,
as well as other steps in wiring. Fig. 2 E shows the
bone removed in the clavicle case.
SELECTIONS.
The French National Population Alliance. — The London Times
states that an organization, with medical men at its head, has
been formed in Paris to stay the French population's decline.
The organizers are Dr. Jacques Bertillon, chief of the bureau
of statistics of Paris, Dr. Charles Richet, professor of the
faculty of medicine in the same city, and Dr. Javal, member of
the Academy of Medicine. For years these men have noticed
with regret that the population of France was not increasing
proportionately with the population of other countries, and
now they come forward with what they believe to be an infalli-
ble remedy for this evil. That some drastic remedy is needed
they insist, as otherwise France must soon sink to the rank of
a second rate, or even a third rate nation. A hundred years
ago the great countries, in other words, the great powers of
Europe contained 98,000,000 inhabitants, of whom 26,000,000,
or 27 per cent., were residents of France. To-day these same
countries contain 300,000,000 inhabitants, of whom 38,000,000,
or only 12 per cent., live in France. These figures speak for
themselves, and the obvious conclusion, according to Dr. Ber-
tillon and his colleagues, is that if the births continue to
decrease at the same ominous rate, France, which was once
one of the most powerful countries in Europe, will soon be one
of the weakest. These gentlemen have begun their novel
campaign by founding a society which is styled "The National
Alliance for the Relief of the French Population." The
defensive measures which they propose to adopt are numerous,
but for the immediate present they will confine their attention
to three points : 1, they will try to get the laws relating to
inheritances greatly modified ; 2, they will try to get all direct
taxes removed from those families which have more than three
children, and 3, they will try to have the laws relating to suc-
cession duties thoroughly reformed. As it is manifest that the
nation's treasury would be seriously affected by the removal
of taxes in the case of all families which have more than three
children, it is proposed to place a tax of 1-5 per cent, on all
families which are childless, or have only one or two children.
There is said to be excellent reasons for these proposed
reforms. The larger a man's family is in France, we are told,
the more he is taxed, both directly and indirectly, with the
result that thrifty parents do not care to have many children.
Moreover, the parents' property must be divided among the
children, and if the children are numerous and the property
small, the disastrous results can easily be foreseen. In other
countries the law of entail is maintained pretty rigidly and
though its operation seems hardly equitable or natural, as
regards younger children, it certainly seems to act in some
degree as a preventive of depopulation. "Remove all burden-
some taxes from fruitful families," say the members of the
National Alliance, "and let Frenchwomen and Frenchmen know
that even from a monetary point of view, it will be fortunate for
them to have many children. Then as the national treasury
must be supported, let us tax those adults who have few or
1896. |
SELECTIONS.
545
no children. Persons who have no children, or only oneor two
children, may reasonably be required to contribute a goodly
quota toward the support of the state, whereas it is improper
and unjust to expect any support from those parents who have
to provide for numerous children. Do this, and Frame will
soon become, as she was in the past, one of the greatest pow-
ers in Kurope ; fail to do this, and France will soon sink to the
level of Denmark, Belgium or Holland." The members of the
alliance intend to hold several public meetings and to publish
several pamphlets setting forth their views. They offer mem-
bership to all who eare to assist them, irrespective of creed or
political opinions. Many persons throughout France have
already announced their adhesion to the program of the Alli-
ance, and it is confidently expected that in the near future the
necessary bills in regard to succession duties and the abolition
of taxes will be presented to the French legislature.
Cumol as a Sterilizing Agent. The American Therapist, July,
contains an interesting abstract of the work done at the Johns
Hopkins Hospital, by Drs. Clark and Miller, with the agent
above named. In January, 1893, a very serious reign of infec-
tion occurred in the gynecologic wards of the Johns Hopkins
Hospital, which was believed to be due to catgut prepared by
boiling in alcohol under pressure. The most perfect means of
sterilization of catgut for surgical purposes is, unquestionably,
by heat. Until the method of Benckisser and Reverdin, 1888,
it was considered impossible to raise any form of animal liga-
ture material to a temperature sufficient to render it sterile
without making it brittle. Reverdin demonstrated that it was
not the oil, as previously supposed, but the hygroscopic water
in catgut, which caused it to become brittle when heated. If
this is driven off by dry heat at a temperature of 70 degrees
C, it can be carried safely up to a temperature of 250 C, with-
out impairing its integrity. The complicated apparatus, con-
sisting of a hot-air oven and a thermo-regulator, however, pre-
vented the general adoption of the methods of these writers.
Brunner found that the boiling point of xylol was 136 to 140
■degrees C, and at once adopted it as a sterilizing medium, but
Kronig found spores occasionally present in catgut, which were
more resistant than the anthrax spores, with which Brunner
had experimented. "After a further research Kronig found
that the boiling point of cumol, a hydrocarbon compound,
ranged between 168 and 178 C, and substituted it for xylol.
After a careful review of Kronig' s article, his method was
adopted in the gynecologic department of the Johns Hopkins
Hospital. Kronig'e method is as follows : 1. Roll the catgut
in rings. 2. Dry it in a hot air oven or over a sand bath for
two hours at 70 C. 3. Heat it in cumol to a temperature (165
C.) a little short of the boiling point, for one hour. i. Trans-
fer it to petroleum benzine for permanent preservation, or if
desirable, leave it in benzine for three hours, and transfer the
sterile Petri dishes. A bacteriologic study of this method by
the writers shows that the sterilization by this method is per
feet, but that the transference from boiling cumol to benzine is
open to serious objection. Clark and Miller have found from
this investigation that benzine is not a germicide, also that it
can not be rendered sterile by heat without danger and, there-
fore, have found it necessary to modify the method of Kronig
as follows : 1. The catgut, twelve strands, is rolled in a figure-
of-eight form, so that it can be slipped into a large test tube.
2. Bring the catgut up to a temperature of 80 C, and hold it
at this point for one hour. 3. Place in cumol, which must not
be abov« 100 C, raise it to 165 C, and hold it at this point
for one hour. i. Pour off the cumol, and either allow the
heat of the sand bath to dry the catgut, or transfer it
to a hot-air oven, at a temperature of 100 C, for two hours.
5. Transfer the rings with sterile forceps to the test tubes
previously sterilized, as in a laboratory. In drying or boiling,
the catgut should not come in contact with the bottom or sides
of the vessel, but should be suspended on slender wire supports
or placed upon cotton loosely packed .in the bottom of the
beaker glass. Cumol, which is of a clear limpid or slightly
yellowish appearance when procured from the chemist, is
changed to a brownish color by boiling. The catgut is allowed
to remain in the sand bath until the excess of cumol is driven
off and it appears entirely free from any oily matter. A period
of one to two hours is usually sufficient to' dry it thoroughly.
From the sand bath or hot-air oven it is transferred with
sterile forceps to sterile test tubes, such as are used for cul-
ture media, in which it is preserved from contamination until
ready for use. Small quantities should be placed in each tube,
to obviate the necessity of opening them too frequently. In
conclusion, it is well to bear in mind that while cumol is not
explosive it is very inflammable, and great care should be
observed in lifting the wire screen from the beaker glass to
prevent drops of the cumol from falling in the flame or on the
heated piece of metal on which the sand bath rests, as it will
take fire, flare up and ignite the fluid in the beaker glass.
Such an accident has occurred three times in our experience."
There has been about one year of practical experience in the
wards of Dr. Kelly and others, and this has left the distinct
record of this agent as being the most satisfactory substance
that has come under their observation for the purposes above
described.
The Relation of the Urine to Disease. Dr. M. D. Hoge, Jr.,
brings together in the August number of the Virginia Medi-
cal Semi-Monthly a collection of diagnostic points showing the
effects of different diseases on the urine, with hints on treat-
ment.
Acute renal hyperemia.- Blood ; albumin (10 per cent, by
bulk) ; small hyalin casts ; quantity increased ; sp. gr. reduced ;
reaction acid. Treatment : Produce a skin reaction — warm
baths, pilocarpin, nitroglycerin, large quantity of pure water.
Passive renal hyperemia.— Quantity diminished ; sp. gr.1.025
1.030 : color dark ; reaction acid ; urates increased ; uric acid
crystals ; mucus increased ; albumin present, but small in
amount ; small hyalin casts ; a few blood corpuscles. Treat-
ment. Increase the arterial tension, digitalis.
Acute Bright' s disease. - Quantity diminished (at first) ; if
quantity increases, either recovery or chronic nephritis follows ;
sp. gr. increased (1.025-1.030) ; color dark red (blood) ; reaction
acid ; urea diminished ; albumin considerable ; hematuria ;
renal epithelium ; dark granular casts ; hyalin casts ; epithelial
casts. Treatment : Non-nitrogenous food, milk, digitalis,
lithia waters, small does of calomel, diaphoretics, hot bottles.
Chronic parenchymatous nephritis. — Quantity diminished ;
sp. gr. normal or diminished ; color lemon or dark brown ;
cloudy by transmitted light; albumin in large quantity ; urea
diminished ; chlorids diminished ; fatty degenerated kidney
epithelium ; dark granular casts ; hyalin casts j fatty casts.
Treatment : digitalis, large quantities of water, small repeated
doses of calomel, warm baths, jaborandi, nitroglycerin, non-
nitrogenous food, milk, iron, strychnin.
Chronic interstitial nephritis. - quantity increased or normal ;
color pale and transparent ; reaction acid ; sp. gr. below nor-
mal ; albumin, very small quantity ; very few hyalin casts ;
granular casts ; crystals of uric acid and calcium oxalate ; urea
diminished ; phosphates diminished. Treatment : Sympto-
matic, biehlorid of mercury in minute doses.
Amyloid kidney.— Quantity increased ; color pale ; sp. gr.
low (1.012) ; reaction acid ; albumin considerable ; hyalin
casts ; waxy casts. Treatment : That of causative disease.
Tuberculosis of the kidney. — Quantity increased ; pale milky
color ; sp. gr. lowered ; reaction alkalin : pus suspended ; hem-
aturia ; bacillus tuberculosis. Treatment : Symptomatic ;
improving the general condition.
Cancer of the kidney. — Hematuria ; albumin in small quan-
546
PRACTICAL NOTES.
[September 5,
tity ; quantity increased ; pus ; acetone ; kidney debris. Treat-
ment : Palliative ; extirpation.
Renal gravel. — hematuria ; quantity normal ; color dark red ;
reaction acid ; pus ; urates and oxalates ; small concretions ;
epithelium. Treatment : Restrict meat diet, no alcoholic or
acid drinks, bodily exercise, vegetable diet, milk, large quan-
tities of water, phosphate of soda, carbonate of lithium,
anodynes.
Uremia. — Urea diminished (200 to 50 grains) ; uric acid
diminished ; quantity diminished ; sp. gr. diminished ; albu-
min ; casts. Treatment : Diuretics, hydragogue cathartics,
diaphoretics.
Diabetes insipidus.— Quantity enormously increased (ten to
fifty pints) ; sp. gr. diminished ; no sugar, no albumin ; color
pale and clear ; reaction faintly acid ; urea increased ; phos-
phates increased ; indican. Treatment : Tonics ; valerian.
Diabetes mellitus. — Color light yellowish ; sp. gr. much
increased (1.030 to 1.045) ; reaction acid ; quantity much
increased ; sugar 1 per cent, to 8 per cent, (half a pound per
day) ; urea increased ; acetone and diacetone ; albumin (occa-
sionally). Treatment : Strict diet, opium, Fowler's solution,
cod liver oil, Silurian spring of Waukesha water.
Pyelo-nephritis ("surgical kidney"). — Color, dirty yellow,
pale and cloudy; foul odor; sp. gr. diminished (1.008 — 1.016);
quantity diminished ; reaction acid ; rapidly undergoes ammo
niacal fermentation ; urea diminished ; albumin present ; pus,
blood, epithelium ; casts of bacteria. Treatment : Astringents,
tannin, alum, lead, antiseptics, salol, chlorate of potash, milk
in large quantities.
Pyelitis calculosa. — Quantity increased; color pale straw;
sp. gr. diminished ; reaction acid ; pus ; albumin ; spindle-
shaped epithelium ; odor very offensive. Treatment : As above
for surgical kidney.
Cystitis. — Pus: blood; albumin: color light; reaction alka-
lin (chronic) ; sp. gr. diminished ; triple-phosphate ; bacteria ;
bladder epithelium. Treatment : Bodily rest ; light diet, large
quantities of fluids, chlorate of potash, salol, gelsemium, tur-
pentine, warm applications, washing out of the bladder, opium,
suppositories.
Febrile diseases. — Quantity diminished : color dark ; sp. gr.
increased ; urate deposits ; hyalin casts : albumin : acetone and
diacetic acid ; urea increased ; hemoglobin : grape sugar : phos-
phates diminished.
Anemia. — Quantity diminished ; color pale ; sp. gr. dimin-
ished ; reaction neutral or alkalin ; albumin (occasionally) :
hyalin casts ; urea increased, kreatinin.
Leukemia. — Reaction acid; uric acid increased; albumin;
phosphates increased.
Chlorosis. — Reaction alkalin ; kreatinin.
Scurvy. —Reaction acid ; pepton (constant).
Gout. — Uric acid diminished : phosphates diminished ; albu-
min ; hyalin casts ; oxalate of lime crystals.
Cirrhosis of the liver. — Quantity diminished ; urates (large
quantity); urobilin.
PRACTICAL NOTES.
Use of Argon in Gonorrhea. — Dr. George K. Swinburne recom-
mends the use of a 10 per cent, solution in the acute stages.
The inflammation is quickly allayed and the discharge rapidly
diminished. — Jour. Cut. and Genitourinary Dis., August.
Indications for Use of Papain.— Papain has been found bene-
ficial in gastric troubles caused by a lack of sufficient HC1
(dose from % to 1 gram three times a day), but it is absolutely
injurious where there is excess of HC1 or an ulcerous lesion. —
Semaine Mid., August 5.
Lactopbenin. — Dr. H. D. Peterson says clinical tests have
shown it to be of special value in relieving pain and reducing
temperature gradually and maintaining it at a lowered degree,
without frequent repetition. It is readily taken by patients
who can not take antipyrin. It is not disagreeable to the
taste and is easily administered. — Med. Recorder, August.
Results of Treatment of Whooping Cough with Ichttiyol. In eight
cases treated it materially diminished the frequency and the
severity of the attacks and shortened the course of the disease.
No inconveniences follow its use and the general health
improves. Dose, according to age, from 0.05 to 0.20 centigram a
day, increasing to 0.60 and 1 gram. — Semaine Mid., August 5.
Section of the Sympathetic in Exophthalmic Goitre. Jaboulay of
Lyons recently cured the exophthalmus, palpitations and
trembling in a case of exophthalmic goitre in a young girl by
cutting the cervical portion of the sympathetic on each side,
above the middle ganglion on the right and below it on the.left.
A slight, transient local congestion was the only inconven-
ience.— Semaine MM., August 5.
Experimental Extirpation of the Stomach and Intestines. Monari
has been experimenting on dogs since 1892 to determine the-
effects produced by removing the stomach and intestines. He
announces that the metabolism of the organism is not essen-
tially affected, permanently, by total extirpation of the stomach.
He also states that as much as seven-eighths of the small intes-
tine can be extirpated without injury. The colon partially
assumes the functions of the absent intestine. If more than
nine-tenths are removed the animal succumbs to inanition.
Monari concludes that man can have at least half of the small
intestine safely removed. —CM. f. Chir., August 1, from Beit-
rage zur klin. Chir., No. 2.
Formalin Gelatin as an Antiseptic. This is a hard, transparent
substance, affected neither by heat, acids nor alkalies, but
decomposed, when pulverized, by the action of the living cells
of the organism in such a way that the antiseptic properties-
are being constantly liberated. Schleich of Berlin asserts that
it will arrest in twenty-four hours any acute suppurating pro-
cess and insure absolute asepsis to the course of every wound.
It is passive on necrosed tissues unless moistened with the fol-
lowing solution : Pepsini, 5.0 ; acid, hydrochlor., 0.3, and
aqu. dest., 100.0, when the disinfecting process goes on a»
usual. It is made by adding 25 drops of Schering's pure
formalin solution to 500 g. of dissolved and cleansed gelatin.
When dry the hard sheets are pulverized ready for use.
Wien. klin. Rundsch., August 2, from Therap. Monats., No. 2.
Treatment of Cholelithiasis with Potassium lodid. -Dunin an-
nounces that we have in potassium iodid a most powerful
remedy for this obstinate disease. He has employed it in over
100 cases with results which he calls " not merely satisfactory,
but amazing." It is especially efficacious in those cases where-
the attacks are not so severe, but are almost continuous, which
is usually the most difficult form to conquer. In one week the
patient is relieved from pain and the region is less sensitive to
pressure, while appetite, sleep and peace return. Dunin admin-
isters 0.3 to 0.6 potassium iodid twice a day for four to five
weeks, and then a systematic course of mineral waters (Carls-
bad) completes the cure. — Therap. Woch., July 19.
Treatment of Enteroptosis with "Yeast" of Beer. This morbid
condition is extremely difficult to cure and often resists every
treatment, even external appliances. Dr. Gi'inzburg has
obtained excellent results by the administration of a piece of
dried beer yeast, the size of a pea or bean, three times a day.
It produces an intestinal tympanism not diagreeable to the-
patient, which lifts and holds up the viscera, counteracting the
tendency to displacement. The gases are due to the formation
of carbonic acid, and do not resemble the gases of putrefac-
tion in their effect on the intestinal absorption. The usual
constipation is relieved and the appetite improves, while the
patient soon begins to gain in weight. As this trouble is more
1SW.]
PRACTICAL NOTES.
547
apt to occur in thin persons, this latter point is of much import-
ance in securing a permanent cure. The only contraindication
is actual gastreetasia. Semaine MM., July 15.
Efficacy of Stypticin in Arresting Uterine Hemorrhages. Styp-
ticin possesses no oxytocic properties, but it has been found
very valuable in arresting uterine hemorrhages, climacteric,
uncomplicated and after retroflexio uteri. No inconveniences
followed its use. It resembles hydraetinin in its chemic com-
position. Wien. Klin. Rundsch., August 2, from Therap.
Monatah., No, 2.
Treatment of Hand Injuries. Dr. William P. Nicolson says
the beaut; of an operation should be sacrificed to the more
practical work of conservatism. Cut away with scissors such
tissue as may be hopelessly destroyed, leaving whatever shreds
of skin remain to cover stumps, even though skin may slough
afterward. If a finger has been crushed completely off, remove
projecting point of bone with forceps, covering the end, if possi-
ble, by means of any remaining shreds of skin. After securing
fragments of fractured bone as nearly in position as possible
and inserting sutures absolutely necessary, he treats practically
all hand injuries by saturation, under rubber tissue, with
listerin, camphorated phenol or similar antiseptics. — Atlanta
Med. anil Surg. Jour., August.
Further Success with Serum Treatment of Syphilis. Boeck of
Christ tana reports seven cases of recent syphilis cured by hypo-
dermic dorsal injections of serum from a tertiary hydrocele.
The effects were most favorable : the primary manifestations
rapidly passed away, and the secondary period was shortened
and attenuated much more than is the case with mercury or
iodin although the latter are more effective in the primary
stage. The amount injected at one time averaged two to three
grams a day or every other day, with a total of 32 to 92 grams
in each case, although one received a total of 300 grams. There
was no other medication. Experiments five years ago with
serum from a patient in the secondary stage failed entirely. —
Stmatme Mid., July 15.
Cysticotomy, the New Operation. — In the Progres MM. for July
i"). llaudouin describes what he calls "the new operation with
a future." cysticotomy, which is for the cystic duct what
choledoehotomy is for the common bile duct, and requires the
same technique. Only one of the ten observations reported
resulted fatally, and that was accompanied by cholecystectomy.
The indication is a large calculus engaged in the cystic duct,
which it is impossible to dislodge by manipulation, or to crush
without injury to the walls of the duct. The retention is
sometimes due to a stricture. The abdomen opened, adher-
ences released, the duct well in view, the calculus under the
finger, the cystic duct is slit lengthwise above the calculus,
and the opening made large enough to extract it without tear-
ing the edges, as the walls are generally inflamed and easily
lacerated. The only question is whether to drain or not, in a
simple cysticotomy, when the adherences have not been num-
erous ; of course a complicated operation requires draining and
even tamponing. The operation is usually simpler than
choledoehotomy on account of the moie accessible position of
the duct. The operation is new to France, the observations
being gathered from English, German and Belgian sources.
How to Sterilize Instruments without Danger of Rust.. Iron, steel
and nickel only rust when exposed to the combined action of
carbonic acid, moisture and oxygen. If any one of this triad is
absent or neutralized the metal remains unaffected. Certain
alkalies neutralize the carbonic acid in water, and when this is
neutralized no rust forms on metals when immersed in it.
After careful experiments, Levai has found that the best alkali
for the purpose is natrium hydrooxydatum causticum (NaOH).
He adds a small quantity of the crystals to boiling water, and
after they are entirely dissolved and mixed, he immerses the
instruments and boils them ad libitum, with never a trace of
rust nor tarnish when they are taken out. One-fourth of 1
per cent, or even less of the natrium is sufficient, but it must be
pure, with no sulphur, as this causes rust. If knives and scis-
sors are wrapped in gauze to protect the edges, they can be effec-
tively sterilized in this way without the slightest injury of any
kind. It is equally effective and non-injurious for drainage
tubes, etc., but it is not adapted for aluminum nor silk and it
softens brushes. If the instruments are left afterward wet and
exposed to the air rust will form, but they can be kept several
hours, if necessary, in sterilized water to which 1.5 to 2 per
cent, of the natrium has been added.— Wien. klin. Rundschau,
August 2.
Malignant Orbital Tumors.— Dr. C. S. Bull's conclusions in
regard to their course and prognosis, as influenced by surgical
operations for removal, are as follows : 1. The prognosis of all
forms of malignant orbital tumors, whether primary or sec-
ondary, is unfavorable ; and if the tumor be primarily in one
or more of tho deep facial bones or their sinuses, the prognosis
is positively serious. 2. Except in the case of encapsulated
tumors of the orbit, surgical interference is almost invariably
followed by a return of the tumor, and the growth of the sec-
ondary tumor is more rapid than that of the primary lesion.
With each succeeding operation the period of quiescence in
the return of the tumor grows shorter, and the rapidity of the
growth increases. 3. The patient's family, and in certain cases
the patient himself, should be told of the serious nature of the
trouble and be warned that complete removal of all the disease
germs is an almost hopeless task. The burden of the decision
as to surgical interference must rest upon the shoulders of the
patient. 4. Repeated operations in these cases undoubtedly
shorten the life of the patient. While it is our duty to oper-
ate in order to relieve severe or unbearable pain, we should
be slow to operate merely for the sake of relieving tempo-
rarily physical deformity, especially if we are convinced that
by so doing we shorten the life of the patient, even if that
shortened life is rendered more bearable. — Am. Jour, of Oph-
thalmology, August.
Two Tumors on the Head of an Infant— The Clinical Journal,
June 3, has remarks on the above subject, made before the
North West London Clinical Society by Mr. Jackson Clarke.
He showed an infant with two tumors on the left side of its
head. The child was brought to him in the out-patient depart-
ment, and its functions appeared quite normal. The tumors
were situated over the upper part of the squamous suture. One
measued 1 by i?4 inch, the other :!4 by % inch. Three possi-
bilities arose in cases of congenital tumors of the scalp, viz.,
meningocele, encephalocele and dermoid tumor. Dermoids
were generally single and subcutaneous, although often con-
nected with the dura mater. It was necessary to remember
that the brain was merely an epidermic structure, and that
some dermoids were quite shut in by the skull and dura mater,
lying occasionally in the substance of the brain. Meningocele
ought to be more or less completely reducible within the
cranial cavity ; but in the child before them that was not the
case. Moreover, meningocele, being fluid, should fluctuate,
and should become tenser when the child cried. This child's
tumors were firm, and the skull appeared deficient at*their
bases, while a piece of cartilage or bone covered the convexity
of the tumor. The only fluctuating spot was at the back part
of the larger and anterior tumor. The tumors did not
pulsate, therefore he had concluded that something had
formed under the skull and elevated up what could be called
normal Wormian bones, and there was a gap in the skull where
that bone would have fitted in had it not been so elevated.
Probably the source of the displacement was the growth of a
meningocele, but the two other kinds of tumor he had men-
tioned could not be excluded, because the Wormian bone would
mask any pulsation. The tumors were not due to the use of
548
PRACTICAL NOTES.
[September 5,
instruments at birth, the labor having been a natural one.
Cephalo-hematoma in a newborn baby was generally subperi-
osteal, and followed the shape of one of the bones, stopping at
the sutures. In the child exhibited, not only was a margin felt
in the skull, which might be simulated by hematoma, but
there was a definite cap of bone to the swelling. Mr. Clarke
said that the treatment was, in the main, on the expectant
plan. He would watch the progress of the case, instructing
the mother to prevent the child receiving knocks or bumps on
the head. If his view was correct, he hoped the Wormian
bone would spread out as the child grew, and the gap thus
become sealed up by the bone.
Injections of Salts of Iron in tbe Treatment of Anemia.— Riva Rocci
of Turin, has a careful study of this subject in the Policlinico
for May. His conclusions are that injections of the salts of
iron produce improved conditions in anemia, but they do not
cure it. They affect the consequences of a pathologic process,
but not the process itself, and the anemia returns if they are
discontinued. They stimulate the reformation of the active
principles of the blood, and also excite a hyperemia more or
less transient, in various organs, which is the greatest danger
from their use. The dose varies according to the case and the
preparation used. The possible inconveniences that may
result are, in the order of their frequence : nausea, vomiting,
cephalea, fever, diarrhea, albuminuria, cylindruria, hemopty-
sis, lypothymia and syncope. They are indicated whenever
there are anemic conditions, when the anemia itself is of
long standing, and other means have been tried and exhausted,
when the condition of the alimentary system forbids the proba-
bility of successful internal medication, and also when it is
urgent to have the anemic condition terminated as soon as
possible. The injections are contraindicated when they pro-
duce gastro- intestinal disturbances, or symptoms of nephritis,
or excessive fever, or when there is danger of hemoptysis. —
Revue Int. de M. el de Chir., July 25.
First Trials of Frigor Therapeutics.— The results of these new
experiments with the excessively low temperatures secured by
Professor Pictet of Geneva are paradoxical and inexplicable.
The patient is lowered into a well in which the temperature is
105 to 110 degrees below zero, centigrade. It is not quite two
meters in depth, and is about 65 c. in diameter. He retains
his clothing and remains in the frigor bath ten minutes, his
head uncovered and a warm covering about his shoulders to
prevent the escape of the cold air and to protect his lungs.
The sensation of this extreme cold is merely a refreshing stim-
ulation, similar to that of a tepid bath, with an afterglow that
lasts several hours. Instead of an increased dis-assimilation
the quantity of urea was diminished 24 grs., 15 to the liter.
The amount of uric acid fell from 0.52 to 0.33; of phosphoric
acid from 4.9 to 2.1, the phosphates from 9.1 to 3.9; while the
temperature in the mouth rose from 36.5 (normal) to 37.4
degrees. The pulse increased (one observation) from 87 to 102
in three minutes. In every case the temperature rose more or
less, and the refreshing sensations with warmth and invigora-
tion were experienced. Five baths cured Cordes of his gas-
tralgia, improved his appetite, stimulated the functions of the
skin and improved a tobacco bronchial cough. In one experi-
ment the bath was not as cold as usual, and rose to -40 degrees
during the ten minutes. The sensations were entirely differ-
ent from those of the other baths and the cold seemed intense,
possibly owing to the fact that there was more humidity, and
the skin therefore more susceptible. Further reports are
awaited with interest— Jour, de Mid. de Paris, July 26.
Reported Rapid Recovery from Phthisis Under the Maragliano
Serum.— The London Lancet, July 4, reports through the med-
ium of its correspondence from Rome that one of the early cases
of the above kind and treatment has been progressing most fav-
orably. The report in part is as follows : An authentic, well-
certified case of treatment of tuberculosis by the Maragliano-
method comes from Spezia. A native of that seaport, A. B.,
aged 21 years, an able seaman by occupation, had since 1893;
been suffering from phthisical symptoms, and on examination
was found to have both pulmonary apices infiltrated with
tubercle. The disease was not largely diffused, but it made
steady progress, and by the beginning of 1894 the area of
destroyed tissue was considerably increased. Both lungs were
very seriously affected and A. B. was placed under Maragliano's
treatment in the clinical wards of the Genoa Hospital. The
injection of the serum was practiced continuously for two
months till the close of Maragliano's summer course, by which
time the patient had so far improved as to return to his native
place. Convinced of the benefit he had received he returned
to the ward as a patient in November of the same year and was
once more subjected, under Maragliano's care, to the serum
treatment. The case, though the progress of the malady had
been arrested, was still a very serious one, and it was not till
the close of July, 1895— eight months from the resumption of
treatment— that substantial cure was effected. Several hun-
dred injections had been practiced, and in the latter weeks of
the treatment it was evident that A. B. was conquering the
malady "hand over hand." He left the hospital at the end of
July, as has been said, absolutely cured and since then has for
six months been regularly on duty in the service of the royal
navy. At present he is at Spezia, the object of no little profes-
sional interest, and described by the physician who last saw him
as "sano come pesce." Maragliano has some severe critics-
among his compatriots, chiefly of the Neapolitan school. But
is fair to add it that even in that quarter testimony in favor of
his treatment is gaining in volume and authority.
Bacterial Diarrhea of Children.— Dr. L. E. Rardon of Cincinnati,
in the Lancet Clinic thus refers to the summer diarrhea of
infants : Astringents formerly extensively used have very
properly been relegated to the waste dump as useless. 1. Sum-
mer diarrhea is caused largely by improper and unclean feed-
ing, and is usually preventable. 2. Bacteria play a very im-
portant part in its development. 3. Hot weather has to do-
only in an indirect manner, as it promotes the growth and
development of bacteria in the food supply. 4. Treatment
consists, first, in eliminating all decomposing food from the-
bowels by cathartics, lavage and colonic irrigation. 5. Drugs
judiciously administered are of great value, but are secondary-
in importance to prevention and management.
Gastro-Intestinal Catarrh. In the treatment of cases of acute-
gastro-intestinal catarrh, due to indiscretions in diet, and
attended especially with nausea, vomiting, diarrhea and abdom-
inal pain, good results are secured in the clinical service of Dr.
Eshner from the employment of the following formula :
R Extract of hematoxylon 8.0
Aromatic sulfuric acid 8.0
Camphorated tincture of opium 96.0
Dose : A tablespoonful every three hours if the bowels are
moved that often ; at longer intervals if the bowels are moved
less often. — Phila. Polyclinic, August.
Intestinal Fermentation with Constipation.
R Ext. aloes gr. vi
Pulv. rhei gr. vi
Benzosol gr. ix
Ext. hyoscyami gr. vi
Misce et ft. Caps. No. xii. Sig. One after meals. — Thos.
Hunt Stuckey, M.D., in Am. Therapist, August
Beri-Beri.—
R Aquas 150.0
Tinct. scillae 8.0
Tinct. digitalis 2.0
Syr. quiniae 30.0
Ammoniaci (liquid) gtt. xii
Misce. Sig. — Two tablespoonfuls in water every three
hours. — J. Dias Ribeiro, M.D., in Dunglison's Coll. and Clin.
Rec., August.
I
1896. 1
EDITORIAL.
549
THK
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ty which Is entitled to send delegates to the Association.
All that is necessary is for the applicant to write to the Treasurer of
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Handing in his own Society, signed by the President and Secretary of
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Ou receipt ol the subscription the weekly Journal of the Association
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eientlemcn already members of the Association should send their
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Original communications are only received with the understanding
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INFORMATION WANTED.
It would greatly facilitate the prompt delivery of the Journal to
those members of the Association living in large cities, if they would
kindly furnish this office with their street address in those cases where
it is omitted from the wrapper of their Journal, as we have been noti-
fied by the post musters of the larger cities that second-class mall mat-
ter not having street address, would be placed In the general delivery
to await call.
SATURDAY, SEPTEMBER 5, 1896.
THE U. S. MEDICAL PROFESSION AND THE MON-
TREAL MEETING OF THE BRITISH MEDICAL
ASSOCIATION IN 1897.
The British Medical Association will meet in 1897
in Montreal. At once upon learning the fact, there will
arise in the mind of every member of the medical pro-
fession of the United States the thought: What can we
do to make the visit to America of our English con-
freres more enjoyable and useful, and to aid in deep-
ening the professional unity, respect and affection
which these two parts of our guild entertain for each
other? Two things are prerequisite: The first is the
establishment of a committee to take in charge the
entertainment of our British and Canadian friends,
and the second is the securing of funds to defray the
necessary expenses.
To this end we suggest that the proper officers of
the American Medical Association at once appoint
three members from the Association to act with
three members to be appointed by the Executive
Committee of the Congress of American Physicians, the
six to organize themselves as they may deem best and
to have entire charge of the collection of funds and
the plans and execution of the same for the entertain-
ment, etc. As to the subscription we have no doubt
sufficient contributions can be obtained from the
various medical organizations of the country or even
from private persons (the writer will give $25). We
should be moved by every honorable motive to make
the American tour of our visitors one of the most
enjoyable and profitable for all concerned. But there
should be no delay in getting to work.
THE USE OF PUBLIC MEDICAL SOCIETIES TO PAY
PRIVATE GRUDGES.
Many years ago we knew of the following case : A
physician of the best standing applied for member-
ship to the principal medical society of the town. He
was vouched for and recommended by the best mem-
bers; there was absolutely nothing said or to be said
against him as a reputable physician; no objection was
made to him; he had in many ways shown himself
strictly ethical in professional and private life, and his
scientific ability was certainly equal to that of the aver-
age of the members. And yet he was " blackballed."
Three members came — were careful to come! — sat
silent when objections should have been raised, sat
silent when the balloting went on, and voted against
the admission of the candidate proposed. By the anti-
quated rules of the society three members were suffi-
cient to exclude, although a hundred should vote in
favor of admission. By one of the old-time fictions of
the society, it should be said, the candidate did not ask
for membership, was not allowed to apply — that would
be beneath the dignity of the body — but instead of this
simple, frank method, he asked his friends to sign his
application, or if fully wise, asked some friend to get the
signatures of others, and then asked the friend to pre-
sent it. The applicant was supposed to be in profound
ignorance of the desire of his' friends to make him
one of their corporate number. It thus came about
that the three blackballed " turned down," not the
applicant, but his fellow members who wished the
applicant admitted. By another figment of the cor-
porate machinery the ballot was supposed to be thor-
oughly secret, but in reality it was not so, and the
three dissenting balloters were at once known not only
to all the society's members, but to the applicant, sup-
posedly in complete ignorance even of the fact that
he had been proposed; and not only to them and
him, but of course to all professional brethren, and
finally to the lay public. This old individual case we
are using only as a text and type of more general
principles, but in passing it may be added that the
motives of the blackballers soon became evident.
They were recognized as unsuccessful rivals of the
candidate in a private occupation, and were simply
jealous of the candidate's success in the private work,
and they determined to injure him by their secret
ballot. These poor dupes of their own envy had used
a public medical society to settle private scores. They
cared nothing for the injustice to the individual or of
the wrong to the society.
But what of the rules of the society that permitted
such proceedings, and what of the plan of using an
organization presumably founded and existing for
strictly professional and scientific purposes? If the
example we have used to typify a method were single
or rare, or existed only in prehistoric ages, there would
be nothing to say, but to any one familiar with medi-
550
PUBLIC MEDICAL SOCIETIES PAY PRIVATE GRUDGES. [September 5,
cal politics and organizations it is a well-known fact
that similar practices are by no means unknown in
our modern world. It is possible that the antiquated
rules governing present-day medical organizations
have not been abrogated, and that self-seeking mem-
bers, in many ways, use them and the societies they
control for their hidden schemes.
If the fanciful figments and supposed ignorances,
and presumed confidences or secrets of the council
chambers and boards of censors were not the shams
they are, it would be a very different matter. But
who does not know that they are most ludicrous
farces? The candidate hears, sees, feels forever the
fact that he has been considered unworthy of mem-
bership, and his professional and public reputation is
injured. If he is of a sensitive nature, the fact can
not help harming his own character, rendering him
morbid, perhaps, and in various ways preventing the
best purposes and realizations of his life. If he
" braves it out," he becomes unduly callous, and per-
haps this injury is greater than the other. Possibly
he may be strong enough to recognize the true status,
and large-minded enough to prevent his indulging in
anything but pity and a good-humored contempt of
the foolish performance. This is the proper course,
but it may be doubted if it often results so. He may
even find not a little pleasure in the boomerang his
unwise enemies prepare for themselves, and laugh at
the fact that one prominent member advises him, after
the custom of the French Academy, to call on the
members of the committee or board of censors hav-
ing his application under advisement, while another
member vows if there is any such " solicitation and
advertisement" he will surely blackball him. He may
even enjoy the feeling that he is barefoot and attempt-
ing to walk a floor strewn with needles and tacks. But
we question his enjoyment!
But if he has any innate sense of dignity and worth,
he will have a disgusted contempt for the imaginary
figments and open secrets of the guarded portals.
Every member knows that he applies, and if he gets
in at all, he does it by " politics " that all ignore and
are supposed to despise. No single word of recog-
nized or official reply comes from his application, and
the irony of the situation is heightened by the fact
that the society hugs its pompous " dignity " in silent
satisfaction while proceeding to the utmost length of
impoliteness and discourtesy. A society or a man has
no genuine dignity without just as genuine courtesy
and kindness, and when these latter qualities are want-
ing, a man of innate dignity may wisely reason that
the assumed dignity of the society is — assumed. Dis-
courtesy is undignified, and corporate discourtesy is
none the less so because, as Sidney Smith said, the
corporation has neither body nor soul for proper treat-
ment. It is just as incumbent upon an organization
to be dignified to an applicant (or supposed appli-
cant) as it is for the applicant to respect the corpora-
tion. It would be infinitely more manly to have the
application made openly and frankly, and if it is
refused to say so officially. A no, ever so blunt anc
brutal, is in every way superior to the savagery of
reply whatever to an inquiry.
And societies are none the less absolved from tr
duty of justice! Every member knows the black
balling becomes at once common talk despite the
hundred fictions of assumed ignorances and secrecies.
The machinery of these circumlocutions and mysteries
and " supposeds " is arrant nonsense, and deceives
nobody. It would not be an absurd thing if some
day some indignant candidate should enter suit for
damages against the organization that had refused him
membership without a single objection raised or
exposed, and thereby injuring his professional and
social reputation. To be sure, no large-minded man
would care enough for the affair to do so, but all men
are not so strong in the estimation of the public or
of themselves to thus contain themselves.
It would appear that some of the rules of some
medical societies need thorough overhauling; that
manly, truly dignified frankness displace sham and
pomposity and a silly secrecy; that societies be as
jealous of their justice and kindness, as of their
"dignity;" that they think what effect their action
and manner of action may have upon the candidate
by refusal of membership, as well as of their own
rights and privileges; that they devise methods of
preventing the use of the organization by greedy,
cranky or stupid members for paying private debts
and grudges; or, of punishing such when obviously
guilty. The welfare of the profession stands above
that of societies, and the welfare of the society must
be placed above that of the piques and bickerings of
its members.
We by no means argue against care in the admis-
sion of new members to a society. We advise greater
care. Objections to a proposed man should be brought
out and discussed, not hidden; blackballers and cranks
who fraudulently use the society in secret ways to
settle personal or clique enmities should themselves
be blackballed before they get in; if the figment of
the society that it chooses and elects its new members
is to be any longer worshiped as a fetich, the society
should see to it that there is no wily and sneaky " pol-
itics" upon the part of members or applicants in get-
ting in. (In the illustrative example we have used,
the candidate could have easily " blocked " or neu-
tralized the scheme of his blackballing friends if he
would have stooped to something like their methods.)
In these days of specialism, it may also be noted,, the
profession in a city is divided up into cliques and
parties, and the hatreds and deep grudges and jeal-
ousies of rivals often become so intense as to override
all sense of decency or justice, and men thus actuated
1896.]
STRENGTHEN THE ASSOCIATION.
551
liould not have it in their power to exclude and injure
.10 they hate or fear. The envies and hatreds of rival
nedieal schools, or the infinitely worse ones of rival
ofessors in the same school, accentuate these intor-
nccinc quarrels, and often reduce the general medical
oiety of the place to a simple stamping: and fighting
mind where men may come to battle out their
aths. but with which the society should have noth-
jg to do. There is room for much amusement and
,.;mv when a blackballed applicant is told by these
iiieii that he is unworthy their professional company!
THE BACILLUS OP PARESIS.
That paretic dementia, or. as it is more commonly
designated, paresis, has in the vast majority of cases
yphilis as its antecedent, is coming to be a generally
tooepted fact. The exact relation of the two disorders
jo each other are. however, still in question, and the
syphilitic or parasyphilitis nature of paresis is main-
_Jned by some and as strongly disputed by others. If
the infection of syphilis were as definitely known as is
that of some other diseases, tuberculosis for example,
the question would be more simple: we could search
for the specific microbe, and if found the identity
would be established. Other like questions have been
settled in this way; the failure to find Hansen's
bacillus in syringomyelia has been considered as con-
clusive against Zambaco's theory of its identity with
leprosy, and still other instances could probably be
cited. With the present uncertainty as to what is
the real nature of the syphilitic infection, there is no
possibility of a definite conclusion as to the identity
of it and that of paresis on purely bacteriologic
grounds, but a very recent Italian contribution is very
significant and suggestive. In the latest issue of the
Annali <li Nevrologia, Dr. Piccinino, one of Pro-
r Bianchi's assistants, reports the results of a
riologic study of paresis in the laboratory of the
Istituto Psichiatrico of the University of Naples.
He examined the cortex in five cases, some of them
with clearly syphilitic histories, others with it sus-
pected or denied, using all antiseptic precautions and
taking the specimens through openings made in the
skull by trephining before the removal of the calva-
rium. as an additional security. Culture experiments
and the usual staining methods gave only indetermi-
nate or negative results; nothing very characteristic
or noteworthy was discovered. The use, on the other
hand, of a staining method only slightly modified
from that of Lustgarten for his syphilis bacillus,
revealed a great abundance in all the tissues, and
especially in the pericellular spaces, of a form appar-
ently not very different from that described by the
above author. The same method was tested as a con-
trol experiment in other brains than those of paretics,
but with a uniformly negative result, and it was only
by this staining reaction that these bacilli could be
detected in the paretic cortex.
This paper has a special importance, in view of the
question of the parasyphilitic nature of paretic
dementia, and reflexly, as it were, also on that of the
value of Lustgabten's discovery. It is a little remark-
able that the research had not been made before.
Had there been more faith in Lustgarten's bacillus
as the cause of syphilis, or had the notion that paresis
is only a late manifestation of that disease been earlier
accepted by physicians, the very obvious suggestion
of this special investigation would undoubtedly have
been sooner taken up. It will be in order now to
repeat Piccinino's observations and to prove their
value by widespread and careful investigations by
our asylum pathologists.
STRENGTHEN THE ASSOCIATION.
The great increase in the membership last year
should be only a beginning. We appeal to each
member to use his influence to secure a new member
by application. Let the good work go on until every
regular physician in the United States is enrolled in
the membership. Of this issue we print 9,000 copies
and it is contemplated to continue to print not less
than that number each week. The extra numbers
will be sent to physicians who are eligible to member-
ship in our Association in the hope that they may
join us. Secretaries of local medical societies in affil-
iation with the American Medical Association, are
requested to use their influence to increase the num-
bers of the great representative organization. Blank
applications for membership will be furnished in any
desired quantity on application.
The great improvement in our Journal is solely
due to the increasing interest taken by the members
in making it better and to the large additions that
have been made to the membership.
The object lesson furnished by the success of our
Journal, should be a sufficient demonstration of what
it means to increase the number of members of the
Association and the readers of the Journal. Let
us unite to make it the greatest medical weekly on
the habitable globe. We have reason to be proud of
the advance made in the past, but let that be as noth-
ing to the improvement in the future. It could be
made the greatest medical weekly in America in one
week, if every present member would secure one addi-
tional one; and if that process were repeated the next
week, the Journal would in two weeks have the
greatest subscription list of any medical weekly in the
world. Will you, dear colleague, favor the Associa-
tion in this way? Cut out an application blank from
the advertising page of your Journal and get your
medical friend to sign it and send it on with the fee
to Treasurer Newman and the object will be gained.
Try it and let the semi-centennial report at Phil-
adelphia next year show more than 10,000 actual mem-
bers. It can be accomplished easily, will you do it?
552
PUBLIC HEALTH.
[September 5,
We may strengthen ourselves and improve our
Journal by strengthening the Association, than
which no organization ever had nobler aims or pur-
poses, and every member will feel happier when he
can truthfully say that he has done all he could to
bring the whole profession in line under the banners
of our Association, marching shoulder to shoulder in
the sacred cause of humanity and science, and keep-
ing step to the music of fraternal sympathy.
CORRESPONDENCE.
Unilateral Orchotomy.
Navasota, Texas, Aug. 4, 1896.
To the Editor: — I herewith give in brief the history 'and
operation of two cases of castration: C. S., aged 15 years;
contracted continued malarial fever, which continued with no
peculiar history until the third week, when orchitis developed
in both testes without any disease of the genito-urinary organs,
either during this attack of fever or previously. Later, it
became complicated and terminated in orchi-epididymitis,
becoming exceedingly painful. During the fourth week I was
called in consultation, finding the morning temperature rang-
ing from 102J-£ to 103 degrees ; evening from 103 to 104 degrees,
with considerable tympanitis, great emaciation, prostration,
intense suffering, a suppurating testicle of left side and the
right one enlarged and painful. Castration being determined
upon, antiseptic precautions were rigidly enforced. Patient
being anesthetized I cut away the suppurating portion of the
scrotum, turned out the testes and ligated the spermatic cord,
nerve and vessels in mass with catgut. All capillary oozing
was then arrested by hot compresses and the wound closed
with silk sutures, leaving no drainage. The wound healed by
adhesion, the other testicle rapidly improved, temperature
declined and general convalescence followed.
A. M. C, aged 65 years. Gave history of slight hydrocele
from boyhood, very gradually increasing. Patient contracted
gonorrhea, which gave him no little trouble, but finally ter-
minating in orchitis, which kept him confined to bed for about
three months ; during which time he became very weak and
emaciated. Temperature ranged from 101 to 103 degrees, due
to pathologic condition of the right testicle. At the end of
third month I was called in consultation. Removal of the
diseased organ was decided on. The cystic portions of the
testis was relieved by the use of the trocar. Then the scrotum
was laid open and the testicle dissected out, as there was
almost a continuous adherent tubercular attachment existed
between it and the scrotum. The spermatic plexus was con-
siderably enlarged and indurated, containing small cysts of
pus. The cord and vessels were ligated as in first case, though
much higher up above the tubercular tissue. The scrotum
was then closed with silk sutures. No drainage was estab-
lished, no suppuration followed ; temperature declined and in
ten days patient was able to be about his business.
D. F. Peeples, M.D.
Dr. Carl Wagfner Disclaims Connection with
the "Milwaukee University."
Chicago, Aug. 28, 1896.
To the Editor:— In regard to the article in the Journal of
the American Medical Association of Aug. 22 ("Another
Diploma Mill in Wisconsin") I would like to state the fol-
lowing :
On August 19 an article came to my hand which contained
my name in connection with an unlawful institution called
the Milwaukee University. I immediately sent a letter, of
which I enclose a copy, to the said corporation. I also sen!
on the very same day letters to the States Attorney of Wis
consin, to the Secretary of the Board of Health of Wisconsii
and to Dr. McDill, a prominent physician of Milwaukee, say
ing that I had nothing to do with that institution whatsoever
and asked the latter to make this known to his friends as fa
as lay in his power and to the medical society at large as fa
as possible ; which he kindly promised to do. Then I begge
the aforesaid parties to kindly inform me what means I should
take to protect my reputation. I need only add that I will be
pleased to appear in court to testify whenever I am summoned.
Very respectfully, Carl Wagner, M.D.
[copy.]
To the Milwaukee University: Gentlemen— Having learned
that you used my name in your announcements as a director of
the Milwaukee University, I ask you to withdraw my name
from the list of your members immediately. I have never
given you my consent to what you have done. I demand that
you take all means within your power to see that my name in
the future will be in no way connected with your enterprise,
and also demand that all legitimate means be employed to
recall the announcement already issued containing my name.
If the above request is not complied with, I will instruct my
attorney to proceed against your institution. Respectfully,
Aug. 20, 1896. Dr. Carl Wagner.
PUBLIC HEALTH.
Medical Inspector for Schools. — The Macclesfield (Eng.) School
Board has passed the following resolution in regard to the
question of medical certificates: "That, with a view to secure
the more regular attendance of children at school, on the one
hand, and to avoid unnecessary prosecution of parents on the
other, a medical officer be appointed, whose duty it shall be to
examine all children sent to him by the clerk, and to report as
to their fitness or otherwise to attend school ; and that the
clerk keep a counterfoil record of children so sent ; and that
the medical officer be paid half-yearly at the rate of one shill-
ing for each child so sent." — Brit. Med. Jour.
A Quaint Hygienic Decalogue.— The Medical News attributes to
the late Dr. Frank H. Hamilton, of Bellevue Hospital Medical
College, the following decalogue of health precepts: "1. The
best thing for the insides of a man is the outside of a horse.
2. Blessed is he who invented sleep— but thrice blessed the
man who will invent a cure for thinking. 3. Light gives a
bronzed or tan color to the skin ; but where it uproots the lily
it plants the rose. 4. The lives of most men are in their own
hands, and, as a rule, the just verdict after death would be —
felo de se. 5. Health must be earned — it can seldom be
bought. 6. A change of air is less valuable than a change of
scene. The air is changed every time the wind is changed.
7. Mold and decaying vegetables in a cellar weave shrouds
for the upper chambers. 8. Dirt, debauchery, disease and
death are successive links in the same chain. 9. Calisthenics
may be very genteel, and romping very ungenteel, but one is
the shadow, and the other the substance, of healthful exer-
cise. 10. Girls need health as much — nay, more than boys.
They can only obtain it as boys do, by running, tumbling — by
all sorts of innocent vagrancy. At least once a daygirls should
have their halters taken off, the bars let down, and be turned
loose like young colts."
Attempt to Copy Michigan's Progress. — In the British Medical
Journal, August 8, is a short article by James Adam Dick,
M.D., vice-president Eastern Suburbs Medical Association,
Sidney, New South Wales, relative to "An Experience in the
Voluntary Notification of Diseases in Sidney." He says :
"Having observed in the pages of the British Medical Journal
since August 31, 1895, the accounts of the movement to estab-
lish a national system of registration of sickness in Great
Britain initiated by Dr. Arthur Newsholme, the Medical Offi-
B96 ]
PUBLIC HEALTH.
553
cer of Health of Brighton, it occurred to the writer that a brief
note describing an effort made in the same direction at the
antipodes, might be of interest to those who are working at
this most important subject. . . . The movement in Sid-
ney had for its origin the example of the sickness statistics of
that progressive body, the State Board of Health of Michigan,
U. S. A. Correspondence was entered into with the secretary
p| Lansing, Mich., who very kindly supplied several valuable
pamphlets and books. The Eastern Suburbs Medical Associa-
tion of Sidney resolved to initiate a scheme for the voluntary
notification of those diseases causing sickness in the area com-
prised by the association." Instead of having weekly reports,
as in Michigan, the attempt was made to get monthly reports.
This was unsuccessful because, while it is quite possible for a
physician to remember to make a report every week, it will
generally be found impossible to remember to make a report
at a given time after a much longer interval ;. therefore, unless
a central office regularly notifies all the observers at the time
the monthly report is due, there is a probability of a general
failure. And, in Michigan, what was commenced made suc-
cessful for a time as a voluntary service by leading physicians,
has since been supplemented by weekly reports required under
the law to be made by local health officers ; and in recent
years more attention has been given to the securing of such
official reports than to those by volunteer physicians. The
writer hopes that the discouraging experiences in Sidney may
not tend to abate the enthusiasm with which Dr. Newsholme
has taken up this subject. This important scheme is one that
the British Medical Association should again take up earnestly
and urge its adoption upon parliament.
Difference in the Death Rates Between the Sexes. — Tables made
up from Massachusetts census reports, covering a period of
more than a quarter of a century, show that from birth to 10
years of age the male death rate is in excess of the female.
From 10 to 40 the female death rate is in excess of the male,
while the next ten years the rate is about the same. From 50
to 60 the percentage of deaths is largest with the males, while
beyond that time the excess is with the females. Among
insurance companies men over 50 are regarded as better risks
than women of that age, and a strong man of 50 is preferred
as a risk to an equally strong woman of 45. Dr. J. M. French,
in the Medical and Surgical Reporter, May 9, calculates that
out of 1,000,000 persons born 511,745 are males and 488,255 are
females, making an excess of 4.81 per cent, of males. Of this
number he estimates that 83,719 males and 65,744 females die
during the first year, which would reduce the per cent, of
excess males to 1.31. At 8 years of age the per cent, of excess
has been reduced to 1 per cent. From then to 18 years of age
the male excess increases to 1.18, at 39 to 2.08, while at 50 the
excess has declined to 0.93 per cent. At 53 the number is
equal. It is believed to be proved by statistics that while more
women than men reach old age, there are more men than
women reach the century mark. In Massachusetts between
1880 and 1890 there were 203 deaths of persons over 100 years
of age, and of these 153 were men and 50 were women. Thus
it seems that while more males than females are born, and
while more males die between certain ages, the percentage is
yet in favor of the males. The fact that men go to sea and
to war, that they engage in more hazardous vocations than
women and are more exposed is urged as an explanation for
the greater death rate between certain ages. The fact also
that women suffer from want of exercise, impure air and
faulty modes of dress is cited to show why more women than
men die at some ages.
An Epidemic of Enteric Fever Among Children.— Dr. A. K. Bond of
Baltimore contributes to the Virginia Medical Sevii-Moiithly a
brief report of "an epidemic of twelve cases of enteric fever
which occurred in a home for destitute children in Baltimore.
The patient's .ages in years were, respectively, 12, 7, 9, 3, 8, 4,
5, 7, 4, 4, 5, 19. The fever lasted from fourteen to eighteen
days in the five youngest, whose ages ranged from 3 to 5 years.
The temperature ranged between 102.3 and 103.5 degrees.
In the next older group it ranged between 104 and 105.5 degrees.
Headache was a frequent symptom at the beginning. There
was no delirium worth noticing, only one or two patients wan-
dering in thought a little at night. The hearing of several
patients was temporarily dulled while in bed. Nosebleed
occurred in several cases at the onset of the disease. Rose
spots were observed in all but three cases. They came in suc-
cessive crops, and were very well marked even in the little boy,
aged 3 years, who for five days had from two to three spots,
old and new, upon the abdomen. The abdominal walls in all
twelve cases were usually natural to sight and touch ; tympa-
nitic tendencies, as well as gurgling and pain in the right iliac
iossa, being found only for a short time in two or three cases.
There was a strong odor about the bodies of several of the
patients, suggestive of intestinal fever. The bowels were not
decidedly loose nor costive. In only a few instances were
characteristic typhoid stools observed. Enlargement of the
spleen so that it reached beyond the ribs was evident in only
one or two cases. The following conclusions were drawn :
That children often bear high temperatures well in this dis-
ease ; that full baths should be very carefully and judiciously
applied, if at all ; that the disease in children under 5 years of
age may easily be mistaken for other digestive disorders or for
bronchitis ; that albuminuria coming on during the fever does
not necessarily lessen the chances of recovery ; that gangrene
of the mouth, if superficial, may in some cases be cured by
permanganate of potassium washes, without caustics."
Prevention of Measles. — Dr. F. J. Waldo, the Medical Officer
of Health in the St. George's, Southwark, London, district
advises the use of more strenuous measures for the prevention
of measles. He writes : " Medical science has not discovered
any means of special protection against measles. Judging
from the signs of the times, however, it seems not unlikely
that some means of conferring in unity against the disease may
be attained in the near future. Such a discovery, by striking
at the root of the evil, would do much to lighten the labors of
the sanitary reformer." The foregoing passage was written in
1890, and three years later we find the following important
counter statements from Dr. Armstong, of Newcastle, a lead-
ing authority in all health matters. In his 1892 report he
writes : " By early knowledge of first cases in an outbreak we
shall be enabled to check the spread of measles and whooping
cough in schools, by preventing children of infected houses
from attending school. Cases of measles would, wherever pos-
sible, be removed to hospital. The fact that measles is infec-
tive during the pre-eruptive period is no argument against the
necessity for taking active preventive measures for the three or
four weeks following, during which time infection still contin-
ues. The magnitude of the existing epidemics of measles and
whooping cough and possible expense incurred in notifying
those diseases in future, is surely no reason for turning our
backs on this most important subject. The same argument
would have applied with equal force to scarlet fever, smallpox,
and typhus fever in 1882, when the question of notification was
under your consideration. That argument, if it had been
admitted, and acted on then, might perhaps have prevented
the reduction of the mortality from smallpox to nil ; that from
scarlet fever to about one-fourth ; and that from typhus to one-
eighth of their magnitude ; . . . which has followed the
notification of these diseases in Newcastle." In conclusion, it
is not too much to say of measles and its death toll that the
question is one of national importance. Its satisfactory solu-
tion is one of the great problems of latter-day preventive medi-
cine. Whether it is to be let alone, as heretofore, or to be
554
PUBLIC HEALTH.
[September 5,
dealt with in a manner worthy of this scientific and progressive
age, must to a great extent be decided by the verdict of edu-
cated public opinion. Experience has shown again and again
that the health reformer can not travel far beyond the popular
standard of enlightenment in these matters. That general rule
holds good even in a matter so closely affecting the common
welfare as the control of measles, one of the most deadly of the
preventable diseases that devastate the populace of Great
Britain. See the Sanitary Record, London, July 24, 1896.
Excessive Mortality by Measles. —The Medical Press and Cir-
cular, in its editorial columns, emphasizes the fact that measles
is not a trivial disease, but on the contrary is the disease first,
after tuberculosis, demanding the attention of the sanitarian.'
The editor says : "Among the preventable causes that swell the
mortality rates, and are at present practically unchecked,
measles and whoopingcough take the foremost place. The ques-
tion of the prevention of measles has been discussed in the cur-
rent number of the Nineteenth Century by Drs. Waldo and
Walsh. They estimate that the case mortality from the disease
in a poor district of the metropolis averages about thrice that
of a rich quarter. They point out that in 1894 measles headed
the zymotic death rate in London with 3,293 deaths, as against
2,670 due to diphtheria, and 2,097 to whoopingcough. But
their chief emphasis is laid on the remarkable statistic deduc-
tion that during the year mentioned measles killed in the
metropolis nearly twice as many persons as scarlet fever, fevers
generally (including typhoid) and smallpox put together. In
considering whether or no the disease should be made notifia-
ble they pertinently remark : 'The wisdom and necessity of
these (preventive) measures have been admitted in the case of
smallpox, of diphtheria, of scarlet fever and other specific
fevers, and of erysipelas. It seems illogical to exclude measles,
which has been shown to cause a greater mortality than any of
the diseases named. . . . Why it should be right to notify
and control, or attempt to control, diphtheria, while measles
and whoopingcough are left untouched, is somewhat of a mys-
tery.' About the main facts advanced in this timely article
there can be no dispute, any difference that may arise will be
on the main conclusion that measles should be added to the
list of notifiable diseases. As to this important question, it
may be broadly stated that if it is the duty of the legislature
to endeavor to prevent the loss of life by preventable causes,
such as scarlatina and smallpox, it is difficult to see why a
similar obligation should not apply to measles and whooping-
cough. The cost of preventive measures in the case of measles
would be, on the face of it, enormous. An outlay of this kind,
however, many economists regard simply in the light of a
national insurance. So far as the people who die and the folks
who pay the direct and indirect costs of sickness are concerned,
it matters not one jot whether the destroyer comes in the shape
of cholera or smallpox, or the more homely, but far more fatal,
measles. Whatever views be taken upon the advisability of
notification, everyone must agree with the concluding remarks
of the authors above quoted. 'In conclusion,' they write,
'it is not too much to say of measles and its death toll that the
question is one of national importance. Whether it is to be
let alone as heretofore- or to be dealt with in a manner
worthy of this scientific and progressive age, must to a great
extent be decided by the verdict of the educated public opin-
ion. Experience has shown again and again that the health
reformer can not travel far beyond the popular standard of
enlightenment in these matters. That general rule holds good
even in a matter so closely affecting the common welfare as the
control of measles, one of the most deadly of the preventable
diseases that devastate the populace of Great Britain.' "
Disinfection Difficulties at Cairo — According to the London
Lancet, Cairo and Alexandria with their hopelessly ignorant
public, a virulent epidemic and a government not habitually
accustomed to repressive acts at variance with the habits of
the people, have all the elements necessary to hamper the
work of sanitary officials. The first instance of rebellion was
an attack in Alexandria upon a cholera ambulance wagon and
a free fight at old Cairo between an Italian disinfector and a
hostile mob. Fortunately, the native court of justice sen-
tenced six men to prison for periods varying from two to six
months for this attack. Then came the revolution of about
oJO Syrian students in the crowded and very sacred university
of El Azhar with its 12,000 graduates, of all ages from early
manhood to gray old age. A Syrian from this turbulent section
was attacked by cholera and removed to hospital, where he
shortly died. The old myth was at once started that the doc-
tors had poisoned him, and when a second case occurred the
doctor was not allowed to remove him. The sheikhs of the
mosque were all absent, and refused to come when invited by
the police to quell the riot. Both doctors and police seem to
have behaved with the greatest moderation, and fortunately
they were all Mussulmans, but when they found that the gov-
ernor, who very pluckily went alone to expostulate with the
rioters, was severely stoned, it was obviously time to put ao
end to the disturbance. Coles Pasha arrived with twenty
picked men with loaded rifles and vainly essayed to open the
mosque door, exposed to a storm of paving-stones from the
wmdows of the precincts. He got the door slightly ajar and
then fired into the mosque over the heads of the crowd. This
was answered by yells and stones, and reluctantly the order
was given to fire at the crowd. This produced an immediate
dispersal and the Syrians flew to their bedrooms to hide. The
police dragged them out, arrested about 500, and marched
them at once to prison. The next day the bulk of them
were released, sixty-five are now being exiled, and fifteen
are going to be brought to justice. The Khedive has
moreover, decided to close the Syrian section of the university
for one year. The greatest credit is due to both Coles Pasha
and the governor for a successful ending of a very dangerous
episode, and they have both been publicly thanked by the
Egyptian government. Since that day there has been no
interference with sanitary officers in Cairo. "In order to
make thoroughly understood the serious and regrettable side
of this incident, we must remind readers that the theological
university of El Azhar is the most renowned in all the East—
for the pious a Rome and Jerusalem combined. A hundred
years ago no Christian was allowed even to pass before its door,
and one of the most hated incidents of the hated French occu-
pation of this country was that Bonaparte converted the
mosque into a temporary stable. It is difficult to believe that
we shall not hear of this incident again. A very widespread
belief is, unfortunately, current in both Cairo and the prov-
inces that low-class Europeans are going about with sweet-
meats to poison the faithful, and that this instead of cholera
is the real cause of the epidemic. One despairs of finding any
method to counteract an unfounded belief of this kind. With
the exception of the English workers nearly all sanitary officers
are Mohammedans, and the greatest care is being taken to
avoid offending any religious feelings."
Health Report.-The following reports of mortality from small-
pox, yellow fever and cholera have been received in the office
of the Supervising Surgeon-General U. S. Marine-Hospital
Service :
SMALLPOX — UNITED STATES.
Tennessee, July 1 to 31, 13 cases, 2 deaths.
SMALLPOX — FOREIGN.
Alexandria, Egypt, June 11 to 17, 3 deaths.
Bombay, India, July 21 to 28, 4 deaths.
Cairo, Egypt, June 11 to 17, 6 deaths.
Guautanamo, Cuba, July 1 to 31, 43 deaths.
Licata, Italy, August 1 to 8, 3 deaths.
Liverpool, England, August 8 to 15, 1 case.
London, England, August 8 to 15, 2 cases.
r 1896. 3
Madras.
Madrid.
NECROLOGY.
555
Madras, India, July 17 to 24, I death.
Madrid. Spain, August t to 11, 28 deaths.
Nantes, France, July 1 to 31, 2 cases.
Naples, Italy, August 1 to 8, 8 oases, 5 deaths.
Odessa, Russia, August 1 to 8, 18 cases, 2 deaths.
Oaako and Hiogo, Japan, July 11 to 2ti, 78 eases, 25 deaths
Pans. France, August 1 to 8, 1 death.
Fsrnanibuco, Brazil, August 4 to 18, 362 cases, 58 deaths
Prague, Bohemia, July 31 to August 7, 4 cases.
Rio de Janeiro, Brazil, July 18 to August 1,27 cases, 4 deaths.
St. Petersburg, Russia. August 1 to 8, 7 cases, 1 death.
Tuxpan. Mexico. \ tigust 1 to 8, 1 death.
Warsaw, Russia, July 25 to August 8, 7 deaths.
CHOLERA.
Alexandria, Egypt, June 11 to 17, 16 deaths.
Bombay, India, July 21 to 28, 17 deaths.
Cairo, Egypt, Juno 11 to 17. 91 deaths.
Calcutta. India, July 11 to 18, 10 deaths.
YELLOW FEVER.
Fort de Franco. Martinique, W. [., August 3 to 6, 2 deaths.
Guautanamo, Cuba, July 1 to 31, 13 deaths.
Matan/as. Cuba, August 12 to I'.i, 29 deaths.
Manzanillo, Cuba, July 15 to 31, 8 deaths.
Sagua la Grande, Cuba, August 8 to 15, 85 cases, 11 deaths.
Vera Cruz. Mexico. August 13 to 20, 3 cases.
Rio de Janeiro, Brav.il, July 18 to August 1, 8 deaths.
NEW INSTRUMENTS.
A NEW SUTURE NEEDLE. MODIFICATION OF
THE HAGEDORN.
BY J. A. DIBRELL, JR., M.D.
PROFESSOR OF ANATOMY, ARKANSAS INDUSTRIAL UNIVERSITY,
LITTLE ROCK, ARKANSAS.
A great number of forceps have been devised during the last
■few years. The almost endless variety seem to have grown
largely out of attempts to adapt them for the use of both the
The above cut illustrates the modified needle as correctlv made for
me by Tiemaim A. Co., of New York City.
•ordinary and Hagedorn suture needles. But in this respect all
of them seem to be, to a great extent, failures. The transverse
and oblique grooves in forceps for the flat Hagedorn needle,
require both of one's hands for its accurate adjustment, and
■when this is done, the needle generally turns or rolls much to
•the annoyance of the surgeon. I have endeavored to obviate
this difficulty and the necessity for so many needle forceps, in
changing somewhat the form of the Hagedorn needle, which
many surgeons prefer to all others, and at the same time I
think, without impairing its usefulness, so that it may be used
in almost any holder.
Simple as is the change in its form, I have had much
trouble in getting it properly made, and then only after num-
erous trials by instrument makers in this country, and by one
in Vienna.
The needle has given satisfaction in my own work, and to
professional friends who have used it.
I have persisted in having it made for this reason, and
because I have been informed on extended inquiry that no
needle like it had been made, or is to be found in the market.
It has the Hagedorn point, but unlike that needle, is not
" curved on the edge," but is flattened in the anteroposterior
direction like the ordinary suture needle, from near the point
to, and beyond the eye, which is in the same direction, and
not on the side, as in the Hagedorn.
This flattened surface on the shaft, enables one to seize the
needle firmly at any place, except near the point and at the
eye.
The cutting point being exactly like the Hagedorn, the
wound made with it is the same, and is not altered in form by
the non-cutting portion of the needle behind the point. It
also appears to penetrate the tissues with as much ease as the
Hagedorn.
The needle can be made in any of the usual sizes or curves.
Most of the needles sent mo by the instrument makers, for
approval, were entirely too heavy, contained too much metal,
with the cutting points unnecessarily large, and the eyes too
small.
NECROLOGY.
William R. Campbell, M.D. (Starling Medical College,
Columbus, Ohio, 1863), at Vanceburg, Ky., of rheumatism,
August 19, aged 58 years. He served as a soldier during the
civil war.
Lucinda Key, M.D., one of the leading women of the col-
ored race and the second woman graduate of the Tennessee
Medical College, at Shelby ville, Tenn., August 27. She was a
successful practicing physician of Chattanooga.
Thomas Killough, M.D. (Northwestern University Medical
School, Chicago, 1873), at Hanover, 111., August 25.
Professor Pajot of Paris, aged 80 ; retired ten years ago.
Founder of the Annates de Gynecologic and the first president
of the Socie'te' d'Obstetrique et de Gynecologic.
J. C. Worthington, Surgeon, U. S. A., long stationed at
Fort Thomas, Newport, Ky, died at Louisville, August 11. He
was in strong affiliation with the profession of the neighboring
cities and left a large circle of friends.
Argyle Mackey, M.D., of Washington, D. C, at the City
Hospital, Baltimore, Md., August 28, from a self-inflicted
pistol-shot wound. To the physicians he explained most
minutely the character of his wound and the causes that were
leading to his demise. He even tried to feel his own fluttering
pulse. He repeatedly felt the tips of his fingers and noted the
slowly decreasing power of circulation and the peculiar sensa-
tions of approaching death. He was as calm as if he had been
one of the professors of the hospital delivering a clinic lecture
at the bedside of a dying patient. He graduated from the
University of Maryland School of Medicine, Baltimore, in 1890.
George D. Holsten, M.D., at New York, August 21. Dr.
Holsten was born in New York in 1857, entered the University
of New York in 1879, and was graduated in 1882. Subse-
quently he became a specialist in dermatology, and won much
success in his chosen line of work. He was president of the
Brooklyn Dermatological Society and editor of a paper devoted
to the interests of the science. Dr. Holsten was at different
times connected with the Eastern District and Brooklyn Throat
Hospitals. He was also a member of the Long Island Medical
Society, Alumni Association and Amphion Musical Society.
E. M. Nell, M.D., warden at the State penitentiary at
Frankfort, Ky., at that place August 21, aged 49 years. He
had been ill about three weeks with typhoid fever. He was
born in Adair county near Gradyville and received his early
education in the common schools. At the age of 17 he entered
the Union Army, serving about two years in the Thirteenth
Kentucky Cavalry. He graduated at the Nashville Medical
College, and soon had a large practice. He entered politics in
1885, when he was elected as representative. When he was
appointed as warden of the State penitentiary he was serving
his first term as State senator. Dr. Nell in the short time he
was warden had made many friends at the capital, and proved
himself extremely efficient as an official.
Elsworth F. Smith, M.D., of St. Louis, Mo., at Fort Mis-
soula, Mont., August 19. Dr. Smith was born in St. Louis
556
SOCIETY NEWS.
[September 5,
seventy-three years ago. His early education was obtained in
a college in St. Charles County, Mo., from which he graduated
and went to St. Louis. In that city he entered the St. Louis
University, and, after graduating, attended the St. Louis
Medical College, from which he graduated in 1848. He went
abroad to complete his medical education, and spent four years
in Paris. On his return to St. Louis he began the practice of
medicine. Through the smallpox and cholera siege he mani-
fested great courage and indomitable perseverance, and won
golden opinions from hosts of grateful citizens. In 1852 he
received the appointment as health officer, and four years later
was offered and accepted the chair of physiology in the St.
Louis Medical College, which he held until 1870. He was a
member of the American Medical Association, St. Louis and
City Hospital Medical Societies.
Jacob Rosenthal, M.D., of Chicago, after an operation for
appendicitis, August 24. Dr. Rosenthal was born at Philadel-
phia, Dec. 7, 1862, the third son of Morris and Jenetha Rosen-
thal. He received his education at the public schools of Phil-
adelphia, graduating with highest honors from the Central
High School in the class of 1878, being of the few awarded
the teacher's certificate for high average. In 1882 he received
the degree of M.A. while a student of the Jefferson Medical
College, Philadelphia, from whence he graduated with honors
in 1888. After graduation he began practicing medicine in
Chicago, and in 1891 stopped practice to take up special
courses of study in gynecology and obstetrics, spending con-
siderable time at various universities of Germany and Austria,
especially with Leopold of Dresden. He returned in 1893 and
renewed his practice in Chicago. Dr. Rosenthal was a mem-
ber of several medical societies and fraternal organizations.
He was attending gynecologist at the Cook County Hospital,
advisory surgeon of the Standard Accident Association of
Detroit, physician to the Hebrew Charities and attending phy-
sician at the Jewish Orphans' Home. He has written exten-
sively for medical journals here and abroad, and was generally
beloved by his colleagues in the profession. A host of friends
mourn his loss.
ing drainage and water supply of various towns, maps prepared
by the State Weather Service showing mean temperature,
rainfall and prevailing direction of the wind for each month,
plans of the hospital for contagious diseases at Harrisburg, etc^
BOOK NOTICES.
SOCIETY NEWS.
Proceedings of the Nebraska State Medical Society. Twenty -eighth
Annual Session, 1896. Pp. 344, cl. Published by the Society.
It contains thirty-five carefully prepared and interesting arti-
cles, and is embellished by the portrait of J. E. Summers, Jr.,
M.D., President of the Society for 1895-9&
Transactions of the American Academy of Railway Surgeons. Annual
Meeting, 1895. Vol. II. Edited by R. Harvey Reed, M.D.,
Columbus, Ohio. Pp. 221, cl. American Medical Associa-
tion Press. 1896.
President C. K. Cole, in his address, congratulates his asso-
ciates on the evidences of the success attained by the Academy
in the short period of one year. There are nineteen carefully
written articles on injuries, sanitation and medico-legal sub-
jects. It contains numerous fine illustrations, including por-
traits of the officers of the Association and views of the Plant
System hospital car.
Eleventh Annual Report of the State Board of Health and
Vital Statistics of the Commonwealth of Pennsylvania,
1895. Pp. 729, cl. Printed by Clarence M. Bush, State
Printer. 1896.
President of the Board, Pemberton Dudley, M.D. ; Secre-
tary, Benjamin Lee, M.D., Philadelphia. It contains the
report of the Secretary, minutes of the meetings of the Board,
reports of inspections, quarantine, disinfections and epidemics ;
reports of conferences and conventions ; circulars and forms in
use ; organisation, by-laws and regulations of the Board ; laws
of the State relating to the protection of life and health, passed
in 1895, etc. It ie illustrated with numerous drawings show-
Pennsylvania and Maryland Union Medical Association. — The ninth
annual reunion took place at York, Pa., August 27. The fol-
lowing officers were elected : President, Dr. Joseph Price,
Philadelphia ; vice-presidents, Drs. C. A. Rahter, Harrisburg ;:
Charles G. Hill, Baltimore ; secretary and treasurer, Roland
Jessop, York.
Sheboygan County (Wis.) Medical Society. — The annual meeting
was held August 24 at Sheboygan Falls. Dr. H. Reineking
of Sheboygan read a paper on aseptic surgery, and there was
a general discussion on tuberculosis. The officers elected for
the ensuing year were : President, C. W. Pfeifer : vice-presi-
dent, Charles Schaper ; secretary and treasurer, O. B. Bock.
The next meeting will be held at Plymouth.
Society of Doctors and Lawyers. — The Medical League Society
of Indiana was organized August 28 at Indianapolis by a num-
ber of physicians and attorneys from various sections of the
State. The object is mutual interest and the avoidance of
friction between the two professions in the giving of expert
testimony. Major C. L. Holstein of Indianapolis was elected
president ; Dr. J. F. Hibbard of Richmond, Judge Cyrus F.
McNutt of Terre Haute, Dr. G. W. McCasky of Fort Wayne,
John B. Cockrum and Dr. M. V. B. Newcomb of Indianapolis,
vice-presidents ; Dr. J. F. Hodges, Anderson, secretary ; Dr.
A. E. Sterne, Indianapolis, treasurer, and John B. Elam,
Indianapolis, heads the executive committee. A committee
reported constitution and by-laws, which will be still further
revised at a meeting to be held in Indianapolis the first Tues-
day in December.
Transportation Arrangements for the Pan-American Medical Con-
gress.—Dr. H. L. E. Johnson, 1400 L Street N.W., Washing-
ton, D. C, has been elected chairman of the Special Committee
on Transportation. All communications relative to rates,
reservation in the special trains, etc., should be addressed to
him. A rate of one fare for the round trip has been secured
between St. Louis, New Orleans and trans-Mississippi points
and the City of Mexico. It is confidently expected that this
rate will be extended over the entire territory of the United
States. Arrangements are in progress for a splendidly
equipped special train of sleeping and observation cars, with
first-class dining-car service. Dr. Johnson will presently be
in position to announce a rate which will include railroad fare,
sleeping and dining car service both ways and in the City of
Mexico, and covering the expense of various side trips to th&
most important historic points in the Republic. Charles A. L.
Reed, M.D., Secretary International Executive Committee.
American Association of Obstetricians and Gynecologists. — The
ninth annual meeting of this association will be held at Rich-
mond, Va., Sept. 22-24, 1896. The following papers will b»
read: " Principles and Progress in Gynecology," president's-
address, Joseph Price, Philadelphia ; "Vaginal Hysterectomy
by the Clamp Method," Sherwood Dunn, Los Angeles ; "Fur-
ther Experience with Appendicitis," A. Van der Veer, Albany ;.
"Relation of Malignant Disease of the Adnexa to Primary
Invasion of the Uterus," A. P. Clarke, Cambridge; "Treat-
ment of Puerperal Septicemia," H. W. Longyear, Detroit;
"Treatment of Posterior Presentation of the Vertex," E. P.
Bernardy, Philadelphia ; "Relation of Local Visceral Disorders
to the Delusions and Hallucinations of the Insane," W. P.
Manton, Detroit; "Differential Diagnosis of Hemorrhage,
Shock and Sepsis," Eugene Boise, Grand Rapids; "Movable-
189(5. ]
MISCELLANY.
557
vidney: Local and Remote Results," A. H. Cordier, Kansas
ity : "Pathology and Indications for Active Surgical Treat-
aent in Contusions of the Abdomen," W. G. Macdonald,
Ubanv : 'Some Causes of Insanity in Women," George H.
■h(\ Sykesville; "Shall Hysterectomy be Performed in
uflammatory Diseases of the Appendages," L. H. Dunning,
Indianapolis: "Dynamic Ileus; with report of cases," J. W.
ong, Richmond : "Faradic Treatment of Uterine Inertia and
Subinvolution," Charles Stover, Amsterdam ; "A Plea for
Absorbable Ligatures," H. E. Hayd, Buffalo: "Treament of
ha Stump." J. P. Baldwin, Columbus; "Limitations in the
teaching of Obstetrics and Gynecology as Determined by
State Medical Examining Boards," William Warren Potter,
Buffalo: "The Philosophy of Drainage; Treatment of the
Pedicle in Hysterectomy or Hystero-myomectomy in the
Abdominal Method," George P. Hulbert, St. Louis: "Removal
Of the Uterine Appendages for Epilepsy and Insanity; a Plea
i for its more General Adoption," D. Tod Gilliam, Columbus;
"Albuminuria of Pregnancy," A. Ft. Eklund, Stockholm;
"Unnecessary and Unnatural Fixation of the Uterus and its
Results." James l\ W. Ross, Toronto; "Sarcoma of the
Urethra," Charles A. L. Reed, Cincinnati; "Appendicitis as
a Complication in Suppurative Inflammation of the Uterine
Appendages, L. S. McMurtry, Louisville; "Gunshot Wounds
Of the Abdomen with the New Gun," J. D. Griffith, Kansas
City : " Tubo-ovarian Cysts with Interesting Cases," A. Gold-
spohn, Chicago : "Obstruction of the Bowels Following Ab-
dominal Section." tieorge S. Peck, Youngstown ; "Memorial
of Dr. Hiram Corsen," Frail] Green, Easton.
Papers are also promised by John Milton Duff, Pittsburg ;
Rufus B. Hall, Cincinnati ; George Ben Johnston, Richmond ;
Walter B. Chase, Brooklyn : Lawson Tait, Birmingham ; Wal-
ter B. Dorsett, St. Louis ; W. E. B. Davis, Birmingham ; E.
Arnold Praeger, Los Angeles. Dr. George Ben Johnston, 407
E. I i race street, Richmond, Va., is chairman of the Committee
of Arrangements, who should be addressed in regard to hotel
accommodations and railway fares. Joseph Price, president :
William Warren Potter, secretary.
MISCELLANY.
Appointment.— Dr. S. S. Bond of Washington, D. C, was
selected as surgeon general of the Union Veterans' Union, at
its meeting held in Bingham ton, N. Y., August 20.
The House of Mercy Hospital, Springfield, Mo., has received a
handsome gift from Garratt Barry, for the equipment of a sur-
gical ward of five beds. The ward will be for men, for general
operations.
Fruit Seeds in Appendicitis. — Only two fruit seeds were found
in the appendix in the course of 200 operations by Roux for
appendicitis. Sixty-five calculi of fecal origin and concentric
formation were found, their peculiar shape showing that they
had developed in the appendix. — Cbl. f. Chir., August 1.
Infection by Pets. — Cats have been suspected of conveying the
infection of diphtheria, and scarlet fever has been traced to
them. To this may be added the unwelcome news that a health
officer has reported a case of smallpox which has been brought
about in the same way ; that is to say, by a cat from an infected
house entering a neighbor's. — Pop. Science, September.
A Vegetable Meat. — In Japan they have what may be called
vegetable meat. The substance is called in the vernacular
"tui-fu." It consists mainly of protein matter of the soya
bean, and is claimed to be easily digestible and as nutritious as
meat. Torfu is as white as snow and is sold in tablets ; it tastes
somewhat like fresh malt. — Popular Science, September.
St. Margaret's Memorial Hospital, Pittsburg, Pa. Ground was
broken August 25. The buildings which will form the hospi-
tal are located on Forty-sixth street, between Lawrence and
Davidson streets. The front elevation will be 350 feet and the
depth 100 feet. The cost $200,000. The hospital was provided
for in the will of John H. Shoenberger. It is to be a memo-
rial for his wife.
Unusual Case of Syphilitic Infection. — The Annate* de Derm, et
de Syph., July, describes a case of syphilitic infection which,
starting from the initial chancre, produced in turn pleurisy,
icterus, phlebitis, acute rheumatism and dermoneuropathy, all
in the course of four months, and only yielding to mercurial
treatment.
Elect the Doctors. — The profession throughout the State
should see to it that every physician who is a candidate for the
next legislature is elected this fall. Dr. Yett, the nominee for
the senate, and Dr. Hill, nominee for the house, from the
Austin district, will be elected without doubt. — Texas Medical
News.
Dittel's Method of Elastic Ligatures of Hemorrhoidal Nodules. —
The Wiener Med. Presse, No. 20, reports the invariable suc-
cess of this method in 269 cases treated. Average length of
treatment, twelve days. The nodules dropped off with the
ligatures in five to twelve days. If the surrounding skin can
be left out of the ligatures, the pain is slight, otherwise local
anesthesia may be required. — Cbl. f. Chir., August 1.
A New Parasite. — A gentleman residing in a comfortable
country home in France, exceptionally careful of his person, has
been infested with a parasite since his return from a short trip
in 1891. It seem to belong to the genus seira, but is not
identical with any of the species described in the text-books.
It does not produce any lesions of the skin, but merely annoys
by its presence in the hair and by crawling around on the neck
and body. It disappears in the winter, but reappears each
spring in spite of the most determined efforts to exterminate
the pest. It is confined to the gentleman himself, the servants
being almost completely exempt. — Union Midicale, August 1.
The Asiatic Ant a Surgical Adjunct. — According to the Independ-
ent, Dr. Miltiades Issigonis, of Smyrna, a Greek naturalist,
has sent a paper to the Linnean Society of London, on a
remarkable use of ants in Asia Minor. It was stated that the
Greek barber-surgeons of the Levant employed a large species
of ant (camponotus) for the purpose of holding together the
edges of an incised wound. The ant, held with a forceps,
opens its mandibles wide, and being then allowed to seize the
edges of the cut, which are held together for the purpose, as
soon as a firm grip is obtained the head is severed from the
body. The author had seen natives with wounds in course of
healing with the aid of seven or eight ants' heads.
Treatment of Malignant Tumors with Toxins of Erysipelas and
Prodigiosus.— Dr. William B. Coley has reported 160 cases
treated, extending over a period of four year : Total number
of cases of sarcoma were 93 ; carcinoma and epithelioma 62 ;
sarcoma or carcinoma 10 ; tubercular 2 ; fibro-angioma 1 ;
mycosis f ungoides 1 ; goitre 2 ; keloid 1. Of the cases of sar-
coma nearly one-half showed more or less improvement ; the
variety that showed the greatest improvement was the spindle-
celled ; the melanotic showed the least. Next in order of bene-
fit was the mixed celled — round and spindle ; then round-
celled, while osteosarcoma closely approached the melanotic
in showing but little change. In a series of nine cases of
melanotic sarcoma no improvement was noticed in six ; very
slight in three. Most of the cases of osteosarcoma failed to
respond to the treatment ; many showed slight improvement,
and one case, a very large osteochondrosarcoma of the ilium,
apparently disappeared and the patient remained well for
nearly a year, when a recurrence occurred. One case of round-
celled sarcoma of the neck of very rapid growth showed very
marked decrease during the first week's treatment, after which
558
MISCELLANY.
[September 5,
time it continued to grow in spite of large doses of the toxins.
He was of opinion that a series of upward of twenty success-
ful cases of inoperable sarcoma (four of which had remained
well upward of two and one-half years), the diagnosis of which
had been established beyond question according to accepted
methods of diagnosis, ought to be sufficient to demonstrate the
real and positive advance that had been made in a field which,
up to this time, had been regarded as absolutely hopeless. —
Johns Hopkins Hos. Bui., August.
Laughter as a Symptom of Disease. —From Austria comes a
curious account of a man suffering from a nervous disease that
manifested itself in paroxysms of laughter. The patient,
whose case was described before the Psychiatric and Neurolog-
ical Society of Vienna, was 30 years of age, and had been sub-
ject for three years to fits of laughter, which occurred at first
every two or three months, gradually increasing in frequency
to a dozen or more a day. The attacks occurred especially
between 9 p.m. and 6 :30 a.m. Some occurred also during the
day, however the patient happened to be occupied. In the
intervals between the attacks, and immediately before and
afterward, the man appeared perfectly well. The attacks com-
menced with a tickling sensation arising from the toes of the
left foot, and the patient would fall to the ground unless he
could reach some place to lie down. When this feeling reached
the level of the left nipple the patient lost consciousness for a
few seconds. Often the patient lay upon his face. The mouth
and eyes were closed spasmodically, the eyeballs turned upward ;
the pupils were dilated and unresponsive to light. At the height
of the attack the patient at first smiled, and then laughed aloud
without other sign of merriment. The entire attack occupied
about two minutes. On two occasions there was protracted
loss of consciousness. — Pop. Science, September.
Permanent Baths. —The Journal de Mid., August 2, contains
a description of the permanent baths at the General Hos-
pital at Vienna, for the treatment of various skin diseases
and cases of extensive destruction of the epidermis. The baths
are of copper in a thick wooden case, and the patient is kept
completely submerged, floating beneath the surface of the
water, sitting up or reclining on a covered trellis, which can be
raised and lowered at will. He remains in this bath day and
night for weeks and months, and is only lifted out to attend to
the calls of nature. Some patients were observed who had
been in the bath for two years. The temperature of the water
is the same as that of the body ; medicaments are added as
indicated. The functions of the organism do not seem to be
affected by this prolonged soaking. The palms and soles swell
and wrinkle at first, but the rest of the sound skin is not
altered, except in rare cases an eczema is produced on the arms
or throat. Where there is great loss of epidermis, as in derm-
atitis exfoliacea and pemphigus foliaceus, extensive burns and
suppurating wounds, the water takes the place of the numer-
ous bandages required, which would fatigue and weaken the
patient. It keeps the surface moist and disinfected, and fore-
stalls complications. It also soothes or prevents the pain when
the papillae are exposed. Similar results are obtained in gan-
grenes, fistulas, syphilis, cutaneous tuberculosis, psoriasis,
lichen ruber, pityriasis universalis, ichthyosis, etc. No other
means can be compared to the permanent bath in the prompt
relief afforded, the rapidity with which the necrosed tissues
are thrown off, inflammation, pain and fever subdued and gran-
ulation and cicatrization accelerated. Erysipelas is the only
skin disease which it does not seem to benefit.
A New Question to be Decided. — According to the American Law
Revieic, an action at law is pending in the circuit court of the
city of St. Louis, involving a new question of law, which is of
importance to the teaching medical profession. The action, it
says, was brought by Anita May George, an infant, by her next
friend, against Dr. Augustus C. Bernays, a very eminent sur-
:is
H
I
geon of that city. The plaintiff, when two years of age, had
swallowed a quantity of concentrated lye, by reason of which
the esophagus became closed, so that for four years she
received her nourishment through rectal injections and through
a fistula established by a successful operation of gastrotomy
The defendant then took the child into his charge and sue
ceeded in opening the esophagus, and enabling her to take her
nourishment in the natural way. His principal operation
were performed at the Marion-Sims College of Medicine, in
the presence of a number of surgeons and medical students,
as well as of the mother of the child. And he afterward pub-
lished a description of these operations, accompanied by a
photograph of the child stripped to the waist, showing where
the various incisions in her body had been made, and illustra-
ting the printed description given of the operations ; but he
did not give the name of the child in the pamphlet, using
instead false initials. Now the mother of the child has taken
it into her head to try to recover heavy damages for the latter,
on the ground that the defendant violated her right of privacy
in two particulars : 1, in allowing outside parties to witness
the surgical operations which he performed upon her ; 2, in
publishing in the pamphlet in question a description of the
operations, together with a photograph of the patient. The
result will be awaited with interest, and it is to be hoped that
the case will not be allowed to rest until it is finally passed
upon by the supreme court of Missouri. Upon the foregoing
meager statement of facts it hardly seems possible that it can
be anything but a judgment for the defendant. At the same
time it will be a decided advantage to have the law on the sub-
ject authoritatively laid down.
Experimental Explorative Operations on the Brain. — A series of
experiments in cerebral explorations for diagnostic purposes
has been recently conducted at the Albert Clinic at Vienna,
which are described in detail in the Cbl. f. Chir. of August 1.
The subjects were dogs, and the instruments used were an
improved drill, the point forming an angle of about 100 degrees,
l1^ to 2 mm. in diameter, with a gauged guard to prevent its
penetrating too far ; a double spoon harpoon, closed to a small
point or spread apart at will, and the usual Pravaz' needles,
harpoons, etc. The object of the experiments was to deter-
mine whether and how far it is possible to explore accumula-
tions of fluids in the substance of the brain or under the mem-
branes, without injury to the patient, and also to secure portions
of the brain and fluids for histologic investigation, through the
smallest possible opening. After narcosis, the skull of the dog
was drilled through in several places, and portions of the dura
mater and cerebrum brought up by means of the spoon har-
poon or needles, curved and straight. The operations were
successful in every case ; there was no hemorrhage, and the
small drill holes in the bones and soft parts healed perfectly
without inflammation. None of the dogs showed the slightest
symptoms of cerebral disturbance, but were as lively and
hungry the next morning and afterward, as if nothing had
happened. Those killed later showed that the wounds had
healed by first intention in both bone and tissue, and that there
had been no bleeding and no adherences. Roser and Braun
have asserted that lack of pulsation in the dura mater usually
indicates an accumulation of pus or a splinter of bone, under
or near it. By means of a small glass tube inserted in the hole
drilled, and half filled with water, the pulsations of the dura
mater were distinctly perceptible as they were communicated
to the water. This effect was also obtained by a closed glass
tube, with the upper end drawn out into a delicate glass thread
at right angles to the tube, which vibratad with the pulsations
of the dura mater.
A Remarkable Operation in Intestinal Surgery; Recovery. — An arti-
cle headed " The resection of ten feet of the small intestine
of a small boy," by Dr. Guiseppe Ruggi, in II Policlinico,
1896. ]
MISCELLANY.
559
Konu-, will attract attention. The patient was a lad of 8 years,
who received his injury by being accidentally but violently
■truck on the abdomen. The abdomen being opened, a loop of
Intestine was found constricted by a bridle of the omentum.
This wan divided, and the gut being apparently uninjured, the
wound was closed. For a few days the boy did very well, but
then all the symptoms of obstruction returned in aggravated
form. One week later the wound was reopened and the intes-
tine was found to be stenosed at the point where the constrict-
ing band had been divided. The intestine was incised longi-
tudinally for a distance of 6 or 7 centimeters, freeing the stric-
ture, and an anastomosis was effected. For some time after
this the child did well, but complained, as he had before the
tirst operation, most bitterly of hunger during night and day,
in spite of the facts that large amounts of food were given, in
addition to rectal feeding. But in two weeks the meteorism,
pain and other signs of intestinal obstruction returned, and it
was determined to open once more the abdomen. A large mass
of the small intestine was found agglutinated together and
adherent to the abdominal wall. On attempting to breakdown
these adhesions it seemed to be effected with comparative ease,
but it was soon seen that the freed parts were deprived of their
mesenteric attachments. Instead of closing the abdomen as
had been done in similar cases, Dr. Ruggi determined to resect
the injured part. He removed successively three portions of the
gat, the entire length being ten feet, nine inches, until sound gut
above and below was reached. The lower incision was six
inches from the ileocecal valve. The extremities of the intes-
tine were united by silk sutures. There were no bad symp-
toms after the operation, and within a few days the boy was
again crying for food. For three weeks, in spite of many
imprudent concessions being made to him, the boy was teasing
night and day for something to eat. Gradually, however, the
food taken seemed to afford some nourishment, and five weeks
after the last operation the child was discharged perfectly well.
At the time of the report, fifteen months later, he was in per-
fect health.
Character of Locality Considered. -The supreme court of Mich-
igan thinks that it may reasonably take judicial notice that a
surgeon's skill depends somewhat upon his experience and
opportunity for witnessing operations, and it is to be expected
that the degree of surgical skill met with in different localities
will be affected by these things. However, a man with no
skill, or inconsiderable skill, should not shelter himself behind
the claim that he is the only practitioner in his neighborhood,
and therefore that he is possessed of the ordinary skill required,
although shown to possess less than the ordinary skill to be
nut with in such localities, or, as the books sometimes say, in
the general neighborhood. And, recognizing that the charac-
ter of the locality has an important bearing upon the degree of
skill requisite, the court holds in the case Pelky v. Palmer,
decided June 2. 1896, that while the instruction of the circuit
judge, taken abstractedly, that a physician charged with mal-
practice was bound to use only such care, skill and diligence
as physicians and surgeons in the neighborhood where he
resided and practiced, and who were engaged in the same
general line of practice, ordinarily have and exercise in like
was perhaps not strictly accurate, yet, in view of evi-
dence showing that the physician in question resided in a city
where there were othec physicians, presumably of average
ability, when compared with similar localities, the party suing
was not thereby injured so as to entitle him to a reversal of a
judgment in favor of the physician. There was also an instruc-
tion in this case that the plaintiff could not recover unless
he showed, by a preponderance of the evidence, a state of facts
from which no other rational conclusion could be drawn that
the defendant was unskillful and negligent, which was the
proximate cause of producing the result complained of ; and
that it was not enough to show a state of things equally con-
sistent with unskillfulness and negligence or the absence of
them. The latter part of this instruction, the supreme court
holds not objectionable ; for, where the inferences to be drawn
from the facts proved are as consistent with skill and diligence
as with unskillfulness, the plaintiff should fail. But it can not
properly be said that the plaintiff can not recover where it is
possible to draw a rational, or reasonable conclusion other
than that of negligence. Therefore, because the language in
the first part of this instruction excluded probability, and
required too high a degree of proof, the court directed a new
trial.
Breaking Up of One of the Hospital Corps Companies, U. S.Army.—
One of the results of the recent tour of inspection of Surgeon-
General Sternberg among the Western military posts has been
the breaking up of the company of instruction at Fort Riley
Kas., and the distribution of the men in small detachments at
some central post in each of the military departments west of
the Missouri River. In 1891 schools or companies of instruc-
tion were established at Fort D. A. Russell, Wyo., Fort Riley,
Kas., and at Fort Keogh, Mont. The intention was to train
men for service in the corps by instructing them in all duties
which the non-commissioned officer or private is liable to be
called upon to perform, such as nursing, first aid and hospital
corps drill, dispensary work, cooking, mess management and
the preparation of official papers pertaining to the hospital.
The organization proposed for Fort Keogh was not completed,
but companies were formed at the two other posts which did
excellent educational work and kept at the disposal of the sur-
geon-general for an emergency a number of men who could be
cut loose from their school duties until the emergency was
passed. During the railroad strikes of 1893 men were detailed
from these schools for duty with the troops on active service.
Later, a hospital corps company was formed at Washington Bar-
racks as of value in connection with the army medical school
recently established in Washington, D. C. , and as a suitable cen-
ter for the distribution of trained men to posts in the Depart-
ment of the East ; and the company at Fort D. A. Russell was
permitted to lapse by failing to recruit it. For the past two
years the centers of Hospital Corps education have therefore been
Fort Riley and Washington Barracks. The great objection to
the continuance of the former company appears to have been
the expense of transporting men from it as a center to posts on
the Pacific coast and in the far north. This was so great as
practically to debar those distant posts from participation in
the benefits to be derived from the system of instruction. By
breaking up the company into detachments and attaching these
for instruction to the hospital department at certain large
posts well scattered over this large territory it is proposed to
retain the advantages of the school method and have spare
men in each military department available for assignment in
emergencies without involving so much expense as heretofore
in getting them where they are wanted.
Nurses as Non-Experts.— In the case of American Accident Co.
v. Fidler's Administratrix, which was an action on a policy of
insurance against death by accident from external causes, the
main question was whether the insured died from typhoid
fever or whether his death was caused by his body coming
in contact with a telephone wire that threw him some ten
feet on his back and seriously injured him. The case was
twice before the court of appeals of Kentucky, May 12 and
June 17, 1896. On the first occasion it reversed a judgment for
the plaintiff, because of the admission of testimony of non-
experts to prove that the deceased died from the effects of the
fall, and not from typhoid fever, as the attending physician
and other medical men testified ; and on the second a petition
for rehearing was overruled. It seems that the widow of the
dead man, her sister and mother and also another party were
permitted to testify, not only to the symptoms of the patient such
560
MISCELLANY.
[September 5,
as would necessarily come to their knowledge when nursing him,
but from those symptoms, to give it as their opinion that the
deceased did not have typhoid fever. They did not pretend to
be experts in medical science or to have nursed more than two
or three typhoid patients. The symptoms manifested by the
patient from day to day and such as one of ordinary observa-
tion could detect, the court says, were properly allowed to be
detailed by the witnesses and to go to the jury as evidence.
And on these statements a hypothetic case could be, as was
done in this case, presented to those skilled in the character
and treatment of diseases and their opinions given as to the
cause of death ; but the court holds that these four witnesses
mentioned were clearly not entitled to express any opinion on the
subject, though it cites the case where the opinion of one who
had been a professional nurse for half a century and his famili-
arity with the disease was unquestioned, was received as entitled
to great weight. On the rehearing the court said that the opinion
of one having no experience in the science of surgery should have
no weight when eminent surgeons are present and have testi-
fied that a limb was improperly amputated, or that it was not
necessary to save the life of the patient ; nor, where the disease
is pronounced to be typhoid fever by educated physicians, is it
competent to prove by one inexperienced in the treatment of
diseases, and who had never made a study of medicine, that
the physicians were mistaken.
Water Famine Among the East London Poor. — The water famine
in the East End of London has become a great source of com-
plaint. Many children, it is said, have died, others are sick
and others are becoming ill owing to the scarcity of water.
Few houses are allowed a supply of more than an hour daily,
and the water furnished has an unpleasant deposit. The
result is that scarlet fever, diphtheria and other diseases caused
by uncleanliness have seriously affected the section. While
the East End has thus been deprived of water, the fountains
in the West End, or fashionable part of London, have been
running, thereby wasting water which would most likely have
saved the lives of many poor children in the unaristocratic por-
tion of the metropolis, although this must be remembered that
the companies that have the water rights in these different
sections are not the same.
Medical Longevity. The London Lancet for June 20 states
that Dr. Salzmann of Esslingen has recently devoted his atten-
tion to determining the average duration of life among
members of the medical profession. After an exhaustive
examination of all accessible archives referring to the last four
centuries, the following are the results arrived at by the zeal-
ous antiquarian. The average duration of a medical man's
life during the sixteenth century was 36 years, 5 months ; in the
seventeenth century it was 45 years, 8 months ; in the eigh-
teenth century 49 years, 8 months, and in the nineteenth
century 56 years, 7 months. It would appear from these data
that, whether the survival be of the fittest or not, the duration
of medical life has been increasing in a marvelous manner.
Should the same rate be maintained practitioners of medicine
may ere long all look forward to centennial honors, by no
means a rosy prospect from the point of view of the neophyte
who, as it is, finds it sufficiently hard to make good his footing
within the densely crowded ranks. According to Dr. Salz-
mann the addition of over twenty years to the average medical
lifetime is due to the advance in medical science, preventive
and curative; so the ironic apophthegm, "physician, heal
thyself," can no longer be launched with any effect. In
a speech delivered some time ago the present leader of the
House of Commons alluded to the possibility of normal human
life becoming extended "to the patriarchal term of 120 years."
Alleged Medical Hardships in Russia. — The London Lancet
refers to the hard lot of the profession in Russia, and to the
many cases of suicide among the physicians in that land.
Italy in suicide, as in homicide, maintains a bad preeminence ;
but in professional suicide, in the self-destruction of votaries
of the liberal arts, particularly medicine, she would appear to
be out-distanced by Russia. Prom a statistical return lately
published, suicide among the practitioners of the healing art
in Russia has reached alarming proportions — a distressing fea-
ture of the return being the comparative youth of the victims.
The majority of them average between 25 and 35 years of age —
all of them in the prime of life and full flush of their powers.
An explanation of the phenomenon is sought in the fact that
the Russian medical man's lot is a particularly hard one. As
in Italy the profession is vastly overstocked in all the cities of
the empire, and in consequence competition is exceptionally
severe — so severe that a physician has been known to hold
consultations from 8 a.m. to 11 p.m. in order to gain the rea-
sonable income of 600 rubles a year. Besides the Russian
municipalities, seconded by the lay press, have instituted gra-
tuitous consultations in public ambulances, by which the
wealthy city of Kiev, for example, withdraws from the legiti-
mate fees of the profession as much as 27,000 rubles per annum.
There the poverty of the practitioner is such that he has been
known to give advice for 20 kopecks (8d.) for each consultation.
:es
id
le
.:
ur
Hippocrates the Founder of an Enduring Ethical System. — It can
not truthfully be said of the Father of Medicine that he is i
"back number." On the contrary a perennial bloom graces
all his decisions about the medical life. Men may come and
men may go, but his wise eloquence flows on forever. The
editor of the Scalpel enlarges upon this thought as follows :
"The Father of Medicine, Hippocrates, has laid down our
ethical code for all time. It is the only one we can recognize
and have recognized. It over-rides all modern definitions,
whether framed by colleges or leading members of the bar.
It is not a question of autres temps autre* mceura. This old
Pagan knew his duty, and his words, sounding along the cor-
ridors of time, appeal to us to-day with all their freshness.
because at the root of his words there is the one great element
which makes all words valuable and vitable, viz., their truth.
The practice of medicine in ancient times was much as it is in
the present day ; human nature has been much the same in all
ages, especially where sex is concerned. Hippocrates knew
probably just as much as the College of Physicians of London
about abortion and about all the secrets connected with it,
and not only about abortion but about the thousand and one
secrets which are brought under our notice, for the life cur-
rents have hardly changed ; the same fears are here, the same
weaknesses, the same suffering, the same vices, the same
repentance, and the physician who hears all the sad stories of
human frailty is still the same. We have followed the teach-
ing of Hippocrates and not of modern men and modern manners ;
we intend to follow it, and we strongly advise all younger
members of the profession to read the Hippocratic oath and to
adopt it. Hippocrates said : 'I swear whatever in connection
with my professional practice or not in connection with it, I
see or hear in the life of men which ought not to be spoken of
abroad, I will not divulge, as reckoning that all such should
be kept secret. While I continue to keep this oath unviolated
may it be granted to me to enjoy life and the practice of the
art respected by all men and in all times, but should I tres-
pass and violate this oath may the reverse be my lot.' The
word 'men' here is used in the generic sense and also includes
women, and the word abroad also admits of definition, for
Hippocrates did not say anything of the law which even in his
time demanded civic duties of the doctor. In France, Ger-
many and all civilized countries, the professional secret is not
only privileged but sacred. In England, with the old school
of practitioners, we have been brought up in the same tradi-
tions. There may be a younger school, but we hope it is a very
limited one, holding different tenets."
1896.]
MISCELLANY.
561
Practice of Medicine in West Virginia.— Section 9 of chapter 150
of the code i if West Virginia was amended in 1895, so that the
following persons, and no others, shall hereafter be permitted
to practice medicine in that State, viz. : 1. All such persons as
were legally entitled to practice medicine in that State Feb. 22,
1895. 2. All such persons as shall pass an examination before
the Stato board of health and shall receive certificates from
such board, as provided. The State board of health, it is
further enacted, shall, at such times as a majority of them may
deem proper, hold examinations for the licensing of practi-
tioners of medicine. Such examinations shall not be less in
number than three during each year and shall be held at such
points in the State as shall be most convenient to those pre-
senting themselves for examination or to the State board of
health. At sueh examinations written and oral questions shall
be submitted to the applicants for license, covering all the
essential branches of the sciencesof medicine and surgery, and
the examination shall be a thorough and decisive test of the
knowledge and ability of the applicants. The president and
secretary of the State board of health shall issue certificates to
all who successfully pass the said examination, and such cer-
tificates, after being duly recorded, shall be deemed licenses to
practice medicine and surgery in all their branches in West
Virginia. The State board of health shall give timely notice
of the time and place of holding each such examination, by
publishing such notice in at least three newspapers of general
circulation in the State, and all persons wishing to present
themselves for examination should notify the secretary of the
State board of health to that effect. No applicant for a license
to practice medicine in West Virginia shall be rejected because
of his or her adherence to any particular school or theory of
medicine. The State board of health shall call to their assist-
ance, in the examination of any applicant who professes the
homeopathic or eclectic school of medicine, a homeopathic or
eclectic physician duly licensed to practice medicine in the
State, and such homeopathic or eclectic physicians so called to
the assistance of the State board of health, shall be allowed
per diem and actual expenses incurred as allowed to regular
members of the State board of health : provided, however, that
the provisions of this and the preceding section shall not apply
to physicians living in other States and duly qualified to prac-
tice medicine therein, who shall be called into consultation into
West Virginia, by a physician legally entitled to practice med-
icine in West Virginia under these sections. Section 17 of the
same chapter of the code is amended so that all moneys
received from the State board of health as fees for examina-
tion, under section 11 thereof, shall be placed to the credit of
the State board of health by the treasurer of the State, and
shall, with other moneys appropriated to the said State board
of health, be used to defray the expenses of its meetings,
examinations, etc.
Changes in Virginia Health Law.— Sections 1714, 1715, 1717, 1724
and 1725, code of Virginia, were amended and reenacted by
an act approved March 3, 1896. The provision, in original section
1714, that the State board of health should not in any way be
a charge upon the State, was dropped. Section 1715 had intro-
duced into it a provision that the board shall have power and
authority, as further directed, to adopt such rules and regula-
tions, and issue such orders as may be necessary to prevent
the spread of contagious or infectious diseases, and to confine
persons infected therewith or who may have recently been
exposed to the same, within prescribed limits. Section 1717
had the provisions added that the salary of the secretary shall
be fixed by the board and that the other members of the board
shall receive no salary, but shall be paid the sum of S4 per day
while engaged in the discharge of theirduties, and their travel-
ing expenses incurred while so employed. The expenses of the
State board of health, which shall not ip any one year exceed
the sum of $2,000, shall be paid by warrants drawn on the*
auditor of public accounts, signed by the president of said
board, and countersigned by the secretary, out of any money
in the treasury not otherwise appropriated. Section 1724, as
now amended, provides that if any member of the State board
of health or a justice of any county shall have complaint, on
oath, made to him, or if he shall have reason to think that
there is on any lot, tenement, or plantation, or on board any
vessel in said county, any person infected with smallpox, or
other dangerous disease, it shall be the duty of said member
of the board of health, or of said justice to issue a mandate in
writing, addressed to two physicians of said county, requiring
them to go to the place so suspected and to examine the per-
sons diseased, if any, and to report in writing their opinion of
such disease, and whether the public's interests require any
action. If it appear to said board of health or said justice from
said report that such person or persons are infected with small-
pox or other dangerous disease, then said board of health or
justice, whichever has first taken cognizance of the case, shall
prescribe such rules and regulations as may be deemed neces-
sary to prevent the spread of such disease ; but the action of
said justice shall be subject to the review of the local board of
health, and for this purpose said board of health or justice may
establish a quarantine at the place or places where such dis-
ease exists, and inhibit any ingress or egress to or from the
same. They may, by proper orders, prevent any railroad train,
steamboat or other conveyance from taking on or putting off
passengers or freight at any point or points in or near the
infected district. For the services required of the physicians
under this section, a reasonable allowance shall be made to
them by the board of supervisors at the next county levy there-
after. Section 1725 is amended, extending power to the State
board of health to have infected persons removed to a hospital
or other proper place.
Lord Wolseley on the Army Medical Officer. — It may be remem-
bered that six months ago at the close of the 71st session, of
the Army Medical School, Netley, England, the speech of Ad-
jutant General Sir Redvers Buller to the graduating class cre-
ated much dissatisfaction in medical circles, civil as well as
military, on account of the low place which he gave to the
army medical officer in the military hierarchy, defining his
duties as those of the doctor merely and overlooking those of
the sanitary officer, although speaking under the roof of the
medical school and in the presence of the faculty instituted to
teach the young officer these very duties. The impressions cre-
ated by that speech can not but be effaced by the spirit of com-
radeship evinced by the Commander-in-Chief, Lord Wolseley,
in his remarks on distributing the prizes, July 31, at the close
of the 72d session. He eulogized the medical department and
raised the army medical officer officially and socially to his
proper plane. According to a summary in the Lancet of Aug-
ust 15 : During the course of a long military career he could
most conscientiously say that some of the greatest friends he
had had in the army had been medical officers. . . . As
they (the young officers) went out to their duties he could
assure them that they would find that no man appreciated the
services of officers — certainly of the medical officers — of the
army more thoroughly than the private. He was extremely
grateful for every kindness ; and he would remind them that
no body of men in the army were more capable of doing acts
of kindness than the medical officers of Her Majesty's service.
When he thought of that building (the Royal Victoria Hospital)
he could not help remembering the two men to whom he
thought they were mostly indebted for it. He knew them both
well and had the greatest admiration for them. He was
referring to Dr. Parkes and Sir Thomas Longmore. The name-
of Dr. Parkes called to his mind the book which he wrote on
Hygiene, which when it first appeared created quite a revolui-
562
MISCELLANY.
[September 5, 1896.}
tion in that science not only in the medical service but through-
out the various parts of Her Majesty's dominions. It was
their duty not only to heal disease, but to do their best to pre-
vent it, and Dr. Parkes was the first man to show them how
disease might be kept away from their barracks. Dr. Parkes
had passed away from them, but his memory would always be
fresh in the minds of those studying there, and his name would
be remembered in the army so long as the hospital continued
to exist. Members of their profession had not only been dis-
tinguished for their medical services. He had on many occa-
sions seen some of the greatest acts of heroism performed by
gentlemen of the department ; and if he was asked to name a
dozen of the very bravest men he had ever met he should
have to include two or three who had been in the medical
department. He would name one at once, because he saw him,
quite lately. Perhaps they had heard of Sir Robert Jackson.
He was with him for a long time ; and if he had to lead a
storming party to-morrow he did not know any man he would
sooner have with him than his friend Dr. Jackson. He went
to Lucknow with his regiment, and the senior medical officer
of the battalion was equally brave and won the Victoria Cross
on the occasion. There were many acts performed by medical
officers which deserved to be recorded on any pages of history
devoted to heroism. He related the dying act of Surgeon-
Major Landon, who, when lingering under what proved to be a
fatal gunshot wound, asked the enemy, into whose hands a
batch of wounded had fallen in an unfortunate expedition, to
prop him up while he injected morphia into a soldier who had
been seriously wounded in order to relieve his suffering. After
which service he fell back and expired in half an hour. Such
an act as that should be talked of and read of in the medical
school and should be known throughout the army. In con-
clusion he begged to wish them the best fortune in the pro-
fession in which they had embarked and to hope that he might
have during the remaining portion of his life many opportuni-
ties of meeting them again.
•
Gleanings.— Fatal pneumonia immediately following a fall into
water ; pneumococci must have been inspirated into the lungs
with the water. Pinkelstein ascribes follicular enteritis to a
new bacillus he has discovered. (Therap. Woch., July 25.)
Query whether the "ainhum" of the negroes and some cases
of syringomyelia, sclerodactylia, etc., may not be forms of lep-
rosy. Cancer of the stomach arrested and pains and cachexia
cured by exposure to the Roentgen ray half an hour, twice a
day for a week, supplemented by milk diet, condurango and
injections of artificial serum. ■ Absolute cure of congenital
incontinence of urine (age 2*2 yearsi by inductive static current
Morton's current, six to eight sparks a second) introduced
with a bougie into the urethra to the vesical sphincter. (Sem.
Med., July 29.) Acute appendicitis treated with opium and
ice ; fifth day the appendix was passed entire in the feces,
with evidences of a circular abscess where it had been joined
to the intestine ; recovery. (Wratsch, No. 22.) Fatal peri-
tonitis ; two pins found in appendix. (CM. /. inn. M. No. 20.)
Goitre experimentally produced by water from the beautiful
Vale of Aosta, noted for its many cases of endemic goitre.
( Wien. Klin. R., July 23.) Four grave cases of infective dis-
ease cured by letting out blood and substituting in its place
an equal amount of serum. {Butt, de V Acad. d. M., July 21. i
Arnheim reports sanoform (di-iodin-salicylic acid methyl
ether, ) non-toxic and fully as effectual as iodoform ; 72 ulcers,
etc., treated; used as powder, gauze, salve and collodium.
(Cbl.f.Chir., July 11.) Borger has invented a thyroid gland
hook to simplify tracheotomy. (Zeit. f. prakt. Aerzte, No.' 8.)
As a means to prevent adulterations it is proposed to hang
up in a prominent place in an offender's establishment the anal-
ysis of the article adulterated, with a notice calling customers'
attention to it. (St. Pet. Med. Woch., July 18.) The healthy
skin and vagina do not absorb medicaments added to baths ;
erythema of the surface must first be produced by cbemic or
mechanical means before there is absorption. (Nouveaux
Remedes, July 18.) Experimental "washing" of the blood
(dogs), leads Bosc and Vedel to conclude that the action of the-
intravenous injections of 7 per cent, salt solution is by the
osmotic action of the NaCl, by the diuretic action of the salt,
direct and indirect, and by elevation of the pressure of the-
blood ; it also acts on the red corpuscles, promotes the nutri-
tion of the organism, and diminishes the globulicide power of
the pathologic serum ; a medium dose injected at the first
symptoms of infection promptly cures ; large doses resulted
fatally ; the preventive action of early injections suggests the
existence of a superactivity of the organism, revealing itself in
reactionary phenomena, already noticed in normal dogs, resem-
bling a natural crisis reaction. (Bull. Mid., July 29.)
THE PUBLIC SERVICES.
Army < liniittew. Official List of changes in the stations and dunes
of officers serving in the Medical Department, U. S. Army, from
Aug. 22 to Aug. 28, 1896.
A board of medical officers to consist of: Col. Dallas Boche, Asst. Sur-
geon-General; Lieut.-Col. William H. Forwood. Deputy Surgeon-
General ; Lieut.-Col. David L. Huntington, Deputy Surgeon-General;
Major Walter Reed, Surgeon; Capt. Charles M. Gandy, Asst. Surgeon.
is constituted to meet at the Army Medical Museum Building on
Wednesday, Sept. 28, 1890, at 10 o'clock a.m., for examination of can-
didates for admission to the Medical Corps of the Army.
Wavy 1'haneres. Changes in the Medical Corps of the U. S. Nary for
the week ending Aug. 29, 1896.
Medical Director David Kindleberger, placed on the retired list Sep-
tember 2.
Asst. Surgeon H. La Motte, ordered to the naval hospital at Norfolk.
Surgeon C. Biddle, detached from the "Monongahela" and placed oi>
waiting orders.
Medical Inspector J. C. Wise, Surgeons J. C. Byrnes and C. Biddle
ordered as a board to convene at Annapolis September S, to examine
candidates for admission to the naval academy.
I'hanire of Address.
Durant, G., from Bradford, Conn., to 12 \V. 46th St., New York, N. Y.
Earles, W. II., from 666 3d St. to 259 llth St.. Milwaukee, Wis.
Fraser, J. N., from MOO Went worth Av. to New Era Bldg., Cor. Blue
Island Av. and Harrison St., Chicago.
Hagens.G.J., from 60688. Halsted St. to (>0.~>3 S. Halsted St., Chicago.
Joui-s, W. A , 680 Walnut St. to 221-222 Spitzer Bldg., Toledo, Ohio.
Kober, G. M., from Winchester, Va. to 1819 Q St., N. W., Washington.
MacDonald.Chas. E., from Liberty Falls to St. John's Hospital, Long
[Bland City, N. Y.
Miles, J. W., from :S.">5 Dearborn Av. to 390 N. Clark St., Chicago.
1'enton, A. B.. from 270 Harrison St. to 184 Ash St., Detroit, Mich.
Percy, J. F., from Mantorvilh', Minn., to (lalcsburg, 111.
Smith, S. L., from Chicago to Neenah, Wis
Simpson, Irwin, from Anamosa, Iowa, to 5034 Washington Av..Chicago.
Watts, G. W.,from 861 W. 66th St. to "The Yale," Station O.Chicago.
LETTERS RECEIVED
Atwood Mfg. Co., AiiK'slniry, Mass.; American Medico-Sur|rioa1 Bulle-
tin, New York; Abbott, VV. C. Ravenswood, 111.; Alma Sanitarium Co.,
Alma, Mich.; Alexander, H. M. & Co.. Marietta, Fa.
Brown, Sanger, Chicago; Bittman, Chas. W.. St. Louis. Mo.; Black-
well, Emily, New York; Burr, C. IS., Flint. Mich.; Bovee, J. Wesley,
Washington, I). ('.; Bernd, Henry & Co.. St. Louis. Mo.
I. II. i... stout'. Alu.; Clare, M. \V., Eureka. Mo.; Crofut, Martha
M. Chicago; Chicago Polyclinic and Hospital, Chicago ; Cox. C. C, Col-
lege Park, Ua.
Davidson Hubber Co.. Boston, Mass. : Dewey, Hichard (2), Wauwatosa,
Wis.; Darling, 0. G., Ann Arbor, Mich.; Detroit College of Medicine,
Detroit. Mich.; Drevet Manufacturing Co., New York.
Eve, Paul F., Nashville, Tenn.; Earle.T.T.. Greenville. S. C.
Freeman, Leonard. Denver, Colo.; Foster, Eugene, Augusta, Ga.;
Foltz. G. \V.. Lima. Ohio.
Graham, H. G., Chicago; Goffe, J. Riddle, New York; Gotham, The
Company, New York.
Hall. C. II., Salem, Ore.; Hummel, A. L.. Advertising Agency (2), New
York; Holland, J. W., Philadelphia, Pa. ; Haggard. W. D., Jr., Nashville,
Tenn.; Hines. VY. Frank, Chestertown, Md.; Holgate, J. R., Allsboro,
Ala.; Haldensteiu. J. (2). New York.
Jackson, Edward. Philadelphia, I'a. ; .lust's Food Co., Syracuse, N. Y.
I.ia Brothers & Co,, Philadelphia, Pa.; Lusk, Z. J., Warsaw, N.Y.;
Lehu & Fink, New York.
Marshall, i lara, Philadelphia, Pa.: McLean, R. A., San Francisco, Cal.;
Marshall, John, Philadelphia, Pa.: Mudrt, II. H.St. Louis, Mo.: Maltine
Mfg. Co., New York: MacDonald, J. W., Minneapolis, Minn.; Meany, W.
B.. St. Louis. Mo.
Nash, A., Joliet, 111.
Park. J. Walter, Harrisburg, Pa.; Prentiss, Spencer B., Washington,
D. C. ; Pautagraph Printing & Stationery Co.. New York.
Randall & Becton, Boston, Mass.; Reynolds, F. R., Ft. Clark, Texas;
Rose, Wm„ Columbia, 111.; Rosenthal. Edwin. Philadelphia. Pa.; Roosa,
D. B. St. John. New York: Rogers, II. W., Cleveland, Ohio; Rio Chemi-
cal Co., St. Louis, Mo. ; Randall. J. N.. Decatur, III.
Shearer; G. H.. Philadelphia, Pa.; Spagl, A., Frankfurt a. M., Germany;
Stowell. Chas. II., Washington, D. C: Seville, F. F, Chicago; Selling,
L. M. Agawam, Mass.: Sampson, F. E., Creston, Iowa: Saxlehner,
Andreas, New Y'ork; Shepard.Chas. H., Brooklyn, N. Y.; Shidler, G. W.,
Y'ork, Neb.
Travis, B.F., Chattanooga, Tenn.; Truax, Chas., Greene & Co., Chicago.
Willson, H. B. & Co., Washington, D. C; Whelplev, H. M., St, Louis,
Mo. ; Wathen, W. H., Louisville, Ky. ; Wingate, O. U. B., Milwaukee.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., SEPTEMBER 12, 1896.
No. 11.
ADDRESSES.
CHAIRMAN'S ADDRESS.
IV! \ored Mora the Section on Ophthalmology at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlauta. Ua., May 5-8, 1896.
in LUCIBN howe, m.d.
BUFFALO, N.T.
It is one of the duties of the chairman of each Sec-
tion of this ASSOCIATION to present an "Address" at
the opening of the session in his department.
Perhaps this custom would be more honored in the
breach than the observance and in the present instance
the time would he better employed by proceeding at
once to the inviting list of papers which the Execu-
tive Committee has prepared. But when one has
been complimented by election to the chairmanship
of the Section which is generally conceded to be the
most active of all the Sections in this Association,
it ill becomes him to avail himself of any excuse and
fail to acknowledge the honor thus conferred upon
him.
Indeed, he assumes a definite responsibility in
accepting this position. For while it is manifestly
impossible for him to present the barest outline of
the year's advance even in this one small corner of
the held of medical science, still, it is his duty to
observe the trend of ophthalmologic thought, to point
out. if he can, the directions in which the lines of
progress may be advanced, or, what is yet more impor-
tant, to sound the alarm if there is danger of any in
our ranks going so far and so fast in their eagerness
for achievement as to overstep the limits of scientific
accuracy, with the inevitable result of retreat, in con-
fusion and in shame, to a more moderate and secure
position. With this in view, I feel impelled to ask
your attention, very briefly, to a growing tendency
among us to regard difficulties of the accommodative
and muscular apparatus as entirely local. I would fain
say a word for that nearly forgotten factor, the " gen-
eral health." This introduction again of a threadbare
subject almost demands apology, especially as, for the
sake of clearness later, it is necessary now at the outset
to repeat definitions which have been agreed upon
long ago. Thus, when we say that the pathologic con-
ditions above mentioned produce asthenopia, it is
essential that we remember not only what that means,
but also the three shades of its meaning.
We must remember that asthenopia is simply the
name of a certain group of symptoms, namely, diffi-
culty or discomfort when attempting to use the eyes
for near work, occasionally a little redness or smart-
ing of the conjunctiva, and nearly always headache —
then called ocular headache. Moreover, we must
remember that this group of symptoms may be depen-
dent upon at least three distinct causes. These we
have long ago recognized as:
1. Accommodative asthenopia, which, being due to
some variation from the normal shape of the typical
eye, as near- or far-sightedness, or to astigmatism in
some form, necessitates an unusual action of the cili
ary muscle and is, of course, to be corrected with a
concave or convex glass.
2. Muscular asthenopia. While this is often asso-
ciated with the accommodative form, it may occur
when the globe is perfectly normal. It is due to an
unnatural action of the muscles on the outside of the
eye, to the recti and possibly to the oblique; it is
recognized by the various tests for unequal muscular
balance, and is corrected by means of prisms, by ten-
otomies, partial or total, or by muscular advancement.
3. Central or neurasthenic asthenopia. In this con-
dition no variation from the normal standard can be
discovered either as regards the action of the ciliary
muscle or the recti or oblique muscles. Or, indeed,
if any such abnormal condition did exist, the asthe-
nopia persists after the patient has received full cor-
rection of the difficulty by means of glasses or otherwise.
While it may appear puerile to repeat elementary
facts at a meeting of ophthalmologists, it is better to
err in that respect than to risk the confusion that
arises from nebulous ideas defined in vague terms.
This, especially for the reason that, in order to
establish the point in question, it is more important
to arrange in proper sequence a few facts already well
known than to bring forward any that are new.
Now, the object of this paper, as above stated, is to call
attention to the too great tendency with most ophthal-
mologists to consider their cases of asthenopia as
belonging to the first or second class. In other words,
we look upon the causes of the symptoms as more local
than general, as is natural enough with those who,
like ourselves, are obliged to focus their entire atten-
tion upon a small field of practice. Especially is
this true because we naturally see a large propor
tion of cases of asthenopia which do require only
local treatment. Indeed, in a few rare instances, ame-
tropia or a faulty muscular balance may produce by
reflex action pathologic symptoms in distinct organs,
which symptoms have apparently been relieved by
the use of suitable glasses. But let us ask ourselves
more exactly concerning accommodative and muscu-
lar asthenopia and it will be evident, I think, how
often we deal with the third form, how often this
becomes in the history of the case what the Tiers
Etat was to the French Revolution, the element
unrecognized or reluctantly acknowledged at first, but
dominant in the end.
Take accommodative asthenopia first. In high
degrees of far-sightedness or especially of astigma-
tism, we learned long ago to expect ocular headaches
or their allied symptoms. We have prescribed suit-
able glasses and the asthenopia vanished, as if by
magic. Then, later, we learned that in certain indi-
viduals lesser degrees, even very minute degrees, of
variation from the normal type also gave rise to the
564
CHAIRMAN'S ADDRESS.
[September 12,
same symptoms, and required likewise to be corrected
with glasses. This is the positive evidence. But we
should look at the negative evidence as well. For if
these same anomalies, which are mathematically defi-
nite, produced invariably the same effect, as we ought
to expect if the asthenopia springs from local causes,
then there would be but very few men, women or
children not wearing glasses. I know of no figures
more instructive on this point than those obtained by
Roosa in his examination of the refraction of a
hundred persons who supposed their eyes to be per-
fectly normal. These individuals, it will be remem-
bered, were of various ages and occupations, and no
person had both eyes absolutely perfect, as shown by
the combined tests of the ophthalmometer, ophthal-
moscope and test glasses, while only 1 per cent, had
one eye in that condition. Among them, too, several
persons were found having as high as one and one-half
or two dioptries of either myopia, hypermetropia or
astigmatism, who were blissfully unconscious of their
defects.
While thus on the one hand, we find constantly such
variations from the normal standard to exist without
headache or any symptoms of accommodative asthe-
nopia, so, on the other hand, are we unfortunately
familiar with the fact that when the very best and
most exact corrections have been made, even under
atropin, this asthenopia obstinately persists in almost
as great a degree as without the correction.
Next, let us glance at the state of our knowledge
concerning muscular asthenopia and arrange before
us, in similar sequence, a few well-known facts. We
can formulate these in the same manner by saying
that while asthenopia usually exists with unequal
muscular balance, the same symptoms also frequently
persist when that fault can not be detected by any
methods of measurement now at our command, or
when, having been present formerly, it has been cor-
rected. On the other hand, eyes which have always
been considered perfect, which never gave their own-
ers a suspicion of asthenopia, have occasionally been
found, on examination, to be in a state of exceedingly
unequal muscular balance. In these cases, even
though exceptional, of course, I am careful not to
include those in which any existing error of refrac-
tion had not been previously fully corrected under a
mydriatic, no matter how slight that variation from
the normal had seemed to be. Moreover, in this con-
nection, I do not ignore at all that very important
distinction which I think should always be made
between the sthenic and asthenic varieties of muscu-
lar asthenopia.
In other words, we have for muscular asthenopia
just what we found before for accommodative asthe-
nopia, namely, that some considerable variations from
the normal type, which theoretically should be cor-
rected, do not demand that, the owners of these eyes
being perfectly comfortable without glasses. And on
the contrary, in many individuals when the variations
from that type are very slight, indeed, practically not
measurable, the asthenopia continues in spite of every
effort, the patients wandering from one office to
another in a vain search for relief.
Now, the question naturally arises, why are we
obliged to make such an exact adaptation of glasses,
or to correct the muscular condition so carefully, with
one class of individuals, and not with the other?
Under these circumstances we fall back upon our
third factor, so conveniently indefinite just then, by
the " accommodative
the " strength of
in
saying that the difference is in
power" of the individuals, or
the muscles " or " vis a targo," as we variously term
it. Evidently, though, this is simply using a phrase
to cover our ignorance.
In this dilemma, unfortunately too common, we
must simply ask ourselves honestly what other condi-
tion exists, or what conditions combine, in that indi-
vidual, to produce the asthenopia? This is a branch
of pathology which, as I said at the outset, is too
much neglected, and in regard to which I venture to
speak only with caution, but it seems safe to say
that what we understand in general as anemia, as
imperfect assimilation and as nerve exhaustion, are
three important elements which, in varying degrees,
separately or together, produce central asthenopia.
Several years ago I measured, with the spectroscopic
bands, the amount of hemoglobin present in indivi-
duals suffering from certain forms of eye disease, a
portion of the results being published then in the
Transactions of the Medical Society of the State of
New York. It was quite surprising to observe how
frequently improvement in these cases corresponded
with a return to the normal condition of the blood.
I can speak with no such certainty concerning
the relation between the condition of the blood
and central asthenopia, but it is fairly reasonable to
infer that the pallid specimens of humanity who come
for glasses and who find relief from a half or possibly
a quarter of a dioptrie, or from correspondingly weak
prisms, would have strong eyes if they had also more
nearly normal blood.
Next, as to imperfect nutrition. There is but
little doubt that this also plays an important role in
aggravating the asthenopia in certain individuals. In
order to test this, about three years ago I placed in a
corner of my office a pair of the small size Fairbanks
scales, noting the weight of those patients to whom
very weak glasses proved beneficial, and was not sur-
prised to find that as appetite improved and weight
was gained, the glasses could often be dispensed with.
Finally, as to the effect of the so-called "nervous"
condition of the individual. It would require too
long a digression to discuss that in any detail, nor is
it necessary, as I think it will be admitted that this is
one element, and an important one, in relation to
asthenopia. In this connection the so-called psychic
effect of glasses, of manipulations or of " operations,"
can not houestly be passed by without some notice.
It is probable that the mere wearing of a pair of
spectacles with simple plane glasses has an effect upon
the minds of certain individuals, similar to that pro-
duced by a hypnotic suggestion. This observation
was made by Dr. Holt at a recent meeting of the
American Ophthalmological Society, and acting on
this hint I provided myself with a number of pairs
of plane glasses. These have been lent to those who
imagined they should have spectacles, or have been
exchanged for weak glasses before prescribed, in a
sufficient number of instances to prove beyond ques-
tion this psychic element. Moreover, I have yet to
meet with the person who fails to appreciate the
advantage of such a trial, or one who is not glad to
be rid of any glasses, when the reason for the experi-
ment has been frankly and fully explained. Most
practitioners also have heard reports of improvement
from their imaginative patients almost before treat-
ment was begun, and certainly the results from some
of the methods of making partial tenotomies, can be
1896. ]
SUBCONJUNCTIVAL INJECTIONS.
565
accounted for more rationally in this way than in any
other.
There are. of course, other general causes tending
to produce central asthenopia which might be consid-
ered in this connection, but which must of necessity
be omitted. It should be noted, however, that while
the error of refraction which produces accommodative
asthenopia remains nearly the same through life, and
while, also, the unequal balance belonging to muscu-
lar asthenopia varies comparatively little, on the other
hand, those conditions of the general health which
upany central asthenopia do change readily. The
application of this fact is practical and familiar. Con-
lasses or prisms which once gave the patient
.-lief can be changed for those which are weaker, or
re voluntarily laid aside altogether when the health
if the patient lias improved. In certain cases after
re have gone through the usual exact routine with
iphthalmoseope. ophthalmometer and various mus-
clar fists, it is tine we do succeed in detecting some
slight anomalies which have existed perhaps for years,
id which are aggravated only temporarily by some
loh fault in the general condition as has been indi-
ited above, and which the family physician himself
i erlooked. Under such circumstances if we then
Iso neglect the general health of the patient and set
ourselves at work to correct only the error of refraction
or the muscular balance, we may be sure of obtaining
little or no improvement at first. But as the patients
re patient, and consent to rest, or to exchange a sed-
entary life for fresh air, or a life of hard work for one
with more relaxation, in such cases relief does come,
but comes very gradually, and this improvement must
lie accredited more to nature's tonics and time than
to any skill in prescribing glasses or to "exercises," or
to any of those measures which in other individuals
are undoubtedly of benefit.
I know that this will be considered by many as her-
esy, but it is none the less the truth. It behooves us
to recognize it frankly and to be on our guard accord-
ingly.
We have reason to congratulate ourselves upon the
advances made during the last few years, especially in
America, in the methods of determining and of treat-
ing accommodation and muscular asthenopia. But let
us beware of rapid progress in these two lines, at the
neglect of a third often equally important.
To avoid that, for our own credit, and for the greater
comfort of our patients, I venture to recall these facts,
already familiar, concerning the relation of the gen-
eral health to asthenopia.
CHAIRMAN'S ADDRESS.
Read in the Section on Laryngology and Otology, at the Forty-seventh
Annual Meeting of the American Medical Association,
at Atlanta. Ga„ May 5-8. 1886.
BY G. V. WOOLEN, M.D.
INDIANAPOLIS, IND.
Gentlemen of the Section: — It is especially pleasing
to me to meet so many of you again, and in this fair
city of the South already noted for its activity in pro-
moting the general welfare of mankind.
I again wish to express to you my sincere thanks
for the high honor conferred in selecting me to pre-
side over this part of our work so dear to us all.
Whatever may be our ideas relative to specialties and
the organization of special societies, it must be con-
ceded that the unity of the profession must be pre-
served, and that much of our best work should be per-
formed in connection with the meetings of this
Association. It is. therefore, fitting that we meet
annually with the profession for special as well as
general work, and the consideration of matters per-
taining to the general welfare of the fraternity. .
It will be a sad day for specialists when this is
neglected. We can not afford to ignore these claims
and I am persuaded that it is the purpose of you who
have helped to further the interests of this section
from its beginning to have no thought of forgetting
this American Medical Association, now old and
honored in its usefulness.
In view of the length of our program, and the desire
of your Chairman that a full discussion of its merits
may be secured, without which our meeting will be
robbed of much of its interest and profit, it is not his
intention to furnish an extended address. In this
respect, and in the preparation of the program it is
desired to depart from former customs somewhat,
hoping thereby to increase the interest of our
meeting.
By collecting papers on allied subjects for indi-
vidual sessions and following them with a speaker
specially chosen to open the discussion it is hoped the
interest will be direct, and much useful information
secured, and thus justify the departure. Indeed it
has been a question with me if this department might
not be extended by the selection of a single individual
to furnish a paper for each session of our future
meetings and of one or more to open the discussion
and so confine attention, thereby securing more
exhaustive work than can be had by our present
methods.
Our specialty is young, but its field is broad, vastly
more so than the uninitiated can know, and our very
best endeavors should be given to bring it up to the
high plain of its importance, and not the least of these
efforts should be put forth annually in this section
here in close contact with our fellows of the other
departments.
ORIGINAL ARTICLES.
SUBCONJUNCTIVAL INJECTIONS.
Read in the Section on Ophthalmology at the Forty-seventh Annual
Meeting of the American Medical Association, held
at Atlanta. Ga.. May 5-8. 1890.
BY EDWARD J. BERNSTEIN, M.D.
BALTIMORE, MI).
Like all other remedial agents, subconjunctival
injections must run the gauntlet of ill-considered
judgments, both favorable and adverse, until its place
shall have been firmly assigned.
Few men, like Abadie, Darier, Deutschmann, Gepner,
Schmidt-Rimpler, Pflueger and Zossenheim have yet
had sufficient personal experience to entitle them to
give conclusive verdicts. In the main, these men
assert, we have in this method a means at our hand,
swift, sure and intense, which under proper precau-
tions and indications should stand us in good stead,
whether e'mployed alone or in conjunction with gen-
eral treatment.
That it is a panacea or infallible, not even an enthu-
siast will contend. Much adverse criticism comes
from those who declare that we have no precise indi-
cation for its employment. Certainly we must, in
part, admit this contention, but should one expect a
hard and fast demarcation in a method so novel?
566
SUBCONJUNCTIVAL INJECTIONS.
[September 12,
Even Darier, who has been working in this line since
1888, admits that he must still often work in the
dark. But are we uniformly successful with opium,
quinin, or the bromids? Shall we give up the use of
the Eustachian catheter because of discouragement
and occasional failure?
Though Rothmund, in 1866, and Segondi, in 1871,
were the pioneers in the use of subconjunctival injec-
tions, it is to the persistence and zeal of M. A. Darier
we owe the present status of the question.
Though rather unfavorably impressed with the
method when I observed it in the fall of 1891 under
Darier, that opinion has been greatly modified during
the past sixteen months. My task shall be to supple-
ment the work of Valude (Annates D'Occulistique,
August, 1893) and to record my own experience.
Upon technique I shall only touch, referring for
more complete data to the original articles and the
many translations, but the following points are worthy
of consideration:
1. Observance of every practical aseptic precaution
— sterile ground, solution and instruments.
2. Thorough anesthesia of conjunctiva with 4 per
cent, (sterile) oocain solution.
3. Use of cyanid of mercury instead of sublimate.
Cyanid hydrargyri is compatible with cocain muri-
ate. Adding 1 per cent, of cocain increases anes-
thetic effect. Cyanid is less irritating than sublimate,
and is taken up as such by the tissues instead of
being converted into the slowly soluble albuminate,
4. The injection is to be made subconjunctivally,
and as far as possible at a tangent with the globe,
and not under Tenon's capsule.
We can avoid the larger vessels by simply rubbing
the lid over the eye once or twice, when they become
visible, and one can readily choose a clear spot. We
are not so fortunate with the fine nerve twigs, and
should we puncture one of these pain will be quite
severe for twenty-four hours.
Muttermilch (Annates D'Occulistique, September,
1894) asks: "Why resort to injections when we know
that fluids reach the interior of the eye by simple
instillation into the sac?" Even if sublimate so given
were absorbed, which he questions, basing conclusions
on Tichomoroff, the dose would be so infinitesimal
that its effect would be nil. "Say you inject one-
twentieth mg., the beginning dose, two-thirds of the
fluid is lost (?) in the conjunctival sac, leaving but
one-third, or one-sixtieth mg. (0.000017), to enter the
eye. Now reckon the volume of the eye at 7 cm.,
you then obtain a dilution of 1 to 400,000 which can
hardly be called an antiseptic solution." Further-
more, he believes whatever good results is from sug-
gestion.
To these we may reply that the action of drugs in-
jected is intensified, and it is a more exact method of
dosage. Pflueger converted the crystallin lens into an
emerald mass by so injecting solution of fluorescin.
Cocain thus used produces a rapid and thorough anes-
thesia of the iris, which simple instillation does very
unsatisfactorily, if at all. But it is objected that this
does not hold true for sublimate, which is converted
into the slowly soluble albuminate in the body. Does
this latter not apply equally as well to its hypodermic
use, and who can gainsay its superiority in accuracy
of dosage, rapidity and intensity of action over the
administration per ora? Yet here we use the cyanid,
which is not, or but feebly so, transformed. Admit
even that all the mercury is so changed, it will none
the less be absorbed. Bocchi demonstrated micro-
scopically the presence of mercury in the tissues after
injections under the conjunctiva.
The assertion that but one-third of the fluid injected
enters the eye is a flight of the imagination and not
founded on fact. Let us even admit this to be true,
yet are his calculations and conclusions erroneous.
Say we inject hypodermically 0.01, the usual dose,
of HgCL for a person of 60 kgm. Remember much
of the hydrargyrum is carried off by the excretory
organs ; the liver takes up and retains a larger propor-
tion; then come the other glands, especially the sali-
vary glands; next, the skin, and finally the other
organs and tissues. Now, how much of this 0.01
goes to the eye? And have we not all seen specifii
lesions actually melt away under its influence? Doe
it not look on the face of it that a larger proportion o:
hydrargyrum enters the eye by this means than by
systemic medication? And is it not also likely tha'
hydrargyrum acts in a much smaller dose than
generally credit? You can not estimate the quantity,
as you see, by saying, "If the eye weighs 6 gm. and
the body 60 kgm. then one-ten-thousandth goes to the
eye."
I propose during the summer to make the actual
experiment, using some such method as suggested by
Dr. Rudolph Winternitz, and promise to report later.
Are we at all sure that drugs injected subconjunc-
tivally enter the eye? Of this there can be no doubt.
"Let us inject a solution of K,FeCy3 subconjunctivally,
and after a short time enucleate the eye and fix the eye
in an alcoholic solution of ferric chlorid (FeXU,).
On making sections we can show that the first solu-
tion entered by way of the lymph channels, for these
show colorless on a blue background. The connec-
tive tissue retains the K2FeCy3 with great tenacity"
(Schwalbe, Anat. Des Auqes). Ovis and Pflueger
have demonstrated China ink — in the lymph channels
— which had been previously injected under the
conjunctiva.
As several writers contend that the main action of
subconjunctival injection, is limited to the anterior
portion of the eye, and therefore preferred to inject,
if at all, under the capsule of Tenon. Carl Mellinger
and Domenico Bossalino determined to find out just
how far fluids so injected would enter the eye and its
neighborhood; they made a series of injections with
sterilized mixtures of China ink. These were well
borne and produced no inflammatory reaction. The
staining particles were found in the lymph channels,
the leucocytes could not be demonstrated as charged
with the material to any considerable extent. They
showed that the particles did follow the large lymph
channels of the whole globe and optic nerve, and that
not only was the eye and nerve surrounded by such,
but the supra-choroidal spaces (by smaller communi-
cating channels) and the intervaginal spaces (Zwisch-
enscheidenraum) as well.
Sublimate thus injected entered the eye as albu-
minate. Neither Bach nor Hess could discover any
sublimate in the interior of the eyes they experi-
mented on, though Bocchi, Brugnitelli, Gallemaerts
and Jolly always recovered small quantities by elec-
trolysis.
Pflueger employs solution trichlorid of iodin (1 to
1,000) . His results in general are not so good as those
obtained by the use of hydrargyrum. Still in retinal
detachment, macular retino-choroiditis, he reports good
results where others meet failure with hydrargyrum.
I
18%.]
SUBCONJUNCTIVAL INJECTIONS.
567
Is it not likely an indication to employ iodin tri-
ohlorid in some of these cases and hydrargyrum in
others? Or are they not at least worthy of trial?
Marti following in the line of Mellinger found equally
good results from the use of weaker solutions of
Bydrargyruin. He declares that subconjunctival
injections act not through any germicidal influence,
hut by art ion on the lymphatic circulation (stimula-
ting its rapidity) thereby causing resorption and
elimination of pathologic products, thus hastening
healing. That his results with salt were equally as
efficacious as with hydrargyrum, with the advantage
of greatly diminishing pain, and furthermore avoid-
ing the adhesion of the conjunctiva to sclera at site of
puncture
To this Darier replies that adhesions only occur
when puncture is made too near the limbus or too
deep under the conjunctiva. Pain is a variable quan-
tity even in the same individual. Sometimes in one
patient an injection will be perfectly painless, while
the next time it will he excessive. He had one patient
who went through a whole course of hydrargyrum
injection without pain, and who complained bitterly
when he once injected distilled water. Darier had
trieil salt solution, iodin triehlorid, soda salicylate and
various other drugs, but is convinced that hydrargy-
rum is most reliable in his hands.
Ajs aoon as Mellinger, Pflueger and the rest prove
their assertion by an array of sufficiently conclusive
observations, Darier says he will be among the first
to admit their utility, and will follow their lead. At
any rate, these men obtain good results from this pro-
cedure, and this is a gain in the right direction. We
must not forget that it is not intended to do away
with general treatment; all that is claimed for it, is
that it intensifies the action of hydrargyrum and
hastens cure.
Mellinger declares the action of subconjunctival
injections to be alterative: possibly hastening the flow
in the lymph channels, thus carrying infectious par-
ticles away more quickly. Gepner is satisfied that it
is the hydrargyrum which is beneficial, because in
two instances he used salt solution with no result;
improvement began immediately after substitution of
hydrargyrum.
Gutman condemns the method. He says it is not only
painful and gives no good results, but often works
positive injury. He characterizes Darier's work as
insufficient and inaccurate. No one who has observed
Darier will question his accuracy or sincerity. As to
insufficiency, this is in a measure true, as Darier
admits, but consider that under his hands, the work
has gone on steadily since 1888. that Deutschmann has
made some 2,000 injections, that between Gepner,
Peunow, Picunoff, Bergmeister, Schmidt-Rimpler and
Grossman some three hundred cases and more are
reported, and we must admit that it is not wholly an
untried experiment.
Yet, Gutman, from the standpoint of experience
gained in twelve cases, would sweep away this whole
structure. Let us examine his own report, and we
see that his results are better than his conclusion,
and that they bear out the utility of this method.
He obtained good results with iodin triehlorid; had
he continued this remedy doubtless his results would
have been better; at any rate we will await the results
of his experiments with NaCl. solution and trust
they will be more extensive, and that he will come to
modify his former opinions.
Gallenga found that corneal ulcerations artificially
produced in rabbits' eyes were quickly healed by sub-
conjunctival injection. This, Muttermilch declares is
without significance, as such heal quickly when
nothing is done, and were it really due to hydrargy-
rum, he might have obtained equally good results
from simple instillation.
According to Muttermilch, "Should one use this
treatment for sympathetic ophthalmia, one would
make the double mistake of using an innocuous means
against a microorganism which does not exist (pro-
ceeding from the standpoint of Deutschmann), for he
says the microbian theory is not alone not proven, but
every pathologic and physiologic experiment, as well
clinical experience, is against such a theory. In ref-
erence to the two cases myopic choroido-retinitis
reported by Gepner as benefited, he is of the opinion
that the rest which the patients obtained in the hos-
pital would have done the same. As to prevention of
post-operative purulent infection, he has the greatest,
doubts, for we know even without this new treatment
few wounds now suppurate, and that it is rare for
iritis to be transformed into irido-choroiditis." In
these latter he is in a measure correct, but when pur-
ulent infection does start often sad havoc is caused
before its progress is checked, and it is right to be on
the safe side. We know Jaeger and Arlt had a per-
centage reaching 95 and 97 in their cataract extrac-
tions in pre-aseptic days. Does this release us to-day
from taking the most stringent precautions? As a
matter of fact, his whole criticism is based on an
experience gained in three cases : One ulcus serpens
cum hypopyon, one kerato-iritis traumatica and one
of ophthalmia sympathetica. In his ulcus serpens
case he ruptured the cornea, most likely because he
did not observe the rule not to inject too near the
limbus, and in the other two he desisted on account
of pain. He further attributes many of the reported
cures to suggestion. The pain induced and a glance
at the list of cases reported cured by this treatment
is sufficient to negative any such theory. A criticism
based on so wide (sic) an experience can hardly be
upheld in the face of so much positive clinical proof
to the contrary. My own personal experience was
gained from seven cases.
Case 7.— Hypopyon keratitis; J. S., 20; recent injury, his
anterior chamber one-fifth full of pus ; marked photophobia ;
much ciliary pain ; lachrymal ducts normal. Typical case.
Patient has been under atropin, pressure bandage and iodo-
form treatment for sixteen days : is worse and in more pain.
Under these circumstances injected one portion of a Pravaz
syringe full cyanid of mercury (1-3000) ; continued the pressure
bandage. Next day hypopyon had decreased and he had the
first night's sleep since his present illness began. Four days
later repeated the injection and four days thereafter the third,
when ulcer was covered with epithelium and case went on to
recovery under simple bandage.
Case 2.- April 2, 1894, M. L., age 26. Keratitis ulcerativa
cum hypopyon. Typical case, in a very much reduced indi-
vidual. Resulted from having baby stick finger-nail into cornea.
Case progressing very unfavorably for eighteen day s. Hypopyon
beginning ; whole cornea cloudy ; injection of cyanid on April
20, followed by three more at intervals of five days. Recovery
began from the first injection. Cloudiness clearing up from
day to day. Cure with small peripheral macula of cornea.
Case 3.-3. W. Had had several attacks of iritis in each eye ;
no luetic history ; borth irides bound down by many adhesions,
the right one almost completely. Could allay pain and inflam-
mation, but could not break up synechia, so performed iridec-
tomy on right eye. Was told to return immediately if any
symptoms of trouble in left eye. In six months some exposure
brought on another attack of iritis. In the face of his old
synechia I feared a total occlusion and offered the alternative
of iridectomy or subconjunctival injections. The latter was
568
SUBCONJUNCTIVAL INJECTIONS.
[September 12,
accepted, and as result of four injections the old adhesions
yielded to the atropia and his pupil is now round.
Case 4.— Keratitis punctata. W. T., aged 30. Typical case
of acquired luetic keratitis punctata. Had been under care
some three weeks and was progressing very slowly. Suggested
subconjunctival injections, which were accepted. After five
injections at intervals of five or six days, patient could return
to work. In this case I can only claim that the injections
hastened the progress, as it was beginning to show signs of
recovery when I began.
Cases 5 and 6 were cases of optic nerve trouble. One, H. J.,
positive luetic history. Came when vision of right eye was
reduced to light perceptions, of left eye to counting fingers at
6 m. Field of vision narrowed and contracted : color sense
also very defective for blues and greens. Typical atrophic
discs in both eyes, showing lamina cribrosa. After routine
treatment had been instituted for more than six weeks, sub-
conjunctival injections to the number of twelve were adminis-
tered, but, except for a light transitory improvement, to no
avail.
Case 6. — Typical tobacco amblyopia, in which cure was
hastened by seven injections and the length of treatment
reduced to six weeks.
Case 7. — Is a case of old choroiditis disseminata in left eye,
■with total loss of vision, and detachment of retina in right.
This case is being treated with iodin trichlorid and result will
only be known in the future.
Let us now turn to special indications for the em-
ployment of subconjunctival medications and see
when and by whom they are endorsed.
In keratitis parenchymatosa general treatment is the
first and most constant indication. Above all hypo-
dermic injection of sublimate, not neglecting atropin,
warm compresses, etc. Special indications calling for
subconjunctival injections are keratitis benigna, kera-
titis circumscripta, keratitis atonica or at least with a
very moderate reaction; here the results are absolutely
marvelous; with each injection one often sees the
gradual recession of the area of infiltration. When
limited to the center of the cornea massage with lanolin
ointment of mercury produces active resorption of old
maculae. (This I have tried in a number of cases with
most excellent results. ) At the period of decline, when
the bulbar conjunctiva has regained its normal state,
these injections will often clear up in a few days what
would otherwise have taken months. In the acute,
violent pannus of keratitis parenchymatosa all local
irritating treatment is absolutely contraindicated, and
this is also true wherever there is stasis of the ocular
circulation.
Deutschmann and Zossenheim (Beitraege zur
Augenh. XV, 1894) agree "that we can often shorten the
treatment to four weeks, while it usually takes twice
or thrice as long."
Gepner would expect good results, though must
acknowledge one of nine cases was cured, the other
eight merely benefited.
Peunow treated twenty-three cases with good results,
best however in those of specific origin.
Picounoff treated between twenty and thirty; com-
mends treatment under above conditions.
Veasey treated two cases. Cured one, stopped
treatment of the other on account of pain.
Abadie endorses all Darier says in this regard.
Chibret, Mellinger and Gosetti have used the
method and approved of it.
Motais was "impressed by the rapidity of recovery."
Gerasimos Materangos treated a number of cases
of traumatic and infectious keratitis in conjunction
with general treatment, best results.
JSchmidt-Rimpler treated nine cases, and does not
Tecommend.
Haab, ten cases, no result.
Keratitis ulcerative!, cum hypopyon. — Its utility is
he
,
here questioned because it has not been applied with
sufficient discernment.
In mild cases, it will produce cures quicker than
the classic treatment. In those of average intensi
the galvano-cautery to the edges of the ulcer is t
first indication together with antiseptic dressing
grave cases where the globe or cornea is threaten
Saemisch incision or galvano-cautery, or both a
necessary. Cure is hastened when followed by su
conjunctival injections (five to ten divisions of th
syringe) made as far as possible from the cornea a:
above all not under Tenon's capsule. In great hype
emia the artificial leech applied to temple helps
Failure to observe these points produced rupture
cornea in Muttermilch's case. Any such formula as
"ulcer of cornea, subconjunctival injections" will
result in numerous failures, while observance of the
above indications will hasten cure.
Gepner "employs it most frequently in ulcerative
forms of keratitis and with best results."
Gagarin — "Good and rapid results up to the clear-
ing of hypopyon; after this not much further improve
ment is noted."
Peunow — "Considerable help, but does not neglect
routine treatment."
Veasey — "As good as other methods."
Abadie— "Highly extols."
Mellinger had brilliant results.
Bocchi — "First injection brought process to a halt
Gossetti — "Very efficacious from the first injection
Grossman and Rogman and myself had excellent
results
Chibret— "Results doubtful."
Masselon — "Altogether negative."
Schmidt-Rimpler — In thirteen cases of ulcerative
keratitis hypopyon. Good results in three. Ques
tionable in eight. Two of simple ulcerative keratitis
gave negative results. He thinks very little of it
this latter and hypopyon keratitis.
Deutschmann prefers galvano-cautery, which
his hands works surer and quicker.
In keratitis lymphatica, Darier, Doufer and Segondi
coincide that the yellow ointment fills every indica-
tion except in grave cases, when the new method giv
good results.
Coppez and Gallemaerts give preference in vase
lar keratitis to subconjunctival injection of potassiu
iodid solution.
In iritis the indications and the contraindic
tions are very subtle. While in many the results a:
beneficial, in others it is not only useless, but posi
tively harmful. Whenever iritis is lighted up wit"
violence, and is accompanied by brisk reaction (deep
pericorneal hyperemia, chemosis, photophobia, etc.)
an energetic antiphlogistic treatment is the first indi-
cation in connection with general treatment of the
proper character. Only after the violence has abated
is subconjunctival injection indicated. Failure to
observe this might provoke an aggravation of symp-
toms in an eye already inflamed, and is no doubt, the
cause of much of the reproach heaped upon this
method and the consequent ill success, whereas those
who have instituted treatment in relatively benign
cases, either at their beginning, their relapse or their
decline have according to Darier obtained conclusiv
evidence of its efficacy, but in benign cases, the old
methods are less annoying and often equally
satisfactory.
I coincide with Gepner, who finds its main indica
1896. J
SUBCONJUNCTIVAL INJECTIONS.
569
ti,.n in assisting to break up old iritie synechia?, or in
the very beginning of the malady, for as Zossenheim
it cures so quickly that complications have no
chance to manifest themselves. It may lx< used with
advantage aeeonling to both these men in occlusion
of the pupil and where we find hypopyon in the ante-
rior chamber. IVunow treated twenty-eight cases with
I results. Pieounoff also had the same uniformly
good results in a large number of cases. Veasey
i cases, prompt and effectual results in all, as
also in eases of chorio-retinitis.
Schmidt-Rimpler nine cases. Cured two cases of
plastic iritis, other results divided as follows: One
cured after thirteen injections; four relatively good
results: two slightly benefited; he recommends fur-
ther use of this method in iritis and irido-choroiditis.
Grossman, Alt and Mellinger also commend its use.
Bergmeister t wo cases. Both cured after the fourth
injection.
Boochi and Masselon do not recommend it in iritis.
Irido-choroiditis. What applies to iritis applies with
greater force in this. In a disease so difficult to treat
and holding out such poor promise, we often proceed
as though groping in the dark, for at times we see one
of those eyes apparently quiescent, react with an
extreme violence to the slightest local irritation. These
are the eases in which we are of ten led to prematurely
perform iridectomy.
With injections one is often surprised to observe
not only amelioration, but at times cure, where one
would not expect such. In certain grave cases, we
are obliged to keep the patient under continuous
treatment, often alternating between general and local,
to give the patient a relative rest.
Grossman treated two cases with good results. Alt
.ported success. PHueger treated his cases with
iodic, trichlorid and reports: one case of serous iritis,
result beneficial; in another no effect; in a third
stopped on account of pain and increasing intra-ocular
tension.
Matarangas — Good results in conjunction with gen-
eral treatment.
Deutsehmann — Iritis specifica, as well asnon-speci-
fica. this method was at its best. He uses no atropin.
rior synechia disappeared, and in four to eight
days the pupil was quite round, dilating and contract-
ing freely and the eye quiet. Saw no recidives; com-
pleted the treatment with mercury internally.
Choroiditis ami retinitis. — When structural lesions
have occurred, it is impossible to speak of cure in the
sense of complete restoration. Much can be done
for those who seek our aid early, to avoid such destruc-
tion by active and prompt methods, among the fore-
i if which stand subconjunctival injections.
Often an appreciable effect is noted from the first
or second injection, and again not until a great num-
ber have been made. In macular choroiditis before cen-
tral vision has been irremediably destroyed, we can
restore if not normal vision, at least bring a consider-
able amelioration, and in so short a time there can be
no doubt of the relation of cause and effect. Darier
claims favorable result in at least 25 per cent, of his
eases, and in 10 per cent, a result which " I can call
surprising."
A.1 iadie claims its efficacy in all degrees of chronic
chorio-retinitis. He condemns the use of potassium
iodid alone or with mercury as manifestly injurious.
Injections of pilocarpin had no effect except when due
to myopia ; certainly not in infectious forms. In obsti-
nate cases he uses subcutaneous injections in
addition.
Venneman — Results excellent.
Grandclermont — Best effect in serious or desperate
affections of middle (vascular) coats of the eye. Above
all in irido-choroiditis.
Gepner--Improvement in many cases of chronic cho-
roiditis. Decided in two cases of myopic choroiditis.
Peunow — Thirty-one cases choroiditis cured by
these means.
Deutsehmann — Especially good results in specific
chorio-retinitis. In non-specific choroiditis best
results from potassium iodid kept up for months. .
Schmidt-Rimpler — One good result in choroiditis;
two doubtful in chorio-retinitis; thinks this is one of
the conditions in which it is worthy of further trial.
Bergmeister — Not specially praiseworthy but recom-
mends further trial.
Alt — Good results in choroiditis exudativa and cen-
tralis.
Bocchi — No specially good results; in this he is sus-
tained by Masselon, Lacquer, Dianoux.
Bull — Positive effect in allaying severity of symp-
toms, and shortening the duration of acute irido-
choroiditis non-specifica.
Seggel reports a cure in irido-cyclitis.
Optic Nerve. — Darier says in all infectious inflam-
mations of the nerve, results are encouraging often after
classic treatment proves unavailing. In retro-bulbar
neuritis often excellent results, though in hereditary
form we secure neither better nor worse results than by
other means. Does not include tobacco and alcoholic
amblyopia which tend to recovery sublata causa.
Where actual atrophy of nerve fibers has set in it is use-
less to expect results. In retro-bulbar neuritis of rheu-
matic ( ?) origin, better results than by salicylates or
mercury.
In compression neurites, obtained very rapid cure.
In specific neuritis, and in one secondary to chorio-
retinitis greater amelioration than by old method.
We may expect good results in recent infectious
inflammations.
" No results to be expected in gray atrophy of tabes,
in white atrophy following old inflammatory processes
occasionally a slow increase of vision is manifest, but
generally only transient."
Grossman, De Wecker, Lindsay Johnson and Mata-
rangas corroborate these opinions. Deutschmann's
results negative in every case. In commenting on this
in his journal, Hirschberg reports a good result in
chronic optic neuritis, also in one of recent origin.
In sympathetic ophthalmia, Darier found subcon-
junctival injections available in a number of cases
characterized by uveitis.
Abadie says: If the injury is not so serious as to
preclude all possibility of recovery, the surface of the
wound should be touched with the galvano-cautery, and
hydrargyrum bichlorid injected under the conjunc-
tiva. It is often thus possible to arrest sympathetic
ophthalmia already declared in the other eye, but if
the traumatism is such that there is no hope of saving,
or if disorder continues in spite of all these means, we
should enucleate the offending eye. The other one
will be benefited by the injections. Personally, I
should hesitate to temporize with an injured eye which
is likely to cause sympathetic ophthalmia. We all
know how many such eyes may remain quiescent for
as long as fifteen or twenty years, to suddenly light,
up inflammation in the other eye.
570
SUBCONJUNCTIVAL INJECTIONS.
[September 12,
Gosetti reports remarkable success in a severe and
recurrent case.
Deutschmann also reports good results in a number
of cases.
Picounoff especially recommends it, here, where we
can usually avoid enucleation.
In scleritis De Schweinitz, Bull, Veasey and others
report some good results among a number of nega-
tive ones.
Many, Abadie and Coppez among the number,
declare that they have thus avoided panophthalmitis
in many cases of cataract and iridectomy operations,
and indeed have checked the disease when it had actu-
ally begun. Rogman corroborates this latter state-
ment.
Gepner says he resorts to subconjunctival injections
in all cases of serious injury where there is still hope
of saving the globe, for two reasons: 1, because we
•can not foretell where we have wound infection before
we see our patient; 2, because in every deep injury we
can not foretell whether sympathetic ophthalmia will
result. Germicidal agents in the lymph channels les-
sen that danger. Seggel reports cure of suppuration
of vitreous after cataract extraction, one case of
threatened destruction of the whole cornea and vitre-
ous from infected wound with prolapsed iris, and also
cure of a case of orbital phlegmon.
Deutschmann says: " As a preventive of post-
operative infection it is of a special utility. Cases
that usually resulted in loss of the eye were by this
means saved useful vision." In this he is upheld by
Gepner and others. He further says: " We can not
compare results of experiments made on animals to
clinical results in man. In animals large deposits are
at once introduced into the eye, which condition bears
no relation to that in post-operative infection."
DISCUSSION.
Dr. G. E. De Schweinitz, Philadelphia — I have used the
subconjunctival injections since 1892 and also advised my chief
of clinic, Dr. C. A. Veasey, whose results have been quoted,
to employ them. My experience is that exactly the same results
are obtained whether the bichlorid of mercury or the physio-
logic salt solution is used, each being equally efficient in suit-
able cases. I have secured good results in iritis, no matter
what its type, provided there is no high inflammatory action.
Good results were also obtained in episcleritis and some types
of keratitis. I have failed, however, to secure good results in
corneal ulcers and in diseases of the deeper coats, e.g., cho-
roiditis. I would call attention to the promptness with which
these injections, either salt or mercuric, relieve pain and
advance resolution in certain cases of inflammatory disease of
the iris and episcleritis, but would also suggest that a relapse
is more likely to occur than when ordinary constitutional meas-
ures are thoroughly employed. I believe that subconjunctival
injections deserve a permanent place in ophthalmic therapeu-
tics, but not to the exclusion of constitutional measures.
Case 1. — A. M., a male Italian, about 40 years of age, pre-
sented himself at the eye dispensary of the Jefferson hospital
for treatment of sore eyes. Upon examination he was found
to have a double syphilitic iritis, plastic in character, the ini-
tial lesion having been present four months. There were pres-
ent the usual symptoms of marked pericorneal injection, intense
pain, photophobia, lachrymation and a contracted pupil with
posterior synechias, these symptoms having been present, accord-
ing to the patient's statement, for four days. In the right eye
the iris is attached to the lens capsule by its entire pupillary
border, except a small portion in the upper and outer quad-
rant, this being the only part that would dilate with atropin.
The media were hazy, and there was an indistinct view of the
fundus which showed an oval disc, with rather large veins,
filled with dark blood, but there were no gross lesions. In the
left eye there was also almost complete annular attachment of
the iris, there being a small free portion on the temporal side,
while the ocular fundus presented practically the same appe:
ance as the other eye. His vision was 10-200 in each eye. A
pin was instilled for twenty-four hours without any improvi
ment in the pain, and with very limited dilatation in the pupi'
He was then given a subconjunctival injection of mercui
chlorid (5 minims of a 1 to 2,000 solution) in one eye, and
subconjunctival injection of sodium chlorid (2 to 10 of a
per cent, solution) in the other eye, and returned on the fi
lowing day with the pupils dilated ad maximum, the pi
entirely gone, and said that he had spent the night free from
pain, the first for about a week. There was absolutely no dif-
ference to be detected between the effect on the two eyes. This
treatment was continued, he being given an injection of mer-
curic chlorid in one eye and sodium chlorid in the other, at
intervals of two or three days, until he had received five injec-
tions of each, no other medication being employed except the
solution of atropin. At the expiration of this time the pupils
were completely dilated, there had been no pain since the first
injection, and it was impossible to say that there had been the
slightest difference in the results of the two solutions. His
vision was 20 30 in each eye, there being some pigment on the
capsule of the lens where the iris had been attached.
Case 2. — C. B., a male, aged 35 years, came to the eye dis-
pensary of the Jefferson Medical College Hospital complaining
of sore eyes that had been present for two days. Upon exam-
ination he was found to have a syphilitic plastic iritis in the
right eye, the initial lesion having been present about six
months. There was a small synechia up and out, the vision
was 20-100 and there were the usual symptoms of the disease
present. In the other eye there was a slight conjunctivitis,
the vision being 20-20. He was suffering from severe pain and
was given an injection beneath the conjunctiva of the solution
of sodium chlorid ; atropin was instilled into the eye, and he
returned on the following day entirely free from pain, the pupil
dilated, the pericorneal injection much less and the photopho-
bia less severe. He was given similar injections on alternate
days until he had had four, no other treatment being employed
beyond the instillation of the atropin solution, when the inflam-
matory condition of the eye had entirely disappeared. No dif-
ference could be observed between the promptness with which
the disease yielded to the injections of sodium chlorid and the
promptness with which other cases had yielded to the injec-
tions of mercuric chlorid. The vision in this case returned to
the normal.
Cose 3. — H. F., male, aged 31 years, consulted me in Febru-
ary of this year for a rheumatic iritis. There was no specific
history, and he had had several attacks of the same character
before, each time being treated by a competent ophthalmic
surgeon who had pronounced it rheumatic in character and
relieving it each time by the use of the salicylates, in addition
to other treatment. The pain was intense, and desiring to see
what effect an injection of salt solution would have, one was
made at once, and other treatment, excepting the instillation
of atropin, withheld. On the next day he returned with a
complete cessation of pain, except when exposed to bright
light, the pupil entirely dilated and a marked reduction in the
inflammatory condition. He was given five other injections,
after which the iritis was practically well, when he was placed
on the anti-rheumatic treatment. Other cases of iritis, syphi-
litic or rheumatic, treated by myself with injections beneath
the conjunctiva of mercuric chlorid, have not shown any advan-
tage over the injections of the solution of sodium chlorid.
Indeed, it is my experience that the latter causes less pain,
and relieves the pain of the iritis just as speedily, if not more
so, than the injections of the mercuric chlorid.
Dr. G. C. Savage, Nashville— I have used only the bichlo-
rid, but found it too painful. When opportunity offers I shall
use the cyanid of mercury. I wish to condemn the practice
of not using atropin in iritis, although subconjunctival injec-
tions of cyanid of mercury may be capable of accomplishing
much. Atropin should never be omitted in the treatment of
iritis, whatever else may be done. I want to go on record as
believing that it would be a grave error to neglect bringing the
iris under the influence of atropin, whoever may recommend
to the contrary.
Dr. D. S. Reynolds, Louisville — I am not persuaded that
any local method of treating iritis, except the persistent use
of an efficient mydriatic, has ever accomplished any desirable
result. The subconjunctival injection of a solution of chlorid
of sodium in cases of synechia following iritis from all causes
ISiKi. J
EXTRA-DURAL ABSCESS.
571
ttoni
frou
is undoubtedly valuable, but I should certainly avoid the use
of any subconjunctival injections during the active stages of
any form of iritis.
Db. A. W. Stirling, Atlanta— I watched the use of this
method in a fair number of cases in London and Paris and
nod it myself, but gave it up because it was so painful.
It will not take precedence over the older methods.
\)n. A. K. Bakkk, Cleveland — Having used the strong solu-
s of bichloridof mercury and found the injections painful,
estimated the amount of mercury which would reach the eye
m a subcutaneous injection as generally used, and determined
that a much weaker solution would probably prove efficient,
1 tried a 1 to 10,000 solution with excellent results in a large
number of e;ise.s, notably interstitial keratitis and central cho-
roiditis. The injections were never painful and the results
appeared as good as from the stronger solution. In private
practice it has been found necessary to combine its use with
the accepted methods of treatment, but with more rapid recov-
ery than when its use is omitted.
Dk. Duhbab Rot, Atlanta— I use the method largely in my
clinic, when' the patients consist largely of the colored race,
who have a treat deal of corneal trouble. In ulcers of Ihe
eornea 1 have had good results, but no better than when 1 use
hot fomentations and iodoform. In post-suppurative trouble
and panophthalmitis and in cases of suppurative iritis I have
used it with success. I have used 1 to 1,000 bichlorid with an
ordinary hypodermic needle, sterilizing both the instrument
and the field before the operation. In iritis I have not seen
adhesions break up and have had no results in choroiditis, but
my experience leads me to say that in ulcerative and suppura-
tive forms of conjunctivitis or keratitis the results are as good
as those obtained by other methods.
Db. E. J. Bernstein I have no experience as yet with
relapses, but one must not forget that neither atropin nor gen-
eral treatment are to be neglected in iritis. As to pain, my
patients had none, or very little, as the result of subconjunc-
tival injections. I am now treating a case of detachment of the
retina by this means without much hope of cure, but because
no other treatment has availed. I believe no one should follow
Abadie in not using atropin in iritis. I should hesitate too
implicitly to follow his lead. In phlyctenular keratitis I should
not think of using this method, as I believe most men agree
that the vellow ointment is all that is needed.
EXTRA-DURAL ABSCESS FROM MASTOID
EMPYEMIA.
Read in the Section on Laryngology and Otology at the Forty-seventh
Annual Meeting of the American Medical Association
held at Atlanta, Ga„ May 5-8. 18%.
BY B. ALEXANDER RANDALL, M.D.
PHILADELPHIA, PA.
When the presence of a "mastoid abscess," declared
by the occurrence of a fluctuating collection of pus on
the surface of the skull behind the ear, only caused
the surgeon to incise and evacuate the abscess, we
heard little of extra-dural or cerebral abscess except
as a curiosity of the postmortem room. Even when
the farther step of opening the mastoid became more
common, it was so often merely in the interest of bet-
ter evacuation and drainage that exploration for the
remoter extensions of the lesions was rare. It is only
since we have more generally adopted the idea urged
by all experienced operators, that every possible trace
of the pathologic condition shall be extirpated at the
operation in the effort to secure immediate cure, that
the relative frequency of extra-dural abscess has been
recognized. The earlier operators looked upon the
middle cerebral fossa and the sigmoid sulcus as
regions dangerous to approach, and perhaps held
their hands as they followed some purulent track lest
it should lead them into these dreaded cavities. The
impetuous entered them oftener than they meant, and
the careless oftener than they knew, while the careful
and conscientious surgeon was gradually learning the
innocuous and beneficent effect of hunting down the
disease even into these and deeper regions. With the
abandonment of the trephine and drill in favor of the
gouge and spoon, much of this fear has died a natural
death. There is less chance of unintentionally and
blindly penetrating the inner table of the mastoid and
wounding or infecting the important structures with-
in. Mastoid anatomy is being better learned and the
rule has grown more common to operate in each case
as though the relations were the most disadvantageous
possible, and to assume no safety that has not been
demonstrated. And with this knowledge that the
middle lobe of the brain may extend down as low as
the upper margin of the meatus and the lateral sinus
be separated by hardly a film of bone from the back
wall of the canal or the mastoid surface at the usual
point of attack, there has grown a proper confidence
in the wisdom of opening the intracranial cavity in
appropriate cases. It should always count as a bung-
ling step when accidentally these cavities are opened,
or an officious one when needless; but the futility
of half measures grows more evident with experience.
One who formerly looked askance at the radical pro-
cedures and views of Schwartze and others who chisel
open the mastoid in scores of cases yearly, finds his
tendency to follow this lead to be limited principally
by his lack of a like material. And since the grippe
epidemics few of large aural practice but have had
growing opportunities to learn the need of such
measures.
We can no longer look upon "mastoid trephining"
(as we may still call the operation whether done with
chisel, burr or spoon) as permissible only as a life-
saving step; nor can we rest content to leave to long
after-treatment the completion of the cure which
might have been more safely as well as more quickly
secured by more heroic thoroughness. It is to be
hoped that American aural surgeons will continue
truly conservative in their choice of cases, methods
and efforts after thoroughness, eliminating all cases
that might be cured by less radical procedures and
sacrificing to brilliancy of immediate result no func-
tion that patience might have saved; but it is also to
be hoped that they will give little basis to the charge
sometimes made by the surgeon, that they are too
timid in their work and shrink from doing their full
duty when half measures are insufficient.
The past decade has seen the publication of hun-
dreds of cases in which there has been extension of
caries from the tympanic inflammation to the dural
surface of the temporal bone, with pachy-menigitis
and outpouring of pus between the bone and dura.
In itself it constitutes no great menace to life, and
the prognosis after drainage is generally excellent.
So little may be the head symptoms caused by it that
its presence is a total surprise to the operator; and
one marvels that lesions so extensive may be wholly
undeclared by the usual signs.
Surprisingly innocuous as the extra-dural abscess
has generally proved if drained outward by nature or
art, the story is wholly different in no small group of
cases. Most of the thrombotic lesions of lateral,
petrosal or cavernous sinus have been secondary to
extra-dural abscess. Many cerebral and cerebellar
572
ABSCESS OF THE MASTOID.
[September 12,
abscesses are due to the previous existence of pus
outside of the dura. Raised here above the normal
level, the dura may present no visible farther disturb-
ance in the form of injection, etc.; yet the overlying
brain is apt to show a discolored depression with pial
injection and commencing softening. Again there is
ulceration of the dura with rupture of the pus either
into the arachnoid space or through the agglutinated
tissue into the brain substance. In other cases the
exact path of the process can not be traced; yet the
extra-dural abscess must be held responsible for the
serious or fatal occurrence.
It is no new matter to point out the dangers of
acute or chronic aural suppuration in these direc-
tions, although the importance can never be over-
stated in any truthful setting forth of the matter. It
is not so generally known how rapid the process may
be. A good illustration was met last year when a boy
came to me with mastoid abscess, supervening upon
a light blow on his chronically suppurating right ear.
Nausea and general malaise immediately followed
and persisted in less degree on the fifth day, when I
first saw him. No changes were visible in the eye-
grounds to suggest intra-cranial involvement; but
fever was marked and operation promptly needed.
This could not be carried out until the second day
following, when the very hard mastoid was very freely
chiseled open, all carious bone in the antrum and
adjacent cells curetted away and smooth, firm walls
left toward the middle and posterior cerebral cavities.
His fever fell, to rise again almost immediately;
pleurisy and then pulmonary inflammation quickly
declared themselves, and he died on the sixth day
after operation. Autopsy showed a septic pleurisy
and pulmonary abscesses; while in the cranium a
cerebellar abscess as large as a plum ruptured on
removing the brain, at the point where it was adher-
ent to the sub-dural collection which extended back-
ward from the tegmen down upon the posterior
aspect of the petrous. Section of the bone showed
no microscopic connection of the intra-cranial collec-
tions with the the tympanic spaces — the intervening
bone being firm and intact, if not healthy. The
nearly total destruction of the ossicles marked the
otorrhea as of long standing; but all the other lesions
had probably developed within the thirteen days after
the aggravating blow. The parietal lobe, where it
rested on the subdural collection was injected,
depressed and softened and would doubtless in a few
days have been the site of a cerebral abscess.
Numerous other instances have come to my knowl-
edge, sometimes only on the postmortem table, rarely,
I am glad to say, in my own patients. Of some thirty
whose mastoids I have opened in the past year, nearly
one-third have had caries which compelled me to
uncover the dura, and in a number of them the
granulations upon its surface, if not the gush of pus
as it was exposed, revealed the fact that it had been
separated from the bone by a layer of pus. In several
cases what seemed at the time a complete operation
left bone of too little vitality behind and a later oper-
ation had to be carried still farther, under the dura;
and in one there was death, probably from a cerebellar
abscess which could not be found.
Doubtless other aural surgeons are meeting the
same experience as myself in these directions and
find their field extending inward deeper than they
can cheerfully follow. The dangers and difficulties
of brain surgery can try the stoutest heart and may
well appall the beginner. But we should not for
get that the general surgeon has only recently entered
this field and that his bravery is sometimes foolhard-
iness. No one should better know the territory to be
invaded than the aural surgeon, who must often guid
the hands that he has called in to wield his instru
ments. And if he does not feel equal to meet th
exigencies of such intra-cranial work when first he
encounters it, he will not generally be doing his full
duty if he does not utilize every opportunity to mas
ter the technique of head surgery on the cadaver and
on the living, and be prepared to act for himself
unless a distinctly better man is at his side.
I-
I
PRIMARY INFLAMMATION AND ABSCESS
OF THE MASTOID; REPORT OF CASE.
Read in the Section on Laryngology and Otology, at the Forty-
seventh Annual Meeting of the American Medical Association,
held at Atlanta, Ga., May 5-8, 1896.
BY DUNBAR ROY, A.B., M.D.
PROFESSOR OF OPHTHALMOLOGY AND OTOLOGY IS SOUTHERN
MEDICAL COLLEGE.
ATLANTA, GA.
Cases of the above pathologic condition are by no
means frequent, hence my apology for presenting the
following:
Mary H., colored, age 10 months, was brought to
my clinic at the Southern Medical College on
account of a swelling behind the left ear, which the
mother said had been forming for the last five or six
days. To all outward appearances the child pre-
sented a fairly healthy and nourished condition. The
mother was very positive in her assertions that there
had been no discharge at any time from the auditory
canal. She was a strong, healthy woman, and with the
exception of enlarged post-cervical glands, no abnor-
mal condition could be found. The child presented
numerous glandular enlargements over various parts
of the body besides a well-marked case of "snuffles."
No history of tuberculosis or syphilis in the family
could be ascertained from the mother, as all the other
children were healthy and the father could not be seen.
Nothing is more uncertain, however, than the his-
tories usually obtained from the negro race, so that
I rarely place any confidence whatever in their
statements.
The child was very fretful, especially when the
region of the left ear was touched. Behind the auri-
cle and over the mastoid a distinct fluctuating tumor
could be diagnosed. The auditory canal was freely
patulous with no moisture upon its wall or any signs
of a previous discharge such as a smooth, hardened
condition of the dermoid layer. The drum membrane
was clear and of normal reflex, showing absolutely
nothing pathologic. The temperature was practically
normal, which still further strengthened the diagnosis
of the abscess being syphilitic or tubercular in its
origin.
The treatment consisted of a thorough evacuation
of the abscess by incision, followed with a curetting
of the mastoid cells which communicated with the
abscess superficially and which was undergoing a dis-
integrating process, packing the wound with iodoform
gauze, and securing the whole with a protective ban-
dage. Internally the child was put upon syrup ferri
iodidi 5 m. three times daily. Under this treatment
the wound healed perfectly in ten days, there was no
rise of temperature and the child's general health was
much improved.
1896.]
ABSCESS OF THE MASTOID.
573
sai
re]
""
an
Six months after the patient was again brought to
(lie clinic with an abscess behind the right ear similar
in «11 respects to the one which had occurred behind
the left. The history was about the same as previ-
ously and absolutely no inflammatory signs could be
Been in theauditory canal or upon the drum, nor any
signs of a previous discharge. The treatment was the
same with excellent results. Since that time the mother
reports that the child has much improved and there
has been no further trouble with the ears.
Perhaps no single bone in the body, if it may be so
called, has received the attention from surgeons and
atomists in the last few years as the temporal bone,
and especially that portion of it known as the mastoid.
And justly has it deserved this attention on account
of the frequency with which it is involved in all
severe inflammations of the tympanic cavity, and its
importance often in the future life of the patient. In
inflammations of the tympanic cavity it is impossi-
ble to conceive of an absolute freedom on the part of
the interior of the mastoid from the same inflamma-
tory congestion on account of the close proximity and
contiguity of the mucous lining. This participation
of the mastoid in the inflammatory process of the
tympanum may not always be recognized by objective
signs, nay. even by the subjective symptoms, yet
pathologic anatomy and operative procedures teach us
that the interior of the mastoid did become affected
simultaneously with this inflammation in the middle
ear as is recognized by the obliteration of the pneu-
matic cells and hyperplastic condition of the antral
mucous membrane. For instance, Zuckerkandl, in
the examination of 250 temporal bones, found only
B6.8 per cent, of the mastoids pneumatic throughout,
in 43.2 per cent, he found the same partly diploetic and
partly pneumatic, while in 20 per cent, of the total
the mastoid presented fatty degeneration, diploetic or
sclerosed condition of the bone substance itself.
So it happens that one can readily trace the origin
of a mastoiditis or a mastoid abscess when there has
been previously or at the same time a severe purulent
otitis media, but when a mastoid abscess exists with-
out any discoverable involvement of the tympanic
cavity, the etiology is more obscure. Cases of pri-
niarv mastoiditis or abscess of the mastoid are among
the rarities, yet such cases have been reported and for
this reason are never without interest.
When I say primary I mean an inflammation or an
abscess originating in and confined exclusively to the
mastoid process, when no inflammatory signs are dis-
cernible in the tympanic cavity either at the present
time or any time previous which could give the exist-
ing process a causal dependence.
Politzer in his last most excellent text-book speaks
of primary inflammation of the mastoid as among the
rarest affections in aural disease. He divides the
inflammation in this region as being limited either to
the periosteum or to the pneumatic cells of the mas-
toid bone proper.
Primary periostitis is extremely rare and is observed
more frequently among adults than among children.
Such cases have been reported by Voltolini, Blake,
Knapp, Jacobi, Turnbull, Swan Burnett, Hotz and
Kirchner.
Dench. in his late text-book, speaks only of pri-
mary mastoiditis without any subdivision, as does
also Blake in Burnett's System of Diseases of the Ear,
while Politzer makes the more minute subdivision as
stated above.
According to this latter author the most frequent
causes of periostitis are cold and trauma, while occa-
sionally no cause whatever can be discovered. The
usual course and termination of this process is either for
inflammation to reach its height in a few days, and the
the infiltrate be reabsorbed without pus forming or an
abscess results with spontaneous bursting through
the walls into the antrum, as observed by Roosa and
Ely, Webster, Knapp and others, or the pus may find
its way into the auditory canals as in a case reported
by Burnett, or finally the inflammatory process may
produce a painless carious condition of the superficial
lamillae of the mastoid to be thrown off with the evac-
uation of the abscess. The same author also recog-
nizes a condition of primary abscess of the mastoid,
and in addition to the causes already given mentions
syphilis, but fails to mention tuberculosis, which must
certainly be placed in this category.
Knapp has reported a case of " primary tuber-
culosis of the mastoid," where there was an
abscess of the mastoid while both the canals
and tympanic membrane presented a normal ap-
pearance. This writer in quoting Schwartze, who
says that primary ostitis and especially primary
tuberculosis of the mastoid process is extremely rare,
declares that " this assertion may be true in general,
but on the other hand as far as bone tuberculosis of
the temporal is concerned the rarity with which we
diagnosticate this affection may be owing to the
omission of special bacteriologic examinations of cari-
ous bones of the ears."
To my mind it would certainly be very difficult to
tell whether the abscess thus discovered over the
mastoid originated in the periosteum or in the bone
proper, especially when upon opening the abscess
you find the bone substance itself involved. In very
young children, like the case reported by me, the
communication between the antrum and the overlying
superficial surface is much more pronounced than in
adults on account of the semi-embryonic condition of
the bone substance ; hence in such cases it is almost a
matter of impossibility to tell whether the abscess is
of superficial or of deep origin. In the newborn,
according to Hartman and Bezold, the mastoid pro-
cess is a mere shell surrounding a large antrum, which
shows the ease with which the walls would be broken.
My observation and opinion is that in primary
inflammation limited entirely to the congestive period,
its origin is most frequently in the periosteum; while
in abscesses, especially those not manifesting any
severe inflammatory swelling over the mastoid cells,
I am in full accord with Clarence Blake who says
that primary mastoiditis is exceedingly rare, and is
usually the result of injury or exposure to cold, or
may occur in the course of syphilitic diseases and, I
may add tuberculosis. He believes that in the
reported cases there has existed, some time prior to
its appearance, an inflammation of the tympanic cavity.
Yet it is conceivable, where the system is thorough/
impregnated with a specific poison, whether congeni-
tal or acquired, that there might be a primary mastoi-
ditis just as an ostitis is liable under the same con-
ditions to occur in any other portion of the body. I
believe that all primary mastoid abscesses are nothing
more than an ostitis the result of either syphilis or
tuberculosis, and by close examination the histories
will bear out this conclusion.
There is one especial point which I have noted in
mastoiditis in children, and that is where the abscess
574
CEREBRAL DISEASE.
[September 12,
is due to syphilitic or tubercular ostitis, the tempera-
ture has always been practically normal, while in those
cases where the cause has been an extension of the
inflammatory process from the middle ear to the mas-
toid cells, the temperature is usually elevated above
the normal at some time during the inflammatory
process.
Before closing I wish to mention similar cases
which have been published by three American con-
freres: S. C. Ayers of Cincinnati has reported two
cases of the so-called primary abscesses, but admits
that there had previously existed an otorrhea, which
to my mind excludes these from the cases of primary
mastoiditis. Wurdemann of Milwaukee has also
reported two cases which were thoroughly cured by
means of incision and packing. Connor of Detroit
reports a oase in a child 10 years of age. The drum
presented a perfectly normal appearance, and there
was no history of a previous discharge. The abscess
was thoroughly opened, parts curetted with the final
result of perfect healing.
In studying the literature of these cases my conclu-
sions are as follows:
1 . Primary abscess of the mastoid is more common
than a periostitis.
2. That this pathologic condition is more frequent
in children than in adults.
3. The most common causes are syphilis and tuber-
culosis, and the latter is much more frequent than
the text-books would lead us to believe.
4. That the prognosis is nearly always favorable,
and a full restoration of the parts is the usual result.
CEREBRAL DISEASE FOLLOWING MIDDLE
EAR SUPPURATION.
Read in the Section on Laryngology and Otology, at the Forty-seventh
Annual Meeting of the American Medical Association.
at Atlanta, Ga.. May 5-8, 1896.
BY M. D. LEDERMAN, M.D.
LECTURES ON DISEASES OF THE NOSE ANO THROAT, NEW YORK POLYCLINIC;
ATTENDING AURAL 8URGEON UNIVERSITY MEDICAL COLLEGE DIS-
PENSARY; ASSISTANT AURAL SURGEON MANHATTAN EYE
AND EAR HOSPITAL, ETC. NEW YORK.
Having lately observed three instances of fatal
cerebral complications occurring in individuals suffer-
ing from suppurative disease of the middle ear, I
accept this opportunity of narrating their histories,
hoping they may prove of some interest.
When we recall the anatomic arrangement of this
cavity, we are impressed with its immediate proximity
to vital structures. The partition that separates the
middle ear from the brain and its coverings, is but a
thin portion of bone, with no diploe. Having little or
no illumination, but being sufficiently supplied with
heat and moisture, the middle chamber is an ideal incu-
bator for the propagation of pathogenic microorgan-
isms. Diseases of a suppurative character affecting
this locality, have many factors to augment their
vitality, but comparatively little resistance to limit
their spread. It requires no stretch of imagination
to picture a purulent inflammation extending through
the roof of the tympanic cavity, and attacking cere-
bral structures.
Observers agree to three forms of pyogenic intra-
cranial invasion arising from middle ear suppuration,
i. e., brain abscess, meningitis, and sinus thrombosis.
According to Koerner,1 almost all brain abscesses,
originating from purulent aural disease, are situated
near the primary collection of pus, in the ear or tem-
poral bone. Jansen, however, could not discover an
extension of the disease from the temporal bone to
the brain in any of the cases of abscess of the tem-
poral lobe upon which he had operated, though the
collections of pus were directly over the tegmen tym-
pani. To reach them, the posterior and upper wall
of the mastoid had to be removed. In 184 instances
of intracranial involvement observed by Jansen, in
three and a half years, at the Berlin Clinic, 148 were
extra-dural abscesses, 35 were thrombosis of the lat-
eral sinus, and only five were brain abscesses. In the
extra-dural lesions, the purulent matter was more
often found occupying the posterior cerebral fossa.
He has observed that extra-dural abscesses are the
most frequent complication of acute suppurative
otitis media. In cases of doubtful diagnosis he rec-
ommends exploratory operations, and further remarks
that deep seated collections of pus are best reached
after removal of the entire posterior wall of the mas-
toid process.
It is not always a simple matter to differentially
diagnose the presence of existing cerebral disease.
When the abscess occupies the motor zone, the direct,
functional symptoms resulting, assist materially in
arriving at a conclusion. If, however, this area is not
involved, it requires careful observation to localize the
seat of trouble. Picque1 remarks, that a persistent,
cephalalgia, referred to a distinct region, with coma
and slowing of the pulse, indicate cerebral suppura-
tion. If the lesion points to an involvement of a
motor zone, this locality should be trephined at first,
and the mastoid opened later. If on the contrary,
indistinct cerebral symptoms arise, the mastoid should
be primarily attacked. Should the unpleasant symp-
toms still persist, further exploration must be carried
out.
In endeavoring to illuminate the haze, which at
times obscures a positive diagnosis in otitic-cerebral
cases, a statement has been made that where bone
conduction is present, the abscess is probably situated
in the cerebrum; if the bone conduction is absent, the
disease is presumptively in the cerebellum. This
theory was deduced from the supposition that the
pyogenic organisms reach the cerebellum by way of
the internal ear. In this manner the infectious pro-
cess spreading along the auditory nerve and its cov-
ering, abolishes bone conduction. Macewan2 claims
that as a rule, the cerebellar abscess arises from the
disease extending from the sigmoid sinus, and not
from the internal ear, so that the seventh and eighth
nerves in the internal ear remain unaffected, and are
capable of performing their function. If the mechan-
ism of hearing is not disturbed, the auditory nerve
will conduct sound both by air and bone, even though
the cerebellar abscess exists. Should, however, the
septic process extend to the cranial cavity through
the internal ear, bone conduction may still be present.
This fact was demonstrated by a case, reported by
Macewan. In this patient auditory conduction was
absent, but bone conduction was more acute on the
affected side, than in the normal ear. Postmortem
examination revealed extensive purulent leptomenin-
gitis, chiefly marked in the posterior fossa, surround-
ing the right internal auditory meatus. The seventh
and eighth nerves passing through the occluded inter-
nal auditory meatus, were swollen and compressed;
while on the healthy side, the same nerves occupied
only one-half of its caliber.
1 Annals of Ophthal. et Otology.
2 British Med. Journal 18-20-1895.
Vol. lv. No. 4.
1896. ]
CEREBRAL DISEASE.
575
Both aerial and bone conduction may he absent
without being the result of cerebellar disease. This
Stay occur if some affection of the auditory nerve
previously existed. In such a case seen by Macewan,
the brain lesion was found to be a cerebral abscess.
From his observations he concludes that whether bone
conduction be present or not, it is not a reliable sign
in localizing the cerebral complication. These con-
tradictory experiences clearly demonstrate that no
symptom can be taken as a cade mecum.
Otitie-eerebral abscess is more apt to be the result
of a prolonged suppuration and not of an acute affec-
tion. Kulenstein,3 after collecting authenticated cases,
could find but eighteen of brain abscess originating
from acute disease of the temporal bone. To this
bomber he adds one of his own, operated upon with a
good result. In all these cases the cerebral disease
was situated upon the side of the affected bone; the
greater number being on the left. Koerner, on the
other hand, found the right side to be most fre-
quently attacked. In two of my cases the disease
was on the right side. Of the eighteen cases above
mentioned, thirteen abscesses were found in the
temporo-sphenoidal lobes and four in the cerebellum;
the situation of the other one is not given. Among the
symptoms observed in connection with cerebral
abscesses were: Irregular fever: persistent head-
ache (being one of the most constant symptoms, due
to intracranial pressure); retardation of pulse; choked
disc: interference with speech (in the left-sided dis-
ease); paralyses (facial, hemiopsia, ptosis, abducens
on the same side). Other manifestations were, incon-
tinence of urine, photophobia, increased tendon re-
flex, hemi-anesthesia and hyperesthesia. Eleven
patients were operated upon. Of these, five died
(two cerebellar, three temporo-sphenoidal); and six
were successful (one cerebellar and five temporo-
sphenoidal).
During past years there has existed a tendency to
wait for pronounced symptoms before attempting to
discover the cerebral complication. Clinic experi-
ence has shown us that temporizing under such cir-
cumstances is not only unjustifiable but frequently
productive of fatal consequences. It matters not in
what portion of the economy a septic focus exists, our
efforts should be directed toward the prompt limita-
tion of its activity. Accepting this axiomatic prin-
ciple pro vero we should unhesitatingly attempt to
check the stride of an infectious process when it has
reached so vital a region. Under present antiseptic
precautions, surgical treatment can be undertaken
without much fear of external contamination. It is
not my intention, however, to sanction hasty and pre-
mature operations in these cases, but rather to sug-
gest the prompt employment of effective measures,
when indications arise. Suppurative otitis media
should not be treated (as is often the case) in a non-
chalant manner. Its serious aspect should be vividly
pictured to the patient, and the possibility of threat-
ening dangers should be emphasized.
Case 1.— M. C, female, 8 years of age, had a chronic dis-
charge from the ears for three years. Under local treatment
the suppuration was checked and no further trouble was
noticed. About two years after the cessation of the aural
trouble the child fell and struck the back of the head with
considerable force. At the time of the accident the child was
unconscious, and on recovery complained of pain in the head.
Three weeks elapsed before any further symptoms appeared.
At this time the mother discovered that her daughter was not
3 Monat. fur Ohrenheilk. 1895.
feeling well and Dr. Charles Hoffman was called. As nothing
definite could be found, the condition was treated symptomat-
ically. Irregular temperature became apparent and some pain
was complained of in the region of the left ear. Recalling the-
former otitic trouble, Dr. Hoffman asked me to see the case-
with him. No local signs of an inflammatory process could
be seen. The temperature was 101 degrees P. rectum. No-
swelling or tenderness of the mastoid or jugular region existed
at this time. Treatment was continued as before.
A few days later convulsive seizures together with a somno-
lent condition of the child was observed by Dr. Hoffman.
Applications of ice were ordered to the head and neck. Drs.
L. Weber, Hoffman and myself saw the case in consultation and
agreed that meningitis existed, but that the character of the
disease could not be definitely diagnosed. As no active ear symp-
toms were found at this visit, a tubercular manifestation was
suspected. Temperature of a septic character persisted and
the semi-stupor was rather more marked. Forty-eight hours
after our consultation pressure over the mastoid revealed some
tenderness. We decided to operate at once. The usual open-
ing was made under ether. The cortical layer of the mastoid
process was found sclerosed, but in chiseling more extensively
some pus was discovered. The quantity evacuated was very
little. Repeated hypodermic stimulation had to be given
while the operation was in progress. The patient's serious con-
dition at this time did not justify further exploration, so the
wound was packed with iodoform gauze. On the following
morning I trephined an opening into the middle cerebral fossa,
three-quarters of an inch above the external auditory canal.
The dura was bluish in color, but did not pulsate. A hypo-
dermic needle was introduced and about a drachm of pus with-
drawn. Two more buttons of bone were removed with the tre-
phine, and the connecting bridges of bone were cut away with
the rongeur. An incision was then made through the membrane,
and fully three ounces of fetid pus escaped. Gentle antiseptic
douching was carried out and the parts packed with gauze.
As in the previous operation frequent subcutaneous stimula-
tion was found necessary.
Paralysis of the right arm and leg had appeared. Pupils
reacted to light in the evening of the day of the second opera-
tion. Coma continued, paralysis of the sphincters was ob-
served, and on the following day dissolution occurred.
Case 1 is an illustration of the irregular course a
temporo-sphenoidal abscess may run. Though pre-
vious ear trouble had existed, no symptoms pointed
to this organ at the beginning of the fatal complica-
tion. The quantity of pus present in this cerebraL
abscess demonstrates that such a state of affairs may
exist for some time without producing characteristic
symptoms. It is possible that the traumatism in this
case may have been an exciting factor. The question
arises, whether we are justified in opening the mas-
toid process or cerebral cavity, in cases presenting a
similar train of symptoms which give evidence of
previous suppurative otitis media, though presenting
no active manifestations.
Case 2. — F. M., aged 16 years, white, was admitted to the
Manhattan Eye and Ear Hospital, Oct. 5, 1895, with the fol-
lowing history : For the past twelve months had chronic sup-
puration of the right ear, resulting from the measles. The
discharge was not constant, but whenever it stopped severe
pain set in, which ceased when drainage was reestablished.
About three weeks before his appearance at the hospital, after
an exposure, he was taken with severe pain over mastoid, in
and around the ear. Pain had been constant since. At this
time the external parts were considerably swollen and tender ;
temperature 100 degrees F. ; pressure in front of tragus caused
pus to flow freely. Under local treatment the patient pro-
gressed nicely until about 2 o'clock a. m., Oct. 6, 1895, when
becoming delirious, he was then sent to the hospital.
Condition on admission : Delirious, restless and anxious
expression. Temperature 104 F. ; pulse 110. Right mastoid
swollen ; slight redness extending well down over neck.
Marked tenderness over mastoid, front of ear. Decided pulsa-
tion in right cervical region. On slight manipulation with
probe and cotton profuse offensive discharge came from ear.
Meatus perforated in postero- inferior quadrant.
Patient was etherized and a mastoid operation done under
strict antiseptic precautions. Small quantity of pus was found
in cells. Wound cleansed with bichlorid solution and packed
with iodoform gauze. Morphin hypodermic was necessary to
quiet during night.
576
CEREBRAL DISEASE.
[September 12,
October 6. Very restless this a. m. Temperature 100 F.,
pulse 110 ; complains of sick stomach, but does not vomit ; does
not take nourishment.
October 7. Temperature 98 F., pulse 110; still restless;
takes little nourishment.
October 8. Extremely restless ; constant tendency to get
out of bed. Temperature 99.6 F., pulse 110. Dressing
removed. Considerable pus in canal and mastoid. Cleansed
and irrigated with bichlorid solution, 1-10000 ; packed with
gauze and bandaged, leaving external auditory canal exposed
for douche, every two hours. Morphin to quiet : strychnin
and spirits frumenti ordered to be given at the discretion of
the house surgeon.
October 9. Still restless ; temperature 100 F. Takes nour-
ishment quite freely. Mastoid dressed as before. Wound
clean and healing.
October 10. Temperature 98 F., pulse 110. Not quite so
restless. Voids urine in bed.
October 11. Temperature 97 F., pulse 120; restless; no
chills ; stimulants increased.
October 12, 8 :30 a. m. Some signs of left hemiplegia. Not
so restless; breathing slightly stertorous; 9:30 a. m., will not
take stimulants. Died with symptoms of compression at
12 :15 p. m.
Postmortem examination showed an extensive cerebral
abscess of the temporo-sphenoidal lobe. A large quantity of
pus escaped after the dura was incised. Four finger tips could
be readily introduced into the abscess cavity. The dura was
thickened and on the cerebral surface of the tegmen a necrotic
area was found. No involvement of the sinus was observed,
the extension of the'disease being by continuity of tissue, and
not through the lymphatics.
On Oct. 11, 1895, the patient was doing so well,
even though the temperature only registered 97 F.,
that further operative interference was contraindi-
cated. Had an opening been made on this day into
the middle cerebral fossa it certainly could not have
saved the patient, as the disease had then assumed
extensive proportions.
Case 3. — Phoebe B., deaf mute, 62 years of age, was referred
to me at the Manhattan Eye and Ear Hospital, May 6, 1895,
for mastoid operation, with the following history :
For past year has had pain in right ear, with scanty dis-
charge. Three months ago, facial paralysis of right side
occurred suddenly. The patient had been operated upon for
aural polypi, which completely filled the external canal. There
was a profuse and very offensive discharge from the- right
canal, which was somewhat benefited by the removal of the
granulation tissue. These growths rapidly reappeared so that
repeated attempts at their eradication had to be made.
On May 5 the mastoid process became boggy and very ten-
der. Treatment failed to relieve the pain and swelling, so
patient was turned over to me for operation.
May 6, 3 p.m. A Stacke operation was performed, together
with the removal of almost the entire tip of the mastoid. The
osseous destruction was very extensive, the dura being encoun-
tered on passing the probe upward. Thorough curetting of
the posterior and inferior surfaces of the diseased tissue was
carried out. Fearing perforation into cerebral cavity, gentle
manipulation in the upper portion of the wound had to be
observed.
May 7. Temperature 99.4 F. Patient doing well.
May 8. Temperature normal. Dressing removed. Some
discharge from the canal which was not offensive. Otherwise
wound clean. Packed as before and ordered cleansed with
peroxid of hydrogen and corrosive sublimate solution.
May 11. Some slough on posterior wall of cavity. Dis-
charge increased, with some odor. The slough was removed
and Labarraque's solution ordered as a cleanser.
May 18. Improving; wound clean and rapidly filling. Tem-
perature normal.
May 20. Granulations exuberant. Touched with caustic.
May 25. A small sinus was found on inner wall of cavity,
filled with pus ; probe showed necrotic bone. Sinus curetted,
cleansed, and packed with gauze.
May 30. Improving ; wound clean ; slight odor from sinus.
June 9. Odor becoming offensive. Some debris curetted
from the wound. Inability to move left arm and leg was
noticed.
June 11. In the morning, a hemorrhage occurred from the
mastoid, appearing through the ear, nose and throat, and sat-
urating the dressings. 7 p.m. Severe hemorrhage through
naso-pharynx. Post-nasal tampon applied. Source of bleed-
ing could not be discovered. '
June 12. Another hemorrhage, which was checked by tam
poning mastoid opening. Hypodermic stimulation.
June 14. Patient gradually grew weaker from the loss of
blood, and died at 6 :30 p.m.
The autopsy revealed marked necrosis of the petro-
mastoid portion of the temporal bone. The probe
could be readily passed into the posterior and middle
cerebral fossae. Ulceration of the sinus was found to
be the cause of the severe hemorrhage. Softening of
the right temporo-sphenoidal lobe of the brain was
recognized.
Owing to the congenital condition of the patient,
subjective symptoms were not readily ascertained.
There can be no doubt as to the chronic character of
the destructive process, as the facial paralysis had
occurred three months previous to the case coming
under our observation. So extensive was the disease,
that after the operation, a probe could be passed into
the mastoid opening for a distance of almost two
inches, measured from the external surface.
Case 4. — Though this case can not be positively classed as a
cerebral involvement, nevertheless I mention its history for the
purpose of emphasizing the difficulty we meet with at times,
in arriving at a correct diagnosis.
James B. , 34 years old, had scarlet fever twenty -five years
ago, which resulted in a chronic suppurative otitis media,
which has been more or less active ever since. During the
past four years the discharge has been more profuse, and fre-
quent attacks of severe pain have been experienced. Relief
from the pain was noticed, whenever the discharge flowed
freely. Blood was at times found in the discharge. On May
24, 1895, he was admitted to the Manhattan Eye and Ear Hos-
pital, with intense pain in the left ear, from which a scanty
flow of pus was observed. Some infiltration of the soft tissues
of the external auditory canal existed. A small perforation in
the postero-inferior quadrant could be seen on careful inspec-
tion. Anterior to tragus, the parts were tender, but no pain
or swelling over mastoid.
General condition. — Patient is anemic, and seems to be suf-
fering severely. Tongue heavily coated ; bowels constipated ;
temperature 103 F. ; pulse 140.
May 25. Bulging of membrane. Tympanum liberally incised.
Hot douching every two hours, and boroglycerid tampons were
ordered ; also calomel, until bowels moved freely.
May 26. Slight improvement. Temperature 101 F. Some
headache and pains in back of neck. Leeches applied. No
definite conclusion could be reached.
May 30. Temperature still high. Griping pains in bowels ;
calomel stopped. Marked tendency to constipation.
June 1. Great pain in back of neck. Temperature 102 F.
Counter-irritation applied.
June 2. Pain somewhat less, but still present. Ice to neck
ordered. Bromid was prescribed.
June 4. Considerable pain in neck. Peculiar discharge
from bowels resembling that of enteric fever. Temperature
104 F. Our medical consultant examined the patient, and
suspected thrombosis of the lateral sinus.
June 5. Chill lasting twenty minutes. Patient much
exhausted. Strychnin and whisky freely administered. Tem-
perature 104.2 F.
June 6. Chill lasting fifteen minutes. Quinin and fluid ex-
tract digitalis given continuously. Temperature 103 F. Dr. A .
H. Smith advised surgical interference. At 8 p.m. I operated.
Periosteum was detached from mastoid with great difficulty.
The bone was found sclerosed throughout its entire extent.
No pus was discovered. On opening into the lateral sinus,
nothing abnormal was found. Sinus and mastoid were packed
with iodoform gauze. During the operation patient received
hypodermic injections of strychnin.
June 7. Recovered nicely from operation.
June 9. Symptoms of abscess of liver appeared, with great
exhaustion.
June 12. Temperature still elevated. Occasional chill fol-
lowed by pronounced depression, which finally terminated the
patient's existence. Unfortunately no postmortem was
allowed. We were inclined to believe that the liver symptoms
were the result of metastasis. A cranial lesion in the form of
a cerebellar abscess was suspected.
We must not overlook the fact that disintegration
of osseous tissue may take place, without causing
painful symptoms. This is especially characteristic
R1896.]
f b tube
DISCUSSION.
577
if b tubercular process; nnd in the region of the ear,
marked destruction may ooour without involving the
integrity of the membrana tympani. Such a condi-
tion is more apt to affect children of a strumous diathe-
sis In such instances the ulceration may soften the
root of the tympanic cavity, and so attack the brain.
It furthermore may generate miliary tuberculosis of
the lung and other organs, by entering the circula-
tion, through the antrum and mastoid cells, or by
penetration into the jugular fossa or sigmoid sinus.
128 East 60th Street
DISCUSSION.
Dr. Max Thornkr, Cincinnati Thepapersare of more than
usual interest, because the question of operative interference
and topographical relations are comparatively new. Ordina-
rily topography of the temporal bone is insufficiently treated
in text books.
The antrum is ordinarily larger and the floor of it is so much
below the level of the aditus that pus can not flow out accord-
ing to the laws of gravitation. Thus it happens that in cases
where the inflammation is violent, before we think it possible,
we have the whole mastoid process converted into a pus cavity.
It has often been said that the ordinary acute otitis media will,
if attended to at once, never lead to serious complications.
This is, however, not my experience. Sometimes serious com-
plications will ensue in spite of all that we do.
Dural abscesses, the essayist stated, may exist some time
without distinct symptoms. Only seven weeks ago I had a
case of acute otitis media following influenza, which was very
serious from the start. The temperature was never lower than
102 and the discharge was profuse for weeks. At the same
time severe pain developed over the temporal bone. All the
symptoms of a mastoiditis were present when, after six weeks'
treatment, I opened the temporal bone. It was one large
cavity tilled with pus and granulations. When cleansed thor-
oughly I found that a small amount of pus had collected below
the posterior and anterior wall of the enormously large antrum
and the dura-mater. About five or six drops of pus escaped
from this location, after enlarging the pin-hole opening which
existed in the bone. The patient made an excellent recovery.
I believe that in a case where we have mastoiditis, which is
not primary, we can not cure it by simply making an incision
through the integument, but only by entering the cavity and
removing the pus. But in cases of primary or secondary peri-
ostitis of the mastoid process, without any accumulation of
pus, I do not see why Wilde's incision should not suffice.
In regard to that part of the paper referring to cerebral
abscesses as one of the possible complications, I will report one
case which I had, only a few months ago, under my observa-
tion. It is interesting on account of the enormous size of the
cerebral abscess. The patient had been in a comatose condi-
tion for three weeks when received at the Cincinnati City Hos-
pital. The history was meager, but it was found that there
had been suppuration for some time previous. It was stated
by relatives that a little piece of bone had been discharged
into the auditory canal. There was a profuse purulent dis-
charge from the right ear which was exceedingly offensive ;
caries of the attic could be determined. Upon opening the
antrum I found it filled with pus and granulations, and the
tegmen tympani bare ; in this a very small perforation was
found, through which a few drops of pus escaped. This open-
ing was gradually enlarged, when a great amount of pus, very
offensive and of a green color, came out. The abscess cavity
was large. After establishing thorough drainage the wound
was closed. The patient recovered from the comatose condi-
tion, but died in thirty-six hours after the operation. It was
the largest abscess that any one connected with the hospital
ever saw, being about the size of a small orange and occupy-
ing the right temporo-sphenoidal lobe. The brain tissue
within one-fourth and one-half inch of the walls of the abscess
cavity was softened and discolored.
Dr. Mylks — My experience has taught me that nothing but
frequent demonstration of these practical anatomic points
will fix them permanently in the mind. The topography of
the antrum and mastoid varies in different cases, and in differ-
ent ages. The doctor has presented some remarkable speci-
mens, but I would have presented them in a little different
way. I leave all the external landmarks on the specimens,
that will not be detrimental to them, as I find that in this way
the mind is better enabled to grasp the situation. A complete
analysis of the relation of every structure is essential in the
proper comprehension, and in the teaching of this department.
It is well to instruct the student so that he can operate safely,
and without penetrating the lateral sinus under any topo-
graphic condition. One good rule in operating is to cut care-
fully and deliberately, and to start by chiseling a broad
beveled opening rather than a round narrow hole. If he
clings closely to the auditory canal, and cuts in a spiral direc-
tion upward, inward and forward, he will reach the antrum
quickly and surely. If you wish to be a little more direct, you
may start a little higher in the suprameatal triangle and chisel
directly inward. The chief thing to avoid is injury to the
facial nerve, which usually comes outward near the junction
of the floor of the antrum and the posterior superior walls of
the tympanic cavity.
In regard to children and to the paper of Dr. Roy, a great
many cases of swelling posterior to the ear, and over the
antrum or mastoid, can be cured by a Wilde's incision. In
that class of cases where there is no pus discharge in the
canal, it is usually due to periostitis or caries either of trau-
matic or tubercular origin, or extends through a small venous
aperture from the antrum, and in certain cases the pus bur-
rows from the attic along the external auditory canal, and
causes local abscess on the roughened area of the mastoid
process. A great many of these cases recover after simply
incising and draining, without curettage or interference with
the middle ear.
Dr. Frank Allport, Minneapolis, Minn. — 1 must take issue
with what has been said concerning the unnecessary frequency
of such operations. My own tendencies are somewhat con-
servative, especially where serious operative procedures are
contemplated, but in this line of cases I emphatically believe
we do not operate enough. The history of the mastoid opera-
tion, and now the history of operations for otitic brain abscess,
leads us through the uncertain maze of the past, when such
procedures were regarded with mingled feelings of awe and
aversion, to the triumphant place now universally accorded
them in the modern annals of surgery, and I predict for them,
and especially the latter, a much higher and more exalted
position than that at present possessed. The time will come
when,the human brain will no longer remain a terra incognita,
but will be successfully explored by the progressive modern
surgeon.
No man should venture upon such surgery unless thoroughly
prepared therefor by accurate anatomic, topographic and
pathologic studies, both theoretic and practical ; but when
thus fortified, and then brought face to face with a case of
this character, he should not hesitate. In a correctly recog-
nized case of brain abscess there is no other course to pursue,
and the patient may as well die from an unsuccessful opera-
tion as from a timorous and too conservative therapeusis. It
is astonishing how much interference the brain will endure, as
is instanced by a case I will briefly recite : The patient was a
man injured in a trolley car accident, producing a basal frac-
ture and bleeding from the ears, followed by some discharge.
Cerebral symptoms ensued, and I was called to diagnose a
mastoid abscess, which I could not do. The consulting phy-
sicians and myself thereupon diagnosed a probable brain
578
ELECTROLYSIS.
[September 12,
abscess and the patient was accordingly trephined. Thor-
ough exploration was made in many directions, starting from
the temporo-sphenoidal lobe, but no pus was found. The
wound was closed and death speedily expected ; but the
patient quickly and completely recovered, whether from relief
of pressure we do not know. So, death need not always be
expected, even when an operation is made and no pus found.
I do not repeat this instance to encourage reckless operating,
but to endeavor to dissipate the reluctant attitude assumed
by surgeons when cerebral operations are mentioned.
It is not necessary for a man to be an aurist to open the
mastoid process. Any surgeon properly qualified may under-
take it, but it should be remembered that the operation has
developed from a mere gimlet-hole opening or vent to a thor-
ough removal of the outside mastoid shell, and a conscientious
following up of every pus avenue, no matter where it may lead.
We never know, therefore, when we open a mastoid process,
what may be the ultimate issue involved, and we should be
prepared to meet and care for any and all emergencies ; and to
treat pus deposits in this locality upon the same general prin-
ciples observed in other portions of the body.
In regard to the method of operating, I prefer the dental
engine, with fresh, sharp burs. It is gentler, quicker and
smoother than the chisel, and the field of operation can be
observed with great accuracy.
Concerning Wilde's incision, I believe it to be indicated but
seldom, but when used, unless a pus deposit upon the outside
of the mastoid is evident, the incision should be made in the
inner, upper and posterior portion of the meatus, as the mas.
toid cells are here much more in evidence than at the hard
external mastoid plate. At best, however, the Wilde's incision
is usually but a temporizing procedure, through which valua-
ble time is lost ; and still I can not say I have never seen ben-
efit ensue through its agency.
Dr. Cline — I have seen some remarkable cases of mastoid
disease and I have been fully persuaded that too many extensive
operations are performed on these cases. I was called to see a
man seventy years old who had a discharge of pus from his ear
for ten weeks, and for eight days and nights could not lie down
on account of pain. On making Wilde's incision the knife
passed into the bone, which seemed soft and pulpy. Pain sub-
sided immediately and he was able to lie down. A draining
tent was introduced, and the second day there was a free dis-
charge of pus. I prescribed iodid of potassium and he made a
rapid recovery without any scraping or chiseling away of the
bone.
In another case the ear had been discharging for fourteen
weeks. The ear was very painful and over the mastoid the
tissue was very much swollen and of a very dark purple color.
His condition was such that, with his previous history, I con-
sidered an operation was indispensable. I directed him to
return home and send for a surgeon in his town and have the
operation performed at once. The doctor who took him in
charge decided to wait a day or two before operating. He put
him on ten-grain doses of iodid of potassium every two hours.
The patient began to improve, in three days the pain had dis-
appeared and in seven days the discharge from the ear ceased,
and since then (two years) he has had no further trouble.
I might detail other cases but these will suffice for the plea
for conservative, early extensive operating and the free use of
the iodids in these cases.
Dr. T. H. Shasted, Galesburg, 111. — I am inclined to believe
that Politzer's ideas on this point are correct. He says that in
the chronic mastoid troubles the thorough operation should be
done. The antrum should be opened, and, if then found neces-
sary, the tympanum also. In acute cases, however, the thorough
operation is seldom necessary. The abscess usually lies in the
vertical portion of the process and does not, as a rule, commu-
nicate with the antrum. If in such cases, we cut down to the
y-
I
antrum, we shall infect those parts when there is no necessity
for it. In those cases where the pus bursts through the cortex
spontaneously, there is very little to be done. We can easily
remove whatever comes away and that is about all there is
be done. It is seldom necessary in such cases to make a tho:
ough operation on the ground of preventing chronic fistulo
discharge. I have frequently seen such cases and they alm<
invariably do well in the course of two or three weeks at i.
longest.
Dr. Roy's case reminds me of my own, that of a lad aboul
18 years of age. There was no suppuration from the ear, nor
sign or history of former suppuration. At the operation I found
very little pus, but some carious bone. I had the case diag-
nosed as primary mastoiditis. But afterward I was somewhai
surprised to receive from his parents a history decidedly di
ferent from what they had first given me. He had had a sligh'
discharge of short duration some years before. No doubt i:
all these cases there has been previous tympanic trouble, of
which the membranic signs have been effaced and the history
forgotten.
Dr. B. Alexander Randall, Philadelphia, Pa. — I wish
merely to refer to the point already made that these mastoid
and tympanic cases are the hot-bed of tuberculosis. Cases
that are not primarily tubercular are here transformed, and
we have the tubercular infection passed into the whole body,
While I do not believe in Wilde's incision, I think the wholi
matter can be set down as largely one of technique ; and thi
way in which we proceed will depend upon our instruments.
Dr. Edward J. Bernstein, Baltimore, Md. — I do not believi
that the relative impunity with which one can enter the brai
constitutes any warrant for the frequency with which some
undertake these operations. I have operated a number of
times with a good percentage of successes ; on the other hand
I have had cases, of late, where everything indicated the
necessity for operation, and I plead with the patient for the
necessary permission, but owing to their persistent refusal, I
was forced to keep to less radical means. Many of these latter
patients recovered and are apparently well. They are not safe
from recurrences, as are those who submit to the radical proced-
ure, but an immunity from attack for one or two years speaks
well for their side of the question. I have never used Wilde's
incision, because Leiter's coil, mercurial ointment, and other
local applications have always served me where the regul;
mastoid operation was not indicated.
d
;
ELECTROLYSIS FOR THE REDUCTION 01
SPURS OF THE NASAL SEPTUM.
Read In the Section on Laryngology and Otology, at the Forty-sevent
Annual Meeting of the American Medical Association,
held at Atlanta, Ga., May 5-8. 1896.
BY W. E. CASSELBERRY, M.D.
Professor of Laryngology and Rhinology in Northwestern University
Medical School (Chicago Medical College): Laryngologist
and Rhinologist to St. Luke's Hospital; Laryng-
ologist to Wesley Hospital, etc.
CHICAGO, ILL.
A year ago I gave the results of recent experience
with electrolysis for the reduction of spurs of the
nasal septum, in a paper read before the section of
Laryngology and Otology of the American Medical
Association,1 and later in another paper before the
American Laryngological Association,2 and it is not
my purpose in this supplementary report to repeat
the technical details of the procedure or to recite
cases at length, but simply to formulate conclusions
bearing upon the exact limitations of this method.
The bibliography having been presented in pre-
vious papers, will be omitted at this time; suffice it to
1 Journal of the American Medical Association, 1895.
2 Transactions of the Am. Laryn. Assoc, 1895; New York Medical
Journal Aug. 81. 1895.
18W.]
ELECTROLYSIS.
579
My, that a few European operators have advocated
the method and some have praised it with seeming
extravagance.
Customarily spurs or excrescences of the septum
Barium arc removed by surgical means, by the knife,
saw and drill, and these are the methods employed by
myself in the majority of cases. In skillful hands
they are more rapid, more precise, and in the case of
targe, bony spurs, certainly more effective than is
electrolysis. The surgical method, however, is more
or less sanguinary and otherwise far from agreeable
to contemplate or experience. In cases of major
degree, where the excrescence is of bone and of large
size, occasioning pronounced occlusion of the nostril,
together, perhaps, with serious secondary catarrhal
symptoms, pressure neuroses, middle ear affections,
or impairment of the general health, one should not
hesitate to sacrifice the spur and if need be by the
surgical method. The operation, the discomfort sub-
sequently for a few days of an iodoform gauze pack-
ing as a preventive to hemorrhage, and even the
substitution for normal mucous membrane over the
operated area of a cicatricial mucosa with its tendency
to dry orustation, are but trifling inconveniences in
comparison with the benefits conferred in properly
selected oases.
But there are cases of minor degree, small spurs of
cartilage or of cartilage and bone and thickened areas
which seem scarcely deserving of surgical treatment,
but which one would like to see resolved for the sake
of the additional nasal space and better drainage
which would thereby accrue to the patient. There
are also patients of delicate physique and those of
highly sensitive and uncontrollable nervous organiza-
tions, and bleeders, also, whom one hesitates to subject
to the regular operation. And, again, there are patients
who willfully refuse an operation, however needed or
suitable the case may be.
To what extent can electrolysis be utilized for the
relief of these subjects and what sort of spurs can be
completely removed, and in which can reduction in
size only be expected?
Concerning the physics of electrolysis it is only
necessary to state that it is a process of chemic disin-
tegration of tissue under the influence of a direct or
galvano-electric current by which water and salts are
separated into their component parts, oxygen and acids
being attracted to the positive needle and hydrogen and
the alkalin bases to the negative needle. With one ex-
ception I have employed the preferable bi-polar method
by which two needles, one representing each pole, are
inserted into the spur. My needles are made of irido-
platinum, which is nearly as stiff and hard as steel,
twenty millimeters in length, about one-half millimeter
in thickness, soldered parallel three millimeters apart
to copper bars, which run through a light handle. Steel
needles are perhaps more commonly employed and I
have used them somewhat.
The process of electrolysis is not to be confounded
with galvano-cauterization. While fine electrolytic
needles can be made to burn by a sufficiently strong
current, my needles as used with a current adequate
for the purpose of electrolysis do not cauterize. The
current strength necessary for electrolysis of nasal
spurs is from fifteen to forty milliamperes, measured
with the resistance of the spur in the circuit, and to
supply this current from fifteen to twenty cells of a
galvanic battery would ordinarily be used with a cor-
responding electromotive force of from twelve to
twenty volts or more. The inconvenience of this
apparatus and especially its unreliability when called
into use only at irregular and prolonged intervals, has
deterred many from trying the electrolytic method. I
sought to avoid these annoyances by adapting the
Edison electric light circuit to the purpose by means
of lamp resistance and the Mcintosh current controller.
It is as easy and readily applied as the galvano-cautery,
except for the few minutes' additional time that its
energy needs to accomplish the work. When used it
is necessary only to adjust the milliamperemeter and
insert the needles.
A current suitable for electrolysis should be char-
acterized by moderately high tension or voltage and
comparatively low current strength or amperage. The
Chicago-Edison current has an elecromotive force of
110 volts, which must be reduced by the current con-
troller. During the last year I have used only eleven
volts or less. The amperage depends on the amount
of resistance in the circuit, but it also can be corre-
spondingly reduced by the resistance of a lamp and
the controller so that with the spur in the circuit it
measures the requisite number of milliamperes. The
current controller was described at length in my
preliminary report. It is designed only for the con-
tinuous current and can not be employed with the
alternating for the purpose of electrolysis, nor is it
adapted to electro-cauterization.
I now employ the controller with only one lamp [in
series] as additional resistance in the circuit, which
aside from the action of the controller reduces the
initial electromotive force to fifty-five volts. During
the year I have used a current of only eleven volts or
less, secured by advancing the decimal slide of the
controller to 1 before the needles are inserted into the
spur, which removes coil resistance sufficient to pro-
vide one-tenth of fifty-five volts or five and one-half
volts. Then, after insertion of the needles, the cen-
tesimal slide is advanced gradually, each point
removing coil resistance in fractions of hundredths,
which occasion little shock, until if need be ten one-
hundredths, or another five and one-half volts are
added. With this arrangement the meter will usually
register from ten to thirty milliamperes, which with
an exposure of seven to twelve minutes is adequate.
The chief difficulty in the reduction of cartilagi-
nous spurs is to determine exactly when sufficient
destruction has been effected, and no rule of guidance
in this regard can be formulated, experience and deli-
cate judgment only being of service. Nor can one
always foretell the range of action or distance from
the needles in all directions to which the destruction
will extend. The ideal action is to produce just
enough disintegration within the spur to lead to sub-
sequent absorption without total destruction of the
surface mucosa, which will therefore be reproduced in
the process of cicatrization more perfectly than is
usual after the cutting operation. If, however, the
action be more intense and the slough produced be
large it will separate as a whole with corresponding
complete destruction of the mucous membrane. In
the same manner by too intense an action a slough
extending through the cartilaginous septum can be
caused and perforation result. This is especially apt
to occur while electrolizing a spur which surmounts
the convexity of a bent or deflected cartilage.
A simple deviation or bending of the septum can
not be corrected or straightened by electrolysis and
its use in such a case can only result in perforation.
580
ELECTROLYSIS.
[September 12,
If in addition to the deviation there is also a spur,
that is, conjoined deviation and excrescence, the
thickening may be reduced or removed by electrolysis,
but the deviation will remain. These distinctions
should be held clearly in mind when considering in
any given case the applicability of electrolysis. It is
true that perforation is prone to happen when oper-
ating on similar cases by the surgical method, for it
is not always possible to estimate exactly the degree
of concavity of the opposite side, and a closely redu-
plicated deflected septum can be mistaken for a spur
and perforation result on cutting it off. But with elec-
trolysis, in addition to these there is the further uncer-
tainty of being unable to tell in advance exactly how
far the action will extend. A close watch should be
maintained in the opposite nostril and the electro-
lytic action discontinued on the slightest mottling in
hue or escape of gas from that side of the septum.
But there is reason to think that too great destruc-
tion can be effected even short of the production
of these danger signals and other safeguards, such
as not inserting the needles too deeply or permitting
the treatment to endure too long, should be kept
in mind. The duration necessary depends somewhat
upon the current strength, but with the meter regis-
tering from fifteen to forty milliamperes I have not
found it necessary to exceed from six to eight min-
utes for the devitalization of cartilage. The continental
authors mention fifteen to twenty-five minutes as
the duration of their seances, which would seem
unnecessarily long for a single insertion of the needle,
although I sometimes, in order to act upon a larger
area, make two insertions at one sitting, which must
then endure for about fifteen minutes.
I have accidentally made one small perforation out
of a total of sixteen cases treated by electrolysis. In
nearly this proportion they will likewise happen from
the surgical treatment. In this one case no appreciable
harm resulted, although I object on esthetic grounds to
perforations and think that all possible care should be
taken to avoid them. Beside, by encouraging incrus-
tation, they sometimes do occasion annoyance.
On the other hand, if one is too timid in the appli-
cation of the remedy, inserting the needle too super-
ficially, using too small a quantity of electricity and
for too brief a time, one will accomplish little or
nothing beyond occasioning a disagreeable inflamma-
tory reaction for a few days. Pain during the treat-
ment need be but trifling, but the sensation is pecu-
liarly disagreeable and tends to cause syncope. This
tendency might be avoided by making the application
in the recumbent position. My arrangements have
not been suitable for this.
As to whether large spurs or ledges of bone can be
resolved by this process of electrolysis opinions dif-
fer. My own experience is decidedly in the negative.
I have been unable to penetrate even by steel needles
the bony parts of spurs and failed to cause their
resolution, even when the needle could be forced into
approximate position. This experience is confirmed
by Newcomb,3 Chiari cited by Lowman,' and others.
On the other hand, Moure 5 and also Bresgen,6 lead us
to infer that they are successful with bony spurs, which
contention is confirmed by Ballinger,7 who, however,
fails to give particulars in this regard. Bone differs
3 Transactions of Am. Laryn. Assoc, 1895. p. 54.
* Transactions Am. Laryn. Assoc 1895, p. 50.
5 The Journal of Laryngology and Rhinology.
6 The Journal of Laryngology and Rhinology. January, 1895.
I The Journal or the American Medical Association, Jan. 11, 1896.
in degree of hardness and, also, it is quite conceiva-
ble that spurs, which consist chiefly of cartilage with
small spicula only of bone running through the cen-
ter, that in addition to the cartilage the bone, by
having the needles run into its immediate proximity,
may be devitalized; but large spurs which consist
chiefly of bone, often of iron-like hardness, will cer-
tainly resist this method.
I have treated by electrolysis sixteen cases, and
these may be classed in three types according to the
composition and location of the spur and the degree
of success attained. With the exception of a case
representative of each type they will be tabulated
without detail and with mention only of salient
features :
TYPE I. — STRICTLY CARTILAGINOUS SPURS.
Case 1. — Mr. H. H. C. M., somewhat advanced in years. He
complained of nasal stenosis and distinct paroxysmal asthmatic
symptoms. Examination disclosed hypertrophic rhinitis, con-
joined with a cartilaginous excrescence of the right side of the
septum, well in front and sufficiently large to approach the
collapsed ala. The galvano-cautery applied to the turbinated
bodies restored the patency of the left nostril, but on the right
side the spur interfered with the attainment of a perfect
result and the symptoms in part continued. Feb. 10, 1896,
electrolysis applied to the spur, thirty-five to forty milliam-
peres, for seven minutes. The result is very satisfactory. A
slight prominence farther back remains, but the space gained
by the reduction of the spur is adequate for comfortable
respiration. It could be wholly removed by a second applica-
tion, which, however, now seems unnecessary. He reports
entire freedom from asthmatic symptoms, disposition to ' 'colds' '
and nasal discomfort, and while this happy result can not be
wholly attributed to the reduction of the spur, that was an
essential part of the treatment. The case exemplifies a con-
siderable class of individuals, who if the less formidable
procedure of electrolysis were not utilized to reduce the excres-
cence, would continue indefinitely to bear with the discom-
forts incidental to the presence of a spur rather than undergo
the surgical treatment. The surface shows cicatricial mark-
ings, but mixed with natural mucosa and there is no annoy-
ance from crustation.
CaseS. — Mr. R., right nostril entirely occluded by a carti-
laginous spur Ave or six millimeters in thickness, which is
implanted upon a slight convexity of the quadrangular carti-
lage. Electrolysis, 40 milliamperes for eight minutes, when
the larger part of the spur had assumed a mottled bluish and
whitish aspect. The large slough separated in two weeks as a
whole. This is the case referred to above, in which a small per-
foration ensued. The result was otherwise satisfactory.
Case3. — Mr. A.G. M. The cartilaginous septum was deflected
to the right and in addition, situated toward the base of the
convexity was an excrescence which projected sufficiently for-
ward to approach the partially collapsed ala and so close the
nostril. Electrolysis was selected because of the nervous dis-
position of the patient, he having so little self-control that the
surgical method might have involved unusual difficulties.
Three treatments, fifteen to twenty-five milliamperes each, for
six minutes were given, special care being taken to avoid a
perforation. By the removal thus of the excrescence, the
deflection remaining, enough space was gained for comfortable
respiration.
Case 4, Mr. M. H. B., and Case 5, Mr. W. M., present few
features not already noted in connection with the others ; in
one somewhat advanced age, and in the other trial purposes
only were the reasons for the selection of this method. The
results were satisfactory in both.
TYPE II. — MIXED CARTILAGINOUS AND BONY SITUS.
Case 6. — Mr. L. C. C. This excrescence is of the kind
which commences anteriorly and runs upward and backward,
following the sutural line of the vomer and cartilaginous plate
of the septum, gathering volume and thickness and terminat-
ing opposite the middle turbinal or pressing into the middle
meatus, reaching quite across the nasal space. January 4 and
January 11, electrolysis to the anterior and middle segments
respectively by the bi-polar method, twenty to thirty milliam-
peres, for seven minutes each. January 18, mono-polar method
applied to the last and most prominent segment, a single steel
needle being used for greater penetrating power, this part of
the ridge being largely of bone and rather thin to accommo-
date double needles. The needle would not penetrate into the
I
1896. ]
ELECTROLYSIS.
581
depths of the ridge and consequently it was passed into its
cartilaginous surface. This treatment was much more painful
than the prevous bipolar applications, ten to fifteen milliam
pores only being tolerated for ten minutes. The final result
to satisfactory , the spur being much reduced in prominence,
the reduction in volume being probably commensurate with
the proportion of cartilage contained in it.
Cis, ,. Mr. M. J. H. and Case s", Mr. W. G. H., had
■purs similar in location and composition to the last described ;
in both of them the opportunity has been accorded to inspect
the parts a year after the cessation of treatment and in both
the degree of reduction of the spur and the amount of nasal
gained thereby was found to be greater than was antici-
pated. Evidently shrinkage continues until cicatrization is
iplete, for a period of several weeks at least.
Master (i. P., a youth with a similar spur, received
three treatments, bi polar method. It would seem that young
persona should be especially amenable to electrolysis on account
of the softer state of the bone.
I toe W. Mr. W. G. B. had had a spur removed by the sur-
gical method some years ago: between the bulge which had
redeveloped and the opposite inferior turbinal an adhesion had
formed. This was divided and space gained by making a gut-
ter like excavation through the bulge by electrolysis.
(Vise //. Miss E. P. is a bleeder, at least I was once com-
pelled to pack the nasopharynx to check hemorrhage after a
trifling operation for adenoids. Her spur of mixed cartilage
and bone has been reduced, not wholly removed by elec-
trolysis.
13. Master D. P., was a failure, because the patient
fainted and was slightly convulsed. I purpose using the sur-
gical method in his case.
Oase IS. I). C. ; presented no noteworthy features beyond
a fairly satisfactory result: and in one other (Case 14) of this
type tlie treatment is not yet completed, but the indications
point toward a partial reduction only.
4. Spur or excrescence, and not deviation of the
septum, is the subject of this paper. Electrolysis is
powerless to correct deviated septa of any form.
34 Washington Street, Chicago.
DISCUSSION.
TYPE III. — BONY SPURS.
Ctoea l'< and It; have previously been reported in detail.
They were large bony spurs of ivory-like hardness, into which
needles could not be made to penetrate and upon which elec-
trolysis made but slight impression. In all such I have since
recommended the surgical method.
( 'onclusions. — There is little occasion to modify
the opinion expressed in conclusion a year ago, that
while effective in many instances, its scope of appli-
cation should be limited in accordance with the fol-
lowing principles:
1. Strictly cartilaginous spurs can be thoroughly
removed by electrolysis; one, two, or even three
operative sittings being required. It is more tedious
and less brilliant than the surgical method, but it is
not accompanied by liability to hemorrhage. It is
pot to be indorsed as a universal substitute for the
surgical method in even this limited class, but it is a
serviceable measure for exceptional individuals of
both this type and Type n, e. g.: a. For quite small
spurs and thickened areas, b. For patients of delicate
physique and those of highly sensitive or uncontrol-
lable nervous organization, c. For "bleeders." d. For
those who decline the surgical method.
'2. As demonstrated by the cases reported under Type
II, it will not thoroughly remove spurs which belong to
that large class of mixed cartilaginous and bony sub-
stance; but it will reduce them in size. The majority
of such cases would therefore better be treated surgi-
cally, as being the more thorough method; but
instances will arise as above indicated in which the
surgical method being inexpedient, benefit may accrue
from the use of electrolysis.
3. As demonstrated by the cases reported under
Type in, large spurs composed mostly of hard bone
can not be successfully treated by electrolysis, for the
reason that needles can not be caused to penetrate
properly, and further, it is doubtful if the process is
adequate, even if the needles should penetrate, to the
resolution of hard and dense bone en masse.
Dr. John O. Roe, Rochester, N. Y. — The point that Dr.
Myles has made in regard to the. ill advised attempts fre-
'liiently made to enlarge the vestibule of the nose by cutting
out the interior of the passage, is well taken. This procedure
invariably results in decreasing the size of the opening instead
of enlarging it, for the reason that when a portion of the con-
striction is cut away, the circumference of the uncut portion is
correspondingly lessened, and when the cut edges become
coaptated during the process of healing, the lumen of the
passage is made smaller. The vestibule of the nose may
become narrowed by a variety of causes. In those cases in
which it is obstructed by an exostosis which we frequently find
in the floor of the vestibule, this exostosis should be removed
subcutaneously in order to leave the mucous' membrane
uninjured, thereby avoiding the contraction of the passage.
This is best done by making an incision in front of the emi-
nence down to the bone and raising the mucous membrane
together with the periosteum over the entire elevated portion
of the exostosis. By cutting through these tissues on the pos-
terior side they can be raised out of the way and the bony
growth removed either by drill or saw. When this is com-
pleted, the mucous membrane of the periosteum can be replaced,
leaving the passage of the nostril unobstructed. The vesti-
bule of the nose is often also very much narrowed by the col-
lapse or dropping inward of the ate of the nose from a weak-
ening or partial paresis of the dilator naris muscles, thus
allowing the ate to be drawn inward against the septum dur-
ing inspiration, thus increasing the obstruction to ingress of
air. I have removed this difficulty by making one or two inci-
sions through the cartilage of the ala, and inserting a dressing
into the nostril sufficiently large to distend the ate quite
widely until the cut made through the cartilage has become
firmly healed and fixed in this position, thereby maintaining
the nostril freely open and preventing the collapse of the ate
on inspiration. I was also much interested in Dr. Casselberry's
paper on the reduction of spurs of the nasal septum by elec-
trolysis, although I have never employed that method. I have
not done so for the reason that I have always disposed of spurs
and ridges of the nasal septum by what seems to me to be a
very much easier and simpler method — by simply cutting the
spur away. If the spur is located on the cartilaginous portion,
I employ a suitable small cartilage knife for its removal, and if
located on the osseous portion of the septum I remove it with
a saw or the Curtis drill. 1 have not attempted the more com-
plicated methods because my patients do not object to having
these obstructions removed in this manner. In the case of
removing a small enchondroma, it can be so easily and quickly
done with the knife that if the parts are thoroughly anes-
thetized with cocain the patient is neither alarmed nor incom-
moded by the operation, and sometimes scarcely realizes that
anything unusual is taking place. In regard to the danger of
denuding the parts of mucous membrane, I have never experi-
enced any difficulty in this respect after a cutting operation, if
but a limited portion of the membrane is removed. Even in
some cases where quite an extended area of mucous membrane
is removed, I have observed it from day to day spread over the
parts when maintained thoroughly aseptic, so that in a short
time the site of the operation, from the loss of the mucous
membrane, could not be perceived. After the use of the cau-
tery, however, I have observed extensive scars and areas in
which the mucous membrane had been replaced by fibrous
tissue, thereby causing much annoyance from the dryness of
the nose and the formation of scabs and crusts over the parts
582
NEW MEXICO AS A HEALTH RESORT.
[September 12,
in which there were no mucous glands to lubricate the part.
Dr. Max Thorner, Cincinnati, Ohio— I would like to refer
to Dr. Myles' paper. The obstruction of the nasal vestibule is
by all means the worst thing that can happen after operations.
In the operation advocated by Dr. Myles I think we have
means to prevent such occurrence. One case I had was that
of a young man who had been kicked on his nose by a mule,
and there was entire occlusion of the right nostril. I made
the incision and occlusion followed, and it was as bad as before,
if not worse. Later on I made a flap from the upper lip,
turned it upward into the nose and sewed it to the inner sur-
face of the ala nasi, after having loosened it from its adhesions.
Then I packed the nostril with iodoform gauze. The result
was not an ideal one, but the improvement was great and
permanent.
In regard to Dr. Casselberry's method, I have used it in
about eight or nine cases and my results and experience were
about the same as his. I use it only in cases where the
patients are timid and nervous. The current in Cincinnati is
stated to be about 110 volts, but it varies from 108 to 115. I
cut it down to eight volts, and use from three to six milli-
amperes. The apparent difference in strength of current used
by Dr. Casselberry and myself is that I use a different meter,
one made by Hirschman of Berlin, which is extremely deli-
cate and accurate. His whole apparatus is very reliable, no
shocks of any kind are experienced by the patient, as the
increase or decrease of strength of current is very gradual. A
water rheostat is used. My experience as to results corre-
sponds closely to that of Dr. Casselberry. Bony spurs are not
at all affected by it ; the best results are seen in soft cartilag-
inous excrescences. No pain is felt by the patients, although
in one case, that of a very nervous woman, peculiar, dizzy
sensations were complained of. Only the bi-polar method
should be used.
Dr. Hanau W. Loeb, St. Louis, Mo. — I was impressed with
the statement of Dr. Myles in regard to maintaining an open-
ing. I remember one case in which there was complete
stenosis as a result of smallpox ; there was complete adhe-
sion of both edges to the septum. To maintain the opening I
used two rubber tubes, which were made after the fashion
of Simrock's spectrum. These were worn without discomfort
for six months, later being worn only at night, and at present
there is a complete opening.
Dr. W. E. Casselberry, Chicago— I tried to make it plain
in my paper that it was not my custom to attempt to reduce
all spurs of the nasal septum or even all cartilaginous spurs
by the process of electrolysis ; that I selected the cases for
this method of treatment in accordance with the size, loca-
tion and composition of the spur and somewhat in accordance
with the degree or timidity or nervousness of the patient,
some cases objecting or being unsuited to the surgical
method. I was led to test electrolysis for two reasons : First,
on account of previous disagreeable experience from hemor-
rhage by the surgical method even in trivial cases, and second,
by the remarkable results that seemed to have been obtained
by Moure and others by electrolysis. I examined it to find
out what was in it, and I regard it as a useful addition to
my resources for the treatment of this class of cases, but by
no means worthy of exclusive reliance. Regarding secondary
hemorrhage, of course, it is possible, but I have not met with
it. Electrolysis should not be confused with galvano-cautery ;
they have nothing to do with each other and I do not use
them for the same purposes.
To Check a Sneeze or a Cough.— Dr. Brown Sequard, in one of
his lectures, said : " Sneezing can be stopped by pressing on
the nerve of the lips near the nose. Pressing on the top of the
mouth very hard is also a means of stopping coughing, and
many say the will alone has immense power."— Pop. Science
News, August.
NEW MEXICO AS A HEALTH RESORT.
Read in the Section on State Medicine, at the Forty-seventh Annual
Meeting of the American Medical Association at Atlanta,
Ga., May 5-8, 1896.
GEO. M. KELLOGG, A.M., M.D.
CHICAGO, ILL.
The Rocky Mountain region, especially the moun-
tains and the upland plains of New Mexico, is a land
lifted up by nature into the pure serene for the gen-
eral invigoration of the race. New Mexico belonging
to the Rocky Mountain crest, its eastern slope and a
larger portion of Arizona belonging to their western
slope, has perhaps, the most equable climate known.
There are no extremes of winter cold or of summer heat;
while there is a notable absence of dampness in air
and earth. Little moisture is left for this region
after the hot winds of the Southern Pacific are wrung
dry by the coast ranges. The elevation of this coun-
try from four to eight thousand feet is just sufficient
to prevent that oppressiveness of summer heat which
otherwise would be severely felt in these latitudes
from 32 to 37 degrees north. The winter months
throughout this region owing to the ever present sun-
shine, and the positive shelter of the mountains, afford
the most satisfactory retreats for invalids.
The purity of the air is shown by the absence of
atmospheric dust and disease germs. Its notable
clearness over the plains has been remarked for many
'years. Objects are clearly seen at great distances
which in ordinary atmospheres would be hidden by
fog and dust. The sun is visible nearly every day of
the year and often for months without a cloud-fleck
to obscure its radiance. The sun's heat is really
grateful instead of oppressive. The native when
enfeebled by illness or age basks in the sun. It is
the best medicine that he knows. It renews his youth
by renewing life at its springs. The invalid or vale-
tudinarian feels at once the mild stimulus. Simply
to breathe the air seems a luxury and a delight.
A noted peculiarity of this upland country is the
coolness of the nights, even in the extreme of summer.
The earth heated by the sunshine freely radiates its
surplus at night, there being no blanketing clouds to
intercept or confine. Uninterrupted and balmiest
sleep is thus insured, bringing healing on its wings,
while the absence of insects to torture is an addi-
tional security. It is certain, that change of climate
as a curative measure, promising though it be, requires
means in abundance to secure its best results. But,
as though nature were willing to bestow her best
resources, on the poor as well as the rich, the benefit
of this climate is open to all at a minimum of cost.
The least expensive structures afford ample security
and shelter at all seasons. Nourishing food can be
obtained on an average at its cost at our great popula-
tion centers. Fuel too, cheap and abundant, is largely
unnecessary where the sun's largess is so ever pres-
ent and grateful. Not, to mention the beautiful and
abundant building stone, the Mexican adobe houses
are delightfully cool in summer and warm in winter.
These can be made with materials at hand, or by
larger outlays, can be constructed as luxurious as could
be wished. Along the leading routes of travel such
might be conveniently located and nowhere be more
than an hour from skilled physicians and needed sup-
plies. While the elevations of New Mexico from four
to eight thousand feet all possess the same general cli-
matic features, each altitude has some especially desir-
able quality. The plains are more uniformly dry and
.
1896.]
NEW MEXICO AS A HEALTH RESORT.
583
their winters are less vigorous than in or near the
mountains. In all these sections the atmosphere has
the same characteristic clearness save for occasional
dust storms. The mountains catch the greater part of
the vain and snow, and furnish the chief water courses
and supplies for irrigation, etc. The summer rains
from duly 15 to September are chiefly seen in the
mountains and are usually transient. In the plains
they are much less frequent and there is an almost
entire absence of dew. Nature as though to confound
the wise, shows vegetable life in hundreds of native
species flourishing in the plains with wonderful health-
fullness, unvisited by mold fungus and vermin so inim-
ical to plant life in damp regions. The cryptogamous
plant world which elsewhere sends its spores and dis-
ease producing germs across the world is almost
unrepresented in the mountains and plains. Fungi,
mosses, terns, lichens and liverworts, which thrive so
signally in the damp and dark, find small encourage-
ment in the sunshine State. The experiments of Tyn-
dall to demonstrate the purity of the atmosphere in
Alpine glaciers can be repeated most satisfactorily in
the plains and foothills of the Rocky Mountains at an
elevation of from four to six thousand feet. At such
elevations in the plains putrescence is almost impossi-
ble. The ordinary ranchman knows he can, with
impunity, hang his venison or beef under a tree or
shed for weeks even in the summer. The manifold
vermin of the infusiorial and insect world are not
tempted to climb or fly to this region from their
eastern homes.
Most men believe that in the general upbuilding
and economy of the earth " some steadfast purpose
runs."
Have not these mountains been pushed up in accord-
ance with a plan which involves the general good of
the race. The genius of modern civilization may be
maritime, but that of the most ancient periods cer-
tainly was not. The early home of the Caucasian race
was in the uplands of Asia. The shepherds on the
oriental mountains studied and named the stars ages
before the first frail shallop was launched from the
shore. The early Phoenician navigator had learned
elsewhere to trust the stars before he ventured his
fortunes upon the waves. The Aztic and Peruvian
civilizations originated in the mountains and upland
plains of the western continent. It may well be that
those influences which led them to cultivate religion,
art and science in the early periods still remain as a
heritage to future mountain dwellers. History in
certain broad senses repeats itself. It is at least cer-
tain that nature has upreared these mountains in order
to diversify the conditions of mankind to vary their
industries, their resources and character. The physi-
cal well-being of the race as well as its moral and
intellectual nature, may here again find its highest
expression. It is certainly possible for such as can
not have the privilege in crowded and stifled cities to
live clean and healthful lives in our mountains. Even
in the most prolonged summer heats sunstroke is
unknown in New Mexico. Diseases associated with
malaria are excessively rare. Acute rheumatism,
pleursy and pneumonia seem only incident to special
and unnecessary exposures to cold night air and sub-
terranean damps peculiar to a miner's and cow-boy's
life.
The diseases for which the mountain climate may
be claimed as a prophylactic are first, those deadly
diseases of infancy, summer complaint and cholera
infantum. Abdominal disorders are rare. Typhoid
fevers are but feebly represented by the dreaded
" mountain fever," which is neither so deadly or com-
mon as those dreaded diseases are in the East. There
are some neuroses like chorea which seem to be aggra-
vated in this country.
I have observed among native New Mexicans that
heart disease, functional or organic, does not seem in
any respect more common than in the Mississippi
Valley and pursue much the same course. Pure neu-
ralgias seem positively benefited by this climate.
Tuberculous, bronchial consumption, and asthma are
most uncommon among the native population. Inva-
lids with lung disease seem often greatly relieved and
cured by simple residence. But, where the lungs are
riddled by disease and tied down by adhesions, the
very rarity of air becomes a great disadvantage. Such
cases are the great opprobrium of traveling patients
who succumb to the inevitable " heart failure" of
which so very many die before they reach a secure
haven. The striking feature of the mountain coun-
try is the diathermancy of the air. Less heat is
absorbed by the atmosphere than in lowlands. This
obviates in great measure the oppressiveness of the air.
Moreover, there is on this account an immediate and
gerat difference between temperatures in the sunshine
and in the shade. This difference has been calculated as
equal to 1 degree F. for every 230 feet vertical ascent.
This gives for elevations of 6,000 feet above 20 degrees
F. difference. But the effect of sunshine in the absence
of aqueous vapor in overcoming its direct depressing
influence is something for which there is no accurate
measure. Perhaps there is at the crest of the conti-
nent an electric or other earth aura which ameliorates
the sunshine and causes it to quicken the pulses of
life.
Statistics have proved that the West Indian islands
and the Gulf States are unfavorable for most lung dis-
eases and rheumatic fevers as well as abdominal dis-
orders, generally, being hot beds of malaria. The same
is true of the climate of India. The boasted climate
of Nice and Mentone save for a short period of the
year is found a signal failure. This is true of all the
islands of the Mediterranean. Except the parched land
of Egypt, no region has been admitted by English
authorities as especially favorable for lung trouble.
Egypt, however, is the home of the plague, cholera,
of abdominal disease, and ophthalmia and a thousand
discomforts. Great Britain in her ambition to possess
the world has accomplished one important matter at
least, though with great expense of life and treasure.
She has tested many climates by means of her army.
Her health and death rolls have established the
extreme unhealthfulness of Gibraltar, the islands or
shores of the Mediterranean, of the Black Sea, of India,
China, the valley of the Nile, the West Indies and
Central America and Demarara. Canada and Australia
and her own foggy shores have given the best returns
for salubrity as shown by England's army reports — a
sad record at best. The Kerghees steppes near the
Caspian, though below the sea level, owing to its dry
air has been observed like the valley of the Nile favor-
able for tuberculous disease. In the elevated plain of
Persia and Armenia, at elevations of about six thousand
feet, phthisis is much benefited.
In the Alps at St. Moritz, on the river Inn in the
valley of the upper Engadine are spas and winter
cures where some happy results are experienced, des-
pite harsh air and inclemency.
584
ALCOHOL OR NO ALCOHOL IN TYPHOID FEVER. [September 12,
The elevated plains of Anahuac in Mexico have borne
for several centuries a reputation for salubrity. The
plain of Quito directly under the equator, at an
elevation of nearly nine thousand feet, has a well
established claim for general healthfulness, as also
have Montana, Potosi and still greater elevations.
New Mexico, with its clear dry air, affords a great
contrast to many mountain regions, in particular to
the Alps. These, placed between near and sharply
contrasted seas — the superheated Mediterranean, the
fierce, cold Baltic and the storm swept Atlantic have
ever been the cradle of climatic excess. The moun-
tain tops are eternally capped with snow and glaciers;
their valleys are the hot beds of miasm and dampness,
where consumption and cretinism prevail. The cold
sides of the Alps are to-day, however, lined with
hotels and pensions for invalids, who try to imagine
themselves benefited by gazing on ice-clad peaks and
mountain torrents. There is this to proclaim, and it
is of higher importance than the story of matchless
fertility, or of hills seamed through with the precious
metals. In the Rocky mountains there is an area of
1,000 by 300 miles with a climate the most serene and
invigorating of all that have been tested or in any
proper manner demonstrated.
ALCOHOL OR NO ALCOHOL IN THE TREAT-
MENT OP TYPHOID FEVER.
Bead in the Section on State Medicine, at the Forty-seventh
Annual Meeting of the American Medical Association,
held at Atlanta. Ga.. May 5-8, 1896.
BY J. B. GARBER, M.D.
DUNKIRK, IND.
There is no disease in the entire catalogue of human
ailments that is of more concern to both the physi-
cian and the patient than that of typhoid fever. It
attacks the young, the old, the rich, the poor, the
high, the low, the monarch and the slave, and while
the disease has a special fondness for certain ages and
conditions yet none are exempt even after having once
had an attack.
It is found on the mountain top and in the valley,
and an epidemic may begin on the mountain top and
spend its force in the valley as was the case in the
noted "Plymouth epidemic." It is both epidemic
and endemic, and no physician who engages in the
general practice of medicine will continue long ere
he comes face to face with this dreaded destroyer of
family ties and human comfort.
The diagnosis and symptoms of the disease have
been studied and discussed since the dawning of the
present century. Since the year 1813 it has been
recognized as a distinct ailment, and in the year 1829
Louis gave it a name, but even then it was supposed,
as its name indicates, to be a milder form of typhus;
and not until nearly twenty years later was a differ-
ential diagnosis made; finally, in the year 1880 the
bacillus typhosus was discovered and since that time
we have been trying to obtain a remedy or plan of
treatment that will destroy the germ without destroy-
ing the host. As to the medical treatment of the
disease you will no doubt hear enough before this
meeting closes to convince you that it is still unset-
tled and as to whether it can be aborted or not I
leave for others to discuss, especially those who are
engaged in this line of work. But there is another
side of this question, and that is the sustaining of
the vital forces while the disease is in progress.
It is the steering of the ship through the storm that
marks the successful mariner. The successful guide is
he who avoids all dangerous routes. Likewise the
practitioner is judged by the result of his work ; his rate
of mortality is what marks the successful physician
and especially is this true in the treatment of typhoid
fever. We believe sustaining the vitality of the
patient is of as much importance as the medical
treatment of the pathologic conditions present; also
that any agent which contributes to this end is a great
aid in the successful management of a case.
What influence does alcohol have in thus sustain-
ing the vital forces of the patient through this trying
ordeal? Let us first refer to some of our authors and
notice briefly their teachings on this subject. Von
Ziemssen, in an article which appeared in the Asso-
ciation Journal of 1887, closes by saying, "It is
better to give too much alcohol than too little."
Another able writer in the Medical Press and Circu-
lar of 1887 says: "A very important point in the
treatment of typhoid fever consists in the administra-
tion of alcohol. When we have a long continued
febrile process it is requisite and necessary to give
wine in all cases, without exceptions, from the first."
The same author tells of the enormous amount that
may be taken even by those who are not accustomed
to its use. Another wiiter of the same year says, "In
the treatment of typhoid in children, for food, give
bouillon, barley water, lemonade and milk, and if
there is much prostration alcohol and extract of bark."
These are only a few quotations showing the teach-
ings of the last decade and we will hastily pass to the
instruction given in our latest text-books.
Dr. Osier, in his first edition, 1892, says : "Alcohol
is not necessary in all cases, but may be given when
the weakness is marked, the fever high and the pulse
failing." In his latest edition, 1895, the same lan-
guage is used, showing no change in the author's
opinion, or an oversight in revision.
Professor Whitaker, in his "Practice," tells us that
"alcohol is the best whip for a flagging heart, in a mild
case in the form of wine, in a severe case in the form
of whisky and in the most protracted cases the alcohol
should be given in the form of brandy." He also
says: "A threatened collapse may be bridged over by
a cup of black coffee with a teasp&onful of cognac,"
and closes the paragraph by informing us that nitro-
glycerin, 1-100 in doses of 3 drops in whisky is one
of the most powerful agents we possess.
Bartholow, in the last edition of his "Materia Medica
and Therapeutics," after discussing the subject of
alcohol at some length, closes by saying: "The chief
utility of alcohol in these diseases [referring to fevers
and other depressing maladies] is not as a stimulant
but as a food. It furnishes material, easily oxidizable,
which can be applied as nervous, muscular and gland
force," and then says, "it should be given with milk,
eggs, broth and other suitable aliment." The same
author says that the action of alcohol on the nervous
system is that of a narcotic.
With such indefinite statements as to the action
and use of so potent an agent as alcohol on the system
is it any surprise that the mortality runs from 10 to
30 per cent? In reference to the medical properties
of alcohol there is a difference of opinion. It may be
germicidal, but this property can not be utilized in
the treatment of typhoid fever. So we come at once
to the question of greatest importance. Is alcohol a
food and does it assist in tiding the patient over a
crisis.
1896. !
DISCUSSION.
585
A food as defined by Dr. Chapman in his "Physi-
ology." is any substance, inorganic or organic, solid
or liquid, that will nourish the body and renew the
material destroyed in producing the phenomena of
life. The same author says that alcohol can be of
no benefit to the system, for it is found as such in the
organs untransformed or is excreted unchanged;
hence, it can not supply any want by simply passing
rough the system and if it is burned up it must
tert'ere with the oxidization of other substances,
such as tat. etc. He further states that alcohol dimin-
ishes the amount of urea excreted and the action of
the skin, interfering with natural combustion, thus
preventing the whole nutrition of the body; and then
closes by stating that as a medicine it is indispensable.
This alcohol is a peculiar drug; it has been found
in the brain unchanged, excreted likewise, yet as a
medicine is indispensable. What medical property
has it that can be made use of with benefit to the
patient of typhoid fever?
.Methinks I hear some one answer, "a food to nourish
the patient;" another, "antipyretic to reduce the
fever:" ami still another, "a stimulant to tide over the
crisis, to whip the lagging heart." Does it rest or
strengthen a tired horse to whip him into a trot?
Alcohol has a paralyzing influence and all the effects
of its use. which seem to be the result of stimulation,
can be shown to be those of paralysis. The first
effect of alcohol on the brain is that of paralysis and
affects the faculty of reason, and as Bunge says, "the
emotional life is brought into free play unhampered
by the guiding strings of reason." The same author
states that another paralytic symptom which is erro-
neously regarded as one of stimulation is found in
the deadening of the sense of fatigue.
Dr. Kellogg, in an excellent paper published in
the December Bulletin, after reviewing the physiologic
relations of alcohol as set forth by Professor Bunge,
closes with the following language: "In view of such
testimony as this how is it possible for anyone still
to maintain the old error born of the ignorant and
pernicious idea that alcohol is a food, a tonic, a stim-
ulant, a rejuvenant and a conservator of energy. It
would seem to be time that physicians were consider-
ing this question of the medical use of alcohol seri-
ously and conforming their practice to the facts of
science instead of the traditions of our medical fore-
fathers and the formulas of obsolete text-books."
How is it to-day with the young doctor as he leaves
his alma mater, his diploma under his arm ? Among
many other delusions and theories that fill his mind
is one that alcohol is useful in all diseases and condi-
tions, from the bite of the poisonous snake to puer-
peral hemorrhage. In one pocket he carries a dose
book containing a list of poisons and their antidotes,
and perchance a copy of the code of ethics. In the
other his medicine case filled with tablets and tritu-
rates of all kinds, from nitroglycerin to sulphate
magnesia. I have wondered why some enterprising
drug company did not make tablets of alcohol. How
convenient they would be. Thus armed, the young
disci pie of Esculapius goes to the field of battle. It
is not long till this young soldier comes in contact
with a case of typhoid fever. The symptoms are not
just like those described in the books or heard in the
lecture room, but while he is waiting for something
to happen the patient passes into the second week of
the disease. By this time the symptoms are more
marked and by exclusion a diagnosis is made and
time is hastening us into the third week, which is one
of debility and depression, and the first thing thought
of is alcohol, which is given freely. If it is well
mixed or alternated with suitable nourishment the
case may terminate favorably; if not the alcohol only
hastens the end.
We believe the mortality from typhoid fever has
been gradually lowering, and no doubt is due in a
great measure to the non-use of alcohol in the treat-
ment of the disease. There is hardly a week passes
that some of our journals do not report a series of
cases treated without the aid of alcohol in any form.
I used alcohol in the treatment of the disease until
two years ago, when I became alarmed at the mor-
tality, bo I changed my plan and in 1894 I treated
thirty-seven well-marked cases of varying degrees of
intensity. I had two fatal cases, and in both of
them I had used alcohol. In 1895 I treated thirty
cases of about the same type with no death. I only
used alcohol in one of them and it caused me more
trouble than any of the others. As this case was
in the family of a saloon-keeper I could not con-
trol the matter, and they would give it during my
absence. On my return I would find the face
flushed, the temperature high, the pulse rapid and
the patient nervous. By close inquiry I would find
that some of the family had given just a little good
whisky, which had been in the house for twenty
years.
In closing, I wish to state I am well convinced that
in the treatment of typhoid fever our patients will do
better and stand a better chance of recovery if we
abstain entirely from the use of alcohol in the treat-
ment of the disease.
DISCUSSION.
Dr. J. N. Quimby — It can not be said that the author of
this paper is at all prejudiced. He has tried the alcoholic
treatment thoroughly. I have also tried the use of it. I grew
up at a time when it was regarded as a panacea for all the ills
that flesh was heir to. It was a food, a stimulant and a nerve
supporter. It was just after the attention of the world was
drawn to Liebig, who made the fatal mistake of thinking that
because it had a certain amount of carbon it supplied what
was needed in the body, when, in fact, it is no carbon. We
started with the mistaken idea that alcohol was a stimulant
and supported the body ; that it would act as a powerful
nutrient to the blood, but that it must not act as an anes-
thetic. It is impossible for anything to act as food when it
acts as a narcotic. We have been using it because our fore-
fathers recommended it. We did not take the trouble to
analyze and see what it was. A valuable example is that of
the soldier (Martin) wounded in the abdomen, the wound
healed but the aperture remained open. Through this a physi-
cian was able to study the process of digestion. Whenever he
used alcohol in any form it always interfered with digestion.
There are the practical tests of Summerville, Richardson and
thousands of others that have been made, and notwithstand-
ing that fact, the majority of the medical profession continue
to use alcohol as though it was food, stimulant and supporter
of the basal nerves, when, in fact, those who have paid atten-
tion to the matter have concluded that it is neither one or the
other, and yet, if you give a small dose it interferes with diges-
tion, because it precipitates the pepsin of the gastric, and any-
thing that does that is not a supporter. For the last twenty
years 1 have not used a drop of alcohol. Give a certain
amount of nourishment but do not destroy that with alcohol.
In my cases there is generally a higher rate of cures than of
those who use alcohol. I was once called in consultation over
a very old gentleman, to whom the physician was giving alcohol,
586
DISCUSSION.
[September 12,
a glass of champagne and one ounce of brandy. I decided
that he had an uncertain pulse. It seemed to have a better
volume, and I took into consideration that he was soothed with
alcohol. You know 5 per cent, is a large portion. It is dan-
gerous to introduce 10 per cent. Notwithstanding all the
stimulants the patient died. I believe he died from alcoholism
rather than typhoid fever. I give this as an example where we
are making a grave mistake in using alcohol, because we know
it is a narcotic, it paralyzes the mind and muscles. To admin-
ister it as a heart tonic will do more harm than good, because
it is not a heart tonic but a narcotic.
Dr. McDaniel of Alabama — I have some knowledge of this
subject of alcohol, as we all have of every remedy we use. A
man of my years has frequently heard these conflicting views
and has witnessed the results as claimed of the different
remedies. I do not wish to controvert nor yet to advocate
what has been said here on the subject ; my object is to enter
a protest against extremism. I look upon alcohol as an anes-
thetic, and I believe is a fertilizer of the basal nerves. Illus-
tration is one of the most powerful arguments brought into
discussion. We are asked, what effect does alcohol have upon
the vital actions and the functions of the body in health or
disease? Suppose I take a small alcohol lamp and put a match
to the wick. The first thing I know the alcohol is burned up.
There has been some heat generated when the alcohol was
burning and when the small wick was burning out. If we
give alcohol to the patient it comes up to the capillaries of the
lungs, which we call the wick of the human lamp. It keeps
up the temperature of the failing, feeble patient. If he is dis-
posed to get cold, if he verges beyond the stage which you
describe, I think you have witnessed that this supplementary
food was of some use. I don't believe we understand theories
fundamentally enough to base an exclusive dogma on the
action of experiments ; but when I see the results on patients
in typhoid fever I know something about the action of alcohol.
I was once extremely prostrated with typhoid fever. A friend
gave me sweetened water with cognac brandy and nutmeg
grated over it. My nerves were all unstrung and I was toss-
ing from side to side ; but in fifteen minutes my nerves were
quiet and easy. I have tried stimulants hundreds of times in
that nervous condition of the system, and I know no other
nerve tonic which can equal it. It will produce perspiration
in a dry, raspy skin, and will produce sleep where there is
insomnia. I know that alcohol does good sometimes. There
are two sides to this question and we should not go to either
extreme. Let us say it does have an important function. If
you experiment upon yourself and are benefited by the use of
alcohol, it is the alcohol which makes you feel so much better.
Dr. Quimby — I admit there is always apparently some bene-
fit to be derived, but the point is, if alcohol has done so much
good, which we admit to a certain extent, if it has saved one
life, for that life it has saved I can cite over one hundred
which it has destroyed. Therefore it can be treated on the
practical point that there can not be found a case where
alcohol will do for which other remedies may not be substi-
tuted that will do better. You hesitate about giving opium
for fear of the danger that will result from the appetite created
for it, and yet you prescribe alcohol. When you look over this
broad land and see how many homes are beggared, how many
graves filled from want, destruction and disease, and realize
that this is done by the use of alcohol to a very large extent,
I say if we possibly can avoid it, let us do so. There is
much to be learned in reference to alcohol. It is not only
injurious, but creates comment among the laity regarding the
medical profession ; then, too, there is the condition which the
poisonous element of alcohol leaves one in. We have a double
poison, that of alcohol and by urea. It prevents the destruc-
tion of tissue which ought to come out of the body. If not
cleared of the poison that the system secretes daily, you are
sure to suffer from the effects of it. We have also much to
learn in reference to the modus operandi of alcohol. It creates
within the body an irregular form of appetite and habit. For
these and countless other reasons we should make use of the
many remedies which can accomplish all and more than the
good resulting from the use of alcohol without its baleful effects,
Dr. Hibberd — It has been stated that a stimulant was om
which was founded on nutrition. Is that true? Is not a stim
ulant something which renews strength in the tired organ
and alcohol that which spurs them on to renewed activity?
Depression comes simply because the active agents have been
overtaxed ; but there is that corresponding rest in depres-
sion until it shall recover the average strength. I think this
definition of a stimulant is incorrect.
Dr. Kober — It seems to me the Doctor's statement is
somewhat misleading as to the effects of alcohol on the sys-
tem. It is very difficult to understand that alcohol produces
a paralyzing effect upon the heart muscle, when we all have
seen the stimulating effects of a greater or less quantity of
alcohol. The statement was made that it interferes very
seriously with urea elimination. This may be the case in
advanced stages of Bright' s disease, but is certainly not the
usual effect of alcohol. It has a stimulating effect on the kid-
neys. In regard to the particular effect of alcohol, the Doctor
made a statement that whenever 10 per cent, of alcohol was
taken in the blood it would prove destructive. That may be
so, but I am inclined to think that he is confused in hii
ideas in regard to the operations that are going on in tb
stomach.
Dr. Cochran — I am only going to express my gratification
that alcohol has found some friends in this section of the
American Medical Association. I think all of those books
are unscientific and based upon indirect information. I recog-
nize fully the value of alcohol. I can say it has been a bless-
ing to the human race and so far as I am concerned, am sure
that I would not be alive but for it. We should not allow
personal prejudice too much latitude. As to killing people, I
suppose it does ; but how much time and alcohol does it
require? As to destruction of property, it probably makes
some people poor, but that is caused by abuse and not the
use of alcohol. To combat that theory is the apparent benefit
with which it is almost universally used. The most prominent,
the wealthiest and most successful men use alcohol apparently
with good results. When General Booth made the celebrated
investigation into the causes of pauperism in East London,
which cost many thousands of dollars and filled two or three
volumes, he found that only 13 per cent, of the pauperism of
East London was traceable to inebriety. There are many
things connected with alcohol in the system that we do no
know. I feel that the fact that it has always been used is a
sufficient reason for its having some valuable qualities.
Dr. Garber — I do not wish the Society to understand that
I am an extremist on this question, I simply wish to learn, and
have been much benefited by the suggestions ; there are a
few things which have been said that I think should be
referred to. In fact, some have drifted away from the sub-
ject and discussed the question from the moral standpoint. I
did not refer to that in the paper. I believe that the trouble
originates greatly from the teachings of the text-books. They
teach that it is necessary in all of these cases. One brother
has spoken of it saving his life in typhoid fever. I think under
the same conditions hot water with some ordinary stimulant
would have had the same result. The last gentleman on the
floor has made the statement that most of the successful men
have been in the habit of drinking. I would refer to Rocke-
feller, and Daniel of Ohio, as well as many others who are
strictly temperate and yet have attained great success and
achieved some prominence. He also spoke of the pauperism of
East London. I have been connected with the Ohio Peniten-
i
896.]
TRANSFUSION, INFUSION AND ANTO-TRANSFUSION.
587
tian in an official capacity and the result of my observation is
that 70 per cent, of 1,940 convicts come there directly or indi-
rectly from the use of alcohol. I mention that as regarding
the moral side of the question which I have heretofore avoided
discussing. One gentleman used the burning of an alcohol
lamp as an illustration ; on the same principle why not use gas-
olin or make a decoction of coal products and other things
we use outside of the body, for oxidization. I do not believe
alcohol can be oxidized in the system. It can be burned out-
side. We would not think of inhaling natural gas because we
use it for illuminating purposes. A few inhalations would
satisfy us. 1 think. I have followed it with much interest,
but 1 yet believe it is a bad thing to use alcohol in the treat-
ment of typhoid fever.
TRANSFUSION, INFUSION AND ANTO-
TRANSFUSION; THEIR COMPARA-
TIVE MERITS AND INDICATIONS.
Head before the Kentucky State Medloal Society.
BY AUGUST SCHACHNER, M.D., PH.G.
DEMONSTRATOR OF ANATOMY LOl ISVILLE MEDICAL COLLEGE; VISITING
SURGEON LODISVILLE CITY HOSPITAL.
LOUISVILLE. KY.
Whenever a number of measures of a more or less
varied ami changeable character are advanced for the
fulfillment of a long existing demand, it means an
absence of unity in the selection of the proper measure
and a general distrust in a satisfactory adjustment of
the demand. This is clearly illustrated by the number
of procedures that from time to time have been recom-
mended to overcome the depressing and even fatal
condition following enormous hemorrhages.
The fact that the operation of transfusion is but
rarely performed at the present time, and that of infu-
sion faring but little better, tempted me to refreshen
the subject somewhat more than a month ago before
one of our local societies. Since that time I have
been impressed more than ever with the neglect to
which these operations have been subjected and the
importance of bringing them before the eyes of those
engaged in operative work.
1 may be pardoned for borrowing from my former
paper the historic outlines in connection with the
development of these minor operative procedures.
The first intimation of transfusion can be found in
the 833d and 334th verses of the seventh book of
< kid's Metamorphoses, "Veteremque haurite cruorem
Ut repleam vacuas juvenili sanguine venas." This
carries us back to the time of Christ, and from then
down to the present period: "a long but unbroken
chain can be traced running through the Hebraic and
Egyptian medical records." In 1492, or more than a
hundred years before the circulation was understood,
Pope Innocent VIII. was struggling with his last ill-
ness. He was attended by a Jewish physician who,
it is supposed, was prompted by the idea noted in the
verses of Ovid and performed transfusion with the
blood taken from three Roman youths. In 1615
Andreas Libavious, of Halle, wrote an article upon a
charlatan who is supposed to have performed trans-
fusion. In 1628 another appeared under the author-
ship of Johann Colle; coupled with these came the
discovery of the circulation by Harvey, which was
directly responsible for the vigorous attention which
the learned men at that time gave to the subject.
In 1652 an apparatus for arterio-venous transfusion
was contrived by Folli, of Italy. In 1666, Richard
Lower drained a good sized dog by tapping the jugu-
lar vein. When the animal was exhausted he filled
the vessels with blood drawn from a cervical artery of
a second dog until the animal had recovered; he then
drained the same animal a second time and again
filled his arterial system with blood from a third dog,
thus completely changing the blood twice in the same
animal without any unfavorable consequences. This
represents the first well-authenticated experimental
maneuver made in the direction of transfusion.
This aroused an interest in the Royal Philosophical
Society, and it was then believed that a remedy had
been discovered which was not only capable of curing
disease but by means of which the aged could be
transformed to the youthful and the immoral could
be changed to the moral. So strong was the belief
in the latter, that a trial was actually undertaken by
Lower and King.
At that time a religious fanatic by the name of
Arthur B-oga, 30 years old, offered himself in consid-
eration of a guinea as willing to undergo the experi-
ment, which was conducted, in the presence of the
Bishop of Salisbury and a large and brilliant audi-
ence, by Lower and King. Six to seven ounces were
withdrawn and ten ounces of arterial blood from a
sheep was injected. This operation was again suc-
cessfully performed on the twelfth of December of
the same year by the same operators.
It must be noted, however, that these experiments
were preceded by others performed by Jean Dennis
and Emmerez in Paris in the year of 1667, and to
whom the honor of the first successful transfusion in
a human subject is due. Dennis employed the blood
of a lamb, and several times repeated the operation
upon several different subjects with almost uniform
success, so far as the transfusion was concerned.
These operations aroused a vigorous and jealous oppo-
sition in Germany, France and Italy, and were partly
terminated when Dennis narrowly escaped a trap that
had been set for him, but notwithstanding his inno-
cence, it had involved him in a criminal case.
From this time enthusiasm began to lag and mat-
ters continued with a varied interest until 1818, when
James Blundell, the obstetrician, placed transfusion
upon a scientific basis, at the same time giving a
method for its correct performance. To Blundell is
likewise due the honor of first employing human
blood instead of that of lower animals for the trans-
fusion. With this the history of transfusion can be
dismissed. In parting we might add that there are
but few procedures known to medicine whose his-
tories are more replete with incidents that are as
varied, interesting, pathetic and amusing as the his-
tory of transfusion.
Before entering upon the subject of transfusion, it
is well to glance at the conditions which are produced
by the loss of large quantities of blood.
In dangerous hemorrhages death may ensue from
one of two causes, i. e., either from the absolute loss
of blood itself or from a fatal reduction of the intra-
vascular pressure. In the first instance, the amount
of blood is insufficient to meet the demands necessary
for the sustenance of life. This makes the case
unmistakably clear, and the indications are more
blood, or death must ensue. In these cases nothing
short of transfusion will fulfill the requirement; for-
tunately, however, these constitute the minority. In
the majority of cases the death following hemor-
rhage is not due to the direct loss of blood itself, but
rather to a disturbance in the mechanism of the cir-
588
TRANSFUSION, INFUSION AND ANTO-TEANSFUSION. [September 12,
culation. Let us glance at the physiology of the cir-
culation.
Two factors must be considered : First and fore-
most, the force of the heart, and second, the elasticity
and contractibility of the arteries. If the heart has
an insufficient volume of blood, or perhaps more
properly speaking, volume of fluid, for blood is not
absolutely necessary for this feature, there is an irreg-
ularity in its contractions and a serious crippling in
the proper working of its valves, and in consequence
we have a condition at once produced which for the
time being, can be compared to the worst variety of
valve lesion, so that the heart not only fails in send-
ing out the required amount for nutrition, but also for
the closure of the valves. Aside from this, the
amount of blood sent out is not sufficient to produce
the necessary dilatation by means of which the elastic
nature of the large arteries are enabled to propel the
force of the heart to the more distant parts of the
body.
When this state of affairs exists, the indication for
an increase of the intravascular pressure is equally
plain and the requirement then is more fluid; whether
that be blood or salt solution is immaterial.
TRANSFUSION.
By transfusion we mean the injection of the blood
of one individual into the vessels of another. Al-
though this operation has been variously designated
by different writers as both safe and unsafe, there can
be no doubt that in the hands of a careful operator,
all possible elements of danger can readily be elimi-
nated.
Indications. — From the history of transfusion it is
apparent that formerly its range of application was
far more extensive than its merits justified, and in
view of this state of affairs the disappointments natu-
rally were quite frequent. This largely aided in rele-
gating it to the disuse to which it was subjected. At
present any factor may serve as an indication for
transfusion, which reduces the quantity of the blood
so that the remaining volume is unable either by rea-
son of the reduction, or incapable by reason of any
alteration to which it may have been subjected, to
carry on the functions necessary for the sustenance of
life. The principal conditions which such a state-
ment would comprise, would be either an acute
anemia, dependent upon an extensive hemorrhage, or
a paralyzation of the oxygen carrying power of the
red corpuscles, carbonic oxid, or other similarly toxic
gases. We would still scarcely regard such conditions
as morphin or atropin poisoning, leukemia, chlorosis
and a host of other pathologic states as justifiable
indications for the employment of transfusion.
Modus operandi. — There are a few practical feat-
ures in connection with the operation of transfusion
which deserves special attention. During the cholera
epidemic of 1866, Von Graefe raised the question as
to whether the centrifugal should be given the prefer-
ence over the centripetal method ? Whether it would
be better to inject the blood into the arteries rather
than into the veins? The advantage urged in sup-
port of the centrifugal method was that since the
capillaries intervened between the arteries and veins,
the blood in its passage through the capillaries was
subjected, as it were, to the influence of a strainer
which safely withheld any air or emboli which might
be present in the transfused blood. The arteries
which were employed were either the radial, tibial or
even perhaps the brachial. Although this method
has the endorsement of Billroth, Landois, Heuter
and others, it has likewise many very able opponents
who have pointed to the force necessary for the cen-
trifugal method which not infrequently resulted in a
rupture of the capillaries with accompanying gangre-
nous conditions.
Another question to be decided is whether or not
the blood should be defibrinated and whether we
should select the venous or the arterial blood? Refer-
ring to the former of these two questions, we are safe
to say that the verdict is almost unanimously in favor
of the defibrinated blood. It has been said that the
integrity of the corpuscle is considerably affected by
the defibrination of the blood, but this is somewhat
problematic. However, the dangers of a partial or an
entire coagulation which attended the use of non-
defibrinated blood, fully justifies the defibrination.
As to the second question, there are reasons why
the venous blood is to be preferred to the arterial,
namely, the veins are more accessible than the arte-
ries. The tapping of a vein is simpler and is attended
with less subsequent dangers than accompanies the
opening of an artery, besides the blood, although
venous in character, rapidly becomes arterialized dur-
ing the act of defibrination. In addition to these we
might ask, should the transfusion be direct or indi-
rect, i. e., should the blood pass directly from the ves-
sels of the donor into the vessels of the receiver with-
out any exposure to air? To this we are inclined to
say that we believe it to be far safer to employ the
indirect method.
The extreme tendency on the part of the blood to
coagulation, and the grave result which attends the
introduction of even a minute embolus, not to speak
of the chances of the introduction of air, even at the
hands of a careful operator, makes us unhesitatingly
declare in favor of the indirect method.
Should the transfusion be undertaken for the relief
of a poisoned condition of the blood, such as results
from the exposure to carbonic oxid gas, the individ-
ual should be subjected to venesection before the
transfusion is undertaken. In the performance of
the operation no elaborate outlay of instruments is
necessary. Two or three bowls, a reversible aspirator,
a glass rod and a scalpel, all of which being in a per-
fectly aseptic state, will fill the requirements. Every-
thing in connection with the operation must not only
be perfectly aseptic but must be heated to 105 or 110
degrees F. When all is in readiness, the blood is
withdrawn from the arms of one or two donors into
one of the aseptic bowls, the amount varying from
five to fifteen ounces, according to the circumstances
of the case. It is rapidly defibrinated by whipping it
with a glass rod and then straining through a piece of
sterile gauze into an aseptic bowl. This whipping
may be carried out for a minute and a half before
straining, but still better is to whip for a minute and
strain whipping, whipping it a second time and again
straining through a fresh piece of gauze. The actual
operation must be performed within ' two or three
minutes, and the greatest care must be exercised that
all of the air has been forced out of the syringe and
tube before the injection is commenced.
Dangers of transfusion. — The possible dangers
that may attend the operation of transfusion are :
Phlebitis, sepsis, embolus and the introduction of air
into the veins; all of these can be readily eliminated,
if the operator exercises care in the transfusion.
1896.]
TRANSFUSION, INFUSION AND ANTO-TRANSFUSION.
589
INFUSION.
By infusion we understand the introduction of non-
Banguineous fluids into the circulation. Although
the popularity of this measure is but of recent date
it- real history, however, can be traced as far back as
the year 1677, when Johannes de Muralto of Zurich
practiced the injection of milk into the vessels of one
of the lower animals. The term infusion, however,
as applied to-day carries with it the idea of a salt
solution having the same strength as the serum of the
blood. The advantages of this operation over that of
transfusion are manifold, especially since death, in
the majority of instances, is not due as much to the
insufficiency of the remaining quantity of blood as it
is to a disturbance of the mechanism of the circula-
tion. By the use of the salt solution the dangers
common to transfusion are all minimized and espec-
ially the dangers from emboli are entirely absent.
This widens the field of its usefulness so that the
indications for its use are not wholly confined to con-
ditions following alarming hemorrhages, but include
any pathologic state attended with a feeble pulse
which is dependent upon a diminution of the intra-
vascular pressure which makes it one of our most
valuable measures for combating profound shock.
This property of restoring the tone of the circula-
tion in a condition of shock is not entirely due to the
increased intravascular pressure, but also due to the
stimulating influence which the salt solution has upon
the heart. This fact, however, has not received the
recognition which it deserved, for it has been but a
little more than a decade since it has practically
received any attention.
In the year 1881, transfusion lost most of its esteem
as a life saving measure in alarming hemorrhages.
At this time E. Schwartz published his paper, "Ueber
den Werth der Infusion Alkalischer Kochsalz Losung
in das Uefass System bei Acutes Anemie." From
this time the adherents to transfusion have been
abandoning it in favor of infusion, not that the latter
can ever completely replace the former in every case,
but because it can successfully replace transfusion in
most cases, and where such is possible it is always
given the preference, owing to its greater safety and
convenience. In view of these advantages, it is proper
that we employ the saline infusion in all alarming
hemorrhages.
This operation is uniformly followed by an improve-
ment in the circulation. Should, however, the im-
provement in the circulation last but a brief interval,
it is plain that the amount of blood remaining is
incapable of carrying on the condition necessary for
life and then it is evident that transfusion must be
performed in addition to infusion.
In addition, it has been pointed out by other authors
that the saline infusion protects the internal organs
from a too rapid and extensive abstraction of their
parenchymatous fluids, which nearly always occurs
after an extensive hemorrhage.
By saline infusion we mean the injection of a solu-
tion of sodium chlorid having the same strength as
the serum of the blood (0.6 per cent.) into the veins
of the bloodless subject. Some add to this a trace of
sodium hydrate or sodium carbonate, while others
contend that this addition is unnecessary anil that
should either the carbonate or hydrate exist in propor-
tion of more than a trace, their presence would become
positively injurious. Again, others dissolve the salt
in a weak saccharin solution, or the infusion has been
successfully carried out by Thomas and others with
pure fresh milk.
As for the proper performance of infusion, there
are beveral features to be observed. First of all, the
solution should have a temperature of about 100
degrees F. The infusion must be made with a slow,
steady and not too strong a stream. Ordinarily,
sufficient force is obtained by raising the funnel or
the vessel containing the solution to the height of an
ordinary arm's length ; should this convey the solution
with too much force, the latter can easily be regulated
by lowering the container to the desired level. The
quantity to be employed must depend upon the nature
of the case. It is not necessary in every instance to
employ as much solution as the amount of blood lost;
all that is required is to inject just enough of the sol-
ution to restore the tone of the circulation. Ordin-
arily twelve to fifteen ounces can be considered as the
minimum quantity to be used for ordinary purposes,
but from twenty to twenty-five ounces may be used in
alarming hemorrhages.
The operation itself can be divided into three
stages : First, the exposure of the vein, preferably at
the bend of the elbow. In the second stage there is
one feature that deserves emphasis, the transfusion
tip should only be introduced into the vein while the
fluid is running. The observance of this precaution
not only washes apart the lips of the opening in the
vein, but affords an absolute safeguard against the
introduction of any air, which is one of the chief
dangers associated either with transfusion or infusion.
The third step consists in ligating the punctured vein
and applying an aseptic compress.
The principal points in connection with the opera-
tion are: To have all steps performed in an aseptic
manner, to be careful that the infusion is not made
too rapidly nor with too much force, otherwise there
will be danger of over distending and paralyzing the
already much enfeebled heart. Care should also be
exercised that too much fluid is not employed which
might give rise to a two-fold danger. 1. By the
unfavorable influence upon the corpuscles by the dil-
ution of the blood. 2. By raising the intravascular
pressure to such a degree as to occasion a rupture of
one of the smaller vessels in some vital part of the
economy. It is exceedingly important that great care
should be exercised to have the salt solution abso-
lutely free from any minute floating bodies, which if
present might act as emboli producing death or per-
haps a gangrene of one of the extremities.
Before dismissing the subject of transfusion and
infusion we desire to recall the fact that owing to the
extreme cerebral anemia which exists after dangerous
hemorrhages, either of these operations can and should
be performed without the use of an anesthetic. In
this condition all manipulations are practically of a
painless character and owing to the enfeebled heart an
anesthetic would only be adding an additional danger.
ANTO-TRANSFUSION.
By anto-transfusion we understand the forcing of
the blood by means of elastic bandages from the
extremities to the more vital centers. The indications
for this can be summed up as follows : Shock or any
condition attended with relaxation and diminished
vascular pressure. Again, this is very useful in guard-
ing against accidents in anemic subjects during chlor-
oform narcosis.
590
OVAKIAN TUMORS COMPLICATING PREGNANCY. [September 12,
SUMMARY.
In conclusion I beg to submit the following:
1. In enormous hemorrhages the resulting danger
are more frequently due to the reduced intravascular
pressure than to the actual loss of blood.
2. In view of this the indications point more decid-
edly toward infusion than transfusion.
3. That transfusion has not received the attention
which its merits justify.
4. In transfusion we possess a measure which in the
severest hemorrhages is the only agent capable of
restoring the vital functions.
5. The indication for transfusion includes any con-
dition which reduces the total quantity of blood to a
fatal degree or which alters the character of the blood
to such an extent as to render it incapable of sustain-
ing life.
6. When the transfusion is performed for the relief
of a poisoned condition of the blood it should be pre-
ceded by venesection.
7. Centripetal is to be preferred to centrifugal trans-
fusion.
8. In centripetal transfusion the injection should
be made with a slow steady stream, carefully avoiding
undue force.
9. In withdrawing the blood from the donor the
veins afford an easier, safer and better source than the
arteries.
10. Indirect transfusion with defibrinated blood is
safer than direct transfusion with non-defibrinated
blood.
11. In alarming hemorrhages infusion should be
performed before transfusion; should however, the
improvement be transient in its nature, the infusion
must be supplemented with transfusion.
12. In addition to hemorrhages the indications for
infusion include any pathologic state attended with a
feeble pulse which is dependent upon a relaxed con-
dition and a diminished intravascular blood pressure,
namely, shock.
13. Restoring the tone of the circulation by infu-
sion is not wholly dependent upon the increase of the
intravascular pressure, but is in part due to the stim-
ulating influence which the salt solution has upon the
heart.
14. In performing transfusion or infusion after an
enormous hemorrhage, the use of an anesthetic is not
only unnecessary but absolutely dangerous.
15. In the anto-transfusion we have a valuable
measure for combating shock and preventing accidents
in anemic subjects during chloroform narcosis.
OVARIAN TUMORS COMPLICATING PREG-
NANCY ; WITH REPORT OF A CASE.
Read before the Chicago Medical Society, June 15, 1806.
BY C. S. BACON, M.D.
Professor of Obstetrics, Chicago Policlinic.
CHICAGO. ILL.
Within the last ten to fifteen years the manage-
ment of this interesting and important, if somewhat
uncommon, complication of pregnancy has become
much more uniform, with a corresponding improve-
ment in the prognosis. While formerly the let alone
policy, the induction of premature labor and the
puncture of the tumor were methods quite commonly
employed, now the much better results obtained from
ovariotomy are generally known and recognized, and
this mode of treatment has been substituted for the
others. Two questions of much interest are still
undecided. One is, Which is the better route to
reach the tumor, the abdomen or the vagina? The
other is, What is the best time to operate? The
following case is presented because it may have some
bearing on these mooted questions and because the
casuistic contributions are not yet too great:
Mrs. C, aged 32 years, Ill-para. Family history good
Nothing abnormal in menstrual history. First pregnancy,
four years ago, was without complications. Labor was slow
and forceps were applied, probably unnecessarily. Laceration
into the rectum with severe hemorrhage resulted. A few
months later I was first called in and repaired the laceration.
During the examination a small tumor was noticed on one side.
The differential diagnosis was not made between a small cyst
of the ovary, a parovarian cyst and a pedicled subserous myoma
of the uterus.
Soon after the operation the patient again became pregnant.
This pregnancy was also undisturbed. I attended her confine-
ment, which was quite normal. After labor the adnexa tumor
was again noticed as a rather hard mass, to the side of the
uterus, about one inch in diameter.
May 4, 1896, the patient came to me, to arrange for her next
confinement. She had removed from the city to a suburb.
She had no suspicion of anything abnormal and complained
only of feeling unusually weak with much distension of the
abdomen. Her last menstrual period occurred Nov. 1 to 4,
1895. Fetal movements were first felt March 17, 1896, i.e., in
the twentieth week. She therefore would be in the beginning
of the twenty seventh week of pregnancy.
Examination disclosed the following condition : The uterus
lay in the left side of the abdomen, the fundus being but a
finger's breadth below the ribs. The child lay with the head
presenting, freely movable above the pelvis and corresponding
in size to the supposed age of the fetus. In the right side of
the abdomen, extending about two inches above the navel, was
a tumor which could be distinguished from the uterus by a
groove which ran along between it and the uterus one to two
inches to the right of the median line. Through the vagina
the pelvis was found filled with a tumor apparently in connec-
tion with the tumor in the right side of the abdomen. The
cervix was reached above the symphysis a little to the left of
the middle line.
May 12, in the twenty-eighth week of pregnancy, I operated
at the Policlinic Hospital, with the valuable assistance of Pro-
fessor Henrotin. On opening the abdomen the large veins of
the pampiniform plexus, feeling like coils of intestine, were
found lying in front of and to the left side of the tumor, which
was not adherent. Its contents were evacuated through a
trocar and an attempt made to follow the sac to its pedicle.
Then it was found that the tumor arose from the left broad
ligament, a fact that could have been suspected from the loca-
tion of the pampiniform plexus on the left side of the tumor.
With considerable difficulty the sac was pushed under the
gravid uterus, its broad pedicle ligated and the sac removed.
The abdominal wound was closed with deep sutures through
the skin and muscular layers, and two rows of continued
sutures through the peritoneum and the muscular fascia. A
small accidental incision of the peritoneum covering the uterus
had been closed with three sutures.
The tumor sac, which held nearly two quarts of brownish
transparent fluid, was plainly of ovarian origin.
For thirty -six hours after the operation the patient had con-
siderable pain, for which she received three or four hypodermic
injections of one-fourth grain morphia. There was also con-
siderable nausea for two days, but after free action of the
bowels she became easy and made a good convalescence.
Except for a temperature of 101.2 degrees the evening after
the operation there was no fever. As a special precaution
against premature labor she was kept in bed till the twenty-
third day. She then got up and improved rapidly in strength,
and on June 7 felt perfectly well and planned to leave the hos-
pital the next day. During the night, however, labor pains
came on, resulting in the delivery of a living child June 8,
9 a.m., not quite twenty-eight days after the operation. The
labor was not unusually painful and the abdominal wound,
which had perfectly healed, was not disturbed. The placenta
was delivered shortly afterward by the Duncan mechanism.
Its uterine surface contained several old hemorrhagic fibrinous
patches and was quite friable. The child was 43.5 cm. long
and weighed about three pounds. It was not very vigorous,
and was kept in an improvised couveuse and fed every hour.
In spite of this attempt to save it the child became cyanosed
and died about eight hours after birth. The patient was
!
18%.]
OVARIAN TUMORS COMPLICATING PREGNANCY.
591
rather weak after labor and had a temperature between 100
and 101 for two days, which then became normal. She is now,
one week later, perfectly well.
This oaso illustrates the rapidity of growth of ova-
■an tumors during pregnancy. Two years ago, at
the last confinement, the tumor was not more than
one inch in diameter. There were no symptoms indi-
cating anything abnormnl in the pelvis before the
beginning of pregnancy; hence we may conclude that
the growth of the cyst went on hand in hand with
the development of the egg. It was, no doubt, at
first located posterior to the uterus, and as it gradu-
ally grew to till the pelvis the uterus was crowded up
into the abdomen. Perhaps because the patient was
in the habit of lying on her left side, the uterus came
to occupy the left side of the abdomen, while the
tumor, as it rose out of the pelvis, came to lie to the
right of the spinal column.
Two views have prevailed concerning the influence
of pregnancy in modifying the rate of growth of an
ovarian tumor. Koeberli held that the growth of the
tumor might be retarded by pregnancy on account of
•an increasing pressure and cessation of ovarian activ-
ity. A case of Spencer Wells is often cited in sup-
port of this view. A patient had a dermoid cyst
for eighteen years which decreased in size during suc-
cessive pregnancies and increased after labor. On
the other hand, most cases, like the one reported,
support the views of Spiegelberg, who held that
ovarian tumors grow more rapidly during pregnancy
on account of the increased supply of blood to the
pelvic organs. This also accords with the fact that
other pelvic tumors, especially fibromyomata of the
uterus, increase rapidly in size during pregnancy.
There are probably three chief factors which deter-
mine the rate of growth, namely, the supply of blood,
the degree of pressure on the tumor and the nature
■ot the tumor. In reference to the last element it is
well known that dermoids do not grow as rapidly as
ovarian or parovarian cysts with fluid or colloid con-
tents. The effects of pressure are seen in cases
of tumors which are confined to the pelvis. They
may cause much pain and disturbance of the bladder
or rectum, and become serious obstacles to labor, with-
out growing to a large size.
In my case the diagnosis was made without diffi-
culty, thus supporting the statement of Schroeder
that, with a careful examination repeated if necessary,
and making use of anesthesia, a diagnosis is always
possible. Yet a mistake is often made. Quite fre-
quently the pregnancy has been recognized and the
complicating tumor overlooked. Generally, in these
cases, the tumor is small and may cause no disturb-
ance during confinement. If it be located in the
pelvis and not spontaneously drawn up into the abdo-
men, it becomes an obstacle to labor which, unde-
tected, leads to the most dangerous obstetric opera-
tions. Forceps are applied, great force is employed,
the tumor is ruptured and hemorrhage or peritonitis
•with death results. Or the soft parts are severely
torn, and bleeding with probable infection cause
severe illness or death. If the unrecognized tumor
be large and labor be not obstructed, it may be mis-
taken for a twin.
Again, the pregnancy may be overlooked in the
presence of a tumor. This was true in eight out of
135 cases of ovariotomy during pregnancy collected
by Dsirne. In several of these cases pregnancy was
mot discovered, even after opening the abdomen, until
the gravid uterus was punctured or incised for a
supposed tumor sac. Should the uterine cavity be
opened, either through mistake in diagnosis or acci-
dentally, it should be emptied of its contents and its
walls united as in a conservative Ceesarean section.
The symptoms which indicate pregnancy in the
presence of an ovarian tumor are the cessation of
menstruation and the usual symptoms of uncompli--
cated pregnancy. The symptoms of a tumor when
the fact of pregnancy is established are sometimes
prominent and often nearly lacking. If the tumor is
in the pelvis, the bladder and rectal symptoms with
bearing down pains and backache are present. If
large, the distension of the abdomen with dyspnea
and disturbance of the functions of the kidney and
liver are to bo expected. Yet it is remarkable how
often nearly all symptoms may fail, as illustrated in
my case, and then we must rely on physical signs,
never omitting the vaginal examination.
If the diagnosis be made during pregnancy, the
method of management must be determined by the
urgency of the symptoms calling for immediate inter-
ference, and the probable result to be expected from
leaving the case to nature or from active treatment.
Pressure on the heart, lungs, stomach, liver or kid-
neys, due to a large tumor in the abdomen, result-
ing in dyspnea, edema, symptoms of intoxication, etc.,
may call for immediate relief. A tumor confined to
the pelvis may also cause so much disturbance, both
directly and reflexly, as to render its removal desir-
able. Another indication for interference may be the
danger of abortion. Jetter found among 215 cases,
36 of abortion and premature labor, i.e., about 17 per
cent. Pregnancy may be interfered with in one of
two ways. The disturbance of the uterus caused by
pressure of the growing tumor may directly bring on
uterine contractions, or the same pressure may limit
the blood supply to the fetus and cause its death,
thus secondarily producing labor pains. Twisting of
the pedicle with resulting shock or hemorrhage into
or rupture of the sac, may also call for immediate
interference during pregnancy.
If no interference be instituted and pregnancy go
on to term, it may end in various ways. The progno-
sis has been variously given in different statistic
tables. Litzmann records twenty-four deaths in fifty-
six labors, i.e., 43 per cent. Jetter gives the death
rate at about 30 per cent. Heiberg, as quoted by
Milller, found among 271 cases that one-fourth of the
mothers and three- fourths of the children died.
The most favorable termination is when the tumor
opposes no obstacle to the expulsion of the child.
Sometimes when the tumor at first lies in the pelvis
there is spontaneous reposition, i.e., it is spontane-
ously drawn up into the abdomen so that the child
can be born. In still other cases it is possible to dis-
lodge the tumor from the pelvis by manual interfer-
ence. This is the treatment that should be tried first
in all cases where the tumor is discovered after labor
has already begun. One should always make use of
anesthesia, and also place the patient in a favorable
attitude, such as the knee-chest position. Care should
be taken not to rupture_the sac.
If the tumor can be gotten out of the way so as to
allow the expulsion of the child, it often falls again
into the pelvis and prevents the delivery of the pla-
centa. Here a second reposition, not always very easy,
must be made.
The dangers from the fumor are not yet over when
592
OVARIAN TUMORS COMPLICATING PREGNANCY. [September 12,
the uterine cavity is emptied. If the tumor again
returns to the pelvis it may compress the cervical
canal and cause a lochiometra. Post-partum hemor-
rhage may be caused by adhesions between the tumor
and the uterus, preventing efficient uterine contrac-
tions. But the most dangerous of all complications
are those due to rupture of the tumor or to its rota-
tion and the twisting of the pedicle. Lawrence reports
ten cases of this kind requiring laparotomy, and Con-
damin among others calls special attention to this
danger. Suppuration of the tumor is also a frequent
occurrence after labor. So common are these results,
and so dangerous, that it has become the rule to
remove the tumor very soon after labor. Schroeder
recommended to wait six weeks, but more recent
reports seem to justify a much earlier operation. In
case any serious symptom arises denoting one of the
complications just described, immediate laparotomy
is at once to be done.
It is thus seen that considerable danger is to be
anticipated even in the favorable cases where the
tumor either causes no obstruction to labor or when it
can be removed from compromising the parturient
canal. Yet much more serious is the prognosis where
the tumor can not be raised out of the pelvis. If it
be a monolocular cyst with fluid contents it may be
evacuated with a trocar from the vagina. If it be
multilocular or if the contents be colloid, or if we have
to do with a dermoid cyst it becomes necessary to
make an incision into the posterior vaginal wall and
break up the contents with the finger. If the tumor
be solid it must bo removed, through a vaginal incision
if that be possible, if not by laparotomy. Should it
be impossible to remove the tumor by either route a
Caesarean section must be made. In case the vagina
be incised, either for the purpose of breaking up and
evacuating the contents of a tumor, or to remove the
tumor it is desirable to close the wound before the
passage of the child in order to obviate infection or to
prevent further tear. This is often difficult to accom-
plish because the head generally enters the pelvis as
soon as the tumor is removed. An attempt may be
made to prevent this undesirable rapid progress by
elevating the pelvis and keeping the head in the abdo-
men.
The results of the obstetric operations, the appli-
cation of forceps and version with manual extraction,
are so bad that they should be done only in the most
exceptional cases. Version should never be done in a
head presentation and forceps, with a mortality of
over 50 per cent., are rarely to be used. If the head be
firmly wedged between a solid tumor and the side of
the pelvis so that the removal of the tumor is impos-
sible perforation and craniotomy is the safest proced-
ure.
When labor is obstructed and no interference at all
is instituted the outcome is generally fatal. The
woman may die undelivered from exhaustion, or from
rupture of the uterus or from infection. The cases
are slightly more favorable when the cyst ruptures. If
the contents are those of a dermoid the peritoneum
will probably be infected and peritonitis result. Cases
have occurred when the vagina has ruptured and the
tumor extruded followed by the birth of the child.
Since the dangers during labor are great and even
if these be overcome the dangers of the puerperium
are considerable it becomes important to investigate
the results of interference during pregnancy. Three
methods have been advocated: induction of premature I
labor or abortion, puncture of the sac and ovariot-
omy. The first method which was championed by
Barnes is now entirely given up since the results of
ovariotomy are so much improved. It sacrifices or
greatly jeopardizes the life of the child and leaves the
mother with the tumor and exposed to all the dangers
that arise from its rupture, torsion or suppuration.
Puncture of the sac was warmly advocated. Twelve
or fifteen years ago even by so eminent a laparotomist
as Sir Spencer Wells. It is now generally given up
during pregnancy for the following reasons:
1. It gives only temporary relief since the sac often
refills very quickly. Atlee punctured a cyst sixteen
times and then was obliged to perform laparotomy.
2. There is danger of injuring large blood vessels.
Whoever has seen the large veins of the pampiniform
plexus during pregnancy must have this danger clearly
in mind. In my case 1 first mistook them for coils of
small intestine. One never knows wdiere they lie, on
account of the rotation of the tumor, or, as in the case
reported, the displacement of the tumor to the oppo-
site side from which it originated.
3. The uterus may be punctured or injured. This
has happened a number of times. Should the acci-
dent occur Caesarean section should at once be made.
4. The peritoneum may become infected by the
contents of the cyst escaping through the opening
made by the trocar.
5. The formation of adhesions with their resulting
consequences are an objection to puncture the same
as in non-pregnant conditions.
These two palliative operations being discarded
there remains to consider only ovariotomy. The
results of this operation have been shown so satisfac-
tory by recent statistics that now there is almost uni-
versal agreement in advising it. The most recent col-
lection of cases was made by Dsirne in 1893, who has
given synopses of the reports of 135 cases. Among
these there were eight deaths, being a mortality of 5.9
per cent. The cases since reported would probably
not increase the rate of mortality. This shows that
the mortality rate for ovariotomy is not greater dur-
ing than in the absence of pregnancy.
At this point I may consider the question. Which is
the better route to reach the tumor, through the
abdominal wall or through the vagina? Until quite
recently the abdominal route has been selected because
it was supposed to furnish a better oversight of the
field of operation and enable one to meet the compli-
cations that may arise. Especially when the tumor
lies more or less in the abdomen it may be difficult to
remove it per vaginam. It may be multilocular or it
may have colloid contents and there may be adhesions.
The advantages of a vaginal operation are well recog-
nized by those who have followed the recent progress
of vaginal celiotomy. It leaves no scar in the abdo-
men to become a hernial opening, and it is a much
slighter operation and thus less likely to disturb preg-
nancy. When we look back to the case reported we
see that the vaginal operation would have been easier.
The cyst could have been emptied and the sac pulled
down and tied off without difficulty. There was con-
siderable disturbance of the uterus in replacing the
sac under it. Recent improvement in the technique
of vaginal operations has led to the performance of
many vaginal ovariotomies and I predict that in the
future the operation will be employed much more
commonly in these cases.
Another very important question concerning ovar-
189(5.]
FIELD HOSPITALS IN BATTLE.
593
iotomy during pregnane} is its influence in interrupt-
Imjjt gestation. Olshausen found pregnancy inter-
rupted in 20 per cent, of the eases collected by him
numbering 82, wlnle Dsirne in 114 eases 1'ouiid the
percentage of interruption to be 22 per cent. Differ-
ent explanations have been given of the way in which
pregnancy is disturbed. Sometimes there is imminent
danger of abortion before the operation. Martin
reports such a ease where abortion was prevented by
the operation. The uterine contractions excited by
the tumor cause placental hemorrhages of greater or
extent. These disturb the fetal circulation so
that the death of the fetus and its subsequent expul-
sion may result perhaps some time after the opera-
tion. Or these hemorrhages occurring before opera-
tion may predispose to still more extensive hemor-
rhages when operative manifestations or vomiting
•excite still further uterine contractions. Any injury
to the uterus as in the separation of adhesions or a
wound of the serous coat would help to excite con-
tractions.
Another cause of abortion is the disturbance in the
blood supply of the uterus due to the ligation of the
ovarian artery. This factor would probably be espe-
cially potent in ease of a double ovariotomy.
It is quite interesting to study the table given by
Dsirne. which shows the effect of the operation in
disturbing pregnancy at different fetal ages.
At Koa.
Ho. i
Interrupt
ions of Preg.
Percentage
2
11
t>
45.5
3
28
4
14.3
4
21
2
9.5
5
10
i
40.0
6
11
1
36.4
7
5
3
60.0
8
5
2
40.0
9
1
1
100.0
From this table it is seen that the most favorable
time for operating, so far as the fetus is concerned, is
during the third and fourth months when only 10 to
15 per cent, of the cases abort. Later 40 to 50 per
cent, of interruptions of pregnancy may be expected.
These results are not very satisfactory and have led
to considerable discussion concerning the advisability
of postponing the operation, in the absence of urgent
symptoms, until the child is viable. Fehling and
Veit have ■contended for this rule. Nearly all author-
ities, however, agree with Schroeder and Olshausen in
advocating operation as soon as the tumor is discov-
ered, because of the danger of abortion, rotation of
the tumor with constriction of the pedicle and peri-
tonitis, rupture of the cyst, dyspnea, etc. It has not
been proven that twisting of the pedicle occurs more
■commonly during than in the absence of pregnancy.
Dsirne found it to occur in only 9.1 per cent, of his
•cases. This is not a much larger ratio than is found
in all cases of ovarian tumors. It is in striking con-
trast to the frequent twisting found during labor and
in the puerperium.
Another objection might be raised to postponing
the operation to the last month of pregnancy where in
at least half the cases labor will be brought on,
namely, the danger of breaking open the abdominal
wound. I am inclined to think that there is preva-
lent an exaggerated fear of the effect of labor pains on
a laparotomy wound. The question can be settled
only by an examination of the records. I have looked
up accessible eases where labor occurred within some
days or even weeks after the operation. In but few
cases was there any reference to the effect of labor on
t he abdominal wound. Generally the reports mention
only an uninterrupted recovery. One of the most
important cases is reported by Pippingskold. He
removed a large tumor from a patient in whom labor
pains had already begun. Labor was completed in a
few hours after the operation with (no hemorrhage
from the stump and no disturbance of the abdominal
wound. The only case I have found where reference
was made to an abdominal hernia was one of
Schroeder's. The operation was made in the fourth
month and was followed by abortion thirteen days
later. The patient afterward had two children and
during the second subsequent pregnancy it is noted
that she was troubled with a large abdominal hernia.
That this would be laid to the abortion is hardly rea-
sonable in viewT of the not unfrequent occurrence of
hernia after laparotomy in the absence of pregnancy.
In my case labor did not cause the slightest disturb-
ance of the abdominal wound.
The question of the time for the operation in its
bearing on the prevention of abortion is one of the
most important. Each case must be decided on its
own merits. If the patient has no children greater
effort should be made to save the child than if she has
a number, especially does this rule hold when the
tumor is double. If the tumor be discovered in the
second month the operation should be delayed a
month or two because the results in the second month
are bad. After the fourth month if the symptoms of
dyspnea, etc., including those of impending abortion,
be not too urgent it may be desirable to wait until the
thirty-fourth or thirty-sixth week provided the patient
can be kept under observation. After operation the
patient should not rise too early and the first symp-
toms of labor should receive prompt attention.
426 Center Street, Chicago.
IN FUTURE BATTLES WHERE SHALL THE
FIELD HOSPITALS BE PLACED?
BY EDMUND ANDREWS, M.D.
FORMER SURGEON OF ARTILLERY AND SURGEON IN CHIEF OF CAMP
DOUGLAS, CHICAGO.
Behind every fighting line there is a danger space
within which lie the wounded. The modem long
range rifles, and the new far reaching artillery have
greatly widened this zone, while the increased rapidity
of fire may sweep the ground with such fierceness
that within its range ambulances can not approach,
litter bearers can not carry off the wounded, and sur-
geons can not work. In case the field is very level
and devoid of shelter, the problem of where to place
the field hospitals, and how to get the wounded back
to them has become one which greatly perplexes
military surgeons.
Take for instance the level plain on which Chicago
stands. From Lake Michigan west to BesPlaines
River, and from Evanston southward to Thornton
extends a level plateau ten miles wide and thirty
miles long, on which the natural eontonr of the
ground affords not the slightest shelter from fire. If
two modern armies should meet on such a plain, what
could be done with the wounded?
The arrangements of the medical department in
battle in a general way are as follows:
A portion of the medical officers accompany the
fighting line to give what is called "first aid" to the
injured, in which they are assisted by a certain num-
ber of fighting privates who have received special
594
FIELD HOSPITALS IN BATTLE.
[September 12,
training, and non-combattant "Geneva Cross men,"
who are still better educated. Whenever there is a
lull in the firing these collect the wounded and make
temporary first dressings.
The main surgical work is done at places called
field hospitals, where are assembled all the surgeons
not detailed to accompany the fighting line. In a
level field, devoid of shelter, these must be located far
enough to the rear so that the assembled patients
shall not be cut to pieces by shot and shell nor the
surgeons and their subordinates killed in such num-
bers as to stop the work. How far back must these
hospitals go?
Surgeon Major Girard asserts that men may be
wounded by the new rifle at 7,300 yards, which is
over four miles. I think this is probably a misprint
in the Major's article. At any rate no military officer
will waste his ammunition at such ranges. Others
advise to locate the field hospitals at 3,000 meters
behind the fighting line. This is about two miles.
Others say 2,000 yards, which is a little over one
mile. After much study of the subject, aided by con-
ference with the best military surgeons, and fighting
officers, I have come to the following conclusions:
It is the artillery and not the small arms which will
prevent the field hospitals in level ground from taking
a position anywhere near the fighting line, because
the shrapnel shells reach much farther than musketry.
Still the distance back to a fairly tenable hospital
ground is exaggerated in many minds by the popular
accounts of the great range of modern projectiles.
The immense ranges of two, three, or four miles are
only obtained by aiming up in the air at high angles
and trying to drop the shells from the sky, as it were,
among the enemy. This kind of fire is so very inac-
curate, that it rarely hits anything, or endangers any-
body. Now, artillery ammunition is costly, and very
heavy to transport. It is therefore very precious and
is reserved for nearer work. No commander will
waste it by tossing it loosely all over the country.
The artillery begins effective work at about 2,500
yards. It directs its shrapnel shells so as to explode
them about fifty yards in front of the line aimed at,
that the fragments and contents as they move onward
may spread out in a cone and fly in the faces of the
opposed troops. The fragments of shell and the en-
closed bullets are thus dispersed in the air and soon
lose their force. Hence a field hospital some little
distance from the line is not in great danger. My
observation is that a few badly aimed shells which
have failed to burst at the proper point occasionally
come into the vicinity, but they are not numerous
enough to render the hospital untenable. Highly
educated officers say that even on a level field sur-
geons can work without great risk 2,000 yards from
the enemy, or a little over a mile. As their own lines
will be nearer than those of the enemy, the field hos-
pitals can usually be carried up to within 1,200 yards
of where their own fighting line commences to meet
many losses. But even this distance is too great to
allow of getting the wounded back, if the enemy per-
sists in sweeping the ground clear of all moving objects.
However, armies do not throw away much needed
ammunition, by uselessly firing when there is no
charge impending. Most of the firing comes in gusts,
with lulls, and sometimes long intervals between.
During the firing the injured should lie as flat on the
ground as possible, getting behind any available shel-
ter which may exist. When a lull comes, efforts can
be made to get them back. About 70 per cent, of the
wounded are able to walk and can go back of them-
selves. The remaining 30 per cent, have to be carried.
Just here is the weak point in surgical arrangements.
Although there are four Geneva Cross bearers to each
litter, the carrying back of injured men long distances-
is a most exhausting labor. Lieutenant v. Kries of the
Austrian army has experimented on the ability to-
stand this work. He found that the bearers rapidly
broke down with fatigue. Thirty-two bearers, carry-
ing eight litters, brought back a distance of about
1,200 yards only 32 men in about three hours; that is,
the bearers can bring that distance in three hours-
only one man to each bearer, and at the end of the
three hours they were exhausted and could do no-
more.
Now, the bearers number 2 per cent, of the fighting
force. In a division of 10,000 men there will be 200
bearers carrying fifty litters. In the 10,000 men en-
gaged, if the loss is severe, there will be 2,000 hit.
Of these about 600 will be killed and 1,400 wounded.
Of these about 980 will be able to walk, and 420 will
require litters. The 200 litter bearers will be able to
carry back 200 men to a field hospital 1,200 yards dis-
tant in three hours, and the bearers will be so far
exhausted as to be obliged to stop, leaving 220
wounded at the front. If the action is only half as
severe it would be possible to carry in all the wounded.
At this rate as the ambulances can not work any
nearer to the front than the surgeons, it will be im-
possible to clear the field except by slow degrees, and
perhaps by working all night, and searching the field
with lanterns.
Lieutenant Melville of the British army comes to
similar conclusions. He says in a British brigade of
4,000 suppose 10 per cent., or 400, to be hit. About
30 per cent, of those struck will be killed, leaving 280
wounded. About 180 can walk and 100 will have to
be carried, and it can be just barely done by com-
pletely exhausting the 80 bearers, if none of them are
shot. If the action is more severe and 20 per cent.
are hit, 100 will remain on the field after the bearers
are exhausted. This looks discouraging; however it
shows the great importance of lightening the work of
the bearers by getting the field hospitals as close to
the front as possible, even if the danger of the sur-
geons is increased.
The conclusion is this: If the field of battle is
level and destitute of shelter, and the enemy insist
on keeping the field swept of everything that moves,
the wounded must lie where they are, with such first
aid as the surgeons in front can give them, until the
action is over, or the fighting lines move on else-
where, and then the field hospitals must move up into
their midst.
The opinion in army circles is that in the exigen-
cies of battle, the fighting officers will not detail men
from the ranks to aid the bearers, except when neces-
sary to retreat before uncivilized hordes, who would
murder the wounded if left behind.
The foregoing discussion is all based on the sup-
position of a level field such as surrounds Chicago.
Fortunately such fields are few. In my own experi-
ence I never was in an action where there were not
numerous hills and valleys, or at least considerable
undulations of ground or standing timber. In these
cases fighting lines stretch themselves along the
crests, where the soldiers can lie just behind the sum-
mit ridge and fire over. The first aid stations can
18%.]
RETRODEVIATIONS OF THE UTERUS.
595
thou be olose to the lines and the field hospitals need
not be far off. I have sometimes located them less
than 300 yards from the front, and even ambulances,
conspicuous marks as they are, can sometimes be
driven along the hollows, taking the wounded directly
from the first aid stations.
Surgeon Fischer, of the Austrian army, thinks the
number of wounded will be greatly increased. It
seems to me that this popular idea is erroneous. Most
of the fighting will be at greater distances than it was
formerly, and the new guns are no more accurate than
the old ones. Beside, experience shows that even
well disciplined men can rarely be made to stick to
their work after 30 per cent, of their number are hit.
This old rule will be as true in the future as in the
past, and no change in weapons will prevent men
from shrinking from danger when it exceeds their
fortitude.
Fischer also thinks the mortality of the wounds
will be doubled, but Melville dissents from that
conclusion.
The facts point in two directions. A few wounds
will perhaps bleed more than the old ones, on account
of swift shots cutting more like a knife than slow
ones, but we must remember that the injuries will be
inflicted at greater distances, when the bullets have
Largely lost their velocity.
Close shots will tear and shatter more in conse-
quence of what is called the "explosive effect," but
these only occur at near range. Most of the injuries
will take place at greater distances, and the bullets
being very small, the wounds will on the average be
less fatal from shock, and less open to septic infection.
Many will heal by first intention.
On the whole. I think that no more men will be
hit than formerly, and that of those wounded more
will recover.
Finally, all the utensils and everything about the
field hospitals must be made as simple and portable
as possible, so that they can be thrown into the
wagon and rushed forward, at a moment's notice, to
where the wounded lie, as soon as the fighting admits
of the advance. In this way the men can be taken
care of without waiting for the slow, interminable
and exhausting work of litter bearers.
3530 Prairie Ave., Chicago.
E. WERTHEIM'S NEW METHOD OF RE-
STORING RETRODEVIATIONS OF
THE UTERUS THROUGH
THE VAGINA.
BY A. J. HOSMER, M.D.
ASHLAND, WIS.
The operation consists in shortening the round lig-
ament through the vagina. The technic of the oper-
ation in uncomplicated cases is as follows: After the
necessary antiseptic precautions, the patient is placed
in the exaggerated lithotomy position. (A curette-
msnt is performed, when indicated.) The limbs are
supported, retractors used, and the cervix uteri is
seized with bullet forceps and drawn down, as in
vaginal hysterectomy. With a scalpel, a transverse
incision about one and one-half inches long is made
at the anterior utero-vaginal junction, down to the
uterus. Now with the index finger or with blunt
pointed scissors, the uterus is separated from the
bladder. The vesico-uterine space (anterior cul-de-
sac), or rather the peritoneum lining it, is reached
with ease. The peritoneum is seized with two anatomic
forceps and opened between them with the scissors.
The incision is then extended transversely about an
inch each way. Now while still holding to the ante-
FlGUBE 1.
rior peritoneal flap with one of the forceps, a needle,
with medium sized silk, is passed through it and
attaches it to the cut edge of the anterior vaginal wall.
Figure 2.
Two other stitches are used attaching peritoneal flap
to the cut edge of the vagina, thus entirely covering
the raw surface of the bladder. Easily now with the
Figure 3.
fingers one can reach the body of the uterus and ascer-
tain its condition as well as the state of the Fallopian
tubes and ovaries. When necessary, loosen adhesions,
replace ovaries, remove small subserous myomas, etc.
596
APPARATUS FOR FRACTURE OF CLAVICLE.
[September 12,
Next, unfasten the bullet forceps from the cervix,
allowing it to go back as you roll the body of the
uterus forward into the vagina or at least into plain
view. If there are no adhesions, the uterus comes
forward without force. If there are adhesions they
are easily reached with the fingers and separated.
The round ligament is the first cord in sight and
can be seen, examined and differentiated from liga-
mentum proprium and Fallopian tube. The ligament
is seized from one to two inches from the horn of the
uterus, with bullet forceps and drawn out, thus neces-
sarily doubliny it upon itself. With medium sized
silk, its approximating doubled surfaces are sewed
together. By thus folding it upon itself by the use
of three or four stitches, the round ligament can be
shortened from six to nine centimeters.
The otherround ligament is treated in like manner,
and thus the uterus is held up and anteverted. The
stitches holding the peritoneum to vagina are now
cut and the two peritoneal surfaces re-united. The
transverse incision at the utero-vaginal junction is
then sewed vertically thus lengthening the anterior
vaginal wall, and shoving the cervix back.
A little gauze is placed in the vagina and the oper-
ation is finished, in most cases without having tied a
blood vessel, and unless the wound has been infected,
without danger.
There is no danger of injuring the ureters, if the
operation is done as described above, as they are
shoved out of the way. In cases where there is a
relaxed vagina and an anterior colporrhaphy is needed,
instead of making the transverse incision, an ellip-
tic piece can be removed from the anterior vaginal
wall, and the bladder separated from the uterus directly
under the eye. The round ligaments are treated as in
the first case. In sewing up the vaginal wall you have,
of course, done an anterior colporrhaphy.
This operation was first made by E. Wertheim of
Vienna, in January, 1890, and his first publication of
the same appeared in the Centralblatt filr Gynolkol-
ogie in February, 1896, since which time it has been
performed about twenty-five times and with perfect
results.
Its advantages over the Alexander- Adams operation
are: 1, it leaves no visible scar; 2, the operation is
easier to perform, the ligaments being larger at this
point and easy to find; 3, the transverse cut in the
vagina, sewed vertically, assists in anteverting the
uterus; 4, it allows perfect access to the pelvic viscera,
thus permitting of minor repairing at the same sit-
ting, when indicated; 5, the operation is less dan-
gerous.
Its advantages over any method of anterior fixation
which will prevent the free growing of a gravid uterus
are very apparent. The bladder is left in its normal
position. A subsequent pregnancy will not be hin-
dered, as the shortened ligaments can stretch as in the
normal state. That every antefixation which will pre-
vent the free growing of a gravid uterus is likely to
be the source of danger, is well illustrated in Milan-
der's report (Zeitschrift filr Geburtshillfe und Gynd-
kologie. Bd. xxxiii, Hit. 3). In fifty-four cases of
full term labor after ventrofixation, eleven were oper-
ative, four forceps, two Csesarean sections, four turn-
ing and one extraction.
The uterus is not only anteverted, but it is held up,
as one can very easily prove by doing the operation
upon the cadaver, and the organ is not antefixed, but
held in its normal position by its normal attachments.
This operation I have witnessed frequently in
Schauta's operating room, and the ease and rapidity
with which it is done, beside its many advantages over
other known methods, is my excuse for sending this
report.
For the past year, I have not had access to any
medical journal except the Journal of the Ameri-
can Medical Association, hence if this method of
E. Wertheim's has been reported in an American
medical journal, I am ignorant of the fact.
A NEW APPARATUS FOR FRACTURE
OF THE CLAVICLE.
BY EVAN O'NEILL KANE, M.D.
KANE, PENN.
The treatment for fracture of the clavicle is almost
uniformly unsuccessful. Were it not that the result-
ing rounded shoulder, narrowed chest and bone
deformity do not materially injure the patient, the
best surgeons would be continually mulcted in mal-
practice suits.
Front. A, chest pad ; B, spring on sound side : C, shoulder pad and
spring on injured side; D, doited lines indicating ordinary sling; E,
elastic strap and buckle.
It is true that if the patient can be placed for three
or four weeks upon his back; a narrow cushion below
and a shot- bag above, a perfect result may be obtained;
but few can bear with so irksome a treatment for so
comparatively trivial an injury. No other methods
of treatment produce perfect results; and all are
painful or even prejudicial to the patient's health.
Many of these apparatus are now discarded as cum-
brous, complicated and unsatisfactory, the pad in the
axilla sooner or later exerts so much pressure upon
the nerves and vessels as to require its removal.
Bandaging the arm across the chest, rarely attains
more than fixation and the prevention of falling of
the shoulder, while it so cramps the arm and constricts
18%.]
UNUSUAL CONGENITAL DEFORMITIES.
597
the chest as to make it unbearable for sensitive
patients.
The plaster of paris figure of eight and the adhe-
\ e plaster dressing are fairly satisfactory, if they can
endured, but they are, especially in warm weather,
very difficult to be borne for more than a few days,
unci when removed the arm on the injured side is
sometimes so paralyzed, swelled or cramped as to be
nearly useless for a number of days, while, the results
are not perfect in either case.
The displacement in fracture of the olavicle may
generally be stated as occurring inward, forward and
downward, while on account of the difficulty of over-
coming the shortening incident upon muscular con-
traction considerable over-riding is present.
On account of the difficulty of obtaining a proper
point d'appui but one of the deformities is ever com-
pletely obviated, i. <-., the downward displacement
that shoulder. Thus the spring passing from the
back pad around the sound side to the chest pad holds
the whole apparatus in position, although, allowing
full play to the respiratory muscles, while the spring
passing from the same position behind, around for-
ward and over the shoulder on the injured side, by its
continued traction backward drags the shoulder with
it, prevents over-riding or angular deformity of the
bone and yet allows motion. The elastic strap though
not necessary is an additional security against slid-
ing of the apparatus. It is fastened to the back pad
and passes around the thorax on the injured side to
be attached to the chest pad in front, and with quiet
patients can often be dispensed with.
The same result is attained and maintained per-
manently when the apparatus is in position as that
transiently produced by the surgeon when he grasps
the shoulder and draws it backward in setting the
bone; and which he is unable to retain with his
dressings when he relinquishes his grasp unless he
places his patient in the dorsal decubitus.
In addition, an ordinary sling is required in order
to keep the shoulder from falling, but this does not
cause any discomfort. The apparatus, which can be
taken off or put on as readily as the simplest rupture
truss, may be removed every night when the patient
retires. He must then, however, lie upon his back,
preferably along a narrow cushion. This he is glad
to do on account of the additional freedom and com-
fort afforded. It requires no skill on the part of the
attendant to replace the apparatus when the patient
arises in the morning.
This contrivance may readily be constructed with a
combination of slots and set screws to enable it to
serve for either right or left side and for various
breadths of shoulders.
In my hands it has been productive of perfect
results, as well as affording far less discomfort than
any other method of treatment which I have adopted
and, though more expensive than ordinary bandages
and adhesive plaster, it pays both surgeon and patient
amply for the slight extra expense in the comfort it
affords, and the freedom from deformity which fol-
lows its
Back. A, back pad; B, spring passing forward around injured
shoulder to terminate in front in small shoulder pad ; C, spring pass-
ing around chest on sound side to terminate in large pad on middle of
chest; D, set screw and slot in spring; E, elastic strap.
usually rectified by some form of sling. I am omit-
ting the treatment by dorsal decubitus.
By my spring-lever apparatus and a sling I believe
I have obviated all the difficulties formerly met, secur-
ing to my patients fair motion of the thorax and com-
parative freedom to the hand and arm of the injured
side; a perfect co-aptation of the fragments; freedom
from shortening and practically no deformity with a
minimum of discomfort. My device consists of a
combination of springs and pads with an elastic strap.
The springs, two in number, are fastened, one on each
side, by a screw bolt to a large pad behind, each ter-
minating in front in another.
One pad, large and circular, acts as a counter pres-
sure upon the chest from in front; the other, a smaller
one at the termination of the spring on the injured
side, is arranged to press upon the anterior surface of
use.
SOME UNUSUAL CONGENITAL
DEFORMITIES.
Read before the Tenth Annual Meeting of the American Orthopedic
Association, at Buffalo, May 18-20, 1896.
BY JOHN RIDLON, M.D.
Professor of Orthopedic Surgery, Northwestern University Medical
School; Senior Orthopedic Burgeon to St. Luke's and Michael
Reese Hospitals, and 8urgeon-in charge of the Home for
Crippled Children, Chicago.
Believing it to be the duty of a specialist to present a
record of unusual cases to his associates, I beg to offer
for your consideration a brief report of the following
cases that have come under my observation during
the past three years.
Case 1. Congenital constriction bands, etc. — H. D., male,
2',i years old, the first child of healthy parents. There is no
physical defect or deformity in the family for at least three
generations. The pregnancy and birth were uneventful and in
all respects normal. The mother is unable to offer any sug-
gestions as to a possible cause for the deformities.
Left hand : The index finger was joined (webbed) to the ring
finger, and the ring finger to the little finger from the tips
nearly to the junction of the proximal and middle phalanges;
and the middle finger was amputated at the end of the proxi-
mal phalanx and was pointed (conical). Otherwise the hand was
normal.
598
UNUSUAL CONGENITAL DEFORMITIES.
[September 12,
Right hand : The index finger was joined (webbed) to the
ring finger as in the other hand, and the middle finger was am-
putated and conical (see Pig. 2) ; but the little finger instead
of being webbed as in the other hand was incircled by a con-
striction band between the root of the nail and the distal joint
(see Fig. 2). Otherwise the hand was normal. When first seen
by me all the webbed fingers on both hands had been
amputated at the end of the proximal phalanges as shown in
Figs. 2, 3 and 4.
Left foot : A constriction band incircled the great toe.
Otherwise the foot was normal.
Right foot and leg : The foot presented a moderate degree of
talipes equino-varus. This had only been treated by occa-
sional gentle hand stretching by the mother. Around the
FiGUHE^l.— Case 1. Congenital constriction band and talipes eqnino-
varns.
ankle was a constriction band (see Figs. 1 and 2) having the
appearance of cicatricial tissue, about a quarter of an inch
in width. This band creased the soft parts very deeply, about
three-eighths of an inch at the front of the leg and about seven-
eighths of an inch at the posterior and inner side. The mother
reported that at birth there were no voluntary movements in
this right foot, but that at the time the fingers were amputated
this constriction band around the ankle was incised trans-
versely in three places, and that since that time there have
been some voluntary movements in this foot, and that these
have increased under rubbing and manipulations. No other
deformities or peculiarities were found.
Treatment: Under the impression that there would
be no difficulty in looking up the literature of the
subject, I arranged to operate on the constriction
band about the ankle, but I was not able to find a
report of an operation upon such a case. I therefore
made two circular incisions around the leg, one above
and the other below the band and dissected it out. I
found little or no subcutaneous fat beneath the band,
which appeared to involve only the skin except at the
points of the three transverse incisions already referred
to. At these points the cicatricial tissue extended
deeply; it was dissected out. The skin and superfi-
cial fat and connective tissue were then dissected up
for about half an inch entirely around the leg, both
above and below; these edges, bridging over the
crease, were brought together and autured, and dressed
without drainage. The result, a year later, is shown
in Figs. 3 and 4.
The equino-varus was operated upon about four
and a half months after the operation upon the con-
striction band, by subcutaneous division of the
Achilles tendon, manual rupture of the posterior liga-
ment of the ankle joint, and subcutaneous division of
the anterior half of the deltoid ligament.
Case 2, was one of congenital constriction bands very much
like Case 1, but only affecting the lower extremities. The
parents of the patient refused operation ; it has been lost sight
of, and my notes of the case have also disappeared.
Figure 8.— Case 1. Showing result of operation on constriction
band. ,
Case 3. Congenital amputations. — Male child, 3 months
old when first seen. Born with both legs amputated at the
knee joints, and left arm amputated at the elbow joint. No
other congenital deformity or defect. This was the third child
of healthy and well formed parents, and the mother knows of
no congenital deformity in either her family or her husband's
family. The child died in Cook County Hospital before photo-
graphs were obtained.
Case 4. Congenital rickets. — Congenital rickets is, in my
experience, exceedingly rare. Indeed, this is the only case I
have ever seen. For the photographs of this case and the his-
tory I am indebted to Dr. John L. Porter, late House Surgeon
to St. Luke's Hospital, Chicago, and now assistant to the Chair
of Orthopedic Surgery in the Northwestern University Medi-
cal School.
This child ( Figs. 5 and 6 ) was born at St. Luke's Hos-
pital, Chicago, on Feb. 3, 1896, in the service of Dr. J. C.
Hoag. Weight at birth 7 pounds. The head presents
a typical cranio-tabes, the entire vault from the frontal
1896.]
UNUSUAL CONGENITAL DEFORMITIES.
599
prominences to the cerebellar fossre of the occipital
bone and between the two parietal bosses being soft
and membranous and without ossification. There are
small centers of ossificatian at each of the above
named centers. At birth the parieto-occipital, parieto-
frontal and parietotemporal articulations overlapped.
In the upper extremities there was marked enlarge-
ment at the distal epiphyses of the radii. In the
lower extremities there was a marked exaggeration of
the anterior and outward curves of the femora, but
the most marked deformity was in the anterior and
outward bowing of tibia? and fibula?, together with
the enlargement of the distal epiphyses. The feet
tended somewhat toward the equino-varus deform-
ity. Tenderness to pressure and manipulation was
noticed very early at the enlarged epiphyseal junc-
tions and to some degree over all bony prominences.
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Figurb 4. — Case 1. Another view after operation.
The photographs, Figs. 5 and 6, were taken on the
tenth day after birth. They do not show the bowed
femora nor the anterior bowing of the shins to advan-
tage.
The mother, 36 years old, has had ordinarily good
health since childhood. She has by a former hus-
band two other children aged 15 and 4 years, both in
^ood health and free from deformity. No history of
syphilis in the mother or in either husband can be
obtained. During the last pregnancy the mother has
been in extremely poor circumstances, and has been
at work with poor hygienic surroundings and insuffi-
ciet nourishment up to the date of confinement.
Case 5. Congenital reeurvated knees; knock-knees : talipes
equino-varus; spina bifida, with incontinence of feces: and
■convergent squint. — The child, a female, was 21 months old
when first seen by me ; at the time the photographs were made.
According to the mother's statement the knees were reeurvated
about20 degrees at birth, and very little passive motion at the
joints was possible. Under manipulation the motion has in-
creased. They can now be extended (reeurvated) to about the
degree above mentioned, and can be flexed about 10 degrees
beyond the straight as shown in Fig. 7. The patella can only
be felt as minute hardish nodule in the tendon extending from
the quadriceps femoris muscle to the tibia on either side.
The knock-knees and the talipes equino-varus, both
of only moderate degree, are shown in Figs. 8 and 9.
The spina bifida was the size of a small orange and
of firm consistency. The mother stated that it had
been much larger prior to the operation by the fam-
ily physician. The operation appears to have been
simply suturing the tumor through and through. A
crease, apparently the suture line, appears on each
side; one of these is seen in Fig. 7.
The incontinence of feces apparently depends upon
the spina bifida. The urine is passed with unusual
frequency, but there can not be said to be real incon-
tinence.
Figure fi.— Case of congenital rickets, showing anterior and outward
curvature of tibia and enlarged epiphyses of tibiae and radii.
The convergent squint is seen in Fig. 8. It is not
of marked degree and is seen sometimes in one eye
and at other times in the other. The bridge of the
nose is sunken and the frontal prominences are pro-
tuberant.
The child appears mentally deficient. The parents
and the other children are healthy and well formed,
and the mother can offer no plausible explanation for
the defects in this child.
Case 6. Congenital polio-myelitis anterior. — C. S., female,
9 years old when first seen by me. The mother states that at
the birth of the child the labor was very difficult and prolonged ;
and she believes it was dry labor. Dr. Charles Oilman Smith
was the attending physician and Dr. W. W. Jaggard, the con-
sultant. Both are now dead and no positive record of the con-
dition at birth can be obtained. Dr. Smith, however, advised
operation on the feet. Dr. Charles Adams advised against the
operation and none was done. Later, the late Dr. Mathias Roth,
of London, England, prescribed elaborate and minute forms of
600
UNUSUAL CONGENITAL DEFORMITIES.
[September 12;
massage, and the use of steam to induce muscular contraction.
Under his direction day braces and night braces were worn.
Mr. Bernard Roth has not been able to find any record of this
case although the mother is positive that he saw the case with
his father. Still later, Dr. Dobie, and his son. Dr. Henry
Dobie, of Chester, England, advised an operation, but the
advice was not taken and Dr. Roth's treatment was continued
for some years.
Figure 6.— Case of congenital rickets and cranio-tabes, showing
unossified portion of skull with exception of fontanelles.
The child did not walk until 2| years old. The
braces ordered by Dr. Roth and made by Ernst, of
London, were copied by Sharp & Smith, of Chicago,
and she continued to wear them until seen by me.
Figure 7.— Case 5. Showing spina bifida, and full degree to which
flexion of knees was possible.
At that time, both feet were held in full extension
(equinus) without lateral distortion. The anterior
part of the feet was broadened and the Achilles ten-
don attached to the inner side of tbe posterior border
of the os calcis in each foot as it usually is in con-
genital talipes equino- varus; the leg muscles were
shrunken, and the whole general appearance of the*
legs and feet, taken with the history of the case, ledi
Figure 8.— Case 6. Showing knock-knee and talipes varus-
Figure 9. — Case 7. Showing deformities of fingers and toes.
me to look upon the case as an ordinary case of j con-
1896. 1
SELECTIONS.
601
genital equino-varus and to prognosticate a develop,
ment of strength in the dorsal flexors of the foot when
relieved of the strain of the extended position.
I divided the Achilles tendon subcutaneously, and
had no difficulty in fully dorsal flexing the feet. Good
union of the out tendons took place at the end of two
weeks. After this the patient was allowed to walk in
braces that prevented the toes from dropping beyond
a right angle with the legs, and massage was given
•daily. At the end of a year and a half the feet
remain in good position, but there is no ability on the
part of the patient to dorsal flex the feet. Had the
■case been one of ordinary congenital talipes equino-
varus normal strength in the dorsal flexor muscles
would ere this have developed; but from the results of
treatment 1 can only conclude that the deformity was
•due to an intrauterine attack i if poliomyelitis anterior.
Case 7. Congenital constriction bunds. — I am indebted to
Dr. ("lias. E. Thompson, of Scranton, Pa., for permission to
publish the following case :
,). 1... male, it years old, robust and strong in every way (Pig. 9).
Father, mother, three brothers and three sisters living, well and
well formed. The mother attributes the deformity to the fact
that during the third month of her pregnancy she tied a cord
tightly around her own finger to stop the bleeding from a cut.
At the birth of the child the following deformities were
noted :
Right hand : Constriction band around the middle finger, in
front of the nail on the dorsum and somewhat farther back on
the palmar surface. See Fig. 9. Otherwise the hand is
normal.
Left hand : All of the middle finger beyond the distal end of
the proximal phalanx wiis absent "except a mere thread"
which the mother removed. The remaining stump is shown in
Fig. 9. Otherwise the hand is normal.
Right foot : Distal phalanx of great toe amputated : and two
distal phalanges of second toe amputated. Third toe has no
nail. Otherwise the foot is normal.
Left foot : Great toe and second toe amputated as in the
right foot. The third toe is considerably longer than its fel-
lows. There is a constriction band surrounding the second
phalanx ; on the dorsum it approaches the third phalanx and
on the palmar surface it approaches the first phalanx. The
fourth toe is very much smaller than its fellow on either side.
The fifth toe is normal as is the foot in every other respect.
SELECTIONS.
On Solid Preparations for Internal Use.— The past decade has
wrought great changes in the administration of medicine.
Responding to the more esthetic demand of the age, medi-
cal practitioners have quite largely dispensed with the older
forms of liquid mixtures, and adopted the solid and more
elegant products of the pharmacal art. While dry medica-
tion has been increasing in favor for the past twenty years,
history discloses some of the errors its votaries have been
led into. First was the sugar coated pill period, which set
in about 1870 and reigned supreme until about 1880, when it
was superseded by the gelatin coated pill, despite the attempt
to stampede its followers in 1875 by the compressed pill. For
ten years the gelatin coated pill was the favorite form, until
the general use of gelatin capsules relegated it to the insoluble
and unsatisfactory sugar pills of the patent medicine men.
The introduction of the tablet triturate some ten years ago
met with much favor for the administration of alkaloid salts,
and represented a convenient form for the ready preparation
of solutions for hypodermic and antiseptic use. But, as dis-
closed by the history of other forms of medication, the original
purpose of the tablet triturates was perverted, and in the
modified form of compressed tablets, the "idea" was extended
to comprise nearly every combination of remedies, irrespective
of therapeutic uses, and in utter defiance of well-known chemic
and pharmaceutic laws and principles.
For the purposes of studying the administration of solid
substances, they may be grouped, from a therapeutic point of
view, as follows :
Powders.— The medicinal agent in a finely divided condition,
either alone, associated with some other agents or triturated
with some inert substance. The object to be attained is either
quick solution, absorption or local effect, which is produced in
the degree that the mixture is finely powdered. Following the
law of solution, the greater extent of surface presented to the
solvent action, the more the process of solution is facilitated.
With most substances the effect is a question of absorption,
which is again dependent upon solubility. The only exception
to this are sugars and gums, which dissolve so readily, and the
solution formed is so viscous, as to interfere with complete
solution except under certain conditions.
Troches, lozenges, tablets, pastils and similar forms by what-
ever name, mixtures of medicinal substances intended for
solution in the mouth. — The medicinal agent is incorporated
either with a dry diluent, such as sugar, and the mixture made
into forms by compression, or into a mass with an excipient
and then divided into various forms, as in pills. The medicinal
agent is mixed with the diluent or excipient, which, being
sugar or gum, slowly dissolves by the heat and moisture of the
mouth and serves as a vehicle for the gradual distribution and
solution of the medicinal agent. A prolonged local effect is
thus produced upon the surfaces of the throat and respiratory
organs.
Pills. -Medicinal agents designed for slow solution and
retarded absorption in the stomach and intestines. These are
made into a mass with adhesive substances, gum, sugar, etc.
(excipient), which, responding to the exception noted in rela-
tion to solution, permit the gradual solution of the mass, and
consequently retard the effect of the medicinal agent. The
complete solubility of a pill is of course essential in order to
assure the desired action, and for this reason such excipient
must be selected as will not react with the medicinal agent, so
as to cause the mass eventually to become hard and insoluble.
The essential property of a mass and therefore of a pill is a
physical condition which will insure softening; then gradual
disintegration and finally complete solution in digestive or
intestinal fluids. A pill may be so hard as to be brittle (comp.
cathartic pill) and yet be perfectly soluble, and again when so
hard the pill may be almost insoluble in the liquids of the
body. The salts are generally not adapted to the pill form
unless mixed with extractive or saccharin matter as in the case
of the compound cathartic pill, and compounds of mercury,
antimony, etc. The salts of the alkaloid are largely adminis-
tered in this pill form and may become quite insoluble in course
of time. Even the substances mostly used as excipients, sugar
and gum, while inert therapeutically, it must be remembered
are not chemically inactive and may produce compounds more
or less insoluble upon change and exposure. This is true in a
greater degree when two or more chemic agents are combined
in a pill. For example, bismuth subnitrate and calomel made
into a mass with mucilage or glycerite of starch affords a pill
which, upon standing, becomes as hard as cement and entirely
insoluble. Reactions take place between chemic substances
like these, no matter how carefully selected the excipient,
which either impairs their solubility or renders them otherwise
unfit for therapeutic uses.
The medicaments adapted to the pill form administration
may be said to comprise the following :
Tonics, hematinics, stomachics, hepatics; purgatives, lax-
atives, cathartics, anthelmintics ; ecbolics, emmenagogues,
antispasmodics ; antigonorrheal, aphrodisiacs.antiaphrodisiacs.
The medicinal agents adapted to the troche or tablet form
of medication are confined to the following :
Astringents, antacids, aromatics; expectorants, pulmonary
sedatives ; demulcents, emollients, vermifuges.
602
SELECTIONS.
[September 12,
Powders.— These comprise by far the greatest number of
remedies, but the following are chiefly represented by this form
of medication :
Emetics, diaphoretics, sialogogues; sedatives, narcotics,
hypnotics ; tonics, antiperiodics, antipyretics.
The objection to powders is the disagreeable taste of many
remedies. Since this has been overcome by the use of cachets
or konseals it leaves in this modified form powders as the most
elegant form in which a very large class of remedies may be
dispensed. It enables the physician to formulate his own pre-
scriptions instead of prescribing ready-made combinations,
and also affords the pharmacist the opportunity to practice his
art for the preparation of medicines.— Read by C. S. N. Hall-
berg, Ph.G., at the Forty-fourth Annual Meeting of the Amer-
ican Pharmaceutical Association, Montreal, Aug. 15, 1896.
Reduction and Fixation of Fracture of the Zygomatic Arch.— Dr.
Rudolph Matas describes his method in a case of fracture
without laceration of the overlying tissues : As the injured
area was extremely sensitive, a general anesthetic was admin-
istered. The usual antiseptic precautions were carefully
observed. A long, full curve (semi-circular) Hagedorn needle,
threaded with silk as a carrier, was made to penetrate the skin
about one inch above the midpoint of the displaced fragment,
and was carried well into the temporal fossa under the broken
bone. Then the point of the needle was raised and made to
emerge about half an inch below the lower border of the broken
arch. As the needle was pulled out a strong silver wire about one
foot long was attached to the silk carrier and dragged through
the tract of the needle so as to form a metallic loop under the
misplaced bone. By twisting the ends of the wire together, a
loop was formed which permitted strong and easy traction to be
made on the broken fragment. Traction was begun by pulling
directly upward and outward. The displaced fragment yielded
and instantly returned to its normal position with a snap. The
contour of the arch was immediately restored and the displaced
fragment showed no disposition to relapse into its abnormal
position. Notwithstanding the apparent permanency of the
reduction, it was not deemed prudent to trust the fracture
without a more- permanent support, and the following simple
plan was adopted to secure permanent fixation : An ordinary
glass slide of the kind used for mounting microscopic sections,
after careful sterilization, was wrapped in a layer of iodoform
gauze and placed over the seat of the fracture with its greatest
length corresponding to the long axis of the zygoma. The
slide was long enough to rest upon the malar prominence ante-
riorly and upon the temporal root of the zygoma posteriorly,
thus resting upon two fixed points. After twisting the wire
firmly over the splint, it was evident that the bone could not
be displaced. The dressing waa then completed by applying a
layer of sterilized gauze and absorbent cotton over the slide as
a dressing, the whole being held in place by a roller head
bandage.
On the second day following the reduction, a thin shell of
vulcanite or dental rubber, molded to the shape of the normal
zygomatic prominence, was prepared by a dentist and substi-
tuted for the glass slide. The wire which held the fragment
in position was not removed, but twisted over the vulcanite
shield. The new splint was now covered with a layer of
absorbent cotton soaked in flexible collodion and applied with-
out any additional dressing. The patient was confined to his
room only twenty-four hours. On the ninth day the wire,
splint and all dressings were permanently removed. There has
been ever since (about fifteen months), a total absence of scar,
deformity or inconvenience. — New Orleans Med. and Surg.
Jour., September.
Physiologic Study of the Uterus.— Keiffer's thesis on the uterus
is winning him honors at home and abroad. It is based on
the most extensive and thorough research- work, with the myo-
graph and manometer on dogs and other animals. He states
as the results of his experiences : 1. That the uterus in dog»
contracts under the influence of central and peripheral excita-
tion of the median, crural and sciatic nerves. Also of the pari-
etal and visceral peritoneum, and of the pelvic organs. Also-
of the vagus, both central and peripheral. Also of the direct
excitation of any point of the genital apparatus. 2. The crural
nerve can suspend, by reflex action, the tonicity of the uterus.
He has observed, in fact, remarkable relaxation of the uterus
caused by exciting the central and terminal segment of this
nerve. He explains this fact by the inhibiting influence
exerted by the spinal cord on the uterus, and pheripheral exci-
tation of the crural nerve, sets this influence in play. 3. The»
pneumogastric nerve is not a direct excito-motor of the uterus.
Frank has already established this in regard to the bladder.
But Keiffer found that excitation of the central end of the
pneumogastric produced a most active response. The action
is therefore, reflex. There was no response to excitation of
the central end of this nerve after section of the spinal cord at
any point in the dorsal or lumbar region. Hence centripetal
excitation of the pneumogastric must act through the media-
tion of the motor centers in the spinal cord. Every excitation
of the peripheral end of the vagus invariably produced very-
decided curves. But if sufficient atropin is administered to
the animal to inhibit the suspension action exerted on the
heart by exciting the vagus, with the accompanying modifica-
tions in arterial pressure, or if sufficient chloroform is given to>
extinguish the reflex sensibility of the vagus, there is no motor
reaction, not even when the strongest electric stimulus is
applied. 4. Asphyxia causes tonic contractions of the uterus
by the action of the asphyxiated blood on the lumbar genito-
spinal centers. In all of Keiffer's experiments, arresting the
respiration produced extreme constrictive muscular activity in.
the uterus. As soon as respiration became reestablished, the
muscular activity subsided to normal. This phenomenon does
not appear after destruction of the lumbar portion of the
spinal cord. 5. The cervix uteri is a true sphincter like the
other muscular rings, of the body, but resembles most the iris.
There is no antagonism between the muscular activity of the
body and that of the neck of the uterus, but both combine in
a succession and combination of movements to produce the
maximum effect in shortening the uterus and dilating its out-
let. The cervix as it opens obeys the suspensive action of its
circular sphincter, but also and principally, the constrictive
action of its radiating fibers, and a longitudinal constriction of
the vagina and of the body of the uterus. 6. The tonicity of
the uterus is maintained by the reflex activity of the lumbar
portion of the spinal cord. 7. The tonic center seems to be
located in the dog, on a level with the principal part of the
fifth lumbar vertebra. 8. In the coordination of the muscles
of the body and of the neck of the uterus, opposite effects may-
be produced in one or the other of them, at the same time, and
by the same excitation. 9. The pneumogastric is not an
excito-motor nerve, nor a direct moderator of the uterine
sphincter. 10. Asphyxia contracts the cervix ; then relaxes it.
11. Acute anemia produces complete relaxation of the cervix;
uteri ; transfusion produces constriction. The proof that the
tonicity of the cervix is maintained by reflex activity proceed-
ing from the spinal cord, lies in the following facts established
by these experiments : 1. That the cervix can support a pres-
sure indicated by a column of liquid that varies with the exci-
tation, if the cord is intact. 2. That the height of this column,
and consequently the amount of pressure supported, can be
increased or diminished at will by exciting the lumbar portion
of the cord (fifth lumbar vertebra). 3. That destruction of the
spinal cord in the vicinity of the fifth lumbar vertebra para-
lyzes the cervix to a greater or less degree. 4. That destruc-
tion of the region of the spinal cord below the fifth lumbar
vertebra completely abolishes the sphincter function.. It even
L896.]
PKACTICAL NOTES.
603
relaxes the entire uterus. 5. It is probable that this point in
the spinal cord corresponds in the dog, to Budge' sgenito-spinal
center, which varies in different animals. In conclusion Keif-
fer seeks to establish an absolute physiologic similitude
between the uterus in mammals and the human uterus, basing
his statements on the development of the embryo, and on a
long array of clinical facts which confirm what he has
learned in his experimental investigations. —Annates de laSoc.
Mid.-Chir. dr Liege for July.
Success of Ichthyol in Tuberculosis. —The efficacy of ichthyol in
the treatment of whooping cough, ozena, urethritis, etc., has
been announced in these columns, and the Journal de Mid. de
Paris of August 9, now adds an enthusiastic recommendation
of it as an effective weapon in our struggle with tuberculosis,
the first article which has appeared in France, although Scarpa,
I" una and Cohn have been advocating it for Borne time, with a
record of 300 eases treated. The writer is Le Tanneur of the
Helle\ •illeConsumption 1 lospital and Dispensary. He describes
his experiments to determine the antiseptic power of ichthyol,
and suites that absolute sterility is secured with 5 percent.,
although the shape of the Koch bacillus is altered and its
development much retarded at 2 per cent, and even less. He
administered it to his patients in capsules (Chiron's) 0.25 cen-
tigram each, from four to twenty-four a day. No effect was
observed under six to eight capsules. He commenced with
two and increased to twenty per day, taken three times a day,
during the meals, but there is no necessity for so much caution
DOW, as none of the fifty cases treated ever showed any incon-
venience from its use, and several cases of complicating diar-
rhea and gastric disturbances were found to be cured by it.
The cough was much improved owing to the liquefaction of the
sputa produced by the ichthyol, which also cured the conges-
tion of the bronchial tubes. The color of the expectorations
changed from green to yellow, then to gray, and finally to the
ordinary color of mucous secretions, a long stride toward
recovery, even in the minor point that they ceased to cause
gastric disturbances when swallowed. The dyspnea is relieved
at once by the liquefaction of the sputa and the decreased
congestion, which rests the heart and raises the general tone of
the system. Pain in the intracostal region is also much
relieved, probably for the same reason. The general health
does not show improvement as soon as with hypodermic injec-
tions of guaiacol, but it arrives and progresses none the less
surely, and the patients gain flesh much more than with guaia-
col. Several gained seven to eight pounds in the first month,
others four, and two-thirds of the cases showed marked
increase in weight. The sweats also diminished, but appar-
ently only as the general health improved, as this effect was
not noticed as promptly as with creosote or guaiacol. The
appetite was not unfavorably affected as frequently by guaia-
col, but was improved and restored to normal in many cases.
One of the ten observations he records was a man of 41. Pri-
mary tuberculosis, coughing and expectorating for four years,
without relief from creosote or any remedy. Fever 102 degrees
every day. Dullness at the upper part of both lungs. Gained
six pounds in one month of ichthyol treatment. Coughs only
in the morning and "feels strength and respiration returning."
Another, 67. Bronchial catarrh for thirty years. After one
month of ichthyol treatment cough entirely gone, and "feels
better than ever." Another, 35. Advanced case of tubercu-
losis. Strength entirely gone. After ono month, "Aspect of
astonishing health." Coughs less than a quarter of what he
did previously.
Le Tanneur concludes by stating that while ichthyol is by
no means the long-sought specific for this terrible disease, yet
great benefit is derived from its use as a substitute for creo-
sote and guaiacol when, as so often happens, the system has
become so habituated to them that they fail to affect it. It is
especially indicated in bronchial tuberculosis, which it most
promptly relieves. Its disagreeable odor renders the use of the
capsule imperative.
PRACTICAL NOTES.
Success of Serum Treatment of Oriental Plague.— A telegram
from Yersin announces that he has succeeded in curing twenty-
five out of twenty-seven cases of the bubonic plague with his
anti-plague serum from his laboratory established in Annam a
year ago. The usual mortality is 95 per cent. — Bulletin Mid.,
August 12.
Thermotherapeutics of Gonorrhea.— Neisser has stated that the
gonococcus loses its power of development at a temperature of
113 degrees. Callari has found that the normal male urethra
will bear tqis temperature and the female two degrees higher.
He has been treating gonorrhea with injections at 113 degrees
and reports a progressive disappearance of the gonococci in the
majority of cases with this treatment. In order to avoid
unnecessary congestion, he injects a 6 per cent, solution of
cocain ten minutes before. — Gaz. degli Osp. e delle Clinic,
August.
Successful Treatment of Ozena with Ichthyol.— It is reported from
Vienna that ichthyol will cure the fetid breath in ozena more
rapidly and permanently than any other known remedy. After
washing off the crusts with tepid water, two or three syringes
of a 2 to 5 per cent, solution of ichthyol are injected into each
nostril, the head held well forward and the mouth open to avoid
swallowing the liquid. The rhino- pharyngeal mucous mem-
brane is then swabbed with a cotton wad dipped into a 25 to 30
per cent, solution of ichthyol. It is also stated to be the best
treatment for dry pharyngitis, with or without complicating
ozena. — Simaine Med., August 12.
Fragrant Antiseptics. — In cases of foul smelling cancers, etc.,
the odors are completely disguised if the room and bed are
well sprayed with a mixture of alcocol, 500 gr., essence of
thyme and essence of lavender, 50 gr. each. This agreeable
disinfectant also possesses powerful antiseptic properties.
Huchard recommends a similar antiseptic spray for the apart-
ments of tuberculous patients : guaiacol 50 grams, eucalyptol
40, phenic acid 30, menthol 20, thymol 10, essence of cloves 5
and alcohol at 90 degrees, q. s. to make one liter. — Gaz. Mid.
de Liege, August 20.
Hypodermic Alimentation with Saccharin Solutions.— Some recent
experiments at Munich with persons in normal health prove
that artificial alimentation is possible in this way. Dextrose,
levulose and maltose injected in a 10 per cent, solution were
entirely assimilated by the organism, while cane or grape sugar
were rejected and eliminated in toto by the kidneys. The
slight pain that followed the injections was cured by massage.
The best method of making the injections is to use a glass
receptacle with a rubber tube and T-shaped canula. A needle
is inserted into each branch of this canula, so that an injection
can be made into each thigh at the same time, and a whole
liter injected in fifteen or twenty minutes. The amount was
increased progressively from 100 to 1000 c.c. Former experi-
ments at Wiirzburg failed of success probably because the
solutions were too strong. — Semaine Mid.. August 12.
Treatment of Syphilis with Mercuric lodid Hemol. — As this is the
only preparation that contains iron, its use is indicated when-
ever a tonic action is desired. It is effective and simple,
although no internal medication takes the place of frictions
and injections. Rille reports thirty-seven cases he has treated
and eighteen from Neumann's practice. A few slight transient
inconveniences followed its use occasionally, but they were
less than with any other internal medication. He administered
it as follows : 10 grams Robert's mercuric iodid hemol ; 0.8
604
PRACTICAL NOTES.
[September 12,
decigrams opium powder, and q. s. licorice powder ; made into
fifty pills ; taken two or three times a day, after meals. He
recommends it for anemic and scrofulous cases of syphilis. —
Annates de Derm, et de Syph., July.
What is Indicated by the Tongue.— A white tongue, according
ing to Dr. Ardhill, indicates febrile disturbance ; a brown,
moist tongue, indigestion ; a brown, dry tongue, depression,
blood poisoning, typhoid fever ; a red, moist tongue, inflamma-
tory fever ; a red glazed tongue, general fever, loss of diges-
tion ; a tremulous, moist and flabby tongue, feebleness, nerv-
ousness ; a glazed tongue with blue appearance, tertiary
syphilis. — Pop. Science News, August.
New Method of Preserving Specimens with the Original Coloring.—
Some preparations a year old were exhibited recently at the
Academie de Me"decine by Melnikoff-Rasvedenkoff of Moscow,
which appeared as fresh and perfect in their coloring as if
they were only a few hours old. According to this new
method the fresh organ is placed in formalin, an aqueous solu-
tion of formaldehyde at 40 per cent., which toughens and dis-
colors the tissues. At the end of twenty-four hours the piece
is transferred to alcohol at 95 degrees, and left six to eight
hours. In this bath the organs recover their previous coloring
and the blood a tint as if the vessels had been freshly filled.
The piece is then placed in an aqueous glycerin solution of
potassium acetate. (Acetate 30, glycerin 60 and dist. water
100. ) This sets the color permanently. After this it is removed
to the final preserving fluid, made by boiling together 100 grams
of gelatin and 600 grams of water, to which are added 350 cubic
centimeters of solution of potassium acetate. After filtering
this through a double filter, 700 cubic centimeters of glycerin
are added, and the process is complete. — Bulletin, August 4.
Actinomycosis of the Lower Jaw. — Ducor of Paris reports a
case of an enormous tumor on the lower jaw, with great emacia-
tion and general distress. The patient belonged to the upper
classes and submitted to treatment from twenty surgeons, dur-
ing eight years before a correct diagnosis and relief were ob-
tained. Ducor suspected and established the presence of the
ray fungus, and secured great improvement with potassium
iodid, 2.5 grams per day, painting the intra-buccal surface of
the tumor with tincture of iodin, and injecting it into the
parenchyma, mixed with equal parts of glycerin. Potassium
iodid in this case again, showed itself the specific remedy for
actinomycosis, although the lesions were of too long standing
to expect complete recovery. There is no doubt that this dis-
ease is far more frequent than is generally supposed, but fails
of recognition, so that the possibility of actinomycosis should
be borne in mind in any tumor of the jaw. In this case it was
found that the patient had the habit from her youth of chew-
ing grains of wheat, etc., and picking her teeth with the stems.
See this Journal, July 11 and 25, pages 98 and 226. — Bulletin
de V Acadimie de M6d., August 4.
Treatment of Malarial Splenic Troubles with Oleate of Rue and
Cyclamen. — In a communication to the Gaz. degli Osp. e delle
Clin., August 9, Colasuonno remarks that physicians in Italy
have especial opportunity to observe the effects of malaria, and
that he has had a wide experience in treating splenic disorders,
which are the most important manifestation of chronic malaria,
as the spleen is not only the chief seat of the localization of the
active agents of the disease (Maragliano), but owing to the fre
quent hypertrophy produced, it causes a series of ills, espe-
cially if the organ becomes displaced. He then proceeds to
announce with confidence that he has established the efficacy
of a combination of oleate of rue and cyclamen roots as a
remedy for malarial splenomegalia, and has even' secured com-
plete recovery in a case of wandering spleen. This was a
woman of 40 who came to the hospital at Naples to have an
operation performed, as the enormously hypertrophied and
displaced spleen caused by chronic malaria was producing
intense gastric disturbances. Instead of an operation the
region was frictioned five to ten times a day with the oil of rue
and cyclamen. At the end of a month of this treatment the
spleen had been reduced to its normal size and position, and
has remained normal during the seven years since. He used
equal parts of crushed cyclamen roots and oleate of rue made
from the leaves, which he has well rubbed into the region, with
massage.
Ununited Fracture — Use of Bone Ferrule. — The patient sus-
tained a severe fracture of the humerus some months ago as the
result of a gun-shot wound. There was great loss of the shaft of
the bone with paralysis of the musculo-spiral nerve. The case had
been operated upon on the Pacific Coast, at which time several
fragments were removed and the remaining ones wired to-
gether. Unfortunately there was no attempt at reunion. On
April 2, we operated upon this case and found that there was
great longitudinal diastasis of the fragments of the bone and
also those of the nerve. The fragments of bone were fresh-
ened obliquely and a bone ferrule slipped over the point of
their approximation. These ferrules are made from the femur
of an ox and have been but partly decalcified. The distal end of
the nerve was easily found in this case, while the proximal end
was found with great difficulty. After succeeding in finding
it, however, we sutured the ends and surrounded the point of
union by muscular tissue, in this way preventing the implica-
tion of the line of union of the nerve with the cicatrix of the
bone. At the point of the fracture we now find considerable
definitive callus. The ferrule has taken the place of the pro-
visional callus. We have every reason to believe that this case
will soon recover. I know of no more effective way of uniting
compound fractures, whether primary or secondary, than that
by means of fixation with bone ferrules. The limb was dressed
with a simple right angle.splint, held in position by a plaster
of paris dressing, which included the shoulder. The bone
ferrule will be absorbed in from six to eight weeks. — Dr.
Nicholas Senn in the Clinical Review, September.
Veratrum Virlde in Puerperal Eclampsia.— Dr. C. D. Hurt says :
Veratrum viride is a nervous sedative, a muscular relaxant, a
glandular excitant. When taken into the system it lessens
the susceptibility of the sensory nerves, and modifies the action
of the spinal cord and vasomotor nerves. At the same time, if
coma exists it has a property of removing it and restoring the
mental functions. Other remedies for puerperal eclampsia
have their places, and some of them are valuable ; but no one
meets all the indications as does veratrum viride. Taken in-
ternally chloroform acts as a sedative narcotic, operating chiefly
through the nervous system, independent of vascular action or
congestion or without any beneficial influence on the latter
condition. Veratrum is a sedative, operating through the ner-
vous system, relieving coma, and removing congestion, and
eliminating certain effete matters by stimulating the secreting
organs. Bromid of potash and chloral are too feeble, unrelia-
ble and slow in their action. Morphin stupifies, lessens pain,
but is objectionable in locking up the secretions. Apomorphia
produces greater distress with fewer good effects. Venesec-
tion is admissible in all robust patients or cases of plethora, by
removing a certain amount of effete matter from the system
and encouraging easier and more rapid dilatation of the os. In-
deed, with venesection and the judicious use of veratrum there
is no condition of the os not dopendent upon actual stenosis
which will not yield to parturient pains and avoid the necessity
of incising — a surgical dexterity into which some obstetricians
are easily tempted. Veratrum is suited to the treatment of
eclampsia, whether antepartum or postpartum, unless chronic
disease or excessive anemia be present. — Atlanta Clinic,
August.
18%.]
EDITORIAL.
605
THE
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tied by the postmasters of the larger cities that second-class mail mat-
ter not having street address, would be placed in the general delivery
to await call.
SATURDAY, SEPTEMBER 12, 1896.
JANUS.
The name of the two-faced Latin deity has been
given to a bi-monthly journal, the first issue of which,
for July and August, 1896, has just reached this conti-
nent from its headquarters in Amsterdam, Holland.
JANUS looked backward as well as forward that he might
have ever in view the lessons of the past for his guid-
ance in the uncertainties of the present, and he is
thus made to symbolize the intentions of the Editor-
ial Start' of this new undertaking in medical literature,
the "Archives internationales pour l'Histoire de la
Medecine et la Geographic m<5dicale," or rather this
attempt to resuscitate, under the conditions of the
present day, an undertaking which failed under those
of half a century ago; for although to many this
Jmiiis is a new thing, to those who are versed in the
archives of medicine it is Janus Redivivus. This is
shown in an enthusiastic introductory paper written
by Professor Stokvis of Amsterdam, at the request of
M. le Directeur Dr. Peypers of the same city, who
modestly characterizes himself as too little known out
of his immediate circle to be the proper accoucheur
for an international journal.
Fifty years ago, that is in 1846, an era of extraordi-
nary progress dawned upon medical science. The
heavy chains of the philosophy of the age, with which
the natural sciences, together with the science of
medicine in Germany had been riveted, were broken
forever. The microscope and other new appliances
for physical research, with newly discovered chemic
methods, led to a return to experiment and careful
observation. Hypotheses and systems were rejected,
while facts developed by the methods of natural
science conduced to the recognition, one after another,
of many hitherto unknown biologic phenomena of
the greatest importance to the science of art and med-
icine. The cell was already appreciated as the primi-
tive element of life. Henle had already published
his Anatomy, in which he continued the immortal
work of Bichat. The predecessors of Pasteur in
following the light of Schwann and Helmholtz had
already shown that fermentation is a vital process
which ceases as soon as the conditions needful to the
life and development of the microorganism are with-
drawn; and the medical world was on the verge of the
discovery that every special fermentation is deter-
mined by a specific microorganism, and that those of
the alcoholic, acetic, lactic and butyric fermentations,
are distinguished one from the other, not only by
their function, but by their form. At this time medi-
cine became permeated with new blood. The fruits
of the genius of Corvisart, of Laennec and of
Cruveilhier, had been planted, improved and propa-
gated by Skoda and Rokitansky of the school of
Vienna. Henle was preparing his Rational Path-
ology. Claude Bernard, who unveiled so many of
the mysteries of animal and vegetable life, was already
close to his discovery of the glycogenic function of
the liver. The brothers Weber had just announced
the first illustration of an inhibitory nerve. Traube
was beginning his beautiful series of researches in
experimental pathology, and Virchow, the grand mas-
ter of our modern pathology, revealed in this year the
pathogenesis of fibrin in the vessels, of embolism of
the pulmonary artery and of leukemia.
In the midst of this era of progress the original
Janus was started by Henchel of Breslau, aided by
many foreign collaborators. It may be observed that
a number of National Archives had been launched
before this, and had foundered because one country
alone was unable to sustain a historic review on the
paying basis of a practical journal, just as at present
it is claimed that one country alone, even though that
country be the United States of America, can not
maintain a minor metal on a parity with a major
metallic element. Even Henchel's international
effort failed. The medical world was too busy look-
ing forward to have time to look behind in this formal
way. Janus failed in 1848, but its editor, aided by
Heusinger of Warbourg, and others, reestablished it
in 1851. Despite, however, the enthusiasm of a few,
it again failed, because the active members of the
profession took but little interest "in the important
papers on the history of medicine and medical geo-
graphy which it contained."
Now, in the year of 1896, when, as in 1846, the
medical world is on the qui vive for fresh develop-
ments, Janus redivivus est. Will it succeed? Have
606
" THE NEW NURSE " AGAIN.
[September 12,
we time to look back? Do we need to look back with
full face? Few systematic articles in this Journal of
the American Medical Association fail to bring
their subjects up from ancient times to date. This
testifies to the use made of our medical libraries. Is
this enough, or do we require a new and special jour-
nal? All sorts and conditions of men make up the
world, and all sorts and conditions of minds make up
the medical world. The energetic, enthusiastic work-
ers are in advance on the skirmish line; but should
there not be cautious, conservative minds surveying
the pathways which led to the present position, the
better to indicate those which should be pursued for
final triumph? We think so. We think that Janus
has a mission; for when we find among many notable
European names on the Editorial Staff those of Pep-
per, Osler and Sternberg, and among the collabo-
rators the names of N. S. Davis and Nicholas Senn,
of Jacobi, of New York, and of Hare and Guiteras,
of Philadelphia, we must conclude that the Interna-
tional Archives will prove their value and meet that
success under the conditions of the present age which
was denied them half a century ago.
"THE NEW NURSE" AGAIN.
Being a woman, it follows that in the universal pro-
cess of rejuvenation and modernizing to which every-
thing is to be subjected the nurse must also be made
over. It might seem that the professional nurse were
herself such a modern product that any remaking after
the manner of the new woman, would be a wholly
superfluous proceeding. But in England, at least,
protest has apparently become necessary, and we sus-
pect it may be about time for Americans to reconsider
the questions of over-education or mal-education,
proper functions and delimitations of the nurse. Dr.
Malcolm Morris in The Practitioner for July, 1896,
has some rather sarcastic remarks upon the subject.
To us at least, and pondering the matter from our
point of view, Dr. Morris seems to be somewhat too
ironical. Perhaps the dreams and ambitions of our
American girl are kept well in petto and are only
awaiting power and greater storage to break into the
expression which has piqued the transatlantic editorial
pen. Doubtless American gallantry would have been
slower to snip or snub the nursoreal ideal or tendency.
We are proverbially more generous to our sisters than
the nation which has labored so long and only at last
half successfully to permit a deceased wife's sister to
cast sheep's eyes at the widower of her defunct sister.
We may be too impulsive but our generosity is equal
to permitting the deceased wife's sister the freest
privileges and ambitions.
But surely she is a better nurse than any man, and
we are all happy to acknowledge that these modern
doctoring days are much easier for us, and the prog-
nosis in the patient's case is far better than it was
before we had the nurse's beautiful conscientiousness,
and gentle patience to aid us. Dr. Morris even
denies the fact which we thought so true and well-
recognized as to be pure platitude, that the presence
of the young women in the wards and private rooms
of the hospital has been the principal and persistent
cause of a decided improvement in hospital manners,
student brutalities and vulgarities, and even in pro-
fessional characteristics. " The type of Bob Sawyer
was extinct long before the ' lady-nurse' came upon the
scene," he says and otherwise dashes the poor girls
with the quintessence of his irony, ending up with
the wild lunge that the softening of manners is due
more to " the fear of the examiner" than the subtle
influence of the nurse. In all of which we fear the
Englishman has let his prejudice get the better of his
generosity and courtesy. We believe no American
physician would for one moment deny that not only in
the past but in the present time the whole atmosphere
of the ward and clinic is purified of the former
vulgarity and rowdyishness by the silent presence of
"petticoats," the white-capped priestesses of dig-
nity and purity hovering about, dextrous in service,
and often as powerful in influence when they only
" stand and wait."
The only fear we have as to the matter of " over-ambi-
tion" and " over- education " of nurses concerns their
physical and neurologic ability to do their work, and
receive and digest the scientific food they seem both
willing and eager to have given them. If they could
safely do so, we do not see why they should not have all
the lectures and examinations on "surgical anatomy,"
or upon any other subject related to their calling, they
are pleased to desire. But precisely this doubtful " if "
gives us pause. We feel like finding a way out by
lengthening the course of study or apprenticeship so
that there shall be greater freedom, or at least some
little relief from the frequently frightful and inhuman
over- work and over- worry of their schools. This is cer-
tainly easy of accomplishment, because now there are
so many girls wishing to enter the schools that, by rea-
son of the greater numbers possible, the hours of work
might be shortened and the drudgery lessened. In
this way the standards of character and acquirement
could be raised without endangering the health. We
have no such fear as seems to glare at one from
between the lines of our English contemporary, that
any one, even a nurse, can be too highly educated for
the most menial occupation. We have no tendency,
thank heaven, to look upon the nurse as a menial or
as a servant. It is rare indeed that one will hear an
American physician speak to a nurse in a harsh or
dictatorial manner, and as if she were a common maid-
of-all-work.
There is one aspect of the nurse question to which
we have seen no allusion in any of the contro-
versies, and which may deserve a passing wprd.
1896.]
THE LOWERING DEATH RATE.
607
Women arc natural politicians, born partisans, good
in execution and obeying, poor in loading and order-
ing, it is proverbial that the worst enemies of some
women are other more fortunate or shrewder women,
ami that in stoves or factories the harshest and most
unkind "heads of departments'' or "bosses" are
those women who are put in authority over other
women. Prom all this it results that instances have
been known in which the chief nurse has been an
inexhaustible fountain of trouble and injustice. In
the first place, she is almost certain to have a favorite
doctor or two, and to be as "hateful" and intriguing
toward others she does not like, as she is more than
kind and intriguing toward her favorites. Worse
than this, her partisanship is almost certain to be
hotly active in the matter of favoritisms and anti-
pathies to the girls who must be as tools in her hands.
She gives her favorite doctor her favorite nurses, and
to the unfortunate whom she detests she allots the
poor child who has justly or not incurred her ill-will.
No one so keen as she to find symptoms of "nursitis"
in the medical student or young resident physician,
and to trace the infecting materies morbi to its source
with a certainty and celerity any bacteriologist might
•envy. In the legal manner of speaking, justice is
liable to fall with an all too heavy hand upon the
weaker party. It has been also whispered that at
limes she allows herself a greater freedom in the
matrimonial game than she gives her competitors,
and that wily and subtle-minded physicians have
made use of the favor of the chief nurse to further
the getting of patients, the delivery of lectures, and
other ways of self-seeking forbidden men of greater
self-respect. However all this may be, it would seem
well not to allow too much autocratic power and
authority to her ladyship until it shall have been
proved, by some fifty years of service, that she will not
use it except justly among the poor voiceless creatures
with whom she has such numerous and devious means
of unjust subjugation or reward, or as relates to the
hardly more important matters of professional life or
therapeutics.
THE LOWERING DEATH RATE
There is certainly no more astonishing and gratify-
ing fact in modern civilization than the enormous
decline and still progressively decreasing death rate of
the more progressive and best governed countries.
We have in England a proof of the fact which, owing
to the length of time over which they extend, and
the accuracy of the statistics, brings the result clearly
before the mind. Estimated by quinquennial
periods the general English death rate per 1,000 from
1858 to 1895 was as follows: 22.22, 22.58, 22.42, 21.96,
20.79, 19.40, 18.90, and 19.04 respectively. In Lon-
don alone, the largest civilized city in the world, the
rate has been reduced to about 17, while certain dis-
tricts of the metropolis have reached as low a rate as
14, 13, and even 12.
In the United States, with less concentration of
population in large cities, we must confess the shame-
ful fact that human life is more recklessly and need-
lessly sacrificed to the brutality of politics and sani-
tary heedlessness than in older countries. It is noth-
ing less than a disgrace that in our smaller cities, and
with the injuries of bad hygiene less necessary, we
y<t are killing off our citizens at the rate of from 5 to
10 per 1,000 faster than in European cities. Think
of what this means in a city the size of greater New
York! If her death rate is 5 per 1,000 greater than
it need be, one shudders to contemplate the many
thousands of citizens needlessly murdered every
year.
In some of our cities the condition makes this fact
still more evident and startling. Accurate figures
are not before us as we write, but we believe that in
a number of moderately sized cities the death rate has
been reduced to a remarkably low figure. It has
lately come to our notice that in one of our cities,
Buffalo, by the persistent and heroic labors of the
energetic health officer, the rate has been reduced to
11.67. If we are not mistaken, this is the lowest ever
made by any city of the world of equal size. If the
saving of one life is worthy of medals and public
honors, what kind of medals and honors should be
awarded to Dr. Wende for the thousands that are
living in that city to-day, who under a less thorough-
going sanitary management would have died? And,
on the other hand, what rewards should be given
other cities where the death rate is double that of
Buffalo? Perhaps their problems have been harder
and the difficulties more insuperable, but perhaps,
also, they have not. Leastwise, they have not been
so proportionately to the contrast in the death
figures.
Buffalo's death rate in the year preceding Dr.
Wende's accession to the office of Health Commis-
sioner (1891) was 23.48 per 1,000 population; prior to
that it had averaged above 20 per 1,000. In 1892 the
rate was reduced to 19.98, to 19.03 in 1893, to 16.76 in
1894 and to 13.95 in 1895. For the first six months
of 1896 the rate is 11.67, with prospect that the year
will see it not far from 12 per 1,000.
All physicians know the essential prerequisites of
such a reduction of disease: A reorganization at once
upon a thoroughly business-like and scientific basis of
the health department and the stamping out of the
causes of disease. In Buffalo the immediate reporting
of cases of contagious disease by telephone was made
mandatory; visitation and vaccination in the public
schools instituted; the sealing up of an emergency
inletof sewage-polluted water supply followed. Weekly
examinations of the water are continued to this day;
a thorough and watchful reorganization (with prose-
608
EDUCATIONAL NUMBER
[September 12,
cution of delinquents) of all the conditions surround-
ing the milk supply was made; food and drug inspec-
tion ; tenement house inspection ; a justly tyrannical
oversight of all drainage, plumbing, etc.
It must not be forgotten, also, that the death rate
alone does not represent the expense either in suffer-
ing or dollars to the community. Dr. Farr estimates
that for every death there are on the average two
years of illness in a given community. It is need-
less to emphasize the tremendous significance, to
those with open eyes and humanitarian feelings, of
the thousands of years of prevented illness and suffer-
ing, shown in the foregoing figures.
There are many lessons to be gleaned from these
figures, but there are one or two that we can not omit
to notice:
1. In a general way it can not be denied that this,
the greatest good that has been brought to humanity,
is in the main due to medical science, and to the vir-
tue of medical men. Either in the long historic series
of preparations for the realization of the endeavor, or
in actually and practically working it out, or in both,
the medical profession has undoubtedly been the chief
instrument. Without undue self-satisfaction we may
lay no little emphasis upon the fact and justly claim
that although our work is with disease, and our wage
drawn from the conflict with disease, yet there is not
one lay citizen more glad, probably none so genuinely
happy as we, that we are stamping out disease and
death. Surely few or none are so unsatisfied with the
result, grand as it is, and so resolutely determined to
go on and make the blessing still greater. We have
reduced the death rate in the last twenty-five or thirty
years, of smallpox from 219 to 22 per 1,000; of typhoid
fever from 373 to 135; of typhus fever from 81.4 per
million to 2; of phthisis from 2,565 to 1,512, and so on.
As to scurvy, leprosy, the plague, cholera, malaria, etc.,
they are fast becoming mere names in the history of
medicine. But is the community grateful? Witness
our half failures, and half successes, with more abso-
lute failures, to wrench from the public even the sim-
plest essential medical practice acts! The public
loves its quacks far more than it does us.
2. And what is this precious public for whom we
labor, not oidy not doing for the elevation and pro-
tection of the profession, but what is it doing for its
own sake, more directly, in founding and supporting
bacteriologic and hygienic institutes, boards of health,
etc? If we had the money wasted on paper cutters,
pocket books, and luscious luxuries by our legislators
we could pay the expenses of a dozen such institutes
and save the lives of a hundred thousand people in a
few years. Suppose even we could have a few of the
millions now given as bribes to fraudulent pensioners!
This public can endow theologic schools and chairs to
teach boys Hebrew, Latin and Greek, etc., but where
is the endowment to be found to endow medical col-
leges or chairs where shall be taught the saving of
life?
3. Not only may we complain of not being helped,
but we have to fight against opposition. Take the
crying abuse of turning a medical Health Officer out
of office in obedience to the criminal demands of
"practical politics." The place-hunter and spoilsman
must have his turn regardless of the community's
health and rights. The term of office of an Officer of
Health should and must be made unlimited and solely
dependent upon success and capacity. It is simply
disgusting that just when the year or two of experi-
ence has begun to fit a man for the efficient discharge
of his complex duties, he should then be turned out
to make way for a novice.
EDUCATIONAL NUMBER.
For the convenience of students, and the informa-
tion of the profession generally, we shall issue an
educational number next week. It will be seen that
in the last decade, gigantic strides have been taken in
bringing up the average standing of the medical col-
leges. The increase in the facilities for laboratory
instruction is one of the gratifying features of the new
exhibit.
There are many alleged medical schools not
accounted for in this exhibit, but as a rule they ought
not to be considered. We have been informed that
there are about fourteen medical schools in Chicago
alone; only a few of these have any reason for exist-
ence, and if rigid requirements were insisted upon
they would close their doors.
The struggle for existence is at the root of the evil ;
finding themselves unable to compete with the real
college professor in obtaining practice from the pub-
lic, these persons, with others of the same ilk, start a
so-called medical college, and become " professors"
themselves. There are few statutory requirements;
an act of incorporation can be obtained for a silver
dollar in any stage of depreciation, a building rented,
and a flaring sign put across its front. Verily, the
" professors" are as plenty as the leaves of Vallam-
brosa. If we look into the equipment of these raw-
institutions, we find the Laboratory wofully lacking
in the most ordinary apparatus, and like Do-the-boys
Hall, squalor and filth are the most prominent char-
acteristics. The only wonder is, that such men, with
such miserable equipment, can find students; but they
flourish in some way. The cure for this evil will come
when the real medical colleges have endowed chairs,
and the professor no longer enters into bread-and-
butter competition with the general profession. Then
it will be possible by statutory enactment to prevent
the establishment of improper and imperfectly
equipped schools. It should be a simple thing for
the legislature of any State to fix a minimum stand-
ard of equipment. If this were done the tone of the
medical school would be much higher, and the pro-
fession generally better pleased with them.
18W. 1
CORRESPONDENCE.
609
CORRESPONDENCE.
Dislocation of Hip.
Clyde, N. V., Sept. 2, 1896.
To tin- Editor:— In looking up some of the literature rela-
tive to dislocations of the hip, I especially noticed the remarks
made when reviewing the work of Dr. Allis relative to some
difficulties attending the reduction of the same, and which I
found in the Journal of April 10 of this year.
M \ notice was especially attracted by them, as they reminded
ma of a case which came under my care in 1859, where the head
of the femur was upon the dorsum, which I failed to reduce
by every known means except that by Chapman imanipula-
. afterward revived by Dr. Reid, which I did not try. Dr.
Hekl was then a resident of Rochester where, as now, was also
the home of "our own" Moore.
When obliged to give it up, and having visions of a suit for
malpractice (as the accident was in a poor family), I sought
the aid of Prof. K. M. Moore to help me out of my trouble. He
in his goodness of heart not only personally came to my rescue,
but also brought Dr. Reid with him, saying: "This is Reid' s
hobby, and we will let him reduce it by manipulation." After
arriving at the house, and when everything was in readiness,
Dr. Reid began his manipulations. After vainly trying for a
long time he did not succeed, and gave up the reduction of it
by what was then called his method, and requested me to
apply Jarvis' Adjuster, hoping that with it it might aid in an-
other effort by manipulation.
By this time the mercury was as high as it could conve-
niently climb in the thermometer, and all hands stripped as for
a pugilistic encounter. Dr. Reid again renewed his attack
and succeeded in changing the locality of the head from the
dorsum to the thyroid foramen, where it is at this day, and
where I have, from that time to this, wished the head of the
young man was also, as he and his friends for a long time were
unceasing in their denunciations of me, and even went so far
as to consult an attorney. The attorney's reply, I afterward
learned, was. "You can not recover against the Doctor with
such men as Moore and Reid at his back." That ended all
thoughts of prosecution, but not the vehemence of the young
man's and his friend's abuse.
There was to me a gratifying sequel to this case which was
this : Five or six years after the circumstances above related,
a messenger came for me in great haste to visit a young man
who had been thrown from a horse, and whose leg was thought
to be broken. I visited him, not suspecting whom I was to see.
1 found a fracture of the femur at its lower third. As I was
about to make preparations, the young man said, "Doctor, you
have had something to do with this leg before," whereupon
making some inquiries, I learned that he was the young man
who had denounced me so savagely some years before. I rose
from my chair and said to him, "Then you are the individual
who, some years ago, was unremitting in your denunciations
of me for not having done what two distinguished surgeons
also failed to do. I am glad you have enlightened me. I
would have reduced your fracture and done for you to the best
of my ability, but I shall not place myself in a position for
history to repeat itself. You must secure the assistance of
another surgeon."
It was pleasing tome to hear him beg and promise that what-
■ever the result might be, if I would assume the care of
his case, he would never murmur. Another surgeon was
called and what the outcome was I am unable to say, as he
lived in another town, and beside that I never made an inquiry.
This communication is intended more especially to refer to
the cause of our inability to reduce the dislocation, which
cause was the one given by Professor Moore at the time, the
"untorn portion of the capsular ligament," and he went so far
as to say to the mother of the young man (she was a widows
"If you will let me take him to the hospital I will cure him by
cutting down and liberating the head of the bone," but she
declined.
This was thirty-seven years ago, years before antisepsis was
thought of, and when, if I remember correctly, cutting into a
joint was considered fatal so far as future use of it was con-
cerned, if not fatal to the life of the patient. I well remember
that on our way home Drs. Moore and Reid had a warm dis-
cussion relative to the propriety of the operation which Dr.
Moore had urged upon the mother, the latter strenuously
opposing it as it would be fatal. Dr. Moore would have made
it, however, regardless of the amount of opposition which
could have been arrayed against it, had he had the
opportunity.
At this late day even, I don't forget how gratifying it was
to me to know, poor as I was, that I was warmly sheltered
under the wings of Drs. Moore and Reid, as suits for malprac-
tice were much more frequent then than at the present day,
for obvious reasons. D. Colvin, M.D.
Treatment of Phthisis Piilmonalls.
Knickerbocker, Texas, Aug. 29, 1896.
To the Editor: — As a country doctor, debarred by semi-
invalidism from leaving a dry and salubrious climate to drink
fresh draughts of knowledge at the founts of learning perpet-
ually flowing in every modern medical center, I derive no little
satisfaction and mental profit from noting the progress of
medicine as recorded weekly in our Journal.
Having found that while in my own person the progress of
pulmonary phthisis is satisfactorily arrested by climatic and
hygienic measures, these nevertheless fail for obvious reasons
to act so favorably upon many other invalids who resort hither,
I therefore naturally feel a profound interest in every new
therapeutic claim which relates to the treatment of consump-
tion. Although somewhat skeptical of the confident claims
advanced in behalf of every new treatment of phthisis since
Bergeon failed and Koch fell short of success, I yet cherish
the hope that with the onward march of medical progress, a
greater measure of success than ever before lies just ahead of
us. And, so, when experienced and eminent bacteriologists,
like Dr. Paquin and Professor Klebs, offer a serum or a definite
product of the bacteriologic laboratory scientfically prepared
by experts and favorably reported on by clinicians, I am dis-
armed of my natural prejudice sufficiently to accept the scien-
tific basis on which their preparations are claimed to act, and
in selected cases to give them a trial. But when "A New
Treatment of Phthisis," as presented by Dr. Hubbard Win-
slow Mitchell in the Journal of August 15, prescribes a for-
mula of simple chemic agents, supported by extraordinary
curative claims based on two .years' observation and an exten-
sive list of cases treated, my old skepticism returns rampant
on noting the indefiniteness of the composition of the "fluid"
recommended.
In view of the magnitude of the claims made for a "fluid"
composed of so simple ingredients, I wish to protest against
the inexactness of the published formula, to which, after
giving the list of chemicals entering into its composition
(designated for the most part by unofficial terms) is appended
the direction: "Sodic carbonate, potassic carbonate, equal
parts added in sufficient quantity to bring the solution to the
proper (sic) degree of acidity." In the name of suffering
humanity, what does this mean? Let us suppose in the
absence of a working formula for the preparation of this "fluid"
that an experienced pharmacist shall possess sufficient practi-
cal technical knowledge of chemistry to prepare a .5 per cent,
aqueous solution of chlorin, being guided in his efforts by the
quantitative tests of the A per cent, official solution of the
pharmacopeia, and then should fail to guess the exact quan-
610
BOOK NOTICES.
[September .12,
tity of sodic carbonate and potassic carbonate required "to
bring [Does he mean reduce?] the solution to the proper degree
of acidity?" In the event of failure to secure the expected
therapeutic results, would rural practitioners like myself, who
live far from chemic laboratories, be expected to draw their sup-
plies of this new "fluid" from an expert who prepares it under
the immediate supervision of the author and inventor of the
"fluid?" If not, why is a formula presented which would be
compounded exactly alike by probably no two pharmacists out
of a thousand, who might attempt to follow its directions?
It seems to me if the Doctor reports his discovery for the
benefit of humanity and for the instruction of the medical
profession, he should supply a plain working formula of the
"fluid." But if it is to be made only by experts and under his
own personal supervision, and is to be had on the market at so
much a bottle, then the Journal should send its bill to the
laboratory for advertising, at regular rates.
Boyd Cornick, M.D.
The Polish Physicians of Chicago.
Chicago, Sept. 2, 1896.
To the Editor: — I have the honor to announce to you, that
on Aug. 29, 1896, the Polish physicians of Chicago organized
in a society, to be known by the name of ' ' Towarzystwo Lek-
arzy Polskich" (Polish Physicians' Society), and filed the arti-
cles of incorporation. The articles were signed by the following
physicians : Drs. Ed. Czerniewski, M. Dowiat, M. Orglert-
Kaczorowska, J. P. Kaczarowski, M. P. Kossakowski. W.
Kuflewski, J. Piszczak, W. J. Sieminowicz, W. Statkiewicz,
B. P. Strzyzowski and J. Ziolkowski, and Dr. R. L. Lande from
Milwaukee, Wis.
The directors elected for the first year are : President,
J. Piszczak, M.D. ; vice president, M. Orglert-Kaczorowska,
M.D. ; secretary and treasurer, W. Statkiewicz, M.D.
The purposes of said society are purely scientific.
Meetings will take place alternately at each member's home.
The first regular meeting will take place at Dr. W. Statkie-
wicz's, 3315 Laurel Street, Chicago, at i p.m. on the 12th inst.
Very respectfully, W. Statkiewicz, M.D.
Pan-American Medical Congress.
To the Editor: — I expect to attend the Congress as delegate
from the American Medical Association. Is it necessary to
send my name and fee to the secretary general, City of Mexico?
G. B. G.
Answer :— Send your registration fee, 85 (gold), to Prof. Dr.
Van Francisco Bastillos, Calle de Tabuca, No. 7, City of Mex-
ico, Republic of Mexico.
BOOK NOTICES.
Twentieth Century Practice. An International Encyclopedia
of Modern Medical Science. By leading authorities of
Europe and America. Edited by Thomas L. Stedman, M.D.,
New York City. In twenty volumes. Volume VIII. "Dis-
eases of the Digestive Organs." New York : William Wood
& Co. 1896.
As was the case with Vol. VI, it has again been found neces-
sary to issue the eighth volume out of the regular order. The
publishers say Vol. VII will be the next to appear, upon the
publication of which the series will be consecutive as far as
Vol. VIII. The present volume has been prepared by eight
different authors, four Americans and four Germans; is illus-
trated by 100 original engravings and includes diseases of the
mouth, diseases of the esophagus, diseases of the stomach,
pancreas, peritoneum, animal parasites, and diseases caused
by them, and the treatment.
The contributors are B. Parquhar R. Curtis, New York ;
Max Einhorn, New York ; Reginald H. Fitz, Boston ; James M.
French, Cincinnati ; J. C. H. Huber, Bavaria ; Warner Kiimmel,.
Hans Leo, of Bonn, and Johann Mikulicz of Breslau.
The chapter on diseases of the mouth has been written by
Mikulicz and Kiimmel, and with the usual thorough manner
of the Germans, we have it beginning with the anatomy of the-
parts. Fitz has written a chapter in a very satisfactory manner
on diseases of the esophagus ; Max Einhorn on diseases of the
stomach. Naturally, we expected to see a good deal on the
subject of gastroscopy, as no one in this country has given
more attention to it than Dr. Einhorn. A good deal of atten-
tion has been given to different apparatus for lavage, and this
chapter is well illustrated. The chapter on diseases of the
pancreas has been written by Professor Leo and although short
is very concisely written. The chapter on diseases of the peri-
toneum by B. F. R. Curtis is an excellent one and under this
head the author has included appendicitis. The chapter on
animal parasites and the diseases caused by them, by J. C. H.
Huber, is a very exhaustive resume of the subject.
The volume is fully equal to its predecessors, which is paying
a high tribute to the general merits of the work.
Treatise on Surgery by American Authors for Students and Prac-
titioners in Surgery and Medicine. Edited by Roswell
Park, A.M., M.D. Vol. I, General Surgery, with 356-
engravings, 21 full page plates in colors, and monogravures.
Philadelphia and New York : Lea Brothers ifc.Co. 1896.
This work, which has been announced for some months, has
been issued. The contributors to the volume are W. T. Belfield,
Herbert L. Burrell, Duncan Eve, John A. Fordyce, Frederick
H. Garrish, William A. Hardaway, H. A. Hare, James M. Hol-
loway, Henry H. Mudd, Charles B. Nancrede, Roswell Park,
John Parmenter, Joseph Ransohoff, Chauncey P. Smith and
Edmond Souchon. Of the surgeons contributing to the volume
all but two are members of the American Surgical Association.
The editor states that the chapters on auto intoxications and
on the surgical sequela; of acute non-surgical diseases are
practically new. The first volume contains the more general
subjects of surgical pathology, the general principles and
theory of surgery, and surgery of the tissues. Of the chapters in.
the book, those on hyperemia, the blood, inflammation, ulcer
and ulceration, gangrene, auto-infection, surgical fevers, sur-
gical diseases common to man and animals, shock and collapse,
scurvy and rickets, the sequela; of other infections and diseases,,
poisoning by animals and plants, acute intoxications, cysts and
tumors and surgical diseases of the osseous system (sixteen of
the thirty-two) have been furnished by Dr. Park ; that of
syphilis by Dr. Fordyce ; gonorrhea and its sequelae by Dr.
Belfield ; control of hemorrhage, burns, scalds, frost bites and.
minor surgery by Dr. Parmenter ; anesthesia by Dr. Hare ;.
surgical diagnosis by Dr. C. P. Smith ; methodic report of a
surgical case, an elaboration of which appeared in this Journal,
by Dr.' Souchon ; wounds, gunshot wounds, processes of repair
and treatment of wounds by Dr. Nancrede ; surgical diseases
of the skin by Dr. Hardaway ; diseases of the muscles, tendons,
tendon sheaths and fasciae by Dr. Burrell : lymphatic vessels
by Dr. Gerrish ; surgical injuries and diseases of the veins by
Dr. Holloway; injuries and diseases of the arteries, including
aneurysm, by Dr. Duncan Eve ; joint and joint structures and!
operations on joints by Dr. Joseph Ransohoff ; fractures and.
dislocations by Henry H. Mudd.
The volume is well illustrated and well edited. As will be
seen, the editor has himself been the author of one-half of the
book.
Deformities : A Treatise on Orthopedic Surgery, intended for Prac-
titioners and Advanced Students. By A. S. Tuppy, M.L., Lon-
don, F.R.C.S., England. Illustrated with 15' plates, with
302 figures, of which 200 are original, and by notes of 100
cases. London and New York : McMillan & Co. 1896.
This volume is the outcome of several years' work by the
author at the National Orthopedic Hospital, the Evelyn Hos-
pital for Sick Children, and for some time in the Orthopedic
1896.]
PUBLIC HEALTH.
611
Department at the Westminster Hospital. The author, how-
ever, has not only made a record of his own work, but has
given a fair account of the deformities as at present under-
stood. It is pleasing to note that he has quoted freely from
Bradford and Lovett of this country, and pays a graceful trib-
ute to our Orthopedic Association by saying : "Above all, I
can not omit to express my sense of indebtedness to the many
admirable writers who have recorded their experiences in the
transitions of the American Orthopedic Association."
There are nine chapters on deformities of the spine, consti-
tuting Section One : four chapters on deformities of the neck,
chest and upper extremities, constituting Section Two; Sec-
tion Three has only one chapter, that on rachitic deformities ;
Section Four, deformities of the lower extremities, has nine
chapters : Section Five, ankylosis, congenital displacements,
deformities resulting from cerebro spinal paralyses and
arthrodesis.
The illustrations are fair, and the type is large and clear.
The lux'k is timely, and. although conservative, is fully up to
date. We quite ai;ree with the author's estimate of the ad-
vantage of tarseetomy, in which he states : " Cases in which
tarseetomy is necessary are very few and form a very small
percentage.'- We commend the book as one being in every
way satisfactory.
Ptomains, Leucomaias, Toxins and Antitoxins, or the Chemical Fac-
tors in the Causation of Disease. By Victor C. Vaughan, Ph.
IX. M.D.. and FREDERICK C. Novy, Sc.D., M.D. Third
edition, revised and enlarged. Lea Brothers & Co., Phila-
delphia and New York. 1896.
It has been apparent for some years that the study of bac-
teriology is fast returning to its ancient home in the chemical
laboratory and that the products of bacteria are more impor-
tant than the microbes themselves. We have heretofore
expressed our opinion of the usefulness of this book, and have
to state that that high opinion has been increased by glancing
at the third edition. The work has been brought down to
date and will be found entirely satisfactory as a book of refer-
ence on the subjects named, and as well for careful study.
The arrangement and scope of the work remain the same as in
former editions. The number of pages has been increased
from 391 to 604. In these bacteriologic days, no medical man's
library can be considered complete without a copy of this
painstaking and exhaustive compilation. That the volume
grows from edition to edition is evidence of the careful
character of the work and the thoroughness with which the
field of medical literature has been gleaned.
Wharton's Minor Surgery and Bandaging. By Henry R. Whar-
ton. M.D., Demonstrator of Surgery in the University of
Pennsylvania. New (third) edition. In one 12mo. volume
of 594 pages, with 475 engravings, many being photographic.
Cloth, $3.00. Philadelphia: Lea Brothers & Co., 1896.
The issue of the third edition of Wharton's Minor Surgery
and Bandaging affords pleasing evidence of the correctness of
the favorable opinion which we expressed on the issue of the
first edition. We are of the opinion, however, that many of
the illustrations might be omitted as being no longer appli-
cable to modern methods. For example, the scissors figured
on page 218 for skin grafting are scarcely used, as Thiersch's
method has effectually supplanted the others. The old spring
scarificator, on page 191, has probably never been seen by a
physician under 35 years of age. Petit's Tourniquet, on page
283, might also be consigned to an antiquarian resting place.
We do not see in the notice of fixed dressings the paper
pulp bandage which has of late come into use, nor do we find
in the book a statement of elastic bandages, such as support-
ers, suspension bandages, abdominal bandages, and other
items which we would suggest should be included in future
editions. These suggestions, however, do not detract from
the general merit of the book, which is very great, and we trust
that when we have the pleasure of reviewing the fourth edi-
tion, which is in our judgment bound to come soon, the
author will bring his rovision quite up to date. The publish-
ers have done their part of the work well.
Transactions of the American Microscopical Society. Edited by
the Secretary. Eighteenth annual meeting held at Cornell
University, Ithaca, N. Y. Volume xvii. Buffalo, 1896.
The papers of this flourishing society are usually carefully
edited and well illustrated ; those in this volume of transac-
tions are no exception to the rule. A large portion of the
papers are decidedly interesting to medical men, such, for
instance as "The Action of Strong Currents of Electricity
upon Nerve Cells," by P. A. Fish; "The Comparative Mor-
phology of the Brain of Soft-shell Turtle and the English
Sparrow," by S. B. Gage; "Formalin as a Hardening Agent
for Nerve Tissues," by William C. Krauss, and the "Process of
Life Revealed by the Microscope, a Plea for Physiologic His-
tology," by Simon Henry Gage.
Eleventh Annual Report of the State Board of Health of the Common-
wealth of Pennsylvania, 1896. — This report consists of the sec-
retary's report, the minutes, reports of committees, and reports
of inspections of various towns, cities and counties throughout
the State, appendices on quarantine, etc. It shows a vast
amount of labor on behalf of the board and the great benefit
conferred upon the State. The board is fortunate in having
as its secretary, Dr. Benjamin Lee, whose long and faithful
service entitles him to recognition beyond the usual meed of
State health officers.
PUBLIC HEALTH.
Another Source of Infection. — It is well known among occulists
that the opera glasses which may be hired in most theaters
frequently become the medium for 'spreading very serious eye
diseases. — Pop. Science News, August.
Inspectors of Mercantile Establishments in New York.— The
Board of Health September 1 appointed eleven inspectors,
eight of whom were women. The law under which the factory
inspectors are appointed directs that no child under 14 can be
employed in a business establishment. Children between the
ages of 14 and 16 must be provided with certificates from the
board of health, showing that they are competent physically
to do such work as would be required of them by their
employers. The inspectors also look after the sanitary arrange-
ment of all large business houses and workshops, with a view
to the health interests of the employes.
Health in Michigan August, 1896.— Reports to the State Board of
Health show that for the month of August, compared with the
preceding month, typhoid fever, cholera infantum, dysentery,
cholera morbus, erysipelas and remittent fever increased in
area of prevalence. For the month of August, 1896, compared
with the average for August in the ten years, 1886-1895, typhoid
fever was much more than usually prevalent, and intermittent
fever, consumption, remittent fever and inflammation of bowels
were less than usually prevalent. Consumption was reported
present in August, 1896, at 217 places, typhoid fever at 100,
scarlet fever at 34, diphtheria at 34, whooping-cough at 27 and
measles at 25.
High Infant Mortality in Canada. — The Union MM. de Canada
for August gives the statistics for 1895 in the Province of Que-
bec as follows : Population, 1,515,492 ; births, 58,653 ; deaths,
31,696, of which over eleven thousand were due to contagious
diseases. Over ten thousand were children from a day to 1
year old, and 5,220 were children from 1 to 5 years ; a total of
17,532 children, or more than half of the total number of
deaths. It ascribes this high mortality to the lack of knowl-
edge of preventive science in contagious diseases and to neg-
lect. Where the parents are ignorant, it should be some one's
612
PUBLIC HEALTH.
[September 12,
duty to instruct them in the necessity of isolation and disin-
fection and limit a contagious disease to the first one or two
attacked. It also states that another cause may be the policies
paid by certain life insurance companies, which speculate on
the "little last-comer," so that the parents receive S75to§80 if
it dies. It protests against this practice as "immoral from every
point of view." We note also that the deaths from intestinal
diseases (4,068) were nearly twice as many as from tubercu-
losis (2,791).
Report of Committee on the Contagiousness of Tuberculosis in
Hospitals; Isolation Recommended. The committee appointed by
the municipal authorities at Paris to investigate this subject,
report the necessity of separate quarters for tuberculous
patients, or at least the necessity of separating them from the
rest in special wards appropriated to their exclusive use in the
present hospitals, which they claim is feasible. Also the
decentralization of tuberculous patients by removing them to
special sanatoria in healthy localities. Letulle also suggests
the establishment of curable tuberculosis colonies in Algiers
and Corsica. They also demand that the patients and attend-
ants should be carefully educated to understand the necessity
of prophylactic measures, with penalties enforced for neglect-
ing them. The attendants must also be selected with care, and
all rejected that show any tendency to morbid conditions of
the respiratory organs. They found that 1,296 of the total of
4,470 attendants connected with the hospitals of Paris were
already diseased, 651 with bronchial affections and 526 with
pulmonary tuberculosis. There have been 599 deaths among
them during the past ten years, 217 due to tuberculosis and
154 to other diseases of the respiratory organs.
Greater New York City Health Department.— Chapter xix of the
proposed charter, which relates to the Health Department, has
been prepared by the Sub-committee on Charter of the Greater
New York Commission for the consideration of the local sani-
tary officials. The chapter contains more that thirty thousand
words, and has seven titles, as follows : 1, Powers and duties
of the department and its officers ; 2, marriages, births and
deaths ; 3, duties of physicians and others ; 4, enforcements of
orders and ordinances ; 5, reimbursement for expenses ; 6,
abatement by suit ; 7, tenement and lodging houses. In many
respects the proposed chapter is a consolidation of the laws as
they exist, and the title relating to tenement and lodging
houses carries the intent of the Tenement House Commission.
Of the head of the department the draft says : "There shall
be a Department of Health, the head whereof shall be called
the Health Commissioner. The Health Commissioner may be
appointed and may be removed at will by the Mayor, and his
term of office shall be coextensive with that of the Mayor
appointing him, and until his successor shall have been
appointed and qualified. The authority, duty and powers of
the Health Commissioner shall extend over the waters of the
bay, up to and within the quarantine limits, as established by
law, but shall not be held to interfere with the powers and
duties of the Commissioners of Quarantine or Health Officer of
the Port. It shall be the duty of the Health Commissioner to
make an annual report to the Mayor of the city of New York,
of all the operations of his department for the previous year.
The Mayor may at any time call for a more full report, or for
a report upon any portion of the work of said Commissioner
whenever he may deem it to be for the public good so to do."
In regard to bureaus, the sub-committee provides for two, those
of the Sanitary Superintendent and the Registrar of Records, as
at present. Nuisances are to be treated as they have been
heretofore, and the control or surveillance of noxious industries,
trades or enterprises likely to be objectionable. The control
of contagious diseases remains unchanged. These provisions
apply to vaccination, disinfection and production of antitoxin
by the Department of Health, and the sale of vaccin and anti-
toxin and disposition of proceeds of sale: "For the purpose
of more effectually preventing the spread of smallpox by the
thorough and systematic vaccination of all unvaccinated per-
sons, and for the relief of persons suffering with diphtheria
and other infectious diseases residing in said city, the Depart-
ment of Health is hereby empowered to continue or organize a
corps of vaccinators and of other physicians, within and subject
to the control of the Bureau of Sanitary Inspectors, to appoint
the necessary officers, keep suitable records, collect and pre-
serve pure vaccin lymph or virus, and produce diphtheria anti
toxin and other antitoxins, and add to the Sanitary Code such
additions as will most effectually secure the end in view. Said
Department of Health may take measures and supply agents,
and offer inducements and facilities for general and gratuitous
vaccination, disinfection, and for the use of diphtheria antitoxin
and other antitoxins, and may afford relief to and among the poor
of said city, as in its opinion the protection of the public health
may require. Whenever the amount of vaccin lymph or virus
collected by the said corps or of diphtheria antitoxin and other
antitoxins produced shall exceed the amount required in the
proper performance of its duties, the said Department of Health
may authorize the sale of such surplus lymph or virus and diph-
theria antitoxin and other antitoxins at reasonable rates, to be
fixed by the Health Commissioner. The avails of such lymph
or virus and diphtheria antitoxin and other antitoxins shall be
accounted for and paid to the Chamberlain, and shall be set
apart and constitute distinct funds, to be known respectively as
'the fund for gratuitous vaccination' and 'the antitoxin fund,'
and they shall be subject to the requisition of the Health Com-
missioner for the purposes named in the preceding section. "In
case of extreme measures being necessary to prevent the spread
of disease, the Commissioner may cause any avenue, street,
alley or other passage whatever to be fenced up or otherwise
inclosed, adopt suitable measures for preventing all persons
from going to any part of the city so inclosed, forbid all
communication with the house or family infected with
any contagious, infectious or pestilential disease except
by means of physicians, nurses or messengers to carry the
necessary advice, medicines and provisions to the afflicted,
and adopt such means for preventing all communication
between any part of the city infected with a disease of a
pestilential, infectious or contagious character and all other
parts of the city, as shall be prompt and effectual. There are
other strenuous provisions against neglect that may cause the
spread of disease. In regard to coroners, the draft provides
for returns and reports and notices of calls for inquests, and
the Sanitary Superintendent is given the power to order the
burial of a body in certain circumstances. There is also a
requirement that information in regard to diseases shall dis-
seminate to local authorities elsewhere information that may
be useful in regard to any disease. Quarantine officers and
the department are to cooperate. The Sanitary Code of 1873,
as amended, is declared to be binding except as it may be
altered, amended or annulled by the Commisioner. The Health
Commissioner is directed to establish offices in the Borough of
Brooklyn and may appoint for this borough and that of Wil-
liamsburg a Deputy Commissioner and a Deputy Sanitary
Superintendent and a Registrar of Records, with such clerical
force as may be required. The Commissioner may also have a
secretary and a chief clerk, and adopt a seal for the depart-
ment and establish useful regulations. The draft provides
for the appointment of fifty Sanitary Inspectors and may
appoint eight men at the discretion of the Commissioner and
there may be a sanitary engineer. Provisions in regard to the
reporting and registration of births, marriages'and deaths are
the same as at present, and the duties of physicians and others
are set forth as under the present regulations. The enforce-
ment of laws and ordinances is set forth in a codification of
existing laws. — Standard Union.
I
189(5.]
NECROLOGY.
613
NECROLOGY.
James W. Anawalt, M.D., at the Military Soldiers'
Pome at Dayton, Ohio, August 26. He practiced medicine in
preensburg for over twenty-five years. About ten years ago
he sustained a stroke of paralysis, from the effects of which
ho never fully recovered. Dr. Anawalt had an excellent mili-
tary record, having served in the late war. He went as a sur-
geon of the Eleventh Regiment, Pennsylvania Volunteers, and
afterward was chief Burgeon of the Eleventh and One Hundred
and Thirty second Regiments. He graduated from Jefferson
Medical College in 1855. He was 68 years old.
•I. A. Blouse, M.D. (Department of Medicine, University
of Pennsylvania. Philadelphia. 1891) of York, Pa., August 27,
aged U >ears. -Henry L. Harrington, M. D., (Rush Medical
College, Chicago, 111., 1875) at Chicago, 111., of consumption,
August .11, aged 50 years.
E. Numsk. M.D.. Paris, age58. The distinguished surgeon
and writer, one of the editors of the Heme de Chirurgie and
contributor to many medical journals, former president
ie de Chirurgie, and of the medical section of the French
tattoo for the Advancement of Science, professor of
anatomy and clinic surgery. His most recent works are on
the early history of surgery in Prance, to which he devoted
the strength remaining from his long struggle with pulmonary
disease. Among his other works are classic articleson cutane-
ous transplantations, surgical treatmentof the nerves and veins,
treatment of tetanus with chloral, sub-periostean amputations!
arthrotomy of the knee, lesions of the intestines in strangula-
infeetive myositis, suture of the sphincter in anal fistu-
las, emphysema of the neck from rupture of the trachea dur-
ing labor, and many others, the last mentioned having been
read at the Academic de Medecine within a couple of months.
A km an ii Dkspius. M.D., age 62. A well known hospital
surgeon and medical journalist of Paris, where his father had
also been a hospital surgeon before him. He was noted for
his ready wit and paradoxical views and conduct, "the intel-
lectual type of the true gamin of the boulevard." He refused
to recognize that surgery had made any progress since the
sixties, and ridiculed the idea of asepsis and antisepsis, cling-
ing to his prehistoric dressings and poultices to the last. The
ProgriM Medical, August 8, remarks that if he had lived in the
United States, or even in Germany, his fantastic ideas on the
subject of surgery might have brought him into serious
trouble, adding, "Sometimes it is just as well to be living in
France.'' But his pupils adored him. He served in the
Chamber of Deputies with zeal and wisdom ; was editor of
the Franc, Medicale for a while, and his numerous writings
are valuable and interesting, although he repudiated the use
of mercury. He was made Chevalier of the Legion of Honor
for saving from captivity the wounded he was tending after a
battle during the war. The Roman Catholic journals are
lauding his memory for his indefatigable efforts to prevent the
removal of the Sisters of Charity from the hospitals, to make
way for trained lay nurses, while this is cited by other jour-
nals as a typical instance of the inconsistency of the professed
freethinker and atheist.
Dr. Henry K. Pusey died on the 2d inst., at Garnettsville,
Ky., at the home of one of his daughters. Dr. Pusey was
nearly 70 years of age. His early education was received at
Mount Auburn and he received his degree of M.D. from the
Medical Department of the University of Louisville. He prac-
ticed his profession in Louisville for a number of years and
during the governorship of Hon. Proctor Knott he was
appointed as Superintendent of the Insane Asylum at Lakeland,
near Louisville, serving during that term and again under Gov-
ernor Brown after four years' retirement. When he took charge,
the number of inmates was 300 and the buildings inadequate
and inconvenient; when he relinquished his office to make way
for his successor appointed by Governor Bradley there were
1,200 inmates and the buildings modern in every respect and
the methods of treatment the latest and best that has been
devised. Dr. Pusey was a member of a number of societies
devoted to the discussion of the insane, among them being the
Medico- Psychological Association, the Medico- Legal Society of
New York, the Southern Association of Superintendents of
Insane Asylums and others. Dr. Pusey was a recognized
authority upon hospital architecture and sanitation, and it was
he who first suggested the advisability of building the houses
for the insane no more than two stories high. The Board of
Directors for the Asylum recognized the excellence of his ideas
and the value of his accomplishments and they warmly
approved all of his propositions for the improvement of the
facilities of the institution. Knowing him thus the Directors
gracefully testified their appreciation of him by naming the
latest building addition to the institution "Pusey Hall," and
put the name on a tablet of granite over the door. A year ago
when the doctor gave up his work at the Asylum he was
already a sick man and he told his close friends that he
believed his life work was at an end. He accordingly began
to set his affairs to rights and awaited the end with Christian
fortitude. The board of directors passed suitable resolutions
at a meeting held the Saturday after his death.
SOCIETY NEWS.
Reading (Penn. ) Medical Association.— This association has elected
the following officers for the ensuing year : President, James
W. Reiser ; vice-president, Daniel Longaker ; secretary, S. T.
Schmehl ; treasurer, Walter Rigg ; representative to the Board
of Managers of the Reading Hospital, C. W. Bachman ; censors,
Henry Landis, J. L. Bower and C. M. Kurtz ; curator, Henry
Landis.
Douglas County (Wis.) Medical Society.— This society held its
annual meeting at Superior, Wis., September 2. The officers
elected for the ensuing year were : John Reeve, president ; H.
J. Orchard, vice-president ; George Saunders, treasurer ; C. S.
Conkey, secretary ; John Baird, L. B. Shehanand L. A. Potter,
censors.
Mississippi Valley Medical Association.— At the twenty second
annual meeting at St. Paul, Minn., Sept. 15 to 18, 1896, the fol-
lowing papers will be read :
President's Address, H. O. Walker, Detroit, Mich.
Address on Medicine, Harold N. Moyer, Chicago, 111.
Address on Surgery, Horace H. Grant, Louisville, Ky.
The Clinical Significance of the Child's Fontanelle, I. A.
Abt, Chicago, 111.
Proprietary Prescriptions, W. W. Allison, Peoria, 111.
A New Operation for Cleft Palate, Truman W. Brophy, Chi-
cago, 111.
Some Rarer Forms of Keratitis, Carl Barck, St. Louis, Mo.
The Results of Operations per se in Cases of Tubercle and
Cancer, A. C. Bernays, St. Louis, Mo.
Mastoid Diseases ; Their Medical and Surgical Treatment,
S. S. Bishop, Chicago, 111.
Rupture of the Choroid Coat, J. H. Buckner, Cincinnati,
Ohio.
Operative Treatment of Pterygium, Eduard Boeckmann, St.
Paul, Minn.
Treatment of Some Inflammatory Diseases of the Gastro-
intestinal Tract, Gustavus Blech, Detroit, Mich.
Kola, Gustavus Blech, Detroit, Mich.
A Report Of a Case Illustrating the Value of Secondary
Physical Signs in the Diagnosis of Cardiac Diseases, R. H.
Babcock, Chicago, 111.
Rhinoscopic Examinations in General Practice, B. M. Beh-
rens, Minneapolis, Minn.
Irregularities in Delivery Due to Short Umbilical Cord,
Guido Bell, Indianapolis, Ind.
Gastrojejunostomy in Gastrectasis, A. H. Cordier, Kansas
City, Mo.
614
MISCELLANY.
[September 12,
Conventional Treatment of Heart Diseases versus Positive
Treatment, Ephraim Cutter, New York, N. Y.
Tonsillotomy by Means of the Cautery Blade, J. Homer
Coulter, Chicago, 111.
The Newer Remedies in Otologyand their Results, G. I. Cul-
len, Cincinnati, Ohio.
Infant Feeding ; The Anti-dyscrasic Action of Cow's Milk,
M. F. Cupp, Edinburg, Ind.
Ether and Chloroform ; Their Comparative Merits as Agents
for the Production of General Anesthesia, W. S. Caldwell,
Freeport, 111.
Appendicitis; To Operate or not to Operate, J. H. Dunn,
Minneapolis, Minn.
Syphilis as an Etiologic Factor in the Production of Tabes
Dorsalis, C. Travis Drennan, Hot Springs, Ark.
Preventive Medicine. J. O. DeCourcy, St. Libory, 111.
Certain Misconceptions Regarding Cardiac Murmurs and
their Significance, Arthur R. Edwards, Chicago, 111.
A New Method of Fastening the Broad Ligament in Alex-
ander's Operation, J. Frank, Chicago, 111.
Choledochotomy in America, with the Report of Four Cases,
Alex. Hugh Ferguson, Chicago, 111.
Pleuritic Effusions and their Treatment, G. Fiitterer, Chi-
cago, 111.
Rational Operations for the Cure of Retroversions and
Flexions, A. Goldspohn, Chicago, 111.
A Demonstration of the Therapeutic Action of Antitoxins,
E. M. Houghton, Detroit, Mich.
Stirpiculture, Florence W. Hayes, Terre Haute, Ind.
On the Importance of Physical Signs other than Murmur in
the Diagnosis of Valvular Diseases of the Heart, Jas. B. Her-
rick, Chicago, 111.
The Neural Factor in Clinical Medicine, C. H. Hughes, St.
Louis, Mo., Honorary Fellow of the Chicago Academy of Med-
icine.
The Value of Medicinal Antipyretics in View of Newly
Acquired Knowledge Respecting the Nature of Acute Infec-
tious Diseases, Talbot Jones, St. Paul, Minn.
Treatment of Syphilis, J. H. Jelks, Hot Springs, Ark.
The Physiologic Treatment of Typhoid Fever, Elmer Lee,
Chicago, 111.
The Pathology and Treatment of Suppurative Salpingitis,
F. F. Lawrence, Columbus, Ohio.
The Lumbar Enlargement of the Spinal Cord, L. Harrison
Mettler, Chicago, 111.
Indications for and Demonstrations of Removal of the Gas-
serian Ganglion, J. B. Murphy, Chicago, 111.
The Surgical Treatment of Pyloric Obstruction, Wm. J.
Mayo, Rochester, Minn.
Conditions which may Simulate Organic Obstruction of the
Rectum, Thos. H. Manley, New York, N. Y.
Multiple Operations in Pelvic Disease, H. P. Newman, Chi-
cago, 111.
Nerve Sutures and other Operations for Injuries to the
Nerves of the Upper Extremities, A. J. Ochsner, Chicago, 111.
Submucous Linear Cauterization ; A New Method for Re-
duction of Hypertrophies of the Conchas, N. H. Pierce, Chi-
cago, 111.
The Treatment of Experimental Tuberculosis in Animals by
the Use of Blood Serum, Paul Paquin, St. Louis, Mo.
The Pathology of Idiocy, Frederick Peterson, New York,
N. Y.
Chorea, Curran Pope, Louisville, Ky.
Electro-diagnosis and Electro-therapeutics Simplified, Hugh
T. Patrick, Chicago, 111.
Trunk Anesthesia in Locomotor Ataxia, Hugh T. Patrick,
Chicago, 111.
The Use of Oxygen in Chloroform Narcosis, C. B. Parker,
Cleveland, Ohio.
My Favorable Experience with Diphtheria Antitoxin, D. C.
Ramsey, Mt. Vernon, Ind.
The Physiology of the Peritoneum from Experiments, Byron
Robinson, Chicago, 111.
Some Fads and Fallacies of Modern Rectal Surgery, Leon
Straus, St. Louis, Mo.
Pregnancy Complicating Operations on the Uterus and its
Appendages. Remarks with Cases, R. Stansbury Sutton, Pitts-
burg, Pa.
The Significance and Occurrence of Capillary Pulsation in
Nervous Diseases, A. E. Sterne, Indianapolis, Ind.
Twenty-seven Cases of Croup, E. W. Sanders, St. Louis,
Mo.
The Necessity af Vivisection, E. B. Smith, Detroit, Mich.
Gunshot Wound of the Liver ; Report of Case Involving
Diaphragm and Lung ; Operation Successful but Fatal Ter-
mination Two Weeks Later from Pneumothorax, J. H. Taul-
bee, Mt. Sterling, Ky.
Further Report on the Treatment of 500 Cases of Gastritis
(Demonstrations), Fenton B. Turck, Chicago, 111.
The Rapid Cure of Gonorrhea, Fred C. Valentine, New H
York, N. Y.
Some Unusual Cases of Appendicitis, Weller Van Hook
Chicago, 111.
Mastoidectomy in Caries of the Temporal Bone, K.
Wheelock, Ft. Wayne, Ind.
A Further Contribution on the Use of Dry Heat in th
Treatment of Chronic Joint Affections, W. E. Wirt, Clev
land, Ohio.
A Further Contribution to the Ocular Treatment of Epi-
lepsy, Casey A . Wood, Chicago, 111.
The Decadence of the General Practitioner and the Reign of
the Specialist, D. S. Maddox, Marion, Ohio.
Additional papers have been promised by the following :
Augustin H. Goelet, New York, N. Y. ; Henry Hatch, Quincy,
111. ; R. C. Heflebower, Cincinnati, Ohio ; Bransford Lewis, St.
Louis, Mo. ; I. N. Love, St. Louis, Mo. ; A. H. Meisenbach
St. Louis, Mo. ; H. O. Pantzer, Indianapolis, Ind.
MISCELLANY.
ac-
tnd
P.-A. M. C. Delegate. Dr. H. B. Lowry, of Omaha, has been
appointed delegate from Nebraska to the Pan-American Med
cal Congress.
Jefferson Appointment. — Dr. Roy Harris, who has been pr;
ticing medicine in Atlanta, Ga., for the past five years, an
teaching chemistry in the Southern Medical college, has
accepted a professorship in the Jefferson Medical college of
Philadelphia. He will teach pathology in that institution.
He graduated from Jefferson College.
Dr. Carlos F. McDonald, president of the New York State com-
mission in lunacy, has resigned, the resignation to take effect
September 30, and Gov. Morton has appointed Dr. Peter M.
Wise as Dr. McDonald's succcessor, the appointment to take
effect October 1. Dr. McDonald's term would expire by lim-
itation in May, 1901, but he retires to resume private practice.
Husband Can Recover Expense for Medical Attendance. — In Minne-
sota, the supreme court of that State holds, in McDevitt v.
City of St. Paul, decided July 24, 1896, a husband may main-
tain an action against a municipal corporation for the recovery,
among other things, of moneys expended by him for medical
attendance on his wife on account of personal injuries received
by her by reason of a defective sidewalk.
A Question for the Jury.- -It is a question for the jury to deter-
mine, the supreme court of Minnesota holds, in the case of
Hale v. Life Indemnity and Investment Co., decided July 17,
1896, whether a man can be addicted to the drink and morphin
habits, and grossly intemperate, and his family and his inti-
mate business and social associates not discover it. It can not
be assumed that he can thus conceal these habits, if he in fact
has them.
Marinesco's Pilgrimage.— The Semaine Midicale has sent Mar-
inesco on a scientific pilgrimage to the different centers of
progress to interview the leading neurologists of the day. His
letters from London, Edinburgh, Brussels and Liege, as they
have been published the last few weeks, form an interesting
Hsuml of the present status of neurology, and contain some
things that have not yet been officially announced in the way
of biologic investigation.
Preventive Treatment of Hydrophobia.— Dr. A. Lagorio informs
us that 532 patients have been treated at the Chicago Pasteur
Institute since its inauguration July 2, 1890. The patients
treated have been divided into three classes : 1. Those bitten
by animals recognized and ascertained to be rabid by the con-
trol experiment made in the laboratory, or by the deaths of
other persons or animals bitten by the same animal (183). 2.
Those bitten by animals recognized to be rabid by the symp-
toms of rabies shown during life (237). 3. Those bitten by
animals strongly suspected to be rabid (112). Only two deaths
1896.]
MISCELLANY.
615
lhave been reported, giving a mortality of 0.37 per cent. There
■were 4S3 persons bitten by doge, 24 by cats, 13 by horses, 5 by
skunks. 2 by wolves, 1 by a mule, 1 by a pig, and 2 by hydro-
phobic human beings.
Illinois' New Hospital for the Insane.— The corner stone of the
new Northwest, in Hospital for the Insane was laid at the vil-
lage of W'atertown. eight miles east of Rock Island, by Gover-
nor Altgeld. Sep*. 5. The Thirty-eighth General Assembly
made an appropriation of $100, (XX) for an institution to be
located north and west of the Illinois river. The site com-
prises 400 acres on the bluffs overlooking the Mississippi river,
which was purchased and presented to the State by Rock
Island County and city and the town of Moline. The plans
contemplate a system of eight groups of buildings, to be ar-
ranged in radiating lines from the main building, connected
by hallways.
Must Give Notice of Trial for Insanity.— An inquiry and trial in
the probate court in Kansas, had upon an information charg-
ing one with being a person of unsound mind and incapable of
managing his own affairs, the court of appeals of that State
holds, In re W'ellman, decided June 12, 1896, should only be
had after notice to the person alleged to be insane, and after
opportunity has been given such person to be present at the
trial, in person or by counsel. An adjudication of insanity that
is made without such notice and opportunity to be heard, it
holds is a nullity, and void, and a commitment thereunder to
the insane asylum is illegal.
Physicians Can Testify as to Stains.— After both an examination
thereof, under a microscope and a chemical analysis, the
•supreme court of South Carolina holds, in the homicide case
of State v. .Martin, decided July 11, 1896, that physicians are
clearly entitled as experts to give their opinion as to the char-
acter of stains found on a piece of floor. That the latter was
not taken from the house in which the defendant lived at the
time of the alleged homicide until a few days before the trial,
after the defendant had moved from it, and while it was occu-
pied by another person, it is further held did not render it
inadmissible in evidence, though the force of the evidence
•was perhaps weakened by these circumstances.
Gleanings.— Confirmation of favorable effect of lecithin on
the quality of the blood, general growth and psychic develop-
ment ! dqga ). Milk from typhoid patient produces character-
istic agglutinations the same as serum. (See this Journal,,
page382. | i Semaine Mid., Augusts.) Editorial urges imme-
•diate intervention in all wounds of the abdomen caused by fire-
-arms. Many lives would be saved if the internal perforations
were sutured at once as a matter of course, no matter how
trifling they may appear. {Union Mid., August 8.) First
•decade of the Paris Pasteur Institute, 17,337 patients treated,
••83 deaths. {Gaz. Mid. de Liege, August 13.) 7,857 of the
29,747 students in the universities of Germany are studying
medicine, i Wien. Klin. Rundsch., August 9. ) Mackenrodt
•asserts that the only way to avoid infection in hysterectomy
for carcinoma is to perform it entirely by thermo- cauteriza-
tion. (Gaz. Mid. de Paris, August 15.) Ten per cent, for-
mol compresses found very effective in relieving and improving
inoperable ocular tumors. (Semaine Mid., August 12.)
London has 600,000 houses, with an average of 7 inmates to
•each ; New York has 115,000 with 18 inmates each, and Paris
only 90,000 with 25 inmates each. (Journal aV Hygiene,
August 6.)
The Phone ndoscoae. — The newly invented phonendoscope is
■designed to be used by physicians and surgeons for detecting the
presence of disease by sound. The instrument consists of a cir-
cular flat metal lx>x or tympanum, having on its one surface two
apertures for the attachment of the rubber ear tubes, while
the other surface is formed by a' thin disk which is readily
thrown into vibration. The best results are obtained by sim-
ply applying this disk to the surface to be examined. By an
ingenious contrivance a second disk can be superposed upon
this one and a vulcanite rod attached to the former, so that
the area of auscultation may be extremely circumscribed. The
conduction of the sounds is only slightly diminished by the
use of this rod, which thus combines the principle of the solid
stethoscope with that of the tympanum. The rod furnished
with the instrument is about two inches in length, but it is
stated that there are other rods of various lengths, to enable
the "phonendoscopist" to receive sound vibrations of the nat-
ural cavities which communicate with the exterior of the body.
It is useful as an aid to auscultation, and yet not likely to
entirely supersede the use of the stethoscope. It may also be
found useful in class demonstration, since it would be easy by
means of branched tubes to enable several persons to listen at
the same time. The instrument will be particularly useful for
the following purposes : In auscultation of the sound of the
respiratory organs, in the circulation of the blood, and of the
digestive organs in the healthy body as well as in the sick ;
the sounds made by the muscles, joints and bones ; the sound
of the capillary circulation ; the slightest sounds produced in
any diseased condition of the body ; hence it is possible to
draw on the body dimensions, the position or any alteration in
the position of the various organs and of the fluids which have
gathered in the most important cavities in the body. — Pop.
Science News, August.
Coffin Carrying. -It is observed with some curiosity that our
distinguished guest, His Excellency, Li Hung Chang, with
certain other members of his suite, carry coffins with them as
part of their baggage. It is said that this custom arises from
distinction in classes whereby as it is highly probable that the
remains of the illustrious dead might be defiled by touching or
mixing with the common or unclean carcasses not belonging to
the celestial or one of the same class. It has been said that
one of the best means of longevity is the frequent contem-
plation of death and the tomb and it would seem that the
oriental custom has its advantages, as in case of accident it
would be unfortunate to be compelled to depend upon an
American undertaker, who might prove a veritable iconoclast
in handling the remains of a distinguished Chinaman.
Compensation Must be Allowed. — A servant employed in the
Merchant's Hotel in the city of Detroit, Mich., was taken ill
June 1, 1894. Her disease was pronounced measles by a phy-
sician. As she failed to improve, the proprietor of the hotel
telephoned the board of health that he feared the case was
smallpox. In reply, the contagious disease clerk at the health
office said it was all right, only a case of measles, and it would
be best to carry out the orders of the physician referred to.
June 6 the girl died. An investigation was made by the health
board and the case pronounced smallpox. The officers of the
board of health immediately took possession of the hotel and
placed it in quarantine, confining therein thirteen persons, sev-
eral of whom were subsequently stricken with smallpox and
detained in the hotel and there treated by the board of health.
The quarantine continued until June 29, after which the board
of health disinfected the premises and destroyed a considerable
portion of the furniture which had become infected. They
contended that what was thus done by them was necessary in
the interest of the public welfare, and that the loss must be
borne by the proprietor of the hotel. But the supreme court
of Michigan takes a different view of it. Safford v. Board of
Health of City of Detroit, decided July 8, 1896. It says that
it thinks it is within the contemplation of the law that, when
property is used or destroyed or services rendered under such
circumstances as in this case, compensation should follow. It
also holds that it is the duty of the board of health to pass
upon the question of the amount of compensation, and where
they refuse utterly to award compensation, that a writ of man-
damus may be invoked to compel them to do so.
616
MISCELLANY.
[September 12, 1896. J
Can Answer Hypothetic Questions.— If a physician, who has
professionally attended upon and prescribed for a person, and
has also observed such patient while not thus in attendance,
can give an opinion as to his condition, based upon facts he
observed while not acting professionally, and excluding from
his mind what he observed while in attendance, the appellate
division of the supreme court of New York says that it can see
no reason to doubt that he may also give an opinion upon a
hypothetic state of facts stated in a question which excludes
all knowledge of the condition of the patient which he derived
while in professional attendance. The only objection, it fur-
ther states, in the case of Meyer v. Standard Life & Accident
Insurance Co., decided July 7, 1896, that can be urged to a
doctor, who has been in medical attendance upon a person,
giving an opinion in answer to a hypothetic question as to the
condition of his patient, is that the knowledge he derived while
in attendance might affect his answer. But the same objec-
tion exists to the physician's giving an opinion founded upon
observation of his patient while not in actual professional
attendance. Mr. Justice Landon, in a concurring opinion,
says that the trial judge in the court below decided, in effect,
that the attending physician could not answer the hypothetic
question solely upon its hypothetic basis, but would to some
extent base his answer upon his professionally acquired knowl-
edge of the patient's actual condition. His reviewer, on the
other hand, thinks that, as this is a question of fact, it should
be decided upon evidence. It can not be assumed, as a mat-
ter of law, that the physician could not answer the question as
a hypothetic one, wholly uninfluenced by his personal knowledge
of the patient's condition. He therefore suggests that the
proper practice would be to examine the attending physician
preliminarily as to his ability in this respect.
The Richard Formogen Disinfecting Lamp.— This little apparatus
resembles a lamp in its appearance and is as easy to manage,
while it generates formic aldehyde in sufficient quantity and
strength to disinfect perfectly any apartment, allowing 36 grams
of methyl alcohol to the cubic meter. The vapors of the methyl
alcohol pass through a wire screen into a reacting chamber
enclosed in platinum, with twenty holes through which the
heated air enters, producing brilliant incandescence of the
platinum and transforming the vapors of the alcohol into formic
aldehyde, according to the familiar formula: CH40+0—
CH2O+H2O. Infected gauze is perfectly sterilized in six hours,
and the vapors have such penetrating power that infected
threads rolled in 250 grams of cotton are found absolutely
sterile.— Oaz. Mid. de Liige, August 20, from the Brussels
Clinique.
.Louisville.
Feeble Minded Institute.— There seems to be a disagree-
ment between the governor and the commissioners of this
institution as to the advisability of rebuilding the institution
which was burned not long ago. The governor is not in favor
of its being rebuilt and in this he is opposed by the commis-
sioners. There seems to be some trouble in regard to the col-
lection of the insurance money as it is claimed that there was
negligence on the part of the officials in not keeping enough
water in the tank for use in case of fire. The children are all
comfortably housed in the out houses which have been used
for shops and which were used for a similar purpose after the
fire in 1889. It is understood that a majority of the commis-
sion favor rebuilding and that will likely be done as soon as
arrangements can be made as to the insurance money.
THE PUBLIC SERVICES.
Army Changes. Official List of changes in the stations and duties
of officers serving in the Medical Department. U. S. Army, from
Aug. 30 to Sept. 4.1896.
Lieut. Col. Alfred A. Woodhull, Deputy Surgeon General, granted leave
of absence for one mouth and ten days, to take effect about Sept. 15,
1896.
Majoi Henry S. Turrill, Surgeon, upon being relieved from dutv at Ft.
Riley, Kan., is ordered to Willets Point, N. Y.. relieving Major Egou
A. Koerper. Surgeon. Major Koerper, upon being thus relieved, is
ordered to Ft. Crook, Neb., for duty.
First Lieut. Frederick P. Revnolds. Asst. Surgeon, is relieved from duty
at Ft. Clark, Texas, and ordered to Ft. Mcintosh, Texas, for duty,
relieving First Lieut. Robert S. Woodson, Asst. Surgeon. Lieut.
Woodson, on being thus relieved, is ordered to Jackson Bks..La.,for
duty at that station, relieving Capt. Junius Powell, Asst. Surgeon.
Capt. Powell, on being thus relieved, will report to the president of
the examining board, appointed to meet at the office of the Surgeon-
General of the Army, for examination for promotion, and upon con-
clusion of examination is ordered to Ft. Riley, Kan., for duty, reliev-
ing Major Henry S. Turrill, Surgeon.
Navy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending Sept. 5, 1896.
P. A. Surgeon E. R. StittMo duty in the Bureau of Medicine and Surgery.
P. A. Surgeon C. H. T. Lowndes, detached from the naval hospital, Phil-
adelphia, and ordered to the Washington navy yard.
Asst. Surgeon L. Morris, ordered to the naval hospital, Philadelphia.
Asst. Surgeon G. D. Costigan, ordered to the naval laboratory for
instruction.
Marine-Hospital Changes. Official list of changes of station, and
duties of Medical Officers of the U.S. Marine-Hospital Service, for
the sixteen days ended Aug. 81,1896.
Surgeon P. H. Bailhache. detailed to represent Service at meeting of
American Public Health Association, Aug. 24. 1896.
Surgeon George Purviance, relieved from duty at Philadelphia, Pa., and
directed to proceed to St. Louis, Mo., and assume command of Ser-
vice, Aug. 25, 1890.
Surgeou J. B. Hamilton, when relieved from duty at Chicago. 111., to pro-
ceed to San Francisco, Cal., and assume command of Service, Aug.
25. 1896.
Surgeon J. M. Gassawav. granted leave of absence for thirty days from
Oct. 1, 1890, Aug. 24, '1890.
Surgeon John Godfrey, when relieved from duty at San Francisco, Cal.,
to proceed to Chicago, III., and assume command of Service, Aug.
25, 1890.
Surgeon W. A. Wheeler, when relieved from duty at Ellis Island. N. Y.,
to proceed to Ciucinnatf, Ohio, and assume command of Service,
Aug. 25, 1890.
Surgeon C.E Banks, to proceed from Washington, D. C, to Boston. Muss.,
fortemporary duty, Aug. 21.1896.
P. A. Surgeon D. A. Carmichael. granted leave of absence for thirty days
from Sept. 5, !S90. Aug. 17. 1890.
P. A. Surgeon Eugene Wasdin, granted leave of absence for five days,
Aug. 25. 1890.
P. A. Surgeou S. D. Brooks, directed to rejoin station, St. Louis. Mo., and
when relieved from duty at that place to proceed to Port Townsend.
Washington, and assume command of Service. Aug. 25. 1890.
P. A. Surgeon J. H. White, relieved from special duly at Key West, Fla.,
and directed to rejoin station at New York. N. Y., Aug. 24,
Detailed for duty in connection with immigration Bervloe at Ellis
Island. N. Y., Aug. 25. 1890.
P. A. Surgeon P. M. Carrington. to proceed to Chicago, 111., and assume
temporary command of Service. Aug. 25. 1806,
P. A. Surgeon I. J. Kinyoun. detailed to represent Service at meeting of
American Public Health Association, Aug. 24, 1896.
P. A. Surgeon T. B. Perry, detailed to represent Service at meeting of
American Public Health Association. Aug. 24. 1896.
P. A. Surgeou 6. T. Vaughau, detailed for duty in connection with
immigration service at Philadelphia, Pa., Aug. 25, 1896.
P. A. surgeou J. O. Cobb, when relieved from duty at Cincinnati, Ohio,
to proceed to New York. N. Y., for duty, Aug. 25, 1886.
P. A. Surgeon W. G. Stimpsou, relieved from command of Service at
Port Townsend. Washington, on arrival of P. A. Surgeou S. D.
Brooks. Aug. 25. 18(6.
Asst. Surgeon E. K. Sprague, when relieved from duty at New York,
N. Y.. to rejoin his station at Boston, Mass., Aug. 27,
Asst. Surgeon H. S. Cumming. when relieved from duty at Norfolk, Ya.,
to proceed to Evanivllle. Ind.. for temporary duty, Aug. 25, 1896.
Asst. Surgeon J. B. Greene, to proceed from Baltimore. Md.. to Cleve-
land, Ohio, for temporary duty ; upon completion of which to rejoin
station, Aug. 25, 1896.
Change of Address.
Clarkes, Wm. E.. from Chicago to 485 Park Av.. River Forest, 111 .
Fest, F. T. B., from Plank Road, Mich., to Amov. China.
Isbecter, R. T.. from 1928 Indiana Av. to 21s Wabash Av., Chicago, 111.
Mackee. L. V. G., from Brant Rock to Attleboro, Mass.
Marr, W. L„ from 5451 Lake Av., Chicago, to 74U1 Madison Av., Grand
( rus-itig. III.
Mullen,!'. R.. from Marcus to Akron, Iowa.
Wimberly, J. S., from Sanford to Sunlight, Ga.
LETTERS RECEIVED
Angier Chemical Co., Boston, Mass.; Allen, J. M, Liberty, Mo.; Adkin-
son.L. G., New Orleans, La., (2); Abbott. W. C. Ravenswood. 111.
Brumbaugh. G. M„ Washington, D. C. ; Burr, C. B., Flint, Mich.; Bai-
ley. F. & E. Co., Lowell, Mass.
Christopher, H., St. Joseph, Mo.: Cannaday, A. A.. Roanoke, Va. ;
Caldwell, M. S.. Freeport. 111. : Clark, M. ('. ,t Sons. Albany, N. Y.
Dibrell, J. A. Jr., Little Rock. Ark.; De Courcy.J. O., St. Libory, HI.;
Daniel, J. B., Atlanta, Ga.
Fest. F.T. B., Plank Road, Mich.; Frisbie, J. F., Newton, Mass.; Frei,
G. A. T. Co., Boston. Mass.
Gould, Geo. M., Philadelphia, Pa.
Hartmau, F. E.. Denver. Colo.: Hypes, B. M.. St Louis, Mo.; Haven,
O. D., Ravenna. Ohio; Hoggard, W. D.. Nashville, Tenn.
Janseu, E., Astoria. Ore. : Jackson, Edward, Philadelphia, Pa.
Kebler, E. A.. Cincinnati. Ohio. (2).
Learning, J. K., Cooperstown.N. Y.: Lehn & Fink, New York.N. Y.
Mulford, H. K. Co.. Philadelphia, Pa.; Miller, F. A.. Chicago, 111.; Itik-
kelson, M., Wells, Minn.; Moore's Newspaper Subscription Agency,
Brockport, N. Y.: Mink, Arthur E., St. Louis. Mo.; Malre, 1.. E., Detroit,
Mich.; Mettler. L. Harrison. Chicago, 111.
Quin, Heurv W., New York. N. Y
Rogers, W. B.. Memphis, Tenn.; Rogers, L. L., Kingston, Pa.; Reed &
Carnrick, New York, N. Y.
Sherman. E. if.. Stuart Iowa: Sloman, S. A. <fc Co., Detroit, Mich.;
Shearer, Gilbert H.. Philadelphia. Pa.: Silver, D. R., Sidney, Ohio;
Strueh, Carl. Chicago, 111., (2) : Seidler, W. J., Newark, N. J.
Totman, D. M. Syracuse, N. Y.
Yaughan.V. C, Ann Arbor, Mich.
Wiley, Z. K.. Baltimore, Md.; Woody, Samuel E., Louisville, Ky. ; Wax-
ham, F. E., Denver, Colo.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., SEPTEMBER 19, 1896.
No. 12.
ADDRESS.
INTRODUCTORY ADDRESS.
in the Section on Neurology mid Medical Jurisprudence, at the
Forty seventh Annual Meeting of the American Medical
taaoeiatton, held at Atlanta, lia.. May 5-.S, 1896.
15V T. I). CKOTHERS, M.D., Chairman.
HAKTPOBI), CONN.
This Soot ion of Neurology and Medical Jurispru-
dence 1ms reached a position in the department of
medicine of intense practical interest.
Every practitioner is confronted with questions of
neurology, and the legal relations and possibilities
which arc constantly springing out of the present
conditions. Nerve strains and drains, and vast com-
plex states of neurosis are increasing yearly. Half a
dozen text-books and a score or more of pamphlets,
and monographs have been published in English
during the past year, exclusively on nerve diseases.
This is only a small part of the literature which is
appearing in journals devoted to this specialty, and in
iety reports and general journals of medicine.
The topic of medical jurisprudence has been
enriched with at least four encyclopedic volumes,
and over a dozen separate works and almost innumer-
able papers, lectures, essays, reports of cases, and the
renewed activity in the many societies devoted to this
special study. Literally a new field of medicine is
coining into prominence.
To the average practitioner there is something ap-
palling in the significance of these topics. That is
their magnitude and intricate relations to the every
day practice, create a feeling of despair in being able
to understand and apply the facts which are becoming
so numerous.
In neurology the impression has been fostered, that
only specialists with laboratory experience and facili-
ties for accurate measurement and tests of the nervous
system are able to judge wisely of these cases. This
is wrong. Neurology is a general topic, to be studied
by both the specialist and general practitioner.
The specialist with his means and appliances for
exact scrutiny of the phenomena of nerve disorders,
approaches it from one side; the practitioner with his
observation of symptoms, and comparative study and
grouping, from the other. Both may reach conclusions
in harmony or differing widely, or both be in error.
Not unfrequently the specialists will make a diag-
nosis based on the readings of instruments of preci-
sion, and mechanical studies of phenomena of nerve
action, that is not confirmed by the subsequent his-
tory. The general practitioner, will study the symp-
toms of the same case, and make a correct diagnosis
from a comparison and study of appearances. This
indicates that laboratory training and researches are
not the absolute essentials for skill in diagnosis of
nerve diseases.
I think the great demand in medical training to-day
is to teach how to observe accurately, and how
to estimate and compare the results of observa-
tion. In nervous diseases more than in other branches
the symptoms point to some local or general lesion
and it is the meaning of these " distress signals" that
will enable us to understand the disorder present.
The mapping of certain symptoms and the reasoning
of their meaning is simple enough, but their verifica-
tion from repeated studies and confirmation by time
and events is the final test. I think neurology and
jurisprudence require more accurate observation of
symptoms, and a higher degree of analytic skill and
judgment than in any other problems of disease. In-
struments of precision and laboratory researches are
limited, but the approach from the clinical side, trac-
ing back objective and subjective symptoms to their
first causes, requires the highest type of pure reason-
ing and judgment. Neurology carries us beyond the
boundaries of gross material life.
The defects of nerve and nerve fibers and their
relation to each other, are practically a very small part
of the subject. The realm of the psychical is still
an unknown continent, and yet its laws and forces
appear in every case that calls for treatment. Pre-
ventive medicine, the germ theories, the mysteries
of chemic physiology, and all the vast range of " new
lands" which are opening up before the student, are
insignificant compared with the unknown power of
mind, brain force and what is called nerve energy. No
one can plead incapacity to work in this field. Its
facts are everywhere open to observation.
Every person carries in his individual mental life
mysteries, the solution of which is of the highest im-
portance to the race. The mental and nervous element
in disease, in injury, in surgical operations, the
changes of mind arid its influence over the body, the
meaning of the phenomena of hysteria, and the terms
neurasthenia and the constantly increasing names of
symptoms of brain failures, are all " polar regions of
mystery." We are confronted with the fact, that the
present treatment of crime, insanity and drug manias
by legal methods has not kept pace with the march
of science. That the densest superstition prevails in
the practice of the courts, and medical men are called
on to harmonize the errors of the past with the teach-
ings of the present. Who will wonder that expert testi-
mony of this character will fail, and fall into disrepute.
The jurisprudence of to-day can not be a modern edi-
tion of past medical theories and teachings of science.
It must be founded on new facts of mind and matter,
new discoveries of the relations to environment and
human life, and the new physiology and psychology
of the brain. Every year our relations become more
and more complex. The demands for new adjust-
ments of life and living call for new energies and
create new sources of exhaustion. The brain and ner-
vous system falters and retrogrades and the legal rela-
tions change. Out of harmony with the environment
618
BEST METHOD OF TEACHING GYNECOLOGY.
[September 19,
clashing with existing conditions requires a new juris-
prudence and new conceptions of responsibility and
duty. Neurology is no longer the field of the spe-
cialist; it belongs to general medicine, to the country
and village physician, to the city practitioner, and
comes into the realm of every student of medicine.
Jurisprudence is equally broad in its requirements
and application to every day life. If you will study
the program of the several Sections you will notice
how intimately neurology has become associated with
the ever varying topics of medicine. If you will turn
to your individual experiences and present conditions,
and inquire of the mental phenomena, which is ever
pressing for solution, some conception of the subject
will dawn upon you. The study of the mental phen-
omena of neurology promises more startling discov-
eries than in any other field. The time has come for
every student of medicine to assist in clearing up this
realm of mystery and superstition. The quackery,
humbug and delusions which infest these unknown
phenomena of mind and matter will pass away. When
neurology comes into general science, when juris-
prudence become an exact study founded on cer-
tain definite facts, then the injustice and odium of
the present will pass away. Our individual duty is to
note and examine the phenomena of mentality and
the various states of brain and nerve action and seek
to discover laws which control them, and the causes
and conditions which govern their origin and progress.
The one central fact should never be forgotten, viz. :
All nerve phenomena, and brain activities are the
operation and manifestation of fixed and definite
laws, whose movements are as exact and uniform as
the stars above us.
In this confusing whirl of brain and nerve force,
there is no accident or chance. All normal and ab-
normal manifestations spring from definite causes
which may be known and anticipated. It would be
reckless to deny the possibility of stamping out nerve
and brain diseases in the future with the same cer-
tainty that the germ diseases are prevented. It is sim-
ply a question of knowledge of the facts which is the
highest province of science to point out.
ORIGINAL ARTICLES.
THE BEST METHOD OF TEACHING
GYNECOLOGY.
BY DENSLOW LEWIS, M.D.
PROFESSOR OF GYNECOLOGY IN THE CHICAGO POLICLINIC; ATTENDING
GYNECOLOGIST AND OBSTETRICIAN TO THE COOK COUNTY
HOSPITAL, CHICAGO.
At the last meeting of the American Medical
Association there was some discussion relative to the
best method of teaching the different branches of
medical science. If this subject received attention, as
far as gynecology is concerned, I have yet to see a
report of what was said. I believe, however, that the
usual method of teaching this comparatively new and
certainly very important department of medicine fails
of its purpose in many instances.
The primary object of a medical education is to
train the faculties of observation and then to teach
the- application of peculiar knowledge for the allevia-
tion of distressing symptoms and the relief of the
responsible pathologic conditions. The task is most
complicated, and it is not surprising that in many
instances the student, who, perhaps, has passed a bril-
liant examination, fails ignominiously when con-
fronted with the exigencies of actual practice.
Perhaps the fault is not exclusively his. Perhaps
the medical education he has received, while teaching
him many facts, has not taught him how to apply
them. Perhaps, in the attempt to teach all that is
known, too little effort has been taken to teach how
to make use of knowledge. Too often it is forgotten
that the science of medicine finds expression only in
the application of the art.
Gynecology has been defined by Ssenger as the sur-
gery of the female genitalia. It is, however, much
more than this. It includes a knowledge of venereal
diseases ; it must take into consideration diseases of
the bladder, ureter, kidneys and rectum; as a matter
of fact it often comprises all operations within the
pelvic and abdominal cavities, and for its proper
understanding the principles of obstetrics must have
been mastered.
Before commencing the study of this extensive and
important department of medical science it is obvious
much preliminary work must be done. Anatomy,
physiology, bacteriology, pathology, uranalysis, vene-
real diseases, obstetrics and general surgery must first
be studied in detail. To minds thus fortified by a
definite knowledge of medical facts, trained to pro-
cesses of analysis and capable of logical reasoning so
that sensible deductions may be made from true pre-
mises, the teacher of gynecology must endeavor to
appeal so that the student having eyes may see, hav-
ing knowledge may understand, and having common
sense may appreciate at its true value what he sees
and understands. He should not only be taught what
to do but why he does it. The teacher, being neces-
sarily a man of experience (otherwise, he should not
presume to teach) will have favorite methods which
he will advocate. He should not, however, fail to
remember that his individual methods arc only of
value if the reasons which induce him to resort to
them are sufficiently apparent to demonstrate their
superiority. His duty to the student is to explain nil
well recognized methods of procedure and to compare
their value not alone in connection with the case
under consideration, but in reference to other similar
cases as well.
Text-books at best can give but a general idea of
gynecology. I do not condemn their use. On the
contrary I believe the systematic study of some man-
ual to be advantageous. It teaches what to expect
and, in the hands of an expert quiz-master, such a
book unquestionably aids in the acquisition of indis-
pensable facts. The peculiar tasks of the teacher of
clinical gynecolgy can not be supplanted by any book
or by any system of recitation. The Froebel method
of instruction is particularly necessary in imparting a
knowledge of gynecology. Manual training is here
indispensable. During his student days the medical
man must be taught to see what there is to be seen
and to perfect his sense of touch. Otherwise his
teaching is superficial, his knowledge imperfect, and
as a rule the result of his practice most deplorable.
To explain what I consider to be the best method
of teaching gynecology it is perhaps preferable to
refer to hypothetic cases. The women who serve me
as subjects for clinical instruction are either ambula-
tory patients, able to be up and about, often able to
work, or bed-ridden patients, incapacitated in conse-
quence of some acute or chronic indisposition, often
of a serious character.
I
18%.]
BEST METHOD OF TEACHING GYNECOLOGY.
619
Let us suppose that a patient presents herself at
the dispensary. My second assistant writes out her
history in full in accordance with specially prepared
blanks which are designed to show a complete state-
nun! of important facts in the fewest possible words.
The nurse then places the patient upon the operat-
ing table in the dorsal position with a sheet covering
the legs and genitals. A curtain suspended from the
ceiling falls alnmt the patient's waist as she lies upon
tlte table and separates her from the students so that
her face is not seen. I first refer to the history of the
case. The patient, for example, may have had three
children, the youngest being now 2 years old. Her
last labor may have been pn>t acted, necessitating the
application of forceps. The birth of this child was
followed, we will suppose, by an illness. that kept the
patient in bed for six weeks and was accompanied by
lever. Since that time the patient has never been
well. She has suffered from pelvic pains varying in
decree but usually more severe during menstruation.
She has become anemic and weak. She is consti-
pated and notices a constant leucorrhea. Such a his-
tory, variously modified by individual circumstances,
is a eominen record of many dispensary cases.
1 introduce the right index finger and notice a lacer-
ation of perineum and cervix. With the fingers of
the left hand placed on t he abdomen over the symphy-
sis the uterus is recognized as somewhat larger than
normal, freely movable and not specially sensitive to
touch. As the bivalve speculum is introduced the
existence of a leucorrheal discharge is observed.
Now what shall the teacher do under these circum-
Btances? He has an opportunity of doing and saying
a number of things, all eminently proper and all of
value. Having recited the history of the case and
baying made a cursory examination of the patient, he
may now deliver a didactic lecture on one or more
features thai suggest themselves to him, and in that
manner occupy all the time at his disposal. It must
be acknowledged that such a procedure is useful; and
that the presence of the patient, even if no one touches
her, serves to forcibly direct attention to her condition.
I confess I often show in the amphitheater women
who have recovered from placenta previa, postpartum
hemorrhage or eclampsia, and I am confident their
presence lends interest to any remarks that are made
concerning the case. In a case like the one we are
supposed to have before us such a procedure is, in
my judgment, not the best method of teaching. In
place, therefore, of delivering a lecture on trauma-
tisms of parturition, subinvolution, puerperal infec-
tion, endometritis or any other subject which might
very aptly be discussed in this connection, the teacher
will realize that his chief object is to point out what
there is actually to see, and to instruct the student in
the proper method of determining what is to be done.
His efforts will be directed toward conveying definite
knowledge, but he will chiefly endeavor, by emphasiz-
ing important facts, by referring to points of similarity
and difference due to anatomic conditions and etio-
logic factors, to train the student to view the matter
under consideration in all its relationships, more
especially in reference to actual diagnosis and treat-
ment. The teacher must, moreover, understand that
he fails in his efforts if he tries to teach too much. In
considering ordinary cases he must necessarily repeat
much that he has already said. This is desirable
rather than objectionable, but he should be able to pre-
sent the same facts, from different standpoints, so that
his remarks are always of sufficient interest to com-
mand the attention of the student.
In the case under consideration the teacher will
point out the bi-lateral laceration of the cervix. By
means of tenacula he will demonstrate how the cervix
should be after trachelorraphy. He will explain where
incisions should be made, and speak of the " plug of
cicatricial tissue/' which is often a bug-bear to many
students, and he will show where sutures should be
passed after proper denudation of the laceration.
Each student in turn sees the pathologic condition
present. Each student sees the appearance of the lacer-
ation as it exists, and also as it should appear when
repaired. Several of them take the tenacula in hand
and demonstrate the necessary operative procedures.
While the students are thus engaged the teacher
may refer to the hypertrophic changes that occur in
consequence of cervical laceration. He may speak of
the increased danger of infection at the time of labor
in consequence of traumatism, and may mention how
infection may extend by continuity of mucous surface
through uterus and tubes, or through the placental
site. He may show how a laceration can extend be-
yond the cervix even into the peritoneal cavity, and
may call attention to the possibility of serious hem-
orrhage arising from such a laceration during labor
and being mistaken for postpartum hemorrhnge due
to imperfect uterine contraction; he may explain the
necessity of immediate operation in such an event.
He may also explain Dtihrssen's method of cervical
incision in cases requiring immediate delivery, and
he can point out how dangerous rupture into the
peritoneal cavity is prevented by multiple incisions
which obliterate the portio vaginalis. Incidentally
he refers to more extensive lacerations of the cervix —
the stellate lacerations — which may be practically
inoperable and may necessitate an amputation of the
cervix, and with the tenacula he demonstrates the
operation of Schroder and others.
The patient is now placed in the left lateral posi-
tion and a Sims' speculum is introduced. The won-
derful perspicacity of our first master in gynecology
is referred to and the advantages of his position and
his speculum are pointed out. Emmet's discovery
and operation are spoken of and the steps of the trach-
elorrhaphy are again demonstrated by other students
taking the tenacula in hand. In connection with
this demonstration the teacher may consistently speak
of the dangers of undue traction in operative efforts
on the uterus, or in the course of the examination.
Howard Kelly's "third hand" may be mentioned and
the possibility of separating adhesions, rupturing a
peritoneal abscess or forcing pus from a pyosalpinx
upon the peritoneum may be explained.
The speculum is now withdrawn, the patient is
again placed in the dorsal decubitus and we proceed
to the digital and bi-manual examination. While
doing this it may be well to explain the inadvisability
of using the uterine sound in most cases. The possi-
bilities of exact diagnosis by other methods, the dan-
ger of infection and traumatism, and above all the
relatively insignificant character of the knowledge
that will be gained in ordinary cases by intra-uterine
exploration will deter us from resorting to the use of
the sound without preliminary disinfection and dila-
tation in special cases where intra-uterine exploration
is clearly indicated, that is, when the benefits to be
derived from this method of examination are plainly
evident.
620
BEST METHOD OF TEACHING GYNECOLOGY.
[September ly,
As the vulva is now examined by separating the
labia a slight perineal laceration will be observed.
Attention is called to the fact that the closure of this
laceration has resulted in cicatricial tissue, very differ-
ent in appearance from the vaginal mucous mem-
brane. The ordinary appearance of the virgin vulva
and the vulva in the nullipara is demonstrated by
bringing the parts together with the fingers or tena-
cula. The gaping of the vulva with perhaps slight
cystocele or rectocele is pointed out and the possibility
of extreme degrees of these conditions is demonstra-
ted by inserting a male sound into the bladder and
the finger into the rectum. The remains of the hymen
are shown and various matters of medico- legal impor-
tance are discussed.
As the examining finger is now introduced refer-
ence is made to the difference in sensation as observed
in virgins, nulliparae and in women who have borne
children. The absence of a perineum pressing against
the anterior vaginal wall is commented on. The
sensation of a lacerated cervix, somewhat hypertro-
phied is mentioned. With the examining finger still
in the vagina, the fingers of the other hand are
placed over the symphysis and the uterus and
its adnexa are palpated. Attention is called to
the fact that the fundus uteri is usually felt just
over the symphysis, and not over the region of the
umbilicus. The student is also impressed with the
fact that the finger in the vagina is intended simply
to steady the uterus, and that extreme pressure up-
ward is painful as well as useless.
Matters of interest in relation to the uterus are
mentioned. The mobility, size, position and degree
of tenderness are referred to. The student is taught
first to recognize the fundus uteri, and after carefully
but gently palpating the uterus he is instructed to
pass the examining finger in the vagina to one side of
the cervix, while the fingers of the other hand upon
the fundus are carried outward so that abnormalities
of tube or ovary may be appreciated. Each student
in turn now examines the patient under the imme-
diate personal supervision of the teacher. It is sur-
prising how varied are the difficulties experienced by
different students, and how quickly a little individual
assistance will enable the student to successfully pal-
pate the pelvic organs.
It must be remembered that many practitioners of
great experience have never attempted a gynecologic
diagnosis. They have vague ideas of the use of the
uterine probe and sound, they consider the adjust-
ment of suitable pessaries a matter of special skill,
and they attach undue importance to the variations in
the positions of the uterus. The possibility of map-
ping out the pelvic organs by bi-manual palpation is
not seriously considered. The importance of recog-
nizing the changes due to inflammation and the rela-
tive value of different pathologic conditions due pri-
marily to infection is not fully appreciated.
While the student is being taught to palpate the
pelvic organs he is shown normal and abnormal speci-
mens of the female genitalia. He observes, for
instance, the size of the tube in a normal specimen,
and also in a case of salpingitis or pyosalpinx. As
he looks at these specimens he realizes the condition
of the tubes in the woman he is examining, and I
believe his impressions of the condition of the patient
are rendered more vivid and more exact by observing
the specimens at this time.
The remarks of the teacher while a number of the
Z
ibe
ss
id
>1-
:
students are in turn examining the patient, will nec-
essarily be varied, as many patients with almost iden-
tical histories will constantly present themselves,
will be found advantageous for the teacher to e:
deavor to impress certain facts in connection wi
each case, not attempting to exhaust any portion
the subject, but rather to help the student to ma;
accurate observations, to arrive at sensible concl
sions, and above all to appreciate the limitations ol
his examination.
He may, for instance, explain how infection may
proceed through the uterus and tube and on to the
ovary and peritoneum. He may demonstrate results
by showing specimens of abscesses of the ovary
pyosalpinx. He may speak of ovarian and parov
rian cysts, and of tumors of the uterus, ovary, tub
and broad ligament. He may advantageously discuss
inflammatory conditions of the cellular tissue, and
may also refer to extravasions of blood and the devel
opment of pelvic abscesses, discussing their localizi
tion and usual course in consequence of the anatomii
conformation of the parts.
In a word, the instructor is now teaching first of a
diagnosis, which depends upon facts. He must speak
of facts, that is, of the various possibilities compati-
ble with the history, and he must teach the student
to arrive at a conclusion by showing him what he may
expect to find, and then what he actually does find.
He must not only explain, for instance, that a mass
felt between the fingers is a pyosalpinx; he must show,
as well, why it can not be anything else. Finally,
he must determine the proper course of treatment, and
must show clearly and distinctly not only why the
treatment recommended in this particular case is the
best treatment, but also why other methods of pro-
cedure, while sometimes of value, are inferior in merit
to the plan proposed. Thus alone can be perfected a
differential diagnosis worthy of the name.
The course of procedure described is applicable to
all dispensary cases. Each student should see every-
thing there is to be seen and thoroughly understand
what he sees. He should personally examine every
case, make his own diagnosis and determine the best
method of treatment. All vague and erroneous ideas
should be exploded by demonstrating facts, and all
vagaries of treatment should be exposed by a thor-
ough explanation of the reasons that dictate the plan
of treatment proposed.
In teaching how to operate, the ideal method would
be for each student to operate under the supervision
of the teacher. Such a method is manifestly imprac-
ticable in the great majority of instances, and for this
reason the best method of teaching the student how
to operate is for him to observe how his teacher does,
watching every step of the operation and understand-
ing how and why every incision is made and every
suture passed. It is evident such a method is incom-
patible with the performance on the part of the
teacher of brilliant and theatrical exhibitions of his
skill. It must be remembered that he is not demon-
strating his ability as an operator; he is doing the
best he can to show each student how the different
steps of the operation are to be undertaken, and
he explains why each step is necessary or expedient.
The teacher instructs the student so that he may oper-
ate. There is no endeavor— at least there should be
none — to impress the student with his teacher's won-
derful dexterity and exceptional ability.
I have elsewhere described my "phantom perineum"
L896.]
VALUE OF PHYSIOLOGIC STUDY.
621
Which has been ' used in my clinics for many yenrs.
1 have within the past two years perfected a "phantom
oervix" and quite recently have been able to manufac-
ture a "phantom" of the uterus, tubes and ovaries for
the purpose of demonstrating various gynecologic
operations. These •■phantoms"' are of different col-
ored cloth made into bags to represent different organs
and layers of tissue.
tn the case of the perineum 1 hey show the neces-
sity of a true restoration by actually restoring the parts
to tin- position they occupied prior to the injury.
The operations of fiegar, Emmet, Martin, Tait and
others can lie exemplified, and it can be clearly dem-
onstrated how the fundamental principle is subserved
regardless of the differences in detail of operative
technique.
In the case of the cervix, Emmet's operation,
Dtihrssen's incisions, the closure of an extensive lac-
eration at the time of labor, and the different proced-
ures for amputation of the cervix, can all be clearly
demonstrated,
It is my practice to show the different steps of the
operation on the "phantom" while one of my assist-
tants operates on the patient. In a perineorrhaphy or
cervix operation the students walk around to see the
denudation after it is made. They then see the
sutures as soon as they are passed, and finally see the
result when the sutures are tied. At the same time
they see each detail of the operation as \t is demon-
strated on the "phantom.'* They may not be im-
pressed with the cleverness of the operator, but I
honestly believe they learn how to operate, each for
himself.
In abdominal operations I first invariable insist
upon the lucssity of absolute asepsis, and I explain
the methods adopted for securing surgical purity on
the part of the patient ami the operator. The abdom-
inal incision is made rather long so that the structure
of the abdominal wall may be demonstrated. For half
an inch perhaps the skin alone is incised. For
another half inch the incision extends through the
superficial fascia. Then the aponeurosis is incised
and the separation of the muscular fibers is shown
down to the aponeurosis beneath. Finally the sub-
peritoneal , fat is incised and an opening is made
through the peritoneum.
As the students now walk around the patient each
one sees the different layers of the abdominal wall
which are demonstrated by means of dissecting for-
ceps. While this is being done comment is made
upon the relative thickness of the different structures,
the variations of the blood supply and the necessity
for controlling it, the advisability of avoiding the
linea alba so as to secure stronger union.
By means of scissors the abdominal incision is now
made to include all tissues and the omentum is shown.
Incidentally the appearance of the peritoneum is
demonstrated and the possibility , of adhesions of
tumors, intestine, etc, is alluded to. The patient is
now placed in the Trendelenburg position. The intes-
tines are allowed to fall forward or are pushed out of
the way, and a laparotomy sponge of gauze is intro-
duced. Again the students walk around so that each
Bees the fundus uteri, the tubes, the ovarian cyst, the
subperitoneal fibroid, or whatever pathologic condi-
tion may be present.
Supposing the case to be a pyosalpinx, the teacher
i Annals of Gynecology, Vol. vili p. 670, Chicago Clinical Review,
May, 1M5.
now introduces two fingers and feels for the fundus
uteri, explaining what he is doing. He then passes
his fingers behind the uterus and breaks up adhesions
so that the mass may be dislodged. He brings it out
of the abdominal incision and transfixes it in the
usual manner. The students again inspect the tumor
and observe how the ligature is passed and tied. They
observe the stump after the mass has been cut away
and notice the space it occupied prior to its removal.
While the teacher is at work in this manner he
explains his reasons for each step of the operation
and he refers briefly to modifications of the method
that might be necessitated by certain complications.
He explains the Staffordshire knot and his assistant
demonstrates it on a towel. In the same manner
other methods of ligating are shown and reasons are
given for preferring the method adopted. The treat-
ment of adhesions to intestine or different pelvic vis-
cera is mentioned, and the advisability of vaginal
incision in certain cases pointed out.
The indications for drainage are spoken of and the
different methods discussed. The question of the
"toilet of the peritoneum" and flushing out the peri-
toneal cavity are raised and definite directions are
given. Finally, in closing the abdominal wound, the
substance used and different methods adopted are
explained and their relative value discussed. The
students see the sutures in place and they notice how
they are tied. They then see the application of the
dressings and perhaps the hot bricks that are placed
around the patient when she is put back to bed.
It is probable that I have indicated by what has
already been said just what I mean by the best
method of teaching gynecology. It is, I think, un-
necessary to particularize further. To do so were to
present a syllabus of my lectures on the different
topics of gynecology.
It is evident the best method of teaching is not the
best method of showing the phenomenal ability of the
teacher. It is questionable if the latter method is of
much benefit to the student. It must be remembered
that he comes to learn. He will soon be thrown on
his own resources. The fact that his teacher is a great
man will help him but little in his extremity.
The student comes to us to learn and it is but
proper he should be taught. He wants to see no
operative pyrotechnics or only incidentally. The
province of teachers is to teach. Their first duty is
to help the student to help himself, and the method
adopted should have that end constantly and pre-
eminently in view.
217 Fifty-third Street.
THE VALUE TO THE MEDICAL STUDENT
OF PHYSIOLOGIC STUDY.
BY JOHN A. BENSON, M.D., COLUMB.
PROFESSOR OF PHYSIOLOGY COLLEGE OF PHYSICIANS AND SURGEONS
CHICAGO; PROFESSOU JURISPRUDENCE OF MENTAL DISEASES,
CHICAGO SCHOOL OF LAW.
In a superstructure like that of the art and science
of medicine wherein we find the various subdivisions,
so imbricated and intimately related to and connected
with each other that injury to or removal of any one
would endanger the integrity of the whole, it is
manifestly improper, and in fact impossible to attempt
to place a greater value on any one part than can be
ascribed to any and every other. For in such a
whole no particular fractional part excels any other
as far as specific value is concerned, and the value
622
VALUE OF PHYSIOLOGIC STUDY.
[September 19,
and dignity of the whole equal the sum total of the
individual parts. And indeed were we to attempt to
remove or neglect any part, no matter what, we
would not merely be subtracting a fractional value or
dignity and thereby lessening the total by just so
much as would be subtracted, but we would be seri-
ously attacking the safety of the whole building and
peradventure would find its walls toppling over and
falling about our ears with a fearful clatter. But if
we find that any one part can be discovered as having
borne parental relations to any other, we can of a
certainty recognize such importance; for the son,
even though acquiring equal or superior dignity to
his father, must ever respect that father, and the
progeny must defer to the procreator. By reasoning
on this line I purpose to demonstrate the nobility of
physiology among its confreres and to give reasons
why special and careful attention should be given
thereto, and why our college authorities should
appreciate the great benefits to the student of
thorough and correct physiologic teaching. What is
physiology ? The answer to this question opens up a
field far wider than is usually imagined. Physiology
has been defined as being the study of the phenomena
of life, teaching us the direct causes of these phe-
nomena, the varying conditions under which they
appear, their coincident chemic and mechanical
accompaniments, their modes of operation and their
results. From the department of physiology we
learn all that can be known concerning the active
functionating organism with its various subdivisions
each working in its own particular manner, each
function modified, accelerated, retarded or inhibited
to meet the requirements of the economy at large, and
the whole structure endowed with personality and
imbued with vitality. So far we find physiologic
lore to be of interest to the natural scientist outside
of specific medical application, but to the practical
physician I will now endeavor to show that physi-
ology is an absolute sine qua non, and he must pay
strict attention to this branch before he can hope to
become a diagnostician, a pathologist or a therapeutist.
I imagine that it is hardly necessary for me to
remark that a physician devoid of diagnostic ability,
of pathologic knowledge or therapeutic skill is totally
unfit to attempt to practice the profession of medicine;
and I desire here to record myself in the most posi-
tive manner as being of the opinion that such ability,
knowledge and skill are in direct ratio to thorough-
ness and completeness of physiologic study, and that
when any individual has without such thorough and
complete study, attained even considerable success in
medical practice, he remains an empiricist and can
never be considered a scientific physician. A man, a
work of art, or a piece of machinery we describe as
being perfect, as being good, or indifferent or even
bad. We use these terms relatively, comparing the
object under examination with a known and accepted
" standard " which may be abstract or concrete; and
a principal duty of our wise men, of our physicians,
our teachers, our artists and our scientists is to estab-
lish a " standard " in each of their several lines.
There is nothing " new " in disease. It is a modifica-
tion or an alteration of the normal; a perversion of,
or a departure from the " standard " and it is the duty
and the prerogative of the physiologist to give the
practicing physician the "standard "he has to use.
This " standard " is the living human body in a con-
dition of healthy physiologic equilibrium, with all
its various subdivisions working harmoniously
together and constituting a perfect whole. After
the student has become familiar with the normal
action of this magnificent piece of mechanism, then
and only then can he study the deviations therefrom
which we term "disease." For example; of what
use would it be for the tyro to place his ear to the
chest of a patient suffering from cardiac disease?
How would he know but that this tumultuous heav-
ing, these varied sounds were the usual condition of
affairs? First let him note all the characteristics of
the heart's action, its rhythm, the accompanying
sounds, the events taking place during the cycle, and
the results and bearings of these events on far and
near portions of the animal economy; then the slight-
est deviation from the known standard will mean
something, and its specific value can be appreciated.
A man practicing the profession of medicine without
any " standard " to guide him, would resemble t"
unfortunate who was
" Condemned in labor or the arts to drudge
Without a second and without a judge."
the
Groping in the darkness of the impenetrable shade
of ignorance, such a man could never advance, and
would have to be placed in one of two categories, to-
wit: knowing and appreciating the deficiencies and
weaknesses of his position he would endeavor to ameli-
orate them, he would seek a way out of the darkness,
and his voice would ring out for truth and light, as a
" Child crying in the night
A child crying for a light
And nothing in its language but a cry. "
For such a man there is hope. Or else blind and
self-satisfied, he would recklessly stride along through
the valley and the shadow firing blank shots into
space and noting his own splendid marksmanship.
Such a man is scientifically dead; for him there is no
hope, no resurrection. Whose is the fault fundament-
ally in either case? The fault is at the door of the
guides, of the teachers, of the leaders, of those who
permitted or allowed such a lamentable condition to
become possible.
This subject is one near and dear to my heart and
peradventure were I not to call a halt and exert a
reflex inhibitory influence on my pen, it might, by
exercise, develop such strength and amplification as
to emancipate itself from my autocratic grasp and
galop along indefinitely. Worse and more pitiable
then would be the fate of the distinguished Editor of
the Journal, than even that of the guests of Helio-
gabalus. For whereas the latter were smothered in
roses, the former would of a certainty be drowned in
"copy."
I imagine though that I have given in outline good
and sufficient reasons for devoting time and attention
to physiologic work; the next question that faces us
is how should physiology be taught? To this I
would answer that the work must be done in two ways:
first, by direct observation; and second, by didactic
explanation. In the first place I would familiarize
the student with the well-developed, healthy, living
human body as a whole, and his preliminary study in
this regard I would have similar to that pursued by
art students in painting and sculpture; that is the
study of the nude, as conducted by director French
of the Chicago Art Institute. Such a course of gross
physiologic anatomy, modified somewhat perhaps to
meet the requirements of the medical student, I hold
to be of vast value. Then I would insist on a full
• 1
anil complete laboratory course, not such a course as is
hut too often given (on paper in an annual announce-
ment ) but a thorough and painstaking course super-
vised by the professor of physiology himself, who
would thus come into direct personal contact with
eaeh and every member of the class. Such work
would he of the greatest value not only in inculcating
physiologic data, hut also in teaching the student how-
to think, how to draw and comprehend deductions
from personally recognized conditions, how to explain
to himself and reason out for himself the relations of
abstract and concrete causes and appreciated results,
and the bearings thereof. The master words for sue-
in the attainment of actual knowledge are
••direct observation," and only by this means can
positive results be reached. Analogical deductions
ami inferences ate unreliable and dangerous, no
matter how ounningly traced, and theonly data which
can stand criticism are those born of experimental
investigation. Structure and function are most inti-
mately connected, and yet we find that we can not
with a certainty depend on the structure of an organ
as indicating its function. The two can only be co-
related when direct examination demonstrates the
fact of their association.
The lower we descend in the scale of life, the
simpler do we find structure; in the lowest planes,
the simplest. In these latter we note the existence
of individual unicellular organisms without specific
subdivisions, each part performing equally all the
various vital functions. Thus the unicellular organism
is uniform, simple and general, possessing the funda-
mental property of irritability and likewise the capa-
bility of initiating movement. This cell is therefore
automatic and contractile, and at one and the same
time is excretory, reproductive, andgenerally metabolic
and motile, all these functions being exhibited
equally by the same mass of protoplasm. As we
mount higher we find various portions of the organism
Incoming more skillful in performing a few functions,
and this for each part soon is narrowed down to one
special function. At the same time, to a greater or
lesser extent, the part becoming so specially educated
withdraws from the performance of general functions.
Each part becoming special renders the whole more
complex, and we have anatomic changes taking place
coincident with the educational amplifications. The
accompanying conditions are; with relation to func-
tion, "specialization;" with relation to structure,
" differentiation. "
In order that we should acquire as distinct and clear
an understanding as is possible of these complex,
specialized and differentiated structures, we must
begin our study at the lowest plane of life and note
carefully the physiologic, histo-chemic and anatomic
attributes of the simplest forms there to be found;
continuing our observations on the same lines and
mounting gradually higher and higher, we ultimately
reach the most complex combinations. And further,
in arriving at explanations of the structural, chemic
and functional phenomena that confront us in the
higher planes, we must go back to the period when
these highly complex forms were themselves of simple
degree. In this way embryology enters into our field
of research, and in comparing the amplification and
development of animal life generally with that of an
individual member of some particular species, as for
instance a human being, we find that we can aptly
characterize the one as being a simulacrum of the
VALUE OF PHYSIOLOGIC STUDY.
623
other, the only marked difference being the element
of time which however may safely be left out of con-
sideration.
At the highest point in the scale of life we discover
the exact opposite of what we studied in the lowest,
and we find the organism now to be multiform, com-
plex and special. Each one of the various parts of
such an organism, has to be studied separately, in
order that we should determine as far as possible its
individual characteristics, and this study should be
begun in the particular tissue after isolation from the
economy as a whole. Then entire organs or appara-
tus of associated organs have to be considered and
this can only be done by experimental observation
upon the living structures.
Last of all the functionating entity must be observed,
all the parts, all the organs, all the associated appa-
ratus of organs brought into relation with each other
and working in harmonious or alternating action.
This must all be done on the living body, aided by
dissections, schema, working models, charts, diagrams
and so forth.
In pursuing such work the teacher will be required
to devote a certain amount of time to both structural
and chemic analyses of the tissues, so physiology and
histo-chemistry are indissolubly united. These obser-
vations, examinations and experiments require labor-
atory work. Here under the direct guidance of the
physiologic professor, each student works as an indi-
vidual alone and to a great extent apart from his co-
laborers, but at stated and frequent periods the entire
class should meet the professor in the lecture amphi-
theater for didactic instruction. Here the laboratory
work is fully explained and amplified, deductions are
made, theories are advanced, causes and effects are
considered, opinions are reduced, and work on similar
lines in other portions of the world is reviewed; while
the laboratory illustrations are supplemented by
working models, sketches, charts, schemes, etc. Again,
frequent convocations should be held at which the
professor should question each student on the previ-
ous wqrk, and this should be looked upon as being as
valuable as the other modes of instruction, as the
student's ideas on the subject-matter can be elucidated
and he can be materially assisted.
Speaking with an authority born of experience and
study, I would say : 1. The physiologic course should
be included in the curriculum for both the freshman
and sophomore years. 2. Sufficient time should be
given for at least five days in each week during the
course, to laboratory work and explanatory or didactic
instruction. 3. Once at least each week there should
be a physiologic convocation in which the previous
work should be carefully reviewed. 4. The chair of
physiology should be a salaried position, as it is im-
possible for a practicing physician to properly admin-
ister its duties and bear its responsibilities. This chair
is about the only one in a medical college which, to a
practicing physician, has no commercial value, and
the work of the incumbent each year is not by any
means accomplished when the lecture course is
finished. During vacation time original research,
individual observation, review of the work of others,
travel, visits to foreign and domestic universities and
colleges and their laboratories, all are matters that
will occupy time; in short as soon as one course is
completed, preparations for the next should be initia-
ted, for no scientific physiologist can depend on this
year's notes for the next year's course; he can not '
624
MEDICAL COLLEGES.
[September 19,
stand still, but must gain or lose, advance or retreat.
5. There must be a fully equipped laboratory in all
that the words imply, with a complete zoologic addi-
tion. 6. In the freshman year there should be a
preparatory course on physiologic artistic anatomy.
"There are many other details in this connection that
time and space will not permit me now to dilate upon,
but I would conclude by expressing the positive
opinion that unless the fundamental elements of the
positions above outlined by me are in force in a med-
ical school, such school is not doing its duty either to
the students or to the profession at large, and does not
deserve to stand in the front rank. In a very large
majority of our institutions of medical learning,
physiology is slighted and ignored, and money and
time are spent and much advertising indulged in
concerning the so-called practical branches, the
authorities forgetting that there is no branch so
sternly practical to both the under-graduate and the
post-graduate as is physiology.
THE MEDICAL COLLEGES OP THE UNITED
STATES.
The Editor of the Journal a few weeks ago ad-
dressed a circular to the Secretary or Dean of the
various Medical Colleges, requesting them to state
their plan of education, including the requirements
for admission, the facilities they possessed for teach-
ing, and the cost of attendance.
The general response to the circular has produced
the very complete summary here presented.
It should be remembered that these statements are
those prepared by the schools themselves and in no
way changed in this office.
ASSOCIATION OF AMERICAN MEDICAL COLLEGES.
The Association of American Medical Colleges,
requires for all members that candidates for matric-
ulation will be allowed admission, subject to the con-
ditions prescribed by Article III of the Constitution
of the Association:
ARTICLE III.
Section 1. — Members of this Association shall require of all
matriculants an English composition in the handwriting of the
applicant of not less than two hundred words ; an examination
by a Committee of the Faculty, or other lawfully constituted
Board of Examiners, in higher arithmetic, algebra, elemen-
tary physics, and Latin prose.
Sec. 2. — Graduates or matriculants of reputable colleges or
high schools of the first grade, or normal schools established by
State authority, or those who may have successfully passed
the entrance examination provided by the statutes of the State
of New York, shall be exempt from the requirements of Sec-
tion 1.
Sec. 3. — Students conditioned in one or more of the branches
enumerated as requirements for matriculation shall have time
until the beginning of the second year to make up such defi-
ciencies ; provided, however, that students who fail in any of
the required branches in this second examination shall not be
admitted to the second course.
Sec. i. — Colleges granting final examination on elementary
subjects to junior students shall not issue certificates of such
final examination, nor shall any member of this Association
confer the degree of Doctor of Medicine upon any person who
has not been first examined upon all the branches of the curric-
ulum by the Faculty of the College granting the degree.
Sec. 5. — Candidates for the degree of Doctor of Medicine
shall have attended three courses of graded instructions of not
less than six months each in three separate years.
Sec. 6. — Students who have matriculated in any regular col-
lege prior to July 1, 1892, shall be exempted from these
requirements.
THE SOUTHERN MEDICAL COLLEGE ASSOCIATION.
The Southern Medical College Association makes
the following requirements, viz.:
Every student applying for matriculation must possess the
following qualifications :
He must hold a certificate as the pupil of some known,
reputable physician, showing his moral character and general
fitness to enter upon the study of medicine.
He must possess a diploma of graduation from some literary
or scientific institution of learning, or certificate from some
legally constituted high school, General Superintendent of
State Education, or Superintendent of some County Board of
Public Education, attesting the fact that he is possessed of at
least the educational attainments required of second-grade
teachers of public schools ; provided, however, that if a stu-
dent, so applying, is unable to furnish the above and foregoing
evidence of literary qualifications, he may be permitted to
matriculate and receive medical instruction as other students,
and qualify himself in the required literary departments, and
stand his required examination, as above specified, prior to
offering himself for a second course of lectures.
The foregoing certificate of educational qualifications, at-
tested by the Dean of the medical college attended, together
with a set of tickets showing that the holder has attended one
full course of medical lectures shall be essential to attendance
upon a second course of lectures in any college belonging to
the Southern Medical College Association.
(1) ,189-
Dean of Medical Department of University of Tennessee —
Nashville Medical College:
Dear Sir — Mr of , is a gentleman
of good moral character. I recommend that he be allowed to
enter upon his medical studies in your college. He has been
my pupil . . . months.
Yours,
[Sign here] . .
(2) ,189-
Dean of Medical Department of University of Tennessee —
Nashville Medical College :
Dear Sir — I have examined Mr , of
and find his scholastic attainments equal to those requisite for
a second-grade teacher's certificate in our public schools.
Yours,
Supt. of Pub. Instruction.
BIRMINGHAM MEDICAL COLLEGE.
BIRMINGHAM, ALA.
This College requires an attendance of three terms
of six months each before application for graduation,
and a general average of 75 per cent, for a degree.
The school has good hospital advantages and abun-
dant clinics, and furnishes splendid facilities for the
study of medicine. There is an excellent building
well arranged for medical instruction, and well equip-
ped laboratories. W. H. Johnston, M.D., Dean.
MEDICAL COLLEGE OF ALABAMA.
MOBILE, ALA.
The thirty-first annual session of this institution
will begin Oct. 12, and continue six months. The
Faculty offer a curriculum that has been carefully
and systematically graded. The chemic, microscopic,
surgic and pharmaceutic laboratories are fitted in
accordance with the most modern and advanced ideas,
and afford ample and convenient facilities for the
practical work exacted of each student in these depart-
ments. The dissecting rooms are large and well ven-
tilated, and material for practical anatomy abundant.
Medical and surgical clinics are held daily at the City
Hospital and College Dispensary. Fees, including
laboratory course $100 for each session. Diploma
fee, $25. The requirements for matriculation and for
obtaining the degrees are set forth in the annual
announcement, which will be sent upon application.
Geo. A. Ketchum, M.D., Dean.
ARKANSAS INDUSTRIAL UNIVERSITY.
MEDICAL DEPARTMENT, LITTE ROCK, ARK.
Four years graded course. Twenty-three profes-
MEDICAL COLLEGES.
625
lore and teachers. Fees each course $58; matricula-
tion fee paid once, $5. Graduation fee, $25. Re-
sources for clinic instruction, Pulaski County Hospi-
tal, Little Rock City Hospital, Little Rock Infirmary.
Daily clinics.
Regular winter course begins Nov. 2, 189(5, and con-
tinues six months. Preliminary course begins Oct. 5,
.1. A. DibrelL M.D., President and Dean of
Faculty.
E. K. Dibrell, Secretary.
COOPER MEDICAL COLLEGE.
8AN FRANCISCO, CAL.
Thanks to the generosity of its President, L.C. Lane,
this school is amply provided with facilities for
instruction. Its handsome buildings, its hospital and
its endowments and funds represent half a million of
dollars. An educational qualification or an examina-
tion is required before admission. Four courses of lec-
tures are necessary to complete the curriculum, except
for such as have through-college education or otherwise
accomplished the work required for the first year,
The regular or long term begins June 1 and continues
six months. The short term begins February 1 and
continues three months. The graduation exercises
take place in December. The regular course is held
in summer and autumn. The objections to the sum-
mer which obtain on the Atlantic border are entirely
unknown here. The dryness of the atmosphere pre-
vents decomposition; thus dissecting can be cprried
on with far more comfort and satisfaction than during
the winter or summer months in other climates.
Excellent clinical facilities are offered at the City and
County Hospital and at the extensive College Dis-
pensary. The Lane Hospital, adjoining the College,
now just completed, will accommodate a hundred
patients. A fee of $130 is charged for each of three
courses: Matriculation fee $5; demonstrator's $10;
graduation $10.
Henry Gibbons, Jr., M.D., Dean; William Fitch
Cheney, M.D., Secretary.
UNIVERSITY OF CALIFORNIA ; MEDICAL
DEPARTMENT.
SAN FRANCISCO, CAL.
The sessions begin September 1, and continue eight
months. During the term all the branches of
medicine and surgery are taught, didactically and
clinically. Regular clinics are held three days in
the week at the City and County Hospital (450
beds), where the professors of the practical chairs
have charge of wards and possess every advantage
for the instruction of students. There is also an
active clinic conducted three times a week at
the College Dispensary, where large numbers of
patients are examined and treated before the classes.
Didactic lectures are given daily by the professors,
and evening recitations are held several times a week.
The dissecting room is open throughout the entire
year. Material is abundant and costs but little.
The facilities for bedside study have been largely
increased of late, and the student will find opportu-
nities at his command which, for comprehensiveness,
are nowhere surpassed.
The Medical Department of the State University
was one of the first in the United States to adopt the
four years' term of study. No student can present
himself for final examination until he has attended
four annual courses of medical lectures and clinics.
Graduates of accredited literary and scientific col-
leges, and such as have completed two years of the
natural science department of a recognized university,
are admitted to the second class without examination.
Fees: Matriculation (paid but once), $5; demon-
strator's ticket, $10; fee for each course of lectures,
$100; graduating fee, $25.
For the annual announcement and catalogue giving
regulations and other information, address R. A. Mc-
Lean, M.D., Dean.
DENVER MEDICAL COLLEGE.
MEDICAL DEPARTMENT OF THE UNIVERSITY OF DENVER, COLO.
( Incorporated in 1881.)
The next session of the school begins Sept. 8, 1896.
The Faculty is composed of fifteen professors and ten
assistant professors and lecturers. The school offers
exceptional advantages to students who can not com-
plete their college work in the rigorous eastern climate.
Colorado is justly noted for its mild winters, and
students coming to Denver can pursue their medical
studies in the school surrounded by amply equipped
laboratories, by large clinics and by an active, inter-
ested corps of teachers. The College is a member of
the Association of American Medical Colleges and
confirms to every requirement of that Association.
Fees: Matriculation (annually), $5; tuition, $75;
graduation (not returnable), $25; demonstrator's
ticket (including material), $10; chemic laboratory
ticket, $10; pathologic and physiologic laboratory,
extra. No tuition fee is required from students who
have paid for and attended three full courses of lec-
tures in this College. Such students are admitted to
the fourth course upon the payment of the matricula-
tion fee only.
Samuel A. Fisk, M.D., Dean; E. R. Axtell, M.D.,
Secretary.
GROSS MEDICAL COLLEGE.
DENVER, COLO.
The College is legally chartered under the laws of
the State of Colorado. It was established in 1887 and
has made such rapid progress that at present it stands
foremost among the medical colleges of this section.
Being a member of the Association of American Med-
ical Colleges, it complies with all the requirements
of this Association and has adopted the four-year
course of study.
This institution is well equipped for medical instruc-
tion, containing four large lecture rooms, abundant
laboratory room and facilities. In close proximity to
it is a large free dispensary, which furnishes abun-
dant material for clinical instruction. It is situated
within a few blocks of the County Hospital, at which
regular clinics are held and bedside instruction given.
The tuition fee is $75 each for the first three years
and $30 for the fourth year. There is no graduation
fee and no hospital fee.
Thomas Hayden Hawkins, A. M.. M. D., Dean;
Robert Levy, M.D., Secretary.
UNIVERSITY OF COLORADO ; MEDICAL DEPART-
MENT.
DENVER, COLO.
This school is a member of the Association of
American Medical Colleges and gives a graded course
of four years, the term extending from the first week
of September to the third week of May.
The first year's course is given at the university in
Boulder, where the facilities for instruction in the
fundamental sciences are excellent. In order to
626
MEDICAL COLLEGES.
[September 19,
obtain superior clinical advantages the instruction of
the second, third and fourth years is given in Denver.
The dispensary of the school and hospitals of Denver
furnish a large amount of clinical material.
The climatic advantages of Colorado enable stu-
dents to pursue their studies here who could not do so
elsewhere.
Tuition : For residents of the State, $35 per year;
for non-residents, $45. Graduation fee $10.
For further information apply to Clayton Park-
hill, M.D., Dean; Howell T. Pershing, M.D., Secre-
tary.
YALE UNIVERSITY, DEPARTMENT OP MEDICINE.
YALE MEDICAL SCHOOL, HARTFORD, CONN.
In the fall of 1810 a charter was granted to the
President and Fellows of Yale College and the Pres-
ident and Fellows of the Connecticut Medical Soci-
ety, authorizing them to unite according to the
terms of certain " Articles of Union," before agreed
upon, for the establishment of a medical seminary,
to be styled the Medical Institution of Yale College.
Two years later the school was organized, and in the
fall of 1813 instruction was begun.
While the attention of the student is particularly
directed to those branches which can be studied to
advantage only in a well equipped medical school, the
value of clinical instruction is fully appreciated and
amply provided for. The curriculum consists chiefly
of recitations of assigned readings in text-books, sys-
tematic laboratory work and personal instruction in
clinics.
Terms of admission : Candidates for admission
must be at least 18 years old, and must present satis-
factory* testimonials of moral character from former
instructors or physicians in good standing. Each
candidate must present proof that he has passed the
matriculation examination of some scientific, literary
or professional college in good standing, or present
testimonials from the proper officer that he has pursued
the course at some high school, academy or preparatory
school approved by the faculty, or he must pass an
examination in the following subjects:
REQUIREMENTS FOR A DEGREE.-
1. He must be at least 21 years of age, and must
sustain a good reputation for moral character.
2. He must have spent three years as a student in
this school, or if but one or two years in this school,
he must have pursued such studies in some other
recognized institution, as are considered by the fac-
ulty to be the equivalent of the remainder of the full
term of study. The last year must have been in this
school.
3. He must have passed to the satisfaction of the
faculty the prescribed examinations of the course;
and he must have presented a satisfactory thesis on
some subject relating to medicine. The thesis should
be presented to the dean on the third Wednesday
before Commencement.
Fees and expenses first year: Matriculation (paid
but once), $5; tuition, $140; practical anatomy (includ-
ing instruction and material), $10. Second year: Tui-
tion, $140; practical anatomy (including instruction
and material), $5; practical pharmacy, $5. Third year :
Tuition, $80; graduation, $30.
Herbert E. Smith, M.D., Dean.
MEDICAL DEPARTMENT COLUMBIAN UNIVERSITY.
WASHINGTON, D. C.
The seventy-fifth session begins Sept. 30, 1896. The
numerous advantages afforded by the City of Wash-
ington for the study of medicine are well known. The
clinic facilities of four large hospitals are open to
students of the college. The new Congressional
library, almost completed, will give the students addi-
tional advantages scarcely to be equaled in any other
city.
The course extends over four years, and the annual
fee for all expenses is $106.
The bacteriologic and pathologic departments are
under the direction of an accomplished teacher, who
is also in charge of the Army Medical Museum of
the city. Extensive experiments upon the antitoxins
are being conducted by the biochemic laboratory of
the Department of Agriculture, and by act of Congress
the Government laboratories are available to students
for clinical instruction.
D. K. Shute, M.D., Dean; E. A. De Schweinitz,
Secretary.
MEDICAL DEPARTMENT, GEORGETOWN
UNIVERSITY.
WASHINGTON, D. C
The next session of this school will begin October
1, and continue until May 13, 1897. The four years'
course is obligatory. Instruction is given by lectures,
recitations and demonstrations in the lecture rooms,
as well as by practical exercises in the dissecting
room and the various laboratories, which are espe-
cially well arranged and equipped for this most
important method of modern teaching. Ample and
excellent facilities for clinical instruction are fur-
nished by the hospitals and dispensaries. Positions
as resident physicians in these are secured by compet-
itive examination. Congress has opened the Govern-
ment museums and libraries to students of medicine,
greatly enhancing the facilities otherwise furnished.
The fees are: Matriculation, payable but once, $5;
lectures and laboratories for each year. $105. No
other charges except a small one for anatomic mate-
rial.
J. W. H. Lovejoy, M.D., President; G. L. Magru-
der, M.D. Dean.
HOWARD UNIVERSITY, MEDICAL DEPARTMENT.
WASHINGTON, D. C.
This school opens its twenty -seventh session, Octo-
ber 1. It has a graded course of four years. Each
college year continues seven months. Students are
required to complete the studies in each year before
being promoted to the next succeeding year. A thor-
ough training is given in histologic, biologic, patho-
logic and chemic laboratories. The Freedmen's
Hospital is upon the grounds of the college and
affords ample clinic facilities to the student to
study surgery, obstetrics, gynecology and practice of
medicine. The tuition fee is $60 per term. Small
laboratory fees are charged to meet the necessary
expenses. The college is coeducational. Students
are instructed and examined in the following branches:
Physiology, anatomy, chemistry, toxicology, materia
medica, therapeutics, obstetrics, gynecology, practice
of medicine, surgery, minor surgery, neurology, his-
tology, bacteriology, pathology, ophthalmology, otol-
ogy, pediatrics, medical jurisprudence and psychiatry.
T. D. Hood, M.D., Dean; C. B. Purvis, Secretary.
ATLANTA MEDICAL COLLEGE.
ATLANTA, GA.
This college was established in 1854 and has been
1896. |
MEDICAL COLLEGES.
627
in continuous operation since except during the war.
The school requires throe terms of six months each
ami regular oourses in the cheniic, baoteriologio and
pathologic laboratories. Clinics are held daily both
at the college and at the city hospital, to which the
students have access. Written examinations are held
at the end of each session, and students must show
satisfactory progress before they are allowed to
advance to the next course.
The college building is especially commodious, hav-
ing three large lecture rooms, each with a seating
capacity of 200 and in addition a modern amphithea-
ter arranged to seat 300 students.
The tecs are $100 for each session, diploma $30;
these fees are adhered to and under'no circumstances
is any reduction given to students. W. S. Kendrick,
M.D. Proctor.
MEDICAL COLLEGE OF GEORGIA.
MEDICAL 11KCARTMENT UNIVERSITY OF GEORGIA.
U'CCSTA, GA.
Organized 1832. Three years graded course, six
months in each year, October 1 to April 1. Faculty
has under its exclusive control three large hospitals, the
policlinic, the city dispensary and the out-door obstet-
ric service. From these sources abundant clinic mate-
rial is always on hand for clinic instruction of
students. Clinic teaching occupies a prominent place
in instruction of students. Every member of the
graduating class is accorded a two weeks residence in
the hospitals. Preliminary educational qualifications
required of students; proficiency in arithmetic, ele-
mentary English, geography, spelling, United States
history, and English composition. Fees: Matricula-
tion *">; practical anatomy $10; general course of
instruction 875; diploma or graduation fee $30.
Sagene Foster, M.D., Dean; Thos. D. Coleman,
A.B.. M.D.. Secretary.
COLLEGE OF PHYSICIANS AND SURGEONS.
CHICAGO, ILL.
The fifteenth annual course begins September 22,
and continues for seven months. A spring course is
also given, for which there is no additional charge to
students in the college. The spring course of 1897
begins April 21 and ends June 30. The curriculum
of the college is graded, and four years are required
to complete the course. Instruction is didactic and
clinic and by laboratory teaching. Instruction dur-
ing the first two years is largely by laboratory work;
in the last two years largely clinic.
The equipment of the college includes the college
building proper, which contains the lecture rooms,
clinic rooms; a six-story laboratory building; and a
college hospital. All of these buildings are amply
furnished for the purposes to which they are sever-
ally devoted. The college hospital has recently been
acquired by the purchase of a modern hospital build-
ing formerly occupied by the Post-Graduate Medical
School. This gives the college a hospital of 125 beds
with three aseptic operating rooms and a clinic
amphitheater. The clinic material at the disposal of
the college is large enough to insure the hospital
being kept full all the time. Hospital service is a
part of the senior class work. In the course of a year
each student gets practical bed-side experience of the
most varied kinds.
The class is divided into sections for the purpose
of pathologic work in the hospital; so that the
students are given training in exact methods of tech-
nical examinations, and gain at the same time a cor-
rect appreciation of the relative importance of the
pathologic and clinic elements of their cases.
Clinics are given daily in the County Hospital by
members of the Faculty. There are also autopsies
daily at the county morgue to which the students
have access.
The college has abolished formal final examinations,
In lieu thereof, the students are graded upon their
daily work, upon their recitations and upon exami-
nations held during the course of the year. One-
fourth of the time of each teacher is given to quiz-
zing. Nine scholarships of the value of $100 each
are awarded to the students who make the best
records in the college. The annual fees are $110.
There are no extras.
William Allen Pusey, M.D., Secretary.
CHICAGO POLICLINIC AND HOSPITAL.
A clinic school for post-graduate instruction in
medicine and surgery, Chicago, 111. It is conveniently
located in a populous district which furnishes an
abundance of clinical material. The instruction is
entirely clinic and offers unequaled facilities for the
general practitioner to personally examine cases and
follow out the latest approved means of diagnosis
and methods of treatment.
Clinics covering all departments of medicine and
surgery are in progress daily from 8 a.m. to 5 p.m.; a
well equipped bacteriologic and chemic laboratory is
a notable feature of the institution and affords the
practitioner an opportunity to become acquainted
with the most important modern branches. As all
clinics are conducted throughout the year, students
may enter at any time. The fees are moderate and
vary according to the number of branches taken and
the length of time one desires to remain.
Truman W. Miller, M.D., President.
Fernand Henrotin, M.D., Secretary.
NORTHWESTERN UNIVERSITY MEDICAL SCHOOL
(CHICAGO MEDICAL COLLEGE).
CHICAGO, ILL.
This school was the first in this country: 1, to en-
force a standard of preliminary education ; 2, to adopt
longer annual courses of instruction; 3, to grade the
curriculum of studies.
The laboratory building contains laboratories of
physiology, histology, anatomy, pathology, bacteriol-
ogy, chemistry, pharmacology and pharmacognosy of
the most modern form and with best equipments.
Davis Hall is a very perfect out-patient infirmary,
where twenty-five thousand patients are treated annu-
ally.
A feature unique to this school is the grading of
clinical instruction and the maintenance of small
clinics by greatly multiplying them so that students
may obtain individual instruction. Forty clinics are
conducted weekly at Mercy and St. Luke's Hospitals
and Davis Hall.
Instruction is given by lectures, recitations, confer-
ences, laboratory and clinic methods. Numerous
electic courses are offered to students who desire
them, either that, they may obtain " honors" or special
knowledge. These courses are chiefly laboratory or
combined laboratory and clinic.
The requirements for admission are a diploma from
a recognized college, school of science, academy or
high school, or an examination in English, arithme-
tic, algebra, physics, Latin and any one of the follow-
628
MEDICAL COLLEGES.
[September 19,
ing: chemistry, general biology, zoology, botany or
German.
College opens Oct. 6, 1896; Commencement is June
17, 1897. The fees are, matriculation $5; annual $100;
laboratory (for first and second years) $10.
The Faculty consists of thirty-seven professors and
forty-three instructors and demonstrators.
N. S. Davis, M.D., Dean.
NORTHWESTERN UNIVERSITY WOMAN'S MEDI-
CAL SCHOOL.
CHICAGO, ILL.
This school was founded in 1880 as the " Woman's
Hospital Medical College." In 1892 it was incorpor-
ated with the Northwestern University. It is con-
ducted as a regular school of medicine for the educa-
tion of women only.
Students graduating in 1899, and subsequently, are
required to attend four graded courses of lectures, of
not less than eight months each.
Instruction is given by didactic lectures, recitations,
clinical lectures and practical work. Objective
methods are given a prominent place.
Practical instruction is given in the laboratories of
anatomy, chemistry, histology, physiology, pathology,
bacteriology and pharmacy. Modern methods are
pursued in all these laboratories.
The Cook County, the Mary Thompson Hospital
for Women and Children, The Wesley, The Woman's
Hospital of Chicago, and various other hospitals to
which the students have access, afford excellent facil-
ities for clinic instruction. Through these various
hospitals and the college dispensary there are unusual
opportunities for practical obstetric work. Each
day of the week one or more clinics are held in the
college building.
A matriculation fee of $5.00 and an annual fee of
$75.00 are required. An extra charge is made for
tickets for laboratory and hospital courses.
POST GRADUATE MEDICAL SCHOOL AND
HOSPITAL.
CHICAGO, ILL.
It has just completed a magnificent building, thor-
oughly equipped for modern scientific post-graduate
instruction; convenient surgical amphitheaters, fine,
well-lighted laboratories and clinic rooms, comforta-
ble reading and smoking rooms, automatic ventila-
tion, electric lights and elevator.
The college is located at 2404 Dearborn Street, in the
medical center of Chicago, and with unequaled hospital
advantages, an abundance of clinic material, com-
prehensive and advanced curriculum; large working
faculty and a continuous course throughout the year.
Students may matriculate with equal advantage at
any time and receive a post-graduate course that is
unsurpassed.
For particulars address Franklin H. Martin, M.D.,
Secretary.
RUSH MEDICAL COLLEGE.
CHICAGO, ILL.
The fifty-fourth course of lectures of this institu-
tion begins Sept. 29, and continues eight months.
The new laboratory building, in which are located
the anatomic departments and all the laboratories,
presents an unexcelled series of working rooms for
the undergraduate. No more extensive and thor-
oughly equipped dissecting room is to be found in
any medical college. Every student is required to
take special courses in laboratory instruction in his-
tology, pathology, bacteriology and materia medica as
well as in chemistry. The laboratories for these dif-
ferent special courses are extensively and thoroughly
equipped.
A special feature of the instruction in this institu-
tion is the large number of men attending exclusively
to teaching by recitations in the different classes
divided into sections.
The clinics of this College are an especial feature of
its instruction. Nearly all of them are held in the
afternoon. In some of them the students are required
to make their examinations and to defend their diag-
noses before the class. The adjoining Presbyterian
Hospital affords facilities for clinical instructions un-
surpassed anywhere. A vast amount of surgical oper-
ations of all kinds is housed in this hospital and stu-
dents of this college enjoy the advantage of such
operations in the clinics to an extent equaled by no
college in this country.
The Central Free Dispensary connected with the
College affords about one thousand patients monthly.
They are extensively utilized for clinical purposes
throughout the year.
Fees: The general ticket $125, and the matricula-
tion fee $5.
Edward L. Holmes, M.D., President.
James H. Etheredge, M.D., Secretary.
CENTRAL COLLEGE OF PHYSICIANS AND SURGEONS.
INDIANAPOLIS, IND.
The Faculty have remodeled the college building
at an expenditure of $4,000: this also includes the
superb equipment in the several laboratories. The
advantages for clinical teaching are greatly enhanced
by the college dispensary, which is in charge of two
physicians appointed by the faculty. The staff phy-
sicians that have been selected from the faculty also
hold clinics at the Indianapolis City Hospital, St.
Vincent Hospital, Deaconess Protestant Hospital and
the Indianapolis City Dispensary.
The college is a charter member of the Association
of American Medical Colleges and has adopted the
four-years' graded course of lectures. The instruc-
tion consists of didactic lectures, practical demon-
strations and personal laboratory investigations. The
eighteenth regular session will open Sept. 23, 1896,
and close March 24, 1897. The fees of the regular
course are as follows: Matriculation. $5; laboratory
ticket (anatomy, chemistry, bacteriology, pathology
or histology), $5; general ticket. $40; demonstrator's
ticket (anatomy, chemistry, bacteriology, pathology
or histology), $10; hospital ticket (includes all hos-
pital fees), $6; graduation fees, $25.
Joseph Eastman, M.D., LL.D, President; T. B.
Eastman, A.M., M.D., Secretary and Dean.
FORT WAYNE COLLEGE OF MEDICINE.
FORT WAYNE, IND.
The college was organized in 1879. The length of
term is six months with a four years' graded course.
The expense for fees in all the departments will be
about $75 per year.
Clinics are held in the St. Joseph and Hope Hos-
pitals, where there is an abundance of clinic mate-
rial, both surgical and medical. The special advantages
are, that in these hospitals many capital operations
are made in the presence of the students, the seniors
being assistants.
The college has fifteen professors and five lecturers.
C. B. Stemen, M.D., Dean.
I
1896.]
MEDICAL COLLEGES.
629
MEDICAL COLLEGE OF INDIANA.
INDIANAPOLIS, IND.
Twenty-sixth annual term begins October 2 and
ends April -. Matriculation. $5; laboratory ticket.
$5; professors" tickets. 840; demonstrator's ticket. $10;
graduation fee, $25; hospital tickets. $0. Clinics are
given at the city hospital. St. Vincent's Hospital,
Bobb's Free Dispensary, city dispensary and college
dispensary. Daily clinic instruction throughout
the course. The clinic, histologic, pathologic and bac-
tariologic laboratories, dissecting rooms and mu-
seum are thoroughly appointed and complete, and no
extra charges for same. The munificent gift of Dr.
William Lomax of Marion, Ind., added to the former
resources and equipment of the college enables the
trustees to construe! and equip an ideal modern med-
ical college, which shall meet the most exacting
demands for advanced, thorough medical education.
.los. \V. Marsee. M.D., Dean.
IOWA COLLEGE OF PHYSICIANS AND SURGEONS,
.MEDIC \1. OKI' ARTMEST OF DRAKE UNIVERSITY.
DKS MOINKS. IOWA.
The fifteenth annual session will begin Sept. 16,
1896, and continue twenty-four weeks.
The fees are: .Matriculation. $5; general lecture
ticket. 845: final examination, $5; hospital, $5; prac-
tical anatomy. $10; chemic laboratory, $10; bacterio-
logic, $10. The college has new quarters, with ample
laboratory facilities. A large number of new micro-
scopes have been recently purchased, and the course
in chemistry, bacteriology and histology is the same
as in other first-class schools. Clinics will be held
one-third of the time at the Cottage and Mercy Hos-
pitals. The county and city patients are treated at
Cottage Hospital and afford an abundance of clinical
material. The Mercy Hospital is a large new build-
ing, with a capacity of seventy-five beds. This
affords good clinic advantages; in fact, better than
any other hospital in the State.
The faculty consists of fourteen professors and nine
lecturers. All have had from two to twenty years'
experience as teachers. The course is four years'
attendance upon lectures. The requirements of
admission are those of the Iowa and Illinois State
B< lards.
Lewis Schooler, M.D., Dean.
STATE UNIVERSITY OF IOWA, MEDICAL
DEPARTMENT.
IOWA CITY, IOWA.
The twenty-seventh annual session begins Sept. 16,
1896, and continues six months, closing in March,
1897.
The requirements for graduation are those of the
Association of American Medical Colleges and the
State Board of Medical Examiners. Fully equipped
laboratories in pathology, histology, chemistry and
pharmacy, and full clinics in all branches. Special
advantages to advanced students in assisting at clinics
and observing treatment of cases at Mercy Hospital.
Positions as internes in all State hospitals open for
limited terms of service to graduates passing meri-
torious examinations.
Fees : Freshman year, $63; sophomore, $48; junior,
$33, and senior, $38. No charge for dissecting mate-
rial.
For catalogue, address W. D. Middleton, A.M., M.D.,
Dean, or E. W. Rockwood, M.D., Secretary.
KEOKUK MEDICAL COLLEGE.
KEOKUK, IOWA.
The regular fall and winter session opens in Sep-
tember and continues for six months.
The faculty is composed of experienced medical
teachers. Clinics regularly at St. Joseph's Hospital.
A ten weeks' reading and recitation course follow-
ing the regular winter session is provided.
Fees for regular session: Matriculation, $5; lecture
fees, including hospital ticket, $28; graduation fee,
$30. .Material at cost.
J. A. Scroggs, M.D., Secretary.
HOSPITAL COLLEGE OF MEDICINE.
MEDICAL DEPARTMENT CENTRAL UNIVERSITY OP KENTUCKY.
LOUISVILLE, KY.
The regular session of this college begins in Jan-
uary and end in June. The course of instruction is
conducted by ten professors and fifteen tutors, dem-
onstrators, and assistant instructors.
Freshmen are required to present evidences of good
moral character, and satisfactory preliminary educa-
tion, in documentary form. The course of study is
graded and divided into three annual terms of six
months each.
Candidates for the degree of Doctor of Medicine
must be 21 years old, of good moral character, must
have studied medicine four years, including prelim-
inary reading with a preceptor, and have attended
three complete courses of lectures, no two of which
shall have been taken within a period of twelve
months, and the last of which shall have been in this
institution. He must have dissected during at least
two sessions, and have attended two courses of clinic
and hospital instruction.
The course of study at this college, in addition to
the usual didactic lectures and quizzes, embraces two
clinics every day in the college building; not less
than four clinic lectures every week at the City Hos-
pital, beside bedside instruction in the wards of the
City Hospital and College Infirmary.
Fees: Professors', $75; practical anatomy, includ-
ing material, $12; bacteriology and histology, labora-
tory fees, first year, $10; chemical laboratory, second
year, $10; surgical laboratory, $10; fee for final exam-
ination (not returnable), $30; hospital fee required
by the city, $5. No fee is charged for intermediate
examinations.
P. Richard Taylor, M.D., Dean.
KENTUCKY SCHOOL OF MEDICINE.
LOUISVILLE, KY.
It is midway between the North and the South, and
holding its session from January to June inclusive,
is the pioneer spring and summer graduating school
of this country.
It began in 1817 as the Medical Department of
Transylvania University, but separated and took its
present name in 1850. Since that time its success
has been remarkable, having as many as 550 students
at a time. It has given medical education to more
than five thousand physicians. With an efficient and
experienced faculty of thirty teachers, ample and
thoroughly equipped laboratories and a large modern
hospital of its own. recently erected, adjoining the
college, this school is offering facilities for practical
and thorough instruction unsurpassed in this coun-
try. It is a strictly one-priced college, each student
without exception paying the same. For catalogue
write to Samuel E. Woody, M.D., Dean.
630
MEDICAL COLLEGES.
[September 19,
NEW ORLEANS UNIVERSITY, MEDICAL DEPART-
MENT.
NEW ORLEANS, LA.
This institution has a four years' course of study
of five months each. The tuition fee is $30 per ses-
sion, while good board and room, with fuel, light and
washing, can be obtained in private families for from
$12 to $15 per month. The total expense of the ses-
sion need not exceed $125. The building is situated
on an open, airy space and is a large three story brick,
well lighted and ventilated. Street cars lines from
all parts of the city make it easily accessible. The
second story is used exclusively for a hospital and
nurse training department, where students have the
advantages of experience in the sick room every day.
The city with its 250,000 inhabitants and large tran-
sient population affords excellent clinic advantages.
The next session opens September 15.
C. F. Dight, M.D., Dean.
MEDICAL DEPARTMENT TULANE UNIVERSITY OF
LOUISIANA.
NEW ORLEANS, LA.
Since 1893 this college has occupied a new and
extensive building, with five large and fully equipped
laboratories. Students are admitted without pay-
ment of any hospital fees to the great Charity Hos-
pital, which has more than 30,000 patients annually
and thus provides unsurpassed practical advantages
(clinic, anatomic, etc.) for the study of medicine. A
gymnasium for the use of students is attached to the
college. The most recent improvements consist of
numerous and important additions to the laboratory
of the professor of chemistry, and the reorganization
of the college library, rendering it more useful and
accessible to students and the medical profession.
' For catalogue and information address S. E.
Chaill<§, M.D., Dean.
BALTIMORE MEDICAL COLLEGE.
BALTIMORE, MD.
This college was organized in 1881. Within the
past five years it has expended $200,000 in the erec-
tion and equipment of a college and hospital which
contains every modern facility and appliance required.
Its laboratories are equal to those of the best institu-
tions of this country. Its Faculty contains twelve
professors and over forty associate professors, lec-
turers, demonstrators and assistants.
Its hospital and out-door department furnish abun-
dance of material for clinic instruction. It has a
special lying-in hospital of over thirty beds in addi-
tion to its out-door obstetric clinic. This college is a
member of the Association of American Medical Col-
leges and has adopted the four-year graded course
according to the regulations of this Association.
During the past session its classes numbered over 514
students.
Clinics are conducted by the professors and their
associates during the entire year.
The dental department of the college has one of
the best equipped buildings in this country.
A preliminary course of lectures will begin Sep-
tember 1 and continue until October 1.
Tuition fees and laboratory fees included range
according to classes from $100 to $125. Board and
lodging near the college from $3 to $8 per week.
For catalogue apply to David Streett, A.M., M.D.,
Dean.
BALTIMORE UNIVERSITY SCHOOL OP MEDICINE.
BALTIMORE, MD.
The preliminary course begins September 1. The
regular winter course begins October 1.
The curriculum is graded. Attendance upon three
winter courses of lectures is required for graduation.
In addition to didactic lectures, two hours daily are
devoted to clinic instruction. Clinic material abun-
dant. Large hospital and dispensary. Lying-in De-
partment for teaching clinic obstetrics.
Send for catalogue, and address Z. K. Wiley, M.D.,
Dean.
COLLEGE OF PHYSICIANS AND SURGEONS.
BALTIMORE, MD.
This college is a member of the National Associa-
tion of Medical Colleges. It requires four sessions of
six months each to graduate. The fee is $100, which
includes all laboratory and matriculation fees. The
clinic work is a special feature in the method of
instruction. Small ward classes are formed so that
each student can receive personal instruction in the
diagnosis and treatment of diseases. The obstetric
department affords excellent facilities for every
student to learn practically the management of labor
cases and all conservative operations. The chemic,
histologic, anatomic, pathologic and bacteriologic lab-
oratories are modern and well equipped. The free
dispensary in the heart of the city affords an abun-
dance of cases for clinic lectures.
Thomas Opie, M.D., Dean.
JOHNS HOPKINS UNIVERSITY, MEDICAL DEPART-
MENT.
BALTIMORE, MD.
The medical department was opened for the instruc-
tion of students October, 1893. It has in addition to
resources of the Johns Hopkins University and the
Johns Hopkins Hospital available for its use a special
endowment fund of $500,000. It forms an integral
part of the University and is in close affiliation with
the Johns Hopkins Hospital.
The requirements for matriculation are higher than
those of any other medical school in this country.
Those who are admitted as candidates for the degree
of doctor of medicine must possess a degree in arts or
in science from an approved college or scientific
school, and in addition must be able to read French
and German and must have had a year's collegiate
training with laboratory work in physics, chemistry
and biology; or they must furnish evidence by exam-
ination that they jDossess the general education im-
plied by a degree in arts or in science and the knowl-
edge of French, German, physics, chemistry and
biology indicated. Men and women are admitted
upon the same terms.
The required course of instruction continues
through four years, the academic year beginning the
first of October and closing the middle of June. The
first two years are devoted mainly to anatomy, physi-
ology, physiologic chemistry, pathology, bacteriology
and pharmacology, and the last two years to practical
medicine and surgery.
Abundant clinic material is afforded by the Johns
Hopkins Hospital and Dispensary, this Hospital being
unsurpassed by any in the world in the perfection of
its arrangements. The clinic amphitheaters and lab-
oratories are in the hospital buildings. Physiology
is taught in the biologic laboratory of the University,
which is one of the largest and best equipped in this
MEDICAL COLLEGES.
681
country. The pathologic laboratory is a four story
building on the grounds of the hospital. This build-
ing contains the autopsy theaters, the pathologic
museum, the bacteriologic laboratory, the physiologic
ehemie laboratory ami rooms for instruction and
vial work in all departments of pathology.
The charge for tuition is $200 per annum. There
are no extra charges tor instruction in any depart-
ment or for laboratory courses.
In addition to the regular course of instruction for
undergraduates in medicine, special coursesof instruc-
tion have been given to physicians in pathology and
I the clinic subjects since the opening of the Johns
Hopkins Hospital in L889. These are to continue. A
fee of $100 covers all of these special courses for phy-
sicians. The separate courses can be taken by pay-
ment of a fee of $25 or $50 according to the subject
chosen.
William H. Welch. M.D.. Dean.
I'NIVERSITY OF MAR) LAND.
!
BALTIMORE, MI).
The School of Medicine is one of the oldest insti-
tutions of medical education in America, ranking fifth
in point of age among the medical colleges of the
United States. Beginning with the modest number
of five graduates, comprising the first graduating class
in 1810, the list of graduates in medicine of the Uni-
versity of Maryland now numbers 4,574 names, among
which are to be found some of the most noted names
connected with the history of medicine in our coun-
try. While the policy of the faculty of physic has
been one of wise conservatism, it has at the same time
never been behindhand in the march of educational
progress, and has often been the first and always among
the first, in the adoption of measures tending to
improvement in methods of medical teaching and to
true elevation of the standard of medical education.
One of the advantages of the University over other
schools of that day was gained in 1823 by the erec-
tion of its own hospital, separated from the college by
the width of the street and known as the University
Hospital. Beside important additions and improve-
ments to the University Hospital, the faculty has in
the last few years expended and is now expending
large amounts in the establishment and equipment of
its lying-in hospital, its laboratories of chemistry, his-
tology, pathology and bacteriology, and is therefore
in a position to offer to students of medicine and
graduates, a course of combined didactic, clinic and
laboratory instruction which will compare favorably
with that offered by any medical school in the L^nited
States. The course of study embraces three annual
graded courses of not less than six months each.
Fees for the three years' graded course: Matricu-
lation (paid each year) $5; practical anatomy (paid
two years) 810: full course of lectures (first year)
$100; full course of lectures (second year) $100;
full course of lectures (third year) $100; graduation
fee, $30.
R. D. Cole, M.D., Dean.
WOMAN'S MEDICAL COLLEGE.
BALTIMORE, MD.
The college was incorporated Feb. 14, 1882, being
the fourth institution of the kind founded in the
United States, and the first in the South. It is man-
aged by twelve trustees, and has thirty-six professors,
lecturers and assistants. It requires for graduation
attendance upon four annual sessions, lasting each
eight months. With reference to entrance require-
ments it follows the regulations of the American Med-
ical College Association, of which it was one of the
founders. It occupies a group of buildings on the
corner of Hoffman and McCulloh Streets, two of
which it owns. It has laboratories of chemistry, his-
tology, pathology, embryology and bacteriology. One-
fourth of the time of lectures is devoted to quizzing.
It has a general and also a lying-in hospital of its own.
Clinics are also given at the Presbyterian Eye, Ear
and Throat, Bayview, and the Hospital for Crippled
and Deformed Children, by members of its faculty.
It has a large out-door obstetric clinic. Pharmacy is
taught and examined upon. There is a course of
lectures on psychiatry by a well-known specialist.
There is a library and a flourishing medical society of
127 members. The fees are $100 annually; $75 for
missionaries; $30 additional for graduation; $5 deposit
for breakage. There have been fifty-nine graduates.
I. R. Trimble, M.D.. Dean; Eugene F. Cordell,
M.D., Secretary.
CLARK UNIVERSITY.
WORCESTER, MASS.
Graduate courses in psychology, physiology, neu-
rology, etc. Special attention given to the study of
the brain and central nervous system, with laboratory
work and clinics. Exceptional opportunities offered
in the sciences underlying the study of medicine.
G. Stanley Hall, M.D., President.
COLLEGE OF PHYSICIANS AND SURGEONS.
BOSTON, MASS.
This college is now entering upon its seventeenth
annual course of lectures.
The course is graded and comprises four years of
study with four annual courses of lectures. Each
course extends from the third Tuesday in September
to the third Wednesday in June.
Rules and requirements are those of the Associa-
tion of American Medical Colleges, of which this col-
lege is a member.
A good knowledge of English, Latin, algebra and
physics are necessary for matriculates.
Extensive clinic advantages are under its control.
The school is now prepared to furnish facilities for
chemic, histologic, bacteriologic and other laboratory
work. Located near Boston City Hospital, in a part
of the city where good board and rooms may be
obtained convenient to the college. Women are
received and admitted to the same rights and privi-
leges as are accorded to men. Extra advantages for
observing clinic and dispensary work.
Matriculation, $5 yearly; lecture fee, $125 per year,
or cash in advance for four years, $400; laboratory
courses, $5 each; dissecting and operative surgery
material at cost.
For catalogue and further particulars apply to the
registrar.
Augustus P. Clarke, A.M., M.D. Dean: George F.
Shurtleff, M.D., Registrar.
TUFTS COLLEGE MEDICAL SCHOOL.
BOSTON, MASS.
This is the only regular medical school open to both
sexes in New England that is recognized by the
Massachusetts State Medical Society.
Entrance examination is required, and to students
who matriculate for the first time in 1896 four years,
of attendance.
The course is graded and all the branches of med-
o32
MEDICAL COLLEGES.
[September 19,
ical science are taught. Abundance of clinic facili
ties. Fees $115. The regular course of lectures for
the session of 1896-97 will commence September 30
and continue for eight months.
For further particulars and catalogues address C. P.
Thayer, M.D., Secretary, 74 Boyleston St., Boston,
Mass.
Albert Nott, M.D.. Dean.
UNIVERSITY OP MICHIGAN.
DEPARTMENT OF MEDICINE AND SURGERY.
ANN ARBOR, MICH.
This school requires for admission a diploma from
a first class high school or its equivalent. The course
extends through four years with nine months in each
session. The first two years are devoted to scientific
work, a large part of which is done in the laboratories.
The last two years are given to clinic work.
The fees are as follows: Matriculation fee for
Michigan students is $10; for all others $25. This
fee is paid only once. Annual fee for Michigan stu-
dents $35; for all others $45. Diploma fee, all alike,
$10. The laboratory fees amount to about $50 a year.
The total amount of fees paid to the university dur-
ing the whole four years' course is for Michigan stu-
dents about $300, and for others about $340.
Victor C. Vaughan, M.D., Dean.
MICHIGAN COLLEGE OF MEDICINE AND SURGERY.
DETROIT, MICH.
The regular term of the college will commence
September 23 and will continue six months. The
spring term will open April 7 and close June 19.
An addition to the college has been made this term,
in the form of a building fifty by sixty feet, to be
entirely devoted to the use of the Emergency Hos-
pital Free Dispensary.
The special advantages pertaining to the college
are that all lectures and demonstrations are given at
the one location, the college building and the Emer-
gency Hospital Free Dispensary, the lying-in clinic,
and in fact all the clinics being under one roof.
Send for catalogue to L. E. Maire, M.D., Secretary.
HAMLINE UNIVERSITY.
MEDICAL DEPARTMENT MINNEAPOLIS COLLEGE PHYSICIANS AND
SURGEONS.
MINNEAPOLIS, MINN.
This school was organized in 1883 as the Minne-
apolis College of Physicians and Surgeons, and in
1895 became the Medical Department of Hamline
University. The course consists of four years of
eight months each and fulfils the requirements of all
State boards. The faculty consists of twenty- three
professors and eight lecturers, not including demon-
strators and assistants. The college building is within
five minutes' walk of three leading hospitals and four
dispensaries, so that the clinic advantages are excel-
lent. The approaching term begins October 5. The
fees are: Matriculation, $5 (payable only once);
general ticket, including lectures, demonstrations,
etc., $65.
J. W. Macdonald, M.D., Dean.
UNIVERSITY OF MINNESOTA.
COLLEGE OF MEDICINE AND SURGERY.
MINNEAPOLIS, MINN.
The ninth annual course of lectures begins Octo-
ber 1, and continues until the first week in June.
Four courses of lectures in different years is required
of all applicants for the degree of M.D. All pupils
entering this department of the university after 1898
will be required to furnish credentials equal to an
"in course" matriculation of the academic depart-
ment of a recognized college of literature, science or
the arts. The State has invested $150,000 in build-
ings and equipment in the last three years. They are
located upon the campus of the general University in
Minneapolis. There were 243 matriculants in attend-
ance the last season, 47 receiving the degree of M.D.
The department is directly connected with the gen-
eral University, being amply supported by the State.
Perry H. Millard, M,D., Dean.
BARNES MEDICAL COLLEGE.
ST. LOUIS, MO.
Six months terms: three separate years' graded
course. Begins September 21. Matriculation. s.">;
lecture ticket, $40, and anatomic ticket, $10. Usual
laboratory charges. Half rate concessions to physi-
cians' and clergymen's sons and graduates in phar-
macy and dentistry. A few $10 scholarships to well
attested worthy sons of indigent physicians, widows
and others granted on proper presentation of suitable
cases.
First course students are required as a precedent
for admission to show a good English education by
certificate of graduation from a literary college, acad-
emy, normal or high school, or of examination
approved by the State superintendent of public
schools, in English grammar and composition, arith-
metic, algebra as far as quadratics, elementary physics,
United States history, geography and Latin (equiva-
lent to one year in high school ) : 80 per cent, grade
required in these branches. Previous matriculates at
other medical, dental or pharmaceutic colleges and
graduates in medicine are exempt from this rule.
Clinical facilities embrace city general hospital,
insane hospital, Woman's Hospital and other corpor-
ate hospitals, to which members of the faculty have
access, and new and enlarged college and dispensary
clinics. Thus, while its fees are moderate and con-
cessions to the worthy are liberal, its curriculum and
preliminary requirements secure educated classes.
C. H. Hughes, M.D., Dean; Pinckney French,
M.D., Secretary.
BEAUMONT HOSPITAL MEDICAL COLLEGE.
ST. LOUIS, MO.
The college will begin the fall session September
22. It gives the three sessions graded course of
instruction; maintains a high standard of require-
ments and has a well-earned reputation for thorough
and practical teaching. Its building is well located
and arranged and its laboratories are completely
equijDped with all things necessary for advanced
investigation and demonstration. It offers special
advantages in clinic teaching, having exclusive con-
trol of three large hospitals and two dispensaries,
which furnish clinic material in abundance and in
great variety. The destruction of the St. Louis City
Hospital by the recent cyclone has not materially
affected the clinic supply at this institution.
W. B. Outten, M.D., Dean; John T. Larew, M.D.,
Secretary.
ENSWORTH MEDICAL COLLEGE AND HOSPITAL.
ST. JOSEPH, MO.
The college is an endowed institution, with a full
corps of experienced teachers and is properly equipped
in its several departments. Its requirements prece-
1896.]
MEDICAL COLLEGES.
(533
dent to matrioulation are those prescribed by the
Association of American Medical Colleges and the
Slate of Missouri. It affords the special advantage of
an abundant outdoor clinic during the sessions at the
hospital, as well as those afforded by the city hospital
ami State lunatic asylum. The tuition fee is $50 for
each session. In honor of Mr. Ensworth. the school
grants a scholarship to each Congressional district of
theState. The Ensworth has under its direct con-
trol the largest hospital in the Central West.
Thomas 11. Doyle, M.D., Dean.
KANSAS CITY MEDICAL COLLEGE.
I \NS\S CITY. MO.
This is one of the oldest schools in the West; was
established in 1869. The twenty-eighth annual ses-
sion begins September l."> and continues twenty-six
weeks. The course of study is grr.ded and extends
over three years. The college building has been
enlarged, new laboratories and lecture rooms having
been added.
The clinic facilities of the school are large, and
practical bedside instruction is a prominent feature.
Clinic material is supplied by St. Joseph's, German,
Municipal and St. Margaret's Hospitals, supplemented
by a Large dispensary service, medical, surgical and
obstetric.
The annual announcement has been issued and will
be forwarded upon request.
•1. 1). Griffith. M.D.. Dean: Franklin E. Murphy,
MR. Secretary.
MABION-SIMS COLLEGE OF MEDICINE.
ST. LOUIS, MO.
The Marion-Sims College of Medicine, which was
organized in 1890, has met with much success. This
has been due to the untiring energy of the faculty,
and to the disposition of its teachers to equip and
maintain a medical institution fitted in line with the
most advanced methods of medical instruction. A hos-
pital was built by the faculty immediately adjoining the
oollege, which has been a most valuable aid to the
instruction in the institution. This hospital, known
as the Rebekah Hospital, has afforded a great sup-
ply of clinic material. The school is well equipped
with appliances of all kinds necessary for instruction
in medicine. Its ehemic, microscopic and physiologic
laboratories are modern and complete. The college
dispensary is large. A dental department has been
added which bids fair to meet with the same success
that the medical department has recived. The length
of the course is six months.
The fees are as follows: Matriculation (paid but
once), $5; entire lecture (each year), $50; final exam-
ination (not returnable). 825: dissecting ticket, $10;
single professor's ticket ( where the entire course is
not taken ). 820: general ticket for sons and brothers
of physicians and sons of clergymen, $25; lecture fee
for three years, including matriculation, dissection
and examination ticket, if paid in advance, $150; hos-
pital and clinic tickets free.
H. W. Loeb, M.D., Secretary.
WASHINGTON UNIVERSITY.
MEDICAL DEPARTMENT, ST. LOUIS MEDICAL COLLEGE.
ST. LOUIS, MO.
This institution has had for more than half a cen-
tury successful annual sessions. It was one of the
first among the medical institutions to enforce a
graded course and to insist on a three years curricu-
lum (since 1880). Long experience in the advanced
methods of teaching enables it to present to the stu-
dent a well considered and consistent course of study.
Histology, comparative and practical anatomy are
demonstrated in a well supplied laboratory and per-
fect dissecting rooms.
The apparatus and the facilities for experimental
and original research in physiology are in charge of a
professional physiologist. Biology and pathology
have each well supplied laboratories in which practi-
cal work is assigned to the individual student. Clinic
facilities are abundant and well utilized. For in-
formation apply to H. H. Mudd, M.D., Dean, or E.
M. Senseney, M.D., Secretary.
MISSOURI MEDICAL COLLEGE.
ST. LOUIS, MO.
The oldest seat of medical learning west of the Mis-
sissippi, will enter upon its fifty-sixth year of instruc-
tion Sept. 22, 189(5. Three graded courses of lectures
of six months are necessary for graduation. A high
preliminary education, including Latin, is necessary
for admission. The fees are $100 a year. Number of
students in attendance 240. The number of cases
treated during the past year in the two dispensaries
conducted by the faculty, and from which clinic ma-
terial is largely drawn, was 16,389; operations per-
formed 1,084. The St. Johns, the Polyclinic and the
Bethesda Hospitals are under the exclusive control of
the faculty, besides clinics are given in the city and
other hospitals attended by the professors. The mu-
seum is very large and rich, and the laboratory equip-
ments rarely excelled. P. G. Robinson, M.D., Dean;
H. M. Whelpley, M.D., Secretary.
ST. LOUIS COLLEGE OF PHYSICIANS AND
SURGEONS.
ST. LOUIS, MO.
It is one of the three oldest medical colleges in St.
Louis. The Preliminary Session begins Tuesday,
September 1. Regular Session, Tuesday September
8, closing Wednesday March 17. The faculty num-
bers eighteen professors ably assisted by a corps of
competent lecturers and demonstrators.
In the new building the laboratory and clinic
equipment is complete. The surgical amphitheater is
supplied with all the latest improved appurtenances
to that line to work and nowhere in this section of the
country can better surgical opportunities be found;
material being drawn from the Merchants and Me-
chanics Hospital, St. Louis Baptist Hospital, City and
Female Hospitals, City Insane Asylum and Poor
House.
Fees are extremely moderate for the high grade of
instruction offered; matriculation $5, general lecture
ticket, $50. To sons and brothers of physicians and
sons of the clergy $25. Special terms to graduates in
pharmacy and dentistry. Write for catalogue to Dr.
Waldo Briggs, Dean.
UNIVERSITY MEDICAL COLLEGE.
KANSAS CITY, MO.
It requires of the student, before entering the col-
lege that he be either a graduate of a reputable liter-
ary college or, upon examination, show that he has a
good English education and sufficient knowledge of
Latin to translate and define medical terms; that he
read one year under a preceptor, to the extent of hav-
ing read the text- books of medicine; that he shall
attend 80 per cent, of the lectures and clinics of a
634
MEDICAL COLLEGES.
[September 19,
three years' graded course of six months each before
applying for graduation.
The college building is large and has seating capa-
city for 500 students. It has ample room for its
chemic, bacteriologic, histologic and pathologic labor-
atories, which are all abundantly supplied with all the
appurtenances for thorough teaching. It has a large
corps of didactic and clinic instructors.
Its resources for clinic material are excellent. All
Saints Hospital in the same block is under its control,
where a school for trained nurses is taught. At its
free dispensary in 1895 there were forty thousand pa-
tients treated distributed among the different depart-
ments. This dispensary runs all the year to which
students have free access, and three or four hours
daily (except Sunday) is devoted to clinic teaching
by the professors. In its obstetric clinic there were
324 cases of obstetrics furnished during the sessions
of 1895 and 1896. It has access where clinics are held
at All Saints Hospital and the seven other hospitals
in Kansas City. Matriculation fee $5.00. Lecture
tickets first and second years $60 each, third year $50.
Examination for graduation $20.
James P. Jackson, M.D., Dean.
UNIVERSITY OF THE STATE OF MISSOURI,
COLLEGE OF MEDICINE.
COLUMBIA, MO.
Organized in 1872.
Students must pass in the work of each class and
year before admission to the next class or year.
Instruction is given by lectures, recitations, clinic
teaching and laboratory work.
The length of the session, nine months, renders it
practicable to distribute the different branches among
the teachers in the most satisfactory manner, and in
their natural order and succession. The student is
thoroughly drilled each day by examinations upon
the lectures of the previous day, and by recitations
from text books.
The students are taught the use of the microscope,
in relation to both pathologic and physiologic studies.
The methods of bacteriologic investigation are taught
by practical work in the laboratory.
Among the advantages offered by this school is the
privilege granted, without further cost, to all students
who enter the medical department, of pursuing such
studies as they may desire in the academic course.
Academic students may take anatomy and physiology
in the first year of the medical course, preparatory to
entering on the full medical course after graduating
in arts or science. Such students are admitted to the
second year's medical class.
Conditions of admission: Candidates for admission
to the medical department must possess a good com-
mon school education. This is the minimum require-
ment, and evidence that the candidate possesses the
requisite knowledge must be attested by certificates
of former instructors or must be shown by examina-
tions conducted by the Faculty.
Fees: First year matriculation, $20; second year
matriculation, $50; third year matriculation, $50.
A preliminary course of nine months will be given
in chemistry, biology, physics and Latin.
A. W. McAlester, Dean. Woodson Moss, Secretary.
JOHN A. CREIGHTON MEDICAL COLLEGE.
OMAHA, NEB.
The curriculum of this school is graded, and attend-
ance upon four annual terms, of seven months each,
is required. Instruction is carried on by means of
lectures, recitations, laboratory work and clinics. The
laboratories for chemistry, physiology, histology,
pathology and bacteriology are very large, well lighted
and well equipped for the teaching of these branches
in a thorough and modern manner. The dispensary
and hospital clinics furnish ample material for clinic
instruction in all branches. The St. Joseph's Hos-
pital, a magnificent structure, of three hundred
beds, is under the exclusive control of the faculty of
this college. The new college building, nearly com-
pleted, is one of the very best in the West.
D. C. Bryant, M. D., Secretary.
OMAHA MEDICAL COLLEGE, MEDICAL DEPARMEXT
UNIVERSITY OF OMAHA.
OMAHA, NEB.
The curriculum is graded and divided into four
annual courses of seven months each.
Preliminary examination is required of all appli-
cants for entrance not in possession of literary cre-
dentials outlined by the Association of American
Medical Colleges.
The college building is new and contains an out-
door dispensary, two large lecture halls, museum and
laboratories of anatomy, physiology, pathology, hist-
ology and chemistry. The laboratory equipment is
sufficient for a class of two hundred students.
Instruction is given by means of recitations, class
room work, demonstration, lectures and clinics.
Clinics in all branches are furnished by a large out-
door dispensary, the Omaha, Presbyterian, Douglas
County, Immanuel and Clarkson Hospitals.
Graduation requirements in compliance with the
rules of the American Medical College Association.
Fees for each session $70.
W. O. Bridges, M. D., Secretary.
DARTMOUTH MEDICAL COLLEGE.
HANOVER, N. H.
" The plan of teaching in this college includes a term
of lectures with quizzes, from the middle of July to
last of November, and a term of recitations and labor-
atory work from January 1 to June 20 each year.
The Hitchcock Hospital affords excellent facilities
for clinic instruction. The fee for the lecture
course is $82 ; for recitation term, $40.
Entrance examinations in English, Latin, elemen-
tary physics and chemistry are required unless candi-
dates have already properly performed the work.
Ten months' attendance in this school each year
for three years, or three full courses of lectures and
four years of study under a preceptor are required for
graduation. They must pass written examinations in
anatomy, chemistry, physiology, surgery, practice,
obstetrics, gynecology and therapeutics.
O. P. Frost, M. D., Dean.
ALBANY MEDICAL COLLEGE, MEDICAL DEPART-
MENT OF UNION UNIVERSITY.
ALBANY, N. Y.
Three years graded course which will be increased
to four with session of 1897-98. Hospital and clinic
advantages excellent, clinics being held in Albany,
St. Peters, Child's and County Hospitals and Eye
and Ear Infirmary. With the coming session the
new Bender Hygienic Laboratory, for the study of
pathology and microscopic work, will be opened to
students. Fees: Matriculation, each year, $5: each
lecture course, $100; dissection, chemic, histologic
and pathologic laboratories, each $10.
1896.]
MEDICAL COLLEGES.
635
For catalogue and further information, address,
Willis (\. Tucker, M.D., Registrar.
BELLEVUE HOSPITAL MEDICAL COLLEGE.
NEW YORK.
The Collegiate year embraces a winter session and
a spring session. The winter session for 1896-97 will
begin Sept. 21, 1896, and continue for twenty-six
weeks.
The recitations, lectures and clinics for the spring
session will begin March 22, 1897. and continue for
twelve weeks. Attendance on the winter session only
is required for graduation.
N\w matriculates for the session of IS',17 98 and
thereafter will be required to present tickets show-
ing attendance on four regular courses of lectures
and certificates of four years' study of medicine as
conditions for graduation.
Students who attend the regular session of 1896-97
or have attended one or more regular sessions at the
Bellevue Hospital Medical College before 1896-97
mav complete their courses in accordance with the
present requirement of three years.
RESOURCES FOR CLINIC INSTRUCTION.
Bellevue Hospital receives annually between five
and six thousand patients. Medical and surgical
eases of all kinds are admitted except cases of conta-
gious diseases.
The City Hospital on Blackwell's Island receives
annually between eight and ten -thousand patients.
A considerable number of the patients admitted into
this hospital are affected with venereal diseases.
The Bureau of Medical and Surgical Relief for out-
door poor is in the college building and furnishes
most of the eases for the clinics held in the college
lecture room. The number of new patients treated in
this department in 1S95 was 17,479.
FEES AND REGULATIONS FOR THE THREE YEARS' COURSE.
The matriculation fee, to be paid before any other
tickets are issued, is So for each year. The fee for
each one of the three courses required and for each
additional course is $150. The fee for dissections, to
be taken during the first and second years, is $10 for
each year. The fee for the regular laboratory courses,
to be taken during the third year is $20. The fee for
specimens mounted in connection with the Carnegie
Laboratory course is $2. The fee for the examina-
tions at the end of the second year is $15. The fee
for the final examinations is $15. The fee for final
examinations for those who have taken their first two
courses at other colleges is $30.
Communications relating to the business of the
college should be addressed to Prof. Austin Flint,
Secretary.
LONG ISLAND COLLEGE HOSPITAL.
BROOKLYN, N. Y.
The regular term of 1896-97 will begin Sept. 28,
L896, and continue until March 31, 1897. The read-
ing term will begin April 1, 1897, and continue until
June 18.
Beginning with the regular term of 1897-98, the
course of instruction will be more thoroughly graded
and will consist of four collegiate years of eight
months each. The reading and recitation term will
be abolished as separate terms after 1897 and merged
into the regular term.
Through the munificence of Mrs. C. H. Polhemus
of Brooklyn, a magnificent building is now being
erected as a memorial to her husband. This building
will be occupied by the dispensary and college, and
will cover an area of 67 x 92 feet, and be 115 feet in
height. The instructions of the donor to the archi-
tect are to make it the most perfect building of its
kind that money and skill can construct. It will be
completed in June, 1897, and ready for the opening
of the collegiate year 1897-98.
The success of the plan of the Long Island College
Hospital depends mainly on two important facts:
1. The hospital and dispensary, in which 21,485
patients were treated in 1895, are under the immediate
control of the Regents, and are therefore, available at
all times for practical instruction.
2. The courses of instruction are given in the hos-
pital buildings, so that the student, without loss of
time, is brought in direct contact with patients, not
only in the amphitheater, but also in the wards of the
hospital.
The city of Brooklyn contains more than 1,000,000
inhabitants, being the fourth city in the United States
in point of population.
The fee for the regular term is $125. Board can be
obtained at $5 a week.
J. H. Raymond, M.D., Secretary.
NEW YORK POLYCLINIC MEDICAL SCHOOL AND
HOSPITAL.
NEW YORK CITY.
The winter session of the Polyclinic opens Sept. 15,
1896, and will continue to June 15, 1897. The ses-
sions of the school, however, are continued through-
out the year, the summer session being from June 15
to September 15.
It is a school of clinic medicine and surgery for
practitioners only. No didactic lectures are given.
The clinics are held in the lecture rooms of the school
and in the operating rooms of its hospital.
The operations done here embrace every variety of
surgical work not only in general surgery but also
operative treatment in the special branches of the eye,
ear, throat, gynecology, etc. An immense amount of
clinic material is supplied from the dispensary which
is submitted to the members of the class at specified
hours for personal examination and study under the
guidance of the various teachers.
Operative courses upon the cadaver in the different
departments are also given.
A general ticket admitting the holder to all the
lectures and operations is issued: Twelve months,
$350; six months, $250; three months, $150; six
weeks, $100.
For further information address J. Riddle Goffe,
M.D., Secretary.
NEW YORK POST-GRADUATE MEDICAL SCHOOL
AND HOSPITAL.
NEW YORK CITY.
The New York Post-Graduate Medical School and
Hospital has just entered upon its fifteenth winter
session. Five hundred and forty-two physicians from
all over this continent have attended the courses at
the institution during the past year. More than one
thousand operations were performed in the hospital,
which is one of the largest in the city, containing
special wards for babies and children, while nearly
twenty thousand patients were treated in the out-door
department. Recent discoveries have revolutionized
medical and surgical methods and a man whose med-
ical education ended fifteen years ago is not a phy-
636
MEDICAL COLLEGES.
[September 19,
sician or surgeon within the present meaning of the
term. Post-graduate medical instruction is for the
purpose of furnishing to these graduates in medicine
a means of refreshing their knowledge. It supplies
them with the opportunity of coming in direct con-
tact with disease by means of the special courses we
give in all departments of medicine.
D. B. St. John Roosa, M.D., LL.D., President.
NIAGARA UNIVERSITY.
MEDICAL DEPARTMENT.
BUFFALO, N. Y.
1883,
The medical department was organized in
with the motto "Higher Medical Education."
Requirements for matriculation are an equivalent
knowledge of Latin as found in Arnold's "First Latin
Book," in addition to the State Board of Regents'
certificate, which can be obtained by all graduates of
any registered high school in the country, or the
equivalent obtained in foreign countries.
Duration of course is from October 1, 1896, four
years. Matriculants prior to this time are allowed to
graduate in three years under certain conditions.
Free scholarship is obtained by competitive exam-
ination in higher mathematics and Latin.
Fees: General course of instruction, annually,
$75; registration fee each year, $5; perpetual ticket,
$200; laboratory fees reasonable.
The clinic resources embrace : Buffalo Hospital of
the Sisters of Charity (bedside instruction), Emer-
§ency Hospital, Buffalo Woman's Hospital, Buffalo
tate Hospital, Providence Retreat, St. Francis Hos-
pital, Edward Street Lying-in Asylum (150 confine-
ments yearly average), Edward Street Infant Asylum,
The Erie County Hospital, Charity Eye, Ear and
Throat Hospital, Buffalo German Orphan Asylum,
The College Dispensary, Nose and Throat Depart-
ment of the Buffalo Eye and Ear Infirmary.
Lectures begin Oct. 1, 1896: examinations close
May 6, 1897; commencement exercises Mav 12. 1897.
President, John Cronyn, B.A., M.D., Ph.D., LL.D.
Secretary, Harry A. Wood, M.D.
UNIVERSITY OF BUFFALO MEDICAL DEPARTMENT.
BUFFALO, N. Y.
The fifty-first regular session opens September 24,
and continues thirty weeks. The lectures will be held
in the large, new, three-story building, containing
three ampitheaters and rooms for dispensary patients,
chemic, pathologic, histologic, and pharmaceutic lab-
oratories, thoroughly equipped with modern conven-
iences. Instruction by lectures, recitations, labora-
tory work, and clinics. Clinic advantages unexcelled.
Fees: Matriculation, $5; regular term, $100; per-
petual ticket, $200; laboratory, $40; dissection, $20,
($10 each year) ; examination fee, $30 ($10 each year) .
For further particulars address,
John Parmenter, M.D , Secretary.
COLLEGE OF MEDICINE, SYRACUSE UNIVERSITY.
SYRACUSE, N. Y.
This college will hereafter occupy its new four-
story building, which contains nine commodious,
thoroughly equipped laboratories and lecture rooms.
For clinic teaching it has the use of two hospitals, a
dispensary and a State Asylum.
The college year begins the first Tuesday in Octo-
ber, and ends the second Tuesday in June. Entrance
examinations, which must be passed unconditionally,
will be held at the college, October 6, at 2 o'clock, p. M.
Fees and expenses, including lectures, laboratory
work, clinics, use of library, microscopes and other
apparatus, examinations and graduation, $125, annu-
ally, payable in advance. Rooms and board can be
obtained on very reasonable terms.
It may be remembered that for twenty years, co
mencing sixteen years before State legislation co
pulsion secured uniformity in the length of coursi
this college has maintained a three years' grad<
course. It was the first in the State, and the third
the United States to adopt this system of higher
medical education, and it has already adopted the
four years' course.
Ninety-two per cent, of its graduates have passed
successfully the State Regents' licensing examination.
For announcements and other information, address.
H. D. Didama, Dean, or D. M. Totman, Registrar.
UNIVERSITY OF THE CITY OF NEW YORK, MEDICAL
DEPARTMENT.
Fifty-sixth year. The session will begin in Octo-
ber. Attention is called to the fact that the curricu-
lum has been entirely remodeled and greatly improved.
Special clinics: Ophthalmology, otology, laryngol-
ogy, orthopedy, pediatrics, skin diseases, venereal dis-
eases, nervous diseases.
Examinations are held at the close of each year.
The marks received for proficiency in practical work
in the laboratory, dissecting room, etc., are added to
the final examination marks in each corresponding
subject.
The college possesses a corps of sixty-four profess-
ors and instructors in its various departments; and in
addition to well-equipped laboratories and a dispen-
sary where 20,000 visits are annually paid, it offers to
students exceptional facilities for practical instruction
at the bedside in Bellevue Hospital, which is directly
opposite the college buildings.
Fees; For course of lectures, $150; matriculation,
$5; demonstrators' fee, including material for dissec-
tion, $10; final examination fee, $30.
For further particulars and circulars, address the
Dean, Prof. Chas. Inslee Pardee.
WOMAN'S MEDICAL COLLEGE OF THE NEW YORK
INFIRMARY.
NEW YORK CITY.
The college gives a graded course of four years-
The building is new and convenient. It has excell-
ent dissecting rooms, well equipped laboratories for
practical instruction in chemistry, histology and
pathologic anatomy, a reading room and library. The
college adjoins the infirmary of sixty beds, and the
dispensary in which over 7,000 patients are treated an-
nually. These and a large out-practice are utilized
fully for clinic instruction. Besides the daily college
classes, the senior students receive daily clinic instruc-
tion in small groups. Special clinic courses are given
for them in Bellevue Hospital, the Blackwell Island
Hospital for the Insane, and the Willard Parker Hos-
pital for Contagious Diseases. Every student attends
ten cases of obstetrics under direction. Students can
attend operations and clinics in several of the city
hospitals.
Fees for course of four years, $515. Dr. Emily
Blackwell, Dean.
. LEONARD MEDICAL SCHOOL.
(SHAW UNIVERSITY.)
RALEIGH, N. C. '
Sixteenth annual announcement. Next session opens
1896.]
.MKDICAL COLLEGKS.
G37
November 2, Length of session twenty weeks; mint
mum expense for the your for board, room-rent, fees,
books, cic. $70.
We do nol claim the Leonard Medical School is the
host in the world, but wedo claim, and justly, that young
men who graduate from the four years' course of the
Leonard Medical School are equipped as few institu-
tions equip them, to successfully practice their profes-
sion, and that this is done at a phenomenally small out-
lay of money on the part of the students.
A hospital building has been erected and will be
used during the term for affording the students the
best possible clinic instruction.
For catalogue and full information write to Chas.
F. Meson o. President.
NORTH CAROLIN \ MEDICAL COLLEGE.
DAVIDSON, N. C.
This college lias a nominal connection with David-
son College and has the advantage of the scientific
equipment of this old institution. The chemic and
electric departments are unusually well furnished.
Anew laboratory is to be equipped this Fall. In the
department of pathology and bacteriology, there is, in
process of erection, a new brick and granite building
to be used for class work and hospital purposes.
Length of session eighl months, three of such ses-
sions constituting a complete course, leading to grad-
uation.
Matriculation fee. $5; tuition, $75: board and lodg-
ing $10 to $15 per month.
J. P. Munroe, M.D., President.
CINCINNATI
COLLEGE OF
SURGERY.
MEDICINE AND
CINCINNATI, OHIO.
The forty-sixth year of college instruction begins
Oct. 1. 1896, and continues until April 14, 1897. It has
a faculty of twelve professors, four demonstrators, and
nineteen assistants. The course of study, require-
ments for admission, advanced standing, and gradua-
tion are those indicated by the American Medical
College Association, of which organization this school
is one of the original members.
Facilities for didactic instruction, clinic, observation
and laboratory work are in accord with the best medi-
cal schools of this country. The college is coeduca-
tional for the sexes, sitting and study rooms are con-
veniently arranged.
The hospital advantages afforded medical students
in Cincinnati are unexcelled. Nearly every professor
in the Cincinnati College of Medicine and Surgery
holds a hospital staff position.
S. C. Ayers, A.M., M.D.,Dean; W. E. Lewis, M.D.,
Secretary.
CLEVELAND COLLEGE OF PHYSICIANS AND SUR-
GEONS.
MEDICAL DEPARTMENT OF THE OHIO WE8LEYAN UNIVERSITY,
CLEVELAND, OHIO.
Formerly Medical Department of the University
of Wooster.
The course of instruction is four years with terms
of eight months each. The fees are $100 for each
separate year for general and hospital ticket. Matri-
culation and examination fee $10 annually extra. In
addition thereto a laboratory deposit of 820 is charged
to cover cost of material, a portion of which is return-
able to the student in case material to that amount is
not used.
The first two years of instruction in this school is
devoted entirely to the primary branches, much of
which is taught by the laboratory method, requiring
of the student individual work. The last two years
are largely clinic, the student spending most of his
time at the Cleveland General Hospital, the medical
management and direction of which is exclusively
under the faculty.
It will be observed from the foregoing statement
that the first two years of student life are devoted to
such work as will fit him for a clear comprehension of
the advanced work, and that the last two years are
eminently practical, fitting him especially for assum-
ing the duties of active professional life.
H. W. Rogers, M.D., Secretary.
LAURA MEMORIAL WOMAN'S MEDICAL COLLEGE.
CINCINNATI OHIO.
With the session of 1895-96, the college adopted
the four-years' graded course.
The sessions are of seven months each, beginning
the last Tuesday in September, and ending the last
Thursday in April. The college with the hospital
adjoining, is complete in all departments, the labora-
tories being newly and fully equipped. The clinic
advantages include the large and varied clinics of the
Cincinnati Hospital, the Presbyterian Hospital, the
College dispensary, the eye clinics in Prof. Holmes'
Ophthalmic Hospital, and the obstetrical cases of the
Maternity Society, under Prof. Stewart.
The fees are: Matriculation $5; general fee (paid
annually) $50; the practical anatomy and laboratory
fees $10 each; Cincinnati Hospital ticket (for third
and fourth years' classes) $5; graduation fee $25.
J. M. Withrow, M.D., Dean.
S. E. Allen, M.D., Secretary.
MEDICAL COLLEGE OF OHIO.
CINCINNATI, OHIO.
The Medical College of Ohio, now the Medical
Department of the University of Cincinnati, is the
oldest medical school west of the Alleghenies, having
been founded in 1819. Four courses of lectures are
required. Fees $100 per annum. With the beginning
of the session of 1896-97 the college will be in its new
location on McMicken Avenue, and in newly erected
buildings. Its chemic, histologic, pathologic and
bacteriologic laboratories are newly and thoroughly
equipped. The large college dispensary with the
Cinncinati Good Samaritan and Ohio Maternity
Hospitals afford abundant clinic material.
Jas. G. Hyndman, M.D., Secretary; W. W. Seely,
A.M., M.D., Dean.
MIAMI MEDICAL COLLEGE.
CINCINNATI, OHIO.
It requires the four-years' graded course. The ses-
sion begins Oct. 1, and ends April 1. The fees are,
matriculation $5; tuition (annually) $100. This
includes all laboratory tickets and dissections. Grad-
uation $25; hospital ticket $5.
In addition to the regular didactic and laboratory
courses exceptional clinic advantages are possessed.
The Ophthalmic Hospital building has been leased
for the daily out-door college clinics, which have an
average daily attendance of 200 cases, and ten mem-
bers of the faculty give bedside instruction in the
wards of the Cincinnati Hospital in medicine, surgery,
obstetrics, gynecology, ophthalmology and otology
in addition to the clinic lectures given in the amphi-
theater of that institution. This hospital admits
5,300 cases yearly, is within half a block of the college,.
638
MEDICAL COLLEGES.
[September 19,
and the college hours accommodate themselves to the
hospital clinics.
N. P. Dandridge, M.D., Dean.
OHIO MEDICAL UNIVERSITY.
COLUMBUS, OHIO.
The University comprises the departments of med-
icine, dentistry, pharmacy and midwifery; each
department having its own faculty and separate apart-
ments for general class work.
The main building is a fine structure, specially
planned and erected for University purposes. A new
four-story building is used solely for laboratory pur-
poses. There are two amphitheaters, ten recitation
rooms, twelve laboratories, dental operating rooms,
library, museum, and free dispensary rooms.
The plan of instruction is by assigned topics and
recitations and clinic lectures. Hospital facilities
are provided by the Protestant and University Hospi-
tals, which place all their clinic material at the dis-
posal of the University staff for the purposes of clinic
instruction, the Ohio Penitentiary, the Columbus
State Hospital and free Dispensary.
The combined Faculty consists of fifty-four pro-
fessors, instructors and adjuncts.
Length of term, seven months; fees $50 in each
department. Medical department, member of National
Association of American Medical Colleges. Dental
department has been recommended by the council of
National Association of Dental Faculties for mem-
bership.
The University has adopted the four-years' course.
giving separate instruction in each year.
G. M. Waters, A.M., M.D., Dean; J. U. Barnhill,
A.M., M.D., Secretary.
STARLING MEDICAL COLLEGE.
COLUMBUS, OHIO.
The fiftieth annual session of Starling Medical
College, Columbus, Ohio, opened on August 19, 1894.
The college is one of the oldest in the State, and has
a fine building, with all the modern equipments. Its
hospital facilities are of the best, material being sup-
plied from the two largest hospitals in the city, one
being in the college building. Students are required
to study cases at the bedside, and instructed in physi-
cal diagnosis.
Information as to terms can be had by addressing
Thos. C. Hoover, M.D., Registrar.
TOLEDO MEDICAL COLLEGE.
TOLEDO, OHIO.
The sixteenth annual session will begin October 1,
in its splendidly equipped new college building, and
continue six months. The school requires four years'
attendance for graduation. The clinic facilities are
excellent. There is no other medical college in the
city, and it has the active support of the profession,
not only of the city, but of the northern part of the
State. It has the entire material furnished by two
large general and one lying-in hospital. The fees are
as follows:
Matriculation, to be paid but once, $5; professors'
tickets, for each session, $50; practical anatomy
ticket, including material, each course, $10; chemic
laboratory, $5; microscopy and bacteriologic labora-
tory, $10; hospital tickets (obligatory), $5; gradua-
tion fee, $25.
For $175 paid in advance, a perpetual ticket (not
transferable) will be issued, which will entitle the
holder to attend four or more courses of regular
J. H.Pooley, M. D., Dean. Wm. J. Gillette, M.D,
Secretary.
WESTERN RESERVE UNIVERSITY. MEDICAL
DEPARTMENT.
CLEVELAND, OHIO.
Presents a three-years' graded course, each year a
term of eight months. Instruction by recitations,
lectures, clinics, quizzes and practical training.
Ample laboratory, dispensary and hospital facilities
and equipments are provided for all students. Tickets
for year, $100; tickets for whole course, S250. Special
courses as desired, and advanced students given
standing accdrding to assured acquirements. Year
begins middle of September.
G. C. Ashmun, M. D., Registrar.
UNIVERSITY OF OREGON, MEDICAL DEPARTMENT.
PORTLAND, ORE.
The medical department of the University of Ore-
gon is located at Portland, Oregon, a city of nearly
100,000 inhabitants, where the excellent facilities
afforded by Good Samaritan, St. Vincent's and Mult-
nomah County Hospitals offer advantages for clinic
instruction equal to those of many cities of much
larger size because of the very large extent of terri-
tory from which patients are drawn. This school is
a member of the Association of American Medical
Colleges, requires advanced matriculation examina-
tion, four courses of lectures of six months each,
practical work in clinics, anatomy, chemistry, bacteri-
ology, etc. Its courses are graded, examinations
being held at end of each year for advanced grading.
Fees are graded according to time of attendance:
Matriculation, $5; first year, $130; second year. $130;
third year, $100; fourth year, free; examination
fee, $30.
S. E. Josephi, M. D., Dean.
Curtis C. Strong, M. D., Secretary.
WILLAMETTE UNIVERSITY OF OREGON, MEDICAL
DEPARTMENT.
SALEM, ORE.
This college is permanently located at the capital
of the State, and is now entering upon its thirty-first
year. The course of instruction continues through
four years, in accordance with the highest and best
standard of modern advancement.
The regular course of instruction will begin Sep-
tember 29, 1896, and continue six months. The
school is conducted in entire harmony with the Asso-
ciation of American Medical Colleges, adhering
strictly to the requirements of that association.
Fees: First year, matriculation, $5; lectures, $130;
second year, lectures, $130; third year, lectures, $100;
fourth year, lectures. s:>0: examination fee, $30. The
medical faculty of the college have entire and exclu-
sive control of the Salem Hospital, insuring to the
students all clinic advantages that can reasonably be
procured from such sources.
J. Reynolds, M. D., Dean.
W. H. Byrd, M. D., Secretary.
UNIVERSITY OF PENNSYLVANIA, DEPARTMENT OF
MEDICINE.
PHILADELPHIA, PA.
Founded in 1765. The course of instruction ex-
tends over four years, with one session beginning
October 1 and ending on the second Thursday of
1896.]
MEDICAL COLLEGES.
639
Jane in each year. Tlie tuition fee admitting the
Student to all the lectures and including all the labor-
atory work, dissection, etc., is $200 per annum. The
instruction is conducted in the Medical Hall, the
Laboratory Building, the Hospital of the University,
Maternity Pavilions, Wistar Institute of Anatomy
and Biology, and the Laboratory of Hygiene. Prac-
tical work in the various laboratories is part of the
curriculum and is required of every student. Attend-
ance on the clinic instruction given in the amphi-
theater as well as bedside instruction in the wards of
the University Hospital is a part of the daily duty of
the students.
John Marshall. M. D., Dean.
JEFFERSON MEDICAL COLLEGE.
PHILADELPHIA, PA.
A graded four years' curriculum in college is
required of those who take the medical degree.
The matriculation fee is paid but once: the annual
ticket is $160; no diploma fee.
Beside the medical hall and the old laboratory
building, this fall there will be opened the new patho-
logic and bacteriologic laboratories equipped at heavy
outlay. The college hospital provides a wealth of
clinic material unequaled in America. It has 140
beds and in the out-patient departments over 300
cases are treated daily. In the maternity department
there were 159 obstetric cases and 2,385 visits. Each
student had bedside instruction in midwifery. With
these facilities it is possible to train the student in all
the branches of medicine.
J. W. Holland. M.D., Dean.
MEDICO CHIRURGICAL COLLEGE.
PHILADELPHIA, PA.
The session at the college opens October 1, and
continues until April 2<>. when examinations begin.
It contains laboratories for physiology, chemistry,
pathology, hygiene, experimental therapeutics, his-
tology and pharmacy.
Free quizzing at this college is one of its charac-
teristics. Quizzing is done by the professors and
instructors.
Its course consists of three years and is of a very
practical nature. During the coming session it will
have a new clinic amphitheater with a seating capac-
ity of 600. It equals if not surpasses any clinic
amphitheater now in existence in its arrangement so
as to meet the demands of modern efficient clinic
teaching.
The new hospital contains 150 beds. The fees for
the tickets are *120 for each year.
All communications should be addressed to Isaac
Ott, M.D., Dean, Medico-Chirurgical College, Phila-
delphia.
PHILADELPHIA POLYCLINIC AND COLLEGE FOR
GRADUATES IN MEDICINE.
PHILADELPHIA, PA.
It was organized in 1882 to give practical instruc-
tion to graduates only. It has a Faculty of thirty-
two professors, assisted by forty-four lecturers,
adjunct professors and instructors.
The hospital is fully equipped for purposes of treat-
ment and teaching. There are two dispensary floors,
clinic amphitheater, operating and sterilizing suites.
There is a five-story laboratory building connected
with the hospital, containing necropsy and dissecting
rooms, surgical, chemic, pathologic, bacteriologic and
neurologic laboratories, all of which are fully
equipped with the latest improved apparatus and offer
every facility for original research.
Courses may begin at any date. The situation of
the hospital is almost equi-distant from the Univer-
sity of Pennsylvania, the Jefferson Medical College,
and the Medico-Chirurgical College, and near to the
Children's, Rush Consumption, Wilis Eye and Ortho-
pedic Hospitals
A general ticket entitling the student to attend all
the clinic departments is issued for one week at $20,
six weeks for $90, three months for $150, and one year
for $850. In all cases an extra fee is charged for any
laboratory course.
S. Solis-Cohen, M.D., President. Max J. Stern,
M.D., Secretary.
WESTERN PENNSYLVANIA MEDICAL COLLEGE.
PITTSBURG, PA.
The regular session begins third Tuesday in Sep-
tember and continues six months. During this ses-
sion, in addition to four didactic lectures, two or
three hours are daily allotted to clinic instruction.
Attendance upon four regular courses of lectures is
requisite for graduation. A four years' graded course
is provided. The spring session embraces recitations,
clinic lectures and exercises, and didactic lectures on
special subjects; this session begins the second Tues-
day in April and continues ten weeks.
The laboratories are open during the collegiate year
for instruction in chemistry, microscopy, practical
demonstrations in medical and surgical pathology,
and lessons in normal histology. Special import-
ance attaches to "the superior clinic advantages pos-
sessed by this college."
For particulars address Prof. T. M. T. McKennan,
Secretary.
WOMAN'S MEDICAL COLLEGE OP PENNSYLVANIA.
PHILADELPHIA, PA.
The course is four years with an entrance examina-
tion in English, physics, arithmetic and Latin. The
following laboratories furnish thorough practical
instruction: histologic and embryologic, chemic,
physiologic, anatomic, bacteriologic, pathologic and
pharmaceutic. The instruction in hygiene is supple-
mented by laboratory work and there is a department
for attendance on cases of confinement. Bedside
instruction to small sections of the class is given by
the physician in charge of the Woman's Hospital and
clinic professors and instructors in this and other
hospitals. The total expenses including the gradua-
tion fee are $516.
For further information address Dr. Ruth Webster
Lathrop, Sub-Dean, Philadelphia, Pa.
MEDICAL COLLEGE OP SOUTH CAROLINA.
CHARLESTON, 8. C.
Three years' graded course; good hospital advan-
tages; well equipped chemic, pathologic and bacteri-
ologic laboratories; modern dissecting room ; excellent
teaching facilities and ample clinic material. Every
facility afforded for a thorough course of instruction
by lectures, demonstrations, quizzes, laboratory work
and frequent clinic. Lectures begin Oct. 6, 1896.
Commencement exercises April 1, 1897.
Fees: First year matriculation $5, lectures $100,
laboratory fee $5; second year lectures $100, labora-
tory fee $5 ; third year lectures $80, laboratory fee $5.
No further charge for dissecting and hospital ticket,
or diploma fee.
640
MEDICAL COLLEGES.
[Septembek 19,
College of Pharmacy two years' course, fees, first
year $45; second year $80. Women admitted to med-
ical and pharmaceutic courses. For catalogue and
other information address Francis L. Parker, M.D.,
Dean.
CHATTANOOGA MEDICAL COLLEGE.
MEDICAL DEPARTMENT OF GRANT UNIVERSITY.
Splendid new college building, largest and most
elaborate in the entire South, into which the school
has just moved prior to opening its eighth annual
session.
Six hospital laboratories, abundant material for dis-
section and excellent general equipment. Six months'
term and three years' graded course. Requirements
those of the Southern Medical College Association.
Tuition fees average about $93 per annum. Large
faculty covering every separate branch of medical
instruction. Practical teaching and personal drill are
special features. Climate delightful, board cheap,
scenery picturesque, city healthy — a resort for inva-
lids from everywhere, and shows lowest mortality of
any neighboring city.
E. A. Cobleigh, M.D., Dean; J. R. Rathmell,
Secretary.
MEDICAL DEPARTMENT UNIVERSITY OF
TENNESSEE.
NASHVILLE, TENN.
The Medical Department of the University of Ten-
nessee was founded as the Nashville Medical College
in 1876 and became in 1879 connected with the Uni-
versity of Tennessee. The curriculum of study
extends over three courses of lectures with special
laboratory courses. It has now connected with it
thirteen professors, nine instructors and six demon-
strators. Among its professors may be mentioned
Prof. Paul F. Eve and W. K. Bowling. Its sessions
occur from October through March of each year.
Paul F. Eve, M.D., Dean.
MEMPHIS HOSPITAL MEDICAL COLLEGE.
MEMPHIS, TENN.
It is a member of the Southern Medical College
Association, three terms of six months each being
required for graduation. The school enjoys excellent
clinic advantages with material obtained from the
city hospital, St. Joseph's Hospital and its own free
dispensary, where several thousand applicants receive
treatment yearly. The college is well equipped with
laboratories for microscopic and chemic work under
the charge of a corps of experienced instructors. The
Faculty is composed of some of the ablest men in the
South, all being men of large experience in the teach-
ing of their general branches. The fees for instruc-
tion are $75 per course; graduation fee $25, 'returnable
in case applicant fail or does not apply for examin-
ation.
W. B. Rogers, M.D., Dean.
SEWANEE MEDICAL COLLEGE, UNIVERSITY OF
THE SOUTH.
SEWANEE, TENN.
The college is now in session, with a fair class. Its
regular course opens about July 1, and continues six
months.
The pride of the school consists in its thorough
course in the principles of the various departments of
medicine and its excellent laboratory facilities.
It is a member of and governed by the laws of the
"Southern Medical College Association" except in
requirements for matriculation; its standard is with
the highest.
It has been demonstrated that the summer and fall
seasons in this elevated mountain retreat, offer rare
facilities for the successful study of medicine.
The expenses of attending the school are quite
moderate.
J. S. Cain, M.D., Dean.
TENNESSEE MEDICAL COLLEGE.
KNOXVILLE, TENN.
Was one of the first in the South to extend the
regular course to six months, and to require attend-
ance upon three courses of lectures as an essential for
graduation; its great success is a source of special
satisfaction to the friends of the school. Knoxville,
with its suburbs, has about 50,000 inhabitants.
A hospital on the college grounds, costing $30,000,
was completed in 1895. Fees for each course $65, or
for the three courses a perpetual ticket is provided at
a cost of $150. This includes everything except
graduation fee of $25.
J. C. Cawood, M.D., Dean.
UNIVERSITY COLLEGE OF MEDICINE.
RICHMOND, VA.
The University College of Medicine was organized
and chartered with the three independent departments
of medicine, dentistry and pharmacy, Dr. Hunter
McGuire President of the combined faculties.
The course of study comprises three sessions of
seven months each. Tuition fees $100 with no extras.
The professors and instructors number forty-eight and
constitute the medical and surgical staff of the Vir-
ginia Hospital and Richmond Eye, Ear and Throat In-
firmary. Students also have the clinic advantages
of the City Almshouse Hospital. The arrangements
for obstetric service are ample, and every student
receives personal instruction in all the clinics.
The college buildings are large and were erected
for their special purposes, containing fifteen separate
apartments designed to meet the requirements of di-
dactic instruction with practical laboratory work so
essential to a modern scientific training.
There were 239 matriculates during the last session
Hunter McGuire, M.D., LL.D.,'President.
Paulus A. Irving, M.D., Secretary.
THE UNIVERSITY OF VIRGINIA, MEDICAL
DEPARTMENT.
CHARLOTTESVILLE, VA.
The session begins the 15th of September and con-
tinues without intermission for nine months. The
course is graded and extends over three years, chem-
istry, histology, bacteriology, and human anatomy
being taken up for the first session ; physiology, path-
ology, materia medica, and obstetrics for the second;
and the remaining studies in the medical curriculum
for the third. Optional courses are also offered in
embryology, practical pharmacy, and toxicology.
The University fees including tuition, matricula-
tion, laboratory and diploma fees are for the first year
$160, for the second year $140, and for the third year
$100. These cover all charges for anatomic and
laboratory materials.
The characteristic features of the school are the
extreme thoroughness of the teaching, the ample
practical courses in human anatomy, histology and
bacteriology, and the carefully conducted clinics given
at the free dispensary operated by the University.
Each student not only hears the lectures but comes
1896.]
GONORRHEAL CONJUNCTIVITIS.
641
under the individual instruction of the professor. This
is especially important for the laboratory and clinic
courses. In addition to the clinics at the dispensary,
those at the Piedmont Hospital in Charlottesville are
utilized.
Under the laws of the University, each professor
charged with the duties of instruction is required to
give his whole time to the collegiate work, and hence
lie courses are of unusual thoroughness.
Win. M. Thornton, LL.D., Chairman of Faculty.
UNIVERSITY OF VERMONT, MEDICAL DEPART-
MENT.
BURLINOTON, VT.
The thirty-fourth annual course of lectures will
>egin in January and continue six months, ending in
Inly.
This extension of the term will increase the scope
if the instruction, and prove of great advantage to
'ie student. The preliminary term has been abol-
slieil. No private courses by any of the professors
kill lie tolerated by the faculty.
Instruction will be given in the following branches:
Anatomy, physiology, chemistry, materia medica and
therapeutics, practice, obstetrics, surgery, diseases of
children, medical jurisprudence, neurology, ophthal-
mology and otology, gynecology, dermatology, vene-
real diseases, pathology and bacteriology, hygiene,
sanitary science and examinations for life insurance.
Laboratory courses at this college in urinary
analysis, histology, pathology and bacteriology, and
practical work in physical diagnosis, surgery and
demonstrative obstetrics, are now compulsory.
The instruction is given by scholastic and clinic
lectures, by recitations and by practical manipula-
tions by the student.
The clinic advantages are in many respects unsur-
passed.
For further information address A. P. Grinned,
M.D., Dean.
WISCONSIN COLLEGE OF PHYSICIANS AND
SURGEONS.
MILWAUKEE, WIS.
The fourth annual course of lectures will begin
September 22. The length of the course is twenty-
seven weeks, exclusive of the holiday vacation, the
term ending on April 5, 1897.
This institution adopted the four-year course in
1895, and all students matriculating this year and
hereafter will be required to spend four years in col-
lege work, unless their previous studies have entitled
them to apply for advanced standing.
The fees for the course, including laboratory and
lecture fees, and anatomic material, are $95.
Clinic cases are furnished by the Presbyterian Hos-
pital, which is in the exclusive control of the faculty
of the college, and by the College Free Dispensary.
W. H. Washburn, M. D., Secretary.
Caroid.— A vegetable digestive ferment, derived from the
plant known as carina papaya, or "paw-paw" (not the indigen-
ous plant but an exotic found growing wild in Polynesia and
now cultivated in most tropical countries). Caroid is a con-
centrated extract of the juices of the plant, made by cold
methods, thus preserving the ferment in all its strength and
freshness. Its action, contrary to that of pepsin, on the one
hand, which acts only in acid media, and of diastase, pancrea-
tin etc., on the other, which act only in alkalin media, is
equally good in both acid and alkalin fluids. The dose is from
2% to 5 grains. — Nat. Druggist, September.
GONORRHEAL CONJUNCTIVITIS; ITS
TREATMENT.
Head In the Section on Ophthalmology at the Forty-seventh Annual
Meeting of the American Medical Association,
at Atlanta. Ua., May 5-8, 1899.
BY LOUIS J. LAUTENBACH, A.M., M.D., Ph.D.
Burgeon to the Pennsylvania Eye and Kar Infirmary: Nose and Throat
Physician to I he Odd Fellows' Home; late Chief of the
Eye Clinic of the German Hospital, MO.
PHILADELPHIA, PA.
Conjunctival diseases are.among the most frequent
of eye affections, but each year as the general prac-
titioner's special knowledge increases, he undertakes
more and more the treatment of the inflammatory eye
affections, especially of the appendices of the eye, and,
in consequence, the specialist sees less and less of
these troubles, except when present in an aggravated
form. The study of conjunctival diseases is not only
important in relation to their treatment but as they
are very often symptomatic of other local or general
conditions it is especially necessary to have a most
intimate knowledge of their various aspects. Again
their seriousness is not so much per se as in a weak-
ening of the surrounding structures, thus giving rise
to secondary inflammatory conditions.
Of these conjunctival inflammations there are sev-
eral which are specific or general in their origin,
bearing a marked resemblance to each other which
can be traced not only in their origin but in their
course and treatment as well. I refer especially to
the diphtheritic, epidemic, gonorrheal, blennorrheic
and trachomatous forms of conjunctivitis. All are occa-
sioned by a specific germ and therefore all are contagi-
ous, all except the latter appear as localized epidem-
ics, and formerly this was present often as an acute
epidemic; all are of an acute type and rapid in
their progress, all extend rapidly to various adjoining
structures, especially to the cornea, tending only too
often to the production of most serious lesions. In
fact, blindness as a result of these specific inflamma-
tions is only too prevalent. This entire class of in-
flammations should be directly under the supervision
of the State. A move in the right direction has
been the passage of laws for the reporting and proper
treatment of cases of ophthalmia of the newborn,
which have now been passed by the legislative bodies
of numerous States.
Blennorrheic conjunctivitis, the ophthalmia of the
newborn and the gonorrheal conjunctivitis of the
adult, are in many ways the most important and
serious of eye inflammations, causing more than one-
tenth of all the existing blindness, and in addition,
occasioning partial loss of sight in twice as many.
While the gonorrheal form is less common than oph-
thalmia neonatorum, it is not the less virulent and its
results are often more serious. Some years ago I was
assured by a member of the staff of a prominent gen-
eral hospital that up to that time no case of gonorrheal
conjunctivis had left the institution without having lost
the sight of one or both eyes. So serious were these
cases looked upon in the immediate past that many
institutions refused to receive them, basing their
refusal both on its contagiousness and its origin;
undoubtedly the bad results obtained had some weight
in occasioning such a decision.
The ill results following a case of gonorrheal con-
junctivitis can usually be attributed either to the
usual indisposition of the patient to admit the cause
of his trouble or his want of knowledge thereof, occa-
sioning the consequent delay of treatment; second,
642
GONORRHEAL CONJUNCTIVITIS.
[September 19,
the rapid progress of the disease with the consequent
swelling of all the tissues in and about the eye, occa-
sioning destruction of important eye structures by
pressure and interference with the circulation and
nutrition of the parts; third, a want of thorough
cleansing; fourth, a want of proper treatment.
The first of these is sufficiently familiar. How
often do we see these cases progressing even to the
pustular stage without application for treatment hav-
ing been made, either because the patient did not
recognize the ailment, or recognizing it, hoped to con-
ceal it. In this way considerable mischief is often
done before aid is sought. The seriousness of the
disease is occasioned more by neglect of prompt treat-
ment than aught else; a day lost may mean the loss of
the sight. The public generally should understand
that in eye diseases a stitch in time saves not only
nine, but sometimes a whole lifetime of darkness.
The rapid progress of the disease, extending within
two or three days through the infiltration stage with
distended lids and chemotic conjunctiva into the pus-
tular one with sometimes, almost simultaneously,
ulceration and breaking down of the cornea, is unfor-
tunately too frequent. To one unaccustomed to such
cases or not having a true realization of their violence
and virulence, the progress may be so rapid that serious
results are produced without sufficient effort having
been made to avoid them. In these cases the rapidity
of the disease should be anticipated and guarded
against by appropriate advice and treatment.
The need of thorough cleanliness is apparent, but
the method of its accomplishment may not be so
clear. Cleanliness in such cases means the effective
removal of all discharges on the conjunctiva and in
the folds thereof, and the decomposition and removal
of all discharges and gonococci which may lie in the
various minute fissures and crevices between the epi-
thelial cells of the superficial layers. In these cases
the cleanliness must be considered part of the treat-
ment, and usually is the most important part. Many
will recover without other treatment, whereas, local
applications without cleanliness will often avail
nothing; it is the one essential to be adhered to
religiously.
To thoroughly cleanse an eye the seat of a gonor-
rheal inflammation is often no easy task. The swol-
len lids with the tenderness and photophobia make
it peculiarly difficult, and when there is maceration
or ulceration of the cornea it is yet more so, as there
may be the added danger of bursting the ball by the
necessary manipulations.
I will outline the method which in my work I fol-
low as rigidly as circumstances will allow. I first wipe
off the lids and any discharge which appears between
them with a piece of absorbent cotton saturated with
a 3 per cent, solution of peroxid of hydrogen. I
invariably use the Oakland peroxid on account of its
comparative purity and freedom from acidity. I then
instill between the lids, with a pipette, about twenty
or thirty drops of the same solution and continue this
until there is little or no bubbling. I then evert the
upper lid and instill into the opened palpebral folds
more peroxid, and then wipe the parts with absor-
bent cotton wet with the solution. I then treat the
lower lid in the same way, being sure to thoroughly
cleanse the cul-de-sac. I replace the lids and gently
rub the ball at all parts of the lids, with the finger
tips. I then take a saturated solution of boric acid
and repeat with it all the manipulations described
above, doing this very thoroughly and using the solu-
tion liberally.
The peroxid cleanses the surface and serves to destroy
any diseased conjunctival epithelium and penetrates
the crevices and interspaces where the pus and gono-
cocci have collected and decomposes these masses,
bringing the detritus to the surface. Allowing the
peroxid to lie in contact with these diseased structures
for a few minutes serves to so thoroughly decompose
them that they are readily removed by the subse-
quent washing with the boric acid solution. This
solution not only washes off the foreign matters but
also relieves the burning sensation of the peroxid
and while soothing the eye serves to produce a heal-
ing effect upon the ragged but healthy epithelial cells.
In addition to this personal cleansing of the eye
which I insist upon doing at least once or twice a
day, the patient is to have his eye thoroughly
cleansed by the nurse with a saturated solution of
boric acid at least every hour and in some cases
every half hour. If the swollen condition of the lids
renders this cleansing difficult, the severity of the
disease makes it only the more imperative.
It seems evident that no treatment can exercise
its normal effect without the thorough cleansing
above described. These cases are of such a nature
that the neglect must be eliminated — the treatment
must be most vigorous and thorough.
The local medicament of most value in these cases
is undoubtedly the solution of nitrate of silver. In
all the germ diseases of the conjunctiva its use is
invaluable. I use it of a strength of from 10 to ISO
grains to the ounce — the more severe and active the
inflammation, the stronger the solution. It is to be
applied thoroughly with a cotton wound probe (never
with a brush) over the palpebral conjunctiva, carried
into the cul-de-sac and then to the ocular conjunctiva,
carefully avoiding the cornea. This application is to
be made by the physician once or twice a day as
necessary and is to be followed by the instillation of
4 or 5 drops of castor or olive oil which eases the pain
and lessens the friction of the roughened and diseased
conjunctival surfaces. In addition to this personal
application, a one or two grains to the ounce solution
of nitrate of silver is to be instilled into the eye by
the nurse from two to four times a day, invariably
after washing with the boric acid solution. If the
cornea be ulcerated, the treatment is to be as thorough
as is consistent with safety, avoiding the use of the
strong nitrate solution on the cornea or its accidental
access thereto.
If chemosis be present, I invariably incise the con-
junctiva in numerous deep lines radiating from the
cornea so that the subconjunctival infiltration may
gradually find vent and thus afford sufficient room for
the natural increase in the amount of the exudate, and
at the same time by decreasing the tension, lessen the
abnormal pressure on the corneal border.
In addition to the above, I use ice bags and iced
cloths whenever the inflammation is peculiarly viru-
lent, or there is very much swelling of the lid or
chemosis, and use atropia or eserin locally whenever
I have corneal involvement, the choice depending
upon the tension of the ball as well as the location
and extent of the ulceration and the general consti-
tutional peculiarity of the patient ; in those inclined
to rheumatism, all other things being equal, I always
prefer to use eserin. I have also found ice to be
invaluable in the early stages of corneal involvement,
1896.]
CICATKICIAL SKIN FLAPS.
643
when the cornea first appears hazy. In fact in all
corneal inflammations 1 have found the use of ice
peculiarly beneficial in preventing the disorganization
of this tissue.
A matter which I have not touched upon but which
lft of supreme importance, is the prevention of the
disease attacking the sound eye. This is accomplished
by thorough attention to the affected eye. which I hope
1 have fully explained, and preventing the discharge of
the diseased eye from infecting the sound one. This
is attempted by many by closing the healthy eye with
a watch glass or adhesive plaster, carefully applied.
1 formerly built a dam of shoemaker's wax upon the
bridge ot the patient's nose, carrying it well down
toward the tip and up on the forehead, directing the
patient never to lie upon the unaffected side. While
still occasionally using this method, I rely more on the
bandaging of the sound eye and its regular daily
cleansing by the physician before he treats the affected
one. Tlie cleansing is that outlined above, consisting
first of the use of a 3 per cent, peroxid of hydrogen
solution followed by thorough cleansing with a satu-
rated solution of boric acid, then drying the eye and
covering it thoroughly with a roller bandage, first
dressing the eye with absorbent cotton covered with
waxed paper.
By this method of bandaging, even though the dis-
charges soak into the bandages, the waxed paper pre-
vents their access to the eye, and should the germs
surmount this barrier they will be absorbed by the
Ootton wad. which is an efficient sterilizer, and even
though it were possible to penetrate through this they
will meet a closed eye, which they can not enter.
Another advantage of the bandaging is the rest given
the healthy eye, thus preventing excessive motion in
the diseased eye. and it will be found that corneal
involvement will be more rare, and when it occurs it
will be less severe.
In B few words the treatment can be summed up as
rigid cleanliness carried to the extent of destroying
and removing the gonococci and all the broken down
cells, with sufficient stimulation afterward to increase
the normal cellular activity, stimulating thus the
reparative processes, meeting the complications as
they arise, promptly and vigorously. The treatment
of the unaffected eye to consist of rigid cleanliness
with slight stimulation, careful bandaging and exclu-
sion of the discharges from the diseased eye.
THE USE OF CICATRICIAL SKIN FLAPS
IN THE OPERATION FOR ECTROPION
OF THE UPPER LID.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting ol the American Medical Association at
Atlanta. Georgia, May 5-8, 1896.
BY F. C. HOTZ, M.D.
CHICAGO.
In my paper on skin grafting read last year at our
meeting in Baltimore, I pointed out the superiority
of Thiersch's skin grafts over the thick skin flaps
usually employed in the operations for ectropion of
the upper lid. I said, "occasionally, however, the
skin flaps taken from the vicinity of the everted lid
possess all the conditions necessary for a perfect cos-
metic result." I had in mind the thin, glistening
cicatricial skin which usually covers the vicinity of
the everted upper lid. In several cases where the
eyebrows had been destroyed to such an extent that a
large flap could be cut from this cicatricial skin above
the lid, I used such skin flaps as a substitute for the
lost lid skin, and found that, contrary to the general
belief, these flaps could be transplanted as successfully
as the flaps of normal skin, and that their use has
FKiUBR 1.
several decided advantages over all other methods of
transplantation.
For these reasons I wish to report a case in which
a cicatricial skin flap was used: In January, 1889, a
boy 14 years old was admitted to the Illinois Chari-
table Eye and Ear Infirmary to be relieved of com-
plete ectropion of the upper lid of the left eye and
lower lids of both eyes, the result of extensive caries
644
DISEASES OF THE NASAL CAVITY.
[September 19,
of the orbital margins, when the boy was 4 years oldl
As the operations on the lower lids have no specia.
interest, it is sufficient to state their reposition was
accomplished by the well-known V-shaped incision
combined with Arlt's operation for shortening the
overstretched lid border.
The border of the everted upper lid of the left eye
was drawn up and fixed to the temporal portion of
the supraorbital margin, and above it a large stretch
of cicatricial skin extended far into the frontal and
temporal region (indicated by the dotted area of the
pictures). The temporal half of the eyebrows had
been destroyed, and their absence made the following
operation feasible:
From a point (Fig. 3, a) near the inner canthus an
incision was carried obliquely upward past the end of
the eyebrows, well up into the cicatricial skin above
FlGUBE 3.
the supraorbital margin, and then continued at a con-
siderable distance from the lid border in a curved line
downward to a point (c) about six millimeters from
the external canthus. The large skin flap (abc)
mapped out by this incision was carefully dissected
from the underlying scar tissue down to the lid bor-
der, with which it was left connected. The lid, then,
was released from all cicatricial adhesions and replaced
in its normal position.
\
FlCl'RE 4.
The cicatricial skin flap (abc) shrank considerably
as soon as it was detached from its basis; but in antici-
pation of this contraction, it had been cut so large
that, after shrinking, it was still sufficient to cover the
whole lid. It was spread out over this surface and its
margin (ac) fixed to the upper border of the tarsal
cartilage by four silk sutures.
The large wound (abc) above the lid was covered
by sliding into it a skin flap (Fig. 4, bde) from the
temporal region, its margin bd being united with ab,
and de with the margin ac of the new lid skin. This
flap also contained a great deal of scar tissue. The
small wound remaining at the temporal side of the
transplanted flap was left to heal by granulation.
The healing was uneventful, and the accompanying
picture (Fig. 2), taken five months after the opera-
tion, shows the excellent result of this procedure.
This operation supplies the replaced lid with a thin
and light skin which adapts itself nicely to the con-
figuration of the lid and does not restrict its move-
ments. In this respect it is fully equal to the Thiersch
grafting, over which, however, it has the advantage
that the lid need not be rendered immobile by sutures
or ligatures for a number of days.
But the most important advantage of this operation
lies in the fixation of the new lid skin to the tarsal
"^TTTTT^
Fig. 5. — Operation completed.
cartilage. This fixation renders the lid skin indepen-
dent of all tissue changes which may take place in
the supratarsal region. No amount of shrinkage of the
transplanted flap in this region can cause a reever-
sion of the lid, because the firm union of the lid skin
with the upper border of the tarsal cartilage makes it
absolutely impossible that the contraction of the
supratarsal tissues could affect the lid skin and the
lid border.
MALIGNANT DISEASE OF THE NASAL
CAVITY SHOWING THE VALUE OF
EAKLY DIAGNOSIS.
Read In the Section on Laryngology and Otology at the Forty-seventh
Annual Meeting of the American Medical Association, held at
Atlanta, Ga., May 5-8, 1896.
BY J. H. SHORTER, M.D.
MACON, OA.
I will mention briefly a case of what proved to lie
malignant tumor of the interior of the nose, to show
what differences of opinion as to diagnosis, there
may be among competent men.
It was the case of a gentleman, sent to me from
Milledgeville, Ga., about a year ago. He complained
of a lump on the side of his neck under the jaw, and
a feeling of obstruction in the left nostril.
I found a large polypoid growth in the upper part
of the left nasal cavity, which I presume sprang
from the ethmoid, and which I thought presented
the appearance of malignancy. I removed a large
piece, examined it, and also had it examined by a
competent microscopist, who pronounced it a carci-
noma. I informed the patient's family physician of
the confirmation of my opinion, and recommended
an immediate operation, as the only hope of relief,
though I did not think the growth could be radically
removed without resection of the superior maxilla.
, I did not see the patient again. The family became
very much alarmed after my diagnosis, and sent him
to a specialist well known throughout the South. This
gentleman disagreed with my opinion, pronounced
the trouble syphilis, and promised a speedy cure.
1896. !
CHRONIC CATARRHAL DEAFNESS.
645
Notwithstanding vigorous medical treatment, he
grew worse and began to lose flesh, and suffer great
pain. 1 wrote and suggested that he go to some hos-
I, where lie could have the best advantages. He
then went to Now York, consulted a well known sur-
geon, who had sections of the tumor made for micro-
scopic examination. It was decided to be a fibroma
and non-malignant. The surgeon removed the growth
by section below the orbit, resecting the malar and
pari of the superior maxillary bones, promised the
patient complete recovery and no recurrence of the
disease.
(hi returning home, his physician wrote me as
above. 1 replied that 1 sincerely hoped for favorable
outcome, hut much doubted it.
About three weeks later, the tumor reappeared,
and the patient died at the expiration of three months
with probable extension into the cranial cavity.
There was headache, paralytic trouble, and great
exophthalmus.
The diversity of opinion in this case appears to me
as being unusual; one of the foremost men in the
South pronounced it syphilis, another eminent sur-
geon of New York pronounced it non-malignant, both
after careful examination, yet the patient succumbed
promptly to what was evidently cancerous disease.
DISCUSSION.
Dr. D. Bkadkn Kyle, Philadelphia — In regard to micro-
scopic examinations as mentioned in Dr. Shorter's case, I find
that it is not always possible to make a diagnosis from the
tissue sent for examination, but if certain rules are followed
the examination is of value. In a microscopic examination we
must take into consideration the fibrous stroma, the blood
vessel, and the cells, and their relations to each other. In the
case reported I would like to know whether there was any ulcera-
tion of the tumor. In the mucous membranes, especially of the
upper air passages in which there is very little connecting tis-
sue element and where it lines a bony cavity, the small round
cell i embryonic) of inflammation would resemble a sarcoma
very much and if there was ulceration you would find the
vessels beneath mere sluice-ways and lacking vessel walls,
nothing more than an attempt at organization of the embryonic
tissue, and not necessarily malignant, although resembling
sarcoma. Such an eminent authority as J. Bland Sutton
states that it is impossible to differentiate this condition from
sarcoma. As carcinoma spreads by the lymphatics, has
distinct and well outlined vessel walls, I do not understand
how the mistake in diagnosis could be made.
SOME OBSERVATIONS MADE DURING
THE TREATMENT OF CHRONIC
CATARRHAL DEAFNESS.
Read in the Section on Laryngology and Otology, at the Forty-seventh
Annual Meeting of the American Medical Association. held at
Atlanta. Ga.. May 5-8. 1896.
BY THOS. H. SHASTID, A.B., M.D.
GALESBORG, ILL.
The treatment of chronic catarrhal deafness may be
considered under three heads: Treatment of the ear
directly, attention to the throat and nose, attention to
conditions of the body in general.
As regards treatment of the ear directly, I wish to
speak only of intra-tympanic operations. As a way
out of the confusion that seems to exist regarding the
propriety of the application of these procedures, I
have divided them for the purposes of my own prac-
tice into two well-defined classes. Into the first of
these I have placed such procedures as, while of
doubtful utility to the hearing, are of some, though
slight, danger to life. These are the operations for
the removal of one or more of the ossicles with or
without part or all of the drum membrane, and mobil-
ization of the stapes. These procedures, as much
recorded (and perhaps much more unrecorded) expe-
rience goes to show, are often followed, even when
performed under strict antiseptic precautions, by
severe suppuration; and, as they do not very often pro-
duce a really valuable increase in the hearing power,
I do not think that even total deafness can justify
their employment. The second of the classes into
which I divide intra-tympanic operations consists of
single and multiple incision of the drum membrane,
partial myringectomy, plicotomy, traction on the
handle of th9 malleus, tenotomy of the tensor tympani.
These operations are often productive of much good,
seldom, if ever, of harm, and are moreover, when
properly performed, entirely unattended with danger.
Such procedures, even though by no means uniformly
beneficial, are proper in cases in which they are not
positively contraindicated and in which inflation and
massage and treatment of the nose, throat and general
system have not proved beneficial.
I report a case that possesses considerable interest
from its bearing on the topic of intra-tympanic oper-
ations. A lady, aged 30, had been deaf from catarrh
for several years. Inflation and massage and treat-
ment of nose and throat conditions had produced no
benefit. I, therefore, applied Lucse's sound. The
immediate result was gratifying. The hearing for
both acoumeter and voice rose to nearly treble its for-
mer power. Within twenty-four hours, however, the
patient returned as deaf as before. Again I applied
the sound; again the result was brilliant; again the
patient returned no better than before. Then I did a
tenotomy of the tensor tympani, but without effect.
At the end of twenty-four hours the patient returned
and requested me to apply the sound again. This I
did, with good result; but this time, and this is the
point that is particularly worthy of note, the improve-
ment was of comparatively long duration, lasting
nearly three months. Encouraged by the measure of
success in this case, I tenotomized the tensor in three
other cases in which the pressure sound was produc-
tive of good but temporary results, but, so far as I
could tell, without any effect whatever on the duration
of the improvement. These four cases, taken together,
impressed upon me the fact that the mechanical
problem in cases of chronic catarrhal deafness, so far
from being anything resembling a constant one, is of
almost infinite variation, and that it is impossible to
tell with certainty in advance whether a given opera-
tion will prove of benefit, but that in all cases of great
severity and unamenable to other treatment, every
intra-tympanic operation should be tried which offers
a reasonable hope and which does not endanger either
hearing or life.
While speaking of intra-tympanic operations, I
desire to call attention to an improvement in the shaft
and handle of instruments intended for such opera-
tions, which, though it was described in the "Arch-
ives of Otology" some three or four years ago, has not,
I believe, received the general adoption it deserves. I
refer to the shaft and handle of Dr. Barclay. In instru-
ments mounted according to Dr. Barclay's idea the
handle is joined to the operating shaft by a lateral shaft
in such manner that the axis of the handle, prolonged
forward, intersects the axis of the operating shaft
646
RELATIONS OF CRIME TO INSANITY.
[September 19,
exactly at the operative extremity. I have had sev-
eral instruments mounted in this manner, and find
that it gives a precision and lightness of touch unat-
tainable by any other means. I believe that Dr. Bar-
clay's idea constitutes a real progress in otology.
Apropos of the effect upon the hearing of nasal and
pharyngeal treatment, I urge the importance to the
hearing, of vibration or massage of the nasal and
pharyngeal mucous membranes when these structures
are the seat of atrophy. The loss of hearing accom-
panying this throat and nose condition is not invari-
ably slight, though it is usually asserted to be so,
being in some cases great enough to interfere seri-
ously with ordinary conversation. I believe that in
these cases massage of the nose and throat mucous
membrane, if persisted in for some time, will result in
relieving a large proportion of them of a measure of
their embarrassment. Such has been my experience,
and I think that I have exercised reasonable care in
the exclusion of other possible causes for the improve-
ment. The only instrument that I have used has
been Dr. Freudenthal's vibrator. I have seldom seen
any improvement until the massage has been con-
tinued for a long time.
Under the head of attention to conditions of the
body in general, I report a case in which the hearing
was very powerfully affected by belladonna. A patient
whom I was treating for chronic catarrhal deafness
would, at irregular intervals, suffer a very consider-
able aggravation of his trouble. This would in a few
days quite, or nearly, disappear, only to return in a
few days more. The exacerbations were not accom-
panied by symptoms of cold, but by unusual dryness
of the mucous membrane of the throat and nose. On
inquiry I found that the patient was occasionally tak-
ing a purgative pill which contained, among other
ingredients, a quarter of a grain of the extract of bel-
ladonna. Naturally associating the belladonna with
the dryness, I directed the patient to observe whether
or not his periods of increased deafness followed the
use of the pill. He reported that they really followed
its use. Then, in order to eliminate as possible
sources of error the influence of suggestion and also
of the various drugs which the pill contained other
than the belladonna, I ordered a discontinuance of
the pill and then each time the patient came to me I
administered to him a tablet, sometimes a blank one,
sometimes one containing a quarter of a grain of the
extract of belladonna. Each time the tablet contain-
ing the balladonna was administered the patient suf-
fered this aggravation, but at no time did he experi-
ence an increase in deafness after the administration
of the blank tablet. It would seem that the deafen-
ing effect of the drug was exerted chiefly upon the
middle ear; for the patient's ordinarily somewhat
increased cranial perception was still further increased
whenever he took the belladonna. I thought the
increased difficulty in hearing arose from impairment
of sound conduction due to inspissation of secretion
among the tympanic folds and the ossicles.
Roentgen Ray Locates Bullet Through the Skull. — The last
Deutsche med. Woch. (August 13) brings us actual photo-
graphs of the heads of a couple of Eulenburg's patients, in
which the Roentgen ray discloses and locates a bullet inside
the skull. The photograph was taken with the head of the
patient resting on the plate holder, with the Crookes' tube
about 24 c. above.
SOME RELATIONS OF CRIME TO INSANITY
AND STATES OF MENTAL ENFEEBLE-
MENT.
Read in the Section on Neurology and Medical Jurisprudence at the
Forty -seventh Annual Meeting of the American Medical Asso-
ciation, held at Atlanta.Ga.. May 5-«. l89o.
BY H. E. ALLISON, M.D.
MEDICAL SUPERINTENDENT MATTEAWAN STATE HOSPITAL.
FIbHKILL LANDING. N. Y.
Any study of penology should consider not only
crime and its punishment, but should also investigate
the mental and physical state of the criminal, his
capacity and his needs. There are conditions both of
body and mind either congenital or acquired which
render a person dangerous to himself and others, and
attempts to repress criminal acts and to protect societ v
from their consequences and their repetition can never
be in any great degree successful until we look in part
to the individual and examine him as to his status as a
man. With this end in view and especially in the
case of the young, who are first offenders, the courts
should place criminals in secure custody where they
should be confined upon indeterminate sentences and
undergo careful observation and training at the hands
of men capable of judging just what corrective or
remedial measures are needed and for what length of
time the convict should be deprived of his liberty.
The anthropologic study of the criminal has of late
years interested scholars and especially medical men,
and there has been much written and much active dis-
cussion as to the relations the criminal bears to him-
self and to society. As medical men we are interested
in the criminal himself: and not so much in the nature
and character of crime and its punishment, except as
incidentally it involves the study of the man. A
great deal of stress has been laid upon marks of
degeneracy in the criminal and while we admit the
existence of many physical anomalies and mental
obliquities among the inmates of our penal institu-
tions we can not point to any one feature or group of
peculiarities that necessarily stamps the subject as
certainly belonging to the criminal class. To a large
degree, however, these factors are useful to enable us
to judge something of the probabilities which attach
to a person's pursuing a criminal career and aid us in
adopting reformatory methods, educational, disciplin-
ary and therapeutic, by which we may combat and
change inherent or acquired conditions. We can
realize that a child with an excellent heredity and a
healthy body and mind is more insured against, a
criminal career than one presenting all the stigmata
of degeneracy. Society has greater natural safeguards
in the one than in the other.
The two great determining influences for good or
evil are heredity and environment. The medical aspect
of crime is more concerned with the former, although
the latter can not be disassociated from the question.
Environment being susceptible to educational influ-
ences and removable, either in a degree or entirely, is
more related to the province of the sociologist. It is
probable that to environment must be credited the
greater number of criminal acts, as the early teaching
and training of the child influences largely his subse-
quent career. Hereditary defects follow closely as a
causative factor in the genesis of crime. Out of 6,151
admissions to the Elmira Reformatory, insanity and
epilepsy in progenitors were clearly present in 11 per
cent, of the number and to this should be added
a proportion, uncertain in quantity, wherein ances-
1896.]
RELATIONS OF CRIME TO INSANITY.
047
tral history in this respect was untrustworthy
or not ascertainable. Drunkenness in ancestry was
dearly traced in 38 per cent, and was doubtful
in 12 per cent. more. Insanity, epilepsy and intem-
perance, therefore, appear to exert their potent influ-
ence upon those who become the inmates of penal
institutions. Necessarily such prenatal conditions
must produce degenerative conditions which are
stamped upon the offspring. The question arises as
to the treatment of such eases. Is it wisdom to deter-
mine that it shall be altogether punitive and retribu-
tive? It should be the purpose of the law to afford
every opportunity for the correction of defective
organization by reformatory methods. The physical
and mental status of the criminal should be improved
by industrial and eduoational means, the earlier the
better, and by efforts directed toward the full deveolp-
ment of bodily health. The complex influences of
heredity and environment should not be considered as a
mitigation of the crime nor should the fact that the
criminal is often a degenerate person be urged in con-
donemenl of it. His condition modifies but does not
expiate his fault. He. should be confined as an exemp-
lary measure but the commitment should still further
direct that he should not be released until it was
nably assured that he was morally, mentally and
physically tit to be at large.
Out of the same number of admissions to Elmira
before mentioned the physical health was reported as
"debiliated, diseased and impaired." in 11 percent, and
the quality of the inmates' physical condition was found
to be "'low and coarse" in 30 percent. The mental
capacity was tabulated as "deficient or only fair" in 19
percent. Qnt of 596 cases admitted in 1893 to the
Eastern State Penitentiary of Pennsylvania, 20per cent.
was classified mentally as "dull, simple, very weak or
bad." In addition to this, the age at which convictions
are found is such that opportunity is off ered in youths
to effect reformatory results. Out of 1275 inmates of
Sing Sing Prison. 42 per cent, were sentenced before
the age of 25 years, and out of 6151 inmatesof Elmira to
which institution young offenders are especially com-
mitted 90 per cent, were admitted between the ages
of from 16 to 25 years. There is therefore in criminal
anthropology much to engage the attention of the
medical profession in connection with the subject of
reformatory methods in relation to heredity, intemper-
ance and crime. A further interest attaches to the
resulting conditions of degeneracy and to repressive
and eradieative measures which should lead either to
the reformation or permanent sequestration of the
individual. Many abnormalities of the cranium and
of the body and its appendages have been described
as peculiar to the population of our penal institutions.
Asymmetry of the skull and head, of the body,
anomalies of the ears, the teeth, the jaws, the palate
and of the sexual organs are all indicative of prenatal
influences which affect the individual adversely and
relegate him to a place among the defective classes.
The moral sensibilities are stifled or altogether want-
ing and the impressionability of the criminal in this
direction is slight or absent in the great majority of
eases. They are devoted to excitement through alcohol-
ism, sexual excesses or perversions of the sexual instinct
and to every form of pleasurable stimulation of the
appetites and passions. All these influences tend to
mold the physiognomy, which in the popular mind
and in a general way is often an index to character.
A great deal of careful study has been expended by
scientific men upon the physical characteristics of
delinquent man. It appears to be established that
among the great mass of criminals there does exist a
defective physical and mental organization, an insensi-
bility to moral influences and a predominance of
degenerative and atavistic traits. Their instinctive
faculties are often well developed and they have a
large degree of cunning. Persons who are absolute
idiots are not found among convicted criminals. The
unfortunate condition of those who are thus affected
prohibits them from being capable in the eyes of the
law from the commission of crime, and they are not
convicted. This condition, when pronounced, attracts
attention in early life and invites care on the part of
parents or guardians and such defective subjects are
usually placed under proper restraint either at home
or in custodial institutions. Their recognized place is
in a school for feeble-minded children or in custodial
asylums or homes. Neither are the insane as a rule
found confined in prisons or in penal institutions;
though insanity may be developed among those con-
fined there. Many criminals, however, are on the bor-
derlands of each condition. The higher the state of
civilization the greater the differentiation between the
grades of the defective classes and the more intelli-
gent are the methods of care exercised in dealing with
them. The aim in the education of the feeble-minded
as well as of the deaf and dumb and blind is to render
those so afflicted able to care for themselves in a
measure and to relieve society in as large a degree as
possible from the burden of their support. There are
thus converted into productive units what otherwise,
without training and care, would remain dangerous
and troublesome factors. The care of the insane is
based upon similar economic principles. In the treat-
ment of criminals however measures are still adapted to
punitive and retributive ends rather than to such as
tend to promote the correction of inherited and acquired
deficiencies by securing the reformation of the crimi-
nal. There are more reasons why the instinctive
criminal who has failed of reformation and received
several convictions should be for a long term, or per-
manently, deprived of his liberty than exists for the
detention of the insane and other dependent classes.
Out of 981 annual admissions to Sing Sing Prison in
1894, 66 per cent, had served one or more previous
sentences and out of the total population of 1365 for
that year 14 per cent, were known to have received
from three to eight convictions. Numbers of recidi-
vists in prisons are undoubtedly insane or possessed
of a very unstable mental equilibrium which is dis-
turbed by trivial causes.
In the State of New York convicted cases who ex-
hibit mental derangement are transferred from all the
penal institutions to the Matteawan State Hospital
upon the certificate of the prison physician, approved
by the agent and warden of the prison or other officer
in charge.1 This method of commitment is now modi-
fied. When a convict is so committed he is, upon recov-
ery before the expiration of his sentence, returned to
penal custody. If his sentence expires while he is still
insane he is detained in the hospital until such time as
he shall recover or be released under bond to the cus-
tody of his friends. This practice has led to the accu-
mulation at the hospital of 137 cases with expired
terms but who are still insane out of a total population
of 325 convicted inmates. Many of these cases are
defective naturally and confinement in prison has
1 This law hail passed and took effect July 1, 1896.
648
RELATIONS OF CRIME TO INSANITY.
[September 19,
developed some degree of mental disturbance which
often passes away, but even after their normal condi-
tion is restored it frequently is a question whether to
retain them permanently as inmates of the asylum or
to return them to prison. The fact that they have been
determined sane by the courts at the time of their
trial would seem to indicate that before the law they
are considered responsible and therefore proper sub-
jects for release. The great majority of these cases
are addicted to vicious and immoral practices and to
sexual indulgences. Their influence is corrupting
and as a rule debasing. They display to a marked
degree abnormalities of physical structure and cer-
tainly belong to a degenerate type of humanity. As
a rule when at large they are intemperate in their
habits and irregular in their ways of living. The
form of insanity which affects them is not of an active
or actually maniacal form, but is rather a quiet state
of depression with delusions often of persecution. It
does not reach an acutely maniacal type but rather
seems to be an intensification of natural instability
attended with morbid feelings of suspicion and of
actual hallucinations of hearing and sight. There
is not as a rule much display of intellectual power
in their descriptions of their own subjective states.
Their mental capacity is generally limited and their
insanity consequently does not show much idea-
tion of the higher and finer attributes of the mind,
either of morals or intellect. As a rule, their moral
sense is defective and their mental development
below the average. Criminals who become insane
are. in general, low-grade examples of the race. On
the contrary, the inmate of an ordinary lunatic asylum,
as n rule, is a patient possessed of good character,
who has been self-supporting and is of a social, kindly
and well-disposed nature. He is often possessed
of a trade or calling in which he is more or less pro-
ficient, or he has been accustomed to labor regularly
and honestly for his living. Upon his convalescence
he becomes useful to the institution in those directions
in which he is proficient and often in chronic condi-
tions of mental disease he obtains intellectual diver-
sions and physical exercise through occupation which
benefits not only himself but others. The convicted
insane, however, are a different class. They have
engrafted upon a naturally defective mental and physi-
cal constitution, an early bent or training, the result
in part of their environment which renders them
dangerous factors in any community. Devoted to acts
of housebreaking and inclined to thefts or robbery,
upon convalescence or in chronic states, they turn
their skill in such directions, toward escaping from
custody. They are prone to associate together, to
sustain and assist each other; they use their talents
before employed in burglarizing and forcibly entering
houses, to efforts now to get out of custody. The
insane are said never to combine, but insane convicts
will do so. The ordinary insane and the insane con-
vict are not members of the same guild.
Occasionally a patient is committed to prison who is
insane and whose crime is the result of such insanity.
His mental condition may not have been recognized
at the time of his trial and conviction; or the plea
may have been put forward and failed as a defense.
Such cases are quite different, both mentally and
physically, from the ordinary inmates of the prison.
They are properly classed among court cases, to whom
we shall allude. The plea of insanity, however, while
in many cases looked upon with disfavor by the public
a
;
•t
yet often results in a duration of confinement which
averages longer than a definite sentence imposed by
the court.
In order to secure the proper certification of con-
victed cases from the penal institutions who may
regarded as insane, the State of New York in the
revised insanity law presented to the Legislature this
winter, proposed to adopt the following procedure,
which is a modification of the present method: When-
ever the physician in connection with any penal insti-
tution shall certify to the warden that any inmate
therein is insane, the warden shall notify the judge
ot the district wherein the said prison is located who
shall appoint two physicians to examine into the
prisoner's mental condition and, if insane, the- judge
shall order his confinement at the Matteawan State
Hospital, there to be detained during the term of
his sentence unless sooner recovered, when he is to
be remanded to prison. If he is still insane at the
time his sentence expires, he shall remain in confine-
ment until in the judgment of the medical superin-
tendent he is fit to be at large. This procedure sub-
stitutes an examination by two physicians and a
judicial order of commitment in the place of th
simple certificate of the prison physician and order o
transfer by the warden.
There is a second and very important medical aspec
of crime. A certain class of the insane commit crimes
as the result of their insanity, not for the sake of gain
nor for the ordinary and sane motives which actuate
most men, but by reason of delusions or mental de-
rangement. A person whose mind is thus disturbed
may offend the law by reason of some overpowering
false belief. He may assault another in the frenzy of
a semi-conscious state of epilepsy. He may act with-
out adequate motives or from the weakest of motives
as in the case of a pronouncedly demented person.
These acts are not the result of any instinctive or
acquired criminal habits or desires, but arc the pro-
ducts of an actively diseased brain. The real animus
which actuates the perpetrator may be a lofty one. it
may be in the eyes of the patient an act of self-defense
against imaginary enemies, the product of an insane
delusion which controls the patient's mind, or it may
simply be a purposeless unreasoning crime perpe-
trated without a motive in an automatic or semi-
conscious state. These patients present a strong con-
trast physically, intellectually and morally to those
commited from penal institutions. They are freer
from those anomalies of physical development and
growth which are so often found among those of the
criminal type. There are among them more persons
who have attained to a fuller stature and higher
development, their cranial configuration and physi-
ognomy and conditions of bodily growth betoken a
better type of manhood.
Intellectually they show a greater natural endow-
ment and a higher degree of education. Their delu-
sions are more systematized and exhibit a wider range,
spread over a larger field, embracing a much greater
complexity of thought and. arrangement. Their idea-
tion is more vivid and relates to a greater variety of
subjects in trades, business, law, medicine, religion,
literature and the natural sciences, showing greater
educational advantages and a higher cultivation and
greater capacity of mind. Naturally they differ
from the criminal class very decidedly. They have a
higher ethical sense, a broader appreciation of the
responsibilities imposed upon themselves and a greatei
1896.]
RELATIONS OF CRIME TO INSANITY.
649
regard for the duties which they owe to others and to
society. They arc freer from vicious habits and
intemperance and from unnatural sexual practices,
and express an abhorrence of many things which the
criminal regards with favor or indifference.
The nature of the crimes committed by uncon-
victed cases and those admitted to the asylum from
prisons show an equal divergence. The former are
acts largely directed against the person in the nature
of assaults to do harm, while the latter consist of
burglaries, thefts, robberies and crimes against prop-
erty for gain. Among 1,733 patients admitted to the
Matteawan State Hospital the ratio of crimes com-
mitted against the person by the eases from the courts
compared with those from penal institutions has been
as follows:
Convicted Unconvicted,
alt to harm 1 to 'i'3
Murder, manslaughter, etc l to
Crimes against property where the motive was sim-
ply gain, show an inverse ratio.
Convicted. Unconvicted.
Burglaries 8 to 1
Larcenies •»., to l
Robber; 7 to l
Persons adjudged insane show a large preponder-
ance of crimes against the person with intent to harm,
while convicts who become insane while in prison are
as a rule charged with offences against, property. The
degenerate individual who commits a crime for which
he is arrested usually sins in the direction of appro-
priating something which for one reason or another
he covets. He is disposed to acts of theft and rob-
bery. He wishes to gratify in some way his appetite,
and has very little regard for the property rights of
others. He is incapable of resisting impulses to do
wrong in these directions and constitutes a member
of an unstable, weak and defective class of individu-
als. The cases from the courts, however, are not gov-
erned by these lower motives. Their acts are defen-
sive acts, not as a rule aggressive, in the proper use
of that term. They endeavor to avoid the necessity
which they think exists to commit assaults to protect
themselves. They may believe themselves poisoned,
the victims of conspiracy, or in danger of their lives.
They think and act as ordinary men would act but
their premises are wrong and they are led by delu-
sions which govern them. The commission of an
assault with no good motive discoverable raises the
presumption of insanity. The motive will often be
round to be simply the promptings of disease. The
insane know the difference between right and wrong
in the abstract, and reason very clearly upon the sub-
ject, but in relation to their own particular act they
can not form a rational judgment. This has led to a
confusion as to the responsibility of a person charged
with crime. He may know it is wrong to kill, but
through his diseased brain imaginary voices prompt
him: sights, sounds and all evidences of his senses
mislead him and he is influenced to believe that what
he apparently hears and sees is real. In relation to
his particular act he does not know that he has done
a wrong. He may know the nature of the act,
whether it was homicidal or intended to be such, but
he regards it as of the same quality as an act of self-
defense and therefore as to this act he is unable to
form a proper judgment. Many cases are improperly
adjudged insane and committed to prisons for life, or
executed, simply as a result of the misapplication of
the legal test of responsibility. One-sixth of the life
men committed to the jjrisons of New York are
inmates of the Matteawan State Hospital. Their
insanity has been recognized after conviction and
while serving terms of imprisonment.
Crime in one of its medical aspects may be
regarded as in part the product of degeneracy caused
by a bad heredity and intemperance in ancestry com-
bined with a bad environment. An effort should be
made to reclaim and reform the individual by efforts
directed toward improving his mental condition and
t lie development of his mind and body in early life
by educational measures involving thorough mental
and physical training and manual instruction in some
self-supporting industry. Proper moral and relig-
ious training is essential, in which should enter the
true spirit of Chistianity as well as its forms, and
which should permeate the life of the institution.
The mind, the morals and the hands should be culti-
vated as far as possible. If the criminal be found
incorrigible he should be placed for a long term of
years in some penal institution or committed to the
custody of a criminal lunatic asylum, there to remain.
Aside from these conditions let his term of imprison-
ment be determined by his conduct within limits
fixed by the court.
In the other medical aspect which relates to
those features purely the. outcome of disease, no
personal responsibility can be attached to such
offenders, but they should be placed in safe cus-
tody in an asylum, if possible in one devoted to the
care of the dangerous insane. While they should not
be imprisoned and punished as criminals, yet society
should be most carefully guarded against their acts,
and their release in the event of recovery should be a
matter to be most conservatively considered. As a
fact, the ratio of recoveries in such cases is not large.
Hallucinations of the special senses are common,
especially of hearing, and the disease is essentially
chronic. Persons who commit murders or assaults
upon life are not as a rule habitual criminals, and if
their mental condition is questioned in court they
should be carefully examined. The motive should be
sought for, and if one is found, its origin should be
determined, whether it had its inception subjectively
in the diseased brain of the patient, or arose from
external causes, such as affect men in general in their
conduct. The absence of motive should also be
given its weight. The unreasoning and semi-uncon-
scious act of an epileptic, while it might relegate him
to an asylum for life, should not place upon him the
stigma of a felon. Serious crimes against the person
are not usually committed by demented persons, yet
they occasionally happen, and when they do, the well
known and established character of the defendant is
easily determined. The adoption of intelligent
measures for the suppression and minimizing of
crime is a subject that will always demand atten-
tion. It is a social question connected with gov-
ernment, and has many legal relations, but has as
well a broad medical side to which the attention of
the profession should be turned. Much may be done
to awaken public interest in reformatory methods and
to create a proper sentiment in relation to the custody
and care of criminals, particularly such as are of the
degenerate type or who suffer from the effects of an
outbreak of actual insanity. The punishment of the
criminal has more to do with the personality of the
individual than with the crime itself. The subject is
closely connected with questions relating to immi-
gration and the importation of the degenerate, the
650
SUKGERY OF THE KIDNEY.
[September 19,
defective, the insane and the habitual criminal. It
relates to the sequestration of all so affected, which
custody not only confines the individual but limits for
a time or permanently the exercise of his reproduc-
tive functions.
SURGERY OP THE KIDNEY.
BEING A STUDY OF A SERIES OF CASES IN WHICH
METHODS OF DIAGNOSIS AND TREATMENT
ARE ILLUSTRATED.
BY BAYARD HOLMES, B.S., M.D.
PROFF.SSOlt OF SI'KOF.RY IN THK col.l.F.fiK OF PHYSICIAN.- AND
SIKGKONS OF CHICACO.
PERSISTENT RENAL HEMATURIA.
There are still many dark chapters in pathology
and clinical medicine. To one of these belongs the
subject of this paper. It can only be illuminated by
calling the attention of the profession to the clinical
features of these obscure cases and bringing to light
the experience of the profession, which lies hidden in
the literature and the note books. This paper tries
to accomplish these two things and leaves for the for-
tunate pathologists the task of demonstrating the pa-
thologic lesions of what seems to be a clinical entity.
Renal hematuria is to be distinguished from hemo-
globinuria by the presence of blood corpuscles in the
urine coming from the kidney in the place of urine
stained with the coloring matters of blood.
The case here recorded and the collection of those
relatively similar from recent medical literature seem
to point to an unknown condition, or series of condi-
tions, of which renal hematuria is the principal symp-
tom. This condition has been met with in nearly all
the hospitals of the world and it has been given, in
the hospital reports, that clinical diagnosis, hematu-
ria, which is so unsatisfactory to the pathologist.
Thus, in the Berlin Charite, during five years ending
1893, there were 124,000 admissions, of which 22 re-
ceived the diagnosis of hematuria. In the English
reports this diagnosis is still more frequent.
Renal hematuria is common enough in injury of
the kidney, in nephritis, in acute infectious diseases,
in scarry, in tuberculosis of the kidney and in cal-
culus and new growths in the kidney. In the case
before us the bladder showed no evidence of tubercular
disease. The examination of the urine rejected
nephritis and the examination of the blood excluded
malaria. No detritus or formed elements, such as
might reasonably be expected in cancer or other
tumors could be found. No tubercular bacilli could
be discovered in the sediment. The history had, to
be sure, a distinct trend toward an acute local disease
of the left kidney, but the condition of the urine from
the two ureters pointed to a bilateral or to a constitu-
tional disease.
This case, however, was carefully examined, the
general conditions noted, the complete genito-urinary
examination made and the contraindications to the
removal of the left kidney, required by the clinical
diagnosis, were made imperative.
The study of hematuria should always be prose-
cuted with the greatest care and exactness. The pos-
sibilities of tuberculosis, tumor, cancer and calculus
are such grave possibilities that no means of diagnosis
can safely be omitted. The urethra should be dilated,
the bladder examined with the cystoscope and the
catheters passed into each ureter, and even up to the
pelvis of the kidney.
pyone-
ust not
rded in
The danger of producing a ureteritis or a pyone-
phrosis, by the use of the ureteral catheters must not
be forgotten. Nevertheless no case is recorded ir
which an unfavorable result has followed ureteral
catheterization in the hands of experienced and care-
ful operators. Casper1 reported before the Medical
Congress at Wiesbaden, that in 250 cases, of both
men and women, in which the ureteral catheters had
been used by him no case of infection had occurred.
This procedure, like every other surgical operation,
should, however, be employed only when adequate
indications for it exist, and should, when such indi-
cations are present, never be neglected.
Synopsis. A multipara, 39 years old, with no history of
hereditary or personal hemophilia: an acute painful attack
in the left side accompanied with hematuria, which continued
two years. This hematuria increased by exercise. .1 tender
It'll kidney. Less than the normal amount of very bloody
urine from the le/l ureter: more than the normal amount of less
bloody urine from the right kidney; rest in bed and milk diet
tritium! improvement. Autisyphilitictreatmentadded; great
improvement.
Mrs. O, 39 years old, was placed in my care in St.
Luke's Hospital on April 14, 1896. She was a thin,
anemic woman. She had never had malaria. Her
husband has had an uncertain venereal history. Her
mother is still living, but has some sort of skin dis-
ease of an unknown character. Her father died from
an operation for hemorrhoids. No history of hemo-
philia in the family. One sister died of acute pul-
monary tuberculosis. The other members of the
family are in good health. Menstruation began when
she was 13 years of age and was regular up to the time
of the present illness. She was married at 18 years,
had one child now 16 years old, and some years later
had a miscarriage. Her present illness began two years
ago with pain in the left side in the region of the
kidney and with bloody urine. She was sick in bed
at the time with chills and fever for several weeks.
She does not know whether the pain or the bloody
urine appeared first. During this sickness poultices
were applied to the left side and back. The pain has
been almost constant ever since. Bloody urine has
been the most pronounced symptom of the disease.
It is greatly increased on any exertion. The patient
has lost twenty-five or thirty pounds and now weighs
about 100. She is excessively anemic. The heart's
action is violent on the slightest exertion. No evidence
of disease could be found in the nose, throat, eyes, ears,
or lungs. There was no heart murmur, no lymjjhatic
enlargement, no enlargement of the spleen or thyroid.
Since this disease began menstruation has been irreg-
ular, sometimes missing two or three months and the
flow has been very scanty and watery. On admission
she was put on a milk diet, her temperature was 99
degrees F., pulse 72, respiration 22. Twenty-eight
ounces of dark bloody urine of an acid reaction and a
specific gravity of 1.016 was passed in twenty-four
hours. No pus, casts or formed matter, except blood
corpuscles, could be found in the sediment, which
was precipitated by the centrifugal machine. Exam-
ination of the kidneys demonstrated a body moving
with each inspiration in the site of the right kidney:
in the site of the left a similar body could be felt much
less movable and very sensitive to a rolling pressure.
The examination was easy on account of the spareness
of the patient and the relaxed condition of the abdom-
inal walls. The other abdominal organs seemed to be
in normal position and of normal size. The spleen
1 Berlin kiln. Wochenschrift, Vol. i, 18%.
L896.]
SURGERY OP THE KIDNEY.
651
was certainly not enlarged. The heart's apex was
three inches from the median line, and while sitting,
a little below the fifth interspace.
On April 11. the left ureter was catheterized and
one cubic centimeter of urine, dark with blood, was
oollected in fifteen minutes. This urine after the
removal of blood and albumin, contained 17 grams of
urea to the liter. The right ureter was also catheter-
bed. There wore 10 cubic centimeters of bloody
urine passed in fifteen minutes, containing 2S grams
of urea to the liter. By vaginal examination the
ureters could not be felt and they were certainly not
thickened or enlarged. The interior of the bladder
was pale as were all the other mucous membranes of
her body. There were 3,500,000 red blood corpuscles
per cubic millimeter in her blood. She had had sev-
eral wounds, but never any symptoms of hemophilia.
It was evident from the examination that the dis-
charge of blood in the urine was not a local disease
and the anemia contraindicated the removal of the left
kidney, which seemed to perforin some little function.
The patient was. therefore, put to bed on a milk diet
and after a time of no improvement, antisyphilitic
treatment was begun. During two months of this
treatment the patient gained twenty pounds and the
amount of blood in the urine was greatly diminished.
At a recent examination of her urine, about July 15,
great improvement was noticed. The urine free from
blood and albumin is high colored, -4 or 5 on Vogel's
scale. There is about one-half the normal quantity
in twenty-four hours, namely 500 cubic centimeters.
The normal solids are also about one-half the normal
average except uric acid which is relatively in excess
and absolutely normal. The albumin is 0.2 percent,
by weight. The urea is 26 grams in twenty-four
hours. There are no formed elements in the sediment
except a few red blood corpuscles.
This is a very interesting case from the clear history
of the disease of the left kidney, the large amount of
blood in the urine and the almost absolute clinical
indications of a unilateral disease, which might be
helped by the removal of the left kidney. The exam-
ination of the urine from the two ureters, however,
seemed to me a complete contraindication to the oper-
ation as it demonstrated the same disease on the other
side. The anemia also was a contraindication to any
operation, which did not promise to entirely arrest
the hemorrhage. The value of catheterizing the
ureters is not better shown than by this case. Before
any operation is undertaken on the kidney both
ureters should be catheterized and the results com-
pared with the combined urine for twenty-four hours.
The pathology of this case is undemonstrated. It
is evidently not a case of malaria, as the blood exam-
ination and the small spleen plainly showed. There
were no parasites in the urine. Neither ureter was
enlarged. Enlargement of the ureter might be
expected in suppurative or tubercular disease of the
corresponding kidney. The fact that some improve-
ment was made under antisyphilitic treatment might
be considered by many a positive diagnosis, but to me
this fact does not warrant the conclusion. There are
many casesdn the literature which resemble this one
in nearly all particulars.
In December, 1890, Senator2 presented before the
Berliner Medicinische Gesellschaft an interesting
of renal hematuria. The patient was a girl
lit years old, who gave a history of hereditary
hemophilia. The cystoscope showed that the blood
came from the right ureter. Rest was tried without
success. The kidney was exposed by lumbar incision
and appeared normal. The hematuria was so great
that extirpation of the kidney was considered neces-
sary to save the life of the patient, which was threat-
ened by the anemia. Sonnenburg, who was present,
agreed in the conclusion of Senator to perform
nephrectomy. When the kidney had been removed
it still appeared normal. Microscopic examination
discovered the fact that the hemorrhage occurred
inside Bowman's capsule and that the urinary tubules
contained blood. In the discussion Senator referred
to three other cases of a similar nature, one reported
by Sabatier.3 The patient was a woman 30 years old.
Pain in the region of the kidney came on suddenly,
with dyspnea, vomiting, strangury and bloody urine.
The hematuria continued seven years. The patient
gave a tubercular family history and had a cough.
Repeated examinations showed tenderness of the right
kidney, but no tumor. The other abdominal organs
were perfectly normal. There was no gravel and no
pus in the urine. During the year her case was under
observation various diagnoses were made, namely, 1,
tubercular kidney and rheumatism ; 2, tubercular peri-
tonitis and uremia; 3, paroxysmal hemaglobinuria; 4,
nervousness, simulation, and 5, calculous nephritis.
Oct. 16, 1886, Sebatier extirpated the right kidney.
No stone was found and the microscopic examination
did not demonstrate anything abnormal except a slight
sclerosis. Sabatier considered the kidney perfectly
sound. After forty-eight hours of bloody urine the
last trace of blood disappeared and the patient recov-
ered perfectly. Shede ' is also quoted by Senator as
reporting the following case: A strong, well man, 50
years old, with no hereditary taint, had very bloody
urine for years, coming on after taking a cold drink.
The bladder was found normal. The urine contained
red and white corpuscles in their normal ratio to each
other, but no other formed elements. Through a supra-
pubic cystotomy opening the two ureters were cath-
eterized. This procedure showed that the blood came
from the left ureter alone. Five days later, July 1, 1889,
the left kidney was explored through a lumbar incision.
It did not appear abnormal and nothing was found in
the pelvis. It was, however, removed, but the micro-
scopic examination demonstrated no adequate cause
of the hematuria. Lanphear ' observed a case of
hematuria in a man 55 years old, but he did not cath-
eterize the ureters and made the diagnosis of renal
hematuria by washing out the bladder with boric acid
solution and finding the fresh injection clear.
Broca" recites a case which is interesting in this
connection. The patient, well until the present ill-
ness, was confined two years before with a perfectly
normal puerperium. She served nineteen months as
a wet nurse. Menstruation began nine months after
confinement. In July, 1890, one month after wean-
ing the child, hematuria appeared with indistinct pain
in the right side. This advanced little by little with
increasing pain in the right lumbar region ; in the
left side there was only occasional tenderness. After
thirteen months of hematuria, very great lassitude
appeared. One physician diagnosed a downward dis-
. li
. : Cber renal Hrimophilie.
Nophraigie hcmaturique.
Berlin kiln. Wochenschrift.
Revue de Chirurgle. Paris,
2 Senator,
1891. No. 1.
'■> Sabatier :
1888, p. 02.
* Jahrsbi'icher dea Hamburger Stadtkrankeuhauses, 1889.
•'■Lanphear, E.: An Obscure Case of Hematuria. Journal of the
American Medina l Association, Chicago, 1894, vol. 22, p. 117.
,; Broca, A.: Hemophilic rC'nale et hemorragles renales sans lesion
connue. Ann. malad. des org. genito-uriu. December, 1894.
652
SURGERY OF THE KIDNEY.
[September 19,
placement of the kidney, a truss was worn without
improvement. Sixteen months after the beginning
of the hematuria Broca first saw the patient and on
strong pressure only could tenderness of the right
kidney be demonstrated, but no enlargement or dis-
placement. There was no colic. The urine was uni-
formly mixed with blood. There was frequent and
painless micturition. The patient was in good con-
dition and had a good appetite. A most careful exam-
ination of the urine gave no evidence of tuberculosis
and no evidence of carcinoma. Rest in bed and a
milk diet were tried without effect on the hematuria,
which lessened a little during menstruation to increase
again after it was over.
On Dec. 17, 1891, the kidney was laid bare through
a lumbar incision, peeled out of its fat capsule and
brought to view in the wound. Inspection and palpa-
tion failed to demonstrate anything abnormal. Ex-
ploratory nephrotomy revealed nothing more. This
diagnosis was confirmed by Hartmann and Terrier, who
stood by. The kidney and wound were closed, the
latter without drainage, and recovery followed. The
first urine passed after the operation was bloody, after
that there was no more hematuria and no more ten-
derness in the right kidney. The patient was seen
occasionally for three years and she remained per-
fectly well. It would have elucidated this case if the
ureters had been , catheterized. We do not know
that the blood came from the right kidney alone.
Passe t7 describes an interesting and obscure case of
renal hemorrhage in a woman who had four children.
The first attack came on after menstruation and the
next one six months later. It was considered a case
of vesical hematuria and was treated by injections of
nitrate of silver solution. Cystoscopy was impossible
on account of the hemorrhage. Digital exploration
discovered a small tumor (?). Suprapubic cysto-
tomy was performed and the bladder found perfectly
normal in appearance, the ureters were catheterized
and the blood found to come from the right ureter
alone. On account of the anemic condition of the
patient it was not thought best to do nephrectomy at
once. The bladder was sewed up and the patient
recovered. The urine became clear and continued so
for two years, when a transient attack of hematuria
came on again. No similar attacks appeared during
the following year during which she was under
observation.
A somewhat similar case is reported by Stavely.8
The patient was , a multipara, 39 years old, who
noticed blood in the urine two months after the birth
of her last child. It was intermittent, but at last it
came on every other week. She was anemic, 3,172,-
000 red, 10,000 white corpuscles per cubic millimeter
of blood. The urine was very bloody and contained
110,000 red blood corpuscles per cubic millimeter of
urine. No tubercle bacilli could be found in the urine.
The bladder was found clear, the left ureter was
catheterized and 10 minims (.66 cubic centimeters)
of reddish yellow urine containing blood corpuscles
was passed in five minutes. This was repeated on the
following day, but it was not possible to pass the
sound into the right ureter in the ordinary manner.
An incision was therefore made in the base of the
bladder and the right ureteral orifice exposed and cathe-
terized. The urine from the right kidney contained a
id l
7 Passet. J. : I'ber Hiimaturie und renale Hiimophilie, Ceutralb. fur
die Krankheiten der Harn- und Sexual-organe, v. 5. p. 397-405.
8 Two cases of Hematuria with catheterization of the ureters and ex-
ploratory nephrotomy, Johns Hopkins Hospital Bulletin, March, 1893,
.25.
trace of blood, the wound in the bladder was closed with
silk- worm sutures. The left kidney was then exposec
and explored by a deep incision into the back of the
kidney down to the pelvis. No disease could be found.
The wound was closed. The patient recovered and
the hematuria disappeared.
The second patient was probably 35 or 40 years old
had borne children. A year ago she suddenly devel-
oped hematuria without any known cause, which
hematuria had continued, with slight exacerbations
ever since. The urine had a specific gravity of 1.020.
It was slightly acid and contained quantities of blood
but no casts. The ureters were catheterized simul-
taneously by touch. The bladder was full of methyl
blue solution at the time. In fourteen minutes, 20
minims (1.3 cubic centimeters) of dark bloody urine
was obtained from the left kidney and 10 minims (.66
cubic centimeters) of clear amber urine free from
albumin from the other. The left kidney was exposed
and incised along its back while the renal vessels were
compressed between the thumb and finger, but no dis-
ease could be detected. The kidney was closed with
gauze drainage. The wound was also closed. The
amount of blood in the urine gradually disappeared
until the fifteenth day after the operation, when it
was all gone and never returned.
Denny ' of St. Paul, Minn., reports a case of per-
sistent hematuria and uses its ultimate recovery with-
out operative procedure as an argument against early
operation. It would be more logical from these data
to insist upon an exact and absolute diagnosis. The
history is very clear, but no positive diagnosis was
made and as the man, who was 39 years old recovered
promptly with vesical injections of nitrate of silver
solutions, and has since remained well, it is possible
that he suffered from hemorrhage of the bladder.
1. Renal hemorrhage can be demonstrated only by
the catheterization of the ureters and kidneys, and
these procedures should always be accomplished
before nephrotomy or nephrectomy. The Pawlick or
Kelley instruments may be used with females, but
the Casper or Nitze instrument must be employed in
males.
2. The patient should undergo a most careful
observation in the hospital and a protracted rest in
bed with a milk diet before an exploration of the kid-
ney is made.
3. There is some unknown pathologic condition of
which hematuria is a symptom, which has not yet
been explained, and this condition seems to be relieved
in some cases by nephrotomy and in others by palpa-
tion of the exposed kidney.
LITERATURE.
Goldstein, L. : Hematuria, Klinisches Handbuch der Harn- und
Sexualorgane. Oberlander, Leipzig, 1891.
Gumprecht, F. : Die Fragmentation der rothen Blutknrperchen und
ihre Bedeutung fiir die Diagnosi der Hiiniaturien. Deutscbes Arch. f.
klin. Med. Leipzig, 1894, v. 53, p. 45-60. Miiuchen med. Wochenschrift,
Aug. 7. 1894.
Hiimaturie aus unbekannter Ursache, 1 Fall. Jahrsb. u. d. Chir. Ab.
d. Spit zu Basel. 1891-95, p. 108.
Kuuter, R. : Kin e'genthi'imlicher Fall von Hiimaturie, Berl. klin.
Wochenschr. 32. 1895, p. 195.
Lanphear, E. : An obscure case of hematuria. Journal American
Medical Association, Chicago. 1894, v. 2-2. p. 117.
MacCormac. Sir W. : Clinical lecture on some causes of hematuria,
Clin. Jour. London, v. 8. 1896-97, p. 65-78.
Mercandino, F.: Un caso di ematuria. Boll. d. clin., Milano, 1895,
V. 12, p. 437-441.
Oliver. T. : Hematuria and its significance. International Clinic.
I'hila., 1895, 3, p. 5-9-6.
Outten, W. R. : Hematuria. Med. Fortnightly. St. Louis. 1894. p. 39-44.
Passet, J.: fjber Hiimaturia und renale Hiimophilie. Centralb. f. d.
Kr.mkheit d. Harn und Sex. Org. Leipzig. 1894, v. 5, p. 897-406.
Rho. F. : Ematuria ed altre emorragia senza apparenti lesione orga-
niehe. Glor. med. d. r. eserclto, etc. Roma. 1898, v. 40, p. 1141-11 59.
9 Boston Medical and Surgical Journal, Vol. 132, p. 183, 1895.
1896.]
SELECTIONS.
653
Ki\a. .v.: EmatPrla da amorrutla glomerulars. Cliu mod
is*;, v. -.'. i>. 1 1
aabaUer: Nephralgia htmaturlqoa. Rev. de Chirurcie Paris
..
tor: 1 ber renal lliimopliille. Berlin klin. Wochensclirift
ISM, So. 1. s. 1. 9
Klrenze,
1.S88
(JXATION OF THE ENSIFORM PROCESS.
liV LUCIEN LOFTON, M.D.
NT TO THK CHAIR Or kNATOMY, kND ASSISTANT IIKMONSTR \TOR OF
ANATOMY, SOITHKKN Mil. I, Ml nil
ATLANTA, GA.
Dislocation of the xyphoid appendix is a rare
oourrence, and only a few instances have been
eoorded. Owing to the rarity of this aocident, I
teem it important to give it publicity.
The patient, a German, asted 33 years, and of
of a robust build, consulted me for what he termed
chronic indigestion'1 about one year ago. He
the following history: About three years prior
iming to the city he was in Philadelphia on a
visit. During his meanderings he inbibed too freely
ami mistaking a lamp post for the middle of the side-
walk ran againsi it with greal force, receiving a terrific
blow, as he explained, about the "pit "of the stomach.
The blow felled him to the pavement where he lay
unconscious for a few minutes. He was removed to
his hotel where he rested fairly well the night of the
accident. During the night he vomited freely sev-
eral times, which seemed to give him relief. The
next morning the patient left for his home before
medical attention was summoned. After his return
home the man was enabled to transact his usual farm
duties after an elapse of two or three weeks. The
patient has lived in this city for some time and has
for the past several months been a sufferer from indi-
gestion, which he says was invariably accompanied
by vomiting. This is especially the case if he lies
down directly after eating.
Upon examination I found a complete luxation of
the ensiform cartilage from the gladiolus, which
could be moved easily in all directions.
This manipulation wave the man some pain, and
d him to say several times he "felt sick at the
stomach." I tried all manner of palliative measures
which proved useless. I suggested an operation with
a view to anchoring or extirpating the offending mem-
ber, but this was not acceded to. The man has been,
for the past half dozen months losing flesh steadily,
and his weight is now, I learn, in the descendency.
Since consulting me a short while ago, I am in-
formed, the man has moved to some point in Texas.
306 Equitable Building.
SELECTIONS.
Anti-Choleraic Inoculations.— Dr. W. J. Simpson submits the
results of the anti-choleraic inoculation work as carried on in
Calcutta during the past two years.
The vaccins used for this work are prepared in the labor-
atory by a specially trained medical officer and the inoculations
in the busteesand other parts of Calcutta are done by another
medical officer.
The following records of the inoculations are kept in the
Health Office:
1. A daily register filled up at the time of inoculation con-
taining name, father's name, sex, age, caste, occupation, resi-
dence and place of inoculation ; also any relative who may be
inoculated.
2. An alphabetical register containing the names of the inoc
sulated with the above details, so that ready reference can be I cholera, seventy -seven being among the uninoculated and
made as to whether a person attacked with cholera has been
inoculated.
3. A ward register showing the residence of the inoculated
people, so that when any particular locality is affected with
cholera the inoculated in that locality may be easily found.
The number of people inoculated during the period under
iv\ iew was 7,(590 ; of these 5,ar>3 are Hindus, 1,476 Mahomedans,
and 361 other classes. Considering that the system is a new
one, that the inoculations are purely voluntary and everything
connected with them has to be explained before the confidence
of the people can be obtained, and considering how long new
ideas are in taking root among the general population, and in
this case it is not merely the acceptance of idea, but such faith
in it as to consent to an operation, the number is certainly
satisfactory for a beginning.
The present problem can be compared with the introduction
of vaccination against smallpox in Calcutta. It took twenty-
five years before the number of vaccinations reached an average
of 2,000 ; whereas the inoculations against cholera have in two
years nearly doubled that average. This is proof that in spite
of the difficulties which every new movement naturally has to
meet with, there are large numbers of people anxious to avail
themselves of the protective effect of the inoculations.
There is a certain discomfort produced by the inoculations,
such as an attack of fever lasting about twenty-four hours,
pain at the seat of inoculation on moving, thus interfering with
heavy physical work for about thirty-six hours. The discom-
fort is not, however, worse than that induced by vaccination
when the vesicles have risen well, and it has the advantage of
not lasting nearly so long. The method of inoculation has
been recently simplified by dispensing with the first vaccin,
the second now being used directly in smaller doses. This
increases slightly the degree of discomfort, but does away with
the necessity of undergoing two inoculations. As in vaccina-
tion, the symptoms after inoculation, i.e., the degree and dura-
tion of the fever and local effect vary according to the idiosyn-
crasy or peculiarity of constitution of the inoculated person ;
but it is necessary to prominently bring to notice that although
all sorts and conditions of individuals, weak and strong, sickly
and healthy, young and old, well nourished and badly nour-
ished, and often persons suffering from chronic diseases have
been inoculated in every instance without exception, the inocu-
lations have proved perfectly harmless. In several instances,
like that lately in Serampore, reports have been spread that
injuries have followed the inoculations ; on investigation it has
been proved by the official medical and civil authorities that
these reports were absolutely untrue. Since the system is new
and disquieting rumors are harmful it is important that the
Commissioners should know the real state of things in order
that they may be able to give assistance in dispelling any false
notions on the subject.
When an epidemic, such as cholera, attacks a town there are
always localities and classes of the population which are not
reached by the infection, while on the other hand, even among
those who are actually exposed to the infection there are a
number who escape owing to their hereditary or gradually
acquired powers of resistance. As a rule outbreaks occur in
particular localities and houses. The investigations on the
effect of the inoculations are made exclusively in those houses
in which cholera has actually occurred, the object being to
ascertain and compare the incidence of cholera on the inocu-
lated and not inoculated in those houses in which inoculations
have been previously carried out. For this purpose affected
houses in which inoculations have not been performed and
inoculated houses in which cholera has not appeared are
excluded as they do not generally furnish a reliable basis for
comparison.
In seventy-six houses there were eighty-nine deaths from
654
SELECTIONS.
[September 19,
twelve among the inoculated. The following is an analysis of
the observations showing the relative resistance to cholera of
the inoculated and not inoculated and the distribution of the
occurrences in time.
As in six houses in which uninoculated people were attacked
and the inoculated escaped, the number of inoculated present
was under one-tenth of the total inmates, thus allowing
very little chance of the inoculated being affected ; these are
not counted in the subjoined tables. As regards the rest
the result is the following :
Among the uuinoculated members after — 1, 2, 3, 4, 5, 6, 9,
Among the inoculated of the same households after 0, - 2, 3, 4,
12, 13, 15, 17, 22, 34. 37. 44. 57, 62, 63, 71. 95, 99, 109, 114. 118, 119, 120. 129. 132, 139.
143, 162, 189, 191, 203 240. 251. 271, 281, 284, 800, 309, SIS, 319, 834, 856, 859, 362.
- 219,
37U. 372, 378, 383, 384,
. 391, 398. 391, 401. 404, 408, 416, 433, 446, 448, 453
-421, 459.
724, and 738 days.
785 and 73s days.
472. 493, 498 675. 720, '
512, 688,
This statement shows that : 1, during the first 4 days after
the inoculation cholera occurred among the inoculated and
non-inoculated, though in a smaller degree among the inocu-
lated ; 2, after the first 4 days there was a period of over a year
when there was almost absolute freedom among the inoculated,
while among the non-inoculated in the same houses cases were
occurring during the whole year ; and 3, after this period cases
began gradually to reappear among the inoculated as well as
among the non-inoculated.
The grouping of the data according to these three periods
gives the following results In the houses where cholera occurred
during the first 4 days, a period in which the protective influ-
ence of the vaccin is gradually asserting itself, there were 169
uninoculated individuals, who had 6 deaths (3.59 per cent.)
and 3 attacks ending in recovery, and 259 inoculated persons
who had 5 deaths (1.93 percent.) and 1 attack with recovery.
In the houses where cholera occurred during the second period
extending over a year, there lived 502 non-inoculated who had
42 deaths (8.37 per cent. ) and 5 attacks ending in recovery, and
269 inoculated who had 1 death :0.37 per cent).
In the houses where cholera has occurred during the third
period, i.e., more than a year after inoculation, there were 238
uninoculated who had 23 deaths (9.66 percent.) and 3 attacks
with recovery, and 96 inoculated who had 6 deaths (6.25 per
cent. ).
Thus a comparison of the proportion of deaths among the
inoculated and non-inoculated in the three periods gives the
following result : During the first period of 4 days the number
of deaths among the inoculated was 1.86 times smaller than
among the not inoculated. During the second period lasting
over a year the number of deaths among the inoculated was
22.62 times smaller than among the non-inoculated ; and dur-
ing the third period, i.e., more than a year after the inocula-
tion, the number of deaths among the inoculated was only 1.54
times smaller than the non-inoculated.
Of the six inoculated belonging to the last group, who were
attacked more than a year after inoculation, five had received
only one inoculation with the first weak anti-cholera vaccin,
and the sixth, inoculated on June 3, 1894, had two inoculations
given in very weak doses, as was practiced before the observa-
tion made in July and August, 1894, in the East Lancashire
Regiment in Lucknow. In this observation at Lucknow it was
shown for the first time that the effect of weak doses with
which the inoculations were begun in India, tends to disappear
as time goes on and is confirmed by the Calcutta statistics.
This fact brings the Calcutta statistics into conformity with
those obtained in other parts of India and thus confirms the
accuracy of the observations made. Since the latter part of
1894 the doses used in the treatment and the strength of the
vaceins have been increased, with the object of producing a
more lasting effect. But no figures are as yet available to
demonstrate whether by such increased doses the object we
aim at is actually obtainable.
Without excluding the occurrences of cholera in the inocu-
lated during the four days necessary for treatment, and con-
sidering the results for the whole period of time, from the
first day of the operation in Calcutta up to the end of last
month, the results are as follows: 654 uninoculated individuals
had 71 deaths (10.86 per cent.), while 402 inoculated in the
same households had 12 deaths (2.99 per cent). This shows
that notwithstanding the incomplete protective effect of the
first four days and the gradual disappearance of the resistance
in those inoculated with weak doses of weak vaccins, which a
large number of the inoculated people have received, the mor-
tality amongst the inoculated, compared with that of the unin-
oculated, was in the proportion of 1 to 3.63, giving a reduction
of mortality of 72.47 per cent, or in other words, in houses
where inoculations were performed, and which were subse-
quently visited by cholera there occurred for eleven deaths
amongst the uninoculated, three deaths amongst a similar
number of inoculated.— Ind. Med. Record, August 1.
The Dangers of the 'Cycle.— The Lancet for July 11 has a well-
considered special article on the above subject, which con-
cludes as follows : "Two serious sources of danger are the use
of the crowded roads by learners and the hiring of machines to
novices. A busy road would seem to be the last place a sensi-
ble person would select for learning to ride a bicycle, yet three
deaths have taken place from this cause within the past few
weeks. The hiring out of bicycles to children and roughs bent
on what they call a 'spree' should be checked by law. It
should be quite possible to license those who let out cycles for
hire, and such persons should be made responsible if an acci-
dent occurs through the letting out of a machine to an incom-
petent person. Our contemporaries who are devoted to the-
interests of 'wheeling' have, we know, already done good
service in this respect, but we venture to assert that if they
would impress even more strenuously upon the cycling public
the importance of strictly attending to some such simple rules
as the following much good would ensue. These rules are not
intended to be exhaustive nor are they for the expert cyclist,
although even the experienced rider should not ignore them.
Thoroughly examine your machine before starting on a jour-
ney. Do not ride without a brake, which should be attached
to the back wheel if possible. Beware of tram lines, especially
when they are wet. Avoid turning sharply on a wet or 'greasy'
road. Pass horses at a slow speed. Never take the feet off the
pedals when riding down hills. Do not ride with the hands off
the handles, especially in crowded thoroughfares. Ride care-
fully when passing side streets or the carriage entrance to
houses. Before attempting to pass another vehicle ring the
bell when at least twenty yards distant. This will give the
rider time to see what the intentions of the driver of the
vehicle in front are, and will enable the cyclist to take precau-
tionary measures in time should such be necessary. When
riding in parties vehicles should be passed in single file.
Warning by the bell should be given in as gentle a manner as
possible. The sudden ringing of a loud gong is apt to cause a
pedestrian to lose his presence of mind and run into the very
danger it was the intention of the cyclist he should avoid.
When riding behind vehicles in a crowded thoroughfare be
prepared to dismount at a moment's notice if necessary. Keep
on the proper side of the road. Ladies should not attempt
to ride in the public thoroughfare until they have absolute
control over and confidence in their machine. They should
keep as near as possible to the curb and ride slowly. Those
who wear a skirt should see that it is not too long. It should
be lined in front with some glazed material to prevent fric-
tion, and all loose drapery which is likely to be caught by
the wind and perhaps caught in the machine should be avoided.
In addition we would suggest that persons who let out cycles-
for hire should be under the control of the police. It should
1896.]
PRACTICAL NOTES.
655
be a punishable offense to let out machines not in proper
Older, and no child or other incompetent person should be
allowed to hire a machine. It should be possible for the police
to prevent novices learning in the public thoroughfares."
On the Management of the Tuberculous at Hotels.— The Pennsyl-
vania Society for the Prevention of Tuberculosis, under the
presidency of Dr. Lawrence F. Flick, has published circulars
of information for gratuitous distribution. The third tract of
tlie series treats of the duties of hotelkeepers in relation to
their itifeeted and mm infected guests. Among the points
brought out are the following: The linen, etc., of consump-
tives should be washed separately and should always be well
boiled before being washed. The persons to whom such arti-
re given to wash should be properly instructed as to
what to do in order that they too may be protected. As far as
practicable, consumptives in the advanced stage of the disease
should be assigned to separated tables, in order that their table-
wart" and linen can be kept apart from those of the other tables
and washed separately. All such tableware should be boiled
before washing. "All parts of a hotel or boarding house which
are likely to bo frequented by consumptive guests should be
well supplied with cuspidors in which there should be at all
times a germicidal fluid. This fluid should be changed once a
day and the cuspidors should be thoroughly scalded with boil-
ins: water. In conspicuous places throughout the house and
especially in the rooms assigned to consumptive guests, there
should be notices requesting guests never to eject sputa into
anv place other than the cuspidor, and suggesting that a hand-
kerchief should never under any circumstances be used for the
reception of such sputa where a spittoon is at hand. When
out upon the lawn, or in any place where a cuspidor is not of
convenient access, the sputa should be ejected into paper
handkerchiefs, these to be placed, upon returning to the room,
in a receptacle furnished for that purpose ; such handkerchiefs
should not be thrown into the ash bin but burned by the cham-
bermaid. After a room has been occupied by a consumptive.
it should be carefully cleansed before another guest is assigned.
Where the rules already laid down have been observed, wiping
the walls, floor and furniture with a sponge dampened with a
germicide solution, whisking the rugs with same solution,
and sending the sheets, blankets and pillow cases and coun-
terpanes to the laundry, will be all that is necessary. Where,
however, no care has been observed and the consumptive
has been careless about spitting on the floor, or into
linen, silk and muslin handkerchiefs, or where the bed
clothing has been visibly soiled with broken down tubercular
tissue, it will be necessary to carefully rub the walls with fresh
bread and then wash them with a strong germicide solution,
to wash the floors and furniture with the same strong solution,
to have all the bed linen and blankets thoroughly boiled and
to have the rugs and other articles which can neither be sub-
jected to strong germicide solution nor boiled, sent to a reno-
vating place and steamed."— Annals of Hygiene, September.
PRACTICAL NOTES.
Silico Fluorid of Mercury.— This salt has been recommended as
being twice as energetic as corrosive sublimate as an antiseptic.
It is far less poisonous than the latter salt, hence it deserves
attention. It is used in aqueous solution 1 to 1,000.— Pharm.
Era, September 3.
Acrocyanosis.— Crocq described at the recent Neurologic Con
gress in France a disease he has observed
young women, which he calls acrocyanosis.
Raynaud's disease and also Charcot's blue edema, yet it is dis-
tinct from both. Raynaud's disease ebbs and flows, with
severe pains, a tendency to the formation of gangrenes and
in two hysteric
It resembles
phlyctenw, and a loss of sensibility in the skin. Acrocyanosis
on the other hand, is a permanent condition, without severe
pains or the other symptoms above. Charcot's blue edema is
accompanied by paralysis, paresis or contractions, which are
all absent in acrocyanosis. The three diseases all originate in
disturbances of the nerve centers, but he considers the latter
essentially a hysteric vasomotor phenomenon.
Plastic Surgery. — The Jour, des Sciences MM. de Lille for
August 15 describes a case where a cutaneous epithelioma on
the ankle, 12 by 9 centimeters, was removed, a pear-shaped
living flap from the thigh sutured in its place and the leg
Hexed against the thigh in a plaster cast. A small flap cut
above was twisted around to cover the center of the open
space, leaving only a couple of unimportant spaces at each
end uncovered.
Treatment of Measles. — Dr. C. S. Merriman says that when
the eruption does not appear or when it recedes we have com-
plications. In such cases he employs the following treatment :
Take a flannel blanket, wring it out of water as hot as the
hand can bear and wrap patient up in this, with cold cloth on
the head. Keep him in the pack about twelve or fifteen min-
utes ; then transfer him to a dry blanket and allow him to cool
gradually. This brings the eruption to the surface and relieves
the mucous and serous membranes. If necessary give anti-
pyretics for the fever and sedatives for the cough. He never
has complications when this line of treatment is used. When
there is bronchial cough he prescribes a combination of terpin
hydrate and codeia sulphate made into an emulsion with syrup
of acacia.— K. C. Med. Ind., September.
Further Experiments with Serum Treatment of Cancer.— The
Revista Chilena de Hijiene, No. 6, describes at length the
treatment of a number of cases of inoperable cancer with serum
from asses and goats that had been inoculated with cancerous
tissues. The results were not as favorable as those obtained by
Richet and Hericourt, the only effect being the improvement of a
few symptoms, the most notable, the relief from pain. The dis-
charges also ceased to be fetid. The general health improved
at first, but afterward grew worse, with increased emaciation
and cachexia. The other symptoms were unaffected. He
injected usually 2 c.c. every other day, or less frequently,
never more than a c.c. on account of the tendency to produce
fever. He adds, with the odd Spanish inverted interrogation
point: i will larger doses secure better results? And he
remarks that our impotency in these malignant cases, fully
justifies these hazardous experiments.
Use of Forceps in France and Germany. An article in the Revue
Int. de M. et de C, August 10, compares the statistics of the use
of the forceps in obstetric cases in France and Germany, greatly
to the advantage of the French methods. The superiority of
Tarnier's forceps which are used in France, to Noegele's which
the Germans use, is one cause of the better results obtained.
But the chief cause is the method of applying the forceps. In
France the head of the fetus is seized symmetrically from ear
to ear, the axis of the blades corresponding to the occipito-
mental diameter, except in superior strait cases. The practice
in Germany is the reverse of this. The forceps are applied
symmetrically to the axis of the pelvis, and the fetal head is
seized as happens to be convenient. The statistics show the
results in the frequent lacerations and elevated fetal mortality.
Treatment of Phlyctenular Keratitis.— Dr. M. F. Coomes com-
mends a solution of eserin as the best remedy. It is a myotic,
contracting the pupil closely, and by so doing excludes the
excessive amount of light, and reduces intolerance to a mini-
mum. In addition to the mechanical action upon the pupil, it
also produces contraction of the capillary blood vessels, stimu-
lating them, and bringing about a healthy condition of the
ulcer, which can be accomplished by no other agent so readily.
656
PRACTICAL NOTES.
[September 19,
The solution need not be strong, two grains to an ounce of
water being quite sufficient for most cases. And its applica-
tion should be made twice a day, and if there is great intoler-
ance of light, three times a day. He advises no other local
application. — Louisville Med. Mo., September.
Chronic Cystitis.— Dr. S. B. Johnson used the following form-
ula in a severe case of chronic cystitis :
H. Syr. yerbae santae 32.0
Syr. simplex 64.0
Eucalyptol 16.0
Aquae destil 16.0
M. S. Shake well. Dose, a teaspoonful every two hours.
The patient was unable to pass his water without the aid of
a catheter, and his urine was loaded with mucus. In the
course of a week he began to pass his water without the aid of
the cathether. In addition to the use of the eucalyptol he
gave the following to keep the urine alkalin :
B . Comp. infusion buchu 470.0
Bicarbonate soda 4.0
Bromid of potassium 7.5
M. S. Shake well. Dose, a wineglassful every four hours.
Under this treatment the patient recovered, and he attrib-
utes the rapid improvement to the action of the eucalyptol. —
Northwestern Lancet, September.
Absorption of Iron by the Organism.— Gaule's interesting experi-
ments to determine the method of absorption of iron in the
organism are described in the Deutsche Med. Woch., No. 19.
They confirm Hall's statement that the absorption occurs in
the duodenum alone, and not in the stomach or small intestine.
Not only organic compounds of iron are absorbed, but also the
inorganic, like ferric chlorid, but they have first to be trans-
formed into an organic compound by combining with certain
substances in the intestine. The iron is absorbed by the
epithelium of the duodenum first, and then by the central
lymphatic vessels of the villi. As early as two hours after the
iron is administered, the quantity of iron in the pulp cells of
the spleen is much larger than normal. The process of absorp-
tion of the iron is perfectly normal, and does not require any
change in the usual processes.
Treatment of Gout with Piperazin. Dr. Hager describes his vic-
tory over the gout in his own person, in the Pharm. Post, No.
30. After various experiments he found that he had con-
quered his old enemy with piperazin taken three or four weeks,
in fractional doses, with soda water. After the swelling and
pains had disappeared, he continued with diminished doses a
while longer, 2.5 to 3.0 gr. per diem. The remedy seemed to
lose its diuretic power in the course of two or three weeks, and
he increased its efficacy at such times by supplementing it with
a diuretic, using a decoction of bean pods for the purpose,
taken in weak coffee, or with milk and the piperazin, or with
the piperazin alone. There were no inconveniences at any
time from its use, even at 3 grams a day continuously.— Therap.
Woch., August 23.
Pain after Laparotomy. Dr. Byron Robinson has reoperated
on a number of cases for annoying abdominal pains which
massage, electricity, etc., did not relieve and concludes that the
pain in peritoneal adhesions is due to the checking of the peris-
talsis in a viscus with a long pedicle and an active peristalsis
of the sigmoid flexure, loops of small intestines, Fallopian
tubes and bladder. The chief site of the adhesions is the cut
ends of the Fallopian tubes or some point of the abdomen de-
nuded of its peritoneal endothelia. Adhesions about fixed
organs, as the liver, spleen, flexures, etc., do not induce pain,
as their limited rhythm is not materially checked. In reoper-
ating we should free all the highly peristaltic organs and cover
up with peritoneum all exposed mucosae or denuded endothelia.
—Memphis Med. Monthly, September.
Treatment of Tuberculosis with Baths of Rarefied Air.— Vergara
Lope and Herrera of Mexico have constructed an apartment
where they give baths of dry, equable and highly rarefied air
to tuberculous patients. Although they consider it merely an
attempt, its success fully justifies further experimentation on
a larger scale. They conclude a modest report of what they
have been able to accomplish in relieving congestions, strength-
ening the lungs, etc., with these words: The desideratum is
to keep the patients night and day, and for a sufficient length
of time to really accomplish a cure (not merely an occasional
bath as with our present accommodations), in a highly rarefied,
dry and even atmosphere, such as is not to be secured at any
known natural point. (The variations in temperature in the
mountains destroy much of the therapeutic effect otherwise
obtainable there.) One chamber is not enough, but a whole
series, fitted up with every comfort and hygienic appliance, and
rendered attractive in every way to the patients in their volun-
tary confinement. — Revista Quincenal, July 15.
Serum Therapeutics. — Roger concluded his important address
on this subject at the recent French Congress of Internal Medi-
cine with these words : In spite of such numerous trials and
investigations, serum therapeutics has only produced actually
undeniable effects in the treatment of diphtheria. It has proved
less efficacious in man than we were led to expect from our exper-
iments on animals. Animals are easily inoculated with disease,
while man succumbs only if there is some morbid predisposition
or lack of tone in the organism. The serum only works, besides,
after a certain period of incubation, and even if administered in
time, we are not sure of obtaining a cure as the serum is impo-
tent in regard to the concomitant auto-intoxication. This is the
reason why it is impossible to deduce conclusions as to its effect
on man from the effects obtained on animals. This is why
the experiments in the laboratory are more successful than in
the clinics, and why the old methods are not to be abandoned
for the new. According to my opinion serum therapy is not
destined to supplant the other methods ; it should only be
considered another weapon to use concurrently with the rest.
This rule applies even to diphtheria. In a case of puerperal
fever, no matter how great our confidence in serum treatment
we should never trust to it alone, but employ all our known
weapons to combat the phenomena produced by multiple
causes, with means we know to be multiple in their effects.
Although it is hazardous to forecast the future, we do not
believe that serum therapeutics is destined to revolutionize
the art of healing. Its indications must be defined and its use
combined with other methods. This is the road for the clini-
cians to follow. At the same time the experimenters will be
improving the antitoxins and eliminating the useless or harm-
ful substances that accompany them. These are the tasks of
the immediate future, and when completed new progress will
have been accomplished in medical science and new benefits
accrue to humanity.
The Effect of Erysipelas Toxins upon Malignant Growths. — Drs.
L. A. Stimson, A. G. Gerster, and B. F. Curtis, at a recent
meeting of the New York Surgical Society, submitted the fol-
lowing report upon the use of erysipelas toxins in the treat-
ment of malignant disease : " We believe that in the instances
of apparent cure or marked improvement the correctness of
the diagnosis is open to doubt. We therefore submit : 1. That
the danger to the patient from this treatment is great. 2.
Moreover, that the alleged successes are so few and doubtful in
character that the most that can be fairly alleged for the treat-
ment by toxins is that it may offer a very slight chance of
amelioration. 3. That valuable time has often been lost in
operable cases by postponing operation for the sake of giving
the method of treatment a trial. 4. Finally, and most import-
ant, that if the method is to be resorted to at all, it should be
confined to the absolutely inoperable cases." — University Med.
Magazine, September.
I
>.]
THK
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EDITORIAL.
657
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| ly which is entitled to send delegates to the Association.
All that is necessary is for the applicant to write to the Treasurer of
the Association, l>r. Henry P. Newman, Venetian Building, Chicago,
MiiiR him a certificate or statement that the applicant is in good
if! in his own Society, signed by the President and Secretary of
icty. Attendance as a delegate at an annual meeting of the
delation is not necessary to obtain membership.
ti receipt of the subscription the weekly Journal of the Association
11 he forwarded regularly.
ntleinen already members of the Association should send their
nnal subscription to the Treasurer, or direct to the Journal office.
All communications and manuscript of whatever character, intended
for publication in the Journal, should be addressed to the Editor, and
all communications relative to the business of the Journal, proof
sheets returned, or In regard to subscriptions, should be addressed to
The Journal or thi American medical Association. 61 Market Street
lental Buildings), Chicago.
nal communications are only received with the understanding
that they are exclusively contributed to this Journal.
said
aunt
INFORMATION WANTED.
It would greatly facilitate the prompt delivery of the Journal to
lliose members oi the Association living in large cities, If they would
kindly furnish this office with their street address in those cases where
it is omitted from the wrapper of their Journal, as we have been noti-
fied by the postmasters of the larger cities that second-class mail mat-
ter not having street address, would be placed in the general delivery
to await call.
SATURDAY, SEPTEMBER 19, 1896.
THK EXAMINATION OP SCHOOL CHILDREN'S EYES.
An examination of the eyes of 8,125 London school
children has just been completed by Mr. Carter, and
sent to the Education Department; when we consider
the methods of the examination we are surprised to
learn that only 39.15 percent, were possessed of " nor-
mal vision.'" We say in view of the methods of
examination, because it is of this aspect we would
BUggesI a qualifying word. It seems from the ab-
stracts of the report at hand that to the teachers was
allotted the task of separating the sheep from the
goats, in other words they were to ascertain by pre-
scribed methods the pupils that had " normal vision."
Those thus diagnosed were apparently not further
considered by the ophthalmologists. The fact will
doubtless provoke a smile from American oculists,
at least from every one worth considering. What
public school teacher is capable of diagnosing the
refractive condition of a pupil's eye? Having diag-
nosed '• normal vision " how utterly meaningless is the
fact ! It is as devoid of significance as the findings of
the divining rod. Because, no mydriatic being used,
it is, as we all know, precisely the cases that have
considerable refractive errors covered up by the
accommodation, leaving "normal vision," that have
the most decided reflex disturbances, headaches,
denutrition, etc. The smile of the skilled refractionist
becomes something very different from a smile when
he thinks of the astigmatism uncorrected in that 39.15
per cent, of normal eyes! And then the remaining
60 per cent., if we had a mydriatic examination of
these, of what interest and value it would be to know
accurately the precise refractive errors and muscle-
balances! Astigmatism was, of course, found to be
extremely rare, whilst with us the eye without astig-
matism is almost a wonder. " Slight and moderate
degrees of hypermetropia are the most common
conditions, and the defect, if it is to be called a defect "
(italics ours) "is scarcely sufficient to require the use
of glasses, and would not be likely to lead to more
than a sense of weariness in children who were under-
fed or taught in badly-lighted schools." This is not
ludicrous; it is pitiable! Precisely when food is
scarcest, and the lighting the worst, then is the
greatest need of relieving the eye from strain. We
are glad to learn that there is no evidence of an
increase of myopia in the London children.
Another noteworthy finding is much amblyopia not
to be accounted for by errors of refraction. (Again
we must recall that the examinations were made by
the ophthalmoscope and without a mydriatic.) This
amblyopia is accounted for by the fact that city
children are not exercised in seeing distant objects,
but only such as are not farther than the street- width
or room-dimensions! Our " ophthalmic surgeons "
find other causes for amblyopia, but our English
confreres smile at our testings of the ocular muscles
and of astigmatism. It should be recognized as a
fundamental principle that all examinations of school-
children's eyes are utterly valueless to science, and
the conclusions drawn from such testings are equally
valueless or positively misleading, even concealing
the truth, that are not carried out by means of a
mydriatic, that do not include a precise estimate of
the astigmatism, the anisometropia, and the muscular
incoordinations or balances.
MEDICAL EXAMINERS AND MEDICAL TEACHING.
During the past seven years the course of study in
the majority of the Medical Schools of the United
States has risen from two years of five months each,
to four years of at least six months each. This
advance has not been brought about by the action of
any one force, but it has been accomplished by the
coordinate action of the various State boards of health
and by the cooperation of the better class of medical
schools in the Association of American Medical Col-
leges. This increase in time has, in many schools,
been accompanied by a greater advance in the meth-
ods of teaching and in the scope of the curriculum.
The laboratory method of teaching for histology,
pathology and various other subjects has been gener-
ally adopted. The amount of laboratory work and
its quality has not, however, been just what could be
desired. In some schools only a few hours a day for
a very brief period is required, while in others a large
amount of time is spent in the laboratory, but the
pedagogic method of presenting the subjects to the
658
MATERIA MEDICA AND THERAPEUTICS.
[September 19,
students has not always been carefully considered.
The order of the laboratory has been frequently neg-
lected and students have been allowed to form extrav-
agent and slovenly habits and sometimes even have
been instructed in erroneous methods of observation
and faulty methods of reasoning. The shiftless habit
which some teachers practice of preparing histologic
specimens, mounting and distributing them to the
class instead of requiring each student to catch, kill
and prepare his specimens for himself, is all too
prevalent. The method of requiring drawings of
histologic specimens to be made is desirable and cor-
rect, but to permit the use of illustrated text books to
define characteristics which poorly prepared speci
mens fail to discover, is pernicious. Many institu-
tions with clinic advantages have neglected to pay
that attention to the conduct of clinics which the real
needs of the students demand. The students them-
selves look for tragic operations and crowd the lapar-
otomy room while they neglect the tedious work of
percussion, palpation and auscultation in the quiet of
the dispensary. Lecture work still continues to
occupy the most prominent place in the course and
consume the largest amount of time. The medical
library has not yet been utilized as an engine of med-
ical education and most of our graduates still go out
with little or no knowledge of the use of the store-
houses of medical thought and experimental investi-
gation.
It is probable that the length of the course of study
has been sufficiently extended and that the work of
the next ten years for medical education will be
directed to improved methods of teaching. It is nec-
essary now for the colleges to combine and demand
of the State examining boards a rational, flexible and
practical examination and one which will bring to the
front those men who have most studied the healthy
human body, the diseased body and the methods of
preserving health and treating disease. Written
examinations only will not do this. They encourage
pedantry, cramming and a "cuckoo" style of recita-
tion. Actual examinations at the bedside with all the
paraphernalia of diagnosis and therapeutics must be
substituted at once for the examination at the table.
It is not enough to say that this would be expensive
and would consume too much of the examiner's valu-
able time. The examinations are not designed for
the comfort of the examiner, but rather for the
improvement of the education of students. The
great expenditure of money and labor required of the
medical schools by the four years' course must be
seconded by equal expenditure by State boards.
When such examinations are instituted it will be
easy to separate the wheat from the chaff and to
designate those medical schools that give a real med-
ical education. Until this is done any crowd of
young quiz masters can outdo the best equipped col-
lege and the most experienced faculty.
THE TEACHING OF MATERIA MEDICA AND
THERAPEUTICS.
Materia medica has been the bete noire of the med
ical student. The study of its dry and categorical
details has been largely a matter of mental gymnas-
tics. In its teaching, instructors have sought to make
it more acceptable to the mental palate of the pupil
by a liberal admixture— with the uninteresting story
of drug origins, pharmaceutic preparations and dose
tables— of therapeutic facts. Until recently the text
books have adopted the confusing method of merging
the treatment of these two, usually allied, but deserv-
edly distinct topics. Their greater dissociation is
desirable for the better development of each subject
and for the adaptation to each of its own proper
method of study.
Dr. Henry M. Bracken, of the University of Min-
nesota, in an article printed recently in the New York
Medical Journal, has been the first, publicly, to rec-
ognize the necessity for a departure from the custom-
ary mode of instruction in these branches. His
recently published work, "The Outlines of Materia
Medica," is in evidence to prove the possibility of
their divorce without damage, at least, to the teaching
of the primary subject. It does not meddle, by any
serious intention, with the question of therapeutics.
Its author holds that these branches, wisely associ-
ated under a single chair, have, nevertheless, their
proper places in different parts of a medical course.
His claim that a certain amount of knowledge of gen-
eral chemistry and physiology should be pre-attained
by the beginner in materia medica is in reason. He
adopts, in the first instance, the chemic and biologic
arrangement in the study of drugs, the only arrange-
ment which fits the laboratory method of teaching.
For materia medica must come into line with hist-
ology, anatomy, physiology, chemistry and pathology
as laboratory studies. The day of the didactic lecture
in the treatment of such a topic has gone by. Of no
subject is the lecture a more awkward vehicle of
instruction.
The student of materia medica should be, to an ele-
mentary degree, a pharmacist. He should see and
handle crude drugs and their eligible preparations.
He should understand the principles of compounding
by practice in the art of preparing materials and put-
ting up prescriptions. Then, and not until then,
should he be taught the physiologic action of drugs.'
And here the laboratory idea again comes forward.
The pupil should observe, by illustration, the methods
of studying physiologic action in animals and, so far
as possible, in men. He should learn the limits of
comparison between physiologic action in the human
and in other forms of life. All drugs should be rec-
ognized with caution— not to say suspicion— whose
physiologic effects have not been ascertained or can
not be scientifically determined. Such a principle
1896.]
COMPLICATIONS IN CASTRATION.
659
would tend to the eventual elimination from the
materia medioa of a large mass of remedies which
have ceased to have any clinical importance and never
possessed any real therapeutic value. It would go far
toward checking the modern heresy of therapeutic
nihilism if the materia medioa were once and forever
barged of these discarded and impotent ngents.
Having accomplished this riddance, it would be
equally effeotive, in the encouragement of therapeutic
faith, in these days of commercial enterprise and
pseudo-scientific ingenuity among the manufacturing
chemists, it* the laws should require the submission of
all new remedial agents to a bureau of scientific
in\ estimation connected with a National or with State
boards of health. It is remarkable that we should so
long have persisted in taxing the student of medicine
with the command of weapons, which, in his practical
armamentarium, he will never use — which his teacher
himself would never employ. Is it any wonder that
the graduate, in his mental confusion of drug values,
should fall back upon patent preparations or proprie-
tary formula'?
In a later year therapeutics has its place. It
should be taught as an independent study, with its
relations to the physiologic action of drugs well elab-
orated from the laboratory standpoint and its clinical
side developed, less in the lecture room than at the
hospital bedside and in the dispensary clinic.
By these methods materia medica and therapeutics
may be effectively taught and will cease to be classed,
as they are now, among the bugbears of the cur-
riculum.
THE VITAL AND PSYCHIC COMPLICATIONS IN
( ASTRATION FOR PROSTATIC HYPERTROPHY.
In the current (September) issue of the Annals of
Surgery there appears an interesting paper by Dr.
A. T. Cabot on •' The Question of Castration for
Enlarged Prostate," in which the writer takes, on the
whole, an unfavorable view of the operation as com-
pared with the older one of prostatectomy. He finds
from his analysis of the statistics that, in the matter
of mortality, it (castration) has a less favorable show-
ing than prostatectomy, and conjectures that with
later statistics reflecting the latest improvements in
technique this disadvantage would be still more in
evidence. Prostatectomy has also the further advant-
age of allowing a thorough examination of the bladder
and the consequent discovery and relief of other,
perhaps unsuspected, morbid conditions. Its disad-
vantages are the longer confinement and the possibility
of fistula. It is applicable, he claims, to more cases than
is castration, which is apparently most efficacious in
large, tense prostates compressing the urethra, and is
of little use in myomatous and fibrous enlargement,
while the older operation is, in the hands of a skilful
operator, applicable to the relief of any and every
form of prostatic obstruction. It is, moreover, espe-
cially indicated whenever an inflamed condition of
the bladder makes drainage desirable.
Dr. White, the proposer of the operation and one
of the editors of the Annals, takes up the question of
Dr. Cabot's paper in what seems to be a very ably
written editorial and warmly combats some of his
conclusions. As regards the mortality of castration,
which it would seem Dr. Cabot's statistics make
unduly high, he seems clearly to have the advantage
of the argument, especially as regards the deduction
that the disparity would increase with improved
technique in prostatectomy, for he shows by more
recent statistics a decided reduction of the mortality,
and he further shows from an analysis of Dr. Cabot's
own list that certain fatal cases are included in which
the final result certainly ought not to be attributed to
the operation. The mortality of such an operation as
castration certainly ought to be less, it would seem,
than that of prostatectomy. As he says, Dr. Cabot's
figures are, at any rate, rather small to base such pos-
itive statements upon.
As regards the utility of castration in myomatous
and fibrous tumors, it would also seem that he had at
least as good an argument in its favor as has Dr. Cabot
against it, and he shows that the evidence as to the
tendency to relapse is not adequate to confirm that au-
thor's conclusions. One point mentioned by Dr.CABOT,
however, he neglects — that is the question as to the
effects of castration on the general vitality, which Ca-
bot claims is probably to some extent reduced by the
removal of the organs. That these organs are abso-
lutely without function at an advanced age is most
certainly untrue for many individuals, even as regards
their special reproductive utility alone. It would not
seem improbable therefore that there might yet occur
something at least of that general systemic reaction
that is so marked in the younger individuals after
castration, and that this might manifest itself in a
more rapid failure of the vital energies and a quicker
succumbing to the onset of senile changes. There is
probably a germ at least of truth in the theory of
Brown-Sequard as to the invigorating influence of
the testicular secretion; certainly the experimenters
in organo-therapy have not lost faith in it altogether.
The organs do not atrophy completely, even after
their special sexual function has apparently long been
lost, and it is only reasonable to assume that they still
have some utility in the organism.
The large proportion of cases mentioned by Dr.
Cabot in which mental disturbance followed the
operation is also noteworthy, even if it is not directly
attributable to the character of the operation. We
might perhaps expect some more emotional disturb-
ance from an operation of this kind, associated as it
is with the idea or recollection of the changes that
follow it when performed in youth, and this psychic
660
CORRESPONDENCE.
[September 19,
element is not altogether a negligible matter. It may
even have its share in causing the excessive (as it
would appear) mortality that has followed so slight
an operation.
While Dr. White appears to have fairly replied to
the other objections to the operation, this one is left
unanswered, and it may not be an insignificant one.
Time, of course, will be required to determine its full
value and importance.
. THE LABOR MOVEMENT AND MEDICINE.
The recent celebration of labor day throughout the
country and the great extension and popularity of the
so-called labor movement suggest certain questions
that may become practical ones in the near future.
Every one sympathizes with the desire of the working
classes to improve their condition in all legitimate
ways and the usefulness of labor organizations under
judicious management need not be questioned. That
their managers have not always been judicious is evi-
dent enough, but that is perhaps to be expected and
it is to be hoped that more wisdom may guide their
actions in the future than it has in the past. The
question that concerns us most especially is that of
their extension into certain lines of occupation that
have hitherto been free from these complications.
Medicine, being a liberal profession, is in no danger
of falling into this line; the laws regulating practice
are matters of public hygiene, not of private interest,
though the medical defence associations that seem to
be popular in Great Britain at the present time have
some general resemblance to trades union or labor
methods. There would, it may here be said inci-
dentally, be no better object lesson of the evils of cer-
tain labor methods than a sympathetic strike of doc-
tors, leaving their patients to go, in many cases
literally as well as metaphorically, to the devil,
according to orthodox beliefs. The nearest approach
to this that is likely to occur is what happened, we
believe, in England not long since, when the lay man-
agement of a certain hospital became so obnoxious
that physicians refused to serve on its staff. Such an
event would, however, be more the result of the indi-
vidual expression of professional self-respect than of
any combination analogous to trades organizations.
There are, however, auxiliary to medicine certain occu-
pations the followers of which can not be expected to
be always governed by the high professional motives
that are assumed to control regular physicians, and it
is entirely possible to conceive of what we denomin-
ate labor troubles arising in their ranks. A general
sympathetic strike in very many employments could
easily have the most disastrous effects on the public
health, a railroad strike involving the milk supply for
only a few days in a great city would cause a terrible
increase of infant mortality, and many other like
instances and effects can be easily imagined. To
come down more closely, however, to strictly medical
employments, a strike of hospital employes, especially
if in connection and alliance with a general strike,
would be most disastrous ; yet it is a perfectly con-
ceivable possibility. In certain hospitals this con-
tingency is calculated upon and all employment is
regulated by contracts requiring notice and other
precautionary provisions.
It is not to be supposed that public opinion would
support any long extended movement that would have
gross inhumanity as its consequence, and it is to be
hoped that no labor combination would really delib-
erately attempt to injure or prejudice the welfare of
the helpless and the invalid. It must be remembered,
however, that the greatest wrongs are committed not
through deliberate malice, but by inconsideration and
recklessness, and the inability to see beyond an imme-
diate desired end.
CORRESPONDENCE.
Physicians' Cards.
Anderson, S. C, Sept. 5, 1896.
To tlie Editor: — Is it contrary to the Code of Medical Ethics
or the by-laws of the American Medical Association to use
on a business or visiting card the words " Diseases of Women
and Children," or any other words indicating a special line of
practice? If not those words, is the word "Gynecologist"
admissible? For instance, " Dr. Leptandrin, Cormes, Florida,
Diseases of Women and Children."
Awaiting your reply, am very truly yours, J. O. W.
Answer: The reading of the Code explicitly says : "It is
derogatory to the dignity of the profession to resort to public
advertisements, or private cards, or hand bills inviting the
attention of individuals affected with particular diseases, etc."
— Vide Code of Ethics, "Of the Duties of Physicians to Each
Other and to the Profession at Large." — Art. 1, Sec. 4. Now
this is the exact language of the Code, and is in all well regu-
lated societies regarded as the safest plan to follow.
The Bicycle.
Ironton, Ohio, Aug. 30, 1896.
To the Editor: — I was greatly pleased to see so sensible an
article in the last Journal as that written by Dr. Brown of
Birmingham. That the bicycle has come to stay is an assured
fact. That more people are going to use them is another
assured fact. That we, as physicians, should accept these as
facts and devote more time to the "wheel and its effects" is
also quite as much a fact. For the masses the wheel has come
nearer annihilating space than anything that has so far been
invented. Until we have a practical, low-priced flying machine
people will continue the use of the wheel despite the fact that
it produces pelvic troubles. I do not think, however, that it
will produce as many of them as the same amount of horse-back
riding. It is no more fair to call the hump-backed, ewe-necked ,
pop-eyed scorcher the typical bicycle rider than it is to com-
pare the goggle-eyed thing that rides through Central Park to
one of Buffalo Bill's riders in his Wild West Show. As long
as we have in use the prevailing style of saddle we will have
"the hump" because that is the easiest position. When we
can have a seat that is flat, or nearly so, and receive its support
from the center instead of the ends and has no prominent horn,
then, and not until then, will we have what is to my mind, the
18%.]
NECROLOGY.
661
OOROCt position. I have had one ease of ruptured urethra and
several cases of vesical irritation under my care, but have
never failed to promptly- give relief to the latter when the
proper saddle was prescribed. When a fond mother asks me
if 1 think her daughter can ride a wheel I say, "Yes, if the
saddle is right." When a man asks me if he can ride a wheel
1 suv. "If you pet the right saddle and then use a little com-
mon sense." There are many good saddles now being manu-
factured and if we will use our influence in the right diroction
"the hump" and vesical irritation will soon be things that are
not charged up to the bicycle. I have been a constant user of
the wheel for three years, averaging about fifteen miles a day,
the year round. Being compelled to investigate the saddle
question, I went into the subject a little more seriously than if
some one else were the patient, but since having the saddle
rijrlu 1 feel as much freedom from pain and danger as if I were
riding in a carriage. Prescribe the wheel for your patients,
•but sec that the saddle is right."
Lester Keller, M.D.
NECROLOGY.
Diagnosis of Knee Joint Affections.
Minneapolis, Minn., Sept. 12, 1896.
To tin- Editor: — White it is usually a comparatively easy mat-
ter to make a diagnosis in tuberculosis of the knee, it is possi-
ble to be mistaken, as illustrated by the following cases :
i'usr 1. -A young man 19 years of age came to the writer
■with a knee which had been pronounced tubercular by a num-
ber of physicians who had seen it. It had already been treated
by iodoform and iodin injections. He gave a history of having
sustained a slight injury about a year before the writer saw
him, and some time afterward the joint began to swell and
became painful.
When he came to me he had an enlarged white joint with
enlarged veins. There was flexion, atrophy, muscular spasm
and severe pain which was much worse at night. He was put
in bed and extension made by means of weight and pulley. In
about a month his pain was relieved, the deformity overcome
and the swelling seemingly diminished. At this time there
was no question in the writer's mind but that the knee was
tubercular. A plaster cast was applied and the patient allowed
to go out on crutches.
After a very few weeks the pain returned ; the swelling in-
creased and the patient returned to bed, where he remained
until he died three months later from an osteosarcoma. At
that time my belief was that the sarcoma was secondary to
tuberculosis, but the probability is that it was sarcoma from
the beginning.
Case .'.—A lady, 49 years of age, was brought to me, who
had a knee which was decidedly enlarged and which had been
pronounced tubercular by many of the eminent surgeons of
three different cities. An independent diagnosis of tubercular
synovitis was made and excision advised. There was local
swelling and heat, and what seemed to be a tubercular abscess
in the popliteal space. There was flexion and tenderness upon
pressure, but comparatively little pain. The family physician,
acting upon the advice of a consulting surgeon, had tapped the
joint some time before, drawing off quite a quantity of serous
fluid, after which he injected iodin. The patient accepted the
advice of myself and all the other surgeons (except one who
wanted to try iodoform injections) and requested me to excise
the joint. The patient had a hemophilic joint, and died one
week after the operation, from acute anemia.
These rare and unexpected cases may occur in any joint, but
the above are the only cases occurring in the writer's practice.
James E. Moore, M.D.
Alexander Buchanan, M.D., New York City, September 2,
from complication of diseases from which he had been suffer-
ing for several years. He went to Sands Point early in the
summer, but becoming worse ho was taken to the Post-Gradu-
ate Hospital where he died. Dr. Buchanan was born in Glas-
gow sixty-flve years ago. He came to New York in 1856, but
returned to Scotland to study medicine and graduated from
the University of Glasgow in 1860. In 1862 he graduated from
the New York Medical College. He was a Fellow of the Royal
College, of Physicians and Surgeons, Glasgow, a member of
the New York State and County Medical Associations and a
member of the New York County Medical Society.
A braham Livezey, M.D. , at Yardley, Pa. , August 31. He was
at one time professor of obstetrics at the Woman's Medical Col-
lege of Philadelphia. He had been suffering for thirty years
from lupus of the face. He was born in Solebury township,
Pa., in 1821, and graduated from Princeton College in 1842,
and from Jefferson Medical College in 1845.
Asbury M. Day, M.D. (Albany Medical College, Albany,
N. Y., 1860), at Parmington, Del., September 4, aged 60 years.
William K. Conaway, M.D. (Jefferson Medical College,
Philadelphia, Pa., 1890), of Ridgeley, Del., September 4.
Charles Lotin Hildreth, M.D., of Southampton, N. Y.,
who was gaining prominence among the younger poets and
writers of this country, died at the residence of his wife's sis-
ter, Mrs. Mary Kyle Dallas, on August 12. He was 40 years
old and leaves a widow who is an authoress. There are no
children. Dr. Hildreth' s death was due to nervous prostration
brought on by the intense heat of the week previous.
Matt Youno, M.D., the oldest physician of Ashland, Ky.,
died August 26.
J. L. Benson, M.D., aged 79, died at his home in Nobles
ville, Ind., September 8. He was a surgeon of volunteers dur-
ing the war, and had practiced medicine for fifty years.
NEW INSTRUMENTS.
A NEW SELF-RETAINING NASAL SPECULUM.
BY J. R. STRAW, M.D., ASHLAND, WIS.
Late House Surgeon Baltimore Eye, Ear and Throat Charity Hospital,
Baltimore, Md.
I have realized, as has I presume every other rhinologist,
the need of an absolutely self-retaining nasal speculum, To
obviate this, about two years ago I devised the instrument
Work for the Association.— Let every member get a new mem-
ber before the close of the year ! Try it now ! Let us reach
the ten thousand mark in the semi-centennial year.
Figure 1.
illustrated in the accompanying cuts. As an inventor is always
an enthusiast on his own devices, I have hesitated to recom-
mend it to the profession, fearing it would prove, as many
other instruments, useless for its designed purpose.
Knowing this fact, I have used it for the last two years, and
am thoroughly satisfied as to its merits and practicability,
especially for operations on the nose.
Cut No. 1 represents the instrument with fenestrated blades,
consisting of three, on a straight, square bar, those on either
end being movable, the central stationary. This latter or
central blade is placed on one side of the septum, while the
dilating blade on the opposite side of the nose to be dilated, is
662
SOCIETY NEWS.
[September 19,
brought firmly up against the septum and then, on the Lennox-
Browne principle, locks itself. These two blades acting as a
clamp on the septum, can not possibly slip ; the other blade is
then pressed out against the alae of the side to be dilated, and
also locks itself on the same principle.
Cut 2 represents the instrument in situ.
Figure 2.
The instrument is also made with solid blades, which protect
the parts especially when the galvano-cautery is used. If
desired the middle blade can be made adjustable, so that it
can be extended back to protect the septum for some distance
if necessary, although the cut does not show this.
I have recently had one made with solid blades, which I
find more satisfactory than the one shown in the cuts. The
original instruments have been made for me byGuinand Bros,
of this city.
SOCIETY NEWS.
The Watertown (N. Y.) Medical Society has reelected the follow-
ing officers for the ensuing year : President, J. M. Crawe, Sr. ;
vice-president, Gilbert Cannon ; secretary, C. N. Bibbins ;
treasurer, J. M. Crawe, Jr.
The American Electro-Therapeutic Association will hold its sixth
annual meeting at Boston, Mass., September 29-30, and
October 1.
Address of the President, Dr. Robert Newman, New York
City. "The want of education in electro-therapeutics in
medical colleges."
Reports of committees on scientific questions :
On induction coils and alternators. Mr. A. E. Kennelly,
Philadelphia, Pa.
On meters. Dr. M. A. Cleaves, New Y'ork City.
On static machines and condensers. Dr. W. J. Morton,
New Y'ork City.
On constant current generators and controllers. Dr. W. J.
Herdman, Ann Arbor, Mich.
On electrodes. Dr. C. R. Dickson, Toronto, Canada.
On electric light apparatus for diagnosis and therapy. Dr.
J. H. Kellogg, Battle Creek, Mich.
Papers :
What can be done by means of the use of electricity to
avoid surgical operations? Dr. G. Betton Massey, Philadel-
phia, Pa.
Electricity in chronic nonsuppurative affections of the
uterine appendages. Dr. P. Shavoir, Stamford, Conn. Dis-
cussion by Dr. G. Betton Massey, Philadelphia, Pa.
Electricity in the treatment of diseases of the throat and
nose. Dr. O. B. Douglass, New York City.
Accidents and risks in the use of street currents. How
far are they practicable and safe in the use of electro-thera-
peutics? Mr. J. J. Carty, E. E., New York City.
Electricity in the treatment of diseases of the larynx. Dr.
W. C. Phillips, New York City.
Digest, showing the danger to patients and operators, the
utter unreliability of fuse wires, resistance coils and
incandescent lamps as a preventative of excess flow of cur-
rent into patient. The liability of and danger due to the
crossing of operator's wire, by wires carrying high tension
current, both direct and alternating. Mr. John J. Cabot,
E. E., Cincinnati, Ohio.
Experiments upon the effects of direct electrization of the
stomach. Dr. Max Einhorn, New Y'ork City.
Electricity in diseases of the stomach. Dr. David D.
Stewart, Philadelphia, Pa.
The static current of the post-apoplectic state. Dr. John
Gerin, Auburn, N. Y.
The electric principles generally used in medical treat-
ment. Prof. William L. Puffer, Boston, Mass.
The relations of physics to physiology. Prof. A. E. Dol-
bear, Tufts College, Mass.
Electro-therapy in the treatment of the nervous. Dr.
W. S. Watson, Fishkill-on-Hudson, N. Y.
The role of electricity in the treatment of uric acid dia-
thesis. Dr. J. G. Davis, New Y'ork City.
Some observations in electro-therapeutics. Dr. D. R.
Brower, Chicago, 111.
The physics of the production of the X rays. Mr. Edwin
Houston, Philadelphia, Pa. ; Mr. A. E. Kennelly, F.R.A.S.,
Philadelphia, Pa.
Treatment of strictures by electrolysis vermis any other
treatment. Dr. F. H. Wallace, Boston, Mass.
"The Newman method of urethral electrolysis." Its
advantages and reasons why some operators fail. Dr. Fran-
cis B. Bishop, Washington, D. C.
Faradism in gynecology. Dr. R. J. Nunn, Savannah, Ga.
The motor dynamo— adapted to electro-therapeutic work.
Dr. W. J. Herdman, Ann Arbor, Mich.
The application of electricity to surgery. Dr. J. W. Herd-
man, Ann Arbor, Mich.
A summary of the ultimate results in eighty-six fibroid
tumors, treated by the Apostoli method. Dr. G. Betton
Massey, Philadelphia, Pa.
Some experiences and experiments in the construction of
high tension coils and electrodes. Dr. Frank W. Ross, A.M.,
Elmira, N. Y.
Electricity considered in its relation to surgical gynecol-
ogy. Dr. O. S. Phelps, New York city.
A clinic report of case of rectal phlebitis treated with
galvanism. Dr. D. B. D. Beaver, Reading, Pa.
On the electro-therapeutics of the constant current. Mr.
A. E. Kennelly, F.R.A.S., Philadelphia, Pa.
The New York State Medical Association will hold its thirteenth
annual meeting in New Y'ork City, October 13, 14 and 15.
Address by the President, Dr. Darwin Colvin. "Medica!
expert testimony."
The technique of intubation in children, some remarks on
the time for operation and after treatment. Dr. Thomas J
Hillis, New Y'ork County.
Functionless organs, are there any? Possible use of the
appendix vermiformis. Dr. Nelson L. North, Kings County.
The elongation of retracted muscles in club foot. Dr. T. M.
Ludlow Chrystie, New York County.
Special report on Criminology. Dr. Austin Flint, New
Y'ork County.
Brief comments on the materia medica, pharmacy and thera-
peutics of the year ending Oct. 1, 1896. Dr. E. H. Squibb,
Kings County.
Discussion on Surgery : "Prostatic enlargement."
The discussion will be opened by Dr. J. W. S. Gouley, New
York County.
The treatment of fecal fistula with reports of cases. Dr.
Frederick Holme Wiggin, New York County.
Amputation of the lower third of the leg, with periosteal
flap." Dr. Joseph D. Bryant, New York County.
Suture of the liver for incised wounds. Dr. Stephen Smith,
New York County.
Operation for rectal hemorrhoids and prolapse by submucous
ligature. Dr. Benjamin M. Ricketts, Cincinnati, Ohio.
1896.]
PUBLIC HEALTH.
663
The practical uses of Roentgen's discovery as applied to sur-
gery ; with illustrations. Dr. Reginald H. Sayre, New York
County.
The treatment of otorrhea and its importance. Dr. Edward
B. Dench. New York County.
The relation of nose and throat affections to diseases of the
Mr. I>r. PrankS. Milbury, Kings County.
Temperature as an element in prognosis. Dr. John Shrady,
New York County. .
Diphtheria. Dr. Thomas G. Acker, Westchester County.
On the treatment of inebriety. Dr. T. D. Crothers, Hart-
ford. Conn.
Further remarks on the domestic test for albumin in urine.
Dr. John G. Truax, New York County.
A successful plaster-of-Paris bandage cutter. Dr. Sidney
Yankauer, New York County.
The physiologic deductions regarding the usefulness of
so railed animal extracts. Dr. H. A. Haubold, New York
County.
Two interesting cases of surgery of the kidney. Dr. J. E.
Janvrin, New York County.
Recent investigations concerning eclampsia. William T.
husk. New York County.
Puerperal eclampsia; studied with reference to pathogene-
sis and therapeutics. Dr. George T. Harrison, New York
County.
The palliative treatment of cancer of the cervix and bladder
in women. l>r. Nathan Q. Bozeman, New York County.
Rare complications in two cases of hysterectomy. Dr. Ely
Van de Warker. Onondaga County.
One point in the treatment of endometritis. Dr. William H.
Robl), Montgomery County.
Address on surgery. Dr. Charles Phelps, New York
County.
The vitality of cutaneous epithelium, with report of clinic
observations in skin grafting. Dr. Zora J. Lusk, Wyoming
County.
Acute amnesia. Dr. William D. Granger, Westchester
County.
The duty of the public to the physician. Dr. William M.
Bemus, Chautauqua County.
Supplementary notes upon tendon grafting and muscle
transplantation for deformities following infantile paralysis.
Dr. S. E. MUliken, New York County.
The medico-legal aspect of prison reform. Dr. Ernst H.
Schmid, Westchester County.
A uscultatory percussion. Dr. Louis L. Seaman, New York
County.
Druggist versus doctor. Dr. Henry B. Van Zandt, Schen-
ectady County.
The peripheral neuralgias, traumatic and toxic. Dr.
Thomas H. Manley, New York County.
The passing of venesection. Dr. H. D. Didama, Onondaga
County.
A class of fatal cases, presumably due to intestinal pto-
mains. Dr. E. D. Ferguson, Rensselaer County.
PUBLIC HEALTH.
Report of the Bureau of Health of Denver, Colo. — Total number
■of deaths for August, 163; cases of phthisis contracted else-
where, 24 ; death rate per 1,000 per annum, 13.04 ; death rate,
excluding phthisis contracted elsewhere, 11.12; males, 86;
females, 77.
Typhoid in Marion County, W. Va. — The typhoid epidemic in
Marion County, W. Va., is spreading rapidly, the deaths mul-
tiplying daily. New England has 125 cases with an average
daily death rate of 2. Every family in Riversville has one or
more cases. Barnesville is in the same condition, five deaths
occurring there on September 7. In consequence of the epi-
demic, the mining business is greatly disturbed and in some
localities partially suspended.
Diphtheria and Typhoid in Chicago. — During the five days end-,
ing September 7 seventeen deaths from diphtheria were
reported to the health department, a daily average of 3.4, or
more than for any corresponding period since the epidemic of
the winter of 1895 96. On September 4 seven people died
from typhoid fever, breaking the record since 1892. The
health department says the prevalence of the disease is due to
impurities in the drinking water. During August of this year
typhoid claimed sixty-four victims, against fifty-nine for the
corresponding period of 1895. About five hundred cases are
reported at present in the city.
The Old-time Enemies of Water. A writer in Hospital has
made a partial collection of the sentiments of the ancient as
opposed to the virtues and values of that blessing, water. In
fact, he says, there are very few old writers who say a good
word in its favor. The "Venerable Bede" (673-735) prescribed
the following general directions : " In June of a morning a cup
of cold water, fasting ; for July the same, but in October for
sweetening the blood, for the expulsion of stone, and for heal-
ing the lungs, instead of water one should take the milk of
goats or sheep and should not wash very often ; in February
one should foment the limbs ; in August he should not refresh
in cold water, but in January he should plunge his body into
warm water." One or two writers only are concerned to main-
tain that, " when begun in early life it [water] may be pretty
freely drank with impunity," and they quote the curious
instance given by Sir Thomas Elyot in his " Castelof Health,"
(1534) of the Cornish men, "many of the poorer sort, which
never, or very seldom, drink any other drink, be notwithstand-
ing strong of body and like, and live well until they be of great
age." Thomas Cogan, the medical schoolmaster of Manches-
ter fame, confessed in his " Haven of Health," 1589, designed
for the use of students, that he knew some who drank cold
water at night or fasting in the morning without hurt ; and Dr.
James Hart, writing about fifty years later, could even claim
among his acquaintance "some honorable and worshipful
ladies who drank little other drink and yet enjoyed more per-
fect health than most of them that drank of the strongest."
The phenomenon was undeniable, but the natural inference
was none the less to be resisted. Sir Thomas Elyot himself is
very certain, in spite of the Cornish men, that "there be in
water causes of divers diseases, as of swelling of the spleen and
liver." He complains oddly also that "it flitteth and
swimmeth," and concludes that " to young men and them that
be of hot complexions it doeth less harm, and sometimes it
profiteth, but to them that are feeble, old and melancholy it is
not convenient." "Water is not wholesome drink by itself for
an Englishman," was the verdict of Andrew Borde who was
author of a Breviarie of Health, and who died in prison (1549),
probably for debt, since it was his habit to make humorous
speeches at fairs and who originated the sobriquet of " Merry
Andrew." But the most formal indictment against water is
that of Venner, who, in writing in 1622, ponderously pro-
nounces " to dwellers in cold countries it doth very greatly
deject their appetites, destroy the natural heat and overthrow
the strength of the stomach, and consequently confounding
the concoction, is the cause of crudities, fluctuations and wind-
iness in the body." But be this as it may, allowance must be
made for the numerous marshes and lazy streams of the day,
which may have unconsciously pointed the moral of avoidance.
Besides too there may have been rampant the usual excuses for
intemperance, and the growing favor of boiled, or for the matter
of that, malt drinks. For even at this late date the ingenuity of
man is not so much wasted upon a pure water supply as upon
the varied flavors of the shops, especially during a heated term.
There are no fears especially if the compound is well sugared,
and defies an analysis of its elements. Man yearns for the
toothsome rather than for the salubrious.
Safe Drinking Water for Travelers. — Mr. Budgett Meakin, a
globe trotter of renown, writes for a London newspaper some
cautions about drinking water away from home. He says : "It
is my opinion that it is a practicable undertaking to procure
good drinking water abroad, derived not only from personal
experience in France, Spain, Italy, Switzerland, Germany,
Holland, Belgium, etc., on the continent of Europe, but also
664
BOOK NOTICES.
[September 19,
on all three of the other continents. Not that the liquid sup-
plied has always been of ideal purity, but that I have never
suffered in any way from having remained throughout staunch
to my pledge to abstain from all intoxicating liquors as bever-
ages, though I must confess to the charge of a somewhat
immoderate use of drinking water. In almost every large
town on the continent I have been surprised at the quality of
the supply, regarding which I have invariably made inquiry of
local people other than hotel proprietors, who can hardly be
considered disinterested persons. Wherever there has been
the least doubt, I have felt safer in using aerated water as
likely to be the best procurable on the spot, or when doubt
was strong, apollinaris or Hunyadi, or other mineral water.
Then these were, very rarely, not procurable or insufficient, I
have had my drinking water boiled for at least ten minutes
and, if need be, filtered. In such cases tea has always been
my stand-by, a small box full of a decent quality being always
ready in my handbag. For filter, let me warn tourists against
all stone or charcoal block systems after they are once clogged
and work slowly. The block must then be thrown away and
replaced by a new one. For this reasons the filters that can be
recharged in afew moments with fresh charcoal, giving an abso-
lutely new medium as soon as required are far preferable. All
others soon become sources of danger instead of protection. The
filtering when needed should precede the boiling, unless soup
is required, though it is astonishing how often this natural order
is thoughtlessly reversed. A pocket or small table filter can easily
be carried in the lunch basket. It is well to inform the waiter
on your arrival of your teetotal principles before he begins to
recommend the cellar and to insist, on that account, on having
the water bottles on the table and in the bedroom thoroughly
well washed and refilled for your use. It is no use telling me
that wine is purer, for I have seen how wine is made, and have
trodden the wine press myself in Spain. When one is driven
by thirst to doubtful water the best plan is to rinse the mouth
well and gargle, or even to wet the face, neck and hands as
well. Careful mouth-washing after rich food is an invariable
ally to the total abstainer, and is invariably practiced by the
Mohammedans, the abstemious races of India and many others.
Before filtering muddy water, a little water will precipitate
much of the suspended matter, and so will other substances
less convenient in traveling. On country excursions there is
no preparation like a bottle of cold, unsweetened tea, just
bitter enough to prevent a mouthful being swallowed after
the thirst is quenched. I have found an average of one pint
a day sufficient for long rides in the sun in summer. Thus
with a little care, the subtle excuse of bad water is disposed
of, an excuse, which does much more evil than we hear of
in England. 1 am convinced that more travelers suffer from
eating too much meat and that too fast, than from the water,
and from inattention to the regular performance of digestion,
which is an invaluable index. My own custom is to eat in
every land the local food with such exceptions as pigs, carniv-
orous things, putrid (not rare) meat and shellfish; and I have
been duly thankful in every clime for the best of health and
good sleep."
Health Report. — The following reports of mortality from small-
pox, yellow fever and cholera have been received in the office
of the Supervising Surgeon-General U. S. Marine-Hospital
Service :
SMALLPOX— FOREIGN.
Antofogasta, Chile : July 24 to 31, 1 case, 1 death.
Bombay, India : August 4 to 11, 4 deaths.
Callao, Peru : August 2 to 16, 24 deaths. •
Gibraltar : August 16 to 23, 2 cases.
Licata, Italy : August 15 to 22, 3 deaths.
Madras, India: August 1 to 7, 1 death.
Madrid, Spain : A ugust 18 to 25, a3 deaths.
Montevideo, Uruguay : July 18 to 25, 3 cases, 1 death (vario
loid).
Moscow, Russia : August 8 to 15, 3 cases, 1 death.
Naples, Italy : August 15 to 22, 9 cases, 5 deaths.
Odessa, Russia : August 15 to 22, 4 cases, 3 deaths.
Pernambuco, Brazil : July 18 to 25, 50 deaths ; July 25 to
August 1, 51 deaths.
Rio de Janeiro, Brazil : August 1 to 15, 33 cases, 4 deaths.
St. Petersburg, Russia : August 15 to 22, 2 cases, 1 death.
Warsaw : August 15 to 22, 5 deaths.
Yokohama : July 17 to 31, 2 deaths.
CHOLERA*.
Egypt : Cairo, August 4 to 10, 14 cases, 4 deaths ; Alexan-
dria, August 9 to 15, 22 cases, 21 deaths.
During the period from August 4 to August 15 there were
1,008 cases of cholera and 554 deaths from that disease reported
from towns and districts in the interior of Egypt. From the
beginning of the epidemic to August 14 the figures are : 17,453
cases, 14,498 deaths. "In the Port of Alexandria to August 14
there have been 970 cases, 821 deaths.
India: Bombay, August 4 to 11, 21 deaths; Madras, August
1 to 7, 2 deaths ; Calcutta, July 25 to August 1, 8 deaths.
YELLOW FEVER.
Brazil : Rio de Janeiro, Aug. 1 to 15, 7 deaths.
Cuba : Cienfuegos, Aug. 23 to 30, 6 deaths ; Cardenas, Aug.
16 to 29, 65 cases, 22 deaths ; Havana, Aug. 27 to Sept. 3, 100
cases (?), 60 deaths ; Matanzas, Aug. 26 to Sept. 2, 31 deaths ;
Santiago, Aug. 22 to 29. 14 deaths ; Sagua la Grande, Aug. 15
to 29, 145 cases, 24 deaths.
BOOK NOTICES.
Transactions of the Medical Society of the State of California. Ses-
sion of 1896. A. P. Woodard, Chairman, W. W. Kerr, A.
H. Taylor, J. M. Williamson, M. H. Woolsey, Committee
on Publication. W. A. Woodard & Co., San Francisco,
Printers. 359 pp. Cloth.
W. G. Cochran delivered the address of welcome, which was
responded to in a happy manner by R. Beverly Cole, M.D.,
Ex-President of the American Medical Association. Presi-
dent W. Le Moyne Wills, M.D., in his address, ably discusses
the subject of medical progress, etc. He calls attention to the
subject of transportation of tuberculous patients and says it is
time the different States should give it attention, and if the
railroad companies will not discriminate and protect healthy
passengers, the States, through their medical officers and the
profession, must protect themselves and those entrusted to
their charge. The book contains, in addition to reports of
committees, lists of members, etc., some thirty-eight interest-
ing papers.
A Manual of Clinical Diagnosis by Microscopical and Chemical Meth-
ods. For Students, Hospital Physicians and Practitioners.
By Charles E. Simon, M.D., Late Assistant Resident Phy-
sician Johns Hopkins Hospital, Baltimore. In one very
handsome octavo volume of 504 pages, with 132 engravings
and 10 full page colored plates. Cloth, 83.50. Lea Brothers
& Co., Philadelphia and New York. 1896.
The special feature of this work on diagnosis is indicated in
its title, namely, the application of chemistry, and it is a fact,
beyond controversy, that the great preeminence of certain
European classes is due to the greater attention paid to chemis-
try, physiology, bacteriology and diagnosis. The author says :
"It is curious to note that, notwithstanding the great impor-
tance of clinic chemistry and microscopy, but little attention
is paid to these subjects, either by hospital physicians or by
those engaged in general practice. This lack of interest is
referable primarily to the fact that systematic study of these
branches has heretofore been greatly neglected, not only in
American medical schools, but also in those of Europe."
The laboratory method of diagnosis, when taken in connec-
tion with the well-known physical signs, makes the practice of
medicine truly a science, and we can not have coo many books
of this character.
The directions for examination of the various fluids of the
body and the excreta are so clear and explicit, that it does not
require an expert to follow out the tests as laid down in the
book. The work is well illustrated, and some of the illustra-
tions, being in colors, are beautiful.
L896.]
MISCELLANY.
(565
A Manual of Venereal Diseases. Hy Ja.mks R. IIwdkn, M.D.,
Chief ol Venereal Clinic, College of Physicians and Sur-
geons, New York ; Profenot ol ( lenlto-urinary and Venereal
Diseases in the Mori km I Department of the University of
Vermont, etc in one IStmo volume of •iti.'i pages, witli 47
engravings. Cloth, U.6Q, Lea ISrothers & Co., Publishers,
Philadelphia and New York. 1896.
In this little manual students and practitioners will find a
practical dissertation on the three venereal diseases — gonorrhea,
soft chancre and syphilis, with their complications and sequelae.
Tin- general line of treatment and the formulas given tire those
advocated by Prof. U. \Y. Taylor of New York, in his clinic. The
discussion of the history and statistics of these diseases, which
usually takes up a large portion of a volume, has been omitted
from this manual. The illustrations are fair; the mechanical
execution of the work is all that could be desired. We notice,
however, that the Otis instrument figured on page 103 is an old
pattern, and not the instrument having a tunneled extremity
for the passage of the guide, which is that we believe most
recently used and figured in the volume of Park previously
noticed. For examination purposes, and those preparing for
examination, the manual will be found very useful.
Jackson's Ready-Reference Handbook of Skin Diseases. TheReady-
Keferenee Handbook of Diseases of the Skin. By George
Thomas. 1 icKSON, M.D., Professor of Dermatology, Woman's
Medical College of the New York Infirmary and in the Uni-
ty of Vermont, Chief of Clinic and Instructor in Derma-
tology. College of Physicians and Surgeons, New Y'ork. New
edition. In one 12mo, volume of 589 pages, with 69
illustrations and a colored plate. Cloth, 82.75. Philadel-
phia. Lea Brothers* Co., 1896.
In this the second edition of this work the author has added
siderably both to the text and illustrations.
The greatest defect is that it gives too much space to the
recipe, and too little to pathology and etiology. Practical phy-
sicians who form their opinions upon the analysis of the symp-
toms and history of a case rather than its disease label will
regret this. The work however is a useful one and this edition
will doubtless have a great sale.
MISCELLANY.
Dr. Charles A. L. Reed has been elected gynecologist and ab-
dominal surgeon on the staff of the Cincinnati Hospital, vice
Dr. T. A. Kearny, resigned.
Illinois Medical College Commencement.-- The second annual
commencement exercises of the Illinois Medical College, Chi-
cago, were held September 10. A class of ten, three of whom
were women, received the degree of Doctor of Medicine. The
Bishop prize for the highest grade in clinic surgery was won
by William P. Sterman.
A New Cycle Ambulance has been invented by Dr. Honig of
Berlin. It is not drawn by horses or men in the ordinary way,
but is propelled by cyclists, and consists of a kind of litter
resting on a frame with five wheels, three in front in the form
of an ordinary tricycle, and two at the back.— Albany Med.
Annals, September.
Homage to Pasteur.— An interesting feature of the recent
International Congress of Applied Chemistry at Paris, was
when the members repaired to the Cathedral of Notre Dame
and defiled past the chapel where Pasteur's remains are lying,
leaving there a magnificent wreath of cut flowers, with an
appropriate inscription. They went from there to the Institut
Pasteur, where they witnessed several antirabic injections,
and closed the day by visiting the stables where the immu-
nized horses are kept.
Connection between Rachitis and Humidity. -A study of rachitis
or English disease, as it is called, is published in Wratsch,
No. 17, which asserts that it is a physiologic condition in local-
ities with a relative annual humidity of 80 per cent., while it
m yer appears where the annual humidity is 8per cent., except
under exceptionally favorable circumstance for its evolution,
and is unknown in localities with less humidity than this. —
St. Petersb. Mid. Woch., No. 7.
Post-Uraduate Medical School of Chicago.— The Post Graduate
Medical School of Chicago moved into its new building
and new location tit 2400 Dearborn Street, Sept. 1, 1896. The
new building is an ornate structure, seven stories in height,
constructed as a clinic school and a clinic hospital. The school
is complete having the most modern lecture rooms and labora-
tories. The hospital has accommodations for 100 beds. One
floor is artistically furnished for private patients. There are
fouroperating roomsof the most modern construction, including
an amphitheater operating room, which will accommodate 300
students. The building is lighted with electricity and is pro-
vided with elevators. The location is selected because of its
superior clinic advantages. Within a distance of ten minutes'
ride from the school proper are the St. Luke's, Charity, Michael
Reese, Mercy, Woman's and Wesley Hospitals. Clinical
instruction will begin in the new quarters at once.
Criminality of Hygienists. A witty article in the Revue Medi-
cate de Paris laments the growing scarcity of the sick and the
increasing numbers of physicians. It denounces Jenner, Pas-
teur, etc., as guilty of depriving their colleagues of their daily
bread and wrecking the profession. Especially is this the case
in the cities where prophylactic and hygienic measures are
most strictly enforced and the sick number less in proportion.
It adds a few figures in confirmation from the death records
of Paris during the last ten years, stating that the figures to
date for 1896 show even more marked reduction :
Deaths caused by 1886 to 181(0. 1880 to 1895.
Smallpox 1,271 656
Scarlet fever 1,225 946
Measles 6,671 5,192
Diphtheria 8,3a3 7,588
Typhoid fever 5,904 3,493
Vaginal Hysterectomy.— In cases where hysterectomy must be
an operation of election there may be conditions that will
require the vaginoabdominal or the suprapubic method. The
following are some of the reasons why vaginal hysterectomy
should be preferred to celiotomy : 1. There is less shock and
more rapid and complete convalescence. 2. In pelvic suppu-
ration there is less danger of septic infection from soiling the
peritoneum. 3. Absence of suture or mural abscesses, and of
sinuses following the use of drainage or an infected ligature.
4. Immunity from ventral hernia. 5. A lower mortality, ,
fewer post-operative complications, and a more complete restor-
ation to health in a relatively greater number of cases. The
above are facts, as shown by the statistics of the most success-
ful operators in celiotomy and vaginal hysterectomy ; and in
vaginal hysterectomy many of the cases were inoperable by any
other method.— Dr. William H. Mathew, in Am. Jour. Obst.,
September.
Defective Breasts a Sign of Degeneracy.— Hegar appeals to young
men on behalf of posterity to select women with well developed
breasts for their wives, and suggests that the young women
can retaliate by refusing to marry a man unless he can produce
a record of having been a "breast baby." He quotes statistics
to prove that inability to nurse a child is a sign of degeneracy,
and produces degeneracy. We note among the facts he cites
that in a certain district which supplies large numbers of wet
nurses to the city, the percentage of men physically incapable
of military service amounts to 30 per cent., while in the neigh-
boring districts where the mothers remain at home with their
families, it is only 18 per cent. He also remarks upon the
surprising numbers of deformed nipples encountered in the
hospitals. Fehling mentions "hollow nipples" as occurring in
6.7 per cent, of his obstetric cases. Hegar warns mothers not
to allow the clothing to constrict the growing breasts of their
666
MISCELLANY.
[September 19,
daughters, and urges general hygiene as the best method to
develop them.— Deutseh. Med. Woeh., August 20.
Influence of Sugar on the Energy of the Muscles.— Schumburg
states that he has been experimenting with Mosso's ergograph
to determine whether sugar increased the muscular power as
some assert, or whether the increase in energy observed is due
to psychic influences. He found that the sugar produced no
perceptible effect on fresh, unfatigued muscles, but that
muscles fatigued from previous severe exertion were strength-
ened to a noticeable degree. This effect was attained whether
the muscles were strong or weak. — Deutseh. Med. Woch.,
August 20.
The Pan-American Congress. -The committee in charge suggests
to the home members climatology and a study of yellow fever
and its disappearance as the altitude increases, as special sub-
jects in which home talent might render great service to science.
Also the study of leprosy and of the endemic ' 'pinta. ' ' Typhoid
fever and malarial disorders are also of universal interest, and
the physician of Mexico has especial opportunity to observe
them under varying conditions of climate, etc. Another sub-
ject for which he is especially qualified is the changes under-
gone by the organism in adapting itself to varying altitudes.
The Mexican surgeon is also peculiarly an authority on the
wounds produced by "cold steel." It also sensibly advises
the home members not to expatiate on the deficiencies, but to
reserve such facts for the national gatherings, and in the
international congress, to dwell rather on what has been accom-
plished in their country.
Treatment of Chlorosis with Ovarian Extracts.-Spillman and
Etienne have treated six cases of chlorosis with ovarian ex-
tracts with satisfactory results. They say of the ovary that it
is a gland with an external secretion, the ovum ; that it is also
a gland which eliminates by means of the menstrual flow the
excess of organic toxins, while at the same time it is a gland
with an internal secretion, like the testicles, and this internal
secretion plays an important part in the general nutrition.
When the ovaries are diseased, these three functions of the
gland are modified or abolished, and with the suppression of
the menses appears that special intoxication, chlorosis. This
general morbid condition prevents in turn the restoration of
the ovaries to normal conditions. Administering ovarian tis-
sue or extract favors the elimination of the toxins and intro-
duces into the organism an antitoxic principle which seems to
exert a beneficial effect on the general health, to increase the
number of corpuscles and cause the reappearance of the
menses. They administered fresh ovarian tissue from lambs,
or the same desiccated, and also extracts prepared by the
Brown-Sequard-d'Arsonval method. Mairet added to their
communication to the French Medical Congress, that his expe-
rience confirms their statements and also the fact that the injec-
tion of blood and the products of other glands, notably of the
testicles, improves the general nutrition. Teissier remarked
in regard to the injection of renal extracts, that they attenuate
accidents of renal origin by augmenting the elimination of
poisons through the urine.- Bui. Mid., August 26.
Creation of Universities in France There are no universities in
France at present as we understand the term, but recent legis-
lation to take effect in 1898 unites the separate "corps de
facultes" which now have charge of higher learning into
organized combined institutions similar to those in other coun-
tries. Fifteen cities have "corps de facultes," and half of
them have all four departments, medicine, law, science and
philosophy, but these departments have been heretofore sepa-
rate entities, with no interests in common, their expenses paid
by the government and the receipts from students paid to the
government. The new law merges these separate faculties
into universities, which are to retain a certain proportion of
the fees from students, with other privileges depending upon
the number of students they attract. It is evidently an
attempt to foster a spirit of emulation and catholicity of cul-
ture. A letter to the Deutseh. med. Woch. commenting on
the new order of things, mentions the strictly obligatory nature
of the French courses ; three absences from a course without
an excuse and one's name is dropped from the list and one
loses the trimester. There is no such thing as academic option
in France except in regard to the conventionalities and police
regulations. It adds that there is more license allowed in
Paris, at least, in these respects than anywhere else in the
world probably.
Pathologic Study of the Kidneys. Mircoli describes in the Oaz.
degli Osp. e delle Clin, of August 23, a series of experiments
on rabbits to investigate the beginnings and course of renal
lesions, as such lesions usually come under observation in the
clinics only in the latest stages. He found that one diseased
kidney was apt to infect the other, also that lesions of the con-
nective tissue and of the epithelium and albuminuria have a
characteristic tendency to become aggravated and progress-
ively chronic. The albuminuria in interstitial nephritis is the
exponent of the various stages of the development of the mor-
bid condition, rather than of the intensity or extension of the
process ; its disappearance may therefore coincide with the
maximum of the lesions in the connective tissue. He also
established the fact that a localized lesion tends to extend
along the route of the connective tissue, and ultimately to
affect all the viscera, with a diffuse alteration.
Fat as a Factor in the Production of Hernia. -Tillaux and Cham-
ponniere assert that the original cause of almost all hernias,
congenital inguinal hernia excepted, is an exaggerated devel-
opment of adipose tissue, or the other extreme, emaciation.
The tendency to obesity should be combated on this account
with gentle gymnastics, especially balancing, and the frequent
use of mild purgatives to keep the intestines empty, with suit-
able diet, little meat, no alcohol in any form, and other means
to keep the functions of the skin and kidneys active, hot dry
or steam baths, mineral waters, &c. Elderly persons should
seek gentle exercise, avoid effort in defecation and coughing,
and also not lie too much in bed nor sleep too long. It is often
best to precede an operation with antifat treatment of this
kind. In certain cases of distressing hernia, surprising relief
is sometimes obtained by reducing the obesity. — Bulletin de
V Acaddmie de M., August 25.
Reinfection of Syphilis.— The recent specialist Congress at
London and also the French Congress of Internal Medicine,
devoted considerable time and discussion to this question.
Cases were described in each that seemed to prove conclu-
sively the fact of recovery from the first attack and reinfection
later. But the French and some others still cling to the theory
that once a syphilitic, always a syphilitic, or as the English
specialist remarked : "The soul of a syphilitic will rise syphili-
tic at the Judgment Day." Fourrier in France and Ogilvie at
London cited convincing cases of reinoculation, but the latter
protested against confounding the question of reinfection with
the question of curability, as reinfection may occur in the
midst of tertiary symptoms, as he has had occasion to observe,
while on the other hand, he thinks that even if there is no such
thing as reinfection, still this does not prove the incurability of
syphilis, as immunity is not synonymous with disease.
Applied Chemistry. — The recent International Congress
decided that the word "extractive" should be henceforth
dropped as vague and unnecessary. The term "azoturic
proportion" will also supersede the term "coefficient of azotic
oxydations" in the analysis of urines, to express the propor-
tion of azote in the urea to the total amount of azote in the
urine. In determining the amount of uric acid, the Salkowski-
Ludwig method is to be used where extreme accuracy is desir-
able, but the Deniges' method is sufficient for all practical
1896.]
MISCELLANY.
667
purposes. In testing physiologic ami pathologic liquids, they
are do longer bo be manured by bulk, but by weight, with a
standard quantity in a standard platinum capsule, fora stand-
ard length of time and under standard conditions of tempera-
ture. This system is already followed in analyzing sugars,
wines and foods. The standard of acidity is to be the number
of cubic centimeters in normal alkalin thud. Gastric juice is
bo be the only exception to this. Its acidity will be estimated
as hydrochloric acid, with phenolphthalin for the indicator.
Further efforts were made to unify the Codex, and the con-
gress officially resolved to appoint a committee in each coun-
try bo establish the standard of purity for each medicine, and
the quantities of the active principles contained in it, with a
statement of the methods of dosage and the corresponding
proportions in foreign pharmacopeias this official analytic
supplement to be included in each Codex.— From the Bulletin
((c FAead. da 1/., August 11.
•Wisconsin Eclectic Medical College of Milwaukee," Wis We
have received of Or. C. K. ( lay of Windsor, Vt., a letter which
encloses various circulars of the Wisconsin Eclectic Medical
College. It seems that the Medical and Surgical Directory
wrote Pr. Gay. and receiving no reply, placed B star opposite
his name : whereupon the diploma mill people write a letter to
1 >r. Gay. which runs about as follows :
'■ We notice your name in a Surgical Directory, but with a
star appended, to which a foot note reads: 'No report
received in answer to inquiry regarding graduation.' It by no
means intends to convey the idea that the person so designated
is not a graduate : yet naturally in such a case the presump-
tion is fair that this is so. If, however, it should be that you
are a graduate and have a regular diploma, then we can but
tender our most sincere apologies for troubling you in the mat-
ter. But, on the other hand, if you are not a graduate and
have no regular diploma, then the perusal of the enclosed
prospectus can not fail to be of the most primary importance
and interest to you. We would also desire to draw attention to
the fact that to practicing physicians our fees are much reduced
from the regular rate. To this class our fees are $35 all inclu-
sive. As proof of our legal standing and right to confer the
degree of M.D. we can supply certified copies of our charter at
SS cents each, simply covering the cost of certifying officer's
fee. Trusting soon to hear from you and standing ready to
answer any or all questions you may wish to submit, we are
" Yours very sincerely.
"Wisconsin Eclectic Medical College."
They also inclosed in this letter a reduced cut of their
diploma, the original of which, according to the veracious cir-
cular, is lSxii. This reduced cut bears the names of Fred
Rutland. Ph.D.. M.D. ; Charles Podmore, M.D. ; Rosa Demp-
ster, M.D. : Jules Gordon, M.D., Prof. Anatomy; William
Newton, M.D. ; Horatio Myers, M.D. We also infer from cer-
tain insignia on the bottom of this valuable document that
there are five ribbons attached thereto, of the colors respec-
tively, black, red, white, blue and old gold. This seems to us
most brazen effrontery. The papers in the case have been for-
warded by us to the A ttorney -General of the State of Wisconsin.
Solidified Casein Casts and Improved Bandages.— Soloview states
that fresh caseum mixed with one-eighth its weight of liquid
ammonia, makes a gluey mass that is especially adapted for
casts, on account of its lightness and cheapness, while it
answers every purpose. It has to be made on a cast first taken
of the part and removed with a longitudinal section. The
caseum cast is then made on this with first a layer of felt, held
in place with a piece of flannel, then the drilling soaked in the
caseum glue is wound around it twice, with a layer of fine
shavings between each layer. An outer layer of the caseum
drilling completes the cast, which is then placed in the oven to
dry until next day, when it is ready to be applied to the
patient. A caseum corset retains its shape on a child for four
months, but it is apt to crease on an adult in time unless it is
strengthened by a fewsplints or bones. (Semaiiie Mid., August
2t ;. i Thilo of Riga, also writes to the St. Petersb. Med. Woch.
August 15, that he derives great advantage from a piece of
white felt laid over the ankle or knee, in applying a compress-
ing bandage for sprains, etc. It enables the bandage to be
drawn much tighter than usual, without injury to the wounded
joint. He slits the felt or makes an oval opening over the most
sensitive part, and thus the pressure on top of this elastic pro-
tector can be indefinitely increased. The patient can even
resume his ordinary occupations with a bandage of this kind,
and the best results follow its use.
Prevention of Suppuration In Acute Pelvic Inflammations. Wm.
R. Pryor, M.D., says : The observation and experience of six
years with conservative curettage have taught me to surely
expect a complete recovery in cases of acute endometritis with
salpingitis and peritonitis when seen early in first attack. For
two years, in all such cases, I have operated as follows : The
uterus is thoroughly curetted and irrigated. All instruments
being changed, in a few minutes the cul-de-sac is opened and
a wide blunt dissection made in the vagina and cul-de-sac by
separating two fingers. The fimbriated ends of the tubes are
opened if found closed. All serous-fluid accumulations are
evacuated, and the pelvis wiped dry. No irrigation is here
used. I then pack from three to five yards of iodoform gauze
into the pelvis, each strip being about three inches wide. The
uterus is next tightly packed as is also the vagina. A self-
retaining catheter is introduced. On the third day the vaginal
gauze is removed together with that in the uterus. The vagin-
al gauze is renewed, but the uterine packing is not, unless the
uterus be large. The gauze in the pelvis is removed in a week
or ten days under chloroform and another large pelvic packing
is made. The results of this operation are most gratifying.
The lymph which is thrown about the antiseptic dressing dis- .
appears in a few months and the uterus becomes perfectly
movable. Accidents have never happened and I have been
uniformly successful in preventing suppuration. In several
cases of relapsing salpingitis I have met with large hydrosal-
pinx and broad ligament cysts. These were merely incised
and evacuated. — Med. Neios, September 5.
Amendment of South Carolina Law as to Commitment of Insane. —
The South Carolina enactment approved Dec. 24, 1894, to fur-
ther regulate and provide for the admission and discharge of
patients to the lunatic asylum and promote the management of
the same, was amended by an act approved in March, 1896, by
adding the following proviso to the end of section 5 thereof :
That the superintendent of the Lunatic Asylum, now known
as the State Hospital for the Insane, shall receive into his cus-
tody and detain in said hospital for a period not exceeding five
days, without an order from the judge of probate, any person
as insane whose case is duly certified to be of violent and dan-
gerous insanity and emergency by two reputable physicians,
which certificates shall be separately signed and shall conform
to all the requirements as now provided by law. In addition
to such certificates, an application, signed by a trial justice,
mayor or alderman, intendant or warden of the county, city or
town in which such insane person resides or is found, shall be
left with the superintendent of said state hospital for the
insane, and said application shall contain the answers to the
list of interrogatories now in use by the regents of said hospital ;
provided, further that when such insane person is committed
and received in said hospital for the insane, the party commit-
ting such person shall give a bond in the sum of one hundred
dollars to the treasurer of said institution, with condition that
he or she will within five days procure an order for the com-
mitment of said patient as now provided for by law, and failing
therein said insane person shall be removed or discharged by
the superintendent of said institution and suit brought by him
(if he sees proper to do so) on said bond for the cost of mainte-
nance of said person while confined. For the duties required
of the judge of probate, under the provisions of this act, he is,
668
MISCELLANY.
[September 19,
by further amendment, allowed the sum of five dollars. And
the following fees and charges, it is further enacted, shall be
paid for the conveying of insane persons to the hospital ; to the
officer or person conveying said insane party, 82 per day and
12 cents per mile one way, and out of which said mileage herein
allowed shall be paid all the costs and expenses of said insane
person. If it shall be necessary to employ a guard to assist in
conveying such insane person, such guard shall receive one
dollar per day and his actual railroad fare. Said charges shall
be paid out of the county treasury on order of the supervisor.
Some Unrecorded Symptoms of Tetanus. De Brun writes from
Syria to the Acad<?mie de Med. that tetanus is often encoun-
tered there, and is not infrequently produced by the use of
cautery, which is quite a popular remedy. He has had seven-
teen cases under observation and records certain symptoms
which are not noted by the authorities. One is the obstinate
constipation, resisting purgatives and enemas, and returning
after each laboriously secured evacuation. Another is the
ravenous appetite in sub-acute or chronic cases. Thirst is
torturing in all, and often the only service that can be rend-
ered the sufferer is to keep the parched lips and mouth' con-
stantly moistened. Other symptoms are the tenacious and
sometimes absolute insomnia, and the frequent and violent
sweats, which persist at irregular intervals even after recovery
in some cases, so severe that the patient has to return to bed.
But they have no critical significance, and do not attenuate
any of the symptoms. There is also an invariable and intense
desire to keep changing the position. He mentions three cases
in which the tetanus had shortened certain muscles, producing
a strange inability to sit or lie down directly, to step on the
heels, to open the mouth wide, etc. He describes at length
one case of this kind, following cauterization of the shoulder
for a contusion, the wound dressed afterward with chick-peas.
It was three months and a half before the shortened muscles
were brought to approximate normal length. His treatment
was chloral, 10 to 14 grams a day, in fractional doses, 3 to 5
grams of antipyrin, and for one fortnight, 2 to 1 hypodermic
injections of % milligram of sulphate of atropin, with exercise
of the muscles the last six weeks. Teissier refers in half a
dozen words to this shortening of the muscles : "Occasionally
certain contractions persist a long while."
Expert Evidence as to Cause in Malpractice Case.— The question :
"Is it legally competent, in order to show malpractice, for a sur-
gical expert, with the results of a surgical operation performed
nearly two years prior before him, either through his own per-
sonal examination and investigation of that result, or through
a hypothetic question placing the results before him, to give
an opinion as to the cause or causes that produced the results?"
was presented by the case of Tullis v. Rankin. The trial court
held that it was not. But the supreme court of North Dakota
reaches the opposite conclusion, as stated in the opinion handed
down July 2, 1896, while admitting that the question is close,
and that authorities can be found that give support to the
ruling of the trial court. It is doubly important to note the
facts, as it is said that each case heretofore involving the ques-
tion seems to have been ruled to some extent by its own
attendant circumstances. In this case, the plaintiff had his
foot run over and crushed by the cars on May 5, 1893. On
that same day his leg was amputated by the defendant, and he
was sent to a hospital where he remained about two months.
The wound never entirely healed, and the pain never left it,
until after a second amputation was performed by three other
surgeons, in March, 1895, when the limb healed, and all pain
ceased. These gentlemen were severally sworn as expert wit-
nesses for the plaintiff. They testified in detail as to the con-
dition of the limb and the patient at the time of the second
amputation. After having so testified, each was asked : "What,
in your opinion, was the cause of the condition in which you
found the limb at the time you made the examination and
amputation?" And to one of them, a hypothetic question was
put incorporating the facts to which the plaintiff had testified
as to his injury. Conceding that the ultimate object was to
show that an improper or unskillful amputation was the cause
of the condition, the supreme court still holds that the ques-
tions as asked should have been answered, and on that ground
reverses a judgment which had been given the defendant,
ordering a new trial. The opinions, if given as anticipated, it
says would have concl uded nothing. They would have gone
to the jury for what they were worth. It was still open to the
defendant to show that the original amputation was skillfully
and properly performed ; still open to him to show that other
circumstances and events influenced or produced the results ;
still open to him to show by other expert testimony, if he
could, that the opinions of the plaintiff's experts were unwar-
ranted in scientific surgery. Courts as a rule, it is also said
in this case, entertain an aversion to expert testimony, par-
ticularly medical and surgical expert testimony, and that expe-
rience no doubt warrants the aversion ; but it is not to be
excluded on account of the embarrassment its weight or lack of
weight may cause a jury.
New Light on the Pathologic Processes in Cholera.— Federn makes
the surprising announcement in the Wien. Med. Pres.se, No. 25
that he finds with the sphygmomanometer that the pressure of
the blood is increased in cholera, instead of being lowered, as
is stated by all the authorities from Griesinger to Leyden.
This increased pressure can not be due to any stronger action
of the heart, but rather to increased resistance in the vascular
system, commencing in the splanchnicus region and probably
spreading thence to the entire system. This throws a new
light on the nature and course of the choleraic processes. Two
factors must unite to produce this elevated pressure : the
thickening of the blood from transudation, and increased
resistance in the vascular system. When this resistance is
great a slight transudation is enough to produce cardiac fail-
ure, and when both factors are acting powerfully the course is
rapid. These facts show that the old methods of treating
cholera wore faulty in two respects : First, in considering the
transudation in the intestines as of less importance than stim-
ulating the action of the heart, at the beginning of the asphyc-
tic stage, when the diarrhea grows less or ceases entirely,
although the necropsies show that the transudation persists.
This error can be remedied by tannin enterocleisis. The sec-
ond error was in directing all the efforts toward stimulating
the action of the heart, as it was never suspected that the
pressure of the blood had been elevated by increased resistance
in the vascular system. The results of Federn's observations
will be that henceforth the effort will be to resist this tendency
in the vascular system, and it may even be possible to prevent
the asphyctic stage altogether. The problem of how to
respond to these indications is still unsolved, as it has scarcely
yet confronted practical medicine, except in the case of angina
pectoris. But reasoning from analogy, Federn advocates the
general use of calomel from the start, instead of beginning
with astringents and opium, as, in most cases, increased blood
pressure proceeding from the intestines is the result of irrita-
tion of the splanchnicus usually produced by constipation.
Federn has also observed an elevated blood pressure reduced
by natrium salicyl. in large doses, four to six grams, antipyrin,
phenacetin, salipyrin in doses up to two grams, morphin,
codein and chloral hydrate ; but the most powerful effect is
obtained by chloroform narcosis. Cramps of the capillaries
are an important factor in the fatal termination of cholera, and
thus the use of chloroform, our most powerful remedy for
cramps of all kinds, is already indicated. He also suggests
faradization of the intestines, which is sure to lower the press-
ure resulting from partial atony, but querito whether it is
practicable in cholera, on account of the tendency to muscular
cramps, even in the bowels. — Therapeut. Woch., August 9.
18%.]
MISCELLANY.
669
Cerebral Localization.- President Pitre's address on this sub-
ject at the French Medical Congress last month, forms an inter-
iWflg supplement to the editorial in this Journal July 18, page
161. After a historic sketch and a description of the neuron,
he referred to the two groups of cells which histologic investi-
gation reveals in the cerebral cortex : the pyramidal cells, with
their long axis cylinders, passing through the internal capsule
into the subjacent bulbo medullary centers, and the second
group of cells, smaller and of various shapes, which are entirely
contained in tho gray cortical matter in a network of associated
cells. Histologic anatomy reveals absolutely nothing in regard
to the functions of the latter. But we have learned to know them
by clinic observation, thanks to the arrangement of the elongated
neuron processes in t he internal capsule. Any injury to the inter-
nal capsule is liable to affect these elongated processes located in
it, while not affecting at all the smaller associated cellswhichdo
not extend into it. He quoted various writers who have estab-
lished from clinic experience that injury to the capsule and its
cell processes produces motor and sensory disturbances, but
never psychic. The intellect, the memory, the will, etc., are
never atlected by injury of the internal capsule alone. The
psychic functions reside in the innumerable associated neurons,
the second group of cells referred to above, whose branching
terminals ramify all through the gray matter of the convolu-
tions in ever}- direction. These neurons not having any cap-
sular process, and not being grouped in anatomically isolated
islands, are not accessible to our methods of investigation.
They even escape anatomo-clinic study, owing to that indeter-
minable extension and far-reaching influence of any lesion of
the cortex, even the most limited. Everything tends to prove
that the functions we attribute to them are not localizable. It
is certainly a vain quest to seek for the seat of the memory, the
intelligence, the will. These words represent entities in schol-
astic language, but in fact, they are only abstract terms, which
mislead us into a false conception of the complex phenomena
they represent The intelligence is in physiology, something
analogous to what we mean in economics by the State. This
word State is also a substitute which represents by an abstract
terni, an infinitely complex reality, an organized power which
acts through a multitude of agents, subordinate one to the
other, and distributed throughout the entire territory in such
a way that it would be necessary to suppress the entire army
of officials of all kinds, in order to destroy at one blow the ad-
ministrative, judicial, military, collegiate and religious mechan-
isms which combined, constitute the State. The mind is
"fragmented" in the same way. Each cerebral cell contains
a part of it. Xone is its exclusive organ. We have no grounds
at present to suppose that there is anywhere, a conscience
center, a judgment center, an intellect center, etc. According
to the present status of our actual knowledge, we must consider
the gray matter of the convolutions as the essential organ of
psychic elaborations. They operate in the network formed by
the terminal ramifications of the polymorphous cells of the cor-
tex. This extremely complicated network in which, so far, we
have been unable to establish any precise localizations, is con-
nected with the periphery by the system of pyramidal cells with
the long processes, whose functions are to receive, to record
and to preserve the sensory images which form the first mate-
rial for the mental operation, and the motor images which are
the final product. Those which serve for the sensory impress-
ions are distributed through the sphenooccipital lobes ; those
which serve for the motor impressions, through the fronto-
parietal lobes. This explains why lesions of the anterior lobes
of the brain are not so important physiologically as lesions of
the posterior lobes. The former produce disturbances in the
sensory images perceived, but the latter prevent the formation
of motor impr^sions and the transmission of will-impulses.
This is the explanation, unless I am mistaken, of the struc-
tural identity of the convolutionsshown by the histologists, and
of their functional diversity, which has been established again
and again by thousands of exact, incontrovertible facts accum-
ulated by investigators and clinicians of all schools and in all
lands.
Physician Commended Under Unusual Circumstances.— The Lon-
don Lancet, August 8, tells tho following pitiful story of a
woman's death and a physician's trying situation. It so hap-
pens that the good acts of the medical man were recognized—
but what might not have been the jeopardy of his whole pro-
fessional life, if some one or more had found it to his or their
interest to lie about him. As the Lancet well says, the situa-
tion fairly "teems with difficulties," and dangers as well. The
story is this : "An inquest was recently held at Chelsea touch-
ing the death of Miss P. T. Handford, who died aged 34 years
after having miscarried. On J une 25, 1896, she consulted Dr
C. J. Harrison, who prescribed for her for anemia. She then
said, 'If I tell you a secret will you keep it?' and upon Dr.
Harrison replying in the affirmative she mentioned that she
was pregnant. July 8, she went again and suggested that
Dr. Harrison should procure abortion for her. This he
absolutely refused to do and dissuaded her as strongly as pos-
sible. On a subsequent occasion she repeated her request with
the additional inducement of a blank check. Dr. Harrison
again refused, and July 22 Miss Handford arrived at his house
looking very ill and fainted in the consulting room. As she
was obviously very ill and had profuse hemorrhage Dr. Harri-
son allowed her to remain in his own house and communicated
with her friends. The cousin of the deceased arrived, and
later in the evening the patient asked the nurse in attendance
to write a statement for her, in which she said that Dr. Harri-
son had refused to bring on a miscarriage, so 'this morning
feeling desperate I went to a doctor in town, his name I
refuse to mention, and he did something to me and told me
that I should be all right, and as I walked toward home I
turned faint and decided to go in and see Dr. Harrison before
going home, and he allowed me to lie down ; but I grew worse
and fainted, and it was decided that I should stay here all
night.' On the day following the deceased had a miscarriage,
but went on well up to Friday, July 24, when the temperature
went up. Dr. Herbert Spencer and Dr. Bradford saw her and
considered her fit to be moved to Cheyne-walk, where she died
upon July 27. Mr. A. J. Pepper, who made the postmortem
examination, said that the deceased had nephritis. The uterus
was healthy, but abortion had recently taken place. The
cause of death was uremia from nephritis aggravated by the
abortion. At the adjourned inquest on Wednesday, August 5,
a verdict of 'Wilful murder against some person or persons
unknown' was returned, and the jury adding : 'We wish to
take some appreciative notice of the unselfish and Christian
humanity of Dr. Harrison.' This is a very sad and very familiar
story. We believe we are right in saying that the procuring
of abortion otherwise than for reasons which can be medically
justified is banned by the civil and ecclesiastical law of every
civilized country, and as constructive murder it is right it
should be so. But the whole question teems with difficulty.
It certainly appears unjust, and very possibly is actually so,
that a woman who, driven and harassed by shame and fear
resorts to the questionable remedy of abortion should be liable
to severe punishment, while the man who is equally responsi-
ble for the child goes free. Of course he is not responsible for
the criminal act of the woman ; but he is morally responsible
in so far as he shared in bringing about the condition which
made her resort to crime, and morally he is guilty although we
fail to see how he can be made legally accountable."
Atlanta.
Southern Medical College. — Several changes have been
made in the faculty of the Southern Medical College. Dr.
Henry F. Harris, the former professor of chemistry and clinic
670
MISCELLANY.
[September 19, 1896.]
medicine, has resigned to accept the appointment of associate
professor of bacteriology in the Jefferson Medical College of Phil-
adelphia. Dr. Harris is one of the Sou th's most able and ener-
getic workers, and his researches in the field of amebic dysen-
tery gives him prominence in this country. He has given much
time to the study of this semi-tropical diarrhea, and will in a
short time publish an interesting illustrated article on this
subject. Dr. Ashby M. Purse of this city, has been appointed
to succeed Dr. Harris as professor of chemistry in the South-
ern Medical College. He will fill the chair of chemistry with
judgment and ability. Dr. G. G. Roy has been succeeded by
Dr. C. D. Hurt of this city as professor of materia medica and
therapeutics ; Dr. Roy will remain with the college as an eme-
ritus professor. Dr. Nicolson, the dean of this institution on
the death of Dr. Powell, its founder, was made president by
unanimous vote of the board of trustees. Dr. Nicolson' s rank
as a surgeon is well known. Dr. J. G. Bourns, late of Ann
Arbor, has been elected professor of bacteriology, pathology and
histology. Dr. Lucien Lofton of Atlanta, has been appointed
assistant to the chair of anatomy, and assistant demonstrator
of anatomy.
The Atlanta Medical College has made the following
changes : Dr. H. P. Cooper will fill the chair of anatomy lately
occupied by Dr. W. S. Armstrong, deceased. Dr. Hubbard of
Atlanta, has been appointed assistant to the chair of materia
medica.
Insolation.— A number of deaths have occurred in Atlanta
and the immediate vicinity as result of heat stroke. Among
the number, several children have succumbed. The immunity
or resistance of the negro is noticeable. A fatal case of sun-
stroke among the colored men hardly ever occurs here.
Governor Atkinson recently appointed Dr. J. B. S. Holmes
to succeed Dr. Olmstead on the regular board of medical exam-
iners of Georgia.
Why is it that the Georgia State Board does not look after
the herd of wandering quacks that infest the city and the
State?
Dr. I. B. Diamond, recently of the Johns Hopkins Univer-
sity, was last month elected to the position of pathologist to
the Grady Hospital.
Cincinnati.
The mortality report for the week gives : Zymotic diseases
4; cancer 8; phthisis pulmonalis 11; other constitutionals;
local 40; developmental 12; violence 8; under 5 years 28;
total 86 ; annual rate per 1,000, 12.77 ; corresponding week 1895,
124 ; 1894, 95.
The Academy of Medicine held its first meeting of the win-
ter September 14. Dr. Albert Freiberg presented a paper on
" Sub-phrenic Abscess following Appendicitis."
A movement is on foot to organize a hospital for the care and
treatment of the colored race in Cincinnati and vicinity. Dr.
Frank W. Johnston is at the head of the monument.
Diphtheria is spreading throughout the Mill Creek valley.
Dr. Joseph Eichberg, and Dr. S. E. Allen announce their
removal to the "Lancaster" No. 22, W. 7th Street.
Charles Collins, a well known G. A. R. veteran has been
appointed to succeed James Sherlock as supervisor of the
Branch Hospital.
The matter of the investigation of the Hygeia Medical Col-
lege has at last been finally disposed of by the State Board of
Medical Examiners, who have decided that the graduates from
this institution will not be recognized as graduates and will have
to pass the examination before the Board in order to be allowed
to practice in the State.
The annual report of the Health officer, just issued, shows
a balance on hand of 84,835.93 out of an appropriation of $44,-
393.23 set aside for the maintenance of the Health Depart-
ment. The milk inspector made 2,755 visits to dairies and
prosecuted 25 cases for violation of the milk laws, of which
21 resulted in a conviction ; 100,103 cows were inspected and
stock valued at 854,116 was condemned. The Health officer
recommends the establishment of a central disinfection station
for the thorough disinfection of all goods subjected to the
influence of contagious diseases, public baths and the estab-
lishment of an isolation hospital.
The City Board or Health of Mt. Sterling, Ohio, have
ordered the public schools closed and all public gatherings
stopped on account of the prevailing epidemic of diphtheria.
The members of the Hempstead Medical Association of
Portsmouth have decided to prepare a black list of all persons-
who refuse or deliberately neglect to pay physicians' bills. The
arrangement is to go into effect October 1, and medical treat-
ment is to be refused to all persons whose names are on the list
unless paid for in advance.
A case of fatal epistaxis occurred at Van Wert, Ohio, last
week. The various methods for the checking of the hemor-
rhage were adopted but without avail.
Mississippi Valley Medical Association. The officers elect are :
President, T. Hunt Stuckey, Louisville ; Vice-President, Chas.
A. Wheaton, St. Paul ; Second Vice-President, Paul Paquin,
St. Louis ; Secretary, Henry E. Tuley, Louisville. Place of
next meeting, Louisville, Ky.
THE PUBLIC SERVICE.
Army Changes. Official List of changes In the stations and duties
of officers serving in the Medical Department. U. S. Army, from
Sept. 5 to Sept. 11, 1896.
The following named officers will report in person on Tuesdav, Sept.
22, 1886, lit 10 o'clock, a.m., to Colonel Charles H. Alden, Asst. Sim
eral, president of the examining board appointed to meet at the ofliee
of the Surgeon-General U. fe. Army, for examination as to their fitness
for promotion ■
Captain William B. Davis, Assistant Surgeon.
Captain William \V. (.ray. Assistant Surgeon.
Captain Louis Brechemin, Assistant Surgeon.
Captain Louis A. La Garde, Assistant Surgeon.
Captain John M. l'.;tnister. Assistant 8urgeOH.
Captain Aaron II. Appel. Assistant Surgeon.
Captain La Garde is relieved from duty as Attending Surgeon and
Examiner of Recruits at Boston, Mass., to take effect upon the comple-
tion of his examination, and ordered to Fort Kobinson, Nebraska, for
duty.
Channre of Address.
Cobb, J. O.. from Cincinnati, Ohio, to U. S. Marine Hospital. New York.
Dudley. Lewis W., from Chicago to Alma Sanitarium Co.. Alma. Wis.
Eaton, Roy R., from Ithica to Lowell. Mich.
Ferguson, R. V., from Guthrie to Hodensville. Ky.
Ferguson, J. W.. from Canaau to West Salem, Ohio.
McMillen, It. M.. from Kingwood to 1821 Chapline St.. Wheeling, W. Va.
Makuen, G. Hudson, from Cresson to 1419 Walnut Si , Philadelphia, l'a.
Ross, Geo. M., from 8628 State St. to 1216 Masonic Temple, Chicago.
Wadsworth, Chas, C, has removed his office and residence to 1104 Van.
Ness Av., San Francisco, Cal.
LETTERS RECEIVED.
Alta Pbarmal Co., St. Louis, Mo.; Ames. II. P. II., Springfield, Mass.
Bovee. J. Wesley, Washington, D. C. ; Busey, S. C, Washington, D. C;
Bishop, S. S., Chicago.
<oone, Bathena, I'eoria, 111.; Christopher, Hiram. St. Joseph, Mo.
Damrell it UDham, Boston, Mass.; DIdama, H. D., Syracuse, N. Y.;
Dussan, A. Eustace, New York; DeSchweiuiu, G. E., Philadelphia, Pa.;
Davidson, T. W„ Oneida, 111.
Elliott, A. R., New York.
Feiel, A., Columbus, Ohio.
Govie, E. T., Woodstock, Vt.
Humel. A. I.., Advertising Agency, New York : Harrison, C. F., Perry,.
111.; Hunt, Mary H., Boston. Mass.; Henel, Emil.New York; Harmison,
D.C., Bath, 111.; Horner, Frederick, Marshall, Va.
Jenkins, J. F.. Tecumseh, Mich.
Lautenbach, Louis J., Philadelphia, Pa. ; Latta, Samuel W., Trenton,
N.J.
Meanv, Wm. B., St. Louis, Mo.; Murdoch, J. D., Pittsburg, l'a. ; Massiu-
ger, C. J., Millvill. . X. J
Neal, J. H.. Rochester, N. Y.
Quales, N. T.. Chicago.
Schwab, L. W., Chicago; Straw, J. R., Ashland, Wis.; Shastid, Thos. H.,
Galesburg. 111. ; Sharpe. N. W., St. Louis, Mo. ; Spalding, Warren C. New
York; Shimonek, F.. Milwaukee, Wis. ; Scherlng & Glatz, New York ;
Spencer, John C. (2), San Francisco, Cal.
Tracy. J. L., Toledo, Ohio; Taylor, Geo.H. & Co., Chicago.
Von Koerber, P. E., Loup City, Neb.
Wilber, M. R., Neenah, Wis.; Widmeyer, J. N., Rolla, N. D.; Wolff,
Arthur S., Brownsville, Texas.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., SEPTEMBER 26, 1896.
No. 13.
ORIGINAL ARTICLES.
OF
THE sTATlsnr EVIDENCES OF THE VALUE
VACCINATION TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Road before the American Medical Association nt the Jenner Centennial
Celebration, held at Atlanta, Ga., May, 1898.
ISY EUGENE FOSTER, M.D.
PBOnsaoa OF principles and practice op medicine and state medi-
cine and dean of the FACCI.TY OP THE MEDICAL DEPARTMENT
IN1VKRS1TY OF GEORGIA, AUGCSTA, GA.
bing however beneficent can escape the criticism of the times in
which we live. The criticism ol vaccination, often passionate and vio-
lent, related cliictly to points which, however interesting they may he,
leave the main question nnatTeeted. We may speculate about the possi-
bility of the potency of vaccine being exhausted in the human family;
we may Ik- surprised to find that people with good vaccine scars some-
times have smallpox : we may dispute as much as we please about the
average period when re-vaccination may be considered a prudent safe-
guard ; hut after all we find that we rest in a security against the horrid
pestilence of smallpox unknown to former generation?." — Dr. George
Derby.
Mr. President and Gentlemen: — By invitation of your com-
mittee on the celebration of the anniversary of the discovery
of vaccination, I appear before you this afternoon. Your
greatly beloved and renowned Nestor, Dr. Davis, has most ably
and charmingly made you acquainted with much of "The
Work and Character of Jenner." The learned Surgeon Gen-
eral of the United States Army, Dr. Sternberg, has delighted
and editied you in his masterly presentation of the question,
"The Scientific Basis of Vaccination." In my paper I am
limited to "The Statistic Evidence of the Value of Vaccination
to the Human Race. Past, Present and Future."
The gnat Jenner has long since gone to his reward ; vaccina-
tion has reached a century old ; millions of human lives, as I
shall show, have been preserved by the fruits of Jenner' s genius ;
yet to-day, no less than one hundred years ago, thousands
upon thousands of men, some intelligent though designing,
some intelligent though deluded, the great mass of them
fanatical and ignorant, decry vaccination as not only being of
no service to humanity, but positively a nuisance injurious to
health and life, while millions of our fellow men are utterly
ignorant of, or indifferent to the matter.
The study of statistics, gentlemen, is dry, uninviting, irk-
some to the vast majority of men. 1 therefore fear that I shall
at least fail to interest, if indeed I do not weary you. I crave
your attention for the reason that however dry and wearisome
statistics may be. it is only by careful, critical study of statis-
tics that we are enabled to rightly estimate the value and the
magnitude of the immortal Jenner' s discovery. In life, Jenner
wisely and persistently insisted that the decision as to the
value of his discovery should rest upon "that keenest of all
arguments for or against the practice of vaccination, those
which are engraved with the point of the lancet." I am here
to present such an argument.
Standing as I do on this occasion to speak for the illustrious
dead, I have attempted to so gather and marshal the statis-
tic evidences of the value of his discovery that every intelli-
gent, fair-minded man can know the truth about vaccination.
I propose to present you statistic data from almost every
civilized country upon earth, indubitably proving that vacci-
nation duly and efficiently performed is absolutely prophylactic
against smallpox, and innocuous to human health and life.
Be not frightened at the mass of manuscript before me, I shall
read only a fractional part of it, and leave the balance to be
studied at your leisure after it shall have been published.
That I may present in an orderly arrangement the data bear-
ing upon my subject I will lay down certain propositions and
furnish the facts relative to each as it is reached.
Unless you are familiar with the history of smallpox in pre-
vaccinal times, and know what it is at the present day inde-
pendent of vaccination, you can not form a proper estimate of
the beneficent results of Jenner's discovery. I shall, there-
fore, first show what smallpox was in pre-vaccinal times ; and,
second, what it is to day in individuals and communities who
neglect to avail themselves of its benefits.
Proposition 1.
Smallpox uncontrolled by vaccination was one of the most
universally /)/•< walent and destructive diseases of the human
race. I shall first show this by historic records both profes-
sional and non-professional.
Prior to the introduction of vaccination, smallpox, except in
remote or isolated populations, having infrequent and difficult
intercourse with the business world, was a well nigh universal
disease, existing continuously as an endemic in large commu-
nities, and breaking loose from its endemic haunts every few
years' it assumed epidemic and not infrequently pandemic pro-
portions. All classes, conditions and ages of people were
attacked by smallpox. While most fatal and prevalent in the
over-crowded homes of the poor, it spared not the dwellers in
mansions nor the palaces of kings.3 So universally prevalent
was smallpox that it was quite exceptional in populous com-
munities for anyone to reach adult age without having been
attacked by the disease/1 In 1518 smallpox concurred with
fire and sword and famine to complete the depopulation of
St. Domingo.4 In the sixteenth century smallpox invaded
Mexico,5 destroying three million, five hundred thousand of
her population. In 1563 smallpox invaded Brazil and extermi-
nated whole races of men. In the Province of Quito (accord-
ing to De la Condamine) it caused the death of 100,000 Indians.
It decimated Siberia" and Kamschatka.7 Several times this
destructive disease has well nigh depopulated Greenland and
Iceland." Under the devastation of this cruel and relentless
enemy communities literally dissolved themselves.9 Remote
and unprotected populations in North America have been most
cruelly scourged by epidemics of smallpox.10
i Hillary on Smallpox, Loudon, 173S.
2 Burnett's history of Mary and William; Walpole's letters, 1750.
Pepys fcvelyn. St. Simon Besenval, Vehse, etc.
3 Hillary, ioc. eit„ Haygarth, Smallpox, Loudon, 1798.
I John Simon K.C.B., K.K.S. First Report Royal Commission Enquiry
on Vaccination 1839.
sPrescott (Conquest of Mexico Vol. 6.) describes this epidemic as
"sweeping over the land like fireoverthe prairies, smiting down prince
and peasant leaving its path strewn with the dead bodies
of the natives, who perished in heaps like cattle stricken with the mur-
rain. Dr. Strieker (Oppenheim's Zeitsche Vol. 34), referring to several
subsequent epidemics of smallpox in Mexico says: In 1779 its ravages
were dreadful. In the capital alone nearly 9,000 died out of 24,661
attacked. He then contrasts with the above periods the history of
smallpox since vaccination. He says: In 1829-30 wben smallpox was
most severely epidemic, vaccination was almost always protective. In
1880-31 there died in New Leon 1,740 persons, without a single vaccinated
person having contracted the disease.
o Pallas (Reisen, St. Petersburg, 1770) cites more than one epidemic of
smallpox in Siberia, and in referring especially to the Ostjaks (vol.8, p.
50) mentions this disease as the chief obstacle to an increase of their
numbers.
'Capt. Cook (Voyages to Pacific Ocean 1785) refers to the first appear-
ance of smallpox 1767 in Kamschatka as "marking its progress with
ravages not less dreadful than the plague, and seeming to threaten their
extinction."
i John Simon (loc. cit.). 1734, Greenland was first invaded by small-
pox and lost by this one disease about two-thirds of her population,
iceland bad been invaded by smallpox seventeen times prior to 1707. In
this year 18,000, out of a total population of 50.000, died by this cruel dis-
ease. Crantz's History of Greenland, London, 1767, referring to the
epidemic of 1707 says: "Empty depopulated houses and unburied
corpses, some within and some without the houses, were commonly
encountered. In one Island they found one girl with the smallpox on
her and her three little brothers, the, father having first buried all the
people in the plsce, had laid himself and his smallest sick child in a
grave raised with stone, and ordered the girl to cover him. Sir George
Mac Kciizie (Travels in Iceland, Ediu. 1811) speaking of smallpox in Ice-
land says : "Its ravages have been such as to render this disease
important even in the political history of the island."
9 Rine.in his treatise on Cowpox. says, that after such a dispersion
the capital of Thibet once remained for three years without inhabitants.
He also, in referring to smallpox near the end of the 18th century speaks
of a tribe of esquimaux on the Labrador coast having been put to flight
by this disease and did not return for a space of three years : that their
country had become a desert, without a living soul in it. but they found
the skeletons of 500 persons who had fallen victims to that horrible
disease. Dr. Mead's works describes the Hottentots on a particular
occasion as drawing lines of defense against any communication with
the sick, and shooting all who attempted to pass.
i" Catlin (Letters and Notes on the Manners and Customs of the
672
THE VALUE OF VACCINATION.
[September 26,
So much for the epidemic prevalence of smallpox in those
portions of the world having less constant and direct relations
with more populous centers. In Europe, as might have been
expected from constant intercourse of peoples of towns and
nations, the disease was, in the run of years, as deadly as in
the places above cited. "Its strength indeed was differently
distributed. Not as in Greenland, twice or thrice in a century,
but incessantly, that fatal sickle was in motion, and the har-
vest counted from day to day. Instead of coming after long
absence on masses of population entirely unprotected against
the infection, it recurred in each place so frequently that, for
the most part, at any given moment, a more or less considera-
ble majority of the inhabitants would have faced the danger
before they would have obtained against its attacks that pro-
tective exemption which was generally the good fortune of
survivors. But it is a moderate computation that for every
five persons thus, at the price of much past suffering, almost
secured against the disease, one at least must have died."
John Simon.
Macauley," the great English historian, speaking of the
smallpox near the close of the seventeenth century: "That
disease (smallpox) over which science has since achieved a suc-
cession of glorious and beneficent victories, was then the most
terrible of all the ministers of death. The havoc of the plague
had been far more rapid ; but the plague had visited our shores
only once or twice within living memory ; and the smallpox
was always present, filling the churchyards with corpses, tor-
menting with constant fears all whom it had not yet stricken,
leaving on those whose lives it spared the hideous traces of its
power, turning the babe into a changeling at which the mother
shuddered, and making the eyes and cheek of the betrothed
maiden objects of horror to the lover. Toward the end of the
year 1694, this pestilence was more than usually severe."
Sir Gilbert Blaine12 says : "It is greatly within the truth to
assert that smallpox has destroyed a hundred for every one
that has perished by plague."
Dr. Black, Lussmileh, Prank and several other reputable
writers, estimated that the average annual mortality from
smallpox in Europe alone was in pre vaccinal times 494,000.
Within the London bills of mortality13 smallpox, when not at
its worst, averaged a fourteenth of the annual total deaths ; a
fourteenth too, at times when that total, as compared with the
population, represented, perhaps, double our present death rate.
North American Indians, London. 1841) says: "Thirty millions of white
men are now scuttling tor the goods and luxuries of life over the bones
and ashes of twelve millions of red men, six millions of whom have fal-
len victims to the smallpox." Again, I would venture the assertion,
from books that I have searched and from other evidence, that of the
numerous tribes which have already disappeared, and of those that have
been traded with, quite to the Rocky Mountains, each one has had this
exotic disease in their turn, and in a few months have lost one-half or
more of their numbers. Loyd, Translator of Prince Maximilian's
Travels in the Interior of North America, in the preface of the work
wrote the following description of an epidemic of smallpox among the
Indians, and says the general correctness of the details have been con
firmed to him by several travelers who had subsequently visited those
nations. " The disease first broke out about the 15th of June 1887, in the
village of the Mandans, a few miles below the American Fort Leavens-
worth, from which it spread in all directions with unexampled fury.
The character of the disease was as appalling as the rapidity of the
propagation. Among the remotest tribes of the Assiniboins from 50 to
100 died daily. The patient, when first seized, complnins of dreadful
pains in the back, and head, and in a few v.ours he is dead; the body
immediately turns black, and swells to thrice its natural size. In vaiu
were hospitals fitted up in Fort Union and the whole stock of medicines
exhausted. For many weeks together our workmen did nothing but
collect the dead bodies and bury them in large pits; but since the
ground is frozen we are obliged to throw them into the river. The
ravages of the disorder were the most frightful among the Mandans
where it first broke out. That once powerful tribe which by accumu-
lated disasters, had already been reduced to 1.500 souls, was extermin-
ated, with the exception of 80 persons. Their neighbors, the Big-bellied
Indians and the Ricarees, were out on a hunting excursion at the time
of the breaking out of the disorder, so that it did not resch them until a
month later : yet half the tribe was destroyed on the 1st of October and
the disease continued to spread. Very few of those who were attacked
recovered their health, but when they saw all their relations buried. and
the pestilence still raging with unabated fury among the remainder of
their countrymen, life became a burden to them, and they put an end to
their wretched existence, either with their knive-* or muskets, or by
precipitating themselves from the summit of the rock near their settle*-
nii-ut. The prairie all around is a vast field of death, covered with
unburied corpses, and spreading for miles pestilence and infection.
The Big bellied Indians and Ricarees, lately amounting to 4,000 >ouls.
were reduced to less than the half. The Assiniboins. 9.000 in number,
roaming over a hunting territory to the north of the Missouri as far as
the trading posts of the Hudson's Bay Company, are, in th'i literal sense
of the expression, nearly ex'ermiuated. They, as well as the Crows
and Blackfeet, endeavored to fly in all directions, but the disease
everywhere pursued them. At last every feeling of mutual compassion
and tenderness seems to have disappeared. Every one avoided the
others. Women and children wandered about the prairie seekiug for
a scanty subsistence. The accounts of the situation of the Blackfeet are
awful. The inmates of over 1.000 of their tents are already swept away.
They are the bravest and most crafty of all the Indians, dangerous and
implacable to their enemies, but faithful and kiud to their friends.
But very lately we apprehended that a terrible war with them was at band
and that they would unite their whole remaining strength against the
whites, but the smallpox cast them down, the brave as well as the fee-
M. De la Condamine14 estimated that one tenth of the deaths
in France were from smallpox. In 1805, Dr. M. Laborde, in
an article entitled "An Account of the Introduction of the
Vaccine Disease into the Isles of France and Reunion," says :
"I had been a witness of the variolous epidemic which had, in
1792, swept off one fourth the population of the Isleof France."
Rosen claims that one tenth of the deaths in Sweden were
annually from smallpox.
Two15 millions of the inhabitants of the Russian empire died
of smallpox in a single year. In Russia previous to the dis-
covery of vaccination it was estimated that a seventh part of
the population perished by smallpox. See "Cross History of
Variolous Epidemic in Norwich, England, 1820."
In Boston, Mass.,16 in 1721, out of a population numbering
11,000 people there were 5,759 cases of smallpox, of which 844
were fatal. Thus it is shown that more than one half of the
inhabitants had the disease, and one thirteenth died of it. In
1730 there were 4,000 cases, with 200 deaths. In 1752 there
were 5,000 cases of smallpox out of a population numbering
15,684, with 539 deaths. In 1764 there were 5,646 cases. In
1776, 5,292 cases. In 1792, 8,346 cases of smallpox.
Sir Gilbert Blaine says : "When there was no vaccination in
our navy, one-fifth of all the men enlisted died of smallpox."
Bernouli,17 writing in 1840, said :
"Great as were the ravages which the plague often caused in
Europe, smallpox carried off more victims in the last century
than the former disease did in any other. Certainly smallpox
is not so deadly as either the plague or cholera. Formerly one-
third of the cases among little children terminated fatally, but
altogether only one-sixth to one-eighth of the total number of
cases. On the other hand the disease (smallpox) had become
an endemic contagion in Europe, which no where completely
died out, to which nearly all individuals were susceptible, and
from which but few escaped before even their tenth year. Of
100 adults only about four or five remained unattacked. It
was calculated that two- thirds of all children born succumbed
to it. In former times, too, there was greater probability of
an individual dying from smallpox. According to the London
list of 1708 to 1750 eight out of every one hundred deaths were
caused by smallpox. In Berlin the smallpox mortality from
1783 to 1797 was one-twelfth of the total. Those who were
carried off by that disease were naturally almost all chil-
dren."
ble, and those who were once seized by this infection never recovered
It is allirmed that several bands of warriors who were on their march to
attack the fort, all perished by the way. so that not oue survh ed to con-
vey the intelligence to their tribe. Thus in the course of a few weeks,
their strength and their courage were broken, and nothing was to be
heard but the frightful waitings of death in their camp. Every thought
of war was dispelled and the few that are left areas humble as famished
dogs. No language can picture the scene of deflation which the coun-
try presents. In whatever way wegowesee nothing but melancholy
wrecks of human life. The tents are still standing ou every hill, but no
rising smoke announces the presence of human beings, and no sound
but the croaking of ravens and the howling of the wolf interrupt the
fearful silence. The above accounts do uot complete the terrible intel-
ligence we receive. There is scarcely a doubt that the pestilence will
spread to the tribes in and beyond the Rocky Mountains, as well as to
the Indians in the direction of Santa Fe and Mexico It seems to be
irrevocably written in the book of fate, that the race of red men shall
be whollv extirpaied in the laud in which they ruled, the undisputed!
masters, till the rapacity of the whites brought to their shores the mur-
derous firearms, the enervating ardent spirits, and the all-destructive
pestilence of the smallpox. According to the most recent accounts, the
number of Indians who have been swept away by the smallpox, on the
western frontiers of the United States amounts to more than 60.000 ."
In Drake's Indians of North America (page 677-8i he says: "Scenes
of wretchedness have been recorded in our early pages, occasioned by
malignant diseases, among Indians of our own land. We are to relate
the doings of death on a broader scale, in the regions of the upper Mis-
souri. In October last (1837) the smallpox was still raging over that
vast country. Up to the first of that month, the Mandaus were reduced
from 1,600 to 31 souls; the Minetarees from 1.000 to 500. and they were
still dying fast. The Ricarees, who had recently joined them, were
hunting by themselves, when the disease was raging among their
friends, and were uot seized by the horrible malady until a month later.
They numbered 3.000. and half of them were in a few days swept away,
and hundreds of the survivors were killing themselves in despair,
some with their own spears and other instruments of war, and some by
casting themselves down high precipices along the Missouri. The
Blackleethad known no such foe before it reached the Rocky Moun-
tains and swept away the people in a thousand lodges.
ii Macnulev's History of England.
12 Public Health, Dr. Guy.
13 John Simon, loc. cit.
l'See English Kdlton De la Condamine on smallpox. Translated
by Dr. Maty, 1755. "De la Condamine estimated that smallpox destroyed,
maimed oroisfigured one- fourth part of mankind." Williams I Elements
Of Medicine I. p. 20-2) quotes the French Minister of the Interior as
estimating (Report on Vaccination 1811) the former annual mortality by
smallpox to have been 150,000 persons. Other writers, Ring among them,
state the number to have been less than stated by De la Condamine
and Williams, thoueh enormous in amount.
is Godfrey. Dr. Edward Jenner's discovery of Vaccination.
lSReoortbf a committee appointed by the United States Sanitary
Commission (1863) to prepare a paper on the Value of Vaccination in
Armies.
ii Page 10. Minutes of Evidence Royal Vaccination Commission of
Great Britain. Published 1890.
1896. ]
THE VALUE OF VACCINATION.
673
Proposition 2.
Smallpox in a population unprotected by vaccinnation is as
generally prevalent and fatal disease at the present day as in
tlii' pre vaccinal period.
In 1878-73, in a few months, in the town of Brunei,1'' in Bor-
neo. 4.000 out of a total population of :!T>,000 died of smallpox.
On the Cold Coast," in 1871, smallpox is described bv Acting
Administrator Salmon as deciminating the population. He
•ays: "Nothing bul the active interference of the local gov-
ernment could have saved the people from annihilation."
At Ceara, in Brazil, smallpox killed 40,000 out of a total
population of 70,000. These facts were reported by Mr. Ash-
Inuv. Member of Parliament for Brighton, who visited the
■pot about the close of the epidemic.
\t Tamatave, Madagascar, according to the report of the
United States Consul, smallpox in 1877 destroyed 800 citizens
within two months. The disease attacked all "who had not had
smallpox or been vaccinated. The disease was confined almost
exclusively to the natives, the foreign residents having been
previously \ accinated.
I )r. Makcna describee an epidemic of smallpox in the Argen-
tine Confederation from 1846 IS as "sweeping with the wings
of death over that enormous tract of country which extends
from the seaboard of the Atlantic on the East to the Corderilla
of the Amies on the West. Throughout this whole space it
may he said that hardly a singlo house or ranch escaped its
fearful visitation, wherever the current of human intercourse
reached, and such was its fatality that I have known thirty
children taken in one morning from the houses of one quadra
of a street 150 yards long. Whole families were swept away,
and, in short, the terrors of the plagues of former times were,
if not surpassed, fully equaled by this horrible scourge. But
that which struck me as most truly remarkable was that not
one of those English people who had been vaccinated at home,
and whu had the large, deep, oval thimble-mark on one or both
arms, ever took the disease."
In California, according to the reports of Doctors Logan,-"
Gibbons and Hatch," who personally witnessed the disease,
smallpox prevailed to a greater extent than was ever before
known, and with a virulence and fatality which has not been
surpassed. It was, if possible, more severe in private prac-
tice than in hospital. Dr. Hatch, in Sacramento, reports 1
death in 3.2 in hospitals and 1 in 2.9 in private practice, mak-
ing the rates for deaths for both 1 in 3. This agrees with
the observations of Dr. Logan, who reports 1 death to every 3
in Sacramento, and 1 to every 2.5 in San Francisco. When
we bear in mind that the usual death rate for smallpox, before
the introduction of vaccination, did not exceed 1 in 5 or 6, we
will agree with Dr. Logan, "this fatality is almost unprece-
dented in the annals of this disease."
The reports of the Indians were brought by traders and do
not furnish data upon which to make a statistic statement,
nevertheless all :u;ree in representing the manifestation and
ravages of the disease as fearful. In many instances whole
encampments were attacked and large numbers were swept off.
In Cincinnati, the epidemic, though not so virulent as in
California, was the severest and most extended of any former
visitation. During the months of November, December, Jan-
uary and February, 1868 69, the Cincinnati Board of Health
had 2.674 cases of smallpox reported to it, and 511 deaths,
making 1 death to every 51.,. This is deemed by many as a
higher death rate than actually occurred, as it is claimed that
some physicians did not report their cases of smallpox to the
health officer. One thousand additional cases will certainly
cover all unreported ones, and would make the death rate
about 1 in 7.
How can we account for the extreme severity of the epidemic
at these three points?
In California, Dr. Logan, physician to the Smallpox Hos-
pital. Sacramento, says: "The primary and chief cause is
inattention to vaccination. The large proportion of deaths
that have occurred, especially in children, and in a certain
class of the floating population of California, particularly the
Mexicans, South American or Californian nativity, shows that
the extensive prevalence of smallpox in our midst is not due to
the failure of the anti-variolus power claimed for vaccination
but to the neglect or absence of its protecting influence."
From far-off India2- comes a most convincing argument,
which I quote from a medical journal : "Although the epi-
demic of smallpox visited the northwestern provinces of India
in a fearful manner, causing 58,800 deaths in the single year
of 1878 all attempts at introducing vaccination as a protective
measure were resisted by the superstitious natives. They
looked upon smallpox as a visitation from a deity, called by
them Sitta, whose anger had to be appeased with special sac-
rifices and plagues. The faithful Hindoos considered it an act
of impiety to still further incite the wrath of the deity by the '
administration of unholy medicines or vaccination. In spite
of all this, however, vaccination, although under peculiar cir-
cumstances, was gradually introduced among the natives.
The Thakers, a tribe that still practices infanticide to a horri-
ble extent, first allowed their female children to be vaccinated,
being convinced of its fatal termination, and hoping thereby
to get rid of this superfluous progeny. All the sons, however,
were carefully guarded against vaccination. Smallpox broke
out in four of their villages a short time afterward, which car-
ried off nearly all the boys while the girls escaped the disease.
This unlooked for termination induced the natives to resort to
the opposite practice, compelling the boys to be vaccinated
while the girls were left unprotected. Beside this, a large
number of cases were observed where children were concealed
by their families from the vaccinators ; in almost all instances
these died, while those vaccinated escapeu smallpox." Even
one such remarkable and unanswerable illustration as this
should convince every one of the utility of vaccination, but I
have only commenced my arguments and will continue to give
you more interesting ones.
Mr. Alexander Wheeler, Darlington, England, an ardent
an ti- vaccinationist, in a paper entitled "Vaccination in the
Light of History," London, 1878, says: "In India smallpox
carried off 101,397 people in 1875."
Hirsch, in, his work, "Handbuch der Historisch geographi-
schen Pathologie," says that between 1866 and 1869 smallpox
killed 140,000 natives in Bombay and Bengal. In the whole of
India, 1873 and 1874, 500,000 inhabitants died of the disease.
(See Second Report Royal Vaccination Commission of Great
Britain. 1890, p. 10.)
To-day the terrors of smallpox are almost forgotten ; only
occasionally the disease attacks a population unprotected by
vaccination. In 1884, in San Salvador-'3 smallpox carried off
nearly one-fiftieth part of the population.
Proposition 3.
In every nation upon earth where vaccination of the popu-
lace has been generally resorted to a marked decrease in the
smallpox death rate has invariably followed.
While statistic data are not available from all countries
using vaccination as a weapon of defense against smallpox,
the great English sanitarian, John Simon, with the assistance
of Mr. Hailie, has prepared a table which conclusively demon-
Approximate average annual death rate by smallpox per 1,000,000 of
living population.
Tfrms of years respect-
ing which particu-
lars are given.
Territory.
i- The Troth ahout Vaccination by Ernest Hart, London, 1880.
>'< Hart, loc. clt.
-"Medical Review of the year 1868 in California, by T. M. Logan, M.D.,
Physician to Smallpox Hospital. Sacramento.
• I Report on t»e Epidemic of California, in 1868, Transactions of the
American Medical Association, vol. 20. page 518.
« Vacciuation. Joseph Edwards, M.D., p. 27-8, Philadelphia, Pa., 1882
1777-1806 and 1807-1850. 'Austria, Lower . . . .
1777-1806 and 1807-1850., Austria, Upper, and Salzburg
1777-1806 and 1807-1850. Sty ria
1777-1806 and 1807-18i0. Illyria
1777-J806and mks-mso. Trieste
1777-1806 and 1807-1850. Tyrol and Vorarlberg
1777-1806 and 1807-1850. Bohemia
1777-1800 and 1807-1850. Moravia .
1777-1806 and 1807-1850. Silesia (Austrian).
1777-1806 and 1807-1850. Galieia
1787-1806 and 1807-1850. Bukswina
1817-1850. Dalmatia .'
1817-1850. Lomhardy
1817-1850. Venice '
1881-1860. Military frontier
1776-1780and 1810-1850. Prussia (Eastern Provinces).
1780 and 1810-1850. Prussia (Western Provinces).
1780 and 1816-1850. Posen
1776-1780 and 1810-1850. Brandenburg
1776-1780 and 1816-1850. Westphalia
1776-i780and 1816-18110. Rhenish Provinces. . . .
1781-1805 and 1810-1850. Berlin
1776-1780 and 1816-1850. Saxony (Prussian). .
1780 and 1810-1850 Pomeranla
1810-lwo. Silesia (Prussian) '.
1774-1X01 and 1810-1X50. Sweden . .
1751-1800 and 1801-1850. Copenhagen
Og a
2,184
1,421
1,052
518
14,046
911
2,174
5,402
5,812
1,194
8,527
hi
8,821
2,272
1,911
2,181
2,648
908
3,422
719
1,744
'2,050
8,128
840
501
446
244
182
170
215
255
198
676
516
86
87
70
288
556
856
743
181
114
90
176
170
180
310
158
286
strates the great and positive benefits in controlling smallpox.
This table shows two varieties of facts : "1, how many persons
in each million of population died annually of smallpox before
the use of vaccination ; and, 2, how many persons in each
aa U.S. Consul Murphy. Loc. cit. Berlin.
674
THE VALUE OF VACCINATION.
[September 2(5,
million of population have annually died of smallpox since, the
use of vaccination." The author draws the conclusion, as the
reader may also do, between the case of Sweden in the twenty-
eight years before vaccination and the forty years afterward :
"During the earlier period there used to die of smallpox, out
•of each million of the Swedish population, 2,050 victims
annually ; during the latter period, out of each million of pop-
ulation, the smallpox deaths have annually averaged 158." "Or,
taking to metropolitan cities, you find that in Copenhagen, for
the next half century, 1751-1800, the smallpox death rate was
3,128, but for the next half century only 286 ; and still better
in Berlin, where for twenty-four years preceding the general
use of vaccination, the smallpox death rate had been 3,422, for
forty years subsequently it has been only 176. In other words,
the fatality of smallpox in Copenhagen is but an eleventh of
what it was ; in Sweden, a little over a thirteenth ; in Berlin
and large parts of Austria but a twentieth." These statistics
show that the adoption of vaccination has been followed by a
reduction of the smallpox mortality to a tenth and a twentieth
of its former magnitude.
Dr. William Ogle, superintendent of statistics in office of
Registrar General, in first report of Royal Vaccination Com-
mission, 1889, in comparing the mortality from smallpox in our
day with that of the seventeenth and eighteenth centuries,
said :
"1 have taken as a basis for comparison the ten years from
1871 to 1880, which are the years which include the great out-
break in London in 1870-71, so that those years represent a time
when smallpox was particularly abundant in London. Taking
those ten years, I find that in round numbers, the smallpox
deaths were 20 in 1,000, from all causes. I then go back 100
years to the corresponding decennium in the eighteenth cen-
tury, 1771-1780, and I find that the smallpox deaths were then
97 in 1,000. Then going back another hundred years, 1671-80,
I find that the proportion was 66 in 1,000 ; so that in the
present century smallpox as measured by its proportion of
deaths to deaths from all causes, has been from three to five
times less common than it was in those previous times ; and it
is plain that if the death rate of the eighteenth century and
the death rate of the seventeenth century was higher than it
is now, smallpox must have been very much more prevalent,
because a large proportion of a larger number of deaths
occurred from it. Of course it is only an assumption that the
death rate was higher in the seventeenth and eighteenth cen-
turies than it is now."
Dr. Hopkirk presented the following table to the Royal
Vaccination Commission :
Table A.* — Table showing for the city of Berlin the number of inhabi-
tants, deaths from all causes and the deaths from smallpox in tin*
years 1758 to 1774 and 1782 to 1872, and in particular for each of the
years of smallpox epidemics. (Zeitschrift des Konigl. Preuss. Stat.
Bureau. Jahrgung 12, 1*72; Art. "Die Pocken-Epldeiuie in Berlin,
1870-72," by Dr. Guttstadt.)
Quinquennial
average for.
1758-1762 .
1763-1767 .
1768-1772 .
1773-1774 .
1783-1784 .
1785-1789 .
1790-1794 .
1795-1799 .
1800-1804 .
1805-1809 .
Inhab-
itants.
95,671
122.008
180,186
188,892
185,400
145,000
165.612
177.225
152,014
Total
number of
deaths.
Percent. Deaths
of deaths from
to inhab- small-
itants. I pox.
4,726
4,088
5,591
4,885
5,214
5,268
5,984
6,192
7,823
4.93
8.81
4.29
3.«5
3.85
3.63
8.61
3.49
4.82
443
487
449
396
463
Pslj
a j act:
£ = 22~
~ -c -/. ~ z
8.28
11.00
6.85
9 11
9.84
8.53
6.52
7.48
6.36
Influence of Vaccination.
1810-1814 .
1816-1819 .
1820-1824 .
1825-1829 .
1830-183-1 .
1885-1839 .
1810-1844 .
1845-1819 .
1850-1854 .
1855-1859 .
lXHn-1861 .
1865-1869 .
1870 . . .
165,000
198,098
210,000
230,000
255,000
285,000
825.000
880,000
408.000
450.000
690,000
690,000
5,525
5,974
5,930
6,686
8.622
8,566
9,062
11.070
11,270
12.736
16.276
28.808
26.594
3.33
51
3.02
80
2.82
9
2.91
31
3.40
48
3 01
52
2.79
44
2.84
7
2.76
19
2.83
83
2.76
176
3.88
182
3.02
171
0.74
1.34
0.15
0.46
0.55
0.60
0.49
0.06
0.14
0.00
1.08
0.78
0.64
Years of Smallpox Epidemic.
94,483
(Garison
wanting.)
5.26
13.20
1766 .
177(1.
1786 .
1780 .
1801 .
1864.
1871 .
1872 .
125,878
4.652
3.0"
1,060
188,590
5,123
3.83
987
147,388
5,077
3.44
1,077
118,717
5,990
5.00
911
(Garison
wanting.)
178,7011
7,681
1.31
1.626
632,749
17^48
2.81
617
826,341
32,362
3.92
5,084
....
28,763
8.48
1,100
22.08
19.26
21.21
15.25
21.17
3.15
15.70
3.82
•See Appendix II, p. 231, Second Report Royal Vaccination Commis-
sion of Great Britain, 1890. By Dr. A. F. Hopkirk (Jena).
John Simon presented the following table (see Royal Com-
mission on Vaccination, first report, 1889, page 88).
General and Differential Annual Death Rates in London per lon,noo
living, at seven different periods during the 226 years, 1629-1854.
=
c *:
a "■ >.
Bill of Mortality.
s = s
IS So
Causes of Death.
« -
1629-35
1660-79
1728-57
1771-80
1801-10
I83l-:!fl
1810-:> 1
180
417
426
502
204
83
40
16
47
87
48
94
88
58
Consumption. . . .
1,021
1,255
905
1,121
716
567
828
14
19
5
5
?
3
12
146
349
218
225
131
181
•V.I
What does the ratio of epidemics teach us? Read it. The
report of the Epidemiological Society of London says : First,
during ninety-one years, previous to inoculation, there were
sixty five distinct and well-marked epidemics, which is a ratio
of 71.4 epidemics in one hundred years ; second, during sixty-
three years in which inoculation was practiced, and that to a
great extent, there were fifty-three distinct and well marked
epidemics, which is a ratio of eighty-four epidemics in one
hundred years ; third, during the last fifty years, in which
vaccination has been practiced and inoculation declared illegal,
there have been twelve epidemics of smallpox, which is a ratio
of twenty-four epidemics in one hundred years.
To go back to Jenner's day we find the following testimony
from his papers : "From 1762 to 1792 the number of persons
that died of smallpox in the Danish dominions amounted to
9,728. About the year 1802 vaccination was first introduced,
and the practice became general but not universal ; however,
fifty-eight persons died of smallpox in the year 1810. Vacci-
nation, by order of the king, was now universally adopted and
smallpox inoculation prohibited, and from the year 1810 to the
year 1819 not a single case of smallpox has occurred. From
Bombay, I learn the smallpox is there completely subdued, not
a single case having occurred for the last two years."
Drs. Seaton and Buchanan, in 1863, examined more than
fifty thousand children in the national schools and workhouses
in England to attempt to determine what proportion of them
were unvaccinated, what proportion had formerly been vacci-
nated, and the number among those vaccinated who had con-
tracted smallpox since vaccination.
Classification of Children.
Number
examined
of each
class.
Without any mark of vaccination
With doubtful mark of vaccina-
tion.
With mark or marks of vaccina-
tion !
Number
in each
clasfl that
had traces
of
smallpox.
1,010
311
aflS
-Cjs:
300
59
1 .78
Lord Jeffrey, in 1807, at that time editor of the Edinburgh
Review, a man most thoroughly skilled in the principles of
searching and rigorous applications of the rules of evidence,
highly endorses the value of vaccination, and says of Jenner's
claim, " not until he had vaccinated some hundred children,
and put them, at different intervals, to the test of inoculation
for smallpox without effect, that he ventured to publish his
discovery, in the year 1798, in a treatise, followed up the year
after by a still longer list of such experiments and observa-
tions." In the same article he adds, "When the practice of
vaccination was discussed and confidently recommended, in
1896.]
THE VALUE OF VACCINATION.
675
1S(X>, by all the eminent practitioners in London, this was done
only after full consideration of its efficacy, as compared to
Inoculation for smallpox ; that Dr. Woodvillein particular, phy-
sician to the smallpox hospital, then stated that within the
last six months he had vaccinated there 7,500 persons, the half
of whom had been since inoculated with smallpox matter
without the slightest effect being produced in any instance."
The report of the Faculty of Medicine at Prague to the
Minister of the Interior, requesting information for the Gov-
ernment of Gieat Britain relative to the results of vaccination,
lers one of the most interesting tables of any known to me.
From this vast storehouse of facts the following summary is
taken: Prom 17!>t! to 1802 inclusive, the average annual popu-
lation observed was 3,039,722 ; total average number of deaths
annually from all causes, 94,955 ; total deaths annually from
smallpox. T.tiT:! : showing one death from smallpox to every 396
of the population, and the deaths from smallpox to the total
number of deaths was one in 12'o. From 1832 to 1855 inclu-
sive, during twenty-four years subsequent to introduction of
vaccination, with an average population of 4,248,155, total
deaths annually were on an average 131,412. The average
number of deaths annually from smallpox was 287,724 ; show-
ing deaths from smallpox to population to be 1 in 14,741 ; deaths
from smallpox to total number of deaths, 1 in 457. Among an
average annual population of 143,122 persons vaccinated and
1,891 unvaccinated, the cases of smallpox annually existing
were 388 among the vaccinated, and 355 among the unvacci-
nated population, i.e., one case of smallpox occurred among
;ie!7 vaccinated : one case of smallpox occurred among 12 unvac-
cinated. These tables further show the following facts : One
fatal case of smallpox occurs among 7,166 vaccinated; one
fatal case of smallpox occurs among 40 unvaccinated. In the
C J rand Duchy of Baden similar fruits have followed vaccina-
tion. Reliable statistics show that for a long number of years
of compulsory vaccination with an average annual population
of 1,800,000, only 100 cases of smallpox occur each year, and
only 13 of this vast population have died each year of small-
pox.
In Great Britain from 1750 to 1800, of every 1,000 deaths, 96
were from smallpox. From 1800 to 1850, of every 1,000 deaths,
SC were from smallpox. During the latter period the popula-
tion was quite generally, but by no means universally, vacci-
nated.
In the German States, where more attention was paid to
vaccination, the following were the results obtained : Before
vaccination of population, deaths from smallpox amounted to
66.5 per 1,000 ; subsequent to vaccination, 7.66 per 1,000.
Dr. Marson of England, from the records of his great hospi-
tal experience, shows the merits of vaccination : "The small-
pox death risks of no vaccination are to the death risks of
the very worst vaccination as three to one ; to the death risks
of the best vaccination as seventy to one."
From an experience of twenty-one years in Bohemia among
four millions of population, the testimony of that country
most strikingly illustrates the value of vaccination. Among
the vaccinated population contracting smallpox the death rate
was but 5.1 per cent ; the death rate of the unvaccinated was
29.8 per cent.
The most reliable statistics, and at the same time the fairest,
upon the value of vaccination, are to be found in the records
of the army, for here alone is it possible to compel thorough
vaccination of the entire population. Infringement of per-
sonal liberty, so dearly availed of as the shibboleth of the
civilian, is treated with merited contempt in the army when it
contravenes the rights of others. Vaccination having been
decided an individual and collective benefit, the soldier has no
choice in the matter ; he is compelled to submit to it. In thus
protecting himself he at the same time benefits his comrades.
To the honor of the surgeons of the army and navy be it said
they are able, fearless and conscientious sanitarians, and in no
other department have the rich results of sanitary science
shown forth so conspicuously. Sir Gilbert Blaine says prior to
vaccination, " Smallpox was one of the greatest embarrass-
ments to the operations of armies." Let us see how it was after
vaccination.
By reference to the statistics of sickness and mortality in the
army of Great Britain for the twenty years from 1817 to 1836
inclusive, the following data are to be found. (Every soldier
is vaccinated upon entering the army.)
In the dragoon regiments and guards, with an aggregate of
44,611 men, with a total mortality of 637, but three deaths
occurred from smallpox.
At Gibraltar, with an aggregate of 60,000 troops, with a
total mortality of 1,291, only one death was caused from small-
pox.
Among the British and white troops in the West Indies, with
an aggregate strength of 86,000, and a total mortality of 6,803 ;
and among the black troops, numbering 40,000, with a mortal-
ity of 1,645, not one fatal case of smallpox occurred, although
during this period several epidemics of smallpox decimated
the islands.
Among the troops at Bermuda, Nova Scotia, Cape of Good
Hope and Mauritius, for twenty years, there was not one death
from smallpox.
In Western Africa, while smallpox was ravaging the inhab-
itants unvaccinated, not a case of smallpox occurred among
the white soldiers who had been vaccinated.
From 1818 to 1836 inclusive, in an army of 40,000 aggregate,
British troops at Malta, while smallpox was playing sad havoc
among the unvaccinated inhabitants, in repeated epidemics,
there were only two deaths from this disease in the vaccinated
army.
During the same period in Ceylon, among the white soldiers,
with a total mortality of 3,000, there were only four deaths,
with eight cases, from smallpox, notwithstanding repeated epi-
demics of the disease among the natives.
In the British troops serving in the United Kingdom from
1859 to 1864 inclusive, the following were the results of vac-
cination : Total number troops, 473,483 ; cases of smallpox,
664 ; deaths from smallpox, 40 ; showing the ratio per 10,000 of
strength to be: Cases of smallpox, .14; deaths from small-
pox, 0.84.
In the British navy — home force — for the same period of
time, 1859 to 1864 inclusive, the following dataf are furnished :
Total mean strength, 127,660 ; cases of smallpox, 416 ; deaths,
29 ; ratio per 10,000 of strength : cases, 33 ; deaths, 2.3.
Since 1803 to 1863, among the thousands of vaccinated chil-
dren admitted into the Royal Military Asylum of England,
there has not been a case of fatal smallpox. This testimony
is the more striking since the records show that during that
time four deaths occurred among those who had previously
had smallpox.
Pboposition 4.
As vaccination became more general smallpox decreased in
extent and fatality.
Dr. Ogle reviews the statistics of smallpox in England and
Wales from 1838 to 1887 inclusive, accurately kept in the office
of the registrar general — the civil register having been com-
menced in 1837. The registrar general's returns show the
smallpox death rate and the smallpox deaths in proportion to
population for each year during the period 1838 to 1887, except
the four years 1843-6, during which four years no returns were
tabulated in the registrar general's office. Dr. Ogle then pre-
sented the table marked A hereto appended. This table shows
that the smallpox deaths in 1838 reached 1,064 per 1,000,000, and
that only one year in the forty-nine years (1871) did'the smallpox
deaths ever approach that of 1838. He then divides the deaths
in these forty-six years into three periods. First, 1838 to 1858,
inclusive, in which vaccination was nominally compulsory, but
no effectual means of enforcing it, practically optional. In this
period the smallpox death rate was 408 per 1,000,000 popula-
tion. The second period, 1859 to 1871 inclusive, in which vac-
cination laws were more efficiently enforced (though not thor-
oughly carried out) the smallpox death rate was 223 per
1,000,000. The third period, 1872 to 1887, when compulsory
vaccination was thoroughly enforced, the smallpox death rate
per 1,000,000 population was 114 ; thus demonstrating a
marked progressive decrease in the smallpox death rate corre-
sponding in time with the changes in the vaccination laws.
The decline from 1838 to 1887 was about 7.2 per cent.
ENGLAND AND WALES.
Table A.— Deaths from smallpox per 1,000,000 living, 1838-42 and 1847-87.
Year.
Deaths.
Year.
j Deaths.
Year.
Deaths.
Year.
Deaths.
1838. .
1839 . .
1840. .
1841 . .
1842 . .
1848 . .
1,084
589
661
400
168
1851 . .
1852 . .
1853. .
1854. .
1855. .
1856 . .
1857 . .
1858. .
1859 . .
I860. .
18C1 . .
1862. .
1863. .
389
401
171
151
134
119
204
332
195
188
66
80
289
1864 . .
1865. .
1866 . .
1867 . .
1868 . .
1869. .
1870 . .
1871 . .
1872. .
1873. .
1874 . .
1875. .
1876 . .
367
303
141
116
93
70
116
1,015
824
101
91
40
103
1877. . .
1878 . . .
1879 . . .
1880. . .
1881. . .
1882 . . .
1883. . .
1884 . . .
1885. . .
1886. . .
1887. . .
178
79
25
29
124
54
1844 . .
39
1845 . .
87
1846 . .
107
1847. .
1848 . .
246
397
264
262
13
21
N. B.— The above figures include deaths from ehickenpox.
Dr. Ogle next considers the question of the possibility of
this decreased smallpox death rate being attributable to.
improved sanitation rather than vaccination. He submitted
the following table :
676
THE VALUE OF VACCINATION.
[September 26,
Table B. — Mean annual deaths from smallpox at successive life
periods, per 1,000,000 living at each such life period, 1847-58, 1854-71
and 1872-87.
Period.
Vaccination optional
1847-58
!. Vaccination obliga
tory, but not efficiently
enforced, 1854-71
I. Vaccination obliga-
tory, but more efficiently
enforced by vaccination
officers, 1872-87
All
ages.
0-5
5-10
10-15
15-25
25^5
805
1,617
837
94
109
66
223
817
243
88
163
131
114
242
120
69
122
107
45 and
upward.
22
52
In this table the period of optional vaccination begins with
1847, not with 1838, because the deaths were not abstracted in
combination with ages until 1847.
He, Dr. Ogle, then points out the fact that if the decreased
death rate from smallpox had been attributable to improved
sanitary conditions under which the population lived that all
ages would have shared in the benefits. But the table just
refered to demonstrates that with the marked decline in the
smallpox death rate (72 per cent.) that no such thing resulted.
The table demonstrates : 1. That during the first five years of
life the lessened smallpox mortality was 85 per cent. 2. In
children between the ages of 10 and 15 years it declined 27 per
cent. At every, age period subsequent to 15 years the mortal-
ity actually increased. 3. From 15 to 25 years the smallpox
death rate increased. 4. From 25 to 45 years of age the small-
pox death rate increased.
Again to show that improved sanitation did not produce the
result claimed for it by antivaccinists, the record shows that
the decrease in the general death rate during the period in
question was but 9 per cent, while the decreased smallpox
death rate reached 72 per cent. The comparative decrease in
zymotic diseases was as follows : Measles, 9 per cent. ; whoop-
ing cough, 1 per cent. ; smallpox, 72 per cent.
To further demonstrate Proposition 4, I cite the following
tables. A glance at these tables conclusively demonstrates
the vastly decreased smallpox death rate of those countries
rigidly enforcing vaccination over those whereir^ vaccination is
optional, or nominally compulsory.
Smallpox in Europe, 1879-1885.*
Countries.
Italy (284 chief places) . . .
England and Wales
Sco'laud
Scotlaud (8 cities)
Ireland
German Empire (148 cities).
Prussia
Austria
Austria (15 chief cities). . .
Switzerland (12-15 cantons)
Switzerland (17 cities).. . .
Belgium
Belgium (70 cities)
Holland
Sweden
Sweden (89 cities)
Denmark (chief cities). . .
Spain
Spain (70 cities)
European Russia
Period.
1881-84
1880-84
1880-88
1881-84
1880-85
1881-84
1880-83
1879-83
1879-82
1880-83
1881-83
1880-84
1880-84
1881-84
1880-83
1880-89
1880-82
1881-84
1881-84
1882
Popula-
tion.
7,149,256
26.413,861
3.745,485
1.253.087
5,174,836
8.790.783
27.807,012
22.184,454
1,543.656
1,749.601
439,848
5.655,197
1,781,269
4,225.065
4,579,115
690,309
564 914
16,858,721
2,828 977
78,590,594
Deaths
from
smallpox.
4,673
8,823
43
26
628
793
3,254
77,988
6,205
238
105
11577
2,182
963
758
143
20
67,032
14.793
22,236
Ratio
per
10,000.
1.63
0.67
0.08
0.05
0.20
0.23
0.29
7.05
8.43
0.33
0.80
4.09
3.15
0.57
0.41
0.69
0.12
8.46
13.07
2.96
* Buck's Ref. Handbook, p. 526, Vol. vii.
Mortality from smallpox per 1,000,000 living in.+
Countries without compulsory
Countries with compulsorv
vaccination
vaccination.
Holland.
Prussia.
Austria.
Bavaria.
Sweden.
Scotland.
1865
324
132
1866
406
292
62
1867
154
251
253
31
1868
40
181
190
342
5
1869
14
191
101
354
19
1870
196
183
97
183
34
1871
4355
2.8(9
1,048
78
428
1872
1,021
2,621
612
81
720
1878
05
356
3,173
176
261
328
1874
95
1,754
47
936
360
1875
36
17
461
22
1876
1877
186
80
-r See Second Report Royal Vaccination Commission, page 238.
Table showing, for the years 1871-74, the mortality from smallpox in
Prussia per 100,000 inhabitants. (Lotz, "Pocken und Vaccination," p.
88, after Guttstadt.)
In the old Provinces without compul-
sory vaccination.
1. Prussia
2. Brandenburg
3. Pomerania
4. Pusen
5. Silesia
6. Saxony
7. Westphalia
8. Rhiueland and Hohenzollern
In the new Provinces with compulsory
vaccination.
9. Schleswig-Holstein
10. Hanover
11. Hesse-Nassau
I 1871
224
340
237
455
214
277
255
264
1872
503
282
249
682
321
176
209
106
1878
80
24
15
128
58
28
14
6
180
77
1873
3
24
21
3
2
9
1874
46
81
45
1
18
0.7
3
4
I am indebted to Surgeon-General Sternberg, U. S. Army,
for a translated copy of an article from the Hanover Courier
relative to the effect of compulsory vaccination in Europe,
furnished by the U. S. Consul General at Berlin, 1893, to the
Secretary of State, U. S. From this article I make the fol-
lowing extracts :
The European States in regard to their position in connec-
tion with the question of vaccination may be divided into three
categories :
1. Those — and these are the majority — which have only the
facultative vaccination, but which warmly recommend and
urge it : France, Austria, Russia, Belgium, Spain, etc.
2. States with obligatory vaccination, but without obliga-
tory revaccination, as England, Sweden, Denmark.
3. In the third category stands Germany, which is the only
state in which— since the imperial vaccination law of 1875 went
into operation — vaccination and revaccination are obligatory.
Picking out a state from the second category we can clearly
see the blessing of vaccination in the case of Sweden. There
died there of smallpox annually from every 100,000 inhabitants :
a. Before the introduction of vaccination from 1774-1800,
165.82.
b. After the introduction of facultative vaccination from
1801-1815, 55.60.
c. After the introduction of obligatory vaccination from
1816-1883, 18.20.
The result in Prussia has been far more favorable since the
introduction of the imperial vaccination law. In the decade
1875-85 there died of smallpox annually in Prussia from every
100,000 inhabitants 2.23, in England with obligatory vaccina-
tion three times as many, in Austria where there is no com-
pulsion twenty seven times as many, while before 1875 there
were as many smallpox deaths in Prussia as in Austria.
In France with facultative vaccination there died in 1886 and
1887, in Paris alone, more persons from smallpox than in all
Germany, namely, 1886, 218 in Paris, 193 in Germany ; in 1887,
389 in Paris, 108 (less than one-third as many) in Germany.
The following figures speak for other years. From 100,000
inhabitants there died of smallpox in
Germany.
England.
1.0
Belgium.
Austria
1886. .
. . 0.4
20.5
38.1
1887 . .
. . 0.35
1.8
10.2
41.2
1888 . .
. . 0.2
3.6
14.3
In Spain with 12,000,000 inhabitants, in 1888 there were
14,378 smallpox deaths or 120 to 100,000; in 1889, 8,472 small-
pox deaths or 70 to 100,000.
The difference is shown still more clearly and conclusively
by comparing districts bordering upon one another. In 1889,
of smallpox deaths there were in Bohemia 3,329, or 60 to
100,000, in Moravia 1,100 or about 52 to 100,000; while in the
adjacent parts of Germany the numbers were :
Prussian Silesia 35 = 0.85)
Kingdom of Saxony 7 = 0.29 [ per 100,000
The Bavarian frontier districts. 22 == 0.79 )
Independent of the imperial vaccination law are the vaccina-
tion regulations in the German army. In Prussia ever since
1834 recruit vaccination has been the general practice. The
result is clearly to be seen. From 1825 to 1834, that is before
the introduction of recruit vaccination, the average smallpox
death rate was 364 to 100,000. It was greater than that of
the civil population, which on the average was 268 to 100,000.
With the introduction of recruit vaccination the smallpox
death rate at once decreased considerably and permanently ;
leaving out of consideration the war years, it has only once
since reached the height of 65 to 100,000, being much lower
than the death rate of the civil population, which up to the
1896.]
MEDICAL EXPERT TESTIMONY.
677
time of the introduction of the imperial vaccination law
remained unchanged, about 208 to 100,000.
The vaccination regulations worked admirably in the war of
IS. 1 1 71 ; in spite of the very great danger of contagion, in an
arm\ averaging 600,000 men there were :
Smallpox cases 2,746 = 465 / inr> ,wi
Smallpox deaths 146 = 24.7 \ Per l00'(m
For the entire Herman army this rate was more unfavorable
awing to the fact that individual contingents had new and,
therefore, not fully perfect vaccination regulations. In the
entire army of 788,200 there were :
4, 836 smallpox cases =613.4) lmmn
ITO smallpox deaths = 35.3 \ pe lul,-u,HJ
On the other hand the losses in the French army from
nallpox were much greater. It is impossible to fix exactly
te Dumber of deaths, but it is supposed that 23,469 is the
trrect number. The figures given for single corps do not
mtradict this estimate.
For the garrison of Paris (170,000 men) the number of cases
from October 1870 to March 1871 was reported at 11,500, the
deaths at 1,600. The small garrison of Langres (14,629 men)
lost more from smallpox between September 1870 and March
1S71 than the entire German army (788,213 men), in twelve
months; namely 334 against 278.
Likewise in times of peace the advantage over the French
and Austrian armies, due to protective vaccination, which is
enjoyed bj the Prussian amy (inclusive of the Twelfth Royal
Saxon and Thirteenth Royal Wt'irttemberg army corps) is
apparent. In the fifteen years 1873 88 there were in the Prus-
sian army only .'XX) cases of smallpox (including doubtful cases)
and .'! deaths, while in the French army there were 7,807 cases
and 698 deaths, and in the Austrian army 10,974 cases and
1,034 deaths. These two armies, therefore, had respectively
two and three and one half times as many smallpox deaths as
there were cases of smallpox in the German army. In 1887
A ustria introduced recruit vaccination and atonce the number
of smallpox cases and deaths became smaller than ever before.
(To be continued.)
REMARKS UPON MEDICAL EXPERT TESTI-
MONY AND PROPOSED RELATIVE
LEGISLATION.
Read in the Section on Neurology and Medical Jurisprudence at the
Forty seventh Annual Meeting of the American Medical Asso-
ciation held at Atlanta. Ga., May 5-8, 1896.
BY A. WALTER SUITER, A.M., M.D.
CHAIRMAN COMMITTEE ON LEGISLATION, MEDICAL SOCIETY OF THE
STATE OF XK1V YORK.
HERKIMEK, N. Y.
The amount of earnestly thoughtful consideration
which has in recent years been given to the subject
of medical expert testimony, both by the legal and
medical professions, may be said to be enormous, and
yet the great desideratum — its just and equitable reg-
ulation— is far from being accomplished.
The remarkable divergence of individual opinion as
to the feasibility of the various plans proposed ; the
complexity of interests involved; the multiplicity of
phases in which the subject in general may be made
to appear in practical application, together with the
necessary constant observance of certain sovereign
ami inalienable rights which are, under our govern-
mental system, guaranteed to the meanest and the
highest in like degree, all combine to make of this
veritable quaestio vexata a problem so difficult of solu-
tion as almost to suggest an utter impossibility as to
its final and satisfactory adjustment.
It seems indisputable that so long as testimony as
to facts and what is commonly termed opinion testi-
mony, differ so widely and yet merge so closely, and
so long as the laws and the courts do not recognize
the fact that doctors in general are not experts indis-
criminately, and that no witness is qualified to express
an authoritative opinion upon any subject who does
not possess special knowledge derived from special
study and experience, just so long will this great ques-
tion continue to be the be~te noire of our profession.
It is universally conceded, and justly so from the
medical standpoint, that the present method of taking
testimony requiring expert opinion is defective in the
extreme, and in many instances in practice absurd
anil ridiculous; attorneys, for example, taking advan-
tage of the circumstances, frequently select and sum-
mon to the stand to pose in the attitude of medical
experts upon the gravest and most momentous scien-
tific questions, members of the profession whose only
medal qualification consists in having agreed with
their employer to express a satisfactory reply to the
hypothetic statement which supposedly covers the
facts in the case at bar, or under consideration.
An instance in point in the writer's observation is
amusing — the medical witness, when examined upon
topics requiring expert knowledge of the important
subject of antisepsis in the treatment of wounds,
indignantly scouted the idea of making use of corro-
sive sublimate in his practice, but triumphantly
declared that he did use the bichlorid of mercury
instead !
And yet, with the existing confusion in the matter
of differentiation between the expert and the non-
expert, the courts would charge due consideration by
the jury of the opinions and declarations of such a
witness upon equal footing with those of the most
accomplished specialist.
Herein lies the greatest fault in the prevailing sys-
tem, namely, the absence of determining rules whereby
the special qualification of the witness in a particular
branch of medical science may be known and estab-
lished beforehand; and the unlimited privilege which
in the usage of courts is possessed by attorneys and
counsel to select for themselves, regardless of qualifi-
cation, the witnesses whom they are to present as
experts in a given case, and who become ipso facto
the honest partisans of their employer, especially
when he fixes their compensating fee.
Another unjust phase of this matter relates to the
frequent discriminating inequality between the prose-
cution and defense in their relative ability to indulge
in the expensive advantage of employing experts to
testify in their behalf.
A notorious and likely to be celebrated case is now
pending in the courts of New York City which fully
illustrates this point.
The district attorney, with the city treasury to
draw upon, is said to have engaged the services of an
array of talented experts whose fame can scarcely be
matched. Two are to appear upon the subject of
chemistry, two upon that of materia medica, two to
take charge of the pathologic aspects, and one is
employed to expound the special subject of toxicology.
By membership in their faculties the staff will repre-
sent the following great institutions: The University
of Michigan, the College of Physicians and Surgeons
of Columbia University, the University of the City of
New York and the University of Pennsylvania. In
addition to this a very noted doctor-lawyer has been
hired to arrange and adduce the scientific testimony
in the case.
On the other hand, and in consideration of such
formidable preparation on the part of the People, the
pertinent question is very naturally asked by a prom-
inent New York newspaper, "How is the poor defend-
ant to get experts from Michigan and Pennsylvania,
the first in their profession to testify for her?" '
This unfair relation of the almost always impe-
678
MEDICAL EXPERT TESTIMONY.
[September 26,
cunious accused in criminal cases is by no means
uncommon, and its injustice is too apparent to require
•extended comment.
It would seem in this era of specialism in study and
practice that the line might without great difficulty
be satisfactorily established whereby the status of an
expert in a given department could be previously
obtained and certified. But the standard of qualifi-
cation obviously must be defined by and through the
medical profession in such manner as to command the
entire respect of the courts, and merit the approval of
the public at large. This, it may be said, has already
been practically done, but advantage can never be
taken until the system of taking expert testimony has
been so radically changed that the proper restriction
as to the manner of selection and appointment has
been regulated, to the extent that the expert witness
shall in all cases be an officer of the court, and occupy
a position with reference to the subject concerning
which he is to express an opinion of absolute inde-
pendence and impartiality.
In this view the function of the expert would be
advisory in the strictest sense. He would, and should,
be the mentor and censor both to the court and jury,
and thus would the average jury be relieved of the
always too great responsibility of determining upon
questions of such scientific delicacy as to require a
technical knowledge that presupposes years of study
and experience to attain.
Nothing can be more absurd and contradictory to
the professional mind than to call together twelve
men, selected for the most part because of their
ignorance and stupidity and their unfamiliarity with
the facts and circumstances, and compel them to sit
in judgment upon the radical and sometimes chaotic
disagreement of opinions of those whom education
and years of continuous practical application have
qualified them to express. The unintelligent jury-
man is thereby exalted to the lofty position of an
arbiter upon the points at issue, obliged in the brief
period of time to qualify himself as such, and system-
atically deceived, misled and narrowed as to the
aspects of the case which he is permitted to consider
under the rules of evidence.
Paradoxical as it may seem, however, there is a
strong measure of doubt whether this system of con-
sideration and decision by juries even of the kind
referred to can be improved, for the simple reason
that no other plan has yet been devised which would
not have similar defects and be open to the same, and
perhaps greater, objections.
A very distinguished jurist, writing reminiscentially
of his experience as associate justice of the United
States supreme court in support of the existing trial
by jury, declares in effect that the differences and
disputes of the members of that august court leading
up to decisions do not materially differ from those of
the average petit jury, and that notwithstanding their
profound legal learning the actuating motives and
influences are essentially the same, particularly as to
matters of fact.
Furthermore, if reform could be accomplished in
criminal jurisprudence by the modification of the
jury system it would be impossible as, it is hardly
necessary to state in this presence, the right to trial
by jury must forever remain inviolate under constitu-
tional provision. For the same reason it may also be
1 Editorial, New York Sun. April 26, 1896.
said that the right of a defendant or plaintiff to call
his own counsel and witnesses and cross examine those
opposed to him can not be denied or in any degree
curtailed.
It follows then that if reform in the presentation of
medical expert testimony is ever to be accomplished,
it can not be by way of any change in the jury sys-
tem of trial at present in vogue. It is much more
possible that it will come through an improved and
acceptable method of obtaining, and submitting for
deliberation by the jury, the associated scientific facts
and relations.
In the judgment of the writer the following propo-
sitions would seem to fairly comprehend the circum-
stances :
1. The appointment of a commission of experts by
the court in each case requiring it, the experts to be
especially qualified by educational experience as such.
2. The, establishment of an educational curriculum
and a period of service in each branch of medical
science by which the qualifications of an expert wit-
ness may be known and certified.
3. Just and adequate compensation commensurate
with the character of the service should be awarded,
and should in every instance in criminal cases be paid
from the public treasury upon the certificate of the
presiding judge. In civil cases the compensation
might or might not be fixed by the court, but should
be taxed as costs to abide the event, or, by agreement,
the expense might be equally divided between the
contestants in the action.
With these somewhat desultory remarks, for which
it is not pretended that they convey any new or orig-
inal ideas, but that they simply express the individual
thoughts of the writer and endorse the views that are
commonly entertained among those of the profession
whose opinions are entitled to carry the weight of
authority, your attention is respectfully invited to a
brief history of the movement which is now in prog-
ress, and is rapidly assuming influential and promis-
ing proportions in the State of New York, looking to
the correction of the evils of the prevalent method as
far as may be by appropriate legislation.
During the session for 1895 of the Medical Society
of the State of New York, a special committee, com-
prising some of the most noted and competent alien-
ists and medico-legal authorities of the State, was
appointed to cooperate with the standing committee
on legislation to duly consider the subject and report
the most feasible plan of procedure.
Soon thereafter an extensive correspondence was
undertaken among the prominent jurists, alienists
and medical experts of the country, in order to obtain
a symposium of essays illustrative of the relative per-
sonal status of the individuals addressed for the sub-
sequent guidance of the committee.
With notable unanimity, the opinions expressed in
all the replies received were substantially the same in
regard to the main propositions.
All agreed, first, upon the growing necessity for the
reform; second, that the true solution of the problem
consists in the appointment, by the common consent
of the court and the contending parties, of a commis-
sion, or a board, of experts, in each case, to act in an
advisory capacity in the presentation of the scientific
aspects to the jury; and third, that absolute inde-
pendence can only be secured by an arrangement
whereby the honorarium shall be a public charge, the
value of the service to be determined by the court,
l»'tr.
L E
TI.MONV.
679
thus divesting the proceeding of the eon.
acter so much to be depl reel
The greatesl difexsil if opinion rata.ivii
with reference to the ;i minting p
eating thai the appoin
governor, and that the >oard Bhould b<
one; many believing that the State should
bicted for the purpose iter the method in.-. a
practice in continental Kurope. Other
a permanent board should be defidg
Commission in Lunacj and be of a non-part
Btoter; and still others who expressed the \i bw that
the appointing power should be vested in thel m'rd of
regents of the State univemty, the] to pass Imn the
qualifications of the incumbents in the same Dmuned
that medioal practitioners are now licensed iftet
examination by the State board of \amin > I
that it be unlawful to designate any person to give
expert testimony who does not possess the regent's
certificate setting forth that he is duly qualified.
A general commission was suggested, to be perma-
nently established by statutory enactment to repre-
sent all departments of science (and perhaps mechan-
ics ) upon which requisition might from time to time
be made when the occasion should be such as to
demand the service of an expert.
A special commission for each case was more com-
monly advised, to be named by the presiding judge,
and to be composed of three or five members, one or
two to represent the prosecution, one or two to repre-
sent the defense and one to be nominated as the
special representative of the court; all questions of a
technical nature to be submitted to them and their
replies and conclusions to be in turn submitted to the
court and jury, any or all of the experts to be subject
to subsequent cross examination upon the report ren-
dered should the parties to the action so elect.
With these data at hand, which seemed to contain
a complete consensus of the general trend of thought
upon the subject, the committee compiled a condensed
report in the form of a preamble and resolutions
which were promptly acted upon and unanimously
adopted.
In accordance therewith, a proposed law was form-
ulated under the intelligent direction of Dr. Carlos P.
MacDonald, the president of the State Commission
in Lunacy, and its introduction into the State legis-
lature secured by the writer. It is believed that the
bill embodies in substance the required measure of
reform in criminal cases, recognizing of course the
fact that no bill can be drawn which would be
entirely free from constitutional restrictions.
State of New York. No. 1943. Int. 1375. In Assembly.
March 26, 1896. Introduced by Mr. Scherer — read once and
referred to the committee on the judiciary.
AN ACT
To regulate the employment of medical expert testimony in
criminal proceedings.
The People of the State of New York, represented in Senate
and Assembly, do enact as folloivs : •
Section 1. Whenever any person in confinement, under
indictment for the crime of murder, attempt to murder, man-
slaughter, arson, highway robbery, forgery or other felony,
may desire to present medical expert testimony in his defense,
whether of a medical, surgical or chemical nature, he shall so
inform the court at the time of his arraignment for trial,
whereupon the presiding judge before whom such trial is
pending shall appoint such number of experts as he may deem
necessary to adequately represent both the prosecution and
the defense, and the compensation of such experts shall be
fixed by an order of the court at a rate that shall be reasonable
for professional services of such a nature. The experts so
d shall le persons of repute and qualified in the
\\ science to which the question calling for
Lapert opinion rejktes ; and shall have full and free access to
»!»■ c idence ad dined on the trial, as well as to the defendant,
if \ issue involves his mental or physical state. On the
ir examination, tho said experts shall submit
court for tmnsmission to the jury as evidence a report
i- vriting, attostel by their oaths, setting forth their conclu-
sion, together wisp the facts upon which such conclusion is
.•I on either side shall demand it, the experts
may be sworn an witnesses, but their examination and cross
examination as sun shall be limited to the facts and opinion
contained in their report to tho court.
ion -. All acts or parts of acts inconsistent with this
act are hereby repealed.
Section :t. This act shall take effect immediately.
It may be surprising to state that at the first hear-
fore the committee on judiciary to which it was
ed, although the bill was carefully scrutinized
v revision commission (the State board
of reference upon the phraseology of laws) the advo-
cates of the measure were confronted by a question
involving the doubtful constitutionality of the pas-
sage relating to the subject of cross examination.
Contention was m ade that cross examination could not
be confined strictly to the matters contained in the
report adduced, and that the defendant would still
have the right to go outside of the report and call
witnesses to combat the testimony therein; and in
case of his acceptance of the special expert commis-
sion such circumstances would place him in the posi-
tion of attacking the testimony of his own witnesses.
You will agree that this is a knotty point, and
observe how difficult a task it is to frame a law that
would be entirely free from similar antagonism.
Another objection may properly be mentioned:
In a recent editorial comment1 attention was
directed to an apparent ambiguity of expression
regarding the report of the contemplated special com-
mission, namely: That it does not specify as to
whether the experts shall submit their report collec-
tively or as individuals. If collectively, it may still
be a question whether a majority and a minority
report shall both be permitted, or a unanimous
declaration required.
Of course the bill should be amended in this
respect.
The proposed law will be modified in a way to meet,
if possible, every objection raised, and upon that
point it is hoped that some helpful suggestions may
be made by the members of this section.
This legislative proposal is now pending in New
York with no real expectation that it will be enacted
during the current session. That would be almost
unprecedented in so important a matter. But it may
be written down that no effort will be spared nor
opportunity neglected until the desired reform has
been achieved.
The contest will be continuous and uninterrupted,
and it is expected that the profession throughout the
United States will give all aid and support possible,
as favorable action in New York will greatly tend to
influence similar legislation in all other States of the
Union.
By way of comparison, it will not be amiss to intro-
duce at this point the text of a bill which was pre-
sented to the legislature of the State of Minnesota
several years since (1893), and about the same time
in the legislature of Illinois in practically the same
form.
This formulation was first reported to the Minne-
i American Medico-Surgical Bulletin, Vol. ix, page 55C.
680
INSANITY IN COURT.
«TY
[September 26,
sota State Medical Society by Dr. B. J. MerriSl,
chairman of the section on medical jurisprude^.
The proposition was very carefully studied in comi1'.'
tion with the movement in New York State :
Be it enacted, etc. /.
Sec. 1. — In all cases pending in the courts of this State, civil
and criminal, before or at the time of the trial of said cases,
the judge of said court, when it is made to appear to him that
the appointment of experts upon medical, scientific or mechan-
ical questions is desirable, may appoint such experts to exam-
ine into the subject matter in controversy, said experts so
appointed to be selected in reference to their impartiality
between the contending parties ; the number of such experts
in each case to be fixed by the court.
Sec. 2.— In all cases where experts are so appointed, the
court is to fix their compensation, and in all criminal cases
direct the payment of the same in the same manner as wit-
nesses on the part of the State are paid ; in all civil cases the
amount so fixed and determined by the court shall be taxed as
disbursements by the successful party.
Sec. 3 The court may order such experts to examine into
any medical, scientific or mechanical question, and after such
examination to testify in court in reference thereto.
Sec. 4.— The testimony of said experts so appointed by the
court, shall be prima facie evidence of the statements and
conclusions as to the questions in reference to which said testi-
mony has been given.
Sec. 5.— The court may also fix and determine the amount
to be allowed such experts for and on account of any medical,
scientific or mechanical examination, analysis or test, which
the court may deem advisable to have made, and direct the
payment thereof, or permit the taxation thereof as costs as
hereinbefore provided.
It is understood that considerable effort was made
to secure the passage of this proposal in both the
States mentioned, but it was successfully opposed in
both instances. The bill has great merit, however,
and should have met with a better fate.
It will be noted that it differs from the New York
bill in several important respects:
1. It provides for civil as well as criminal cases.
2. It permits of unlimited examination and cross
examination of the experts appointed, and does not
specify a written report to the jury.
3. It makes provision for the regulation of analyses
and tests in all cases requiring it, and also prescribes
the payment of adequate fees for the same.2
4. It includes questions of a mechanical nature, but
does not specifically mention those relating to surgical
subjects, although the construction likely to be placed
upon the terms "medical" and "scientific" would
probably make satisfactory application.
Originality has not been attempted in this paper,
nor has effort been made to treat any phase of this
absorbing question to any extent exhaustively. It is
simply what its title implies, namely, "remarks upon
medical expert testimony and proposed relative legis-
lation."
The drafted formulas are placed before the section
in the belief that suggestive and critical discussion
will lead to conservative results.
Let it be borne in mind that the New York pro-
posal is nobody's pet, and the same may doubtless be
said of the one introduced for comparison.
The true motive of all concerned is to secure the
adoption of a wise and beneficent measure which will
comprehend the requirements of the occasion, correct
the prevailing abuses, and elevate our moral standing
before the courts to the dignified position to which it
is justly entitled.
Eeform is urgently needed. The "cause is ripe"
and the demand is rife.
2 In New York State the penal code provides for chemical and other
scientific analyses upon the order of the court, the compensation to be
fixed by the district attorney and paid by the county treasurer upon the
district attorney's certificate.
INSANITY IN COURT.
Read in the iJferfion on Neurology and Medical Jurisprudence, at the
>rt> -seventh Annual Meeting of the American Medical
Association, held at Atlanta, Ga„ May 5-8, 1896.
I5Y L. HARRISON METTLER, A.M., M.D.
CHICAGO, ILL.
W li the rapid growth of knowledge and the steady
development of new forms of industrial activity, the
employment of expert testimony for the instruction
of the "courts is becoming more of a necessity every
year, fhiis is admitted by all. The present method
of seetjing this testimony is acknowledged to be both
defective and inadequate. On account of this faulty
method, expert testimony itself is occasionally most
unjustly criticised and ignorantly ridiculed. From
the method of its engagement to the system of expert
testimony in general the blame has been transferred,
and some narrow minded jurists have even cast slurs
and insults upon the experts themselves, thus com-
pletely losing sight of the real cause of their dissatis-
faction, namely, the ancient and absurd method in
which the expert is brought before the court. Lord
Campbell revealed a partial comprehension of the
trouble, when he said that "skilled witnesses come
with such a bias on their minds to support the cause
in which they are embarked that hardly any weight
should be given to their evidence." What gives rise
to this bias might have been asked of the noble lord.
He insinuates his answer in the statement that they
come "to support the cause in which they are em-
barked." In other words, the expert is a biased indi-
vidual, just as my Lord Campbell himself would have
been, had he been engaged and remunerated by one
or the other side in the contest. To secure an
unbiased legal opinion from my noble lord, it was
necessary for the State to elevate him to the bench
and to pay him a wholesome sum out of the public
treasury. Experts are human beings with the same
human frailties as lawyers and judges, and I have a
suspicion that among experts there is a larger, or at
least equal number of individuals who honorably
decline serving, and who often forego a most tempt-
ing fee when they discover that their scientific testi-
mony will be damaging to the parties who have sum-
moned them. As he is now placed the scientific
expert is not an ex parte witness and Lord Camp-
bell's biased insinuations in regard to the honesty of
the expert, reflects more unfavorably upon the legal
profession and the legislative powers, in whose hands
the maintenance of the present defective system so
largely rests.
Once a judge of Maine declared that if there be
any kind of testimony that is not only of no value,
but even worse than that, it is in his judgment that
of medical experts, all of which criticism is highly
commendable if the honorable judge is at the same
time exerting his influence to induce his own guild
to institute the needed reforms by which medical
expert testimony may be able to exercise its proper
function and to reveal to the court the value which
the rest of the world recognizes it possesses. A New
York judge very judiciously classifies witnesses as.
liars, blank liars and experts, which is all very face-
tious and may be allowed to pass as a very judicial joke.
Mr. Weil, a lawyer of some acumen, once said: "The
fact is the average lawyer does not qualify himself to
examine an expert, he qualifies himself only suffi-
ciently to conceal his own ignorance." I do not think
L896. |
INSANITY IN COURT.
681
the average medical expert can be charged with such
an unwarrantable delinquency.
Maudslev suggested as a means of softening the
virulence and disgraeefulness of the disputes between
lawyers and dootors in our courts, the abolition of
capital punishment. In the words of Mills: "Some
of our learned judges are not without blame for this
stale of affairs. The decidedly antagonistic stand
which they seem ever prone to take against reputable
physicians in habeas corpus and other cases in
which questions of medical opinion are at stake, has
put the profession into such a frame of mind that in
Philadelphia — and it may be the same throughout the
country many physicians now refuse altogether to
make affidavit." It seems to me that these "learned
judges"' are so easily biased, considering the freedom
from onesided influences which their position and
income enjoys in comparison with that of the experts
as it now is. and considering the large amount of hon-
esty of opinion expressed by experts, even under such
unfavorable conditions, that these same judges are
constitutionally less fitted to administer justice in
court than are the experts they antagonize fitted to
give scientific testimony.
Those who recognize the faultiness of the present
method of expert examination anticipate very little
reform for a long time to come. The legal fraternity
has almost complete control of the judicature and
legislation of our country. The medical profession
has comparatively little to do with either. Now the
trend of law and medicine are almost in diametrically
opposite directions. Legal judgments are founded in
large measure upon precedents; they are based upon
authority which generally is better the more ancient
it is; to a considerable degree the legal mind looks
backward for its guidance. On the other hand medi-
cine, being a science, looks forward and to-day recog
nizes facts and formulates principles that it scarcely
dreamed of yesterday. Our modern judiciary system
is hoary with age; and its strength and dignity rest
largely upon its antiquity. On the other hand much
of our knowledge of insanity is of very recent date,
being founded upon discoveries in anatomy and phy-
siology made within the last decade. At one time
mental diseases were so little understood that there
were perforce no experts upon them; their manifesta-
tions were simply strange facts, the decision of which
was as much within the capability of the layman as
of a medical man. The acts committed by an indi-
vidual on trial for insanity could be as well established
and the insanity itself (which was necessarily of a
gross form ) could be as well determined by an ordinary
jury as by any body of professional men. The only
questions to be solved were the commission of the acts
and whether a supposedly sane person would have
committed the same acts. The absence or presence
of a rational motive and the power to distinguish
right from wrong, were the only plausible and appar-
ently reliable tests that could be applied. The psy-
chology of that day was about as well acquainted with
insanity as the law itself was; hence it readily acqui-
esced in the legal tests then formulated. Now, however,
all this has been changed, at least in regard to our
knowledge of insanity; whereas our system of judica-
ture has remained the same. In regard to the concep-
tions of mental phenomena, law and medicine started
out together upon the same path but the paths soon
diverged, and now have become so widely separated
that there needs to be an entire readjustment in regard
to medico-legal questions. Medicine recognizes to-day
special and complicated forms of insanity. It has
discovered since the formulation of the old legal tests,
particular varieties to which these tests are wholly
inapplicable. It has uncovered the physical lesions
for some of them at least. The diagnosis of them is
now a matter of greater refinement and depends
upon much more subtle symptoms than such signs as
the inability to distinguish right from wrong or the
absence and presence of certain motives. In a word
our system of administration of justice has not kept
pace with the progress of science; it has not read-
justed itself to the newer scientific state of affairs.
Perhaps the most glaring fault in the present man-
agement of expert testimony, is its engagement by the
opposing counsel. Human nature has its weakness in
scientific men as well as in lawyers and when experts
are thus hired they are almost forbidden to be experts
by being made partisans. Even were the condition
so Utopian that none bat honest experts could be
secured, that those whose opinions were found to con-
flict with the interests of the side engaging them
would refuse to testify, there would always be some,
equally honest, whose opinions would differ, especially
upon points of science still open to controversy. They
would be engaged and thus the court room would
become the scene of a scientific debate much to the
dismay and confusion of an uninformed jury. Such
is the way things are managed at the present time.
The counsel fixes the medical opinions for the court and
then hires those experts, or self-styled experts, who
will be most likely to support his side of the contest.
Between the two sides a rhetorical display of scientific
quibbling is presented for the edification of the court
and jury; more often a roaring farce is performed;
the judge becomes incensed, the jury falls into hope-
less confusion, and the few deserving experts in the
case are brought to shame and made the victims of
most unjust sarcasm. Volunteer experts would be
better than those paid like partisans for one side or
the other; but as volunteers would be hard to secure,
experts paid by the court or government should be
employed and only such experts. That would be one
step toward the elimination of the partisanship feeling
in regard to expert testimony.
But the counsel tell us that their purpose after all
in the cross-examination of opposing experts, is the
elucidation of scientific facts and not the hearing of
any scientific opinions; that one layman is as capable
of deciding facts as another; and that a jury of lay-
men should be the only body to decide upon such
facts; for the establishment of the truth or falsity or
rather the presence or absence of facts in the case
being tried, is the fundamental object of our great
jury system. In the words of Hornblower (Hamil-
ton's System of Legal Medicine, Vol. n, p. 131)" The
primary object of expert testimony is not to prove
opinions but facts in the shape of rules of science as
are generally recognized." And again, the counsel
tell us that the present method of engaging experts is
the best because it carries out most effectively the
great principle in our system of judicature, that every
man under accusation has the right to interrogate and
to confront his accusers and witnesses. Both of these
arguments of defense set forth by our legal friends,
are right in principle but wrong in practice as medico-
legal questions are considered to-day. When the
power of distinguishing right from wrong was the
test and apparently the only test of insanity, and
682
INSANITY IN COUKT.
[September 26,
when fads, scientific medical facts, were scarce in
regard to the many mental phenomena of health and
disease, the present system of our courts would have
been fully adequate to lead to a decision. To-day,
however, every intelligent man admits that there are
new facts revealed by science that none but a skilled
specialist can recognize. This is true of all the sciences
as well as of medicine. The court, for instance, does
not submit to a jury of laymen an abstruse chemic
question but takes the facts detailed by an expert
chemist and instructs the jury to accept them as
detailed. The discovery of arsenic in a man's stom-
ach is not left to a jury to decide, nor is its presence
or absence dependent upon any arbitrary legal test,
such as the discernment between right and wrong for
insanity; but an expert chemist is called and his ob-
servations accepted as proof of the presence or absence
of the poison. Likewise the decision of insanity in a
case on trial should not be left to a jury, because in-
sanity is diagnosed to-day upon finer symptoms than
the mere power to discern right from wrong, etc. The
fact of insanity can be affirmed only by a special stu-
dent of the disease and the majority of laymen would
be confused and embarrassed by what to him would
be clear and self-evident. Furthermore, in many cases
of insanity the only facts comprehensible to a lay jury
would be certain strange acts, delusions, etc.; but to
the expert those isolated, scattered facts, which would
seem to mean so little to the average layman, might
indicate a great deal. Hence, while to the jury the
experienced expert may be able to enumerate only a
limited number of facts within their comprehension,
he from a long study of similar cases may be capable
of giving a most valuable opinion in regard to the
sanity of the prisoner. Certain impulses such as
homicide in acute mania, suicide in melancholia, cer-
tain delusions as that of grandeur in the early period
of general paralysis, religious exaltation, illusions and
hallucinations in other special forms of mental
derangement, may when described to an average jury
as isolated facts or more general principles, bear very
little weight, because such a jury has not been im-
pressed with the importance of those isolated facts as
evidences of mental aberration, by seeing them
repeated and duplicated in hundreds of similar cases.
The experienced expert, on the other hand, has seen
such and from the few apparently unimportant/acfe
is able to give to the court the opinion that the pris-
oner is a victim of one or other form of insanity.
I believe, therefore, most emphatically that an
expert should not be put into the position of a ivitness.
Often he has witnessed so little in regard to the pris-
oner at the bar as to render his testimony in regard to
the facts about that prisoner's mental condition of small
worth. The expert should occupy a judicial position,
so that after a thorough examination of the prisoner,
he can give a full and unbiased opinion of his mental
condition, based upon the thorough examination and
his large experience in the study of like cases.
The increased refinement in the diagnosis of mental
diseases at the present time, demands the exercise of
an experienced judicial mind. It asks for something
more than the bare statement of a number of isolated
facts. A genuine expert is to-day, in the light of our
increased knowledge, something more than a witness;
he is a judge with an opinion to offer or he is at least
an adviser capable of guiding the court's opinion. His
worth is much diminished by putting him in the atti-
tude of a mere retailer of certain scientific facts, which
in their isolated presentation may throw but a limited
light upon the case in hand.
The same explanation accounts for the inefficiency
of the hypothetic question as a means of obtaining an
expert's opinion. This form of examination prevents
the expert from rendering a judicial opinion. As it
is now employed it brings into prominence symptoms
of little importance and suppresses others that may
be of the greatest significance. If it is to be made
use of at all (and the instances in which it is of any
value are testamentary cases in which the maker of
the disputed will is dead), it should at least be worded
and presented by the court and not by either of the
opposing factions. In the framing of the hypothetic
question as it is now done, the partisan spirit enters
and so construes the facts of the case as to make them
appear otherwise than they actually are. Granting,
however, that the question should be framed by the
two sides in such a way as to eliminate every suspi-
cion of partisanship, it may be presented to the expert
and court in such a manner from the legal or lay
standpoint as to be perfectly meaningless or com-
pletely unanswerable to the expert. In such a case
an expert will wisely decline to say anything, for he
will be obliged to keep within the limitations set for,
him and though he may know that a single word of
explanation upon his part would change the whole
face of the question, that word will usually not be
allowed him. Thus his valuable knowledge will be
lost in the trial. If he foolishly attempts to answer
the question, and thus more often than is agreeable
puts himself in a position not well fortified by his own
explanations, he will sooner or later come to grief in
the hands of the opposing lawyer, and appear before
the jury in a most ridiculous and self-contradictory
plight. This is not an uncommon exhibition in our
courts, and it is one of the chief causes of the dis-
repute in which experts are held.
I believe that every case in which insanity is
entered as a plea should have a separate medical trial.
This need not in the least remove the case out of the
jurisdiction of the court; for the same judge may pre-
side and in accordance with the result of the medical
trial, the prisoner may be sent to an asylum or referred
to the ordinary court for a civil trial. In the latter,
however, all questions as to the mental condition of the
prisoner should be excluded. This would undoubt-
edly diminish the number of insanity pleas now
entered for the defense of criminals. The criminal
as well as his lawyer would hesitate before coming
under the examination of a carefully selected com-
mission of medical experts; whereas now he is almost
certain he can confuse an ordinary jury and so secure
a verdict not in accordance with his deserts. The
very weakness of the present system is exposed in the
enormous number of insanity pleas that are annually
brought before the courts. Criminals recognize a
source of strength in their own defense, in the diffi-
culty experienced by the average jury in deciding
upon a case of insanity. It is the greater misfortune,
however, that the disadvantage works also the other
way, for it is a notorious fact that the gallows has
more than once ended the life of a poor demented
creature, irresponsible for his deed and sent into
eternity by the unjust verdict of a confused and igno-
rant jury of laymen. It has been argued that a sepa-
rate medical trial or examination before a commission
of experts would thwart the very purpose of our time-
honored jury system, in which a man charged with a
18%.]
EXPERT TESTIMONY.
683
orime is given the privilege of meeting face to face
his accusers and of receiving his sentence at the
hands of his peers. Now, I maintain that the present
mode of examination is the one which contravenes
the spirit of this fundamental legal maxim. If a
man accused of a crime, enters a plea of insanity as his
defense, or if he is suspected of being insane, he for
the time being stands as the representative of someone
of the many forms of mental disease. In a word, he is,
as it were, that disease itself, whether he is attempting
tunterfeit it or is actually its victim. It seems
to me. therefore, to be a self-evident proposition and
one that is almost axiomatic, that in the abstract the
peers of such a man are those who know most about
the disease which he is manifesting. The latter in
their knowledge of it are equally its representatives,
and they, like the prisoner, stand, as it were, in its
place: certainly more so than any layman who knows
Dothing about such a disease. There can be no sort
of parallelism or comparison drawn, in the abstract,
between the victim of an abstruse and delusive, form
of insanity for which lie stands in reality as the living
representative, and a lxnly of ignorant, inexperienced
jurymen gathered haphazard from out the street, who
have probably never seen or heard of the simplest
forms of mental aberration and for whom a few hours'
hurried explanation of it in a crowded, somniferous
court-room ran only afford a vague and uncertain
opinion. Why, a class of first-year medical students
would constitute a better jury than such a one for the
trial of insanity, while the trial itself would be more
in the spirit of our great jury system, for the medical
students would, at all events, have seen a little of the
possibilities and probabilities of disease. For a mili-
tary misdemeanor a soldier is tried by a court-martial,
it being understood that his peers are those who know
most about the military rules and regulations that he
has broken. A clergyman is tried for heresy by his
fellows, because they alone are his peers in knowing
most about the doctrines which he is supposed to
have denied. Likewise a crime done by a supposed
lunatic should at least have a separate medical exam-
ination to determine at least the lunacy of the crim-
inal, for the legal peers of such a criminal are those
who know most about the vagaries of lunacy.
In conclusion, then, I believe that the present
method of examining cases of insanity in our courts
is unjust because:
1. The engagement of the expert by the opposing
counsel is prone to bias the expert and to nullify the
truthfulness of his testimony.
'I. The discovery of a number of isolated facts
( which is the affirmed purpose of an examination in
court) is not in the present advanced state of our
knowledge of mental phenomena, the most reliable
way to diagnose insanity.
3. The value of an expert's testimony is vitiated by
the fact of his being placed in the position of a wit-
nees to testify to certain isolated facts, instead of the
position of an adviser to the court to give his full
and unbiased opinion.
4. The hypothetic question hampers even the most
learned experts and in the end often places them in a
contradictory and absurd attitude from which it is diffi-
cult for thotn to recover.
■ >. The present system does not carry out the
abstract spirit of the law that every man shall be
tried by his peers; but on the other hand works
injustice in many cases of real insanity and favors the
exercise on the part of criminals of feigned insanity.
<>. The old legal tests of insanity, which are of a
more or less popular character and were sufficiently
adequate for the guidance of the average jury in
former times, are not tenable to-day in the advanced
state of our knowledge of mental phenomena and
their manifestations.
The remedy I have already hinted at consists in
the separation of the medical from the civil trial. The
former is to be conducted in the presence of the
judge by a commission of learned and experienced
exports appointed by the supreme court or in
any other way that will keep the appointments
beyond the influence of politics; this commission to
be remunerated by the State in accordance with the
dignity and seriousness of its decisions. If the result
of this trial or examination by the commission of
experts, be that the prisoner is insane, no appeal is to
be allowed, but the prisoner is to be removed to an
asylum for medical treatment. If, however, the com-
mission decides that the prisoner is not insane, then
he is to be submitted to a civil trial in the ordinary
way and punished or acquitted in accordance with
the verdict.
4544 Lake Avenue.
EXPERT TESTIMONY IN DISPUTED CASES
OP INEBRIETY.
Read tn the Section on Neurologv and Medical Jurisprudence at the
Forty-seventh Annual Meeting of the American Medical
Association, at Atlanta. Ga., May 6-8. 1886.
BY T. D. CROTHERS, M.D.
SUPERINTENDENT WALNUT LODGE HOSPITAL, ETC.
HARTFORD, CONN.
During the past year several very important cases
have brought out the most widely divergent expert
testimony, clearly showing the need of new study of
this subject.
Disputed cases of inebriety are increasing every
year. Not the petty contests of police and criminal
courts, where the questions raised are technical for
partisan purposes, but facts of great interest and pro-
found questions of science on which large issues
turn. In one case, the final disposition of over a mil-
lion dollars turned on the question of the normal
condition of the mind of a testator who used spirits
to excess. In another case a forgery which impli-
cated many persons, depended on the judgment of
experts relating to the motives of an inebriate. Sev-
eral murder and homicidal cases have been disposed
of on the testimony of medical experts. The final
issue of all these cases has been the subject of diver-
gent views in both legal and medical circles.
The usual criticism that expert testimony is pur-
chasable and unreliable to the highest degree, has
become a common observation in court rooms. In
reality the ordinary expert testimony that is vague
and confusing becomes so through the faults of the
legal battles of lawyers.
In every case two theories are assumed and the
struggle is to prove the one and disprove the other.
Facts, theories and statements of every possible
character are gathered, grouped and twisted in every
way possible for this purpose. Scientific opinions of
every description that seem to sustain one view or the
opposite, are marshalled and placed in their best form
to carry conviction irrespective of the truth. The
central object of the opposing counsel is to prove the
truth of their side of the question and not to ascertain
B84
EXPERT TESTIMONY.
[Septembek 26,
the actual facts or principles of equity involved, and
expert medical testimony is called for this special pur-
pose. Consciously or unconsciously, the expert
becomes a partisan and, with the counsel, believes a
certain theory true, and in his efforts to sustain this
position, under the cross fire of the opposing lawyers,
appears to a great disadvantage. The fault is not
that of the expert, it is the vicious legal system of
ascertaining facts.
Suppose two physicians enter upon a partisan con-
test to prove that a given case is one of typhoid or
simple derangement of the digestion, and each one
gather and twist all possible facts to sustain his the-
ory. The failure of both to secure the real facts and
make clear their position would be inevitable. Take
these two men in court with care-testing counsel to
sustain and coach them. Then have the subject
obscure and not clearly defined in fact or theory, and
the wonder would be how any truth could be ascer-
tained by such methods.
The present methods of securing medical men to
sustain opposite views, by grouping a mass of state-
ments which are half truths and distorted, strained
conceptions, and enlisting physicians to defend them
by assuming that they are complete facts, is danger-
and utterly subversive of truth. The common expe-
rience of presenting to the expert a view of the case
which supports the theory the counsel is called to
defend, and convincing the expert that this is true,
then retaining him on the trial is the beginning.
Then the trial begins with the expert in possession of
a certain class of facts which he is soon biased to
believe.
In the meantime he has fortified these opinions by
reading and examination of all the possible authori-
ties, and grouped all the facts which support and
make the theory clear. On the trial he hears the
other side, but the constant presence of the counsel
who is defending the theory he has been retained to
support, neutralizes and explains away the opposing
facts. Every night the counsel literally coaches the
experts by arguments and explanations, and strength-
ens his former convictions wherever they may have
been shaken by other testimony.
Finally, the expert is a partisan who is fully con-
vinced of the truth of the theory he is called to sup-
port. He goes on the stand and under the cross fire
of counsel fails to make his theory clear, or impress
any one with respect for his fairness and scientific
accuracy. He is prejudiced from the start; his scien-
tific sense of judicial examination of facts is enfee-
bled; he has become, unconsciously or otherwise,
imbued with a strong bias in the belief of the accu-
racy of a certain class of facts. Of course the pecu-
niary fees will in some cases add to this, but in most
cases unconsciously. On the stand opposing experts
who are equally partizan and confident of the truth of
an opposite theory are able to detect and expose the
errors of the other. Finally, the expert testimony
becomes a mere word battle in which all the energies
of each side are concentrated to win their theory.
The "hypothetical case," which is supposed to group
all the facts in one picture, is made to prove and
disprove opposite theories by the merest word jug-
gling, and the emphatic affirmative and negative ans-
wers demanded still farther confuse the real facts in
question.
There can be no question that the fault is in the
system, not in the medical men, who wisely or unwisely
try to reach accurate conclusions along impassable
paths and roads of study. The most celebrated cases
which turn on medical testimony, and those of minor
interest, show the same confusion of means and
efforts to reach the facts, and the hope of change and
improvement is removed to some future, when med-
ical testimony will be given in commission and on
paper, as exhaustive independent studies of the facts
at issue.
There is another phase of expert testimony which
needs a new study from a different standpoint. I
refer to the disputed cases in which the question of
how far, and to what extent, has the use of spirits
impaired the brain and influenced the act in ques-
tion. Strange as it may appear, the medical answers
to this question are very largely colored by the pre-
vious convictions and personal habits of the expert.
This is illustrated by life insurance applications in
different sections of the country. Certain medical
examiners will consider the continuous use of spirits,
with an occasional attack of delirium tremens, of no
importance as impairing the risk of the life of an
applicant. In like manner a noted physician swore
that the continuous use of spirits for twenty years
would not necessarily impair the capacity of the
brain. Of course the honesty of the witness must be
assumed, but his prejudice and evident partisan atti-
tude was apparent. We have reached a position now
in psychologic research when the paralyzing effects
of alcohol on the brain and nervous system can be
asserted as an established fact. The fascination
which causes it to be repeated and become a daily
drink is from its narcotic properties. It brings relief
from pain, rest and a sense of comfort which requires
repetition and increasing doses to keep up. Its
action provokes a desire for more and the injury
of to-day seeks relief from the same drug to-morrow.
This use may be continuous or in paroxysms, but in
all cases there is positive injury, unknown in its nature
and extent, until finally it manifests pronounced
symptoms of degeneration and disease.
In any given case, where the history indicates con-
tinuous or paroxysmal use of spirits for any period
of years, the inference of mental impairment and
defects will be supported by an appeal to the facts.
It may be safely asserted beyond fear of contradic-
tion that no one can use spirits for any length of time
and be sane and of sound mind. Any act which is in
dispute, performed by a moderate or continuous
drinker, is open to suspicion. In the history of any
case, if the use of alcohol and other narcotics is estab-
lished, the expert has a starting point from which to
examine and study physical and psychical changes
that show the real condition. The study of the
drink history is the key that will clear up many of
these cases. A practical illustration is found in the
famous Ross case. Here, a homicide and suicide was
committed, and a will written at about this time was
contested. His conduct before and after the will was
not unusual, but his drinking history showed contin-
uous use of spirits in large quantities daily. From this
it was evident that his mind was enfeebled, and
although acting along lines of automatic activity he
was clearly unstable and likely to explode any moment
into some form of insanity. The more accurately his
drink history was known the clearer the insanity of
his case became.
The drink history is a very essential factor in the
study of the symptoms and is of more importance
1896.]
EXPERT TESTIMONY.
685
than ohange of conduct, appearance and thought.
These may remain substantially the same, or be so
concealed as to escape observation.
The mental state of a person at a certain time and
in certain circumstances is to be judged from a great
variety of conditions. This study should begin with
heredity, family diseases, peculiarities and surround-
ings. Then go on to birth, nutrition, culture, diseases.
injuries and surroundings. This leads up to the vast
range of influences and their power over the mind
and body, and furnishes a comparative clear concep-
tion of the physical and mental conditions present.
Then comes the question of the disputed act, what-
ever it may be. Was this natural and along the line of
his usual activities? Was the act and its motive reas-
onable and natural to him? Was it a natural sequel
to his drinking history, or any other line of conduct?
These and other questions can only be answered by
an appeal to the facts, and this appeal must be
addressed not to one side of Ins physical and mental
history, hut to all sides. The expert must analyze
groups and study all the conditions, and as in the
diagnosis of disease, it is a question of facts and their
meanings, not of theories or rulings of courts, or law
questions. The case is one of murder or crime of
magnitude, and the question is the mental state of
the man. The legal method is to begin with the act,
and go hack and forward for evidence to explain it.
In other words to first make an exhaustive study of
the act. then go back in the history for evidence and
indications which would point to this, or go forward
for facts which would follow such a deed. If it is a
will or forgery, or theft or assault, it is assured the
act itself furnishes evidence of the condition of the
mind which inspired it. The expert testimony is con-
centrated on the act; this is the same as requiring the
medical man to form an accurate opinion of a typhoid
or other case entirely from the present symptoms.
To properly realize the state or conditions of the man
at the time of the act, a life history must be gathered
and studied, particularly the drink history. These
facts of heredity of disease, of surroundings, of occu-
pation.of manner, of life, of his ambitions and purposes
and customs and. habits. Then the use and effects of
alcohol on his life, and the changes, if any, which fol-
lowed from its use. These and other contributing
and influential forces followed up to the disputed act
like links in a chain are all connected and all fore-
shadow the act in question, and all serve to show the
real condition of the mind at the time. With these
data to judge from, the experts would find no diffi-
culty in making a correct diagnosis. From this point
of view all theories would grow out of the facts, and
no questions of gathering facts to support a theory
would be thought of, and all studies of the act would
follow as a stage in the history of the case.
Conduct and thought are the avenues through
which unsoundness of mind is seen, and yet they are
only properly compared by a study of a previous his-
tory. The continuous use of spirits, as a rule, is man-
ifest in changed conduct and thought, yet this change
may not pass the limits which would attract attention.
This is seen in states of insanity where a semblance
of reason remains, and much of the thought and con-
duct are apparently sane. To illustrate : A man killed
his wife, and the act seemed sane and with motive.
His conduct and thought before and after had no
appearance of other than conscious reasoning of cause
and effect. He was tried and convicted of murder.
The defense of insanity rested on his drinking habits
and the coolness of the act. It was treated with con-
tempt. On the second trial a thorough study of the
case showed an alcohol and epileptic ancestry. Severe
diseases in infancy, neurotic defects and disorders of
childhood. Early use of spirits to excess at puberty,
then a degree of moderate drinking from this time on.
Five years before the crime he suffered sunstroke.
From this period on paroxysms of anger and strange
impulsive acts frequently occurred, acts without rea-
son at the time, which he manifested much anxiety to
explain afterward. The acts were committed in a
sudden impulsive way, the explanations seemed an
afterthought and an effort to make clear what was
unusual and strange before. Some of these explana-
tions were clear and rational, others were strained and
peculiar. In all cases there was a suspicious frank-
ness about his statements that suggested some con-
cealed delusion. He used spirits daily in small quan-
tities, and every four or six weeks he would drink to
stupor at night in his room. The next day his man-
ner was changed, he was more talkative and excited,
and seemed anxious that full explanations should be
made of every event and act. In business he was more
exact and methodic, and more irritable and intol-
erant of the errors and failures of those associated
with him. He was sentenced to prison for life, and
in a few months developed well marked epilepsy. It
was evident that for years he had suffered from
premonitory epilepsy, and the homicide was the result
of this condition.
Recently a postmortem of a man hung for murder
revealed a tumor in the brain, which had evidently
been the growth of years. The man was an inebriate,
had murdered a companion, and exhibited cunning to
conceal the crime. His mental condition had been
questioned, expert testimony could not define the dis-
ease from the act, and no particular history of the case
was made. Seen from the facts of the postmortem,
the crime was the act of an insane man. A diseased
brain unable to reason and control its acts had been
misjudged and judicial murder added to the first
crime.
In a celebrated case of a clergyman whose conduct
and impulsive drinking had been the subject of much
social scandal, and on several occasions resulted in im-
prisonment, a postmortem at death revealed the real
causes. A fragment of a ball received in the late war,
was found incysted in the skull pressing on the brain.
His life had been prominent by great extremes of
character and conduct.
An eloquent, model clergyman and a low dishonest
inebriate; great intellectual brilliancy and childish
dementia, with paroxysmal explosions that were inex-
plicable. Expert medical studies had failed to detect
the physical nature and causes which were clearly
manifest by the symptoms. These studies were dis-
missed with the terms sin, vice, moral depravity, and
given over to the devil. Such echoes of the dark
ages are fortunately receding and growing fainter, and
the medical man of to-day who uses these terms in
explanation of strange conduct is sadly belated. The
drink history is an unmistakable evidence of degen-
eration, of disease, of central brain failure to realize
and control conduct and acts. While the expert may
not be able to trace the exact lines and forms of
known and defined insanities, he can always deter-
mine general principles of cause and effect. The use
of spirits is a specific range of causes deteriorating
686
KEFOEM IN MEDICAL EXPEKT TESTIMONY.
[September 26,
and destructive to all healthy normal brain power.
The problem is how far the use of alcohol is a cause
or a symptom in any case. How far it breaks up and
injures the capacity to reason naturally on events and
their meaning. This must be determined in each
case from the separate facts and history. The expert
must start out on a new original study in each case.
He must start from the fact that the medical ques-
tions in the disputed case, are purely matters of cause
and effect. The criminal or unjust act, the strange
unusual reasoning, and the suspicion of brain failure
are all susceptible of demonstrations from accurate
exhaustive study.
An officer in the English India service was a mur-
derer and forger. He was convicted and before sen-
tence was placed under the care and observation of
expert asylum physicians. In a few months a well-
marked case of general paralysis appeared, and it was
evident that the crimes had been committed in the
preliminary stage. The experts in this case could not
make out the form of the disease from the facts at
command, although the evidence was clear that some
form of degeneration was present; later and more
exhaustive studies revealed the true condition.
The facts I wish to emphasize in this study are on
the errors of the present methods of examining med-
ical men in open courts on questions of facts relating
to science. The great difficulty is avoiding a parti-
san attitude and taking sides in a disputed case. The
legal methods of, from a brief study of the act in dis-
pute, forming a theory, and bending all energies to
support and defend it, are dangerous and thoroughly
unscientific. The haste and confusion in which a
medical man is expected to study supposed facts and
ascertain their real meaning, and prove a hypothetic
question, state positive convictions, is utterly subver-
sive of truth. In every case the physician should
insist on time and full opportunity to satisfy himself
as to the actual conditions present in a desperate case.
He should also insist in stating the reasons and facts
on which his conclusions are based, and not be con-
strained to affirmatives and negatives where each
answer depends on certain conditions which will vary.
The second fact which should receive prominence
is the drink history in a desperate case. Here the
same errors prevail. Theories of alcohol and its
effects which have come down from the past together
with legal conceptions of responsibility, must be put
aside as misleading. Has alcohol in any degree
raised the vigor and mental capacity of the person
who has used it? Has his thought and conduct been
more rational and normal from its use? If this
can not be answered in the affirmative from the facts
the opposite must be true. In all cases the fact that
alcohol was used by the person whose mental condi-
tion is questioned opens up a new field of study.
Here critical analysis of facts will point out states
of poisoning or marked degenerations that exist.
Dogmatism here is fatal to the reputation of the
expert, he must adhere closely to general principles
and appeal constantly to facts. He must examine
and reexamine the facts persistently to eliminate all
possible errors. The medical expert should take the
position of a judge and give the conclusions and the
facts on which they are founded, then he rises to the
level called for by science and truth. Medical men
called to give facts of science in court to-day should
keep above the levels of courts and battles of counsel
to maintain the power which their position demands.
THE NECESSITY OF REFORM IN MEDICAL
EXPERT TESTIMONY.
Read in the Section on Neurology and Medical Jurisprudence at the
Forty-Seventh Annual Meeting of the American Medical Asso-
ciation at Atlanta, Ga.. May 6-8, 1896.
BY DANIEL R. BROWER, M.D.
PROFESSOR OF MENTAL DISEASES. MATERIA MEDICA AND THERAPEUTICS,
RUSH MEDICAL COLLEGE ; PROFESSOR OF MENTAL AND NERVOUS
DISEASES, WOMAN'S MEDICAL SCHOOL, N. W. UNIVERSITY,
CHICAGO, ILL.
The members of this section, without a dissenting
voice, will agree with the title of this paper, and feel
keenly the discredit brought upon the profession at
every important trial where medical expert testimony
is employed.
A trial, as I am writing this, is going on in Chicago
in which a dozen medical witnesses are arrayed against
each other on the question of the responsibility of a
dipsomaniac, one set testifying that he is responsible
for the killing of his wife, and the other that he is not.
Similar discreditable displays have been witnessed in
this city in the Cronin and Prendergast cases: indeed
every city and every such trial is a most serious reflec-
tion on the integrity and capacity of the medical
profession.
Medicine is not pure empiricism. Medical juris-
prudence is a great compilation of scientific facts, and
their judicious use is essential for the establish incut
of justice in many cases. Medicine is a learned, as it
is a self-sacrificing profession, and under proper pro-
tection and with proper legislation, medical expert
testimony can be relieved of the stigma that is attached
to it. It ought to be no longer possible for lawyers
to find physicians, who will have standing in courts,
to build up this theory, or that theory of a case, as
the necessities of the prosecution or defense may
require.
This medical expert testimony is not only con-
demned by the leading thinkers of our own profession,
but the legal profession in this country and Great
Britain has been equally emphatic in its condemna-
tion; for example, we find Lord Campbell of England,
remarking, "Skilled witnesses come with such bias on
their minds to support the cause in which they are
embarked, that hardly any weight should be given to
their evidence." ' Again, Judge Davis of this country
expressed an opinion that "if there is any kind of
testimony that is not only of no value, but even worse
than that, it is that of medical experts. They may
be able to state the diagnosis of a disease more
learnedly; but upon the question whether it had, at a
given time, reached such a stage that the subject of
it was incapable of making a contract, or irresponsible
for his acts, the opinion of his neighbors, if men of
good common sense, would be worth more than that
of all the experts in the country." 2
Again, another American judge has spoken almost
as strongly : "There seems to be but one opinion as
to the fact that this kind of testimony is extremely
unsatisfactory. We are more and more confirmed in
an opinion that the difficulty comes largely from the
manner in which the witnesses are selected. If the
State or the courts do not esteem the matter of suffi-
cient importance to justify the appointment of public
officers, it is certain the parties must employ their
own agents to do it; and it is perhaps almost equally
certain that if it be done in this mode, it will produce
two trained bands of witnesses in battle array against
1 TracvPeer.10 Clark & Fin., 191.
■i Neal case, cited 1 Redfleld on Wells, ch. iii, 101, par. lil.
L896.]
DISCUSSION.
687
each other, since neither party is bound to produce,
or will be likely to produce, those of their witnesses
who will not confirm their views."8
T»ylor, in his work on Evidence, observes: "It is
often quite surprising to see with what facility and to
what extent these views can be made to correspond with
the wishes or the interest of the parties who call them.
They do not indeed wilfully misrepresent what they
think, hut their judgment becomes war] >ed by regard-
ing the subject in one point of view, that even when
conscientiously disposed, they are incapable of ex-
pressing a candid opinion."'
In my opinion the time has come for a reformation,
and 1 ask the cooperation of this Section in the
efforts that are being made to devise some plan by
which the present methods may be improved.
The International Congress on Forensic Medicine,
which met in Paris in ls>'.». representing as it did. the
best thought of the times on medical jurisprudence,
deliberated thoroughly on this important question,
and formulated the following proposition, which was
adopted: "To guarantee the interests of society and
of the accused, in all medico-legal investigations, at
least two experts shall be employed. These shall be
appointed by the judge."
Six of the medical societies of Chicago have had
the subject under serious discussion, and as a result
a joint committee of eighteen was appointed, of which
the writer had the honor to be made chairman, and
this committee, after due deliberation, have formu-
lated and adopted the following draft of a bill.
A Draft of a Hill for an act authorizing the Judges of criminal
jurisdiction in the State of Illinois, to appoint persons to
act as expert witnesses :
Be it enacted l>i/ the People of the State of Illinois in the
>ly represented, Thatthe Judgesof the Circuit
and Superior Courts of the State of Illinois, be and the same
are hereby authorized to appoint in the month of January of
each year, persons who shall act as expert witnesses in the
medical and other sciences in giving opinion upon the evidence,
as presented in a hypothetical form, of criminal causes that
may be on hearing in the courts presided over by the said
judges. Such expert witnesses shall hold their said appoint-
ments for one year, or until their successors are appointed and
Qualified. They shall be entered as expert witnesses upon a
list of such witnesses kept by the Circuit Clerk, and the said
Clerk shall issue a certificate of appointment as such expert
witness to the person appointed as above.
Sec. 2. Such expert witnesses shall be citizens of the State
of Illinois, and shall be known in the communities where they
reside for their professional competency and personal probity,
and if physicians, they shall have been at least five years in
regular and active practice. When expertopinion is desired in
any cause pending in a criminal court, the trial judge presiding
in such cause may. at his discretion, summon for duty under
this act, such expert witnesses to the number of three. Such
expert witnesses shall be paid for their services by the county
in which the trial for which they are summoned is held, in
such sums as may be named by the judge.
Sec. :5. It shall be the duty of such expert witnesses to give
an opinion on the evidence as presented in hypothetical form
in the ease in which they are called. Such experts shall be
subject to cross examination by both prosecution and defense ;
but such cross examinations shall be limited entirely to the
subjects embraced in their opinion.
Sec. i. In criminal cases previous to trial, if the State's
Attorney deems it advisable to have expert opinion, he shall
state to the court having jurisdiction of the cause, and the
judge receiving such statement may summon expert witnesses
to serve under this Act.
This bill with slight amendments passed one branch
of the Illinois Legislature, but failed to reach a vote
in the other. It met with much more favor than was
anticipated and an effort will be made again this
winter to secure its passage.
3 Gay v. Mut. Ins. Co.. 2 Bigelow. Life Ins. Cos.
* Taylor on Evidence, p. 73, par. 60.
discussion on papers of dbs. suiter, mettler, crothers
and brower.
Dr. Huohes, St. Louis, Mo. I think that the question of
expert medical testimony is a far more difficult question to
determine by legislative enactment than at first sight appears.
The court is undoubtedly entitled to an amicus curiae in
every question of mental aberration; the court can solicit
counsel, friendly counsel, from science to aid it in forming
its conclusions and judgments. The only thing that seems
to be in the way is the neglect of legislators and other author-
ities, to provide means for the compensation of this counsel.
But after you shall have secured for the court all it requires
or may ask in these cases, you still have the inalienable
right of the individual accused or arraigned to have such
testimony as his case, in his judgment or the judgment of
his counsel, may demand. He still has the right, after you
shall have enacted laws providing for expert medical testi-
mony to be given in the interests of the court for the enlight-
enment of the court, to as much testimony in his behalf, or
that will contribute to enlighten the jury, as may be neces-
sary to accomplish that purpose and to secure his rights
before the law. The chief difficulty in this whole question of
medical expert testimony is not so much in the fact that the
principle of giving expert testimony by experts as such before
the jury, and for the consideration of the jury, is objection-
able, as in the quality of the expert testimony itself ; and
the suggestions of Dr. Suiter meets my approbation entirely
in regard to the efforts made to determine the quality of
experts who shall be admitted to testify. I do not coincide
with the views of Dr. Crothers in regard to the general weak-
ness of medical men in their judgments in regard to expert
medical questions. I do not consider that a medical mind is
naturally less logical or weaker than the average mind.
Some medical minds, like a few legal minds, and a great many
more clerical minds, are lacking in trained logical discern-
ment. If a man assumes to be an expert, he should think
as an expert and cultivate the judicial faculty of mind and not
go into cases biased, not decide upon the presentation of the
case only conditionally by one side. I have never made any
such mistakes as Dr. Crothers is talking about, although I am
a western medical expert, and I have never made the mistake
of committing myself to an attorney in any question irrevoc-
ably. I have taken facts given to me by attorneys and given
conditional opinions, for which I have always exacted a consid-
ation for the opinion itself, without regard to the use that
might be made of it. I never took a contingent fee in my life.
I have taken fees for time of service, conditioned that I might
be required for so many days' service, provided the opinion
that I had given, and which was paid for at the time, proves
to be satisfactory, supplemented by another opinion when all
the testimony was in, with the understanding that I was to have
all the opposing testimony before my final conclusion was
reached, where that was practicable. There is no reason why
medical men that aim to be experts in court should not elevate
expert medical testimony in such a manner as to stop this out-
cry against it. Medical men make no more errors in judgments
than lawyers. Lawyers say that the errors of medical men are
buried in the ground, but the errors of lawyers are before us
constantly ; the decision of one court is reversed by another,
and lawyers have to have a succession of courts, appellate
courts, supreme courts, to correct the errors of judgment of
the lower courts ; and the arraignment does not hold good in
regard to medical expert testimony.
The question in regard to the effect of alcohol in questions
of mental aberration, is not whether the man has drunk so
much or so little, not whether the man has had such and such
drinking habits, and then a conclusion that therefore that
man must be out of fix mentally ; but it turns upon the ques-
tion of disease which can be established by methods of obser-
688
DISCUSSION.
[September 26,
vation familiar to all psychologists, neurologists and alienists,
and that is the underlying question in all cases of mental
aberration, whether it be produced by alcohol or irregular
habits or over-strain. The toxic effect of alcohol does not
prima facie make a lunatic. There must be an inherent
instability of nerve element in the organ, brought about by
repeated potations destroying the integrity of the cell or neuron
that gives final instability to mental operation. And the
alienist, interrogating his patient carefully and finding that to
be the fact, says to the court that he believes this man is dis-
eased, or is insane and irresponsible, and because he is so dis-
eased that his mental operations are not normal, they are out
of harmony with his natural character ; and thus the individ-
ual is placed in disharmony with his environment. The change
has come over that individual by reason of disease, and alcohol
has been the exciting and it may be the predetermining effect
or the chief factor. The individual that makes a business of
going into court upon the hypothesis that because a man
drinks whisky and commits a crime he is therefore insane, will
be exposed in error by a judicial- minded lawyer, capable of dis-
cerning appearances from real facts by the proper logical pro-
cesses.
The criteria of all mental aberration resolve themselves into
the question of disease. If it is not a question of disease,
medical men have nothing to do with it before the courts ; it is
out of the province of the alienist or of the neurologist. If it
is only a question of conjecture based upon the knowledge of
the man having drunk alcohol, in the case of alcoholic insanity
anyone can conjecture that that was probably the reason the
man committed the crime. But in every form of mental aber-
ration it is a question of disease, whatever may be the exciting
cause. So far as all forms of aberration are concerned, except
those rare forms which may be called hereditary, and which
even in those instances are marked by a departure from natural
habits of thought, feeling or action of the individual, we are
enabled by careful interrogation of the patient to establish the
systematic evidences of disease in the individual's brain and
mind, just as we determine the existence of disease in the
body. All disease is a perversion of the physiologic action of
the organism or of the organ from the normal ; and all mental
aberration is that same thing. It obeys a certain law as any
other physical disease. The substratum of all mental disorder
being physiologic disorder of the brain, you have manifesta-
tions just as in any other diseased organ. You come back to
the proposition of Cabani and you find it almost the same. We
do not say that the brain secretes thoughts as the liver secretes
bile and the stomach secretes gastric juice, but it obeys these
same laws and it displays thought upon the same condition,
and if it is out of order so as to constitute the condition of irre-
sponsibility, the character of the brain's functioning will be so
transformed as to make the brain act unnaturally, just as the
liver acts unnaturally, the spleen, pancreas or any other organ
of the body, the intestinal tract, the bladder, the heart ; and
that organ will be out of harmony with its environment in the
organism. Its functioning will be disturbed in relation to the
organism and in relation to the individual's environment, and
so will an individual's character be transformed and changed,
thus placing him out of harmony with his surroundings. It is
not difficult for the average medical expert to detail all forms
of mental derangement, whether they are produced by alcohol
or other causes in that category, and be able to make the thing
plain by the cooperation of the reaction tests applied to the
urinary excretions, by the ophthalmoscope and other plans
within our reach to confirm the conclusion that that man's
brain is deranged, and that the departure from the natural
habits of thought, feeling or habit of that individual which
attracts our attention is the result of that brain disease. These
conditions can generally be placed very plainly before the court
by experts, so as to bring conviction to the average jury, and
at the same time reflect a reasonable amount of credit upon
our profession and not make the impression that medical men
merely guess at these conclusions.
Dr. Moyer — The subject can be divided naturally under two
heads : 1, that the personal attitude of the medical expert tes-
timony as given in our courts, is defective, inadequate and even
offensive in the eyes and to the mind of man ; 2, such being
the case, the remedies that are proposed to overcome these
defects.
Regarding the first proposition, I do not regard the present
system of giving expert testimony as nearly as bad as has been
stated here. Now and then there is a case presented, in which
there has been a gross miscarriage of justice, or perhaps a con-
flict of the evidence which is simply appalling. Such a case
attracts public attention forthwith, and the whole theory of
our present medical jurisprudence is condemned. I believe
that there are a large number of cases, both civil and criminal,
tried in our courts, in which the present system is adequte
and effective, in which the truth is ascertained, and just ver-
dicts are rendered. This is the rule ; the exceptions to it are
the cases which attract the attention of the public and most
medical men.
I do not, however, advocate the present system of giving
expert testimony as the best, as I think that it is capable of
improvement, but we should approach the subject with care,
and we should make very short steps in advance, lest we fall
into a worse state of affairs than we have now.
If we consider some of the causes by which medical expert
testimony is made difficult, I think we can approach the ques-
tion of reform with a little clearer apprehension. The fault is
not all with the method in which experts are summoned ; it is
not due to the fact that the lawyer goes to the physician's office,
explains to him his theory of the case on a partial statement of
the facts, secures his testimony, and makes him a partisan.
There are other objections and other difficulties that are inher-
ent in the constitution of society and human individuals them-
selves. Human institutions are not perfect ; I do not think
that our legislatures are perfect. There is no remedy that can
be devised which will bring about a perfect result ; the ques-
tion is whether its defects are to be less than the present system.
The causes of these defects are partially in the nature of
things, the defectiveness of individuals, the defectiveness of
jurisprudence generally. But there are also defects in ourselves
and in medicine. Medicine is not an exact science. The opin-
ions that medical men give in courts are largely based upon
judgment and experience. We can only have a perfect medical
jurisprudence when we have an exact medicine; that seems a
long distance in the future. In view of the fact that medicine
is in an inexact state, some subjects almost chaotic, with wide
divergences of opinion, we should approach the subject of a
remedy with very great care, and an attempt to make a wide
and sweeping departure is very ill-advised. We do not know
exactly what the truth is in a great many cases, and even though
we may agree on the major proposition in a given case as to
where the truth lies, there may be a large number of minor
propositions admitting of a wide difference of opinion. As long
as this is the case it does not behoove us to set ourselves up as
judges in a court of law. We do not know enough about med-
icine yet to do it ; we have to improve medicine very much
before we can take such a strong ground.
I now pass to a consideration of the remedies which are pro-
posed. These are naturally divided into different classes : those
which, according to the continental system, would limit the
function of the jury ; would make really a jury of experts, not
subjecting their opinion to cross-examination, but the jury to
take their decision on that part of the case as final. The other
system, as has been recited in the bill from New York, and the
one from Illinois, consists not in sweeping away cross-examina-
tion— limiting it somewhat perhaps as in the case of the bill
L896. |
DISCUSSION.
«89
from New York —but simply changing the manner in which
experts are to be summoned ; giving them some definite stand-
in g : providing for compensation tor these experts, and doing
Kwaj . so tor as possible, with bias among them.
In this respect I agree with the bills that have been pre-
sented but I shall never give my consent to any other step in
this direction until that has been taken.
As to this New York bill, it does not seem to contain any
definition of expert testimony. That would seem to be an
important omission. What is expert testimony? Is it opinion
testimony ; if so, where does the difference between fact testi-
mony and opinion testimony come in? Lay persons give opin-
ions in court ; they can give an opinion in most of our States
as to the insanity of a person. "Do you think such a person
was insane?" It is perfectly competent for any witness to
answer that question.
Then, there is absolutely no provision in this bill for another
exceedingly important testimony; that is, shall a person who
is previously in possession of facts be allowed to give opinions
as well? It is proposed to summon into court medical experts,
presumably not familiar with the facts in that particular case,
(This is provided for in the Illinois law by hypothetic state-
ments, i A man makes a postmortem examination ; he is sum-
moned into court, and his opinion, as well as the recital of the
facte of the postmortem, are asked for. Perhaps his opinion
is more valuable because based on things he sees at the time;
better than any subsequent opinion formed by hearing a relation
of the facts. In this New York law we are met at once with that
question : Shall a man who has previously examined a patient (a
blood stain, or the contents of the stomach) be allowed to give
his opinion under this law or not ; or shall the opinion on the
case be solely confined to these experts? Under the New York
law the h\ pothetic opinion can alone be given experts who are
all summoned. It seems to me that this is a fatal defect in
the drafting of this bill.
Dr. Boghbs Have you been asked on the witness stand to
give your opinion hypothetically, and then, in a second opin-
ion, to give your opinion upon all the hypotheses in the case,
M well as upon your own information?
Dr. Mover— In Illinois that is a very common form of ques-
tion. When a postmortem examination is made there may be
no man accused, and no man on trial. Is the man who makes
that postmortem examination to go into court, and give his
opinion as to what the cause of death is? That opinion is
formed long before anybody is arraigned for tria}. Shall he
give that opinion?
Dr. A. Walter Suiter— That is what he made the postmor-
tem examination for.
Dr. Mover — It seems to me, that this is one of the defects
in the bill ; that a person may be liable to be put in possession
of facte long before a trial, for instance, the direction of
a bullet wound, the facte of postmortem examination ; a
stomach is submitted to a chemist for examination, perhaps
under the suspicion only that there has been foul play. There
is no case in court, there is no man arraigned. Then a man is
summoned as a fact witness, and he states what he found at
that postmortem examination. Is he to be permitted to give
his opinion? It seems to me that that class of testimony is
shut out by that bill, and that is the most valuable kind of
testimony that comes into a court of law ; the opinion formed
at the time of personal examination.
Regarding the view of the matter brought out by Dr.
Crothers, I think he carries his opinion as to the effect of ine-
briety too far.
He says that experts are required to make yes and no
answers to leading questions. There is no court in any State
of the Union where such a practice prevails. He can qualify
his answer until his exact idea is placed before the jury.
Dr. Rohe — I am much more favorably disposed toward this
Act of the New York Legislature that was not passed than
Dr. Moyer seems to be. However, it does not cover the sub-
ject fully ; an additional section would be advisable.
During the past winter it has been one of my duties, as a
member of the Committee for the Baltimore Neurological
Society to prepare amendments to the Maryland Code, so far
as relates to lunacy. When the criminal procedures are
against lunatics, or in the cases of suite againBt lunatics, there
are certain means by which the defense of insanity may be
brought before the court and tested. It was proposed in these
amendments to authorize the court in any case where one was
accused or on trial, that the court should be authorized to
appoint a commission of three physicians qualified and
advanced in medical science, and experienced in the treatment
of insane persons, who should go into court and hear the testi-
mony (if it be that the trial were going on), and then consider
the testimony, and report to a court, under oath, their find-
ings. If they did not agree, or if the court for any reason were
satisfied with the findings of a commission, the court may dis-
charge that commission and appoint another commission, or
revert to the old established form of inquiry by a jury. The
object was to get a report which was the expression of all the
members of the commission, and that that commission could
be cross-examined by either the prosecution or the defense. It
was not a prosecuting commission or a defense commission ;
it was a commission of the court itself.
I rather decidedly object to bringing in any question of civil
procedure. When a question of money is involved, the person
who can get the best lawyers and the best experts, can win
the case.
But here is a case where an individual's life is at stake ;
where the person accused has no money ; where the State has
to pay expenses. The State ought to select and be responsible
for the expert testimony in this case.
Dr. Marcy, of Massachusetts In Massachusetts we are suf-
fering, perhaps more than any other State, from the necessity
of reform in this respect. The best men in Massachusetts will
not appear as experts in courts. I myself have refused to go
into courts except in the defense of another practitioner. I
only express the opinion that is common in our State. I am
glad to tell you that the legal profession feel it themselves as
strongly as we do that something must be done to correct
the abuses which have arisen.
In a discussion we had in Boston not long ago the judiciary
of the State met some of the very best members of our profes-
sion, and this seemed a common ground upon which to meet :
that the judges themselves should have a large power in select-
ing the class of medical experts who should be considered as
a sort of judicial body, to which these questions should be
referred.
Dr. H. S. Drayton, of New York- For several years past
the Bar Association of New York has been discussing this sub-
ject ; the Society of Medical Jurisprudence in New York City,
also the Medico-Legal Association, and by reference to the
proceedings of either of those societies it will be seen that for
the last four or five years this matter has been one of constant
discussion. It has been under the consideration specially of a
commission, and every year at Albany the matter is brought
up for discussion in some way.
The matter of a commission appointed by the court in each
case seems to be chiefly favored, and yet that is not univer-
sally approved. Some favor a commission appointed by the
State, but politics would be likely to intervene.
With regard to the giving of testimony in court, I have had
a little experience, and I have never been very badly used or
abused by lawyers. I remember that celebrated case of Car-
lyle Harris. Nearly every great man, every physician who
stood before the country as an expert, as eminent in his
department of particular service, was very seriously treated by
690
DISCUSSION.
[September 26,
Dr. Sullivan, the prosecuting counsel of the city. Dr. Sulli
van, having a good medical education, used his knowledge as
far as possible for the purpose of mixing up the professional
witnesses, and seemingly did it very successfully. However, I
think that Dr. Wood and the other physicians did not sufifer
very much in the opinion of the communities at large, for the
reason that the common sentiment is not so much in favor of
the lawyer side of the subject as it is of the medical side.
In regard to answering questions yes or no, a hypothetic
question was given to me in a case in Newark, N. J., in a mur-
der case. I had had an opportunity to examine the accused
very carefully, and told the lawyers who wished me to testify
just my opinion, in fact I wrote it out very carefully and said,
"If you are satisfied that that opinion, if ventilated in court,
will meet your requirements or your wishes, I will testify."
In New Jersey the witnesses in these cases are paid for by the
county, and it i3 not a matter of a fee from the defendants. I
testified there, and at the close of my testimony a hypothetic
question was administered. I think it was about five minutes
in length and I was required to answer "yes" or "no." I
answered it practically "no," but I turned to the jury and made
a statement. The counsel for the prosecution endeavored to
stop me. Then I turned to the Court: "Your Honor, may I
be permitted to answer this question in my own way?" He said :
"Certainly : by all means explain your views to the jury." In
that case I was the only physician on that side who received a
fee ; my bill was honored without any discount.
In New York I have pursued the same policy ; when invited
to be a witness, or take part in any case, I have examined the
accused, examined into the case, and written out an opinion,
and I would suggest that that is a capital thing to do. Your
attitude in regard to the case will be clarified, and you will
be understood as representing certain opinions.
Dr. Bishop, of Pennsylvania The question that concerns
us most is in regard to the selection of these witnesses, whether
these experts should be permanent officers or only chosen for
the particular time. I have seen a good deal of legal testi-
mony, having been interested in a good many contests, and I
find the great trouble is that the physician when he gets upon
the stand is inclined to make a speech. Doctor, preacher and
lawyer, when they get in the witness stand, think it is an excel-
lent occasion to air their knowledge and try to mak« a speech.
If they are asked a hypothetic question, and then asked to
answer "yes" or "no," all they have to do is to say they do not
understand it. If you do not understand a question make the
lawyer explain it.
Dr. Moyer -Dr. Drayton refers to some difference of opin-
ion as to how these commissions should be appointed, or as to
how long they should remain in force. There has been none
between those who have taken part in discussing this question.
None have ever favored a permanent commission. That is
what we know as the continental system. We agree that the
best method is the appointment of separate experts bythe court
for each case.
Dr. Suiter We in the State of New York do not force this
bill, and simply want to correct it so as to cover every detail.
We are ready to receive suggestions at any time. This is in
the hands of some of the most competent experts and alienists in
the State of New York, and we are making a determined effort
to have this matter corrected in some degree. The question as
to whether civil cases should be included in this bill, came up,
and for reasons which have been very well stated by Dr. Rohd,
the civil cases were left out. We thought this bill would be an
entering wedge and there could be subsequent legislation
when the proper time came for it.
Dr. Drayton was incorrect in his statement that this subject
was being constantly brought up in Albany. I have had
charge, more or less, of medical and medico-legal legislation
for a great many years in the State of New York, and this sub
ject has not been brought before the legislature during that
time. There is no dispute in reference to the method of appoint-
ment, so far as the State of New York is concerned, and every-
body is agreed that the appointment should be made by the
court and the county bear the expense.
Dr. Hughes — It often becomes necessary for what are some
times termed speeches to be made by the medical expert — that
is, the elaboration and elucidation of his testimony. No med-
ical expert on the witness stand is obliged to suffer himself to
be confined by attorneys to a categorical answer, and whenever
an expert permits it, when his meaning can be further eluci-
dated, he puts himself at the mercy of the attorney against
him. It is a favorite method of attorneys with experts on the
witness stand to propound questions which they think admit
only of a categorical answer, and secure only such answers ; or
questions which they wish to have answered only categorically.
The medical expert should always be on the alert for that kind
of interrogatory, because it is always the business of the law-
yer to make the witness his witness : his questions are always
so framed, if he be an adroit attorney, so as to favor the point
which he wishes to elucidate. It often becomes necessary,
then, for the expert to decline to make a categorical answer,
and to so frame his answer that it can not be misunderstood,
and if this involves making a speech, then he should make that
sort of a speech. When I was young in psychiatry and the
guest of Dr. Isaac Wray, he told me : " Some day you will be
called into court, and I will tell you one thing from my experi-
ence, and that is, never to permit a lawyer to compel you to
give his kind of an answer, that is, a categorical answer when
you know that science requires a more elaborate answer." I
have never followed any other rule. I do not think it is neces-
sary for a medical expert, who knows the subject upon which
he is testifying, to be outwitted by a lawyer. Of course, if he
does not understand his subject up to the degree of enlighten-
ment which his day affords, he ought not to go on the witness
stand ; if he does so know it, there is no danger of any lawyer
knowing more than he does.
I would say that this was an enactment proposed, with this
additional qualification put right here in the ninth line (refer-
ring to copy of New York law proposed) :
"The presiding judge before whom such trial is had may
appoint such experts as he may deem necessary to adequately
represent both the prosecution and the defence,".
" Not by the recognized legal right of both prosecution and
defense to such additional expert testimony as they may deem,
with consent of the court, essential to the maintenance of their
cause," etc.
A man who is on trial for his life is entitled to all possible
defense, and no one can deprive him of the right of summon-
ing individuals to testify in his behalf. If this right were
attempted to be abridged by statute, it would have to go to
the supreme court, and it would be declared unconstitutional.
In our State the law is defective in regard to compensation,
because you can get such expert testimony as you are able and
willing to pay for, and the State has to rely on voluntary expert
testimony. Thus the State is crippled in prosecuting the case.
We ought to favor this enactment, because it is a step in the
right direction, and it does not complicate the question of
expert testimony very much. The legislature should have
their attention called, and it is proper that this body should
call their attention, to the fact that there are glaring defects in
the provisions as to the qualifications of medical experts.
Operation and Cure of Perforating Tumor in tbe Duodenum. — Land
erer reports the first case of this kind on record in the Mitth.
a. d. Gr. d. M. u. C. No. 2. The usual difficulty is in the
clinic diagnosis, but whenever an ulcus ventriculi perforatum
is diagnosed and the operation discloses nothing wrong in the
stomach wall, the possibility of a duodenal tumor should be
borne in mind. — Wien. K. Rund., No. 33.
18%.]
INTOXICATION AND INSANITY.
691
INTOXICATION AND INSANITY.
Read in the BMtlon on Neurology and Medical Jurisprudence, at the
Forty svMMitli Annual Meeting of the American Medical
Association at Atlanta. Georgia* May »s, is'V,.
BY J. T. SEABOY, M.D.
TUSCALOOSA, ALA.
1 will be glad to limit the meaning of the word
intoxication, in this paper, to the injurious effects on
tin' oerebrum of toxie agents present in the eireula-
tion. Toxie agents in the blood, of course, have their
ehemic effects upon other structures, but in the ordi-
nary interpretation of the word, the symptoms of
intoxication are those that belong to the brain. I will
use the word in thai sense.
This organ is exceedingly sensitive to the action of
certain agents; so much so, in certain instances, that
ii seems to be tlie only organ affected, or affected so
far in advance of others that their disturbance is not
appreciated. The exceedingly soft colloid character
of the functionating central parts of its nerve cells
ami fibers render them the most sensitise of all the
structures of the body to some agents; and their
excessively rapid functional motion is most delicately
disturbed.
The nervous system, indeed the whole body, may
he divided into sensating and non-sensating structure.
'Plus is only a fact in a comparative sense, because
there are no defined limits of the property of sensi-
bility anywhere in the living world. The broad gen-
eralization is commonly admitted, that all livinq struc-
tures are more or less sensitive. In biology there is
an advance of grade in this property as we ascend in
the classification of species. Within the body of
man the property is more decided and distinct in some
organs and parts than in others. The nerve centers
particularly have it as their function, and, among
them, it improves in delicacy and distinctness until
we reach the cerebrum, where its most refined excel-
lence is called consciousness. In man, so "central-
ized" is the faculty, that all conscious action may be
■aid to be cerebral. Sensibility in the human being
is carried to such a degree of centralization that the
cerebrum is practically the only sensorium. It is the
i of all "feeling."' the physiologic ego. The rec-
ognition of this as a physiologic fact will explain many
phenomena of the brain; in that of intoxication it
gives ready explanation to many of the symptoms pro-
duced.
In intoxication the conscious feeling of the man is
affected and subjectively interests him most. His
"feelings" are altered, and he is concerned favorably
or unfavorably as he is comforted or discomforted.
In addition to being physiologically the conscious
organ, the brain is also the organ that adjusts the
entirety we call " the man " to his environment. The
other nerve centers have also adjustment as their func-
tion, but they adjust the organs of the body inter-
nally to each other. The brain adjusts externally.
The comparative excellence of structure and func-
tion of one man's brain makes him excellent in his
external activities, and the comparative weakness or
defectiveness of another man's makes him less excel-
lent or competent. We judge of the integrity and
functional capacity of this organ by the emission* it
makes, which in the aggregate go to make up the
exhibitions of the man's intellectual capacity and
constitute what we call his conduct and character.
We judge, therefore, of the effect of a toxin and
of the degree of intoxication by the man's recital of
his own "subjective" feelings; and we judge "objec-
tively " by the " symptoms " shown in his brain's emis-
sions. The symptoms of intoxication have been dis-
cussed in medicine since medicine first began. Because
it relates seriously to the transcendently most impor-
tant organ in the body, it is a live question.
There are a great many agents that act intoxicat-
ingly. Some enter the circulation from within the
body, are produced there; others are introduced from
without.
We hear much said now-a-days about (luto-intoxi-
cation, by which is meant the intoxication that is pro-
duced by toxins produced within the body. The
unqualified word intoxication popularly means the
series of symptoms produced by alcohol, or some
other such agent, introduced from without.
The word insanity is more properly a popular or a
legal term than a medical one, which fact occasions
the trouble often found by doctors in giving a medi-
cal definition to it for legal use. Legally, insanity
relates to conduct alone, and not especially to the
brain condition that produces it. The gradually
increasing popular recognition of the fact, however,
that all conduct, good and bad, excellent and defec-
tive, depends upon brain condition, has led, of late
years, more and more to the popular and legal refer-
ence of all cases of defective conduct to the medical
profession, in the same way other defective functions
are referred to them.
Properly, because it is a legal term, insanity simply
means that the person has reached such a degree of
aberrant conduct that he has to be supported, con-
trolled or restrained by others, or by the State — he is
disabled to that degree. It is always a question of
degree and a matter of opinion. The doctor's opin-
ion is taken as of most value.
Insanity indicates an extreme degree of cerebral
defectiveness, which implies that there are other
grades of impairment above the insane level. This
is a fact open to every day verification, and it is a fact
particularly related to the subject before us. Intoxi-
cation can be shown to be the cause of different grades
of defective conduct ranging all the way upward from
the insane level.
Cerebral intoxication varies in the person according
to two factors or sets of factors; the first is the char-
acter of the agent and the amount of it in the circu-
lation ; the second is the peculiarity of the particular
brain, peculiar in the way of being more or less sensi-
tive to the particular agent, or peculiar in the way of
being inherently defective, which abnormality is ren-
dered more apparent by the action of the toxin. In
other words, intoxication varies according to the toxin
and the dosage, and according to the abnormality or
idiosyncrasy of the particular brain. .
Subjectively considered, by the man himself, the
toxin produces discomfort or comfort. This is the
direction in which he first considers it or principally
considers it. In the action of many, probably of most
toxins, the sentient result is that of less conscious
activity, which means less sensation, or a more com-
fortable state.
Consciousness occurs only when there is functional
action going on in the cerebrum; when there is no
cellular- motion, there is no consciousness; this occurs
naturally in sleep and artificially in anesthesia; when
the brain is partially rendered less capable of func-
tionating by the ehemic action of a drug, there is
diminished sensibility — more comfort. Comfort is a
692
INTOXICATION AND INSANITY.
[September 26,
negative condition, meaning no discomfort. Discom-
fort is a constant or most frequent condition of many
brains to whom all cerebral or bodily effort is more or
less painful. Cerebral hyperesthesia is a very frequent
condition as a part of neurasthenia or cerebrasthenia.
In this condition, the over-sensitiveness, in time, is
increased by the injurious or chemic effect of the toxin.
If the agent simply stiffen or slightly harden the deli-
cate structures so as to prevent or to make, less their
functional activity, it produces less consciousness —
more comfort. This varies with the character of the
toxin, but in time produces hyperesthesia or neuras-
thenia.
In intoxication there is more or less a sense of inca-
pacity, dullness and confusion; sometimes, a more
comfortable state because there is lessened sensibility.
Sometimes, on the other hand, cerebral effort or activ-
ity produces more discomfort, so that, as a sequel to
continued intoxication, comes hypersensitiveness with
irascibility, irritability, forgetfulness and worry, all
exhibits of cerebral impairment. If the person is
naturally erratic or peculiar or hypersensitive, he is
rendered more so. A cerebrum tending already toward
hypochondria, melancholia, mania or paranoia, is more
inclined that way. In short, intoxication always injures
the cerebrum for the time being, sometimes perma-
nently, and in certain persons increases original defec-
tiveness to the permanency and grade that is called
insanity.
Toxins, such as ptomains, leucomains and other
toxic albuminoids, arise from the disintegrations of
disease in the system ; and there are also natural waste
products which, if retained in the circulation, prove
highly toxic, such for instance as are eliminated by
the kidneys, the liver, the bowels and the lungs.
Infection comes into the circulation from many direc-
tions; the scavengering of the system is most impor-
tant work on that account.
Micro bic disintegration of cerebral structure proper
is not often seen. Inflammation of tubercular bacilli
occurs in the meninges, and other meningeal inflam-
mations are said to be microbic ; cerebral syphilis
may be this. Upon the true functionating structures
of the cerebrum, however, microbes most often have
no direct, but indirect effect by the toxins they pro-
duce elsewhere.
Diseases affecting the general system, like the exan-
thems, fill the circulation with toxins. Some brains
are very sensitive under these conditions, and delirium
is a consequence; there are always more or less con-
fusion, dullness, listlessness and incapacity, as a conse-
quence of such intoxication. In the extreme of life,
in articulo mortis, the complete arrest of cerebration
from this cause, in a large number of cases, removes
the pain and distress of dying.
Cerebral toxicity, from disease in different organs
of the body, varies with the organ. Diseases of those
organs, whose function it is to remove waste toxic
material, are always serious to the brain. The kid-
neys, liver, alimentary canal, lungs and skin, are
organs of this character. We often have the unre-
moved waste toxins of the system in the blood added
to those directly produced by the inflammatory dis-
ease of the excretory organ. Acute rapid disease of
such organs often produces delirium ; more chronic
disease for this reason sometimes gradually induces
the more permanent condition of insanity. The deli-
rium and the insanity indicate, usually, brains already
sensitive, weak or defective.
In an insane hospital, where the worst eases of
defective cerebra are found, it is very easy to note the
effects of auto-intoxication. The part the digestive
tract plays in the rfile of insanity is often very evi-
dent. In conditions of certain forms of dyspepsia,
particularly in conditions of constipation or torpidity,
auto-intoxication can be shown, and its relief demon-
strated by removing the toxin by cathartics and ali-
mentary disinfection. Stercoremia, copremia, and
the common condition, " biliousness," afford instances
of it.
A large proportion of the insane suffer from some
form of nephritis, and to it can be traced many of
their more insane periods or " spells," when the already
weak or defective cerebrum is made more aberrant by
uro-toxicosis.
Toxemia in women, during gestation, and after their
confinement, during uterine involution, especially if
there is sepsis, and during lactation, is by no means
an uncommon thing. Puerperal mania or insanity in
some form, is a result in extreme cases. It is a rare
thing that the parturient woman shows no signs of
intoxication in some of its milder forms.
A long chapter could be written on auto-intoxica-
tion. Literature on this subject is getting more and
more abundant. I have said enough to show its
importance as it relates to insanity.
Intoxication by agents introduced from without is
a frequent occurrence and, as it relates to brain hygi-
ene, is little appreciated.
As physicians, we would be very much handicapped
in our practice if we did not have cerebral toxins
among our medicines. They constitute a very popu-
lar line of drugs; popular with the doctor, because
popular with his patient. All anodynes and anes-
thetics are of this class. Most frequently, the urgent
symptom to be relieved in our patient is pain or dis-
comfort. Pain is a brain condition. If disturbed or
disintegrating action in distal parts can not be con-
veyed to the sensating brain by nerve lines that we
have rendered incapable of transmitting by our toxin,
there is no sense of it; or, if we render the cerebrum
unconscious by our toxin, we accomplish the same
object, there is no pain. We accomplish artificial
anesthesia with such an agent as chloroform by a
complete suspension of cerebral functions, while the
functions of the lower centers, which adjust internal
actions, are left to continue. If we push the anes-
thetic farther we suspend them also, fatally to our
patient.
Toxins nowadays are known also to have injurious
effects upon peripheral nerves. Peripheral neuritis
is now ascribed most often to this cause, in conjunc-
tion with exposure, fatigue, or some such condition
which renders these nerves more sensitive to the toxin.
Peripheral pains, such as make so prominent a symp-
tom in grippe and dengue, probably have this source
— headaches, sometimes.
I believe it is true, under certain conditions or with
some toxins, toxicity can be of the peripheral nerves
at the same time and by the same agent that the cere-
brum is affected. The difference between an anodyne
and an anesthetic may be this; the one affects more
generally the nervous system, the other principally the
cerebrum. This distinction is necessarily not well
drawn. It is a good hypothesis, however, that ano-
dyne or anesthetic effect in the relief of pain or
discomfort occurs by the arrest of the function of the
transition of motion along nerve lines or, most fre-
18%.]
CONTROL OF TUBERCULOSIS.
o93
quontly, by the arrest of conscious motion in the cere-
hrmn. The anodyne, oooain, administered hypoder-
inically. hardenfl ohemioally the nerve lines leaving
the locality, so there is no transition of motion to the
.sensorium from the part, amino pain; though later,
wo have its anodyne effect on the cerebrum, obtund-
ing in a general way the sense of disintegrating action,
or pain.
The effects of alcohol, on the other hand, generally
begin in the cerebrum; though we do have local anes-
thesia in the stomaoh, and in time, in some cases,
neuritis in the periphery as an effect of it. We may
correctly suppose that whenever we arrest or abate
pain with a toxic agent, we do it most often in the
brain by hardening the axis-cylinders of nerve lines,
or the central part of nerve cells, in this way prevent-
ing or lessening their functional motion. A good
deal is being written to show the changes in the nerve
cells of the cortex, in the way of enucleation, diminu-
tion in size, and changes in length and shape of
processes by the continued use of certain toxins.
Degeneracy of axis-cylinders in nerve lines elsewhere
is also reported. The cerebrum (the sensorium) is
the most important organ that suffers; it is impaired
by the excessive or the continued use of anodynes
and anesthetics, in numbers of instances.
In many persons the effect of the continued use of
such agents on their peculiarly susceptible ordefective
eerebra is so injurious as to increase the original con-
dition of over-sensitiveness to neurasthenia, or to carry
their original defectiveness or weakness to the stage of
permanency and degree called insanity. The continued
use of such agents as luxuries, because of the artifi-
cial comfort they give, works wide-spread harm. The
popular anil extensive use of alcohol and nicotin as
luxuries, not to mention other toxins, leads to increase
of cerebral and neurotic defectiveness and disease and,
in some, induces the extreme cerebral condition of
insanity. A narco-maniac or an inebriate, in the large
majority of cases, has had an original defect of brain,
preceding his drink habit, that has been rendered
more decided by repeated intoxication. The brain is
a very much abused organ, and one sorely omitted in
our private and public salutation. In the use of such
agents as luxuries, the brain effect is the one sought
after, and in proportion to the amount taken and the
length of time, injury is done. Intoxication, owing
to inherent peculiarities, is more injurious to some
brains than to others.
DISCUSSION.
Dr. Frederick Peterson of New York — I think this question
of intoxication as the cause of insanity bears strong testimony
to the progress of psychologic medicine of late years, because of
the increase in the number of the cases which are put under
the heading of toxic insanities. Formerly by toxic insanity
we meant merely alcoholic insanity, or insanity due to lead
and other poisoning, or cases of bisulphid of carbon poisoning,
etc. Hut since the investigations in regard to the toxins manu-
factured in the body, we have come to look upon a large num-
ber of other cases that were formerly considered idiopathic or
without etiology, as cases of toxic insanity. Beside, I think
it is now pretty well believed that many cases of recurrent and
of acute mania and cases of melancholia and hypochondriasis
may properly come under that heading. The means of dis-
covering whether it was really due to auto-toxicism are not
always efficient. In certain cases that are due properly to
putrefactive or fermentative changes in the intestinal contents,
we have the means of ascertaining, sometimes by testing the
urine. Usually the discharges from the bowels give no par-
ticular evidence of auto-intoxication, although in cases whero
there is intestinal intoxication we do sometimes find that there
are periodic attacks of gaseous diarrhea. Our chief proof,
however, of this probable etiology of many cases of melan-
choly and mania, is in the treatment by intestinal antisepsis
and diet. I think the chief means of treating these oases is
by a properly regulated diet, milk, vegetables, etc., by the
washing out of the stomach and intestines with hot water, and
by the use of certain antiseptics, like salol, given in fairly
large doses, two hours after meals. I have found that remark-
able success could be attained by such means.
CONTROL OF TUBERCULOSIS FROM A
STRICTLY MEDICO-LEGAL
STANDPOINT.
Read in the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical
Association, at Atlanta, Ua.. May 5-8, 1896.
BY CHARLES WILSON INGRAHAM, M.D.
BINOHAMTON, N. Y.
How far can legal measures, whether municipal,
State or National, be carried to control tuberculosis?
This is now one of the leading questions before the
medical profession in this and in other civilized
countries. That decisive legal interference will be
necessary before tuberculosis can be brought under
control, there is no doubt. In the minds of all, phy-
sicians, legislators and tuberculous invalids them-
selves, who have given the question more than ordi-
nary thought, the necessity of legal control is realized.
It is estimated by competent authorities that 450
persons die every 24 hours in the United States from
tuberculosis. A disease which is responsible for a
human fatality so large and so continuous should be
classed with dangerous contagious affections, as one
requiring the strictest hygienic management designed
to minimize the infection arising from each individ-
ual case. No one expects to obtain a complete
destruction of tubercular infection as it is generated,
and only a comparative control of the infection may
be expected at best. The medical profession is
unanimously agreed that it is not the tubercle bacil-
lus alone which is responsible for the immense mor-
tality of tuberculosis. It has been proven repeatedly
that a certain percentage of human beings are more
or less completely immune against tuberculosis, and
such may be repeatedly exposed to the infection of
the disease in a concentrated form and still escape
contracting it; while again a certain percentage —
and unfortunately it is a much larger percentage than
the former instance — become affected from compara-
tively slight exposure to infection. So, therefore,
constitutional idiosynocrasy, not always synonymous
with constitutional degeneration, is an important fac-
tor, though tuberculosis can not develop even in the
most susceptible without the presence and activity of
the tubercle bacillus. It will require generations,
even though the most corrective modes of living are
carried out, to eliminate hereditary tendencies to
tuberculosis to a noticeable degree, and the most that
we can do in this generation is to initiate a movement
in the right direction and leave future generations to
do the rest. What we can not do as regards decisive
constitutional improvement, we can do as regards the
infection of the disease.
The question is, how far can the Government carry
legal measures designed to control tuberculosis, and
not infringe upon the natural rights of American
citizenship. We can not, nor is it necessary to treat
694
CONTROL OF TUBERCULOSIS.
[September 26,
the tuberculous patient as though he were a leper, but
we can, I believe, form and apply a legislation which
shall be just to the consumptive and the public, and
at the same time have the desired effect of controlling
tubercular infection.
There is scarcely an intelligent person of the pres-
ent age who does not thoroughly understand that
tuberculosis is a contagious disease, but for all this
the public at large do not seem to comprehend the
necessities of the situation with the keenness that
they appreciate the contagious nature of smallpox
and diphtheria, and until they do we can scarcely
expect them to make any decisive changes in their
present customs regarding tuberculosis. Tubercu-
losis is such a common disease that laymen, as a rule
have but little fear of it from a contagious standpoint,
and look upon those who demand that strict means
be employed to destroy the contagious elements as
alarmists, or as individuals who wish to increase the
misery of unfortunate invalids. At the present time
there is little encouragement returned to those who
endeavor to inform consumptive invalids of the dan-
gers which they, through carelessness, expose others.
That the majority of consumptive invalids are a dan-
ger and menace to health and life in their respective
neighborhoods can not be doubted, and yet it is easily
possible for them to overcome any and all dangers.
Intimate knowledge of the disease fosters intelligent
action and cooperation. Therefore it should be the
effort of every physician to do all in his power to
disseminate appropriate information among his tuber-
culous patients.
With this brief introduction I will come at once to
the main consideration of my paper, namely, what
legal measures are necessary in order that we may
immediately effect a reduction in the prevalence of
tuberculosis, eventually gain control of it, and finally
exterminate it; that is, exterminate it so far as is
possible to exterminate an infectious disease. There
are jive measures of leading importance which must
be adopted and enforced before we can expect to see
tuberculosis controlled.
1. The strict registration at the office of local boards
of health, whether country, village or city, of all resi-
dences in which consumptive invalids reside, in order
that such residences and surroundings may be thor-
oughly disinfected after the removal of such invalids,
before the house, apartment or room is reoccupied.
2. Systematic monthly inspection of all factory
employes, to exclude from factories tuberculous
workmen, which is necessary, not alone as a means of
protection to fellow laborers, but to increase the
chances of recovery of the sick ones who might in
their desire, and oftentimes necessity to labor and
earn, sacrifice their only chance of recovery. Fac-
tory infection is a prominent source of disseminating
tubercular disease, and I have in mind several large
manufacturing establishments to which I have dis-
tinctly traced the cause of many cases of tuberculosis;
not to confinement associated with factory work, but
to infection deposited in and about the floors,
machinery and furnishings.
3. The thorough instruction of all tuberculous
invalids capable of affording personal medical attend-
ance. Experience has shown that family physicians
have thus far not accomplished as much as might
reasonably have been expected, in impressing upon
the minds of consumptive patients the necessity of
destroying all infectious matter. I believe it is neces-
sary for the health officials to assume the entire
responsibility of instructing this class of consumptive
invalids in all the details outside of medical treat-
ment, concerning their disease. I think family phy-
sicians will welcome the day when the health officials
assume this responsibility. It would not in any way
infringe upon their professional relations with their
patients, and would relieve them of a great anxiety.
4. The next measure I would suggest is the erection
of State hospitals for the compulsory care, treatment
and education of the indigent class of consumptives.
By education I mean their instruction in hygienic
matters, not alone as concerns tuberculosis, but in
every sense of the word hygiene, as applied to every-
day life. By the indigent class, I mean those inva-
lids who can not afford suitable medical attendance
and necessary medicines, and nourishing preparations
upon their own responsibility. Persons who in health
would be capable of caring for themselves and fami-
lies in comfort, might, being afflicted with tuberculo-
sis, become so reduced financially as to be classed in
this instance, as indigent. In these State hospitals
there should also be sentenced by health officials for a
greater or less term, according to the seriousness and
persistence of their offense; those persons not eligi-
ble from financial circumstances, who might persist in
carelessly exposing others to the infection of tubercu-
losis, for without doubt many consumptives who even
with a competent knowledge of the infectious nature of
their disease would not exert any effort to protect
others. Unless the State hospital plan for the care
of indigent tuberculous persons is instituted on a
National scale, we can not hope to gain any apparent
control over the disease, for the majority of such
indigents in their ignorance and carelessness scatter
sufficient infection to perpetuate tuberculosis, though
all other sources were perfectly eliminated.
5. My final suggestion is the extermination of
tuberculosis from among dairy and stock herds, in
order that human beings may not be exposed to the
disease through the medium of meats and milk.
This portion of the subject is receiving active atten-
tion at the hands of many of the State boards of
cattle commissioners and State boards of health, but
they are greatly handicapped in their work, and
until the measures previously enumerated are
attended to. they can accomplish but little to control
the spread of tuberculosis among cattle. When the
cattle commissioners go into a dairy herd and slaugh-
ter one-third, two-thirds or more, as the case may
demand, their efforts may be compared to the surgeon
who has by active means, healed an external ulcer or
sinus due to constitutional causes, without removing
the constitutional cause; the ulcer is sure to break
out again, and so is tuberculosis in the dairy herd,
for it must be remembered that the cattle become
diseased principally through the carelessness of
human beings, and so long as the present condition
of affairs is allowed to continue, the control of tuber-
culosis in dairy herds will be an impossibility, and all
efforts toward such control an immense and unneces-
sary expense to the government.
This then is the brief summing up of what I believe
to be necessary, and I see nothing in any of the five
measures advocated which would in any way infringe
upon the legal rights of individual consumptives,
under the laws of the United States. The medical
profession must not wait for the politicians to inaugu-
rate suitable medico-legal measures as regards tuber-
18%. 1
SURGERY OF THE NASAL VESTIBULE.
695
oulosis. If we await action from purely politioal
sources we will live to Bee the ratio of deaths from
tuberculosis doubled. The A.mkku'an Medical Asso-
ciation, as the greatest representative body of physi-
cians, is an appropriate organization to take the initial
stops. There is no doubt as to their abilty to do
what is necessary to be done.
SltUi l.i;V OF THE NASAL VESTIBULE WITH
K EFEB ENOE TO CERTAIN FORMS OF STE-
NOS1S AND FACIAL DISFIGUREMENT.
Read in the Section on Laryngology and ot.ilogv.at the Fortv-seventb
Annual Meeting of the American Medical Association, at
Atlanta. Oa,, Mav 6-8. 1896.
Bi Robert Cunningham myles, m.d.
ieor of Otology and Adjunct-Professor of Rhlnologyand Laryn-
\ at the New York Polyclinic; Surgeon to the Nose and Throat
Departmant of the Churcli lntinuary and Dispensary; Assistant
■ ■on to the Nose and Throat Department of t lie New Am-
sterdam Bye and Ear Hospital; Member of the American
Laryngological. Rhinologlcal and Otological Society;
academy of Medicine: American Otological Sod
ety; County Society.
NIW YOKK.
The surgery of the nasal vestibule has not received
that serious and careful attention which its import-
ance demands. Abnormalities in this region not only
obstruct thegateway to physiologic respiration, but also
disagreeably alter an otherwise pleasant facial expres-
sion. Frequently operative procedures achieve a cos-
metic result which were intended only to relieve
nasal stenosis. It would be well to define the nasal
vestibule as being that part of the nasal fossa which
extends inward from the margins of the anterior nares
from one-half to seven-eighths of an inch. Nearly all
of this part of the nasal fossa is lined with scaly or
pavement epithelium, and the balance of the nasal
membrane is covered with ciliated and non-ciliated
columnar epithelium. Attempts to enlarge the lumen
of the vestibule by excision of the surface tissue, ex-
cluding a part of the septum, almost invariably produces
the opposite results, by narrowing it. The contraction
is usually due to the large amount of fibrous tissue in
the membranes beneath the pavement epithelium. I
have seen many cases in which the patients have been
made worse by operations, where the surgeons did
not recognize nor consider these principles, and the
results were especially bad in those cases where the
amateur or persistent rhinologist worked under the
theory that the way to make a hole larger was to bore
off or excise its walls; but the theory worked with the
logic of the Irishman's ditch — " the more he cut off it
the longer it got."
In former times when the electric trephine was used
much more frequently than now, it was not uncommon
to see cases where the membrane, and sometimes a
part of the bone, had been removed from the floor of
the nose, at the point where there is an elevation
caused by that part of the nasal process of the super-
ior maxilla, which extends downward and inward to
the anterior nasal spine. In these cases the cica-
trized membrane forms in a web-like manner across
the floor, and extends from the septal wall across to
the outer side beneath the junction of the ala and the
nasal process. This condition greatly diminishes the
ingress of air and the egress of secretions. I soon
learned that any attempts to relieve the condition by
cutting or excision only made it worse. I adopted
the method of passing a small trephine through the
band, along the floor, and afterward inserting a string
or a small tube, leaving it in for a few months, until
the healing was com plete ; carrying out the process used
in piercing the ear lobes. When practical it is best
to leave the tube in place for about six months, until
t he elements of the tissues shall havo become absorbed
and fixed. It is a simple matter to remove the bridge-
like band by making a section on either side with a
Grafe knife, and afterward insert a Berens cork or an
Asoh's perforated tube for a week or two. The
results have been almost invariably good, usually leav-
ing a little excess of elevation of the floor at the point.
I have had three cases of complete occlusion of the
vestibule: One the case of a girl 18 years of age, who
informed me that her left nostril had always been
stopped, and that she had only been able to force a
little air through the right side. Examination demon-
st rated a membranous occlusion about one-third of an
inch within, extending from the superior part of the
vestibule, near the upper lateral cartilage, down to the
floor. There was a pin-hole perforation through the
one on the right. After using cocain locally and
hypodermically, I cut through the membrane, which
was about one-quarter of an inch thick, above and
below, put in the rubber tubes, and finally cut away
the tissue from top to bottom. I placed three rubber,
tubes, successively, side by side, sewed them together,
and introduced them into the fossa; they were worn
for a few months with most excellent results.
One of the cases was in a man 17 years of age. He
was unable to breathe through either nostril, although
a little air could be forced through the right one. I
opened the right nasal fossa, after ' the manner
described in the other case; the membrane was about
an inch thick and extended from the floor to the
anterior end of the middle turbinated body ; the fossa
remained patulous and satisfactory. On the left side,
after cutting through the fibrous web in the vestibule,
I found that the fossa was obliterated, and the space
from the anterior to the posterior nares, and from the
middle turbinated body to the floor, was filled with
fibrous and cartilaginous tissue. I trephined and cut
through about two and one-half inches of solid adhe-
sive tissue; this caused severe pain, the cocain crys-
tals and deep injections did not seem to obtund the
parts effectively. I had no trouble in keeping the
parts beyond the vestibule open, as they have no
tendency to adhere or contract when they are not in
contact. The vestibule was kept open by the usual
method. The patient's general health improved
rapidly; he slept well; the nervous system recovered
from an extremely depressed state.
I will not have much to say concerning procedures
for improving the general appearance of the nose, for
the subject is of sufficient importance to require an
individual paper.
There are two methods which are being employed:
one, the implantation of metal plates and supports; the
other is carried out by cutting or sawing the bones,
cartilages and tissues, removing some parts, transpos-
ing others, and fixing the parts temporarily with
apparatus, until they are permanently fixed by inflam-
matory adhesions, caused by the fractures or the
incision into the parts.
Dr. John O. Roe of Rochester is a pioneer in the
latter method, and it has been my fortune to see some
wonderfully artistic work which had been done by him.
There is a great field for exercise of genius in the
department of cosmetic nasal surgery, and the ques-
tion as to whether the progress will be made through
the surgery of the external nose, or through the ves-
tibule, is to be decided in the future. I think that
696
SURGERY OF THE NASAL VESTIBULE.
[September 26,
the avenue will be through the anteriors nares, on
account of the external scarring.
There are certain forms of partial stenosis which
are due to deflections of the anterior part of the tri-
angular cartilage within the vestibule of the nasal
fossa.
For several years past I have been operating for the
relief of this class of vestibule stenosis with satisfac-
tory results. There are two conditions which usually
confront us in these cases ; first, a projecting anterior
extremity of the triangular cartilage, which extends
across the vestibular space and approaches the mar-
gin of the ala; the second condition embraces the
various forms of deflections with more or less thick-
ening of the convex side of the cartilage. Since so
many authors have written extensively and advocated
various methods for relieving this latter condition, I
have decided not to discuss the subject on account of
time and the length of the paper that would be
required to treat it in a manner its importance
demands.
In those cases which come under the head of the
first condition, the space between the ala and the pro-
jection is so narrow that when inspiration takes place
in a rapid manner the atmospheric pressure forces
the ala against the cartilage. These patients become
accustomed to contracting the muscles on the side and
front of the face for the purpose of pulling the ala
away from the cartilage. Others sleep with the hand
on the cheek, instinctively elevating the ala. This
condition, may be overlooked, especially when the
nasal speculum is introduced, consequently it is well
to test the inspiratory capacity without it, with the
mouth closed, and also with each nostril respectively
closed.
I have attained but little success in attempting to
replace this tip by fracturing the convex cartilage in
the opposite nostril, and afterward maintaining the
segments in position with mechanical appliances until
union takes place.
The operation consists of first carefully cleansing
the vestibule and then making it aseptic with solu-
tions of 5 per cent, carbolic acid and 1-1000 bichlorid
of mercury. After this the anterior part of the fossa,
posterior to the vestibule, is carefully packed with
bichlorid and iodoform cotton. Extreme precaution
is used in regard to asepsis in everything. A perpen-
dicular incision is made about two or three milli-
meters posterior to the margin of the projecting
cartilage. The incision is usually about an inch long
and extends down to or near the floor. The peri-
chondrium and the mucous membrane are dissected
from both sides of the cartilage, and a piece about ten
to fifteen millimeters in length and two to four milli-
meters in width is removed with great care, especially
in reference to making a counter opening in the mem-
brane. I never remove the anterior upper part of the
cartilage, which is left for the purpose of sustaining
the tip of the nose in its proper position. Delicate
knives, periosteal elevators, Dr. Noye's eye speculum,
a small needle holder, the smallest size curved needle,
and a pair of self-registering rat-tooth forceps are the
most essential implements. I have found in certain
cases a small knife with short, lateral curve very use-
ful in making the transverse cut for severing the
cartilage. The wound is very carefully cleansed, all
blood clots and ragged edges are removed and the
parts are brought together with very fine silk sutures.
In the majority of these cases the wound unites by
first intention and the after-treatment consists of fill-
ing the vestibule with aseptic cotton, and leaving it
in place from two to three days. The results are
beneficial from a respiratory sense; the appearance is
much improved, and a decided improvement in the
quality of the voice usually follows.
Another form of vestibule stenosis, which ought to
be placed in the second class, is caused by a deflection,
and circumscribed ecchondrotic growth or enlargement
on the convex side of the triangular cartilage, can be
relieved by this method of sub-perichrondial dissec-
tion. In case 3 the atmospheric pressure has caused
a depression in the space between the ' upper and
lower lateral cartilages; the stenosis was almost com-
plete when he applied to me about one month since.
I dissected out a large growth, which was situated on
the septum opposite the depression, and three-
quarters of an inch from the margin of the anterior
nares. Cocain made the operation painless. The
wound was brought together with four stitches; it
united by first intention; in five days the dressing
was left off and a small glazed line was all the evi-
dence to indicate the place of operation. The ste-
nosis was relieved and the breathing through the
nostril was comfortable.
DISCUSSION.
Dr. John O. Roe, Rochester, N. Y.— The point that Dr.
Myles has made in regard to the ill-advised attempts frequently
made to enlarge the vestibule of the nose by cutting out the
interior of the passage, is well taken. This procedure inva-
riably results in decreasing the size of the opening instead of
enlarging it, for the reason that when a portion of the con-
striction is cut away, the circumference of the uncut portion is
correspondingly lessened, and when the cut edges become
coaptated during the process of healing, the lumen of the
passage is made smaller. The vestibule of the nose may
become narrowed by a variety of causes. In those cases in
which it is obstructed by an exostosis which we frequently find
in the floor of the vestibule, this exostosis should be removed
subcutaneously in order to leave the mucous membrane
uninjured, thereby avoiding the contraction of the passage.
This is best done by making an incision in front of the emi-
nence down to the bone and raising the mucous membrane
together with the periosteum over the entire elevated portion
of the exostosis. By cutting through these tissues on the
posterior side they can be raised out of the way and the bony
growth removed either by drill or saw. When this is com-
pleted the mucous membrane of the periosteum can be replaced,
leaving the passage of the nostril unobstructed. The vesti-
bule of the nose is often very much narrowed by the col-
lapse or dropping inward of the ate of the nose from a weak-
ening or partial paresis of the dilator naris muscles, thus
allowing the ala? to be drawn inward against the septum dur
ing inspiration, thus increasing the obstruction to ingress of
air. I have removed this difficulty by making one or two
incisions through the cartilage of the ala, and inserting a dress-
ing into the nostril sufficiently large to distend the ate quite
widely until the cut made through the cartilage has become
.firmly healed and fixed in this position, thereby maintaining
the nostril freely open and preventing the collapse of the ate
on inspiration. I was also much interested in Dr. Casselberry's
paper on the reduction of spurs of the nasal septum by elec-
trolysis, although I have never employed that method. I have
not done so for the reason that I have always disposed of spurs
and ridges of the nasal septum by what seems to me to be a
very much easier and simpler method — by simply cutting the
spur away. If the spur is located on the cartilaginous portion,
I employ a suitable small cartilage knife for its removal, and if
18%.]
NASAL HYDRORRHEA.
i;<)7
located on the osseous portion of the septum I remove it with
a saw or the Curtis drill. I have not attempted the more com-
plicated methods because my patients do not object to having
these obstructions removed in this manner. In the case of
removing a small enehondroma, it can lie so easily and quickly
done with the knife that if the parts are thoroughly anes-
il with eocain the patient is neither alarmed nor incom-
moded by the operation, and sometimes scarcely realizes that
anything unusual is taking place. In regard to the danger of
denuding the parts of mucous membrane, I have never experi-
enced any difficult} in this respect after a cutting operation, if
but a limited portion of the membrane is removed. Even in
some cases where quite an extended area of mucous membrane
is removed, I have observed it from day to day spread over the
parts when maintained thoroughly aseptic, so that in a short
time the site of the operation, from the loss of the mucous
membrane, could not be perceived. After the use of the cau-
tery, however. 1 have observed extensive sears and areas in
which the mucous membrane had been replaced by fibrous
tissue, thereby causing much annoyance from the dryness of
the Dose and the formation of scabs and crusts over the parts
in which there were no mucous glands to lubricate the part.
|)k. M .\\ Tiioknkk, Cincinnati, Ohio — I would like to refer
to Dr. Myles' paper. The obstruction of the nasal vestibule is
by all means the worst thing that can happen after operations.
In the operation advocated by Dr. Myles I think we have
means to prevent such occurrence. One case I had was that
of a young man who had been kicked on his nose by a mule,
and there was entire occlusion of the right nostril. I made
the incision and occlusion followed, and it was as bad as before,
if not worse. Later on I made a flap from the upper lip,
turned it upward into the nose and sewed it to the inner sur-
face of the ala nasi, after having loosened it from its adhesions.
Then I packed the nostril with iodoform gauze. The result
was not an ideal one, but the improvement was great and
permanent.
Db. Kami W. Loeb, St. Louis, Mo. I was impressed with
the statement of Dr. Myles in regard to maintaining an open-
ing. I remember one case in which there was complete steno-
sis as i result of smallpox; there was complete adhesion of
both edges to the septum. To maintain the opening I used
two rubber tubes, which were made after the fashion of Sim-
rock"s spectrum. These were worn without discomfort for six
months, later being worn only at night, and at present there
is a complete opening.
XASAL HYDRORRHEA.
Read iu the Section on Laryngology and Otology, at the Forty-seventh
Annual Meeting of the American Medical Association, held
at Atlanta. Ga.. May 5-8. lS9ti.
BY D. BRADEN KYLE, M.D.
PHILADELPHIA, PA.
True nasal hydrorrhea is an exceedingly rare con-
dition, not being mentioned in many of our works on
nasal diseases. It is true there are many conditions
which simulate this, but the well authenticated cases
are rare. Let us first review the subject as to cause.
No special lesion can be named, the peculiar dis-
charge being present under so many different condi-
tions. It may follow trauma, with escape of cerebro-
spinal fluid, but probably an injury of that degree
would prove fatal. It may be associated with nasal
growths, as polypi, but in the one case thus far
reported Bosworth thinks the polypi were the result
and not the cause. Nerve lesions, as involvement of
the fifth pair; this would act in two ways, both nerve
influence and blood supply would be altered and the
condition would properly constitute a reflex neurosis.
Carious teeth and cerebral lesions may be exciting
causes in the same way. Malaria in the chronic form;
the repeated chills driving the blood to the internal
organs and chronic congestion, in addition to the gen-
eral anemic condition produced, with the necessarily
lessened vascular tone, may cause the entire mucous
membrane to become cyanotic. Atrophy of the optic
nerve existed in at least one case. Hardie quotes
seven cases in which optic atrophy existed, but does
not give the references.
The cases in which no mention of any circulatory
lesion is made and some lesion, as of the ethmoid or
antrum existed, does not prove it the cause, as these
lesions may be present without true nasal hydrorrhea.
In reviewing the cases thus far reported, it is my
purpose to exclude all, excepting those cases, the
reports of which include the clinic history, and in
which the hydrorrhea existed independently of any
associated nasal lesion. After a careful search of the
literature on the subject I have been able to coliect
twenty-seven cases; sixteen collected by Bosworth,
with two reported by him; three by C. E. Bean; one
by A. R. Anderson; two by Hardie and Wood: one
by Keiper, one by Emory Jones, and the one reported
in this paper. The following is a tabulated list of the
cases thus far reported:
The first sixteen were collected by Bosworth, and
the seventeenth and eighteenth were reported by
him.
1 Reis London Medical and Surgical Journal, 1884,
Vol. iv, p. 823.
2 Forster New York Medical Times. 1852, Vol. n, p. 113-115.
3 Elllotson Medical Times and Gazette, London, 1857, Vol.
xv. p. 290: also Brown's Arch,, Vol. in, p. 005.
4 Davies Lancet, 1870, Vol. n,p. 292.
5 Tillaux Trait*? d'anat. topograph. Second Edition, Paris.
1978, p. 62.
6 Paget Medical Press and Circular, London. 1878. N. S.
X xvi, p. 432 ; also. Trans. Clinical Society .Lou-
don, 1879. p. 43.
7 Althaus Brit. Med. Jour.. 1878. Vol. n, p. 831, also Med.
Chir'l Traus., Vol. MI. p. 29.
8 Fischer Deutsche Ztschr. fur Chir., Leipzig, 1878, Vol.
XII, p. 3(19.
9 Speirs Lancet, 1881, Vol, I. p. 369.
10 Leber Graefe's Arch., Vol. xxix. 1. -J7H.
11 Nettleship, Opbth. Review, London, 1883, Vol. II, p. 1-8.
12 Priestley Smith. . . Ophth. Review, London, 1883, Vol. n, p. 4.
13 Priestley Smith . . Ophth. Review, London, 1888, Vol. u,p. 4.
14 E. B Baxter Brain. Vol. iv, p. 525.
15 Mathiesen Norsk Magazine for Laegevidenskaben. Jau.
1877, p. 41.
16 Vieusse Gaz. Hebd. 1879, No. 19, p. 298.
17 Bosworth Diseases of Nose and Throat. Vol. I, p. 201.
18 Bosworth Diseases of Nose and Throat, Vol. I. p. 2H2-263.
19 C. E. Bean 14th Annnal Congress, American Laryngologi-
cal Association.
20 C. E. Bean 14th Annual Congress, American Laryngologi-
cal Association.
21 C. E. Bean 14th Annua! Congress, American Laryngologi-
cal Association.
22 A.R.Anderson. . Brit. Med. Jour , London, 1892, Vol I, p. 276.
23 C. M. Hardie and . New York Medical Journal Vol. 52, p. 264-8.
P. A. Wood 1890.
24 Hardie & Wood. . . New York Med. Jour., Vol. 52, p, 264-8, 1890.
25 G. F. Keiper . . . . New Y'ork Medical Jour., Vol. 58, p 101,1893.
26 Emory Jones . . . Ophth. Review, Vol. vii, No. 78, p. 97.
27 D. Bradeu Kyle. . . American Medical Association, ilay 8, 1896.
Bosworth in his text- book very properly divides the
reported cases into two classes: 1. Those in which the
escape of fluid is passive and painful and which
phenomena he explains by involvement of the trifacial
nerve. 2. Those in which the fluid gives rise to
intense irritation. Yet this does not differentiate as
to the irritating nature of the fluid, but is rather a
classification as to symptoms and not varieties. A
review of the cases reported gives such a variety of
causes that a classification would be impracticable.
The history of the case I wish to report is as follows:
Two years ago the patient — male, aged 40, first pre-
sented himself for treatment. His general condition
was fairly good. For about six months he had had a
profuse watery discharge from his nostril, which was,
when he presented himself for treatment, constant,
but which at first had occurred at usually irregular
698
NASAL HYDRORRHEA.
[September 26,
intervals; sometimes as often as three or four attacks
daily. The discharge was clear and profuse, although
no definite estimate of amount could be made, the
reaction was alkalin; it gave the patient a sensation as
of strong salt water snuffed within the nostrils and
was very irritant, not only to the mucous membrane,
but also to the muco-cutaneous surfaces. The attacks
at first were usually preceded by headache and severe
sneezing, which came on suddenly and without warn-
ing, and were followed by profuse discharge. With
the beginning of the discharge both the headache and
sneezing were relieved.
An examination of the nostrils during the attack
showed the mucous membrane of the anterior cavities
swollen, edematous and boggy, often entirely obstruct-
ing nasal breathing. The membrane did not present
the appearance of acute hyperemia, but more that of
a chronic congestion, being of a dull bluish-red or
pink tinge. The naso-pharynx and pharynx were
slightly involved, but not to the extent of the anterior
passages.
On examination between attacks, the mucous mem-
brane, though slightly edematous, was paler, the color
apparently being due to a pigment deposed within
the cells (which later proved to be the case); the
membrane on pressure was soft and boggy, and press-
ure left indentations, which slowly filled, a character-
istic of passive congestions. The naso-pharynx was
slightly paler than during the attack. This condition
continued for several months, the attacks becoming
more irregular, yet more frequent until when he had
been under my observation for five months the dis-
charge was almost continuous. The general appear-
ance of the patient was that of a severe attack of hay
fever. There was no evidence of antrum or ethmoid
disease.
I had the eyes examined, with negative results. I
made careful and repeated examinations of the urine,
suspecting possible uric acid diathesis, but while the
urine was of a rather low specific gravity, from 1.012
to 1.018, the chemic analysis revealed nothing except
a low per cent, of urea, but by the increased amount
of urine the total daily excretion was from four to five
hundred grains. Microscopic examination showed
no casts, but many leucocytes, and desquamated
epithelial cells, which, from their shape and condition,
being water-soaked, evidently came from high up in
the urinary tract. During this time, although I had
tried every known remedy, he gradually and persistly
grew worse. In looking up the literature of the sub-
ject, I noticed malaria mentioned as a possible cause,
and on questioning the patient, he said that one year
before the beginning of the attacks, he had had ma-
laria. I also discovered that before living in Phila-
delphia he had been in a distinctly malarial district.
"While at the beginning his general condition was
good, during this time he was losing flesh, although
not rapidly. I then examined his blood for evidence
of malaria.
The blood examination showed, by the Thoma-Zeiss
hemocytometer, 4,800,000 red corpuscles per cubic
millimeter; white, 8,000. Hemoglobin, by Von
Fleishl's hemoglobinometer, was 60 per cent, of nor-
mal. There was considerable free pigment. The red
corpuscles, while about 3,000,000 showed almost a nor-
mal appearance, the remaining 1,800,000 were irregu-
lar, crenated and corrugated, some few showed seg-
mentation and the peculiar kidney-shaped corpuscles
were present. The leucocytes were normal.
any,
Careful examination did not show much, if
enlargement of the liver and spleen.
Tube inoculations had been made repeatedly from
the nasal secretion and while growths showed many
bacteria present, yet never was there present any but
what had been found in other conditions, or the ordi-
nary bacteria found in abnormal discharge from the
nares. The only one present which is decidedly irri-
tating was the streptococcus, although out of repeated
inoculations this particular germ was found only twice
and then not in any number, thus excluding bacteria
as a probable etiologic factor.
A small piece of tissue was removed from the left
nostril, and hardened in picric and chromic acid solu-
tion, infiltrated with acacia, frozen and cut. The sec-
tions showed a small round cell infiltration of the sub-
in ucosa, and dilated vessels with thinned walls. The
epithelial layer was desquamated, the cells showing
cloudy swelling and granular and hydropic change;
the connective tissue cells were pigmented.
After the blood examination, as the patient told me
quinin made him nervous and irritable, I gave him
bromid of quinin, in 5 grain doses every four hours
and in addition 1-16 grain of the double sulphid of
arsenic, which is a so-called alterative tonic. This
treatment internally, with local applications of benzo-
inol, to which had been added to each ounce menthol
2 grains and oil of sandal wood 3 drops, was kept up
for over two months. The patient after two weeks
showed slight improvement and at the present time,
while not entirely relieved, is comparatively well. The
attacks are very slight and usually follow exposure or
over-exertion.
From a review of the cases, I think the majority, at
least, belong to the second class and that in these if
not in all nasal hydrorrhea is a symptom or local man-
ifestation of a constitutional condition. I regard the
constitutional lesion as varying, but in the second
class of cases, in which the one reported belongs, as
usually associated directly or indirectly with some
circulatory lesion in which the venous return is inu
peded, producing in the nasal mucous membrane a
cyanotic condition, analogous to congestive lesions in
organs, as the lungs, liver and kidney, largely made
up of mucous membrane, and not necessarily the site
of acute local inflammatory conditions-. Mucous mem-
branes, when repeatedly congested, tend to remain so,
allowing the leakage of serum into the perivascular
tissue which, when near the surface, becomes edema-
tous and the epithelial cells undergo, in their effort to
elaborate the excess of fluid, hydropic degeneration:
the membrane relieving itself and again becoming
infiltrated, accounting for the recurring attacks.
Practically the condition may exist in any mucous
membrane as is shown in the case reported by Miles,
in which this condition existed in the mucous mem-
brane of the intestines. The lymphatic supply may
be involed as shown in one of the cases reported by
Miles (Trans. Internat. Ophth. Congress, Heidelberg,
1888). Because of the intra-vascular pressure the tis-
sue would undergo simple atrophy and impair to a
great extent sensation, and cases with this induced
condition must not be confused with those properly
of the first class.
Owing to the varied symptoms and etiologic factor,
no regular plan of treatment can be formed; but each
case must be treated as to cause, and irritation during
the attack should be relieved by sedatives.
18%.]
OPERATIONS IN THE NOSE AND THROAT.
699
UNCOMMON ACCIDENTS FOLLOWING
OPERATIONS IN THE NOSE
AND THROAT.
Ki':ul In tin- Stviiou on l.iiryiii:ol(ii;y mill otnioRy, at the Forty-seventh
Anic.iiil Mct'tiiiK "1 'tin' Anu'rk'im Medio*] Association,
«t Atlanta, lia.. Mav B-8, ISM.
I!Y MAX TMOKNKK, A.M., M.D.
,\c OTOLOGY, CINCINNATI COI.LItGg
OK MK1MCINK ANP Sl'lioKKY: l.A KY NGOLOQHT AND
AIR1ST, CINCINNATI HOSPITAL. WO.
Olin INN ITI, OHIO.
It is now almost ten years that the late Professor
Nusslmuni commenced his monograph "On Accidents
in Surgery" with these words: "Of surgical acci-
dents, avoidable ones as well as unavoidable, there are
so many, that if one would attempt to enumerate
them all one would hardly know where to begin and
where to end. Unfortunately, owing to human vanity,
almost exclusively successful cases are reported, while
unfortunate events are not published, although one
unfortunate accident is often more instructive than
ten successful eases."' Such considerations have
prompted me to report to you to-day a number of
aooidents following operations in the nose and throat,
whioh have happened during the last eleven years. I
do not attempt to enumerate all or even the majority
of undesirable sequela' that 1 have seen; but I pur-
posely omit all BUch eases, as are frequently observed
anil have often been described, for instance lacunar
tonsillitis or pharyngitis following intra-nasal opera-
tions; acute purulent otitis with or without compli-
cations, adhesions forming in the nose, epistaxis, etc.
But 1 shall confine my remarks to a few cases which
are rather remarkable on account of their rarity.
Cage /. Functional aphonia, following cauterization of
the pharynx for chronic follicular pharyngitis. The patient
was ■ young lady, 18 years old, who was studying elocution.
She was referred to trie on account of her voice failing during
any prolonged attempt at loud reading or speaking. She had
a well developed chronic lateral and follicular pharyngitis, and
some remnants of adenoid vegetations, in cushion shape, at the
vault of the pharynx.
Treatment consisted mainly in galvano-cauterizations, re-
peated at intervals of from eight to twelve days. One day,
after a number of treatments had been given with a very
noticeable improvement of the voice, a large hypertrophied fol-
licle, situated nearly in the center of the posterior pharyngeal
wall was cauterized, when suddenly the patient said in a whis-
per that her voice was gone. There was complete aphonia. I
was naturally alarmed. Upon laryngoscopic examination the
image was found to be the same as in functional aphonia ; the
vocal cords approximated during an attempt at phonation for
an instant, but separated again at once. This condition lasted
for a few days, when it vanished almost as suddenly as it had
appeared, without any special treatment. There was at no time
a recurrence of this reflex phenomenon, although the same
treatment was continued for some time, with the result of
entirely restoring the voice of my patient. This patient was a
strong and healthy young woman, and did not at that or any
time thereafter belong to the great army of hysteric women.
Case 2. Temporary amaurosis following cauterization of
the nose. Mr. J. H., 40 years old, was under my care about
ten years ago for nasal polypi. A great many of them were
removed by the cold wire snare. When the nose was thor-
oughly cleared there remained a few very small ones in the
crevice between lower and middle turbinated bodies, which
could not be engaged in the snare. I decided to destroy them
with the galvano-caustic burner. One day, following such a
treatment on the previous afternoon, Mr. H. called on me in
great excitement, telling me that he could not see with the
right eye, the side operated upon. The eye, upon examination,
did not show any difference from the normal ; he could dis-
criminate between light and dark, could see objects held closely
before his right eye, but could not count fingers at a distance
of five feet. Ophthalmoscopic examination was entirely nega-
tive. Vision improved after five days and was gradually and
entirely restored within four or five weeks.
Case 3. Loss of memory following an insignificant opera-
tion in the nose. A boy of about 16 years of age, from one of
the interior towns of Ohio, was operated upon for almost com-
plete nasal obstruction. There was a marked deviation of the
septum and enormous hypertrophies of the lower and middle
turbinated bodies. These hypertrophies were removed at
intervals of from four to six weeks, the boy returning to his
home after each operation. After two or three operations had
been done, without any untoward symptoms, the boy returned
for another operation. This time I succeeded in removing but
a small piece, the size of a green pea, from the middle turbin-
ated. There was but moderate hemorrhage, but as the boy
had just passed through an attack of tonsillitis, I decided not
to do any more. I saw him the following day at 10 a.m., found
him apparently in good condition, and he left on an afternoon
train. When he arrived home about four hours later, he was
in an almost absent minded condition. During the night the
family physician telegraphed me to inquire what anesthetic
had been used. I learned the following day from a letter of
the physician that the boy had a high temperature when he
arrived, his conjunctiva were hyperamic, pupils dilated, he was
complaining of headache, and above all was absolutely uncon-
scious of everything that had happened since he left home.
The pain and fever subsided within two days ; the pupils
became again normal : but the loss of memory remained for
about six weeks, during which time his mental activity was
very much impaired. Gradually during the course of the next
two or three months, all his mental faculties returned, although
the memory remained sluggish for some time. When I saw
him several months thereafter, he was in perfect health and
his parents had the courage to have the treatment continued,
which was thoroughly successful without any further accident.
Case 4. Intubation in an adult followed by a fatal edema
of the larynx after extraction of the tube. J. B., 18 years
old, had been suffering eight years from what was considered
asthma, the dyspnea having increased of late to an alarming
extent. The history was entirely negative ; syphilis could not
be traced. The patient appeared to be in great distress. His
respiration was labored, noisy and accelerated ; on exertion his
face had a livid color and was covered with a cold, clammy
perspiration. The stenosis of the larynx was extreme. The
ventricular bands were greatly thickened and the vocal cords
buried in masses of infiltrated tissues. The encroachment on
the lumen of the larynx increased in the subglottic space, the
opening for breathing being scarcely the size of a thin lead
pencil.
The smallest tube of the intubation set for adults was intro-
duced without any difficulty. It was well oiled and the larynx
had been previously anesthetized with a 5 per cent, solution of
cocain. The tube is somewhat larger than the largest tube of
the set used for children. The patient could readily breathe
through the tube and complained of no pain. It was my inten-
tion to permit the tube to remain in the larynx for twenty-four
hours, but on the following morning, about fifteen hours after
the introduction, the patient returned and begged me to
remove the tube. He stated he was greatly annoyed by it and
could not take any food whatever. I extracted the tube with-
out any difficulty, with the understanding that it was to be
reintroduced in the evening. The patient was greatly relieved,
was able to take some water, and left my office after a few min-
utes feeling comparatively comfortable. About fifteen minutes
later he was found dead on the sidewalk, about a half square
from my office. He had walked about one and a half squares
when he felt bad and asked the driver of a passing wagon to
take him to my office. Scarcely had he been seated when he
fell back and died before he could be lifted from the wagon.
A physician who happened to pass there shortly afterward
found no sign of life.
The unfortunate accident can be easily explained. After
the pressure exercised for fifteen hours by the tightly fitting
tube upon the infiltrated tissues had been suddenly relieved a
subglottic edema ensued causing a fatal issue within a short
time. This rather unusual case teaches us a lesson to keep a
patient upon whom intubation for a chronic stenosis has been
practiced, under strict surveillance for some time after the
extraction of the tube.
Case 5. Severe spasmodic cough and neuralgia after a
nasal operation. Miss B. K., aet. 24, consulted me on
account of excessive sneezing which had been troublesome for
several years, but had become well-nigh exhausting of late.
The anterior and lower portion of the left middle turbinated
was enlarged to almost the size of a cherry, of a deep purple
hue, and touching the septum. Upon the lightest touch with
the probe an excessive fit of sneezing was sure to follow,
which would immediately stop after the application of a 4 per
cent, solution of cocain. This hypertrophy was removed with
the cold snare. One half hour after the operation the patient
had a most severe attack of coughing, a symptom which was
700
OPERATIONS IN THE NOSE AND THROAT.
[September 26,
entirely new, and not long thereafter a most intense neuralgia
of the left side of the face developed ; nothing short of morphin
and chloral hydrate would give her rest during the following
night. The neuralgia lasted for several days when it gradually
disappeared, while the spasmodic cough vanished only after two
and one- half weeks. There was no local condition present that
could account for it, the wound having nicely healed without
any disturbance and without further interference. There was
afterward no return of these symptoms, nor of the sneezing.
These few cases are reported simply for the reason
that they appeared to me somewhat unusual. In fact
all of them at the time, when my experience was less,
were rather alarming, although fortunately, with the
exception of the fourth case, they ended well. Yet,
as any one is likely to meet at any time with acci-
dents which are not common, and which can not be
expected according to our usual experience, I thought
thsse cases, collected at random from my note book,
of sufficient interest to be placed on record.
DISCUSSION.
Dr. J. E. Logan, Kansas City, Mo. — I have had some experi-
ence similar to Dr. Thorner's. My patient was similarly affected
with this extreme irritability of the nostrils and experienced a
great deal of the same trouble of excessive sneezing. I only
refer to the case to make this suggestion, that in most of these
cases the focus of irritation is in the anterior chamber. I have
found that the application of the galvanic cautery to the mid-
dle turbinate has brought me better results than complete or
partial removal with the snare. In this patient I removed
considerable portion of the middle turbinate and packed with
iodoform gauze, and for several months afterward the patient
had a disturbed sense of smell. He was troubled with the
odor of iodoform for months. It disturbed me, and while in
New York I had him go to a friend of mine and he confirmed
my opinion that it was due to the very nervous temperament of
the patient. The sneezing did not return, but the perverted
sense of smell remained for six or seven months.
Accidents liable to happen as the result of operations in the
nasal cavity are many, for the reason that the nose and throat,
especially the laryngeal cavity, are the seats of great reflex
action, more so probably than any other cavity of the body and
I am not surprised that the removal of the enlarged follicle
was the cause of the aphonia. I have found the cause of this
sudden aphonia to be very hard to explain. In the case in
which there was involvement of the cords without loss of mus-
cular power it would lead me to suspect hysteria ; the cords
would be under the control of the patient to a certain extent.
I have had this experience with hysteric patients.
Dr. W. E. Casselberrv, Chicago, 111. — I wish to say in sup-
port of Dr. Thorner, that I believe one may have temporary
impairment of the voice reflexly produced by operations on
neighboring parts independently of a suspicion of hysteria.
In one case of combined operation for tonsils and adenoids on
a boy 5 years of age, the tonsils being removed with the cold
wire snare, after the operation he spoke in a high unnatural
voice, which lasted for about six days, when he gradually
regained his proper tone. It could not be ascribed to other
than irritation of peripheral nerves.
In reference to the case involving the middle turbinated body,
I would ascribe the loss of memory to the use of cocain. I
have seen some curious temporary mental effects produced by
it. In regard to the middle turbinated body, I would say that
while I have advised operations upon it under certain con-
ditions, I think we should be cautious. From the intimate
association of the vessels of the middle turbinated body with
the cerebral meninges, it is perhaps surprising that serious
results should not be more frequently encountered. Operations
upon this body should be restricted to those cases in which
there is a very clear and decided indication therefore.
Dr. Cline— In Dr. Thorner's case in reference to the aphonia
I am inclined to think that it was the result of the cocain. I
recall three similar cases which I think were due to it. One,
a man of very nervous temperament whose sphincter muscles
were paralyzed for several hours. He also seemed to be unable
to speak, which I attributed to the cocain. I am not in favor
of the free use of cocain unless I know my patient.
Dr. Thorner— The discussion has been partly diverted to
cocain poisoning which I did not consider. The operation
which caused the temporary loss of memory was done on the
soft parts of the middle turbinated and not on the bone itself.
Operations on the middle turbinated are much more dangerous
than on the other parts. If you will examine the connections
closely you will readily see that it is a dangerous place to oper-
ate and the wonder is that we do not have accidents more fre-
quently. As to the operation for the removal, I always prefer
the cold snare. This simply cuts away the bone as clean as
can be done. The old way of tearing out is certainly dangerous.
The galvano-cautery is also very dangerous here. I have heard
of a number of deaths that were the result of cauterization.
And how many are not reported? There are others who favor
the removal with the cutting forceps, which if properly done is
also well adapted for operations of this kind.
The principal danger of operations in this vicinity lies in the
anatomic relations. We have the immediate region of the
orbit separated from the ethmoid cells by the lamina papyracea.
We have also the nerves and blood vessels passing through the
foramen opticum, through the flssura sphenoidalis, etc. The
rcx)f of the nasal cavity is thin and separates it from the brain.
And yet there are and will be cases which must be operated
upon.
Dr. John O. Roe, Rochester, N. Y.— In regard to the case
in which the effect of the cocain seemed to be quite unusual,
I am also of the opinion that all the manifestations were the
result of cocain. Some patients are so extremely susceptible
to its influence that all sorts of neurotic manifestations are
caused by it. Notwithstanding this fact I daily use cocain in
my work freely and indiscriminately without the slightest bad
results. With patients who are so extremely susceptible to
cocain we must use it with great care. In the case of a patient
under my care not long ago, one single drop of a 4 per cent,
solution put into her nose would cause agitation of the heart,
and a few drops would cause extreme dyspnea, so much so that
suffocation would seem imminent. I was obliged to resort to
general anesthesia in order to perform the necessary operation
in her nose. I find that by giving these patients quite a large
dose of tincture digitalis a short time before employing the
cocain and giving whisky in sufficient doses to very nearly
intoxicate, this susceptibility to cocain is overcome, so that all
these unpleasant symptoms and cocain complications are
entirely obviated. In the case of the patient just referred to,
I have had occasion recently to do a slight operation on her
nose, and by the use of digitalis and whisky I was enabled to
use all the cocain necessary to complete the operation without
pain. In regard to the cerebral complications resulting from
operations in the nose, I have observed in the cases reported,
that these complications more frequently result from operations
upon the middle or superior turbinated bone than in any other
portion of the nose. These bodies are a portion of the ethmoid
bone, which is closely connected with the cranial cavity, and it
is for this reason that under certain conditions disturbances in
these parts may be transmitted to the meninges.
Dr. Robert C. Myles, New York, N. Y.— As for the fainting
from the use of cocain I think it is very common. I have
adopted the plan of preventing the solution from extending
over a larger area than that on which I intend to operate, and
I believe a strong solution is better than a weak one. I also
employ the reclining position as a remedy. I have noticed in
a number of cases that were in the incipient stage of fainting,
when they were placed in the horizontal position they recov-
18%.]
DISEASES OF THE EAR, NOSE AND THROAT.
701
ered at once. Sometimes a hot room will cause fainting. A
peculiarity is that there is very little absorption about the
tongue and throat, but in the nose it is very rapid. In regard
to operating on the middle turbinated I think that the old way
of tearing the body away with forceps is unsurgical and unsafe.
The membrane continues through the cribriform plate into the
cnuiiuiu, and it is remarkable that serious consequences are
not reported more frequently. The turbinated body can be
removed neatly and effectively with the ethmoid clippers or
scissors and a cold wire snare.
A c 1. 1 N tt( 'A L S'lT 1 >Y ( >K TWENTY-ONE THOU-
SAND CASES OF DISK ASKS OF THE
EAR, NOSE AND THROAT.
BY BETH SCOTT BISHOP, B.S., M.D., LL.D.
On to the Illinois Charitable lye ami Ear Infirmary ; Protestor of
Otology »n Ilu' Posl Gradual* -Medical School and Hospital;
Proiaatforol Dtaeasea of the Nose. Throat and Bar In
tin* Illinois Mrdu-al Collage, etc.
I'Ull'Ai.o.
The following statistic table of 15,800 cases, com-
bined with a table of 5,700 oases already published,
represent the reoords of ^1,000 treated during the past
seventen years at the Illinois Charitable Eye and Ear
Infirmary in Chicago. The following table was com-
piled for me by my assistant. Dr. Charles L. Enslee.
My tirst classification was instituted for the pur-
pose of establishing a basis of calculation of the influ-
ence, if any, exerted by occupation, age or sex in the
causation of diseases of the ear. nose and throat.
The condition of each patient at the time he first
presented himself at the clinic is presented to deter-
mine the relative frequency of the different diseases.
As is common in charity hospitals, a considerable
number of those who applied for treatment belonged
to that class of laboring people who have no definite
trade or fixed occupation. In order to facilitate
Investigation and simplify the tables as far as possi-
ble, all those occupations that were closely related to
each other in nature and effects were grouped under
one heading. For example, under the classification
of clerks were embraced salesmen, bookkeepers, office
employes, etc.; with teamsters were grouped car
drivers, peddlers, etc.; cooks and bakers were classified
together; brass molders, iron molders, etc., were classi-
fied with iron workers; plumbers, gas and steam
fitters appear together; such closely allied occupa-
tions as stone cutters, stone masons, bricklayers and
plasterers in which the influences and exposures are
very similar, are grouped together under the head of
day laborers, a term borrowed from the laborers
themselves.
The combined tables show that of the 21,000 cases,
there are 11,119 patients with occupations, classified
under twenty-eight headings. Of this number, 3,813
had out-door work and 7,306 in-door. About 34 per
cent, are out-door occupations and 66 in-door; or
about twice as many in-door occupations as out-door.
The largest number of any one class were in-door
workers. 3,045 domestic servants. Next in order
were about half that number of the out-door class, or
1,508 day laborers. Then follow groups of the next
highest numbers; 858 clerks, 460 iron workers, 452
carpenters, 400 sewing women, 378 factory workers of
all kinds, all in-door occupations before we reach the
out-door class again in going down the scale.
While the great stores and factories furnish a large
number of patients, the homes contribute 5,615
females, including the servants, seamstresses and
women without occupation, or more than one-fourth
the whole number of the combined tables. These
facts are significant when we take into account the
slight difference between the number of males and
females affected under the age of 15 years. Out of
6,162 children under 15 years of age there were 1,484
boys and 1,590 girls between the ages of 6 and 15
years; and 1,641 boys and 1,447 girls under 6 years.
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l From the writer's forthcoming book on Diseases of the Ear,
and Throat (in press).
TUB A1SIIREVIATIONS EMPLOYED ARE:
W. No.— whole number.
Ext.— diseases of the external ear.
?.*
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702
TREATMENT OF DETACHED KETINA.
[September 26,
F. B.— foreign body.
In. <J.— inspissated cerumen.
Fur.— furuncle.
Ac. R.— acute inflammation of the right middle ear.
Ac. L. — acute inflammation of the left middle ear.
Ac. 2. — acute inflammation of both middle ears.
Ac. S. R. — acute suppurative inflammation of the right middle ear.
Ac. S. h. — acute suppurative inflammation of the left middle ear.
Ac. S. 2. — acute suppurative inflammation of both middle ears.
A. 8. & N.— an acute suppurative inflammation of one middle ear,
with a chronic non-suppurative inflammation of the other.
C. N. R.— chronic non-suppurative inflammation of the right middle
ear.
C. N. L. — chronic non-suppurative inflammation of the left middle
ear.
C. N. 2.— chronic non-suppurative Inflammation of both middle ears.
C. S. R.— chronic suppurative inflammation of the right middle ear.
C S. L.— chronic suppurative inflammation of the left middle ear.
C. S. 2.— chronic suppurative inflammation of both middle ears.
Au. I*. — aural polypus.
M. D. — mastoid disease.
Int. — diseases of the internal ear.
D. M. — deaf mutes.
N. Ph. — naso-pharyngeal catarrh.
Ad.— adenoid growths in the vault of the pharynx.
Hy. T.— hypertrophied tonsils.
Of all these children 3,037 were girls and 3,125 boys,
leaving a difference of only 88 more males than
females .under 15 years. Between the ages of 6 and
15 years there were 106 more girls than boys. Under
6 years there were 194 more males than females.
Sex seems to have no influence in the production or
prevention of diseases of the nose, throat and ear. It
appears that up to the age of 15 years both sexes suf-
fer nearly equally. Possibly a reason for this may be
found in the similarity of the lives and habits of the
sexes during this early period. But the classes of
society that afford clinical material at the medical
charity institutions are such that necessity requires
them to abandon the pursuit of an education at about
the fifteenth year, and to enter upon bread-earning
vocations. Thenceforth the divergence in habits anil
environment increases. The males are either out of
doors more than before, or confined chiefly to mercan-
tile houses and factories. The females become domes-
tics, clerks, shopgirls and seamstresses.
An interesting question pertains to the relative
frequency of diseases of the right and of the left ear,
and of diseases of one ear as compared with diseases
existing coincidently in both ears. The above table
shows that in acute inflammation of the middle ear
there is but a very slight difference in the frequency
of involvement between the two ears, and both ears
were affected in 24 per cent, of all the cases. In acute
suppuration of the middle ear again there is too
little difference between the two ears to take into
account. In 15 per cent, of all these cases both ears
were involved.
In the 5,849 cases of chronic non-suppurative in-
flammation of the middle ear the two sides were
about equally affected, but a great contrast is now
offered in the relative frequency with which both
ears are involved in the various middle ear diseases,
for in this instance nearly 82 per cent, of all the
cases presented bilateral aural affection. Sufficient
importance must be attached to these undeniable
figures in formulating our prognosis when only one
ear is already diseased, for it follows, almost as the
night the day, that if one ear has become seriously
affected, especially with the sclerotic form of dry
catarrh, the other becomes subject to the same destruc-
tive process.
In chronic suppurative otitis media the two ears
suffer nearly equally, and it appears that both ears
are simultaneously affected in a little more than 60
per cent, of the cases. In 3,149 instances of unilat-
eral diseases of the ear, there was an excess of only
37 cases of the right over the left. This fact is men-
tioned particularly because the opinion has often
been expressed that one ear was much oftener affected
than the other, some specialists believing that the
right was affected, by far, more frequently than the
left ear.
The tables show that about 13 per cent, were
afflicted with nasopharyngeal diseases, but the actual
number would be much in excess of this figure. The
Infirmary being an eye and ear hospital strictly, not
as great prominence has been given to the nose and
throat affections as would be desirable, this part of
the diagnosis sometimes being entered on the patient's
cards instead of upon the record books.
About 0.8 per cent, had diseases of the mastoid
process, which was nearly twice as prevalent in males
as in females.
Deaf mutes formed about 0.5 per cent, of the 21,000
cases. There were three times as many males as
females.
The largest number of any one class of diseases
were 8,858 with chronic non-suppurative inflammatory
processes of the middle ear, or 42 per cent, of the
whole number. Next in numerical order come 3,664
cases of chronic suppurative inflammation, or 17 per
cent.; and the next highest number, 1,010 cases of
acute suppuration, or 5 per cent.
Children under 15 years of age constitute about 29
per cent., or more than one-fourth of the whole num-
ber of cases. Very many of them dated back to
attacks of scarlet fever, measles and the earaches, and
" running ears " of infancy, so that a much larger
percentage than appears should probably be credited
to the period of childhood. Only a small proportion
of the children were brought for treatment during
the acute stage of inflammation. Only about 10 per
cent, were acute cases, leaving 90 per cent., or nine
times as many who had not applied for treatment
until the inflammation had reached a chronic stage.
Indeed, only 13 per cent, of the adults were seen in
the acute stage of their troubles.
Columbus Memorial Building.
ELECTROLYSIS IN THE TREATMENT OF
DETACHED RETINA.
Read in the Section on Ophthalmology, at the Forty-seventh
Annual Meeting of the American Ueaiea3 Association,
held at Atlanta. Ga„ May 5-8. 1880.
BY W. T. MONTGOMERY, M.D.
CHICAGO, ILL.
Within the past few years various remedial agents
have been advocated with more or less enthusiasm in
the treatment of detachment of the retina. One of the
more recent of these agents, and one which from its
action and the nature of the disease seemed to promise
as much or more than any other treatment, is elec-
trolysis. One of the most full and encouraging reports
on the application of electrolysis in detachment of the
retina, is by Dr. Terson, and was published in the
last July number of the Annates cPOculistique. Dr.
Terson reports twelve cases treated with one recovery
which had lasted nine months, and five improvements
which had persisted for from two to nine months.
Within the last six months four cases of detachment
of the retina have been treated in the Illinois Chari-
table Eye and Ear Infirmary, two by myself and two
by Dr. B. Bettman. In the treatment of these cases
we, in the main, followed the recommendations of Dr.
Terson. Positive electrolysis was used; the eye was
punctured by the strong platiniridium needle at some
point of the sclerotic corresponding to the detach-
1SW.]
THE ABUSE OF WATER IN SURGERY.
703
lnont and a current of five milliamperes applied for a
period of one minute. The eye was thoroughly ooeuin-
bed so that the puncture was made without pain, hut
when the current was turned on the patients coin-
plained of severe pain. In Case 2 the pain was so
severe as to prostrate the patient and he absolutely
refused to submit to it again. In Case I the pain was
severe enough to bring out beads of perspiration.
The after-treatment consisted of the instillation of a
1 per cent, solution of atropin sulphate, the compress
bandage and rest in l>ed for one week. No noticeable
reaction followed treatment in eit her case.
/. Andrew J. F., age 29, mechanic, Norwegian, July
:!0. 1896, was admitted into 111. Charitable Eye and Ear In-
Brmarj . Patient states that the sight of his right eye has
always been poor, V bright light = amblyopia. Eight days
as struck on the left eye with a piece of wood, and this
rye lias been almost blind since. On examination, external
appearance of eve normal. The ophthalmoscope shows large
blood clot in vitreous. Vision Bngers at six feet. Pressure
bandage applied, and small doses of hydrargyrum bichlorid
and potassium iodid was ordered, and the patient kept quiet.
August 90, patient was discharged with V 2090, some small
Boating opacities of vitreous remaining. September 80, pa-
tient was readmitted with extensive detachment of the retina.
V motions of hand in temporal field. Patientsays his sight
failed suddenly the day before. Ophthalmoscope shows
almost complete detachment, only a small area of nasal portion
remaining. Treatment: rest in bed, bandage and hypodermic
injections of the muriate of pylocarpin, saline cathartics.
October 16, no improvement. Electroylsis used. Bandage
and quiet. October 25, no change. Needle used again, but
owing to breaking of wire in holder battery did not act and
operation resulted in simple evacuation of subretinal fluid.
December 5, patient thinks he can see better. Field is enlarged
but can not distinguish objects. Electrolysis again used.
December. 15, field and vision not so good. Is now about as it
was before electrolysis was used. Patient was transferred to
Dr. W. 11. Wilder, who injected sterilized rabbit's vitreous,
ding to Deutschmann. Violent reaction followed, but this
subsided within a week. There was no improvement of vision.
Jan. 7. 1886, patient discharged as incurable.
U. l\, age 65, laborer, American, was admitted
into Infirmary Oct. 23, 1895, with umbrella detachment of
retina of right eye. Left eye lost from the result of an injury
years ago, Present trouble came on suddenly three months
No history of an injury or previous trouble. V motion
of hand. Electrolysis used November 6. No improvement.
Electrolytic needle used again, but as in Case 1, the battery
did not work, the result being only puncture of sclerotic and
escape of subretinal fluid. December 5, patient thinks he sees
a little better, but we can not detect any change in the detach-
ment. Patient refused to submit to further operative treat-
ment, and was discharged at his own request. Feb. 14, 1896,
patient readmitted with acute glaucoma, which he states came
suddenly one week ago. Pupil widely dilated. T -f- 3. Eye
totally blind. Pain excruciating. February 27, pain contin-
ues. Eye excised.
( hue •'.'. P. L., age 40; laborer, Irish, was admitted into In-
firmary Dec. 30, 1895. Left eye blind for three years as the
result of an injury. Vision of right eye began to fail three
months ago. On examination cornea clear, pupil dilated,
numerous floating opacities in vitreous. T — 1. No distinct
vision and only poor perception of light. Detachment of the
retina in upper and temporal portions. Pilocarpin treatment
used until Jan. 10. 1896, without any improvement. Electrol-
ysis used. The eye was bandaged and patient kept in bed.
January i">, no improvement. Electrolysis again used, mak-
ing three puncture. March 25, still no improvement. No
further treatment.
'Vise 4, — M. B., age 67; farmer, Irish; admitted Dec. 26,
1886. Right eye normal. First noticed flashes of light in left
eye three weeks ago. Eight days ago he suddenly noticed cloud
before eye, as he expressed it. On examination, cornea clear,
pupil dilated. T — ? Detachment of retina above, hangs down
and nearly covers optic disc. No distinct vision. The pilocar-
pin treatment was used without benefit. Jan. 20, 1896, elec-
trolysis, single puncture. February 15, no improvement.
rolysis repeated, the sclerotic being punctured three times
at this sitting. March 22, no improvement. Patient dis-
charged by request.
The cases we have reported were all of extensive
detachment. Only one, Case 1, can be claimed as
presenting conditions fairly favorable for successful
treatment. This patient was young, his general con-
dition was good and the detachment recent when the
electrolysis was first used. Of the other cases, their
ages wore r>5, 40 and 67 years and the detachment, had
existed from one to four months. If we are warranted
in drawing any conclusions from such a meager report
they would be: 1, that the treatment is exceedingly
painful, but is not immediately followed by severe
reaction; 2, that it is valueless as a curative agent in
detachment; 3, it may be a factor in exciting inflam-
matory glaucoma, as occurred in Case 2.
THE ABUSE OF WATER IN SURGERY.
BY EDWIN WALKER, M.D., PH.D.
EVANSVILI.K, IND.
The art of antiseptic and aseptic surgery has
advanced with the science of bacteriology. Surgical
technique has changed as our knowledge of germ life
has advanced. While some observers before Lister
seemed to have had a vague idea of the relation
between wound infection and microorganisms, to him
belongs the credit of putting first the knowledge,
scanty as it was, into a distinct shape and to practice
antiseptic surgery. He acted on the knowledge at
that time and his failures were in a great measure due
to the lack of that information we now possess. He
supposed the chief source of infection was from the
air. Tyndall's observation seemed to prove this, con-
sequently he bent his energies to devise a means of
purifying the atmosphere.
( hily a few years ago, when operating rooms were
small and the air was laden with carbolic spray, the
operator and patients were deluged wTith antiseptic
solutions. These stood in puddles on the floor so
that one had to wear rubber boots or wooden shoes.
I have seen a carbolic spray play directly in an
abdominal incision for an hour. Great emphasis at
that time was placed on the preparation of the room in
which the operation was to take place. The walls were
wiped down and the floors scrubbed with antiseptic
solutions. Since, however, we have found that infec-
tion from the air is very little, and the number of
organisms contained in it is so small that the danger
is practically nil when compared with other modes of
access, viz.: hands, instruments, dressings and fluids
during the operation. Experiments have shown that
even in apartments where decomposing fluids are
present, as in water closets, the number of micro-
organisms in the air is very small. This knowledge
has led to the abandonment of cumbersome methods,
and little by little we have evolved a simpler and
more reliable technique.
Perhaps no greater change has occured than in the
use of water and antiseptic fluids. Many accidents
were due to the over- use of the latter, and they were
responsible more than anything else for the tardy
adoption of antiseptic surgery. Many deaths charged
to the new method were due to ignorance of principles
and excessive use of poisonous agents. This subject
has been fully discussed and the danger fully set
forth by many observers; still we find surgeons who
think it necessary to irrigate a clean wound or wipe
it out with sponge or gauze, moistened in some anti-
septic solution. The danger of infection from the air
is very slight, and if the hands of the surgeon, his
instruments and sponges, have been rendered strictly
704
THE ABUSE OF WATER IN SURGERY.
[September 26,
aseptic, the introduction of antiseptic fluid in the
wound is entirely superfluous. It has been proven
that blood serum is a reliable antiseptic ;which is non-
irritating and makes the very best covering for a cut
surface, and it is fully able to render harmless all the
germs that will enter the wound from the atmosphere.
An antiseptic solution, or even water, is not only
unnecessary but absolutely harmful. Bichlorid
solutions produce superficial necrosis and any fluid
damages more or less the integrity of the tissues,
besides they furnish the very moisture necessary to
the development of the bacteria. I do not wish to
dwell at any length upon this branch of the subject,
for I believe that most surgeons have long since
abandoned the use of antiseptics during operations.
I have referred to it because recently I have seen sur-
geons insult clean wounds in this manner. I heard
not since, that a surgeon of some prominence in this
State filled wounds with protonuclein, thinking
thereby to hasten union. It seems almost incredible
that anyone would introduce dead elements to replace
the living; for even if protonuclein does contain the
corpuscular elements, they certainly could not be as
reliable as the fresh blood.
It is especially with regard to the use of water that
I wish to speak. Most surgeons have within the last
few years much curtailed its use. Landerer in 1889
recommended wiping with dry bichlorid gauze and
packing the wound carefully to control hemorrhage
and remove all surplus blood, so that the wound would
be dry when it was time to close it. The dry method
has been adopted partially at least, by most surgeons
and is considered by all a marked advance. Few,
however, fully appreciate the extent it should be
applied and many operators still use too much fluid,
too much irrigation and too much wet sponging. In
most recent articles I find irrigation recommended
after many operations, which in my experience have
done better without, and we will have much better
results when we abandon irrigation except in those
cases where mechanically, it is impossible to remove
foreign substances or septic material in any other
way, and these cases will become gradually less as we
apply efficient means of drainage and keep the parts
dry afterward.
The first objection against water is that, as ordi-
narily obtained, it is not sterile. When emergency
operations are undertaken, boiled water is rarely at
hand, and if it is it has to be cooled with water that has
not been boiled. Washing the wound with water that
is not sterilized is a hazardous proceeding and is
liable to carry more infection than it washes out. The
following, taken from Warren's pathology, page 787,
fully expresses the idea : " A cubic meter of air may
contain from 1,000 to 20,000 germs, but in a drop of
putrefying fluid millions of bacteria may exist.
Schimmelbusch reckons that the number of germs
that settle upon a space a decimeter square amounts to
about sixty or seventy during one-half hour's time in
V. Bergmann's operating theater. In a cubic centi-
meter of water of the river Spree, which flows past the
clinic, it is estimated there exists about 27,000 germs.
Assuming, now, that a boatman should injure his
hand and should wait one-half hour in the clinic
before it is dressed, he would receive upon the surface
of the wound, covered probably with a blood clot,
between sixty and seventy bacteria. If, however, he
attempted to ' cleanse ' the wound in the Spree water
and bind it with a dirty handkerchief, the number of
organisms that would come in contact with the wound
would amount to probably between thirty and forty
millions."
I know it will be argued that water is easily steril-
ized by boiling, but unfortunately we usually have to
delegate that part of the work to some one who
is uneducated in aseptic methods. Who of us has
not in our haste, after carefully boiling the water,
found it too hot for use, cooled it with plain water,
and then to ease one's conscience a few bichlorid
tablets were dropped into it; or having directed some
one to get the water ready, have seen the temperature
tested with a dirty hand or it is brought in a vessel
which has been in service in every branch of house-
hold life. It is practically impossible, even with
trained help, under the most favorable circumstances,
to attain absolute asepsis, and when that part of the
work devolves on those who are not especially trained
it is sure to fail.
To test this subject I had three trained nurses pre-
pare three pitchers of water, telling them that it was
to be used for an operation. They each washed out a
pitcher with sapolio and scalded it with boiling water,
then after boiling the water thoroughly for one-half
hour poured it into the pitcher, and covered it care-
fully with a clean towel. The result of a bacterio-
logic examination by Dr. Kerth, showed germs in
two of them while one was sterile.
If we have prepared our hands and instruments
and the skin of the patient properly, in any clean
operation, dry wiping with sterilized gauze will
remove all blood and render the wound dry and clean.
Blood clots and the tissue which may be cut away.
can be removed without one drop of moisture, and
these wounds will heal more kindly and are less fre-
quently infected than where water is used.
Thus far I have only spoken of clean wounds, but
I believe the same is true of infected wounds and in
cavities, mucous and serous, where infection exists
prior to the operation. I do not speak dogmatically
because sufficient experience has not been collected
to fully establish the fact, but from my observation
dry sponging has been more efficient than irrigation.
I do not include in this assertion, cavities, sinuses,
etc., which mechanically are almost impossible to
clean without water. When this is the case, after
thorough washing, the parts should be dried and effic-
cient drainage established and dry methods employed
afterward.
In operations in the uterine cavity the same gen-
eral rules should be followed. After curetting for
endometritis or removal of the products of conception
before the third month when not infected, I never
irrigate. Since abandoning washing out with anti-
septic fluids, my cases have done much better. The
packing remains sweeter and the discharge following
is less. Twice in the past year I have been compelled
to empty the uterus at the second month for vomiting.
(I may add by way of parenthesis, that they were the
only two cases in which I have had to resort to this
measure.) In both, the os was dilated by steel instru-
ments, and with the curette and Martin's forceps the
fetus and membranes were removed, the cavity wiped
out with sterilized gauze and packed with iodoform
gauze. This was done under strict aseptic precau-
tions. In neither case did the temperature rise to
100, or was the pulse at any time above normal.
After the third month and where infection has
occurred, it may be better to irrigate in some cases,
1896.]
AN AMERICAN PHYSICIAN IN MEXICO.
705
on account of the difficulty of removing all foreign
matter without it. I have, however, treated a large
number of this class entirely by the dry method with
most satisfactory results.
It is possible, rapidly and thoroughly, to remove all
debris even in quite a large uterus with the finger, a
dull curette and curetting forceps. I have not had
the accidents so often spoken of in this connection,
due to instrumental interference. The unfavorable
sequence (pelvic inflammations, etc,) are often due,
to the forcing of pus through the tubes by the irriga-
tion. 1 have known peritonitis to follow irrigation
of the uterus several times. I am very partial to the
use of .Martin's heavy forceps in these cases. With
them the uterus can be more rapidly emptied than by
the curette alone, and in many cases they are more
efficient than the curette or fingers. I have never
had any unfavorable results from them. So far, I
have not treated the infected puerperal uterus by the
dry method, nor has it to my knowledge been em-
ployed by any one, but it has been so successful in
my hands in smaller infected uteri, that I shall try it
the next ease 1 have to treat.
Formerly I performed operations on the cervix,
vagina and external genitals under constant irrigation
with antiseptic solutions, and later with sterilized
water, as was the general custom. The later works
on gynecology ( Keating and Coe) recommend it.
Since adopting the dry methods my results have been
much more satisfactory. So much so that I have
entirely abandoned irrigation in all operations on the
genital tract. No water, not even a wet sponge is used.
1 use irrigation to cleanse the parts before the oper-
ation, but after the first cut, not a drop of water is used.
Irrigation in the abdominal cavity, while still em-
ployed by many operators, has been entirely aban-
doned by a large number. It seems impossible to
wash out with any degree of thoroughness the abdom-
inal cavity. In aseptic cases it is certainly superflu-
ous, and in pus cases the careful protection of the
cavity by gauze, and wiping out with the same mate-
rial, has been more satisfactory in the hands of many.
Careful, thorough work renders irrigation superfluous
except in rare instances. The dry method seems to
me more rational, and in my experience has been
attended with better results. This method possesses
great advantages to the surgeon who does much of
his work in their patients' homes. He can pack his
bag with everything he needs thoroughly sterilized,
and after he has disinfected his hands, use absolutely
nothing on the premises. When I go from home to
perform surgical operations, I take everything I need
except the water to wash my hands, and I think by
this method I exclude many avenues of infection.
If antiseptics or water are used, it adds that many
more chances of trouble. The instruments should
not be immersed in any fluid for the same reason.
Simplicity all along the line is the watchword, and
every additional detail may furnish a loophole for the
entrance of the enemy. A fair trial will convince
any surgeon of the superiority of the dry method.
Magnan's Sign in Chronic Cocainism. — Ribakoff has had occasion
to observe a couple of cases of severe chronic cocainism in
which Magnan's sign was the predominant symptom. This is
a hallucination of the cutaneous sensibility, characterized by
the sensation of a spheric foreign body under the skin, varying
in size from a grain to a nut. This sensation is peculiar to
this intoxication and its differential value should be more gen-
erally recognized. — Gaz. d. Osp. e d. Clin., August 4. *
EXPERIENCE OF AN AMERICAN PHY-
SICIAN IN MEXICO.
A CASE OF MALIGNANT EDEMA — A MEXICAN FUNERAL.
D. H. GALLOWAY, Ph.G., M.D.
CHICAGO, ILL.
The patient was a laborer, 38 years old, who had
received a crushing injury to the foot from a car wheel,
which passed over it high up on the instep. The
accident happened on Sunday and he arrived at the
hospital Tuesday afternoon, sixty hours later, after a
journey of 200 miles.
The injured foot had been wrapped in cotton waste,
such as is used about the engines for cleaning pur-
poses. I sent for a Mexican physician and then pre-
pared to operate, with the assistance of a couple of
servants. I put the patient to sleep with chloroform,
changed to ether and then gave the cone to one of the
servants. The leg was prepared for amputation just
above the ankle, the operating table being outside the
house in the shade of the building. As I began to
operate the Mexican doctor arrived and greatly to my
relief took charge of the anesthetic. I placed the in-
struments in two basins on two chairs so that I could
reach them without much difficulty, as I had to procure
my instruments as well as do my own sponging. In
one pan I had a knife, a saw, a pair of artery forceps and
a needle threaded with silk. The other pan contained
a few other instruments which I thought might be
needed. As the bone was sawed through the doctor
took it in his hands to lay it down thus getting them
covered with blood and pus. I picked up an artery
and put on a ligature and then looked for more but
could not find any. The doctor noticing my diffi-
culty, wiped his hands on the patient's clothing and
swept his fingers over the stump in search of other
vessels which might need tying. As he also was un-
successful, I motioned (we could only communicate
by signs, as I could not speak Spanish and he could
not speak English and we had no interpreter) to him
to loosen the Esmarch bandage so that we might find
the other arteries by the bleeding. He did so but no
blood appeared, even downward stroking of the leg
failed to reveal any spots bleeding sufficiently to
require tying. The wound was then closed in the
usual way with silk sutures, a drainage tube put in
and a dressing put on. Before closing it however, I
irrigated very carefully with a solution of bichlorid of
mercury, in the hope that I might remove the infec-
tion implanted by the doctor's hands and with the
expectation that I would discover, at least, a second
artery that would need a ligature. We now turned
our attention to a rather insignificant injury in the
other leg, a triangular wound of the skin over the
thickest part of the calf, exposing the muscles which
appeared to be uninjured. This was carefully washed
out with a bichlorid solution and an iodoform dress-
ing put on. On Wednesday I repeated the irrigation
of this wound, which seemed to be in good condition.
On Thursday the dressing was saturated with a bloody
fluid and I irrigated it several times with hot bichlorid
solution. Friday the discharge was more copious and
the leg slightly swollen. In washing it, I separated
the muscles with my fingers and irrigated very thor-
oughly between them. All day the swelling increased
so that at 4 o'clock the leg seemed ready to burst with
the tension and it was almost black. Bloody fluid ran
in a stream through the mattress to the floor. Several
incisions were made from the knee to the ankle, the
706
AN AMERICAN PHYSICIAN IN MEXICO.
[September 26,
first one was three-quarters of an inch deep and gaped
nearly two inches.
My Mexican friend predicted that the patient would
die before morning but suggested that he have some
medicine. At my request he wrote a prescription
which I took to the drug store. The druggist gave me
two bottles full (one was not large enough ) ; one held
about twenty-four ounces and the other sixteen
ounces. Directions: half a teacupful every three hours.
Amputation was out of the question, and the patient
died the next morning, five and a half days after the
injury. The stump of the amputated leg was healing
well with very little suppuration.
Never having seen a Mexican funeral, I thought
this a good opportunity to do so. The patient died
at 4:30 a.m., and at 7:30 the Mexican physician wrote
out an application for a burial permit. This I took
to the "civil judge," who copied the document entire
into a large book. He then asked my name, age,
birthplace, whether married or single and the number
of children I had. The last question followed the
previous one, though I had just said that I was
unmarried. I signed my name to what he had written
in the book, paid $1.25 and was given the permit.
This was taken to the custom house, endorsed by an
official there and we were free to proceed with the
funeral. A coffin was obtained for $2.50. It was
made of light wood, painted black and trimmed with
white stripes. A cross was painted on top and "1898"
on the head end.
The body was wrapped up in the sheet on which
it lay and put into the coffin. Four cargadores, hired
for the purpose (at 50 cents each), put it upon their
shoulders and took it to the graveyard. In twenty
minutes we arrived at the "Cemetery of the Angels."
This is surrounded by a high stone wall through
which we enter by an iron gate under an imposing
stone archway. On passing this gate we came into
an enclosure of, perhaps, five acres, containing quite
a number of monuments. This was the "yard of the
first class." Walking through this we passed by
another gate into a second enclosure of about the
same size constituting the "yard of the second class."
The entire surface of the ground here was level except
for irregular piles of earth here and there, and bare
except for seven or eight small mesquite trees. Not
a spear of grass! Not a flower! Near the middle
there was a row of ten open graves, about five feet
deep and separated from each other by about a foot
of earth. The loose earth was piled up in a windrow
at either end of the row of graves. Here the bearers
set down their burden. An attendant, who had fol-
lowed from the entrance with two short ropes and five
shovels, took the permit, the coffin was opened for his
inspection but he disdained to look. The lid was put
on again and fastened with two or three small nails
driven in with a small stone picked up near by. The
coffin was then lowered into the grave nearest the path
and the five men began shoveling in the dry earth,
talking and laughing, meanwhile; but about what, I
did not know.
While they were thus engaged I employed myself
examining the mound of earth under my feet. I was
standing on a human femur. On looking more care-
fully I found that the earth was covered and filled
with human bones! A tibia, a scapula, a radius, half
a dozen ribs in a pile, part of a pelvis, bones of hands
and feet without number! Easily fifty bones in sight
without disturbing the earth a particle! Meantime
the grave was full, no mound being made, one of the
cargadores said "lista" (ready or done), and we turned
away. The burial over, the funeral services ended!
Antonio Hernandez under the sod! No, under the
sand, gravel and the bones of his predecessors in this
particular spot. Four hours before, he began his last
long sleep, now begins his last long rest ( ?) No, five
years hence his bones will be notified that their lease
is up and they must move. The landlord wants the
ground for another tenant. Then his skull, per-
chance, may sit on a pile of earth, as two skulls sat
to-day, and watch his successor take his place. The
bones of his hands and feet will be a part of the earth
which fills the grave over the newcomer.
I made inquiries and found that this cemetery was
eighteen years old and that every five years the ground
is reopened for new burials. The bones are supposed
to be gathered up and deposited in a trench du^ for
that purpose, but that many of them are returned to
help fill up the newly opened grave, I, myself, wit-
nessed. The rich buy lots and dig graves eighteen to
S twenty-four (!) feet deep, in order that their bones may
not be exhumed in the next turning up of the soil.
What an impression is made on one accustomed to
the orthodox funeral at home! The darkened room
or church, the expensive felt-covered silver-trimmed
coffin, the crape, the flowers, the people with their
sympathy and tears. The pall-bearers, dressed in
black, with white gloves and bared heads. The hearse
with its somber plumes and black horses, the long
procession of carriages; the cemetery, with its tries
and grass, flowers and monuments; the throng of
people about the open grave, the measured loins of
the minister repeating the solemn burial service, all
culminating in the "ashes to ashes, dust to dust."
as the clods roll in upon the coffin.
To one who carried such an impression of what a
funeral ought to be, the Mexican way seemed forbid-
ding enough.
But is not that, in some respects, a better custom
than ours? The object in putting a body into the
ground is, or ought to be, to resolve it into its ele-
ments. There it is put in as light a coffin as pos-
sible and buried in dry soil where disintegration
will rapidly take place. Here we put it in a strong,
sometimes a metallic, coffin and inclose this in an
outer box; thus retarding decomposition as much as
possible. There a funeral costs $6 or 87, hen- even
the poor will spend $100 or $200 on a funeral, for
coffin, carriage, flowers, etc., even when they are too
poor to pay the doctor or even buy the decent neces-
sities of life. If prejudice is so great that crema-
tion can not soon be made general, people might,
as a step in the right direction, be compelled to use
coffins of wickerwork or very light wood so that
nature's work of purification might be facilitated,
and not retarded.
In five years, buried in Mexican soil, the body
disappears, except the bones. Investigations in our
cemeteries would reveal a very different condition.
We should not regard with such horror the customs
of other people without considering the end sought.
The feeling of abhorrence we have for new or strange
customs is only relative and disappears when we
become accustomed to them, particularly if any good
end is attained thereby.
As I left the cemetery I was approached by the
attendant with a request for money to buy pulque
for himself and the cargadores. Returning to the
mm.]
A NEW FIGURE-OF-8 PEDICLE LIGATURE.
707
hospital, 1 took the mattress, bedding, dressings and
indeed everything combustible which lnul been about
the patient, into the back yard, saturated it with kero-
sene ami burned it. The room was scrubbed, then
washed with a solution of carbolic acid and left open
and unoccupied for some time. There were other
patients in the hospital who had wounds, but none
of them became infected.
•2iK) O&kwood Hiuilevard.
A NEW FIGURE-OF-8 PEDICLE LIGATURE.
i;y p. shimonek, m.d.
MILWAUKEE, WIS,
The following pedicle ligature is, so far as I know,
original:
I have used it with much satisfaction for the last
nine months. It is an improvement upon the old
Figure 1.
Worlliob ligature, because it can be quickly tied,
whether it be used singly or as a continuous ligature;
for very broad pedicles only one knot is required; the
Figure 2.
threads cross naturally when passing through the
pedicle. It is better than the Tait ligature because
of its applicability to any breadth pedicle and can be
safely tied, and without any trouble whatever.
An armed needle is passed through the pedicle, as
shown in Fig. 1. That part of the ligature passing
through the eye of the needle is withdrawn from it,
as shown in Fig. 2. We now have the needle and
ligature passing through the same opening in the
pedicle, and yet are independent of each other. Take
that part, of the ligature corresponding with the
handle of the needle, carry it half way around the
pedicle and pass it through the eye of the needle as
shown in Fig. 3.
FlGUln: :].
Now withdraw the threaded needle from the pedi-
cle, thereby forming a loop upon one side of the ped-
icle, the ends passing and crossing through the same
opening appear upon the other side and may be tied,
Figure 4.
as shown in Fig. 4, or, in a very broad pedicle that can
not be securely tied with one figure-of-8, the needle
may be passed throxigh the pedicle at a distance of
one-half inch or more, threaded with one of the free
ends, then unthreaded of that end and again threaded
708
SELECTIONS.
[September 26,
with the other one, and so on, until the entire pedicle
is encompassed and the free ends tied.
307 Grand Avenue.
A HANDY FORM OF HOT SNARE FOR
TONSILLOTOMY.
BY HENRY GRADLE, M.D.
CHICAGO.
It is acknowledged by many throat surgeons that
the galvano-cautery snare is the best instrument for
the removal of tonsils, because its acts very efficiently
and prevents bleeding. Any one who has used either
the hot or the cold snare for tonsillotomy has been
able to observe that the wire loop slipped over the
tonsil, after the latter has been pulled forward with a
tenaculum or appropriate forceps, will grasp a larger
portion of it than can be sliced off with any form of
guillotine. But with slight experience the snare will
be found even more thorough than the use of bistoury
or scissors. The cold wire, however, is quite painful
and with a Wyeth's snare it may even happen that the
wire is pulled out of the stylet instead of cutting com-
pletely through the tonsil, if the gland is fibrous in
consistency. The hot wire on the other hand cuts its
way as easily as a sharp knife, even if only a dull red
heat is employed. As this degree of heating is suffi-
cient to stop all bleeding it is unnecessary to bring the
wire to more than a dull red glow and indeed we only
inflict more pain and produce a slower healing wound
by heating the wire beyond this point. Since the cur-
rent raises the wire progressively to a higher tempera-
ture as the loop gets shorter, it is best to press on the
key and accordingly close the current in an intermit-
tent fashion. The wound heals a little more slowly
than a clean cut with the knife. But if the wire is not
unnecessarily hot I find the wound entirely cicatrized
in from five to ten days, according to the size, which
is perhaps, two days more than for a corresponding
tonsil cut with the knife.
The hot snare prevents bleeding entirely. If a few
drops of blood appear they are due to unsuccessful
grasping with the tenaculum. However trivial the
bleeding may be in most tonsillotomies, anyone who
has ever worked over one of the "exceptional" cases of
tonsillar hemorrhage can appreciate the advantage of
a bloodless operation. Even if fatal cases are very
rare, annoying bleeding from tonsil cuts is not uncom-
mon, especially in adults.
My reasons for devising a new instrument are the
weakness of the ordinary snare canulae and especially
the loss of time incurred in wiring the hot snare as it
is found in the market. I have hence designed a
snare for tonsillotomy, which, however, can be used
for any other purpose where straight and not very
thin tubes are applicable. It consists of a handle
made of two parallel brass bars, 11 cm. long, mounted
in rubber blocks at both ends. A third rubber block
slides along the bars when guided by the fingers
inserted through the rings on the block, while the
thumb rests in the ring at the rear end of the handle.
The sliding block holds two insulated steel stylets
which when pushed forward, protrude through the
two canulae in front of the handle just far enough to
allow a wire to be slipped through the eye in each
stylet. The two canul«, 9 cm. long and 2.5 mm. thick,
are insulated by separation along their length and by
a soft rubber tube slipped over the end, while their
ends are strengthened by wire wound around the rub-
ber insulation. Steel (piano) wire is a better mate-
rial for the loop than platinum on account of its stiff-
ness. The instrument can be used with a loop nearly
11 cm. in circumference, but this size is rarely
required. If a few suitable lengths of wire are pre-
pared with their ends bent sharply, as shown in the
accompanying cut, the burnt or softened wire can be
replaced in a few seconds.
As shown in the figure the current enters the instru-
ment through the cords permanently attached beside
the rear ring, passes along the brass bars to the stylets
directly through metallic contact in the front block as
well as indirectly through the canulae to the stylets
and wire loop. Good connection is thus assured. I
have not been able to devise a better place for the key
which establishes the circuit than in the length of the
cords twelve inches from the handle. Experience in
over twenty-five operations has taught me that this
arrangement is a practical one. The hand which
seizes the tonsil with the tenaculum (put through the
wire loop) presses the button as soon as the loop is
in place.
The instrument has been made for me by Messrs.
Sharp and Smith of this city.
SELECTIONS.
The Less Frequent Hazards of the Bicycle; Defects of the Tandem
Wheel. — The editor of the Boston Medical and Surgical Jour-
nal, July 23, comments upon some of the less common acci-
dents of 'cycling as follows :
"Although the worst casualties usually occur to riders
going at high speed, there are certain conditions which render
falls even when going at a low rate of speed serious and disfig-
uring. Of these the principal js that in a large number of
cases, particularly those which are due to suddenly running
into an obstacle, the weight of the head and body being carried
18%.]
SELECTIONS.
70<>
high, ami the legs arrested by the handle bars, the head, and
particularly tin' fare, is the first to reach the ground. A man
taking a 'header' from a horse starts from such a height that
In- may turn a complete somersault and land in a sitting pos-
ture, tint the bicycle is so low that the victim strikes the
ground face Bret, and when he has plowed over a few yards
of gravel or pavement, his physiognomy is usually somewhat
altered. A particularly dangerous accident is the breaking of
the front fork of the wheel. Here the victim never has time
to get his hands before his face, and fracture of the nose and
jaw with scrums laceration of the soft parts almost invariably
results. These falls arc so quick that before a man has time
ho let go of the handlebars his face strikes the ground. In
fact in headers from the bicycle generally, there is no time to
let y. i of the handle bars in order to protect the face. Sprained
wrists and broken arms arc therefore comparatively rare, while
broken noses and serious lacerations of the face, mouth and
eyelids are common. Bruises, sprains and abrasions of the
shoulders occur if the face escapes. The danger of the break-
ing of the front fork is especially great in the case of the tan-
dem wheel, where the fork has to bear the- weight of two
instead of one, and the danger from any Haw in the steel of
which it is constructed is consequently greater. The writer
has recently seen two young women who were seriously disfig-
ured by falls due to the breaking of the front forks of second-
grade tandem bicycles. The moral for young men who wish
to give their sweethearts a taste of the joys of riding tandem
would seem to to be to buy none but a first grade wheel and
take the front seat yourself. Although accidents to the face,
head and shoulders are the more common, fractures of the legs
and bruises and sprains of the knee occasionally result from
bicycle accidents, and internal injuries are by no means
unheard of. A case of rupture of the pancreas due to a blow
in the epigastrium by the handle bar has recently been reported.
The bicycle is proving itself so important a means of providing
fresh air and healthful exercise to a vast number of people
that the good done by it greatly overbalances the harm result-
ing from occasional accidents, most of which can be avoided
by careful tiding and by the selection of a well-constructed,
standard wheel."
Fifty Cases of Pernicious Anemia. The London Lancet, August
89, refers editorially to the work done in recent years in the
elucidation of pernicious anemia, and analyzes the report by
Dr. Richard C. Cabot of Boston on fifty carefully studied
cases of that affection. The Lancet commends Dr. Cabot's
work in regard to the corpuscular changes, especially as to
coloration and shape. The observer has not found the pallor
of the corpuscles equally marked in all cases. Where deform-
ities in shape were present one of the commonest is the
absence of any central biconcavity, the corpuscles being
swollen up and taking appropriate stains in a smooth, even
manner quite different from the normal corpuscle.
•Variations in shape (poikilocytosis) were more apt to be
present, if at all, toward the fatal end of the case. Of thirty-
six cases in which this point was noticed ten showed little or no
variation from the normal shape. The deformities when pres-
ent usually belonged to one of a few types such as are usually
pictured in connection with the disease. The racquet-shaped
and sausage shaped cells were specially common. These vari-
ations of shape were not commoner in pernicious anemia than
in any severe case of secondary anemia or chlorosis. This
opinion coincides with that of other modern observers,
although at one time it was held that the condition of poikilo-
cytosis was one peculiarly characteristic of the pernicious
form. According to Dr. Cabot's experience, the distorted
forms of the red corpuscles were not infrequently absent in
pernicious anemia — in more than one-fourth of his series. The
variations in size were more constant than deformities. They
were present in 90 per cent, of these cases, both microcytes
and macrocytes being seen. Here, again, Dr. Cabot corrobo-
rates the writings of other authors. Most of the latter, how-
ever, lay more stress on the large numbers of microcytes which
are usually seen, frequently in groups of twenty or more
together, while macrocytes, as a rule, are only present in small
numbers. The increase in the average diameter of the cor-
puscles was present in eighteen of this series, so far as could
be judged by measuring a few corpuscles in each case and then
endeavoring to apply the standard so obtained to a large num-
ber, a method easily adopted in ordinary clinical work. Very
frequently the large corpuscles showed the lack of biconcavity
mentioned above. The Ehrlich-Biondi method, which was
used in all these cases, stains normal red corpuscles straw yel-
low. In nineteen cases of the series there were present cer-
tain red cells which contrasted distinctly in color with the
clear yellow of the surrounding corpuscles. The color of
these atypically stained cells varied through various shades of
brown to purple. This reaction is not so well known as the
other properties of abnormal red cells and is worthy of further
investigations. In only one of the thirty-five cases examined
were nucleated red corpuscles wanting. In the thirty four
others there wore seen from 1 to 568 nucleated red cells in the
space covered while making a differential numeration of 1,000
white cells. As many as nine different varieties of nucleated
red cells were noted in addition to tho cells with dividing nuclei
(some of them of normal size, some as large as any megalobast)
and cells showing kiryokinetic figures. In no case was there
observed any sudden and marked increase in the number of
normoblasts, such as has been mentioned by some writers as a
point of favorable import. As a rule, the number of megalo-
blasts steadily increased as the patient grew worse, while the
relative proportion of normoblasts diminished. Cases where
the whole number of nucleated corpuscles, or the proportion
of megaloblasts, was relatively large seemed to be neither better
nor worse off than those where only a few were to be found,
but on the whole it is to be concluded that an increase of
these cells in the blood of any one case is a bad sign."
(ialvano Cautery In Uterine Surgery.— Dr. Charles Jewett, in
the Brooklyn Medical Journal, September, offered some
remarks on the claims of cautery in the treatment of uterine
cancer and of procidentia. These remarks were made in the
course of a discussion before the Brooklyn Gynecological
Society on true and false methods in this branch of surgery.
Dr. Jewett contended that the cautery had not received the
attention that it deserves. The first and most obvious advan-
tage is its complete antisepsis, an attribute that can not be
marred by the carelessness of either the operator, assistant or
nurse. In certain cases, no doubt all the diseased and infected
tissue can be removed, and the results reported by Dr. John
Byrne and his associates commend the operation as one deserv-
ing to stand side by side with hysterectomy until experience
has proven that hysterectomy gives better ultimate results
than the mere removal of the diseased tissues with the cautery
knife." The cautery knife is, too, a very valuable adjunct for
at least the first step in vaginal hysterectomy. It frequently
makes this part of the operation a bloodless one, and it obviates
the necessity of hemostatic sutures in the vaginal wall at the
close of the operation. It is one which I have used with satis-
faction. Theoretically, total ablation, on the other hand,
appeals to the judgment of the surgeon in cancer of the uterus,
as it does in cancer of other organs. In carcinoma of the
breast the surgeon considers it necessary to remove not only all
the diseased tissue, but the entire mammary gland, and with
it the pectoral muscles and all of the lymphatic glands that are
known to be or that might be involved. A similar rule is
enforced in the treatment of cancer generally. If there is any
criticism on the Doctor's method it is the uncertainty that the
operation reaches all the infected tissues of the uterus. With
reference to the theory offered as to the action of the current
on the structures left behind, I can not agree with him. The
current which runs through the cautery knife passes from one
pole of the battery to the loop or knife and back again to the
other pole of the battery, none going out into the tissues. I
assume that the galvano-cautery does not differ in effect from
any other kind of cautery. The action of the instrument must
be simply that of a hot knife or iron. The tissues are disin-
fected, the cancerous elements are destroyed, only so far as the
slough goes ; at least that is my belief. The use of the cautery
in the treatment of procidentia is a method we are familiar
with through the teachings of Dr. Byrne. No doubt the
results are quite as permanent as in many cases of ventral fixa-
tion and of most other operations for the purpose. The effect,
I take it, of the knife is to set up an inflammation, with result-
ing proliferation of tissue, which blocks the pelvis and holds
the uterus up. The inflammatory products must be absorbed
in time — I am glad to know it is ten years in some cases — but
ultimately we must expect the uterus to come down again."
710
SELECTIONS.
[September 26,
The .Medicine of Life Insurance Is yet In its Infancy. — The editor of
the Medical Examiner offers the following thoughts upon the
higher plane of insurance :
" Insurance medicine is yet in its early stages. Within the
last fifty years it has made great advances. There is no doubt
that in the course of time, for that is a great element in the
collection of statistics of this character, greater accuracy will
be reached in everything relating to the medical phase of life
insurance. The best medical men of the profession are needed
and sought for to act as examiners — men who are capable of
accurate observation and of securing accurate records. While
the first is possible, the latter is not always so, as applicants
will not state or do not know the facts in all cases. Conclusions
drawn from inaccurate data are themselves defective, and
allowances in practice must necessarily be made. But no
department of an insurance company is beyond the reach of
law. If the status of a company as reported to the insurance
department of a State, is found to be below the required stan-
dard, the causes are immediately sought for and the appro-
priate remedy is applied. If the medical department in any
part of its organization is found to be at fault, then the State
will require such changes to be made as will remedy any defect
discovered. These defects are so far-reaching and cumulative
that they can not be otherwise than disastrous if allowed to
exist. The medical department of an insurance company is
one of the necessary and important divisions of its organiza-
tion. Upon its efficiency and integrity depends the very exist-
ence of the company."
come when the general practitioner will be consulted only as to
the advisability of calling a specialist and whom to call. AU
this can but tend to belittle the family physician in the eyes of
his patients, limit his ability and impair his usefulness, to say
nothing of his loss from a financial standpoint. The physician
who has no confidence in himself can not expect others to trust
him with their lives. I believe there will always be room for the
well-equipped general practitioner, unless he persists in turn-
ing away all of his most interesting cases. By so doing he will
help educate the rising generation to believe that they are to
depend on the family physician to treat slight ailments only."
The Narrowing Field of the General Practitioner — The following
is a portion of an essay by Dr. Onslow Gordon of Brooklyn in
Weir's Index, inculcating a higher self-confidence and a less
constant reliance upon specialists. He holds that specialism is
overdone to an extent injurious to general medicine, and a
concert of action is needed. He further says :
"Within comparatively few years the field of the general
practitioner has been very much narrowed, and present indica-
tions point to still greater inroads upon his field of usefulness.
Should he be crowded into such narrow quarters that he will
be unable to exist, the fault will be largely his own. It require!
but a moment's reflection to convince one that the number of
good, all-around physicians is rapidly growing smaller and that
the tendency is toward specialism. While I have nothing to say
against specialism in medicine, and would not wish to go back
to the time when there were no specialists, as we owe very much
to them, and there are certain lines along which they can do
better work than the man who tries to cover the whole field of
medicine and surgery, 1 think that the general practitioner is
too dependent upon them at the present time. A very large
number of physicians (especially the younger members of the
profession) are doing a larger business as distributors of cases
than as practitioners of medicine ; 'they shake the bush and
the specialist gathers the fruit' There is not a member of
this Association that has not repeatedly seen the specialist
called upon to open a simple abscess, remove wens, dilate for
anal fissure, remove tonsils, ingrowing toe-nail, perform circum-
cision and do an innumerable number of operations that the
family physician should blush to decline. All surgical cases
are sent to the surgeon, gynecologic cases to the gynecologist,
throat and nose work to the laryngologist, heart and lung
affections to the chest specialist, nervous diseases to the neu-
rologist, diseases of the rectum to the rectal specialist, genito-
urinary ailments to the gento-urinary surgeon, joint and bone
diseases to the orthopedic department, eye and ear troubles
(however slight) to the ophthalmologist, and skin diseases to
the dermatologist ; we can also find specialists who will call us
good fellows if we will turn over our stomach, kidney and
hernia cases ; yet there are very few specialists who will decline
to treat a patient, no matter what his ailment may be, if the
money is in sight. While the people of moderate means still
tolerate the family physician as an obstetrician, the more
favored in worldly goods are looking for a specialist when an
accoucheur is desired. If matters continue on these lines, the
specialist, or more properly speaking, the general practitioner,
will leave for himself possibly acute coryza and constipation.
The tendency to rely on the specialist has grown to such an
extent that there are many physicians who will not remove a
retained placenta, suture a recently lacerated perineum, how-
ever simple, open an abscess or venture a diagnosis in any
obscure case. It is the custom of the times that makes them
hesitate to rely more on their own judgment and call into
action the ability their patients have a right to expect them to
have. It has been well said, 'The wise and brave conquer
difficulties by daring to attempt them.' Perhaps the time will
The Lancet on the Health of Chicago. The London Lancet for
August 29 has the following interesting annotation about
Chicago's health, taking up anew, although in an incidental
manner, the thread of certain investigations that were made
by that journal in 1893, at the time of the great exposition.
The annotation opens by referring to the report, printed in
April of that year by a special Lancet committee, or "Sanitary
Commission," of inquiry concerning the water supply of Chi-
cago, and says :
"When, three years ago, we undertook an investigation into
the drainage and water supply systems of the city of Chicago
we acted primarily in the interest of our own countrymen who,
in the year 1893, were visitors to the great exhibition ; but as
we then remarked, the matters examined were of even
more abiding importance to the residents in Chicago than to
her visitors, and it was very gratifying to us to gather from the
way in which our action was received by the city authorities
that they took the same view. Since that date our own oppor-
tunities of collecting information concerning the sanitary his-
tory of the city have naturally been occasional only, but we
have from time to time heard with a lively interest of "the prog-
ress of the large engineering works required to secure efficient
drainage on the shores of Lake Michigan and the effective use
of the boundless supply of excellent water which the lake
brings to the city's door. A return from the Bureau of Vita)
Statistics, for a copy of which we are indebted to the courtesy
of the Commissioner of Health, shows that the effect of the
water supply upon the health of the city is made the subject
of constant and watchful attention and certainly the results
of the observations made illustrate in a very striking manner
the close— we might even say exact— relation between the two.
This is well exhibited by a diagram which accompanies the
Commissioner's report for the month of June last in which the
mortality rates from intestinal diseases for six months are col-
lected. Upon this diagram one curve shows the varying con-
dition of the water supply, the badness of the water in the
sense of pathogenic quality being measured by the height of
the curve in successive weeks ; a second curve shows in the
same way the weekly series of mortality rates due to typhoid
fever ; and a third a corresponding series of mortality rates due
to other acute intestinal diseases, such, apparently as enteritis,
gastroenteritis and diarrhea. Between the water curve and
the second mortality curve the correspondence is most striking.
The water supply was at its worst in the week ending Decem-
ber 28 last ; the mortality from intestinal diseases was greatest
in the following week. The water curve shows culminating
points in the weeks dated January 25 and February 15, in each
case followed by a maximum point in mortality from intestinal
diseases a fortnight later. A marked amelioration in both
conditions is indicated throughout the month of March, but
in April, May and June the water supply became again patho-
genic and within a week the mortality curve exhibits a corre-
sponding increase, both curves approximating closely to that
reached by them respectively in the mor.th of January. In
fact, the dependence of the one upon the other might almost
be expressed by a mathematic formula. In the case of typhoid
fever the correspondence is not so close and the difference is
characteristic. The bad water maximum of December is fol-
lowed after an interval of five weeks by a typhoid fever maxi-
mum in the end of January, and although the typhoid curve
does not respond with the same precision as the curve of other
intestinal diseases to the water maximum of the following
April there is a traceable rise in typhoid fever mortality during
June and it is matter of common observation that this disorder
is. less rife in the spring than in the after part of the year.
Altogether the statistics produced from the health department
of Chicago are most suggestive, eminently instructive and of
much more than simply local significance."
Clinic Teaching in the Modern Hospital.— The Sanitary Journal
of Glasgow, June, 1896, considers the subject of ampler pro-
vision for the use of clinic material at the infectious disease
18% ]
PRACTICAL NOTES.
711
hospitals, especially in now hospitals and in respect of the
plans of proposed hospitals. The writer Bays :
'•The primary duty of laying down the best known condi-
tions by which the hospital may be rendered the best possible
Instrument for the treatment of disease being fulfilled, there
remains to be recognised the clear duty of rendering it also an
efficient teaching institution. 1 regard this duty as a very
close second in Importance to the first. Ten years ago scarcely
one and one-half per rent, of the medical graduates of Edin-
burgh had obtained their knowledge of fevers from clinic
study. It has only been since the treatment of infectious dis-
ease was taken over by the city that anything like general
attendance at fever clinics has been given by the students of
our medical school. Such attendance has now been made
compulsory by the medical authorities. In the new hospital,
we shall. I feel sure, as heartily afford facilities for clinic
instruction as we have done hitherto in the old building.
"What 1 desire mainly to urge with regard to the hospital as a
teaching institution is that, in constructing our new hospital,
the city will have a unique opportunity to render, at a compar-
atively trifling cost, one of the most valuable services to the
Edinburgh school of medicine that it has ever received. That
service lies in providing adequate laboratory accommodation
for bacteriologic research, and for the investigation of the
whole natural history of all kinds of febrile disease. The
Edinburgh school has never yet been able to take its proper
place in relation to this all important field of inquiry. The
prosperity of its medical school tends, in no small degree, to
the general prosperity of the city. Whatever, therefore, the
city may do to promote the interest of the medical school,
famous as it has been and is still, will be in reality a contribu-
tion to the best interests of the city itself. Down to the pres-
ent time almost all the material which our increasing fever
hospital affords for scientific investigation has gone to waste.
Notwithstanding what has been generously provided by the
Royal College of 1'hysicians at its own charges, we have no
adequate means of conducting such systematic inquiry as that
which is carried on in the principal medical centers of the con-
tinent. The opportunity to meet this great defect now lies to
our hand. In every well appointed fever hospital on the con-
tinent, but especially in Germany, well-equipped laboratories
are found, where students and graduates conduct methodic
and patient investigation into every aspect of every kind of
infectious disease. There is also provided a museum for the
preservation of preparations made by the investigators, and
there is. likewise, adjoining the laboratories, a well constructed
postmortem room with the requisite appliances. Let it be the
graceful part of the city to provide the necessary accommoda-
tion for the purpose now pointed out, which it is in a position
to do in the simplest, most economic and yet most effective
way. It may be assumed that the medical school will not be
slow to do its part in making the best use of facilities so
provided. ' '
PRAGTI6AL NOTES.
Dry Heat of High Temperature in the Treatment of Chronic Joint
Affections. The apparatus which Dr. WTm. E. Wirt employs
consists of a copper drum twelve inches long and nine inches
in diameter, fitted at each end with a wooden ring and a hood
of thick rubber. Having protected the back of the knee with
cotton, it is enclosed in the apparatus, and heat applied to the
outside by means of a Bunsen burner. Most patients tolerate
a temperature between 250 and 300 degrees F., provided three
holes are made in the drum to secure proper ventilation and so
keep the air dry. This treatment gives immediate relief to
pain and increases temporarily the mobility of the joint. —
Boston Mill, mid Surg. Jour., September 1Q.
Modern Treatment of Progressive Polyarthritis Deformans. — Phy-
sicians are too much inclined to consider this disease incurable.
Its pathogenesis is still obscure, but it is probably due to some
infection which rapidly localizes itself in the nervous system.
It attacks both adults and young people, starting with one or
two acute seizures, develops from below upward, attacking
symmetrically the articulations of the members and then of
the trunk, but scarcely ever causes visceral lesions. The
usual internal remedies for rheumatic or gouty tendency, sali-
cylate of soda, preparations of colchicum and alkalins in large
doses, usually fail to produce any effect in this disease. The
only internal modicines which prove effectual are iodin and the
iodids combined with preparations of arsenic. It can be com-
menced with small doses of iodid or tincture of iodin, taken in
the middle of the two principal meals, 4 to 5 and even 10 drops
of tincture of iodin in a class of wine or of can 8UCr4e or syrup
of bitter orange peel in water. Or else a teaspoonful of the fol-
lowing : Two grains each of potassium iodid and sodium iodid
in L20 grams of dist. water. After fifteen days of this treat-
ment it is to be suspended and a teaspoonful of the following
taken in the same way with the meals in a tablespoonful of
iodotannic syrup : Sodium arseniate 0.05 gram in 120 grams
of dist. water. The sodium arseniate can be roplaced by
Fowler's solution taken in progressive doses, increasing from
3 drops at each meal to 0 drops and then decreasing a drop a
day until the original dose is reached. This treatment is to be
continued several months, alternating the arsenical medication
with the iodids. If, as sometimes happens, the iodid is not
borne well, the tolerance can be increased by associating with
it belladonna and arsenic in the following proportions : Potas-
sium iodid, 4 grams ; sodium arseniate, 0.02 gram ; neutral
sulphate of atropin, 0.001 gram, and 120 grams of dist. water.
Take one teaspoonful in the middle of each of the two principal
meals, in half a glass of Vichy water (Hauterive). In combin-
ation with this internal medication there should be external
treatment to ward off the threatening anchylosis in the joints.
They must be frictioned with a stimulating liniment, and as
the frictions are to be made daily, irritation of the skin should
be carefully avoided. The following is a good liniment for this
purpose : Liquid ammonia, 50 grams, with 100 grams each of
balsam of Fioravanti and spirit of lavender. The frictions may
be followed by slight massage, but it is best not to massage the
articulations and avoid imparting too active movements to the
diseased joints. The different methods of electrization have
all proved impotent, even long continued currents applied to the
atrophied muscles consecutive to arthritis of this kind. Alka-
lin and salin baths, very hot and prolonged, sometimes produce
good results, asalsohydromineral treatment at Aix-la-Chapelle,
Dax, Saint-Armand, Ragatz, Bourbonne les-Bains, Bourbon-
l'Archambault, etc. But in the torpid periods of the disease,
to combat the articular deformities and restore mobility to the
anchylosed members, mud and sand baths are excellent. These
have been recommended for many years, but it is only compar-
atively recently that the establishments at Dresden (Dr. Flem-
ing), Kostritz near Leipsic (Dr. Sturm), atBerlin (Dr. Grawitz)
and especially at Lavey in Switzerland (Dr. Suchard), have
really rendered these baths practicable. The Grawitz method
enables baths to be taken at home in an ordinary bath tub at
122 degrees, but the best results are obtained at Lavey where
the establishment is fitted up with appliances for whole or
partial baths of sand, evenly heated to 122 and 140 degrees,
absolutely free from gravel, clay, calcareous or organic matters.
The partial baths are considered best as they do not debilitate.
These baths produce an excessive cutaneous secretion which
has been found to benefit to a surprising degree sciatic and
chronic rheumatism and gout. They also modify very favor-
ably cases of arthritis deformans. The Lavey water is also
beneficial in rheumatic disorders.— Rev. Int. d. M. et d. Ch.,
August 20, from the Gaz. hebd., May 24.
Influence of Cold Baths on the Circulation.— A series of experi-
ments on typhoid fever patients and persons in health, as well
as numerous experiments on animals, lead Breitenstein to
assert that the number of corpuscles in the blood greatly
increases in the course of a cold bath, but as this can not be
due to the formation of new corpuscles, it must be that cor-
puscles more or less stagnant in the viscera and other interior
portions of the organism, are drawn to the surface by the
effect of the cold bath. — Revue Int. de M. etde Ch., August 25.
712
PRACTICAL NOTES.
[September 26,
Abortive Treatment of Coryza. — Lermoyez orders a snuff made
of hydrochlorate of cocain, 50 centigrams ; menthol, 30 centi-
grams ; salol, 5 grams ; boric acid, 20 grams. A large pinch of
this snuff, finely pulverized, every hour. Or a spray of a tepid
and boiled solution of hydrochlorate of cocain at 1 per cent,
every two or three hours. He also recommends a snuff powder,
slightly antiseptic but not irritating, made of hydrochlorate of
cocain, 50 centigrams ; menthol, 25 centigrams ; salicylate of
bismuth and sugar of milk, each 5 grams. Brand's method is
to wet a piece of blotting paper every hour with 10 drops of
the following mixture : Pure phenic acid and liquid ammonia,
each 5 grams ; alcohol at 90 degrees, 10 grams ; acq. dest. , 15
grams, and inhale it a few seconds. — Gaz. Mid. de Liige,
August 27.
Vaselin in Erysipelas. — Koester has been using vaselin in ery-
sipelas for three years and studying its effects as compared
with other remedies. He announces now that it is fully as effica-
cious as the rest, the fever lasts no longer, the lesions extend
no more and the complications occur with no greater frequency.
It is therefore much to be preferred, as it is so simple, and has
none of the inconveniences inevitable with toxic and irritating
substances. — Revue Int. de M. et de Ch., August 25.
Maragllano Serum in Tuberculosis.- The Gaz. degli Osj). e delle
Clin, of Milan, is constantly publishing reports of the results
of treatment of tuberculosis with the Maragliano serum, and
one cure after another is described, although the concession is
made that the cure like the disease itself, is slow. The
graphic reports certainly establish the fact that the fever dis-
appears with the use of the serum, and Prof. Massei concludes
a recent address on the subject with these words : "The dizzy
rate of progress at this end of the century in all that regards
therapeutics is shaking up old bones and revealing new ideals.
Genius and perseverance have enabled Behring to cancel
Napoleon's denunciation of medical science as he stood. at the
bedside of his nephew dying of diphtheria : 'This terrible
scourge to humanity is a disgrace to science.' As an Italian,
as a physician, as a man, I prophesy that the anti-tuberculosis
serum is destined to as great a fate as the diphtheria antitoxin
and that the name of Maragliano will rank in time among
those of the great benefactors of humanity, Jenner, Lister,
Pasteur and Behring."
Radical Cure of Hydrocele. — Incision with partial removal of
the sac is to be resorted to when the sac is found to be thick-
ened, or where it protrudes far into the inguinal canal. A
modification of this operation is suggested, which it is believed
will greatly simplify the usual procedure : It is performed by
making a free incision over the long axis of the tumor, divid-
ing the structures down to the sac, at the same time being care-
ful not to open it. By means of an Allis's dry dissector, the
scrotal tissues are quickly separated from the tunic, which is
left slightly adherent posteriorly ; this being the portion of the
sac which covers the cord and is not disturbed. The sac is
then made tense, fixed by means of a tenaculum, opened by a
touch of the knife, and the fluid allowed to escape. The sac,
having been thoroughly dissected from the scrotal tissue, is
removed in a single piece by means of the curved scissors.
The bleeding vessels are ligated and the wound dried. Should
there be much hemorrhage from the edges of the cut sac, it
must be controlled by a continuous suture passing completely
over the margin. The portion of the tunica vaginalis lying
over the cord is swabbed with carbolic acid, the wound irri-
gated with 1 to 1,000 bichlorid solution, a small drainage tube
inserted, and the parts closed by silkworm-gut suture. An
antiseptic dressing is then applied. The drainage tube is
removed after twenty-four hours ; the sutures after the seventh
day. — Dr. Orville Horwitz, in Jour, of Cut. and Genito-Uri-
naryDis., September.
To Remove Fish Bones From the Throat.— Fish bones can some-
times be expelled from the throat by giving from four to six
ounces of milk, and forty minutes later an emetic dose of zinc
sulphate. The vomit of coagulated milk carries the bone
before it as a rule.- -General Practitioner, July.
Alcohol in the Treatment of Carcinoma. Dr. H. C. Howard
reports satisfactory results from hypodermic injections of abso-
lute alcohol, to which, if there is an open ulcerating surface,
is added from 15 to 25 per cent, of tannic acid ; this solution
is also employed as a dressing to the surface. Of carcinoma
of the breast he says: "I have employed this treatment in
ten cases. Nine of the patients recovered and are in good
health ; in one case secondary extension to the liver took place.
In these cases, it is my custom to pass the needle through and
below the tumor and during the retraction of the needle to
inject ten or fifteen minims of absolute alcohol into the tumor.
This injection is repeated in four or five points in the tumor.
The injections are repeated at intervals of two or three days
and the time required for the complete removal of the growth
is ordinarily about three months." Medical Standard, Sept.
Treatment of Hemoptysis. — Letters addressed to representative
physicians of Chicago, by Dr. Robert H. Babcock, request-
ing a statement of their treatment of pulmonary hemorrhage,
elicited twenty -seven replies from which the following summary
was tabulated : Eighteen insist upon absolute physical rest in
recumbent or semi-recumbent positions, and three added that
they permitted no talking. Cold to the chest is ordered by
thirteen, usually in the form of ice. Nine administer opium
and eight morphin hypodermically. Ergot is employed by
fifteen, a few however stating doubt as to its utility. One
administers Tancret's ergotin subcutaneously in doses of from
6 to 8 minims. Eleven are positive that ergot has no efficacy
in controlling pulmonary hemorrhage. Six make use of acetate
of lead, either with or without opium ; two, tannic acid ; two,
gallic acid ; one, dilute sulphuric, and another aromatic sul-
phuric acid. Six prescribe ipecac — five, the syrup, and one
the powder in an emetic dose after the manner of Trousseau.
Pour give aconite, and two veratrum viride. Salt is recom-
mended by seven, one of whom administers the salt freely,
either by the mouth in water or in the food, or by the rectum
(3J of salt to 3j of tepid water), or subcutaneously in the form
of a normal salt solution. Pour advise mild laxatives, but do
not specify the one employed, with the exception of the advo-
cate of salt, quoted above, who recommends phosphate of soda
because "of the physiologic fact that the phosphate present
holds the other salins in solution, thus making the common
salt taken more effective." One only employs sprays to the
larynx and trachea of solutions of "liquor ferri subsulphatis,
10 to 20 m. to gj, or the tincture of the chlorid of iron, from
20 to 30 m. to 3J of water, repeated three or four times daily.
One says he uses phenacetin internally, depending upon the
cause of the hemorrhage, and (after the attack) rest, light diet,
and tincture of iron internally. Two speak of employing liga-
tures to the extremities, close to the trunk, during the attack,
one specifying slight constrictions of the lower extremities to
prevent the return flow of blood to the lungs. Dr. Babcock
states that for the hemoptysis of active hyperemia, he quiets
the cough — preferably by phosphate of codein, J4 to '., grain
hypodermically, or % to 1 grain by the mouth ; prescribes
syrup of ipecac in frequent doses until nausea is produced ;
and orders an efficient but not severe aperient, preferably
Hunyadi or Rubinat water. If the hemorrhage arise within a
cavity and be profuse, he orders the immediate injection hypo-
dermically of one-fiftieth or even one twenty-fifth of a grain
of sulphate of atropin. This dose promptly produces pro-
nounced physiologic effects, but is not dangerous, and the
initial increase in the heart's rate and vigor is offset by the
vasomotor paresis occasioned, which diverts the blood to the
periphery. — Medicine, September.
1896. !
EDITORIAL.
713
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to await call.
SATURDAY, SEPTEMBER 26, 1896.
THE LANGUAGE OF MEDICAL TERMINOLOGY AND
MEDICAL CONGRESSES.
An Eastern medical weekly ( published at a center
cf culture with a university richly endowed in all its
departments) editorially endorsed the cant of an
English pedant against the use of Greek in medical
terminology on the ground that: "Even when scientific
coinages have been adopted into the language of the
people, it is not always certain that men of fair cul-
ture correctly analyze them into their original con-
stituents and real significance.'" This is clearly an
apology for the "fair culture" of the following review
of a "quiz compend" in the same number of this
weekly: "There is a tendency to the use of Latin
headings for familiar diseases which is to be depre-
cated, stomatomycosis for instance might well be
written "thrush' and 'coprostasis" might be simpli-
fied into 'lead poisoning.' " The "fair culture" which
could turn into Latin such familiar Greek as stoma-
tomycosis and coprostasis and could mistranslate the
last into "lead poisoning," is one evidently not pos-
sessed by the vast majority of regular (American)
physicians who, whether classically educated or not,
have a sufficient working etymologic knowledge of
Greek to avoid such blunders. The widespread nature
of this working etymologic knowledge of Greek, a
credit to the United States, argues for Greek as the
international medical tongue. The English medical
pedant, so admiringly quoted in the weekly of "fair
culture" aforesaid, argues against the growing use of
Greek in scientific terminology, with the futile British
cant crushed by Macaulay (seven decades ago when he
foresaw the conquest of Latin by Greek in scientific
terminology) with the following vivid logic {Edin-
burgh Review, February, 1826): "The vocabulary of
Latin is miserably poor, and its mechanism deficient
both in power and precision. The want of the defi-
nite article and of a distinction between the preterite
and the aorist tenses are two defects which are alone
sufficient to place it below any other language with
which we are acquainted. In its most flourishing
era, it was reproached with poverty of expression.
Cicero, indeed, was induced by his patriotic feeling
to deny the charge. But the perpetual recurrence of
Greek words in his most hurried and familiar- letters
and the frequent use which he is compelled to make
of them, in spite of all his exertions to avoid them, in
his philosophic works, fully prove that even this great
master of the Latin tongue felt the evil which he
labored to conceal from others.
"The Latin language is principally valuable as an
introduction to the Greek, the insignificant portico of
a most chaste and majestic fabric. On this subject
our confession of faith will, we trust, be approved by
the most orthodox scholar. We can not refuse our
admiration to that most wonderful and perfect machine
of human thought to the flexibility, the harmony, the
gigantic power, the exquisite delicacy, the infinite
wealth of words, the incomparable felicity of expres-
sion in which are united the energy of the English,
the neatness of the French, the sweet and infantine
simplicity of the Tuscan. Of all dialects it is the
best fitted for the purpose both of science and of
elegant literature. The philosophic vocabularies of
ancient Rome and modern Europe have been derived
from that of Athens. Yet none of the imitations have
ever approached the richness and precision of the
original. It traces with ease, distinctions so subtle
as to be lost in every other language. It draws lines
where all the other instruments of the reason only
make blots. Nor is it less distinguished by the facili-
ties which it affords to the poet. There are pages,
even in the Greek dictionaries, over which it is impos-
sible not to glance with delight. Every word suggests
some pleasant or striking image, which wholly uncon-
nected as it is with that wThich precedes or that which
follows, gives the same sort of pleasure with that
which we derive from reading the Adonis of poor
Shelley, or from looking at those elegant though
unmeaning friezes in which the eye wanders along a
line of beautiful faces, graceful draperies, stage char-
iots, altars and garlands."
With the nineteenth century evolution of science,
Greek, in the contest for existence in scientific term-
inology, conquered Latin (once the dominant lan-
guage of culture) as the fittest to survive. That this
victory of Greek will continue there seems no reason
to doubt. Greek owes its dominance in science not to
714
THE MICROBE AS A FACTOR IN EVOLUTION.
[September 26,
the cloistered scholar but to the working scientist for
the practical reasons laid down by Macaulay, whose
prophetic notions as to Greek have been more than
fulfilled. Greek has naturalized itself in every Euro-
pean tongue as the language of science; even German
terms give way to it in all but nativistic German cant.
It is an open question whether the very qualities
which render Greek of such value in scientific termin-
ology do not unsuit it for debate, which to-day seeks
expression in terse terms. The dominance of English
is due to its monosyllablic peculiarity, in which it sur-
passes all Caucasian tongues. The readiness with
which English, adopting loan words, modifies them to
its own terse grammatical forms, aids its progress. It
is intruding even on the French in France as witness
les "five-o'clockers" ( women attending 5 o'clock teas),
and la "struggle-for-existence." English orthography
and pronunciation are its chief defects. Here Greek
as a practically dead tongue (destitute of the shift-
ings due to evolution) has an advantage somewhat
offset by differences between British and European
continental pronunciation; differences daily becom-
ing less. Greek is not taught as a colloquial but a
literary language, which unsuits it for debate. French,
the language of diplomacy, as we have repeatedly
said, has the enormous advantage ( for medical con-
gress) of being a tongue in which foreigners under-
stand each other better than they do native French-
men. Italian has the great advantage of approxima-
tion to phonetic orthography, but lacks the terseness
and energy of French and English. German is
widely known as a literary tongue to medical scientists
but is involved and open to orthographic and pho-
netic objections. The difficulties in the way of one
language for medical congresses are such as can only
be removed by evolution. On this the growth of
English-speaking communities must exert an enor-
mous influence. The attempt to found a world lan-
guage (volapuk) on English by German philologists,
is a recognition of this influence which must increase
with scientific development in North America, Aus-
tralasia, South Africa and India. Greek will, how-
ever, remain the language of scientific terminology.
The international medical spoken language will take
many decades to produce and meanwhile international
medical congresses will probably continue to be
polyglot, notwithstanding the ease with which French
could be made available for these gatherings.1
THE MICROBE AS A FACTOR IN EVOLUTION.
The beneficent as well as maleficent microbe has at
last achieved recognition as a factor in human evolu-
tion, of which fact a recent review by Prof. E. Ray
Lankester of a work by a Mr. Archidall Reid
("The Present Evolution of Man," Chapman & Hall,
i See the Journal, Vol. XXV, p. 1065.
Language."
"The International Scientific
1896) in the September number of the Fortnightly
Review, is in evidence. Mr. Lawson Tait, many
years ago, wrote a paper showing that the law of nat-
ural selection appeared to be suspended in the case
of man, and Mr. Reid, independently recognizing this
fact, seeks to find the real agencies that take its place.
War, exposure, famine, the struggle with wild beasts,
all the elements that entered into the evolution of the
savage or primitive man are ineffectual now, and the
survival of the fittest must depend on other determin-
ing causes than those that so obviously prevail
throughout the animal kingdom. Mr. Reid finds the
chief desired factors in the germ diseases which are
now in all parts of the world producing changes and
a selective process " tending to the evolution of new
generations of men endowed with other qualities than
those possessed by the rejected of this agent." Tu-
berculosis, syphilis, and all the other civilized scourges
introduced among and decimating or exterminating
the native races of various portions of the world, are
there, as elsewhere, only culling out the unfit and
leaving their survivors in a higher, or better, or more
resistant stage of physical development. What we
have long called acclimatization is, according to this
author, only a synonym for evolution, and when applied
to races instead of individuals is solely the result of
the accumulation of hereditary inborn variations.
Whatever of truth there is in these ideas is not new
to the medical public, but as applied to evolution it
seems to have struck so eminent a biologist as Professor
Lankester as a novelty. We have long recognized the
fact that many non-self-protective infections appear
to produce a racial immunity, that familiarity with
them breeds a sort of physiologic contempt, and that
this is an important element in the adaptation of the
species to its special environment. But its relation
to general racial evolution or devolution has not so far
been a question of very great medical interest.
Disease germs are, however, not the only apparent
evils from which Mr. Archidall Reid sees beneficent
results to the race, he finds alcohol and opium also
elements in the improvement of mankind by their
selective action in removing the unfit from among us.
In this he is not original; the same idea has been
offered by others, notably, by Dr. Berry Haycraft
in his work, "Darwinism and Race Progress." Like
all other human vices or weaknesses these bring on
individual degeneration and weed out their victims,
but that any race becomes immune to their effects is
something that so far has not been satisfactorily
proven. The findings of the English opium com-
mission, which seem to be taken as gospel by the
author and his critic, as to the habituation of the
Indian races to opium, were too clearly "for revenue
only" and have been riddled by competent authority
in India itself. There has been as yet no such con-
venient authoritative government statement in regard
1896.]
SECOND STATE HOSPITAL FOR INSANE OF MARYLAND.
715
to alcohol ami his argument as far as this agent is
concerned rests only on assumptions.
The question of human evolution under present
OOnditions is. as Professor Laxkkster admits, a very
complicated one. and no single cause or series of such
ean be made to cover all the possibilities. The fact
that evolutionists are looking to medicine and pathol-
ogy for suggestions and theories which, while novel to
them, are familiar to the physician is worth a passing
thought.
THE SECOND STATE HOSPITAL FOR THE INSANE
OK MARYLAND.
Another pariah has been redeemed from opprobrium
as a soeial outeast. The bars and shackles which
restrained the sufferer with a mind diseased, have been
relegated to the scrap heap upon which thumb-screws
and branding-irons have been cast. The creature,
formed in the physical image of the Clod of the Uni-
verse, no longer wallows as swine, nor crawls on hands
and knees with the beasts of the field, chained by the
waist, like Nebuchadnezzar. The "lunatic asylum''
has given place to the State hospital, under the super-
intendence of medical men of the highest profes-
sional attainments. The higher medicine of the close
of the nineteenth century, which has made State
boards of health. State boards of medical examiners
and State licensing boards the arbiters of proficiency
and responsibility, has lifted the attending physician
of the asylum for the insane from the status of a sub-
servient to the steward, manager or executive officer,
by whatever title known, to the supreme control and
direction of the hospital in which the most pitiable
of afflicted invalids are sought to be restored to
health, or tenderly cared for when unable to care for
themselves.
The medical control of these institutions has
brought about a complete revolution in their adminis-
trative systems with new methods of hospital con-
struction. Dr. P. M. Wise's notable work in this
direction in the St. Lawrence State Hospital at
Ogdensburg, N. Y., upon which Governor Morton
has set the seal of approval by appointing him to the
head of the Lunacy Commission, is about to be
further developed in the Second State Hospital of
Maryland, for which the ground has only recently
been broken. To the enlightened and progressive
late governor of that State, the Hon. Frank Brown,
and his successor, the Hon. Lloyd Lowndes, the one
a democrat and the other a republican, and to an
enlightened and liberal General Assembly, in which
party lines and interests were for the time ignored,
is due the projection of an institution in which the
physician will have the untrammeled opportunity of
carrying to its highest possible development the mod-
ern rational view of the treatment of insane invalids.
When the necessity for accommodations for the
insane of the State, beyond the capacity of the hos-
pital at Spring Grove, near Catonsville, Md., which
was completed for occupation in 1872, compelled the
legislature to make provision either by the enlargement
of the existing institution or the creation of another,
it judiciously consulted the superintendent in charge
for the past five years, Dr. George H. Rohe, and
wisely determined upon a new establishment, and
after constituting a Governing Board of Managers,
consisting of the governor, State treasurer and State
comptroller, as ex-officio members, with six colleagues
to serve six years, two being renewed every second year,
intrusted to them the selection of a site and the deter-
mination of the character of the new institution. In the
matter of site they associated with them a professional
advisory board consisting of Dr. Rohe as chairman,
Prof. Henry M. Hurd, of Johns Hopkins Hospital,
and Dr. James F. McShane, health officer of Balti-
more, with regard to the sanitary and other require-
ments of the contemplated structure. The result has
been the acquisition of the Patterson estate of Spring-
field, an ancestral domain of 728 acres near Sykes-
ville, on the Baltimore and Ohio railroad, about thirty
miles from the city of Baltimore — an ideal locality for
the purpose as to elevation, diversified surface, abun-
dant water supply, drainage facilities, amount of
arable farm land, accessibility with isolation, well
wooded and traversed by rapid brooks discharging
into the Patapsco river, with an attractive landscape
and as equable climatic conditions as are to be found
within the State.
The old Patterson manor-house has been converted
into quarters for the superintendent, an annex wing
containing the senior assistant's and secretary's quar-
ters, offices, board rooms, visitors' rooms, store-rooms,
etc., pertaining to the general administration. The
distinctive professional feature of the new establish-
ment is to be the erection of independent groups of
hospital buildings, the number of these groups being
indeterminate and dependent entirely on the future
needs of the State. The several groups are to occupy
elevations at considerable intervening distances, and
each is to be complete in itself as to the accommodation
and care of its invalid inmates, the preparation of food,
messing, attendance, etc., with quarters for physicians
and attendants, the latter not being allowed to live in
the patients' buildings, where they are only when act-
ually on duty, and where they are consequently not
permitted to sleep or loaf. The first of these groups
is that now under construction on a hill about twelve
hundred feet east of the superintendent's quarters,
and consists of three detached pavilions and a fourth
or "service building." Each pavilion will contain
from fifty to seventy-five beds, with common living
rooms entirely apart from the dormitories, and a sig-
nificant departure has been made in the very large
proportion of general dormitory space to single rooms.
716
DISFIGUREMENTS OF SMALLPOX.
[September 26,
The practice of isolation is not to be encouraged.
The asylum notion is to be subordinated to the hos-
pital idea, the inmates being taught to consider them-
selves only as sick persons under treatment for remed-
iable ailments. Every inmate who can be employed
outdoors will be put to work at farm labor, or during
bad weather will be given occupation with others as
assistants in the kitchens, store-rooms, laundries,
stables and workshops, and all required to go into the
wash-rooms after their work and before entering the
dining or living rooms. During the summer they
will be required to bathe outdoors in an artificial lake
along with the attendants or a medical officer. The
pavilions are two-storied, and a most commendable
feature are the fire escapes — short, wide stairs com-
pletely inclosed by brick walls, large enough to empty
the several wards in two minutes. Two of the fire
escapes in each building are to be used frequently as
means of egress, in order to familiarize patients with
their purpose.
The first group of buildings is to be completed and
occupied before ground shall be broken for the second,
thus permitting improvements in plan, the desirability
of which experience may demonstrate, and a similar
course will be pursued with the third, fourth and as
many subsequent groups as may be required, the
extent and conformation of the grounds making this
possible. Thus it may be claimed that it is an insti-
tution that will never be completed while the proba-
bilities of advance and development exist, since in
the distant future, when the latest child shall have
outstripped the eldest, the latter may be demolished
to give place to a better.
When it came to be known that the patrimony of
one of the aristocratic families of the State was to
become a "lunatic asylum," the sentiment of the
neighborhood was outraged, many of the residents
being in real dread of the fancied dangerous element
coming among them. Curious visitors and tradesmen
after a while found the farm and tenant houses on the
estate occupied provisionally by persons whom they
supposed to be all employes, and only later discovered
to be chiefly lunatics — the dreaded "madmen," and saw
the customary operations of the cultivation of the ex-
tensive fields performed by men whom from their dress
they learned to recognize as wards of the State. Admi-
ration for the humane methods they saw in operation
followed upon the sense of security from possible dan-
ger from the crazy folk; the local dealers and shopkeep-
ers profited by the vicinage of a large able-bodied com-
munity, until now all classes are proud of the splendid
establishment which they foresee is to be one of the
most notable of its kind in the world.
We have felt it due to the profession that this
admirable and satisfactory consummation of the
modern idea of caring for the insane should be
made known by this brief sketch of its details,
looking upon it as a matter in which every member
of the Association should feel the highest prider
and as further illustrating the ability of medical
men to exercise administrative and executive func-
tions as well as the merely therapeutic and sanitary
duties of State and National establishments. This
has long been the practice in the United States Army
and Naval Hospitals, and the United States Govern-
ment Hospital for the Insane, although not many years
ago a retrograde attempt was made by the Navy to
transfer the executive control of these to officers of the
line, in face of the unsatisfactory working of this plan
in certain European services; but it is now so well
understood in this country by educated laymen legis-
lators, that the proper care of the sick involves some-
thing more than the mere administration of drugs,
and that the subject of expenditures for quarters,
food, fuel, light, clothing and attendance is a neces-
sary element of that care and is, therefore, the proper
function of the medical officer and one he can only
properly perform unhampered, that no fear need be
entertained that his right to do so will ever again be
questioned. Of this the prospective success of the
Second Hospital for the Insane of the State of Mary-
land, under its able, energetic and progressive super-
intendent, Dr. Rohe, in whom the State authorities
have shown their confidence by intrusting him with
its erection, development and control, gives additional
assurance.
THE DISFIGUREMENTS OF SMALLPOX.
In the last volume of the St. Thomas Hospital
Reports, Dr. Robert Cory contributes an interesting
line of proof as to the condition, as to vaccination, of
persons who are scarred by smallpox.
We are apt to forget how great a blessing vaccina-
tion is until an outbreak of smallpox opens our eyes
to the terrible nature of the disease from which the
labors of Jenner protected us. Even those who live
through the sufferings of variola not infrequently
bear traces of the attack in loss of sight or painful
disfigurement for life. Noticing the tendency to
belittle the value of vaccination, Dr. Cory commenced
in November, 1884, his investigations with the intent
of placing on record the result of his labors. In 1888
he had collected notes of 152 cases, which he pub-
lished in the "Transactions of the Epidemiological
Society " of that year. Up to the time of writing he
had collected 448, of these, 210 were admittedly
unvaccinated before their attack of smallpox, or
46.87 per cent., and these admittedly unvaccinated
people had smallpox at the average age of 6.58 years.
Continuing he remarks:
" This age is indeed high when compared with the
average age individuals were attacked with the dis-
ease in the last century ; however, there are three cir-
cumstances to be borne in mind. First, the greatly
1896.]
BOOK NOTICES.
717
diminished prevalence of smallpox in the present day
to that which obtained in the last century. It fol-
lows, therefore, that the opportunity to become affected
is accordingly not so great, and this would delay the
average age at which unvaceinated individuals con-
traet the disease. Secondly, a large proportion of the
unvaecinated individuals die of the disease, and these
would, in the main, be infants; hence, we have a con-
siderable portion of the youngest eliminated by death.
And thirdly, only those who have been obviously
pitted with smallpox are dealt with in this paper."
The editor of the Medical Press mid Circular,
thereupon offers the following comment:
Of those who professed to having been vaccinated
'I'.k II percent, had no scar of vaccination. And, as
a matter of fact 70.31 per cent, of those pitted by
smallpox bore no evidence of having been vaccinated.
Now, as Dr. Cory says, the proportion of the unvac-
einated to the vaccinated in London is not more than
f> per cent., yet we have seen that people pitted with
smallpox are to the extent of 52.51 per cent, un-
vaceinated. If there be no protective power in
vaccination, how can this be explained? We think
our readers will agree with the author of the paper
that vaccination is a marvelous preventive of
smallpox, and that his labors have done much to
demonstrate the fact.
CORRESPONDENCE.
Professional Complaints.
In a timely article of the Medical and Surgical Reporter.
with the above caption, the writer touches upon many points
which might be amplified almost into treatises.1 The inspira-
tion of the editorial is a symposium by six teachers in a con-
temporary popular magazine regarding the hardships of their
position in life, the emphasis being upon the monotony of their
vocation, inadequate pay and the influence of politics. Of the
first of these complaints, we are called upon to say but little
inasmuch as a grievance it is common to every pursuit ; of the
second, the complaint of our own profession, is entitled to more
consideration, while the third seems never destined to be
divorced from the growing paternalism of all institutions.
Our writer says very truly: "We believe there can be no
dispute that the professional class is too large. Our own pro-
fession numbers at least twice so many men as are needed to
care for the health of the country ; the legal profession, even
with its many collateral opportunities, is overcrowded, and a
considerable share of the clergy are a dead weight on society.
Jn professions like that of the teacher which can
be filled with comparative ease from without, candidates inev-
itably tend to become the puppets of outside politics and the
man who prefers to stand upon his own merits becomes unpleas-
antly aware of the pernicious tendency. On the other hand,
the professions at whose entrance greater barriers are erected,
like our own, or the ministry or the military are pervaded by a
tendency to the development of an intra professional intrigue
which perhaps gives rise to more feeling and has as great dis-
advantages as the methods often brought to bear to secure
advancement in the profession of pedagogy. Such things are
no doubt regrettable, but so long as the supply is greater than
i See also this Journal, August 8, " Medical Grievances."
the demand and the spirit of competition for mere place is so
keen there is no remedy."
By way of corroboration rather than addition, we may con-
tinue the subject with other pertinent reflections, chief among
which are the reports of absurdly lar^e incomes. These par-
take of the egotistic form and indirectly, as intended, furnish
pabulum for public gossip. A little analysisof the factors at once
exposes the fallacious statement. Every physician's duties
are more or less personal, in truth do not belong to the class
that can be made available by the labor of others. Here at
once is a limitation to anything beyond a mere living. The
temptation to embark in enterprises based upon the honesty of
promoter! is strong we know, but all faith in the childlike
hlandness of human nature is doomed to discomfiture. As
such the physician should content himself with his lot in life,
that of being " passing rich" upon a moiety, of taking the con-
sequences of what his business friends not unjustly style foolish
philanthropies, and in order to avoid the sneers of his brethren
wo might even advise him to cherish some variety of code in
secret. What else can he do but be content, he can not hope
for wealth, inasmuch as ho is destined to end his career, if long
enough, with a salary or sanitarium. But hold, virtue is its
own reward and the much quoted "room at the top" converges
into an apex upon which an equilibrium can with difficulty be
maintained. At all events, what one of all our host would enjoy
a solitude where our ambitions could be no better satisfied?
Umbra.
BOOK NOTICES.
Index-Catalogue of the Library of the Surgeon-General's Office, United
States Army. Authors and Subjects. Second Series, Vol. i.,
A — Azzuri. Washington : Government Printing Office. 1896.
This volume, according to Deputy Surgeon-General D. L.
Huntington, includes 6,346 author titles, representing 6,127
volumes and 6,327 pamphlets. It also contains 7,884 subject
titles of separate books and pamphlets, and 30,384 titles of
articles in periodicals. The value of the Index Catalogue to
medical science can not be over-estimated, and it is pleasant to
know that the work is appreciated in Europe as well as in
America. Congress, in making annual appropriation for this
work, has acted wisely.
The arrangement of the volume is the same as that of the
first series.
Tenth Annual Report of the State Board of Health of the State
of Ohio for the year ending Oct. 31, 1895. Columbus : 1896.
This volume shows that this Board is keeping pace with the
sanitary advances made in other States, but they are seriously
handicapped by being without any proper system of vital sta-
tistics. "No one," says the report, "knows the number of
deaths or the number of births that occurred in Ohio during
the past or in any other year. Thousands die and thousands
are born of whom no official record is made or can be obtained.
Crime is made easy, the settlement of estates and legacies dif-
ficult, and a study of the causes of death and means for their
removal impossible from the lack of such records." The
work is edited by Dr. C. O. Probst, the efficient secretary.
Food in Health and Disease. By I. Burney Yeo, M.D., F.R.C.P.,
Professor of Therapeutics in King's College, London. New
(2d) edition. In one 12mo volume of 592 pages, with 4
engravings. Cloth, 82.50 Philadelphia and New York :
Lea Brothers & Co., publishers. 1896.
This book, which for some inscrutable reason appears to have
been dipped in an indigo pot, is a valuable reference book for all
interested in practical dietetics. Indeed, it might be fairly
claimed for this study that every rational human being is prac-
tically interested in the subject, some of them intensely so. A
work therefore upon such a subject naturally has a very wide
circle of readers. Dr. Yeo has divided the work into two principal
parts, the first of which relates to the food in health, giving its
718
PUBLIC HEALTH.
[September 26,
nature, origin and purpose, classification, nutritive value and
uses of the different classes : Animal foods, vegetable foods,
beverages and condiments, et cetera. The second part treats
of food in disease, in general, and with reference to particular
diseases, artificial digestive agents, hospital dietaries, sterili-
zation and Pasteurization of milk, and concluding with select
recipes for invalid dietaries and a copious index. No general
practitioner can afford to be without a good work on dietetics,
and this of Yeo's takes rank with those of the higher order.
A Manual of Materia Medica and Pharmacology. Comprising all
Organic and Inorganic Drugs, which are and have been
Official in the United States Pharmacopeia, together with
important Allied Species and Useful Synthetics. For Stu-
dents of Medicine, Druggists, Pharmacists and Physicians.
By David M. R. Culbreth, M.D., Professor of Botany,
Materia Medica and Pharmacognosy in the Maryland College
of Pharmacy, Baltimore. In one handsome octavo volume
of 812 pages, with 445 illustrations. Cloth, 84.75. Philadel-
phia and New York : Lea Brothers & Co., publishers. 1896.
This work treats of official drugs ; those once official and
subsequently dropped ; allied species of organic drugs and the
unofficial synthetic compounds. The work is thus seen to cover
a somewhat different field from the ordinary work on materia
medica. Botany has been fully drawn upon in the descrip-
tion of medicinal plants, and the illustrations are superb. We
think the author has made a serious mistake in ignoring the
Centigrade thermometric scale and the metric system of
dosage. The author says this was not done to disparage the
metric system but because the old apothecaries weight is still
universally used. This will indeed be news to the Committee
on Revision of the Pharmacopeia. If all books were con-
structed on this principle no reform could ever be effected, or
any advance made in the methods of scientific knowledge.
We regret this the more as the step is deliberately taken in the
face of the movements now going on in Great Britain, and the
past decisive action of all our own scientific bodies.
From other standpoints the book can not be too highly
commended.
The Methodical Examination of the Eye, being part 1 of a guide
to the practice of ophthalmology for students and practi-
tioners. By William Lang, F.R.C.S., Eng. Cloth, pp. 96.
London and New York : Longmans, Green & Co. 1895.
This work was written for the instruction of the surgeon who
is beginning the special study of ophthalmology and as well for
students. It is well illustrated, and its teaching is sound.
A Pictorial Atlas of Skin Diseases and Syphilitic Affections, in
in photo-lithochromes from models in the museum of the
Saint Louis Hospital, Paris, with explanatory wood-cuts and
texts. By Ernest Besnier, Physician to the Saint Louis
Hospital, Member of the Academy of Medicine, President of
the Dermatological Society of France ; A. Fournier, Physi-
cian to the Saint Louis Hospital, Professor of the Faculty of
Medicine, Member of the Academy of Medicine ; Tenneson,
Physician to the Saint Louis Hospital ; Hallopeau, Physi-
cian to the Saint Louis Hospital, Member of the Academy of
Medicine, Professor agregre' of the Faculty of Medicine ; Du
Castel, Physician to the Saint Louis Hospital ; with the
cooperation of Henri Feulard, Curator of the Museum,
formerly Chef de clinique of the faculty at the Saint Louis
Hospital ; Secretary L. Jacquet, Medecin des Hopitaux,
formerly house physician to the Saint Louis Hospital,
secretary of the Dermatological Society of France. Edited
and annotated by J. J. Pringle, M.B., F.R.C.P., Assist-
ant Physician to the Department for Diseases of the
Skin at the Middlesex Hospital, London. London : The
Rebman Publishing Co., Ltd., 11 Adam Street, Strand.
Philadelphia, Pa. : W. E. Saunders, Publisher, 925 Walnut
Street. For sale by subscription only. Part 4. Price, 83 a
part.
The contents of this volume consist of four plates : Mycosis
Fungoides, Psoriasis, Tubercular Leprosy of the Face, Mycosis
Fungoides, and various illustrations accompanying the text.
We know of no work which will bring before the reader the
magnificent models in the museum of the famous Saint Louis
Hospital, so well as these. The coloring is very close to life
and is an aid to diagnosis alone; even without the explana-
tory text it would take the highest rank.
Hare's Practical Diagnosis.— Practical Diagnosis. The use of
Symptoms in the Diagnosis of Disease. By Hobart A mory
Hare, M.D., Professor of Therapeutics and Materia Medica
in the Jefferson Medical College of Philadelphia, Laureate of
the Medical Society of London, of the Royal Academy in
Belgium, etc. In one octavo volume of 566 pages, with 191
engravings and 13 full-page colored plates. Cloth, $4.75.
Lea Brothers & Co., Philadelphia and New York. 1896.
There are few medical subjects Dr. Hare has not written
upon, and his flowing pen not only ornaments the topics
touched, but he seems always to hit upon the most practical
way of conveying instruction. We recently had the pleasure
of noticing a work on diagnosis, in which chemistry of the nor-
mal and pathologic fluids, was made to assume the chief role
in diagnosis. Here we have a work in which semeiology, the
visible symptoms with which we are confronted, is made to
tell the story of the patient's pathologic condition, the natural
or Hippocratic method. The work is profusely illustrated and
the illustrations are fine. The title of the volume is not a mis-
nomer in this instance, for it is indeed a practical diagnosis.
An excellent index concludes the volume.
A Vest-pocket Medical Dictionary. Embracing those terms and
abbreviations which are commonly found in the medical
literature of the day, but excluding the names of drugs and
of many special anatomic terms. By Albert H. Buck, M.D.
New York : William Wood & Co. 1896.
This is truly a vest-pocket book, being 33-3 inches long, 2%
inches wide and 58 inch thick ! This little book will be found an
excellent one for student's use. There may be critics who would
object to see "Paget's Disease of the Nipple" defined as an
"eczema," or the statement that "pyo nephrosis" is a necessary
or common sequence of hydronephrosis ; and above all, students
should be taught the etymology of words used in medical
science, altogether omitted from this little lexicon. Neverthe-
less its form is most convenient, and it is destined to be
immensely popular. We therefore urge the author to include
the etymon of each word in the next edition.
PUBLIC HEALTH.
Typhoid in Kankakee (III. i Insane Asjlum. It is reported that
there are thirty cases of typhoid fever at the Illinois Eastern
Hospital. Impure drinking water is supposed to be the cause.
The Female Criminal and the Prostitute. — The new book with
this title eompletes Lombroso's remarkable work on the
"Criminal," which is already a classic in anthropology. It is
divided into several parts : The normal woman, the criminal
woman, anthropometric and pathologic anatomy, biology and
psychology of the female criminal.
Ontario Boards of Health Must act for Themselves.— The Ontario
court of appeals holds, in the case of Township of Logan v.
Hurlbut, decided in June, 1896, that, under the laws of that
province, where members of a local board of health allow a
person suffering fram an infectious disease to go into an adjoin
ing municipality, they are liable to repay to that municipality
moneys reasonably expended in caring for the sick person and
preventing the spread of the disease.
Ohio Law as to Public Buildings, Extended. — Section 2572 of the
Revised Statutes of Ohio has another time been amended, in
this instance extending the penalties which it denounces for
not providing proper exits, means for extinguishing fires, or
not having the required inspector's certificate relating thereto,
to the owner or person having control of any college, academy,
seminary, infirmary, sanitarium, children's home, or other
building used for the assemblage or betterment of people, in a
municipal corporation, or in a county or township of the State,
which county or township provision is also a new introduction
ISiHi.]
PUBLIC HEALTH.
719
to the section, and will equally apply to the owner or person in
control of a hospital, medical institute, asylum, opera house,
hall, theater, church, or school house, previously being the
persona mentioned in the law.
Tobacco and Cholera. A recently published report of investi-
gations of the effects of tobacco during the epidemic of cholera
at Hamburg states that there were no live microbes after
twenty four hours in the cigars made up with water containing
L, 600,000 cholera microbes to the cubic centimeter. There
wore no traces of microbes to be found in any of the cigars
manufactured at Hamburg during the course of the epidemic.
The microbes die in half to two hours exposure to tobacco
■moke, Brazil. Sumatra or Havana tobacco. The smoke of
any cigar kills the microbes. The smoke kills in five minutes
all the microbes in the saliva. Another fact established is that
none of the persons employed in the tobacco factories at Ham-
burg, aontraoted cholera.— Oaz. degli Osp. e delle Clin.,
August 20.
Typhoid Fever Cause by Ice Cream.— According to the Boston
Medico! and Surgical Journal, August 27, a considerable, but
not widely extended, outbreak of typhoid fever occurred dur-
ing the latter part of July in the town of East Barrington,
X. H. The cases were all traced to a single source. The first
case was an unrecognized one, the patient being unwell but
helping about the house and doing part of the milking. It is
supposed that he must have in some way contaminated the
milk, as by going to stool and not washing his hands before
returning to his milking. The water supply was carefully
examined and found to be all right. On Friday evening a
party was given at the house and the guests were given ice
cream made at home from the milk supply above referred to.
Within the next ten or fourteen days fourteen of the guests
came down with typhoid fever— eight in the town of Barring-
ton, of whom one died ; two in Lee ; one each in Dover,
Rochester and Woodbury, X. H., and one in Haverhill, Mass.
All of these out-of-town cases were guests at the party. No
other cases occurred in the town, and all were partakers of the
cream.
The Offensive Water-Supply of Brooklyn. The New York Times,
September 5. refers as follows to the water-supply of Brooklyn,
that has been the source of numerous complaints during the
past two months : "The people of Brooklyn will read with a
feeling of relief that the reports which show that at last both
the Department of City Works and the Health Department are
engaged in a thorough investigation concerning the condition
of the water supply. The engineers are inspecting the several
sources from which water comes, and the Health commissioner
has been authorized to spend a little money for the chemic and
bacteriologic analyses which are needed. The examination of
the water in the reservoir of final distribution seems to prove
that the supply has not been polluted at the sources, but is
affected injuriously after it has passed into the mains and
delivery pipes.
" In some parts of the city the water has been bad .for many
weeks. It may not have been loaded with the germs of the so-
called water-borne diseases, but it has been repulsive in appear-
ance and odor and clearly unfit to be used. It is probable that
the health of the people has suffered but little by reason of the
presence of the objectionable matter in the supply, but even if
this matter beonly a vegetable growth the accumulation of itin
a condition of decay should be prevented, because the presence
of it can not be beneficial and may be injurious to consumers.
With respect to the treatment of this problem there has been
inexcusable delay. It is admitted by the Department of City
Works that the water has been in this bad condition for about
two months. The facts now disclosed by recent inquiry might
have been ascertained some weeks ago.
They should be used
promptly and with energy now and the good name of the Brook- 1 fcine, In'aU branches7in"your State?
lyn water supply should be restored if an effective method of
purification can be devised."
The Mayor of Brooklyn has given to the Department of
Health, from the emergency account, the sum of $3,000 to be
expended Upon a survey of the water- sources, reservoirs and
conduits. It is behoved that the city authorities have been
awakened to the importance of a permanent bureau of water-
investigation— both chemic and bacterial— to be located upon
the water-shed, and at some distance from the city. It is the
estimate of those who are expert in the establishment of such a
laboratory that not less than 820,000 will be needed, in the first
year, for plant and running expenses. It is probable that this
grant will be made, and be placed in the hands of the Depart-
ment of Health.
Higher Education in Missouri. —State Superintendent of
Schools, John R. Kirk, who has just finished the examination of
applicants for admission to the medical colleges in the cities of
St. Louis, St. Joseph and Kansas City, has made his report
public. The examinations were carried on under the direction
of the State Board of Health and were the result of the agita-
tion last winter against the wholesale graduation of licensed
physicians who were incompetent to practice their profession
and were a menace to the public health. Although the exam-
inations prescribed by Superintendent Kirk were not severe
and were calculated to test the student's general information,
and did not require a technical knowledge of any of the branches
touched upon, over one-half of the prospective medical students
failed to pass them. On this account the outlook for a large
or even fair matriculation of students for the coming year is
very poor. Of the three cities visited by Superintendent
Kirk, only twenty-four applicants took the examination, and of
these only eleven succeeded in passing. Last year at this time
there were nearly 100 freshmen already admitted to the three
medical colleges in Kansas City alone. Dr. Willis P. King,
secretary of the State Board of Health, who has been more
instrumental perhaps than any other member of the board in
securing the new regulations, defended it with much vigor.
" I am heartily in favor of the new system," he said. "It
can not help but effect a great and beneficial change in the
present way of turning out incompetent doctors. We have in
this State between fifteen and eighteen so-called medical col-
leges. That is a third more than in the State of New York and
twice as many as there are in any other State. Our schools
have been like brick mills. All that was necessary was enough
mud, and the doctors were manufactured as fast as the
machines could be operated. I look for many of these little
institutions to close, for the licensing of young and incompetent
men to go out into the State and experiment on helpless citi-
zens is a crime and an outrage which I propose to try and stop.
There are too many incompetent physicians now, and the
rapid overproduction of them is alarming to one who knows
what butchery and death their ignorance can cause. The
State Board of Health will keep up its fight, and in time we
hope to rid the State of this class of practitioners."
Other States would do well to follow the example of Mis-
souri.
Medical Diplomas in Michigan.— A "great many inquiries are
received at the department of State in regard to the existence
of a law providing for the registration of physicians, and fre-
quent questions are asked as to the validity of certain diplo-
mas, issued without examination or residence, and ostensibly
entitling their possessors to the right to practice in Michigan.
As an example of this class of correspondence, the following
extract from a letter received by Secretary of State Gardner
from a Canadian attorney, may be quoted :
"Is it necessary for a physician to register with any State
medical association or council before he can lawfully practice
medicine in your State. Is the diploma of the Wisconsin
Eclectic Medical College, of Milwaukee, conferring the degree
of M.D. (without residence or examination), upon a pharma-
cist duly licensed by the province of Ontario, sufficient in and
by itself, to permit its holder to practice the profession of med-
720
SOCIETY NEWS.
[September 26,
The reply of Secretary Gardner contains information of
interest to the holders of fraudulent diplomas, as well as to the
county clerks who have in many cases registered them, suppos-
ing such registration compulsory under the law, although well
knowing the fraudulent character. The reply was as follows :
"Registration of diplomas is required only in the office of the
county clerk. No State board or council passes upon the val-
idity of diplomas. There is nothing in the law requiring or
authorizing a county clerk to register a bogus diploma, i.e.,
one issued without residence or examination. The act refers
to the 'graduate' (presumably in the usual sense), of any legally
authorized medical college, and elsewhere provides for the
return by supervisors of graduates of 'regularly established
and reputable colleges.' To this category the possessor of a
diploma issued by a fraudulent institution evidently does not
belong."
ASSOCIATION NEWS.
Section on Obstetrics and Diseases of Women.
Milo B. Ward, Chairman, Topeka, Kan. ; George H. Noble,
Secretary, Atlanta, Ga. : Executive Committee, Jos. Eastman,
Indianapolis, Ind. : P. H. Martin, Chicago, 111. ; J. T. Johnston,
Washington, D. C.
As an effort has been made to keep a mailing list of the mem-
bers of the American Medical Association interested in the
Section on Obstetrics and Diseases of Women, please be kind
enough to publish a notice to the effect that all members desir-
ing to participate in the proceedings or to attend the meetings
of this Section should send their names and addresses to the
undersigned, as no communication concerning papers, pro-
gram, etc., can be had with members not upon the proposed
list. Most respectfully,
Geo. H. Noble, Sec'y, 186 S. Pryor St., Atlanta, Ga.
Other medical journals please copy.
The Ophthalmologic Section Reprint.
Gentlemen desiring to subscribe for the reprint of the Oph-
thalmologic Section, 1896, will please send their names to this
office at once. Unless seventy-five subscriptions are received
the volume will not be printed.
SOCIETY NEWS.
Utah State Medical Society. — The second annual meeting of the
Utah State Medical Society will be held at Salt Lake City,
Utah, October 6 and 7. Program : Address of welcome, Hon.
Heber M. Wells, Governor of Utah ; The etiology and man-
agement of suppurating pleurisies, Philo E. Jones, Salt Lake
City ; Amputation of thigh for tuberculosis of knee joint, with
cases, H. J. Powers, Ogden ; When and how should the State
assume sanitary control in new settlements? Maj. A. C. Girard,
Surgeon U. S. A. ; Neurasthenia, R. W. Fisher, Salt Lake City ;
Auto-intoxication, Augustus C. Behle, Salt Lake City ; Sup-
purative Keratitis, S. L. Brick, Ogden ; A report of some cases
of skin grafting in the treatment of burns and ulcers, S. H.
Allen, Provo ; Lead poisoning, K. A. Kjos, Salt Lake City ;
Irregularities of typhoid, Chas. F. Wilcox, Salt Lake City ;
Evolution and revolution in pelvic surgery, H. D. Niles, Salt
Lake City : Hysterectomy, F. S. Bascom, Salt Lake City.
National Association of Nurses. — A convention representing
different training schools and alumnae associations, met
September 2, in order to organize an association of nurses,
which shall cover the United States and Canada. A constitu-
tion was drafted which will be submitted to the different
bodies represented for their ratification. The object of the
proposed association is to unite, protect and elevate the pro-
fession of nursing, and in drawing its outlines those of the
medical associations have been to some extent copied, and the
preamble of the American Medical Association largely
drawn upon. The training schools and alumnae associations
included in this convention were the Royal Victoria ; the
Toronto General ; the Massachusetts General ; the New Haven :
Presbyterian of New York City ; Bellevue, and the New York ;
the Brooklyn City ; the Orange Memorial ; the Pennsylvania ;
University of Pennsylvania, and the Philadelphia ; the Johns
Hopkins ; the Garfield ; the Rochester City ; the Illinois ; the
Farrand ; and St. Luke's, Chicago.
Virginia State Medical Society. — This society began its twenty-
seventh annual session at Rockbridge Alum Springs, Va., Sep-
tember 8-10, with a large number in attendance. The session,
was opened by an address of welcome from Hon. A. H. Graham,
of Texas, on the part of the Springs management. This was
followed by an address to the public and profession by Dr.
C. T. Brady of Marion, Va. His subject was "Moderation and
Aim in Education." The speaker dwelt with especial empha-
sis on the importance of universal temperance and the
avoidance of excesses in youth. Other interesting papers
followed. .The officers chosen for the ensuing year were Pres
ident, George Ben. Johnston of Richmond ; vice-presidents,
W. C. Day of Danville, T. W. Simmons of Martinsville, L. H.
Keller of Luray ; recording secretary, Landon B. Edwards of
Richmond ; corresponding secretary, Jno. F. Winn of Rich
mond ; treasurer, Richard L. Styll of Hollins. J. Allison
Hodges was elected to deliver the address to the public and
profession at the next annual session at the White Sulphur.
Dr. Hunter McGuire's prize of §100 for the best essay on the
status of serum therapy was awarded to Dr. Charles M. Black-
ford of Lynchburg.
Wayne County Medical Society. — At the regular meeting of the
Wayne County Medical Society, Thursday evening, September
10, Dr. R. Harvey Reed read a paper on "Malignant Neo-
plasms." The meeting was well attended. Dr. Theo. A.
McGraw, in discussing the subject, said : "The subject of
malignant neoplasms is such a large one that one hardly
knows where to begin in discussing it. It has been the pre-
vailing opinion, until very recently, that all of these troubles
arise exclusively from local conditions or local irritations, and
that there is nothing constitutional about a caDcer or sarcoma
or any other tumor in the beginning ; that is to say that what-
ever is constitutional is the result, not the cause, of the affec-
tion. I think that modern pathologists will hardly concur now
in the theory of the purely local origin of cancers and tumors
without being able, nevertheless, to closely define what there is
in all neoplasms that is constitutional. I believe that there
is something constitutional in every neoplasm or growth, not
only of a malignant form, but of a so-called local or benign
form, and that the origin in some way takes place directly from
the cells which compose it, and.that they begin to grow rap-
idly. I can conceive no other way to account for the growth
of any tumor unless there is that loss of control upon that part
of the organism so that the cells multiply and the part enlarges
and grows just so fast and no faster, in other words, the con-
trol which allows of tissue growth just sufficient to the needs
of the organism ; in the case of benign tumors the check on
multiplication is not so entirely lost as in some forms of malig-
nant growths. When we have a growth of any tumor, it means
that whatever it is that keeps away or retards growth in that
part, has been lost or has been weakened, so that my concep-
tion of a tumor is something constitutional. Now the Doctor
has described very well the different forms of malignant
growths to which we have to adapt our means of treatment.
The only treatment in my estimation is complete and thorough
extirpation. Toxin has been tried in malignant tumors of
every description in St. Mary's Hospital, and in private prac-
tice, and in no one case have we had any success whatever. I
was talking with some New York surgeons when we had them
here, and their report was that no one excepting Dr. Coley had
18W.J
NECROLOGY.
721
had any success with toxins in the treatment of malignant
growth*. Now I do not think just as Dr. Reed says, viz., that
there is one case in ■ hundred curable by this morbid treat-
ment, but the future may open up the possibility to us of
something good. As far as our present knowledge is concerned
there is just one thing to do with a malignant tumor, and that
is to extirpate it, and extirpate it thoroughly, and if there is
one need that modern surgery has now it is the perfecting of
radioed methods of operation. The surgeon does not see all
if cancer or sarcoma. Why, just takecancer of the neck
of the uterus and turn it over to the surgeon. He operates and
experts to cure his patient. The surgeon should always be
consulted in cases of malignant growths ; the sooner the better ;
the earlier the more chance for final cure and the saving of
life."
Dr. Hal C Wyman said : "I would like to call attention to
some successful methods and some unsuccessful ones. The
particular notion in regard to cancer, and I use the term in a
general sense, is that it is something that is to be helped by
some irregular or clandestine method or operation, and for that
reason quacks thrive. It is my belief that the regular physician
may accomplish a great deal by constantly preaching the abso-
lute necessity of early operation. If he will call up to the
minds of the laity or patients suffering from carcinoma or sar-
coma, that under modern methods of asepsis, and under anes-
thesia, the removal of these growths, when done early, is not
fraught with much danger to life, or with any pain ; in other
words, that the removal of these neoplasms, when done by a
scientific surgeon, is not essentially dangerous. If he will
bring out these facts prominently before the public we could
see these cases earlier and could have the privilege of remov-
ing tumors in time. The early removal of these tumors fre-
quently leads to their non-recurrence. Even when they reap-
pear a second time or a third time, or even a fourth time,
removal has finally been followed by non-reappearance. I can
see the necessity for the public to understand the need of early
operation, and if they would only realize the fact that under
anesthesia there is no pain and almost absolute safety, and
also that with asepsis the danger from the wound is only a
minimum, they would appear earlier for operation. So far as
the operation is concerned it may be performed, except in rare
without much danger, and it is the duty of every med-
ical man to use every means in his power to secure an early
operation. I am sorry that the profession is so at sea in regard
to the matter, but we may find something in the future that will
be of service to us. I can see the possibility of some anti-
toxin for cancer, like the diphtheritic antitoxin, and one which
may take the place of operation. I would not say one word
against the endeavor that is being made to find a cure. I
think when a physician allows one of these cases to leave his
hands and turns it over to the quack, he does wrong. I am
glad that we have a little hope in regard to the possibility in
the near future of the discovery of some toxin or antitoxin
which will prove curative."
Dr. R. Harvey Reed, in conclusion, said : "You are all well
aware of the fact that cancer and consumption have from the
most ancient times been looked upon by the laity as incurable,
and that is the reason why, as my friend, Dr. H. C. Wyman,
says, these patients go to the quacks, because the quacks hold
out luring inducements, the like of which we are not permitted
to advance on account of our medical ethics. I hope that
whatever I have said here to-night will stir up the profession
to investigate this matter, and above all means do not turn
over these cases to someone who knows nothing about hand-
ling them, and above all things do not allow them to go to the
so called quacks. It is the combined study, the combined
work upon these diseases, that helps us in the treating of them.
I believe that in the study of these diseases that we should, as
do our explorers of the North Pole, keep right on, no matter
what the result. In other words, keep right on till vou get
there."
NECROLOGY.
Charles H. Chalkley, M.D., at Richmond, Va., of inflam-
mation of the brain, September 13, aged 36 years. He gradu-
ated from the Richmond College and entered the Medical Col-
lege of Virginia, from which he graduated in 1880. Soon after
he became a physician, he was appointed adjunct professor of
chemistry at the Medical College of Virginia. He held this
position until the University College of Medicine was estab-
lished when he accepted the chair of chemistry and also became
professor of medical jurisprudence and toxicology, which he
held up to the time of his death. He also held the professor-
ship of chemistry at the Mechanics' Institute.
F. W. Hance, M.D., a pioneer physician of Freeport. 111., at
his home in this city September 16, of heart disease. He was
born in Ohio in 1822 and was graduated from the Medical
Department of the University of Pennsylvania in 1849. He
came to Freeport in 1853. He was elected mayor of the city in
1861 and also served as president of the Second National Bank.
D. J. Mosher, M.D. (Detroit Medical College, Mich., 1869),
at Norwich, N. Y., September 8. Orin M. Ward, M.D.
(Bellevue Hospital Medical College, New York City, 1877) at
Duncan Falls, Ohio, September 14, aged 45 years.
James Edgar Chancellor, M.D., at Charlottesville, Va.,
September 11. He was descended from a long line of Americans
of English descent— the lineage running back to 11)66. When
Gaultier le Chancellor, as law officer of the crown, crossed over
to England with William the Conqueror, as his chief legal
advisor, the surname of Gaultier was dropped and it came by
successive changes to be written Chancellor. From this fam-
ily the name of the town of Chancellorsville is derived, a town
made famous by the sanguinary conflict which took place there
during the recent civil war. Dr. Chancellor was born in Chan-
cellorsville, Va., Jan. 26, 1826; was educated at the classical
Academy at Fredericksburg, Va. ; matriculated as a student
of medicine in the University of Virginia, session 1846^17, and
graduated from the Jefferson Medical College, Philadelphia,
1848. Immediately after graduating he entered into an active
practice, locating in his native county, at Chancellorsville.
Subsequently he removed toCourtland, the county seat, where
he enjoyed a large practice up to the outbreak of the civil war.
In 1861 was commissioned assistant surgeon in the Confeder-
ate Army, and assigned to duty at the General Hospital, C. S.
A., at Charlottesville, Va. ; was commissioned full surgeon in
1862. In the spring of 1864 he was sent to the battle fields of
Wilderness, Spottsylvania Court House, and Richmond, as a
member of the reserved corps company of surgeons.
In October, 1865, he was made demonstrator of anatomy in
the Medical Department of the University of Virginia, which
position he filled until shattered health, from a dissecting
wound, necessitated his resignation in 1872. He was a member
of the Medical Society of Virginia since 1871, and its president
in 1883; permanent member of the American Medical Asso-
ciation since 1875, and the American Public Health Associa-
tion since 1878. In 1885 he served as professor of diseases of
women and children in the University of Florida at Tallahassee,
and also filled the chair of anatomy in the same school ; he
resigned both chairs and, returning to Virginia, was' appointed
by the governor a member of the State Medical Examining
Board in 1890. He has made frequent contributions to the lit-
erature of his profession, among which are named " An exhaus-
tive paper on the origin and use of natural mineral waters of
the United States;" "Ancient medicine, its history, etc.;"
" Cremation and inhumation compared ;" " Uses of iodoform
in specific diseases;" "Removal of fibroid growth involving
right parotid gland," 1863.
William Henderson Wilkes, M.D., died in Waco, Texas,
August 14. He was born in Raymond, Miss., in 1833, and
722
MISCELLANY.
[September 26,
enlisted in the Confederate Army as a private, from which he
was retired with the rank of Brigadier-General. In 1868 he
began practice in Waco, where he remained with the interval
of a year during which he was a professor of obstetrics and dis-
eases of children in Kansas City. In 1882 he was elected mayor
of his city, and in 1885, was reelected. In 1888 he declined the
chair of the theory and practice of medicine in the Texas Med-
ical College in Galveston. In 1891 he became president of the
Texas State Medical Association. In April of the present year
he again became mayor of Waco, and died in office after an
illness of six weeks. He was a graduate of the University of
Nashville in 1855.
William M. McLaury, M.D., at New York City, September
8, of cerebral hemorrhage. He had been in poor health for
some time. Dr. McLaury was graduated from the University
of the City of New York, Medical Department, in 1860. He
was a member of the New York County Medical Society, the
Academy of Medicine, the Physician's Mutual Aid Association,
the Northwestern Medical and Surgical Society, New York
Society of Medical Jurisprudence and New York Academy of
Anthropology.
William Cranch Bond Fifield, M.D., at Boston, Mass., of
heart disease, September 10. He was born Aug. 27, 1828, in
Weymouth, Mass. His family traced its ancestry beyond even
early colonial days to England, where it gave the name to the
town of Fifield. He was a graduate of Phillips Exeter Acad-
emy and of the Harvard Medical School in 1851. He went to
England and took the full course in the Royal College of Sur-
geons. He was a licentiate of the Royal Ophthalmic Hospital
and a member of the American Medical Society of Paris. From
the beginning of his practice in Boston over forty years ago he
took a high position in the profession. For fifteen years he
was on the staff of Boston City Hospital and was on the con-
sulting staff at the time of his death. He had also long been
a fellow of the Massachusetts Medical Society.
Edward S. Farrington, M.D., at New York City, September
7, aged 31 years. He was educated at Yale, and was a gradu-
ate of the College of Physicians and Surgeons of New York,
class of 1892. Dr. Farrington was connected with the outdoor
work of Bellevue and New York Hospitals.
William R. Bricker, M.D. (Medical Department of the
Western Reserve University, Cleveland, Ohio, 1857) at Shelby,
Ohio, September 7. He was among the oldest citizens of
Shelby, practiced his profession there over 50 years, having
celebrated his 51st anniversary September 5. He was born in
Schaefferstown, Pa., October 6, 1820.
Alexander H. MgAdam, M.D. (Department of Medicine of
the University of Pennsylvania, Philadelphia, 1863) at Phila-
delphia, September 9, aged 57 years. He was, for seven years,
physician of St. Mary's Hospital, and since 1869 had been
prominently connected with educational matters in Phila-
delphia.
William M. Kelly, M.D. (Medical College of Indiana,
Indianapolis, 1870), at Knox, Ind., August 28.
MISCELLANY.
For the Deaf and Dumb of Ohio. -The law has been amended so
that it now provides that no person shall be received in the
institution for the education of the deaf and dumb of that
State under 7 (instead of 8) yearsof age, or remain there longer
than twelve (instead of, as heretofore, ten) years.
The Megaloscope.— The Ungarisches Arehiv f. Med. No. 3,
describes an instrument constructed on the principle of the
telescope which magnifies the objects shown by the endoscope.
The illustrations are specimens of the work of the megaloscope
showing the finest details of various sections, urethritis granu-
losa, etc., in the natural tints. — Wien. k. Rund., No. 33.
Ohio Charitable Societies Can Sell Real Estate. Section 3,794 of
the revised statutes of Ohio, providing when and how religious
societies may sell, exchange, or mortgage their real estate,
whether held in trust or not, has been amended, among other
respects, by extending its application to any charitable society
or association, and this whether the trustees are willing to take
steps in the matter or not.
Contrast Staining. Bacteria and cell-nuclei can be different-
iated rapidly and easily by first staining the prepared dry sec-
tion with a diluted watery solution of methylene blue, then
rinsing it in water and after drying, placing it in a watery
solution of eosin, 0.1 to 100, for one minute to a minute and a
half. The eosin drives out the blue and takes its place in the
tissues, while the bacteria retain the blue longer. This method
is recommended in the Deutsch. med. Woch., August 20, as
exceedingly simple and sufficiently accurate for general
purposes.
Ink for Writing on Glass.— Nouveaux Remedes, August 24,
describes a new ink that will write on glass, and can take the
place of paper labels on bottles, etc., as it is indelible. It is
made by dissolving 20 grams of brown lacquer (not heated i in
150 c.c. of commercial alcohol, and mixing this, a drop at a
time, with a solution of 35 grams of borax dissolved in 250 c.c.
of distilled water. It can then be colored as preferred ; 1 gram
of methylene violet, for instance, will produce a handsome ink.
A Child in Legal Definition. I n a case brought under a statute
"for the prevention of cruelty to children," the supreme
court of Georgia holds, Collins v. State, that the word " child"
as used therein, means one of tender years, or a person between
infancy and youth, and that a male person who has attained
the physical strength and stature of manhood, and who is
"almost as large as his father, but not quite as strong," is not
a " child," in the sense in which the word is used in such law.
Confirmation by Bacteriologic Diagnosis of Epidemic Cerebro Spinal
Meningitis. When Heubner announced his discovery on the
living of the microbe of this disease, he remarked that lumbar
puncture would become still more important as a means of
differentiation. Ftirbringer now reports several cases diag
nosed by lumbar puncture promptly and accurately, with the
discovery of the meningococcus intracellularis in the spinal
fluid. The cultures showed the characteristic diplococci
enclosed in the capsules which refracted the light like a halo
around them. The cocci were often assembled in four, six and
eight pairs, especially in the older cultures. The median
dividing line in the pairs of cocci forming tetrads was very dis-
tinct and noticeable. Gram's solution usually decolorized them
like the gonococcus, but occasionally the microparasites partially
retained their coloring. — Deutscli. med. Woch., August 20.
New Jersey Law as to Indigent Insane Amended. The New
Jersey statute of 1895, respecting hospitals for the insane and
the admission of indigent patients thereto, was amended by an
act approved March 26, 1896, omitting, in the first part of Sec-
tion 1, the clause apparently tending to restrict its application
to any county "in which there is a hospital for the insane,"
and providing that application for an investigation of a case
may be made not only to any judge of the court of common
pleas in such county, as heretofore, but also to any judge of a
criminal court established in a city of the first class in such
county, while police justices are deprived of jurisdiction.
Provision for Ohio's Aged Deaf and Dumb. — A law was passed in
Ohio, April 27, 1896, providing that any incorporated associa-
tion organized for the purpose of providing a home for aged
and infirm deaf and dumb persons may enter into a contract
with the board of county infirmary directors of any county for
the care and maintenance at such home of any aged or infirm
deaf and dumb person who may be an inmate of the county
infirmary or who may, under the laws of the State, be entitled
tS%.]
MISCELLANY.
723
to admission thereto. And in every such case the county in
which such infirmary is situated shall, during the period such
pnoa may remain in such home, pay to such association,
annually, a sum equal to the per capita cost of maintaining
inmataa in the infirmary of such county.
Decision Relative to License to Practice In Colorado. Attorney
General Carr has recently decided thiit the State Medical
Hoard of Colorado has no right to revoke a license to practice
except after conviction of some penal offense. Denver Mul.
Times, September.
Improvement in Transportation of the Wounded. —Meyer of Ber-
lin, has invented a new spring floor for ambulances which
oo four rubber balls lx.: cm. thick and 12'.. cm. in diam-
eter. The balls are tilled with air and held in place by bowl
shaped rests above and below fitted with springs. There can be
twn of these floors, one above the other to secure extra elas-
ticity, ikulsrli. nied. H'(i(7/.. August 20.
Traces of Poisons in Normal Urine.— Kossa accidentally noticed
indications of poisons in normal urine, and further investiga-
tions confirmed this experience, disclosing traces of arsenic,
copper and mercury in the urine of numerous healthy individ-
uals examined. He is inclined to think that these substances
are not totally eliminated by the organism, and that in time
the accumulated amounts might have an important bearing in
certain medico-legal cases.— -Wien. hi. Rund. No. 33, from the
I'ngtir. Anii. f. .1/. '.. No. 3.
Petroleum from Linseed Oil. The paper read by Professor
Sadtler at the recent A. Ph. A. meeting was a record of some
very interest hit; experiments upon linseed oil. It was shown
that by subjecting this oil to destructive distillation, under
pressure, various products identical with certain petroleum
hydrocarbons can be produced. This fact is of greater signifi-
cance than is at once apparent. It bears directly upon and
affords proof of one of the two theories regarding the origin of
petroleum. These theories are, one that petroleum is of ani-
mal, the other that it is of vegetable origin. Possibly both are
true. Without discussing the theory of animal origin, Pro-
fessor Sadtler's results would seem to prove the theory of vege-
table origin. Plmrm. Era, September 10.
Ohio's New Electrocution Law. — By law passed at the recent
session of tlie ( >hio legislature, the mode of executing a death
sentence must, in every case, for a crime committed after
July 1, 1896, be by causing to pass through the body of the
convict a current of electricity of sufficient intensity to cause
death, and the application of such current, it says, must be
continued until the convict is dead. This must be done by the
warden of the Ohio penitentiary, or by a deputy, not only
within the walls of the penitentiary at Columbus, but also
within an inclosure so constructed as to exclude public view.
Moreover, all such executions or electrocutions, must take
place before the hour of sunrise of the designated day.
Healing of Wounds among the Negroes of Africa. — A surgeon
writes to the Deutsch. vied. Woeh., August 20, from Kamerun,
expatiating upon the almost miraculous way in which the
wounds of the negroes there heal without complications. He
describes a dozen cases of severe wounds, among them five
received while out on an expedition, compelled to march
through pouring rain with no food but wild bananas, and
exposed to the constant fire of the natives at close range, the
bullets often nothing but scraps of iron so that the wounds
resembled those made by an explosion, and with no surgical
attendance for twenty-one days, as it was not a military expe-
dition. The recoveries were rapid and complete with no com-
plications : in some cases a surprising lack of sensitiveness in
the parts woUnded. He is inclined to ascribe this extreme
power of reaction to a race peculiarity, as the absence of wound
infecting bacteria in the primeval wilds is not absolutely estab-
lished, although they must certainly be rare. In fifteen
months of residence there he has never heard of such a thing
as puerperal fever, and has only had one phlegmon in 906
patients treated. He remarks in conclusion that the surgeon
in West Africa is certainly justified in proceeding with the
utmost audacity in the conservative treatment of his black
patients.
Russian Jury Discounts Expert Testimony. — In a recent case
where a young wife admitted killing her husband, it was
brought out that she had a sister who evinced a sudden aver
sion to her husband on the night of her marriage, and, there-
after being placed under medical observation a report was
rendered by the expert that she had probably committed the
crime while suffering from the psychologic equivalent of epi-
lepsy, it being observed that she frequently suffered from such
complete absences that she did not recognizo those around her
and that in these instances there was a complete failure of the
reflex action of light upon the eye ; yet, nothwithstanding this
expert testimony, she was placed on trial by jury, convicted
and condemned.
Ohio Institutions to be Inspected. An Ohio law was passed in
April, 1896, which provides that every private or public hospi-
tal, reformatory home, house of detention, private asylum and
any institution exercising or pretending to exercise a reforma-
tory or correctional influence over individuals in the State of
Ohio, shall be open at any and all times to the inspection of the
commissioners of the county in which such institution is situa-
ted, or the board of health of the township, or other munici-
pality in which any such institution is situated. It also makes
it the duty of each and every county commissioner to visit,
unannounced, every such hospital and other institution in his
county at least once in every six months, to note the sanitary
condition thereof, and the condition and treatment of the
inmates thereof. And it shall be the duty of the county com-
missioners to file a full and complete report of the investiga-
tions of such institutions with the prosecuting attorney of the
county, which report shall be open to the examination of the
public. Any official agent or employe, or other person refus-
ing to permit or in any manner interfering with the inspection
of any such hospital or other institution, by the county com-
missioners of the county, or by the board of health of the
municipality in which the same is situated, shall be deemed
guilty of a misdemeanor, and shall, upon conviction, be pun-
ished by a fine of not less than $25, or six months' imprison-
ment, or both, and for each subsequent offense a fine of not
less than $100 and six months' imprisonment.
The Peppermint King— According to the Chemist and Druggist,
July 25, Mr. H. G. Hotchkiss of Wayne County, New York,
bears appropriately the above title. About fifty years ago
that gentleman kept a store at Phelps, near the Wayne County
line in the peppermint belt. Mr. Hotchkiss had taken pep-
permint oil from farmers in payment for goods until he had
on hand so much of it that he would lose money if he could
not dispose of the lot for 81,000. The problem was to find a
market for all that oil from an unknown peppermint-producing
district. He put his oil in tin cans and took it to New York
City. None of the drug houses would buy it, because they
did not believe that it was pure. This emergency brought
the business ability of Mr. Hotchkiss to the surface. The
now old-fashioned 21 ounce, lipped ink bottles had just come
in and Mr. Hotchkiss purchased a lot of them, removed his
peppermint oil from the tin cans, and after satisfying himself
that it was as pure as any oil then on the market, placed it in
the bottles, hermetically sealing them, and consigned the oil
to a house in Hamburg, naming his price if the oil was
accepted. At the end of several months' waiting Mr. Hotch-
kiss received a draft for the amount he had asked for his oil
and an order from the Hamburg house for another consign-
724
MISCELLANY.
[September 26, 1896.]
ment. Most of the oil was sold back by the German firm
to the dealers in New York who had refused to have any-
thing to do with it when Mr. Hotchkiss offered it to them
at first hand. The demand for Wayne County oil grew so
rapidly that the cultivation of peppermint became the chief
occupation of the Wayne County farmers. Mr. Hotchkiss
gave up all other engagements and devoted his whole atten-
tion to the growing and distilling of peppermint. The aver-
age annual yield of peppermint oil in Wayne County is now
15Q.000 pounds, nine-tenths of which is controlled by the
Hotchkiss family of Lyons. Mr. Hotchkiss still packs the
Wayne County oil in bottles made after the exact pattern of
the bottles in which his original shipment to Hamburg was
packed in 1844. For years the Wayne County oil was con-
sidered by the trade superior to all others, but the distinc-
tion between Wayne oil and Michigan oil has now been
dropped from most of the New York price lists.
Are Deaths from Anesthetics due to Failure of the Respiration or
of the Circulation. — Despite the dicta and the experiments of
Surgeon-Colonel Lawrie of the British army to the effect that
the breathing claimed the undivided attention, the London
Lancet has been engaged in a series of exhaustive inquiries.
The members of its commission have investigated 716 deaths
from chloroform.
The report presents three series of cases : Series A, derived
from the report of the Committee of the Royal Medical and
Chirurgical Society, contains 86 cases of death under chloro-
form ; series B, derived from an analysis of the fatalities
recorded between the years 1860 and 1891 in various British
and foreign publications, contains 596 cases, and series C,
derived from the inquiries made by circulars, contains 27 cases
from hospitals and 7 from private practice. All these were
carefully examined in such a way as to eliminate, as far as pos-
sible, the personal belief of the examiner, and to preserve only
what had been placed on record by competent persons who
were present when death occurred. According to this testi
mony, in the 716 deaths from or during the administration of
chloroform, the pulse was observed to fall first certainly in 183,
and propably in 44 more, or more than 31.5 per cent. The
respiration was noted to fail first in 73 cases, and probably in 7
more, or only about 11 per cent. Both functions are said to
have failed simultaneously certainly in 58 cases and probably
in 19 more ; and in 322 the point was not noted with sufficient
accuracy to justify the statement of any conclusion. But the
fact remains that, in nearly one-third of the whole number of
fatalities, the recorded opinion of those present was in favor
of the result having been due to the failure of the heart rather
than to failure of the respiration. It is pointed out, also, that
experiments on animals are apt to be misleading, because the
subject selected would usually be healthy, while most human
subjects in the operating room are diseased. It is suggested,
also, that deaths during surgical operations not of a severe
kind sometimes occurred before the discovery of anesthetics
and were vaguely attributed to shock. The cause, whatever
its nature, probably still exists, and its victims are charged to
anesthetics. The objection to ether as an anesthetic by most
English surgeons has been based chiefly upon the slowness
with which it operates and the distress which its administra-
tion causes to many patients. Both these disadvantages have
now been overcome by combining nitrous oxid with the ether
fumes until unconsciousness is produced. Instead of the ether
cone an apparatus similar in some respects to that in a well-
equipped surgeon dentist's office is employed. The patient
breathes easily into the mouthpiece, the first three or four
inhalations being of the gas alone. The ether fumes are gradu-
ally substituted. In two minutes the patient is unconscious,
and there is no choking or distress such as the ether alone often
produces. The latest report upon the possible dangers of
chloroform is likely to lead to the rapid introduction in this
country of this new and safe form of anesthesia.
To Recover Medical Expenses. In cases of personal injury of a
plaintiff through the negligence of a defendant, the supreme
court of California says that there is no doubt but that, under
a proper pleading, the injured party may recover for such
necessary medical expenses as he may have become liable to
pay though not in fact paid before suit brought. But the alle
gation of the complaint must correctly describe the expense as
to being one that had been paid or simply incurred. Thus,
the court reverses, in McLaughlin v. San Francisco & S. M. Ry.
Co., decided July 31, 1896, a judgment for the plaintiff, hold-
ing that evidence that the plaintiff had incurred a liability to
pay $750 was not admissible under the allegation of his com-
plaint that in attempting to be cured he had necessarily ex-
pended, in doctor's bills, the sum of §750.
Hospitals.
The Virginia Hospital, Richmond, Va., which has under-
gone most extensive repairs and improvements, after having
obtained a handsome and commodious addition, is receiving
patients again, after having been closed since July 1. The
entire building has been remodeled, and taken in connection
with the commodious "John Pope Annex" just completed,
makes this one of the most modern and best equipped hospitals
in the South.
New York Floating Hospital Work.— There were 46,253
women and children carried on the Floating Hospital during
the season of 1896. More than seven hundred cases of severely
sick children were treated in the wards without a death taking
place on board.
THE PUBLIC SERVICES.
Army Changed. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Sept. 12 to Sept. 18. 1896.
Captain William B. Davis, Assistant Surgeon, is relieved from duty as
Attending Surgeon and Examiner of Recruits in New York City, to
take effect upon the completion of his examination for promotion
and ordered to Fort Brady, Mich., relieving Captain Charles Rich-
ard, Assistant Surgeon. Captain Richard, upon being thus relieved
is ordered to New York City as Attending Surgeon and Kxaminer of
Recruits.
Captain Louis Breehemin, Assistant Surgeon, is relieved from duty as
Attending Surgeon and Examiner of Recruits. Baltimore, Md., to-
take effect on completion of his examination for promotion, and
ordered to Fort Sherman, Idaho, for duty.
Captain W. Fitzhugh Carter, Assistant Surgeon, will be relieved from
duty at Fort Sill, Oklahoma Territy. Oct. I, 1886, and ordered to
Baltimore, Md., as Atte ding Surgeon and Examiner of Recruits.
First Lieutenant William E. Purviance, Assistant Surgeon, is relieved
from duty at Fort Sherman, Idaho, and ordered to Fort Columbus,
New York, for duty relieving First Lieutenant Thomas J. Kirkpat-
rick, Jr.. Assistant Surgeon. Lieutenant KIrkpatrick, on being thus
relieved, is ordered to Fort Douglas. I'tah, for duty relieving First
Lieutenant George D. DeShon, Assistant Surgeon. Lieutenant
DeShon, on being thus relieved is ordered to Washington Barracks,
D. C., for doty.
Navy < nangreH. Changes in the Medical Corps of the U. S. Navy for
the week ending Sept. 19, 1896.
Medical Inspector Daniel McMurtrie, promoted to medical director
from September 8.
Surgeon L. G. Heneberger. detached from naval hospital Widow's Island,
Maine, ordered home, and then await orders.
Change of Address.
Brooks, 8. D., from St. Louis, Mo., to U. S. Marine Hospital, Port
Townsend, Washington.
Hull, Geo. 8.. from Chambersburg, Pa., to Pasadena, Cal., Box 176.
McGahan, C. F , from Bethlehem, N. H., to Aiken, S. C.
Pritchard, W. B., from 347 W. 58th street, to 106 W. 73d Street, New
York, N. Y.
Reichman, Max, from 624 8. Center Avenue, to 616 W. 12th Street,
Chicago, 111.
Woodbuiy. Frank, has returned to his office and residence at 218 8.
16th Street, Philadelphia, Pa.
LETTERS RECEIVED
Ayer, N. W. & Son, Philadelphia, Pa.: Alma Sanitarium Co.. Alma,
Mich.; Alta i'harmacal Co., St. Louis. Mo.; Allenburger, C. A., Shelby.
Neb.
Blodgett, F. J., New York, N. Yr.: Battle Creek Sanitarium, Battle
Creek. Mich.
Christopher, H., St. Joseph. Mo.; Cantrell, G. M. D., Little Rock, Ark.;
Cleaves, Margaret A., New York, N. Y.
Dussau, Auibel Eustace, New York, N. Y. ; Drevet, Mfg. Co., The, New
York, N. Y.
Ellis, W, H., Barron, Wis.
Freeman. Leonard, Denver, Colo.
Goss, E. L.. Sheffield. Iowa; Gutten. B. C, Oahkosh, Wis.
Hadenstein. I., New York, N. Y.; Hughes, C. H., St. Louis, Mo. ; Haugh-
ton, R. E., Richmond, Ind.
Johnson <fc Johnson, New Brunswick, N . J.
Kilbride, Thos. F., Ayrshire, Iowa; King, E. A.. Sweet Home, N.C.
Lnanoo Rubber Co., Boonton, N. J.; Laughlin Pen Co., The, New
Haven, Ind.
Musgrove.Thos. VV„ Fairhaven, Wash.: Merrick, M. B., Passaic, N. J.;
tlcNew, II. I... Honey Grove. Texas: Martens. E. J.. St. Louis. Mo.
Nolder. 8.M., Fairmount. Ind.; Noyes. Guy, L., Traverse City, Mioh.
Richardson, E. H., Atlanta, Ga.: Reyburn. J. A., Elkhorn. W. Va.:
Rawson, A. A.. Corning, Iowa; Reed & Carnrick, New York,N.Y\; Riley,
N. H., Boulder, Colo.
Straw, J. R., Ashland, Wis.; Shertzer. A. Trego. Baltimore, Md.;
Stearns. F. & Co., Detroit. Mich.; Seaman, Frank, New York. N. Y.; Small,
Freeman E., l'ortland. Me.
Tompkins, Christopher. Richmond. Va. ; Truax, Greene & Co., Chicago.
Vandervort, F. C, Bloomiugton. 111.
Wood, E. S.. Fairmount. Kan., Walton, Ernest F., New York, N. Y. ;
Willinghom, R. H., Niagara, Ky.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., OCTOBER 3, 1896.
No. 14.
ORIGINAL ARTICLES.
OTOMASSAGE- IN SUPPURATION OF THE
BAB; ITS VALUE FOR THE RELIEF OF
DEAFNESS AND IN THE TREAT-
M EXT OF THE SUPPURATION.
Kt-mt by title in tin' Section on l.nryiik'oloKy ami Otology. at the Forty-
seventh Annual Meeting of the American Medical Association,
held at Atlanta, Ga., May 5-8, 1886.
1-Y 1. Ol' IS J. LAUTENBACH, A.M., M.D., Ph.D.
Surgeon to the l'ennsylvaiiia i: ye and Ear Infirmary: Nose and Throat
I'hysieian to the Odd Fellows' Home; l.ate Chief of the
I v. Clinic of the German Hospital, etc.
FHILADKLPHIA, PA.
I" pon several occasions 1 have presented various
aspects of oto-massage, but, beyond having noted in one
of my papers that I considered the deafness occasioned
by suppurative disease of the middle ear peculiarly
favorable in its reaction to massage, I have not pub-
licly considered suppurative disease in connection
with the subject. I have often been asked the value of
the method in the deafness and tinnitus, the results of
suppurative disease. On expressing my opinion that
it was of especial value in both conditions, I have
naturally been lead to explain why this was the case.
In considering the value of massage in the treatment
of cases of suppurative disease or of the defects from
suppurative disease, the subject naturally divides itself
into two parts: 1, the consideration of its application
and value in cases undergoing suppuration: 2, its im-
portance in those in which the suppuration has ceased,
deafness being present with or without tinnitus.
Eliminating for the present all the acute suppura-
tive cases, those attended with extreme pain and
swelling of the parts, we will study a typical case of
chronic suppurative disease. It will present, in addi-
tion to the discharges, which may be meagre or pro-
fuse, watery or ropy, colorless, pustular or bloody, a
greater or less degree of deafness with or without tin-
nitus, accompanied usually by a full or swollen feel-
ing within the ear, with perhaps a little tenderness
and with occasional attacks of pain.
The usual treatment for such cases has been careful
cleansing of the meatus and middle ear, usually by
syringing with warm or medicated water, followed
occsionally by cleansing with peroxid of hydrogen
solution, and then after thoroughly drying the ear
with cotton and perhaps using the Politzer bag or the
Siegle speculum, or both, the insufflation of some
drying or absorbent powder, such as aristol, iodoform
or boracic acid. The ordinary mild cases are apt to
do fairly well under such routine treatment, especially
if it be persisted in, and they often develop a decided
improvement in hearing, as well as a marked diminu-
tion and, frequently, an entire cessation of the ear
discharges.
In contradistinction to this the" dry method is used
by many. The meatus is carefully wiped out with
cotton, after which, if a probe can be passed through
the perforation, the middle ear is cleansed as thor-
oughly as possible. Then by means of the Politzer
air bag and Siegle speculum, the discharges lying low
down in the ear are forced toward and through the
perforation in the membrane and the middle ear and
meatus are again cleansed with dry cotton, after which
drying powders are used.
An objection to be urged against the first method
above outlined is the syringing of the ear. In my
opinion this, in many cases, prevents the cessation of
the discharge; the water or medicated liquid finds its
way into the deeper parts of the ear and not being
removed, lies there and acting as a foreign substance,
excites irritation and inflammation in the surrounding
tissues and thus increases the amount of the discharge.
Of late, the dry method has come more and more into
vogue. It has the advantage of removing foreign
matters from the ear cavity without subjecting the ear
to the possible disadvantages of having the pus
replaced by other foreign particles. But both methods
fail in entirely removing the exudated materials from
the middle ear cavity — the former method washing
out much of the discharge and diluting the rest — the
latter removing considerable but allowing some of the
discharge to lie on the floor of the tympanum, as well
as leaving a layer of the discharge adherent to all the
surfaces and an especially large amount to remain in
the attic and on the ossicular structures. In these
cases to remove the discharges which otherwise are
irremovable I employ massage instruments, using
them as cleansers and dryers of the middle ear cavity.
To illustrate this method of using massage I will
briefly outline the treatment of an average case of
middle ear disease with suppuration. Finding that I
am dealing with a case of suppuration of the chronic
type, I dry out the meatus with a cotton-covered
probe and if the perforation in the drumhead be suf-
ficiently large to allow of it, I by the same means
cleanse the middle ear as much as I am able, then by
the Siegle speculum I suck out as much of the pus as
possible and dry the meatus once more, then I inflate
with the Politzer bag and force out a little more dis-
charge, which I remove with the dry cotton. I then
apply to the patient a pneumo-massage apparatus of
medium strength and gradually increase the suction. I
succeed in drawing into the meatus and about the per-
foration of nearly, if not, all of the discharge which may
have adhered to the crypts and along the walls of the
middle ear. After drying with cotton, I once more use
the pneumo-masseur and again dry, after which I use
the drying powders or astringent antiseptics, if any of
these be neccessary. If the ear discharge be too thick
or too firm for removal in this manner I then soften
the discharge by the use of 3 per cent, solution per-
oxid of hydrogen, after which I proceed as above
outlined.
In using the pneumo-masseur for the purpose of
726
OTO-MASSAGE IN SUPPURATION OF THE EAR.
[October 3,
removing the adherent discharges from the middle
ear cavity, I try to use it as forcibly as necessary
without in any way imperiling the integrity of
the structures, especially avoiding the production
of any hemorrhage. I have found by experience that
I can usually commence with an exhaust pressure of
two ounces to the square inch, and gradually increase
it to about half a pound to the square inch, often as
much as a pound, and rarely up to two pounds to the
inch. With an exhaust from half a pound to a pound,
the discharges are usually quickly removed, in from
three to ten minutes, 300 or less strokes per minute
usually sufficing.
Previous to my using the metronomic masseurs, I
endeavored to accomplish this same effective cleans-
ing by the use of the Siegle speculum but, necessa-
rily, the results were indifferent. Since I have used
the pneumo-masseur in the manner described I find
that I can stop the suppuration more quickly than
formerly, and often accomplish this result without any
therapeusis to the ear whatever. This, however, is
not usually the case, and to a considerable extent I
rely upon stimulating and drying powders in connec-
tion with thorough cleansing and drying.
In acute cases I apply the suction massage just as
soon as is possible, believing that adhesions, ulcera-
tions and destruction of the tissues result often from
the pressure of the discharge, from its direct corrosive
effect and its fermentative results as well as from the
progress of the inflammatory affection.
As soon as the pain is sufficiently allayed so that
the treatment is bearable, I apply to the ear either the
metronomic ear masseur or a little electric suction
pump and clear the middle ear of all its discharges
and accumulations. By securing a clean surface early
in the course of the disease I hasten reparative
action and avoid the ofttimes destructive effects of
the decomposition of unhealthy pus.
These ear discharges lying in the middle ear,
envelop the ossicles, fill up the space between the
promontory and the membrane, and generally occupy
all possible spaces, gluing all together. As a
result of this we have occasioned abnormal adhe-
sions between the ossicles and between the ossicles
and the surrounding walls, as well as occasionally
ligamentous bands between the membrane and sur-
rounding structures; again, in other cases, the disease
results not in a tying together of the various parts,
but a rending asunder of normal structures, in ulcer-
ations, necroses and sloughings.
In the one case we have anchyloses, adhesions,
abnormal growths and thickenings followed often by
sclerotic changes, in the other we have necrotic
changes with often loss of one or more of the ossicles
or greater destruction of the tympanic membrane or
ulceration of the mucous lining of the middle ear with
inflammation extending, perhaps, into the mastoid or
involving the internal ear. It is on account of these
often serious results that there is an urgent necessity
for prompt action, with the idea of restoring the parts
as soon as possible to as nearly a normal condition as
can be attained. It is therefore necessary if anything
can be gained by pneumo-massage, to apply it as early
as is admissible.
In some cases I have used the masseur during the
acute stage of the attack with marked benefit, allay-
ing the pain and for the time being increasing the
amount of suppuration and apparently shortening
the attack. I presume the reason for this is that
much of the pain in these cases is occasioned by the
retention of the discharges, the tissues being filled
with discharges which, finding no outlet, have com-
menced to burrow more and more deeply, the infiltra-
tion ever extending, and when the pressure from the
central inflammatory area is released by means of the
exhaust apparatus, the tissues adjoining empty them-
selves of their contained discharges, thus relieving
much of the abnormal tension of the surrounding
infiltrated zone, the lessening of the pressure
relieving the pain, and the frequent application
of the method tending to prevent extension of the
inflammation.
From my experience with this method of cleansing
the ear, I am convinced that there would be fewer cases
of secondary involvement of the internal ear if the
practice above outlined was more generally followed.
When we consider that the cases of internal ear dis-
ease are the most difficult and unsatisfactory with
which the ear surgeon has to deal, the necessity of
their avoidance is evident. I know of no other meas-
ure of relief which exercises such a powerful influence
in the avoidance of this complication.
I very much desire to go more deeply into the sub-
ject and illustrate it by cases, but I find this to be
impossible as I wish to refer to another aspect of the
matter, the improvement in hearing brought about by
oto-massage in suppurative cases as well as in cases of
deafness occasioned by suppurative disease.
Strange as it may seem, I have found in no class of
my chronic ear cases such marked improvement of
impaired hearing as in those in which the defect was
caused by suppuration. Sclerotic changes are rare in
these cases until long after the subsidence of the sup-
purative disease. I will refer to two such cases of
deafness, the result of suppurative disease. Two years
ago I reported the case of a woman 38 years old who
had scarlet fever in her first year. When I saw her
the ears were discharging and there was very poor
hearing power. After she had been using the mas-
sage treatment for some months, not only did the
discharge stop, but the hearing improved so much
that she had no conscious difficulty in hearing con-
versation; the watch being heard twenty inches ( \ '.' >
from the ear. The progress of this case was a steady
gain in hearing power from the commencement.
From the time of my report to the present there has
been no diminution in hearing power.
I will briefly note another case. Miss O. M., 15
years old came to me Dec. 1, 1894, for chronic sup-
purative disease of the left ear. There was a large
perforation and a fair amount of whitish discharge.
not very gluey. There was no watch hearing on con-
tact. I treated her ear without massage and succeeded
in about four months in stopping the suppuration,
but the perforation did not heal. I endeavored dur-
ing another two months to heal the perforation, with-
out success. The hearing distance had improved at
this time to hard contact hearing for the watch. I
then endeavored to restore the hearing by means of
massage, using the pneumo-masseur, but especially
the phono- masseur, neglecting the perforatian. hoping
it would heal spontaneously. Now, after ten months
of such treatment (one visit per week), she hears the
watch at ten inches, the perforation remaining
unhealed.
In these cases the two kinds of massage are valu-
able— the phono to stimulate the nerve, which is more
easily accomplished in such cases by reason of the
1896.]
STRICTURE OF THE TRACHEA.
727
perforation allowing the sound to be carried more
direotly to the internal ear the pncumo-inasseur being
used to break down adhesions and restore abnormal
or diseased parts to more healthy action by reason of
the stimulation thus produoed.
To indicate the value of phono-massage, the follow-
ing experiment will serve. April 2(>, 1896, I tested
the hearing of the right car of Mr. CM., aged l'S, and
found it to be for the watch one-quarter inch. His is
a case of old suppuration with bone involvement —
one which lias goneon for twelve or fifteen years and
which he thought was incurable. The strong phono-
masseur was used on his ear for forty minutes with
the result that the hearing for the watch was increased
to one and one-quarter inches. This increased hear-
ing usually gradually disappears unless the treatment
is regularly applied. If this be done it usually increases,
the amount depending on the nature of the case. This
immediate increase in hearing is a very frequent expe-
rience in my work, and one which I usually secure ex-
cept where then' has been most extensive destruction
of the middle or internal ear structures. In dry sup-
purative cases whore I do not succeed in producing an
almost immediate temporary increase in hearing dis-
tance, my conclusion is that permanent results are very
difficult to attain.
In conclusion the facts may be summed up as fol-
lows: In acute suppurative conditions, pneumo-
inassaLre should be tried and if the application be not
too painful it will relieve the swelling and the sever-
ity of the inflammatory pain and shorten the attack;
the purpose of this suction massage being to remove
from the ear all possible suppuration and thus, by
relieving the tension, lessening the frequency of ulcer-
ations and necrotic processes and preventing adhe-
sions and deep infiltrations of the surrounding tissues.
In cases of suppuration that have passed the acute
stage the pneumo-masseur is to be used for the
purpose of relieving the ear of its discharges and for
the relief of extreme tension, preventing ulcerations
and necroses, as well as to overcome the formation of
adhesions and for the stretching, absorption and
destruction of these adhesions when formed, and to
stimulate the drumhead and its connecting structures
to normal, functional action. The phono-masseur is
to be used in these cases for the purpose of restoring
to the ear nerve and its terminals the normal tone and
overcoming the sluggishness to response engendered
by inaction and disease.
In cases of deafness following upon suppurative
disease the pneumo-massage is useful for limbering
up the diseased and stiffened tissues, to restore their
normal action and tone, and to break or stretch abnor-
mal adhesions, to overcome anchylosed joints and give
to the ossicles their normal motion, while at the same
time improving the circulation of all the middle ear
structures — the phono-massage being again used for
its effect upon a sluggish, diseased and non-responsive
nerve ending.
1723 Walnut Street.
Intravenous Injections of Sublimate in Ocular Affections. — Ange-
lucci has found rapid and thorough recovery follow the use of
intravenous injections of 20 centigrams of sublimate and 60
centigrams of chlorid of sodium, in 100 grams of distilled
water. The dose increasing from 2 to 16 milligrams. The
cases favorably affected were all of syphilitic origin : Iritis,
irido-choroiditis, papillo retinitis, etc., but the results were
negative in all non -syphilitic troubles. -^Revue Gen. d'Ujihth.,
August 31, from Arch, di Ottalm.. No. 3.
STRICTURE OF THE UPPER PORTION OF
THE TRACHEA SUCCESSFULLY TREATED
BY DIVULSION THROUGH THE
LARYNX.
Read in the Section on Laryngology and Otology, at the Forty-seventh
Annual Meeting of the American Medical Association,
held at Atlanta, Ga., May :>■«. isms.
BY JOHNO. ROE.M.D.
HOCHKSTKU. N. Y.
The following case of stricture of the upper part of
the trachea, due to organic contraction, can not, on
account of its rarity, fail to be of interest.
On November 23, 1895, Miss D., aged 27 years, was
referred to me on account of frequent and urgent
attacks of dyspnea, which had for a considerable time
been exceedingly distressing to her. She gave the
following history: In March, 1888, she had a severe
attack of diphtheria, from which it was thought at
the time she had fully recovered. During the follow-
ing year, however, it was noticed that she had edema
of the feet. The edema was found to be associated
with albuminuria and was ascribed to that cause.
Notwithstanding this she enjoyed a fair degree of
health.
In October, 1890, she became hoarse nearly every
day as evening came on. This hoarseness continued
until December, when she began to have considerable
difficulty in breathing. The family physician found
a swollen condition of the larynx, which he regarded
as a consequence of the albuminuria. He treated her
with steam inhalations, compelling her to remain in
bed for about three months continuously with the
object of maintaining a uniform temperature and pre-
venting her from contracting cold. During this time
her health was very good and she gained ten or twelve
pounds in weight; although she had one or two severe
attacks of dyspnea, lasting three or four days at a
time. These were attributed entirely to the renal
disturbance, since albumin and casts were found in
the urine.
After a time the dyspnea subsided and in April,
1891, she began to go out. Shortly after, however,
she took cold, and had another severe attack of dysp-
nea, lasting several days. As warm weather came on
her dyspnea disappeared. Her voice during the
period, since her first attack of hoarseness, had re-
mained quite clear.
In August, 1891, she went to Canada and remained
there until fall, feeling quite well. She continued
to feel quite well during the fall, but during the
winter she had frequent attacks of dyspnea, very sim-
ilar to those of previous winters. During the follow-
ing summer she had no special difficulty in breathing,
although during July, August and September she
was aphonic.
During the fall of 1892, she had at times much
difficulty in breathing, and that winter she spent in
Southern Pines, South Carolina, where she gained
much in general health. Her breathing, however, was
not materially improved, although the atmosphere
there was remarkably dry. She came home May 1,
1893, and during the following summer was quite well,
having little or no difficulty in breathing.
During August the cartilaginous portion of her nose
began to diminish in size and for about a year after-
ward there was a gradual settling of this portion of
the nose. During November, 1894, she had inflam-
mation of the right lung, which nearly proved fatal
and very much increased her difficulty in breathing.
728
ORTHO- AND PARA-CHLORO-PHENOL.
[October 3,
During the following winter her dyspnea was fre-
quently very urgent. These attacks of dyspnea were
aggravated very much by accumulations of mucous
below the obstruction in the trachea, which she had
great difficulty in expelling. After expulsion of these
accumulations her respiration was for a time very
much improved. As the warm weather came on, her
dyspnea diminished, and during the summer of 1895
she was quite free from it, and felt very well. As in
previous years, when the cold weather came on, her
trouble increased, and last October her dyspnea became
very urgent, although her voice remained quite clear.
On November 23, when she came under my care,
there was found on examination a chronic subglottic
laryngitis, with considerable infiltration of the sub-
glottic region. About three- fourths of an inch below
the larynx there was an annular constriction, which
appeared something like a membranous formation.
Notwithstanding the fact that no history of syphilis
could be obtained, as the girl's character was beyond
question, the sinking in of the nose appeared more or
less positive evidence that the trouble was of a speci-
fic nature.
Previous to the time that her nose began to diminish
in size, her dyspnea was attributed entirely to the
albuminuria, and she was treated accordingly, but
after this manifestation it was thought that a specific
trouble must be the cause of the difficulty. Since it
seemed so certain that it must be of that nature, I
placed her upon an antisyphilitic treatment, in both
large and small doses, but with no benefit whatever.
In fact, the dyspnea was aggravated by it, whereas
iron and strychnia improved her condition.
Locally I attempted to reduce the subglottic laryn-
gitis by sprays and insufflation of a power composed
of tannin, sugar of milk, and a small quantity of
morphia. This appeared to lessen the subglottic con-
gestion, but had no effect in lessening the constric-
tion in the trachea.
On December 4, the dyspnea became so urgent that
suffocation seemed imminent, necessitating either
tracheotomy or intubation of the larynx. The latter
was resorted to and the tube was retained for two
days, when it became so irritating as to require re-
moval. It had the effect, however, of so enlarging
the constriction that the dyspnea for a considerable
time entirely disappeared. The constriction gradually
returned, and in February it again became necessary
to introduce the tube.
As the tube was being introduced by the aid of the
mirror, she suddenly threw her head forward, bring-
ing the end of the tube quite forcibly against the
anterior portion of the trachea. As she jumped back,
the tube was brought out. She at once, however,
experienced complete relief from her dyspnea, and on
the examination of her larynx, I found that the tube
had broken down the anterior portion of the constric-
tion so that the lumen of the anterior portion of the
trachea was quite free.
Seeing that this constriction could be disrupted, I
introduced a pair of Grant's forceps, with blades closed,
until they piassed below the constriction. I then
opened the blades until the widest portion of them
nearly filled the trachea. Holding the handles firmly
I drew the blades up in the constricted portion, so
dilating it as to break down much of the posterior
portion of the constriction and leave the trachea quite
tree. As the glottis did not permit the forceps to
open wide enough to fully break down the stricture,
I had a pair of dilating forceps with double-jointed
blades so constructed as to increase the expansion of
the lower blades to the full width of the trachea and
to completely obliterate the stricture.
Since that time the constriction has shown little or
no tendency to return. An occasional dilatation of
the trachea with the forceps is sufficient to maintain
the opening. The respiration and voice are quite
normal. By following up the dilatation of the trachea
in this manner when there is a tendency of the con-
striction to return, I have every reason to believe that
a permanent cure will be effected.
This has been to me an exceedingly interesting
case, being one of chronic subglottic laryngitis, to
which was added organic constriction in the upper
part of the trachea. This case is of special interest
on account of the uncertainty as to the exact cause of
the condition, and also on account of the history of
repeated attacks of dyspnea extending over so long a
period.
How much of this trouble we may ascribe to album-
inuria, it is difficult to say. We all recognize the
condition of edema of the larynx and aphonia, asso-
ciated with albuminuria, which we term albuminuric
aphonia, and we know that specific taints uncontrolled
by ordinary antispecific remedies may excite all sorts
of conditions. Subglottic laryngitis is a disease that
is not of frequent occurrence, and is therefore not
commonly met with in our daily work. We know,
however, that its cause is frequently involved in
obscurity, although it is usually associated with lym-
phatic affections and the conditions termed scrofula;
that it occurs usually in young females from fifteen
to twenty-five years of age, and that the treatment
which proved serviceable in this case is the one that
is recognized as the most beneficial in simple chronic
subglottic laryngitis. Simple absorption of the tis-
sues of the nose without ulceration results only, so
far as I am aware, from a specific cause. We must
therefore believe even in the absence of every other
manifestation that the underlying cause was a latent
hereditary taint of a specific character which produced
the subglottic laryngitis and ulceration of the upper
portion of the trachea and the resulting stricture, as
well as absorption of the tissues of the nose.
DISCUSSION.
Dr. J. E. Logan, Kansas City, Mo.— Is it not probable that
this case is more or less of a specific type? The Doctor states
that it was simply a settling of the cartilaginous septum
unattended by any ulceration, and that the bony septum was
intact. This would make it a very peculiar and interesting
case. I have seen many of those cases which had no evidence
of external ulceration, but there would be an ulcerated condi-
tion of the septum.
A FEW REMARKS ON THE CLINIC USE OF
ORTHO- AND PARA- CHLORO-PHENOL.
Read Id the Section on Laryngology and Otology, at the Forty-seveutb
Annual Meeting of the American Medical Association.
at Atlanta. Ga.. May 5-8. 1896.
BY CONRAD BERENS, M.D.
ONE OF THE WILLS HOSPITAL SUBSEON8. PHILADELPHIA, PA.
In the University Medical Magazine for October,
1894, there is a brief note of reference to ortho-chloro-
phenol, quoting N. Simanoffski, who is reported to
have used it for reducing hypertrophies of the mucous
membrane overlying the inferior turbinates of the
nares. Simanoffski made but a preliminary report,
and referred also to para-chloro-phenol. The endorse-
L896.]
ORTHO- AND PARA-CHLORO-PHENOL.
729
incut of ortho-ohloro-pbenol waa of such a nature that
1 was induced to make some trials with it, as well also
as of para-chloro-phenol. Ortho-chloro-phenol is a
heavy limpid liquid of exceedingly irritating and
pungent odor. It is rapidly soluble for clinic pur-
poses in glycerin, and from this may be reduced in
strength again anil made soluble in water. For clinic
purposes the para-chloro-phenol, which occurs in
amorphous crystals, is best used by fusing to the end
of a probe. In my work I have fused the crystals to
silver. Para-chloro-phenol is not so satisfactory clin-
ically, and is very much more cumbersome and incon-
venient in its application. The conclusions of
Sohourmo in regard to its irritating properties, par-
ticularly in laryngeal conditions, are fully borne out
by clinic experience. There is no denying the cor-
rectness of the statement of Spengler (Brit. Med.
Jour. 1896, No. 1,827), as to its antiseptic properties,
hut 1 would take issue with him as to its efficacy
oompared with ortho-chloro-phenol. My experience
having taught me that the latter is just as active an
anesthetic, and is a very much more convenient form
for olinic purposes. The use of ortho-chloro-phenol
for the reduction of engorgement of the erectile tissue
overlying the inferior turbinates is much more satis-
factory than the cautery — with less destruction of
tissue and less intense reaction. In acute engorge-
ment of the erectile tissue, I have found nothing more
satisfactory than its application by means of a small
dossil of cotton dipped in the drug and applied antero-
posterior^ to the parts after they have been prepared
By the use of cocain. The effect of the cocain having
passed off after the thermo-electric cautery has been
applied, patients as a rule complain of intense pain,
and frequently of epistaxis, not to mention the enor-
mous inflammatory swellings and frequent adhesions
to the septum. Ortho-chloro-phenol is slightly anes-
thetic, and this anesthesia is more persistent than
that of cocain. As a consequence after the action of
the cocain has passed off that of the ortho-chloro-
phenol continues, and the patient reacts without any
inconvenience. There being less inflammatory reac-
tion it is natural that there should be less deeply
seated initial lesions, but the drug has no place in
the treatment of true hypertrophy, or hyperplasia
of the region under discussion. In ulcerous condi-
tions more especially of the septum nasi, the applica-
tion of the glycerole of ortho-chloro-phenol 10 per cent,
has invariably proved satisfactory in my hands. In
ozenatous conditions after freeing the nares from the
offensive accumulations, and thoroughly cleansing
the nasal mucous membranes with dry absorbent cot-
ton. I have found nothing that will so quickly remove
the offensive odor of the disease as two or three applica-
tions of 10 per cent, ortho-chloro-phenol in glycerin.
In these cases I persistently but very gently rub
the solution over the diseased parts, and the patient
is much gratified by the sudden removal of the
offensive odor of the disease. I have yet to see how-
ever a case cured by the application of this or any
other drug; that is, having no longer necessity for
any applications to the nares. In laryngeal condi-
tions I found that it will not in any sense take the
place of ichthyol or iodoform as a local application.
If a caustic effect is required, as for instance upon
deeply seated ulcers or upon granulations in the
pharynx, it is not to be considered, as its effect is too
mild to be taken into consideration. In laryngeal
diseases the results oi persistent application have not
lead me to resort to its use excepting in the event of
failure of lactic acid, ichthyol or boro-glycerin. In
three out of fifteen cases of laryngeal tuberculosis in
its very incipiency, I have found ortho-chloro-phenol,
in full strength, to give better results than any other
local application. In two instances, most gratifying
results were obtained by the application of 10 per
cent, ortho-chloro-phenol to large ulcers of the epi-
glottis, both occuring in cases of advanced tuberculosis.
For the removal of growths of any sort in the
larynx, I would not encourage the use of the drug, as
it is not only slow, but also liable to cause acute
inflammatory reaction — in one instance, giving rise
to very severe dyspnea. In aural diseases its use
has been attended by more gratifying results than
those gained by the use of any other drug. The
application of a pledget of cotton saturated with the
10 per cent, of the glycerol of ortho-chloro-phenol to
an incipient furuncle of the external canal, in many
instances has resulted in the abortion of the disease,
while no dressing has proved more satisfactory after I
have been compelled to open the furuncle in the
canal. Though I have used a dossil of cotton satu-
rated with it as a dressing after opening the furuncle
I have never yet seen a recurrence of the disease at a
sufficiently early date to warrant me in believing that
there had been any material allowed to remain in the
ear disinfected. A small pledget of cotton saturated
with the solution and applied to the point of
attachment after removal of polypi of the external
canal, has always proved effectual both in destroy-
ing the extremely offensive odor, and in encourag-
ing a rapid healing of the parts. In suppurative
otitis media it has proved exceedingly effectual in
10 per cent, in glycerin. I will cite but one case
as an illustration of many. Miss E. M., aged 22,
applied to me in July, 1893, with chronic suppurative
otitis media of the right ear; more than two-thirds of
the inferior portion of the membrana tympani had
been absorbed. The suppuration had continued with
more or less severity and an offensive odor, since the
early childhood of the patient. I employed every
method for the relief of the symptoms and checking
the disease, even curetting the floor of the middle ear,
where the disease seemed to be confined, the attic not
appearing to be involved. Boro-glycerin in 50 per
cent, solution, ichthyol, nitrate of silver, zinc, nitrate
of sanguinaria, douches, powders as iodoform, aristol,
etc., were used without result. The discharge con-
tinued to be offensive and muco-purulent in charac-
ter, no matter how thoroughly the application at the
previous visit had been made. In December, 1894,
after having thoroughly cleansed the parts I inserted
a pledget of cotton saturated with 10 per cent, ortho-
chloro-phenol in glycerin. The patient was in-
structed to return the following day. To my surprise
the entire appearance of the parts had changed, the
mucous membrane had become more healthy in
appearance, and the discharge had lost its odor and
golden yellow color. In five days and after three
applications the discharge entirely ceased, and has
not recurred since, excepting in the spring of 1895,
when the patient was attacked by an acute rhinitis,
and three days afterward complained of discharge
from the ear. A single application of ortho-chloro-
phenol caused this to cease after twenty-four hours,
and there has been no discharge since. The patient
as a rule complains of considerable burning pain on
the first introduction of the cotton saturated with the
730
THE ELECTRO-CAUTERY SNARE.
[October 3,
drug, but this rapidly subsides and leaves a sense of
comfort. It has been my custom to dress the ear
daily, or not later than every other day, and in no in-
stance of chronic suppurative otitis media have I had
any but the most gratifying results in its use. In acute
suppurative otitis media I have found that in any
strength it seems to aggravate the disease. The great-
est objection raised to the use of the drug comes from
the patient, who complains of its odor. Even weak
solutions of the drug unquestionably give rise to an
all-pervading and pungent smell that is more pene-
trating than that of iodoform. This objection, partic-
ularly in the application of the drug to the ear, may
readily be overcome by closing the external meatus
with a small piece of absorbent cotton. In conclusion
then, I have no hesitation in recommending the fur-
ther clinic use of ortho-chloro-phenol in the belief
that it will prove a valuable addition to the pharma-
copeia of the rhinologist and aurist, and prove itself
worthy of the fullest confidence, especially in those
cases where the commonly resorted to medicaments
have not only failed to relieve the patient, but have
disappointed the expectations of the surgeon.
THE ELECTRO-CAUTERY SNARE AS
AN EXCISING AGENT IN DIS-
EASES OF THE NOSE
AND THROAT.
Read in the Section on Laryngology and Otology at the Forty-seventh
Annual Meeting of the American Medical Association
held at Atlanta, Ga., May 5-8, 18%.
BY HANAU W. LOEB, A.M., M.D.
Professor of Diseases of the Nose and Throat, Marion-Sims College of
Medicine, Surgeon to the Nose and Throat Department of the Re-
bekah Hospital, Missouri Pacific Hospital, East St. Louis
Protestant Hospital, Grand Ave. Free Dispensary, etc.
ST. LOUIS, MO.
It is only a natural sequence which impels one
who has given the electro-cautery snare a trial for the
treatment of one of the various conditions for which
it is recommended, to extend its application, to find
new uses and to confirm those whose work has forced
them to admit its growing utility. Especially is this
to be expected in view of the recent improvements in
electric appliances.
At the meeting of the American Medical Associ-
ation at Detroit in 1892, I presented an electric snare
which ' I had devised, and stated its indications
and uses in nose and throat diseases. Since that
time I have, by greater opportunity, enlarged its
sphere of usefulness and fixed my own views in favor
of a wider range of application of the electro-cautery
snare in nose and throat affections. Prom its very
nature it is adapted for amputation or excision. Any
organ or growth or portion thereof which can be
engaged within the snare may be removed, without
danger of hemorrhage, for not only will there be less
hemorrhage than when a knife or cold snare is used,
but absolutely no bleeding in the vast majority of
cases.
The snare, which was exhibited before this body
four years ago, I again present though it is unmodi-
fied, except, that in order to accommodate the increas-
ing field of application, it has been made in two sizes.
By reason of its ready separation, its simple con-
struction and its constituents, it is easily cleaned.
Being covered with hard rubber it is not open to the
objection which the old time snares received on
account of their lack of cleanliness.
Until over three years ago, I relied upon the ordi-
nary galvanic and storage batteries, without complete
satisfaction; constant attention was required to keep
them in order and even when the greatest care was
observed the battery would often fail at the critical
moment.
In December, 1892, I began to use the Aloe con-
verter and since that time I have never been subjected
to any annoyance on the part of the appliance sup-
plying the current. The converter is applicable only
to the alternating current and is similar in its design
and purpose to the transformers which are now used
to reduce electricity of high electro- motive force to a
lower tension.
The instrument which I have, reduces the voltage
from 104 to 1, 1J, 2, 3, 4, 5, 6, 7, or 8 volts, and is
therefore suitable for the cautery or the light.
In construction, it consists of iron core with a large
primary coil of fine wire and a smaller secondary coil.
The ratio of turns of the wire in the primary and
secondary coil will depend upon the transformation
required. Thus when the voltage of the house cur-
rent is 104 to secure one volt the primary would have
416 turns to 4 of the secondary; for 2 volts the ratio
would be 416 to 8, for 4 volts, 416 to 16; for 8 volts
416 to 32. From 4| to 6 amperes are required for the
proper action of the snare with No. 5 piano wire (J
mm. in diameter).
Lichtwitz2 describes a fairly elaborate instru-
ment which he uses and which he presents as one by
means of which the quantity of electricity may be
measured. He finds that ten amperes are necessary
for ordinary tonsils and twelve for the larger, when
the wire used is \ m.m. in diameter.
There are several very good appliances in use for
utilizing the constant current which alone is avail-
able in some cities.
It therefore follows that at the present time no one
need deny himself the use of the electro-cautery
snare on account of electricity producing apparatus;
for, whether the current be alternating or direct the
supply will be reliable and precise. For some years
a valid objection was entertained to the platinum
wire on account of its lack of firmness. Since iron
or steel wire has replaced it however, the same degree
of stiffness of the loop is obtained whether the cold
or hot snare be used.
1896.]
THE ELECTRO-CAUTERY SNARE.
731
The eleetro-eautery snare is from the very nature
of things of but recent use. So far as I can learn
Middledorf was the first to employ it in the
removal of tonsils.
According to Kijewski and Wroblewski' the
gelvano-oautery snare was used by Koehler and Kor-
Beniowski 5 to remove a large polypus which filled
the entire nasal cavity. Voltolini, " in his great treatise
upon the galvano-oautery considered the value of the
snare lessened by reason of the insufficiency and
inconstancy of current.
Since the publication of this work and especially
since the introduction of an apparatus which provides
for the regular and certain supply of electricity, this
and the somewhat similar objection of Beverly Rob-
inson ' are answered. So satisfactory has been this
answer that the advocates of the electro-cautery snare
have increased immensely, until they include many
who are willing to replace by it many operative pro-
eedures which legend and practice had almost estab-
lished forever. In fact the most enthusiastic advo-
eates are those who have had most experience with it
and its greatest opponents are generally those who
have used it infrequently or not at all.
Thus Sendziak ' complains that Jurasz, after employ-
ing the eleetro-eautery snare in only two cases, came
to the conclusion thai it was inconvenient, painful
and disagreeably to the patient on account of the
odor it leaves.
The eleetro-eautery snare has been recommended
and employed in the following diseases of the nose
and throat:
1. Nose: O, anterior and posterior turbinal hyper-
trophies: h, polypi and other benign growths; c, malig-
nant neoplasms; d, spurs.
2. Rhino- pharynx: a, polypi; b, fibromata.
3. Pharynx: a, hypertrophied tonsils; b, tonsillar
neoplasms: c, palatal neoplasms; d, elongated uvula;
c. hypertrophied lingual tonsils.
4. Larynx: a, neoplasms.
I. NOSE.
1. Anterior and posterior turbinal hypertro-
phies.— In these conditions the electro-cautery snare
is almost ideal, permitting the operator to remove
quickly the redundant and hypertrophied tissue by
means of an operation which is bloodless notwith-
standing the great vascularity. It is quite as easy to
engage the hot as the cold snare and the celerity, the
painlessness and freedom from hemorrhage should
commend the former over the tedious cold snare.
Sajous 9 prefers the electro-cautery snare for posterior
turbinate hypertrophies, stating that it is necessary to
use a rhinoscopic mirror in order to see the seat of
operation. I consider that this is not only unneces-
sary, but awkward. A far better plan is to place the
finger in the rhino-pharynx and thus guide the loop
over the hypertrophied tissue.
McBride "' says it should be used whenever the tis-
sue can be engaged and Greville MacDonald " prefers
the electro-cautery snare for the removal of large
pieces of the turbinated in spite of the objection that
it induces considerable inflammation in the neighbor-
hood from the generation of steam and that the cica-
trization is delayed. I can not permit this objection
to go unchallenged for at least in my own cases it has
not been revealed. Among the laryngologists who
consider the cold snare as superior for anterior and
posterior hypertrophies, may be mentioned Onodi,12
Zwillinger,18 Polyak," Eaton,15 Hack,1" while Baum-
garten ", Schmidt 18 and others commend the hot
snare.
2. Polypi and other benign growths. — The essen-
tial advantage of the electro-cautery snare in the
removal of polypi is the fact that so many may be
removed at one sitting ; whereas it requires consider-
able time to dispose of a number by means of the
cold snare; with the hot snare it is only the question
of a few minutes. The smaller instrument which I
have devised is quite as convenient and easy of appli-
cation as any cold snare, and one needs only inquire
of a patient who has had both methods applied, to
learn that the hot snare is far more agreeable, less
painful, more rapid, less bloody and more preventive
of recurrence. So far as the inflammatory and infec-
tive sequelse are concerned after a thorough trial of
more than four years, I am convinced that they are
no greater in one than in the other. In one single
case, an acute otitis media followed the separation,
doubtless influenced by the unwarrantable exposure
to which the patient subjected himself. The opera-
tion was performed in the morning and before night
the patient had permitted himself to be drenched by
rain several times. He failed to report at my office
until the fourth day after the operation. I feel there-
fore that the hot snare may be held blameless of this
result. Surely the lessened time of operation should
make infection less apt to occur than with the cold
snare with which too often no aseptic and antiseptic
precautions are taken.
McBride 10 in this connection makes the assertion
that it is better to use the electro-cautery snare, when
it is desired to remove all the polypi at one sitting.
Ingals19 uses the electro-cautery snare but prefers
the cold, while Greville MacDonald " claims that there
is no advantage over the cold snare, while there is the
greater disadvantage of inflammatory action induced
by heat and steam generated by the hot wire.
In answer to this, it may be stated that the heat
and steam which MacDonald and others claim are
generated will not produce any bad results if the
snare is properly applied and used. If the wire is
drawn tight the tissue which is influenced by the heat
will be so constricted and the time of its application
so insignificant, that it can have but little influence
in this regard. It is often difficult, sometimes impos-
sible, to observe the cauterized stump, demonstrating
that at least in many cases the effect of the heat and
steam is nil.
Schmidt 18 states that after using the cold snare for
three years he returned to the electro-cautery. This,
I am sure, will be done by many if they give the latter
a fair trial. I am inclined to agree with Ball20 and
others that cauterization of the base resulting from
the galvano-cautery ablation of polypi is productive
of good results. In keeping with the progress of
rhinology, I do not believe that mere cauterization of
the base will prevent recurrence. Indeed my common
practice now is to remove all larger polypi with the
hot snare, and if the bone is found affected the smaller
polypi with the diseased bone are then removed.
The electro-cautery snare is also available for the
removal of other benign growths in the nose, and I have
used it with good effect in fibroma, adenoma and papil-
loma. In one case of fibroma which projected from the
rhino-pharynx, the vascularity was very great, the
growth bleeding upon the slightest provocation; yet,
the electro-cautery snare caused the loss of but a few
732
THE ELECTRO-CAUTERY SNARE.
[October 3,
drops of blood. In the case of adenoma I first used
this instrument but in the later recurrences abandoned
it, since on account of the softness of the tissue and
slight amount of blood which was lost, I could operate
quite as well with forceps.
Zarniko21 inclines to the cold snare for removal of
inflammatory fibroma, claiming that if it is applied as
he suggests, the loss of blood will be inconsiderable.
8. Malignant tumors. — The electro-cautery snare
has in this class but a limited range, which is in the
direction of securing a portion of the growth for
microscopic examination.
4. Spurs. — Although advocated by a number of
laryngologists, I have never taken kindly to this form
of treatment. The saw, drill and curette are eminently
more satisfactory. The electro-cautery snare is by
no means as free from objection in operations upon
bone and cartilage as upon softer tissues.
II. RHINO-PHARYNX.
1. Polypi and fibromata. — These may well be
considered together as the terms are used interchang-
ably by many. In appropriate cases the belief seems
to be fairly general that the hot snare is of greatest
service, although the electrolytic treatment seems
destined to overshadow all other forms, except where
a more serious operation is indicated. However, many
still maintain the superior value of snaring where this
is possible. Thus Michelson22, Lincoln23, and Schmidt26
report cases of rhino-pharyngeal fibroma treated in
this way. I have used the electro-cautery snare in
two cases of rhino-pharyngeal polypi with success
and without return. In a case of rhino-pharyngeal
fibroma with projections into the nasal cavity I snared
off as much as was possible to reach with the instru-
ment. On the whole the efficiency of the electro-
cautery snare in rhino-pharyngeal tumors depends
upon the possibility of engaging the growth in the
loop and its extent and attachment.
III. PHARYNX.
1. Hypertrophied tonsils. — In the removal of
hypertrophied tonsils, the electro-cautery snare has
received greater attention than in any other affection.
After this method was introduced, according to Licht-
witz 2 the operation lost caste but was revived through
the writings of Knight, Loeb, Grarel, Schmidt, Heryng
and Sendziak. All of these continue to favor the
electro-cautery snare except Knight, who writes 24, after
a complete resume upon the subject of hemorrhage
following tonsillotomy that he favors the guillotine.
Flatau26 intimates that those who have experienced
serious hemorrhage after tonsillotomy are much in-
clined to replace the tonsillotome with the electro-
cautery or electro-cautery snare and McBride 10 states
that its use is only justifiable in preventing hemor-
rhage, which he states is a rare contingency. Bresgen26
dismisses its consideration with the remark that there
is no reason for its use as it does not prevent hemor-
rhage. Bosworth27 objects to the procedure on the
ground that it requires ten to fifteen minutes and
Potter28 advised that the snare be not adjusted too
deeply on account of the sloughing beyond the seat
of cauterization.
Ingals19 favors the cold snare. On the other hand
there is a great array of experienced advocates of
electro-cautery tonsillotomy. Lichwitz2 is strong in
his preference. Yerwant29 states that it is more prudent
to use the electro-cautery snare in adults so as to
obviate hemorrhage. Heryng80 has given his evidence
in its favor for hard fibrous tonsils, extensive hyper-
trophy and hemophilia. Sendziak18 advocates it for-
cibly and conclusively, stating that any one without
prejudice will be entirely satisfied with this method.
Schmidt18 favors the electro-cautery snare beyond all
other tonsillotomy instruments. He denies that it
requires a longer time than the operation with the
tonsillotome and insists that it is to be preferred on
account of the certainty that hemorrhage will not
occur. Huguenin31 advises the use of the electro-
cautery snare whenever tonsils are pedunculated and
Helot32 also prefers this instrument. There is to my
mind no question as to the safety of galvano-cautery
tonsillotomy so far as hemorrhage is concerned. A
few cases of hemorrhage following this operation have
been reported, but never a serious one. They could
all probably be explained upon a satisfactory basis.
In more than 300 tonsillotomies with the electro-
cautery snare I have nerver observed a loss of more
than a few drops of blood. In only one case was there
a secondary hemorrhage, which doubtless resulted
from a lack of attention on the part of the patient. I
think this will compare favorably with the experience
of those who use the knife or tonsillotome. In fact
the proof is stronger when it is considered that
the hemorrhage would be far greater if the advocates
of the knife would remove as much as is ordinarily
removed with the galvano-cautery snare.
Numerous instances of hemorrhage after tonsill-
otomy attest to the possible seriousness of such an
occurrence. Heryng3" collected fifty-nine cases of
severe and even serious hemorrhage; other cases have
been reported by Blairs,33 Fuller,34 Catuffe,35 Moure,16
Thorner,37 Jessop38, and Lennox Browne.351
Another great advantage which the galvano-cautery
snare possesses over the tonsillotome consists in the
large amount of tonsillar tissue which it is possible
to remove and the precision of the operation which
makes it possible to remove just what one desires.
With the tonsillotome the amount of tonsil removed
is purely accidental. If the instrument possesses a
fork or lifting device, the amount will depend upon
the pulling power of the fork, which to the surgeon
can not be known until after the excision. If there
is no fork, the pillars of the palate will limit the
removal, and therefore it must be very exceptional to
remove the entire tonsil. Quite different is it with
the electro-cautery snare. It is my custom to pull the
tonsil from its palatal bed by means of a pair of sharp-
toothed forceps and then engage the wire so that it is
possible to remove the entire tonsil. I have again
and again made so complete an excision that not a
vestige of tonsil tissue remained. This I do not con-
sider a dangerous practice; at least it has been emi-
nently satisfactory up to the present time. I can
corroborate the experience of Schmidt,18 who states
that he has frequently seen enlarged tonsils of which
one-fifth only had been removed by previous tonsil-
lotomy.
As to the great length of time which some writers
maintain is necessary in operating with electro-cautery
snare, the expression is born of inexperience, for no
one who undertakes it a number of times can fail to
acquire sufficient dexterity to operate with celerity.
It never should require more than one minute, pro-
viding the apparatus is in proper working order; con-
sidering the improvements that have been made,
nothing short of this is to be anticipated. On the
whole it must be admitted that the electro-cautery
L896.]
THE ELECTRO-CAUTEKY SNARE.
733
Bare is to be oommended for the removal of hyper-
txophied tonsils in that it obviates all danger fr6m
hemorrhage and makes the operation one of precision,
not one of the purest guess-work.
Byen in tonsils whioh are impacted between the
palatal pillars it will be found of service, since in
almost every case it will be possible to pull out a
portion and engage it in the snare, thereby not only
securing the advantage of cauterization, but also the
removal of a portion of the hypertrophied tissue.
■J. Tonsillar neoplasms. — Any tonsillar growth
which has not involved and attached itself to neigh-
boring structures is susceptible of excision with the
electro-cautery snare. This does not imply that the
mere removal with the snare will constitute a cure
for such an affection. However, if the growth involves
the tonsil alone, and the entire tonsil is removed,
the method should offer at least as good a result as
any other. In a case of lymphosarcoma of the tonsil
1 snared off a large piece of the tumor for microscopic
examination, without causing any hemorrhage and
without influencing the growth of the tumor. Wolf-
enden'" states that he removed a sarcomatous tonsil by
means of the electric snare, and I consider it a pro-
cedure which should be utilized in the earlier cases.
;>. Palatal neoplasms. — Tumors of the palate which
may be engaged within the loop are suitable for
removal with electro-cautery snare. I have used it
twice for palatal papillomata.
I. Elongated uvula. — In my previous paper1 I
called attention to removal of elongated uvula by
means of the electro-cautery snare, which I had prac-
ticed for some time. Shortly after this DeBlois41 in
a paper before the American Laryngological Associa-
tion, took a similar position. Lennox-Browne42 states
his preference for the galvano-cautery where the uvula
is thin, but he does not specify the snare. He oper-
ates by pulling the uvula downward and cutting it
with the galvano-cautery where he desires. On the
other hand Morgan43 and Ingalfl" prefer the oold
snare. That hemorrhage is a possibility, one needs
only to refer to the paper upon this subject written
by Morgan in which attention is called to a great
number of instances of uvular hemorrhage collected
from ancient and modern medical literature.
Besides entirely preventing all possibility of hemor-
rhage the hot snare operation finds an indication in
the ease with which the uvula can be engaged, the
perfect stump which remains, the smaller amount of
pain succeeding the operation as compared with
ordinary uvulotomy. It is my practice after the uvula
has been properly cocainized to permit it to fall into
the loop and after deciding exactly where the section
is to be made, to draw the wire tight and send the
current through. So pleasing are the results from
this method of operating, that I now use no other
plan.
.">. Hypertrophied lingual tonsil— My own experi-
ence in this particular affection is confined to one
case-, however, it seems to offer an inviting field at
least. Sendziak 8 commends it highly.
IV. LARYNX.
1. Neoplasms— Some writers are disposed to favor
the electro-cautery snare in these affections, but it
seems to me that there are serious objections on the
score of inaccessibility, impossibility of keeping the
site in perfect view, the danger of inflammatory re-
action and the possibility of the excised tumor falling
into the larynx. These are, however, the judgment
of opinion rather than of experience.
In conclusion I desire to state that the electro-
cautery snare has a possible indication in laryngeal
tumors and nasal spurs: an inviting one in hyper-
trophied lingual tonsils, palatal, tonsillar and rhino-
pharyngeal growths and a certain one in the removal
of hypertrophied tonsils and turbinates, nasal polypi
and elongated uvula.
3559 Olive St.
BIBLIOGRAPHY.
i Loeb: An Improved Galvano-Cautery Snare; Its use in the Nose
and Throat. Journal of the American Medical Association, Oct. 22, 189 2
- Licbtwitz: Weber die Abtragung der Hypertrophischeu Tonsillen
Itlttelst der Blektriohen Gluehschlinge. Archiv fiir Laryngologie und
Rhinologie. Bd. il.
M iddledorf : Galvanokaustik ; ein Beitrag zur Operativen Medicin.
Breslau. 1854. Quoted by numerous authors.
' Kljewski and Wroblewski: Zur Operatlonsfrage der Nasenrachen
tnmoren. Archiv fiir Laryngologie una Rhinologie. Bd. ii, p. 78.
■ Koehler and Korzeniowski : Pamietuik Towarzystwa Lekarskiego,
1858, Bd. 10.
» Voltilini : Die Anwenduug der Galvanokaustick. 1872.
' Beverly Robinson : Heating's Cyclopedia of Diseases of Children.
Vol. ii.
* Sendziak: Quelques Remarques sur l'emploi de l'ause galvano-
causttque dans l'brpertrophie der amygdales. Revue de Laryngojogie,
d'Otologie etde Rhinologie. Tome xm.
» Sajous: Diseases of the Nose and Throat. 1S89.
i" McBride: Diseases of the Throat, Nose and Ear. 1892.
n Greville MacDonald : Diseases of the Nose. Second Edition, 1892.
u Ouodi : Revue de Laryngologie, d'Otologie et de Rhinologie.
Tome xv.
13 Zwitlinger: Revue de Laryngologie, etc. Tome xv.
i* Polyak: Revue de Laryngologie, etc. Tome xv.
I» Eaton : Transactions of the IX. International Medical Congress, 1887.
16 Wilhclm Hack: Ueber eine operative Radical-Behandlung bes-
timmterFormeu von Migrane. Quoted by Eaton.
" Baumgarten: Revue de Laryngologie, etc., XV.
i« Schmidt: Die Krankenheiten der Oberen Luftwege, 1894.
m Ingals: Diseases of the Chest. Throat and Nasal Cavities. 2nd
Edition. 1872.
2'i Ball : Diseases of the Nose. 2nd Edition, 1894.
21 Zarniko: Die Krankenheiten der Nase, etc.. 1894.
2a Miehelson : Journal of Laryngology and Rhinology, 1889.
21 Lincoln : Journal of Laryngology and Rhinology, 1894.
2* Burnett: System of Diseases of the Ear, Nose and Throat. Vol. ii.
2a Flatau : Nasenrachen und Kehlkopfkrankeiten.
-'"Bresgen: Krankheits und Behandlungslehre Nasen, Mund und
Rachenhoehle.etc. 1896.
21 Bosworth: Diseases of the Nose and Throat. Vol. ii.
28 Potter: Medical News, 1888, Vol. lii.
29 Yerwant : Arch. Ital. di Otol. April, 1894. Quoted in Revue de
Larvngologie xv.
30 Heryug: Internat. Centralblatt fiir Laryngologie, Rhinologie, etc.
Bd. x. From Gazeta Lekarska, 1*92, Nos.41,42. 4S.
31 Huguenin: Concours Medical. 1892,p. S04. Reviewed by Internat.
Centralblatt fiir Laryngologie, etc. Vol. ix.
32 Helot: Internat. Centralblatt fiir Laryngologie. Vo. IX.
33 Blairs: Albany Medical Annals, February, 1888.
3* Fuller: American Journal of the Medical Sciences, 1888.
M Catuffe: France Medicale, Jan. 4, 1889. From Journal of Laryn-
gology. 1889.
M Moure : Journal of Laryngology, 1890.
•I Thorner: Cincinnati Lancet-Clinic.
38 Jessop: British Medical Journal, June 3, 1893. From Journal of
Laryngologv, 1893.
39 Lennox-Browne: Lancet, Jan. 20, 1894.
«o Wolfenden : Journal of Laryngology. 1889.
*i DeBlois : Journal of Laryngology, 1893.
*2 Lennox Browne: Diseases of the Throat.
«3 Morgan . The Value of the Snare In Performing Uvulotomy. Mary-
land Medical Journal, Sept. 26, 1885.
« Morgan : New York Medical Journal, XLiv, 1886.
DISCUSSION.
Dr. W. E. Casselberry, Chicago, 111. — I think the success
of treatment by the electro-cautery snare depends very largely
upon the perfection of one's apparatus. I think that Dr. Loeb
deserves a great deal of credit for having designed an appara-
tus by which he can gauge and perform these operations with
facility. He is fortunate in having his converter and an alter-
nating current. I have been unable to find a satisfactory
galvano-cautery rheostat by which to use directly the Edison
or continuous current, so I use the storage battery. I use for
this purpose the double American cell, keeping it stored con-
stantly by the Edison current in connection with my light so
that the flow of the current from the battery seems to be uni-
form. I am not accustomed to take out nasal polypi with the
cautery snare. I formerly did it but have stopped for the
reason that it makes the nose sore. I can remove about as
many as I care to at one sitting with the cold snare. I remove
tonsils in adults sometimes by the cautery snare. It has the
advantage of avoidance of hemorrhage and the disadvantage
of making a very sore throat. I think, to remove the uvula by
the cautery snare, I must make a more painful wound than by
the usual method.
Dr. Hanau W. Loeb, St. Louis, Mo. — I expected to hear
more criticisms than have been made and I think perhaps they
734
ON BONY GROWTHS INVADING THE TONSIL.
[October 3,
would have been deserved, for I am sure that my love for the
electro-cautery snare has made me rather dogmatic. I use a
better instrument than those usually employed. Most of the
instruments have too large a handle and are too heavy, but I
have somewhere in the gray matter of my brain a little handle
in view which will greatly obviate this trouble.
I think Dr. Casselberry deserves a great deal of credit for
his faithful work with that abominable machine, the winding
cautery snare. I use the Mcintosh handle, which has a sliding
arrangement by which the loop is tightened in a moment.
It is unfortunate that in so many cities the direct current is
still used. Since the consolidation, however, of the Edison and
Thompson companies, they are not using them so much, and
soon the alternating current will be utilized in all of the larger
cities. In reference to trouble from cauterizating the adjoin-
ing part, if the wire is drawn tight before sending the current
through this will be obviated. The trouble with the instru-
ments is that you have to pass the wire through the cannula
and then back again. In mine there are two perforated wires
which are threaded like a Sajous snare.
There is no question but that in many cases the inflamma-
tory reaction from the electro-cautery is greater than the cold
snare, for the reason that the surface is free from all germs ;
since I have become more familiar with the use of the instru-
ment I have severe inflammatory results less frequently. It is
the best in operating upon the uvula because one is not required
to pull down try? tip in any way. I simply let the uvula fall
into the tip and turn on the current. In the scissors operation
you are apt to cut off more than is necessary of the mucous
membrane, and in addition the inflammatory results are greater.
I have presented this paper because there is a scantiness of
literature in regard to the cautery snare for operations in the
nose and throat. I hope that when we next speak on the sub-
ject, I will have more in favor of it.
ON BONY GROWTHS INVADING THE
TONSIL.
Read in the Section on Laryngology and Otology, at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta. Ga., May 5-8. 1896.
BY ALEX. W. STIRLING, M.B., CM. (Edin.);
D.P.H. (Lond.)
ATLANTA, GA.
The cases which I bring before you are interesting,
I think, from the points of view of both the anatomist
and the practical surgeon.
The first is that of a young lady of excellent per-
sonal medical history. Her only complaint had been
slight chronic hypertrophic rhinitis, and for a few
years some enlargement of the tonsils, especially the
right, both of which secreted caseous matter and were
at times a little painful. The inferior turbinated bones
and the varicose veins of the lingual tonsil had been
cauterized by one throat specialist, another had cau-
terized her right tonsil, and a third had cauterized
cysts in both.
When tired she frequently complained of pain
which she believed originated in the right tonsil and
radiated thence to the mastoid and the right nasal
bones, as well as to the right eye and shoulder. When
squeezing out secretion she could feel a local tender-
ness in this tonsil.
On examination with the finger I was able to make
out a hard immovable mass coming from behind the
tonsil forward underneath it to the level of its ante-
rior surface, but forming practically part of its sub-
stance. Its point is rounded, apparently about one-
eighth of an inch in diameter, but becoming broader
and somewhat flattened laterally as it extends outward,
backward, and slightly upward. The finger pressed
in front enters an angle formed by it and the inferior
maxilla, and when pressed behind it enters another
angle formed by its approximation to the right side of
the vertebral column. The tenderness felt on pressure
appears to be due to the nipping of the tonsillar.mucous
membrane between the finger and the hard body.
Nothing of the kind can be discovered on the left
side.
The second case consulted me on account of larye
polypi of both nostrils from which she had suffered
for years. She is 64 years of age, has asthma and a
week cardiac muscle, but otherwise is in good health.
There is nothing of note in her family or personal
medical history. On examining her throat I observed
a slight protuberance just above and in front of her
right tonsil. With the finger I found it to be nearly
the same as that described in connection with Case 1,
with the following points of difference. In the sec-
ond case it exists on both sides, though it is not quite
so prominent upon the left side; it is also higher,
farther forward, perhaps a little thinner, and with a
more apparent upward direction.
The growth is quite immovable, and there is no un-
natural tenderness on examination. The patient has
never had the slightest trouble with her tonsils. I
have been able to examine the throat of one of her
daughters, but could find nothing unusual there.
The third case is a brother of Case 2, aged 66. He
likewise has been free from throat affections or any
infirmity which might have a bearing on this subject.
On both sides he has the same peculiarity, but differ-
ing from the previous cases in that the hard masses
arc altogether in the posterior part of the tonsils, are
much longer, reaching a full finger breadth below the
level of the lower tonsillar border, are perhaps rather
more slender and, for nearly half an inch of the lower
end on either side, cartilaginous to the touch and mov-
able.
The question now arises, what are these substances?
They are evidently not tonsillar calculi, because they
have none of their characteristics except tenderness.
In view of the fact that they have given rise to no
symptoms whatever in two cases, and from their for-
mation, position, and immobility, it seems to me cer-
tain that they are not the result of disease, but that,
they are rather congenital peculiarities, having how-
ever a distinct interest in cases of disease in their
neighborhood.
In endeavoring to come to a decision relative to their
origin, let us examine the bony structures from which
they might arise, for they can be nothing else than
bone. They all arise on the outer side of the throat,
and it may be from the lower jaw, the vertebral col-
umn, or the base of the skull. If they came from the
lower jaw to which they closely approximate, they
would move along with it, but not one of them does
so. They do not come from the bodies of the verte-
brae, because the finger can exclude these. The
pterygoid plates are too far forward; the spines on the
posterior extremities of the wings of the sphenoids
are rather less unlikely, but they too are somewhat too
far forward and are distant. It is much more likely
that the growths are simply prolongations of natural
prominences than entirely new formations ; by a pro-
cess of exclusion we are limited to the transverse pro-
cesses of the. vertebrae and the styloid process.
The tonsil is situated on the level of the upper part
of the body of the axis or of the disc between it and
the atlas. The transverse process of the axis is small
and does not move on rotation of the head. The bones
under consideration do move along with the head on
rotation, and come into much greater and visible
prominence when the head is turned toward the side
opposite to that under examination.
We are therefore reduced to the atlas which is as
1896.]
PORTABLE COMPRESSED AIR APPARATUS.
735
regards rotation of the head a part of it. and the sty-
loid process. To which of these the bones belong isa
question of interest chiefly in view of the possibility
of their becoming carious or involved in an operation;
for disease affecting the styloid process might spread
to the main body of the temporal hone, and the deli-
cate structures in relation with it, and if the atlas were
in any way injured at least a serious condition of
things might arise.
Upon this atlas, kindly lent to me by Dr. Grandy, with
this skull, the posterior limb of the transverse process
which ought to. but does not. join with the anterior to
complete a foramen, is nearly an inch in length, and
were it longer would reach the region of the tonsil if its
curve were continued, or were a little accentuated: and
its direction would correspond fairly well with that of
the growth especially of the first case.
The direction midsize of these growths afford no
satisfactory point for differentiation. Neither does
the movement of rotation, and the oidy way to distin-
guish between them, of which I have been able to
think, is that the skull proper moves when the head is
nodded, which is not the case with the Atlas. These
bones move with the head on nodding, and I therefore
conclude that they are styloid processes. Other argu-
ments in favor of this view are the presence of carti-
laginous terminations in the case of the male patient,
and the well-known variability in length of the styloid
processes. I have been able to obtain little or no assist-
ance from literature in making my diagnosis. Among
the books on anatomy and diseases of the throat which
1 have been able to consult, I have found only one
reference to such a condition as this. A few cases of
-is of the bodies of the vertebra*, having no
resemblance to these, have been recorded. Three
widely-known specialists on throat diseases with whom
I have been in correspondence, and one of the most
experienced of European anatomists have all informed
me that they have never seen such a condition as I
described to them.
The one reference to any such which I have seen is
in Bcheoh'8 book on diseases of the mouth, throat and
nose. He refers to a case "described from the ana-
tomic point of view by W. Gruber," and another from a
clinical aspect by Lticke, while Weinlechner is said to
have broken away a piece of bone which caused incon-
venience in swallowing. These are recorded as
abnormally long styloid processes.
This condition of the tonsil is not to be looked
upon as a mere anatomic curiosity, for in two at
of my three cases an attempt at tonsillotomy
might have been met with considerable difficulty had
a correct diagnosis not been previously made, and it
might be of consequence in other operations in that
region. As regards treatment, there is no necessity
to interfere in the cases of the elderly people. The
tonsils are troublesome in the first case, and it is a
question whether removal of part by the guillotine,
cautery or otherwise, or even the breaking up of it with
a blunt hook might not result in so tightly stretching
the mucous membrane over the bone as to produce pain
or even ulceration and exposure of the osseous tissue.
Personally, unless in case of urgent necessity, I should
be averse to removal of the latter on account of possi-
ble secondary mischief in the bone, or of interference
with the attachments of muscles and ligaments.
DISCUSSION.
Dr. W. E. Casselberry, Chicago, 111. — I saw these very
interesting cases. The first case to which he has reference, is
a very distinct pointed prominence on the right side occupying
the location of the anterior pillar, which covers it more than
the tonsil, although when it is stretched forward the tonsil
will cover it. The curvature inward and the position would sat-
isfy me that it was a styloid process turned inward toward the
throat. The other case had much the same condition but is not
so pronounced. The committee agreed that the case was an
abnormal styloid process. It is of some importance in connec-
tion with possible operations on the tonsils. In regard to
operating, laryngologists should take palpation more into con-
sideration. Upon palpation they would discover that there was
something of a hard nature and would be warned against
operating! I do not think anything serious would occur if an
operation was attempted ; I think the instrument in both
cases would slide over the projecting point rather than go
through it. I would not make a tonsillotomy in that case or
cauterize it, because the somewhat enlarged tonsil affords a
useful padding to the short-pointed projecting styloid process.
PORTABLE COMPRESSED AIR APPARATUS
AND NASAL SAW.
Presented to the Secttou on Laryngology and Otology, at the Forty-
seventh Annual Meeting of the American Medieai Association,
at Atlanta. Ga., May 6-8. 18»>.
Dr. E. Fletcher Inoals, Chicago, 111., presented a portable
compressed air apparatus, with the following remarks : This is
a compressed air apparatus designed for treating patients where
Portable Air Compressor, One-quarter Size.
we are obliged to carry an apparatus with us, as for instance
in going to theaters to treat actors ; or for the use of patients
who need a high air pressure for making applications to the
..<>-
k=&
Adjustable Saw, One-half Size.
larynx or Eustachian tubes. It consists of a cylinder eight
inches in length and three and a half inches in diameter, capa-
ble of withstanding eighty pounds pressure. The cylinder has
a movable head that will slide in so that the spray tube, pump
and all other parts of the apparatus may be placed inside the
cylinder when not in use. To use it the head is drawn up
against a rim with a rubber washer and quickly fastened by
clamps that make it air-tight. The air tube is one and a half
736
HYSTERIC DEAFNESS.
[October 3,
feet in length, so that the patient can hold the cylinder in the
lap while the application is being made. A bicycle pump is
employed, which is of convenient size to go inside the cylinder
when packed, but is of sufficient size to enable one to easily
obtain forty pounds pressure. The cylinder filled with com-
pressed air by this means holds sufficient to throw a strong
spray the length of time necessary for treating five or six
patients.
The price of this first apparatus, without a case was 815, but
as more are made the manufacturers say they can be furnished
in a leather case with space for a reflector, throat mirrors and
extra solutions, if desired, for 815. The case complete with
the extra space for other instruments will measure only eight
and one-half inches in length, four inches in width and five
inches in height, or without space for head mirror will measure
eight and one-half inches in length, four inches in width and
four inches in height.
Dr. Ingals also presented a nasal saw with an adjustable
handle that could be set at any angle. The instrument was
provided with two blades, one to cut forward the other back-
ward. It had proved very satisfactory. It was made entirely
of metal.
HYSTERIC DEAFNESS.
Read bv title in the Section on Laryngology and Oto'ogy, at the Forty-
seventh Annual Meeting of the American Medical Association
at Atlanta. Ga., May 5-8, 1898.
BY H. V. WURDEMANN, M.D.
Director Wisconsin General Hospital and Secretary of the Association;
Oculist and Aurist to the Milwaukee Children's Hospital and to
the Milwaukee County Hospital for the Chronic Insane.
MILWAUKEE, WIS.
That protean affection, hysteria, may be considered
a purely functional disease. There is, however, usu-
ally some concomitant affection or lesion which may
be deemed to be the cause. This may excite a local
hysteric attack in a patient predisposed by mental
or moral influences. Some actual injury or shock to
the part is in many cases the predisposing cause for
the local manifestation. Affections of the sight are
frequently seen; indeed, in most hysteric persons it
is possible to find some defect of the visual field.
Hysteric deafness is very rare. In the Medical
Xars, Feb. 14, 1891 I reported such a case. Since
that time two more have come to my notice :
Case 1.— Hysteric deafness and blindness in a woman after
injury to the head.
Aug. 29, 1892, a woman, age 42, was sent to me on account
of monaural deafness. She gave a history of a railroad acci-
dent a few days before in which she had been struck on the
left side of the head : had been prostrated and in bed after
arrival in this city. She claimed to have had severe. pain in
the left ear the day before and discovered that this was totally
deaf.
Status Presents: Patient very nervous and excited. There
was a contusion with swelling over the left orbit and malar
bone of same side, which patient thought was broken, but
examination showed no evidence of fracture. The vision of
this eye was slightly reduced for distance and she claimed that
she was not able to read ordinary print. Objective examina-
tion of the eyes was negative ; the refraction and fundus nor-
mal ; pupillary reaction and pupils normal. Contraction of
the visual field" on the affected side. Examination of the ear
showed a normal drumhead and no visible cause for the pain
or deafness. She could only hear loud sounds on this side.
That of the right was normal. Tuning fork placed on vertex
was heard only on the right side and not at all on the left by
aerial or bone conduction. There was no tinnitus or aural
vertigo at this time. Two days later the left ear appeared
totally deaf. She complained of great pain in the back and
leg of this side and of hypresthesia. She asserted that the
whole of this side was weaker than the other. Objective exam-
ination showed left hemihyperesthesia and a questionable
hemiplegia. Treatment advised was absolute mental and
bodily rest with bromid of kalium and valerian. Diagnosis at
the time was hysteric deafness, the locality of the functional
disturbance being probably influenced by the character and
place of the contusions. A prognosis was given of probable
recovery either after the effect of the primary shock had passed
away or after the lapse of some weeks.
One month later I examined her again, finding that she
could hear a loud voice but could not understand spoken words
on the left side ; hearing on right side normal as on first exam-
ination. Objective examination negative. Tuning fork only
heard on the right when placed on the vertex. She was excit-
able and had an anxious countenance and complained of pain
in the back of the head with creepy sensations and weakness
on the left side of the body. Also had pain in the ear and
roaring sounds which were immediately relieved by weak gal-
vanic electricity. Patient had a fainting fit in the street car
on returning home from my office. The vision was blurred for
reading in both eyes in a few minutes. There was now no
contraction of the visual fields and the vision was normal for
distance. About three months later the railroad company
having settled with a moderate sum for damages, the hearing
gradually came back to the affected side, and examination one
year later showed that it was normal.
Case 2.— Hysteric deafness and blindness in a child after
pulling the ear.
Nov. 9, 1893, an anemic child, aged 11, had trouble at school
several weeks before when the teacher pulled her right ear.
She became totally deaf on that side and partially so in the
left within a few hours : complained of her sight and was light
shy. Was given near-sighted glasses (—1 D.) by a jeweler,
with which she claimed she could see better, and without
which she kept her eyes closed.
Status Presens: The child was apparently apathetic and
stolid. The right concha was red and exquisitely tender to
the touch caused, as I observed, by furtively pulling the ear
when she thought she was not being watched. The membrana
tympani were normal. She has slight hypertrophic rhinitis
forwhich the mother had been douching the nose with a syringe
and salt water. Patient could not understand what her mother
said, although she had been shouted to for a couple of weeks,
but she was apparently observant of our conversation. On
taking the child aside I found that she understood me when I
talked in an ordinary tone of voice. All tests for hearing were
useless.
Her vision was R. and L. 6-18 with her glasses and without
them she would not read any letters. I explained the case to
the mother and commenced at once to make a decided mental
impression upon the child, i. p., to hypnotize her. I told the
mother in the child's presence, in a manner to give her the
impression that I did not wish the patient to hear what I said,
"that I was about to do an operation that would cure her at
once." The child seemed apathetic but responded to the
usual hypnotic suggestions and on brisk Politzerization with
chloroform vapor, could immediately hear ordinary conversa-
tion, her mother's voice as well as mine. Hearing tests showed
that she could hear the acumeter, the watch, whisper, voice
and tuning fork at a normal distance and in a normal manner :
besides this she could read all the test letters to (i VI without
glasses. These were taken away from her, but a subsequent
examination showed that the eyes were 1 D. hyperopic. The
child would not allow of a second Politzerization without hyp-
notic influence, but the effect of the one given was sufficient to
cure the case. Tonic treatment was instituted, and as long as
the case was under observation (six months) no return of the
hysteric symptoms recurred.
I can not ascribe either of these cases to malinger-
ing entirely, although in many cases of traumatic
hysteria there is a tendency toward deception. It is
probable that the disturbances of special sense in both
cases were entirely beyond personal control and were
only to be cured by outside suggestion. The first
case would not submit to such treatment, but in the
second it was thoroughly successful. I have seen
other cases of hysteria relieved in quite as remarkable
a manner.
805 Grand Avenue.
Amblyopia Consequent to Chronic Endometritis. Monte Mor
describes in O Brazil Medico, August 1, a case of almost total
blindness accompanying chronic uterine disturbances. Dila-
tation and curettement with antiseptic injections, etc., cured
the endometritis in fifteen days, and with it the amblyopia.
He queries whether the visual trouble could have been of hys-
teric origin, but adds that the duration, over a year, argues
against this supposition.
UStKi ]
ANATOMIC CHANGES IN RETINAL DETACHMENT.
ITHE ANATOMIC CHANGES IN TWO CASES
OF RETINAL DETACHMENT.
737
Kemi iu the Section on Ophthalmology, at too Forty-seventh Annual
Meetlug of the American Medical Association, at
Atlanta. «a.. May 6-8. ISM.
BY ROBERT L. RANDOLPH, M.D.
BALTIMOKK, MP
I have selected these two cases as being fairly
typical of the two principal conditions leading to
retinal detachment: first, a spontaneous detachment
due to fibrillary degeneration of the vitreous body,
and the second ease was one where a small round-cell
sarcoma had lead to propulsion of the retina away
from the choroid.
In case one the detached retina as it sprang from
the papilla appeared like a funnel having a neck about
one-fifth of an inch long and which at this distance
from the papilla commenced to assume the funnel-
like shape. The retina was detached below, all the
way around to the ora serrata. Above at a point one-
sixteenth of an inch posterior to the ciliary muscle it
was lying in position. From this point it turned
backward and then passed directly down to a point
which lay in the pole of the Lens, and from here took
a course forward and then upward and finally lost
itself in the ora serrata. That part of the funnel
which hail an upward direction was thrown into
numerous and intricate folds and enclosed in its
meshes a mass of vitreous body, while that part which
passed below was composed of the entire thickness of
the retina which appearetl quite normal. The peculi-
arity of this portion was the absence of folds. The
inner surface of the retina at the widest part of the
funnel was covered with a thick mass of vitreous body
and the angle which was formed by the ciliary body
in front and by the retina behind, as it fell backward
ami downward from the ora serrata, was filled with
Coagulated material and fine fibrillar, which latter
d forward and served to form numerous bridges
across this angle. The ciliary processes were covered
posteriorly with several layers of the vitreous fibrillae.
The zonula was not distinguishable as such, it no
doubt being merged into the vitreous fibrilla?. That
portion of the vitreous lying between the retina and
choroid was empty. No doubt we had a fluid here
during life. At some points anteriorly could be seen
what are described by Nordenson as the choroidal
tufts, which appeared like little bridges uniting the
retina and choroid. There was nothing worthy of
note about the choroid and the same could be said of
the ciliary body, iris and lens. There was a great
quantity of material in the interior chamber which
was probably transudate, coagulated by the hard-
ening process.
Microscopic Changes. — The changes in the retina
were very noticeable and particularly in the anterior
part of the eye. The anterior portion of the detached
retina was the seat of the most marked degenerative
changes, the retina itself resembling closely a reticu-
lated tissue in which there was hardly a trace of the
several layers. Posteriorly it was easy to recognize
the several layers but they gradually disappeared
toward the ora serrata and the only evidence of a
layer was a single row of granules which marked the
course of the external granular layer. The layer of
rods and cones was intact in several places but this
condition was usually found in the posterior half of
the eye. At those points where the retina was thrown
into very intricate folds this layer was more apt to be
absent, but even in this situation it was sometimes
present. In those situations where the layer of rods
and cones was absent its place was filled by a mass
of albuminous drops, which were arranged in layers
one on top of the other. On the inner surface of the
retina one could see the meshes of the vitreous
fibrilla?, which appeared to be exercising traction upon
the surrounding retina. This layer of fibrillse was
tolerably rich in nuclei. In one place the retina had
carved around so as to form a loop, on one side of
this loop all the layers were to be seen with the
exception of the ganglion cell layer. The layer of
rods and cones could be plainly seen as well as the
external limiting membrane. On the opposite side
of this loop the only layers which were present were
the external granular and the external molecular, the
latter to a very limited extent. The inner layers in
this situation had been pulled out of all shape by the
vitreous fibrilla?. The external granular layer pre-
sented generally a very irregular border line appear-
ing at points as papilla-like projections, due I think
to the folding of the retina. The layer which occu-
pied the usual position of the nerve fiber layer and
which to a large extent was that layer, was the seat of
numerous nuclei. The radiating fibers of Miiller
showed generally a wavy course. The line of demar-
cation between the ganglion cell layer and the nerve
fiber layer was difficult to make out. This was no doubt
to be attributed to the traction exerted upon the nerve
fiber layer by the fibrilla? and also by the very irregu-
lar course followed by the radiating fibers. Asa rule
the ganglion cells had dropped out of the section and
it was impossible to identify this layer. An examin-
ation of the neck of the detachment, or as I have
called it, the neck of the funnel, showed no remains
of the vitreous body.
This neck appeared to be a mass of connective
tissue in which it was impossible to distinguish any
of the retinal layers though it seemed to be made up
largely of the granular. At the papilla there was no
semblance of the retinal structure. There was too at
this latter point a notable absence of blood vessels.
Upon the neck of the detachment on all sides there
were resting several layers of albuminous drops. The
fibrilla? were for the most part devoid of nuclei.
They often appeared as though they came directly
out of the retina and made their way into the vitre-
ous body or as though they were prolongations of the
radiating fibers, so intimate was their connection
with the latter.
< 'horoid. — On the inner surface there were several
layers of albuminous transudate resting on the pig-
mentary layer of the retina, which layer had remained
behind as it usually does in such cases. Increased
nucleation was everywhere present throughout the
choroid, and further than the points just mentioned;
there was nothing noteworthy in this part of the eye.
The vitreous body was entirely wanting in the poste-
rior part of the eye. Just behind the lens it seemed
to be transformed into granular debris devoid of
fibrilhe, while in other portions it was composed
apparently of the fibrilla? which have been described.
The lens, iris and ciliary muscle were normal.
The chief points then about the pathologic anatomy
of this case were: 1. The widespread atrophic degen-
eration of the retinal layers and especially of the layer
of rods and cones. As a general thing the granular
layers were the only ones which were preserved. 2.
Swelling of Mtlller's fibers. 3. The presence of
^38
ETIOLOGIC FACTORS IN RETINAL DETACHMENT.
[October 3,
albuminous drops in various localities, especially
between the choroid and retina and along the neck of
the detachment, and finally the transformation of the
vitreous body into the fibrillse.
The second case was that of a boy aged 7 years who
came to the Johns Hopkins Hospital early this
spring. His parents had taken him to an oculist
several months previously and at that time his eye
was not thought to be in a serious condition. He had
been complaining for the last three weeks of severe
pain in his right eye and his parents had noticed a
whitish yellow reflex from this eye. This was very
noticeable when he came to the hospital. The ten-
sion of the eye was decidedly elevated and the con-
junctiva was injected. Vision in this eye was com-
pletely gone. I advised enucleation and the eye was
removed the following day. The macroscopic condi-
tion was as follows: The tumor involved almost the
entire nasal half of the retina, filling up that side of
vitreous space both above and below. It extended
backward and seemed to proceed from the nasal side
of the optic nerve and, advancing into the vitreous,
stopped at a point about a quarter of an inch poste-
rior to the lens. Over the area occupied by the
tumor there was no trace of the retina to be seen.
On its free side the growth was quite nodular and one
of the nodules projected across to the temporal side
of the eye and almost reached the retina on that side.
The retina in the temporal side of the eye was
completely detached.
Microscopic changes: The tumor was scant in
intercellular substance and was made up of small
round cells. Blood vessels were quite numerous and
they were usually filled with red blood corpuscles.
Large areas of the growth failed to take on the hema-
toxolin stain but stained with eosin. These were
evidently necrotic areas. Hemorrhages were fre-
quently seen. Wherever the tumor was present the
retina was indistinguishable, the tumor having grown
into it. The tumor cells were found in the optic
nerve as far back as a quarter of an inch from the
papilla. The vitreous body had been crowded over
to the temporal side of the eye and transformed into
the characteristic fibrilhe, which were exerting trac-
tion upon the retina and had pulled it into intricate
folds in the anterior portion of the eye and just
behind the lens the traction was enough to pull the
retina backward to such an extent that there was
only a short, narrow bridge separating the latter from
the growth. The layer of rods and cones was no-
where visible, and as in the first case, the ganglion
cells had dropped out of the section. The internal
and external granular layers were clearly definable
from the equator around to the ora serrata. The
retina posterior to the equator was very much thick-
ened and broken down, failing to stain. At one point
only, and for a very short distance, the external limit-
ing membrane could be seen. The fibers of Muller
were somewhat swollen and had a wavy course, which
more or less disturbed the position of the retinal
layers. The choroid nearly everywhere had been
attacked by the growth ; large and small heaps of sar-
coma cells were present in this coat, and generally
they were resting under the pigmentary layer of the
retina, which latter was pushed up. This condition
extended around as far as the ciliary region on the
nasal side and on the temporal side a short distance
from the papilla. There were no albuminous drops.
The principal changes in this case were the conver-
sion of the vitreous body into fibrilhe and the atrophic
degeneration of the retina in the anterior part of
the eye.
It would seem then that fibrillary degeneration of
the vitreous body is to be found in both classes of
cases. In the case of spontaneous detachment it was
evident that the fibrilhe were largely concerned in
pulling away the retina from its normal position and
from the arrangement of the retinal folds shrinkage
or contraction from within must have been going on.
In this case there was a considerable exudate consist-
ing of albuminous drops resting on the membrana
limitans externa, which exudate no doubt played a part
in separating the retina and choroid. These two con-
ditions would explain the detachment in the first case
and similar ones. In the second, the presence of the
sarcoma was sufficient to lift the retina from its posi-
tion, though even here it was clear that the retina was
subject to a force from within which helped to pull it
still further away from the choroid. I failed to dis-
cover a rent in the retina in either case.
In conclusion, then, the most striking anatomic
change in these two cases was the fibrillary degenera-
tion of the vitreous body, a condition which I think
is found more or less in every case of retinal detach-
ment, and which probably is the chief element in the
pathogenesis of the disease.
ETIOLOGIC FACTORS, OTHER THAN MY-
OPIA, IN THE PRODUCTION OF
RETINAL DETACHMENT.
Read In the Section on Ophthalmology, at the Forty-seTenth Annual
Meeting of the American Medical Association, held at
Atlanta, Ga., May 5-«. 1896.
BY H. O. REIK, M.D.
Assistant Surgeon. Baltimore Eye, Ear and Throat Charity Hospital
and Assistant in Ophthalmology and Otology. Johns
Hopkins Hospital.
BALTIMORE, MD.
Of all cases of retinal detachment, between 40 and
50 per cent, occur as the result of high degrees of
myopia with the severe choroido-retinal changes that
attend this refractive condition. In must of these
cases the separation occurs spontaneously, but even
in those in which it is the direct or immediate result
of traumatism the eye has been previously prepared
for this accident by the weakening of its tissues. In
a study of the other 50 or 60 per cent, we are com-
pelled to attribute their origin to quite a variety of
causes.
The first of these to consider, because of its fre-
quency, is trauma. Whether the eye be myopic or
hypermetropic, diseased or healthy, a wound and par-
ticularly one that penetrates the sclerotic and chor-
oidal coats, may give rise to intraocular changes that
result in disorganization and separation of the chor-
oid and retina. A myopic eye, or one that is the
subject of choroidal or retinal disease, is predisposed
to detachment, and in such cases often a very slight
blow will produce very serious consequences. Any
severe blow, or injury about the head, may produce
detachment, and Dr. Maher has reported a case which
he believes, and with apparently good reason, to have
been caused by the use of forceps at birth.
The next largest number of cases are the result of
pathologic conditions of the choroid or retina pro-
duced by those diseases of the kidneys which may be
grouped under the general title of albuminuria. It is
not uncommon to find associated with Bright's dis-
ease a retinitis or choroido-retinitis with more or less
IS'.tf. I
ETIOLOGIC FACTORS IN RETINAL DETACHMENT.
739
impairment of the vision, and in a small percentage
of these eases detachment takes place. The anatomic
seat of tlic eye lesion in this disease is probably the
blood vessels, and as the supply vessels of the retina
are end arteries any interference with their function
is not compensated for as readily by collateral circula-
tion as would be the ease in other parts of the body.
So. almost always an extensive edema of the retina
exists, which, owing to the loose attachment of that
tissue, gives rise to the production of delicate
folds in the membrane and later these may amount to
a positive detachment, with its tendency to spread
over the greater part of the fundus. Occasionally,
however, the detachment is brought about in a differ-
ent way. The vessel walls are sclerosed and weak-
ened by the general disease, and any influence which
tends to suddenly increase the blood pressure causes
a rapture of the vessel wall with consequent hemor-
rhage, and the blood clot, if it be sub-retinal, pro-
duces a mechanical separation of the retina from its
bed. It would appear from the cases reported that
detachment occurs most frequently in that class of
kidney troubles in which we have to deal with what
is known as the small granular kidney. As very many
of the reports, however, do not state the pathologic
nature of the kidney lesion, it is difficult to arrive at
any definite conclusions in this direction. The above
supposition, however, is what one would naturally be
led to expect, as it is in association with the small
atrophic kidney that retinitis albuminuria is most
common. .lust as the retinal inflammation may occur
in any form of nephritis, either acute or chronic, so
may detachment be the ultimate result.
The class of cases which probably offers us the
most favorable prognosis is that occurring in the
albuminuria of pregnancy, for here, if necessity arises,
the cause of the disturbance may be removed, and
with that element withdrawn there is a remakable
tendency to spontaneous recovery. There seems to
be no particular time in the course of pregnancy
when we may anticipate retinal complications, as
retinitis has been observed in every month, yet it is
probably most liable to occur in the latter part of
gestation, when the greatest tendency to general
edema exists. Schoeler reports cases of two sisters,
both of whom suffered during pregnancy from de-
tachment of the retina without any signs of albumin
or retinitis.
The following case of retinal detachment was
related to me by Dr. Randolph. It is especially inter-
esting as having occurred during labor. The woman
was the mother of eight children and always had easy
labors. Just before the birth of the ninth child her
physician had made a thorough examination of her
urine but had not discovered anything pathologic.
The labor was an exceedingly painful one and lasted
for twenty-four hours. At the height of one of her
pains, and just after she had made a violent effort,
she noticed that everything became blank before her
right eye. Since then she has been practically blind
in that eye. When seen by Dr. Randolph there was
nearly complete detachment of the retina in the right
eye, the left eye being quite normal. The case was
seen a few days after the labor. I think that the vio-
lent efforts and straining which she was constantly
making led to a rupture of one or more of the retinal
vessels which discharged their contents beneath the
retina, thus forcing the latter away from the choroid,
producing a detachment. When we consider the
frequency of subconjunctival eochymoses following
great efforts at stool or in children with the whooping
cough, it is not strange that hemorrhage from the
deeper vessels of the eye should have followed the
violent efforts of a woman in labor.
A few cases of detachment due to diabetic retinitis
have been reported, but such cases are extremely rare,
as diabetes is but seldom complicated by retinal
disturbances.
Galezowski found it, I think, in about 2 per cent,
of his cases; syphilis is given as the cause, and the
same writer reports four cases the apparent result of
sympathetic ophthalmia.
Dr. Mathew Owens of Brisbane, reported in 1884
two rather peculiar cases of double retinal detachment
occurring in previously healthy eyes, as the result of
sunstroke. Both men were cattle rangers and the
sunstroke was followed immediately by detachment.
The men were young and there was no history of any
diseased condition that might have predisposed them
to detachment. In considering the cases Dr. Owens
offers the following as a possible explanation: "It was
shown by Boll that eyes which have been exposed to
the influence of various colors are affected very differ-
ently as regards the pigment epithelium layer. If
eyes have been exposed to red or yellow, or kept in
darkness, the pigment layer is quite easily separated
from the retina, but not so if exposed to white, green
or blue. The retina and pigment are so closely united
that they can not be separated. . . . The eyes of both
patients had been exposed for some hours to the sun's
glare, retinal hyperemia was present, sunstroke came
on ; the sinuses of the brain being engorged there was
an impediment to the return of the blood to the brain
from the congested fundus, effusion of serum took
place, and the retina was quite ready to be detached
because its pigment layer had been exposed to the
yellow glare of the dried up ground." It is a rather
unique explanation, and one which in my opinion is
somewhat forced.
Erysipelas of the face and neuralgia of the fifth
nerve in a small number of cases, have appeared to be
the cause of retinal detachment.
Separation may be produced mechanically by
hemorrhage or by sero-purulent exudates such as
occur in purulent choroiditis or in phlegmon of the
orbit. Tumors in the choroid or retina, or a cysticer-
cus developing beneath the retina may also be causa-
tive factors. The tumors are usually glioma, or,
choroidal sarcoma.
In every case of detachment the cause should be
determined, if possible, because of its important bear-
ing on the treatment. Rydel has given statistics to
show that 5 per cent, of all our blind have become so
from retinal detachment. Despite the greatest care
taken, however, in examining these cases, there still
remain a large percentage in which no cause for the
lesion can be ascertained. In these cases the patient
usually gives the history of having been perfectly
healthy, with an eye that was either emmetropic or
hypermetropic, and no exposure to injury of any kind.
The first symptom is a slight cloudiness of the vision,
or a limitation of some portion of the visual field. It
is not attended by pain and it is only the loss of vision,
more or less complete, that causes the patient to con-
sult an oculist. Some have thought that disturbances
of the sexual nervous organization might be an ex-
planation of a few cases, and in that connection quote
Hutchinson as saying that "sexual abuse may produce
740
TREATMENT OF DETACHMENT OF THE RETINA.
[October 3,
degeneration of the vitreous," but I can find no case
recorded where there is any conclusive evidence of
this having been the cause. Sudden suppression of
the menses may result in hemorrhage, and that in
detachment.
The pathology of this affection has not been satis-
factorily explained. It was formerly held that the
retina was pushed forward by a transudation from the
choroid. This hypothesis now has few adherents.
A second theory, now generally known as the Leber-
Nordenson, and which is the one most generally
accepted, attributes the attachment to traction from
the vitreous side. The active cause here is held to
be a shrinking of the vitreous, which ruptures the
retina and permits the fluid from the vitreous cavity,
pressed out by the contracting tissues, to pass through
the rent into the subretinal space.
This hypothesis assumes not only a shrinking of
the vitreous, but an adhesion between the vitreous
and retina and a rupture of the retina previous to its
detachment.
That rupture of this membrane necessarily precedes
its detachment I do not believe. I can not see the
need of this supposition in regard to a tissue so loosely
attached to its bed as is the retina, and, furthermore,
if it does always occur we should be able to see it in
a greater number of cases. In a very large percentage
seen, even in early stages, it is impossible to find a
rupture and even Leber, who considers it so important
to his theory, found it positively, in relatively fresh
cases, in only about 50 per cent.
It may be that in some cases, at least, the change
in the vitreous humor is a chemic one, which leads to
an interchange of fluids between that body and the
blood vessels of the choroid, and that detachment is
produced in accordance with the diffusion theory.
This theory, so ably advanced by Raehlmann, has not
received the consideration it would seem to merit.
Though the immediate cause of displacement is so
obscure it is probably safe to say that the vitreous is
always the seat of pathologic alteration, though such
changes may not be, and often are not, apparent by
ophthalmoscopic examination. One can hardly con-
ceive, except in case of intra-ocular growth, or of sub-
retinal hemorrhage, of detachment occurring when
the vitreous is of normal consistency and exerting its
usual pressure on the surrounding parts.
TREATMENT OF DETACHMENT OF THE
RETINA.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8. 189«.
BY CASEY A. WOOD, M.D.
CHICAGO. ILL.
Without taking your time with a historical sketch
of the various remedies employed in the treatment of
detachment of the retina I may say that the earliest
efforts of the ophthalmic surgeon were directed to
puncturing the subretinal sac, as it was found that this
usually brought the displaced membrane into its nor-
mal position. As, however, the detachment was
found to occur a second or a third time or, indeed in
many cases, as often as it was replaced, various expe-
dients were resorted to with the hope of rendering the
cure permanent.
Before speaking of these matters in detail let me
remind you that replacement of the membrane does
not necessarily mean a restoration of the lost visual
function, although it is a sine qua non of that restora-
tion. Nor do the visual acuity and the extent of the
visual field form a proper measure of the success of a
remedy for detached retina as such. A badly dam-
aged retina (as in the long standing cases) perfectly
replaced may give results much less satisfactory io
the patient than an imperfect replacement of an other-
wise healthy membrane — such as we commonly find
in recent examples of this disease.
I pass over the treatment by rest in bed, with or
without such adjuncts as bandages, the local use of
eserin and atropin, the internal administration of
salicylates, purgatives, diaphoretics, potassic iodid.
pilocarpin injections, starvation, iridectomy, sclerot-
omy and puncture of the sclera, to take up certain
other surgical proceedings that are now claiming
attention as being more or less novel.
I had been attached for nearly a year to Professor
Scholer's Klinic in Berlin when he first began to
experiment with intra-vitreous injections of iodin in
this disease. Consequently, I have had excellent
opportunities of observing its effects. Although much
was hoped and expected from the procedure and a
number of cures have certainly resulted from its use,
the evidence is on the whole against it as a dangerous
and by no means certain remedy. That numerous
eyes have been entirely lost from the employment of
Scholer's method, I am obliged to confess, and I do
not think that, even in its modified form, one would
be justified in employing it. Most of you will also
recollect Gelpke's experience. The patient, a healthy
man, 66 years of age, with detached retina, received
under strict precautions a vitreous injection of three
drops of iodin mixture. In tiro days he had <t puru-
lent choroiditis and in six days he died of acute
meningitis.
Other less active and more certain expedients may
be employed to produce all the effects which Scholer
claims for the iodin injections. We may dismiss,
also, as needless and dangerous, the injection of irri-
tating fluids — such as potassic permanganate, sug-
gested, I think, by Darier — through a puncture in the
sclera. To this category, too, belong De Wecker's
device of a gold suture and Galezowski's catgut suture,
all three intended to produce local inflammatory areas
and so bind choroid and retina together.
Wolfe of Glasgow, made a long incision (6-10 mm.)
through the sclera, the underlying conjunctiva being
pulled away by hooks, and so obtained free and con-
tinued drainage of the subretinal fluid. In fifteen
eyes he had improved vision (lasting five months to
a year) from \ to 1-50; in five cases the results were
nil, and in two instances the eyes were lost. Even
when performed under strict aseptic precautions the
danger of infection through these large wounds must
be considerable.
Gillet de Grandmont first advised electrolysis of
the subretinal fluid. Simi of Florence, among others,
has successfully tried this method in a case of recent
detachment, using a 5 milliampere current for sixty
seconds, and two weeks subsequently the same current
for seventy seconds. There were signs of reaction in
both iris and vitreous and the exudation disappeared,
but the detached portion remained opaque and was
clearly outlined from the healthy retina by a pig-
mented line.
Terson of Toulouse, from a study of twelve cases in
which he employed electrolysis of the post-retinal
fluid, believes that the method of Gillet de Grandmont
1896.]
TREATMENT OF DETACHMENT OF THE RETINA.
741
with a single needle attached to the positive pole is
superior to those of Abadie and Scholer, the latter of
whom employed the bipolar plan — making two punc-
tures iii the globe.
Posterior OptrfkcdntotoMy, Gralezowaki1 formerly
relied on iodin injected into the post retinal pocket
i L886) with aspiration of the contained fluid. If neces-
sary he followed this with a catgut suture, passed
like De Wecker's earlier gold stitch, through all the
eye coats. This latter procedure usually succeeded
in binding the retina to the choroid but as it was fol-
lowed in two instances by severe intraocular inflam-
mation lie abandoned it in favor of the operation
which he now recommends as free from danger and
quite as successful. He calls it posterior ophthal-
motomy. The instrument used is in the form of an
are of a circle, like a curved needle, so that a suffi-
ciently large puncture and counterpuncture can be
made and a sufficient number of retino-choroidal
cicatricial points produced to keep the detached mem-
brane in place when it has once returned. He has
already followed this plan some seven times -in five
cases with partial, in two with great success. In one
instance <>f a man aged 50, with a double detachment,
of long standing on the left side, but recent on the
right, he obtained a complete cure in six weeks. The
linear cicatrices could be made out with the mirror;
the visual field and central acuity were very greatly
increased.
Probably the most recent, original and important
contribution to the rational treatment of retinal
detachment has been made by Deutschmann of Ham-
burg, which first appeared in his Beit rage zur Aiii/cii-
heilkunde, although he has since (in May, 1895) given
an abstract of the brochure in the Deutsche med.
Wochenschrift. He prefixes the account of his
methods by a reference to Erik Nordenson's work
with Leber.
A part from certain rare forms of the disease, detach-
ment is due not so much to a primary deposit of
water from the choroid behind the retina as to the
dragging upon this coat by a diseased and shrinking
vitreous. The detachment is merely one of the signs
of the vitreous disease. Nordenson shows that with-
out losing its transparency the vitreous develops a
fibrillar quality, decreases in volume and in shrinking
allows the vacant space to be filled with serous liquid.
This change in the consistence of the vitreous body
is not unfrequently accompanied by proliferation of
the vitreous elements as well as by a chronic inflam-
mation of the choroid. Portions of the thickened
vitreous remaining firmly attached to the retina are,
with it, liable to be dragged toward the center of the
posterior chamber. Deutschmann's first proceeding,
yr\richhem\mesX('tiItaiit(/l(fxl:<ir]>('r(hirchsehneidiing,
is intended to sever all connections between the
shrinking vitreous and the retina, to allow of a free
communication between the posterior chamber and
the serous collection behind the retina, to empty the
latter space so that the freed retina may return to
its normal position, and lastly, to produce adhesion
between choroid and retina at certain points; these
indications are met by the following operation: The
previously atropinized eye is cocainized and a double
edged knife, of the Grraefe pattern, is introduced at
the chosen spot, the conjunctiva being pushed to one
side. It pierces all the ocular coats, sclera, choroid,
and the detached retina. Thence the knife is passed
i (.al.z.wski : Mem. et Bull, de la 8oc. frs. 1895, p. 170.
obliquely through the vitreous mass until it touches
the opposite wall of the bulb. It is now carefully
moved to and fro toward either side making a vitreous
discission and is finally removed, and a light occlusive
and antiseptic bandage applied. Slight hemorrhage
occurs at the point of entrance of the knife and in-
flammatory action is set up about the incision points
in both choroid and retina. This latter process is re-
lied upon to permanently fix the retina to the choroid
and so resist any subsequent pulling of the vitreous.
The patient is now kept in bed for eight to four-
teen days, until the ophthalmoscope shows that the
case is cured. The atropia is continued for several
weeks longer. When the retina does not lie perfectly
flat, on the day after the operation, a delay of a few
days may be made in the hope of its complete return
to the normal position. If this fails the same proced-
ure is to be resorted to, as often as is required, until
the desired effect is obtained. Deutschmann has oper-
ated ten times upon the same patient with good results
at last. He thinks that repeated thrusts of the knife
are safer than, and as effective in inducing a sufficient
degree of adhesive inflammation between the retina
and choroid as the application of the Paquelin or
electro-cautery point to the sclera, or, piercing that
also, to the choroid and displaced retina beneath.
He refers in his short article in the Deutsch. med.
Woch., to eleven patients treated by him, to date.
Upon four the Paquelin cautery was employed and
the sclera pierced. Of these four, two were partially
relieved and two not benefited. Of the remaining
seven, where the cautery was omitted, total replace-
ment ef the retina was obtained in six instances, with
decided improvement in vision. This satisfactory
condition has persisted in one case for four years,
three cases two years, one case one year and one five
months. In the case, where least benefit accrued, only
one operation was made, the patient declining further
interference.
The author advises this operation in those more
favorable cases, where the displacement is recent and
not too widespread and where disease of the coats is
not advanced.
In another class — in their nature more hopeless — he
has employed quite a different and novel remedial pro-
cess, which he styles " Kaninchenglaskorpertrans-
plantation." This was first tried on a patient 28 years
of age, with bilateral detachment of the retina. The left
eye had suffered a sudden and total separation of the
retina from the choroid. The eye was soft and vision
was reduced to perception of light in the upper part
of the field. Both anterior and posterior retinal
spaces were filled with a sero-sanguineous fluid.
Deutschmann removed this bloody serum and with
an ordinary hypodermic syringe injected into the
empty vitreous cavity the freshly prepared, aseptic
vitreous of a young rabbit, diluted with a | per cent,
solution of common salt. The addition of the steril-
ized salt solution was intended to allow of easy flow
of the vitreous as well as to act as an irritant and bind
the choroid to the retina. The result was marvelous.
The operation was performed Feb. 4, 1894. On April
28, V = ^ViT i on July it was ]^ and Jager No. 3. F. of
V. for white was uncontracted and has so continued.
Deutschmann has, to May, 1895, performed this
operation on six patients and seven eyes, and in four
obtained results that hitherto would have been
regarded as impossible. In all, central vision before
the operation was reduced to perception of light or
742
RETINAL DETACHMENT AND EDEMA.
[October 3,
shadows and most of them were cases of total detach-
ment.
In case 2, which was of many years standing, there
was beginning secondary cataract; V= eccentric
finger-counting at four feet. Result: Useful central
vision, replacement of the detached retina and enlarge-
ment of the eccentric field to twice its previous size.
Case 3, total detachment from injury. V= hand move-
ments. Visual result not very encouraging. V=finger
counting at 2 and 3 feet eccentrically.
In the other cases the result was uniformly favora-
ble. The patients have been under observation for from
a year in Case 1 to five months in Case 6 after the
replacement of the retina. This operation may have
to be repeated two or even three times and it must be
remembered that an inflammatory reaction follows
each injection.
Detachment of the retina does not occur often in
this country, but I have on my records six cases that
consented to be treated for a sufficient length of time
to make my experience with them worth mentioning.
The treatment for two scleral punctures, one iridect-
omy and the other three had prescribed for them
continued rest in bed with pilocarpin injection. Only
in one case, treated by puncture and pilocarpin, was
there a permanent cure, the retina being replaced, the
visual field expanded, and the central vision now
equals finger counting at seven feet, although at one
time it was reduced to perception of light. This con-
tinued for nearly a year, when I lost sight of the pa-
tient. My experience of this disease in my own prac-
tice, public and private, and in that of others lead me
to think, with Bull of New York, that we have as yet
discovered no better device than that resorted to with
occasional success by the older ophthalmologists, viz. :
rest in bed, bandages, atropin and the internal use of
some absorbent. Instead of the long continued use
of pilocarpin, especially when that drug is ill borne
by the patient, we may substitute soda bicarbonate
and potassic iodid, well diluted with water. In all
recent cases where the eye is quiet and there is no
vitreous strand to sever, conjunctival puncture of the
sclera may do temporary good and vision may be im-
proved. Division of fixed membranous bands in the
vitreous may be done without causing much reaction
and may prevent extension of the disease. He does
not approve of Scholer's method.
In conclusion, this review of the treatment of
detached retina would be incomplete without a refer-
ence to spontaneous cures. Many such cases are
recorded; indeed one may safely say that of all the
histories of cures, temporary and permanent, at least
10 per cent, were accomplished without treatment. So
numerous and well authenticated are they that I think
that a large percentage of the results obtained after
iridectomy, after removal of the lens, from the use of
atropin, bandaging, pilocarpin, etc., even some cases
of cure following posterior operation, are really
brought about by local and general rest — by putting
patients in such a position that they can not by over
exertion of any kind make a bad matter worse. The
retina, having meantime broken loose from its con-
nections with the shrinking vitreous, returns to its
natural position — and the treatment, medical or sur-
gical, receives the credit.
This is the proper season to increase the member-
ship in the Association. Let everyone secure one !
REPORT OF A CASE OF RETINAL DETACH-
MENT AND EDEMA OCCURRING IX
CHRONIC BRIGHT'S DISEASE.
Read in the Section on Ophthalmology, at the Forty-seventh Annua)
Meeting of the American Medical Association, held at
Atlanta, Ga., Mav 5-8. 1896.
BY LOUIS F. LOVE, M.D.
OPHTHALMIC SURGEON TO 8T. MARY'S HOSPITAL, HOUSE OF
GOOD SHEPHERD, ETC.
PHILADELPHIA, PA.
When we take into consideration the blood condi-
tions existing in albuminuria, it seems strange that
the occurrence of retinal edemas and detachments arc
not more frequently found. The vitreous body is
undoubtedly nourished from its surroundings, and
Raehlman long ago demonstrated that by injecting
strong salin solutions into the vitreous he was able to
produce retinal detachment and that the fluid secreted
was densely albuminous, so that it seems rational to say
that any cause which produces profound changes in the
circulation would interfere with the balance of osmosis
between the vitreous body and the choroidal vessels.
I believe that by a careful chemic and microscopic
examination of the general blood conditions, espe-
cially the liquor sanguinis, we might be able to bene-
fit, at least, some of our patients to whom we are at
present useless. In detachments taking place in high
myopias or resulting from inflammatory conditions,
this line of investigation would be of no avail; but in
those cases arising without apparent cause, such as we
occasionally see in emmetropic eyes, that such a
research might be of use. This case is reported for
the reason that it is not only rare, but because of the
unusual prolongation of life.
C. D., a short, stout woman, aged 54 years, applied
for treatment Oct. 26, 1892, giving the following his-
tory: Had always enjoyed good health. Lately
slight headaches and dyspnea upon exertion. She
is the mother of five children, three living, no miscar-
riages, menopause at 46. Four years ago her vision
in her right eye failed suddenly. About two weeks
ago she noticed a dimness in the left eye. The pres-
ent eye conditions were as follows: O. D. V. =
counting the fingers at ten inches. O. S. V. = y{f +
S. 2D. = f j} + S. 4D. type ID. 12c to 25c. The eyes
are rather deeply set, ocular and tarsal conjunctiva
pale, the arcus senilis well marked above, the color
of the irides brown, right pupil 3 mm. and very slug-
gish to light; left pupil about 2-£ mm., active to light.
Anterior chambers shallow, strong reflexes from both
lenses. Right eye Tn — left Tn.
Ophthalmoscopic examination O. D : A few very
fine floating vitreous opacities; the nerve decidedly
atrophic; the vessels diminished in size and a retinal
edema extending well out when an extensive retinal
detachment was plainly seen superiorly and inferiorly,
giving the characteristic delicate gray undulating
tremulous protruding membrane. The vessels could
be traced from the papilla out into the detachment,
and in places showing sharp bends and partially hid-
den from view by the folds of the separate surface.
The disc is seen best with -f- 3D., the detachment
with about + 7D. Left eye lens seemingly hazy,
disc very red gray, veins slightly enlarged, arteries
normal in caliber, carrying poor blood, a large area of
hemorrhagic extravasation in the macula region and
a few white plaques found just above the disc. H. = 4d.
Examination of the urine was as follows: Straw
color, acid, specific gravity 1018; albumin in moderate
Ivm; ]
RETINAL DETACHMENT AND EDEMA.
743
•mount, no sugar; microscopic examination hyalin
OKSts, [His cells and few blood corpuscles.
The patient was under the care of Dr. J. C. Wil-
son, who saw her on four or five occasions, between
Nov. 1. L892, and March of the following year. His
report to me was as follows: There was cardiac
hypertrophy, accentuation of the aortic second sound
and slight pre-tibial edema. She improved in respect
to the headaches and restlessness while under treat-
ment by strychnin and nitroglycerin, together with a
carefully regulated dietary.
The woman was not seen again until Nov. (5, 1895,
three years after the first examination. O. D. V. =
light perception only. O. S.V. = i;; +K. 2D.V. = $«.
Ophthalmoscopic examination shows vessels thread-
like in the right eye. apparently similar conditions
of retina as existed when first seen. The left
eye. the nerve quite gray, vessels about normal in
size, in the macula region a brownish black area, and
above the disc there are characteristic changes of an
old retinitis Brightii. The patient states that her
general condition is about the same, enjoying fairly
good health; site has taken no treatment since March,
iy.ri. but adheres somewhat to the regulated dietary
as ordered by Or. Wilson.
\~ifrl Frankford Avenue.
DISCUSSION ON PAPERS OK DRS. RANDOLPH, REIK, WOOD,
AND LOVE.
Dr. J. A. White, Richmond — In considering the etiologic
factors nf detachment we are to eome extent groping in the
dark. Apart from myopia, tumors, subretinal hemorrhages
ami effusions, I do not think we have any very sure founda-
tions for explaining the many cases we meet with where there
is no apparent cause whatever. It is important to know the
cause in order to decide upon the method of treatment, but
in many cases this can not be established. When we come to
consider the treatment we are still as badly off as we were
many years ago. The old treatment of rest, diaphoretics,
pilocarpus, etc., give us as good results to-day as any of the
operative procedures. It is only in the recent cases of detach-
ment that we have had any satisfactory results from any of the
methods. I have tried rest, iridectomy, sclerotomy, paracen-
tesis and sclero-puncture. I do not advise operative measures
except in recent cases where the macula is involved, and even
then I do not if there exists a condition likely to lead to
hemorrhage. Electrolysis may be a good thing ; certainly
much has been claimed for it. The galvano-cautery is too
dangerous, and should be placed in the same category as the
injections of iodin. Deutschmann's method has been men-
tioned, but neither he nor anyone else has had sufficient
experience with it to warrant very favorable reports. One
method that has not been mentioned here is that of Strau.
He frees the conjunctiva from the sclera over the site of the
detachment, makes three little slits in the sclera, and then
unites the conjunctiva over this with sutures and allows it to
heal. He then makes injections in this region of a 1-5000
bichlorid solution, and has claimed very good results. It is
simply an experiment, like all the others, and may be dis-
carded. I have not tried the injections of rabbit's vitreous
according to Deutschman. I have watched a few cases in
private practice from their start. One was in a physician and
associated with myopia. He has a low grade of myopia and
wears a — 2.50 D for distance, and with it has had for fifteen
years almost perfect vision. Recently he said that he had a
little spot in his eye ; I paid no attention to it, thinking it
simply a musca volitans. Some time later he complained of
an increase of this spot, but I could not find any opacity with
the ophthalmoscope. Later a slight spot became visible, look-
ing like a floating string, and I then told him that his vitreous
was undergoing liquefaction, though he never had any altera-
tion of the refraction or any changes in the choroid that I
could determine. Soon I noticed a secondary detachment, and
although we gave treatment by rest, pilocarpin, etc., at once,
in sixty days the detachment was absolutely total. He from
the first refused an operation, because he was well acquainted
with the subject, and knew the slight chances of success.
Dr. Lyman Ware, Chicago- 1 did not for a moment ques-
tion the correctness of the report of Dr. Terson's cases, but I
was not convinced that electrolysis was the cause of the result.
Is the using of a positive pole a rational treatment? One of
the tirst things settled in regard to the use of electricity was
that the positive pole produced coagulation and the negative
pole diffusion. Would not absorption be best brought about
by the use of the negative pole? The fact that we have such
a variety of treatments offered shows that none are very satis-
factory.
Dr. A. R. Baker, Cleveland — I wish it were possible to make
a more scientific classification of these cases. In the case of
hemorrhage, tumor or trauma the detachment is simply an
incident, and in those cases produced by Bright's disease, if
the cause could be removed the case would recover. Formerly
I made a sclero puncture, but lately I have omitted that.
Besides rest I give them diaphoretics, and in some cases we
have found considerable benefit. One case where there was
almost complete detachment in one eye existing for a number
of years was followed by detachment in the other eye. I kept
him under treatment for six months, and discharged him with
fairly good vision. About three years later I found him back
in the hospital, blind and without any prospects of recovery.
Treatment is very unsatisfactory.
Dr. G. E. De Schweinitz, Philadelphia— I would deprecate
the report of cases of retinal detachment submitted to opera-
tive interference, before sufficient time has elapsed to test the
sufficiency of their cure. I would suggest that Deutschmann's
result in human beings with injections of sterilized vitreous be
repeated in animals.
Dr. D. S. Reynolds, Louisville I am unprepared to accept
the details of the pathologic changes described by Dr. Ran-
dolph. It is by no means clear that the drawings furnished
are sufficiently accurate to support the accompanying descrip-
tive language. The normal retina can not be shown to contain
pigmented layers, yet Dr. Randolph's report contains a refer-
ence to that impossible condition. In my own experience
results have been in some cases very encouraging at first, but
in a few months fatal relapses have occurred. In persons
under fifty years of age, in good robust general health, medic-
inal treatment often yields brilliant results, but in nearly all
cases subsequent return of the detachment of wider areas
surely comes on in due course of time. I have seen it most
always in myopes, but never in any but progressive cases. My
attempts at operative treatment have yielded results in no wise
more encouraging than that by the salicylates, pilocarpin and
the iodids, with rest in bed. Much remains yet to be done
before we may claim any permanent recoveries from any
treatment.
Dr. R. L. Randolph — While nothing positive has been
added to the therapeutics of this subject, I think we have gone
over the whole field thoroughly, and it is always a help to
know the present status of any subject.
Dr. A. R. Baker, Cleveland — The question has often been
suggested to my mind whether we have detachment in this
class of cases. I have seen but few except in high degrees of
myopia, and become so accustomed to think of it in this way
that I have almost quit looking for any other cause.
Dr. P. W. Higgins, Cortland, N.Y. — In looking up the sub-
ject of edema of the retina in Bright's disease, I noticed one
cure reported by Brecht (Archives f. Oph., Vol. xviii, 2, p. 102)
of marked detachment of the retina in nephritis. He con-
siders it very rare and due to some predisposition.
744
MEDICAL PARIS.
[October 3,
THE USE OF CAUSTICS FOR EPITHELIOMA
OF THE LIDS.
Read in the Section on Ophthalmology at the Forty-seventh Annual
Meeting of the American Medical Association held at
Atlanta. Ga., May 5-8, 1896.
BY FRANK TRESTER SMITH, A.M., M.D.
PROFESSOR OF DISEASES OF THE EYE. CHATTANOOGA MEDICAL COLLEGE.
FORMERLY ASSISTANT SURGEON NEW YORK OPHTHALMIC AND
AURAL INSTITUTE.
CHATTANOOGA, TENN.
This subject was suggested by the following case
which came under my observation.
Frank S., age 64, of Chattanooga, at the age of
43 had had the right eye destroyed by an explosion.
The ball was shrunken and the lids adherent, so that
this eye was entirely useless.
The left upper lid presented an ulcer about one-
third inch in diameter covered with a dry scab; on
the inner and outer sides there appeared to be a blis-
ter. The trouble began twelve years ago from a small
scab which was picked off from time to time and the
ulcerated surface had gradually grown larger. A few
days before, some empiric had made an application
which had caused the ulcer to double in size, after
which the borders had become blistered. A soothing
application was prescribed with the idea that the
blisters would disappear, but the bases became hard
and the contents gelatinous. The case did not im-
prove after several weeks' treatment. The diagnosis
of epithelioma was made, and an operation, consisting
of the total removal of the inner half of the lid and
supplying its place by a plastic operation, advised.
The patient was myopic and presbyopic. Left vision
20-200 with 2 dioptry concave lens 20-70. While
preparing for the operation the patient came under
the care of an empiric who by means of some caustic,
apparently destroyed the pathologic growth, and it
was replaced with a smooth cicatricial tissue, leaving
the lid intact and much more useful and ornamental
than any plastic surgery could have devised.
The case suggests that in some cases of epithelioma
of the lids, especially where we can not operate, that
caustics should be used. In this case the pathologic
tissue extended so as to require the removal of the
entire thickness of the lid by any cutting operation,
and any surgeon would certainly have removed at
least half the lid and even then there would probably
have been a reappearance of the tumor. Nearly all
this was removed and the lid left in good shape, with
the loss of a small amount of tissue, by the use of
caustic in unskilled hands. It can but suggest that
if the caustic had been carefully and thoroughly
applied the cancer cells would have been thoroughly
destroyed.
Dr. A. R. Robinson, of New York, called attention
to the advantages of the use of caustics in the treat-
ment of cutaneous epitheliomata in an instructive
paper read before the Tri-State Medical Society of
Alabama, Georgia and Tennessee in 1895. For use
about the eye he recommended a solution of chlorid
of zinc in a 20 per cent, solution of cocain.
The objection to the use of caustics, in this loca-
tion, is that some of it may come in contact with the
eyeball and cause ulceration. For this reason these
growths are removed by cutting.
The advantages of the caustic over the knife are
that there is usually less destruction of tissue, and
with the destruction of the same amount, the result
is surer, because the necrosed tissue is surrounded
with an inflammatory zone and the products of the
inflammation tend to destroy the pathologic cells for
a distance beyond the part extirpated. This is more
likely to be the case if the wound is allowed to sup-
purate, as it is generally conceded that the toxin of
germs which produce suppuration are destructive to
the cells of epitheliomata.
Some of the caustics have an elective action on the
cancer cells. This is notably the case with arsenious
acid, which should be used weaker than in Marsden's
paste ; three parts of acid to two of gum acacia. It is
said this will not attack normal tissue for twenty
hours. It is believed that by having the case under
constant observation during the application, that
caustics can be used safely on the lids, in many cases,
to the advantage of the patient. I am aware that this
position is opposed to that of most oculists but I
have been told that some of the members of this Sec-
tion have used caustics instead of the knife. How-
ever, I have been unable to find any literature on the
subject.
MEDICAL PARIS.
NOTES FROM MY SKETCH-BOOK.
BY L. HARRISON METTLER, A.M., M.D.
CHICAGO, ILL.
In his powerful romance, "Les Mysttres de Paris,"
Eugene Sue, who, by the way, was a physician and
the son of a physician, paints a vivid picture of
Parisian low life, locating most of his scenes in the
crowded tenements and narrow alleys which once
occupied the ground now covered by the immense
buildings of the Hotel Dieu. When these buildings
were constructed, only a few years ago. the remains
of the historic Hotel Dieu, as well as many another
ancient landmark, were swept out of existence. The
He de la Cit6, with the noble old cathedral of Notre
Dame, the gruesome Morgue, so strangely fascinating
to Dickens, the Hotel Dieu, so often pictured in his-
tory, poetry and romance, the Pulais de Justice, the
oldest monument in the city, and the matchless Sainte
Chapelle, the gem of medieval architecture, consti-
tutes only a small section of modern Paris, but it is
the richest in historic lore and romantic anecdote.
In one of the ancient streets, now vanished on
account of the encroachments of the Hotel Dieu,
dwelt the shrewd physician, Theophraste Renaudot,
who, in 1630, printed the first Parisian newspaper,
La Gazette de France. The wily Theophraste had
observed something of the power of human curiosity
and had cunningly undertaken to gather news from
all quarters for the amusement of his patients. Of
course his clientage rapidly increased and in a short
time he was more in fashion than any of his practic-
ing brethren. But all Paris could not be expected to
be on the doctor's sick list at the same time, and were
even such a pleasant thing possible his suite of apart-
ments would not be able to accommodate such a glo-
rious rush of practice. Accordingly the doctor
decided to publish weekly some fly-sheets, containing
the latest news from other countries. For this he
needed a license and obtained it cum privilegio in
1632. The success of the venture surpassed the most
golden dreams of even the medical imagination.
Similar fly-sheets had already been issued in Venice,
for which a small coin, una gazzetta, was asked,
whence comes the name of our modern gazettes.
One day as I was coming out of the Hotel Dieu, a
student, with whom I happened to get into conversa-
1896.]
MEDICAL PARIS.
745
tton and to whom I had just mentioned several
special clinics which I had learned were to be given,
asked me where I obtained my information in regard
to all these things. Of course I told him and then
wondered if old King Clovia did not turn over in his
grave to think thai a Chioagoan must needs inform a
descendant of the proud Franks in regard to his cher-
ished Maison Dieu. The Hotel Dieu Hospital, or
Clod's Hostelry, known in early history as the Maison
Dieu. is said to be the most ancient hospital in
Europe. The actual date of its foundation appears
to be in doubt, though there aro reasons for thinking
that it had its origin under Clovis, King of the Franks,
who flourished during the latter half of the fifth cen- j
tnry. Saint Landry, who was Bishop of Paris about:
the middle of the seventh century, is the reputed!
founder. It is probably this hospital that is men-
tioned under the name of St. Christophe in a char- 1
chapels on the river bank. For nearly a hundred
years after this it was wofully neglected, but when
Louis .\ 1. ascended the throne its prosperity revived.
This king did much to favor it, and built the exquis-
itely beautiful gothic portals of the two chapels near
the Petit Pont, which, together with the elegant
renaissance gable belonging to the Salle du L6gat,
were the particular artistic features of the building
until its destruction by fire in December, 1772, when
many of the sick inmates perished and the rest were
hastily received by the archbishop in Notre Dame.
Henry IV. added two wings and greatly increased the
revenue of the hospital. Were it not for the frightful
loss of life and the burning of the charming chapels,
the destruction of the old hospital was a blessing rather
than otherwise. It was small, badly arranged, and
anything but architecturally beautiful. Victor Hugo
describes its front as "furrowed and rugged" and
PABIS, LOOKING NORTHWEST FROM THE TOWERS OF NOTRE DAME CATHEDRAL. HOTEL DIEU IN THE FOREGROUND.
ter of 829. The Maison Dieu was not the direct off-
shoot of a monastery, as many other hospitals were.
In accordance with the decree of Charlemagne, £>ro-
mulgated in 816, that at each See one of the canons
should govern the hospital, and that the latter should
always be near the cathedral, the Maison Dieu was
erected within the shadow of the Notre Dame cathe-
dral and was. until quite recent times, under the con-
trol of its chapter. At first it was more than a mere
harborage for the sick. It was a charitable organiza-
tion, embracing every form of aid to the poor and
outcast. The first building to bear the name of
Hotel Dieu, on the south side of the Place du Parvis
Notre Dame, was commenced by Philippe Auguste,
who named its first ward the Salle St. Denis. Queen
Blanche of Castille added the Salle St. Thomas. It
was then almost entirely rebuilt by St. Louis, who
added especially the Salle Jaune and two associated
says its roof from the tower of the cathedral looked
as though it were "covered with pimples and warts."
The next building that was erected to take the
place of the old Hotel Dieu was devoid of all special
features in the way of art and architecture. What
little effect it did produce upon the artistic eye was
completely lost by its juxtaposition to the great
cathedral. It consisted of several irregular masses of
buildings, and its portal, erected in 1801 after designs
made by Clavereau, was severely plain and Doric in
style. Beneath its peristyle stood the statue of the
philanthropist Montyon, who was buried (1838) here,
according to his desire, in the midst of the poor and
sick. It was in this building also that the famous
poet Gilbert died in 1780. In the reign of Louis XVI.
the over-crowded condition of the hospital was a dis-
grace to the city of Paris and to the science of medi-
cine. The monarch attempted some relief by erecting
746
MEDICAL PARIS.
[October 3,
four auxiliary establishments in the suburbs, namely,
the St. Louis Hospital, the St. Anne Hospital, the
Hospital for Incurables and the Hospital for Conva-
lescents. A horrible picture of the wards at this time
was given by Tenon, the president of a committee of
investigation appointed by the Academy of Sciences.
Convalescents were seen by the local commissioners
in the same room with the sick, the dying and the
dead. The insane were confined in neighboring
rooms and apartments and kept the other wards in a
continual state of excitement with their ravings.
Operations were performed in the same room or ward
in which there were beds containing other patients.
In the days before the use of anesthetics we can
well imagine that the cries and contortions of those
undergoing operations would have anything but a
favorable effect upon the other patients. During the
French Revolution the name of the hospital was
changed to L'Humanite. Finally the whole conglom-
eration of inadequate and unsightly buildings was
demolished, an increased area was secured and the
present vast, homogeneous and elegant edifice was
inaugurated in August, 1877, under the direction
of the architect Diet. It is an immense oblong
stone building surrounding a courtyard of ample
dimensions. The arrangement of the wings, grid-
iron-like, is the happiest imaginable for the intro-
duction of air and sunlight into the interiors. Over-
looking the courtyard is a peristyle or open porch all
round the building where convalescents may sit in
the open air. The work of the hospital comprises a
service of about 810 beds. Of these 430 are for men
and 380 for women. Medical cases take up 555 beds
while 255 are given over to surgical cases. The his-
tory of the government of the hospital is interesting.
Until 1505 it was under the management of the chap-
ter of Notre Dame. After that year it was looked
after by a committee of lay governors, eight in num-
ber, selected from the citizens of Paris. The selec-
tion was made by the mayor and aldermen and the
appointments confirmed by the parliament. In 1654
the number of directors was raised to twelve. In
1690 Louis XIV. made some alterations in the gov-
ernment and formed the Grand Committee, including
in that committee the archbishop of Paris, the former
presidents of parliament, of the taxation court, of the
court of alms, the commissioner of police and the
mayor. To-day it is under the control of the Assist-
ance Publique, one of the departments of the Pre-
fecture of the Seine, as I explained in my last sketch.
The oldest paper in its rich collection of archives is
dated 1157, and from 1531 to the present there is a
complete unbroken history of its work. Such is the
story in brief of God's Hostelry, Paris, the oldest hos-
pital in Europe, and one of the greatest in the world.
Within its walls medicine has had one of its firmest
strongholds and from its wards have issued many
discoveries in science. Did I say the poet Gilbert
died here? Many another poet has died here
too; yea, and statesman and artist and soldier and
king, whose names have never been emblazoned on
the escutcheon of fame. Sickness is a great leveler
of the human race; births and deaths emphasize the
equality of man. A hospital is a place for thought,
a great hospital awakens reflections that only eternity
can answer.
As a frequent visitor to the Hotel Dieu I was
intensely interested in some of the differences between
French and American hospital methods. One day I
accompanied a group of students, who were being
instructed by the surgeon Kermisson, a spare, active,
wiry sort of a man, who always wore a skull cap,
through the wards. The operator hastened from one
bed to another, examining this patient, performing
a slight operation upon that one, prescribing for
another, while the class arranged themselves as best
they could about the foot of the bed, to see and hear
what was being done. This walking through the
wards has clearly its advantages for the student but
disadvantages for the patient. The latter is excited
and made nervous and it seemed to me was unneces-
sarily exposed to the contamination and germs of dis-
ease brought in by the students from the street. When
an operation was to be performed a screen was placed
by the attendants around a table at one end of the
ward and the patient carried from the bed to the
table. The patient, especially if it were a child, would
scream and kick and thus disturb the entire ward.
The morning visits of the staff were therefore always
a time of excitement and turmoil, and in many
respects the manner of them seemed to me to be
unfortunate and primitive in the light of the scien-
tific knowledge of the present day. Among the group
of students, men and women, about twelve or fifteen in
all, elbowed one another for a closer view or rattled
their tongues in chatter like flying shuttlecocks.
Modesty appeared to be an unknown quantity in such
a group; science and knowledge alone were the guid-
ing spirits. The exposure of the patients was at first
something quite shocking to an American's sense of
delicacy.
CJpon another occasion at the end of a long ward I
found a tall Japanese screen, behind which stood an
operating table with a woman on it undergoing elec-
tric treatment for a fibroid tumor. Apostoli, to whom
I had just been presented, was managing the opera-
tion himself, while the students pushed and crowded
against each other, jammed their way in and out or
stood tip- toe, craning their necks unmercifully to
get a glimpse of what was in progress. My sym-
pathy went out for the poor woman, for she was of
enormous dimensions, and that with a goodly sized
tumor thrown into the bargain must have made the
journey of life for her a matter of no mean affair.
And then to think after carrying all that flesh and
blood along the rugged via mtce, to fetch up at last
upon an operating table at the end of a long and
crowded hospital ward, with half a dozen men per-
forming a private examination upon her and a dozen
or more idle, curious French students (plus one
American) looking on! Strange, indeed, are the
destinies of some folks! For the happiness of her
fleshly mortality I hope the tumor was reduced, but
I have my doubts about it, never having yet seen so
fortunate a termination in the electric treatment of
fibromata. Apostoli, whom I afterward had the
pleasure of meeting at a banquet and reunion of Des
Trente, a non-professional society of congenial ladies
and gentlemen, given by way of novelty upon the first
stage of the Eiffel Tower, I found to be most enthusi-
astic, yet sufficiently conservative in regard to the
possibilities of electricity. His ideas have been so
extensively published that it is unnecessary for me to
dwell upon them here.
Of the staff of the Hotel Dieu, the acquaintance of
none afforded me more pleasure than that of the late
Professor Germain-See and of the distinguished sur-
geon Tillaux. The first time I met the former, he was
18%. J
MEDICAL PARIS.
747
seated at a small table surrounded by several students
in one of the medical wards. He bore his years
remarkably well and his kindly old face lighted up
with a pleasant smile as he chatted about America
ami some of the good that was being accomplished by
us. He was not a large man nor imposing in manner.
His countenance was round and friendly, his head was
bald and he wore close-cut side whiskers, leaving only
the front and under part of the chin clean shaven. In
accordance with the law of the hospital, Germain-See
should have been retired many years, as he was past
the age at which the government allows a man
to hold a hospital position. So great, however, had
been his Bervioes to medicine and so distinguished
was his name, that an exception was made in his case
and an extension of his time gladly granted. His
didaetie lectures were always well attended. In a
small and poorly lighted room his class usually assem-
bled, while he himself with one or two assistants would
ited behind a long, green baize-covered table. He
always remained seated while lecturing, making use
occasionally of brief notes. His style was ideal for a
scientific discourse. It was decisive and clear-cut,
and as the speaker leaned over the table toward his
hearers and emphatically voiced his dogmatic opinions
one could not help admiring the preciseness, the
optimism and the fertility of resources evidently
acquired by long years of valuable experience in con-
test with disease. At times sparks of gentle humor
would flash out of the discourse. It was always a
quiet, incisive sort of wit, rather than a broad rollick-
ing humor. Instead of a peal of laughter, it would
merely produce a lively titter among the students,
which would subside as quickly as it had arisen.
In physique, disposition and manner, Tillaux is the
very type of the old-time surgeon; large, portly, full
of inspiring confidence, moving about with a heavy
tread and always speaking in an assertive, command-
ing tone of voice. To "assist'7 (a word used by the
ever-polite Frenchman for one who is merely a visitor)
him in one of his morning visits to the wards of the
hospital is good surgically and psychologically. I
was more than once inclined to wish that some of our
younger surgeons had somewhat of the old-time dig-
nity and courtliness about them. It would not add
one whit, of course, to their skill, but it certainly
would lend a grace and pleasing manner to their
noble art, and it would have somewhat of a beneficial
effect upon the unstable, nervous condition of many
of their patients. Appearances count for something
sometimes. I would that I had space to relate more
of what 1 saw at the famous Hotel Dieu, but I would
then have to omit another great hospital, probably
better known than the Hotel Dieu and that without
doubt through the association of the world-renowned
Charcot.
From his residence, a typical elegant French apart-
ment on the Boulevard St. Germain, not far from the
artistic Pont de Solferino. the late Professor Charcot
was wont to drive in his handsome brougham and
pair every morning between 9 and 10 o'clock to the
Salpetriere Hospital at the other end of the city. A
pleasant way to reach the hospital, however, is to
take one of the flying little propellors on the river
and after a delightful sail past many ancient and
modern landmarks, to land at the Pont d'Austerlitz.
A few steps along the broad but not particularly ele-
gant Boulevard de l'Hdpital will bring one in front
of an old-fashioned building, over the doorway of
which will be seen engraved the words, Hospice de la
Vieillesse. Fannies. Not far away rises the vast
Halle aux Vins, which would presumably charm into
ecstasies our bibidous friends; nearby are the famous
Jardin des Plantes, especially interesting to medical
men as having been founded by Richelieu at the sug-
gestion and solicitation of Labrosse, physician to Louis
XIII. How much more influential medical men have
been and are to-dav in the history and government of
France than they are in America. Why?
The Salpetriere, named after a large saltpetre man-
ufactory that was once in the vicinity, is said to be
the largest almshouse in the world. It consists of an
irregular assemblage of buildings with surrounding
gardens, courts and promenades, all covering an area
of about seventy-four acres. A brick wall surrounds
the whole. Altogether the various buildings com-
prise forty-five large blocks. These are lighted by
more than five thousand five hundred windows. Louis
XIII began building the institution as an arsenal,
afterward using it to relieve Paris of the numerous
beggars produced by his wars. It was also used as a
kind of general hospital. Additional constructions
were added to it at various times. Louis XIV con-
ferred upon it a large grant of lands and under this
monarch its main building was erected after the
designs of Liberal Bruant, the architect of the " In-
valides." The most interesting architectural feature
is the church built in the form of a Greek cross in
the center of the grounds, and containing a fine altar,
dating from 1(570, beneath the center of the large
octagonal dome. Many of the main buildings are
arranged in parallel lines with an archway beneath
connecting the intervening courtyards. The first of
these buildings that one comes to after entering the
gateway is the Batimcnt Mazarin built by the cardi-
nal of that name for the aged and infirm women, who
during their youth were servants in the establishment.
Their lodging was given to them gratuitously ; they
were allowed the same food they had been accus-
tomed to as servants and which was better than that
given to the paupers; but they were paid no wages.
In one of the yards with graveled walks and shady
trees stood about a dozen brick buildings with over-
hanging roofs after the style of the Swiss chalets.
Each interior was a single apartment about fourteen
feet square and was for the accommodation of a special
class of insane. The Salpfitriere is devoted to the
care of the aged infirm, the insane, the epileptics, the
idiots and the defective children. The hospital proper
was a detached building of three stories and an attic,
and contained twenty-four " salles des malades." The
" salle aux bains" is arranged in the " rotunde" with
sixteen baths, each being surrounded with a white
curtain and abundantly heated. In 1850 a central
workshop was organized for manufacturing and repair-
ing, for destroying old linen and bedclothes and for
preparing lint for dressings, etc. There are shops
for carpenters, joiners and carriage makers. The
wash-house built on an immense scale bleaches every
year, it is said, 1,500,000 pieces of linen, not only for
the hospital but" also for the Hotel Dieu, the Charity
and the Hopital des Cliniques. All except the in-
sane department is open daily for visitors. The
inmates have special days upon which they may
receive their friends. On Sundays and fete days they
may wear whatever clothing their fancy dictates but
on other days the costume of the hospital, blue in
summer and gray in winter, must be donned. There
748
THE EVIDENCES OF INSANITY.
[October 3,
•are entertainments, including music and dancing,
arranged for the inmates. The cooking for the whole
establishment is done in one immense kitchen. The
insane of course eat in their own special dining room.
The individual allowance consists of 10 decagrams of
bread, 13 decagrams of meat, 45 centilitres of bouillon,
a dish of vegetables, some dessert and 12 centilitres of
wine. As for the insane department, the asylum is
of course a very old one but its management is quite
in accord with the most modern requirements. It will
always be interesting on account of its association
with the great reformer Pinel, a large and magnificent
painting of whom striking off the chains of the grate-
ful patients, hangs over the platform in the room in
which Charcot held his public clinics.
In 1662 the institution contained nearly 10,000 peo-
ple. During the Revolution the number of indigent
females, the males being always sent to the compan-
ion institution the Bicetre hospice out on the road
toward Fontainebleau, was 7,000 or 8,000. Since
that time the population has been steadily reduced
and the management correspondingly improved. Sta-
tistics in regard to the number of inmates are obvi-
ously subject to much variation. In 1889 the total
population consisted of about 6,311 souls; of these
590 were of unsound mind.
In passing it may be of interest to state that the
Hospice de Bicetre, named from John, Bishop of
Winchester, Bichestre, Bicestre or Bicetre, was
founded by Richelieu in 1632 for retired soldiers. It
is a most ungainly looking structure and resembles
more an impregnable fortress than a hospital. It is
for men what the Salpetriere is for women, and with
its rich clinic material Dejerine and others are doing
some splendid work. The guillotine was first started
in its deadly career here and within its walls Victor
Hugo has placed the scene of his powerful story Le
Dernier Jour d' un Condatnn£.
Much to my regret so much space has been already
occupied that I can do but little more than men-
tion the clinics of Professor Charcot. Having been
the fortunate recipient of an autograph invitation
to the home and public and private clinics of this
great man, I had somewhat in my sketchbook that
might have proved of interest. His uniform courtesy
and kindliness, his warm feeling for America and
Americans, his enthusiasm and sincerity, his immense
learning and clearness in imparting knowledge, his
marvelous tact, gentility and preciseness could have
elicited only praise from anyone who happened to
know him, let alone from one who was his warm
admirer. It is no wonder that, when he was gone, his
great scientific attainments and his charming person-
ality made it difficult for the authorities to fill his
place. The story of his life, which has been often
told, is a standing encouragement to every ambitious
young doctor of slender means. Work, hard consci-
entious work, seems to have been its guiding motto.
Professor Charcot held his public clinics in a
special hall at the Salpetriere every Tuesday and
Friday morning from 9 to 12 o'clock. Occasionally
he would be delayed until near 10 oYJock. The hall
was a long narrow room, lighted by small, square old-
fashioned windows, with a large platform at one end
and an ascending row of benches for the students.
Over the platform hung the large painting of Pinel. On
the platform were a long table for the use of his priv-
ate pupils and assistants, and a series of high back
benches for invited guests and the patients to be pre-
sented to the class. Aside from a loud-ticking clock
over one of the doors, the walls were devoid of every
sort of ornament. From a small door leading out
from an anteroom, we would follow the professor on
to the platform, making a goodly sized procession of
assistants, secretaries, students, guests, visitors and
patients. The class upon the audience benches con-
sisted of about one hundred and fifty men and women,
intent, studious and ready with note books to take
down the first words uttered by the lecturer. The
professor always wore a small, tight-fitting scull-cap
and remained sitting during the entire discourse.
His style was smooth, regular and systematic, resem-
bling a memorized sermon, and showing a calm, com-
plete mastery of the subject in hand. Rarely, he
would get up to make some examination himself upon
a patient or indicate some point he was impressing
upon a diagram. Usually his assistant, Gilles de la
Tourette, would do that for him. He used very few
gestures and generally would keep his gaze fixed upon
the back of the room over the heads of the students,
as though he were in a sort of reverie. He rarely
attempted any humor, and when it did arise it usually
had its origin in the patients or something apart from
the speaker himself. Whenever he was lecturing
upon any one special disease, he would line up a num-
ber of patients, as many as twelve or fifteen some-
times, upon the platform. If it were necessary he
would insist upon their divesting themselves of every
stitch of clothing, so that as some one said, they
looked like a row of innocent Fiji Islanders. Rarely, if
ever, did he put the women to this wholesome exposure.
When the hour of noon arrived, a large gong would
sound, the last sentence would be completed and in a
quiet, methodic way the professor would suddenly
rise and vanish through the side door.
In his daily private clinics, in a small room before
half a dozen or more pupils, he would appear less
methodic and showed more of his natural disposi-
tion toward friendship and personal intimacy. Here
all kinds of cases would be examined, discussed and
minutely studied. To observe him make a differential
diagnosis, as for instance, between hysteria and syrin-
gomyelia in a man without a clear history, was a treat
in close logic and correct inference. The French
nation are reputed to be a neurotic people. At all
events they present to the science of medicine a goodly
amount of psychosis and neurosis for study. Sappy
was it that so calm, industrious, logical and dispassion-
ate an observer as Charcot arose and studied amongst
them. The debt which not only neurology but the
whole of medicine owes to this master can never be
repaid and will probably scarcely ever be equaled by
another.
4544 Lake Avenue.
THE EVIDENCE OF INSANITY; AN OUTLINE.
BY J. SANDERSON CHRISTISON, M.D.
CHICAGO. ILL.
GENERAL CONSIDERATIONS.
The whole question of insanity hinges on the origin,
the support and the < I is play of ideas. Its pathology has
nothing distinctly characteristic, being merely a
measure of functional incompetence whatever the
coexistent facts. But as all motion is potential in
ideas, ideation has its equivalent in molecular change
and thus mental aberration has its physiologic con-
comitants.
L896. j
THE EVIDENCES OF INSANITY.
749
No mortal oan be said to be free from errors of fact
or opinion of one kind or another, but comparatively
few resist demonstration logical, or objective refuta-
tion. An idea that docs not tit with popular belief is
not necessarily a delusion. Indeed, if it does not
clash with any demonstrable principle or particular
fact, it can not be regarded as a delusion, for we have
no other means of proving it false than by such evi-
dence. It may be an intuitive prophecy or the pro-
duct of a genius. The grand steps of civilization
were often due to conceptions which at their birth
were commonly regarded as "off" or insane, and it is
Quite in keeping with the order of things that excep-
tionally profound minds should discover truths
beyond the ken of contemporaneous comprehension.
The common mind, the non-meditative, is so much a
product of our political, educational and social
machinery that comparatively few think deep enough
to think much differently, and the machine-made
creature or social puppet is regarded as quite sane
though he may hold all the delusions agoing, which
by and by are exploded by what he may call a "crank."
The higher walks of life are hardly freer from delu-
sions than are the lower, to- wit: Only a few years
ago, the so-called Darwinian theory of evolution be-
came epidemic in certain learned circles although
based on absolutely nothing but circumstantial evi-
dence. Since then many of its votaries have so quali-
fied the theory that it has lost its original peculiarity
of something from nothing, and now it stands for
little more than the progress of a plan as yet too
feebly perceived to reveal much of origin and pur-
pose, but disclosing the immutability of entities
(characteristic or essential powers) by which chaos
is precluded and progress assured. What is potential
in plan must be specific and definite in form, and can
never intrinsically be less or more in essential charac-
teristics. One word more on this point: Laws of
nature are said to be immutable; they must be, or
chaos would result. But laws are not separable from
things t entities ). they are identical with their proper-
ties: therefore specific entities are immutable. Again,
specific entities must be created, not evolved (form
and activity are conditioned by environment and have
reference to growth and chemic union). They can
not lose their intrinsic (specific) qualities unless we
say it is a law that laws are not necessarily immuta-
ble, which is a reductio ad absurdum. Evolution is
extension not addition. I am not writing to prove
the delusional nature of Darwin's hypothesis, which
by some has been accepted as an established fact.
But the logical results of a truth are not acts of insan-
ity. Some twenty years ago when the theory was
dominant, and while its sister delusion " spontaneous
generation " also had a spurt, a young Englishman,
while out of employment and discouraged, suicided
by jumping from a river bridge. He left a note stat-
ing *' man is but a monkey, so I didn't care to live."
This was not an accurate statement of Darwin's idea,
but it contained the popular notion having a fatalis-
tic principle. What is the criterion for this suicide's
act? Was the act that of insanity, or was it a logical
result of prospects, both immediate and remote, in
the light of the existing conditions?
But the history of civilization is full of popular
delusions varying and vacillating, and sometimes
violently active. They were originated as they also
now are, by circumstantial evidence, a form of sugges-
tion, and prevailing by virtue of a common fitness,
a common degeneracy. The familiar biblical expres-
sion, " my sheep " implies both the idea of enfeeble-
ment and the need of a leadership to overcome the
prevailing delusions and conditions therefrom. It
applies now as then, for just as water can not rise
above its own level, so the individual mind can not
transcend its own powers of comprehension without
extrinsic aid. He needs the stimulus of a reinforce-
ment, coordinate with cosmic plan. It is a curious
fact that in spite of the self-evident truth of our abso-
lute dependence, we almost totally ignore it, and by
our acts imply that the world was made wrong. This
is the root of criminality, which is the remote or im-
mediate background of all insanities, and moral pal-
sies— their last analysis.
Definition of Insanity. — A delusional state of
mind fixed against reason. By this I mean that a
delusion exists either manifest, subconscious or latent,
just as any idea may be, and that neither the logic of
facts nor objective evidence are effectual to dissolve.
It applies equally to fleeting and fixed delusions.
Reason is futile for dissolution, although it may
sometimes have a subduing or eclipsing effect for a
time more or less brief. This state is due to such a
degree of brain inefficiency, that the energy produc-
tion is inadequate for the attention required for a
complete conception of the situation. By a manifest
delusion I mean a delusion so dominant that most of
the subject's conduct is regulated by it; by a subcon-
scious delusion I mean a delusion which is not mani-
fest unless elicited by inquiry; by a latent delusion I
mean a delusion which practically does not exist in
definite form, but has existed, and although inquiry
may only elicit a denial, certain circumstances may
evolve it and in a violent manner, as in some forms of
epilepsy and recurrent mania. Such cases are both
the most dangerous and most difficult to pass upon.
Character of Delusions. — A delusion is an idea
which is incorrect in time or in place, or is non-exist-
ent in fact. It becomes an insane delusion by virtue
of its fixity against reason — the futility of argument.
Origin. — Insane delusions have three origins:
1, delusions due to more or less remotely acquired
errors of perception and with present mental incom-
petency— centric delusions; 2, delusions due to percep-
tive perversions of sensation arising within the ner-
vous system, and with present mental incompetency —
hallucinations; 3, delusions due to perceptive perver-
sions of sensation arising at the periphery or end
organs, and with present mental incompetency — illu-
sions. All three forms involve perception, reason and
will.
Support. — 1. An insane delusion may be more or
less plausible by virtue of circumstantial evidence, as
when some of the factors are truths, as is sometimes
the case in delusions of conspiracy to deprive of
property or personal liberty. 2. An insane delusion
may be monstrous, by containing a claim against all
evidence or possibility, such as a claim to be the
" mother of God " or a " horse." In my opinion many
such delusions are not real, but sportive, as their sub-
jects' conduct is commonly very inconsistent with the
delusions.
Display. — 1. An insane delusion may be ; a, active
or directly manifest and unreserved; b, subconscious
or indirectly manifest and reserved; c, latent, as in
lucid intervals, when it has no formal existence. 2.
They may be: a, persistent, b, changeable, c, recurrent.
3. They may be of: a, grandeur, as of wealth, power,
750
THE VALUE OF VACCINATION.
[October 3,
rank, form, etc. ; b, persecution, as of poisoning, tor-
ture, defamation, etc. ; c, debasement, as of personal
vileness or incompetence, etc.; 4. They may exist
with: a, excitement, b, depression, c, composure.
The more centric physiologic concomitants of in-
sanity are indicated by the degree of promptness, per-
tinence, distinctness, fluency and coherence of speech.
The other physiologic concomitants, which may or
may not be present, are tremors, palsies, incoordinate
muscular movements, sensory defects, nutritional
changes and emunctory irregularities in addition to
the purely psychic phenomena.
It may be stated as a rule that the less the physio-
logic concomitants are manifested the more obstinate
the insanity, because the more insidious and subtle
is the centric (cortical) defect. It also may be said
that as a rule hallucinations with insanity indicate
the worst prognosis owing to their being due to a
more gross physiologic disturbance of centric areas
than are purely centric delusions, and which when
they do not speedily recover, generally result in a
more serious and permanent damage to the brain.
Illusions being due to peripheral perversions are as a
rule the least serious indications.
Whatever of abnormal mind is not included in my
definition of insanity will come under the headings of
moral palsy and criminalty.
Definition of moral Paresis. — A defective power of
inhibition (will) to such an extent that although the
subject may know a particular act is wrong, he is unable
to refrain from doing it under special exciting cir-
cumstances or provocation. It is due to a defective
action of the brain which may be caused by cranial
injury, shock, fever, poisoning, inherited fault, habits
of dissipation of one kind or another, etc. It includes
some cases of inebriety, neurasthenias (hysteria,
hypochondria, etc.), fad manias (fanaticism), violent
temper, vagrancies, prostitution, etc.
Definition of Criminality. — A disposition of conduct
in which selfness is the ruling principle existing
with the power of discernment and the power of choice.
It is due to a denial or eclipse of first principles.
The incentives are position, wealth and pleasure to
be obtained at the expense of truth, justice and econ-
omy when in conflict with purpose. There is a total
absence of fraternal love in the humanitarian sense.
In criminality there is a delusional origin in refer-
ence to First Principles, and is therefore constitu-
tional. Education is the remedy. In insanity the
delusional state is incidental to a pathologic cere-
bration, and can only be remedied by physiologic
means. The remedy for moral palsy is chiefly
discipline.
THE STATISTIC EVIDENCES OF THE VALUE OF
VACCINATION TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Read before the American Medical Association at the Jenuer Centennial
Celebration, held at Atlanta, Ga., May, 1896.
BY EUGENE FOSTER, M.D.
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE AND STATE MKDI-
CINK AND DEAN OF THE FACULTY OF THE MEDICAL DEPARTMENT
UNIVERSITY OF GEORGIA, AUGUSTA, GA.
(Continued from page 677. )
Proposition 5.
Notwithstanding a marked decrease has occurred in the total
smallpox death rate, a still greater decrease has taken place in
the smallpox death rate among children.
From the mass of statistics at hand to demonstrate this
proposition I select the evidence relative to the value of vac-
cination as shown by the enforcement of the compulsory laws
of Great Britain.
In reckoning the success or failure of compulsory vaccination
in Great Britain, we must remember that the law was enacted
to protect helpless children from the fatal consequences to
themselves of obduracy or carelessness of the parent in failing
to protect them from smallpox by having them vaccinated.
Let us take this epidemic of 1870-73, which has afforded vac-
cinophobists such an arsenal of facts to prove the worthlessness
of vaccination, and see if in enacting compulsory vaccination
laws the State exercised a wise and prudential care of its
infantile population. Prior to the enactment of compulsory
vaccination laws, 70 to 80 per cent, of the annual smallpox
mortality of Great Britain was among oiiildren under 5 years old.
What has been the average annual mortality in this class since
compulsory vaccination? Take England first. The law requires
vaccination of children at three months of age. The compul-
sory vaccination law of 1853 was very defective in that the
machinery provided for registration of births, and vaccinations
thereafter, was not such as to enable the authorities to know
and secure the vaccination of all the children falling within
the provisions of the law. Defective as it was in this respect.
it yet had a salutary effect, for the vaccinations among this
class were more than doubled over the same period anterior to
the enactment of the law. It must be admitted that this result
was largely due to the knowledge of parents that if they failed to
comply they laid themselves liable to a penalty for such neglect.
In a few years we see the annual smallpox death rate reduced
to 55 per cent, of the total mortality from this disease. Fifty-
five per cent, remained the average annual mortality in this
class until the laws of 1867 and 1871 were enacted. By the law
of 1867 a full and proper system for registering compliances
with the compulsory law was inaugurated. Boards of Guardians
throughout the kingdom were authorized by law to compel
such compliances, and were given full authority to appoint
officers whose duty should be to rigidly inquire into all failures
to comply with the law. When such persons were found, these
officers should warn the delinquents to comply with the
law within a specified time, and if such persons failed to heed
the warning the officers were to institute legal proceedings to
require compliance. By the act of 1871 Boards of Guardians
were required to appoint such officers. The epidemic of small-
pox commenced in the latter part of 1870, and we are told that
" only a portion of the population in England under 5 years
of age was within the operation of the act of 1867. During
the continuance of the epidemic a larger proportion came under
its provisions, and some came also under the provisions of the
act of 1871. The result was manifested in a reduction of the
proportionate smallpox mortality under 5 years of age from 55
percent, of the entire mortality from that cause to 33.5 per
cent, in 1871, and to 30 percent, in 1872. The act of 1867, being
in some of its most important requirements permissive only.
had been carried out with various degrees of efficiency by dif-
ferent local authorities. In those places in which the action
taken under it had been tardy and ineffective, the mortality in
young children amounted to or approached its old proportions:
in those places in which such action had been commenced
immediately on the act coming into operation, and been steadily
continued, a remarkable diminution in that proportion was
observed." 2*
LONDON.
Anti-vaccinists gleefully ask : How about the smallpox death
rate of London in 1870-73? Let us examine into the matter.
For twenty years prior to 1871, when the authorities provided
gratuitous vaccination, but when compulsion was really nom-
inal, the smallpox death rate of children under 5 years of age
was more than 50 per cent, of the total smallpox death rate.
From 1851 60 it was 59.5 percent., and from 1861-70 it was 54. 3.
In 1871 and 1872, notwithstanding the negligence of the author-
ities of some of the unions in relation to enforcing vaccination,
the average annual smallpox death rate of children under 5
years of age to the total of smallpox mortality was 36.7. In
the epidemic of 1881 children under 5 years of age contributed
only 27.8 per cent, of the total smallpox mortality of London.-''
In 1872, in Great Britain, only 85 per cent, of the births were
certified as successfully vaccinated. Deducting the percentage
of children having died before being vaccinated, the percent-
age vaccinated to the total births living was 91 percent, certified
as successfully vaccinated.
SCOTLAND.
How about Scotland? Mr. P. A. Taylor makes himself happy-
it Dr. Seaton's Report in Report of Medical Officer of Privy Council,
1874.
B Eleventh Annual Report of Medical Officer of the Local Govern-
ment Board.
1896.]
THE VALUE OF VACCINATION.
751
over the failures of compulsory vaccination in Scotland. Upon
what is his opinion baaed? Let us see. Here is a fair test, for
thecompulsorx vaccination law of Scotland was enacted Jan. 1,
ISf. I. and from that date to Dec. 31, 1871, the report of the
registrar general for Scotland states, that after a deduction had
lieon made of all children who had died before they could lie
vaccinated. 86.5 per cent, of all children alive were certified as
having been successfully vaccinated. One par cent, was certi
tied as being in such health as to prevent vaccination, or having
been repeatedly tried and found insusceptible, and 2.6 per cent,
unaccounted for on the registers. From this it appears that
the children in Scotland under 7 years of age were protected
by vaccination to a remarkable degree. But, aa has been well
said, "it is equally obvious that the whole infantile population
can not be universally vaccinated, DOT constitute a class among
whom if smallpox prevail in the country there could beany
reasonable expectation of meeting with complete exemption
from that disease, for it includes, 1. all who are under the
Age by which vaccination is enforceable, of whom, of course, a
very large proportion would remain unvaccinated : 2, not a few
■Omewhal above that age arc still remaining unvaccinated from
the carelessness of their parents in neglecting to have vaccina
tion done till they had received legal notice of warning and
risking it probably for some time after that: 3, children in
whom there was postponement of vaccination on account of
their state of health; and 1. many doubtless still unprotected
among the cases which had appeared in each year's return as
'postponed,' ' insusceptible,' or ' unaccounted for.' Now, as
there are nearly 120,000 children born in Scotland each year
who until they arc 6 months old do not come under the oper-
tioo of the law : as there are about 1,(KKI of each year's births
carried on as ' postponed' or 'insusceptible' : and as there are
about 2,500 annually respecting whom nothing is known, it is
quits certain that there must always at any given time be
among the young population of Scotland, extremely well pro-
tected as it is on the whole, a considerable actual number of
unvaccinated children."
Now for the results of this unprecedented vaccination in a
community of civilians. From year to year, prior to compul-
sory vaccination, the average annual smallpox mortality in
children under o years of age amounted to 74 per cent, of the
total smallpox mortality in Scotland. To fairly test the prophy-
laxes afforded by compulsory vaccination, we must take the
children under 7 years of age. the epidemic having begun in
1ST I. The returns of the registrar general are only divided as
follows : Those under ."i years of age, 5to 20, 20 to 60, and those
above 80 years nf age. We therefore taKe those under 5 years
of age, they being only those which can be used to test the
value of compuleoiy vaccination. From the enactments of
the compulsory law in 1864, the mortality of this class
steadily declined from 74 | er cent, of the total smallpox mor-
tality, until in the epidemic of 1871 it was for the whole of
;nd just 21.4 of the total smallpox mortality. The mor-
tality for the whole of Scotland had not been ascertained when
Dr. Seaton (from whose reports these data are extracted) ren-
dered his report in 1874. But let us take the eight principal
towns of Scotland, from which to derive further information
on the subject
SMALLPOX DEATHS IN THE PRINCI PAL TOWNS OF SCOTLAND.
At all ages.
Under 5 years
of age.
Death.-, under 5
years ofage; per
cent. <>!' total
deaths.
187] S86
1878 1,687
1878 «W
l874,toJune Inclusive. :>><<2
105
S«2
12-1
Total, W years .
3,192
Well may the registrar general, in his report for 1872, say. in
his comments on that year — "If the same relative mortality
had taken place in children at that age (under G years) as
occurred during the previous epidemics, when they were less
efficiently protected by vaccination, instead of only 362 chil-
dren under 5 years of age having died from smaHnox in the
eight towns during 1872, 3,370 would have died. '1 he enforce-
ment of the vaccination act, therefore, during the seven I revi-
ous years, appears to have had the effect, in those eight towns
alone, of saving the lives of upward of 3,ti00 children " So
much for thedirect proof from the history of Scotland : s tothe
beneficent effect of compulsory vaccination. Now let us com-
pare the relative mortality of children under D years of age in
Scotland with other countries. A glance at the following table
will show the superior effects of the law of Scotland :
SIATON'8 KEPORT, 1874.
towns, er group! of
towns, compared.
Hlght principal towns of
Scotland (population
1,(188,780), 1871-74. . . .
Berlin (population 883,-
.">«!!), 1K71-72
II a mini rg (population
388.874), I871-7a
Lclpslc i population hki,-
1125), 1871
Eight principal towns of
Hoi Ian d (population
008,080), 1870-78
Actual smallpox deaths Smallpox deaths under
under 6 years of age
dUTlng the Whole pe
riod of the epideniir
in eiieh town, ol
group of towns.
750
2 881
1,088
059
4,474.
B years of age during
the whole period of
the e p i d e in i e f o i-
equivalent population
of i.iHiii.iHHiofali ages.
«92
:;,n.s
6,717
8,800
8,445
Compare next the smallpox mortality under 5 years of ago
with the population living under that age, respectively, in the
various towns or groups of towns.-"
Smallpox deaths
Smallpox deaths under 5 years of age
Population. under 5 years old during whole time
Towns, or groups living under during entire pe- of epidemic for
of towns, rum- -r> years of age. riod of the epi- equivalent of popu-
pared. demlc in eachlatious of 100.000
place. children under that
age-
Chief towns Of'
Scotland (il'i yrs.)
Iterliu (2 years.). .
I.eipsic (1 year.). . |
47,488
780
88,093
2,837
8,548
t;;,
508
3.200
7.712
These are the only towns in which the data for this last table
were at hand for comparison when the table was formed in
1874. Assuredly there must be some patent reason for this
variable death rate of infantile populations in the countries
having compulsory vaccination laws. Let us try and find it. A
brief review of the law, together with the manner of its enforce-
ment in the respective places, will perhaps enable us to solve
the problem.
1. Scotland.— We have just seen the wonderful utility of
compulsory vaccination in Scotland in comparison with the
other countries specified in the tables just given. The law is
stringently enforced, and the machinery therefor is complete,
as evidenced by a vaccinated population under 5 years of age
per cent.
2. Berlin.- In Berlin the law required that all children
should be vaccinated at one year of age. No penalty, however,
was attached to neglect to comply with the law, unless smallpox
follows such neglect. The delinquents were rarely prosecu ted,
and agood proportion failed to have their children vaccinated
until they attained school age. All children seeking admittance
to the public schools bad to present a certificate of successful
vaccination before being received therein. Dr. Guttstadt, in
1873. attributed the high mortality in Berlin in the epidemic
(1871 1872) to a large accumulated number of children, whose
parents had failed to have them vaccinated at 1 year of age, as
required by law.
3. Hamburg.— There was not at the time of the outbreak of
the epidemic any compulsory law, and no means to prevent
parents from neglecting to have their children vaccinated,
except a law which required all children applying for places in
the public schools to produce a certificate of successful vaccin-
nation. Therefore it was common to find children who had
attained 2 years of age, and often 7 or 8 years, before vaccina
tion was attempted. This large residuum of unvaccinated
children is sufficient to account for the greater prevalence of
smallpox in Hamburg than in those of Scotland.
4. Leipsic. i The same was substantially true of these as in
5. Holland. \ Hamburg.
IRELAND.
What of compulsory vaccination in this country? triumph-
antly ask the anti-vaccinists. Let us test it first upon the chil-
dren under 5 years of age, the class whom primarily the law
was intended to protect. The compulsory vaccination act of
Ireland came of force Jan. 1, 1864. The machinery for regis-
tration of compliances with the law, as well as the lack of offi-
cers to warn delinquent parents whose children remained un-
vaccinated beyond the prescribed age [six months;, and to take
the necessary steps to enforce compliance with the law, shows
the act to be more defective than that of Scotland.
By the report of the public vaccinators to the local govern-
i Seatou's report 1884.
io2
THE VALUE OF VACCINATION.
[October 3,
merit board of Ireland, compared with the register of births
from 1865 to 1872 inclusive, it is shown that 81 per cent, of the
births were vaccinated by the public vaccinators. (The public
vaccinators do almost the entire vaccinations in Ireland, except
in the large towns. ) In Scotland the percentage of these vac-
cinations has been shown to be 9612 of every 100 births. We
therefore see that in Ireland there is always a very large resi-
duum of unvaccinated children, there being in 1872. 33,440
children who were not vaccinated until they had attained one
year of age. In 1873 there were 19,258 such cases. Let us now
compare the smallpox death rate of this class with the total
smallpox mortality of the periods anterior and subsequent to
the compulsory act. Seventy-nine per cent, of the total small-
pox mortality of Ireland was in children under 5 years of age,
as shown in the report of the epidemiological society in 1853.
Under the medical charities act, and the act of 1858, the public
vaccinators had been enabled to reduce this percentage to 75.
By the operation of the compulsory vaccination act, in 1865
and 1866, the percentage of this class of deaths was reduced to
50. From 1866 to 1871 smallpox was almost wholly absent
from Ireland. When the epidemic of smallpox began in 1871,
it found the children under 7 years of old remarkably well vac-
cinated, and as a consequence we find the percentage of deaths
in this class as follows : 1871, 20.5, and in 1872, 25 per cent, of
the total smallpox mortality.
Now let us take Dublin, one of the cities especially pointed
out by anti-vaccinists as an illustration of the utter failure of
compulsory vaccination. In Dublin, in the two years in which
the epidemic prevailed, there were 1,557 deaths from smallpox.
Of this number 362, or 23 per cent., were in children under 5
years old. Dr. Seaton was unable to give the proportion which
these 362 deaths bear to the total population living under 5
years of age. But he shows the comparative mortality to the
whole population of Dublin, and contrasts these with the fol-
lowing places. The deaths under 5 years of age per million of
living population in each place were as follows :
Dublin 1,150
Right principal towns of Scotland 092
Dundee, 1,534
Berlin 3.448
Hamburg, 5,717
Leipaic 0.200
Chief towns of Holland (5,455
Let us see what has been the result of compulsory vaccination
upon the whole population of Ireland. Prom the census taken
in 1841 it was shown that for the previous ten years smallpox
was the second most fatal disease in Ireland. The deaths in
that period of time were 58,000. When the census was taken
in 1851 it was found to be the third most fatal disease. For
nineteen years previous to the act of 1863, the average annual
mortality from smallpox was, as shown in the twenty first
annual report of the poor law commissioners for Ireland, 2,640.
The compulsory vaccination act of 1863 came of force at the
time of decline of a considerable epidemic. During the first
year, which, it must be admitted, was too soon to be fairly
claimed as wholly consequent upon the operation of the act,
the deaths from smallpox were 854. From 1865 to 1870 inclu-
sive, the smallpox mortality had fallen to such an extent as to
be without precedent in the history of Ireland, being for the
six years respectively 347, 180, 20, 19, 20 and 32. In the epide-
mic of 1871-1872, the deaths from smallpox were 665 in 1871,
and 3,248 in 1872. Now let us compare the smallpox mortality
of Ireland previous and subsequent to compulsory vaccination,
and see what will be the result of the investigation. For nine-
teen years previous to the compulsory vaccination the average
annual deaths from smallpox were 2,624 ; for ten years subse-
quent to compulsory vaccination the annual smallpox deaths
were 583.'-' Therefore we see that under compulsory vaccination
for the ten years of its operation, as compared with the nine-
teen years anterior to it, the deaths were not a fourth of those
in the non-compulsory period.
Propositon 6.
In every epidemic of smallpox, the unvaccinated portion of
the population has, without a single exception, shown a vastly
greater proportional attack rate as well as death rate from
smallpox relative to their numbers than the vaccinated.
STATISTICS PROVING THIS PROPOSITION.
In a severe epidemic of smallpox which prevailed at Norwich
im 1819, Mr. Cross minutely observed 112 families, in all of
which there were cases of the disease ; and the annexed table
shows the result. Among 215 persons unprotected by vaccin-
ation there were 200 cases of smallpox, and of these forty-six
proved fatal ; while among ninety -one vaccinated persons the
2! See Seaton's Report, 1874.
only effects of this terrible infection were: 1, that one girl,
who had been vaccinated nine years, "had a mild disease,
limited to twenty pocks, and lasted only six days before it
began to decline," and 2, that another, who had been vaccinated
five years, went through "the disease in half the time (of her
unvaccinated sister) without danger or detriment, a few very
minute pits upon the tip of the nose being the only permanent
traces."
Number.
Cases
of
Smallpox.
Deaths
by
Smallpox.
Total number of persons In the 112
infected households
003
2»7
HI
215
202
2
200
Hi
1. Protected by previous smallpox's .
2. Protected by vaccination
' 40
By reference to the following table, it will be seen that, in a
number of places observed, the death rate varies among the
vaccinated from an inappreciably small mortality to 12' ., per
cent., that amongst the unprotected, it ranges from 14 • .. to
53.8 per cent.
Death rate per 100 cases.29
Places and times of
observation.
France, 1816-41
Quebec. 1818-20
Philadelphia, 1835
Canton Vaud. 1825-29
Darkehmen (Durkheim's), 1828-9
Verona, 1828-.19
Milan, 1830-51
Breslau, 1830-5.")
Wiirttembere. 1831^-5^. ■ . .
Carnlola. 1834-35
Vienna Hospital. 1834
Carinthia. 1834-35
Adriatic, 1885
Lower Austria, 18S5 ......
Bohemia. 1835-55
Ualicia, 1836
Dalmatia, 1836
London Smallpox Hospital.
1836-58
Vienna Hospital, 1837-50 ....
Kiel, 1852-53
Wiirttemberg, no date
Malta, no date
Epidemiological Society return
no date .-
Total No.
of cases
observed.
Among
the
unprotected.
Among
the
vaccinated.
16,307
240
5,838
134
909
10,240
220
1,442
441
300
1.026
1,102
2,2X7
15,640
1,059
723
9.000
6,213
218
6J68
7,570
4,624
13.12
27
60
24
18.8
46.66
38.33
53.8
27.12
10.25
61.26
14.5
15.83
25-8
29.8
28.5
19.66
80.
n.
38.9
21.07
19.7
1.
1 ,68
0.
2.10
0.
6.66
1.68
2.11
7.1
4.4
1 9 B
0.5
2.N
11.5
6.16
f>.14
8.25
7.
I
0.
8.5
4.2
Compare the relative death rates from smallpox in London
in the epidemic of smallpox for the year ending May 29, 1881,
between the vaccinated and unvaccinated. Here is the table
taken from the Eleventh Annual Report of the Local Govern-
ment Board, 1881-82 :
Death rate of people of
subjoined ages.
Per 1,000,000 of each
age of the
vaccinated class.
Per 1.000.000 of each
age of the
unvaccinated class.
90
01
40.6
8,860
1,520
5,960
Table D.— Number of deaths, and vaccinattonal condition, of those
being over 3 months and under 10 years of age who died from small-
pox in England and Wales, 1881-87.
Vaecinatlonal condition.
Vaccinated
Un vaccinated
No statement
Total
Deaths, 1881-87
115
1,427
1.-1(12
2,974
Note. — The unvaccinated are 90.8 per cent, of those as to whose vacci-
national condition there was information, and 48 per cent, of the whole.
28 Mr. Cross mentions that he met with several who were supposed
to have had smallpox formerly, yet (p. 15) notwithstanding took it on
this occasion ; but he does uot state whether such cases are included in
the above summary. In this epidemic the vaccinated slept iu the same
rooms, and iu some instances, iu the same beds, with those having
smallpox. So also (as quoted by Steiubrenner) in Copenhagen— of 659
vaccinRted persons who suffered in the variolous epidemics, 1823-27, only
5 died, being at the rate of 1 in 132: while of 170 unvaccinated person's
who contracted the disease, more than a fourth seems to have died, and
of 153 others, who professed previously to have had smallpox, there died
81. And similarly in the epidemic of 1828-30, and part of that of 1882-37.
it seems that out of 228 unprotected patients 63 had died; but of 1,373
cases of post-vacoinal smallpox only 14 were fatal.
■!') Brit, and For. Med. Chir. Rev., October, 1857.
1896.]
SOCIETY PROCEEDINGS.
753
Taulk E.— Proportion of iloullis under and over 15 years of age. per 1,000
deal ha from smallpox in vaccinated ami unvaccinated persons respec-
tively, 1881-81 (excluding deaths under 3 months).
Unvaocinated,
Three months and under 1ft years.
Fifteen years and upward
1MB
Total
Vaccinated.
IM
874
1,000
T.viii.k K.— Statistics Of the smallpox epidemic In Chemnitz in 1870 71.
-1 Report Royal Vaccination Commission of lireat Britain, ISM,
cnsch'riit des Koulgl. Preuss. Stat. Bureau. Jahrgang 12.
trt. "Die Pocken Epidemle In Berlin, 1870-79." by 1> Guttatadt.)
- Dr. Max Schultx, w rltlng of Klin/.cr's statistic*, calls attention
to llie tact thai they show there was i case of smallpox to every 2.V,
containing none inn vaccinated persons, but 1 to every M
households containing both vacclnatedand uuvaocioaied persons. The
figures prove the danger which nnvaocinated persons arc to the vacci-
nated, and thereby establish the value of compulsory vaccination.
Vide Impfu schait.etc. Berlin. 1888
I >cal lis. _i ' tiled. Among the deaths are those of
tt7 boys. 17 m a 1. adults. Ill c iris and II female adults All the children
who died were unvaccinated, and of the adults, 8 males and 4 females
he remainder unvaccinated.
Of the '-M'.i deaths. 242 were thus unvaccinated and only 7 of those vac-
cinated, the former category eoutrlbnting «7 u> ami the latter 2.81 per
ecu i of the deaths. Separating the oases ol smallpox among the raoel
nated from those among the unvaccinated persons, we Bnd that of the
former, only o 7:; per cent, died, but that of the latter class 8.18 per cent.
did.
Ofthi i the town hospital 1S4 had been vaccinated. :l" were
unvaccinated. and 8 were doubtful. None ol the vaccinated died, but
11 of the unvaccinated succuml'cd to the disease i is eases of unvacci-
nated children uiiilcr 101.
Hence the accuracy of the following table given by Lotz on p. ."«; of
his "I'oeken mid Vaccination."
Vacciuated.
l'n vaccinated.
Age.
■
0
Deaths.
Mortality.
Per cent.
i
3
3
G
a
a"
oS>
373
528
444
881
288
1M7
10.")
OS
71
71
102
51
98
at
9
7
1
2
1
27.3
9.6
5.9.
6.3
4.0
For the 0th year BG
For tin- 7c ti year. . 40
For the 8th year 98
For the 9th W-ur. 18
:; B
0.9
2.0
1.4
0.0
Total under 10 years ol age . . 965
2,410
220
0.0
{To be continued.)
JS.
SOCIETY PROCI
:EDINC
The American Public Health Association.
[Special Correspondence of the Journal.]
The Twenty-fourth Annual Meeting of the American Public
Health A$soeiation held at Buffalo, N. Y., Sept. 16-18, 1896.
The Executive Committee, in which all the business, other
than reports of committees and presentation of papers, is prac-
tically done, and which is composed of the five officers, six
elected members and the thirteen surviving ex-presidents,
nine of whom were actually in attendance, met at 10 a.m.,
September 14, and was in continuous session the greater part
of the day, and during the intervals of the regular sessions
throughout the week.
Ellicott Square, in which the meeting of the Association was
held, is a marvel of modern construction, occupying the entire
block of ground, the value of the site alone being rated at
$1,000,000, and the cost of the building, complete in all its
appointments, having amounted to 82,350,000 more. The
dimensions of the edifice are 240 x 200 feet, with an interior
court 110 x 70 feet in size, glass roofed and giving abundant
light to the 600 offices, 16 large counting rooms and 40 stores,
besides the quarters of the Ellicott Club, which occupies
nearly the whole uppermost (tenth) floor, and the assembly
rooms on the second, in which the Association held its meet^
ings. The principal room was gracefully and appropriately
draped with the national flags of the United States of America,
Dominion of Canada and Republic of Mexico, which countries
are represented in the membership, but the abominable acoustics
of the hall, due to the numerous intervening columns, and the
medley of noises from the streets, make it a trying ordeal for
the speakers to reach their distant auditors. The extensive
daily programs for morning, afternoon and evening sessions
were carried out without failure, and the interest of the mem-
bers in their work was shown by their persistent attention and
regular attendance to the adjournment on Friday afternoon.
The appointed hour found about two hundred and fifty per-
sons on the floor, the adjoining offices of the Treasurer and Local
Committee being crowded with members awaiting their turns
to register. The Mexican contingent numbered thirty-four
persons and that from the neighboring Dominion almost as
many more. A number of women were present, and as a daily
paper later commented : "Tho languare of some of the papers
opened their eyes to the brusque directness with which scien-
tific sanitarians deal with rather intimately personal problems."
The Association was called to order by the President, Dr.
Kin audi) LuKAtiA of the City of Mexico, promptly at 10
o'clock, and the session opened with prayer by the Rev. Dr.
Thomas R. Slicer of Buffalo, after which the President called
to the platform and introduced to the members the distin-
guished founder of the Association, Prof. Stephen Smith of
the city of New York, and its first President during the years
1S72, 187,'i <ind 1874, after which time he declined reelection.
Dr. Smith, after responding to the enthusiastic welcome which
greeted him, disclaimed any special merit in the creation of
the Association, which he declared to have been the logical
outcome of the times, and paid generous tribute to his associ-
ates in the work, especially Dr. Elisha Harris of New York,
who with himself bore the entire expense of the early meet-
ings. He also instanced Dr. Joseph M. Toner of Washing-
ton, D. C, Dr. Edwin M. Snow of Providence, R. I., Dr. John
H. Rauch of Chicago, 111., Dr. Ezra M. Hunt of Trenton,
N. J., and Dr. Charles B. White of New Orleans, La., the
latter the first of the Presidents to die, although all the others
mentioned, who successively occupied the presidential office,
and were his earnest co workers from the beginning, have sub-
sequently died. He extolled the wisdom of the Association in
having adhered to the practice of placing its mere working
business in the hands of the Executive Committee, and thus
removing disputations and time consuming contentions from
the floor of the general meeting, to the interference with its
legitimate and more important labors. While it has included
some of the best men in the profession among its members,
there were many others who were not medical, among them
the Rev. Dr. Osgood, Dorman B. Eaton, Commissioner of
Education, and others. This Association does not limit its
influence to those in actual attendance at its meetings. The
larger audience outside of the Association give it its distinctive
character. He was especially gratified at the interesting fea-
ture of its development, which has made it eminently all-
American, through the extension of its membership to Canada
and Mexico, and hoped that Cuba and the Central American
republics might also become part of it. This international
association is all the more gratifying since experts in sanitary
science are aware that no single country can protect itself,
except so far as the English system obtains of making localities
clean, instead of remaining apartand trying to fight epidemics.
A clean country is primarily a healthy one. The Transactions
of this Association, he was proud to say, have become an inval-
uable compendium of sanitary science, and Florence Night
ingale wrote, years ago, that she could gather nowhere in
Europe such information as was to be obtained in the reports
and papers published by this body. Perhaps the grandest work
accomplished by the Association has been in the development
and extension of State boards of health all over this Union —
and it is very gratifying to see by the programs the prominent
part taken by officers and members of State and provincial and
municipal boards of health in its work.
On the conclusion of ex-President Smith's remarks, the
Chairman of the Local Committee of Arrangements, Dr.
Ernest Wende of Buffalo, Commissioner of Health of that
city, made the customary announcements of entertainments
tendered the members and their families, which in accordance
with the traditional practice of this Association, were only
such as would not interfere with the purposes of its assembly
The Local Committee had prepared a very attractive, both in
typography and contents, souvenir brochure, edited by Dr.
William Warren Potter, Chairman of the Committee on
Printing, containing well executed portraits and biographic
sketches of the officers, lists of committees and other necessary
754
SOCIETY PKOCEEDINGS.
[October 3,
information especially valuable for new members ; and a nov-
elty in the way of a membership badge, having a gilt buffalo
surmounting and suspending by a tri-colored riband a gilt
emblematic pendant. Each member was further supplied
with a little book of detachable coupons, entitling those duly
accredited to daily afternoon drives in tally-ho coaches,
intended especially for wives and families during the attend-
ance of their husbands and fathers at the sessions, and admit-
ting to excursions and receptions— a most admirable provision
against the intrusion, common to such occasions, of persons
in no way interested in the Association as entertainers or
participants.
The report of the Executive Committee was presented by
the Secretary of the Association, Dr. Irving A. Watson,
Secretary of the State Board of Health of New Hampshire,
who performed this duty for the fourteenth successive annual
occasion, making the usual announcement of the prospective
business of the session, and reporting a communication from
the Association of Master Plumbers of Canada, signed by their
Secretary, J. C. Hughes, of Montreal, recommending the con-
stitution of a committee on sanitation with special reference to
drainage, plumbing and ventilation of public and private build-
ings, and such a special committee of five members was there-
upon authorized. The Executive Committee further recom-
mended the passage of a resolution, introduced by Dr. Samuel
H. Duroin, Health Officer of the city of Boston, reviving the
committee on disinfectants and disinfection, whose former
report has been so many years the standard authority on these
subjects, but which in view of recent experimental research
and discoveries ought to be given the opportunity of including
this later knowledge. The Secretary then reported the names
of fifty-three new members, recommended by the Executive
Committee for election, which was accordingly done by vote of
the Association.
The eminently practical and expeditious manner in which
this Association dispatches its routine and administrative bus-
iness through its Executive Committee, permitted the legiti-
mate work of the session to begin promptly at 10 :45 a. m., with
the "Report of the Committee on Car Sanitation," by Dr.
Granville P. Conn, President of the State Board of Health
of New Hampshire, Chairman. This report attributed much
of the opposition of railway corporations to their disinclination
to submit to the interference with their business and the
expenses which the necessary charges required for their im-
proved sanitation would involve. It spoke of bad ventilation
of passenger coaches as worse than their overheating,
denounced the objectionable practice of closing windows and
locking doors after a trip, instead of throwing them wide open
for thorough airing, and advocated the abrogation of the exist-
ingsystem of urinals. It backed the American railway employe
against the world for disregard of passengers' comfort, and for
habitual insolence nothing could equal the negro porter. It
commended the train de luxe from Paris to Marseilles as an
instance of what can be done to promote the health and com-
fort of travelers and wondered that any one who has had the
opportunity of contrasting this service with the American
system could hesitate to give credit where it belonged.
Two papers on the same subject followed : "Observations on
the Cleaning of Railroad Passenger Cars," by Dr. Domingo
Orvananos, of the City of Mexico, Secretary of the Superior
Board of Health of the Republic of Mexico; "Possibilities of
Contagion of Venereal Diseases in Railway Cars," by Dr. Tomas
Noriega, delegate from the State of Chiapas, Mexico. The
former advocated instead of the customary slipshod method of
washing coaches, that they should be carefully gone over with
sponges saturated with a solution of mercuric biehlorid, that
the coverings of seats and backs should be frequently changed
and washed at every terminal station. Dr. Noriega narrated
instances in his experience of purulent ophthalmias, unmistak-
ably one to infection in Pullman car lavatories, resulting in
total loss of vision of one or both eyes. He said that reform
was necessary especially in beds, lavatories and water-closets,
and that in the latter, impermeable paper covers, to be re-
moved after each visit, should replace the present permanent
wooden seats. In the discussion which followed, Dr. Valentine
of New York quoted the case of a bride, referred to him by
another physician, who had contracted a specific ulcer on her
lip by drinking from a public ice-water cup, and said that in
Antwerp he had seen fresh wooden covers supplied to each
new occupant of a water-closet. Dr. Kinyoun of the U. S.
Marine Hospital Service, said that the hygiene laboratory of that
service under his direction had been long engaged in investigat-
ing railway sanitation, and said that experiments were being
made as to the proper disinfection of cars by subjecting all the
several materials used in furnishing coaches to various pro-
cesses. He suggested the inquiry as to the greater prevalence
of cases of tuberculosis and diphtheria at the railway terminals
and at the resorts for invalids affected with these diseases. He
said the impure water supply in the railway service was
responsible for many cases of diarrheal and enteric diseases,
and declared that it was significant that the presidents and
high officials of these companies do not drink the water they
furnish to passengers.
The "Report of the Committee on Steamship and Steamboat
Sanitation," by Dr. Frederick Montizambert of Toronto,
General Superintendent of Quarantines of the Dominion of
Canada, Chairman, was then read. Dr. Montizambert said he
had little to add to the reports made by the former Chairmen of
the Committee, Dr. Durgin of Massachusetts, in 1891, and Dr.
Gihon, U. S. Navy, in 1893, except to call attention to the
proposed disinfection of ships by the electrolysis of sea water,
a process actually in use by the French companies of the
Messageries Maritimes. At the exhibition at Boulogne sur-
Mer, there was an automatic apparatus no larger than a coal
scuttle, which could be connected with the ordinary electric
plant by a couple of wires and was capable of producing three
hundred liters of electrolyzed sea water per hour. The usual
methods of disinfection, involving the employment of costly
materials, were malodorous and left much to be desired.
Dr. Horlbeck of Charleston, S. C, declared that enough
had not been said about the wretched sanitary condition of our
coastwise passenger steamships, and Dr. Gihon, U. S. \..
described his present knowledge of the deplorable condition of
the saloons of these vessels during their late autumn passages
when crowded with consumptive invalids on their way to health
resorts in Florida.
afternoon session.
The afternoon session began 3 p.m. with a paper on "The
Composition and Infectiousness of Milk," by Dr. James F.
Kennedy of Des Moines, Iowa, Secretary of the State Board
of Health of Iowa, and was an exhaustive inquiry into the
relative mortality of breast-fed children and those fed on milk,
the latter being greatly in excess. He attributed a large pro
portion of the deaths to inanition from dilution with water.
which is not only a fraud against the buyer but a crime against
the children, who are literally starved to death. He narrated
epidemics due to infected milk, which was a greater source of
danger than dilution, and described the many ways by which
morbific germs are introduced into milk— by washing pails
with impure water, by the settling in pails and cans of dried
germs floating in the polluted air of stable-yards, by the
unclean hands of milkers, and after reaching consumers by the
filthy habits of occupants of insanitary houses. He declared
the remedies to be inspection, cleanliness and sterilization.
The next paper on the program was "On Pure Milk," by Dr.
Gardner T. Swarts of Providence, R. I., Secretary of the State
Board of Health of Rhode Island, who deplored the neglect of
milk inspectors and physicians in his own State to ascertain the
actual condition of the milk supply. He said that most of the
enteritis of children was certainly due to filthy milk. He urged
the establishment everywhere of milk farms similar to those
near Buffalo, where the modus operandi of milking and deliv-
ering milk is carried out under the most healthful conditions
and the purity of the milk certified by reputable physicians.
The price of such milk m'ist necessarily be higher, and it is
only by educating the public that they can be made to pay the
difference and to secure immunity from disease, which is more
surely done in this way than by sterilization. There are peo-
ple to day who prefer dirty milk at four cents to good milk
at eight.
The "Report of the Committee on Animal Diseases and
Animal Food" was then read by Dr. D. E. Salmon, D.V. M. of
Washington, D. C, Chief of the Bureau of Animal Industry,
Department of Agriculture, Chairman, who, while describing
how much had been done in the matter of animal diseases, said
that the public still needed to be educated respecting them.
Outbreaks of anthrax were undoubtedly becoming more fre-
quent. While common in Europe, this disease had been rare
here. The spores of the bacillus survive for years and are dis-
tributed through carelessness in the disposal of dead animals.
The carcases should be saturated with coal oil and burned to
ashes. Hides and wool are dangerous and even the hay from
infected meadows used for packing crockery and glass. Tubercu
' losis is the subject of much attention on the part of the govern-
ment, which, however, can only prevent the shipment of
diseased cattle to other States, but has no control over its local
sale. Tuberculous cows and swine are often found in the
! abattoirs, but there is necessity for cooperation between Fed-
; e-al and local inspectors. Some local firms insist on selling
! condemned carcases. The committeo testifi°s to the amica'-le
| relations between the Bureau of Animal Industry and the
1896.]
SOCIETY PROCEEDINGS.
755
State Hoards of Health, due largely to the influence of this
Lwociation. An Interesting part of the report dealt with
rabies, which declared that while then was no need of alarm
ing people, it was a duty to inform the public that such a dis-
ease does exist and is a menace to health and safety. The
Chairman had sometime aw to combat the theory that there
was DO BUCh disease as Texas fever. Is it reasonable to
believe that a disease that has been described for two thousand
years is a myth because a few physicians have never seen a
case. The committee has sufficient positive evidence to estab-
lish its existence and characteristics, and recommends the
measures for reducing the number of worthless dogs be rigidly
enforced, and that all others allowed to run at large be
muzzled.
This group of papers attracted great attention and provoked
a very lively discussion. Dr. BaILHACHB while approving
of the thorough supervision and inspection of dairies and
dairy products recommended by Dr. QaBDMKB T. Swarts,
doubted its practicability. I>r. 1. 1:1: of Philadelphia took issue
with Dr. Kennedy respecting the sterilization of milk, in
which he did not believe we had arrived at a sanitary ultima-
tum. Since the practice two diseases have become prominent
infantile scurvy and rickets which were not recognized
when he studied medicine. Fresh pure milk is better than
sterilized, but he agreed if we are to cook milk at all we had
better do it thoroughly. Boiled milk is better than sterilized.
Dr. IhitiiF.ui) of Indiana, e.x President of the Amekican Medi-
1 \i Association, questioned whether it had been established
that any child had been diseased by milk from tuberculous
cows, taken into its stomach. He had never had a positive, indis-
putable reply to the question : Can tubercle bacilli pass the
digestive organs? Be believed that sterilized milk starved chil-
dren to death. Dr. Lyman of Massachusetts said as it was pos-
sible for a child to be exposed to cold and not take cold, it was
equally possible for it to live in a family where tuberculosis
and similar diseases exist and not contract them. He believed
that the development of the general health by proper sanitary
environments will be a better protection against disease than
any special method of asepsis. Dr. Carter of Des Moines,
Iowa, s.iid it was a frightful fact that dairies are, as a rule,
filthy, that the cows are filthy and kept in filthy places
and milked by men who are both filthy and diseased. He had
employed a man who had been previously employed for two
years and when he saw that he did not wash his hands nor the
cow's udder and remonstrated with him, he declared that he
had never done so ; and a second milker, who had also been
working a year in a dairy, made the same admission. He was
opposed to muzzling dogs and thought a shot gun was a better
protection against rabies. Dr. Holton of Brattleboro, Vt.,
agreed with Dr. Hihbeud and said he had tried to find an
undoubted case where tuberculosis had been communicated
by the milk or flesh of the bovine race and had noc found one.
He believed heredity, etc., accounted for the development of
certain diseases. He had for a year and a half, without know-
ing it. drank milk from a tuberculous cow, subsequently dis-
covered to be the worst in the herd. He called attention to
the danger from substituting patented food for milk.
Dr. Kinyoin and Dr. Salmon controverted the statements
of Drs. Hibberd and Holton that the infection of human
beings by diseased animals had not been established. When we
consider that tuberculosis may be produced in animals by feed-
ing them upon tuberculous tissues and find children die from
tuberculous disease and know that the tubercle bacillus does
penetrate the intestine, we are justified in inferring this as the
•source of their disease. As to making children strong rather
than destroy disease germs, it is the fact that the robust often
■die and the sickly do not. Immunity does not depend on the
strength of the individual. We do not know how frequent
this infection was twenty-five years ago, and we would not
know to-day but for the tests that have been established. How
does Dr. Holton know that the milk he drank was infected?
The next paper, "Contributions to the Study of the Patho-
geny, Etiology and Prophylaxis of Typhus," by Dr. Francisco
de P. Bernaldez, delegate from the State of Oaxaca, Mexico,
was a very able presentation of the subject based on personal
observations in many epidemics, and Dr. Bernaldez's conclu-
sions as to the limited contagiousness of this disease were
accepted without discussion.
The "Report of the Committee on Nomenclature and Forms
of Statistics," by Dr. Samuel W. Abbott of Wakefield, Mass..
Secretary of the State Board of Health of Massachusetts,
Chairman, was read by Dr. Walter Suiter of New York, particu-
larized the latest changes in nomenclature by the College of
Physicians of London, and was supplemented by a paper "On
the Nomenclature of Diseases and Forms of Statistics," by
Dr. Eduard Liceaga of the City of Mexico, President of the
Association, and one "On Need of Uniformity in the Meaning
of the term Stillborn," by Dr. Jesus E. Monjaras of the City
of San Luis Potosi, Mexico, Director of Hygiene of the State
of San Luis Potosi.
Dr. Lindsley of New Haven, Conn., expressed his apprecia-
tion of the great importance of this series of papers. There
were a number of States which do not yet take sufficient inter-
est in vital statistics, and as uniformity in nomenclature is the
essential basis of an exact system of statistics, he hoped the
Committee would be continued.
The paper "On Dengue," by Dr. Henry D. Horlueck of
Charleston, S. C, Health Officer of Charleston, was an interest-
ing account of the great epidemic of that disease at Charleston.
A paper "On Municipal Responsibility for Healthy School-
houses," by Mrs. Ellen H. Richards, . of the Institute of
Technology, Boston, Mass., was read by Dr. Durgin, Health
Officer of Boston, and one "On Woman in Preventive Medi-
cine," by Mrs. Harietta M. Plunkett, President of House of
Mercy Hospital, Pittsfield, Mass., was read by title.
evening session.
The evening session, to which the public was especially
invited, was promptly called to order at 8 p. m. by trie First
Vice President, Lieutenant Colonel Alfred A. Woodhull, of
the Medical Department of the United States Army, who most
efficiently assisted President Liceaga throughout the entire
meeting of the Association. The session was opened with an
address by His Honor Edgar B. Jewett, Mayor of the city of
Buffalo, who very gracefully welcomed the Association to
Buffalo, and invited the members to inspect the administration
of the city's affairs in their bearing upon the public health.
Mayor Jewett was followed by the Reverend Dr. Thomas R.
Slices. He said in part: "I address you tonight simply as a
citizen of the city of the lowest death rate in the United States,
who is interested in conserving the public health of that city
to a still greater extent. The word city is the watchword at
once of your opportunity and your peril. You all have seen
the dwellers in the country violating all of the rules of health
and seemingly being themselves healthier than those who live
in cities. In the grouping of so many together there is a sense
of power that is not found in the country. It is because of
this sense of power that lies in the binding of lives together
that we at once should have a sense of insecurity and a hope
of power. But, more than this, there is that civic conscious-
ness which belongs to every city. Buffalo, as an example, has
no civic consciousness. It has not the civic consciousness
which marks Birmingham, Glasgow or even Chicago. It is, so
far as we have gone, a group of contiguous tribes. I do not
now refer to their nationality, though that is also true, but to
their diverse interests, to their alien training, to their want of
common purposes in this city. Chicago would not be where
it is to day were it not for its civic consciousness, and if it had
not had the opportunity of the Columbian Exposition. Until
civic consciousness arrives in municipal life it is almost a con-
tinuous upgrade for the guardians of the public health. There
is a constant warfare with ignorance and avarice. Some of
us do not know enough to protect ourselves against contagion.
Let me add in conclusion that the Health Department of any
city has no business at that trough from which the politician
feeds. How many of you have not come in contact with that
parsimony that will deny $1,000 for a bacteriologist and spends
$2,000 on a junketing trip for a Board of Aldermen? "
The program had provided for an address on the part of the
members from the Dominion of Canada, by the Honorable
Richard Harcourt, Provincial Treasurer of Ontario and Min-
ister of Health, but having been unavoidably detained, Dr.
Peter H. Bryce of Toronto, Secretary of the Provincial Board
of Health of Ontario, acceptably supplied his place in a brief
extemporaneous address.
This was followed by the .annual address of the President of
the American Public Health Association, Dr. Eduardo
Liceaga, of the City of Mexico, President of the Superior
Board of Health of the Republic of Mexico. The President's
address from the standpoint of a sanitarian in a body of ad-
vanced and experienced sanitarians, was an able and forceful
paper. It was written in English by the President, but was
read at his request by his friend, Medical Director Albert L.
Gihon, U. S. Navy, a former president of the Association.
It related principally to the business of the Association and
went into a history of the growth and development of the study
of public hygiene in Mexico, which Dr. Liceaga said had been
fostered and encouraged under the administration of President
Diaz during the last twenty years. Some of the suggestions
made by Dr. Liceaga were of great value and interest. He laid
before the Association the proposition that it should devote
special attention to the study of contagious diseases, with a
756
SOCIETY PKOCEEDINGS.
[October 3,
view not only to their cure and the prevention of epidemics,
but to the means of preventing the development of individual
cases. The several phases of the subject of epidemics were
taken up separately and treated in an exhaustive manner.
One proposition put forth by Dr. Lice'aga was that isolation
in infectious diseases is not so essential in some diseases
as in others, and that the study of the extent to which it should
be practiced would repay investigation. Another proposition
was that more attention should be paid to the study of the
technique of disinfection. These and many other phases of
the broad subject of contagion could be studied by uniform
methods over a vast extent of territory by the members of the
Association, with great results. Another question which Dr.
Lice'aga thinks merits investigation is the ascertainment of the
period within which any disease is contagious and the person
affected dangerous to his neighbors. This is something in
regard to which much uncertainty still exists, and definite
knowledge in this regard would be of incalculable value. Dr.
Liceaga recommends also that a special committee for the in-
vestigation of the subject of the prevention of disease, particu-
larly by vaccination and inoculation, should be appointed, and
made reference to the newly developed sero therapy, which he
declared was already falling into disrepute through the use of
imperfect or contaminated serum. A committee to devise a
means for the use and sale of only absolutely pure and perfect
serum, should be appointed. In conclusion Dr. Liceaga said :
"Gentlemen of the American Public Health Association, I beg
to offer you my sincere congratulations on our coming again
together in the twenty-fourth meeting of this Association, and
on having selected for the place of our meeting this beautiful
and interesting city, which is so splendidly placed at the East-
ern end of this delicious lake, a lake that supplies the water
for this powerful river that farther on precipitates itself into a
grand cataract, a stupendous marvel of nature that thousands
of pilgrims from all parts of the world come to contemplate and
admire ; in this city which offers to us its hospitality and affords
us an opportunity of again meeting to render our homage to
science and to work together for the physical well-being of our
fellow-creatures."
(To be continued.)
Mississippi Valley Medical Association.
Twenty-second Annual Meeting, held at St. Paul, Minn.,
Sept. 15-18, 1896.
The meeting opened with a very satisfactory attendance,
Dr. H. O. Walker, of Detroit, presiding.
Dr. Charles A. Wheaton, of St. Paul, Chairman of the
Committee of Arrangements, called the meeting to order, and
introduced Archbishop Ireland, who delivered the invocation.
Governor Clough of Minnesota delivered the address of
welcome on behalf of the State. He said he was obliged to
admit that he was no orator, and that he had always been more
or less timid in the presence of a physician, but of his hearty
welcome to the State all members of the Mississippi Valley
Medical Association might be assured.
Hon. F. B. Doran, Mayor of St. Paul, delivered an eloquent
address of welcome on behalf of the city. He referred to the
reputation of St. Paul for hospitality won by the recent
encampment of the G. A. R., and he said that upon that occa-
sion the city had welcomed the men who had preserved the
nation, while now she welcomed the men who preserved the
bodjes of the nation's defenders.
Dr. A. J. Stone delivered the address of welcome on the
part of the profession. He paid a glowing tribute to the pro-
fession of St. Paul, the absence of professional jealousy, dis-
agreement and ill feeling, while he begged to assure the visit-
ing profession that they were most heartily welcome. He also
took occasion to speak of the great help the ladies of St. Paul
had been to the committee in making the arrangements. In
speaking of Minnesota as a health resort, he said it had proved
a Mecca for consumptives, and notwithstanding the fact that
many cases of tuberculosis came to St. Paul when in the last
stage and when beyond all hope, die there, are included in the
mortality, and notwithstanding this fact the mortality of this
city is the lowest of any in the world.
Dr. H. O. Walker took the chair and thanked the speakers
for the welcome they had extended. In casting about for a
subject upon which to deliver the annual address, ho had
decided to relate some experiences he had had rather than
thresh over the various subjects which are dealt with at length
in the various medical journals. He took for his title "Some
Experience of Surgery of the Kidney." (To be published in
full in the Journal.)
The report of the Treasurer was not read, by reason of Dr.
H. N. Moyer's absence on account of sickness.
The program opened in the afternoon session with a paper
by Dr. Truman W. Brophy, of Chicago, who presented a
NEW OPERATION FOR CLEFT PALATE.
He took the ground that the operation should be performed
much earlier than had been done heretofore by surgeons, and
that the idea that the operation should be postponed until the
child reached the age of three to seven years was an erroneous
one for the reason that the changes in the voice would by that
time have become permanent and the correction becomes
almost an impossibility. The operation suggested by the
author was the cutting of the edges of the cleft and then
suturing them by wire sutures secured through a lead plate on
each side of the palate, and made to conform to the same, in
the hands of the author the operation had been uniformly
successful.
Dr. W. H. Daly, Pittsburg, in discussion said : I think the
essayist has made a marked advance in the operation for cleft
palate, the most important point being its adaptability to very
young children, as I think it does away with all former objec-
tions to operating on the young infant. The greatest disap-
pointment I have had in these cases is the poor articulation
which follows the operation, and which is always a source of
great disappointment to the patient and family, who always
expect to hear perfect speech immediately after an operation,
and I think this result will be attained in Dr. Brophy's opera-
tion.
Dr. G. Futterer, of Chicago, read a paper entitled
PLEURITIC EFFUSIONS AND THEIR TREATMENT.
The author took the ground that a bacteriologic examina-
tion should be made in all cases. The diathesis in cases of
pleurisy should also be most carefully looked into, as cases of
uric acid are frequently found in connection with pleurisy ;
these yield readily to the administration of salicylates, and but
about 15 per cent, of the cases of pleurisy are believed to be
pneumatic. The pleurisy of typhoid fever was also considered
by the author, who did not believe it was a mixed infection,
but that it was a distinct condition. As to the presence of
tubercle bacilli in pleuritic effusions, Dr. Fiitterer believed
that they may enter through the alveolar septa and enter the
pleura without producing serious effect in the lungs. The
author has washed out the cavity in fourteen cases with an
antiseptic solution, with success in twelve. The agar culture
should be used to differentiate between tuberculosis and pleu-
risy. The advantages to be gained by this treatment is that
many patients will submit to it when they will not submit to
the excision of a rib.
Dr. Gustavus M. Blech of Detroit, read a paper on the
TREATMENT OF INFLAMMATORY DISEASE OF THE STOMACH.
The author criticised the old routine methods of treating
acute inflammatory disease of the stomach with menthol, ice,
cocain, opium, purgations, cathartics, pepsin, etc., for the rea-
son that they did not cure the patient and the physician was
too liable to delude himself into the belief that he had cured
his patient because he did not return, which the author claimed
was in nearly every instance due to the fact that the treat-
ment did him no good. The reason that was given for the
failure to cure the catarrhal condition of the stomach was that
we are too prone to attempt to prescribe remedies for the relief
of symptoms only and not sufficient attention being given to
relieving the pathologic condition which prevent the digestive
process from being normal. The use of strong antiseptics,
which seem to be indicated, are more likely to do more harm
than good by reason of the destructive action of strong anti-
septics have on animal and vegetable cells. The treatment
may be summarized into :
1, destroy the morbid element which is present in the stom-
ach so as to thoroughly cleanse the mucous membrane : 2, heal
the diseased surface after it has been made aseptic. For the
cleansing the author has found hydrozone the most satisfac-
tory. He uses a tumblerful of lukewarm water containing a
2 per cent, of hydrozone, half an hour before meals. The
nascent oxygen which is set free in the stomach by the oxidizing
agent destroys the morbid element and cleanses the mucous
membrane. As a healing agent glycozone in one to two dram
doses immediately after meals, is recommended. This treat
ment is strongly urged in gastric ulcer.
Dr. F.Hunt Stucky, Louisville, Ky. — I desire to emphasize
the value of perfect lavage in cases of gastritis. I would also
urge the careful attention to dietetics as well as any intestinal
disorder that may exist in connection with the gastritis. There
must also be something in addition to the antisepsis ; the ner-
vous system should be built up and attention paid to any cir-
1896. |
SOCIETY PROCEEDINGS.
757
dilatory disturbance. I believe massage would be valuable in
many of those eases.
l>r. I. N. I.ovk, St. Louis I do not believe in limiting the
treatment to any one agent, the entire tract must always be
kept in mind and the application or administration is but one
of many things to be done. We can not separate one set of
secretory glands from another but muBt give attention to them
all and in these cases I believe especial attention should be
paid to diaphoresis ; massage is also to be recommended in a
certain proportion of cases. I believe there are many persons
suffering today from an auto-toxemia due to a disordered
stomach and that 90 per cent, of these cases can bo laid at the
door of constipation. Lavage of plain water as well as drink-
ing large quantities of water just beforo eating I think a great
help toward starting the current downward and outward. The
habits of lavage has done much harm and I do not believe it
should be intrusted to the patient to carry out.
Dr. W. H. Daly, Pittsburg— I have had anything but satis-
factory results from lavage, the treatment suggested, and do not
favor it. I heartily agree with the speaker regarding the tox-
emia for 1 heartily believe that a very large proportion of these
stomachic diseases are due to toxemia and the most important
thing to do is to consider every one of these cases as a rule
unto itself and treat them individually. A good idea is to give
a lavage of a gallon of water and then empty the stomach by
irritating the throat with the finger when a cleansing result is
desired.
Dr. C. H. Hughes, St. Louis -The most important factor in
the handling of this class of cases is to treat your patient all
over. Medical men of the present day in treating dyspepsia
have been forced to the conclusion that the individual is pos-
sessed of a pneumo gastric nerve and that it plays a most im-
portant part in this disease, which has 6o long been considered
as a local one. You take for example a case of nasal catarrh
which goes the round of treatment at the hands of the rhinol-
ogists, who apply the spray, cautery, remove spurs from the
septum, etc., and what is the result? Are the cases cured?
No ; because the attendant is too prone to treat the disease as
a purely local one and not through the nervous system as
should be done.
Or. F. F. Lawrknck, Columbus — The frequent occurrence
of dyspepsia in connection with gallstones has suggested the
possibility of its being secondary to this condition. We have
all known of cases when the patient has consulted the physi-
cian for the relief of the usual train of symptoms which would
indicate gastro intestinal disorders and without relief until an
abdominal surgeon, looking for ovaries he may remove, opens
the abdomen and finds gallstones, after the removal of which
the gastro intestinal symptoms disappear.
Dr. J. M. Mathews, Louisville I would like to suggest that
the author of the paper did not attempt to treat nasal catarrh,
hysteria, or some of the other diseases the gentlemen have
referred to. The paper dealt with a certain class of gastric dis-
ease and the treatment is precisely what you would adopt
should you have an ulcer or acute inflammation located in
any other region and I think we should bear in mind that if
we want to have successful results we must get at the local
conditions in these cases.
Dr. H. T. Patrick, Chicago— I think there is some value in
the suggestion of the esssayist but I am opposed to the presen-
tation of a cure for a condition as complex in its nature as gas-
tritis without stating more specifically what form it is. 1
think the important thing to do first is to decide upon what
particular form of the disease we have to deal with, then the
cause and we can then apply our cleansing and antiseptic treat-
ment.
Dr. I. A. Abt, St. Louis — We should not for a moment lose
sight of the fact that we have a pathology for all these forms
of gastritis, whether it be from alcohol, tobacco or any other
cause. In making this differential diagnosis lavage will be of
particular value. I am firmly of the belief that many of these
cases are due to toxins.
Dr. J. A. Labrabee, Louisville — I am convinced that the
portal circulation is more often at fault in these cases than is
generally supposed and its correction too often neglected. Ex-
ercise is above all things the most important and should be
insisted upon in order to direct the blood to other and health-
ier channels. While 1 do not propose to discard the use of
antiseptics I will place more reliance on treating the portal cir-
culation.
Dr. W. S. Caldwell, Freeport, Ohio — I use the stomach
tube for diagnosis purposes principally and when I find that
there is neither fluid or debris forming in the stomach I keep
the tube out, although where I find much fluid accumulated in
the stomach in the morning I wash it out with the tube.
Dr. Paul Paqcln, of St. Louis, read a paper entitled :
THE TREATMENT OK EXPERIMENTAL TUBERCULOSIS IN ANIMALS BY
THE USE OK BLOOD SERUM.
i It will bo published in full in the Journal.)
Dr. H. Lonostreet Taylor, St. Paul — I desire to say just
one word on tuberclin and its modifications. Although the
essayist says that it acts by producing an antitoxin, yet this
has not and can not be proved. It may be the true explana-
tion although the observed fact of an active leucocytosis in
tubercular areas during its use is a more plausible explanation.
Tuberculosis in its various manifestations presents such a com-
plicated future and such a complex one that the very existence
of an antitoxin is problematic and even if found it could not be
a specific in the sense that the antitoxins of the acute diseases,
as diphtheria, aro specifics. Tuberculin is very much in dis-
repute here and everywhere, but it has a few constant friends
yet, among whom I stand, and with good reason, for in careful
hands undoubted results are obtained with it. I have, for
instance, only recently seen the glands, in three cases of
undoubted glandular tuberculosis, disappear under its use;
what more convincing experiment could one desire?
In a long series of cases my results with tuberculin have
been eminently satisfactory. With the St. Louis serum, how-
ever, I have not been able to obtain results. All the cases
upon which I have used it grew worse. Still from a short
series no results can properly be claimed, for more than in any
other disease probably are statistics difficult of comparison in
tuberculosis.
Dr. Jos. Muir, New York My experience has been large
and varied in the therapeusis of tuberculous disease and for
years I have used tuberculin and all its modifications, espe-
cially those of Hunter, Maclean, Klebs, Kitasato ; aside from
these, modifications of my own consisting of different percent-
ages of toxic albumoses, the logic being that the maximum of
irritation was gradually reached within and around that im-
penetrable wall, which surrounds all anatomic tubercles. Dr.
Paquin is scarcely satisfactory in his theories regarding the
physiologic action of his serum in tuberculous areas but his
paper is teeming with statistics ; some one has said, Beacons-
field I believe, that statistics consist of three classes, lies,
damn lies and statistics. The curability of consumption can
not be judged by statistics. Its curability has been known
from time immemorial since the days of the early Greeks.
Milk was the great agent in the treatment and continues to be
so to the present time— so from the fullness of statistics I may
cite the case of Professor Emmerickin an article written by him
somewhat over a year ago and in which he gave the history of
ten cases of sarcoma and carcinoma cured by serum obtained of
the erysipelas and prodigiosus toxins. It was afterward proven
that one of the cases referred to had been dead two months
prior to the reading of the report.
Dr. Barclay, Pittsburg, Pa., complimented Dr. Paquin and
congratulated the profession on the earnest and honest investi-
gations made. He felt that the absolute candor of the reports
should command the attention of the profession.
Dr. H. W. Loeu, St. Louis, Mo. I have known several
cases of laryngeal tuberculosis treated with serum and knew of
one case in which Paquin's serum had given remarkably good
results. In others it had been less successful. I consider
serotherapy more promising in the treatment of other forms of
tuberculosis than that of the throat. I will report a case of a man
who, six years ago was examined by six competent physicians
who pronounced the case one of tuberculosis with a fatal progno-
sis. The serum was used and to-day the man feels perfectly well
and all physical signs of the disease have disappeared except a
slight thickening of the arytenoids. I have confidence in the
treatments in laryngeal tuberculosis, and one fact I have noted
is that when first administered the larynx improves wonder-
fully even though it again resume its downward course.
Dr. W. H. Daly, Pittsburg— There is one thing to be
remembered in our enthusiasm over any new remedy for tuber-
culosis and that is a very frequent occurrence to have patients
claim that they are much better whenever a new line of treat-
ment is adopted. It was so with Koch, Bergeon and Edson. I
have tried the latter for a period of three months only to aban-
don it and while using it among some 150 cases of complications
I had developed four marked cases of acute insanity. I regret
that I am forced to admit that I feel that medical science has
done very little toward checking the downward career or in
the diagnosis of this disease.
Dr. A. J. Green, St. Paul The full ability of medicino is
best demonstrated in the treatment of tuberculosis. The sta-
tistics of some of the newer remedies are very encouraging at
first, but they are somewhat altered when we stop to consider
how many cases of enlarged glands and tubercular laryngitis
get well without any treatment. I am still inclined to the
758
SOCIETY PROCEEDINGS.
[October 3,
belief that we must depend more upon climate and high alti-
tude than any thing else.
Dr. Joseph Muir, New York— The treatment of tubercu-
losis is a very vague thing. We should be somewhat guarded
in pronouncing a cure for the reason that many cases for a time
manifest a quiescent stage which simulates cure. As for the
beneficial results of climate, I think more is due to the chaDge
of surroundings than to the climate.
Dr. Chas. H. Hughes, St. Louis, said that one should not
depend on any one remedy in the treatment of consumption.
Dr. Love said he knew of the work and results of Dr. Paquin
in his laboratory, and knew that his results in the treatment of
tuberculosis were as stated.
Dr. Paquin, in his closing remarks, stated that serotherapy
was founded on natural law. It was nature's own remedy he
tried to produce when he prepared tubercle antitoxin. He
believed that serotherapy in tubercle had passed the experi-
mental stage, although by no means perfect. He said that
in the earlier stages pulmonary tuberculosis could be arrested
in at least 80 per cent, of the cases by the use of serum and
proper adjunct treatments.
Second Day.
Dr. Horace H. Grant, of Louisville, Ky., delivered the
address on surgery :
THE RELATIONSHIP OF DIAGNOSIS TO THE FUTURE SURGICAL
PROGRESS.
He said that we must find some common ground for the set-
tlement of our differences ; many of the rect>nt operations are
passing away, owing to the effect of our modern scrutinizing
investigation. We forget there are men in the quiet of their
laboratories doing a work which makes all our wonderful pro-
gress possible. We can not progress much further in tech-
nique of operative skill. Any great amount of paraphernalia
suggests a lack of personal resource in the operator. Almost
every part and organ of the human body has been removed
recently with more or less good to the patient. If we would
make earlier and more careful diagnosis many of the possible
failures would be precluded. No surgeon dare say to the
patient, "If I had known yesterday, or before, so and so, the re-
sult would have been different." Rarely will we fail to secure
an operation if the operator be sure of his diagnosis and demands
an operation. No term in all surgery is so often misapplied as
conservatism. No aim is dearer to the surgeon than the ways
and means of relieving his patient. We must not fall into the
error of making one man great and another man insignificant.
Experience is and should be one of the greatest aids in diagno-
sis. The skiagraph has lately come into importance in surgical
work, and may be made a valuable adjunct in many instances.
Its recent successes are noteworthy. It is yet, however, in its
infancy, and is doubtless capable of still more development.
No one doorway can open to success in surgery. The skill-
ful and intelligent application of prompt relief added to a care-
ful diagnosis will give us the most wonderful and satisfactory
results. What each one finds to do let him do it with his
might.
Dr. E. M. Houghton demonstrated the action of the anti-
toxin on guinea pigs before the Association. He called atten-
tion to the conservative view the profession had taken of the
antitoxins which would have a tendency to avoid the unfortu-
nate experience the profession had had with tuberculin. The
value of laboratory experiments in connection with clinic
observation was emphasized by reason of our being thus ena-
bled to obtain the exact dynamics of the flesh and blood of our
patients and the advantage to be gained in varying our experi-
ments at will. In the case of diphtheria antitoxin the phys-
iologic effect can be foretold with almost the same certainty
that we can predict the formation of hydrogen when platinized
zinc and hydrochloric acid are brought together. The world's
verdict in reference to the clinic value of the diphtheria anti-
toxin is expressed in the report of 615 physicians reporting to
the American Pediatric Society on the use of the serum, of
whom 600 are in favor of its use. A similar commission
appointed by the German government, came to a like conclu-
sion, while Behring claims that after a careful estimate he
thinks that 20,000 lives were saved in Germany alone by the
use of the heil-serum. In England the results are expressed
in the report of the Lancet Special Commission, which report :
That the influence exerted by the exhibition of antitoxin on
diphtheria is at any rate quite as marked as that exerted by
quinin in malaria. Our ignorance of the true action and power
of the toxins and antitoxins was emphasized. The author
claimed that the results obtained by Pfeiffer and his co-work-
ers, in which he showed that if the serum obtained from the
blood of an immune animal be injected into an animal infected
with virulent cholera cultures the animal survives while the
control animals die. This result is not due to the antitoxic
action of the serum but to the bactericidal substances devei
oped when the serum is brought in contact with the living
cells of the animal body. If an animal be treated with large
and increasing quantities of living cultures of the bacillus pyo
cyaneus for several months, the resulting serum will possess
strong bactericidal properties but weak antitoxic properties.
If on the other hand the toxin is used, the resulting antitoxin
will have a strong germicidal and antitoxic action. This may
explain why we get a more potent diphtheria antitoxin when
the horse has been immunized with a diphtheria toxin than
when he has been immunized.
Eight guinea pigs were inoculated before the Association with
diphtheritic toxin, five were then inoculated with the antitoxin
and the second day saw the five in excellent condition while
the other three died.
The Committee on Nominations, consisting of Dr. J. M.
Mathews, Louisville, Dr. I. N. Love, St. Louis, X. C. Scott,
Cleveland, W. N. Wishard, Indianapolis, J. M. Coulter, Chi-
cago, W. F. Barclay, Pittsburg, W. J. Mayo, Rochester,
Minn., J. P. Collins, Hot Springs, G. Blech, Detroit, T. H.
Manley, New York, and E. W. Lee, Omaha, reconsidered the
nomination of secretary, and selected Dr. H. W. Loeb.
Dr. Robert H. Babcock, Chicago, read a paper on :
A REPORT ILLUSTRATING THE VALUE OF SECONDARY PHYSICAL
SKINS IN THE DIAGNOSIS OF CARDIAC DISEASE.
The author claimed that the murmurs are the least reliable
signs of valvular disease and an accurate diagnosis can not be
made unless the secondary signs are recognized. If the heart
be too weak it may be that the murmur can not be detected,
or a grave defect may not be noted. Secondary symptoms are
a modified pulse rate, character and rhythm, leading to a con-
gestion of the veins and internal organs. In some instances
there is systolic venous pulsations of the liver. This is diag-
nostic of insufficiency even if the murmur is not audible.
Dr. Joseph Muir, of New York, read a paper on
REINFECTION IN CONSUMPTION.
(It will be published in the Journal.)
Dr. J. A. Larrabee, Louisville — The paper of Dr. Muir is
unusually attractive, and reflects to ue our individual experi-
ence with consumption. The doctrine of re-infection affords
the only reasonable explanation of the recurrence of arrested
tuberculosis, with which every general practitioner must be
familiar. The principle element in our failure to secure to the
patient the advantage gained by our treatment in cases of pul-
monary consumption consists in our inability to remove the
patient from the surroundings in which his disease commenced.
The air of workshops, the carpets and drapery of the apart
ments, together with the illy ventilated tenements of even the
well-to-do working people, contain abundant seed for the now
more congenial soil. 1 have always believed that if the con-
sumptive could have in the inception of his disease the com-
forts and care which are drawn around him in the late stages
recoveries would be far more frequent. In regard to climate,
I do not think that altitude or latitude are of so much import-
ance as a sterile atmosphere to the bacilli tuberculosis. Some
of the saddest sights which I have witnessed in my travels
both at home and abroad have been doctors' mistakes coming
home in pine boxes. I believe that the best place for a con-
sumptive in the second stage of his disease, when the lung
tissue is beginning to break down, is at home, no matter what
or where that home may be. It is a sad sight to see the suffer-
ing putting up with inconveniences and deprivations, which
home alone can remove, for the questionable advantage of
climate. To this must be added the mental depression conse-
quent upon absent friends and the tender touch of a loving
hand. Yesterday I had something to say upon lavage when
the subject of gastritis was under discussion. To-day I simply
want to change the "1" into a "g" and speak of gavage, by
which I mean a systematic course of forced feeding with most
nutritious food, or in a word, forced nutrition. It has been
sufficiently demonstrated that nutrition may be successfully
forced even where there is no inclination to eat. Every farmer
who has stuffed turkeys in a dark cellar for thanksgiving mar-
ket knows this. If you can make your consumptive patient
gain steadily in weight he will as certainly improve in all other
respects. I have sent very many consumptives to New Mexico
with invariably good results, but I believe that if the United
States government, as proposed, were to build a sanitarium at
Las Animas or Santa Fe and fill it with consumptives, it would
soon become a Lazar house of disease, notwithstanding the
altitude and latitude. Among many of my cases sent to this
place was a young man who was fast succumbing to consump-
tion. He was a blythe and accomplished fellow, and the sole
support of a widowed mother. He had night sweats and copi-
18%.]
Si VIETY PROCEEDINGS.
759
ous expectoration and plenty of bacilli 1 sent him to Las
Animas to "fence ride," herding on a ranch : he rapidly im-
proved His clerical abilitiee attracted the attention of his
employer, who had built a hotel, and he assumed the dutiesof
clerk. In three weeks his symptoms returned ; he wrote me
and 1 told him to get out and go "fence riding" ; he is still
well, but would have died had he remained indoors. No point
is better established than that consumption is a disease of
gation of individuals. It was unknown to the nomadic
tribes, and no point is more important than segregation of
tuberculous subjects. If I have spoken at greater length than
the limit my apology is that such a paper as Dr. Muir has pre-
sented should not ge unnoticed, and without the compliment
which it deserves.
Dr. Hugh T. Patrick of Chicago, read a paper with elabor-
ate illustrations on
THINK ANESTHESIA IN LOCOMOTOR ATAXIA.
In nearly all cases of tabes dorsalis there is a band of anes-
t hesia about the trunk of about the level of the nipple. It is early
in the disease very narrow or even incomplete, or may be
represented by a zone in which the localization of touch is not
normally accurate. The sensory blunting on the legs so fre-
quent in tabes is generally an analgesia: the trunk anesthesia
is ascending, tactile, and the pain sense may be quite normal.
The band of anesthesia does not correspond to the cutaneous
distribution of the intercostal nerves, but to the nerve fibers
arising from adjoining segments of the spinal cord. In some
cases there are two distinct zones of anesthesia indicating
simultaneous involvement of spinal segments at some distance
from each other. The borders are inconstant, ordinarily
retract on continued testing, and vary in position with the
method of examination. The same band of anesthesia may
occur in syphilitic pseudo-tubes as shown by an illustrative
case, as far as known the only one on record. The patient
presented nearly all the principal symptoms of locomotor
ataxia, including a wide band of trunk anesthesia, but a diag-
nosis of syphilis of the cord was made, and on active specific
treatment he made an almost perfect recovery. A zone of
anesthesia much narrower than this one still exists.
Dr. J. Frvnk of Chicago, presented a paper on "A New
Method of Fastening the Round Ligament in Alexander's
Operation."
Dr. J. A. A 1st of Chicago, read on "The Clinic Significance
of the Child's Fontanelle."
Dr. W. J. Mayo of Rochester, Minn., read on "The Surgical
Treatment of Pyloric Obstructions."
Dr. Thos. H. Manley of New York read a paper on
CONDITIONS WHICH MAY SIMULATE ORGANIC OBSTRUCTION OF
THE RECTUM.
The obstructions in the large intestine are of two kinds, viz. :
1, the passive : 2, the chronic or incomplete. The former are
the most rare and dangerous, with few exceptions depending
on hernia, paresis, or occlusion by a new growth. The latter
derange the general health though they seldom immediately
imperil life. They are essentially dependent on habit, occupa-
tion or senile changes, or occur secondarily in consequence of
extrinsic influences. Thsy are more common in the female sex
in consequence of difference in the anatomy and functions of
neighboring organs : and may give rise to such symptoms as
may lead the unwary into suspecting uterine disorders.
By a methodic systematic examination of cases of intestinal
obstruction we may generally be enabled to determine whether
the large or small intestine is the seat of stenosis or occlusion
by certain well defined symptoms and when the large intestine
is the seat of the trouble, we may determine not only the area
involved but likewise whether such obstruction proceeds from
causes of an intrinsic origin or from pressure conveyed through
the other sources.
Dr. I. N, Love, St. Louis — The paper of the essayist is a
most practical one on obstruction in the rectum, which is a
most serious condition. It is serious if present in the male
and doubly serious if present in a woman. There can be no
question on the part of those who have been engaged in the
practice of medicine for any length of time that 90 per cent, of
the diseases of women are dependent on constipation. These
patients suffer not only from general poisoning from accumu-
lated ptomains and auto-infection, as it were, but in addition
there are encroachments and misplacements of the bowels, on
the pelvic organs depending upon the regular accumulation of
the fecal matter which produces mechanical obstruction. The
average woman, be she mother or daughter, has not been suffi
ciently impressed of the danger of constipation. We all know
that the old saying, the standard of comparison as it were,
regarding constipation which was explained in the words "as
constipated as a school marm or an owl," was correct. We
have all met with women young and old, moving in respecta-
ble society, whoso bowels have not moved for ten days, two or
even three weeks, yet these people are surprised if dangerous
diseases overcome them. Fatal inflammation of the periton-
eum and many other similar diseases in women are super-
induced by constipation. We should impress women young
and old that it is not only unesthetic and umartistic, but not
healthful for their bowels not to move every day. Let us im-
press them of the fact that to overcome this condition cathar-
tics and purgatives are objectionable ; they will have removed
the immediate disturbances but they produce weakness and
are agents in the establishment of the constipation habit.
Proper diet and eating of large quantities of fruit, together
with an abundance of pure water, and especially exercise, will
in nearly every case relieve the trouble. Let me emphasize
the importance of the use of a great volume of water morning,
noon and night ; let us teach our patients not to drink water
because they are thirsty, but for the purpose of washing out
their alimentary system of sewerage. The fact that the essay-
ist has cited a case where he with difficulty removed a fecal
mass with the obstetric forceps from the rectum must be
accepted by us. We have all had experience along that line
calling for the scooping out of accumulated masses menacing
the health of the individual. Women are very lax of exercise,
an every day necessity: let us teach them that a proper
open condition of the rectal canal is necessary to cleanliness,
to the system, and cleanliness is next to godliness.
Dr. N. H. Pierce of Chicago, presented a new "Submucous
Linear Cauterization ; a New Method for the Reduction of
Hypertrophies of the Concha;."
Dr. Hugh T. Patrick of Chicago, read a paper on
electro-therapeutics and electro-diagnosis simplified.
Electro-diagnosis is limited to the affirmation or denial of a
lesion of the lowest neuron, that is, of a lesion of the motor
cells in the spinal cord or of the nerve fibers, the peripheral
nerves springing from these cells. A lesion of this neuron
causes reaction of degeneration and this stripped of all unnec-
essary technicalities may be recognized by two variations from
the normal, namely : A loss or very considerable diminution of
faradic contraction and the slow worm-like contraction of the
muscles to interruptions of the galvanic current. In the elec-
tro-therapeutics of organic disease of the nervous system appli-
cations of electricity to the brain may be entirely discarded
as useless. Electricity through the spinal cord is little better.
In diseases of the peripheral nerve it probably hastens recovery
and that current is to be chosen which the better causes mus-
cular contractions. In functional nervous disease electricity
is of more practical value than in organic affections, but it is
almost impossible to determine what proportion of this good
effect is due to mental impression and suggestion. The galvanic
current is to be chosen for facial and intercostal neuralgia, and
sciatica ; the faradic for lumbago, for hysteric and anesthesic
paralysis and pain. The galvanic for exophthalmic goitre and
sometimes for neurasthenic headache and backache. For
facial spasm, tic douloureux, spasmodic torticollis, tremor and
chorea, electricity is useless aside from the mental effect.
Dr. J. A. Larrabee, Louisville -I arise, Mr. President, to
tender my personal thanks to Dr. Patrick for his plain, succinct
and truthful elucidation of the application to bodies of which
we know little, of a subtle fluid of which we know less. I thank
him because he has made the subject of electro diagnosis and
therapeutics plain to my mind, which is a difficult task. Hitherto
papers presented upon this subject have been chiefly inter-
esting to their authors. Dr. Patrick has plainly shown
us what lines are to be expected from electricity. It is not
surprising that electro-therapeutics should afford a fruitful
field for quackery and then it should be surrounded with
all the mysteries of his ingenuity. I will say in conclusion
that I have not found any benefit from electricity in chorea,
nor should I expect that any benefit should accrue if the
accepted pathology of that disease obtains.
Dr. A. J. Ochsner of Chicago, in a paper on
nerve sutures and other operations for injuries to the
nerves of the upper extremity.
It presented the following conclusions :
1. Suture every severed nerve. 2. The earlier the operation the
better. 3. If neither sensation or motion is established within
a year, the nerve should be again exposed, the cicatricial tissue
removed and the ends again sutured. 4. The ends should be
clean cut, should contain neither crushed tissue nor cicatricial
tissue. 5. Tension must be avoided. 6. The wound must
heal without suppuration to secure the best results. 7. Hem-
orrhage should be controlled perfectly to prevent intervening
clot. 8. Carefully prepared catgut is the best suture material.
9. After suturing the ends either direct or "a distance" it is
760
SOCIETY PKOCEEDINGS.
[October 3,
well to stitch a fold of fascia over the united nerve-ends. 10.
The extremity should be placed at rest. 11. The external in-
cision should be ample.
Dr. H. P. Newman of Chicago read a paper on
WOMAN AND HER DISEASES VERSUS GYNECOLOGY.
The author emphasized the following points: 1. As special-
ists we must recognize and exercise the rising interest in a
medical science which shall be preventive rather than curative.
2. Our affiliation should be with the general practitioner and
obstetrician rather than with the specialist in surgery, who
often lacks the special training necessary to an appreciation of
the many disease manifestations in woman, their etiology and
prophylaxis. 3. As we have long made a study of the pathol-
ogy and etiology of woman's diseases and as we know that what-
ever may be acquired can be prevented, our specialists are best
qualified to lead in the movement for the reform of all condi-
tions detrimental to the health of modern women.
Dr. J. H. Coulter of Chicago read a paper on
TONSILLOTOMY BY CAUTERY.
He gave the following conclusions : 1. Do only a small
amount at each heating of the electrode — work five seconds
and allow the patient to rest twenty seconds. 2. Burn only
where you can see what you are doing. 3. Use an electrode
bent at right angles and having a fine point. 4. Do not
attempt too much at one sitting. 5. A strong solution of silver
nitrate is an excellent hemostatic in cases where there is
slight hemorrhage. 6. Be sure the electrode is thoroughly
heated when you attempt to burn. 7. Cut off the portion
loosened at each seance ; it prevents healing by its friction, and
is often an annoyance to the patient. 8. Do not operate if the
gland be acutely inflamed. 9. Always remember the normal
shape of the tonsil, and that one must dissect much more
deeply at its superior portion in order to get all of the patho-
logic tissue. 10. It is sometimes best to cut from below
upward while taking out the inferior portion ; in this conven-
ience should be the guide. 11. By care the operation may be
rendered almost if not entirely bloodless. 12. The indication
in all cases is eventual total ablation. 13. Succeeding steps on
the same tonsil should not be more than ten days apart. 14.
When hemorrhage is met with, stop the bleeding at once with
the heated electrode, and apply a solution of silver nitrate 90
grains to the ounce solution or stronger. 15. Try the method
in suitable cases and I feel confident you will concur with me
in the opinion that it possesses some advantages not found in
any other.
Dr. G. Blech of Detroit read a paper on "Kola."
Dr. F. P. Lawrence of Columbus, Ohio, read a paper on
THE PATHOLOGY AND TREATMENT OF SUPPURATIVE
SALPINGITIS.
He called particular attention to the following points : 1.
The tubal mucosa is a true mucous membrane possessed of all
the histologic elements of mucous membrane. 2. The fimbria?
are prolongations of the folds of mucous membrane with a few
muscular fibers beyond the end of the tube proper. 3. The
closure of the fimbriated extremity of the tube is effected by
first, the unfolding of these plicae and the elongation of the
muscular fibers with coincident inflammatory exudate and not
by adhesion of peritoneal surfaces. 4. The closure of the tubal
ostium results in the formation of a circumscribed abscess. 5.
The pathology of this circumscribed abscess is the same as
that of suppuration with abscess formation in mucous mem-
branes in other parts of the body except in the effect upon
important contiguous tissues. 6. Occasionally the uterine
end of the tube remains patent when we have the abscess of
tube communicating with uterine cavity through which it
may impart, discharge its contents. The treatment of the
tube can not be fixed by any ironclad rule, each case must
be treated as best it can by first, incision and drainage in rare
cases ; second, the vaginal section in a few carefully selected
cases ; third, abdominal section in a great majority of cases ;
hysterectomy in those cases where we find abscess of uterine
wall, tubercular deposits, fibroids or malignant disease of
fundus ; as hysterectomy destroys the pelvic floor, it should
never be performed except when there is some tangible lesion
of the uterus.
Dr. F. B. Turck, Chicago I wish to take objection to the
manner in which the speaker handled the bacteriology and
pathology, in his paper, of the uterus and tubes. In the first
place microorganisms do not peptonize living cells. It is
only necrosed tissues that undergo peptonization. The manner
in which infection takes place is, first a soil is found upon the
surface of the mucosa — the microorganisms may develop in a
mucous bed of cellular lining upon the mucous wall. As
the germs grow in this rich nutrient media toxins are found
which are partly taken up by the underlying gland cells. A
necrosis then occurs and the cells exfoliate and add to the nutri-
ent media. It is then that peptonization of the necrosed cells
may occur. The thinning of a tube is not due to the pepton-
ization of its wall. When inflammation of the mucous mem-
brane of the tube occurs, the membrane first may be thick-
ened, then fluids are formed which distend th<* tube or tubes,
and the pressure in this manner produces a thinning of the
walls.
Dr. H. H. Grant, Louisville— While I believe the position
taken by the essayist is practically the one we must accept, it
is not the ideal one. We are often forced to accept what our
judgment indicates to be a second choice. There are two
arguments not mentioned which, while they are in the minds
of the essayist and the surgeon, are not in the minds of the
general practitioner and the family, and do not assist in
securing consent to operate. These are : First, there exists
always, practically, a septic condition and often a gangrenous
foreign material of a highly dangerous character. Secondly,
there is a large proportion of apparent recovery which are in
fact but partial recovery. When we can so instruct the gen-
eral practitioner that he will understand the patient who lies
before him has within his abdomen a virulent foreign body or
pus sac, he will not hesitate to consent to and advise operation.
Beside this when there is impressed on the patient the danger
of recurrence, even after apparent recovery, he will more likely
accept the operation. With respect to septic peritonitis a
serious question arises. Whether to operate or not is still
unsettled. It is humiliating to decline and often hopeless to
proceed.
Dr. I. N. Love, St. Louis, read a paper entitled " Water."
(To be published in full in the Journal.)
Dr. T. H. Stucky, Louisville- I want to say a good word
for hydrotherapy, but I would take issue with the essayist that
a large quantity of water is always to be taken with meals,
for example, in cases of dilated stomach I do not think it at
all advisable ; it also prevents thorough mastication when
taken with food and thereby prevents complete salivation
which would result in fermentation. I also think that too
little attention is paid to the subject of water in our medi-
cal colleges.
Fifty-seven members of the Association left in a special train
for Yellowstone Park Friday evening and arrived at the Park
Sunday noon. They expect to return in a week.
Second International Congress of Gynecologry
ancl Obstetrics.
This Congress opened at Geneva September 1, with a nota-
ble gathering of specialists from every civilized country.
The first address was made by Bouilly of Paris, with Kelly of
Baltimore and Sanger of Leipsic as " co rapporteurs," and dis-
cussion by Henrotin of Chicago, Pean, Hartmann, Richelot,
Tait, Doyen, Delageniere. Laroyenne, Jacobs, Delettrez, Rouf-
fert, Tournay, etc. Bouilly defined as follows the indications
for simple incision with drainage, through the abdominal or
vaginal wall :
1. An acute pelvic abscess of cellular origin, the point for
the incision indicated by the projection of the collection in the
abdominal wall or in the vagina. 2. Primary peritoneal col-
lections consecutive to puerperal, abortion or gonorrheal lesions,
acute or subacute, or to post-operative peritoneal infection. 3.
Suppurated hematoceles. 4. Encysted pelvic abscess in the
adnexa, unilateral, with not very thick walls, easily fluctuat-
ing, and located low down on the uterus so that it can be pushed
down by pressure in the hypogastric region into contact with
or near, the wall of the vagina. Simple incision is also espe-
cially indicated in acute suppurations of the ovaries or tubes
accompanied by general serious conditions in which the extreme
virulence of the pus contraindicates laparotomy or hysterec-
tomy. This method of treating pelvic suppurations gives better
results and ensures recovery in far more cases than is generally
realized, while if a fistula persists or the suppuration returns,
it does not preclude a later vaginal hysterectomy.
Laparotomy is indicated whenever there is any doubt as to
the character of the lesion or whether it is uni- or bilateral.
The latter consideration is less important in the case of sup-
purations, as it rarely happens that suppuration of one side is
not followed by the same condition in the other. Laparotomy
is also the better method for pockets located high up, when
they are near the horns of the uterus and yet far enough away
from it and from the vaginal cul de-sac for the uterus to retain
a certain independence and mobility ; also when the pockets
are rather abdominal than pelvic, not surrounded by thickened
and indurated tissues, and when they have not produced
repeated pelvi-peritoneal disturbances. The opening of such
\tm.]
SOCIETY PROCEEDINGS.
761
n pocket in the course of a vaginal hysterectomy might pro
dace an acute peritoneal infection by infecting the surround-
ing intestines unprotected by any old barriers of organized
adherenees. Aside from these two restrictions ; uncertainty as
to the nature of the lesion and an elevated location, vaginal
hysterectomy accomplishes all that can be accomplished by
laparotomy in the removal of suppurated tubes and ovaries or
■ small pyo salpinx. It also reaches and cures lesions for
which laparotomy is useless or too dangerous. It is the only
method which reaches purulent collections enclosed in the
appendages, circumscribed by adherenees or merged in
the neighboring parts, and separated from tho great peri-
toneal cavity by solid and organized tracts, actual tibrous
processes which render laparotomy useless and any attempt at
enucleation dangerous. Hysterectomy is also the preferred
method in cases of large, adherent pockets, impossible or diffi-
cult to enucleate, with or without fistulas. It is also the best
method to cure chronic suppurations of the peri-uterine cellu-
lar tissue that have opened spontaneously and formed com-
munications with neighboring organs. In these operations the
purpose is simply to evacuate : the ablation of the uterus form-
i nur an ideal means of draining, through which the collections
discharge and dry up. To extirpate the pocket itself under
these circumstances deprives the operation of all the advan
tages of its simplicity and benignity, and shows a misappre-
hension of its chief advantages. In conclusion he stated that
ablation of the uterus is a factor not to be neglected in the
treatment of pelvic suppurations. Some of tho laparotomists
now remove the uterus along with the adnexa as this ensures
perfect drainage of such marvelous efficiency that it is proba-
bly the cause of the superior results after vaginal hysterect-
omy. A blation of the uterus also prevents future trouble from
that Organ. The immediate recovery is more rapid and the
after effects arc better, while the genital disturbance subse
quent to suppression of the menstrual function seems to be less
after ablation of the uterus with the appendages, than after
ablation of the latter alone. Vaginal hysterectomy therefore,
is the method jmr excellence for treating pelvic suppurations,
and laparotomy only exists on its contraindications.
iger, on the other hand, stated that the tendency in Ger-
many is to favor laparotomy and ligatures, and a more con-
servative treatment. The Germans eonsiderthat it is far bet-
ter to retain as much as possible of the genital organs than to
extirpate them and resort later to the ingestion of ovarian tis-
sue, etc.. as a substitute for them. He rejects absolutely the
idea of vaginal removal of a sound uterus as a preliminary to
operating upon the adnexa, and states that the radical opera-
tion is not justifiable when the abdominal end of the tube is
still open, nor in light cases of purulent salpingitis, abscesses
of the ovaries, chronic, non-purulent affections of the adnexa,
nor in simple, chronic inflammations of the uterus.
It is beter to have a menstruating uterus, even if it is slightly
diseased, rather than none at all. On the other hand, the rad-
ical operation is completely justified in serious suppurations of
the adnexa, pelvic peritoneum, or connective cellular tissue,
when these affections coincide with a serious affection of the
uterus, which alone would justify its removal, and also when
the purulent affection of the adnexa has spread to the uterus ;
also in cases of tuberculous affections. Proximity to the men-
opause is an additional indication for radical treatment. The
objections to vaginal operations are the necessity of commenc-
ing the operation at the uterus instead of at the diseased
■ovaries, also the impossibilty of arresting the operation ; the
incompleteness of the investigation of the field of operation as
other purulent collections, appendicitis, etc.. might exist and
pass unobserved ; the impossibility in certain cases of a
truly radical operation, and the dangers of hemorrhages and
■of injury to the neighboring organs. In the case of slight sup-
puration of the appendages, when the pockets were not opened
in the course of the operation, the peritoneal cavity can
be closed without danger. The Germans prize highly the
method of closing introduced by Kaltenbach and Olshausen,
except in serious cases of radical vaginal operations. When-
ever removal of the uterus is indicated, he considers celio-
salpingo-oophoro subvaginal-hysterectomy as the least, dan-
gerous radical operation. A part of the ovaries can even be
retained with it. Drainage is indispensable in all cases of con-
tamination of the hand of the operator or of an intact region with
virulent pus : also when the hemostasis is not perfect or there
is a discharge of virulent pus ; also where there is a preexisting
fistula, or perforation of the intestine during the operation. He
prefers Mikulicz's method of drainage, and adds that, thanks to
this, the life of the patient can always be guaranteed, with
complete recovery in time. Tamponing also relieves the anx-
iety of those who venture to close the abdomen. He classified
some of the various methods in vogue as follows :
Vaginal methods: 1, anterior colpo-celiotomy (Di'ihrssen,
A. Martin, etc.); 2, posterior colpo-celiotomy (Steel, Hegar,
Hsittey, By ford, Laroyonne, Landau, Mackenrodt, etc.); 3,
anterior and posterior colpo celiotomy (Bode, Von Erlach, Gott-
schalk), in combination with unilateral and bilateral salpingo-
oophorectomy ; 4. colpo-hysterectomy (Plan's uterine castra-
tion) ; colpo hystero salpingo oophorectomy or radical vaginal
operation (Pe'an, Segond, Doyen, Landau). Abdominal meth-
ods : 1, celio salpingectomy and uni- or bilateral celio sal-
pingo oophorectomy ; 2, total celio salpingo oiiphoro hysterec-
tomy (Krug, Polk, Delageniere, Schauta, Bardenheuer, etc.);
.'{, bilateral celio .salpingo-odphorectomy combined with supra-
vaginal hysterectomy (Zweifel, Kelly, Stinger). Mixed meth-
ods: Abdominovaginal hysterosalpingo oophorectomy, com-
mencing usually with the vagina and ending with the abdomen
(Landau), and finally, in a group apart, sacral or parasacral
celiotomy (Hegar, Von Hochenegg, Czerny, Schede, etc.), which
has only been performed by a few surgeons and with strict
limitations.
Kelly's able presentation of his methods was read by the
Secretary < ieneral. Henrotin (Chicago) insisted on the benefits
of immediate vaginal incision with digital exploration, and if
necessary a second opening in the anterior cul-de-sac.
Kichelot (Paris) remarked that extirpation of the adnexa
through the abdomen was not always followed by recovery;
and the surgeon was sometimes baffled by encountering
extremely virulent pus. In every second one of the laparoto-
mies he has performed since 1894 for suppurated adnexa he has
been compelled to finish with double castration. Laparotomy
triumphs where there are organs to be respected, which is, he
considers, its true indication. He added that the tubes and
ovaries are not hoard from after the removal of the uterus, as
often as the uterus after the removal of the appendages ; con-
cluding with the statement that vaginal hysterectomy should
be accepted as the preferred method of treating pelvic suppur-
ations, principally because it avoids the two dangers of lapar-
otomy: infection of the peritoneum and injury to the small
intestine. Hartmann (Paris) urged more general resort to
repose in bed and vaginal antisepsis as the first, and sometimes,
the only treatment needed for pelvic suppurations. He has
also derived great benefit at times from dilatation and curette-
ment, which may prove useless, but in certain cases seem to he
all that is necessary. Pean lauded total vaginal castration as
applicable to all pelvic suppurations of genital origin and sure
to produce better results than any other method of treatment.
Recovery is more rapid the earlier the operation is performed,
and the mortality, in skilled hands, is only from 1 to 4 per cent.
He concluded by mentioning the beneficial results he has
observed occur in from two months to three years after the
operation : disappearance of hysteria in 6 patients, of nervous-
ness in 2, insanity 5, melancholia 1, morphinomania 2, ileo-lum-
bar neuralgia 4, mammary and intracostal neuralgia 3, nausea
and rebellious gastralgia 2, anemia from inanition 2, headaches
and sweats 4, inability to walk 1, gravel and nephritic colic 1,
rheumatic endocarditis 1, bronzed pigmentation 1, and albu-
minuria 2. Pe'an now has a record of 350 operations and
repeats his previous announcement, that total vaginal castra-
tion requires a special set of instruments, such as he has been
using since 1883.
The other subjects discussed at the Congress were : "Surgi-
cal Treatment of Retro deviations of the Uterus," presented by
Ki'istner, Polk and Pozzi, and the discussion led by Martin,
Bouilly, Lawson Tait, Doyen, Jacobs, Edebohls (N. Y. ), Gill
Wylie, Delettrez, Stapfer and Petit ; " Best Method of Closing
the Abdomen," presented by Granville, Bantock and La Torre ;
discussion led by Martin, Tait, Richelot, Laroyenne, Doyen,
Jacobs, Edebohls, Gill Wylie, Byford (Chicago) and Delettrez ;
and "Relative Frequency and Shape of Abnormally Small
Pelvis in Different Countries," etc., which were represented
by Fancourt Barnes, Dohrn, Fochier, Kufferath, Lusk, Rein,
Pawlick, Pestalozzi, Treub and Barry Hart.
Fourth International Congress of Criminal
Anthropology.
This interesting assemblage of the specialists who are fos-
tering this infant science opened at Geneva August 24. Lom-
broso said in the course of his address, in regard to our prisons,
that as at present conducted, the expenses have to be borne by
the law-abiding citizens, and they fail to reform the criminal.
The probation system, with work in mines, penal farms, etc..
should take the place of our present prisons, and criminals
from passion and political criminals should not be imprisoned
at all, as exile alone is more than sufficient punishment. Con-
firmed criminals, epileptics, alcoholics, should receive special
medical treatment, but the efforts of society should be espe-
762
SELECTIONS.
[October 8,
cially directed to bringing up in a moral atmosphere the born
"criminaloids" from the earliest months of their lives, with
absolutely no intercourse with depraved associates and no
opportunity for them to corrupt decent young people. With
this should be combined every possible means to combat alco-
holism, social, religious, with journals, pamphlets, etc., and
constant medical supervision of the "criminaloids." Fran-
cotte spoke of a condition induced by alcohol which he calls
alcoholic somnambulism. The individual acts in an apparently
normal manner, but has no consciousness of his actions, or at
least retains no remembrance of them. He considers it a
legally irresponsible condition, except in cases of premeditated
intoxication. Legrain's address was an appeal that the
importance of alcoholism as an evil and peril to the nation
should be inculcated in every way, taught in the schools and
impressed upon legislators as their guiding principle. Habit-
ual drunkards should be incarcerated, so that they could not
propagate their kind, and compulsory cures legally enforced.
Their children should be taken from them and societies formed
for this purpose. Garofalo suggested that criminals should be
classified as follows : 1, assassins ; 2, violent ; 3, dishonest ; 4,
cynics. Homicidal mania, pyromania and epilepsy would be
included in the first category ; hysteria and kleptomania in the
third and sadism in the fourth. If penal science were relieved
of some of the conventionalities which now encumber it, and
the actual criminals separated from the mere revolts and diso-
bediences, each type of criminal could then receive appropriate
treatment and the science be established on a firm basis. Mal-
arewski stated that the establishment of medico-pedagogic
institutions and agricultural training colonies is the only means
to reclaim children with a predisposition to degenerates, and
that an international medico-pedagogic congress is the only
means to accomplish the organization of such colonies. Other
subjects presented were the influence of the press on crimin-
ality, anarchism from the point of view of criminal anthro-
pology, or as Zakrewski prefers to call it, legal psychopathology,
digital imprints and Bertillon's discussion of the gaps still to
be filled in anthropometry. The members from Russia, Italy
and Belgium were especially prominent in the Congress.— Gaz.
MM. de Liege, September 3.
SELECTIONS.
The Progress of Scientific Medicine and Pharmacy in China; A
Conversation with the Physicians of Li Hung Chang. With the
great Chinese warrior and statesman who has just honored our
country with a brief visit, there came two attaches of the Chi-
nese Imperial Medical Service, Drs. Irwin and Mark, for the
purpose of insuring his health and physical comfort during his
journey around the world. It has been the pleasant privilege
of the writer to call upon these custodians of the bodily welfare
of the Viceroy, and to talk with them in regard to the recent
progress of western medical methods in the Celestial Empire.
Dr. George Mark's manner is most cordial and in every way
pleasing ; his English is so thoroughly excellent, that only his
physiognomy and dress betray his nationality. He is in the
foremost rank of the Chinese students of scientific medicine.
Dr. Andrew Irwin, an examiner and director of the Imperial
Hospital at Tien-Tsin, is a genial Briton, who has come to favor
and position among scientific men who are struggling to sup-
plant the barbarous myths and superstitious practices of the
Chinese physicians by the more human and more scientific
methods of our western civilization. He appreciates the need
of a change of this sort and the value of the progress already
made, and finds pleasure in making known the condition of his
favorite science in the country that has become the scene of
his life work.
When the first medical missionary arrived in China in 1834,
he found the medical methods of the country in a most deplor-
able condition. There was a scanty medical literature, of which
one of the most important works was the Materia Medica of
Li Shi Chan, which is known as the Pun Ts'o Kong Muk. Its
first edition of forty volumes appeared near the close of the
sixteenth century ; the last of the four reprints was issued
in 1826. This materia medica was a most inclusive one
and it necessarily included many useful substances, as is
shown by the following quotation: 'Whatsoever things are
produced in the world — birds, beasts, creeping things and
fishes, which are generated and have blood and breath ; like-
wise flowers and trees, which are generated, but are without
blood and breath ; and also inanimate objects, such as rocks
and hard iron — all of these can be used as healing medicines."
There had been a so-called Imperial Medical College in Pekin
since the thirteenth century, but it imparted no regular courses
of instruction, rarely conferred degrees, and the skill and
learning of the members of its faculty were reserved for the
requirements of the royal family and the members of the court.
The native practitioners were divided into three great classes :
1, the class of specialists, of which there was a subclass for
nearly every division of the human body ; 2, a class whose
attention was given solely to diseases of the internal organs ; 3,
a class that treated only external diseases. A case is often
cited to illustrate this condition of affairs of which it is related
that a man wounded by an arrow was first visited by a physi-
cian for surface maladies. He broke off the shaft of the arrow
at the surface of the body and told the patient that further
treatment must be had at the hands of a physician skilled in
the diseases of the internal organs.
Acupuncture and cautery by the moxa were much in vogue ;
counter irritation was practiced by vigorously pinching the
skin with the fingers, or by harshly scraping it with a stick
dipped in water or oil, and by use of various plasters. The
Chinese were pioneers in the art of massage, a rude form of it
forming a part of the regular operations of the native barber
shops. Surgery was almost unknown and its advance has
been very greatly hindered by the belief that for well-being in
a future state, the body must be kept intact; hence, we hear
of the pulverizing and swallowing of extracted teeth, of the
eating of an excised part, or of its preservation for burial with
the body after death. The medicines used were notoriously
inert in many cases, and were often most disgusting in the
method of their preparation or in their origin. The right to
professional rank had been passed from father to son as prop-
erty is inherited. In the case of a break in the line of succes-
sion, the professional privileges were sold along with the estate.
Almost no study was necessary to inspire the patients with
awe and faith, if the right to practice had been obtained by
either purchase or inheritance from a family having a reputa-
ble ancestry of noted physicians. It has been said that " Were
all of the native practitioners in the empire at once swept away,
the Chinese people, so far as their prospects of health and long-
evity are concerned, would sustain no very serious loss."
During the last half century, the labors of the medical mis-
sionaries and other physicians from America and Europe, have
done much to relieve the immediate sufferings of the people
and have worked a very marked change in the practice of the
native physicians in the more accessible parts of the empire.
Between fifty and one hundred hospitals have been established
by the efforts of various denominational organizations, and
mere than two hundred medical missionaries have taken part
in the work, including more than a score of women. Many
Chinese men and women have been trained for physicians and
nurses in the hospitals, or in private study with the physicians.
An association was formed in 1887, called the Medical Mission-
ary Association of China, of which the official organ is the
China Medical Missionary Journal, at present edited by S. R.
Hodge, of Hankow, and published quarterly at Shanghai by
the American Presbyterian Mission Press. Many medical
works and treatises on the allied sciences have been translated
into the Chinese language. Dr. John G. Kerr, an American
medical missionary who went to Canton in 1854, has been
especially active in this work, having issued more than twenty-
five medical text-books in the Chinese language. Fryer has
translated the chemic treatises of Bloxam and Roscoe, and
also several books on physics, botany, materia medica, etc.
18%.]
SELECTIONS.
763
Tin- late Dr. Osgood, an American medical missionary, issued
a Chinese edition of Gray's "Anatomj " : Hunter lias trans-
lated Squire's "Companion to the British Pharmacopeia."
Martin, Smith, Allen and the Chinese physician Suvoong, are
to be included among the names of those who have made con-
tributions to the literature available for Chinese medical stu-
dents who read only their native language.
If ore than one hundred American and European physicians
onnected with the missions, have taken up their residence
in China, and are engaged in private practice. A Hong-Kong
Medical Society has been formed by the physicians of that
city : a volume of their transactions was published in 1889.
Dr. Irwin mentioned Drs. Manson and Cantlie, since retired,
as among the most prominent of the founders of this society.
Bach of the ports open to foreign commerce has a "Surgeon to
the Customs." In 1870 the Inspector General of Customs
issued a request for a semi annual report from these medical
officers of the different ports in regard to the condition of the
health of foreigners and citizens in their respective provinces,
together with the results of studies of new diseases or of dis-
eases rarely met outside of China. These reports are published
annually under the title '"China Imperial Maritime Customs;
.Medical Report -
Dr. Irwin described the founding and success of the Imperial
Medical College of Tien-Tsin, in connection with the Yang
Ping Yuen (Imperial Hospital of the North), with great pride
and feeling. The first class was examined for graduation in
Qf the eighteen candidates for diplomas, twelve passed.
Dr. George Mark, of the Viceroy's party, was at the head of
his class, of which another member is now in America for the
completion of his medical education. The school was not
reopened until November, 1893. There are now twenty-six
students enrolled, eleven in the second year class and fifteen
just bee inning. The course of study requires four years for its
completion. There is no separate school of pharmacy, but the
students of the medical school are given instruction in the
preparation of medicines. The school and hospital are both in
charge of Dr. Houston, an European. There are four regular
lecturers, one European and three Chinese. The medical
officers of the Navy often lecture also, when their vessels are
stationed conveniently. The hospital has sixty-five beds and
is taxed to its utmost capacity. There is also a hospital for
women, having thirty -one beds, which is in the charge of Mrs.
Dr. Howard King, formerly of Philadelphia.
Dr. Kin Ta Chin, a member of the class of 1883 of the
Imperial Medical College, has been decorated for his services
[inlander of the field corps of the Imperial Medical Ser-
vice during the recent war with Japan, and is now in charge of
the field hospital of the army of North China at Kin Chou.
Dr. Irwin spoke in most complimentary terms of the assist-
ance rendered by the surgeons of our navy during the Japanese
war. Especial mention was made of the work of Dr. Philip
Leech at the Isabella Fisher Hospital, which is superintended
by an American woman, Dr. Rachel Benn : and also, of the
valuable services of Dr. Ames, who has been consulted by the
Viceroy, and who ably assisted at Che Foo in caring for the
wounded from Port Arthur and from the naval engagement of
Valoo. t
"We place no reliance on the medicines of local manufacture,"
said the doctor in reply to a query, "but use only those im-
ported from Europe and America. Many of the large manu-
facturers and dealers have branches or agencies in the Empire.
The government contracts for drugs and medicines are a small
matter in time of peace ; five hundred gold dollars would cover
the whole bill for one year."
There are drug stores kept by foreigners of different nation-
alities, and quinin and some other foreign drug staples are
found on the shelves of the natives shopkeepers.
A number of Americanand English dentists have established
offices in the larger cities, but very little advance has been
made among the native workers. Chinese dentistry is crude
and a fakir's art. Mercurial preparations are used for loosen-
ing the diseased tooth, when it is extracted by means of a string
or rude forceps often with a sleight of-hand accompaniment
to prove to the patient that the trouble in the aching tooth is
due to a worm. A worm is smuggled into the patient's mouth
during the operation, again removed and exultingly exhibited.
Artificial teeth are made from bone and fastened in the mouth
by attaching them to the sound teeth with a wire or a string.
Xow that the government has evidenced its appreciation of
modern scientific medical methods by establishing and main-
taining a school in which they maybe taughtto the youth ofthe
land, and men from all parts of the empire have had occasion
to either experienceor witness their success and benefltsduring
the recent war, we may safely regard this as the era of the
triumph of science in China— we may hope that the day is not
far distant when plasters of powdered tiger's teeth have lost
their repute as remedies for the healing of external injuries :
when jelly prepared from bear's paws has lost its alterative
power ; when potions made from the horn of the hart are no
longer used for the renewal of wasted vitality ; when Chinese
mothers can eat chickens, ducks or turtles without fear of
destroying the hearing or eyesight to their unborn babes, or
can look upon a hare or rabbit with no qualm over a possible
harelip for the unborn one.— E. E. Ewell in Pharmaceutical
Era, September 10.
A Case of "Sadism," or Sexual Perversion with Violent Tendency.
—Dr. Morton Prince, in Boston Medical and Surgical Journal,
reports a case of this nature in a male aged 22 years. By
"Sadism" is meant the association of cruelty or violence with
lust, the name being derived from the notorious Marquis de
Sade, whose obscene novels treated of lust and cruelty.
Dr. Prince's patient before coming under his observation
had been regarded as being the subject of neurasthenia or hys-
teria. His relatives made a diagnosis of general laziness, while
others described him as being not quite right. His mental
state was unknown to others until, after great difficulty, Dr.
Prince obtained a full confession. It was his custom to lie
upon the bed in the daytime and fall into a sort of trance or
day dream state, in which he was apparently between waking
and sleeping. He said he thought he was awake, because if
anyone should knock on the door or come into the room he
would know it. While in this state he used to imagine that
he killed and mutilated women. It was not possible to learn
from him the exact mode in which this habit began, or what
was the original exciting occasion, but his imagination began
in a moderate way and afterward extended. At first, it was
only a single woman whom he imagined he thus mutilated, but
afterward in each "seance" he destroyed great numbers. His
imagination seems to have created actual hallucinations, for he
said that at these times he actually saw his victims with great
vividness as objective realities and had the sensations of
actually killing them ; for the time being his acts were abso-
lutely real to him, and soon a belief in them persisted.
At first it was a single girl whom he mutilated ; he killed
her, tore her to pieces and ate her ; later he imagined that he
lived in towns where it was the custom for the men to destroy
all the women in this way. Then, as the habit grew, the towns
became cities and the cities countries. These countries were
completely depopulated of the women by the men, all of whom
together held these Sadistic feasts.
While indulging in these dreams or hallucinations, he had
most intense sexual excitement with emissions. His habit was
thus a form of masturbation, the peculiarity being the associ-
ation of sexual feeling with hallucinations of cruelty. When
in the waking state he seemed to be at times confused as to
whether he actually committed these imaginary murders or
764
PRACTICAL NOTES.
[October 3,
not ; for while at one time he said he had not, at other times
there was sufficient confusion in his mind to make him think
that he had committed these unpardonable sins and to be in
great misery in consequence ; he would then be in a state of
great penitence, which was not understood by his mother until
this confession was obtained. He also admitted to me that at
times he thought he had actually committed these acts. He
had practiced this habit from the time he was 10 years old
until about 20, that, is up to about two or three years ago.
During the last two years this habit had largely died out, but
there has been (September, 1895) a tendency to recurrence. It
was apparent that such a person was dangerous to the commu-
nity and that at any time there was a possibility, under favor-
able conditions, that he might put what had hitherto been
pure imagination into actual practice ; we therefore sent him
to an asylum without delay. He denied that in mutilating the
bodies of his victims that he selected any particular parts of
the body, as is the case with many Sadists.
His general condition was one of neurasthenia. He had
much depression and suffered from great anguish of mind
from which he broke down and cried at times, saying that he
"suffered intensely," but could not describe very definitely
from what particular feeling ; it seemed to be more an anguish
of mind.
His heredity is bad, and throws light upon the distinctively
degenerate character of his mental condition. His mother was
excessively neurasthenic. One maternal aunt was described
as nervous, with abnormally fixed ideas on certain social sub-
jects, and two maternal aunts suffered from hysteria. A mater-
nal brother was delicate and always on the point of breaking
down. His maternal grandfather was a very able and physi-
cally strong man, with decided elements of genius. He is well
known to the public and recognized to be very brilliant men-
tally, but a man of very extreme opinions. Up to the age of 40
he had a tendency to melancholia. The maternal grandmother
was neuralgic, ailing, neurasthenic. The patient's father was
eccentric and a dipsomaniac. One paternal aunt was well ; a
second was described as having a bad temper and at one time
as having had delirium (about this my notes are confused). A
third had hysteria. Two cousins, sons of the second paternal
aunt, both drank to excess. The first paternal aunt had four
children ; of these, one had a sort of puerperal insanity, from
which she recovered. Two paternal uncles are said to have
died of dissipation.
The early history of this patient is interesting, as showing
the progressive physical descent (facilis descensus averni) of
such a case. Since 2 years of age always more or less out of
order ; 5 years of age, attacks of nausea, vomiting and head-
ache with fever, delirium alternating with coma ; these attacks
were followed by excessive weakness ; slow recovery from weak-
ness which persisted until the next attack, which occurred at
the end of about one month ; he lost flesh and his temper
became irritable, so that he became violently excited and
enraged over little things.
Several eminent physicians of New York were consulted.
One said that he was unable to make a diagnosis. A second
said it was brain disease, and a third said it was lithemia from
the liver. Accordingly he was treated for this last with calo-
mel, with the apparent results that after this he had no more
attacks but only premonitory signs, which were always stopped
by calomel.
This perversion of the sexual instinct is the exciting motive of
many notorious murders. The Whitechapel murderer was
undoubtedly the subject of Sadism. Similar instances are well
known and may be found described in the literature. The
subject is an important one from a medico-legal point of view,
as well as of psychologic interest ; and it is desirable that the
motives leading to crimes of this kind should be thoroughly
recognized. Lust murders, not murders for the purpose of
concealing or committing rape, but violence and murder for
the purpose of inducing sexual excitement in the murderer,
are probably more common than is generally supposed. The
sexually exciting element in such cases is the sight or smell
of blood, or the cutting, tearing. or mutilation of the victim's
flesh. Verzeni found, as he confessed, unspeakable delight in
strangling women, experiencing during the act erections and
real sexual pleasure. Some find delight in actually eating the
flesh or drinking the blood (Leger, Verzeni). Sometimes special
pleasure is found in cutting or tearing out the uterus, ovaries
and genitalia, which are carried away (Whitechapel murderer),
but this is not always the case, and the victims are not muti-
lated in this respect.
A similar perversion is found in the excitement which some-
have in harmlessly cutting, beating or whipping women and
boys. A case has been brought to my attention of a man who
was in the habit of visiting a prostitute whom he used to strike
over the nates with a shingle. No coitus was indulged in.
PRACTICAL NOTES.
Early Symptoms of Diabetes.— Unschuld calls attention to sd
early symptom of diabetes which is seldom mentioned by
writers on the subject, but which is yet frequently found, and
may assist in an early diagnosis of the affection. This symp-
tom consists in cramps in the calves of the legs, and is found
in about 26 per cent, of all cases. The pains occur with espe-
cial frequency in the morning upon waking, and occasionally
also during the night. They are rarely troublesome in the day-
time, unless after a nap or a bath. Cramps of this nature,
occurring in a person in feeble health, should always suggest
the necessity of an examination for sugar. — Health, Septem-
ber 11.
Changes in Urine from Medicine Oleoresins and balsams
(copaiba, sandal oil, turpentine and its derivatives) taken as
medicines often give a yellowish zone at the circle of contact
between the nitric acid and the urine in the cold test for albu-
min. From a ring of albumin, however, this cloud can be
easily distinguished by its solubility in alcohol. Concerning
the test for glucose, many organic medicaments (chloral, chlo-
roform, turpentine, glycerin, salicylic acid, etc. ) give rise to
urinary ingredients which reduce copper solutions to a le68 or
greater degree on prolonged boiling. The phenylhydrazin
hydrochlorate test will differentiate all these reagents from dex-
trose. Sulphur for albumin which contains it) gives a black
precipitate with Boettger's bismuth test for glucose, and hence
must be excluded as a factor if this method be used. — Ed. Den-
ver Med. Times, September.
Hemol Bromid.— The Medical News, August 29, quoting Dr.
Robert in the Tlierapeutishe Wochenschrift, states that that
observer has been seeking to obviate the unpleasant after-
effects of the inorganic bromids and to that end has "been
making trial of an organic bromid which has no injurious effect
upon either the blood or digestion. It contains only 2.7 per
cent, of bromin, as against 67 per cent, which bromid of potas-
sium contains. But only a small portion of the bromin con-
tained in the latter salt exerts any action in the body. Hoist
used bromid of hemol in fifty cases of nervous disease. If a
rapid effect was looked for, two grams (thirty grains) were given
three times a day. One half or one-third of this dose was em-
ployed for a calming effect. In epilepsy and hysteria, he ob-
tained no good results where the inorganic bromids have shown
themselves efficacious. In insomnia, the results were equal to
sodium bromid, without any unpleasant sequelas. The conclu-
sion is that bromid of hemol is not capable of replacing inor-
ganic bromids where a rapid effect is desired. It is indicated,
however, in cases where the sedative and long-continued action
of bromin is sought for."
1896. ]
PRACTICAL NOTES.
765
Diagnostic Value of Percussion of the Vertebral Column. Beeh-
terew oalla attention to the importance of the results attained
by percussion of the sacral region of the spinal cord. He has
derived gnat benefit from it in obscure eases, and urges its
general adoption. He describes one traumatic case with symp-
toms of compression of the cauda -equina, plantar, genital and
perineal anesthesia, spontaneous pains in the joints, pain on
percussion of the sacral region, disturbances in the sphincters,
etc.. with fever. Percussion of the triangle, whose base corre-
sponds to the upper part of the sacrum and the point to the
coccyx, produces in normal conditions a slightly tympanitic
resonance. In this case there was a distinctly limited dullness
and an operation confirmed exactly the diagnosis as to the seat
of the lesion. Caries was disclosed in the serum with a fungus
mass compressing the cauda equina. -Qaz. degli (>*p. e delle
din., August 1
Mechanical Treatment of Sciatic Neuralgia. Negro of Turin, has
cured or materially improved 1(H) out of 113 severe cases of
sciatic neuralgia that had resisted all other treatment, by com-
pressing the nerve. The patient lies flat on his face, the lower
limbs teaching and stretching to their fullest extent, and the
point is found by palpation where the sciatic nervo emerges
from the isehiatir notch, which is usually the most painful spot.
The right thumb is then pressed on the nerve, reinforced by
the left thumb, and the strongest pressure possible exerted for
fifteen to twenty seconds, turning the thumb so as to distribute
the pressure laterally over as much surface as possible without
removing the thumbs. This process is repeated after a min-
ute's rest several times, the pain growing less each time. Five
or six of these treatments on successive days produce good
results. Ilemorabilien, Augusts.
Formic Aldehyde as a Disinfectant, and Method of Application.
At a meeting of the Maine State Board of Health, Professor
Robinson reported that the tests of formic aldehyde which had
been made had given very encouraging results. He exhibited
to the board the workings of a lamp which he had constructed
for its application. The lamp consists of a cylinder into which
alcohol is continuously fed from a tank similar to that of
a German student's lamp. In the top of the cylinder is fitted
a diaphragm of copper gauze consisting of two layers, between
which is a layer of especial material. Upon the application of
gentle heat to the gauze the alcohol below begins to vaporize
and change into formic aldehyde, a gas having the germicidal
•ties of sulphurous acid gas, but in a greater degree.
The vaporization progresses as long as alcohol issupplied. Pro-
: Robinson detailed experiments which had been made at
the Bowdoin laboratories upon pure cultures of disease germs
and upon infected bedding and clothing, by which thegerms were
quickly killed. Subsequent cultures made from infected arti
cleswere found, after exposure of the fabrics to the fumes from
the lam]), to have been absolutely sterilized. About a pint of
the alcohol, vaporized, would supplant the atmosphere in a
room of 3,000 cubic tcet.—Sunilarian, September.
The Hypnotic Potency of Trional.— In an article which appeared
in the Wiener Medieinisehe Presse for April 1 and 8, 1896, and
is summarized in the Wiener Klinische Rundschau for June
21. Dr. Richard Drews, of Hamburg, remarks upon the fre
quency with which the physician finds it his chief task to
secure for the patient a few hours of quiet sleep, so that he
may not only be freed from distress for the time being, but
supplied with fresh ecdurance to battle with the disease. For
this purpose a hypnotic is required that is easily taken, that
promptly induces restful, dreamless, normal sleep, from which
the patient awakes refreshed and strengthened, that is harm-
less and as free as possible from unpleasant collateral and
remote effects, that does not beget a habit, and that can be
taken for a long time.
Judging of trional from its action in thirty cases, Dr. Drews
thinks it such an ideal hypnotic. Nineteen of the patients
were adults and eleven were children. The causes of sleep-
lessness in the adults were neurasthenia once, hysteria twice,
a phlegmon of the hand once, articular rheumatism twice,
muscular rheumatism once, sciatica three times, prurigo once,
trigeminal neuralgia once, a scald of the foot once, intercostal
neuralgia twice, cancer of tho uterus once, and pulmonary and
laryngeal tuberculosis with severe paroxysms of coughing and
profuse sweating at night three times. In the children there
were otitis media three times, meningitis with convulsions once,
chorea once, night terrors twice, epilepsy once, pneumonia
with severe agitation once, and furuncle of the ear once. For
the adults, the dose ranged from fifteen to twenty-two grains ;
for the children, from three to twelve grains, according to the
age. It was administered in strict accordance with Gold-
mann's directions. The adults took it in bed in a cup of hot
mill; and then drank another cup of milk ; tho children took
it in their evening broth or in a cup of hot tea. In cases
accompanied by severe pain twenty-two grains were always
given to the adults instead of fifteen grains. In twenty eight
of the cases the result was invariably a restful, calm, natural
sleep, coming on in tho course of fifteen or twenty minutes,
and on the following morning the patients felt refreshed and
as well as the nature of tho disease admitted of. In two of the
cases, that of phlegmon of the hand and that of cancer of the
uterus, the hypnotic action was delayed for an hour or an hour
and a half, and did not last for from six to eight hours, as in
the others, but only for three or four hours. Both these
patients were sleepy the next morning and complained of
oppression in the head, of headache, and of weakness, and the
one with uterine cancer suffered also with ringing in the ears
and with nausea. These phenomena occurred for several
days after each administration of trional, but strict question-
tioning brought out the fact that it had not been taken in the
precise manner prescribed.
Treatment of Ozena with the Antidiphtberial Serum. — Drs. Bell-
fanti and Delia Vcdova are quoted in the Medical Week. May
1, as follows: Bacteriologic examinations made by the authors
led to the conclusion that ozena is caused by a microorganism
identical in form and cultural peculiarities with Loftier diph-
theria bacillus, though differing from it in diminished viru-
lence. The organism was not only found upon the surface but
also in the depth of the nasal mucous membrane. According
to tho authors, it causes the chemic alterations of the secre-
tion, the fetid odor, and the atrophy of the mucous membrane
and of the bones. These results led them to undertake the
treatment of ozena with diphtheria antitoxin. The results ob-
tained were most remarkable, for of thirty-two patients sixteen
were wholly cured, seven almost healed, five rapidly improved,
and in only four was improvement slow. Tenc.c. of diphtheria
antitoxin was injected every second day or, when possible,
every day. The number of injections varied according to the
age of the individual, the length of time the disease had
existed, and the degree of local and general reaction. On an
•average 30 c.c. were required to effect a cure. At first the
injections caused congestion of the nasal mucous membrane.
Soon thereafter the fetid odor disappears, the secretions become
liquid, and the formation of crusts ceases permanently. The
accidents which compel suspension of the treatment are the
same as those observed in the treatment of diphtheria and are
without danger.
Report of the Employment of the Toxins of Erysipelas upon Malig.
nant Tumors. —In the Annals of Surgery for July is given the
minutes of a recent meeting of the New York Surgical Society,
a part of which refers to the above subject. At that meeting
Dr. L. A. Stimson, Dr. A. G. Gerster and Dr. B. F. Curtis
submitted the following report upon the use of toxins in the
treatment of malignant disease : "Both before and since our
766
PRACTICAL NOTES.
[OCTOBEE 3,
appointment as a committee we have been able to observe,
individually and together, a considerable number of cases
treated by this means, and in no case have we found any ame-
lioration which held out a prospect of ultimate cure. We have,
on the contrary, observed in some cases that the rate of growth
of the disease was much more rapid during the treatment. The
treatment also imposes a very severe tax upon the strength of
the patient, and apparently hastens the cachexia in most cases.
We believe that in the instances of apparent cure or marked
improvement the correctness of diagnosis is open to doubt. We
therefore submit : 1. That the danger to the patient from this
treatment is great. 2. Moreover, that the alleged successes
are so few and doubtful in character that the most that can be
fairly alleged for the present treatment by toxins is that it may
offer a very slight chance of amelioration. 3. That valuable
time has often been lost in operable cases by postponing oper-
ation for the sake of giving the method of treatment a trial. 4.
Finally, and most important, that if the method is to be
resorted to at all, it should be confined to the absolutely inop-
erable cases."
Ecbinococcus in the Liver Cured by Bacelli's Method. The Annali
ili Med. Navale, No. 7, describes the case of a sailor brought
to the hospital with severe pains in the right flank, fever,
dyspnea, insomnia, greatly hypertrophied liver and evidences
of a hepatic tumor. An exploratory puncture confirmed the
diagnosis of echinococcus, as hooks were discovered in the
limpid liquid withdrawn, which contained no albumin and
very little glucose, but chlorid of sodium in abundance. The
only question then was whether it was a unilocular or multi-
locular cyst. In the latter case the tumor is usually solid,
painful on pressure and knobby, with hypertrophied spleen
and a purulent or serous effusion in the peritoneal cavity, with
pronounced icterus and intestinal hemorrhages. These symp-
toms were absent in this case and the diagnosis of a unilocular
cyst was confirmed by the recovery of the patient. Thirty
grams of Van Swieten's solution were injected with a Kursch-
mann syringe and 700 grams of liquid withdrawn. The fever
ceased the fourth day after this injection. Two liters were after-
ward withdrawn with a Potain needle, which completely emptied
the cyst. Appetite and sleep returned and the general health
slowly improved, the liver subsided to its normal size and the
heart and spleen returned to their normal position, but six
months passed before the recovery could be considered com-
plete. —Oaz. d. O. e d. C, August 23.
Straightening the Spine by Wiring the Spinous Processes Together.
— Chipault's new method of treating caries of the spine is
described in the Therap. Woch., No. 35. The spine is straight-
ened and held in this position by wires that fasten the spinous
processes together, so that the orthopedic appliances do not
have to contend with the constant tendency to curvature.
After chloroform the patient is placed on his belly, three
quarters pronation, the back turned to the operator. A longi-
tudinal opening is then made along the spinous processes, two
to three vertebra; above and below the limits of the curvature.
Without touching the interspinous ligaments both sides of the
processes are exposed, and the soft parts drawn aside, the
assistant at each end then pulls the spine to straighten it as
much as possible, and a silver wire is passed through the inter-
spinous ligament above the highest process to be ligated at the
bottom near the root. The wire is then cut, leaving on each
side a piece twice as long as the wound. The ligating is done
with these two ends, crossing them back and forth and passing
them through each interspinous ligament from the highest pro
cess downward until the lowest is reached, when the two
crossed ends are twisted together. The wires must be passed
through the ligaments close to the lower edge of the process
above to afford as firm a support as possible. Each crossing
must be tested to see if it is strong and taut before proceeding
to the next. The soft parts are then sutured without drain-
age, bandaged and the patient is placed in bed. The two diffi-
culties, lateral curvature of the spine and anchylosis of adjoin-
ing processes, are met by boring a hole in the processes in the
latter case, and in the former by extending the end of the wire
on the convex side up to the loop at the top and stretching it
tight, which straightens also the lateral curve. In cases of
lumbar or dorsal caries, the bandage can be changed in five to
six days and in cervical caries in ten, and the stitches removed
from the soft parts. This ligature of the spinous processes is
undoubtedly an advance in the treatment of Pott's disease,
but it only applies to moderate curvaturesof recentorigin, that
have commenced suddenly and developed rapidly and are capa-
ble of reduction in anesthesis, and to weak spines. It is not
adapted to old curvatures or those involving too many of the
vertebra*. The presence of an unopened cold abscess or of
paralysis is no obstacle. Absolute immobilization should follow
the operation.
Arsenic in Scarlet Fever. — A Russian physician, Speransky,
announces that he treated a large family of children with
arsenic as a preventive measure, when one was attacked with
fatal scarlet fever and isolation was impossible. Although they
slept with the sick one, none of the rest took the disease except
the oldest, 18 years, to whom the arsenic had not been admin
istered and the youngest, who had been neglected and had
only received occasional doses, with none at all for several
days before the disease appeared. The arsenic was adminis-
tered in Fowler's solution, half a drop at each of the two
principal meals (8 and 9 years) with half this amount at 3 years.
When the 3-year-old child was taken with the disease he
received half a drop three times a day, with powders of phe-
nacetin and terpin hydrate ; the 18 year-old four drops with
the powders. The arsenic attenuated the disease in a remark-
able manner after it had developed, with no fever after the
first day and the child so well that it was impossible to keep it
in bed. The other cases treated outside showed the same
results, a striking improvement in the course of the disease
after the first day, with complete recovery in a week. The pre-
ventive doses were continued for six weeks. — Semaine Midicaie,
August 2(5.
Hydatic Cysts of the Liver. Bobroff injects salt solution into
the cyst pocket after he has emptied it, to prevent the liquids
from the neighboring organs finding their way into it and rec-
ommends this process to others. In a recent case, after
removal of the hyatid and cleansing of the pocket with gauze,
he excised a piece 12 centimeters long and injected 250 grams
of the salt solution. The inverse edges of the pocket were
then closed with a double row of sutures and the abdomen
closed completely. The wounds healed by first intention with
only a slight rise in the temperature one day, and the patient
left the hospital entirely cured in a month. — Union Med..
August 15.
Hot Water Vaginal Injections.— In the treatment of female pel-
vic diseases by hot water injections Dr. J. H. Burtenshaw gives
the following rules for method of application : 1. Use a large-
sized fountain syringe, preferably one holding four quarts,
attached to a support three or four feet above the body. 2.
Always lie upon the back with the hips slightly elevated and
the shoulders depressed. 3. Use at least three gallons of water
as hot as can be borne — at a temperature of from 110 to 115
degrees Fahrenheit. 4. Take the injection twice daily, morn-
ing and evening, except on the two days preceding and the
two days following the menstrual flow. In cases of chronic
leucorrheal discharge in which additional astringent elements,
to the douche, are indicated, he adds a tablespoonful of the
following mixture to the last quart of water : Pulv. alum, zinci
sulphatis, sodii biboratis, ac. carbolici, aa gj ; aquae, gvj. —
N. Y. Polyclinic, September.
L896.]
EDITORIAL.
7(57
T1IK
Journal of the American Medical Association
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ter not having street address, would be placed in the general delivery
to await call.
SATURDAY, OCTOBER 3, 1896.
THE MURDER OF THE INNOCENTS.
The incidence of mortality in the first years of life
is a well-known showing of all tables of vital statistics,
but its preventable factors are not so clearly recog-
nized, while far behind lags the resolution to make
theoretic knowledge a realized fact. Talk as we may
about the disadvantages of "grandmotherly govern-
ment" and "socialistic legislation," no one can affirm
that in matters of preventive medicine and hygiene
there can be too much governmental oversight. The
wisdom and morality of the few must become that of
the many, and it can only become so by stringently
penal legislation and executive control. Human
nature is at least not yet sufficiently ethical to be
allowed indiscriminate and unscrutinized control over
the young life that comes to it.
Take the matter of child life-insurance as an exam-
ple. Is it not evident that parents too poor to bury a
child should be held too poor to pay premiums on the
insurance of the child's life? And yet this is the
excuse constantly made by parents, either sincerely
or deceitfully, to justify the custom. What a clear
temptation to murder.1
The English medical journals, especially the Lan-
cet, have in late years been active in showing up the
prevalence of this abuse in England, where it is
undoubtedly of greater extent than with us. From
I In tbe Lancet of April 20, ]8H5, amember of tin- Massachusetts
Society for the Prevention of Cruelty to Children said she found fami-
lies in which children were deprived of the most ordinary lie easltlva
of life while money for the insurance of the dying child was put aside.
Several other similar instances equally pitiful >■ re given. The cost of
infant burial i> within the resell of thriftv people, and for i he rest, in
all countries the community is bound to bury when others can not.
an editorial in the Lancet in 1895 (i. p. 428) we
learn that of 4,(52'.) children recently subjected to cruel
treatment, 1,287 'were insured. Another editorial in
the Lancet (1895, i, p. 1(56) on infant neglect, insur-
ance and mortality, among other things says : An
unfortunate infant, whose death was recently investi-
gated by the coronor for the West Middlesex district,
might have been saved by medical aid (which might
have been had for a mere pittance), but the parents
claimed they were unable to pay a physician anything,
yet the insurance premium on the child had been
promptly paid up to its death. Facts like these sicken
the public conscience. The Lancet calls for drastic
reforms, and says the insurance should only be for an
amount of the bare cost of the funeral arrangements
(which is very cheap in England compared to our
funeral rates, we believe). The same editorial urges
that evidence of criminal neglect or mismanagement
should disqualify parents even for the small sum
insured. This seems to us very clever, as it shifts
the burden and expense of proof on the interested
corporation, who would likely be more rigorous in
their search for evidence exempting them from pay-
ment of the policy than the municipal authorities,
ordinarily interested parties.
In May, 1895, Sir Richard Webster read in the
House of Commons a bill providing for the mainte-
nance and encouragement of the mutual benefit prin-
ciple in such insurance, limiting the sum insured to
an average almost as low as that of the friendly socie-
ties, £2 ($10) up to 10 years of age. This bill also
entails upon physicians the duty of inquiring as to
the fact of insurance before granting a certificate of
death, and a like service is required of the register. It
allows a child to remain under the protection of this
act until 16 years of age. The Lancet says : "We
are aware of no present limitation except the inability
to pay the premium, and the average of £L ($20) and
a maximum of more than twice this sum is not
uncommon, while payment in some clubs may be
made partly in spirits. It is significant also that wil-
ful neglect of infants, according to a recent return,
has been shown to be much more common under the
non-mutual system'' (that is, those clubs not organ-
ized by workmen for their mutual benefit). We
know nothing relative to the ultimate disposition of
this act, and are not aware of any legislation in Great
Britain limiting infant insurance. According to the
British Medical Journal (1895, i, p. 291), the reports
of the Select Committees on Friendly Societies, 1875
and 1888, contain a large amount of information upon
this subject.
Francis Vacher (Lancet, 1895 i, p. 254) suggests
that legislation should prohibit all private corporations
or individuals from insuring infants' lives, and that the
government be empowered to enter into an agreement
to inter any child free of cost, on payment of a small
768
CELEBRATION OF INTRODUCTION OP ANESTHETICS.
[October 3,
premium at the nearest post office, thus reducing
cost of insurance and bringing it directly under the
law. Such a measure we do not think necessary or
wise, and for us it is, of course, out of the question.
As to our own country, affairs are in a chaotic state.
In 1895 a bill was reported to the Massachusetts leg-
islature providing that no life insurance company
shall issue a policy upon the life of any child under
10 years of age, living in that State. The penalty
was fixed at $100 for each offence, the law to come
into force September 1, 1895. Whether the law ever
came to vote or not (probably not in these days of
"politics") we do not know, nor whether other States
have attempted similar regulation. Medical men in
charge of the medical departments of life insurance
companies should bestir themselves, both as officers
and members of society, to bring about judicious and
and needed legislative reform.
Another cause of infant mortality is overlying. It
will doubtless surprise even physicians to learn that
one thousand children are each year killed in
London alone by this careless (or perhaps often
intended and criminal) custom. Yet such is the esti-
mate of a London coroner. From an editorial in the
British Medical Journal (1895, i, 36), we excerpt:
There are sad sides to a Merry Christmas, and not the least
sad of these this year has been the sacrifice of infant life from
overlying. On December 27, 1894, Mr. Braxton Hicks held
five inquests on the bodies of children who had died while
sleeping with their parents, the cause of death in the majority
of cases being suffocation. The coroner said he could not per-
suade parents to get cots for their children, and that a thousand
infants were overlain in London alone every year. The matter
is extremely serious. Perfectly healthy children are sacrificed
to the bad habit of making them sleep with their parents. It
is perhaps difficult to draw the line and to separate thought-
lessness from carelessness so gross as to be criminal, but Liver-
pool statistics showing the enormous frequency of deaths from
overlying on Saturday night points to the fact that the care-
lessness is gross, and that unless drink be accepted as a gen-
eral excuse for crime, the action is in a large proportion of
cases criminal. Mr. Braxton Hicks announced that he would
make it a rule in all future inquests of this character to dis-
allow the expenses of the parents, a course which he adopted
in each of the five cases before him. The fight against pre-
ventable diseases is hard enough, but it seems harder still
to prevent the effects of carelessness and folly.
Of infanticide, every physician is well aware that
neither the ancients nor present-day savages have a
monopoly of the practice. In every city there are men
either with or without a medical degree who make
a profitable business by murder, through abortion.
There are many reasons why these criminals can not
be brought within the reach of the law, the principal
of course being the inability to secure evidence
against them. Their "patients" will not tell, but the
evidences of their work are well known to every gyne-
cologist. One thing is, above all things, certain : There
should be compulsory inspection and registration of
all "stillborn" infants. Braxton Hicks (British
Medical Journal, 1895, ii, p. 1540) relates an instance
illustrative of the ease in which a child may be killed
and falsely registered stillborn. The child, plainly
a viable one, after being smothered was boldly thrown
out into the middle of the road to rot. We would
urge upon our general medical associations and socie-
ties the duty of promoting such badly needed legisla-
tion. They might also profitably institute investiga-
tion and control of the disgustingly much-advertised
lying-in institutions where "for a consideration,"
infants after delivery are "supplied with homes."
Undoubtedly it is a difficult matter to educate the
community in the care of children and in the value
of child-life. The law and a sensitive conscience are
agreed that murder of an unborn fetus is as much
murder as of one born, and that infant murder is as
much murder as is adult murder; but ordinarily the
lower classes make an unconscious sliding-scale of
criminality increasing in approximation to real mur-
der of the adult, and beginning with conception, when
and shortly after, "getting rid of it" is by no means
sinful. Against such a tendency in the interest of
civilization and ethics we must all protest with what
power we may. But the efficacy of our protest will
depend upon the numbers that speak, the publicity
of the protest, and the effectualizing of it in legisla-
tive enactment.
CELEBRATION OP THE INTRODUCTION OP
ANESTHETICS.
October 17, 1846. a venous tumor of the jaw was
removed by Dr. Warren without pain, the patient
being placed under ether by Wm. T. G. Morton, a
Boston dentist, and the next day a fatty tumor was
removed, and in a few days, after the performance of
some minor operations, Dr. Hayward, in the presence
of Dr. H. J. Bigelow and others, amputated the thigh
of one Alice Mohan, Morton, as before, administer-
ing the ether.' " From this date," says Lyman, " the
success of anesthesia was placed beyond all doubt.
The great discovery was immediately heralded through-
out the civilized world, and was everywhere adopted
with the utmost enthusiasm."
To properly celebrate the semi-centennial of this
great discovery, the Massachusetts General Hospital
have issued an invitation to a limited number of guests
to participate in the ceremonies. We print elsewhere
a reduced fac-simile of the card of invitation. It will
be noted that nothing in the invitation can be con-
strued into an assertion of priority of use; for the
medical public are now well aware that sulphuric
ether had been used by inhalation for dentistry and
minor surgery by W. E. Clarke and Crawford W.
Long, but it was reserved for the Massachusetts General
Hosjoital to have the first capital operation, and to
make the world hear. She can then with all propriety
and conscious pride celebrate the semi-centennial of
' See Bigelow on " Discovery of Anaesthesia," in Century of Ameri-
can Medicine. Philadelphia, 1S70; and Lvmau on "Aitiflcial Anaesthe-
sia," New York, 1881.
1896.]
CELEBRATION OF INTRODUCTION OF ANESTHETICS.
769
, MHB&2
COMMEMORATION
(7)7^
unmet
<_//^ dfir/t QJ ulruc cJJmionJtratioirC)
<J he uXonour of uourCompa/nu is reaaiefted
(3cUer 16H
aclcrck
y<jrth^jnijtee6
'>j^/fZihk&u^
^or the (Staff
770
LEGISLATION IN REGARD TO EXPERT TESTIMONY. [October 3,
an event that connects her name indissolubly with the
greatest boon that has yet been vouchsafed to man.
The notable gathering that will be present October
16 in that now famous amphitheater, may be warm in
their praises and oratory will no doubt be all that
the occasion demands; but the larger amphitheater of
the world, so far as inhabited by civilized man, will
contain thousands of sympathizers with this move-
ment whose sympathy, unwritten and unspoken though
it be, will be as sincere and earnest as any. May pros-
perity continue to attend the Massachusetts General
Hospital and its staff.
PROPOSED LEGISLATION IN REGARD TO EXPERT
TESTIMONY.
The unsatisfactory conditions that exist in regard
to medical expert testimony, have been the subject of
a vast amount of earnest thought and their discussion
has occupied no inconsiderable space in medical liter-
ature, but as yet the questions that have been raised
seem very far from a satisfactory settlement. That they
are living questions of the day is sufficiently demon-
strated by the contents of the last issue of the Journal,
which contained three valuable communications by
leading men in our profession together with the
equally able discussion that they incited. The views
there enunciated are certainly worthy of respect and
careful consideration, but as the discussion shows,
the solutions offered of the actual difficulties are not
in all ways acceptable. Reform of abuses in medical
expert testimony as they exist in our present methods
of judicial inquiry is most desirable, but no one seems
to have yet discovered the universally applicable cure
for these evils.
The favorite remedy just now appears to be that em-
bodied in the different legislative proposals that have
been put before the law-makers of the three States of
New York, Illinois and Minnesota,viz., the appointment
of a commission of experts by the judge or judges,
either in each particular case or for a given period for
all cases. This would undoubtedly improve matters,
but is open to some very obvious objections. One of
these is stated by Dr. Suiter; the law could not
deprive the defendant of his right to call in additional
evidence outside of the appointed experts and, if he
had accepted these, it might put him in the position
of combatting his own witnesses. Besides this objec-
tion which would occur to a lawyer, there are others
equally apparent to a layman or a physician. The
mere fact stated above that the defendant, say in a
criminal case, can not be bound to confine his expert
witnesses to the list approved by the judges, leaves
open the possibility of nearly or quite all the abuses
now complained of. His witnesses may be qualified
or not, they may be pretentious quacks or they may
outweigh as experts all the official appointees. There
is no assurance that judge-appointed experts will
always be really such ; judges are fallible, and, as
regards medical matters, often ignorant men; they
may be influenced by prejudice, friendship, or parti-
sanship, and in the present state of medical practice
with the numerous schools not discriminatingly
estimated by the laity, the very desire to avoid partisan-
ship might cause a non-medical man or a body of
such, to make injudicious or improper selections. An
official position also, involving public consideration
and compensation will be sought after by the unworthy,
and too often, it may be, with success.
Allowing, however, for these imperfections, such an
enactment as that pending in New York State would
still do away with many of the objectionable condi-
tions that now exist, and might well be welcomed. It
creates no real standard, however, for an expert, and in
this is its failure. The importance of this defect may
be variously estimated, but in some respects it is a vital
one, and how to avoid it is still a problem for consid-
eration. Some provision in the law that no one shall
be considered an expert and have hie testimony
received as such unless he can show that he has had
actual experience in and has devoted a certain number
of years to the study of the subjects in which he claims
to be specially skilled, would perhaps best meet the re-
quirements, and this could be brought in as a part of a
bill fixing the minimum compensation for expert testi-
mony by the State. This last, in view of some recent
judicial utterances, would be an eminently desirable
measure as making the State recognize the difference
between the giving of opinions which are the expert's
stock in trade and ordinary testimony. With such a pro-
vision in the law, also, we would not have the scandal of
specialists in one department testifying as experts in
another, a practice which has been unfortunately, to
say the least, sometimes indulged in by men of repu-
tation and ability, and otherwise unexceptionable
medical practices. A jury of laymen is not likely to
make distinctions between one man of reputation and
another, and the law should not allow them to be mis-
led in this regard by a lawyer's trick, even if men can
be found willing to be his instruments. At present
experts are allowed to estimate themselves and the
result is often disastrous to them and to the general
standing of expert testimony.
Medical expert testimony has probably suffered
more from the present defects in the court practice
than any other kind, and it is full time for the pro-
fession to exert itself in behalf of reform if only for
the sake of its own reputation, which continually suf-
fers under the present order of things.
"The Atlanta Clinic"; Change of Management.— With the Septem-
ber issue of that journal, the editor, Dr. Edward C. Davis
and business manager, Dr. W. L. Champion, retire from con-
trol. This step has been taken on account of the increased
professional business preventing the proper attention to the
details of the journalistic work. They will be succeeded by
Dr. Lucien Lofton as editor and Mr. Ephraim Smith business
manager.
1896.]
SOCIETY NKWS.
771
CORRESPONDENCE.
The Spanish rongnage and the P.-A.M. Congreatt<
New York, Sept. 23, L8O0,
I'o the Editor: Several physicians who think of attending
the Second Can American Medical Congress, to be held in the
city of Mexico, if they could secure the services of a well
known Spanish speaking physician to act as their guide and
general translator, have asked me whether I am willing to go
with them in that capacity. I replied that 1 have no objec-
tions, but in order that the number of physicians composing
the party be still larger will you be so kind as to say a few
words about this matter in the JOURNAL?
There are. no doubt a large number of professional gentle-
men who would willingly go to Mexico, taking advantage of
the reduction of the price of the trip for that occasion, if they
could tind some confrere thoroughly qualified to act as their
cieinme. 1 remain sincerely yours,
Dr. A. M. Fernandez- Vbarra.
235 Thompson Street.
Straw Charcoal with BorloAoId as an Antiseptic.
Valley City, N. D., Sept. 23, 1896.
To the Editor: It may interest some of the Journal read-
ers to know that a mixture composed of one part, by weight,
of muslin sifted straw charcoal to two parts of powdered boric-
acid will heal old ulcers or wounds very rapidly ; fresh cut or
torn surfaces are healed as if by magic. This may be old to
many of the profession, but I never heard of it until I used it.
But even if old it may do no harm to remind all that it is a very
valuable combination. Fraternally
F. H. DeVaux, M.D.
SOCIETY NEWS.
The Central Medical Society of New York.— This Society will
meet at Rochester, X. V. . October 20. Sixteen central counties
of the State are represented in the membership of this society,
which meets annually, alternating between Buffalo, Syracuse
and Rochester.
The American Academy of Railway Surgeons.— This society, after
a very interesting and instructive meeting at Chicago, closed
its third annual session September 25. Chicago was chosen as
the meeting place for next year. The following officers were
elected : President, L. E. Lemen, Denver ; vice-presidents, M.
C. M. Gardner of San Francisco, R. Ortega of Diaz, Mexico ;
secretary, D. C. Bryant, Omaha ; treasurer, C. B. Kibler, Corry,
Pa. ; editor, R. Harvey Reed, Columbus, Ohio.
Canadian Medical Association.— This association has elected the
following officers for 1896-97 : President, V. H. Moore, Brock -
ville, Ont. : vice-presidents : For Prince Edward Island, Peter
Conroy, Charlottetown ; Nova Scotia, J. F. Black, Halifax ;
New Brunswick, Thos. Walker, St. John ; Quebec, J. M. Beau-
soleil, Montreal ; Ontario, W. W. Dickson, Pembroke ; Mani-
toba, R. S. Thornton, Deloraine : North- West Territory, E. H.
C. Rouleau, Calgary : British Columbia, E. B. C. Hannington,
Victoria : general secretary, F. N. G. Starr, Toronto : treas-
urer, H. B. Small, Ottawa. The place of meeting in 1897 will
be Montreal, in conjunction with meeting of the British Med-
ical Association.
The Autopsical Society of Paris.— This twenty-year old Society,
known as La Society d'Autopsie Mutuelle, has grown so rapidly
in membership that it now numbers about one hundred Fellows.
They are nearly all, says the Medico-Surgical Bulletin,
scientists of note, several of whom are women. It has for its
purpose the placing of the brains of its members at the dis-
posal of surviving members for examination and dissection.
Fourteen brains, neatly catalogued, are now contained in a
glass case at the end of the meeting room, and the fifteenth,
which was during life the property of M. Abel Havelacque,
rector of the Anthropologic Society, now rests immersed in
alcohol on the table of the dissecting room, whore the man's •
former associates will meet to weigh, probe, cut and discuss it.
Association of Erie Railway Surgeons. — The annual meeting
was held at Lakewood, September 21. An accident occurred
at the opening of the session which interfered with the pleas-
ure of the gathering. Dr. John L. Eddy, of Olean, the presi-
dent of the association, a well-known surgeon, stepped into an
open elevator shaft and fell to the bottom, a distance of eight
feet. He was at once removed to his room, where it was found
that he had sustained a deep cut across the forehead, a badly
sprained ankle and a severely bruised hip. On account of this
accident to the president, the vice-president, Dr. Webb J.
Kelly of Galion, Ohio, presided. Dr. S. Birdsall of Susque-
hanna, Pa., presented a paper on "Symes ankle-joint amputa-
tions ;" Dr. F. W. Thomas of Marion, Ohio, "Injuries of the
throat" ; Dr. C. C. Kinnaman of Ashland, Ohio, "Symmet-
rical gangrene" ; Dr. C. M. Daniels of Buffalo, chief surgeon
of the Erie Railway, told about his relief and hospital organi-
zation scheme, as intended to be adopted by the company.
Other papers were : "Traumatic spinal neurosis," by Dr. N.
R Harndenof Waverly, N. Y. ; "Painful stumps after ampu-
tation," by Dr. C. B. Kibler of Corry, Pa. ; "Railway shock,"
by Floyd S. Crego, of Buffalo ; "Clinic review of cases the past
year" by Dr. Thomas Manley of New York. The annual ejec-
tion of officers resulted as follows : President, Dr. Webb J.
Kelly, Galion, Ohio : vice-president, Dr. F. W. Thomas,
Marion, Ohio ; secretary and treasurer, Dr. W. W. Appley of
Cohocton, N. Y.
lri State Medical Society of Alabama, Georgia and Tennessee. —
The eighth annual meeting will be held in Chattanooga, Oct.
13-15, 1896. The following partial list of papers indicates that
the session will be of more than usual interest :
Convulsions in children treated with large doses of morphin.
Y. L. Abemathy, Hill City, Tenn.
The therapy of antipyretics. P. L. Brouillette, Huntsville,
Ala.
Cystitis; report of cases. D. S. Middleton, Rising Fawn, Ga.
A new splint for fractures below the surgical neck. G. A.
Baxter, Chattanooga.
Humphrey's operation (amputation of the penis) with pre-
sentation of patient. Cooper Holtzclav, Chattanooga.
Diseasesof the verumontanum (caput gallinaginis). W. Frank
Glenn, Nashville.
Acute pelvic congestion. Valentine Taliaferro, Atlanta.
Operations for abscess of the liver. W. C. Townes, Chatta-
nooga.
Treatment of pus in the pelvis. W. E. B. Davis, Birmingham.
Some remarks on syphilis. W. F. Westmoreland, Atlanta.
Observations on the treatment of specific and non-specific
venereal ulcers. Wm. S. Goldsmith, Atlanta.
Bacteriologic data in the drainage of the peritoneal cavity.
George S. Brown, Birmingham.
A statistical report of some of the more recent remedies
used in the treatment of tuberculosis, and summary of recent
preventive methods of value. R. H. Hayes, Union Springs, Ala.
The Turkish bath ; its therapeutic indications. Louise
Eleanor Smith, Chattanooga.
Microscopic and chemic aids to diagnosis. Katherine R.
Collins, Atlanta.
Vaginal hysterectomy for bilateral suppurative processes of
the uterine adnexa. W. D. Haggard, Jr., Nashville.
Some obstetric complications with report of cases. R. R.
Kime, Atlanta.
Puerperal eclampsia. Searle Harris, Union Springs, Ala.
Puerperal eclampsia. J. E. George, Rockwood, Tenn.
Medicine ; Hippocratic and operatic. John P. Stewart,
Attalla, Ala.
Diseases and treatment of the accessory sinuses of the nose.
B. F. Travis, Chattanooga.
Report of a case of bradycardia. W. C. Bilbro, Murfrees-
boro.
Paper on diseases of the eye. J. M. Crawford, Atlanta.
772
SOCIETY NEWS.
[October 3,
Alec Sterling, Atlanta,
of typhoid fever. J. W.
Dun-
Paper on diseases of the eye.
The Woodbridge treatment
can, Atlanta.
Treatment of cancer of the skin. C. R. Achison, Nashville.
President's address ; the Doctor of Medicine. J. B. Murfree,
Murfreesboro, Tenn.
College of Physicians of Philadelphia— Section on Ophthalmol-
ogy.— A meeting of the section was held March 17, 1896, Dr.
Wm. F. Norris, chairman, presiding.
Dr. George C. Harlan exhibited a case of traumatic enoph-
thalmia in a boy 5 years old, who five months previously was
wounded by the horn of a bull. The right cheek and temple
and the lower eyelid were lacerated, and the inferior margin of
the orbit was chipped. There was complete ptosis. At the
time of examination the tendo oculi was found to have been
torn away and the lower lid was dragged downward and out-
ward by the action of the orbicularis and the contraction of the
cicatrix. The surgeon who attended the patient at the time
of the accident reported that there was considerable orbital
cellulitis with abundant discharge of pus from between the
lids, but there never was exophthalmia. He thought that the
cellulitis was confined to the lower part of the orbit. At present
the eyeball is retracted and has the appearance of being very
much smaller than its fellow. The cornea is situated five milli-
meters behind the plane of that of the other eye. There is
scarcely more ptosis than would result from the depression and
loss of support of the lid. When the patient looks directly for-
ward the palpebral fissure is five or six millimeters wide. He
insists that he sees well with the eye. Though the movements
of the eyeball are much restricted no diplopia can be detected.
There is complete inability to look upward beyond the horizontal
line either directly or to the right or left. Horizontal movements
are normal and the downward excursion is much exaggerated.
Dr. Charles A. Oliver gave the clinical history of a case of
ciliary staphyloma and excavation of the optic disc following
traumatic cataract in a boy 4 years old. The clinical picture
of this case of complicated secondary glaucoma was complete.
Unlike similar cases of sudden obstruction to proper lymph-
stream circulation, there remained from the very first, as shown
by the fields of vision, and as afterward proven ophthalmo-
scopically, an element that may possibly complicate many more
cases of the traumatic type of this disease than is at present
imagined, and that is retinal detachment. Again, the condition
of the vitreous and its peculiarity of opacities, taken in con-
nection with the history of the case, would tend to show that
there was a hemorrhage into that humor which probably might
have been recognized ophthalmoscopically had the patient been
seen a week earlier. These, with a few certain evidences of a
low grade iridocyclitis, made the case still more atypical. On
the other hand, the progressive diminution of the field of
vision ; the gradual distension of the globe and the localized
tissue-bulgings in the upper ciliary regions : the deep and char-
acteristic cupping of the nerve-head': the reapproximation of
the remaining areas of retinal detachment ; and the late, fix-
edly increased intraocular tension all show the certainty of
degeneration even in a young and yielding eyeball when such
tissues are subjected to a persisting increased intraocular
pressure. The case illustrates the results of two conflicting
contemporaneous conditions produced by traumatism : localized
inflammatory reaction and obstruction of lymph-stream circu-
lation.
Dr. George E. de Schweinitz presented a "Further note on
an unusual form of macular lesion following iritis." The
patient, a woman 50 years old, recovered with a nearly normal
sharpness of vision, but with some vitreous opacities from a
violent attack of serous iritis. The eye remained comfortable
for eight months, when she appeared with a positive scotoma
and the ability to see to count fingers only when situated in
the periphery of the visual field. In addition to the positive
scotoma which the patient described as appearing " like a din-
ner plate with a green edge," there was a small absolute sco-
toma about the horizontal level. Ophthalmoscopic examination
revealed an oval reddish area, giving the impression of a disin-
tegrating hemorrhage and containing in the center several
white dots situated exactly in the center of the macular region.
Dr. de Schweinitz referred to the unusually distinct macular
ring which seemed to indicate that there must be some thick-
ening in the periphery of the hemorrhagic area.
Dr. Oliver exhibited a water-color sketch of a case of unu-
sual submacular hemorrhage forming a part of some very curi-
ous lymph extravasations in the retina without any vitreous
disturbances, found in the left eye of a healthy woman 65
years old, from whose eye he had successfully removed a black
cataract by simple extraction about two months previously.
Dr. de Schweinitz gave the clinic history of a patient suffer-
ing from convergent strabismus of the left eye and a very high
myopia 16 D. Ophthalmoscopically, the following lesions
were presented. A small posterior polar cataract, numerous
fine vitreous opacities, and a horizontally oval optic disc, of a
greenish-gray color. The nerve-head was imbedded in the
center of a huge mass of opaque fibers which followed the
course of the principal vessels almost to the periphery of the
eye-ground, in all directions, but less markedly downward and
to the nasal side. A small patch in the macular region was
not covered by the opaque fibers, but was disturbed by super-
ficial choroidal changes. There was almost complete loss of
nasal field, and of the entire center of the visual field, with
exception of a small area to the nasal side of fixation, about 10-
degrees in diameter, within which the white test object was
dimly seen. Colors were correctly appreciated when held in
the temporal field.
In the discussion, Dr. B. Alexander Randall showed a card-
specimen of a case of retained nerve-sheaths in a case that had
been sent to him for supposed intracranial disturbances. In
this case there was an isolated patch situated in the macular
region. Dr. Oliver exhibited the drawing of a case in which
the medullation began at the edge of the disc and divided into
two comet-like processes extending along the lines of the larger
retinal vessels.
Dr. James Thorington, by invitation, exhibited an asbestos
cover chimney with disc attachment for ophthalmoscopic pur-
poses. The original form with the disc attachment he had
made two years previously. The present arrangement showed
that five changes could be made in the disc. 1. The one cen-
timeter opening fulfilled all the purposes of the original chim-
ney. 2. The two centimeter opening permitted greater freedom
of movement on the part of the observer, without moving the
light. 3. The three centimeter opening may be used as a
source of light for the concave skiascope, or for the ophthal-
moscope, otoscope, etc. 4. A round section of cobalt blue
glass for the chromatic aberration test of ametropia had been
added, as likewise : 5. The perforated disc with perforations
and spaces each 1.45 millimeter to test for astigmatism at one
meter's distance.
Dr. Thorington showed a new form of perimetric lenses which
received its name from the fact that their optical center cor-
responds to the points of fixation in the fields of vision. The
reasons given for the recommendation of the lens, were, that it
gives to the eye that form of lens which is consistent with a nor-
mal form of the visual field ; it removes the edge of the lens to a
sufficient distance so that the edge can not be seen to any great
degree while the eye is fixed straight ahead ; and that bifocal
segments can be made much larger. He stated that the
increase in weight need rarely exceed the ordinary form, twenty-
five to thirty grains ; the large size does not attract much
attention ; and the cost will remain the same as in the ordinary
styles used. Upon account of necessary greater weight and
thickness, he believed that this form of lens can not be used.
L896. !
PUBLIC HEALTH.
773
for CUM of aphakia and high myopia, but showed that as this
class i i cases constitutes much loss than one-half of all refrac-
tion cases (37 per cent.), the lens will be accepted in the major-
ity of instances.
Dr. Oliver exhibited and demonstrated a series of micro-
scopic specimens showing the various formsof eyes seen in lish,
reptiles, birds, quadrupeds, and man. He showed the marked
differences in the conditions of the dioptric media; the vary-
ing shapes of the eye ball : the relative positions of the eye in
the head of the animal ; the adaptations for near- and for far-
foouaing ; the arrangements for increase of the interior illumi-
nation : the positions and peculiarities of the nerve structure ;
and the relationship existing intra-cranially between the two
organs, in the aquatic, the terrestrial and the aerial forms of
animal life.
PUBLIC HEALTH.
California's Mortality Report for August. — Reports from fifty
cities, towns, villages and sanitary districts, aggregating a pop-
ulation of 790,138, show a mortality of 865— a death rate of 1.17
per thousand for August, 1896, or 14.04 per 1,000 per annum.
Isolation of Lepers in Russia.— A " leprosorium" has just been
completed at Wenden, and Virchow congratulating the Society
for the Prevention of Leprosy during his recent visit to Russia,
remarked that they had accomplished in this isolation of the
lepers more than the most powerful of the popes had been able
to effect in the days of their greatest supremacy.
Horse-meat Consumption in Paris.— There are at least two hun-
dred horse butcher shops in Paris. The first one dates from
July 1, 1866, since when the consumption has grown continu-
ously. In 1872, 5,034 horses were eaten in Paris; in 1878,
10,000; in L894, 21,227 j in 1895, more than 30,000.
Mortality Report of Connecticut for August.— There were 1,644
deaths reported during the month of August. This was 33
more than in July, and 293 more than the average number of
deaths in August for the five years preceding the present. The
death rate was 23.6 for the large towns: for the small towns
21.6 and for the whole State 23.
Typhoid Fever in the Navy. Surgeon C. A. Siegfried, of the
battleship Massachusetts, reports that on August 31 he was
compelled to transfer from the vessel to the Brooklyn Naval
Hospital the fifth case of typhoid fever that had occurred aboard
since she was commissioned at League Island in June last.
The surgeon is reported as saying that he attributes the dis-
ease to the bad drainage of Philadelphia, and the condition of
that part of the city nearest League Island.
Quarantine Station for Northern New Jersey. Dr. A. H. Doty,
Health Officer of the Port of New York, has applied, through
Dr. H. C. Herold, the Health Officer of Newark, to Governor
Origgs of Xew Jersey, for the establishment of a quarantine
station at Perth Amboy. While all vessels that come to New
York are obliged to stop at the boarding station of the quaran-
tine office on Staten Island, they can land at Perth Amboy
without interference, and there is therefore danger of conta-
gious disease being spread from that point. Governor Griggs,
it is reported, will recommend such a health station in his next
annual message to the Legislature. In the meanwhile he has
promised to use a 810,000 emergency fund which is at his dis-
posal for the suppression of any outbreak of disease, should
the occasion arise.
A Society for the Prevention of Noise. —The formation of such a
society is su ■jested in the North American Review by Dr.
J. EL Girdner. He contends that there is as rightful need for
such a society as for the Society for the Prevention of Cruelty
to Children. It is, indeed, for the prevention of cruelty to
grown people. The continued concussion of noise on the audi-
tory nerve is injurious to the whole nervous system, and is a
great contributing element to the nervous prostration so com-
mon among city dwellers. It is a well-known fact that one
coming from the country is almost stupefied by the multitude
of sounds in a great city. The city man is used to it, but it is
at the expense of vital force, and he undergoes, unconsciously,
a strain that is great and wearing. Dr. Girdner's view is that
a man has as much right to legal protection against an assault
on his auditory nerves by useless noises as he has against an
assault on his nerves of touch, by being whipped or beaten in
any way.
Improvements at the New York Quarantine.— Dr. A. H. Doty,
health officer of the port of New York, is commended by the
Medical Neirs, August 29, for the great degree of efficiency
that has signalized his tenure of office. One of his innovations
is the wearing of a uniform by himself and his deputies when
they are "on duty." The uniform is a badge of authority
especially impressive, normally so we might say upon the for-
eign element that visit these shores for the first time. New
headquarters are in course of construction, a part of which will
be devoted to a bacteriologic laboratory. This laboratory is
already fully equipped and ready at a moment's notice to
vindertake the diagnostic confirmation of suspicious cases, so
that a few hours of delay, while the investigation is being
made, enables the health officer to determine on a scientific
basis, whether a ship must be detained at quarantine or be
allowed to proceed. "This fact is not usually appreciated
by the general public, and the solution of this question of
delay by the present health officer certainly reflects the great-
est credit upon him. If a ship arrives after sundown, instead
of being obliged to lie at anchor for the night in the lower bay,
she is inspected at once and allowed, if in a suitable condition,
to proceed to her berth. If there are immigrants or others
requiring individual inspection, an electric search-light is set
up upon the deck, and under its powerful beams the inspec-
tion is satisfactorily accomplished. If the passengers or cargo
require disinfection, the boat, which the health officer has just
had constructed, will accomplish it tuto, cito et jucunde. A
row of bathrooms on either side of the boat will quickly disin-
fect eight persons by spray or vapor, or both. Clothing, bed-
ding, etc., is all disinfected by steam, in vacuo, in a great car,
such as is in use by the city Board of Health. The cargo
itself is disinfected by sulphur gas, which is carried from the
disinfecting boat in pipes under pressure, and distributed
where needed, as water is distributed with hose. Thus, a
ship, her cargo and her crew, coming from an infected port
could, in a few hours, be sent into the harbor with a clean bill
of health, the safety of the public being assured and the rights
of the shipping-master protected as well. Surely this is a pro-
digious advance over old methods. Should a ship come to our
shores, containing many cases of infectious disease cholera,
for example— there would be no long and vexatious detention
of the well and clean, together with the sick. The former,
after disinfection, would go on their way, and for the latter
the health officer has provided large and commodious barges
anchored near the quarantine islands, isolation being thus
complete and the conditions as favorable as possible for recov-
ery. It is to be hoped that this system may not require the
severe test of experience, but if it should, we see no reason to
doubt its efficiency. If successful, it would redound primarily
to the great credit and praise of the present health officer ; it
would also be a demonstration to the public that its safety in
sanitary matters depends largely upon the endorsement and
support of the medical profession."
Typhoid Fever at Albany, N. Y.— The Bulletin of the North Car-
olina Board of Health, August, gives a resume of some recent
studies on the subject, "Does Good Water Pay?" The writer
takes for an object lesson the state of affairs that exist at
774
PUBLIC HEALTH.
[October 3,
Albany, N. Y., a city whose water supply is taken from the
contaminated Hudson River. He quotes the statements of
Professor Mason of the neighboring city, Troy, to show the
economy that might be exercised by officials in curtailing the
expense account inevitably incident by that water-borne zym-
otic disease, typhoid fever. What is the tax levied annually
by that fever upon a city of 100,000, for instance Albany, N. Y.
Prom statistics given in the five last annual reports of the
State Board of Health, the deaths due to typhoid fever in
Albany average 75 for the year. Rating the money value of
each life at 82,000, this death rate would mean an annual pecu-
niary loss to the city of 8150,000. Funeral expenses are vari-
ously estimated at from 820 to 830. Should we accept the
intermediate value of 825, this item would cause 81,875 to be
added to the above sum, thus raising the total direct loss
through death to 8151,875. But typhoid fever does not always
kill, its mortality rate is commonly quoted at about 10 per
cent. For the present purposes should we assume nine recov-
eries for each death from the disease, and place forty- three
days as the period of convalescence (the average of 500 cases
at the Pennsylvania Hospital), we should have a term of 29,025
days as representing the time lost, per year, by the 675 persons
who have the fever and recover. Thus an annual loss of over
seventy-nine years has to be borne by the city's capital of pro-
ductive labor. This great amount of enforced idleness, when
translated into money value, should very properly be added to
the death loss above estimated. Fixing the rate of wages at
$1 per individual per day, a very low figure, considering that
the bulk of typhoid patients are in the very prime of life, there
is a loss of 843 for wages for each recovery, or a total yearly
loss for the city from this item of 829,025. The cost of nursing
and doctors' bills equals at least 825 per case, which is a very
low estimate, thus adding the further amount of 816,875 to the
gross sum. Expressed in tabular form, this yearly tax im-
posed by typhoid fever in Albany is given, and, upon a most
conservative estimate, it is practically 8200,000, which is 82 a
year for each man, woman and child in the city, or a yearly
tax of 810 for every family of five persons : 75 deaths at 82,000
each, 8150,000 ; 75 funerals at 825 each, 81,875 ; wages of 675
convalescents, during 43 days, at 81 per day, $29,025 ; nursing
and doctors' bills for 675 convalescents, at 825 each case,
$16,875 ; total tax levied annually by typhoid fever upon the
city of Albany, 8197,775. It can readily be seen that public
works which could eliminate a reasonable fraction of this great
tax would pay for themselves in the course of a few years, even
though they were originally expensive. Finally, it is right to
inquire what fraction of the present typhoid loss it would be
reasonable to hope to save if pure water should be served in
the city in place of its present polluted supply. To answer
this question, recourse must be had to statistics obtained from
other cities, covering periods before and after better water
systems had been introduced. Such data have been already
given for a number of cities and communities, and it only
remains to anticipate what will be later said of Munich, and
state that improved water and sewerage have reduced the
annual typhoid mortality from an average of 25.4 per 100,000 to
2.7. Surely pure water pays in a city with such a record, and
likewise it would pay in the neweV but growing cities on this
side of the Atlantic. Americans insist upon being supplied with
much more water per capita than is usually furnished for
Europe, but they are singularly indifferent as to its quality.
It would be a reform of great moment if they could be induced
to curtail the present enormous waste of public water, such as
that of Buffalo, for instance, which is stated to be 70 per cent,
of the entire pumpage, and to spend the money thus permitted
to leak away in a vigorous effort to improve the quality of the
water. No such lowering of the typhoid death rate as occurred
in Munich, San Remoand sundry other places, could be looked
for, perhaps, but a large percentage of the present rate could
be cut off, and we think, from a consideration of the above
figures, that such a reduction would pay. No weight should
be attached to the argument, so often advanced by the indi-
vidual householder, that he and his family have used the
water without evil results for the past fifty years. A single
family is too small a collection of units upon which to base
any estimate touching the question at issue. Placing the
typhoid death rate for Albany, as above, at 75 annually, it
would call for one death in a family of five persons every 261
years, a period much beyond the limit of ordinary family
record."
Vaccination in London Neglected; the Gloucester Epidemic Stamped
Out.— From the parliamentary intelligence reported in the Lon-
don Lancet of August 22, we learn that in Gloucester, during
the thirty weeks ending July 25, there were notified 2,008 cases
of smallpox. That journal further states that "Gloucester
seems to have got rid of the disease and to be able to chronicle
a clean sheet so far as smallpox is concerned, after suffering
2,000 attacks within a period of about ten months. The bitter
lesson taught by this epidemic is not likely apparently to stem
the tide of opposition to vaccination wherever antivaccination-
ists congregate. Proof of this has been seen quite recently in
the parish of Islington, in the different attitude of the vestry,
who, as a health body, are desirous of seeing the vaccination
acts enforced, and of the so-called vaccination authority, to
wit, the poor-law guardians, who are wilfully ignoring the voice
of the vestry ; not only so, but the guardians also decline to
hear what the public sanitary officers of the parish have to say
on the health side of the question. The only consolation to be
derived is to suppose that the reign of the poor law adminis-
trators is probably shortlived now, and the sooner the bodies
charged with safeguarding the public health have a voice in
the matter the better will it be for all concerned." In another
paragraph the same journal makes the following reference to
to the closing up of the epidemic at Gloucester, and to the
expenses borne by its citizens on account of that epidemic :
"The Gloucester sanitary committee have, it appears, discon-
tinued the issue of weekly statements as to smallpox occur-
rences, the health of the city being deemed to approximate now
to its normal condition. It would seem that the expenses con-
nected with the recent epidemic, so far as the guardians are
concerned, have been about 810,280, and that it has been
decided to ask the local government board to sanction the rais-
ing of a loan to meet the case. It will be interesting to know
what is the sum total to which the citizens will have to sub-
scribe in respect of the epidemic in all its bearings. The
expenses appearing on the books of the town council will, how-
ever, we imagine, go but a very little way toward the whole, as
the amount of money which must of necessity have been
expended in one way and another by the public in matters of a
personal character but having direct relation with the preva-
lence of smallpox in the town, must have been excessive. We
know that charitable contributions were made with a liberal
hand."
A Less Stringent Quarantine for Diphtheria.— The Archives of
Pediatrics, in an editorial paragraph, commends the consider-
ate courage of the New York City Board of Health in adopting
a change, not of the highest moment but of importance as
indicating a spirit of concession. The regulations have been by
some considered unduly harsh and arbitrary and as trenching
upon the patient's personal liberty. It further says :
"There was a growing tendency to postpone the sending of
cultures through the fear that patients who might suffer from
very mild attacks of diphtheria might be made prisoners for
days or weeks after every symptom of disease had disappeared.
That experience is not a pleasant one to the family physician.
It was questioned whether the board of health was warranted
in depriving citizens of their liberty unless they were able to
say that the bacilli discovered in the throat, weeks after an
attack of diphtheria, were virulent. It seemed doubtful to
18%.]
NECROLOGY.
775
many men of large expei ience whether the scientific evidence
yet available warranted such rigid measures. The present reg
illations will certainly commend themselves to the practitioner.
They prohibit any person known to have Lfiffler bacilli on their
mucous membranes from attending school or mingling in
Other public assemblies where innocent and unsuspecting per-
sons may become infected. Provision is made for informing
ever} family in which diphtheria occurs regarding tho method
of its propagation and the dangers which may follow from
contact with those who are known to carry the germs in their
throats. This knowledge having been furnished the patient
and the attending physician are privileged, under certain lim-
itations, to assume any responsibility and risk which may arise
from the violation of quarantine. This action is unquestion-
ably wise. It removes the chief objection which has been
raised against sending cultures to the board of health. It will
undoubtedly encourage the earlier sending of cultures, and
hence the earlier and more accurate diagnosis of diphtheria,
and would seem to sufficiently guard the public interest. The
endeavor made during recent years by the Board of Health of
New York to aid the physicians of the city in their battle
against disease can not be too highly commended. The will-
ingness also exhibited to correct errors and to render necessary
regulations as little irksome as possible, is worthy of equal
commendation."
Sanitary Rules for Schools in Indiana. -The Indiana State
Board of Health has issued the following letter of explanation
in relation to the opening of the public schools for the fall
term :
"Simultaneously with the annual opening of the public
school, diphtheria, measles, mumps, scarlet fever and many
other diseases usually increase. This is caused by the congre-
gatmg of the pupils. They mass together and contact spreads
infection. Some few pupils may have just recovered from a com-
municable disease, or they may be from families that have been
smitten and. being infected, they transmit disease to those who
are susceptible. It is reasonable to assume that the suddenly
imposed confinement in the school after a period of freedom
frets the children for a few days, causing more or less nervous-
ness and so resistance is temporarily lowered. In this way
susceptibility may be increased, and sickness may more readily
follow. To do all that is possible to prevent the usual school-
opening increase in illness is the object of these rules.
•• It is ordered in the rules that desk tops and banisters be
washed with soap and water and afterward treated with a dis-
infectant. This is required because it is more probable that
disease germs are planted upon exposed desk tops and banisters
by infected persons, and being transferred by the children's
hands to their mouths, disease results. The washing and dis-
infecting will do much to prevent infection from this source.
• ( )pen water buckets and large tin cups are condemned because
the dipping of water with cups, which are used by many, intro-
duce spittle into the supply ; and beside, open buckets catch
dust and dirt. Diphtheria, diarrhea, sore mouth and other
complaints have been transmitted in this way. This source of
disease may be avoided to a considerable degree by supplying
red tank with a large, free-flowing faucet and a small
cup. The opening of a large faucet will furnish a strong
stream, which will suddenly fill the cup and wash the saliva
from the edge. Ample drainage must be provided for carrying
away the waste water.
"Slates are condemned because of their uncleanliness.
Writing and figures being obliterated, as they frequently are,
with spittle, and as the damp slates readily collect dust, the
danger of transmission of disease in this way is very great.
Small children generally place pencils and pens in their mouths,
and if these articles are promiscuously distributed without
being sterilized, as the rules direct, infection may result. The
t ion of pencils seems necessary to always insure one to
each pupil.
• 'Spitting is prohibited because it is a possible source of dis-
is filthy and is unnecessary.
"These rules may seem trifling and unnecessary to those
who have not given consideratian to modern sanitation, but
the teachers more than any other public officer may secure the
physical well-being of the pupils as well as the intellectual
advancement.
•It is hoped that all the school authorities of the State will
promptly enforce these rules.
"Douglas C. Ramsey, M.D., President.
■.J. X. lhuTV. M.D., Secretary."
( OPS OF BULBS ISSUED.
Rule 1. All teachers of public, private and parochial
schools, all county, city and town health officers and all schoo
authorities shall refuse admittance to the schools under their
jurisdiction of any person from any household where conta-
gious disease exists, or any person affected with any evident or
apparent communicable disease, or any person who may
recently have been affected with diphtheria, membranous
croup, scarlet (ever, whooping cough, contagious skin disease,
measles or other communicable disease, until first presenting
a certificate signed by a reputable physician stating that dan-
ger of communicating such disease is past, and said certificate
is approved and indorsed by the health officer in whose juris-
diction the person may reside.
Rule 2. All teachers of public, private or parochial schools
shall refuse admittance to their schools of filthy or unclean
persons.
Rule 3. All school commissioners, school trustees in cities
and towns and township trustees shall have the school houses
under their control put in sanitary condition before school is
opened and kept so throughout the year. Floors shall be
scrubbed, windows cleaned, desks and all woodwork washed
with soap and water and treated with a disinfectant. Win-
dows shall be in repair, so that ventilation may be made per-
fect. Heating apparatus shall be efficient and in good order
and dirty walls and banisters made clean. Banisters and tops
of desks shall be washed with soap and water and treated with
a disinfectent once each week.
Note. The disinfectant for treating desk tops, banisters,
etc., and for use in urinals and closets may be cheaply made by
the following formula and kept on hand in any quantity
desired. To make ten gallons : Chlorinated lime, 40 ounces ;
soft water, 10 gallons. Thoroughly stir together and let stand
until clear. The undissolved lime will fall to the bottom and
the clear supernatant liquid may be used on the desks, banis-
ters, baseboards, etc. The fresh milky mixture, as well as the
creamy sediment may be used in urinals, closets and sinks.
This disinfectant is not poisonous or dangerous. Chlorid of
lime of the best quality may be purchased in quantity for 5
cents per pound. The cost of the disinfectant is, therefore,
less than 2 cents per gallon. The use of all patent or secret
disinfectants is discouraged by the State board of health.
Rule 4. School commissioners, school trustees in cities and
towns and township trustees shall provide small drinking cups
not to hold over a gill. Buckets or pails to dip from are con-
demned, and reservoirs or tanks of ample size having large,
easy acting, free flowing faucets shall be provided. When
water is drawn direct from public water pipes or pumps, res-
ervoirs or tanks are not required. Ample drainage facilities
for waste water shall be provided and the pupils directed to
allow the cups to flow over when water is drawn. Drinking
cups shall be cleaned and sterilized daily.
Rule 5. Slates are condemned. Paper tablets or pads shall
be used instead. Riveted metal boxes of tin or galvanized
iron with hinged covers and of proper size shall be provided
for each school room. These are to receive pens or pencils,
which must be collected from the children each day, and shall
not again be distributed until box and all have been sterilized
by heating in an oven at or above boiling heat for one-half hour.
School commissioners and school trustees in cities and towns
and township trustees are directed to enforce this rule.
Rule 6. Heating and ventilating shall be looked after with
great care. Every school room shall be provided with a ther-
mometer and a temperature not exceeding 75 degrees Fahren-
heit nor less than 65 degrees be maintained during school
hours. School commissioners, school trustees in cities and
towns and township trustees are directed to enforce this rule.
Rule 7. Janitors when sweeping shall use damp sawdust or
slightly sprinkle in order to prevent dust. Dusting shall be
done with damp cloths. School commissioners, school trustees
in cities and towns and township trustees are directed to
enforce this rule.
Rule 8. The water supply shall be pure and wholesome,
and closet or privy facilities shall be unobjectionable. School
commissioners, school trustees in cities and towns and town-
ship trustees are directed to enforce this rule.
Rule 9. Spitting on the floor of any school building is
absolutely forbidden. Teachers and all school authorities are
directed to enforce this rule.
Douglas C. Ramsey, M.D., President.
J. X. Hurty, M.D., Secretary.
NECROLOGY.
William Turner Wooton, M.D. (Department of Medicine,
University of Pennsylvania, Philadelphia, 1846), at Frederick,
Md., September 14, aged 74 years. He was a member of an
776
MISCELLANY.
[October 3,
old and distinguished Maryland family, was born in Montgom-
ery County, but had practiced medicine in Frederick nearly all
his life. Dr. Wooton was a frequent contributor to leading
medical journals.
John Lawrence Dawson, M.D., at Charleston, S. C, Sep-
tember 17. He was born at the celebrated Mitkin plantation,
near Monck's Corner, in 1815. Was the son of Lawrence
Monck Dawson and grandson of a daughter of Lord Proprietor
Monck. He graduated from the Medical College of the State
of South Carolina, Charleston, in 1836.
After leaving the Medical College Dr. Dawson went to
Paris with Dr. Chazal and spent some time studying and visit-
ing the hospitals. Returning to South Carolina he located in
Summerville. After a year or two, however, Dr. Dawson
returned to Charleston. For some years he was United States
physician to the Arsenal garrison, city registrar and health
officer, holding the offices simultaneously. It was during his
occupancy of these positions, in about 1840, when with the late
Dr. Henry W. DeSaussure, he brought out the census of
Charleston, which has been used as a standard authority
since. Dr. Dawson joined the State Medical Society in 1837
and was prominent in its deliberations. He was a member of
the standing committee, and also treasurer of the Society for
the relief of the Families of the Diseased and Disabled Indi-
gent Members of the Medical Profession of the State of South
Carolina, an organization of which he was one of the founders.
P. F. Beverly, M.D., at one time President of the Ohio
State Medical Society, at Columbus, Ohio, September 18, from
a stroke of paralysis, the third one in a year. Dr. Beverly was
69 years of age, and a graduate of Starling Medical College,
Columbus, Ohio.
Charles Bernacki, M.D., of New York City, at Schandau,
a Saxon watering place, September 17, aged 84 years. He was
born at Starascol, Galicia, studied medicine in the University
of Vienna and, after some practice in military hospitals in
Australian Poland, opened an office in Vienna. After the
political disturbances of 1848 he fled to America. From 1846
he was medical director of the Germania Life Insurance Co.
J. C. Sackville, M.D., of Washington, Pa., aged 82. He
was struck by a Baltimore and Ohio train September 23, and
instantly killed. Dr. Sackville was a cousin of Lord Sackville
West, formerly English ambassador at Washington, D. C,
and a brother-in-law of the English poet, Robert Carr Foster.'
He graduated from the Royal College of Surgeons, London
England, in 1838.
Edward Benkendorff, M.D. (Medical Department, Wash-
ington University, St. Louis, Mo., 1847.) He was a native of
Prussia. A relative of the same name is lord chamberlain to
the czar.
H. H. Hunt, M.D., at Independence, Iowa, September 25,
aged 72 years. He was county coroner for thirty years and was
also a surgeon in the late war.
William H. Perkins, M.D., Long Island College Hospital,
Brooklyn, N. Y., at Hancock, Md., September 11. P. S.
McArthur, M.D., Geneva Medical College, Geneva, N. Y.,
1847, at La Crosse, Wis., September 19, aged 74 years.
MISCELLANY.
Treasurer's Notice. The Treasurer has received $5.00 in cur-
rency from Buffalo, N. Y., which he will properly credit if the
remitter will send in his name with date of remittance.
Dartmouth Medical College.— William Thayer Smith, M.D., of
Hanover, N. H., has been appointed dean of Dartmouth Med-
ical College, to fill the place of the late Dr. Carleton P. Frost.
Dr. Smith has been professor of physiology for a number of
years. Prof. Oilman Frost has been appointed secretary and
treasurer.
Professor Vlrcbow's Birthday. A cablegram states that great
preparations are being made for the birthday of Professor
Virchow, which occurs October 13. Scientists from all paits
of the world, including the United States, will be present with
gifts and congratulations.
Mutilation of Prisoners in Abyssinia.— The Italian government
recently sent an artificial-limb maker to Africa to supply hands
and feet to about two hundred and fifty native soldiers who
had been captured by the Abyssinians and, after having each
a foot and a hand cut off, were set free again, but the unfortu-
nates who have been evirated can find no instrument maker to
come to their relief. Eviration is a cruelty much practiced by
the Abyssinians on their Italian prisoners.
International Scientific Language — In letter a written before his
death by Prof. Billroth to Dr. Jankau he remarks : I recom-
mend the simplest of the Latin languages, Spanish, for an
international scientific language ; after this would come Ital-
ian and French, and among the Germanic tongues, English
alone. English might even be preferable to all others, as it is
one of the simplest. But as the Latin races have no aptitude
for acquiring foreign tongues, it is necessary on account of
their great talents in scientific matters, to make this conces-
sion to them, and select one of the Latin tongues for the inter-
national language.— Gaz. Mid. de Paris, August 29.
Toxicity of Gastric Juice in Epileptics.— Agostini has found that
the gastric juice from an epileptic injected into the abdomen
of a rabbit proves fatal with general toxic and clonic convul-
sions, especially if withdrawn immediately before or after an
attack. Gastric juice from a normal person injected in the
same way does not produce any evil effects. He considers
these facts a valuable indication for the successful therapeutic
treatment of epilepsy, with systematic rinsing of the stomach,
disinfection of the intestines, etc. He found that the toxicity
was diminished by the administration of bromids. -Chi. f.
Phys., August 22.
An Ancient Russian Superstition. A fatal case arising out of
the widespread superstition that a candle made from human
fat bestows invisibility upon its possessor, is reported from
Ostrogozhsk. Two Russian thieves of the district were so
firmly persuaded of the truth of this that they murdered a
youth of their village in order to procure the candles in ques-
tion. Having cut open the body, they removed the fat sur-
rounding the kidneys, and, placing it in a tin box, took it home.
There they proceeded to melt the fat over the fire. Unluckily
for them an old woman, their housekeeper, became suspicious
and informed the authorities. Her statement, coupled with
the mysterious disappearance of the youth, who was a hand-
some and a popular young fellow of 18, led to the prompt arrest
of the ruffians and their ultimate trial for the murder. The
body was discovered, and the portions lacking therefrom lent
further confirmation to the crime.
Can Commit to Insane Asylum.— The supreme court of Louis-
iana holds, in the case of State v. Uniake, decided June 30,
1896, that where a party has been indicted, and his counsel
suggests his insanity, before trial, and a commission is ap-
pointed to inquire into his mental condition, and reports him
to be insane, and the jury returns a verdict accordingly, and
the judge of the criminal district court remands him to the
parish prison, without a commitment to the insane asylum, the
judge of the civil district court has authority, under section
1768, Revised Statutes, to inquire into the facts and circum-
stances of the case, and if, in his opinion, he is dangerous to
the citizens and the peace of the State, to commit him to the
insane asylum of the State.
Right to Have Examination made by Female Physician. Under the
provision of the New York Code that if a female plaintiff be
subjected to a physical examination she shall have the right to
have such examination made by a female physician, a decision
1896.]
MISCELLANY.
777
was called attention to Id the Journal of June 20, page i-i.">.
to the effect that tho fact that the order compels her to submit
to an examination by a physician not of her own sex, is not a
ground for the vacation of the order, she not having made any
effort to have the order modified. But the appellate term of
the supreme court of Now fork, first department, takes a dif-
ferent view of it, as its decision of July 27, 1896, in Lawrence
v. Samuels, shows. It holdB that the provision in question is
for the protection of female suitors, and that the plaintiff in
this case was entitled, as of right, to have inserted in the order
the provision that a female physician make tho examination,
without making any special application for it as a favor or
privilege, and that, in so far as the order appealed from a male
physician named, it must be reversed, with liberty to the
defendant to apply to the court below for the naming of such a
physician as the Code authorizes.
Effect of the X Ray on the Skin. —We have seen it clearly
demonstrated that the ray has an effect upon the skin, but
only after frequent and long exposure to its influence. The
appearance of the skin strongly resembles severe sunburn,
with the accompanying pain, swelling, blistering and discolor-
ation. The congestion in the hand is very marked, and the
hand hanging in the usual dependent position occasions great
pain. We have under observation at present a case in which
the long exposure to the X ray has produced these symptoms,
other exciting causes being positively excluded. The face
showed the same series of changes as the hands. — Canadian
I'riirt., September.
Woman's Inferior Sensitiveness to Pain. Ottolenghi reports in
the CM /. Ktrv, ii. I'sijvli., No. 7. that he has been testing
with Kdelmann's faradimeter the sensitiveness to pain and the
endurance of pain in 082 women. He finds that women are less
sensitive to pain than men. and that this sensitiveness is less
in early life, increases to the twenty-fourth year, and decreases
after that. The higher classes are most sensitive, and degen-
erates the least. He found the latter very obtuse to the sensa-
tion of pain. Endurance of pain varies between much broader
limits in women than in men, reaching a maximum far beyond
the masculine limit, possibly due to great "suggestibility" of
the female sex. "General sensibility" reaches the highest
point in the nineteenth year. He concludes from his investi-
gations that sensitiveness to pain stands in close relation to
the "psyche." while "general sensibility" depends upon the
peripheral nerves. He consider woman's comparative insensi-
bility to pain as a sign of her inferiority to man, as the uncivil-
ized and degenerates are the least sensitive. He also attempts
to prove a connection between this characteristic and her long-
evity.— Cbl.f. P/iys., August 8.
Might be Entitled to Accident Insurance. A physician was
insured "against bodily injuries sustained through external,
violent and accidental means." While he was in his carriage
on the highway, he attempted to administer to himself in his
leg, for extreme exhaustion, medicine with a hypodermic
needle. His carriage suddenly started, causing him to acci-
dentally insert the needle deeply into his leg. This, he alleged
and testified, produced blood poisoning and suppuration. The
physician who attended him recognized it as a case of cellulitis,
with which the morphia used had nothing whatever to do, and
which resulted from the introduction of the needle, together
with some condition of the skin or needle. Five judges of the
appellate division of the supreme court of New York heard
arguments on appeal from a judgment dismissing on the
merits the complaint in an action against the company which
issued the policy of accident insurance, with two of the
five dissenting that judgment is reversed and a new trial
ordered. The court holds, Bailey v. Interstate Casualty Com-
pany, decided July 7, 1896, that the question whether the
injuries complained of were sustained through external, violent
and accidental means, within the meaning of the policy should
have been submitted to the jury. If, in the use of the
needle, an agency that otherwise would not have been in force,
and which was the efficient cause of the injuries, was acci-
dentally set in motion, it says that it sees no good reason
why it might not be found that the injuries were attributable
to the accident as the sole and proximate cause. As to the
contention that the diseased condition of the leg arose from
the use of morphin, and therefore within one of the condi-
tions of the policy that upon the evidence it also holds was a
question of fact for the jury to determine.
Regents Control.— The supreme court of Michigan holds that
the constitution of that State gives the control of the Univer-
sity of Michigan to the board of regents, and that the legisla-
ture has no control over the university or the board of regents.
On this ground it holds unconstitutional Act No. 257, Laws
1895, wherein the legislature provided that the board of regents
should establish a homeopathic medical college as a branch or
department of the University at Detroit and should discontinue
the homeopathic college now maintained at Ann Arbor as a
branch of the university, and transfer the same to Detroit. In
consequence, it denies a writ of mandamus, which was asked
in Sterling v. Regents of the University of Michigan, decided
July 28, 1896, to compel action on the part of the board in
accordance with the legislative will. It also suggests that the
attorney general is the proper party to move in such a case,
and a private citizen does not possess the right, without per-
mission of the court, to apply for this writ to compel a public
board to perform an omitted duty.
The Use of Oxygen After Ether In Surgical Operations. Dr. Wil-
liam A. Morrison, of East Boston, Mass., relates several cases
in the Boston Medical and Surgical Journal in which inhala-
tions of oxygen most effectually and rapidly remove the
unpleasant after effects of ether. From these cases he con-
cludes : 1. That some cases receive much more benefit from
its use than others. 2. That in the most favorable cases aston-
ishing results follow ; the nausea is apparently relieved or pre-
vented, consciousness is quickly recovered, the breath is
entirely deprived of the odor of ether in a very short time, and
the feeling of malaise, so frequently complained of, is absent.
3. That some cases are not benefited (or are positively harmed)
by its use. In another case of his, a man with a gangrenous
foot, convulsions appeared soon after inhaling the gas, and he
was therefore obliged to discontinue its use. He is unable to
state why the man did not tolerate it. 4. That the best
method of administering oxygen after etherization is by the
use of a soft-rubber catheter gently introduced into the nares
until the eye of the catheter is approximately opposite the
opening in the trachea. It seems to him desirable that all
cases in which oxygen has been used after etherization should
be reported, so that the profession should be assisted in deter-
mining what cases are likely to be benefited by the inhalation,
and in what cases its use is contraindicated. This was
recommended by Professor Jackson when ether was first
administered.
Liability for Harshness in Examination. In the personal injury
case of Goodhart v. Pennsylvania Railway Company, which
was decided by the supreme court of Pennsylvania, July 15,
1896, it says that the evidence in regard to the examination
made by a physician on behalf of the defendant was not directed
to the extent of the plaintiff's injuries, but to the severity of
the examination. Its evident object was to persuade the jury
that the character of the examination and the conduct of the
physician in question and his assistants was unnecessarily
harsh and annoying, and was a proper subject to be considered
in assessing the plaintiff's damages. But the supreme court
holds otherwise. It says that it must be borne in mind that a
778
MISCELLANY.
[October 3,
claim was being made against the railroad company for dam-
ages based upon an alleged injury received in consequence of
an accident on its line. In order to determine intelligently the
extent of its liability, it was important for the defendant com-
pany to know the nature of the injury, and the extent to
which the plaintiff was affected by it. This could only be
known as the result of a medical examination made by compe-
tent and experienced physicians. The physician above referred
to and his assistants were selected as proper persons to make
the examination, and advise the company of their estimate of
the plaintiff's condition, and its consequent liability. If, in
the discharge of their professional duty to their employer, they
went beyond what was reasonably necessary and employed
methods and tests that were cruel, and such as the judgment
of the medical profession does not approve, and thereby
inflicted injury on the plaintiff, the supreme court holds that
they were liable for their own trespass, whether committed
with malice or through ignorance. But rudeness and incivility
in the manner in which the examination was conducted, if
rudeness or incivility can be affirmed of anything that was
said or done in that connection, the court insists could throw
no light on the extent of the injury actually suffered by the
plaintiff, and the evidence referred to should have been
rejected. Damages for a personal injury, it says, consist of
three principal items : 1. The expenses to which the injured
person is subjected by reason of the injury complained of. 2.
The inconvenience and suffering naturally resulting from it.
3. The loss of earning power, if any, whether temporary or
permanent, consequent upon the character of the injury-
each of which elements it further discusses.
Specific Immunity Versus Transient Protection in Cholera and other
Infection Processes — Dr. Pfeiffer in a Deutsche Medicinische
Wochenschrift, April 11, having been employed in an inquiry
concerning the different kinds of immunity that can be effected
in the laboratory, offers the following as a part of the results of
his investigations upon the subject of immunity : The cholera
poison is contained in the body substance of the cholera vibrio,
so that dead, as well as living cholera bacilli show marked toxic
properties. The cholera poison becomes capable of absorption
by the disintegration of the cholera bacteria : analogous con-
ditions have been established as regards typhoid fever, anthrax,
chicken cholera, staphylococcus infection, and apparently
influenza. Animals may be rendered immune to toxic doses
of living cholera spirilla, and typhoid bacilli by previous treat-
ment with various substances of bacterial and non bacterial
origin. This protection is transient, and does not depend upon
specific changes in the fluids of the body, and is designated as
resistance, in contradistinction to specific immunity. In the
blood serum of human beings and animals that have been
exposed to the action of the living or dead cholera spirilla or
typhoid bacilli, there occur specific protective bodies, which
are thus capable of rendering aid in differential diagnosis in
cases in which ordinary methods have failed ; and these sub-
stances may be made to accumulate in the blood in concen-
trated degree by properly conducted immunization. In their
relation to chemic and physical agencies, they bear a close
analogy with the antitoxins, from which, however, they are
differentiated by their action. While the antitoxins occupy a
specific relation to certain poisons, and are capable of destroy-
ing these in the animal body, the anti-bodies of cholera and
typhoid fever are incapable of thus acting upon the poison of
typhoid bacilli and cholera spirilla. Their activity consists in
the destruction of the bacteria, but this property makes itself
manifest, as a rule, only in the body, and is capable of demon-
stration outside the body only under special circumstances.
These anti-bodies are also found, though in small quantities,
in the normal blood of animals and human beings. They are
neither bacterial products deprived of virulence, nor combina-
tions of these with components of the immunized organism,
but they are probably entirely new substances resulting from
the specific reaction of the body to a specific irritant. The
evidence points to the view that the anti-bodies are specific
ferments. It is possible that the antitoxins also are specific
enzymes. As fermentative activity plays an important part in
the production of natural immunity, it is possible to relate
natural and acquired immunity, antitoxic and bactericidal
functions to a common general principle. This report as will
be seen, fully sustains the position assumed by this Journal.
in an editorial entitled the "Failure of the Antitoxins."
A Question of Implied Contract.— The defense to an action
brought to recover for medical services rendered the daughter
of the party sued was that the plaintiff was not in active prac-
tice at the time such services were rendered ; that plaintiff
was closely related to the family of the defendant by consan
guinity and affinity, and the families were upon the most inti-
mate terms ; that for thirty or forty years plaintiff and defend-
ant extended hospitalities, courtesies and favors to each other
in the way of kindnesses and substantial benefits, without
charges or any kind of legal obligation from one to the other,
and that a greater part of the time defendant made plaintiff's
home a general stopping place for rest, recreation and refresh-
ments, and it was at these times and on these occasions and
under these circumstances that the plaintiff, as the defendant
then thought and believed, acting as much or more in the
capacity of a friend than as a physician, examined and pre-
scribed for the family of the defendant when indisposed. The
evidence both showed that the services of the plaintiff were
rendered as stated in his account and that the relations
existing between the parties was as stated in the defendant's
answer, and that their conduct and transactions with each
other were the same as alleged. On the trial the court gave a
charge to the jury to the effect that, if the plaintiff's demand
was just and due he would be entitled to recover, and, further,
that if they did not believe such account was just and due,
and was contrary to law and equity, then they should find for
the defendant. The plaintiff asked a special charge upon the
question of implied contract, which the court refused to give.
Under the circumstances the court of civil appeals of Texas
holds, Bonner, v. Bradley, decided June 13, 1896, the trial
judge failed to properly charge the jury, and reversed the
judgment which was rendered in favor of the defendant. It
says that when services are performed at the request of a
party, the law will imply a promise to pay the reasonable value
thereof, unless such request be made and acceded to as a gra
tuitous favor, and that if, at the time the services were per-
formed by the plaintiff, it was not the intention of the parties
that charges should be made for such services, then the
defendant would not be liable therefor.
Twin Extra-uterine Pregnancy; One Fully Developed Fetus of
Fifteen Years' Retention.— The British Medical Journal quotes
Dr. Folet, in Annates de Gynecologic el d'Obstetriqtte, regard-
ing a case of the above nature. The patient, a Flemish woman,
aged 49 years, had an abdominal tumor, dull, uniformly
hard, devoid of all tenderness, movable in its lower part
and extending three inches above the umbilicus, which was
diagnosed as a fibroma, partially calcified, and abdominal hys-
terectomy decided upon. As soon as the abdomen was opened
an edge of bone (one parietal overriding another) was felt
through a moderately thick sac of supple tissue, and the
diagnosis at once amended to one of extra-uterine pregnancy.
The sac did not appear to contain any fluid: it was partially
adherent to the abdominal wall, from which it had to be
detached with caution ; it had many adhesions to the intes-
tines, which were easily separated by the fingers. Only one
ligature was required and the tumor was only retained by
its base, when with a circular rent it burst, and five-sixths
of the sac came away with the contents, leaving a funnel
1896.]
MISCELLANY.
779
harmed by the remaining sixth attached by its outer surface
to tlif pelvic organs. In the interest of the patient no
endeavor wu made to determine the exact relation of the
HO to its surroundings; the edge of the funnel was fastened
by eight silk sutures in the lower part of the abdominal
WOOnd, a large drain wrapped In iodoform gauze inserted in
the peritoneum and the remainder of the incision closed.
Recovery was perfect. The temperature never rose above
37.S degrees C. and in six weeks the cavity of the cyst was
obliterated and the healing complete. The structure of the
i\st seemed to show it to be a tubal one. It contained two
fetuses, one (female) Hi cm. in length, with well formed nails,
had lived to term: it was not. properly speaking, a lithope-
dion ; the tissues, though dense, were supple and nowhere
calcified, and on sections of thigh and arm the skin ami
muscles were recognized by the naked eye and microscope.
The other fetus had died about the third month: the thorax
and head were much compressed, but could be made out and
the members were distinct. The cords of both ended at the
lower end of the sac in a single placenta, the degenerated
tissue of which was represented by reddish-brown matter like
touchwood, and broke into Hakes on the slightest traction.
Some days after the operation it was ascertained through an
interpreter, that sixteen years previous the woman had
become pregnant, having before that had four children at
term. She duly quickened but at nine or ten months had a
false labor: blood and membranes came away and she had
hemorrhage for six weeks. As she ceased to feel the move-
ments of the child and nothing further happened, she per-
suaded herself that she had been mistaken, and that she had
not been pregnant, the more easily because her abdomen dimin-
ished a little in size and her catamenia returned and contin-
ued until she was 46. A doctor whom she consulted two or
three years afterward, while giving no definite diagnosis, depre-
cated any treatment. She was led to apply to Polet on account
of repeated attacks of pain during the last year, probably due
to the peritonitis which caused the intestinal adhesions.
Medico Literary Notes.— A book by E. Bonavia, M.D., has just
been issued by the Longmans, on studies in the evolution of
animals, taking into account the markings of animals as well
as their coloration.
Cruden labored nineteen years on his "Concordance to the
Bible," and immediately after its publication was sent to an
asylum. He never entirely recovered from the mental disease
induced by this gigantic undertaking.
Dr. Conan Doyle lately confessed to the London Authors'
Club that he first began to write to get a little money to pay
some bills. For nearly ten years most of his manuscript came
back to him by return of post. His first profitable article was
for a trade paper. Dr. Doyle says the choicest moment of his
life was when Thackeray patted him, a boy of five, on the head
and praised him. His last book, called "Rodney Stone," has
a good deal in it about the fistic science, which was in its
prime about a century ago.
Messrs. Thacker, Spink & Co., Calcutta, publish a new edi-
tion of "The Indigenous Drugs of India,'' which has been
produced by the Rai Bahadur, Dr. Kanny Lall Dey, in associa-
tion with Mr. William Mair. Fifty copies of the book have
already been purchased by the government of India. The
work is dedicated with permission to the Pharmaceutical
Society of Great Britain, of which Dr. Dey is an honorary
member, and extends to over 400 octavo pages. It will be pub-
lished in London within the current month.
Among the various devices now being tried to relieve Guy's
Hospital, London, of ite financial difficulties, is that of raising
a sufficient sum to permanently endow a bed in memory of the
poet Keats, who served a short time there as a medical student.
In Huxley's "Autobiography" he stands up for truth as
greater than facts, and life than information. He says, "Life
seems terribly foreshortened as they look back, and the moun-
tain they set themselves to climb in youth turns out to be a
mere spur of immeasurably higher ranges, when, with failing
breath, they reach the top. But if I might speak of the objects
1 have had moro or less definitely in view since I began the
ascent of my hillock, they are briefly these : To promote the
increase of natural knowledge and to forward the application
of scientific methods of investigation to all problems of life to
the best of my ability, in the conviction, which has grown with
my growth and strengthened with my strength, that there is
no alleviation for the sufferings of mankind excepting veracity
of thought and of action, and the resolute facing of the world
as it is when the garment of make-believe by which pious hands
have hidden its uglier features iB stripped off."
The Medical Chronicle is the title of the medical journal
conducted by the faculty of the Owens College, Manchester.
This college will open its winter session on October 2, and Mr.
Jonathan Hutchinson has consented to deliver the introductory
address, in the physiological theater of the new medical
buildings.
Mr. C. C. Bell, in Chemist and Druggist, writes of the
medieval names of drug plants. He says many of the English
names occur also in Lyte, Gerard, Parkinson and the other old
herbalists, and a considerable number are still in use, but these
are not now in every case applied to the same plants as for-
merly. Gerard gives others of them in his list of obsolete
names, but when these are deducted a good many still remain
which had gone out of use before he wrote. Among these are
some of especial interest. Donnhoof (spelt "donnhove") is
one. It is the same as coltsfoot, "donn" or "dun" being an
old name for horse, whence comes "donkey" or little horse.
" Wowel" and " feldhove" are names given to the sameplant.
" Cetewale," which the glossaries give as English for "zodoar"
(zedoary, a species of tumeric), appears in Lyte and Gerard as
"setwall" a name for valerian; Chaucer, in "The Millere's
Tale," names it along with licorice. Wermode in these glos-
saries means "wormwood" and is the correct form. Skeat
explains it as " waremood" (preserver of the mind); Mr.
Mowat, with greater apparent likelihood, says it is "ware-
moth" (preservative against moths). This certainly accords
with the French garde robe, and with our old rhyme :
" Where chamber is sweeped, and wormwood is thrown,
No flea for his life dare abide to be known,"
which, however, Mr. Mowat does not quote. Wilde keyn,
again (which appears in the glossaries under vicus quercinus,
and is evidently an echo of the French qui de Chene), is not in
Gerard. Other names calling for particular mention, some of
which appear in Gerard and some not, are "groundswile"
l grounds wallower), an appropriate name for so prolific a weed
as groundsel; "wymalve" (French guimauvej, for mallow;
" hepebrede" (hip-bread, for dog-rose; "horse heal," for
elecampane ; marygold is called " yellebotel," or yellow-bottle.
Shepherd's needle, which Gerard calls "ladies' combe," is
glossed less flatteringly as " pouclesnedele," which, on the
authority of a quotation in Halliwell, may be taken as equal to
devil's needle ; dandelion (dens leonis) as " doleronue ;" holly-
hock as St. Cuthbertscole ; bryony as " wildnep ;" burdock
has given to it the name fllantropos, because its seeds stick to
men'sclothes; duckmeat appears in a particularly interesting
form as " cibus anatis, ang. enedechede" (a clerical error for
"enedmete, "ened" being an old name for duck). Similarly
" paddocstol" recalls the old name for frog or toad. "Cold as
paddocks though they be, Here I lift them up to Thee," says
Herrick's child of her hands in her "Grace before meat."
"Aleon" are distinguished as of three kinds, cycotrium, epati-
cum and caballinum. Opium appears as "opium Thebai-
cutn" (indicative of its geographic source), glossed "succus
papaveris albi" and "opium miconis, succus papaveris nigri."
780
MISCELLANY.
[October 3, 1896.]
The entry immediately following this is a sad muddle, being
" Opium quirrinacium, lesera, quilleya, succus iusquiami,
idem." This is in "Alphita." In the " Sinonoma" "opium
quirrinacium" is glossed "assfoetida idem;" what "quilleya"
is, it is impossible to say ; " iusquiamus" is henbane. This is
only one instance of many hopelessly confused glosses. White,
black and red poppies appear under their respective Latin
names, and of the second we are told that diacodion is made.
Nothing more is said of their use. Cowslip appears under
" paralisis herba" as "cousloppe," meaning cowdung, a not
very poetical name ; " endyve " is under lactuca. The glosses on
dracunculus are interesting as specimens of the fancifulness of
our forefathers : " Dracuncia, asclepias, viperina, pentaria, ser-
pentina, colubrina, basilica (basilisk), cocodrilla (cockatrice),
idem gallice et anglice, dragaunce" ("in English, dragons,"
says Gerard, who gives an equally long, but different, set of
synonyms from Epuleius Barbarus). " Mandragora" as des-
cribed at length are of two kinds, male and female ; no other
name is given to it. "Sene" (senna), again, has as yet no
English form ; and it is interesting to note that both these
plants are mentioned by Shakespeare in the form here given.
"Zinziber" also appears only in this form, and rhubarb only
as reubarbarum.
Hospitals.
New Post Hospital for Fortress Monroe, Va.— The Government
will build a new hospital to cost about 820,000. Plans for the
hospital have been received, and the work will be let by con-
tract after thirty days' advertisement.
Pennsylvania Hospital Annual Report.— The managers of the
Pennsylvania Hospital have issued their annual report, show-
ing that in the Pine Street Hospital the patients remain-
ing in May, 1895, numbered 210. New patients received in the
year to May, 1896, were 2,408; remaining at latter date, 186;
beds occupied, 2,618. A large amount of work was done by
the out-patient department, the visits aggregating 46,197. In
the department for the insane the figures for the year were :
Women, new cases, 88 ; discharged, 82 ; remaining, 233 ; men,
new cases, 77 ; discharged, 91 ; remaining, 181 ; total treated,
587 ; remaining, 414.
A Cottage Hospital at Proctor, Vt.— A new hospital at Proctor,
Vt., was formally opened on August 8. It is a modern build-
ing, a short distance from the center of the town, and arranged
to accommodate ten patients. The first story has an accident
and operating room thoroughly equipped with modern surgical
furnishings. One of the wards is also on this floor. The
domestic and executive arrangements are all in the second
story. The hospital has been built and equipped by the Proc-
tor Marble Company ; and while primarily intended for such
of the employes as may need its services, it is to be open to any
person in the village. The management has been placed in the
hands of a committee of townspeople. The district nursing in
the town, which is already completely established, is now to
be done from the hospital by its training school. The attend-
ing physicians thus far appointed are Drs. J. M. Hamilton of
Proctor and H. H. Swift of Pittsford.— Boston Medical and
Surgical Journal.
Philadelphia.
Dr. B. Meade Bolton, Director of the Bacteriological Labor-
atory, wishes it to be distinctly understood that he is not
responsible for the recent establishment of the plant in the
City Hall for the manufacture of disinfectant solution, known
commercially s: s electrozone. The tests which have been alleged
to have been made in the city laboratory he states were not
made by him or under his direction and that he has not had
anything to do with testing, reporting or publishing anything
in regard to the matter, which is understood to be under the
supervision of the City Board of Health or some of its officials.
The report of the unsanitary condition of the League Island
Navy Yard, arising from the fact that cases of typhoid fever
have occurred recently in several vessels which had been fitted
out at this place, has led to an investigation which is now in
progress by the authorities at Washington. The Board of
Health has not been able to find any case of typhoid fever at
the station or within several miles of it. The water supply is
not derived from the city pipes, but from cisterns tilled with
rain water so that the infection is not due to the use of water
from the Schuylkill, and there is no great prevalence of typhoid
in the city at present.
THE PUBLIC SERVICES.
Army « lianir<s. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Sept. J 9 to Sept. 25. 1896.
A board of officers is appointed to meet at the Headquarters Depart-
ment of the Missouri, Chicago. 111., on Monday. Oct. 5, 1898, nt 10
o'clock, a.m., for the examination of such officers of the Medical
Department as may be ordered before it to determine their fitness
for promotion. Detail for the Board:
Lieutenant-Colonel Albert Hartsuff, Deputy Surgeon-General.
Major Henry Lippincott, Suigeon.
Captain Norton Strong. Assistant Surgeon.
The following named officers will report In person to the president of
the examining board appointed to meet at Chicago, 111., on Monday,
Oct. 5, 1896. for examination for promotion:
First Lieutenant Henry C. Fisher. Assistant Surgeon.
First Lieutenant Henry A. Shaw, Assistant Surgeon.
First Lieutenant Charles F. Kieffer, Assistant Surgeon.
Major John V. Lauderdale, Surgeon, will upon the arrival of Major
Egon A. Koemer, Surgeon, at Fort Crook, Neb., repair to his home
and await retirement.
Major James P. Kimball, Surgeon, is relieved from dutv at Fort Win-
gate, New Mexico, and ordered to Fort Columbus. N. Y.. fur duty,
relieving Major John Van R. Hoff, Surgeon. Major Huff, on being
thus relieved, is ordered to Vancouver Barracks, Washington, for
duty, relieving Captain Rudolph G. Ebert. Assistant Surgeon. Cap-
tain Ebert, on being thus relieved, is ordered to Philadelphia, Pa..
for duty as Httending snrgeon and examiner of recruits, relieving
Captain William W. Gray, Assistant Surgeon. Captain tirav, on
being thus relieved, is ordered to Fort Apache, Ariz., for dnty
relieving First Lieutenant Irving W. Rand. Assistant Surgeon. Lieu-
tenant Rand, on being thus relieved, is ordered to Fort Clark, Texas,
for duty.
Wavy iliiuiscs. Changes in the Medical Corps of the U. S. Navy for
the week ending Sept. 26, 1896.
September 28.— Passed Assistant Surgeon G. A. Lung, detached from the
"Vermont" and ordered to Che naval hospital, Chelsea, Mass.
Passed Assistant Surgeon H D. Wilson, detached from the Chelsea,
Mass., hospital and ordered to the "Baehe."
Pa'sed Assistant Surgeon G. H. Barber, ordered to the Naval Aeademv.
Assistant Surgeon M. K Johnson, detached from the "Bach«" an'<l
ordered to the "New York."
Assistant Surgeon F. C. Cook, ordered to the "Vermont."
Cbanice of Address.
Butler, T. J., from Chicago to Loekport, 111.
Case, C. E., from Tacoma to Everett, Wash.
Johnson. C. W., from 625 Locust St., to 2309 Locust St., St. Louis, Mo.
Todd, F. Waltou, from Coronado to Camp Capltola. Santa Cruz, Cal.
Taylor, P. K., from Kingston, R. I., to 211 W. 139th St., New York, N. i*.
Walsh, T. G., from 330 Grove St. to 869 Greenbush St., Milwaukee. Wis.
Wiggin, F. H., from Littlefield.Conu., to 55 W.36th St., New York, N. Y.
LETTERS RECEIVED.
Alta l'barmacal Co., St. Louis, Mo.; Allport, Frank, Minneapolis
Minn.: Adams. A. L.. Jacksonville. III.
Bernd. Henry <t Co., St. Louis, Mo. : Bourns, F. 8.. Atlanta, <ia. ; Ben-
jamin, D., Camden, N. J'. : Bumstead.J. E.. Dundee. III.
Dewey, Richard. Wawatosa. Wis. ; Drevet M'f'g Co., The, New York.
N.Y.; Douglas, Richard, Nashville, Tenn.; DeCourcy, J. O., St. Libory,
Epley, F. W., New Richmond, Wis.
Feiel, A.. Columbus, Ohio.
Galloway. D. H., Chicago, 111.; Gradle, H., Chicago. III.
Hammond, J. C.Denison, Iowa; Hot Springs League, Hot Springs,
Ark.; Hahn. H. II., Youuestown. Ohio: Haddock. W. J.. Iowa City,
Iowa; Hunwnel, A. L., Adv. Agency, New York, N. Y. ; Hlggins, F. W
Cortland. N. Y. ; Hoffman, J. R., Ottawa. HI.
Imperial Granum Co., Youngstown, Ohio.
Jegi. H. A.. Arcadia, Wis.
Krebs Paul H., Cleveland, Ohio; Kibler, C. B.. Corry, Pa.; Krause
Wm. C. Buffalo, N.Y.
Laughlin Pen Co., (2) New Haven, Ind.; Lautenbacb, L. J., Philadel-
phia, Pa.
McBride, R. E., Gibson City, La.; Merrill, Wm. Stetson, Chicago, 111.;
Marc-hand, Chas.. New York, N. Y.; Mizell, A»G.. Chicago, 111.; Mettler,
L. Harrison, (2) Chicago, 111.: Merrick. M. B , (2) Passaic, N. J.
Nelson, C. D., Greeley. Colo.
Ozone Company, Chicago, 111.
Parmele, Chas. Roome, New York, N. Y.j Pettit, J. W.. Ottawa, 111.
Rockey, A. E, Portland, Ore.; Reed, R. Harvey, Colnmbus, Ohio;
Rosenberry, A. J.. Wausau. Wis.
Schneider, August. Buffalo. N. Y. ; Stowell, Chas. H.. Washington,
D. C: Savage. G. C, Nashville, Tenn.: Spencer. John C.San Francisco,
Cal.; Schieffelin.W. H. & Co.. New York, N. Y.: Steele, D. A. K., Chi-
cago, 111.: Starr. G. L.. Hudson, Ohio; Simmons. Geo. H, Lincoln, Neb.
Tyree, J. S., Washington. D. C. ; Tuley, Henry E., Louisville, Kv.
Wilson, Cunningham, Birmingham. Ala.: Wilson, A. J., (2) Chicago,
111.; Walton Oxygeu Works, New York, N. Y.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., OCTOBER 10, 1896.
No. 15.
LECTURE.
MEDICAL EDUCATION.
Optnlng lecture delivered at Rush Medical College, Chicago.
September -V. 1886.
i;y kdwinklebs, m.d.
PROFESSOR OK PATHOLOGY.
Ladies and Gentlemen: The wish expressed by
my new colleagues that I open the lectures of this
new year of medical instruction by some considera-
tions of our work, laid upon me the somewhat difficult
task of explaining my opinion, in a foreign language,
on the organization of schools in this country, with
which, also. I am not yet perfectly acquainted.
You must not think that this will be a confession
of my Lgnoranoe of American history and institutions.
( )n the contrary. I have always, from the time of my
youth, inspired by the treatises of Ralph Waldo
Emerson, loved this land. At the time of the great
civil war I eagerly studied the work done by your
fathers, who, destitute of everything necessary to
carry on a successful war, decided to live or die for
liberty and humanity.
I was astonished at this time to acknowledge the
origin of a new war hygiene, later further developed
in the great wars of the old country. Comparing the
great losses in the Crimean war, which preceded the
American civil war, with those of the Franco-German
war of 1870, you will not fail to see the great progress
in this new field, principally, as I think, effected by
the distribution of the wounded and sick over vast
areas, by means of the mighty streams.
It seems to me that the American people, impelled
by urgent necessity, became more and more inventive,
and learned more in a few years than it would have
learned in centuries without that impulse.
The wonderful development in this land that you
all know, from your own experience, now followed
during the short period of twenty to thirty years.
All facilities were enhanced by the confidence in the
restored Union; enormous wealth and prosperity, such
as were never known before in history, were arising
from the soil of the new land.
Naturally, then came depression. In the restless
strife for improvement many things, without which a
people can not be happy, were not taken into account.
I only mention the devastation of woods, threatening
a change of clime, unless replanted systematically,
an injury not otherwise to be remedied.
Political and financial influences have more and
more increased the internal difficulties, so that now
will come a time when the labor of the whole land
will be required to sustain this prosperity.
But how will the people endure this change of con-
ditions, the irreparable loss of so many facilities? I
think that they will accept the new position, the
harder strife for life, the conditions of life impaired
and narrowed also by the competition of the whole
world. This confidence is based in the first place, on
historical facts. A people who have surmounted the
hardships of a civil war will find a method also in
this harder time, but in another way.
Not the pioneer and the digger, but the teacher and
educator will be the leaders in the new course. Science
will be the aim and purpose.
The educational question now moves the whole
world. European civilization based wholly on the
old classic traditions of Rome and Greece, has reached,
especially in Germany, a standard in classic education
which seems to be incompatible with the claims of
modern life. Natural science will more and more
supplant the ancient literature and the modern philo-
logist finds that the modern languages have attained a
higher certainty and clearness by which to express
the modern thoughts than the dead languages now
occupying nearly the whole time of the scholar.
The reform of higher school education now com-
mencing in Germany, will save our country from
imitating the so-called classic studies. Let us fill the
mind of the child and the youth with a broad knowl-
edge of earth and heaven, of living beings and dead
material, of human life and thought, history and phil-
osophy, so that they may understand the coming life
and be able to distinguish the good and the evil, the
just and the unjust; religion and morals must have a
prominent part in this system of education. What I
wish to say is this, that for the young man or woman
willing to devote themselves to medical science, a non-
classic education is quite sufficient. But the require-
ments of preliminary education necessary for admis-
sion to our colleges, seem to be totally insufficient.
Unless certain literary colleges have been attended,
an examination in writing, in the branches of a good
English education, including algebra as far as equa-
tions of the second degree, the first book of geometry,
English composition, elementary physics and the
elements of the Latin language should be substituted;
chemistry and physics will be taught in the freshman
year.
I do not find in the program the descriptive natural
sciences, the natural history of plants and animals,
the geology and mineralogy, which contain the
elements of so many parts of the medical science, not
to speak of knowledge of human history, art and
thought. I am quite sure that a great number of our
pupils have completed their education in these direc-
tions, but I doubt if that is the case with everyone.
I do not pretend to propose reformations, but I do
hope to find the young men better educated than the
scanty requirements for admission to the leading med-
ical colleges lead me to believe.
For comparison, I will give a short outline of the
requirements in German universities, in natural his-
tory only. The young men entering the university
have learned a great deal of natural history at the
782
MEDICAL EDUCATION.
[October 10,
gymnasiums, but before commencing the medical
studies they must spend a whole year's course in nat-
ural sciences, such as botany, zoology, chemistry and
physics, including practical work in microscopy and
the chemic laboratory.
If we look at the schedule of Rush Medical College
we will perceive that in the freshman year no more
than 745 hours are devoted to study, in the following
three years from 870 to 1,036. I think that one could
very well dedicate 150 to 200 hours to the study of
botany and zoology in the first year. But this, as
other practical questions, must be considered at
another time. Furthermore, I would wish for a cer-
tain knowledge of the German and French languages,
already required by the Johns Hopkins University,
also some ability in drawing. Without knowledge of
these modern languages the medical student can only
make use of the English literature and translations
from the German and French, but as the greatest
part of medical literature and the most valuable is
published in periodicals, the student can not fully
understand the medical literature of his time without
this knowledge of modern languages. As the devel-
opment of science is a very rapid one, scientific work
is not possible without personal literary study.
But we have given enough detail on medical teach-
ing. Let us now look at the American students and
their qualifications for this science. As I have had
many opportunities to teach Americans in European
laboratories, I am prepared to speak upon that point
with due reservation. First I will say something
about the ladies studying medicine abroad. The
greatest number I had in Zurich were Russian or
other Slavs, German, Swiss and American. The best
prepared for study were Swiss, American and Ger-
man. In diligence they surpassed nearly every male
student and as far as memory is concerned, it was very
difficult for our male students to attain better marks
than the female in the examinations. In the ana-
tomic and microscopic work, over which I made
personal observations, I found American ladies among
my best workers; in the composition of publications
there were some differences, however, depending more
upon the personal character than upon mental facul-
ties. One lady whom I highly esteemed for her
assiduity and very clever work, labored somewhat
under a too much developed pride, declining every
help in the composition of her paper, which, based
upon delicate microscopic researches, would have
made more impression if the points and the deduc-
tions had been more thoroughly discussed. I do not
know if that was a personal propriety, but I can
understand that a woman prides herself on indepen-
dent work; this pride can be a very good support in
the hard work awaiting the doctress. I shall ever
remember another American whom I had the pleasure
to aid in her original work, as the best example of a
medical student, fitted to do any scientific work. In
this direction I must give the American ladies the first
place and I hope to see here the same attainment in
practical medicine.
As to the qualification of American men for scien-
tific medical work, there can be no doubt. From my
youth to the present time I have had many oppor-
tunities to come in contact with them as a teacher,
and can openly express my opinion, that they would
not, in any way, remain behind any other people, only
being handicapped by their preliminary education
and imperfect knowledge of foreign languages. But
these slight defects were compensated for by a burn-
ing zeal for learning. My first experience dates back
to the early sixties, when I was assistant of Professor
Virchow. My first pupil, a man as old as I, was a
Californian and showed, perhaps, more enthusiasm
than your Eastern people, but I will never forget his
open-hearted joy, when he understood a difficult mat-
ter, explained by the inexperienced teacher, in pretty
bad English. And I have made the same observation,
repeatedly, through a quarter of a century. All young
Americans that came to me for study, were brave,
joyful, enthusiastic people, but sometimes a little
deficient in school education. They have all been
my friends.
You, probably, all know the cause of these charac-
teristics. The American life is a practical one, and
the arts and sciences, here, come in second place. But
I am sure this state of things will change before long.
Deficiency in education is more and more improved
and there are many men of the highest and most
refined education in liberal arts and sciences. One
of my friends in Germany, a learned man of high
standing, a deep critic of Gdthe, stated that he was
astonished by American visitors, oftentimes finding
that they had the most profound understanding of
German literature and philosophy. That is a good
indication of what can be done by your people in
medical science also.
In medical practice we can certainly meet any com-
petition, but not in medical science. The reason for
this is to be found in the organization of our medical
schools, which I have already touched upon. I under-
stand very well that these organizations resulted
from compromises and that under given circumstances,
for the moment, higher attainments could not be
demanded without driving a large number of students
into the hands of so-called medical colleges, which
one of my friends designated as "paper mills," a
shameless scattering of diplomas for money.
Regarding these facts I can not find a better remedy
than to place the higher education in the hands of
the Federal Government. This would present many
difficulties, as I know from my experience in Switzer-
land, and I would not like to interfere in practical
questions. But we can take these matters out of
the hands of the government and regulate them. By
"we" I mean all good citizens who find that the pros-
perity of the country depends upon the education of
the people. Very much is done in this direction. For
our prominent scientific institutions are founded by
private individuals, by donations, often rich men
restoring a part of their earnings to the people, the
well-conducted work of whom has procured these
means. A political economist in Germany has named
that the "inheritance of the people." " To give is
more blessed than to receive," said Jesus, the greatest
socialist. Yes, we will bless these rich men who will
help in the education of the people and perhaps pre-
vent the day of wrath. But not alone to the rich
people should the appeal be made to assist in the
educational question. Every physician, every patient
is interested in this work and can afford to promote
the higher medical education. I am sure the generous
American people will favor progress in higher scien-
tific education.
Here arises a very important question: Is the effi-
ciency of such institutions for higher learning assured
by money alone? Can money buy such institutions,
as it can buy railroads or steamships?
1896-3
MEDICAL EDUCATION.
783
The success in original scientific work depends
more upon the worker than upon the external condi-
tions of work. In my youth 1 have seen Helmholtz,
the great physicist, work out his great discoveries in
optics with the simplest means, and calculating with
a child on his lap. The great mathematician, Gauss,
when asked how he had Found his new methods enor-
mously enlarging mathematic conception, replied: "By
repeated thought over the same matter." So we see
that the personal conditions for scientific work are
given everywhere, if there is a quiet place for think-
ing and men apt for this work. An exceptional men-
tal faoulty is not necessary for this, as not every
learned man needs to be a genius. Continuous work
is sufficient it* the right way is laid open. Such indi-
cators (Wegweiser) guiding the seekers after knowl-
edge will arise in every country where learning is
esteemed and supported.
1 have experienced a striking example in my own
life. 1 came to a university, in a land where science
was not much developed, but proud of its great politi-
cal power in a past time. This aristocratic people,
with high self-consciousness, resented bitterly that
so many strangers were called by an intelligent
government to till the chairs at the university. Some
wished to injure the intruders, not personally, but
by diminishing the number for instruction. A pol-
itician of high standing was induced to promote the
attack, which would be adverse to the development
of the university, when one of the professors opened
the eyes of this political leader, showing the true aim
of his associates, by saying: "You, as a liberal and
reformer can not support an action against natural
development. Give good seed to the soil and you
will see good fruit ripen. Learned men can not be
found everywhere. Take what you have and you
will see. that in some generation, you will have enough
support from your own countrymen." Thereupon
the good man ceased to support his tempters and
the chairs of the university are now, after nearly
thirty years, occupied by a great number of native
teachers, universally acknowledged to be of the
highest rank.
What 1 wish to show by this experience is that
higher study needs a thorough cultivation, continued
for a long time. It is the same as with the cultivation
of plants. If King Probus had not planted the grapes
on the borders of the Rhine, the Rhine wine would
not have won its world-wide celebrity. I tasted the
California wines some forty years ago and I was not
pleased with it, but now it is quite a different thing.
As we can not reform the whole system of higher
education at once, we must commence slowly, warm-
ing and protecting the delicate plant sown in a soil
in which, as yet, other plants, industry, farming,
business of all kinds have grown so luxuriantly. If
the soil commences to be exhausted by the one fruit,
the good farmer will plant another. Science is a plant
that has borne very good fruit in old Europe, why
should it not develop here, when a young, fresh
people, free from many prejudices of the old world,
will strive to win the first rank in the great problems
of the human mind?
But how shall we promote strong scientific work in
our department, the medical science? In the first
place you must change your opinion on the tenden-
cies of the college or university. It does not suffice
to have excellent instructors and well educated pupils,
but we must have the will to give or receive more than I
medical instruction, sufficient for medical practice, or
only for the examination. That would be the office
of a high school or a university, in the sense of Ger-
man universities. More • than in other countries,
you will find that these institutions are founded not
only for education, but also for observation.
The difference between a school and a university is
not always comprehended as it should be here, nor in
Europe. As a young professor, I often spoke with
business men about the difficult task of a university
professor, but they did not understand me. "Oh," one
said, " I think, in the first year, that it may be very dif-
ficult to lecture so much, but later one learns that."
This is only too true, many professors learn to repeat
the same lectures, and very amusing anecdotes are
told in Germany about teachers accustomed to do this.
One of these learned professors, reading his lecture
absent-mindedly, also read the foot-note : " Here I
like to make a joke." But I can assure you that this
sort of professors died out, and from that time the
acknowledged glory of German and other universities
commenced to fill the world and attract people from
every country. By these remarks I do not mean to
say that German universities are perfect. As the
devil always sows weeds among the wheat, so there
the high position of professorship has attracted many
inferior people who rely more upon protection than
personal worth, and the egotism of many professors
goes a little too far. Where there is much light there
will also be shadow; but at all events we can look to
German universities as the best examples of our sci-
entific schools. t
The first object of these schools is, and must be to
educate the pupils to scientific and practical work.
We must educate them to be independent observers,
for a physician must have this quality, and without it
he will not enjoy his task. He may fill his position
very well, operate and prescribe, but if he does not
look at his patient with the eyes of an observer he
will fail to see many features of the highest import-
ance. To the superficial physician not trained to
careful observation, one case looks like another and
he will be astonished if the expected effect of a cer-
tain remedy does not appear. It is, as with a savage
people or a flock of cattle to the unexercised eye,
they seem to be all alike; the observer, however, if he
be an experienced traveler or a cattle grower, will see
the differences. Certainly the good physician will
learn, in the office and at the bedside, what he has not
learned at school; but it would be better if he would
go out into the world wholly instructed and experi-
enced. Scientific work, done while a student, will aid
the practitioner.
Hoping that you are convinced of the great import-
ance of this truly dominant question, I will add some
suggestions as to what should be done in this direc-
tion. First, every laboratory should be so arranged
that a certain number of students and also of younger
graduates could work, not in learning the elements,
those must be understood, but for original scientific
work. The smallest problem which we attempt to
solve brings with it more elucidation than the read-
ing and memorizing of a whole text-book. I fear that
in our method of teaching learning, memory is too
much relied upon, recitations prevail and not discus-
sions. With young people, working on problems, there
must be more discussion than recitation. I prefer a
student who does not know so many facts, numbers
or figures, but who understands the connection of facts
784
MEDICAL EDUCATION.
[OCTOBEE 10,
and how to make conclusions from the known to the
unknown.
In the laboratory opened for the work of students,
it is not necessary to give long lectures but to discuss
the matters in a conversational manner.
Whoever is farther advanced in his work, will come
and expound his results to the teacher and his col-
leagues. From the discussion new thoughts will
arise not before given by the teacher. The scholars
can learn without feeling that they are being instruct-
ed. I hear that such a system has been commenced
here in private primary schools; if it is practicable
with children, why should it not be with thinking
men?
But in this matter another side is to be taken into
consideration. If we have such laboratories who will
work in them? The student is busy the whole day
and the young physician must oftentimes attend to
making his living. I do not think that people are
poorer here than in Germany, where all this is done,
but if so, the means for such work must be found
and I do not doubt but it will be. In German uni-
versities we have so-called stipendia, which enable
the poorer student to continue his studies, and beside
that, we do not want to have medical proletarians (a
very good word of Billroth). Whoever undertakes
this noble study should first find the necessary means.
The poor should not be excluded, but they must show
the true qualifications.
For the young graduates, working to perfect their
education, I would recommend the two appointments
which, in my opinion, have made German universities
great; first, the doctorate, obtained by scientific
work; second, the private university teachers (Privat-
Docenten).
The title of doctor, historically, means more than
that of physician; it expresses a scientific qualifica-
tion, shown by original scientific work. For that
degree the publication of a dissertation is required,
that is, a scientific treatise and theses, scientific ques-
tions which the applicant will defend in free debate
against every one.
This venerable practice has been, as all human
things, liable to deterioration, but it has influenced,
in a very ostensible manner, the high standing of the
profession. Innumerable students of medicine have
been compelled, by this custom, to do original work,
or treat clinic observations in a historic and critical
way. Certainly the dissertations have awakened many
literary talents which would have slumbered without
this incitement.
Graduation or examination is necessary for the
Doctorat; the latter is intended to show the qualifica-
tion for scientific work and teaching. It is therefore
indispensable for every physician teaching in a med-
ical faculty.
The private lecturer, privat-docent, is a position
quite unknown in English and American colleges; in
France the professeur agr6g6 occupies nearly the
same position. The title privat-docent is conferred
by the faculty, on application, for a certain branch of
science. He lectures in the same manner as the pro-
fessors, mostly supplying gaps in the regular lectures
or giving lectures on special parts of the science, elab-
orated by his own work. Many of the private lectur-
ers are assistants, and are given the opportunity by
their chief to deliver special courses. Without going
into particulars, one will see that this institution is
highly adapted to the education of professors.
I wish to submit this institution of private lectures
to the earnest consideration of leading men in this
country. Having so far only touched upon the stu-
dent epoch of medical men, we can not make the
whole importance of this discussion quite clear if we
do not explain the standing of our profession and
science in public and private life.
The profound change which our science has under-
gone in the last century will be made clear by some
historic references. In the earliest times medicine
was in the hands of the priests and based only upor
occasional observations such as were made by the peo-
ple. Hippocrates destroyed the secret and put these
ideas into systematic order. The observation of facts
became controlled and the work of physicians sub-
jected to general rules, governed always by moral
laws, highly appreciated at all times by the true phy-
sician. Since that time the work of the physician
possesses a sacred feature. The patient needs to
rely, with full confidence, on the knowledge and the
truthfulness of his physician. He must know that he
can not be deceived, although errors can not be
entirely excluded. If the physician has any doubts
consultation may be sought.
• The medical profession must be so organized that
it will be the best for the public. Quackery and evil
conduct are more contemptible than in any other
occupation. Where the government does not protect
the medical profession it must protect itself, as is
done here by the code of ethics, accepted by the
Ameeican Medical Association.
This organization, securing the interests of the pub-
lic as well , as of the physicians, has sometimes
roused distrust rather than confidence, but a think-
ing man will congratulate himself for having a med-
ical profession caring for its honor. This position of
the profession seems to be one of the principal fea-
tures which attracts the young men to our lecture
rooms. The practice is not so lucrative as in the old
times, when one would say ud(d Galenus opes." The
sense of humanity forms another attraction to the
medical science; if the physician can help, he is
loved as a god, and to the incurable he can always
bring comfort and diminish their suffering.
In our time, in which the strife for gain seems to
reign, the people have double interest that our pro-
fession preserve these feelings, and I hope that the
public will support them. It will be to the interest
of the patient that he follows obediently the prescrip-
tions of his physician. I have seen so many patients
ruined by their feeble, distrustful character, changing
from one physician to another, thus losing the best
time in which they could have been saved. But, on
the whole, I have found the American to be an excel-
lent patient, not excited, not nervous, but quietly
doing and sustaining whatever was necessary. I have
never elsewhere seen so much courage in enduring
pain.
But the position of the physician in our time must
be looked upon from another side. The change in
the medical principles, effected in the last thirty
years, is so enormous that weaker minds could not
follow. On the whole, one can say that the younger
generation has fully adopted the new theory of the
bacterial causes of disease, though not always willing
to make the necessary deductions.
How great this change was may be shown by an
example. The two pathologic conditions, which
alone nearly governed the old pathology, were "fever"
1896.]
MEDICAL EDUCATION.
785
and "inflammation." The seething of bad humors
or juices in humoral pathology, the struggle of the
soul, the Archaus of Staid, through many centuries
formed personifications of disease, very apt to be
attacked by the zealous physician, who mistook the
signs or symptoms of the disease for the disease itself .
Under this delusion such things as "essential fever,"
or (ever in itself were spoken of. Later, under the
auspices of a more developed physiology, one tried to
explain these phenomena by the doctrine of irritation.
Allireeht von Haller has shown that irritability is the
general property of all living substance, a property
consisting in the outbreak of the genuine activity of
the organ, after an external influence has acted as an
irritant. So the muscle will contract, if it is acted
upon by mechanical, electric or chemic influences in
the same manner as it does when irritated by its
nerves through the action of the brain or by an elec-
tric current. The action producing the irritation can
be of very ditl'erent nature, the effect produced upon
the body is always the same. You will understand
this if you think of the works of a clock moving in
the same manner, whether its spring or pendulum be
put in action by the hand, by an earthquake, or by
removing a hindrance.
This theory seems to best explain the two symp-
toms governing, or of disease itself. From Broussais
to Virchow this explanation prevailed, giving very
good indications for therapeutics. If the irritability
of an organ or the whole body is increased, one has
recourse to remedies of a soothing, mitigating action;
if the irritability is deficient, one must irritate; if the
two processes do not help, according to the doctrine
there only remained the counter-irritation (contra-
stimulua). If, for example, an inflammation of a knee-
joint was treated without good result first with cold
later with warm poultices, there remained only a
counter-irritant, the burning. The consequence was
that old country women, shepherds, etc., sometimes
had greater success than learned physicians.
This inadequate doctrine was destroyed by patho-
logic anatomy, which, from the end of the last cen-
tury, was more and more developed in Europe, first in
France and England then in Germany. After many
great predecessors, Rudolph Virchow developed a new
doctrine which seemed, at first, to cover every logical
desire, namely, the cellular pathology.
This doctrine showed the composition of the body
to consist of a great many living organisms, the so-
called cells, bound together by the common action of
Is and nerves. This theory disclosed manifold
processes in disease, in their minutest details; it en-
riched our knowledge, but it did not advance our
therapeutics; to the action of cells was confined the
regulation of irritation. So the cellular pathology was
thought to have found in the action of the cells, the
whole essence of disease, and the question, Why do
the cells act in an abnormal manner? was asked no
more.
For Virchow and for many of his pupils and follow-
ers, the question of cause did not exist. He declined
to go farther, with the oracular answer of a sovereign,
" We can not know all things."
I admire R. Virchow very much, having been for a
long time his pupil and assistant, having learned from
him the finer distinctions of pathologic processes. I
acknowledge that he has enriched pathology more
than any one else before him, but he did not have the
right to command a stop to all other progress in our
science. The word " why" must always be used, if
the knowledge does not cover the whole truth and
does not explain the cause of action.
Already a new dawn announced the bright day of
our present knowledge. Medical historians and
geographers remembering the spread of the great
plagues, and enlightened thinkers, as Henle, had,
contemporaneously with Virchow's cellular pathology,
proclaimed the theory of the external origin of conta-
gious diseases, from living matter, the germ theory
hinted at in oldest popular medicine. The microcos-
mos were opposed by the macrocosmos in pathology.
In our time the investigations in this direction had
commenced, first without regard to pathology. Pas-
teur had detected the origin of fermentation due to
microbes, destroying the physical contact- theory of
Justus von Liebig. But Pasteur declared, fearing to
oppose the dominating school of pathology, that these
discoveries had nothing to do with pathology. When
later, in the seventies, he transferred the germ theory
to pathologic questions, he had to suffer many perse-
cutions, as I know from his own mouth.
Already, many years before Pasteur recognized his
error, the parasite of anthrax was found by two Ger-
man observers (Pollender and Brauell), but were, by
all leading men, declared as inorganized, or if bacte-
rial nature was conceded, as consequent to the disease
or organisms developed in the dying animal.
A sort of madness seemed to have controlled the
defenders of the old doctrine, so that even the excel-
lent experiments of Davaine did not change the
minds of stubborn doctrinaires. Davaine isolated
these organisms and showed that a single one was
sufficient to infect and kill an animal. The develop-
ment being first local, at the place of implantation,
and the general infection could be prevented by
destroying or extirpating the infected part.
Lister developed the same idea, the external infec-
tion in wounds, and commenced a reform in surgery,
which was more and more refined and perfected later.
At the same time I demonstrated the propagation
of certain bacteria in the internal organs of the body
after they had found entrance through natural open-
ings or through wounds. The abundant material of
the Franco-German war of 1870 gave me the oppor-
tunity to show that these organisms, while spreading
in the organs, always precede the cellular derange-
ments. Cultures and infection of animals in these
and other cases of infectious diseases showed the
causal nature of, probably, all contagious diseases.
By separating the bacteria from fluids, in the cultures,
by filtration, we could demonstrate that only the bac-
teria produced the disease. It was shown by Tiegel,
my assistant, and later in Tokio, that the fluid had
only toxic influences (1871 to 1873).
I also was very vigorously attacked from all points,
especially from the medical side, whereas other
learned people, such as Tyndall, were convinced of
the importance of the new development in pathology.
Certainly many imperfections, unavoidable in a new
research, may have given some reason for criticism.
The later researches of Robert Koch and others
decided the battle on the fundamental principle in
pathology. This can be pronounced in the following
thesis: Disease is the struggle of two organisms, the
one invading the other.
If I have explained my opinion clearly enough you
will see what can be done for scientific medical edu-
cation. By my lectures, which I will give in this
786
A MEDICAL ASPECT OF CRIME.
[October 10,
college, I will attempt to inspire the student to do
original work, which is the only way to promote the
scientific standard.
ORIGINAL ARTICLES.
A MEDICAL ASPECT OF CRIME.
Read in the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical
Association, held at Atlanta, Ga., May 5-8, 1896.
BY A. C. CORR, M.D.
CAELINVILLE, ILL.
Aside from the uncivilized barbarism that would
induce a barbarous or half civilized person to commit
outrages on the individuals of a neighboring tribe or
state while practicing obedience to his own tribal laws,
there are exceptions in which the individual is not
true to his own tribal or state laws. These he con-
tinually violates, through some unknown impelling
force that makes him act in utter disregard of the
good, safety and comfort or all. This latter violation
is usually called crime.
Now in all the mutations of the silent revolution
that has wrought so wonderfully since the debut of
an organized Christian civilization, we have room for
so many different phases of a variation of progress
that we have amid a high Christian civilization, great
irregularities in which individuals are untrue to their
assumed, acquired and inherited responsibilities and
obligations, and tend frequently or constantly to
violate those laws, written and unwritten, which are
for the good of all, both living and unborn. Besides
this variation as between civilization and barbarism
as to the highest types of that which we may call
tragic crimes as between nations, there is quite as
much variation or want of consistency in our civilized
Christian and free country between communities and
states. What is a crime in one state or city is not
necessarily such in another. What is a crime in one
section is not in another, and some things that are a
violation of law on one day in the year or week is not
on another. Amid this almost inconceivable and
inscrutable maze of varying conditions, individual
and collective, local and general, we are called on in
this Association, established for the well-being of
society, to discuss the Medical Aspect of Crime.
As far as the discussion in this paper is concerned
it shall be based on the fact, that the brain and the ner-
vous system are the physiologic organ of the mind and
intellectuality, and that every grouping of ideational
activity, or well defined mental faculty has its origin
in the functional activity of brain or nerve cells and
fibers, either local as in areas, or disseminated
throughout the nervous system, or both local and dis-
seminated, and that morality, the ethical sense,
the sense of moral uprightness, of justice, of right
between men, people and things, has such an origin;
that it is a faculty of the mind just the same as the
will of the reason, and that as such it is subject to the
same laws as the functional activities of other organs:
that it is susceptible of being cultivated, of being
repressed, of becoming increased by education and
activity, of being diminished by neglect and occupa-
tion, of being perverted as in diseased conditions
manifested in a class of criminals; that it is deficient
in many persons to a greater or less degree. In other
words there are children, youth, adults and mature
persons who are moral imbeciles from congenital
deficiency of the moral sense.
This faculty of moral sense or morality is the inhibi-
tory faculty of the mind, the let or hindrance to the
human expressions, activity and conduct, modified
by the will, the reason, the judgment, the understand-
ing and the impulses and intellectual delusions.
This faculty of morality is the latest and best
results of man's long continued culture and its exer-
cise is the highest function of his very complicated
cerebral and nervous mechanism.
With this physiologic source and condition of
crime before us its treatment is greatly simplified.
When amid the mutations in progress of development
from barbarism to civilization and advanced christian -
ization, influenced by atavism and connation, the
impulse to commit an act is felt that belongs to the
criminal calendar, that is, to do that which is in dis-
regard of the rights of others and is hurtful to the
well-being of the civil social compact, and is in viola-
tion of law written or unwritten, the individual sense
of justice and moral uprightness intervenes and inhib-
its or sanctions the act, just in proportion to the devel-
opment of the moral faculty of the individual.
Now, would you have crime lessened? Then you
should cultivate and develop the moral sense and
repress the emotions. I can not give here a tithe of
all the details this cultivation would embrace, but
certain it is that some code approximately correct
should be formulated and put in practice expressly
for this purpose. Something that would teach chil-
dren as definitely to exercise the moral and ethical
faculties as there is to teach the exercise and develop-
ment of the reasoning and intellectual or mathematical.
Children should be taught as early as possible that
there is a principle of right and justice in the abstract,
irrespective of any mere religious sentiment or super-
stition. Each child ought to be impressed, if in no
other way, by mere precept in a round of words, that
he who has not an average moral perception is a
moral idiot and is to be held in apprehension as one
unsafe to trust. Lessons in morals ought to be form-
ulated and a spirit of emulation engendered that
would cause them to strive with each other to learn
the most of them. These lessons should be element-
ary and advanced and graded in adaptation to the
ability of each child to grasp and comprehend them.
And every school of whatever character, should be
required to rigidly teach them; for the exercise <>t
morality, to the extent of being just mid upright in
conduct and character, is the best and highest func-
tion of the human brain. In this course each crime
should be designated and its heinousness expatiated
on and a thorough understanding of its turpitude
required, and that its commission and practice would
lead to still further immoral practices in the individ-
ual, propagate the same or similar practices by inheri-
tance to others. And over all this ought to be held
the terror of lawful punishment. For he who can
not or will not learn, let him be deterred by fear of
pain and penalty and let the seal of disapprobation
be placed on every act that violates the least of the
moral code.
This much should be done for the individual from
childhood up, and should not be neglected, and what-
ever religious influence that may be deemed proper
should be added. If anyone can be deterred from
criminal or immoral practices through fear of impaired
future happiness, by all means give him enough to
answer the purpose. It is the practicing that culti-
vates more than the mere tendency inactive.
ISW.]
A MEDICAL ASPECT OF CRIME.
787
At present the public schools in our country,
khlOUgh which most of this grade of work in moral
eultuiv must be done, is incompetent for the task.
There is among school teachers as well as among the
laity in general, no definite idea as to the difference
between morality and religion, between moral
uprightness and the mere ritualistic processes of a
beatific worship.
I once had occasion to investigate this subject
among public school teachers in my own State, and I
dare say they average with those in other States.
Some said morals is a theological question, and if we
attempted to teaoh it in schools it would give rise to
religious sectarian wranglings that would impair the
harmony and usefulness of the school, and if this or
that teacher inculcated his or her moral ideas (reli-
gious views I it would create dissension and indepen-
dence among the patrons of the school because of
their varied religious beliefs. One who was in high
esteem as principal of public schools said in sub-
stance "that the question of how to promote the
morals of my pupils has given me a great deal
of anxiety, and is a matter I never felt satisfied
how to manage, owing to the varied religious views
entertained by my teachers and pupils. I have in
one school a class of six or seven studying natural
sciences, two members of which are believers in the
theory of evolution, and it gives me a great deal of
annoyance and anxiety for fear they will ruin the
morals of the remainder of the class and in fact infect
the whole school."" Other teachers replied to my
queries that they would leave the question of morals
or religion to the Sabbath schools, the churches, the
i ian schools and the colleges. There were still
others who frankly admitted that the question of
teaching morals was not well understood and crimin-
ally neglected.
Now. I do not think I misrepresent the great body
of divines and religious instructors, including all
denominations from pope, priest, bishop, theologic
professor and olergyman to pastor, when I say that they
are not more systematic and definite in their concep-
tion of in what moral uprightness consists and how
crime is to be prevented.
Nor has the legal profession elucidated and pro-
1 a better plan than the hurling of statutes and
sentences of punishment. Now, what shall I say of the
medical profession? Have we elucidated any better
or well devised method of defining morals and culti-
vating the moral sense? In fact I doubt not that
when this point is discussed that it will reveal quite
as wide a range of different ideas as to the moral
sense and faculty of the brain and mind as the classes
to which I have referred.
But having to do with the brain as an anatomic
organ ami its physiologic phenomena, the mind in
the abstract, it is our incumbent duty to determine
whence the source of criminality in the individual
as far as his mental composition is concerned and
what additional plans shall be formulated for its pre-
vention. The conclusions arrived at on this point
shall constitute a basis for the consideration of the
medical aspect of crime.
The moral defect with its criminal tendencies is
always congenital, many times hereditary and always
modified in a greater or less degree by environment
and synergistic injinences.
By congenital I mean the inborn tendency, which
mental condition is a derivative complex, much
like a double decomposition in chemistry, and by
which a mental composition is transmitted congeni-
tally that is unlike either parent in moral perception,
yet like one or the other, or both in many other
respects. This is congenital moral imbecility, while
an hereditary moral imbecility must be like one or
the other or both parents.
The congenital variety of mental complex is that in
which criminal children are born of amiable parents,
or amiable children of criminal parents. Many
instances of both varieties I have observed.
Having established in a fairly plausible way that
the tendency to crime is inborn and consists in a
defective mental composition in which the moral per-
ceptions are weak or deficient and that it may be cul-
tivated like any other mental faculty, it may be well
to consider some one or two conditions of environ-
ment or synergistic influences that cooperate with a
slight or marked criminal tendency to make the crim-
inal. To a large extent all men are creatures of asso-
ciation or environment. Many with only slight ten-
dencies are schooled out of or away from crime.
While many are schooled into it who but for such
synergistic influences would have always remained
guiltless.
Beyond these suggestions I would be recreant to
my trust were I not to arraign the liquor traffic as
being the greatest despoiler of human morals and
well being. While we do in our associated capacity
much to school children and youths out of and away
from crime, yet we tolerate and perpetuate a traffic
that unschools and dissipates much that our well
designed efforts have wrought. The use of alcoholic
beverages is always to degrade and debase the moral
sense in the individual and disorganize society. It
never elevates or cultivates a moral sense, but
degrades and tends to make criminals just in propor-
tion as it is used. It never sent a child to Sabbath
school but has sent many to the penitentiary and the
gallows. If a man uses a thousand barrels of it, it
does not do him as much good, based on his necessi-
ties, as the eating of a teaspoonful of meal.
Its tendency to produce crime and make criminals
can be proven by the history of any county in the
United States where the sale and use of it has been
prohibited for only one year, for just in proportion
to the efficiency of the restricted sale and use of the
beverage among the citizens will crime and crimin-
ality have been diminished.
I do not think that the destruction of the liquor
traffic would by any means prove a panacea for all
crime, but its synergistic influence amid a degree of
moral imbecility is at the present time greater than
all other influences combined.
Some eminent medical gentlemen have argued that
some one or more organic instincts are responsible for
most all the crime, and that a surgical procedure or
operation would prevent crime and reform the crim-
inals. The most remarkable contribution to the dis-
cussion of this character that I have seen is a paper
by Dr. Robert Boal to the Illinois State Medical
Association in 1894, entitled "Emasculation and
Ovariotomy as a Penalty for Crime and the Reforma-
tion of Criminals."
The discussion was made under nine considerations
which were practically these :
1. "We are taught by both physiology and psychol-
ogy that all human beings are controlled in their
conduct and actions, and appetencies are expressed
788
THE PHYSICIAN AND THE CKIMINAL.
[October 10,
through their organic instincts. Of these, two are
of paramount importance. They are love of life and
sexual love. The first is the strongest and outlasts all
others. Next is love of sex, which dominates human
conduct and desires. Its bestowal was wise, but when
uncontrolled it is potent for evil."
2. "The greater proportion of the crimes characteris-
tic of the criminal and vicious classes may be traced
directly and indirectly to the influence of this uncon-
trollable and dominating sexual love. The rapes,
homicides, suicides, defalcations and embezzlements
may be ascribed either directly to sexual love, or to
influences associated with it. So well is this under-
stood that when we hear of the cashier of a bank
absconding with its funds, or a trusted clerk robbing
his employer and betraying his confidence, almost the
first comment heard is, 'Oh, there is a woman in the
case.' With scarce an exception, there are few vices
in the calendar of crime, licentiousness, prostitution,
intemperance, gambling and others that are nameless,
that are not designated, associated with and main-
tained by sexual love."
3. "The physical or structural characteristics of the
criminal and defective classes are produced, repro-
duced and multiplied, and perpetuated by intermar-
riage or sexual commerce of persons of like defects,
and we have accordingly the results of living activi-
ties of matter or what is called heredity."
4. "By the imposition of the penalty of emascula-
tion and ovariotomy we destroy the capabilities of
these defective criminal classes, to inflict injury upon
society, thus depriving them of the power of repro-
duction."
5. "For the purpose of intimidating others from
the commission of crime, while neither cruel nor vin-
dictive it is more terrifying and repulsive, next to
death, than any or all modes of punishment. The
loss of sexuality as a mark of manhood is so utterly
abhorrent to all men that it would be avoided if possi-
ble by all individuals not hopelessly insane."
6. Practically, "By unsexing all constitutionally
depraved convicts we would curtail such production
and aid nature in natural selection and the survival of
the fittest."
Seventh and eighth considerations are conclusions
based on the acceptance of the six preceding referring
to the results and effects of emasculation and ovariot-
omy on the disposition of the individual, and that as
a punishment would not excite revenge, etc.
Ninth consideration is a general statement as to
range of application of the punishment, to the effect
that it might be safely applied to insane persons,
cranks and paranoiacs.
To this ninth consideration I have only to ask,
Would emasculation and ovariotomy change the delu-
sions of the insane and make them safe citizens at
large in society? I have quoted these "Considera-
tions" because they embody an idea that is held by
many both in the medical and legal professions. I
think the idea is untenable as a whole. I discussed
them in a paper before the same society a year later,
when I replied to the "Considerations" seriatim. In
the discussion of this paper Dr. N. S. Davis of Chi-
cago, said, "I have seen nothing in my observations
in human society to make me believe that human
depravity is greatly ruled by simply the sexual organs
in either sex. That they are capable of exerting a
predominating influence in individual cases, as much
and probably a great deal more owing to bad training,
bad education, bad surroundings than to any inherent
vice in these organs, is undoubtedly true, but whether
they have any more tendency to produce crime than
a man's stomach I very much doubt. I think it has
been shown that a well developed dyspeptic is about
as likely to go wrong as almost any other class we
might enumerate. It is not, in my estimation, the
fault of the organs that we propose to excise as much
as it is a fault in the brain that accompanies them,
and if you want to get rid of the tendency to crime
you will have to excise some of the cells of the brain,
if you can find the proper ones, instead of the sexual
organs."
THE PHYSICIAN AND THE CRIMINAL.
Read in tlie Section on Neurology and Medical Jurisprudence at the
Forty-seventh Annual Meeting of the American Medical Asso-
ciation, held at Atlanta, Ga., May 5-8, J896.
BY J. B. RANSOM, M.D.
PHY8ICAN TO THK NEW YORK CLINTON STATE PRISON,
DANNEMORA, N. Y.
The axiom that the proper study of mankind is man
has evidently not long been applied to criminal man,
for careful search reveals a striking dearth of records
in this regard. Until 1841 nothing worth recording
had been done in the special observation of criminals,
and the science of criminal anthropology, strictly
speaking, was only begun in 1854, and not until
Lombroso's work " The Criminal," was published in
1876 did criminal anthropology assert itself as an
independent science.
There are several instances where observations have
been published as to the characteristics of criminals,
but no connected and definite work was done. (Imme-
diately after the publication of " The Criminal," how-
ever, numerous works on criminal anthropology were
published, especially in Italy.) All the valuable work
done in this line is of recent date; good literature in
this field is therefore limited, and carries with it the
conclusion that the whole subject has been surpris-
ingly neglected, and he who would enter this field
of work must find himself somewhat lonely. On
every hand, however, there are evidences of an
arising interest in this feature of social life. In
France, Germany, England and Italy more especially,
criminology is fast assuming the dignity that rightly
belongs to this important and essential science. In
our own country, however, no such concentrated
results have obtained, and the study of criminal man
is a slighted one and the subject little understood.
More striking is this when we consider that such study
is not without necessity, for a glance at the census fig-
ures of the United States will show a proportionate
increase of incarcerated criminals of nearly five times
from 1850 to 1890 inclusive.
Ratio of
Yea'' Prisoners, population.
1850' 6,737 1 in 3,442
I860 19,086 1 in 1,647
1870 ' ... 32,901 1 in 1,171
1880 .... 58,609 1 in 855
1890 ! '.'. 82,329 1 in 757
The number of homicides in 1889 were 3,567 in the
United States, in 1895, 10,500. This, too, in the face
of the fact that society and the courts and geneial
public sentiment has constantly grown more lenient,
and the number of unpunished criminals has largely
increased; as for instance, according to Andrew D.
White, if the whole number of murderers for the six
years last past were in prison there would be 40,000;
as a matter of fact there are only 7,300. Neither is
1896.]
THE PHYSICIAN AND THE CRIMINAL.
789
it because we arc unaware of the existence of crime,
for it is everywhere present; the newspapers of the
day flaunt it in mir faces, and our own observations
make known to us the existence of a large criminal
elass. which is surely and rapidly invading every
department and function of our social and political
life. It is not necessary to enlarge upon this unpleas-
ant feature: it is apparent to every one. The condi-
tion confronts us; it remains to determine the causes
and apply the remedy, ami that without delay. These
causes are many and various, but it will only be
within my province to speak of those which relate to
us as a profession more particularly, and seek to
determine just what our responsibilities are in this
ole field of scientific and sociologic work.
It would seem that a common interest in the study
of man in a biologic sense would have elicited the
very best efforts of the medical profession, inasmuch
as man has always been the humble recipient of all
the experimental work of an aggressive profession
since its conception, but that such has not been the
case is apparent by the very few medical men who
have been engaged in this important branch of sci-
ence. It may be assumed that this was chiefly due
tothe fact that in the early history of medicine, the
profession of that day were so intent upon the prob-
lem of cure, a to them much more important con-
sideration than man himself. In a less remote period
medical men were engaged in the elucidation of theo-
ries, and still more recently earnestly in pursuit of
man's common enemy, the microbe; not that this
work has not been necessary, and of inestimable value
to a common progress, but it does seem paradoxic
that its prosecution should have so completely
■a red its object, man!
Only occasionally had the physician devoted him-
self to this work up to the time of Sampson, Lom-
proso, Forbes Wiuslow, Camper and Lallemant. It is,
however, in our own country that the least attention
has been paid to this subject, excepting in isolated
cases where men like Drs. Arthur McDonald, Jacobi
and Flint, and physicians connected with penal insti-
tutions have urged the necessity of criminal anthro-
pology as a branch of medical work. This has been,
however, so fragmentary and unclassified that it has
not assumed at any time an organized effort in this
direction, and therefore has elicited little interest and
accomplished less; but the rapid advance in this work
recently made in Italy, France, England and Ger-
many, and the alarming ascendency of crime, so dia-
metrically opposed to the progress of our time, the
inability of our present administration of the law, and
of the penal system to cope with the necessities and
conditions of the hour, have forced into consideration
of society and government a problem which should
have had its solution, or at least intelligent recogni-
tion, as paramount to their safety and well being long
ago. As it is in the closing years of the nineteenth
century with all its marvelous achievements, with all
its progress in culture and refinement, society finds
itself confronted by a condition which threatens its
very existence. Society is finding out that it has
nursed or tolerated within its own bosom the upas
which may poison it to death. Aroused to a recogni-
tion of the fact that such a condition exists, it finds
itself in possession of only the crude elements of an
embryo science, which to be adequate to these demands
must be rapidly developed into one, comprehensive and
efficient. Crime and the criminal must receive more
weighty consideration by all concerned, or the integ-
rity and strength of our social and political institu-
tions will be subjected (they are already threatened)
with serious disaster therefrom. Society has hereto-
fore been content to relegate this whole feature to the
courts and the penal code.
It needs no demonstration to show that the modern
trial, sentence and punishment of the criminal, so
largely based upon assumption and in ignorance of
the criminal himself, has measurably failed to protect
society from the rising tide of crime. In spite of the
exercise of their powers crime has continually and
markedly increased. This is in the largest sense due
to the tact that the procedures of the courts and
administration of law, have based their action upon
the theory that its function was first to detect crime,
and then to punish it, losing sight of the fact that all
men are not alike, and that punitive measures could
only be efficient when they take into consideration
the individual characteristics and apply the treatment
to the criminal's special needs. Intelligent trial
and sentence can only be secured when we have a
scientific knowledge of the criminal, the nature of his
crimes and the natural and social phenomena con-
nected therewith. Such an administration of crimi-
nal law can only be obtained by the thorough classifi-
cation of the criminal into distinct and characteristic
types. In the words of Flint: "Before a disease can
be treated intelligently it must be diagnosed."
More especially is this true when those types repre-
sent physical and psychic anomalies.
I think, in the light which recent investigation has
shed upon this subject, that it may be indisputably
asserted that crime is often the natural outcome of
disease, and that into such causation enter many
forms of deviation from the normal standard in both
the physical and mental organization represented by
arrests of growth, deformities, asymmetries, intercur-
rent diseases, as well as psychic aberrations and
disorders.
This whole subject is at present in a state of chaos,
and it is impossible to draw definite conclusions from
the data at our disposal; naturally enough as the possi-
bilities of this field have opened up to view, there has
dawned upon the consciousness of some the idea that
there is such a thing as a natural criminal, and that the
commission of crime is not always the result of a long
process of evil doing, instituted by telling the first white
lie, which precedes the going through of the story book
stages of moral decline which go to make up the aver-
age romantic criminal. This conception leads them
to come hastily to conclusions based upon a few
meagre details and incidents, and with many learned
phrases rush into print seeking to establish the theory
that society has made an awful mistake, and assert
that crime is and always has been a disease. A great
deal is said upon the subject which clearly shows an
utter lack of knowledge and a misconception of the
whole subject.
All this grandiloquent flourishing of pamphlets
and inclination to rush in where wise men fear to
tread might well be expected with reference to a sci-
ence of less than half a century's growth ; neither is
this limited to the over-enthusiastic, for even our most
careful students and painstaking observers in the
enthusiasm of first discovery have made many erron-
eous statements and drawn conclusions altogether
too arbitrary; but when all this cyclonic agitation of
high sounding terms has ceased to confuse our senses,
790
THE PHYSICIAN AND THE CRIMINAL.
[October 10,
we shall see that these conditions are but the natural
accompaniment of the birth of a new science, and that
soon from out all this incoherent mass of nebulistic
data will be crystallized constructive elements, which
when assembled by the skillful and competent men
of our time, will constitute a perfected science of crim-
nal anthropology, applicable to the needs of society,
and protective of the general welfare. In the study
of the criminal there has been a tendency to base all
conclusions upon anthropologic data; even Benedict
and Lombroso have gone so far as to assert the exist-
ence of a criminal brain as a distinct type, which I
think is unwarranted by what has been derived from
still later investigation. To these extreme views I
certainly do not assent, for in the words of Jacobi,
" The criminal can not be considered an entity, but as
a being possessed of characteristics as various as those
of other types of men;" neither would I go so far as
Rondeau when he states that "all assassins are patients
as are all other criminals." I do not believe that all
criminals are diseased in the common acceptation of
the term, nor is all crime the result of such disease.
Many criminals are diseased and present anomalies
of structure as the cause of crime; there are however
criminals who are so from environment, and from the
inhumanity heaped upon them by men. Th'ere are
also criminals of circumstance or accident. Neither
do I believe that the rogue can be told from the
honest man by the shape of his head alone, or by his
physiognomy, or the deformity of his jaws, ears, nose,
or lips, or by any other one of the numerous anomalies
we find in all types of mankind, and especially in the
types representing the lower strata of society, neither
have we as yet the data representing the normal type
of man, with which to compare the abnormal.1 When
we have we can make more positive statements. It is
only by the sum total that an exact estimate can be made
that is by a careful consideration of all the anomalous
conditions which are grouped in and about the crimi-
nal, physically, psychically and socially, and a balance
struck between abnormal tendency and inhibitory
power that a correct conclusion can be reached. It is
the preponderance of tendency which must determine
the character of the individual. There is however
abundant evidence and well established data to show
that crime is largely the natural outcome of disease
in the perpetrator, and that by comparison with other
men, the criminal class shows a preponderance of
anomalous conditions, as for instance, in one of
Lombroso 's tables of the measurements of the skull
we find "that men with normal skulls were three times
as numerous among soldiers as among criminals. Of
men with a noteworthy number of anomalies occurr-
ing together, out of 711 soldiers there are only three
or four, there were three times as many amongst
criminals as amongst soldiers, and there was not one
soldier of the 711 who showed an extraordinary num-
ber, say five or more," and the same is true of physi-
ognomic, psychologic, and physiologic anomalies
amongst criminals.
As a rule special anomalies do not necessarily indi-
cate special tendencies to certain crimes, but as stated
in my paper, "Shall Insane Criminals be Imprisoned
or Put to Death?"2 in the examination of several
thousand criminals, I have been lead to believe that,
as a rule, when in the inherent criminal the right
i It is encouraging to know that there is a decided movement in the
endeavor to establish a normal structural gauge for men, by the use of
instruments and technical observation.
i Referred to later on.
side of the cranium, that is, indicating the right
hemisphere of the brain in excessive development
over the left, especially where there is a marked ful-
ness over the paracentral lobe, the possessor's impulses
lead toward homicide. I have repeatedly been able
to place my hand upon this part of the head of crim-
inals, and designate their crimes to be either assault
or homicide without any previous knowledge of their
history or themselves.
More recent observations have substantiated the
above, especially the last criminal executed at Clinton
Prison for an unusually unprovoked and brutal murder,
the right side of the brain weighing more than the
left.
"To the student of criminal anthropology, however,
every characteristic in the criminal's natural history
has an anthropologic, physiologic and psychologic
value in itself, and must be a technical study," that he
may arrive at a correct conclusion as a whole; there-
fore it is not altogether from apparent anomalous
conditions alone that he would assume that the man
presented a criminal type, or was criminally diseased,
for crime is often due to intercurrent disease; especi-
ally to chronic diseases of the heart, meningitis, tub-
erculous disease, and syphilis; criminals are especially
prone to diseases of the heart. Out of 2,011 men
examined by myself in a general way on admission
into prison, 239 had gross heart lesions, and many
more obscure and less important ones. I should esti-
mate that 25 per cent, of all criminals would show
disease of the heart or of the great blood vessels.
When we consider the relation of the heart to the
circulation of the blood in the brain, we shall under-
stand how a diseased heart can produce brain disturb-
ance. Meningitis is also a prolific cause of crime,
especially those of assault and homicide; this is par-
ticularly noticeable in the latter. It is not necessary
for me to refer to the maniacal tendency due to
inflammation of the meninges. Any one who has
conducted a patient through the several stages of a
meningitis, knows well the effect of the disease ujion
the mental condition. The result of meningitis is
often a thickened patch, a softened area, or a circum-
scribed adhesion, any one of which is capable of
driving the unhappy possessor to the most fiendish
acts of violence; as the spur to the horse, it urges on
the diabolical impulse. In autopsies upon criminals
who had committed assaults or homicides, it is very
seldom, if ever, that some such thickened patch or
atrophic area has not been discovered. In my last case
the adhesions were extensive. M. Dally, from a
twenty years' experience, says that "all criminals who
have been subjected to autopsy after execution gave
evidence of cerebral injury, often undiscovered prior
to autopsy." From my own experience I believe this
injury is usually the result of some form of meningeal
inflammation. Syphilis is well known to cause grave
neurosis, and among criminals a very large percentage
are syphilitic. The effects of syphilis upon the brain,
either in the deposit of gummatous tumors, or in the
production of degeneracy of brain tissues, is a prolific
cause for mental disorders, especially of a temporary
nature. I have seen a number of criminals who were,
no doubt so, from the effect of syphilis, or its injudi-
cious treatment. Tuberculosis is also a prime factor
in the problem of crime. Many a man is a criminal
because of the presence of tubercular toxins circulat-
ing in his brain, or to the poverty which this inability
to earn his livelihood brings him. Almost ever
I
1896. ]
THE PHYSICIAN AND THE CRIMINAL.
791
physician is familiar with what is called the insanity
of phthisis. Several other diseases are distinct causes
for crime, especially those connected with the genito-
urinary organs.
A large amount of data might be offered which
would go to establish the fact that a large proportion
of crime is the direct and natural outcome of some
form of disease, 1 shall not enter into detailed
minutiae or technicalities; neither shall I weary you
with an array of craniometrio figures and anthrop-
ologic data, for such information is best found in the
works of Benedict, Lombroso, Lacassagne, Ferri,
Ferrero. Garofalo and Dugdale, but simply attempt in
a general way to institute a discussion of the relation
of the physician to the criminal problem. I shall
also purposely avoid the Bociologic aspect only in so
far as is necessary to define this relation.
If it he conceded that crime is the result of disease
we shall have a conception of the criminal, which at
once changes the whole application of the principle
of treatment, revolutionizes sociology and annihilates
many of the more primitive methods of the admini-
stration of so-called justice. Surely all efforts should
he directed not toward inflicting upon an already
unfortunate individual still greater misfortune, but in
assisting him to overcome his infirmity. Now if this
was true of all criminals, and if the question of
degree did not enter so largely into the problem,
the whole matter would be simplified; there are,
however, questions of degree and questions as to what
proportion of crime is due to disease, recognizable and
estimatable. Herein lies the opportunity for the
exercise of huge common sense, and in the considera-
tion and treatment of the whole subject, let us be
guided by it.
Much confusion arises from false notions as to what
the criminal is. Too often the criminal is considered
an abstract quantity, as if belonging to a different
Older of beings; such is not the case however, they
are men and women, creatures of hope, of longing,
and of fear. Our ideas of the criminal should not lead
us to think that the mere fact of putting a man behind
the bars, and habilitating him in stripes, at once
assigns him to a different species, for it will be found
that the criminal is much like other men, amenable to
treatment and improvement. The distinction which
criminologists would make in the theory that the
criminal is of degenerate type, does not apply to the
incarcerated criminal alone, but also applies to millions
who have never seen the inside of a court of justice, or
felt the dampness of a prison cell. There is no distinc-
tion from a psychologic or physical standpoint
between the incarcerated and the unpunished crimi-
nal, other than the results consequent upon his envir-
onment.
It is because the conditions which enter into the
criminal make up that lead to the commission of
crime are not better understood, and the naturally
fallacious conception as to what the positive school of
criminology advocates in the scientific treatment of
-crime, that efforts looking toward the improvement
of our methods of treating the criminal are so fruit-
less. The positive school of criminology does not
desire to divorce the criminal from his responsibility
to the law, or mitigate the punishment of crime,
which is its inevitable auxiliary ; it proposes to punish
crime, not, however, in a retaliatory or vengeful way,
but, in so far as is possible, use its punishment as a
means of restoring the offender to his former recti- 1
tude before society and the law, recognizing "that
crime is not always of the free will, but rather a nat-
ural phenomenon which can only disappear when its
natural factors are eliminated." It seeks rather to
adapt measures to conditions rather than attempting
to make conditions fit measures, and recommends a
plan of treatment based upon the classification of the
criminal resting upon scientific anthropologic data.
Equally fallacious notions are entertained as to what
is the part of criminal anthropology in the scientific
treatment of the criminal. The modern criminologist
does not seek to base conclusions upon anthropologic
data alone, but as Ferri puts it: "All that he seeks of
anthropology is this — Is the criminal, and in what
respect, a normal or an abnormal man? And if he is
abnormal, is it congenital or contracted, capable or
incapable of rectification? " This is all, but sufficient
to enable the criminologist to come to positive con-
clusions covering the measures that society can take to
protect itself against crime. This then is the summing
up of the whole matter: 1. A correct and efficient
treatment must rest, as in all other departments of
human affairs, upon the proper classification as a
primary and essential step to proper observation.
2. That such classification to be of value must rest
upon anthropologic data. 3. Inasmuch as anthrop-
ology is scientific and positively medical, the essential
work of classification naturally falls within the physi-
cian's province, and can alone be performed by him.
Not only is the object of classification to admit of a
more intelligent study of the criminal, but it is
through such classification alone that proper treat-
ment can be administered.
The classification of the criminal also predisposes
the necessity of proper classification and grading of
penal institutions, so that when the criminal has been
assigned to his class by the courts, he can receive the
treatment best suited to his individual requirements ;
the insane or weak minded criminal should be sen-
tenced to a hospital for the care of the insane; the
born or habitual to an institution specially calculated
to care for confirmed and incorrigible criminals;
criminals of passion and occasion, to short term insti-
tutions where they could receive treatment looking to
their reform. To accomplish this, all of these institu-
tions should be graded to facilitate their special study
and treatment. The criminal having in him the pos-
sibilities of reform should have opportunity for such
reform. The confirmed and hopeless criminal should
be excluded from society permanently. This phase
of the criminal's treatment is more explicitly treated
of in my pamphlet published in November, 1895,
"The State and the Criminal."
Having been properly graded,every institution devo-
ted to the care of the criminal should be provided with
a physician specially qualified not only for the proper
care and treatment of the ordinary ills of the criminal,
but abundantly able to conduct a proper study of the
criminal based upon anthropologic data and crimino-
logic factors. Not only will such efficiency ensure
proper grading and intelligent treatment of the crim-
inal, but it would furnish to the science of criminology
valuable data upon which to base still further conclu-
sions. The first step in the classification is the appoint-
ment to every criminal court of a competent physician
to assist the court in determining expert questions rela-
tive to the criminal's physical and psychic condition
at the time of trial.
The physician in this work of classification should
792
THE PHYSICIAN AND THE CRIMINAL.
[October 10,
bring to his aid all instruments of precision necessary
to the proper measuring and estimating of the crim-
inal from this standpoint such as the sphygmograph
and craniometer.3 This would only apply to cases
not having been previously examined and recorded.
First in the proper classification of the criminal is
his division into two great classes, curable and incur-
able; in so far as results are concerned, this covers
the whole ground, but that such a division can be cor-
rectly made, necessitates the classification of the
criminal with reference to his type, especially in the
application of treatment to that numerous class of
curable criminals. I have therefore adopted as a most
useful classification that of Ferri, which divided the
criminal into five classes, to wit: 1. The insane crim-
inal: 2. The born criminal; 3. The habitual criminal.
4. The occasional criminal ; 5. The criminal of passion.
It will be found that this classification meets the
largest requirements possible under our present knowl-
edge, but unmixed types of criminals are unknown
and criminals can not be precisely classed under cer-
tain categories, for they frequently exhibit mixed pro-
pensities, and merge from one type into another. And
in one some of the characteristics of several types
may be blended. This classification, however, is a
practical one and based upon sound observation.
The Insane Criminal. — There can be no scientific
distinction made between the criminally insane and
the insane criminal. The distinction is only an asso-
ciate one and refers to conviction. True criminal
science knows no distinction between the incarcerated
and the criminal at large. To him the abnormal con-
dition which controls a criminal act, constitutes the
criminal identity. The courts have shown their utter
inability to differentiate between the insane criminal
and the ordinary. If a man has within him a tend-
ency sufficiently strong to cause him to commit
offences against person or property, he is a criminal,
and if such depends upon an abnormal mental condi-
tion, he is an insane criminal; the only distinction
necessary to make is in a penologic sense, and that is
the distinction between the insane convict and the
insane criminal. The question turns upon the point
of insanity related to responsibility under the law.
To be able to distinguish between the born criminal
with abnormalities of structure and psychic disturb-
ances, and the insane criminal, is sometimes a diffi-
cult thing to do, and I can not agree with those who
deem it an easy matter to decide, so intimately mixed
are the inherent tendencies and anomalous conditions
present in the two types; so frequently the same con-
ditions are manifested in both that it is sometimes
very difficult but not necessarily impossible.
Carofalo's distinction is a good one, and is applica-
ble to a large number of cases. He makes the dis-
tinction, "with the insane criminals, that in the act
itself lies the satisfaction, not the object, while with
criminals the act is only a means to an end." To the
former crime is a pleasure, to the latter a paying busi-
ness necessitating, it may be, diagreeable acts.
Criminals of unsound mind can not all be classed
in the same category if we are to study them intelli-
gently; indeed, it is difficult to make a classification
which is always distinctive.
For my own convenience I subdivide insane crim-
inals into five classes:
:f The time will nodoubt shortlycome when hypnotic suggestion and
the use of special instruments for the measurement of brain impulses,
as related to physical conditions, will be added to the physician's
armamentarium.
1
1. The paranoiac, who are persons exhibiting self
exaltation, systematized progressive delusions, writers
of insane political documents, and with tendencies
toward political homicides which are usually consistent
with their delusions. Guiteau and Prendergast are
good examples of this class.
2. The psychic epileptic. A class not numerous
and who commit the unexplainable murders. This
class of criminals commit outrageous murders during
epileptic seizure, and which seems utterly inconsist-
ent with the circumstances and the perpetrator, and
can not be judged by the ordinary psychology of
criminals. (Ferri.)
3. The phrenasthenic or psychopathic criminal,
who is one of irresistible impulse, feebleness of will,
and with morbid tendencies to private murder. This
class of criminals commit atrocious crimes, appar-
ently without motive and purely from the force of
impulse, or from the satisfaction of the criminal act
itself, (rood examples of this class are Jack the
Ripper and Mrs. Halliday.
4. The morally insane or reasoning phrenasthenic.
The only difference between the morally insane or rea-
soning phrenasthenic is the absence of delusions,
and their perversions are of the sentiments and affec-
tions. (Regis.) "They represent a small class and are
the individuals who apparently with full reason and
judgment commit themselves in an unconscious and
frequently paroxysmal manner to indulge in errors of
conduct and immoral acts which are really pathologic,
and although apparently less insane they are more
profoundly degenerate than the delusion cases, and
have a more marked degree of mental infirmity and
imbecility."'
The fifth class of insane criminals "consists of a
large body of persons tainted by a common and clinic
form of mental alienation, all of whom are apt to
become criminal. This class of insane criminal are
sometimes identical, and sometimes opposed to the
born and occasional criminal." (Ferri.) This class
commit various crimes under insane impulses and are
commoidy degenerates. It is seldom that a criminal
of this class commits an atrocious crime unless under
an impulse of passion.
These classifications are more a matter of conve-
nience and should not be arbitrary; practically, the
whole importance of the determination of the crim-
inal insanity or sanity devolves upon the question of
responsibility, and classification is only useful in arriv-
ing at correct conclusions as to the individual's respon-
sibility under the law.
The Born ( 'rirrrinal. — The born or instinctive crim-
inal is one who most frequently presents anomalies of
organization and psychic aberration; they are crim-
inals the same as other men are mechanics or arti-
zans, and look upon the penalties of crime as the nat-
ural risk incidental to the business; who do not regard
a crime from its moral aspects, but simply from the
risks attendant upon its execution. The born crim-
inal as a rule is deficient in both moral and physical
sensibility. This criminal insensibility is manifested '
in his perfect inability to see the evil side of a crim-
inal act, and to forecast its effect upon himself as a
moral entity; also in his indifference to conse-
quences and to feelings of remorse. He plans and
executes with the whole moral code left out, only as it
is used to escape the penalty which may deprive him
of the exercise of his craft.
The lack of physical sensibility is often marked.
18%.]
THE PHYSICIAN AND THE CRIMINAL.
793
My attention was first called to it particularly while
doing operations upon this class of men. they exhib-
iting no evidence of pain even though the operation
might be painful and to the norma) person excrucia-
ting. One man attempted to castrate himself and
when discovered had succeeded in exposing the testi-
ele. having opened the scrotum throughout, and was
about to cut the cord. This same man under a pre-
vious operation for ligation of the radial artery had
shown almost perfect insensibility to pain. Another
case was that of a man about 30 years of age, in good
health, classed as an ordinary convict, quite inoffen-
sive, but who was drawn into an altercation with a
fellow workman in the repair shop, and who in a fit of
rage walked deliberately across the shop to a small
circular saw. threw on the belt, and without hesitancy
placed his forearm upon the carriage and sawed it
completely off just below the elbow joint. He
seemed perfectly indifferent to the whole affair and to
sutler no pain. He was discharged from prison, was
again incarcerated, is now serving a second term and
is still considered an ordinary convict. Numbers
burn themselves in a most horrible manner to get rid
of doing a moderate task, cut off their fingers and
mutilate and injure themselves in different ways to
carry a point, not because they could endure pain
heroically, but simply because they had learned that
these things did not hurt them overmuch. This
insensibility to pain tends to rapid healing of their
wounds. There is, however, one erotic type of born
criminal who is over-sensitive to all sorts of pain and
suffers exaggeratedly from the slightest injury. This
mora] and physical insensibility at once places the
possess >r in a low order of organization and one largely
incapable of reformation or improvement. From this
class will always come the major portion of incor-
rigil i
The Occasional ( hrimhial. — The occasional criminal
presents rarely marked anomalies of structure such as
characterize the born criminal. This type are more
criminals from environment and circumstances, and do
not present those anomalous conditions that bring them
properly within the province of a medical study; they
are therefore best left to the sociologist, only in so far
as individual cases present psychic and physical dis-
eases requiring medical treatment.
Tin' Criminal of Passion. — The criminal of passion
is one of irresistible impulses, who under the stress
of uncontrollable passion commits crime of which
there has been no premeditation, and for which he
suffers the keenest remorse. "He is usually strong
enough to resist ordinary temptations, but does not
resist psychologic storms which are sometimes act-
ually irresistible." They are of highly neurotic type,
and their study is of interest and consequence to the
physician in that they approximate criminals of un-
sound mind, and it is often a question to determine
as to the sanity of their acts. They are not crim-
inals in the true sense, but rather offenders, victims
of their own impulses.
We come now to consider the physician's relation
to the criminal as regards his treatment. The com-
plete study and treatment of the criminal must ever
be largely a sociologic one. As has been said by
ssagnS: "The criminal is a microbe inseparable
from his culture broth, the social surrounding." And
gradually but surely the purely anthropologic study
of the criminal has given place to a plainly more
sociologic one based upon it.
The treatment of acquired and intercurrent disease
of the criminal falls almost entirely within the field
of labor of the physician to penal institutions, and
should embrace in its operations all of the medical,
surgical, mechanical and therapeutic means at the
disposal of the physician. In the treatment of heart
lesions so numerous among criminals, both gymnastic
exercise and proper medicaments should be used.
For syphilis, constant specific medicaments and
operative procedures should be used, and the same in
meningeal lesions. Tuberculosis: rigid isolation, with
the destruction of the bacilli by every modern means,
and climatic influence should be a part of the treat-
ment. The various manifestations of psychic disorders
and abnormalities should receive generous treatment
by means of spray baths, surgical shock and elec-
tricity. At Clinton Prison, New York, all these ther-
apeutic means are in active operation with beneficial
and successful results. Aside from the treatment of
the physical ills mentioned, it is with the insane, the
born and weak-minded criminal that the physician
will have the most to do in the treatment of psychic
disorders and the development in him of the power to
control brain impulses.
The treatment of the insane criminal falls entirely
within the sphere of the State Hospital for the Insane.
The chief office of the physician with reference to
the insane criminal is his classification and isolation.
This function as now exercised is chiefly directed toward
the examination of the criminal when accused of
crime, and is a medico-legal one, and one which is not
to the credit of our profession, which I set forth in a
paper read before the Medical Society of the State of
New York in February, 1895: "Shall Insane Criminals
be Imprisoned or Put to Death?"
I am pleased to be able to state that there is a good
prospect of remedial legislation in my own State
regarding the exhibition of medical expert testimony
in all criminal trials.
It is not, however, so important to the protection of
society that the insane criminal receive just and
equitable treatment in courts of justice, as it is that
he be apprehended before he is able to accomplish the
execution of his delusional impulses. It is the appre-
hension and detention alone that can protect society
from their depredations. Had Guiteau and Prender-
gast been apprehended, both Garfield and Mayor
Harrison might still have been alive.
We should urge the passage of such laws as would
tend to place some competent medical officer in every
community as having the right of surveillance with
reference to this type of mankind.
In the treatment of the born and habitual criminal,
the first object should be to increase inhibitory power.
The will may be said to be the gateway of the mind,
and through its narrow portals pass impulses for good
or evil, wise or foolish, and it is the exercise of this
faculty that must control the tide of psychic impulses
that seek to find passage to the outer world. Since
inhibitory power is the essential factor, the cultiva-
tion and strengthening of this power should be one of
the chief objects of treatment in the weak-minded
and degenerate criminal, the exercise of certain brain
functions over and over again constitute a habit of
action which becomes routine and natural. If the
will is to be strengthened and habit broken, new-
tracks of association fibers must be brought into play,
dormant brain cells stinralated into activity and the
whole current of thought and cerebration revolution-
794
THE PHYSICIAN AND THE CRIMINAL.
[October 10,
ized. This can only be accomplished by some sudden
shock, either physical or mental.
It is a well-known physiologic law that by severe
mechanic shock we can suspend the function of cell
groups, partially or entirely. It was to this principle
of shock that were due many beneficent effects from
the use of the more primitive forms of physical pun-
ishment in corrective institutions. It is a well-
recognized fact by penologists that the shock attendant
upon corporeal punishment has often resulted in the
cure of certain psychoses. Many a man has been con-
verted from an intractable crank on the border line of
insanity into a tractable and useful one.
I find this view is substantiated by the figures
relative to the commitment of insane convicts to the
State Hospital for Insane convicts, which, prior to
the abolition of corporeal punishment in the prisons
of the State of New York showed .00874 per cent, and
since its abolition up to the present year .01764 per
cent., or more than double the former percentage.
While these figures can not be relied on as alone
affected by this change, they are sufficiently indica-
tive of the relation existing between the two, since
apparently the contributing circumstances would
rather tend to lessen the number of commitments
than to increase them. I am not using these figures
for the advocacy of corporeal punishment, but simply
to show the influence of shock in preventing mental
disease. In the application of all the forms of shock
the effects are produced by the pedagogic impression
made upon the brain, which in the class of criminals
under consideration is always weak and incompetent,
and whose brain cells respond more readily to stimuli
applied through physical sensation.
In a paper read before the Medical Society of the
State of New York upon craniotomy in idiocy, in Jan-
uary, 1895, Dr. Charles L. Dana attributes the bene-
fits derived from operations upon the skull for this
condition as due chiefly to what he terms "Surgico-
pedagogic influences." My own experience has sub-
stantiated this view with reference to weak-minded
and degenerate criminals. My attention was first
called to this in observing that in certain cases where
criminals had been severely handled in fights, and
where the shock was considerable, and especially when
associated with extensive scalp wounds, that these men
usually became more tractable afterward and evinced
marked changes in many ways during the remainder
of their incarceration.
In several of these cases there was an almost com
plete turn about in the disposition and psychic condi-
tion. This led me to investigate, and I found that
by freely cutting through the scalp down to the bone,
and raising the periosteum, still greater improvement
followed. I have now begun a series of operations
upon neurasthenics and weak-minded criminals.
April 1, of this year I operated upon a young man,
aged 22 years, serving a first term in State prison.
Operation for relief of neurasthenia and excessive
masturbation. Patient was extremely nervous, sleep-
less, despondent and apparently becoming demented.
The hair was closely shaven, and under antiseptic
precautions the operation was performed as follows:
Two horse-shoe incisions were made five inches in
length, one on the right and one on the left side of
head, one and one-half inches from the median line
at the apex of the cranial arch. The periosteum was
cut cleanly through, and separated from the bone for
a distance of about one inch all round the incision :
grooves were then cut in the bone, but no bone
removed; the wound was packed with iodoform
gauze and dressed ordinarily. The wounds were then
packed loosely until they healed by granulation. No
sutures were put in. The effects of this operation
were like magic, the young man improved in every
particular, slept well; appetite improved; figure became
erect, took on flesh rapidly ; circulation improved, and
his whole aspect was very much more vigorous.
The habit of masturbation was entirely relieved. I
show you photographs of the young man before, and
fifteen days after the operation. Prior to this I had
circumcised him, and used all other means at my dis-
posal to effect the cure of his habit with negative
results. (This operation is also beneficial in menin-
geal inflammations, and also with thickened and
adherent scalp areas.) This principle has for a long
time been recognized in isolated and incidental ways,
but never to my knowledge has it been understood
thoroughly or applied in any systematic manner.
Here is a wide field for study and experiment, and
I believe that much can be accomplished in the treat-
I
Before operation.
J. R.,
After operation.
Aoed 22.
ment of this class of criminals by the application of
some form of shock. I am contemplating the con-
struction of an electrical apparatus, which will pro-
duce the maximum amount of shock and physical
impression with a minimum risk of injury. Any
means by which powerful influences can be brought
to bear upon the subject will offer the best and most
favorable opportunity for improving the patients.
The treatment of the occasional criminal, and the
criminal of passion does not require special enumera-
tion.
The application of scientific principles of classifica-
tion and treatment of the criminal consideredfrom a
sociologic standpoint, is one fraught with difficulty and
we need not flatter ourselves that apparent good results
will come quickly or that the way is easy; the duty is
plain however and we must walk therein. It has ceased
to be a matter of choice and we must be equal to the
responsibilities which this new field of action enforces.
Already in the half century of its life, the science of
criminal anthropology has recorded brilliant achieve-
18%. 1
THE PHYSICIAN AND THE CRIMINAL.
795
meats in the accumulation of invaluable data and the
elucidation of many valuable truths. These achieve-
ments have come largely through the labor of medical
men: therefore the soundness and efficacy of this
relation of physician to the scientific treatment of the
criminal can not be doubted, nor that it falls properly
within the medical province, for if we interpret aright
the significance of the astonishing developments of
our time and note correctly the movement of modern
medical thought and action, we shall come quickly to
the conclusion that the field of medical work and prac-
tice is rapidly widening and that its mission can no
longer be so entirely restricted to the narrow limits of
the treatment and cure of disease, but more to its
diagnosis and prevention, and its future accomplish-
ments must comprehend much more that appertains
to the safety and welfare of the people. Through the
gateway of laboratory work in our own profession,
and the investigations of the correlative sciences, a
great Hood of light has come; old systems are breaking
up, relations are changing, new adjustments are in
order, the X rays alone is likely to revolutionize the
whole rationale of diagnostic, prognostic and oper-
ative procedure. He who shapes his course by the
experience of the past alone will soon find himself
deprived of the needful appreciation of an enlightened
public. The profession must take to itself larger
spheres of action, must extend its powers, must put
itself in harmony with new conditions; its relation
to society and the community at large must be better
understood. The physician is to become a mentor to
the people, and his efforts like those of his time must
look to the improvement of mankind, not in the con-
coction of monstrous formulas, or in the combination
of nauseous decoctions, but in his knowledge of the
causation and the exercise of his powers in the pre-
vention of disease and the general guardianship of
the home, the individual and the public, So far as
this function has been exercised it has accomplished
much good and has been of incalculable benefit to
society at large; in the protection of our shores from
pestilence, our municipalities from infectious diseases
and the securing of abundant opportunities of health-
ful living the labors of our profession have been
untiring, fruitful and reassuring.
The opening of this new field of criminal anthro-
pology and sociology, embracing the type study of
man. and the resolving of society into its respective
classes offers equal opportunity for the exercise of
high and noble powers.
It is only through the exercise of such a prerog-
ative that the physician can sustain the position in
which the evolutional processes of scientific progress
have allotted to him, and he will only rise equal to the
dignity of this requisition when he shall have assumed
the r6le of a competent student of the bio-psychic
principles and elements which enter into the different
types of criminal man, and society be enabled to pro-
tect itself against crime; a protection too long and
entirely entrusted to the offices of the penal code.
DISCUSSION ON PAPERS OP DRS. CORK AND RANSOM.
Dr. D. R. Brower — In Illinois, our State Society and our
various local societies have, during the past two or three years,
had this question before them on various occasions, and what
is true of the State of Illinois is true of many of the other
States. The question of crime is not a legal question ; it was
until twenty-five or thirty, or possibly forty years ago, a purely
legal question, and to day in its practical application it is a
purely legal question ; but in reality it is a medico-legal ques-
tion ; and, as a consequence of the utter failure of the law
and the church to stay this criminal procession, we have the
results, the vast, marvelous, overwhelming increase of crime.
The only thing that can possibly stay this great increase is for
the medical profession to Btep to the front and teach the intel-
ligent laity that the care of the criminal is as much a medical
as a legal question. There are some things that study of this
question has satisfied me as being established : 1, the increase
of crime ; 2, we state as the cause of this increase of crime a
vicious parentage, bad environment, alcoholism, a constant
increase in the urban population and last, though not least,
the unreasonable manner in which the laws are administered ;
.'i, that the habitual criminal is an abnormal man, which is
shown physically by asymmetry in cranial cerebral develop-
ment and in physiognomy, as well as by anomalies, in physical
sensibilities and in motor activites. One of these anomalies
does not make a criminal man, but in the habitual criminal
these abnormalities are present in a vastly greater amount than
in any other person in the community. There are psychic abnor-
malities manifested by a moral sensibility. This is most mani-
fest and almost universal ; not limited to the moral criminals,
but prevailing throughout the whole great class, leaving out
the few who are classified under the occasional and passionate
criminals. There is a lack of forethought with them ; they live
simply in to-day. And there is a low grade of intelligence, a
prodigious amount of vanity, and an emotional instability.
The practical part, upon which the laity must be intelligently
educated, is what to do with them — how to treat them. The
question is a medico-legal one, and the doctors must come to
the assistance of the church and the law. The social and bio-
logic condition of the person, and not the accident of crime,
should determine the degree and kind of punishment. As our
laws are adminstered to-day, if the theft is a trifling one, the pun-
ishment is but slight ; if the amount taken is a large sum, the
punishment is accordingly great. The reference is not to the
criminal, but to his crime, whereas the crime id a mere inci-
dent, as the theft was $5 because there was not 85,000 to steal.
The measures that are to counteract crime must be, not accord-
ing to the crime itself, but to the condition of the criminal.
In my studies of this question in the institutions of my own
State I found a woman who had been sentenced to our Bride-
well thirty times. She should have been sentenced but once,
and the county of Cook would have been saved the expense of
twenty-nine arrests, trials and imprisonments, while the com-
munity round about her would have been saved a great deal of
perplexity and considerable destruction of property. She had
upon her, as plainly marked as any habitual criminal ever had,
the physical and psychic stigmata of degeneration.
It is this unreasonable administration of our laws that has
probably more to do than anything else with this marked
increase in crime. I would like very much, if it is practicable,
to have attached to every court some person who is skilled in
criminal anthropology who can aid the court in determining
what the sentence shall be. The rule that has been adopted in
some of the courts of Illinois so far as the reformitory institu-
tions are concerned, has been that of indeterminate sentences,
and consider this is a much better plan. If the indeterminate
sentence should be applied to all criminals, and the investiga-
tion of the anthropologic condition of the criminal made in the
institution to which he is consigned, vastly more beneficial
results would follow than by his investigation during the trial.
It is by indeterminate sentences that I think the matter can
best be settled. The only trouble in the State of Illinois, so
far as the reformatories are concerned, is that the maximum
limit is not enough in every instance. In the next place a very
serious interference with the suppression of crime is placing
the pardoning power in the hands of the governor. It should
rather be placed in the hands of a commission skilled in the
subject of criminal anthropology.
796
PSYCHOLOGY OP NARCOTISM.
[October 10,
The plan of disposing of these criminals just before and dur-
ing the trial is a mistake. These supposed criminals are sent
to a common jail and the associations of that jail are vile, and
the man who has not yet been declared a criminal by the law
is there thrown into contact with confirmed criminals. This
is very wrong. There should be established in every commu-
nity detention places where there can be a separation and iso-
lation of these criminals awaiting trials ; and then, when the
sentence comes, there should be three classes of institutions
to which these people are consigned : A reform school for the
juveniles ; reformatories for the curables, and penitentiaries
for the incurables.
Some of our laity think that this medical disturbance in the
matter of crime is for the purpose of relieving criminals of the
penalties of crime. Such is not the case. First to protect the
community ; first to see to it that these criminals, once
arrested, should be kept in custody until they are cured ; that
is the most important point.
It is only through such societies as this, through medical men
and women, that the laity can be educated up to a proper appre-
ciation of this great question. We are going through now pre-
cisely what was gone through at the beginning of the century,
or a little before, in the matter of insanity, when that was
divorced from the custody of the church and the law.
We are to-day pupils in this work of reformation, and very
soon the same results will be accomplished with reference to
the care, treatment and the cure of these criminals— probably
not to the same extent, but similar results will follow as have
been seen in the care and the cure of insanity.
Dr. John Punton — There is no doubt that there is a great
lack on the part of both the medical and the legal professions
in failing to handle these cases properly. These changes
which are proposed, however, would mean an entire subversion
of the constitution of many of the States of the Union ; in
other words, the present status of the legal adjustments of
crime would be undermined and that is a very large matter
for the medical profession to undertake to do. I am in the
main in favor of the reforms outlined, and just in proportion
as we agitate this matter we are aiding not only the legal pro-
fession but also the community in which we live.
Dr. Campbell— That law and the church have failed to
repress crime is well known ; it is now proposed that we of the
medical profession shall take hold of it. The alarming increase
in crime is known to us. But I do not entertain any sanguine
anticipations of the doctors doing much more than the church
and the law have done, if so much. This great increase of
crime can not be attributed to the causes that have been
assigned to it, so far as I have heard here to-night. We have
always had bad education, syphilis, alcohol, bad inheritance
and bad environment. In my opinion this great increase of the
criminal class is owing to the advance of our civilization ; the
increase in the species ; the growing stress that has been
brought to bear upon the means of gaining a livelihood.
These forces are irresistible. They will continue, and crime as
the result of them will continue ; and if all these admirable
suggestions are carried out, I doubt if 5 per cent, of the crime
will be stopped.
Dr. Powell — I think the commission of experienced men
would be a very desirable thing to have.
Dr. Quinby — If we study the results of imprisonment, we
see the victim, instead of being benefited by punishment,
made worse by it. This is due to the method and management
of our criminal jurisprudence. A young man who was well
disposed, whose environments were correct, whose education
was proper, whose bringing up was right, but who became
involved through alcoholism, was thrown among the class of
hardened criminals when arrested, and from that hour, he was
kept there six months for some slight offense, he has become a
degenerate man. He told me that his barbarous treatment
during his confinement is what sent him downward. Now,
could that man have been arrested and treated somewhere
instead of being thrown into prison ; if we could have institu-
tions for treatment, not simply for imprisonment, the results
would be different.
These are all abnormal cases. They are sick, and how do we
treat them — as mentally and physically defective? No. Cruelly,
inhumanely, putting them with criminals, into the charge
oftentimes of men who are themselves brutes.
The criminal classes in this country are largely increasing,
and something must be done to stop this increase. The church
is not in a condition to do it, because these individuals are
sick people, defective physically and mentally, the power of
alcohol always having a tendency to destroy will power ; hence,
the physician is the proper man to give advice.
Dr. Bishop — We feel a little sensitive when the preacher and
the public blame us about things, and we are in the same
position exactly when we blame the church and the community.
We are part of the church, or should be, we are part of the
community, and as citizens we are responsible. There is a great
deal of hypersensitiveness on the part of our good friends who
believe that these criminals as a rule are defective. It seems to
me that very often they are liars.
I think a slight change in the law would be of advantage ;
on the basis of sentencing to prison for a determinate period,
and if at the end of that time they were not cured, and still
unfit for freedom, to keep them in prison for an indefinite
period until they showed that they were fit to be released.
It is an outrage to send men to prison and have them resort
to all sort of crime that it is possible to do inside those walls,
and then set them loose on the world at the end of the time for
which they were sentenced. The mistake is that they are not
made to feel that they can gain something by improving.
There is no question that men are morally deficient as they
are mentally and physically lacking, and the proper place to
treat them is in some school for development.
Dr. Corr — The question is how to prevent crime, how to
prevent the young person who starts out with a small degree
of tendency from cultivating that tendency and from becoming
a criminal. We must improve our society so that we do not
have any of that class born. Dr. Ransom has classified crime
very finely, but we want a classification which shall tell us how
to prevent it. Now, if it be true that the conduct of people is
guided and inhibited by the moral sense and that is a faculty
of the human mind that is capable of cultivation, I ask you to
formulate some plan by which this end can be accomplished.
THE PSYCHOLOGY OF NARCOTISM.
Read in the Section on Neurology and Medical Jurisprudence at the
Forty-seventh Annual Meeting of the American Medical
Association, at Atlanta. Ga.. May 5-8. 1896.
BY W. XAVIER SUDDUTH, A.M., M.D.
CHICAGO, ILL.
Nature intended that man should be a comfortable
animal and enjoy to the full the fruits of his labor.
Man has ordered otherwise, and as a consequence
in the receding days of the nineteenth century, when
art and intellect have reached their highest develop-
ment, we find man, born to be the favored creature of
nature, laboring under self-imposed burdens of society,
oftentimes heavier than he can bear. As a natural
consequence of his pernicious environment he is fre-
quently found seeking surcease from the pains of
existence in self-immolation, temporary intoxication
or suicide, the method adopted depending much upon
his belief in a future state and his relation thereto.
What are some of the steps that have operated to
bring about these deplorable conditions? They can
not be laid to natural causes because there has
1896.]
PSYCHOLOGY OF NARCOTISM.
797
never been a time in the history of civilization when
the actual Deeds of man were to be satisfied with as
little expenditure of vital force as at present. The
cause of the stress of the age must therefore lie looked
for, not in the physical, hut in the psychic domain
of man's nature, and it is to this phase 01 the question
that 1 desire to call your attention to-day.
In that degree that man is able to perform the
necessary duties of life by force of habit so does he
i the labor of existence. The hardest work man
has to Ao in this world is to think. Every psychosis
has its neurosis. New experiences or acts are success-
fully mastered only by the expenditure of thought.
The greater part of the absolutely necessary acts of
existence are performed by rote rather than by
thought Thought labor requires nerve action, just
as surely as locomotion incurs muscular activity; and
while it is true that there is a marked physical differ-
ence between mental and muscular action, yet physi-
ologically considered they both express a condition of
eataholisin that has to be met by metabolism. Ordin-
ary cell went is not necessarily painful. ( )n the other
hand, a certain degree of pleasurable exhileration
accompanies most necessary bodily functional activity.
When, however, exercise is carried beyond a certain
point, so as to 1 lecome forced, it soon becomes painful.
When weariness ensues as a consequence of functional
activity, pleasure ceases and pain begins. Pain is the
absence of pleasure according to our major premise
laid down in the opening sentences of this paper, and
if this be true, then its abolishment does not consist
in self-immolation, but in a readjustment of our rela-
tion to our environment or its more or less complete
reconstruction.
Pain and pleasure are not distinct physical condi-
tions, no matter how intimately they may appear to
be related, but mental states, and therefore require
careful consideration to differentiate them. Pleasure
and pain are often so closely connected that it is with
difficulty that they can be separated. Not only this
but the terminology used to express the two conditions
is inextricably confused. Many people are said to
"cry for joy.'' In fact, so narrow is the division line
between the two conditions that the scale turns upon
the mental state of the individual at the time of exper-
iencing any particular sensation, as to whether he
sutler pain or feel pleasure. The close relationship
between them is thus shown by a case in which the
one merges into other. Continuous stimulation that
at first gives pleasure, in time becomes painful. This
leads to the conclusion that only a certain amount of
pleasure is bearable by human nature, if furnished
without intermission. The system may be surfeited
by pleasure as well as borne down by pain. But what
is it that Buffers r Surely not the physical that alone
experiences wear. No! Pleasure and pain are not
conditions per se, but mental perceptions of sensa-
tions experienced at the time or revived from some
previous experience, through thought images brought
before the mind by association of ideas. Then again,
not only does pleasure easily merge into pain but the
very absence of pain, to him who has suffered, is a
pleasure. The fullest appreciation of the pleasures of
existence are to be had by comparison with painful
experiences happily passed. WThile many of our joys
and sorrows are the result of purely physical sensa-
tions, yet a considerable proportion of our pleasures
and pains are intimately associated with our emotions
and are distinctly dependent upon the peculiar physi-
cal condition in which the experience finds us. Many
of the acutest pains of existence are those of restriction.
Man longs to be free, to cast off the burdens of care,
for even a short space of time, to secure a respite from
the pains of existence — to lose himself; hence his
resort to the use of narcotics. Sad delusion ! The
greatest slave of all is he who seeks his freedom in
t hese deceptive agents. Nine out of ten narcomaniacs
will tell you the some story, when asked as to how the
habit was formed. "I took it to relieve pain," "to
drive dull care away," "to get a little rest," and thus
the chains of habit were forged.
Dr. Carpenter says, " that our nervous system
grows to the modes in which it has been exercised."
That is only another way of putting the fact that we
develop along the lines of least resistence, according
to the bent of our special inclinations, limited and
modified by our peculiar environment. Habits are
more easily formed in youth than later in life, by rea-
son of the fact that the organism is in the formative
stage and the inhibitive feature of the will is less
developed than it is later on. If a young man or
woman reaches the age of twenty without having
acquired any vicious habits of thought, action or appe-
tite, ten to one they will go through life free from
contamination. Nevertheless, physical states of weak-
ness later in life seem to unman the individual and
reestablish, to a greater or less extent, the conditions
prevailing in adolescence. Drugs that may be given
during the crisis of a disease with impunity, if con-
tinued during convalescence are apt to give rise to
drug habits, hence the necessity of discontinuing the
use of stimulants and narcotics during this stage of
the disease and depending upon a nutritious diet and
natural remedies to bridge over this critical period
when the will is weakened and the moral faculties
seem to be more or less clouded.
Narcomaniacs may, for convenience of study, be
divided into three classes:
1. Those who have acquired the habit through
hereditary tendencies, and who find in the use of nar-
cotics a physical pleasure.
2. Those who, though physically strong, yet are
led into the habit by social customs as the result of
environment.
3. Those who turn to narcotics for relief of the
pains of existence.
The psychologic bearing of the several classes is
essentially different when laboring under the spell of
the drug. Members of the first class have, in most
instances, the warning example of degenerate ances-
tors; yet so great is the demand of the system for
sedation that they brave the dangers and public
opinion with a brazen effrontery that is many times
astonishing. They have no desire to reform and their
course is continuously, progressively downward. With
them there is no shadow of turning. They are wholly
given over to evil ways and the sooner they end their
days the better for themselves and mankind at large.
The second class, considerably larger than the first,
much larger in some countries than others, suffers
mostly from the direct effect of the drug because
removed from the moral stigma under which other
classes labor. While its members are seriously handi-.
capped in the battle of life, yet they manage to pre--
serve a tolerable existence, unless the particular nar-
cotic used happens to be hasheesh or opium, and even
against the latter the natives of India seem to hold
a more or less charmed existence.
798
FEIGNED INSANITY.
[October 10,
It is to the third class, however, that I desire to
call special attention, because they are those who
dwell among us: Our fathers, mothers, brothers,
sisters and friends. Brought to their condition of
enslavement, many times by circumstances over which
they have no control, held accountable by an highly
intellectual and moral civilization, they suffer, not
only from the direct effect of the drug used, but from
the goadings of an outraged moral nature. The
members of this class, oftentimes forge their chains
through years of petty indulgence in the use of the
milder sedatives and narcotics. Their case then is
one of slow growth and needs to be studied from that
standpoint. A diseased condition of the will is estab-
lished, in which the individual finds himself unable
to stand out against what he knows to be sin against
the physical body. It was not always so; there were
times when, in the early history of the case, had he
had the right kind of treatment, he could have broken
the bonds of the growing habit with comparative
ease. These diseased conditions of the will form
most interesting psychologic studies and promise to
throw much light upon the rationale of treatment.
In the main, an entirely erroneous idea of the func-
tion of the will prevails. Most persons consider it as
a direct motor force only, confusing it with volition,
which is the act of the will, and thus overlook entirely
its inhibitive aspect. In one sense the will may be said
to be dual; but in any event it represents a state of
the mind, and is, according to James, " a memory of
past acts. " Its parents are desire and feeling and its
offspring are represented in such mental states as " I
wish, " " I will " and " I will not, " which latter is
many times synonymous with " I can not. "
In order that feeling and desire may become motor
impulses, they must be accompanied by a knowledge
of the attainability of the object desired, otherwise a
futile or even no effort is made to attain the object
desired. We thus observe the difference between " I
wish " and " I will " and note that faith is one of the
principal attributes of a strong will. The inhibitive
aspect of the will which enables its possessor to say
no is largely a matter of education. Uncivilized man
knows no master, save want, and when opportunity
for indulgence offers, gives full reign to his unhal-
lowed passions. The tendency of civilization is to
teach the control of the passions through the limita-
tions of environment. Man thus learns to inhibit his
desires and hold in check his feelings through the
inhibitory action of his will. He is thereby enabled
to contain himself within the bounds of decorum and
decency. It is by will power that man is an abstemi-
ous animal and when given over to indulgence he is
simply evidencing the atavistic principle which so
often crops out during the evolutionary process.
Civilization teaches man to " wish " and to " wait " for
many things in this life, upheld by the hope of their
fulfillment in some future existence, if not in this, and
also that by restraining his passions and appetite he
is serving his own best good.
Continued indulgence in the use of narcotics finally
creates an appetite. Like a bad debtor, they promise
much and pay little. The system continually cries
out for relief that comes not. This irresistible crav-
ing is intensified by moral or physical restraint and
the habitue is urged on by his vitiated appetite to
greater and greater indulgence when opportunity
offers. No feat is considered too dangerous to be
attempted to secure the coveted dram; no human tie
too sacred to prevent the fulfillment of his unhallowed
desire, even hope of future salvation is freely given
up for the cup that cheereth but to damn. The
intensity of the passion for narcotics when once the
habit has taken hold upon its victim, points only too
plainly to something essentially different from a mere
physical appetite. Hunger for food, even unto star-
vation, shows no comparison in its suffering to the
agony of the alcoholic inebriate or the opium fiend
when deprived of his wanted potion. Everything
points to a diseased mental state beyond the rjower of
any drug to reach it as an antidote. While drugs
play an important role as alteratives and tonics in the
treatment of inebriety yet there is not a " cure " in
existence, that has any efficacy, that does not base its
permanency upon the "suggestive" methods employed
in effecting the cure. While it is true that some
depend almost entirely upon " drug suggestion " yet
the cures that promise most in permanency of results
have incorporated in them a system of psycho-physics,
using the term medically, that is successful in pro-
portion as it is scientific and comprehensive.
Inebriety, in all its forms, is beyond question a
neurosis and permanency of cure depends upon estab-
lishing an absolutely altered mental state, together with
the maintenance of a healthy environment until such
time as the individual has fully regained possession
of his will, and developed sufficient moral stamina to
withstand the temptations of the open saloon and
social life.
100 State Street.
FEIGNED INSANITY; REPORT OF THREE
CASES.
Read In the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical Associa-
tion, at Atlanta, Gn.. May 5-8. I8M,
BY WILLIAM FRANCIS DREWRY, M.D.
FIRST ASSISTANT PHY8ICIAN CENTRAL STATE HOSPITAL, ETC.
PETERSBURG, VA.
The simulation of insanity is not an innovation
peculiar to modem day schemers, though it is now
frequently resorted to by designing criminals.
In the sacred writings is recorded that the Shep-
herd King of Israel "changed his behavior and
feigned himself mad and scrabbled on the doors of
the gate, and let his spittle fall down upon his beard,"
because he was " sore afraid of the king of Gath."
In order to escape the Trojan war, Ulysses feigned
insanity by plowing the sea-shore and sowing salt
instead of corn. And Lucius Junius Brutus, it is said,
played the imbecile for a purpose.
To detect simulation and to establish the requisite
proof of it, have at all times been matters of more or
less difficulty. Casper met with many cases of the
sort and appreciated the difficulties which they pre-
sented. Says Hammond: " No one, no matter how
skillful an alienist he may be, is beyond the point of
being imposed upon for a short time by persons
assuming to have certain forms of mental derange-
ment." Snell remarks that if a simulator preserves a
complete passiveness and an obstinate silence, it is
not impossible that insanity may be so perfectly sim-
ulated that detection may not be accomplished. Con-
oily Norman regards the question of simulation of
insanity as " one of the most difficult with which alien-
ists have to deal, one requiring much experience, acu-
men and sagacity, if a satisfactory decision is to be
arrived at."
1896. J
FEIGNED INSANITY.
' 799
In his work on " Sanity and Insanity," Mercier says:
•■ There is no form of insanity that may not be simu-
lated by a oase of drunkenness; and when it is not
known, from other sources of information, that these
manifestations are due to drink, no expert in the
world, however skillful, could distinguish between the
insanity that is due to alcoholic poisoning, and the
insanity that is due to other causes."
Tardien and others think, however, that nothing is
BOTO difficult to counterfeit than mental disease and
that the attempt to deceive may be easily discovered
bj a oareful observer. Conolly asserts that he can
•• hardly imagine a ease which would be proof against
an efficient system of observation."
Winn we remember that, besides the fact .that
scores of criminals resort to the insanity dodge to
escape merited punishment, the truly insane some-
times simulate insanity, that simulation itself may be
an indication of mental alienation, and that occasion-
ally there is a tendency of feigned insanity after long
duration to become real insanity, the question of
accurate diagnosis may not always be unattended with
uncertainty and embarrassment. To an experienced
alienist there will of course seldom be any great dif-
ficulty in arriving at a correct conclusion, but to one
with more or less limited knowledge of the various
manifestations of mental diseases, a clever impostor,
with the faculty of imitation wed developed, would
appear somewhat in the nature of a psychic problem.
At all events, before giving a positive answer to so
delicate and important a question as whether one is
insane and therefore entitled to all possible humane
consideration, or sane, and consequently responsible
for his illegal acts, a physician should study method-
ically and scientifically the suspected case, keeping his
conscience pure and undefiled under all circumstances.
" His opinion." says an eminent authority, "should be
founded upon the conception of pure knowledge,
based upon observation and induction."
The question of disease — that and nothing more —
is the one for the physician to determine. Is the
person whose legal or testamentary responsibility is
in doubt, insane — is his mind affected by disease?
That is the problem the solution of which devolves
upon the physician. Says Bucknill: "The element
of disease in abnormal conditions of mind is the touch-
stone of irresponsibility and the detection of its exist-
ence or non-existence is the peculiar and oftentimes
the difficult task of the psychologist."
So. view t lie matter in any way you will, it can be
only a question of diagnosis.
Case 1. — In February, 1895, Isaiah P. was indicted
on the charge of house-breaking and larceny. While
in jail awaiting his trial in the hustings court of a
Virginia city, he suddenly began acting so strangely
that doubt was entertained regarding his mental con-
dition. Upon being arraigned in court his behavior
was so utterly at variance with that of an ordinary
sane man, he was remanded to jail and the trial of his
case postponed, so that his mental condition might be
investigated.
The writer was appointed by the judge to ascertain
whether or not the prisoner was insane. Whereupon
I visited him several times, dealt with him not in the
rOle of a secret detective, but in that of an impartial
physician, and as such proceeded systematically to
inform myself as fully as possible of his history and
symptoms.
History and heredity. — Isaiah was born in 1857, of
were
negro parentage. There was nothing of special interest
connected with his early life. From childhood he
was a bad, indolent fellow. Only two of his family
were ever afflicted with any form of neurosis or of
psychosis. His mother, at 05, was sent to an asylum
in a state of senile dementia. A younger sister died
of phthisis pulmonalis, complicated with melancholia,
while in a hospital.
During a spree some ten years ago (1886. I think),
Isaiah received a blow on the right side of his head
which produced a depressed fracture, but under care-
ful surgical treatment he made a complete recovery,
the only visible result remaining being a slight depres-
sion in the cranium. On more than one occasion he
was suspected of larceny, and finally, in 1888, was
convicted and sentenced to five years in the State
penitentiary.
It was claimed by his family that he had had, since
the blow on the head, several epileptic fits and been
at times " curious in his ways." But in the absence
of corroborative evidence these statements
accepted with a degree of reserve.
Appearance and symptoms. — A careful physical
examination revealed nothing of special pathologic
import. His bodily condition was about normal.
He came into my presence with an air of exagger-
ated excitement, moved about restlessly, took no notice
of his surroundings, looked wild and uneasy, talked
incessantly and foolishly. The almost exclusive sub-
ject of his foolish, incoherent gibberish was "locusts."
He talked about locusts most of the time, but when
questioned he gave answers foreign to the subject of
his apparent or assumed delusion, saying he did not
understand what I meant. All questions were an-
swered very slowly and hesitatingly. When I told
him my business his incoherence and restlessness
became intensified. When unobserved he became
quiet and composed.
Odd sensations in his head were frequently com-
plained of. He would put his hand to his head and
say something was " scrambling about in here."
Memory and intelligence, to all appearances, were
absolutely lost. Apparently he recalled nothing that
had ever happened, nor did he remember any person or
place he had ever seen. He could not or would not
distinguish one piece of money from another, nor tell
a man from a woman.
To every question he gave a negative or an absurd
reply. For instance :
Question. Where were you born? Ans. Caught
ninety-nine locusts to-day.
Ques. How do you feel to-day? Ans. Eat locusts
with butter.
Ques. Let me see your tongue. Ans. Holds up
his foot.
Ques. Did you sleep well last night? Ans. Tell
him all right. Here they come.
Ques. Tell me about the locusts. Ans. Had
bread and shucks for dinner.
Ques. But what of the locusts? Ans. I "don't
understand you.
Ques. How long has your mind been affected this
way? Ans. Some say 49 years; I say 100.
Ques. Have you heard from home lately ? Ans.
Fell in river last night. The locusts are rolling down
the mountains. Let them roll.
He slept well several hours every night, and fre-
quently in day time after he had become very tin. d
from constant exertion and excitement.
800
FEIGNED INSANITY.
[October 10,
I took occasion to remark in an undertone to the
jailor, that if the patient were to sing, become noisy at
night, destructive to clothing, filthy in his habits,
devoid of the sense of pain, my belief in his insanity
would be confirmed. A few days later Isaiah had be-
come so noisy and filthy at night that he had to be
isolated. He had tried to be wakeful, but, negro-like,
he soon fell asleep. His clothes were torn, shoes
thrown away, coat reversed, etc. I thrust a needle
into his flesh at various points, without making any
perceptible impression. Said he did not feel any
pain at all. A few minutes later, when a needle was
suddenly stuck into his back, he forgot to be insensi-
ble to pain and consequently jumped some distance.
My notes show many and various evidences of
Isaiah's clumsy effort to " play crazy," but the above
is quite sufficient to prove beyond any doubt, simu-
lation. I had no trouble in detecting the fraud.
For two months, in fact, until the day he was taken
to the penitentiary to serve out a twenty-three years'
sentence, he continued his efforts to deceive. Finally,
however, he acknowledged the attempted fraud.
In my statement to the court and jury I gave, in
substance, the following as the grounds of my opinion:
1. There was no prodromal stage of indisposition,
malaise or depression preceding the sudden outbreak.
The " attack" occurred in the midst of normal health.
He had few symptoms of any form of insanity that
might begin somewhat suddenly, viz. : transitory
mania, epileptic mania, confusional insanity, acute
hallucinatory insanity, alcoholic mania, none of which
it is possible to counterfeit. Then, the fixedness of
the form of delusion he tried to imitate would exclude
any of the above types of insanity.
2. Sudden development of a fixed delusion regard-
ing one particular subject is not consistent with the
clinical history of any known form of insanity; for
paranoia, monomania or delusional insanity, is of slow
and gradual development and unattended with any
special excitement, loss of intelligence, etc.
3. If he were trying to appear a paranoiac or mono-
maniac, he overlooked many essential points; for in-
stance, when questioned regarding his delusion, he
invariably gave an answer entirely foreign to the sub-
ject; and the peculiarity of expression which so
strongly marks that class of cases, was entirely want-
ing; and, furthermore, there was no excitement or
irritability of temper when contradicted.
4. Loss of memory, reason and intelligence would
occur in dementia, but the quickness with which he
carried out my suggestions regarding the " lacking
symptoms" of insanity, to say nothing about his ap-
pearance and general shrewdness, would preclude any
suspicion of mental decay.
5. Contrary to what is observed in acure mania and
other forms of insanity, there was no sign of insomnia.
The more intense his restlessness, the more profound
the sleep which followed.
6. The hesitancy, extravagance and silliness with
which he replied to simple questions; the absurd, dis-
ordered ideas which flowed slowly and thoughtfully
would not be exhibited in the really insane, whose
ideas form and flow rapidly, disconnectedly and are
not devoid of sense.
7. There were no physical symptoms upon which to
base a diagnosis of either functional or organic dis-
ease of the brain. The injury to the head had left no
perceptible ill result, motor, sensory or mental.
8. The insanity of his mother being a psychosis of
old age, could have but little effect, if any, upon the
offspring of her early life. But the fact that she was
insane and that she had an insane and phthisical
child might be considered, in connection with the
possible effects of the blow on the head, sufficient
grounds upon which a neurotic diathesis or nervous
instability might be based. It is possible that in this
case the head injury might have caused some moral
deficiency.
9. The order of development and the assumed symp-
toms failed to conform to the complete clinical pic-
ture of any recognized type of mental disease.
10. The motive for feigning was not over-looked,
though that was of secondary importance when com-
pared with the history and symptoms of the case.
Case 2. — Another instance of a criminal trying to
escape the stern edict of the law by pretending to be
insane, has lately come under my personal observa-
tion. In this case, however, the ultimate purpose of
the malingerer was accomplished.
Isaac H., a negro youth, had served a few months
of an eighteen year sentence in the State prison, for
murder. He assumed the role of a madman, and by
taking advantage of the lax and crude method of
adjudging one insane in Virginia, he succeeded in
gaining admission to the insane asylum where no
special arrangements are provided for the custody of
insane criminals. Every possible precaution was exer-
cised to prevent his escape; yet Isaac, after a short,
sojourn, very ingeniously gained his liberty and has
never since been heard of. We had diagnosed the
case correctly and were contemplating returning the
prisoner to his legitimate abode. I have not time
here to make an analysis of the case. Suffice it to say,
he so far over-acted the part, and behaved so differ-
ently from any other case of acute mania — the form
of insanity he was trying to counterfeit — the decep-
tion was too flagrant.
The history of the case, the clumsy, over-acted
symptoms, the motive, were all carefully studied, and
by a process of elimination no type of insanity was
left to fit his case. In the words of the distinguished
Dr. Chapin, of Philadelphia : '; The method of arriv-
ing at a conclusion is, bring together all the features
in the history and manifestations of the case and then
decide whether the case corresponds to a type of
insanity, which in all of its features could not be sim-
ulated except by a trained alienist. In this way a
mistake will rarely be made."
Case 3. — Some years ago there was admitted into
the Central Hospital a young colored girl, of intelli-
gence above the average of her race, and with a phy-
sical formation well-nigh perfect. Her case had been
diagnosed " epileptic insanity."
It was some time before I had an opportunity of
seeing her "in a fit." From the post- epileptic condi-
tion I had serious doubt about the genuineness of the
epilepsy. Eventually I saw her repeatedly in her "ter-
rible attacks," as her family had designated the
seizures.
She would cry out suddenly, then fall, snap her
jaws together, make a noise like the bark of a dog,
foam at the mouth and act most maniacally, etc. Then
she would pass into a convulsive state, jerk violently,
tear off all her clothes, assume the opisthotonos posi-
tion, grind her teeth, strike and snap at everything in
reach, and finally pass into a quiet sleep. These vio-
lent attacks would continue sometimes for an hour or
two, after which the patient would become quiet and
1896.]
STRYCHNIN IN PULMONARY CONSUMPTION.
801
composed, hor only complaint being that she felt sore.
Saul she knew nothing of the attacks, when theyoame
on or how they affected her, but expressed great mor-
tification on account of her affliction.
I noticed that the fall was rather guarded, that she
B6V6T bit her tongue or hurt herself in any way, that
the sphincters were never relaxed, that the pupils
were in every way normal, the iris not • insensible to
light. It was evident that sensory perception existed.
She became bathed in hot perspiration, and seemed to
be well nigh exhausted.
The assumed tonic and clonic convulsions were by
no means like those seen in real epilepsy. The post-
epileptic condition she made no attempt to imitate.
The girl was carefully nursed for some time, but
after watching her curious maneuvers a few times, I
told her that she was feigning and that the next attack
she had I should put her in a room and pay no atten-
tion to her whatever. My threat was promptly carried
into execution, and the etl'eet was all that could have
been desired.
She was soon sent home, got married, though has
never had any children, and has ever since remained
free from that "epileptic insanity" which she palmed
ofl so successfully on some of her friends for the sole
purpose, as far as I could discern, of arousing sym-
pathy. There was, however, doubtless some hysteria
in her case.
That there is no established rule or test by which
feigned insanity may be detected, but that each case
must be decided upon according to the history and
symptoms presented, can not be well denied. Alien-
ists everywhere, will bear me out in these assertions.
The individual whose sanity or insanity is being
questioned should constitute the chief object of the
investigation.
Whenever there is doubt about the mental condi-
tion of one charged with crime, it would be well, for
the court to select a committee of competent alienists
to investigate the case and report in writing the result
of their examinations and deliberations. This need
not preclude a cross-examination.
In Russia and elsewhere methods similar to this
prevail. In some of the countries there is, I believe,
a regular court physician who decides all doubtful
medical cases. It has been advocated in some quar-
ters of this country that there be appointed State ex-
perts in insanity to act in all cases where an element
of uncertainty exists.
But the best plan, probably, would be to transfer
the suspect to an insane asylum and keep him there,
under proper safe-guard, for a specified time, in order
that the attending physicians may determine the
question of real or counterfeited insanity.
For the reason that the position often taken by law-
yers is so entirely at variance with the true conception
of the disease — insanity — that medical witnesses, who
have no special knowledge of insanity, are often called
upon to give expert testimony, that physicians are
sometimes utilized by shrewd counsel for partisan or
for sinister purposes, that juries composed entirely of
laymen are not competent to try a case which involves
a question of mental alienation — brain disease — and
finally, chiefly that the ends of justice and mercy
are sometimes thwarted, our system of medical juris-
prudence of insanity is in need of revision.
The increase in the membership during the month of Sep-
tember was very sarisfactory. Let the good work go on !
THE ACTION OF STRYCHNIN IN PULMO-
NARY CONSUMPTION IN RELATION
TO THE NEUROTIC ORIGIN
OF THIS DISEASE.
Read in the Section on Neurology mid Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical Associa-
tion, held at Atlanta. Ga.. May 5-8, 1896.
BY THOMAS J. MAYS, A.M., M.D.
PROFESSOR OK DISEASES OK THE CHK8T IN THE PHILADELPHIA POLYCLINIC,
1ND VISITING PHYSICIAN TO THE RUSH HOSPITAL FOR CONSUMP-
TION IN PHILADELPHIA.
Freedom of thought is the foundation of all prog-
ress; and while this law develops a diversity of opin-
ion in practical therapeutics so great as to give rise to
the belief that no two physicians treat the same dis-
ease in the same way, it is nevertheless true that in
the struggle to relieve and cure disease we consciously
or unconsciously seek and follow methods which
finally lead to adoption of the same prinicples if not
of the same details of treatment. This unanimity in
practice is sometimes reached through certain etio-
logic and pathologic convictions which we hold of
disease; or, as is more often the case, we are driven to
it by the power which comes from witnessing the
successful effects of well directed medication either
in the hands of others or our own, and in spite of any
theory we may possess in regard to the origin or
mechanism of disease.
For a number of years I have said and written
much in favor of the neurotic origin of pulmonary
consumption, and while this theory may not be per-
fect in all its details, I believe that it gives us a more
rational explanation of the causes and nature of this
disease than any other. Not only do I feel convinced
of this, but my experience assures me that the thera-
peutic measures which are directly addressed to the
nervous system are the most effective in the relief and
cure of this disease. Led • by these considerations I
have employed a number of neurotic agents in the
treatment of this disease; the principal one is strych-
nin, to which I shall now devote a few remarks.
Of all the drugs in the materia medica there is none
that compares favorably with the action of strychnin
in the treatment of pulmonary consumption. As is
well known this agent has an elective affinity for the
whole nervous system, but over and above this it pos-
sesses a special influence on the nerves which preside
over the function of respiration. Its action is
reputed to be wholly devoted to the motor nervous
system, but there is reason for believing that it also
affects the peripheral sensory nerves. In small doses
it stimulates, in medium doses it tetanizes, and in
large doses it paralyzes the nervous system. The
dose is a relative or a movable quantity however, for
that which produces tetanus or paralysis at one time
may act as a stimulus at another.
flow, then, does strychnin act in pulmonary con-
sumption? It is taken for granted that the lung dis-
ease is merely a superficial manifestation of disorder
of the pulmonary nerve supply. Therefore the
strychnin primarily raises the tone of the nervous
system as a whole, and of the respiratory nerves in
particular. In this way it not only increases the
resistance of the lung to disease, but it aids digestion,
assimilation and blood-building. Let us say that the
tone of the nervous system is depressed. By employ-
ing strychnin we can do this, but must be careful to
avoid the danger point, yet at the same time this
point must be approached as closely as is consistent
with the safety of the patient. The best way to bring
802
STRYCHNIN IN PULMONAEY CONSUMPTION.
[October 10,
about this object is to begin with a moderately small
dose of the drug, 1-30 grain four times a day, give this
for one week, then increase it to 1-24 grain for another
week, during the next give 1-20 grain, the following
week raise the dose to about 1-16 grain, and so on,
making a slight increase every week until you observe
nervousness, restlessness or twitching of the muscles —
the signs of the beginning of strychnin intoxication.
In most cases these symptoms do not develop until
1-12 or 4 grain or even a larger dose is reached. It
must be understood that the drug is to be given in
these doses four or even five times a day. The object
is to impress the nervous system with the full stimu-
lant effect of this drug. The sooner this end is
attained the better will it be for the patient. For
this reason you begin with small doses and work
upward as rapidly as you can with safety. After the
desired point has been reached the question arises
whether it is better to continue the largest dose or to
resume the original. I think it best not to vary from
this line during the remainder of the treatment, for
you do not wish to lose what has been accomplished.
Keep the strychnin treatment up to the highest level
of safety, but shun the point where its stimulus
extends into the region of tetanus and of paralysis.
It is best, however, to reduce the dose somewhat at
this point. If, for example, it is found that ^ grain
is a maximum dose reduce to 1-16 grain, gradually
increase the dose again until J grain is reached, and
then return to 1-16 or 1-12 grain. After you have
increased and decreased the dose several times you
will probably find that ^ grain no longer produces
any dangerous symptoms, and that you now can give
as much as 1-6 grain. When administered in this
way the drug may be given for an indefinite period to
the majority of phthisical patients.
The remedial effects of the drug show themselves
in various ways. The nervousness, sleeplessness and
pain in the chest will be ameliorated, and perhaps
entirely disappear; the cough, expectoration and dys-
pnea will diminish; vomiting will abate; the appe-
tite improves; the patient gains in flesh and color;
the weak and rapid acting of the heart will become
slower and stronger: the red corpuscles increase in
number, and the patient becomes more hopeful and
brighter.
Of all the drugs in our possession strychnin makes
the most profound impression on the nervous system,
and in my opinion yields a larger measure of benefit
in the treatment of pulmonary consumption than can
be derived from any other single agent. In connec-
tion with it I employ well regulated rest, good food,
quinin, phenacetin, hypophosphites, electricity, cod
liver oil, etc.
I will not weary you by relating any examples from
my experience in confirmation of what I have said,1
but will quote in part a "case of phthisis apparently
cured" which was reported by Dr. William Pepper in
the December (1895) number of The University
Medical Magazine: Female, aged 21, with a decided
phthisical family history, began to emaciate rapidly
in March, 1893. In less than a month she was bed-
ridden and weighed 100 pounds. She had high fever,
night sweats, anorexia, vomiting, copious expectora-
tion and all the physical signs of pulmonary disinte-
gration. She received an egg albumin diet and the
medicinal treatment consisted of 1-100 grain of
l Also see "The Strychnin Treatment of Pulmonary Consumption."
— American Medico-Surgical Bulletin, May 15, 1894.
strychnin nitrate with 1-1000 grain of atropin sul-
phate every two hours hypodermatically; and 1-50
grain of strychnin nitrate with 1-12 grain of the
double chlorid of gold and sodium and \ grain of a
vegetable digestive every two hours by the mouth.
After a few days the amount of gold and sodium was
increased to J grain every two hours. At first she
showed signs of strychnin intoxication, and the
amount was reduced, but she soon resumed the original
dose, and after the first two weeks bore the drug well,
although always just inside the border line of its toxic
action. During April she improved decidedly, and
during May the improvement was also very rapid.
By the latter part of this month she weighed 125
pounds. The abnormal physical signs and the tuber-
cle bacilli disappeared and in September she weighed
132 pounds, and was in perfect health. In August,
1895, she had a slight attack of pneumonia, after
which all the symptoms she had two years previously,
recurred, and her weight fell to 114 pounds. She was
placed on her former treatment, and made a rapid
recovery. On November 1 she again weighed 124
pounds, her cough and expectoration had almost dis-
appeared. No tubercle bacilli have been found since
the previous October.
Dr. Pepper, in summing up the case says, that
among its noteworthy points are the absence from the
treatment of all cough medication and antiseptics, and
the large doses of strychnin and the double chlorid of
gold and sodium with which the system was kept lit-
erally saturated.
There can be no doubt that this was an apparently
hopeless case of phthisis from its very outset, and
great credit attaches to the distinguished prescriber
for guiding it to such a successful termination. The
question arises as to which of the agents played the
most prominent role in bringing about this issue.
From my own experience with the drugs which were
employed I believe that the strychnin is chiefly
responsible for this, although in forming a correct
estimate we must not lose sight of the value of the
nutritious food and the physical rest.
When we take into consideration that insanity,
idiocy, hysteria, chorea, epilepsy, asthma and all
forms of nervous disorder are prone to develop into
pulmonary phthisis; that the former diseases are fre-
quently converted into the latter through heredity;
that all poisons like those of alcohol, syphilis, lead,
mercury, influenza, whooping cough, etc., have the
power of engendering nervous disease and pulmonary
consumption, and as a matter of fact the former are
often followed by the latter disease; and that the
markedly beneficial action of strychnin in this disease
comes exclusively through the nervous system, it
does not require a very great stretch of the imagina-
tion to perceive that the neurotic element plays a
leading part in the etiology of pulmonary con-
sumption.
Perchlorid of Iroo in Treatment of Ingrowing Nail. -Reghi's
method is being extensively quoted, as he has been very suc-
cessful with it. After soaking the foot until the scab is loos-
ened and the pus washed off, a piece of cotton dipped in a 50
per cent, solution of perchlorid of iron is inserted in the un-
gueo-phalangeal groove, and the toe lightly wrapped up. This
is repeated twice a day, the blackish scab that forms removed
each time. The patient remains in bed a couple of days, and
the cure is complete in twenty, although a small piece of cotton
should be worn between the nail and the flesh for some time. —
Bulletin MM., No. 58.
18%.]
FUNCTIONAL DYSPEPSIA OF CHILDREN.
803
FUNCTIONAL DYSPEPSIA OF CHILDREN
WITH ILLUSTRATIVE CASES.
Read tn the Section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association,
held at Atlanta. Ua.. Mav 6* 180t>.
BY J. M. G. CARTER, M.D., Sc.D., Ph.D.
lor oi Preveuttve and Clinical Medicine in the College of Physi-
cians and Burgeon) of Chicago. Fellow of the American
Aci.demv of Medicine, etc.
WAUKEGAK. ILL.
The term dyspepsia is so frequently used by writers
as a synonym for indigestion that one needs to
explain the meaning he attaches to the word. In
this paper it is to be understood as referring to the
condition which permits or encourages acute attacks
of deranged digestion or unnatural distress in the
stomaoh oi bowels from the presence or absence of
normal food or its products. The acute attacks of
interference with digestion are here termed indiges-
tion. Frequent attacks of indigestion may occur in
the course of a ease of dyspepsia.
Functional dyspepsia includes all cases which are
not due to some organic lesion of the stomach.
Many cases of gastritis in children are sequela; of
indigestion and must be carefully differentiated from
functional dyspepsia. But cases resulting from unde-
veloped stomachs properly belong in this class.
From these limitations and explanations it may be
seen that we include under the term functional dys-
pepsia cases which result from some congenital
imperfection in structure, from improper food whether
of quantity or quality, from variations of temperature
especially increased heat, from the presence of bacteria
or their products, from reflexes caused by diseases in
other parts of the body, and from weakness following
or accompanying general illness.
t. I have lately had under my care a baby born be-
fore the termination of the eighth utero-gestation month. It
was small and though perfect in limb and feature, had little
vitality. Its digestive powers were so feeble that its mother's
milk caused it great distress. The mother's milk ceased in a
few days. A wet nurse was secured but was soon dismissed
because relief was not obtained and because the baby seemed
to dislike the milk. Cow's milk, diluted, raw or sterilized or
condensed, was borne but a short time without distress.
.Malted milk food (Horlick's) agreed for a short time, and then
a return was made to cow's milk. These experiments occu-
pied ten weeks. The milk was then predigested. with worse
results apparently than had been experienced before. The
bowels alternated between constipation and diarrhea. Vom-
iting was occasional ; usually the dejecta consisted of the food
unchanged. Fermentation and gaseous eructations were fre-
quent The child continued to grow and gain flesh. There
was no doubt in my mind that the cause of the disturbance in
this case was imperfect or under development of the stomach.
Such cases may persist through childhood and even to adult
life. When they do it is difficult to differentiate them from
another class of cases, which result from cicatrices following
ulcers of the stomach.
/.-I was called to see a baby seven or eight months
old, at the breast. It was emaciated, yet nursed feebly. Exam-
ination of the mother's milk showed it to be poor in quality
but abundant in quantity. The baby suffered pain from gas-
eous distension of stomach and bowels. Vomiting was frequent,
and occasionally diarrhea. Treatment made no special impres-
sion. Then the infant was given cow's milk, but with no bene-
ficial result, rather an increase of the dyspeptic symptoms.
Other changes were made without relief until condensed milk
i Swiss brand) was given. Very soon after this change the
digestive derangement subsided and the little patient began to
gain flesh. The recovery was complete. This case was undoubt-
edly one due to dietetic disturbance.
Case a. — The influence of heat is illustrated by the following
case : I was called in July to see a baby which was suffering
with diarrhea. The patient vomited occasionally, suffered
some distress in the stomach and bowels, took its mother's
milk ravenously ; diarrhea lienteric, except when charcoal,
lime water or pepsin were given, then the discharges were bet-
ter for a time. The child was ten months old. The weather
was very warm. At first directions were given to remove nearly
all clothing, bathe the patient frequently and keep it cool.
The treatment was followed by immediate improvement. The
weather became warmer, the patient worse. The use of cold
water and ice relieved the symptoms. The patient's tempera-
ture was not increased. There were no evidences of enteritis
or colitis. On cool, cloudy days the case was better, on warm
days worse. A change to cow's milk was followed by negative
results, no increase or diminution in symptoms. The patient
recovered when cool weather came.
( 'ase t. That the presence of bacteria may cause dyspepsia
in an infant is well illustrated by the following : Baby F. was
a year old, a bottle baby. It had attacks of stomach derange-
ment every few days or weeks, especially during the summer.
At such times it had colicky pains, distension of stomach and
bowels, vomiting of coagulated milk, with similar coagula
passing from the bowels, causing diarrhea. No fever. When
I was called the condition was such as just described, somewhat
aggravated by the warm weather. Everything about the child
was dirty, an innumerable host of flies trying to clean things
up. The bottle nipple was not clean, having many specks of
milk coagulii and fermented flakes upon it. The bottle was in
the same unhygienic condition. Similar specks were found in
the baby's mouth. Although a microscopic examination was
not made, I was satisfied that the case was one of functional
dyspepsia due to the bacteria and their products engendered in
what was evidently a favorable culture medium. The treat-
ment, which consisted in cleaning up the field for operation and
the use of antiseptics, confirmed the diagnosis by producing a
cure.
Case ,).- Cases of functional dyspepsia due to some neurosis
are rare in young children, but the following I think well illus-
trates a case due to reflex influence induced by disease in some
other part of the body. 1 was called to see a boy 5 years old who
had been suffering with poor appetite and deranged digestion for
some months. Gaseous eructations were frequent, but the stom-
ach was not permanently dilated nor very frequently distended by
gas. Food of almost any variety and kind, whether nitrogenous
or non-nitrogenous, caused more or less distress. Soon pyrosis
and other symptoms made eating dreaded. A few weeks after
the beginning he showed signs of failure of nutrition, began to
be anemic, lose flesh and grow weak. The bowels were regular.
No tenderness of the stomach was manifested and the temper-
ature was not above normal. About two months from the first
indications of disturbance I was called because constipation
had become troublesome and a tumor was discovered in the
lower part of the bowel. Examination revealed no organic
disease of the stomach, but did reveal a sarcoma of consider-
able size in the pelvic cavity, chiefly to the right of the median
line. The tumor, about 4 inches in diameter, pressed upon
the rectum and interfered with the normal evacuations of the
bowel. Perhaps eventually the fermentation and ptomains
occurring in the bowels caused by retained feces were prominent
factors of the gastric as well as intestinal disturbances. The
case passed rapidly to a fatal termination without further gastric
derangements than those due to reflex influences and the
poisoning caused by fecal ptomains.
Case 6'.— The last case I desire to mention was one who had
been prostrated for several weeks with typhoid fever. He was
8 years old and had been greatly weakened by the long sickness.
When the milk diet was no further insisted upon and a gradual
change was made to other food, gastric disturbances in the
way of eructations, distress, distension and heartburn were
frequent. These continued for three weeks. They were due
to the anemic and atonic condition of the stomach and should
certainly be considered functional disturbances. Dietetic care
and recovery of strength and health removed all dyspeptic
symptoms, so that after three weeks and since there has been
no evidence of gastric trouble.
Other cases of anemia and atonic conditions may be accom-
panied by functional dyspepsia, just as in adults.
This brief presentation of cases will help to impress
the writer's views of etiology and treatment of func-
tional dyspepsia. By far the greater number of cases
are due to improper food, the improper administration
of food or to reduced vitality An extended experi-
ence with the use of hydrochloric acid and pepsin will
convince one that the relative number of cases cured
by these remedies is small; in fact, the number bene-
fited will be disappointing. Still we can not rely
exclusively upon dietetic and tonic treatment. An
attempt to render the alimentary canal aseptic is
804
CHRONIC INFLAMMATION OF THE BLADDER.
[October 10,
paramount. The following are the chief indications
to be met in this condition: 1. Correct the food both
as to quantity and quality. 2. Try to render the
stomach and intestines aseptic. 3. Assist nature in
her effort to restore the natural functions and tone up
the system.
1. Too frequently the undeveloped state of the
salivary glands in the first few months of infancy is
forgotten and food, such as rice water and cereal
preparations, is given which can not be digested in
the stomach and in many cases at least is not com-
pletely digested in the intestines. A similar result
may obtain if given in too large quantities later in
life. Under such circumstances the undigested food
becomes a nidus for the growth of bacteria, fermen-
tations result, irritating gases and bacterial products
may cause diarrhea and at times constipation. A too
abundant proteid diet of eggs and meat may in a
similar manner and for the same cause result in putre-
factive decompositions and the gases formed likewise
produce constipation or diarrhea, even in older chil-
dren.
2. The rational treatment in these cases is, of course,
antiseptics. An effort should be made to correct or
remove the cause and give antiseptics. Antiseptics
can not be given in sufficient amounts to overcome
the condition unless an irritating diet be corrected,
especially is this true in nursing and bottle babies.
It is true also in older children. Salicylate of bis-
muth, salol, carbolic acid, charcoal and other antisep-
tics used in these conditions have given me excellent
results. I have treated diarrheas due to indigestion
in the same way with like results. In functional
dyspepsia, however, a habit of indigestion may be
established, as it were, and a tendency to certain
bacterial growths may become persistent. Here it is
necessary to persevere in an antiseptic course of
treatment. I have lately treated bacterial diarrhea of
a very aggravated type, in patients old enough to be
using a mixed diet, by the administration of a milk
diet and salol without other medication and with the
most satisfactory results. Salol may be given in doses
of one to two grains every two or three hours until
improvement occurs. Infants under one year yield
very readily to salicylate of bismuth. Where from
idiosyncrasy or other cause the salicylate is not well
borne, salol in one-half grain doses will frequently be
all that is needed. In many cases minute doses of
calomel act as an antiseptic and afford gratifying
relief. Cases of summer complaint preceded or ac-
companied by functional dyspepsia frequently yield
quickly to the antiseptic treatment. The same is true
of those dyspeptic cases following prostrating fevers,
neuroses and other forms of exhaustion in which there
is fermentation or putrefaction of food due to delayed
or weak digestion and the formation of irritating gases.
The dilatation of the stomach which so frequently
accompanies functional dyspepsia in children is
nearly always due to gaseous distention and is tem-
porary. The removal or diminution of the gas is a
step toward a cure. Where much distention exists
and antiseptic practice does not afford ready relief,
the stomach-tube or a soft catheter may be introduced
through the mouth or nose and the gas allowed to
escape. The general douching of the stomach seems
to me to be less valuable in children than in adults,
but sometimes it is useful to remove offending matters.
The douche is sometimes of value also in atonic cases
where the gastric walls are relaxed by over distention
or a
anemia
weakened condition of the general system,
etc.
3. Finally it is necessary in many instances to give
hydrochloric acid, pepsin, lactopeptin, peptenzyme,
papoid, diastase and similar preparations to help cor-
rect the deranged secretions and assist in digesting
the food. In addition to the administration of these
internal remedies which act chemically or by catalysis,
stomachics, the aromatic sulphuric acid, nitric or the
nitro-muriatic acid and other preparations to stimu-
late the secretions may be needed. An alcohol sponge
bath twice a day followed by inunction with cocoanut
or olive oil to which quinin may be added in suitable
cases, frequently aids materially in restoring the
patient to health and vigor. The use of malt prepa-
rations and other tonics is frequently demanded.
The anemia, neurasthenic or other conditions of
depressed vitality will guide in their administration.
THE TREATMENT OF CHRONIC INFLAM-
MATION OF THE BLADDER, WITH
REPORTS OF TWO CASES OF
CONGENITAL DIVERTICULA.
Read before the Colorado State Medical Society, June, 1896.
BY LEONARD FREEMAN, B.S., M.D.
PROFESSOR Of PRINCIPLES OF SDRGKEY AND SURGICAL PATHOLOGY GROSS
MEDICAL COLLEGE, SURGEON TO THK COUNTY HOSPITAL AND 8T.
ANTHONY'S HOSPITAL,
DENVER, COLO.
Chronic imflammation of the bladder is practically
always due to microorganisms, the one most often
encountered being the bacillus coli communis, which
exists normally in such abundance in the intestinal
canal. The gonococcus, the tubercle bacillus, the
typhoid bacillus, the various pyogenic bacteria, etc.,
are also frequently found. It should never be for-
gotten that it is not a calculus, an enlarged prostate,
a tumor, or a quantity of residual urine which is the
direct cause of an inflammation, but the bacteria
which have in some manner gained entrance to the
bladder in presence of these conditions. Even a
cancer does not produce inflammatory symptoms
until infection has taken place. I had recently under
my care an old gentleman with vesical carcinoma,
whose urine remained free from pus for a considerable
time after the growth began. It is possible for germs
to enter the bladder through the kidneys, the urethra,
and even through the blood, but in most cases cathet-
erization is responsible for simple infection. A vesi-
cal calculus may exist for years without a sign of
cystitis, provided no instrument has been introduced
into the bladder. I have seen a man with an enlarged
prostate whose bladder had been dilated, almost to
the umbilicus, with residual urine for over two years,
and yet the urine when removed was as clear as spring
water.
From a therapeutic standpoint, chronic inflamma-
tions may conveniently be grouped under three
heads: 1, inflammation in connection with the pres-
ence of a foreign- substance — calculus, tumor, piece of
catheter, etc. ; 2, inflammation in connection with the
presence of residual urine; 3, inflammation due to
specific infection, such as gonorrhea, tuberculosis,
syphilis, etc. Under the last heading may be placed
inflammations due to certain microorganisms other
than those of the diseases mentioned.
The first two groups are closely allied. It is not so
much because a foreign substance exists, or because
1896.]
CHRONIC INFLAMMATION OF THE BLADDER.
805
it injures the mucous membrane, that inflammation
ooonrs; but because the bladder is unable to clear
itself sufficiently of objectionable ingredients of the
urine, which remain collected about the substance.
In other words, it is to the residual urine that the
trouble is due. Nevertheless, the divisions given
above are retained for the sake of convenience.
1. Inflammation in connection with foreign sub-
stances.— It is self-evident that rational treatment
indicates removal of the offending substance, be it
stone, tumor or other material. Simple removal is
usually sufficient, provided no obstacle to complete
emptying of the bladder remain, such as atony, a
diverticulum, etc. 1 have observed a cose in which
a stone had existed in the bladder for nearly fifteen
years, where the marked inflammatory symptoms dis-
appeared within a few days after lithotomy had been
performed.
■_'. Inflammation in connection with residual urine. —
This is found in enlarged prostate, stricture of the
urethra, paralysis and paresis of the bladder, certain
diverticula, etc. In case of stricture, the enlargement
of the narrowed urethra is the essential feature of
treatment. The management of other forms is not so
simple, and often taxes the surgeon's resources to the
utmost.
(leneral treatment. It should be appreciated by all
that general treatment is of much less importance
than is usually supposed. The various balsams,
resins and other compounds, so often mentioned in
books and so widely advertised, often do some good,
but as curative agents they are sadly deficient. They
are. nevertheless, prescribed on every hand, frequently
to the exclusion of local measures. Local treatment
in chronic cystitis is the only reliable treatment.
We do not speak at present of "soothing the mucous
membrane" by internal remedies, but of "inhibiting
bacterial growth by means of antiseptics." Good may
be accomplished in this way, although much less than
is often imagined. Perhaps the most satisfactory
drug for the purpose is salol, given every few hours
in 6 grain doses.
The patient's bowels should be kept open, not only
because constipation leads to congestion of the vesi-
cal veins, but because there is no more efficient
method of removing poisonous substances from the
system than through the bowels. The necessity of
proper foods, tonics, cleanliness of the skin, etc., will
suggest itself. Plenty of milk at frequent intervals
does excellent service, both as a food and as a diluent
of the urine.
Local treatment. — The main indications are: 1,
disposal of residual urine; 2, washing out the bladder.
Residual urine. — This must be removed, no matter
how small the quantity. If the urethra will -easily
admit a catheter of sufficient size to thoroughly drain
off not only all traces of urine, but stringy pus and
clots of blood which may also be present, then the
regular use of a catheter will often be sufficient.
When the inflammation is obstinate or severe, a soft
catheter may at times be tied in and continuous drain-
age instituted. This method, which is not exten-
sively used in this country, gives excellent results,
even in cases of enlarged prostate. But if only a very
small or specially constructed instrument can be
employed, or if the patient can not be entrusted to
catheterize himself, or if the channel is irritable, or if
there are other reasons why the use of a catheter is
unsatisfactory, then more radical procedures become
necessary. At the present day the operative meas-
ures most frequently adopted are castration, resection
of the vasa detferentia and suprapubic cystotomy with
retention of a permanent opening. A sufficient num-
ber of cases have been reported for us to say with
considerable certainty that, in general, castration
furnishes the surest and safest means of combating
the evil effects of an hypertrophied prostate. Some
cases of inflammation, however, are so severe, and the
debilitated patient so much in need of immediate
relief, that suprapubic cystostomy should be done at
once, and thorough drainage of the bladder secured.
In all other cases castration is applicable, provided
the nature and consequences of the operation are fully
appreciated by the patient. Among those within the
age of sexual activity there will always be some who
naturally object to the removal of the testicles, no
matter how strongly the operation may be indicated.
For these the older operation of prostatectomy is indi-
cated, although it should not have the preference, on
account of its uncertainty and danger. For patients
who, while recognizing that their term of sexual
activity is past, still object to castration for various
reasons, resection of the vasa deferentia may be
done, although it offers at present a less certain pros-
pect of cure than removal of the testicles.
Washing out of the bladder. — Several points should
be borne in mind in this connection :
1. The bladder must not be over-distended, as this
may keep up a chronic inflammation which would
otherwise tend to subside. There is also reason to
suppose that septic material can in this way be forced
into the mouths of the ureters, thus leading to kidney
complications. No more than four or five ounces of
fluid should be employed, and less than this is often
preferable. A good-sized syringe of hard rubber,
which can be easily used with one hand, is safer and
better adapted to the purpose than a fountain syringe,
although the latter is in general use.
2. The prostatic urethra should be irrigated as well
as the bladder, especially in gonorrheal affections, as
it is often the seat of inflammation which may rein-
fect the adjacent viscus. The catheter should be
slowly inserted while the fluid is being injected until
the fluid no longer appears anteriorly at the meatus,
but passes through the deep urethra into the bladder,
the eye of the catheter being just beyond the con-
strictor muscle. When practicable, it is well to leave
considerable fluid in the bladder, which the patient is
instructed to pass after the catheter is removed, thus
irrigating the channel from behind forward. If the
bladder, however, is insufficient, and the solution not
a mild one, it is better to withdraw it entirely. In
obstinate cases of posterior urethritis it answers an
excellent purpose to occasionally inject a few drops
of concentrated solution of nitrate of silver (\ to 5
per cent.) with an Ultzmann's capillary injector.
3. A single, not a double, catheter should always be
used. The current from a double catheter selects a
short, easy channel for itself, and passes directly from
one eye of the instrument to the other without dis-
tending the folds of the mucosa and cleansing the
bladder as it should.
4. When the organ is not too sensitive, the fluid
should be injected with some force, so as to more
effectively wash the mucosa.
5. The catheter should be soft rubber or linen, as
large as can be used without undue discomfort, espe-
cially when thick pus and clots of blood are present,
806
CHRONIC INFLAMMATION OF THE BLADDER.
[October 10,
and it should not be forgotten that a catheter is just
as large as its eye and no larger.
6. Almost any antiseptic or astringent fluid will
give good results if properly employed. Personally,
I prefer the permanganate of potassium or the nitrate
of silver. The former is both an antiseptic and an
astringent, and its strength can be conveniently
judged by the depth of color of the solution. The
stains are quickly removed with oxalic acid. The
nitrate of silver is less easily handled, but sometimes
gives better results.
7. One daily irrigation is usually sufficient, although
two may be required. Care should be taken not to
carry the treatment too far and cause more harm than
good by undue interference.
8. It is generally more satisfactory to irrigate an
insufficient bladder with the patient standing, as the
viscus is more easily cleansed in this position.
In this connection I desire briefly to mention two
cases of congenital diverticula of the bladder. These
malformations are very rare and present many puzzling
features to the diagnostician. They are similar in
appearance to the diverticula whch occur in inflamed
bladders with hypertrophied trabeculse and obstruc-
tion to the outflow of urine. In congenital diverti-
cula, however, there is not necessarily any damming
back of the urine with distension, and there is little or
no tendency to progressive enlargement. At times
practically a double bladder exists, with a ureter
emptying into each division, but the results are clin-
ically the same — the retention of residual urine, and a
tendency to chronic inflammation and the formation
of calculi.
One case came under my charge a number of years
ago in the Cincinnati Hospital. He was a young man
of good physique, who had experienced no marked uri-
nary disturbance until he suffered an attack of gonor-
rheal cystitis. This proved to be extraordinarily obsti-
nate, and yielded to none of the usual forms of treatment.
There was little or no prostatic enlargement and no
urethral obstruction. It seemed almost inexplicable
to me at the time, that after the man had passed his
urine, a catheter would draw off an additional quan-
tity, and after some moving about of the instrument
in the bladder, still more would be obtained. The
patient shortly died with surgical kidney, and at the
autopsy four or five diverticula were found each
somewhat larger than a walnut. They diverged from
the posterior and inferior walls of the bladder, were
perfectly smooth within, and their openings were
about the size of the little finger.
The second case is a young man of 29, who has
recently been under my care. He is well built and
active botli physically and mentally. Up to the age
of about 14 nothing abnormal was observed in con-
nection with the urinary apparatus except that the
urine appeared to be unusally strong in odor. About
fifteen years ago it became necessary to pass a cathe-
ter, following an injury to the back with hematuria.
Cystitis together with pyuria developed, which per-
sisted for some years. After much and varied treat-
ment, it was finally cured by irrigation. The patient's
health remained good for several years, until, as a con-
sequence of an injury to the back, retention of urine
took place and a catheter was again passed. Cystitis
once more supervened in an aggravated form, and
continued for six or eight years, in spite of the most
strenuous efforts toward its subjugation. During this
period the gentleman was under the care of many of
the world's most eminent surgeons, including Agnew
and J. William White of Philadelphia, Sir Henry
Thompson of London, Czerny of Heidelberg, and
Gruyon of Paris. The presence of a diverticulum was
not suspected even after prolonged and careful examin-
ation with the cystoscope. I mention these names in
order to show that the diagnosis of a congenital diver-
ticulum of the bladder may be exceedingly difficult,
not to say well nigh impossible. When the patient
came under my charge he was in a pitiable condition.
He was forced to urinate, with pain and strangury,
about every twenty minutes, both night and day, and
it was necessary to frequently irrigate the bladder in
order to make life even tolerable. The urine was
loaded with blood and pus, and was offensive in the
extreme; there was, however, little fever. The pass-
age of a Thompson's " searcher " in the effort to find
a stone, stirred up a quantity of decomposed urine,
which called my attention to the possibility of the
existence of a diverticulum, but the idea was 2)artially
dismissed because of the amount of hemorrhage,
which was more consistent with the presence of a
tumor or of tuberculosis. A careful examination of
the urine by Dr. E. R. Axtell and myself failed to
reveal tubercle bacilli, so that the idea of tuberculosis
was given up. A suprapubic cystotomy was made for
purposes of drainage and exploration, especially as
some form of tumor was strongly suspected. An
opening large enough to admit the little finger was
found in the trigonum, to the left of the median line,
which communicated with a diverticulum the size of
a Messina orange, passing upward and backward along
the side of the sacrum to the left of the rectum. The
interior was smooth and nearly spherical in shape.
After the pouch had once been recognized it could
easily be felt by a finger in the rectum. It being
manifestly impossible to remove the diverticulum
through a suprapubic incision, it was decided to drain
the bladder until the cystitis had subsided and then
attempt to close the opening without recurrence of
inflammation. If this failed an attempt could be
made to remove the pouch through the ischio-rectal
fossa. The cystitis rapidly and completely subsided
as soon as thorough drainage was instituted, the
patient improving rapidly in weight and general con-
dition. An attempt to close the artificial urethra was
soon followed however by a reappearance of the inflam-
matory conditions, due probably to infection from the
prostatic urethra. Drainage was again procured and
the entire urethra and bladder subjected to frequent
irrigation with permanganate of potassium and nitrate
of silver. The next proceeding was to drain the blad-
der through a catheter tied in the urethra while per-
mitting the fistulous opening to close. This also
failed, as the posterior urethra proved to be too sen-
sitive to permit the catheter to remain more than a
few hours, despite all preparatory treatment. It was
decided to institute continuous drainage of the blad-
der through the supra-pubic opening, for a time at
least. This was accomplished by means of a soft
catheter, held by a truss-like arrangement, and empty-
ing into a rubber urinal secured to the thigh. The
apparatus, which proved to be very effective, was con-
structed by cutting a small, hollow rubber ball in
half, and passing the catheter through a slit in the
bottom of one of the hemispheres. The section of
the ball fit nicely into the large dimple surrounding
the orifice of the artificial urethra, and served to hold
the catheter securely in place. A hard-rubber plate
1896.]
DANGERS OF BICYCLING.
807
.secured around the waist and under the perineum by
rubber bands held the ball in position. The patient
has been wearing this apparatus in perfect comfort
for about three months, and finds that he is incon-
venienced scarcely at all by his condition, while his
health and energy have been completely restored.
An examination of these two cases presents some
interesting points: 1. Congenital diverticula can exist
for many years without their possessors being aware
of any abnormality. 2. Cystitis may not take place
until infection is caused by catheterization, gonor-
rhea, etc. 3. Cystitis in the presence of diverticula
may sometimes be cured without opening the bladder,
anil remain so indefinitely, provided reinfection is not
brought about. 4. Hemorrhage from chronic cystitis
may be so great as to strongly simulate hemorrhage
from a tumor. 5. Residual urine, without stricture
of the urethra, enlargement of the prostate, or paresis
of the bladder, should be suggestive of a diverticu-
lum. 6. Even in the best hands, the opening of a
diverticulum may be overlooked with the cystoscope.
Perhaps a reason for this is that the mucosa during life
is so congested and folded about the opening as to con-
ceal it. 7. In obscure vesical affections, with cystitis, it
is rational to open the bladder for purposes of explora-
tion and drainage, the preferable incision being the
suprapubic, as ottering the better opportunity for
removal of foreign bodies, if such be present.
DANGERS OF BICYCLING; WITH REPORT
OF A CASE OF ACUTE DILATA-
TION OF THE HEART.
BY WILLIAM C. KRAUSS, M.D.
I'ROFESaOR OF NKKVOIS DI8KA8B8, MEDICAL DEPARTMENT NIAGARA
I'NIVERSITY. BUFFALO. N. Y.
Ever since the great popularity which has attended
bicycling in this country, numerous articles have ap-
peared in the medical and lay press pointing out real
and imaginary dangers liable to beset those attracted
to this sport. These dangers have attended both
sexes, more particularly the female bicyclists, and
consisted in disturbances affecting the pelvic viscera.
No doubt over-indulgence in this pastime can and
will produce congestions and irritations of these or-
gans, perhaps displacements and even inflammations,
but such cases are comparatively rare.
From the moral point of view another danger has
been discovered by the Woman's Rescue League of
Washington : That the bicycle is nothing more or less
than the devil's advance agent, and through the
opportunities which it offers is causing an alarming
increase of immorality among women. The writer be-
lieves this to be true only in so far as it affects those
women upon whom the devil already has a mortgage,
and employs the wheel only as a subterfuge to fore-
close the claim. The wheel has been a great aid to
physicians in the treatment of neurasthenic, hysteric
and hypochondriac women, and the good it has done
to them and the pleasures derived from it by others
will more than counterbalance the harm which those
unable to ride think it has and may create. Pleasure
and health can be derived from bicycling only so long
as the laws of hygiene and common sense are heeded,
and their violation will be followed by disagreeable
consequences.
The male sex is predisposed to that ungaiidy and
unhuman distortion, the " camel's back," as a result
of fa alty posture and ambition for speed, and perhaps
fame. Not only is the spinal column strained and
distorted, but the thoracic and abdominal viscera are
subject to undue pressure, and hence to restricted
movements and imperfect physiologic action. No
sport is a healthy one which in its performance co-
erces the body into an unnatural position, and the
great popularity attained by rowing and base ball is
partly due to the comfort and pleasure which the nor-
mal position of the body insures.
Through long-continued pressure caused by long
rides and faulty fitting saddles, the male genito-urinary
tract is liable to damage, and this should therefore be
carefully guarded against. The dangers which do,
arise, however, from bicycling affect the beginners,
and scorchers mostly, who have not learned the secret
of the sport, namely, moderation.
After consent is obtained from the family physician
to ride, a properly geared wheel should be selected,
with an easy and comfortably fitting saddle, the han-
dle bar raised so as to give the body an erect and
graceful position, and this advice constantly borne in
mind, that the sport should be discontinued at the
first sign of fatigue. As the days go by this fatigue
will grow less and less, and the rider able to take
longer spins as the muscles become firmer and more
accustomed to this form of exercise. The whole sys-
tem undergoes a certain kind of training or physical
education, the heart and respiratory muscles accus-
toming themselves to the necessary strain just as do
the extensors of the thighs and the calf muscles.
Just as over-indulgence results in tiredness and lame-
ness of the leg muscles, so also are the heart and respi-
ratory muscles affected. The heart through increased
work put upon it by long, rapid spins is taxed to its
utmost, and when persevered in, serious damage to the
heart walls or heart valves may result. As Osier truth-
fully says: " Endurance in prolonged contests is meas-
ured by the capabilities of the heart and its essence
consists in being able to meet the continuous tendency
to overstep the limits of dilatation."
One form of heart trouble especially is attended
upon over-exertion and over-fatigue, namely, the acute
dilatation of the heart walls, due to over distension of
the muscle fibers. The cause of this dilatation is an
incomplete exhaustion of the ventricles, generally the
right, during systole, and an excessive engorgement
during diastole with possibly some defective nutritive
change in the muscle fibers. The symptoms arising
from this condition are subjective and objective and
are well illustrated in a case which recently came under
my observation.
James H. C, age 37 years ; height 5 feet 6 inches; weight
138 pounds ; married and has eight children. He had an attack
of rheumatism when 12 years of age, and typhoid fever when 29.
Has always been a hard-working man, employed on the railroad
sometimes ten to fourteen hours daily. About May 1, 1896, he
purchased a wheel and rode occasionally from his home to the
railroad yards, perhaps a distance of half a mile. On May 8,
1896, he accompanied a few friends on a spin into the country
and rode four miles in twenty-five minutes. On dismounting
he noticed a severe pain over the left side of the chest extend-
ing to the neck, also that he was completely "winded," and
the left side of the chest was throbbing violently. After only
a few minutes rest, urged by his friends, he remounted the
wheel and rode home, covering the distance in thirty minutes.
On reaching home he could scarcely breathe, was in profuse
perspiration, trembled all over and was obliged to go to bed.
Vomited during the night ; the following morning he found he
was still in the same condition and was unable to go to work,
and scarcely able to be on his feet. The least exertion caused
his left side to "thump" vigorously, while the vessels in the
neck throbbed so wildly as to make them perceptible. Patient
also noticed a feeling of weakness all over the body and a
808
THE VALUE OF VACCINATION.
[October 10,
stiffness of the knee joints, accompanied always with great
dyspnea.
After remaining idle for several weeks and not obtaining very
much relief, he consulted me on July 20, 1896, for " weakness
and trembling," thinking that he had some nervous disorder;
he stated that his sickness began on May 8, 1896; that he
worked the day previous and up to that day was in his usual
good health.
Status Prasens. — Face has an anxious, apprehensive expres-
sion ; eyes are glassy and facial muscles quivering. Pallor and
emaciation are pronounced. There is a slight tremor to the
head ; is not painful on percussion and has never had headache.
The examination of the eyes was made by Dr. R. H. Satterlee,
of Buffalo, N. Y. "Ophthalmoscope shows hyperopia, right
eye 2 diopters, left eye 1 diopter. No astigmatism could be
discovered. Both eyes have unsteady lateral movement. Left
eye does not move as freely as right eye. Weakness of all eye
muscles, particularly the interni. Accepts no glass at first ;
vision later after wearing R. -4- .50 D., L. + .25 D. for half
an hour, 20 20. These prescribed to be worn two months con-
stantly."
Strength of arms diminished ; dynamometer test shows,
right hand 60; left, 40; tremulous and with increased tendon
and muscular reflex action. The legs likewise are weakened,
also tremulous, and the reflexes are exaggerated. There is no
anesthesia or hyperasthesia of the face, arms or legs.
The chest offers the most important symptoms, both objec-
tive and subjective. The precordial area is largely increased
and reverberates with every heart beat. The apex point is
diffused and impossible to locate. On palpation a tremulous
and purring sensation is experienced which is communicated
to nearly the whole side of the thorax. Percussion shows
increased area of cardiac dullness extending to the right of the
sternum, to the left of the mammillary line and below the
nipple. Auscultation does not reveal any valvular murmurs,
although the sounds are indistinct and diffused. The heart
beats number 130 to 150 per minute.
Urine is increased in quantity, but does not contain albumin
or sugar. Bowels are regular. Sleep is fair but is often
awakened by the heart's action. During the day he is aware of
much fluttering of the heart while napping.
On July 27, 1896, I again had occasion to see the
patient and found his heart in practically the same
condition, beating 130 times per minute, and as
tumultuously as on the former examination.
The history of this case leaves little doubt as to the
correctness of the diagnosis — acute dilatation, and the
cause of such dilatation — over bicycling. The distance
covered and the time would be insignificant to a
trained wheelman, but to one not accustomed to long
rides it was quite an undertaking and was fraught
with serious consequences. In conversation with
beginners in the sport one hears so often, " I rode
eight or ten miles to-day in such a time," or " I rode
a mile in such a time and have only been on the wheel
a few days," and yet these riders may never have taken
any kind of regular physical exercise. They certainly
are imprudent and should be discouraged in their
ambitious tendencies until they are in condition to
endure the necessary strain. To the writer this seems
one of the greatest dangers of bicycling and yet one
of the easiest to avoid.
OF
THE STATISTIC EVIDENCES OF THE VALUE
VACCINATION TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Read before the American Medical Association at the Jenner Centennial
Celebration, held at Atlanta, Ga., May, 1896.
BY EUGENE FOSTER, M.D.
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINF. AND STATE MEDI-
CINE AND DEAN OF THE FACULTY OF THE MEDICAL DEPARTMENT
I MVERSITY OF GEORGIA, AUGUSTA, GA.
(Continued from page 753.)
30 Dr. Kinnis, formerly Superintendent of Vaccination at
Colombo, in his "Report on Smallpox as it appeared at Ceylon
in 1833-4," and in an appendix relating to observation made by
Dr. Forbes in the epidemic of 1830, gives enumerations from
M See first report Royal Vaccination Commission, 1889, p. 75.
which the annexed table is compiled. It will be observed that
the gradation of death rates marked in the last column, though
far less detailed than in Mr. Marson's statement, is to the
same general effect. And in the cases noticed by Dr. Kinnis
himself the difference is further developed ; for he distinguished
persons pretending to have been vaccinated into such as had
no marks, and such as had unsatisfactory marks of vaccination,
and found that the death rate of the latter was 26%, that of
the former 32 1-7. Cases of chickenpox are not included in
the annexed table, and Dr. Kinnis gives at length (pp. 10-14)
his reasons for concluding "that the febrile eruptive disease
known in Ceylon by ihe name of chickenpox arises from an
infectious matter essentially different from that which pro-
duces smallpox and modified smallpox." — Op. cit. Colombo,
Govt. Press, ia35.
Occurrences and fatality of smallpox.
Number | Number
of | of
; cases deaths.
In persons decidedly not vaccinated. . . .
In persons having no marks or but unsatis-
factory marks of vaccination
In persons having satisfactory marks of
vaccination
In persons having marks of smallpox ... I
851
199
187
4
Percent-
age of
41.5
26.1
1.6
Comparison of the number of cases of smallpox which were treated In
the General Hospital at Vienna during the -~> years. 1851-55 inclusive,
as regards the ages of patients and the number of cases which termi-
nated fatally.
Vaccinated.
Not vaccinated.
Age of patients.
Total
number.
Number
of
deaths.
Total
number.
Number
of
deaths.
55
834
892
171
35
9
8
16
48
7
1
1
84
111
83
10
8
8
18
25
From 21 to 80
88
a
From 41 to 50
8
1,995
70
244
71
The number of cases of variola in
namely :
Who had not been vaccinated
various
forms was 2,239,
1,995
. . . 244
Vaccinated as well as non-vaccinated persons were seized
with the smallpox ; still, with this difference, that of the vac-
cinated cases 8';1 per cent., but of the non-vaccinated 33.3 per
cent, were cases of variola vera.
Of the 1,995 vaccinated cases 76, and of the 244 non-vacci-
nated cases 71, terminated fatally.
11 "Interesting and instructive are, moreover, the following
figures which throw light upon the relation existing between
unvaccinated, vaccinated and revaccinated persons becoming
sick or dying of smallpox. According to the memoranda of
certain hospitals, among those who died of smallpox during tlie-
years 1870 and 1871 were :
Unvaccinated. Vaccinated. Revaccinated.
Percent. Percent. Percent.
In Muenster . . .
80
13
(l
70
12
2
In 4 hospitals of
Berlin
54
13
0
70
16
1
66
15
4
81
14
9
In Chemnitz in 1871, among 249 dead were only seven vaccin-
ated persons.
According to Buchanan in 1881 in England, there was only
one victim who had been vaccinated while there were 200
deaths among unvaccinated children from 1 to 2 years old.
In Bavaria in 1882, among the smallpox eaaes were counted
14.6 per cent, vaccinated, 5.8 per cent, revaccinated, 45.5 per
cent, unvaccinated.
In the Imperial General Hospital of Prague during ten years,
from 1847 to 1856, 872 persons were treated for smallpox ; of
these, 819 had been successfully vaccinated, and forty-three
unsuccessfully or not at all. With ten the vaccination or its
result, could not be ascertained in a manner to be relied upon.
Here must be particularly remarked that in 1847, in the afore-
mentioned institution, not one case of smallpox is recorded.
Out of the 872 patients, sixty-three died, and of this number
31 U. S. Consul, Berlin, loc. cit.
1896. |
THE VALUE OF VACCINATION.
809
forty-one were of those who were described as successfully
vaccinated, twenty as vaccinated without Bucceas, and two as
those concerning whose vaccination nothing certain was known.
Leaving out chose concerning whom vaccination nothing
could with certainty be said, it is here shown that of the suc-
cessfully vaccinated the twentieth part died : of the unsuccess-
fully vaccinated the half, while the number of vaccinated
patients was nineteen times greater than that of the non-
vaccinated.
In the Hospital of the Brothers of Mercy at Prague, during
the years 184* to ls.'iii inclusive, 410 patients were treated for
smallpox : of these. ,'!70 were vaccinated, and only forty non-
vaccinated. Of the vaccinated four died; of the non-vac-
cinated live died.
Of the vaccinated (the success or non-success of the vaccina-
tion not being taken into consideration) the ninety-second
part died, of the non vaccinated the eighth part died, while the
number of the vaccinated wasnine and one-fourth times greater
than that of the non vaccinated.
In the Elizabethan Hospital at Prague, during six years,
from 1851 to lSTiti, UScasesof smallpox were admitted ; of these,
His were vaccinated and ten non-vaccinated. Of the vaccinated
two died, of the mm -vaccinated one died ; i. c, one fifty-fourth
of the vaccinated, and one tenth of the non-vaccinated, the
vaccinated patients being ten and four-fifths times the number
of the non vaccinated.
In order to arrive at an idea as to the frequency of attacks of
smallpox during the different periods of life, and the amount of
safety secured bj vaccination, we subjoin the following tables,
which show the rates of mortality among the vaccinated and
non vaccinated patients of the General Hospital, Vienna, during
the period above mentioned :
Kamsey on smallpox. Transactions New York Medical Society.
Ages.
1 to 10 vears. .
11 to --'0 years .
21 to 3i yean
SI to 40 years .
u ami upward
Total
number
of
cases.
118
8,884
2,071
406
M
Vaccinated.
Cases. Deaths.
284
2 .22*
2 .::•_".'
351
85
83
128
21
4
Non-vaccinated.
Cases. Deaths.
184
I or.
342
52
12
74
83
115
24
4
Deaths per 100 cases at each age, as follows :
1-10 11-20
Among 5-317 vaccinated . . . .
Among 186 non-vaccinated .
14.9
40.
3.7
20.4
21-80
5.6
5.9
40.2
41 and
upward.
6.5
88.3
Report of the Faculty of Medicine at Prague, submitted to Minister
of the Interior, November, 1866.
Vaccinated and unvaceinated eases of smallpox which terminated
fatally, accordiug to the official vaccination return (21 years).
Year.
ISM
1887
....
...
....
1M1
1843
....
1-11
1846
ISM
18*7
1848
1849
....
18tl
....
....
1854
....
Total. . .
Average .
•6
a
Smallpox.
Cases.
Deaths.
a
o
1
a
a
is
E2
a
a
|
5
i
1
p"3
a
a
a
a
0
ti
a
a
a
a?
a >
a> c
a
.° a
a
o a
O
M
>
is"
>
■&>
132,727
4,020
505
480
20
186
130,194
3,319
874
215
20
64
120,123
3,071
57
123
4
52
138,527
3,967
101
96
15
32
132,528
3,906
160
168
20
70
140,898
3,585
1.138
966
89
851
189,471
3,482
1/83
1,522
88
382
112,070
3,180
881
70S
39
208
142,81 1
2.874
627
714
21
229
120.0 17
6,109
61
148
7
43
149.012
6,410
55
68
2
90
146,467
5,475
6
50
7
141.268
5,301
19
25
4
132,820
5,718
227
169
17
49
139.523
5,704
575
Oi:,
63
177
156,661
6,314
568
874
14
131
152,294
4,094
16
293
3
43
161,364
8,889
252
231
12
05
145.088
3,067
327
168
3
30
161,318
2,927
457
203
7
61
136,-124
2,348
389
166
8
56
3,005,578
90,130
8,178
7,102
423
2,224
143,122 jf
4.291 ' 'f
389 IT
855 /-j-
20 IT
105 \\
Remarks.— One case of smallpox occurs among :*i7% vaccinated;
I." . non vaccinated. One fatal case of smallpox occurs among 7,166!,.',
vaccinated : lo-:, Don-vaccinated, Among cases of smallpox died the
nineteenth nan of the vaccinated; the third part of the non-vaccinated.
" M. Bousquet," in his detail of the epidemic which pre-
vailed at Marseilles in 1825, states that the whole population
w us estimated at 40,000. Of these, 30,000 had been vaccinated,
"2,000 had had smallpox, 8,000 had neither been vaccinated nor
had smallpox. Of the 3(1,000 vaccinated 2,000 were seized with
smallpox, twenty of whom, or one for overy hundred affected,
died. Of the 2,000 who had bofore had smallpox, either nat-
urally or by inoculation, twenty were attacked, and of these
four died, or one for every five who took the disease. Of the
S.000 who had not been vaccinated nor had smallpox, 4,000 con-
tracted it and 1,000 died, or one in every four. By this it
appears that one-half of the non-vaccinated, one-fifteenth of
the vaccinated, and one-hundreth of the variolated took the
disease. But such was the difference in the comparative mor-
tality of the attack in the vaccinated and the variolated, that
while the variolated part of the population were cut off in the
proportion of one out of every 500, the vaccinated lost only one
out of every 1,500; or, in other words, of an equal number of
variolated and vaccinated cases, three of the variolated died
from the second attack, for every one that died who had been
previously vaccinated."
In Berlin in the year 1872,'* the mortality of the disease was
243 per 100,000 population, and the year after it was 262.
Thereupon vaccination during the first year of life and revac-
cination at the age of 12 years was made compulsory by law,
and with the effect that in the year 1875 the death rate was
lowered to 36 per 100,000 inhabitants ; the next year it was
lowered to 31, the next to 3 and so through later years with an
average annual mortality of 1.7 per 100,000 people. During
the year 1890 only fifty-eight cases occurred in the whole
German Empire, or 1.18 cases to each 1,000,000 of population.
A village in Leicestershire, England, of 1,300 inhabitants
was visited by the pestilence in 1872. All but two of the
inhabitants were efficiently vaccinated and escaped the disease ;
whereas the two unvaceinated persons died of it.
The late Dr. J. H. Rauch, for many years Secretary of the
State Board of Health, has shown that in the Illinois epidemic
of 1881-83, the mortality rate of the vaccinated was approxi-
mately 6 per cent., and of the unvaceinated it was 49 percent.
Corbally has demonstrated that in the Sheffield, England,
epidemic of 1887-88, vaccinated children were, as compared
with the unvaceinated, twenty times less liable to attack from
smallpox, and twenty-four times less liable to die when attacked.
That is to say, the vaccinated children had, as compared with
the unvaceinated, four hundred and eighty fold security against
death from smallpox.
In the Halifax, England, epidemic of 1892-93, the death rate
from smallpox among vaccinated persons was 1.8 per cent.,
and among the unvaceinated it was nearly 41 per cent. No
case occurred in a vaccinated child under 5 years of age, and
in the Leicester epidemic of 1893 no case occurred in a vaccin-
ated child under 10 years of age.
From the records of 5,000 cases treated in the Municipal
Hospital of Philadelphia, according to W. M. Welch in the
New York Medical 'Journal, March, 1894, it appears that the
death rate in that institution in postvaccinal cases, and all in
which there had been an attempt at vaccination are included,
was 16.26 per cent., and the death rate in non- vaccinal cases
was 58.38 per cent.
Seventy-three per cent, of the cases in unvaceinated infants
under 1 year of age ended in death, and no fatal case ccmrred
among vaccinated infants of the same age. Between the ages
of 1 and 7 years the mortality of postvaccinal cases was 5.7 per
cent., and of non-vaccinal cases it was 51.48 per cent.
In Chicago only seventeen cases of smallpox have occurred
in the last fifteen years among the well vaccinated public school
children of that city, whose average number exceeded 200,000.
Dr. Clendenin,3'' health officer of Cincinnati, Ohio, says
that, in the epidemic of smallpox in that city (1868-69) 95 per
cent, of those who died of smallpox were among the unvacein-
ated. He further says that no death occurred from smallpox
in which there was unmistakable proof that the individual had
been properly vaccinated.
Dr. Benj. Lee of Philadelphia, Pa., in his report to the
Pennsylvania State Medical Society, 1873, shows that the
mortality from smallpox in the epidemic then just ceased was
55.9 per cent, in the unvaceinated ; in the vaccinated with one
M I presume that "ungeimpft verbllebene" iu the third column is in-
tended to denote (in comparison with the total births of the year) the
number of infants who remain unvaceinated at the end of the legally
specified time. — [J. S.
33 Transactions American Med. Assn., 1865, p. 270.
34 Vital Statistics, Indiana. 1884, p. 98-99.
3' Dr. W. B. Davis, Transactions, Ohio Medical Society, 1870.
810
THE VALUE OF VACCINATION.
[October 10,
vaccinal scar it was 15.2 per cent., while the mortality among
those having five or more scars was 5.5 per cent.
During 1875 the mortality among 1,866 vaccinated persons
treated in the Riverside Hospital, New York City, was 375,
while among the 405 patients who had never been vaccinated,
200 died.
Statistical tables demonstrating the unquestionable controll-
ing power of vaccination over smallpox might be multiplied
indefinitely, but I have already, I fear, entered too lengthily
into this part of my subject. I will therefore close the statist-
ical data under Proposition 6 by quoting the following :
1. Mortality from smallpox among the vaccinated, doubtfully vaccinated
and unvaccinated. 36
London Smallpox Hos-
pital (1830-67)3' . . . .
Metropolitan Asylum
Board Hospitals* . . .
Cases.
o >
a
10,808 203
13,575 2,180
2,020
3,973
Deaths.
2 =5
a s a
•3 s's
© 3 OS
« O >
> a
790 | 100
1,027 671
Mortality
Per cent.
Si—"
s isa
« :■£§
a jo >
> a
1,048 7.59 40.334.9
1,593 7.56|31.540.0
2. Mortality from smallpox among the vaccinated, doubtfully vacci
nated and unvaccinated, under 10.
Metroplitan Asy-
lum Ho8pitals3».,
Cases.
Deaths.
1.291
30
"3 o
.£ CJ
0 at
a
1.512
H
o >
a
7«
Mortality.
Per cent.
a a
So
& o
= 03
o >
a
4.83 28.4
49.2
Dr. Lyon Playfair in a speech in the British House of Com-
mons, June, 1883, said : "On this point I would refer to the
case of Leipsic, which for eighteen years prior to 1870, had
zealously supported the anti-vaccination movement, and during
that period there had been but twenty-nine deaths from small-
pox, although vaccination had been greatly neglected in the
town. When the pandemic reached Leipsic in 1871 the town
had a population of 107,000, and smallpox attacked 1,027 of this
number, or 9,600 per millon of the population, and out of
23,892 children under 15 years of age, 715 died, being 30,000
per million."
"The statistics of the London epidemic were prepared with
great care, and the mortality among the vaccinated was 90 per
million inhabitants, while among the unvaccinated it was 3,350
per million. In the hospitals 45 per cent, of the unvaccinated
and 15 per cent of the vaccinated died."
Comparative mortality of smallpox after smallpox, and of smallpox
after vaccination.
Smallpox after
smallpox.
Smallpox after
vaccination.
Authorities.
o o
85
Thompson, Edinburgh 71
Chelsea Military Asylum . . . .! 26
Heim. Wiirttemberg Ml
Bosquet, Marseilles 20
Gregory, London 9
Total
166
C-Q55 » „_ oo
O 3J~ 00 O 3J
£ "> C * • «
K 55
4.2
11.5
35.8
20.0
22.2
15.7
310
24
147
2.000 1
789
OJ30 o
S»0 o
OS
0.3
0.0
28.5
1.0
5.8
8,270 109
.3
36 In the statistics of the metropolitan smallpox asylums, the "vac-
cinated" are those who present marks, however imperfect, of a primary
vaccination; the "unvaccinated" those who precent no marks, and in
whose case it is admitted by the patients themselves, or their guardians,
that they have never undergone the operation; the "doubtfully vacci-
nated" those who present no evidence of vaccination but who profess
to have undergone the operation or have no knowledge as to whether
they have ever undergone the operation. It is evident that the "doubt-
fully vaccinated" are really "unvaccinated."
3'Marson: Evidence before the Select Committee on Vaccination,
1871.
It thus appears that, while they who take smallpox a second
time die in the proportion of 15.7 in the 100, they who take
smallpox after vaccination die only in the proportion of 3.3 in
the 100 -a proportion absolutely lower than the mortality of
the mildest disease.
Borough of Sheffield, England. In this Borough in an
epidemic of smallpox during the years 1887 and 1888, Dr. P. W.
Barry, inspector of the Local Government Board, after having
a house to house inspection made throughout these two years,
gives the following report as the result of his investigation :
UNVACCINATED.
There were 5,715 citizens of all
ages returned as unvaccinated. Of
these, 552, or9.7 per cent., had been
attacked by smallpox, and 4.8 per
cent. died.
VACCINATED.
In the borough of Sheffield there
resided 268,397 persons who had
been returned as vaccinated. Of
these 4,181, or 1.55 per cent., had
been attacked by smallpox, and
0.07 per cent, died of the disease.
Of the 68,236 vaccinated children
under 10 years of age 358, or 0.5
per cent., contracted smallpox,
and il, or O.0O9 per cent., died.
Of 196,905 vaccinated persons
aged 10 years and upward 3,374, or
1.9, contracted smallpox and 194,
or 0.10 per cent., died.
Of 2,259 unvaccinated children
under 1U years of age 22s, or ln.l per
cent., contracted smallpox and 100,
or 4.4 cent., died.
Of 8,429 unvaccinated persons
aged 10 years and upward 322, or
9.4 per cent., contracted smallpox
and 174, or 5.1 per cent., died.
The proportions of unvaccinated and vaccinated who were
attacked and who died of smallpox among the inmates of houses
that were actually invaded by smallpox, that is where people
were brought in actual contact with the disease, Borough of
Sheffield, England, 1887-1888. Of course in the general pop-
ulation of the Borough a number of citizens were never brought
into actual contact with infected persons or fomites.
In the whole Borough of Sheffield 18,756 persons of all ages
were enumerated as living in houses invaded by smallpox and
of these 4,703 or 25.1 per cent, contracted the disease, and 474
or 2.5 per cent. died.
The proportions of the population of the vaccinated and
unvaccinated classes respectively, living in invaded houses in
the entire Borough, who had been attacked by smallpox and
who died of the disease, were as follows :
VACCINATED.
Of the 18,020 vaccinated persons
of all ages enumerated as living
in invaded houses 4,131. or 28 per
cent., contracted smallpoxand 200,
or 1.1 per cent., died.
UNVACCINATED.
Of the 786 unvaccinated persons
of all ages enumerated as living
in invaded houses Bint, or 76 per
cent., contracted smallpox and 274,
or 87.8 per cent., died.
CHILDREN UNDER 10 YEARS OF AGE.
VACCINATED.
Of 4,493 children under 10 years
of age 353, or 7.8 per cent., con-
'I smallpox and 6, or 0.1 per
eeni., died.
< m" 13.135 vaccinated persons, aged
lo or upward 3.371, or 88.1 per cent.,
died,
UNVACCINATED.
Of 968 unvaccinated children
under 10 years of age 228, or 86.9
per cent., had smallpox and 100, or
88.1 per cent., died.
Of 469 unvaccinated persons in
years old and upward 322, or 68.6
per cent, .contracted smallpox and
171, or 37.1 per cent., died.
On page 42 of Report of Royal Vaccination Commission the
following facts are to be found giving the proportions of the
population of the Borough of Sheffield of the vaccinated and
unvaccinated classes respectively at these several age-periods
who at the end of the census had contracted smallpox, and
who had died of the disease.
IN THE TOTAL ENUMERATED POPULATION.
VACCINATED.
Of 33,893 vaccinated children
under 6 years of age 121. or 0.36 per
cent., had been attacked by small-
pox and 1. orn.nn:t per cent., had
died.
Of 84348 vaccinated children
aged 5 but under 10 years 232, or
0.67 per cent., had been attacked
and -">. or 0.14 per cent., had died.
Of 32.965 vaccinated persons aged
1(1 but under 15 years 629, or 1.9
per cent., had been attacked and
11, or 0.03 per cent., had died.
Of 27,111 vaccinated persons aged
15 but under 20 years 979, or 3.6 per
cent., had been attacked and 19. or
o.n7 per cent,, had died.
UNVACCINATED.
Of 1,981 unvaccinated children
under 5 years of age I8B, or 6.6 per
cent., had been attacked hy small
pox and 66 (exclusive of children
under one month of age), or 3.3
percent., had died.
Of 278 unvaccinated children
aged 5 but under 10 years 100, or
86 pel- cent., had been attacked and
84, or 12.2 per cent., bad died.
Of S86 unvaccinated persons aged
10 but under 16 years 91, or 38.7 per
cent., had 1 n attacked and 32, or
18.6 per cent., had died.
Of 282 unvaccinated persons aged
15 but under 2n years SI, or 29.8 per
cent., had been attacked and 58, or
ls.s per cent., had died.
The above facts are extracted from the testimony of F. W.
Barry, M.D., inspector of Local Government Board, Oct. 8,
1889, pages 39 to 42 inclusive, Second Report of Royal Vaccin-
ation Commission of England, submitted to Parliament, May
29, 1890.
38 These include cases admitted into the following asylums: Dept-
ford, 1x78-81: Hampstead, 1876-78; Homerton. Smallpox Hospital, 1871-82;
Homerton, Fever Hospital, 1876-77 aDd 1881-82; Stockwell, 1882. 17./.
annual reports of the several hospitals. For further figures consult
report of board of health of the city of Philadelphia, 1872; papers on
vaccination by Mr. Simon, etc.
39 Homerton Smallpox Hospital, 1871-80; Deptford Hospital, 1878;
Stockwell Smallpox Hospital, 1882.
1896.]
SOCIETY PROCEEDINGS.
811
VACCINATUM
of 14,788 vaccinated persons aged
under »i years 1.387. or 2.8
in., had been attaeked aiul
,,w. or 0.15 per cent, had died.
.mi vaccinated persons a#cd
UNVACC1NATKU.
of .ssi unvaoolnated persona
aged SO bu I under :in rears (8, or
10.8 i»r cent, hud been attacked
and 81, or s.t per cent., hud died.
Of 8.0J8 unvaccinated persons
UNVACC1NATKU.
Of tu unvaccinated children
under:, years of age enumerated
M living in invaded houses 188, or
88 per cent., had been attacked by
s m :t!l pox ami (id (exoluslve of chil-
dren under one month old), or 42.9
p«r cent., had died.
of ioh unvaoolnated children
aged 6 but tender 10 years loo, or
1'i.s p.-r rent., had been attacked
and B4, or 81.3 per oent., bad died.
i >f 98 unvaoolnated persons aged
10 but under 15 years HI, or 86 per
]»er cent., had been attacked and
it-', or 84.4 per oent., had died.
of iis unvaoolnated persons aged
16 but under 80 vnirs M.or 86.8 per
oent., had been attacked and 68, or
fd.l per cent., had died.
of 1-J4 unvaoolnated persons aged
SO but under 80 yean 88, or 79 J per
oent., had been attacked and 61, or
cent., had died.
of 1M unvaoolnated persons aged
Bfi \ ears and upward 49, or :il.8 i>er
tent., had been attaeked and 28, or
is. j per oent., had died.
■land upward 880, or 0.97 percent., aged 80 and upward 19, or '-M per
.n attacked and 95, or 0.1 eellt., had been at lacked a lid 2S. or
per cent., had died. 1.4 per eelll., Iiad died.
( )n page 43 of the same report will be found the following
tables as to the proportions of vaccinated and unvaccinated in
the invaded houses by age-periods.
V.ICCINATKD.
(if 4,154 vaccinated children
under enumerated
i ng in in\ aded houses 121, or
6,6 per cent., had been attacked by
lid 1. or 0.0-"' per cent'.,
had did.
of &J88 vaccinated children
i hut under in years .
8.8 per cent., had been attacked
ami ■>. or 0.S1 pet cent., had died.
Of 3,486 vaccinated persons aged
to but under 15 years 629. or '-'■>.-'
(M'reent.. had been attacked and
it. or 0.4 per cent., had died.
Of 8,870 vaccinated persons aged
under SO years 979, or 41.8
per cent., had been attacked and
0.8 per cent., had died.
Of Ijrftl vaccinated persons aired
■JO hut under M years 1,867, or B8.7
per cent., had been attacked and
.' 1 per cent., had died.
(if 6;S90 vaoelnated persons aged
i rs and upward 899, or 17.4 per
cent., had been attacked and 96, or
l.S per cent., had died.
Note. — "Those classified as vaccinated include all persons snecess-
iullv at Bin- period beyond thirteen days prior to the appearance on
1 the eruption of smallpox. As a matter of fact I do not think
there la In which smallpox quickly followed vaccination
or re vaccination when the interval between the operation and the
appearance of smallpox exceeded six or seven days. Those classified
as unvaccinated include all persons who have either never been success
fully vaccinated or whose vaccination was performed for the first time
within thirteen days of the appearance on them of the eruption of small-
pox. In the vaccination census if a person stated that he was vaccinated
that was accepted as correct ; if he stated that he was unvaccinated that
a^aiii was accepted as correct. A certain number were reported as vac-
cinated who really were unvaccinated." Barry, loc. cit.
Question 1988. Dr. Barry continuing (see page 45) said:
I propose to read in very much the same manner as I have
read with regard to the census data, the relations of vaccina-
tion and smallpox as indicated by the health office data. I
first of all take page 190. The total cases of smallpox reported
to the health department to have occurred in the Borough of
Sheffield during the period from the commencement of the
epidemic to the :51st of March, 1888, were 6,088 in number.
Of these it was stated that 5. Olio were of the "vaccinated" as
against 1,053 of the "unvaccinated'' class. In 589 cases, or
8/7 per cent., of the total of all classes attacked the disease
proved fatal. Of the 5,035 persons of the "vaccinated" class
attacked. 246. or 4.9 percent., died : whilstof the 1,053 persons
of the "unvaccinated" class attacked 343, or 32.6 per cent.,
died. In the "vaccinated" class smallpox is reported to have
attacked 97 persons under 5 years of age, of whom 1, or 1 per
cent., died ; 243 between 5 and 10 years of age, of whom 6, or
2."i percent, died; 2,034 between 10 and 20 years of age, of
whom 38, or 1.9 per cent, died ; 1,579 between 20 and 30 years
of age, of whom 87, or 5.5 per cent, died ; and 1,084, aged 30
years and upward, of whom 114, or 10.5 per cent, died. In
the "unvaccinated" class, smallpox is reported to have
attacked 212 persons under 5 years of age, of whom 113, or 46.7
per cent, died : 184 between 5 and 10 years of age, of whom 39,
or 21.2 per cent, died ; 380 between 10 and 20 years of age, of
whom 92, or 24.2 per cent, died : 169 between 20 and 30 years
of age, of whom 65, or 38.5 percent, died ; and 78 aged 30 years
and upward, of whom 34, or 43.6 per cent., died.
Dr. Barry, page 51, Second Report of Royal Vaccination
Commission gives a tabular statement showing the fatality
per cent, of admissions in each hospital and all hospitals in
Sheffield in 1887 and 1888, and says :
From an examination of that table it will be seen that there
is a general correspondence between the fatality rates which
obtained in the several hospitals at the different age periods.
The figures with regard to the Lodge Moor and Ecclesall
Bierlow Hospitals show the chief variations, but in the case of
these hospitals the figures are very small. From the summary
of the figures with regard to all the hospitals, it appears that
the total of 1,798 cases of smallpox, 256, or 14.2 per cent,
proved fatal. Of the total number of cases, 1,351 were of the
"vaccinated" as against 447 of the "unvaccinated" class. Of
the 1,351 persons of the "vaccinated" class admitted, 110, or
8.1 per cent, died : whilst of the 447 "unvaccinated" persons
admitted, 146, or .'12.7 per cent, died. Of the 1,351 persons of
the "vaccinated" class admitted, 67 were under 10 years of
age, and of these 1, or 1.5 per cent, died ; 573 were aged 10 but
under 20 years, and of these 13, or 2.3 per cent, died ;426 were
aged 20 but under 30 years, and of these 42, or 9.9 per cent,
died ; and SIB were aged 30 years and upward, and of these 54,
or 19 per cent, died. The whole of the persons of the "vaccin-
ated" class who died had been vaccinated in infancy only, with
one exception, and the figures show a greater liability to fatal
termination with increasing years. Of 447 persons of the
"unvaccinated" class admitted, 101 were under 10 years of age,
and of these 34, or 33.7 per cent, died ; 205 were aged 10 but
under 20 years, and of these 56, or 27.3 per cent., died ; 100 were
aged 20 but under 30 years, and of these 41, or 41 percent, died ;
and 41 were aged 30 years and upward, and of these 15, or
36.6 percent, died. In the hospitals of course all the patients
were under the same conditions ; they were not being treated
in different class houses, some in good ones and some in bad
ones, but they were all being treated under the same nursing
and with the same general surroundings, and, as I here note
in the report, "except during the first few months of the epide-
mic, very few of the milder cases found their way to the hos-
pitals, and consequently the proportions of severe and fatal
cases were larger there than amongst the population as a
whole." Then dealing in the same way with the fatality of
the cases in hospital, taking all ages. Taking children aged
0-10: "For each individual vaccinated child 0-10 years of age
suffering from a fatal attack of smallpox, 22.4 unvaccinated
children died of that disease." Taking persons from 10 to 20
years of age : "For each individual vaccinated person, 10 to 20
years of ago suffering from a fatal attack of smallpox, 12 unvac-
cinated persons of similar age died of that disease." Then as
to persons from 20 to 30 years : "For each individual vaccin-
ated person aged from 20 to 30 years of age suffering from a
fatal attack of smallpox, 4.1 unvaccinated persons of similar
age died of that disease."
(To be continued.)
SOCIETY PROCEEDINGS.
A merican Association of Obstetricians ami
Gynecologists.
Ninth Annual Meeting held in Richmond, Va.,
Sept. 2H-24, 1896.
First Day — Morning Session.
The Association was called to order at 10 a.m. by the Presi-
dent, Dr. Joseph Price of Philadelphia.
After the usual preliminary exercises, the reading of papers
was proceeded with.
Dr. John M. Duff of Pittsburg, read a paper entitled
PELVIC DISEASES AND THEIR PRINCIPAL CAUSES ; WHAT SHOULD
THE LAITY BE TAUGHT CONCERNING THEM?
He said that notwithstanding the fact that some of the
prominent members of the medical profession had, in talks to
the galleries, held the gynecologists up for ridicule and criti-
cised them severely, he did not think any apology was due
either the profession or the public for the character, or results
of pelvic surgeons. Those members of the profession who had
been devoting themselves to the care of diseases peculiar to
women, had in the face of revilings and professional and public
prejudice worked patiently and persistently until they were
now obtaining results of which they may well feel proud,
results far beyond what the most sanguine expectations of the
hardy pioneers of a quarter of a century ago led them to hope
for. They were to-day charged with irrational radicalism, with
an operative mania, which was gratified without a proper con-
sideration of the ultimate benefit to the patient. Entreatingly
they were urged to adopt more conservative measures, and
thus stop the wholesale mutilation which was going on at
present, which it is claimed is neither scientific nor humane.
Sentiments such as these, endorsed by men of reputation, were
eagerly taken up by the lay press as sensational news and
advertised by pretenders as an endorsement of their methods
of practice, and thus the laity, in the opinion of Dr. Duff, are
taught false notions regarding the nature of pelvic diseases
and their treatment. That there is a great amount of mutila-
tion connected with pelvic surgery, he would not deny ; but
that regular pelvic surgeons were guilty of reckless despolia-
tion was not, he thought, susceptible of proof. Pelvic surgeons
could scarcely be held accountable for the work of general
812
SOCIETY PROCEEDINGS.
[October 10,
practitioners ; and for the work of ignorant egotists and pre-
tenders, who with brazen effrontery undertake operations of
which they are not qualified by character or education, the
pelvic surgeons disclaim all responsibility.
During the period of the evolution and upbuilding of pelvic
surgery no doubt much of the work was crude, and perhaps
too much was done by over-zealous operators. That at this
day, through mistaken diagnosis, operations are sometimes
needlessly performed, no one would have the hardihood to
deny ; but that such cases are as frequent as some critics say
they are, Dr. Duff could not believe. He said the true pelvic
surgeon was governed by nobler purposes, by more elevated
aims. Conservatism in its true sense, the saving of live, relief
from pain and the curing of the patient, was his watchword.
Dr. Duff then dwelt at length upon various pathologic condi-
tions which demand the attention of the pelvic surgeon.
Dr. Walter B. Dorsett of St Louis, followed with a paper
on
DECEPTIVE SIMILARITY OF SIGNS AND SYMPTOMS OF INTRA-
ABDOMINAL DISEASE, WITH CASES.
In order to arrive at a conclusion and to formulate a diagno-
sis in a given case, be it medical or surgical, the practitioner
must exercise care and judgment in the consideration of such
signs and symptoms as are presented. Each should be
weighed, and mental annotations taken as to their value indi-
vidually and collectively.
Dr. Dorsett directed attention to the importance of the fam-
ily and personal history of patients, to the pulse and tempera-
ture, the knoweldge to be gained by manual examination, the
use of analgesics, etc.
Regarding the exploratory incision, it should not be regarded
as an evidence of ignorance, but as a legitimate means of diag-
nosis, and the off-hand diagnostician, or the surgeon who
never makes mistakes, should be looked upon with, at least, a
grain of suspicion. To illustrate his statements, three inter-
esting cases were reported, one of which we give in full :
Mrs. M., aged 28, married eight years, no pregnancies, was
seen by Dr. Dorsett about a week after having recovered from
an attack of malarial fever. Temperature 99, pulse 90, tongue
slightly coated and a tendency toward diarrhea. Complained
of general abdominal tenderness ; palpation of abdomen
revealed a slightly more tender spot at McBurney's point; no
swelling or tumefaction could be felt. A vaginal examination
revealed a retroversion with fixation, no tubal enlargement nor
tenderness could be made out. No vaginal discharge. Diag-
nosis : Gastrointestinal irritation with chronic inflammation
of pelvic contents: diarrheal mixture was prescribed and
patient was told that further attendance would probably not
be necessary. Four days subsequently the temperature was
99.8 P., pulse 100, abdominal palpation revealed a distinctly
tender spot with some swelling at McBurney's point. Patient
stated that she had eaten heartily of Wienerwurst the day
before, and had been awakened during the night by cramps at
the navel. Bimanual examination was again resorted to with
negative result. Appendicitis was diagnosticated at this visit,
first stage. Dram doses of salts were prescribed, and the
patient was urged to go to the hospital, but refused. The
next day she was seen and found sitting in a rocking chair, and
aside from slight tenderness over abdomen, was feeling quite
comfortable. Sa)ts acted freely. Bimanual examination
again gave negative results ; temperature 99, pulse 100.
Patient was ordered to bed and advised to keep quiet. The
case was regarded as better and thought to be out of danger.
The following day the pain became more severe and the patient
came to the hospital of her own accord. Upon examination
the right iliac fossa was found to be exceedingly tender and
fluctuating. Vaginal examination revealed nothing aside from
what was found at the previous examination. Temperature
103, pulse 130. Diagnosis : Ruptured appendiceal abscess.
She was anesthetized and placed upon the table and a section
made in the median line. The la-ge sac was found on the
right side filled with blood and clots, and when washed out a
rent of the posterior layer of the broad ligament was found
which communicated with another rent in the Fallopian tube.
Appendix perfectly healthy, and was not disturbed. A thor-
ough washing out of the sac was done and ligation of the tube
with a portion of the broad ligament, a glass drainage tube
was introduced. Notwithstanding the utmost care, the tern
perature remained high, pulse became worse, the abdomen
became distended, and the patient died on the third day.
Postoperative diagnosis : Ruptured tubal pregnancy without
the usual symptoms. There was no history of shock ; no cessa-
tion of menstruation, or nervous symptoms of pregnancy. No
passage of decidua ; no vaginal discharge of any kind, but in
its stead a good history and train of signs and symptoms of
inflammatory disease of the appsndix.
Dr. Rufus B. Hall of Cincinnati read a paper entitled,
THE MOST POTENT CAUSES OF PELVIC INFLAMMATION.
He claimed that septic infection following labor or abortion
or gonorrheal infection, was the cause in almost every instance.
He says there will always be some cases of septic infection fol-
lowing labor, which are in nowise due to infection from the
attendant, injury to small pelvic tumors, etc. The retention of
the products of conception in abortion is a very frequent cause.
He advises completely emptying the uterus at once after abor-
tion. The Doctor believes the most frequent cause to be
gonorrheal infection conveyed to the woman from a latent gon-
orrhea of her husband. The more he sees of the ravages of
gonorrhea, the more he is convinced of the fact that the pro-
fession is derelict in its duty to its patients in the dissemina-
tion of knowledge upon this subject. The teaching of a few
years ago that gonorrhea in the male could be easily and
speedily cured by a little balsam of copaiba, or oil of sandal
wood, with mild astringent injections, and that the patient was
well as soon as the purulent discharge ceased, is false doctrine
and must be corrected. This must be done by the family-
physician. Dr. Hall does not stand alone when he says that he
has on many occasions been compelled to remove suppurating
tubes and ovaries from women who had contracted the disease
from their husbands, who believed themselves well when mar-
ried. He has no hesitation in saying that gonorrhea is more
destructive to women than syphilis, and believes it is the duty
of every physician to impress upon his male patient the fact
that he is not well as soon as the urethral discharge disappears.
He is a firm advocate of legislation upon this, believing that
every man should have a certificate from the health officer of
freedom from syphilis and gonorrhea before he is granted a
marriage license.
Dr. Henry Carstens of Detroit in discussing the three pre-
ceding papers, said that when prominent ministers of churches
consulted physicians and asked them to produce abortion on
their wives he became discouraged, and thought it was love's
labor lost. Still the gynecologist should keep on preaching
against the evils attending the production of abortion. Regard-
ing Dr. Dorsett's paper, the difficulty attending diagnosis in
some cases was exceedingly great. The gynecologist should
exhaust his diagnostic resources before resorting to abdominal
section. The too frequent opening of the abdomen stimulated
incompetents to do likewise, and as a consequence results were
disastrous, eventually reacting on gynecologists.
Dr. W. E. B. Davis of Birmingham, Ala., does not believe
that gonorrhea plays so important a part in the production of
pelvic inflammation as was heretofore taught. One's concep-
tion of cases of pelvic trouble depends largely upon the class
of practice he has. The cases met with in dispensary practice
are different from those encountered in private work. He
believes that fully 50 percent, of the cases of pelvic inflamma-
tion are due to puerperal infection, either at the time of deliv-
ery at full term or premature delivery. As to tubercular
trouble, more importance is being attached to it as a cause of
pelvic inflammation than it deserves. Those who did consid-
erable operative work knew that only a small per cent, of cases
have their origin in tuberculosis.
Dr. James McFadden Gaston of Atlanta (by invitationi
called attention to the prophylactic management of cases of
pregnancy prior to the period of confinement. Extreme
hygienic precautions might warrant in some instances the use
of antiseptic washes prior to labor, but as there was a great
tendency on the part of some members of the profession to
resort to measures which are regarded as precautionary in the
way of preparing a woman for labor and using washes in
advance of confinement, it struck him this was altogether out
of place, inasmuch as there was a normal condition of things,
and nature should be allowed to take its course unless there
were ample reasons for interference.
Dr. Ernest S. Lewis of New Orleans cited a case in connec-
tion with errors that sometimes arise in the diagnosis o f
abdominal tumors. He operated on a patient last winter for
what he supposed at the time was a small ovarian tumor, but
after the abdomen was opened it turned out to be a retro-
verted gravid uterus.
Dr. F. D. Thompson of Fort Worth, Texas, would like the
essayists to have gone more fully into the point as to when it
was safe for men to marry and have intercourse with their
wives, who had been the subjects of gonorrhea. Many cases of
gonorrhea occurred in married men, and the gynecologist had
before him all the ills and consequences incident to this dis-
ease. How long shall such men abstain from sexual inter
course? These points should be dealt with more fully and
explicitly.
Dr. Lewis S. McMurtry of Louisville considered the view
enunciated by Dr. Hall as to gonorrhea and its relations to
18%.]
SOCIETY PROCEEDINGS.
818
marriage impracticable. Regarding the exploratory incision
for diagnostic purposes, a bmII opening was not always suffi-
cient. The incision should bo sufficiently large to allow the
surgeon to thoroughly explore the abdominal cavity to detect
such pathologic conditions as might be present.
Or. 1.. H. Dinning of Indianapolis cited casesof the imprac-
ticability of making a small incision for the detection of intra-
abdominal pathologic conditions, lie favors an exploratory
opening sufficiently large to make a thorough search.
Dr. A. II. Cordikr of Kansas City, Mo., said, regarding the
possibility of making diagnoses in intra abdominal pathologic
conditions, that in SO per cent, of the cases this could be done
by painstaking efforts.
Dr. Kmvi\ Ricketts of Cincinnati agreed with the previous
speakers that it was exceedingly difficult to diagnosticate
intra abdominal lesions previous to opening the abdomen, and
sometimes the Burgeon aid not know the nature of the growth
even after the abdomen was opened. Cases illustrating tin-
great difficulty attending diagnosis of intra-abdominal growths
were cited.
Dr. E. F. Pish of Milwaukee said that while he did not
believe in promiscuous exploratory laparotomy, he could recall
one case in particular in which the operation saved the patient's
life.
Dr. EtlCHABD H. GlBBONS of New York City thought many
of the cases dealt with in the papers were due to puerperal
contamination, or in some instances to laceration of the cer-
vix, as had been pointed out by Emmet. He believes that
erath gave us the keynote to the class ofinfection pro-
duced by gonorrhea. Relative to diagnosticating intra-abdom-
inal diseases, there was no particular symptom that was path
ognomonic. Dr. (iibbons pointed out the unreliability of Mc
Burner's point, of which so much had been said and written,
and called attention to an article written by him andpublished
in the New Vork Medical Journal.
Dr. Howard W. Lom.y! u; of Detroit emphasized the
importance of educating the laity in regard to gonorrhea. He
believes the teachers of our public schools should be empow-
ered to impart the necessary knowledge regarding the dangers
of this disease and its consequences.
Dr. QbobqB Hf.n Johnston of Richmond presented the
specimen of an ovarian tumor, the first removed under Lister
ism in the State of Virginia so far as he had been able to ascer-
tain. The patient was an unmarried woman, -Jt> years of age.
The tumor was removed March 19, 1879. The tumor with the
sac and fluid contents weighed thirty-four pounds. The oper
ation was performed under the spray and with the elaborate
dressings recommended by Lister, etc. The patient died, how-
ever, from sepsis. In November of the same year he was con-
sulted by Mrs. M.. whom he presented to the Association for
what turced out to be an enormous unilocular ovarian tumor.
Her measurements were 6 feet. 4 inches around the abdomen at
the umbilicus, and :> feet. H inches from the ensiform cartilage
t<i the puhes. The contents of the tumor and sac weighed
ninety six pounds. This operation was performed at the
patient's house with the same care as that of the previous
one.
TUBO-OVARIAN CYSTS WITH INTERESTING CASES.
Dr. Albert Goldspohn* of Chicago read a paper on this
subject. By tubo-ovarian cyst is meant a non-purulent sac
whose walls are composed, in variable proportion, of the walls
of the Fallopian tubes and those of some cystic ovarian or par-
ovarian formation with the coalescence of two or more cavities,
at least one from each, into one, by a free communication. The
fluid contents of such a sac may be serous or hemorrhagic, or
may partake in variable degree of the qualities and character-
istics of the fluid contained inglandular ovarian cystomas. The
fimbriie of the abdominal ostium of the tube may be distin-
guished or not upon the inner or on the outer side of the ovar-
ian portion of the sac, or they may have coalesced with other
structures to form some portion of the walls of the united sac.
The ovarian element in this formation can have originated from
a hydropic Graafian follicle, a cystic corpus luteum, from the
primordial glandular ducts of Pflueger in the ovary, or from
the parovarium. In order to exclude a large number of ordi-
nary tubo-ovarian conglomerates we need to recognize the
following minimum requirements in distinguishing a tubo-
ovarian cyst: 1, the participation of the tube, which is easy
enough from its position and connections ; 2, to prove the par-
ticipation of the ovary by demonstrating some ovarian tissues
in the wall of the sac": 3, that their cavities are united by some
opening through which the mucous membrane of the tube is
continuous with the lining of the ovarian cyst or follicle.
Applying this standard the author has been compe'led to
■exclude a number of cases that have been mentioned as such
cysts, because the three points were not proven in each of the
cases.
The first description of a tubo-ovarian cyst was given by
Blasius in 1834, but the correct name was proposed by Richard
in 1863, who spoke of " kysts tuboovariens" in demonstrating
a number of postmortem specimens. The total number of
authenticated cases that the author has been able to find in
literature is thirty-eight by twenty-five different authors. Dr.
(ioldspohn reported three interesting cases, and called atten-
tion to some interesting features in connection with the anat-
omy as influencing intermittent profluent discharges and show-
ing the Inflammatory element in their causation. From astudy
of specimens, from the results of experience, and from the
arguments of the best authors, the author deduces the follow-
ing conclusions :
1. Tubo-ovarian cysts come to pass in consequence of a plas-
tic Inflammatory union between a Fallopian tube and the
adjacent ovary, after either or both of these organs and the in-
tervening peritoneum have experienced a non purulent patho-
logic change of a cystic character. The septum intervening
between the two lumina disappearing in consequence of press-
ure atrophy from the tension of liquid confined to one or both
sides of it.
2. This union of a distended tube cavity may occur also with
that of a parovarian cyst (v. Ott), or with that of a peritoneal
pseudo cyst (Zedel).
3. In those rarer cases in which the fimbria; are really found
floating in the interior of the main cyst cavity, we must assume
either the congenital anomaly of an "ovarian tube," as was
seen by Schneidemahl in a mare, as a vitium prima? formationis,
or that an ovarian cyst or follicle cyst ruptured, and the ab-
dominal end of the tube dropped into the rent and was united
to its edges by inflammatory action, thus making a joint cyst
and tubal cavity.
Dr. Walter B. Chase, of Brooklyn, followed with a paper
entitled
MIXED TUMORS OF THE OVARY.
Mixed tumors of the ovary have a peculiar interest, for the
reason that, if small, they are often difficult of diagnosis. These
tumors of the ovary may be made up of a variety of cysts, or
may lie a combination of cysts and solid growths. The etiol-
ogy of tumors as a whole is a matter of great importance, both
in the relation to diagnosis and treatment.
The question of what constitutes a tumor might be consid-
ered with profit. Senn, in his recent classical work on the
"Pathology and Surgical Treatment of Tumors," defines a
tumor as "a localized increase of tissue proliferation of embry-
onic cells of congenital or post natal origin." An important
fact concerning true tumors is that they never disappear except
by removal or destruction. Benign tumors always remain
local, while malignant ones are disseminated by migration or
transportation of their peculiar cells, and they always originate
as benign or malignant growths. If the tumor matrix is made
up of embryonic cells of the lowest development, there is
greater liability to malignant growth, than if from tissues sus-
ceptible to the highest physiologic type of development.
Retention cysts of the ovary are not tumors in, a technical
sense, and they never attain large size. Large ovarian cysts
are most often cyst-adenomas and are not developed from
Graafian follicles, but arise from the embryonic structure.
It would seem from what has been said that the genesis of
simple and mixed tumors is divested of much that was mis-
leading and contradictory and reduced to a rational basis. It
also demonstrates with great clearness that tumors are not
only of local origin, but at their inception are congenital.
The case reported, which was operated upon by the author
at St. John's Hospital, Aug. 4, 1894, as reported by Dr. H. P.
De Forest, pathologist to the Methodist Episcopal Hospital,
was a mixed tumor of the left ovary, consisting of a large cyst-
adenoma, containing about two gallons of clear straw colored
fluid, a dermoid intimately united with the cyst-adenoma, con-
taining less than a quart of fluid, leaving true bony pLates in
its wall, and numerous encysted papillomas encrusted within
the walls of both cysts.
Afternoon Session.
Dr. A. H. Cordier of Kansas City, Mo., read a paper on
movable kii>ney ; local and remote results
in which he drew the following deductions: 1. A movable
kidney often produces a dilatation of the stomach with all the
accompanying symptoms of a disease of that organ. 2. It is a
fruitful source of gallstones, because of the pedicle producing
a partial obstruction of the common duct. 3. The bending of
the ureter often gives rise to a hydronephrosis. This, in turn,
is sometimes converted into a pyonephrosia 4. It may pro-
814
SOCIETY PROCEEDINGS.
[October 10,
duce death by a complete strangulation by a torsion of the
vessels and ureter. 5. By dragging on the abdominal aorta
and kinking the vena cava, a condition simulating an aneurysm
of these vessels may be produced. 6. Pain of a referred char-
acter to the region of distribution of the spinal nerves is often
induced by a movable kidney's disturbance of the abdominal
plexus. 7. A general nerve exhaustion (neurasthenia) is often
induced by the interference of this condition with digestion,
assimilation and elimination. 8. Nephrorrhaphy is a safe and
effective surgical procedure. 9. All cases of movable kidney,
if accompanied by symptoms pointing to the kidney as their
source should be operated on. 10. In summing up the local and
remote results of this now often recognized condition, the
author thinks the correctness of the deductions has been fre-
quently demonstrated by the disappearance of each and every
symptom after a restoration and retention of the kidney in its
normal position. 11. Symptoms are not to be relied upon in
making a diagnosis of movable kidney. The physical examin-
ation is the only trustworthy guide.
THE LIMITS OF NEPHRORRHAPHY
was the subject of a paper by Dr. Hugh M. Taylor of Rich-
mond, Va. He conceded the frequency of nephroptosis. Since
he had been systematically looking for movable kidney, he has
found it so frequent in its occurrence that he no longer regards
the experience of Glenard, Linduer, Edobohl and Noble as
unique. His opinion is equally fixed that only a small propor-
tion of the cases met with give rise to symptoms or suffering,
ill health or death, and consequently a majority of cases do not
call for nephrorrhaphy. He favors the classification of neph-
roptosis under three clinic heads :
1. Patients who have displaced kidney do not know it and
suffer no inconvenience whatever from it. This type he thinks
represents by far the largest class.
2. Patients with displaced kidney, who may or may not know
it, who suffer from gastroenteric discomfort and perhaps a long
train of vague neurotic disturbances. In this type he thinks
we find the largest class calling for operative interference.
3. Patients with movable kidney, who are subjects of occa-
sional or frequent mild or severe attacks of renal crises. This
last mentioned is he thinks the least frequent type met with,
but the urgency of the symptoms more frequently demands
operative interference.
Nephrorrhaphy for the relief of gastro-enteric disorder is
limited by our ability to tell to what extent the disorder is due
to renal ptosis per se or to enteroptosis, or to some one of the
many well-known etiologic factors of gastro-enteric disorder.
Nephrorrhaphy for the relief of the condition of Deitl's or
renal crises must be limited by one's success in differentiating
between this condition and that of gall tract, appendicular and
kidney colic due to nephrolithiasis. He accepted as logically
sustained the conclusion that the Deitl's or renal crises is due
to a kink or twist of the ureter with retained urine in the
ureter and pelvis of the kidney. Apart from the violent par-
oxysms of pain (the renal crises) the tendency of ureteral twist
and urinary obstruction to induce hydronephrosis and in excep-
tional instances pyonephrosis, rendered operative interference
more imperative in this class of cases. His protest was not
against nephrorrhaphy, but only its abuse. He conceded the
value of operative interference in many selected cases but
deprecated the tendency toward operative interference merely
because the kidney is movable.
Dr. George Ben Johnston of Richmond, Va., said that some
years ago his attention was called to the subject by encounter-
ing several cases of movable kidney that had been unobserved
either by him or the physician who preceded him in the treat-
ment of these cases for obscure nervous and gastro- intestinal
disturbances, and when he observed the similarity of symptoms
in the first three cases which he saw, he was obliged to asso
ciate those symptoms with the presence of movable kidney.
He prevailed on these women to be operated upon for movable
kidney and in all three cases the results were most gratifying.
Dr. L. H. Dunning of Indianapolis, was greatly interested in
the subject, for the reason that in 1880 he resorted to operative
procedures for the cure of floating kidney, and in connection
with this work he sought to determine if possible some of the
causes which led to movable kidney. He emphasized the
importance of differentiating between floating and movable
kidney, the former being always congenital, the latter acquired
to a greater or less extent. He found by his investigations that
the partially fixed condition of the kidney depends upon three
or four causes, the two principal ones of which were its position
behind the peritoneum, and second the fact that it had an
envelope of cellulo-adipose tissue. A little further investigation
showed that the perinephritic cellulo-adipose tissue was com-
posed of two parts, one fixed, the other movable. The normal
kidney had a range of motion of from one half to three-quarters
of an inch in its fatty envelope.
Dr. Thos. B. Eastman of Indianapolis, reported the case of
a woman, 25 years of age, who came to him with the symptoms
of appendicitis. She also had considerable albumin in the
urine. Operation showed that the appendix was firmly adher-
ent to the kidney. It required considerable force to liberate
it. As soon as liberated the kidney bounded back into place
as though it were rubber. The appendix was removed, the
albumin in the urine ceased, and the woman made an unevent-
ful recovery.
Dr. James McPadden Gaston of Atlanta, directed attention
to the possibility of movable kidney being mistaken for en-
larged gall bladder. The gall bladder is capable of being
pushed back into the lumbar region and carried around in,
front in j ust the same manner as a floating kidney. It behooved
gynecologists to look into this phase of the matter.
Dr. W. E. B. Davis of Birmingham, had seen a number of
cases of movable kidney, and said that at the Charleston meet
ing of the Southern Surgical and Gynecologic Association there
was quite a difference of opinion as to the frequency of the
condition. He believes that movable kidney is a condition
which does not require in all cases operative interference. Of
the number of cases he had seen he had only operated on a
few.
Dr. I. S. Stone of Washington, D. C., related the case of a
woman who, after the operation of nephrorrhaphy had been
performed, gained twenty-five pounds in flesh. In many
instances this procedure brought color back to the cheeks of
patients and made them feel well. He had never seen such
gratifying results from any other operation in surgery except
perhaps from the removal of an ovarian tumor. The patients
made rapid improvement after the operation.
Dr. Joseph Price of Philadelphia, said his experience was
somewhat limited in operating for movable kidney. The im-
provement in the condition of patients so operated upon was
rapid, but there was such a thing as operating too much upon
cases of movable kidney.
Dr. J. Henry Carstens of Detroit, said the line should be
drawn between movable and floating kidney. The trouble
which arose from floating kidney consisted of a twisting of the
ureter and consequent obstruction.
Dr. Richard H. Gibbons of New York, detailed an operation
which had been devised and recommended by a foreigner for
holding the kidney in jjlace in its newly made position.
treatment of periuterine septic diseases.
Dr. W. E. B. Davis of Birmingham, Ala., read a paper on
this subject. Only recently has the extremely radical procedure
of hysterectomy been practiced in this country for septic dis-
eases of the internal genitals. A wave which had its origin in
Paris at the hands of Pean, aided by Richelot, Segond, Jacobs
and others, reached our shores three years ago and has found
a considerable following among our leading operators. The
claim is made that there is no use in leaving the uterus behind
after the removal of the appendages ; in every operation for
septic diseases of the female generative organs which demands
the removal of the tubes and ovaries, hysterectomy should also
be performed, unless there are plain contraindications forbid-
ding it.
It should be the aim of the surgeon to preserve everything
consistent with thorough surgical work, and not to sacrifice im
portant organs because it can be done with only small mortality.
We are told that the uterus has no function after the removal
of the appendages, but this has not been demonstrated, and
on the contrary we know that the sexual life of the woman is
very much better preserved by leaving the uterus, and that the
mental effect is also much better. A slow convalescence, or
even a second operation is preferable to its removal unless very
much diseased. It is a reflection on the correctness of the
reports of complete recoveries of such a large per cent, of the
cases by most excellent surgeons, when the uterus was not
removed, to accept the argument now being made in favor of
hysterectomy in all these cases. As stated by Dr. Davis at the
last meeting of the American Medical Association, he could
not agree with Dr. Sutton and others that pus in the tubes
was due togonorrhea in 75 percent, of cases. He thought that
puerperal infection was rarely the cause of more than 50 per
cent. Tubercular infection was rarely the cause and was not so
important as he claimed. However, the importance attached
to gonorrhea was against the argument for the removal of the
uterus, as the infection from this source was not deep and
could be removed with the curette. Because some patients
were not completely cured by the removal of the appendages
was no argument for hysterectomy in every case where the
bilateral operation was required ; for nearly all these could be
1896.]
SOCIETY PROCEEDINGS.
815
relieved by a thorough curettage. Some large uteri would
require in addition to this a high amputation of the cervix, and
only B small number would need a hysterectomy.
Vaginal incision for the drainage of pus in the pelvis, not
confined to the tubes, was a most valuable method of treat-
ment in a well-recognized class of cases, and had been prac-
ticed for a long time with gratifying results. A large number
of t hese cases require no further surgery. More recently large
pus tubes and ovarian abscesses had been incised and drained
through the vagina with permanent recoveries in a good pro-
|H>rtioii of cases. The uterus should always be curreted at the
same time. These were the very cases where the vaginal
operation and hysterectomy had been recommended so highly
by the French surgeons. Yet a considerable per cent, of
these cases could be relieved by vaginal incision and drainage.
The object of the surgeon should be, not so much toward still
farther reducing the death rate from the operation, but to
relieve the rases and preserve as far as possible organs which
luul k much to do with the woman's health and happiness.
Dr. L 11. Dunning of Indianapolis followed with a paper
entitled
SUM. I. II\ST! KIVl'OMY HE PERFORMED IN INFLAMMATORY
DSBI '. \sl IS OF THE PELVIC ORGANS.
The author discussed only that form of inflammation of the
pelvic organs and tissues denominated diffuse pelvic inflamma-
tion, and drew the following conclusions:
1. We recognize the utility of hysterectomy in a small per-
cent age of bilateral suppuration of the tubes and ovaries in
which the uterus is distinctly septic, and in cases of septic
uteri which can not be cured by other means after bilateral
sal pi ngo oophorectomy.
•J. We oppose hysterectomy as a rule in inflammatory dis-
eases of the pelvic" tissues upon the following grounds, viz. :
id i The uterus is the central organ of the reproductive system
and should not, except upon palpable and urgent cause be
extirpated, (6) It is only in rare cases that the uterus is so
far diseased as to resist the curative effects of appropriate
treatment, (e) The removal of the uterus profoundly affects
the nervous system and emotional nature of young women
deprived of this organ, (d) We oppose the removal of the
uterus from anatomic reasons, to wit : As a result the vagina
is shortened, the anatomic relations of the bladder, sigmoid
and rectum are changed, the elasticity of the pelvic diaphragm
is greatly diminished or entirely removed, che elastic tissue
being largely replaced by sensitive scar tissue. (<') In married
women it often disturbs" the sexual relations of husband and
wife and is apt to induce mental depression. (/) Vaginal
hysterectomy compels the use of drainage because of the
necrosis of tissue and suppuration induced.
SHALL THE UTERUS BE LEFT IN SITU IN EXCISION OF THE
ADNEXA?
This paper was read by Dr. E. F. Fish of Milwaukee, Wis.
The paper was a general defense of the uterus and an argument
in favor of leaving it in situ, if sound, after excision of the
appendages. It takes up and considers the pathologic condi-
tions requiring hysterectomy after salpingo-oophorectomy, as
well as the conditions which do not require it. The author
argues against all operations which leave a degenerate uterus,
such as Hegar'8, Tait's, Martin' sand Robinson's, except under
extreme conditions, and concludes thus : 1. That whenever it
becomes necessary to excise the uterine adnexa, if the uterus is
sound, leave it. ~2. Whenever we excise the tubes and ovaries,
andtheuterus, though in a pathologic condition, in our judgment
will yield to treatment, leave it. 3. Whenever it is necessary
to do an abdominal hystero-salpingo-oophorectomy and the
cervix is healthy, do a supravaginal amputation, as this leaves
the vaginal vault intact, i. Whenever it is necessary to do a
supravaginal amputation, suspend the cervix to the stumps of
the broad ligaments, or anchor it to the abdominal wall to pre-
vent prolapsus vaginae (Baldy). 5. Whenever it is necessary
to do a general ablation, and the cervix uteri is unsound, take
the entire organ because of the danger of carcinoma. 6. When-
ever a subserous or interstitial myoma can be removed without
too great damage to the uterus, do a myomectomy and leave
the organ. 7. Whenever we excise the appendages and leave
the uterus, ventral fixation is not an unsurgical operative
conclusion.
The author's reasons for leaving the uterus were: 1. That
it helps to maintain the woman's sexual integrity. 2. It
relieves the patient of much mental strain and is a prophylac-
tic measure to neurasthenia, melancholia and insanity. 3.
It tends to maintain the family ties unstrained. 4. It obvi-
ates the possibility of vaginal hernia, cystocele and proctocele,
and delays vaginal atrophy, and last of all, it holds up and
prevents shortening of the vagina.
A spirited discussion followed the reading of the above there
papers, and was participated in by Drs. L. S. McMurtry, John
M. Duff, Joseph Price, J. Henry Carstens, Albert Goldspohn,
George H. Rohe, James F. Baldwin, A. B. Miller, Walter P.
Manton, J. W. Bovee, Rufus B. Hall, W. E. B. Davis, E. F.
Fish ; some favored the abdominal and some the vaginal route.
Second Day— Mornino Session.
Dr. J. W. Long, of Richmond, Va., contributed a paper
entitled
DYNAMIC ILEUS.
Intestinal obstruction had been variously classified, but Dr.
Long regarded the classification adopted by Murphy as the
simplest and the most rational : 1. Adynamic ileus, always the
result of intestinal paralysis, due to varying causes, may be
clearly illustrated by such cases as those following injury to
the spinal cord and paralysis due to peritonitis. 2. Dynamic
ileus. This variety formed the subject of the paper and was
discussed in detail. 3. Mechanical ileus embraced such com-
mon lesions as strangulated hernia, intussusception, fecal im-
paction, etc.
We report one of Dr. Long's cases herewith. Mrs. C, was
brought to him on May 27, 1896. She is 21 years old, married
three years, but never pregnant. She is rather below the
medium size and height. In temperament she is of the spoiled
child type, not hysterical but rebellious. It was with great
difficulty that she could be induced to have any local treat-
ment or even take her medicines. After admission to hospital
her obstreperous disposition required all the tact and firmness
of a sagacious nurse. Early in April of this year the patient
had malaria followed by delayed menstruation, pelveo abdom-
inal pain and obstinate constipation. The malaria and men-
strual disturbance yielded promptly to treatment, but the
abdominal pain continued and gradually the ileus symptoms
became more and more pronounced. After exhausting every
other measure to move the bowels the patient was given chlor-
oform and by means of a Rickett's tube he succeeded in wash-
ing away a quantity of fecal matter. Notwithstanding there
was no improvement, the nausea and vomiting recurred oftener
and were more distressing, the pain and tenderness became
worse and a marked degree of tympany supervened. When
she was brought to the hospital there had been no movement
of the bowels for four weeks excepting what was washed away
with the colon tube while the patient was anesthetized. The
history justified the diagnosis of intestinal obstruction, while
the urgent symptoms demanded an immediate operation. The
abdomen was opened by a median incision. No mechanical
obstruction could be found, although a careful search was
made along the whole length of the intestine. The bowel was
moderately distended with gas and congested. A singular fea-
ture, however, was that at three points, two in the ileum and one
in the sigmoid flexure, the canal was constricted sufficient to con-
stitute obstruction. In the ileum one of the constrictions was
about 15 inches from its lower end and 6 inches long, the other
was nearer the jejunum and about 4 inches long. The lumen
was not entirely closed at either point, but was greatly reduced,
being less than half the normal size, while the diameter of the
remaining portions of the bowel was increased on account of
the distention with gas. No peristalsis was observed, but the
contracted portions could be dilated by " milking," the intes-
tinal contents alon^. In the sigmoid the limitations of the
contracted portion were not so sharply defined, but the lesion
was just as evident. The walls were thickened and the caliber
much diminished. Incidentally a small ovarian cyst on the
right side was discovered and removed. As the intestine had
been handled a good deal the abdomen was flushed with nor-
mal salt solution. The incision was closed with two tiers of
sutures, silk for the peritoneum, and interrupted silver wire
for the remaining layers. The recovery was most satisfactory
in every way. The bowels responded to the usual laxatives
and enemas on the second day, and from the first to last there
was not a hitch in her convalescence. The patient left the
hospital in four weeks, and three weeks thereafter took a trip
to Alabama. There could be discovered no evidence of lead,
or ptomain poisoning.
SPONTANEOUS RUPTURE OF UTERUS DURING LABOR AT TERM,
WITH SPECIMEN.
A paper on this subject was read by Dr. B. M. Hypes, of St.
Louis.
Mrs. O., aged 31, of German parentage, general health good,
previous to birth of first child. No history of any constitu-
tional disease. About one year after marriage, aged 26 years,
was delivered of a seven and one-half months child, which lived
but a few minutes. This labor was easy, lasting about six
hours. The midwife in attendance failed to get the after-birth,
816
SOCIETY PROCEEDINGS.
[October 10,
which was removed by the family physician twenty hours after
the birth of the child by means of his hand and the curette.
The woman then suffered for six weeks with a severe case of
metroperitonitis. From this time her health remained
impaired, and for the next few years she was a sufferer from
genernl debility, impaired digestion, and a "sore spot" in the
hypogastrium. Four years from the birth of her first child she
again became pregnant. During gestation, her general health
was much improved. She exhibited no functional disturb-
ances ; her only complaint was the sore spot over the fundus
of the uterus and to the right of the median line. Labor pains
began Sept. 16, 1895, at 10 p.m., at full term. The family phy-
sician was called ; found labor in progress, vertex presentation,
with normal condition of mother and child. The pains were
slight and progress slow. At 2 a.m., September 17, he gave a
dose of morphin and went home. At 9 a.m., upon his return
he found the patient comfortable, with occasional slight labor
pains. He left the house with injunction to call him when
signs of labor became pronounced. Patient remained quiet
during the day. Suddenly at 3 p.m., she was seized with vio-
lent vomiting, followed by the most excruciating pains in her
abdomen associated with rolling and tossing in bed, gasping
for breath, faint feelings, pallid face and rapid exhaustion ; in
short, the usual symptoms of abdominal shock. The family
physician was at once sent for and upon his arrival, at 4 p.m.
found her in complete collapse, with convulsive seizures. The
symptoms, with vaginal and abdominal examination, revealed
to him this dreadful condition : The presenting part receded,
the womb empty, and the child plainly felt in abdominal cav-
ity. The patient had suffered spontaneous rupture of the
uterus. He at once dispatched for surgical aid, but by the
time the surgeon, Dr. Meisenbach, arrived, the patient was
moribund. Still with the hope of saving the child, laparotomy
was hastily performed, and the child, which had escaped
entirely into the abdominal cavity, was extracted from a mass
of blood and amniotic fluid. It had ceased to live, and con-
tinued efforts at resuscitation failed to cause it to breathe.
The child was fully developed, male, weighed six pounds, and
was 18 inches long. The uterus, when removed from body,
presented the following condition : A rupture through fundus
superiorly, extending from half an inch from the entrance of
one tube to an equal distance from the entrance of the other;
the walls, at place of rupture, were comparatively thin. Pla-
centa located at middle third of uterus, anteriorly and to the
right, where the walls were much thickened. Vaginal portion
of the cervix almost obliterated as at term, and dilated
for the ready admission of two fingers. The lower zone of the
uterus exhibited no thinning or formation of Bandl's contrac-
tion ring ; no disease of tubes, ovaries, or placenta. A micro-
scopic examination was made soon after rupture and revealed
fatty degeneration of tissue at point of rupture. The points
of unusual interest in the case are the cause of the rupture,
and its location at the fundus uteri.
Dr. Edwin Ricketts of Cincinnati, Ohio, read a paper
entitled
POERO'S OPERATION AT OK NEAR THE FIFTH MONTH FOR SMALL
FIBROID OF CERVIX, ACCOMPANIED BY HYDRAMNIOS AND
TOTAL RETENTION OF URINE.
The author reported the following case and briefly com-
mented on it :
Mrs. M., white, aged 26, of short stature, mother of two chil-
dren of 6 and 3 years of age, with an abortion at 8 weeks early
in 1895, no specific history, and a patient of Drs. J. B. and C.
M. Warwick, of Lucasville, Ohio. Drs. Warwick first saw her
on Jan. 10, 1896, finding that she menstruated last in the first
week of November, 1895. They also found the uterus enlarged
and firmly bound down in the pelvis, especially to the left, and
extremely tender to pressure. There was uterine hemorrhage
in March, 1896, and again in the following month lasting for
twenty-four hours. Her labors and abortion were prolonged
and severe and accompanied by great suffering, while dilata-
tation in all instances was accomplished with difficulty. From
Jan. 10, 1896, she had no desire to urinate, nor could she void
a drop of urine without the aid of the catheter. Feb. 23, 1896,
she had severe labor pains lasting thirty six hours and accom-
panied by slight hemorrhage, the right portion of the cervix
being soft and the left hard, which condition was also present
at the time of operation. During April and until May 22, the
date of operation, she was very tender over the lower part of
the abdomen, and at times had a temperature above 100, with
a pulse running from 90 to 100.
Dr. Ricketts saw her in consultation at her home April
8, 1896, when for the first time motion of the fetus was barely
perceptible. May 22, Drs. Warwick, Kline, Sellards and Rick-
etts found her abdomen larger than it should be at full term,
which was due to the hydramnios present. There was no dif-
ficulty in moving the fetus freely in the abdominal cavity, so-
thin was the uterine wall. It was considered unwise to delay
surgical interference, and a Porro was therefore performed
under as strict asepsis as the circumstances would permit.
After the abdomen was opened, Dr. Ricketts passed his hand
down into the pelvis breaking up the pelvic adhesions. Upon
the delivery of the fundus of the impregnated uterus through
the abdominal incision, a rubber ligature was thrown around
it low down and tight enough to control any hemorrhage which
might occur. The fluid which escaped upon opening the uterus
surpassed in amount any he had seen delivered per viam
naturalem. After carefully sponging the parts, the wire was-
tightly adjusted below the rubber ligature by means of the
Koeberle clamp, and the rubber ligature then removed. After
the delivery of the placenta, the fundus was amputated, leav-
ing the ovaries and tubes intact. The abdominal wound was
closed with silk worm gut sutures, without stitching any tissue
to the stump below the wire. No drainage tube was used.
The extra peritoneal part of the stump was dressed with gauze,
moistened in glycerin and tincture of iron, the stump being;
held up by the double-hooded pin of Tait. The placenta and
fetus were small for near five months gestation, and the cord
was tied in almost a hard knot, harder than any he had seen.
The fetus had marked cyanosis and gasped but once. Recovery
of the mother was satisfactory.
TREATMENT OF PUERPERAL INFECTION.
Dr. H. W. LoNGYEARof Detroit, read a paper on this subject.
He first spoke of the prophylaxis and under this head of the
difficulty of securing reliable statistics regarding puerperal
mortality of patients under the care of midwives in this coun-
try. The prophylaxis was divided into general and specific.
He spoke of the treatment of infection from abortion and from
childbirth at full term, and presented an instrument for use in
removing the remains of secundines from the uterus, designed
by him. He also exhibited a self-retaining drainage tube of
his own invention and demonstrated its applicability. He
reported two cases of puerperal infection treated successfully
by the use of diphtheria antitoxin serum. He condemned the
performing of hysterectomy for puerperal septicemia except in
very exceptional cases.
(To be continued.)
The American Public Health Association.
[Special Correspondence of the Journal.]
The Twenty -fourth Annual Meeting of the American Public
Health Association held at Buffalo, N. Y., Sept. 15- 18, 1896.
(Continued from page 756. )
Wednesday — Morning Session.
After the customary announcements by the chairman of the
Local Committee of Arrangements, the daily report of the
Executive Committee was made by the Secretary presenting
the names of forty additional applicants recommended for
membership, who were thereupon elected.
The roll of the Advisory Council, which consists of one mem-
ber from each State, Territory, the District of Columbia, the
Army, Navy and Marine- Hospital Service of the United States,
the Dominion of Canada and each of the Provinces, and from
each state, territory and the Federal District of the Republic
of Mexico, eighty one in all, was then called and vacancies
filled by the President.
The scientific work of the day began with the reading of the
Report of the Committee on Disposal of Garbage and Refuse
by the chairman, Rudolph Hering, C. E. of the City of New
York. The elaborate nature of this admirable exhaustive
report precludes any epitome giving a correct idea of the sub-
jects of inquiry. Cities were considered in three classes : 1, the
large, those over 100,000 population ; 2, the medium, those
numbering between 10,000 and 100,000 ; and 3, the small, those
under 40,000- and the various methods of disposing of garbarge
in each, whether by cremation, by filling in and ploughing into
the land, by dumping into the sea, lakes or rivers, or by being
fed to animals, were considered with reference to cost and sat-
isfactory results. The cost ranged from 75 cents to 2 cents
per capita, according to population and the method of dis-
posal. The reduction process in use in about ten cities varied
from 15 to 67 cents per capita. Regarding cremation, the
expense was, in large cities from 2 to 6 cents, medium cities
6 to 10, and in one small city 20 cents. During the past year,
contracts have been made for the introduction of crematories
and one reduction plant in New York City, at a cost of S90,000
or 6 cents per capita. The committee have been awaiting final
1896. |
SOCIETY PROCEEDINGS.
811
results from experiments in Herlin and Hamburg before arriv-
ing at definite conclusions, and. therefore, asks to be continued.
Papers followed on the "Disposal ol the Garbage and Waste
la the Household" by Colonel William P. Morse of the city of
New York; another entitled "A Plea for the Domestic Dis-
posal of Garbage," by Dr. X. EL Wobdih of Bridgeport, Conn.,
member of the State Hoard of Health of Connecticut, and on
"The Disposal of Household Garbage and Excrement," by
Major William S. Tremaine, of the Medical Department of
the U. S. Arm} (retired). They were all based on the drying,
cleaning or combustion of waste by the kitchen range or
attachments to the stovepipe. This group of papers elicited a
in; lively discussion, participants being limited rigidly to rive
minutes.' Dr. GlBON, U. S. Navy, began by suggesting tho
r way of disposing of at least one half the garbage was to
eat it instead of throwing it into the "swill pail," and instanced
the custom in Prance and Switzerland of making palatable
dishes of surplus food as a wiser and more economic course
than throwing it away. Burgeon- General Sternberg, U. S.
Army, spoke of the necessity for the prompt disposal of gar-
bage, because of the danger of dissemination of putrescent
matter In house tlies. Many mysterious cases of diarrhea and
typhoid fever are due to direct contamination of flies, and cases
of cholera have been caused in the same way. Dr. Clark
agreed with Dr. Gihon that the American people cooked more
food than they can eat and consequently wasted it. Dr. Lee
introduced Dr. Yvrian. President of the Health Board of
Titusville. Perm., who described the method of burning gai-
ui that eity. where natural gas is the only fuel. Dr.
CabtEB of Detroit, said if the fluid part of garbage is poured
otf. all the rest can be burned in the ordinary tire box. Dr.
Mitchell objected to the endorsement of Major Tremaine' s
proposal to cremate excrement, as this had been known to pro-
duce typhoid contamination. Dr. Durgin of Boston, said that
of the two kinds of waste material, that collected outdoors and
that in the house, the latter must go through tire to be puri-
fied. He advocated plants situated at various sites in the city
n as short a haul as possible and he did not think the
duty of removing household garbage should be imposed on the
city. Dr. How k of Buffalo, referred to flies as filth dissemina-
tors. He said that if people were required to pay for the
removal of garbage as they do for their gas, they would not
make so much. Dr. Daniel Lewis, President of the State
Hoard of Health of New York, advocated curative stations
<\ ery few blocks for the removal of garbage instead of casting
it over the whole city. Dr. A. N. Bell of Brooklyn, insisted
on the necessity of compelling citizens to dispose of their gar-
bage in their own homes and at their own expense.
The report of the committee on "The Transportation and
Disposal of the Dead" was read by the chairman, Dr. Charles
O. Probst, Secretary of the State Board of Health of Ohio,
and was following by a paper on the "Quick or the Dead" by
Dr. Benjamin Lee. Secretary of the State Board of Health of
Pennsylvania, in which the claims of living over the dead were
set forth. Dr. Durgin of Massachusetts, recommended a steel
casket for deceased bodies and Dr. Smart U. S. Army, spoke
of the contamination of the soil of cemeteries from dead bodies.
AFTERNOON SESSION.
A paper on "Measures for the Prevention of Blindness," was
read by Dr. Augustin Chacon, vice-president of the Ophthal-
mologic Society of Mexico, and delegate from the State of
Aguascaliente8, Mexico.
Dr. Licien Howe of Buffalo, said that a large proportion
of the diseases inducing blindness is preventable, but only pre-
ventable when attended to early, and they are not attended to
early because the persons who have them in charge are apt to
say that they amount to nothing and the cornea is ulcerated
through before they become subjects of treatment. The law
ought to require every case of infantile ophthalmia to be
reported at once to some legally qualified practitioner. This is
done in some States, but in others, as North Carolina, it was
found it could not be passed because it affected midwives. He
offered two resolutions on the subject which were referred to
the executive committee. Dr. Valentine spoke on the same
subject, advocating Crede's method of prophylaxis.
A paper on "Miasmatic Fevers in the State of Sonora," by
Dr. Alberto G. Nonega, delegate from the State of Sonora,
Mexico, and one entitled a "Summary of Sanitary Legislation
in the State of Mexico," by Dr. Maximiliano Alvarez, dele-
gate from that State, were read, and followed by the Report of
the Chairman of the Committee on National Health Legisla-
tion, Dr. Henry P. Walcott, president of the State Board of
Health of Massachusetts, which was read by Dr. Wingate of
Milwaukee, a member of the committee.
The proceedings were at this point interrupted to permit the
introduction and customary reference to the Executive Com-
mittee of resolutions offered by Dr. Coventry of Windsor,
Ont., declaring as the sense of the Association that boards of
health should be absolutely independent of political consider-
ations influencing their appointment or conduct, and by Sur-
geon General George M. Sternberg, authorizing the secre-
tary to receive subscriptions for a monument in the city of
Paris to Pasteur, which brought Medical Director Albert L.
Gihon, U. S. Navy, who is chairman of the Rush Monument
Committee, to his feet, with an amendment substituting the
City of Washington for Paris, and the name of Benjamin Rush
for that of Pasteur.
Papers entitled "Obiter Dicta Concerning Sanitary Organiza-
tion," by Dr. A. Walter Suiter of Herkimer, N. Y., "Some
Thoughts Relative to National Health Legislation," by Dr. U.
O. B. WINGATE of Wisconsin, and "On the Sanitary Adminis-
tration of Unincorporated Districts," by Dr. Henry Mitch-
ell of Trenton, N. J., were then successively read by' their
authors. Dr. Mitchell proposed that the sanitary authority in
each township should be exercised by one individual, that
each local officer should hold office for five years, that exam-
inations of candidates for appointment should be by State
boards of health, and appointments only made from a list of
persons recommended by the State boards, that removals
should be made only for cause, and that the local health offi-
cer should be paid by the governing body for his services.
Dr. C. E. Holgate of New Haven, 6aid, that laws covering
these points had already been enacted in Connecticut, and Dr.
Caverly of Vermont, added that State to the list of those
having a county organization of health officers. Dr. Jones of
Greenwich, Conn., recommended the establishment of a Col-
lege of Preventive Medicine. Dr. Bryce of Toronto, spoke in
behalf of the measures recommended by the committee. Dr.
Lee of Philadelphia, explained the reasons for the delay in
sanitary organizations in Pennsylvania. Dr. Carter of Des
Moines, said that there were three thousand local health
boards in Iowa with as many physicians as health officers.
These are all subordinate to the State board of health and he
believed that all State boards should be similarly subject to a
National board of health. Dr. Daniel Lewis of New York,
was of opinion that the committee should be one of investiga-
tion and not one to make recommendations and he doubted
whether a resolution could be passed in this Association in
favor of a controlling National board of health. Dr. Mitchell
submitted a resolution on the subject of his paper, which went
to the executive committee.
The report of the "International Committee on the Preven-
tion of the Spread of Yellow Fever" was then read by the
chairman, Dr. Felix Formento of New Orleans, followed by
a paper entitled "Contribution to the Study of Yellow Fever
from a Medico geographic Point of View," by Dr. Eduardo
LicEaGO, president of the Association ; and a second "Contri-
bution to the Study of Yellow Fever Epidemic in Cordoba,"
by Dr. Gregorio Mendizabal, delegate from the State of
Vera Cruz. Dr. Formento's resolution recommending a
memorial from the President of the United States to the Span-
ish American countries which are permanent foci of yellow
fever, was referred to the executive committee.
It had been the intention to hold no evening session, but the
desire to hear the paper "On Isolation Hospitals" by Dr. John
L. Leal of Paterson, N. J., was so great that a recess was
taken until 8 p.m., when it was read and discussed by Dr.
Lindsley of New Haven, Dr. McShaneof Baltimore, who exhib-
ited plans of the new isolation hospital of that city, Dr. Barnes
of Boston, Dr. Plunkett of Nashville, Dr. Wright of New
Haven, Dr. Probst of Columbus, Ohio, Dr. Woodward of
Washington, D. C, Dr. Hibberd of Richmond, Ind., Dr.
Gihon of U. S. Navy, Dr. Durgin of Boston and Dr. Woodhull
of U. S. Army, the Association adjourning at 10 p.m., to attend
a reception by the Ellicott Club.
The Mexican delegates celebrated the eighty-sixth anniver-
sary of the Declaration of Independence of the Republic of
Mexico (Sept. 16, 1810) by a banquet at the Iroquois Hotel, and
later joined their fellow American and Canadian members at
the reception at the Ellicott Club.
Thursday — Morning Session.
The meeting having been promptly called to order by the
First Vice-President, Dr. Woodhull, the daily announcements
of the Local Committee of Arrangements was made by Dr.
Lucien Howe of Buffalo, and the Treasurer Dr. Henry D.
Holten of Brattleboro, Vt., presented his annual report, which
was referred to the Auditing Committee.
The funds on hand Sept. 28. 1895. amounted to $ 574.08
Received from sale of Transactions IIS. 40
Ret eived from membership dues 2,075.00
Received lrom advertisement In volume 118.00
$2,885.48
818
SOCIETY PROCEEDINGS.
[October 10,
Expenditures for reporting proceedings, publication
of volume, expenses of Secretary and Treasurer's
offices, expressage, postage and printing of early vol-
umes of Transactions to complete sets, amounted to $1,522.96
Leaving a balance in the treasury of $1, 362.92
The unexpended balance of the "index fund," for in-
dexing the early volumes, is $493.48
The Secretary reported from the Executive Committee, with
its recommendation of passage, the following resolutions, which
had been referred to it :
1. That the Treasurer be authorized to appoint an assistant
treasurer for Mexico.
2. The resolution of Dr. Smart, U. S. Army, to appoint a
special committee of five members to consider and report upon
some method by which international arrangements may be
effected to prevent the transmission of infectious diseases from
one country to another.
3. The resolution of Dr. Coventry of Canada, amended to
read, that the Association views with pleasure the growing
tendency of many States and Provinces not to manage and
control the bureaus of public health by political partisans, and
not to exclude from office sanitarians who may differ politi-
cally from the party temporarily in power. From a scientific
standpoint, as well as in the best interests of public health, we
welcome this tendency and take this opportunity to place our-
selves on record by declaring that it is conducive of the best
interests of public health to ignore political lines in the form-
ation of State, Provincial and other boards of health, and that
a copy of this resolution be sent to the Secretaries of State of
all Federal, State and Provincial governments of the countries
represented in this Association.
4. The resolution of Dr. WiNGATEof Wisconsin, amended to
read, that it is the sense of this Association that the Commit-
tee on National Health Legislation be continued and that
efforts be continued to influence the Congress of the United
States to establish a Department of Public Health at Wash-
ington, D. C.
5. The resolution of Dr. Liceaga of Mexico to constitute a
special committee of five to study the periods during which
each contagious disease is transmissible and the term during
which any person, who has suffered from such disease, is
dangerous to the community.
6. The resolution of Dr. Howe of Buffalo— "Whereas, about
one-fifth of all the inmates of schools and asylums for the
blind are there because of having suffered from purulent
ophthalmia in infancy ; and whereas, the ravages of this dis-
ease can be controlled in almost every case if proper treatment
is begun promptly ; and whereas, most of this blindness is due
to the wilful or ignorant neglect of nurses and midwives, thus
causing unspeakable misery to the innocent victims and great
yearly cost to the State treasury ;
"Resolved, That this Association heartily approves of the
laws already enacted in several States which compel midwives
and nurses to report these cases, under heavy penalty imme-
diately to legally qualified practitioners or to proper officers of
local boards of health ; and Resolved, That this Association
recommends and urges the adoption of similar laws in other
States of the Union or elsewhere wherever practicable."
All which were unanimously adopted.
The Secretary reported the names of twenty-five additional
applicants for membership recommended for election and who
were accordingly elected, after which the scientific work of the
Association was begun and continued in the following order :
Report of committee on "Pollution of Water Supplies," by
Major Charles Smart, Washington, D. C, Chairman ; report
of committee on "River Conservancy Boards of Supervision,"
by Dr. Peter H. Bryce of Toronto, Secretary of the Provincial
Board of Ontario, Chairman ; report of committee on "Protec-
tive Inoculations in Infectious Diseases," by Dr. Charles N.
Hewitt of Red Wing, Minnesota, Secretary of the State Board
of Health of Minnesota, Chairman.
At this point Vice-president Woodhull interrupted the pro-
ceedings to read a telegram just received from the medical
attendants upon the Second Vice-president, Dr. Henry Sewall
of Denver, Colorado, who was prevented from being present by
a serious attack of typhoid fever. The telegram was in reply
to one of sympathy sent by the Association on Tuesday upon
motion of Dr. Montizambert of Canada, and informed the
Association that his case was progressing favorably and thank-
ing it for the interest expressed.
A paper on "The Serum Diagnosis Test for Typhoid Fever,"
by Dr. Wyatt Johnston of Montreal, presented a modification
of the serum diagnosis test introduced by Vidal, which Dr.
Johnston had found expeditious and satisfactory. A paper on
the "Prophylaxis of Typhoid Fever," was read by Dr. J. Eliot
Woodbridge of Cleveland, Ohio, who stated that the flow of
the lake front of the city, which was originally clear white
sand over a sub-stratum of clay, had in the course of recent
years been covered by a progressively increasing layer of slime
several feet thick. He declared that for every case of typhoid
a city government is morally responsible, as all cases can be
traced to bad sewerage or polluted water. The paper was dis-
cussed by Drs. Carmona y Valle of Mexico, Cerna of Texas,
Kinyoun of U. S. M. H. S., Learned of Massachusetts, and
Bailey of Kentucky.
Dr. Durgin of Boston, offered a resolution deploring the
passage by Congress of a law preventing experiments upon
animals, which was referred to the executive committee.
The next series of papers excited the greatest interest and
elicited discussions and inquiries propounded by members to
the authors. "Practical use of Formic Aldehyde as a Disin-
fectant," by Prof. Franklin C. Robinson of Maine; "A Con-
venient Lamp for Generating Formaldehyd Gas," by Dr. A. E.
DeSchweinitz, Washington, D. C. ; "Preliminary Note on the
use of Formaldehyd for Room and Car Disinfection," by Sur-
geon J. J. Kinyoun of Washington, D. C.
afternoon session.
Report of committee on the " Cause and Prevention of Diph-
theria" was presented by Dr. J. J. Kinyoun, of Washington.
D. C. This was followed by papers on : "Diphtheria in Chi-
huahua," by Dr. Miguel Marquez, of the State of Chihua-
hua, Mexico : "On Bacteriologic Diagnosis as governing the
admission and discharge of patients in Diphtheria Hospitals,"
by Professor E. B. Shuttleworth, of Toronto : "On Prophy-
laxis of Paludism," by Dr. Alfonso Ruiz Erdozain of Hidalgo,
Mexico; " Paludism in the State of Morelos and its prophy-
laxis by Sanitary Measures," by Dr. Angel G avino, of the State
of Morelos, Mexico ; "Brief Notes on Public Hygiene in the State
of Tamaulipas," by Dr. G. Garza, of Laredo, Mexico; "On
Public Health in Tabasco, Mexico," by Dr. Juan Mcldson, of
Tabasco, Mexico ; " On Sanitation in Hospitals for the Insane,"
by Dr. George H. Rohe of Maryland; "Should Measles be
Quarantined? by Dr. Henry M. Bracken, of Minnesota:
report of committee on " Causes and Prevention of Infant
Mortality," by Professor Charles N. Hewitt, of Minnesota;
" On Mortality of Infants, the Causes and Means of Diminish
ingit," by Dr. Salvador Garciadiego, of Jalisco, Mexico ; "On
Diarrhea of Children," by Dr. Jose M. Benitez, of Guadala-
jara, Mexico. /
evening session.
Session began with the report of committee on the "Use of
Alcoholic Drinks from a Sanitary Standpoint," by Dr. Fel^ix
Formento of Louisiana. The committee favored the moderate
use of pure wines and beer, and advocated temperance and not
prohibition. A sharp distinction was drawn between such use
and alcoholism from the abuse of ardent spirits. "Spasmodic
and inefficient Sunday laws" were decried and the palm for
hard drinking awarded to Americans as a nation. Wine-pro-
ducing and wine and beer drinking countries were cited as
comparatively free from intoxication. Coffee-drinkers, accord-
ing to the committee, are seldom addicted to the immoderate
use of liquor.
The paper was discussed pro and con by Drs. Carter, Gros-
venor, Bailey, Vice-president Woodhull and Nelson R. Hopkins.
A paper was read "On the Bicycle in its Sanitary Aspects,"
by Dr. Albert L. Gihon. The speaker announced that he
had not set out to assail the bicycle and its ideal rider, but only
the hideously distorted creature whose unnatural posture is
affected by "expert" wheelmen. He adverted to the serious
harm to women from improper saddles, quoting from medical
wheelmen in support of his statements. As a mere matter of
health incentive, he said, pedestrianism remains unrivaled, but
for those who will not walk the bicycle under the restrictions
and limitations indicated may become an useful alternative.
If the bicycle is to merit praise, the ridiculous posture affected
by professional male riders and their imitators must be dis-
countenanced and denounced by wheelmen's periodicals, for-
bidden by wheelmen's clubs and discouraged by reputable
makers and dealers. Girls under the age of puberty should be
restricted by parents, guardians and teachers to short rides,
and no woman of any age be mounted on any other than a wide
elastic seat without anterior horn or central ridge. Lastly, the
gate of the bicyclist should be such as can be maintained with
the least personal exertion. The paper was briefly discussed
by Dr. Carter and Dr. Mosher of Ann Arbor, Mich.
This was followed by a paper ' 'On the Part that Public Instruc-
tion Should Have in the Way of Precaution Against Contagious
Diseases, by Dr. Carlos Santa-Maria of Durango, Mexico ;
"On Public Bathing Establishments, with a Description of the
New Public Bath in Brookline, Mass.," by Dr. H. Lincoln
Chase; "On Public Baths" (illustrated by stereopticon), by
Dr. W. H. Tolman of the city of New York.
(To be continued.)
1896.]
EDITORIAL.
819
THE
Journal of the American Medical Association
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Tins is obtainable, at any time, by a member of any State or local
Medical Society which Is entitled to send delegates to the Association.
All that Is necessary is for the applicant to write to the Treasurer of
the Association, Dr. Henry P. Newman, Venetian Building, Chicago,
111., sending him a certificate or statement that the applicant is in good
standing in his own Society, signed by the President and Secretary of
said Society. Attendance as a delegate at an annual meeting of the
Association is not necessary to obtain membership.
On receipt of the subscription the weekly Journal of the Association
will be forwarded regularly.
Gentlemen already members of the Association should send their
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All communications and mauuscript of whatever character, intended
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sheets returned, or in regard to subscriptions, should be addressed to
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Original communications are only received with the understanding
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INFORMATION WANTED.
It would greatly facilitate the prompt delivery of the Journal to
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it is omitted from the wrapper of their Journal, as we have been notl-
8ed by the postmasters of the larger cities that second-class mall mat-
ter not having street address, wonld be placed iu the general delivery
to await call.
SATURDAY, OCTOBER 10, 1896.
THE AMERICAN PUBLIC HEALTH ASSOCIATION.
The mere enumeration of the reports of special
committees and individual papers read at the recent
meeting of the American Public Health Association
at Buffalo, N. Y. (September 15-18), is sufficient evi-
dence of the amount of scientific sanitary inquiry
accomplished. Four addresses, sixteen reports of
committees and fifty-three papers — seventy-three in
all — constitute a formidable list, and when to these are
added the discussions on these reports and papers,
which are arranged in groups according to subjects,
these discussions being a characteristic of this body,
which it encourages and on which it justly prides
itself, its reputation as a working body can not be
questioned. The Association was actually in session
eight hours on the first day, eight on the second, nine
on the third and five on the fourth, a total of thirty,
the general business occupying scarcely an hour each
day. Giving thirty minutes to each report and limit-
ing voluntary papers to twenty, of which only five
were read by title, and restricting discussions to five
minutes, it will be seen how well the time was filled,
a result accomplished only by the admirable business
methods of this excellent body. The unflagging inter-
est of the old members was shown by the fact that
nine of the thirteen surviving ex-presidents were in
attendance and very actively engaged on duty as mem-
bers of the Executive Committee. Prof. Stephen
Smith of New York City, the founder of the Asso-
ciation and its first President (1872, '73 and '74) in
his address in acknowledgement of his enthusiastic
welcome at Buffalo declared he was especially gratified
at discovering that the Association still adhered to its
early practice of doing its administrative business
through an executive committee, thus taking the dis-
putations and hysteric jangling, by which so much time
is wasted in many large associations, off the floor and
permitting the legitimate work for which the Associa-
tion was organized to be performed. Every resolution
offered is read and upon being seconded referred
without debate to the Executive Committee, by which
it is carefully considered, amended, if thought best,
in substance or language, and referred back the follow-
ing day to be put upon its passage, or quietly tabled in
committee. The confidence in the conclusions of the
committee is such that debate seldom occurs and
dissent rarely. The composition of the committee
justifies this confidence. The five officers, six elected
members, of whom three are renewed annually, and
the ex-presidents secure a judiciary of old and experi-
enced members. Occasionally some disappointed
proposer of a resolution, on finding his hobby not
reported, jumps up with an amendment to the consti-
tution changing the composition of the committee,
usually by leaving out the ex-presidents, but a year
of sober reflection before the retaliating amendment
can be considered, has heretofore saved the Association
the loss of what may be considered its balance wheel.
The participation of the former presidents preserves
a constant policy and preserves it from local influ-
ences, log-rolling and hasty, injudicious legislation.
The duty of the Executive Committee is no sinecure.
It assembles early on the day preceding the annual
meeting and is in session the greater part of that day
and subsequently daily from 8 or 9 to 10 a.m., and
usually at night after the adjournment of the evening
general session, often when matters of importance
have been referred to it continuing its work until two
or three o'clock in the morning. The Executive Com-
mittee investigates every application for membership
and determines whether to recommend the applicant
for election. As stated, it considers every resolution
introduced into the Association, amending it as it may
believe proper, or changing its phraseology. It exam-
ines all papers and prepares the daily programs, and
generally discharges all the working duties of the
Association. An Advisory Council, consisting of one
member from each State, Territory, the District of
Columbia, the Army and Navy of the United States,
the Marine-Hospital Service, the Dominion of Canada
and each of the Provinces, and each State, Territory
and the Federal District of the Republic of Mexico,
besides acting as a nominating committee of officers
and selecting the place of meeting for the ensuing
year, also considers important questions of policy and
makes such recommendations to the Association as
shall best secure its objects. Through this council,
which is virtually a senate of over eighty members,
820
A SLANDER ON THE MEDICAL PROFESSION.
[October 10,
the equal representation of all the constituent nation-
alities and States is obtained, and its recommendations
in matters of vital importance have always been sus-
tained. At the meeting just ended, however, its
selection of the place of meeting for 1897 was reversed
for reasons that had not been presented to it.
The Executive Committee, the Advisory Council
and the Publication Committee (the last consisting
of the Secretary and and two members residing con-
veniently near him), are the three standing commit-
tees, and practically do all the general business, and
the splendid uniform series of volumes of its trans-
actions for the twenty-four years of its existence are
speaking testimony of the value of its sanitary work,
constituting a hygienic library containing information
which Florence Nightingale declared could not be
found anywhere in Europe. To the Chairman of the
Publication Committee, the Secretary of the Associ-
ation, Dr. Irving A. Watson of Concord, N. H.,
Secretary of the State Board of Health of New
Hampshire, now in his fifteenth year of office, is due
the invariably neat and appropriate announcements,
circulars, etc., which are characteristic of this body.
Indeed, Dr. Watson's suggestion of a desire to resign
the Secretaryship (which is a triennial office), on
account of the proportions its duties have assumed,
alarmed the members at the prospect of losing an
officer so exceptionally qualified, faithful and efficient.
The American Public Health Association is char-
acteristically American. In 1884 it extended its
membership to Canada and in 1890 to Mexico, the
membership of both these countries embracing their
most distinguished sanitarians and health officers, who
have been as regular in attendance, as interested in
the work, and as enthusiastic and able contributors as
those from the United States. Two annual meetings
have been held in Canada, in 1886 and 1894, and that
of 1892 in Mexico; and both Ottawa and Toronto con-
tended for the meeting in 1897.
An especially commendable feature of this Associ-
ation is that it is in no sense a junketing body. It
goes where it hopes to do good and devotes itself to
that end. It asks no courtesies and is prepared to
assume all the expenses of its meetings. Nevertheless,
civilities have been everywhere generously showered
upon it and accepted conditional upon their non-
interference with its legitimate work. At Buffalo
the Local Committee arranged its excursions after the
formal adjournment, only requesting that one night
might be assigned for a reception at the Ellicott Club,
but an interesting paper induced the members to meet
before the reception and hold a session of a couple of
hours before presenting themselves at their hosts.'
The system of special committees, covering almost
the whole ground of public hygiene, secures a concert
of inquiry. At Buffalo, sixteen of the seventeen
special committees (now numbering twenty) actually
presented reports, and an examination of the author-
ship of these reports and of the individual contribu-
tions, shows that all but five or six of the seventy-three
writers hold or have held responsible representative
positions as members of State and Provincial Boards
of Health and of the Superior (National) Board of
Health of Mexico, as health officers of cities, and as
Government officials of the United States Army
and Navy and the Department of Agriculture, thus
directing their several lines of inquiry in com-
mon channels. Dr. Stephen Smith claims for the
Association the credit of having developed the system
of State and Provincial Boards of Health into its
proportions. Originally the subject of a special com-
mittee, whose work grew so large that a whole session
was devoted to it exclusively, becoming later a Con-
ference of State Boards of Health, meeting at first
coincidently with the Association and later inde-
pendently, the new organization has never lost interest
in the parent body, as shown by the numbers of presi-
dents, secretaries and members of State and Provincial
Boards of Health who participated in both the business
and sanitary work of the late meeting as chairmen and
reporters of special committees, authors of papers and
disputants in the discussions. Perhaps the crowning
glory of the American Public Health Association has
been the establishment of a fraternal union of the
United States, Canada and Mexico in one body, in
which international distinctions are abolished, and the
sanitary officials of the three countries harmonized in
the interests of a common humanity in a mutual policy
of protection against epidemic importations.
A SLANDER ON THE MEDICAL PROFESSION.
In a medico-legal congress a year or two ago it was
asserted that it was the practice of reputable physi-
cians to deliberately shorten life in cases of painful
and incurable disease. A large portion of the public
undoubtedly accepted this statement as gospel truth
and possibly thought it nothing extraordinary. The
superstition that the orthodox treatment of human
rabies is of this character is held by many of the igno-
rant in the community, and even grosser errors of the
same general nature may be occasionally met with
among them.
The lawyer who made the statement referred to,
defended and advocated the practice and his utter-
ance was, without question, based on no knowledge
but was offered as a part or support of the argument
he was making before the congress. It is a pity his
ideas of the ethics of another learned profession
should have been so hazy, and also that he was not
more scrupulous as to his facts. His ideas were
noticed to some extent by the medical and secular
press at the time; the public had at least a chance to
be enlightened and it is probable that, on the whole,
the utterances did little harm.
L896.]
THE MANIA FOR PROPER NAMES.
821
The not ion, however, that incurable diseases should
be cut short by an expeditious euthanasia is every
little while advanced by some one-sided humanitarian.
The latest comes from California, where a misguided
clergyman offers an elalwrate proposition of a law for
the doing away with the victims of incurable disease.
It provides that "a commission of eight persons of
high character and unassailable reputation be
appointed by the governor of the State, four to be
physicians, and the others to be the district attorney,
the chairman of the health board, and two public spir-
ited citizens of pronounced humane tendencies. The
Bufferer should appeal to the commission with the
consent of liis family, then the ease should be thor-
oughly investigated by the commission, and if the
physicians are satisfied that every known remedy has
been tried, and the case is absolutely incurable and
the patient has Buffered intolerable pain, and the rela-
tives can show that they act from none but humane
motives, and all these points have been settled to the
satisfaction of the commission, it should be empow-
ered gently and humanely to put an end to the misery
of the affected person."
The above in its elaborate legal ordering of homi-
cide is very reminiscent of an imaginative work of
fiction by an English writer of note that appeared
some ten or fifteen years back, and, like it, might be
taken as a satire on certain extreme social and economic
tendencies. The author of the present proposal, how-
ever, is accepted as in earnest, and is probably only
one of a large number who in their ill- regulated phil-
anthropy throw well known moral and social princi-
ples to the winds. It is easy to see to what conse-
quences his line of reasoning would lead, if the idea
of the sacredness of human life were abolished, as
would be necessarily the case with the adoption of
any such plan.
The medical profession owes to itself and to the
public a duty in this matter. It is not that it is
misunderstood and misrepresented; there are many
respectable and even estimable people who are more
or less demoralized by the publication of such propo-
sitions, and public sentiment, which ought to be on
the highest plane, is degraded to a very material
extent by them. Society needs all the safeguards it
possesses and the belief in the absolute inviolability of
human life is one of the most important of these.
There is no need, of course, to say that regular physi-
cians should not encourage any belief in popular
impressions derived from such publications, but there
may be a very positive utility in their actively denounc-
ing them. At all events they should endeavor to cor-
rect any popular belief that our profession sanctions
even the suggestion of the violation of human or
moral laws. It ought to be unnecessary to say that
this should be done, but if we grow familiar with such
charges and consequently neglect or ignore them, we
have no assurance that such neglect will not appear
to the uninformed as a tacit acknowledgment of their
truth. When clergymen make such propositions as
the one here reported what wonder that a credulous
public should think it possible that doctors might be
ready to endorse them or carry them out. The
commandment "Thou shall not kill," would seem
to be binding even upon the clergy. The public
knows little and misunderstands a great deal in
regard to the ethics of our profession and it is not
amiss therefore to occasionally correct a possible
misapprehension that they are not in all respects
strictly in accord with the highest ethical standards.
There is little danger, judging from our past, that we
will protest too much.
THE MANIA FOR PROPER NAMES.
Several of our foreign exchanges are protesting
against the practice of rendering the study of anatomy
more difficult by encumbering the text books with
the names of parts of the body which neither describe
nor locate them, but merely commemorate the name
of some obscure anatomist. The boast of the student
now is that he can quote more proper names than the
rest; but they are of no benefit to him in locating the
parts designated by them. How much better to call
it the anterior sacro-dural ligament than Trolard's
ligament, for instance? It is a longer name, but it
means something, and enables the student to place it
at once.
In surgery the abuse passes all proper limit. It is
not only perplexing to enumerate the various opera-
tions, but in many cases a name has been hastily
applied to an operation not devised by the person
named. It is simply an impossible thing for the
average surgeon to mention seriatim the various
incisions that have had proper names tacked on to
them, and then the question of priority is generally
impossible to settle by any amount of research. One
of our recent dictionaries has devoted much space to
the definition of operations catalogued under proper
names, and as for instruments, many of them have
two or three claimants. The familiar example of a
cranial saw first figured in the " Chyrurgeons Store-
house " of Scultetus, coming to us for a long time
under the name of Hey's saw, and by many still
called by that name, affords ample evidence, if any
more were needed, of the loose practice in this matter.
In medicine there has been a singular passion for
naming diseases for some favorite, or somebody who
is presumed to have been the first to give a descrip-
tion of the disease. In some cases we have conflict-
ing claims of priority, but the number grows with too
great rapidity, and in these days of almost total neg-
lect of the history of medicine, serious and absurd
errors are perpetuated. Now, let us keep close to
822
CORRESPONDENCE.
[October 10,
nature in our nomenclature, and have it as nearly
descriptive of the thing itself as possible. Then we
approach the true scientific ideal.
CORRESPONDENCE.
Medical Education.
Montclair, N. J., Sept. 26, 1896.
To the Editor: — The two editorials upon medical education
in the last issue of the Journal are exceedingly well consid-
ered and show a decided disposition to go to the root of things.
What is particularly pleasing in your remarks is the strong
demand for thoroughness in our medical schools, and the inti-
mation that until better methods of teaching are adopted the
mere lengthening of the curriculum will avail little. The medical
schools seem disposed to indulge in much self congratulation
because a number of them have extended the period of study
required for a degree of doctor of medicine to four years,
and most of them now seem to require more or less preliminary
education. In the latter direction it hardly seems possible
that they can go too far. But the rigid requirement of four
years study of medicine is perhaps not so wise a measure. At
all events it has always seemed to me that the object to be
gained in going to a medical school is a knowledge of medicine
sufficient to enable a man to enter upon the practice of it, and
some men will easily acquire in three years what it will take
others four to accomplish. No two minds are precisely alike
in childhood and as individuals approach maturity these men-
tal differences increase rather than diminish so that it may
prove a hardship and an injustice to a man with an unusually
brilliant and acquisitive mind to be forced to spend the same
amount of time in studying for his degree as the more slow
going individual. Your editorial speaks of bedside examina-
tions of students. In like manner the candidate should be
examined in the deadhouse as to his knowledge of gross path-
ology, should operate upon the cadaver (if living subjects are
not available), should bandage the manikin, etc. He should
compound prescriptions, and be required to detect and demon-
strate incompatables and poisons and should give the anti-
dotes to the latter ; in short he should be put through an exam-
ination which would really reveal what he knows.
No written examination, no oral examination, no bedside
examination, nor even the certificate of good moral character,
alone is a sufficient test of a man's capacity to enter into prac-
tice. But a judicious combination of them all is, I submit,
necessary and should be adopted in each case. Let the exam-
inations last from three to six days. The examining board
should sit constantly or nearly so and the candidate should be
allowed to appear before it whenever he chooses. Let a fee
sufficient to pay the board's expenses, say from §50 to $100,
be charged each candidate. If he only desires to take part of
the examinations, there seems to be no reason why he should
not do so, paying only the fees of those examiners before whom
he chooses to appear.
One student might qualify himself to pass all these examin-
ations in two or three years. Another, who would perhaps
make a sober and more reliable practitioner, would require four
or five years. And and this is the most satisfying part of the
plan — a dullard, a superficial or lazy student, or one whose pre-
liminary education had been quite defective could never pass
at all. What a glorious day it would be for American medi-
cine if such a plan could only be realized ! How such a body of
trained examiners would sift out the weak and badly prepared
candidates ! No amount of cramming would enable a weak or
illy prepared man to pass a competent and trained examiner,
who could take the applicant to the bedside, to the operating
room, to the laboratory and to the dead house, who would
require one or more carefully written papers upon his particu-
lar subject, and any number of answers both oral and written
that he might think proper.
Such an examination as the one outlined used to be required
and I presume still is by the Army Examining Board. When
this board had finished five or six days' examination of a can-
didate, both the board and the candidate felt that the latter
had told all he knew. It was the only fair and satisfactory
medical examination which I ever passed. My examinations
for my degree were trivial, almost foolish, and my examinations
for the hospital were too short and were greatly a matter of
luck.
It has been asserted over and over again that an examina-
tion does not show what a man knows ; and this allegation is
measurably true of such examinations as 1 have last spoken of,
depending for their result as they do upon so many fortuitous
circumstances, as, e. g. , the readiness and assurance of the
candidate in case of oral examinations, and his capacity for
cramming in case of written examinations. But an examina-
tion that takes plenty of time and which attacks the can-
didate's fund of knowledge in various ways as, for instance,
setting the ready and superficial man to write answers which
require thought, accuracy and careful study, and on the other
hand, asking the slow, methodical man, whose written answers
may be good, such questions orally as to reveal whether his
work has covered sufficient ground, or taking the bookish man
to the bedside or the laboratory and letting him show whether
he can put his theories into practice, etc.
If the medical schools, the American Medical Association,
the New York Academy of Medicine and every representative
body of physicians and the profession at large will unite in
insisting upon competent boards of examiners in medicine
(whether they be State or National) we may sometime get such
bodies of examiners and such examinations that the degree of
doctor of medicine shall of itself confer distinguished honor.
Our medical schools and our physicians would in that case no
longer be looked down upon by our foreign confreres. The
greatest good for the greatest number would be attained
because the average physician would be a man of sound educa-
tion and broadened views. This state of affairs would per-
haps be rather near the millenium, but it is really not entirely
beyond the range of possibility. Very respectfully yours,
Richard C. Newton, M.D.
Expert Medical Testimony.
Philadelphia, Sept. 28,
To the Editor: — There have been many papers and articles
written on the subject of expert testimony but none I think so
clearly express what is needed in courts as that published in
our Journal of Sept. 26, by L. Harrison Mettler of Chicago,
under the title of "Insanity in Court."
The Doctor's arguments are so convincing that criticism is
well nigh disarmed. His demand for a separate medical trial
to precede the civil where a plea of insanity is offered, carries
great weight and would seem to be perfectly fair.
The commission, suggested by him, to be composed of
learned and experienced experts appointed by the supreme
court or in other constitutional way beyond the reach of poli-
tics is certainly to be desired.
It is only too true that "the present system does not carry
out the abstract spirit of the law that every man shall be tried
by his peers ; but on the other hand works injustice in many
cases of real insanity and favors the exercise on the part of
criminals of feigned insanity." Such being the case, is it not
time that the great American Medical Association should
assert itself and formulate and pass resolutions in accordance
with the progressive ideas on the subject of expert testimony.
Yours very truly, T. Ridgway Barker, M.D.
1896.]
PUBLIC HEALTH.
823
PUBLIC HEALTH.
Smallpox at Marseilles. Since 1S72 there have only been eight
yuan when the deaths from smallpox at Marseilles have been
less than a hundred, and in 1886 they were over 2,000. There
have already been .'15S deaths in the first quarter of 1896, and
the lax preventive measures render the city a menace to the
rest of Europe. The disease la practically endemic in the Ital-
ian colonies there, which contain about 1(X),000 souls, with
thirty or forty families crowded into buildings that would
scarcely accommodate ten properly,
Oil In Urinals. It has been found that if urinals are coated
with heavy oil, the urine leaves no traces nor odor as it runs off.
The ITS public urinals of Vienna are treated in this way, with
satisfactory results, saving the city £.'$0 a year for the water
■apply of each. Many other European cities have already
adopted the use of oil for this purpose. The urinal is scrubbed
with a broom and plenty of water once a week or fortnight.
When it is quite dry it is painted with thick mineral oil, ob-
tained by distilling petroleum. Another system has a perma-
nent syphon supply of oil. Journal cTHygi&ne, September 30.
Successful Retrovaccination. The Xew York Health Board,
after a long series of experiments, has solved the problem of
retrovaccination, the vaccination of calves with matter taken
from vesicles on children. Early attempts in this direction
gave imperfect results on account of the choice of improper
kinds and methods of collection from the children. A report
submitted by John H. Huddleston, Medical Inspector, shows
that complete success has now been attained in the manufacture
of vaccine virus. In all. fifty calves have been inoculated with
the virus taken from children. In forty-seven of these the
results of the clinical test of the virus thus produced are
known. The test consists in vaccinating three places on each
of five previously vaccinated children. With the virus
obtained from the animals there have been vaccinated 123
children, with a total result of 367 vesicles obtained out of 369
possible. In over 300 cases vaccinated and inspected this
month at the department, 95 per cent, were successful, and the
B per cent, of failures were all revaccinations.
The Distribution of Sterilized Milk la New York and Brooklyn.—
Statistics obtained at the health department show the good
effects of the free distribution of sterilized milk in Brooklyn
under the auspices of the Board of Health, a charitable work
that was made possible through the philanthropy of Mr.
Nathan Strauss. The death rate during the second week of
the recent hot weather among children under five years of age
was only 31.4 of the total number of deaths, which is quite a
remarkable showing when it is considered that the general
death rate was exceptionally high owing to the excessive heat.
It is necessary to go back to the beginning of June to find a
week when the death rate among children was as low as that.
During the period when the heat was most intense Mr. Strauss
sent over to Brooklyn about 1,500 bottles of sterilized milk a
day. A large force of men was employed at the New York
depots, getting the milk ready for distribution, and it was
transported to Brooklyn at the expense of and with the wagons
and horses of the donor. — Boston Medical and Surgical
Journal.
Treasury Regulations Regarding Immigrants. —The Boston Medi-
cal ami Surgical Journal states that the Treasury Department
has issued an order designed to prevent the spreading of con-
tagious disease by immigrants in other places than the port of
entry. It provides that after arrival at a quarantine station of
a vessel upon which there appears, or has appeared during the
last voyage, a case of cholera, smallpox, typhus fever or plague,
and after quarantine measures provided by regulations of the
Treasury Department have been enforced and the vessel given
free pratique, it is ordered that notification of the above-men-
tioned facts be transmitted by the quarantine officer to the
commissioner of immigration at the port of arrival, whose duty
it shall be to transmit by mail or telegraph to the State health
authorities of the several States to which immigrants from said
vessel are destined, the date of departure, route, number of
immigrants and the point of destination in the respective
States of tho immigrants from said vessel, together with the
statement that said immigrants are from a vessel which has
been subject to quarantine by reason of infectious disease,
naming the disease. This information is furnished to State
health officers for the purpose of enabling them to maintain
such surveillance over the arriving immigrants as they may
deem necessary.
Toxicity of Alcohols. Austria, Switzerland and Belgium are
about to, or have already, established two grams per litre as
the maximum of impurities allowed in alcohols, and the latter
country forbids certain substances absolutely. Professor
Kiche in a vigorous address before the Acad, de MeM. protests
against the impression produced upon the public by this and
similar legislation, that it is only the adulterations that render
alcohol injurious. The people should be educated that the
alcohol itself, brandies, etc., are distinctly toxic; and he
asserts that there should not be any government authority,
tacit or official, for its use as a beverage. He adds his
testimony that the spread of alcoholism in recent years is
appalling, and describes the customs prevalent in Normandy,
where the laboring classes, young and old, all take their
coffee two or three times a day, and always with cognac.
The mothers even take a bottle of this "coffee" to their
little children in the creches. At one small town the amount
of pure alcohol consumed per capita is more than nineteen
litres a year — Bulletin, September 8.
The Abolition of British Quarantine The Lancet says that
under a "Public Health Act of 1896" we have this year, will
be done away with the last vestige of quarantine in the United
Kingdom. The principal section of the Act is the first one, in
which power is granted to the local government board to make
regulations, just as they have already done for the purposes of
cholera, as to the hoisting of signals by vessels having any case
of infectious disease on board ; as to the questions to be answered
by masters, pilots and others ; as to the detention of vessels
and persons infected ; and as to the duties of certain individ-
uals under the regulations. The term "epidemic, endemic, or
infectious disease" naturally includes yellow fever and plague,
the only two diseases as to which quarantine was carried out,
and since all the quarantine acts mentioned in a schedule are
repealed, the only method of dealing with these two quaran-
tinable diseases will in the future be that which has now been
adopted for many years as regards cholera. In Scotland and
in Ireland the local government boards of those portions of
the kingdom acquire similar powers, and it may be assumed
that the regulations made in the three portions of the United
Kingdom will be alike in all essential respects. The Act comes
into operation on November 7 of this year, and by that time
new regulations will doubtless have been issued to give effect
to its provisions.
Dangers of Handling Skins. At the request of the French
authorities, Prof. Riche has been investigating the trade in
skins to determine the dangers of handling them. He found
arsenic in skins from China, Chicago, Buenos Ayres, Australia
and Mexico, but he does not consider the danger from arsenic
so serious as the possibility of infection from the anthrax
microbes. He therefore recommends the following precaution
which apply to both and have been promptly enforced in Paris,
where over two million goat skins alone are handled annually
in the tawing works and nearly a million in the morocco fac-
tories, the majority received from China. The bales should
824
PRACTICAL NOTES.
[October 10,
be opened in the open air, or at least in an open shed, the
ground kept wet with plenty of water or some antiseptic. The
workmen should put on special garments closed at the neck
and wrists, or at least a long buttoned blouse, with rubber
gloves. The face, hands, arms and neck should be washed
with an antiseptic immediately afterward, and the locality
carefully swept and irrigated. The bales should never be
carried in the arms or on the back, but always on carts or
barrows, and they should be stacked in the store-rooms in low
piles. The rooms should have openings on all sides and if
there is no communication with the sewers, the refuse water
should be collected in tight cisterns. He also called attention
to the great danger of poisoning from the orpin used in tanning,
which is a mixture of sulphid of arsenic and arsenious acid.
This is applied with a mop, but the skins are then folded and
carried by hand to the pile, which is a frequent cause of ulcer-
ations. He suggests the substitution of sulphid of sodium,
which produces the same effect and would put an end to the
dangerous manufacture of orpin. — Journal d' Hygiene, Septem-
ber 17.
On the Prevention of Ophthalmia Neonatorum.— We have before
us two pamphlets by Dr. Wm. George Sym of Edinburgh bear-
ing upon the conditions that obtain in Scotland regarding
blindness from ophthalmia neonatorum. The more recent of
the papers is an address read before the Medico-Chirurgical
Society of that city, in March, 1896. In it he has briefly
sketched the various modes of treatment and prophylaxis, and
emphasized the importance of cleansing the face of the child
from any contamination acquired during its passage through
the vagina before any lotion was applied or any bathing car-
ried out. Statistics of blindness in the latest census returns
showed that there were more than five thousand alive in Eng-
land and Scotland who were blind from this entirely prevent-
able disease. On comparing the statistics of blindness for
England with those for Scotland it was found that in the
former there were 809 blind persons per 1,000,000, in whom 1
in every 6 was "blind from birth," while in Scotland there
were only 695 per 1,000,000 of the population, and of these only
1 in 7.7'was "blind from birth." Children who became blind
during early infancy were classed in the census papers as
"blind from birth." This marked difference in favor of Scot-
land the author attributed, in part at all events, to the very
much larger proportion of births in England attended by mid-
wives and not by regular practitioners. He urged the neces-
sity of taking the greatest care to see that all women educated
as midwives or midwifery nurses should be thoroughly
instructed in this matter. In the event of the Midwives Bill
passing and being extended to Scotland this would come to be
of paramount importance. Dr. Sym gave an account of the
legislation in force in certain countries with the view of stamp-
ing out the disease. In Austria, Switzerland, eleven States of
the American Union, and other countries, midwives were lia-
ble to more or' less severe punishment for failure to report
cases that occurred in their "practice." The Ophthalmolog-
ical Society's (1885) scheme for giving out to each person
registering a birth a slip bearing a warning as to the danger of
the disease fell through, but in Glasgow and certain other
towns this had been done at the expense of the corporation,
and Dr. Sym urged a similar proceeding in Edinburgh. Con-
trasting medical practice twenty or thirty years ago with that
of to-day, the number of cases of ophthalmia in infants was
vastly less at the present time, and the cases as a rule were
not so virulent.
The Infectious Disease Hospitals of Berlin.— The Sanitary Jour-
nal, June, has a special report on the fever hospitals of Europe.
The institutions at Berlin are reported as having the modern
improvements and a talented staff :
' 'Berlin affords some of the best examples of isolation hospitals
in Northern Europe. There the study of infectious disease is
carried on with the patient assiduity and thoroughness charac-
teristic of German modern science. In the Koch Institute,
established by the famous professor whose name it bears, all
kinds of febrile disease are studied in a series of highly-
equipped laboratories by graduates and students, under the
superintendence of highly qualified experts, presided over by
the Professor himself. In the adjoining grounds, close by the
Charitd Hospital, there is an experimental hospital laid out
by Dr. Koch upon his own principles, in which are treated all
kinds of infectious disease, including tuberculosis and lupus.
Here it may be observed that all over the continent I found Dr.
Koch recognised as the leading medical modern exponent of
the treatment of infectious disease and of bacteriologic science.
His pupils are already among the most prominent teachers in
many continental medical schools, and some of their discover-
ies— notably that of Loftier in diphtheria— have produced
highly beneficial results. The principal hospitals in Berlin for
the treatment of febrile diseases are the Moabit, capable of
accommodating 900 patients, constructed upon the plan of
single floored pavilions and for the most part of wood ; the
Friedrichshain Hospital, built in 1874, affording accommoda-
tion for general as well as fever patients and built in two, and
in one or two cases, three floored pavilions; the Urban Hos-
pital, opened in 1890, with accommodation for 600 patients
of ali classes, showing the most that can be made of limited
space where ground is dear within a large city, and also
built in two or three-floored pavilions, and lastly, the Emperor
and Empress Frederick Fever Hospital for Children, recently
erected by the Berlin municipality, where the results of the
most modern scientific research have been adopted in the gen-
eral plan of the hospital, which is laid out in single-floored
pavilions."
PRAGTI6AL NOTES.
For Infantile Eczema.— Dust with the following powder : Pulv.
zinc oxid. gms. 15 ; pulv. amyli 32 ; pulv. camphor 2. For itch-
ing, paint on the skin : Tr. camphor, tr. benzoin co. tin c.c. 32. —
Dr. C. E. Lockwood, in Med. News. September 26.
New Treatment of Warts.— Laubenburg has discovered that if
a spot is touched with acidum nitr. fum. and then immediately
afterward with acidum carbol. pur. liquef. there is strong
chemic action, the effects of which penetrate deep into the tis-
sues and completely and permanently cure warts, condyloma,
angioma, etc. — Cbl.f. Chir., August 8.
Permanganate of Iron in Eczema. The Monitor Midico, August
1, quotes from an exchange that both dry and serous eczema
are successfully cured by moistening them two or three times
a day with a 1 to 2 per cent, solution of permanganate of iron
applied on a cotton wad. It is also recommended for other
skin affections accompanied by pruritus.
New Needle Lancet for Secondary Cataract. —Stilling of Strasburg,
has been using very successfully in his practice the last year
and a half, a needle lancet shaped like the half of an arrow,
its two cutting edges doing away with the necessity of using
the cataract knife. It is illustrated and described in detail in
the Revue Gen. d' Ophthalmologie, August31.
The Siesta and Digestion.— Some recent experiments are
reported in the Gaz. degli Osp. e delle Clin., of September 1,
which demonstrate that a nap after eating weakens the mus-
cular action of the stomach and increases the secretion of acid.
Repose in a horizontal position, without sleeping, increases the
muscular action without increasing the secretion of acid. The
conclusions are therefore that it is advisable to lie down after a
meal, but not to fall asleep, especially in case of dilatation of
the stomach or hyperacidity.
Multiple Vesical Puncture. Centra describes a case of retention
of urine with serious symptoms due to asymmetric hypertro-
phied prostate. He withdrew the urine by vesical puncture
and in four days the congestion and hypertrophy of the pro-
state were reduced to such an extent that the patient could
urinate normally. The interesting feature of the case was the
number of punctures necessary to effect a cure, three each day.
189(5.]
NECROLOGY.
825
They were made at different points along a horizontal line
commencing 1 cm. above the upper edge of the symphysis
I'ubis, and produced no inconveniences. — Qaz. degli Osp. e
delie Clin., August 30.
Gangrenous Hernias. Bogdanik suggests that better results
will be obtained in gangrenous hernias if the pus and sur-
rounding tissues are cleansed and disinfected before the peri-
toneum is touched. He describes a case thus treated in the
Cbl. f. Chir., August 15, proving the advantages of rendering
the Held of operation a clean wound before proceeding to the
operation proper. He adds that the scissors, knife and a few
clamp forceps are all that is needed if the suture of the intes-
tine is made exact.
Celluloid Soles for Flat Foot.-Kirsch recommends the use of
celluloid instead of metal, for insoles in the prothesis of flat
foot, as they require no skill in making and are exceptionally
cheap, li^ht and easy to walk on. A sheet of celluloid 1.5 to 4
mm. thick according to the weight of the patient, is placed on
a cast of the foot and kept in place by a handkerchief, held by
the twisted ends as a handle. The whole is then dipped into
boiling water for a minute or a half, which softens the cellu-
loid. The ends of the handkerchief are then twisted tighter,
and the celluloid molded to the cast as it hardens. It can be
softened again as often as may be necessary. The edges are
smoothed level, cut into the proper shape and sand-papered,
and the under side made rough to prevent slipping in the shoe.
If the celluloid is painted with soluble glass it becomes almost
fireproof, which is an important improvement for the celluloid
bandages described in the Journal, August 22, page 437, but
is scarcely necessary for an insole. — Cbl. f. Chir., August 29.
Treatment of Sunstroke. Desanti's article in the Caz. degli
Osp. edelle Clin, of August 30, commences with : Do not let
it happen. In enlisting soldiers, for instance, it is much bet-
ter to reject those who are liable to have sunstroke, men with
weak hearts, anemia, or any chronic trouble, and alcoholics ;
in short, all those who have inherited or acquired a tendency
to morbid conditions. When sunstroke occurs, after removing
the patient to the shade and loosening his upper clothing, the
action of the heart must be stimulated and kept up with ener-
getic friction and slapping, and the inhalation of a few whiffs
of ether or acetic acid, water applied to the head, etc., and as
he recovers, some stimulant given him to drink. If the
patient is exhausted from overwork, debility or malarial condi-
tions, an intravenous injection of quinin should be made, or at
least a hypodermic injection (4 grams each of hydrochlorate of
quinin and antipyrin, in 6 grams of acq. dist. heated together.
If the solution crystallizes in the bottle it can be dissolved by
slightly heating it again). He recommends that this solution
should be kept on hand at times when it is liable to be needed.
Certainty as to malarial condition is only acquired by examin-
ing the blood, but as this would be impossible, and as quinin
is comparatively innocuous, it is best to treat in this way all
doubtful cases. In severer cases with asphyxia, traumatic
shock or intoxication from infection, it is of the utmost import-
ance to excite the cardiac contractions, and the loss of a min-
ute may cost a life. Rotter advises an energetic revulsion on
the cardiac region with a moxa, Mayor's hammer or blazing
sealing wax, cauterizing or scarifying a large extent of surface
and scattering salt upon it. Direct excitation of the cardiac
contractions with the electric current has been found effectual,
but an electric appliance of sufficient power to send a current
through the chest is not always at hand. The best and most
practical means to accomplish it is artificial respiration. This
can be Sylvester's method of raising the arms, or Pancini's
raising the shoulders, or Laborde's rhythmic traction of the
tongue, any way to introduce oxygen into the lungs and drive
the blood into the heart. There is no stimulant for the mem-
branes of the heart that compares with the oxygen of the air,
and Desanti has seen persons revive after they have given no
indications of life for several hours. As a supplement to the
above treatment, he mentions the hypodermic injection of sul-
phuric ether, which has a powerful effect in stimulating car-
diac action. The surgeons of the German army are required
to carry a Pravaz syringe on the march with a bottle of ether for
this purpose, which practice, he adds, should be introduced
into every army.
NECROLOGY.
Sir John Eric Erichsen, one of the foremost representa-
tives of British surgery, died September 23. The distinguished
surgeon was born in 1818, of noble Danish descent. He was
surgeon-extraordinary to the Queen, ex-president of the Royal
College of Surgeons of England, and president of University
College of London. His contributions to scientific medical
literature were extensive and important, especially the well
known "Science and Art of Surgery." His "Concussion of
the Spine" and the monograph "Railway Injuries of the
Nervous System" showed his energy in another surgical
division.
N. Ruedinoer, M.D., of Munich, " the last of the old school
of anatomists." His works on anatomy, descriptive, topo-
graphic and systematic, form an important part of the founda-
tion of our present knowledge. His folio atlases are in nearly
every library, and the list of his contributions to science
includes works on anthropology, embryology, histology of the
organs of hearing, etc. It is to him we owe the use of carbolic
injections for cadavers. He was one of the founders of the
Monatsschrift f. Ohrenheilkunde, and of a special magazine
devoted to the anthropology and early history of Bavaria.
G. Lagneau, M.D., Paris, noted for his profound anthro-
pologic and hygienic studies which resulted in many practical
measures of the highest benefit to his countrymen and to
humanity. He was member of the Acadi5mie de Me'decine for
twenty years.
Jules Rochard, M.D., Paris, aged 76, retired Inspector
General of the Service de Sant6 de la Marine, President of the
Acad^mie de M^decine in 1894, of the French Association for
the Advancement of the Sciences, and of various other scien-
tific societies, a brilliant and classic writer and orator, "whose
entire life was an honor and an example to the medical pro-
fession." His numerous works on hygiene, education, epi-
demics, etc., were rounded off by his vast work recently com-
pleted, the Encyclopedia of Hygiene. Among his contributions
to the Revue des Deux Mondes were articles on "Marine Hos-
pitals," "The Role of Alcoholism in Modern Society,"
"Hygienic Education and Mental Overwork," etc. He was
one of the few who seem to have everything to complete their
happiness, international honors, devoted friends and family,
and perfect health until 1883, when he was shot by an insane
person. He apparently recovered from the wound, but the
bullet remained in his breast, and recently produced the
troubles which led to his death. He commenced his career as
a third-class surgeon in the navy, and retained his love of the
sea as a true Breton to the last. His son Eugene is editor-in-
chief of the Union Midicale.
Charles Milne, M.D. (University of the City of New York,
Medical Department, 1873), at New York city, September 28,
aged 56. He was a member of the Medico- Legal Society of New
York. — Henry Hooper Mitchell, M.D. (Depaitmentof Medicine
of the University of Pennsylvania, Philadelphia, 1842), at Elk-
ton, Md., September 27, aged 76 years. William C. Cald-
well, M.D. (University of Wooster, Medical Department,
Cleveland, Ohio, 1869), at Fremont, Ohio, of cancer of the
stomach, September 29, aged 59 years. He was a member of
the Ohio State Medical Society and a contributor to various
medical journals.
826
MISCELLANY.
[October 10,
MISCELLANY.
City Physician of Bath, Maine.— Eben J. Marston, M.D., has
been appointed to this position, vice W. H. Tukey, M.D.,
resigned.
The Detroit Academy and Medical Association upon their first
meeting, Monday, September 7, had pathologic specimens
which were furnished by Drs. H. O. Walker, Carstens and
.Longyear.
To Drill Holes in Glass.— The Bulletin d' Apiculture, No. 119,
states that holes can be easily drilled in glass with an ordinary
trocar or drill, if the spot is first moistened with a drop of the
following mixture : Dissolve 25 parts oxalic acid in 12 parts of
essence of turpentine, and add a chopped clove of garlic. Set
it aside for a week, stirring occasionally. Pour it into a bottle
and keep tightly corked.
Training School for Insane Asylum Nurses. — In response to de-
mands of outside physicians a training school for nurses and
attendants of the Cook County (111. ) asylum for the insane has
been organized and a competent faculty, principally of med-
ical men connected with the asylum, selected. The course of
studies includes physiology, hygiene, therapeutics, massage
and allied subjects.
The Pathological Society of Rochester, N. Y., has petitioned
the city council for an ordinance to allow the Mayor authority
to grant permits for physicians to ride on the sidewalks with
their wheel between 10 o'clock p.m. and 6 o'clock a.m. The
Rochester Herald has a strong editorial recommending the
council to pass the ordinance requested.
Illness of Dr. Hamilton. The editor of the Journal has been
confined to his room, most of the time to his bed, with an
attack of acute bronchitis since September 25. He was present
at the Macewen dinner in compliment to that distinguished
surgeon and the host, Professor Senn, but was ill then and
scarcely able to speak ; since that time he has not been out
of his room. His friends hope that he may be out in a few
days. He was relieved from the Marine Hospital last week.
Retires From the Armenian Field.- Dr. Grace M. Kimball, who
is appointed assistant physician for Vassar, obtained a reputa-
tion for her bravery and work in Van in behalf of the Arme-
nians. Few laborers in that difficult field have remained so
long and continuously without an interval of rest. Worn out
by the prolonged anxiety and the arduous duties of her med-
ical and missionary work, Dr. Kimball has decided to retire
from the Armenian field, and after visiting the hospitals and
schools in Europe, she will begin her college work in January.
Cause of Electric Death. — Experiments have been made by A.
M. Bleile upon dogs in order to determine the cause of death
in electric shock. The conclusion reached is that for a given
animal in a normal condition as to health a definite amount
of electric energy will produce fatal results. It is thought
that the action of the electric discharge is to contract the arte-
ries and increase the pressure of the blood, and that death is
due to inability on the part of the heart to sustain the increased
pressure of the blood so produced. Postmortem examinations
seem to show that the passage of the current does not cause
any anatomic disintegration. — Popular Science, September.
Entertainment to Professor Macewen.— Prof. Nicholas Senn,
president of the American Medical Association, gave a din-
ner at the Chicago Athletic Club, September 28, in honor of
Prof. William Macewen, of Glasgow, Scotland. There were
present : Drs. W. T. Belfield, John E. Owens, Truman W.
Miller, Edmund Andrews, Christian Penger, A. H. Ferguson,
Captain Pilcher, U. S. A., Major Hartsuff, U. S. A., J. H,
Etheridge, E. J. Doering, D. A. K. Steele, Dr. Cole, of Mon-
tana, E. J. Senn, G. Wm. Reynolds. John B. Hamilton, Jas.
A. Lydston. Speeches were made by most, if not all, of those
■■
present, eulogizing the honored guest, from which it can be
inferred that the entertainment lasted into the " wee short
hours ayant the twal," and was of a character well calculated
to delight the genial Bobby Burns himself, had he been pres-
ent at the affair. The editor of this Journal regretted that
illness compelled his early withdrawal.
A Sleep-producing Exercise Preferable to Hypnotics.— Dr. J.
Learned, Florence, Mass., writes to the Boston Medical a
Surgical Journal that he has experienced "infinite- advan-
tage" from moderate and varied muscular exercise as a means'
of inviting sleep. On retiring put in use, by contraction, a
certain group of muscles; change to another before exhaus-
tion to another and thence to another, having a definite rou-
tine, and continue until a sense of fatigue has come. The
brain meantime is asked to keep a record of the respirations
and of the muscular engagements in their order until it, too,
says "Enough!" A few minutes generally suffices. Will
sufferers be willing to use any methods or agents foreign to the
materia medica? Sleep immediately on retiring is restorative.
The drug does not make it so, continuously used. Wine,
tobacco, tea, coffee and late suppers, with social and emo-
tional excitement often delay the hour of sleep. My own per-
sonal needs were at the foundation of this "discourse." Con-
ditions of the heart, digestion and nervous system should not
be ignored in any case of insomnia. The sufferers are abun-
dant everywhere now.
University College of Medicine, Richmond, Va.— At a meeting; of
the faculty of this college Dr. F. S. Harker, who has so effi-
ciently filled the position of adjunct to the professor of histol-
ogy, pathology, bacteriology and Urinology, was unanimously
elected to fill the chair made vacant by the recent death of Dr.
Charles H. Chalkley. Beside the special training which Dr.
Harker has received which fits him for the new chair, he has
shown himself gifted as a teacher. Fa. Med. Semi-Mn.,
September.
Phosphorus Necrosis.— Mr. Edwin Gould, who owns a large
match factory at Passaic, N. J., has recently promulgated an
order that all employes who do not present, within a specified
time, a dentist's certificate that their teeth are in a condition
of perfect repair shall be discharged. The danger of necrosis
of the jaw from the phosphorus used in the manufacture of
matches is well known, and he is said to have been induced to
take this step by the fact that not long since an employe of
one of the Diamond Match factories in Ohio, who had been
attacked with necrosis, sued the corporation for $10,000 dam-
ages.— Boston Med. and Surg. Jour., September 24.
Anent Germs.— Dr. K. N. Bahadhurji of Bombay, in the
Indian Lancet, July 1, 1896, concludes an exceedingly interest-
ing critique upon "The Germ Fad," as so styled by himself,
in the following presentation: "Bacteriologic therapeutics
is but a system of modern alchemy, and rests and proceeds on
incorrect assumptions and daring guesses as conveniently
abandoned as confidently set up Fortunately
the germ scare is cooling down and germs will soon cease to be
the objects of such anxious care and study, and will in time be
consigned, in all probability, to the limbo of exploded myths
which have had their day." The article is a long one and
might advantageously be condensed for the pages of the Jouk
nal, but what has been already quoted sufficiently displays
its decided skepticism regarding the role of the bacillus, the
wherefore of its being, the significance of its appearance, the
explanation of its functions and the embarrassing schemes for
its annihilation. For the present, at least, we must conclude
that there is no uncommon law in the governmental system of
the microorganism, and may we not add no unique personalities,
with extraordinary powers. As has been said, we may multi-
ply corroborations but add only a moiety to our real knowledge.
18%.]
MISCELLANY.
827
Calcified Fibroid from Cremated Corpse.— Dr. Yamagiwa of
Tokio, in Virehow'a Archiv, Vol. cxliv, part 1, 1896, describos
a specimen of calcified fibroid found after cremation in the
ashes of a woman in whom myoma of tne uterus had been
diagnosed during life. She uied of paraplegia at the age of 70.
When 28 she noticed for the first time a tumor in the hypo-
gastrium : next year she married but never bore a child. The
tumor grew slowly till she was 38 ; then it ceased to increase
and became very hard. At 45 the patient lost her husband.
When 50 she complained that the growth had become very
heavy. In 1882 a doctor examined her, and noted that the
tumor was of stony hardness and freely movable. Paralytic
symptoms appeared and lasted for about three years ; they
reappeared seven months before death. Debility and emacia-
tion then followed. Yamagiwa does not distinctly make out
that the paraplegia was due to pressure of the tumor on nerves.
The fibroid removed from the ashes looked like a petrified
human brain. It weighed six pounds and ten ounces and
measured from before backward nearly eight inches, trans-
versely over five and one-half inches, and vertically a little less
than live and one-half inches. On histologic examination
uterine libers were discovered. The mass was due to pure
calcification and there was no ossification.
Tbe Medicine Man of the Congo. Among the Bakete, a tribe of
the upper Congo river, the witch doctor rules supreme. The
following is quoted from a recent lecture by a returned mission-
ary : " The only attempt at religious rites is that practiced by
the medicine man. In each town there are a certain number
of medicine men, or witch doctors ; but the medicine men of
the town have no right to make medicine for their own town.
Once in five yeare strong medicine is made. The doctors gather
outside the town and hold a palaver as to the price to charge
for making medicine, and after long haggling agree on a sum.
They then enter the town and command that houses or open
sheds be built for their accommodation and announce their
intention of making medicine. The people are instructed that
on the next day they must not leave their houses until noon,
and the injunction is implicitly obeyed. Early in the morning
the medicine men go into the woods and surrounding a tree that
they know to be a medicine tree, speak to it thus : ' O tree, we
want medicine from you. We want good strong medicine.
After having partaken of this medicine anyone who shall steal
commit murder, lie or do any wrong let him die.' The last
word is repeated three times. The medicine men take the bark
from the tree, grind it into powder and mixing with palm oil
make it into balls the size of a chestnut. Returning to town
they enter the huts prepared for them, summon the people and
administer the medicine, repeating the words addressed to the
tree regarding the penalty for wrong doing after having taken
medicine. The natives thoroughly believe in the power of the
medicine men."
Regulation of Practice of Veterinary Medicine In Virginia. -A law
has been passed in Virginia, taking effect May 1, 1896, which
permits only two classes of persons to practice veterinary med-
icine or surgery in that State : 1, all persons who were, prior
to that date, practicing veterinary medicine or surgery in that
State ; provided that before Nov. 1, 1896, they shall apply in
writing to the State board of veterinary examiners and furnish
satisfactory proof that they have been in practice in the State
prior to May 1, 1896 : 2, all persons who shall hereafter receive
certificates from such board, and shall in all other respects
comply with the law. Any person shall be regarded as prac-
ticing medicine or surgery within the meaning of this act who
shall profess publicly to be a veterinary surgeon and offer for
practice as such, or who shall prescribe for sick domestic ani-
mals needing medical or surgical aid, and shall charge and
receive therefor money or other compensation, directly or indi-
rectly. But nothing in this act shall apply to residents of
Virginia who confine their practice to the castration and spay-
ing of live stock, nor shall it prevent any person from prescrib-
ing for live stock who does not claim to be a veterinarian or
veterinary surgeon. The board of veterinary examiners men-
tioned is to consist of five members, learned in veterinary med-
icine and surgery, to be appointed by the governor, from a list
of names recommended by the Virginia State Veterinary Med-
ical Association. The board may prescribe rules, regulations
and by-laws for its own proceedings and government, and for
the examination by its members of candidates for the practice
of veterinary medicine and surgery. In case any applicant
shall fail to pass a satisfactory examination he shall not be per-
mitted to stand any further examination within the next six
months thereafter or until the next meeting of the board, nor
shall he have again to pay the prescribed $5 fee ; provided, how-
ever, no applicant shall be rejected upon his examination on
account of his adherence to any particular school of medicine
or system of practice, nor on account of his views as to the
method of treatment and cure of disease ; and provided, fur-
ther, that when, in the opinion of the president of the board,
any applicant has been prevented by good cause from appear-
ing before the board, the president of the board shall appoint
a committee of three members who shall examine such appli-
cant, and who may, if they see fit, grant him a certificate.
Any person who shall practice veterinary medicine or surgery
in violation of this act, shall be fined not less than 850 nor
more than $500 for each offense, and it shall not be lawful for
him to recover by action, suit, motion or warrant any compen-
sation for services which may be claimed to have been rendered
by him as such practicioner of veterinary medicine or surgery.
The Life Insurance Examiner's Decalogue.— The medical Depart-
ment of the Prudential Insurance Company of America has
issued the following ten commandments to their examiners :
1. Carefully read the medical examiner's instruction book.
2. Examine promptly in a quiet place, preferably at the
home of the applicant, and allow no one to be present dur-
ing your examination. 3. Answer each question and each sub-
division of a question. Be explicit in your answers. Avoid
indefinite expressions, such as childbirth, shock, grief, acci-
dent, injury, change of life, don't know, etc. Use ink in
writing. 4. Pay especial attention to the average quantity of
spirits, wines and malt liquors used daily. Give an average of
each. If there is a history of previous excess give full partic-
ulars. 5. Give a full description of any illness in the history
of an applicant, number of attacks, when last, duration and
severity. 6. Describe the duties of the applicant. Explain
trade terms used to denote an occupation. State the line of
business or work. Note if occupation is hazardous or injurious
to health, and see that the true occupation is stated. 7. Give
careful attention to the moral hazard of the risk. 8. Be sure
the urine you examine was voided by the applicant. 9. Be
sure you examine the right person, and that you get the exact
age, date of birth and a full family history. 10. Personally
examine and personally secure and witness the signature of
the applicant.
Substantial Professional Advance in Therapeutics. The editor of
the American Therapist, September, refuses to admit the
gloomy views of those who look upon therapeutics as a thing
of the past. While it may be true that too many practitioners
rely on the empiric use of ready-made pharmaceutics, and
thus forget or never learn the rudiments of pharmacology and
therapeutics, yet the proportion of scientifically and broadly
educated physicians is increasing very rapidly in this country.
The scientific study of therapeutics has never engaged more or
better men than now. The proceedings of representative
medical societies and current issues of legitimate and leading
medical journals include a very satisfactory proportion of con-
tributions on therapeutic subjects. These are the sources
828
MISCELLANY.
[October 10,
from which this journal draws much of the practical and
instructive matter presented monthly to its readers — besides
inspiring and printing many original contributions. One of
our exchanges recently printed a pleasantly satiric letter from
a correspondent who informed the editor that in this period of
specialism, and finding most specialties "done to death," he
had decided to adopt the specialty of general practice. That
is the peg on which our contemporary should hang his
"pessimism." Therapeutics is neglected by the average aspi-
When the first division reached the new building it marched
on to St. Joshaphat's School, while the rest of the marchers
broke ranks and joined the gathering crowds waiting for the
laying of the stone. In anticipation of the ceremony a raised
platform was built in front of the main entrance to the build-
ing. This platform was decorated with the national colors in
flags and bunting. Over the platform was placed a canopy.
In front of this waved the papal colors, surrounded by the
national flag and those of a number of European nations. The
(iBOUND PLAN OF THE ALEXIAN BROTHERS HOSPITAL.
rant for publicity because it seemingly affords no special
prominence ; it is too general. Any 'ology, properly wooed,
brings reputation and distinction. The broadly educated gen-
eral practitioner, without a specialty, is too commonplace for
average ambition. But the study of therapeutics is neverthe-
less indispensable — even in all specialties. Progress in thera-
peutics is constant, and we may hope with undoubting
optimism that the fashion to study and write on drugs and
drug action will spread through all ranks.
platform was carpeted, and chairs were reserved for the invited
guests behind the speakers' platform. At the west end of the
platform was the stone, which was ready to take its permanent
place in the structure after the ceremony. At i o'clock the
platform was filled with guests and members of the Alexian
Brotherhood, waiting for the arrival of the Archbishop and
the procession. One of the earlier arrivals was Mayor Swift."
We are indebted to the Inter-Ocean for the accompanying
illustrations.
THE NEW HOSPITAL BUILDING.
The Alexian Brothers New Hospital in Chicago. -With imposing
ceremonies the corner stone of the new hospital of the Alexian
Brothers was laid Sunday, October 4. About 25,000 people
were present to witness the laying of the stone by the most
Reverend Archbishop Patrick Feehan. There was also a great
parade by various Catholic societies, in which about 15,000
persons took part. The gay uniforms and ecclesiastic regalia
gave an altogether old world appearance to the pageant. The
Inter-Ocean says :
"Along the route the procession was greeted with much
enthusiasm, most of the streets being lined with spectators.
A number of houses were decorated with flags and bunting.
Antitoxin Collective Investigation (Second) American Pediatric
Society. — To the Profession : The American Pediatric Society
are encouraged to ask the co-operation of the profession in a
further collective investigation. Laryngeal diphtheria is
believed to furnish fi crucial test for antitoxin ; the present
aim is to ascertain, 1, what percentage of cases of laryngeal
diphtheria recover without operation, under antitoxin treat-
ment ; 2, what percentage of operated cases recover. The
Society asks for records of cases of diphtheria involving the
larynx, whether operated or not, occurring in private practice
in the United States and Canada, treated with antitoxin. It
is expected that cases occurring this year will be treated with
18%.]
MISCELLANY.
829
reliable preparations of the serum, will be treated early, and
will be given efficient doses. The second reiwrt is designed to
be a study or cases occurring between the closing of the first
report. May 1, 1896, and the closing of the present collective
investigation, April 1, 1897. In order to secure data which
shall make the tables complete, circulars containing blanks for
ten cases have been printed and are now ready for distribution.
It is desired that physicians shall fill out circulars (blanks) as
cases occur, not trusting to memory, and shall urge their
Mends having similar cases to do the sam*. Circulars can be
had by applying to the committee (address below). Several
groups of cases in the first investigation arrived too late and
wore lost to the report. It is desired that circulars as soon as
rilled (ten cases) be returned to the committee. The collection
Of cases must close at the end of March, 1897. For extra cir-
culars (blanks), for returning circulars (filled), and for further
information, address the chairman of the committee : W. P.
Xorthrup. M.D.. 67 East 79th Street, New York, N. Y.
T1IK ACTION OF THK SCH'IKTV V PON THE (FIH8T) REPORT.
1. Donas : For a child over 2 years old, the dosage of anti-
toxin should be in all laryngeal cases with stenosis, and in all
other severe oases, 1,600 to 2, 000 units for the first injection, to
be repeated in from eighteen to twenty-four hours if there is
no improvement : a third dose after a similar interval if neces-
sary. For severe cases in children under 2 years, and for mild
cases over that age, the initial dose should be 1,000 units, to be
repeated as alx>ve if necessary ; a second dose is not usually
repaired. The dosage should always be estimated in antitoxin
units and not of the amount of serum. 2. Quality of anti-
toxin : The most concentrated strength of an absolutely reli-
able preparation. 3. Time of administration : Antitoxin should
be administered as early as possible on a clinic diagnosis, not
waiting for a baeteriologic culture. However late the first
observation is made, an injection should be given unless the
progress of the case is favorable and satisfactory.
Phosphorus Workers in Relation to Life Insurance. The Medical
K.vamincr regards the manufacture of matches as an occupa-
tion that debars its workers from insurance examination.
Around about Frutligan, in the Bernese Oberland district
of Switzerland, a largejjroportion of the inhabitants are idiotic,
due to the phosphorus used in matches. In every house
matches are manufactured, and in every house is a misshapen,
grinning idiot. This condition of things is due to an accumu-
lation of hereditary influence, as the parents and grandparents
for generations have been engaged in this industry. The Swiss,
as well as scientific and philanthropic people generally, deplore
this state of things, and are endeavoring to devise means by
which matches may be manufactured without sulphur or
phosphorus. Chemists are endeavoring to discover some sub-
stance for this purpose.
The same thing occurs in France where matches are made.
In France matches are manufactured by the goverment. The
compensation is very small — something like one sou a hundred.
Matches are made of imported wood. The government endeav-
ored to substitute native wood, but the people objected, because
with native wood they were not able to turn out as many
matches, and consequently could not make as high wages,
which amounted to about from two to two and a half francs a
day. They wanted to be paid by the day instead of by the
piece. As a compromise the old soft wood was allowed them
on the condition that they should work by the piece.
Another source of discontent was the danger attending the
manufacturing of matches. It is so detrimental to health that
they wished government to grant those who do this work a
pension, which was denied. While yet young—say at 25— the
operator will lose his teeth, they frequently beiome paralyzed
and idiotic, as before mentioned, and in nearly every instance
there is experienced some form of ill health. We remember
while a student at Bellevue that the late Prof. James R. Wood
used to hold up before his class a specimen of the lower jaw
which he had taken from a patient who had introduced phos-
phorus into it by picking a decayed tooth with matches. The
consequence was a necrosed jaw. The Professor used
this instance not only to illustrate the danger of the above
practice, but to show that bone would grow again if the peri-
osteum was preserved. In this case the jaw had been repro-
duced. So far as insurance is concerned, those who make
matches or work in phosphorus are not acceptable risks.
They should not be examined if their occupation is known to
be of this character.
Pan-American Medical Congress.— {Telegram to Vie Journal. )—
Cincinnati, Ohio, Oct. 6, 1896. To the Editor .-—The official
train for the Pan-American Congress, Mexico City, leaves
Chicago and Cincinnati November 10, a.m., and St. Louis,
p.m., same date, with sleeping and dining cars on special
schedule for entire trip. H. L. E. Johnson, M.D.
Detroit.
At the meeting of the Detroit Academy of Medicine, Sep-
tember 22, Dr. David Inglis presented a report of "Three
Postmortems."
The first case was a man 64 years of age, who had a history
of previous injury. Four days before the doctor saw him he
had severe headache, but no vomiting. There was some inco-
ordination in using the legs and he found it difficult to climb
stairs. He yawned frequently. These symptoms were pro-
gressive at the time he presented himself. He had consulted
a specialist who reported no affection of his ears, although
there was a history of an attack of inflammation of the middle
ear, ending in suppuration and accompanied by much tender-
ness over the mastoid cells.
The doctor's diagnosis was impending apoplexy, but opposed
to this was the fact, that there was no arcus senilis, arterial rig-
idity, or increased arterial tension. The pulse was soft, 72.
Motor symptoms were bilateral.
Transverse myelitis was then suggested, in favor of which
was the limitation of the motor defect to the lower extremities.
Systemic sepsis was excluded, there being no albumin found in
the urine. There was no evidence of poison from gout or
malaria. The old abscess of the middle ear was considered. The
motor defect in the legs increased, the headaches gave place to
mental dullness and stupor, which ended in coma.
The postmortem revealed no lesion of the brain substance.
The right half was compressed so that there was a space of
half an inch between it and the skull which was filled with
fluid. The ventricles were empty, and there had been a large
amount of subdural sero-sanguineous effusion.
Dr. Inglis said : "The postmortem is instructive in the
following particulars : First, it establishes clearly that conges-
tion of the brain is a reality. Authors, of late, have been
inclined to ridicule the belief in congestion of the brain.
'Gray,' in particular, discredits and resorts to the unscientific
method of showing that no single one of the symptoms of cere-
bral congestions is pathognomonic, and that the prominent
symptoms are frequently met with, individually, in various
conditions."
The diagnosis of impending apoplexy was correct and based
on the signs of severe cerebral congestion. The case was first
a serous effusion, not a hemorrhage ; as first there was com-
pression of the brain, and second, the blood formed a soft and
thin layer everywhere over the cortex, and not a clot as found
from a spreading hemorrhage, nor was it over both halves of
the cerebrum.
The doctor brought out the fact that a diffused lesion some-
times causes very limited local manifestations. In this case
although the entire cortex was involved, sensation was perfect
and the motor defect was confined to the lower extremity. Had
the case been minus stupor and headache, the diagnosis would
have been some lesion low down in the spinal cord. In uremic
poisoning the same principle applies, the poison pervading all
parts of the brain, yet a part only may be selected for its
paralyzing effect.
Another point in the case is that the coma disappeared and
the patient regained consciousness just before death, which
830
MISCELLANY.
[October 10, 1896.]
shows that unconsciousness does not always -depend upon
limited pressure, but upon increasing pressure, and with
decreasing pressure consciousness may return while the path-
ologic conditions remain.
The doctor called his next postmortem a riddle. A boy aged
14, with a history of traumatism of head and back, developed
choreic movements, which were bilateral. He was dull,
abstracted and answered questions slowly. The choreic move-
ments were such that it was impossible to listen to the heart
sounds properly, heart's action was rapid and tumultuous,
speech quite unintelligible.
Six weeks after he was brought to Harper Hospital, where
he was again examined. He recognized Dr. Inglis, but could
not speak. His left arm was powerless, but could use the
fingers slightly, and raised the forearm like a flail. The right
arm trembled on voluntary motion. Appetite ravenous.
Paralysis of left arm occurred some days before death. Drs.
Emerson and Hitchcock thought the case was one of multiple
sclerosis. Dr. Inglis a cerebellar tumor.
A postmortem showed no nodules of any kind, but a large
quantity of serum in the brain. The liver was the seat of
innumerable uniform, thickly disseminated nodules of some
neoplasm. The mesentery contained small nodules, but the
glands of this organ were normal.
This case was presented to illustrate the fact that it is some-
times as well to confess ignorance as to know many things that
are not so. The heart was normal and an operation over an
arm center would have shown sound brain tissue.
The third case was a man aged 25. While blowing water
from a hose he felt a sharp pain in the back of his head. This
occurred in October, 1895. About the end of that year patient
complained of pains over occiput, down the neck and across
the shoulders. No history of head injury. The attending
physician diagnosed rheumatism and treated him for a couple
of weeks. Then eye trouble manifested itself, and he was sent
to Dr. L. E. Maire, who diagnosed optic neuritis. There
gradually developed furious paroxysms of head pains, with
vomiting, and sometimes bilateral convulsions and absolute
loss of sight.
When Dr. Ingils first saw him, the pains were of such a
nature that the patient would cry out. Patellar reflex was
entirely lost, ataxia marked, and when attempting to walk he
tangled his feet and fell or leaned to his right. Was slow in
responding to questions, answering in a loud voice. Was fret-
ful and ate inordinately. Diagnosis, cerebellar tumor, and in
consultation an exploratory operation was advised. He was
trephined over the right lobe of the cerebellum, but no tumor
could be found. The postmortem in the temporal region
revealed minute elevations of thin plates of bone covering
points where it was almost perforated. Twenty or thirty of
these were found and were not confined merely to the region
of the pacchionian bodies, though most numerous at the
median line of the temporal bone. The dura mater was found
altered in structure and the pacchionian bodies enlarged. The
skull was found thinned at many places, especially at the
parietal eminences, where, over an area as large as a silver
dollar, on each side, the bone was as thin as card paper and
could be easily broken with the fingers.
Upon removing the brain a pint or more of sero-sanguineous
fluid escaped, which evidently came from the ventricles. Upon
incising into the brain substance, the trouble was found to be
located in the cerebellum, both lobes degenerate, the left
slightly more than the right. It could only be called a degen-
eration, the substance being broken down into a semi fluid,
resembling pus, though having no purulent odor. The tento-
rium cerebelli was absorbed at the immediate site, and adja-
cent portions of the cerebrum seemed slightly affected. There
were found in parts of the ventricles, small adherent masses
which appeared like granulation tissue.
The diagnosis was confirmed to the extent that there was a
cerebellar lesion, but not tumor of both halves.
In closing his paper Dr. Inglis said the postmortem was
instructive in showing the remarkable thinness of the skull.
Had the patient received a blow upon the parietal eminence, it
might easily have broken in the thin plate of bone. Dr. Inglis
also said that the medico-legal aspect of such a condition
deserved notice.
Dr. J. Flintermann read a paper entitled "Senile Dementia."
The Superintendents of the Poor for Wayne County (Detroit)
have difficulty in finding room for the poor of the county in
their new "county house," and for the insane at the asylum.
In the county house there are 807 inmates and in the county
asylum 368. Dr. E. O. Bennett, since being installed medical
superintendent, May, 1881, has wrought many improvements.
The asylum farm of 160 acres is taken care of almost entirely
by the insane.
The buildings include the "county house," asylum hospital
with chaplain's office attached, Wayne County Asylum, the
new asylum erected in 1894, and double residence for the med-
ical superintendent and book-keeper, the gas-lighting and
heating plant, electric-light plant and outbuildings.
For the last three years no acute febrile diseases have
occurred in the asylum or county house, with exception of
three cases of typhoid that developed in the latter.
THE PUBLIC SERVICES.
Army Changes. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Sept. 26 to Oct. 2, 1896.
Captain Norton Strong, Assistant Surgeon, relieved from duty at Fort
Sheridan, Illinois, and ordered to Chicago, 111., for duty, as attend-
ing surgeon and examiner of recruits in that city. First Lieuten-
ant Joh S. Kulp, Assistant Surgeon, is relieved from duty at Fort
Walla Walla, Washington, and ordered to Vancouver Barracks,
Washington. Captain William Stephenson. Assistant Surgeon, is
relieved from duty at Vancouver Barracks, Wash., and ordered to
Fort Sheridan, 111.
First Lieutenant Powell C. Fauntleroy, Assistant Surgeon, is relieved
from duty at Fort Grant, Arizona, and ordered to Fort Niobrara,
Nebraska, for duty. Captain George McCreery, Assistant Hurgeon,
is relived from duty at Fort Niobrara, Nebraska, and ordered to lios-
ton, Mass., for duty as attending surgeon and examiner of recruits.
Captain William B. Davis, Assistant Surgeon, granted leave of absence
for twenty-five days.
Change of Address.
Bennett. Alice, from Norristown, I'a.,to Wr.entham, Mass.
Grote, H. W., from New Orleans, La., to Room 20, Oakland Music Hall,
Chicago. 111.
Harding. George W.. from Twelve Mile to North Manchester. Ind.
Krousgrill, D., from Wadesville to 605 S. 4th St., Terre Hnute. Ind.
Kilbride. M. Frank, from Spring Lake Beach, N. J., to 2212 Green St.,
Philadelphia, Fa.
Leben80hn, M. H.,from 63d and Morgan Sts., to 692 Sangamon St.,
Chicago, 111.
Motter, Murray Gait, from Head of 80th St., N. W., to 1017 14th St.,N. W.,
Washington, D. C.
Russell. E. S., from Tuscarawas, Ohio, to Room 424, Bissell Block,
Fittsburg, Pa.
Sutton. E. M., from Masonic Temple to 328-829 Woolner Building,
Peoria. 111.
Von Koerber. Paul E., from Loup City, Neb., to Casa de Correos, City
of Mexico, Mexico.
Wright, John, from Clinton, 111., to 297 Reed St.. San Jose, Cal.
LETTERS RECEIVED.
Bernd, Henry & Co., St. Louis, Mo.; Bell. Clark, New York, N. Y.J
Bache, Emmet, New York, N. Y.: Brophy. Truman W., Chicago. 111.;
Bates Whitman Co., The, New York. N. Y.; Bartholow, P.. Philadelphia,
Pa.; Bausch & Lomb Optical Co., Rochester, N. Y.; Boardman, E. O.,
Oterton, Neb.
Charteon, M. R., Montreal, Can.; Chadwick Co.. The, Chadwicks,
N. Y. ; Cutler, H. G., Chicago, 111. ; Caldwell, W. S., Freeport. 111.
Dibrell. Jr., J. A., Little Rock, Ark.; Douglas, Richard, Nashville,
Tenn.; Dower, T J., Livermore. Iowa.
Fisher. John, Chicago, 111.; Ferguson <fc Goodnow. Chicago, 111. ; Foote,
A. E., Philadelphia, Pa.; Ferguson, E. D., Troy. N. Y.
Gibbs, M. D., Hartford, Mo.; Hummel, A. L., Advertising Agency (2)
New York, N. Y. ; Haldenstein, J.. New York, N. Y'.; Hoadley, A. E.,
Chicago, 111.; Hall, Jr., J. Underwood. San Jose, Cal.: Halleck, W. E.,
Washington, D. C ; Hall, Cromwell. Cromwell, Conn.; Hagler, E. E.,
Springfield, 111.; Hammond, Wm. A., Washington, D. C; Higgins, F. W.,
Cortland, N. Y.
Johnson, F. M., Boston, Mass. ; Jelks, Jas. T., Hot Springs, Ark.
Kellogg, E. B., Boston. Mass.; Kellogg, W. H., Palo Alto, Cal.; Kress
& Owen Co., New York. N. Y.
Lee, Frederick D., Milwaukee, Wis.; Learned, J. B., Florence, Mass.;
Little, C. H., Saginaw, Mich.; Luckey, J. E.. Chicago, 111.; Londonderry
Lithia Spring Water Co., Nashua,N. H. ; Lea Bros. & Co., Philadelphia, Pa.
Merrick, M. B . (2) Passaic, N. J.; Mauley, Thos. H., New York, N. Y.;
Mills. H. R.. Port Huron, Mich.
O'Toole, T. J., Eagle Grove, Iowa.
Pope Mfg. Co.. Hartford, Conn.; Pressey., A. J. .Grand Rapids, Mich.;
Penton, A. B .Mackinaw City, Neb.; Parke, Davis & Co , Detroit, Mich.
Rumbald, F. M., St. Louis, Mo.: Reynolds, Arthur R., Chicago, 111.
Stirling, A. W., Atlanta, Ga. : Steruberg, Geo. M„ Washington, D. C.
Warfield, Clarence, Galveston, Tex.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., OCTOBER 17, 1896.
No. 16.
ORIGINAL ARTICLES.
DIAGNOSIS IN DISEASES OF INFANTS
AND CHILDREN.
Read in the Section tin DUeuea ol Children, at the Forty-seventh
Annual Meeting of the Amerirau Medical Association, held
at Atlanta. Ga.. May 5-8. 1896.
HV C. G. SLAGLE, M.D.
MINNEAPOLIS, MINN.
Candor compels me to admit that upon more exten-
sive investigation than I have hitherto made, I found
that nuu'h more had been done and said, and better
done and said, upon this subject than I was previously
aware of, but found the subject matter widely scat-
terod throughout voluminous medical literature.
Inasmuch as we are compelled to study and prac-
tice every department of medicine before we can
become at all skillful in pediatrics, it would be most
unsatisfactory to attempt to discuss diagnosis in this
speoial department without first reviewing the subject
of diagnosis in general, as it applies more or less to
all ages and conditions of life. For we must and do
endeavor to instruct our students, that pediatrics can
never become "a specialty." as that term can only and
properly be applied to the stud;/ and treatment ol dis-
eases of special organs or parts of the body, while pedi-
atrics deals with the entire system; though only with
"little men and women." And as the true " special-
ist" will be successful in his "specialty" just in
proportion as he has mastered all departments of
medicine, so the podiatrist will be proficient in his
"limited practice" precisely to the extent that he has
Learned all other branches of our art.
Some one has well said that the pediatrist must be
a good all-round physician and something more; and
we are here to-day to discuss that something more in
our line; I shall only attempt to consider it more
especially from the standpoint of the college instruc-
tor, and in its relation to our students and young
practitioners. The proper discussion of this subject
would seem to suggest inquiries something like these:
1. What is the import and scope of diagnosis'? Where-
in its intricacies, and what relation does it sustain to
other branches of medicine'? 2. What special fea-
tures does it possess in its relations to diseases of
early Life'? 3. What is the present status of this
department of our art as compared with the past'?
4. Can it be in any way rendered more accessible and
comprehensible to our students and young practi-
tioners'? 5. Is there a demand for a treatise on the
" Diagnosis of the Diseases of Infancy and Child-
hood, general and special, medical and surgical?"
I can not presume to be able to answer all of them
satisfactorily, except in a general way, but have
endeavored to present in as concise form as seemed
I » »sible some suggestions along this line of thought
for further elaboration in the discussion which it may
elicit from you.
If I may be pardoned for an attempt at definition
of my subject, "Diagnosis," before this learned body
of medical men, it would be "the faculty of recog-
nizing diseases so as to locate and name them with
facility by the correct interpretation of their patho-
logic and clinical symptoms, and thus to be able to
differentiate each one from all others."
Of the many difficult problems in medicine which
confront our students on leaving our college halls to
enter upon the general practice of medicine, diagnosis
is the most difficult and puzzling. So it probably
was with most of us, and so it doubtless will be to
them for years to come, despite our best efforts to
assist and prepare them for it.
We will not wonder that proficiency in the art of
diagnosing is difficult to attain when we fully appre-
ciate the fact that it is the practical application of all we
really know of medicine. It is the apex of the grand
pyramid of medical science and art, whose base has
been founded upon the enduring principles of anat-
omy, physiology and pathology. It is, therefore, the
real practical test of every physician's medical educa-
tion and skill, and just in proportion as he possesses
faculties and facilities for correct observation and
analytic reasoning will he become proficient in cor-
rectly interpreting the various phases and symptoms
of disease, and we all appreciate the fact that it
demands even more skill and native tact to rightly
interpret the various peculiar phases of morbid
action in infants and young children, where we are
deprived of the aid of speech, and who are often
unapproachable, than it does in adults where we can
better secure from themselves the history of the case,
the location of the pain and the important subjective
symptoms which they are experiencing.
Diagnosis to the skilled physician is much like
an intricate case at law being tried before a competent
judge, who renders his decision only after all the con-
flicting evidence "is in" and carefully weighed and
sifted. And as anatomy, physiology and pathology
are the "A B C" of medicine, so etiology and symp-
tomatology (illuminated by ample clinical and labo-
ratory investigations) are the "cathode rays" which
illuminate the deeper hidden mysteries of disease and
render them accessible to our comprehension.
Dr. Doming has well said that: "The only endur-
ing foundation for the superstructure of diagnostic
proficiency is in systematic and exhaustive study at
the bedside, combined with diligent and conscientious
research in the laboratory."
It is a lamentable fact that many men in our pro-
fession never make good diagnosticians even after
enjoying ample opportunities. And it has been
demonstrated to me many times during my long pro-
fessional life that many otherwise fairly good practi-
tioners have betrayed the fact that they were more
defective in diagnostic capability than in any other
faculty.
832
DIAGNOSIS IN DISEASES OF INFANTS.
[October 17,
There seems to be with some men something like
"a natural tact" in this matter, which only a compar-
atively few possess in any eminent degree. But if all
can not be Da Costas in this faculty, we probably
have a right to expect that our students can and
ought to be taught to recognize at least typical forms
of disease as they meet them on entering general
practice.
The faculty of correct and systematic examination
of the patient seems difficult for many men to learn.
They seem to proceed in a rambling and desultory man-
ner, as if they had no specific aim, to accomplish
either by questions asked or in their estimation of
the value of essential symptoms. And this, too, not-
withstanding our best endeavors to teach them sys-
tem; and emphasizing the fact that they are often
required to ascertain what the disease is not, in order
to determine what it is: "Diagnosis by exclusion,
negation or elimination" so exceptionally well illus-
trated by Da Costa.
After a thorough familiarity with all the depart-
ments of medicine, and an ability for systematic
examination of the patient, our diagnosis will be
predicated for the most part: 1, upon the "physical
signs" as they appeal to our trained special senses;
2, the symptoms as they indicate deviation of func-
tion; 3. the history of the case as we elicit it from
the patient or friends.
Diagnosis being a science and art, which teaches us
to distinguish one disease from another by tracing
symptoms to the causes from which they originate,
must be valuable not only for purposes of treatment,
but enables us also to form a correct opinion as to
the result of the disease (t. e., prognosis), for without
correct diagnosis there can be no correct prognosis
nor treatment.
We have all seen physicians, with more ingenuity
than skill, excuse their inability to render an exact
diagnosis by assuring the interested parties that an
exact diagnosis is no longer demanded in most cases;
as we do not now treat the name of a disease; but
have learned to search out the indications of treat-
ment and meet them pro re nuta with our therapeu-
tic agents. All of which might sound satisfactory to
the unskilled, but would hardly satisfy a diagnosti-
cian, for he will understand that, as a rule with few
exceptions, we can only learn the "indications of
treatment" by recognizing the disease; that we must
know what the disease is, its true nature and- location
before we can expect to remedy it.
Doubtless many young physicians fail at first in
diagnosis from the fact that they have not yet suffi-
ciently acquainted themselves with normal conditions
and processes of the human system, notwithstanding
we are emphasizing the facts before our students as
much as seems possible that they must become well
acquainted with normal appearances before they can
appreciate the departures or deviations; that they must
know what symptoms mean in individual cases before
they can combat them successfully, and often in order
to illustrate and emphasize our teaching, remind them
of the impossibility of treating successfully such
symtomatic conditions as we meet in eclampsia,
dropsy, jaundice, dyspepsia, constipation, headache or
even pain, fever and many like morbid phenomena,
which we all know are only external exponents of
various internal processes, without knowing the nature
of the proximate cause.
All that has thus far been said and all that can be
said of the intricacies and learning and skill requisite
to meet the complexities of diagnosis in general,
obtains in accentuated form in the diagnosis of the
diseases of infant and children, for we soon recognize
the fact that exact and even early diagnosis, in the
various ailments of young children is more important
often than it would be in adults; partly, it may be, on
account of the demand for early prophylactic measures
being enforced, if it should prove to be an infectious
disease to which young children are peculiarly liable;
as also from the well-known fact that many acute ail-
ments run a more rapid and violent course in early
life. So intricate, indeed, is this matter that few of
us, perhaps, will ever become so gray, experienced and
skillful that we may not sometimes make mistakes in
diagnosis. I yet remember when Professor Yandell
of the University of Louisville, Kentucky, apologized
to the class for his inability to render a diagnosis in
a case which proved upon postmortem to have been gan-
grene of lungs, by assuring us that he had followed
the great Louis through the wards of the hospitals of
Paris and saw him write over some of the beds, for
several days together, "No diagnosis."
Many ailments of young children simulate each
other in clinic features so closely that it is impossible
for a while to render a positive differential diagnosis.
Not long since I saw an attack of what proved to be
typhoid fever in a child diagnosed for several days as
"meningitis," without much suspicion of its incor-
rectness, on account of the peculiar cerebral and neu-
rotic symptoms present, and this, too, by several of
our most skillful and experienced physicians.
Who of us have not, at some time, been perplexed
for a while in rendering a differential diagnosis between
such similar appearing affections as "non-specific
pseudo-membranous laryngitis" and true "diphtheritic
laryngitis," or between convulsions (centric or eccen-
tric) and epilepsy, or between pertussis in its first
stages and catarrhal bronchitis in young children ?
Professor Jacobi has truly said "that there is
scarcely a tissue or organ which behaves exactly alike
in the different periods of life," and the same distin-
guished author reminds us (Cyclopedia of Diseases of
Children) that pneumonia, tuberculosis, typhoid fever,
rheumatism, epilepsy, diabetes and many other affec-
tions of the young differ considerably from the same
affections in the adult in their clinic symptoms, and
even sometimes in iheir anatomic aspect. But of all
the manifold ailments of early life perhaps none are
more generally difficult to diagnose correctly and
promptly than the various protean, nervous and cuta-
neous affections, to determine whether they are simple
or complex, idiopathic, symptomatic or sympathetic;
whether organic or merely local or functional in their
nature.
One of the most unsatisfactory features of diagnosis
in young children has often been the impossibility of
eliciting or of correctly interpreting the "physical
signs" in affections of the heart, lungs, pleura, etc.,
this partly from the deviations of the sound elicited
upon percussion and auscultation, and partly it is often
from our inability to approach or control the child in
a satisfactory manner. I doubt, indeed, whether
physical sounds in the chest afford us the assistance
in diagnosis in young children that they do in adults.
We are constantly reminded also that not only do dis-
eases more frequently hybridize in early life, but also
that many of the causes, symptoms and even diseases
themselves are peculiar to that period of existence.
1896, ]
DIAGNOSIS IN DISEASES OF INFANTS.
s;i:;
It is a recognized fact that diagnosis can sometimes
he either continued or corrected by noting the peculiar
behavior oi our therapeutic agents in special cases,
notably, opiates, antipyretics, digitalis, belladonna,
etc.. iih ire especially liable to be manifested in cere-
bral, cardiac and certain pulmonary affections, typhoid
fever and other diseases in the young. All of these
peculiarities and perplexities in the diagnosis of chil-
dren's affections are being emphasized and elucidated
in many ways by those who arc authority in these
matters, and the advances in pediatrics and helps in
methods of diagnosis within a few decades have been
most gratifying, especially to some of us older mem-
bers of the profession. When I entered the medical
profession in 1869, pediatrics was in its infancy in
this country. I know of but one text-book at that
time exclusively upon "Diseases of Children,'" by an
American author, and t lint was by D. F. Condie of
Philadelphia, and almost without tables and illustra-
tions, which constitute such an admirable feature of
all our recent text-books on pediatrics, which are now
numbered by the dozens.
At that time pediatrics had little recognition in any
of our schools. I remember, however, that a great
impetus in the evolution of this department was
inaugurated very soon thereafter (about 1860) prin-
cipally through the efforts of Professor Jacobi of New
York, who. as you all know, has by his talent, energy,
zeal and enterprise contributed as much as any other
man in America toward the advancement and present
elevation of pediatrics in this country. He it was,
who. nearly forty years ago, took the initiative in
placing this important department of medicine upon
the high plane which it justly merited in medical
science. While his laudable endeavors have been
nobly seconded and supplemented byahost of younger
co-workers of equal talent, energy and zeal, and hence
the names of Jacobi, Condie, Smith, Meigs, Keating,
Pepper. Holt. Starr, Rotch, Chapin, Northrup,
O'Dwyer, Ivoplik, Osier, Gibney, Love, Edwards and
a host of others too numerous to mention here, but of
equal ability, have become known and honored
throughout the world of medicine, more especially by
their efficient labors in this department. And it is
pleasing to know that among these distinguished
names arc the authors of our most popular text-books
on pediatrics. Truly, "by their fruits we shall know
them." America has done well; may their good work
go on.
It is very satisfactory to find that they have done
about all that seems possible to be accomplished in text-
books to facilitate diagnosis for instructors, students
and young practitioners, by so thoroughly illustrating
the phases of disease in early life by introducing
numerous colored plates, photographs, tables of con-
trasted symptoms in similar diseases, temperature and
other charts, analytic tables of blood, foods, urine,
etc., together with details of clinic cases, etc., all of
which prove very helpful to both teacher and student,
and are in pleasing contrast to our text-books of only
a few years ago.
As to the exact assistance which the new science of
bacteriology and the late advance in photography are
yet destined to aid us in this field, can hardly be fully
estimated; but the possibilities seem very great, and
what they have already accomplished seems wonder-
ful, for from the well recognized intimate connection
existing between pathology, etiology, symptomatology
and diagnosis, whatever contributes essentially to the
better understanding of the causes, nature and symp-
toms of disease must afford greater facilities in ren-
dering exact diagnosis, and it is thus the fever
thermometer, camera and microscope have served as
our most valuable agents as "instruments of preci-
sion" in this matter. Nor can we ignore what applied
chemistry has achieved along this line in the investi-
gation of foods, the blood of infants, ptornains, leuco-
mains, urinary analysis, etc., all of which are fully
demonstrated in our late text-books.
Since I began the preparation of this paper at least
two new works on general diagnosis have been
announced as "in press." One on "Clinic Diagnosis,"
by Charles E. Simon of Johns Hopkins Hospital,
1 >eijig " Diagnosis by Microscopic and Clinic Meth-
ods," says the author, and the other, "Herrick's Hand-
book of Diagnosis," by James B. Herrick of Rush
Medical College. As to how far they will meet the
demands in this especial department will soon be
apparent. Prof. J. JL. Smith's publishers have also
announced a new and carefully revised edition of his
popular text-book on " Diseases of Children," rewrit-
ten and profusely illustrated, which will be cordially
received by students and faculty. Professor Rotch
has also announced a revised edition of his admirable
lectures on pediatrics. His style of treating the
subject and method of illustration of the text to facili-
tate diagnosis could hardly be surpassed. Nor must
we fail to accord to the "American Text-book on
Pediatrics" its full share of merited commendation
for its painstaking thoroughness to meet the require-
ments of our students.
While the "Cyclopedia of Diseases of Children"
marks a new era to pediatrics as a monument of
talent and enterj)rise not even confined to this con-
tinent, but cosmopolitan in its research and I shall
venture to assert as bearing directly upon this sub-
ject, that the chapter there on the general diagnosis
of diseases of children by Professor Finlayson of
Glasgow could hardly be excelled in its comprehen-
sive and systematic details of the great general
principles of diagnosis in diseases of children. I
have never seen anything on the subject so com-
prehensive and practical.
But after all the good work that has been done
and is being done to facilitate diagnosis for our
young men just entering the medical profession, it
remains a lamentable fact that a great many of
them are very deficient in the faculty of diagnosis
when put to the test on examinations for gradua-
tion, and on going before the State medical boards
of examiners for certificates to practice medicine.
At least I am sure this is true of our classes in
Minnesota and through the West and Northwest.
This results from several causes, which we are endeav-
oring to remedy as fast as practicable, as, 1, insuffi-
cient literary education on entering our medical
schools; 2, too short course of instruction in most of our
schools; 3, lack of ample facilities for clinic observation
in our smaller cities; 4, text-book instruction in this
particular line too voluminous for the generally limited
time and means of our students.
This, then, can only be remedied by : 1, higher lit-
erary requirements in sortie of our schools upon
entrance examinations; 2, longer and more terms of
study and instruction in the same (at least four or
five years of eight or nine months each); 3, as far as
possible a more earnest endeavor on the part of our
faculties to afford the students more ample facilities
834
DIAGNOSIS IN DISEASES OF INFANTS.
[October 17,
for clinic study and observation in hospitals, dispen-
saries, laboratories, etc.; 4, possibly, by some good,
concise text-books illustrated by copious plates, tables,
etc., on the diagnosis of diseases of infants and chil-
dren, where much of the best literature on the sub-
ject might be carefully revised and compiled and
presented in the best possible form for the study and
limited time and means of our students, only to sup-
plement the good work which has already been done
by our popular authors of text-books on pediatrics.
We, in the Northwest, are realizing more fully
every year the necessity of raising our literary require-
ments on entrance to our medical colleges, and are
doing so as fast as is practicable ; both medical schools
in Minneapolis having now raised their entrance
requirements to a certificate of graduation from one
of our best high schools, or its equivalent of other high-
grade schools, and have also lengthened their curric-
ulum from three years of six months to four years of
eight months each, and hope to be able soon to go
beyond this; thus emulating as fast as possible in
the West the best medical schools in the East.
Applauding as we do most heartily the great advances
being made in such high-grade schools as Harvard,
McGill and some others in the Northeast.
The advance has been gradual but continuous,
from two years of four months each, and almost no
recognition of pediatrics, as in the University of
Louisville and many others when I began the study
of medicine in 1859, to four years of eight or nine
months each, as in most schools at present, and a
thorough recognition of the importance of diseases of
children in all, is truly gratifying; and the preliminary
requirements for entrance to most of our medical
schools have been advanced in like manner.
I believe much of the late advance has been stimu-
lated by the rigid exactions of legislation in creating
and regulating our State boards of medical exam-
iners for license to practice medicine, especiaily in
our great Northwest.
What then is the conclusion of the whole matter?
I think it can readily be summarized about as follows:
The principal factors in acquiring both general and
special diagnostic proficiency are: 1, time; 2, oppor-
tunity; 3, application; and inasmuch as authors and
schools are cooperating to encourage as fast as possi-
ble longer terms of study, more ample opportunities,
and, in every available manner, stimulating the stu-
dents to more diligent application, and with ever
increasing help in all directions, there does not seem
to be much fallow ground to cultivate in this field.
It would indeed appear that about all is being done to
elevate medicine and facilitate diagnosis that can be
suggested, and in conclusion will only say, that
while I have thus in a desultory way endeavored to
emphasize some of the features which my subject
suggests, I entertain a painful apprehension that
my effort has been disappointing to some of you on
account of the importance of my theme. But if it
only succeeds in provoking a discussion, here, along
the lines indicated, I shall have accomplished to some
extent, at least, my purpose in presenting it to you,
insisting, as I beg to do, that its design has been
more retrospective and reminiscent than otherwise,
for it would be difficult indeed to say much new or
original on a subject which has been so well devel-
oped by the greater minds of the medical profession.
In what proportion of cases in young children, i.c ,
under 2 years, does the average physician render a
correct diagnosis on first examination ? Answer: Only
about one-half, and in older children possibly three-
quarters, while an expert may correctly diagnose four-
fifths even in young children, i.e., infants, on first ex-
amination and in older children nine-tenths.
DISCUSSION.
Dr. J. A. Larrabee, Louisville, Ky.— The vital point in
pediatrics turns on the diagnosis. In fact, it might be said
this is to the general practitioner an opprobrium medicatoris.
We all know it is in this department the greatest perplexity
arises and the greatest skill and judgment is required ; and even
then we frequently fail to make a correct diagnosis. Too much
education can not be given. And while I have all esteem for
one who is accredited a peculiar genius of making instantan
eous diagnoses, I believe such men very often make very griev-
ous failures. While we differ from each other in that
capacity as in others, I believe it was Michael Angelo who said,
genius is only another name for hard work. I do not believe
we will arrive at immediate diagnoses unless we do hard work.
It is along this line great stress may be laid on educating med-
ical men. The essayist has spoken of diagnosis, but in my
mind has omitted a very important part, that is the aids to
diagnosis in diatheses. It seems to me the diagnosis is greatly
enhanced by the study of diathesis. There is in every one of
us a weak spot by inheritance. That which would affect one
would not affect another. Hence, in diagnosis we should avail
ourselves of all the knowledge we can obtain. We do know, fam-
ilies travel on family lines, and disease is more prone to come
along these lines. And by seeking along these lines we will be
more likely to arrive at the diagnosis than by rambling. 1
invariably insist, upon the first visit, no matter what the dis-
ease may be, on the complete, careful, thorough examination
of the nude body. In his advice to his students, Hippocrates
said: "View the body outstretched," and that applied to
adults as well as children. If we attempt a diagnosis without
this, when we have not seen the patient before, we will fall
into very palpable errors. How many gentlemen here have
had their attention called to a rachitic condition or a case of
catarrhal pneumonia, in which the child is dying not so much
from the pneumonia as from the general condition? A single
pustule may point the way to the disease better than anything
else. Thus we are to watch closely, for every little point is a
big point. The strain is such we must call in all our senses :
and even then we have not quite senses enough. In closing I
wish to refer to physiognomy in disease. We must study the
countenance of the child and interrogate that.
Dr. Samuel E. Woody, Louisville, Ky. — The diagnosis in
children does offer a great many difficulties not encountered in
the adult. The absence of the power of speech at that tender
age, the excitability of the nervous system, the perversion of
the spoiled child, the fear and agitation of the nervous child,
offer difficulties to be overcome only by the greatest amount of
tact and patience, just the qualities in which the doctors, per-
haps, are oftenest failing. And then, again, diseases run a
very exaggerated course. The progress of the disease is so
rapid, unless we are careful and visit the patient early, we are
not apt to detect the symptoms. The history is rapid. As to
the physical diagnosis being more difficult in the child than in
the adult, I have not found it so. Pain sets its mark most of
all upon the child. Look at the face and you can tell the sick
child at a glance. I believe inspection gives you more assist-
ance in children than in grown people. The examination of
the chest offers greater assistance in the child than in the
adult, especially when the child is asleep. Not only can we
hear through the chest walls better, but the walls are thinner
and we can palpate better. And here lately, since the employ-
ment of the Roentgen photography, we find the thinness and
translucency of the tissues of the child is very important. Only
1896.]
SEPSIS OF THE NEWBORN.
835
lately a photograph of a child has been published, in which the
outline gave also an idea of the density of the tissues. In my
clinic we got good results in the examination of rickets. The
bones made scarcely a shadow, giving ocular demonstration of
It lie diagnosis already made of rickets. I don't think, Mr.
President, there is any Held in the practice of medicine in
which the diagnosis can be, if the proper amount of patience
it used, so easy, so thorough and so satisfactory.
SEPSIS OF THE NEWBORN.
Read iii tlie Section mi Diseases o( Childreu at the Forty-seventh Annual
ng of the American Medical Association at
Atlanta, Qeorgta, May ;Vs, ISM,
lsv HENRI E. TULEY, A.M., M.D.
II ember of the Kentucky State Medical Society; Clinical Assistant to
tin' Chair ol Practice and Instructor in Physical Diagnosis in the
Kentucky 8ohoo] "t Medicine, Louisville ; Visiting l'hysi-
cl;in to tin' Maaonlo Widows' and Orphans' Home:
Associate Kititor anil Manager Mathews'
Medical Quarterly, etc.
I.Ol'ISVU.l.K, k v.
The history of the following case is reported as the
text for a few remarks upon sepsis in the newborn,
not only because of its rarity, but because of the
interest attached to the case in connection with its
etiology.
Baby T. was born on February 1, 189(5, of a healthy
primiparous mother after a normal though rather tedi-
ous labor whioh had to be terminated by forceps.
The child was a male weighing about seven pounds,
eried well and was quite vigorous.
The mother had no vaginal discharge before labor,
but a vaginal douche of 1-2,000 bichlorid of mercury
given her upon the advent of the first pain, none
wove given afterward. Her puerperium was perfectly
normal and afebrile.
A- soon as the head was born the eyes were wiped
and the t'aee was washed, the first bath being given
some hours later. The cord was tied with a piece of
silk from a skein which had been used the day before
in an ovariotomy and some of the same was used the
next day in an abdominal operation without further
preparation. After the first bath the cord was dressed
with talcum powder and wrapped in absorbent cotton.
During the first three days nothing abnormal was
noted with the child, it had a normal temperature,
nursed well though apparently not satisfied, slept welt
and had normal movements. On the fourth day a
temperature was reported of 101.4 degrees in the
morning at 6 o'clock, and it had risen to 104 degrees
by noon. I was asked to see the case at this time by
the attending physician, Dr. L. S. McMurtry, by whose
courtesy I report it now. It was decided that the
temperature was a starvation one and that artificial
feeding was indicated; it was accordingly put upon
cow's milk, well diluted, to supplement each nursing,
temporarily, as the breasts were at this time beginning
to secrete. This reduced the temperature in five
hours to 100.6 degrees, and the next day the temper-
ature was normal and the child seemed as well as
usual. The cord dropped the next day, the fifth,
leaving a moist base, which was treated aseptically and
dressed with talcum powder. The next day the
temperature rose to 102.4 degrees and the child was
reported as listless and slow about nursing. I was
asked to see the child again, at this time and on close
examination found a retracted umbilicus which, on
depressing the edges, was found to contain about
twenty drops of pus, this when wiped away showed the
base or stump of the cord to be fungous in character.
The child did not stand manipulation of the parts
well, pain being caused when they were cleansed, and
there was noted slight distention of the abdomen.
After thorough cleansing of the navel with a bichlorid
of mercury solution, the fungous navel was touched
with a twenty grain to the ounce solution of nitrate of
silver and a powdered boracic acid dressing applied.
This dressing was renewed twice daily and the silver
solution used as before.
The progress of the patient from this time to its
death, three days later, is of no particular interest save
that the temperature rose continuously and steadily
from an initial one of 102.4 to 107 degrees a few
hours before its death. Baths would reduce this a
degree or so, but it would rise again in a few hours.
It refused to nurse and was with difficulty fed breast
milk, which had been pressed out for feeding with a
medicine dropper. The day before its death it had
passed very little urine and had several movements,
which were composed almost entirely of mucus.
The bowels were irrigated with plain water which
regulated this condition to a degree and also increased
the amount of urine voided. On the day it died the
skin was very hot and dry and it was put in a hot air
bath, but this caused so much prostration that it was
removed and stimulation kept up to the time of its
death. A few hours before this occurred its hands and
feet were noticed to become a purplish color, perfectly
cold and this condition had extended to the wrists
and nearly to the knees before death. The abdomen
was much distended and tender, the navel moist and
the granulation tissue covered with pus, though none
could be forced from the vessels by pressure upon the
abdominal wall.
This case is of particular interest because of the
following facts: The child was born of a healthy
mother who had been in the hospital under the daily
observation of the physician and nurses for nearly
one month before her confinement; the labor occurred
under the most carefully prepared aseptic surround-
ings, in a hospital where a great deal of abdominal
surgery is done and no deaths had occurred in more
than a year, and that one in another part of the build-
ing; it was the first case of obstetrics which had ever
been at the hospital; the mother had a perfectly normal
and uneventful convalescene and had no vaginal dis-
charge before labor; the patient had an experienced
trained nurse, on special duty, in charge and more
than the usual care was taken with the dressing of
the cord, careful bathing and talcum powder being
used. The question has arisen "Where did the infec-
tion come from which caused this child's death?"
That it occurred through the navel there can be no
doubt.
The literature of sepsis of the newborn is very
meagre but a number of cases have been reported.
The following routes for infection have been men-
tioned. The umbilical cord and its stump are the
most frequent points of infection; among others
mentioned by Brothers are the following: Accidental
injuries or operations with unclean instruments;
mammary abscess; tongue tie or circumcision; abra-
sions of the buccal mucous membrane, or slight
injuries to the genitals or anus; septicemia of the
mother during intra-uterine life; premature rupture
of the membranes, putrefaction of the liquor amnii
and aspiration of this by the child, causing a septic
pneumonia; a violent vaginitis of the mother acquired
during the last weeks of pregnancy with premature
rupture of the membranes, and septic poisons trans-
836
SEPSIS OF THE NEWBORN.
[October 17,
mitted from the mother, by means of her milk, when
she has septicemia following labor.
Jacobi mentions the gastro-intestinal tract as a fre-
quent site for infection, but in his writings, decidedly
more prominence is given the umbilicus and its care
as a means of prevention of sepsis. The pus of an
ophthalmoblennorrhea or the decomposing lochial
discharge, he also mentions as causes.
In the case reported all of these sources of infection
can be eliminated save the umbilicus. There were no
operations done upon the child, the buccal mucous
membrane was normal, the mother at no time had
symptoms of sepsis, a vaginitis, or decomposing lochial
discharge, and frequent examination of the lungs of
the child failed to reveal any lesion.
The time of infection in the case can not be decided,
but that it did not occur at the time of tying the cord
and its first dressing is certain. There was no septic
condition existing in the cord before it separated, as
it mummified rapidly and was perfectly dry through-
out after the separation. It most likely occurred after
it became detached, through the fungous navel left,
though extra precautions were taken in its care. A
possible cause, perhaps, was by septic matter being
carried through a wet napkin by capillarity, from the
alvine evacuations. It is a common complaint of
nurses that boy babies are with much more difficulty
kept dry, on account of the napkins being wet high
up, thus soiling the bands and cord dressings.
It does seem queer, however, that sepsis should
have existed in this case, in which every attention
was paid to the details of asepsis and antisepsis in the
lying-in-room, especially so when we think how com-
mon it is for no dressing to be applied to the cords of
children of the poorer classes, or if one is applied
it consists of a greased cloth, after which gangrene is
the more apt to occur, or simply a rag with a hole
burned in it, with ashes or soot as the drying powder.
However, the occurrence of sepsis in one case,
where every care has been taken to prevent it, should
not encourage us to relax our vigilence in preventive
treatment. The treatment is still mainly preventive,
and in the majority of cases, sepsis can be prevented.
In a series of 222 cases at the Sloane Maternity Hos-
pital, New York, personally seen by the writer, no
case of sepsis in the newborn occurred and no trouble
with the navel. The possibility of its occurrence,
however, should always be kept before us, careful
sterilization of ligatures and instruments used in sever-
ing the cord should be had, as well as of the hands
before this is done. The ideal ligature is the rubber
one, and the difficulty has always been in obtaining a
method of applying, but in the ingenious instrument
devised by Dr. A. C. Kellogg, which I take pleasure
in exhibiting, with which a small rubber ring is
applied to the cord, all danger of sepsis from the
primary ligature is obviated because of its ready ster-
ilization, and hemorrhage simply can not occur.
The after-care of the cord is important, there should
be a separate bed for mother and child, careful cleans-
ing of the hands before bathing the child, which
should always be done before the mother is attended
to, the avoidance of fatty applications to the cord and
the use of drying powders to facilitate the mummifica-
tion, a very good formula being salicylic acid and
pulverized starch, one part to eight.
The care of the cord is of less importance than the
care of the stump; every detail in the treatment of any
surgical wound should be observed here. Should
there develop an omphalitis, gangrene of the umbili-
cus, an arteritis or phlebitis, the most active stimula-
tion is indicated with prompt attention to the proper
cleansing and antiseptic treatment of the stump, the
only precaution being the avoidance of carbolic acid
as an application. The symptoms of them all are
more or less similar, local appearance of the inflamma-
tion at the umbilicus, it being generally bathed in
pus; peritonitis is always present to a greater or less
degree, also pain and tenderness especially during the
bath, and a septic temperature.
However, there may be no symptoms, the condition
being recognized only at the autopsy table.
Ill West Kentucky Street.
DISCUSSION.
Dr. J. A. Work, Elkhart, Ind. — What substance do you use
on the cord as dressing? Answer : Cotton.
Dr. W. B. Parks, Atlanta — I would like to ask the Doctor
if it would not be well, in the large cords, to make a little mas-
sage and lessen the size of the cord before severing it. That
can be done without any injury, I think, if you dress the cord
near the child and manipulate outward. By a little compres-
sion in this way, you can lessen the edematous condition. I
have done that myself quite successfully in a few cases. I
never like to tie these large cords for fear of there being too
much to be absorbed.
Dr. A. C. Cotton, Chairman- The advantage claimed for
the rubber is its constant elasticity gradually displacing the
Wharton's jelly.
Dr. Hatch — I have never lost a child under those conditions
in my entire practice. It has been my practice during the last
ten years, not to sever the cord until the placenta is born, and
since I have adopted this method have had better success with
the children and they get along better. I do that uniformly
and so far as having sepsis is concerned I have for a great
number of years used thoroughly sterilized silk in tying the
cord. I can see the advantage of this band. Last spring I
tied one of those large cords and thought I had tied it thor-
oughly, and imagine my surprise when a few hours afterward
I was sent for and it was said the baby was bleeding to death.
I can readily see the constant pressure of the elastic band
would have adapted itself to the cord as the edema diminished.
The hemorrhage in this case was due to the edema leaving
the cord, allowing the ligature to slip off.
Dr. Gray —I have been in the habit of doubling a small
rubber band three or four times and slipping it over the cord.
I have done that several times when there was considerable
jelly of Wharton, with good results.
Dr. J. H. Ross — In the country where I practice, I think it
is the custom to use almost any substance at hand for ligature.
I prescribe flax or cotton thread. But I invariably ligate the
cord before I cut it off, and it occurs to me now that perhaps
the chances of infection would be lessened by the ligation
being made before the cutting is done. We have not been
using, in country districts, antisepsis about the cord and I do
not remember a single adverse occurrence in the history of
many hundreds of cases.
Dr. A. C. Cotton, Chicago — Well, we have tied the cord
with almost everything. I have tied it with shoestring and
with a hair string from the head of the woman a good many
189C]
CHOREA.
837
years ago, and no ill results ever followed it. The only ease I
ha\e ever bad of Infection from the navel was long after I had
been connected with a hospital and had been taught surgical
asepsis and practiced it. In my experience and observa lion
sepsis from the navel is a rare thing in our city, and midwives
take no aseptic precaution at all in many instances. That it
should follow in the practice of men who observe aseptic pre-
cautions religiously and not occur in thi practice of people who
do not know the meaning of the word "asepsis" is a mystery to
me. The dischargee ascending the napkin by capillary attrae
tion. is an argument that has been used 'by myself, as those
will remember who heard me at Baltimore and the Illinois
State Medical Society last year. I have substituted anabsorp
tive pad. making the diaper simply a key bandage to hold the
pad in place, the pad being made of such material as to absorb
readily, so the outer retention band is not wet at all.
Dr. Henry Tii.kv, Louisville, Ky. — In the case I have just
related the enlarged cord extended fully five inches directly
from the navel of the child and it would have been impossible
to strip this so as to get a good place to tie the ligature. That
case was used as an argument for the rubber ring. In the
scries of '21- cases t here were some twenty or thirty cords which
hied secondarily, after the tying of the ligature. In some very
fat cords hemorrhage would occur. 1 think this case stands
as a unique one and one which I can not fully explain as to
the cause of infection. Every precaution possible was taken
with the ease, because it was a patient recommended to Dr.
MeMurtry by a friend in Glasgow, and under that recommen-
dation it was with the greatest care the case was watched.
Without any further preparation the Doctor used the ligatures
the next day in an abdominal operation. But still that possible
cause of infection should not be forgotten. I think it does
sometimes occur in that way. I was approached last year by
a prominent professor in one of our colleges in Louisville and
he saiil : "Whatare you going to say about the umbilical cord?"
1 detailed to him the case I suggested. He said : "That is all
a mistake. Just recommend it be left alone entirely ; just turn
it loose and it will take care of itself." To my personal knowl-
edge this professor has had several deaths in the newborn, and
I think if he would examine them carefully, get an autopsy,
he would find the cause to be sepsis. We know sepsis occurs
most frequently from the navel.
CHOREA.
Head In tl»'- section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association', at
Atlanta, «a., Mav 5-K. UBS.
HV HENRY HATCH, M.D.
QUINOY, ILL.
In discussing the subject of chorea I am well aware
that it may. at first thought, seem a dry subject to
you. But in bringing up this subject it is that I may
awaken new life, and bring forth new ideas, and
thereby get a more tangible and satisfactory under-
standing of the etiology and pathology of this very
troublesome disease. Troublesome, not alone to the
patient and friends, but troublesome as well to the
physician, on account of the tenacity with which it
holds to its victim. No disease causes more anxiety
than this disease, chorea, for it is often hard to con-
vince an anxious mother, when her child is never still
on account of the violent nervous movements and
excessive agitations, that it is not very ill, and that
you do not expect a serious outcome.
To launch out in a new channel may cause you to
exclaim, mentally, "Another needless exploring expe-
dition setting out on the pathless sea of chorea," with
no definite port in view, and with an uncertainty
regarding the existence of such a haven.
Chorea has been and is one of the pathologic dump-
ing grounds of the medical world; and many a man
has spent tireless hours in medical research, to find a
remedy which will relieve this troublesome disorder.
In this space the theorist throws his theory, the
pathologist his odds and ends ; the moralist adds a
lew of his trite sayings; and as a result there is a
stupendous wilderness of unknown depth and uncer-
tain quantity. No one has penetrated successfully
this wilderness; many have tried, and if no other
good has been done, the ground has been almost
covered with their failures; so that before long we
will bo aide to traverse the entire field by passing
from one failure to another. Each man can go a little
farther than his predecessor, by using as stepping
stones the perished efforts of those who have gone
before.
The term' chorea, coming from the Greek word,
chorea, meaning a dance, has been handed down from
the middle ages. About the fifteenth century England
was overrun with dancing, or shaking fanatics; many
of whom were sent to prison, as having the devil
within them. People of seemingly deep religious
desires and tendencies were afflicted, for they looked
upon it as an affliction and a direct visitation for sins,
with an unaccountable dancing, jerking, shaking, or
muscle tremor of some sort; this was purely psychic.
During the fifteenth century the city of Strasburg had
so much of the trouble that the magistrates ordered
the afflicted ones to the chapel of Saint Vitus, to do
penance, and to pray for relief. Here is where the
term "St. Vitus dance" probably originated. It may
be of interest to us that St. Vitus was a Sicilian, and a
pupil of St. Modestus; both suffering martyrdom as
Christians under the persecutions of Diocletian, in
the year three hundred, thus gaining their canoniza-
tion. St. Vitus, however, does not hold the undis-
puted claim to the name of the disease, for in other
parts of Europe it is known as "St. Modestus' dance,"
"St. John's dance" and "St. Anthony's dance." Each
saint was supposed to have curative measures in his
keeping. Many other terms have, at various times,
been applied to it. One old author speaks of it as
melancholia saltans, saltare meaning "to dance."
Another as paralysis vacillans. Another as ballismus.
from the word signifying "to leap." Again it is
known as epilepsia saltatoria; as orchestromania, or
the dancing madness. These terms all relate to the
psychic disturbances of hysteric character.
Chorea proper, or Sydenham's chorea, is the disease
as we recognize it to-day; while the Germans make
two classes of it — chorea minor' (our chorea) and
chorea magna, hysteric manifestations, some of which
simulate true chorea.
The disease is preeminently one of early life. Dr.
Stephen Mackenzie has a record of 439 cases, with
the following percentages: Thirty-four per cent,
developed between the ages of 5 and 10 years; forty-
three per cent, between 10 and 15; sixteen per cent,
between 15 and 20 years; with the largest general
percentage for the thirteenth year. See reports 513
cases, and 453 of them between the ages of 6 and 15.
Sinkler 282 cases, with 217 of them between 6 and 15
years of age. There is on record one case in a patient
78 years old. My own experience gives me a record
of forty-six cases, the oldest of which was 40 years,
and a man. Most of my cases have been before the
period of the seventeenth year; and almost all of them
have been females. The records of the same authors
show that chorea, while a disease of early life, is most
frequently a disease of early female life, as my own
experience has shown. It follows closely, or closely
precedes the puberal epoch in the girl. Grower, who
has made a deep study of the subject and who has a
record of more than one thousand cases, gives but 365
cases found in the male. Sachs, with his list of seventy
cases, found twenty-one males. It may be the more
838
CHOREA.
[October 17,
finely balanced nervous organization of the girl,
brought up as she is, more of a hot-house plant than
her brother, leading a sedentary life and under very
artificial surroundings, forced to exert a growing and
naturally irritable nervous system by close applica-
tion to books and music, this, I say, may account for
the preponderance of the statistics for the female.
Chorea is one link of the chain of hereditary
troubles. It is the experience of many authors, and
has been the result of my own observation, that alco-
holism is a very prominent factor in the production
of chorea. Especially so when a woman becomes
impregnated by her husband when in a drunken
debauch. Morphinism and pulmonary tuberculosis,
by transmitting vitiated constitutions, are also prime
factors in the production of this disease. Epilepsy
or migraine is frequently found in the parent of a
choreic child. We can not say, properly speaking,
that chorea is inherited; but we can say that either
its vitiated constitution is inherited from a parentage
which is not healthy or that it has a choreic tendency.
These are hereditary land-marks: The diminished
vigor, the inactive cell structure, the nucleus and
nucleolus burdened with inanition are tissues prema-
turely old. And how often have we seen children
born that are young in years, but carrying the prema-
turely old constitution! It is a disease that believes
the old adage that "Blood is thicker than water."
Arising perhaps from one ancestor, say a maternal
grandmother, who may have had a clear history so far
as ascertained, it manifests itself in one or more mem-
bers of the family, usually choosing the one whose
nervous organization most closely resembles that of
the ancestor, a lasting heritage from generation to
generation.
It is not necessarily a racial affection. While some
writers claim exemption for the American Indian,
their claims are not substantiated; and we must admit
that chorea is like the rain from heaven, falling upon
the Jew and the Gentile, the just and the unjust, the
rich and the poor. Weir Mitchell claims relative
immunity for the Negro race, and so far as my per-
sonal experience goes, having come in contact more
or less with the Negro race, both in hospital and pri-
vate practice, I have never seen a Negro afflicted with
this disease, or anything which had a semblance to it;
but Sinkler reports several cases among the colored
people. While both the Negro and the Indian have
been subject to a tremendous strain for generations,
it has been a physical rather than a nervous or men-
tal strain. And it is usually people of the higher and
more sensitive nervous organizations that have this
disease among them. What is not conducive to the
production of this disease is the fact that the Indian
and the Negro live a rugged, out-door life. Climate
and climatic influences can not be said to give much
light upon the subject. Season of the year is also an
obscure factor, if a factor at all. Rainy, oppressive
days are more favorable to the development of tlie dis-
ease than bright, sunshiny ones, if there is already a
predisposition toward the disease. It has been my
experience that most of my cases have come to me in
the latter part of the winter. Most of them have been
school children, and I could often understand why
they were afflicted with the disease. They were the
offspring of parents of a highly nervous organization,
who were anxious that their children should appear
well in public, and many of them had instilled into
the minds of their children the idea that they must
be at the head of their classes. Take into considera-
tion our modern system of forced education among
children ; the child must go to dancing school, take
music, have five or six studies, and then they all have
their little parties, keeping them out late at night. Is
it any wonder that many of these poor children suc-
cumb under the burdens their parents press upon
them? Even children are subject to blues, and dis-
greeable days are bad for that ailment. I have not
forgotten my own many despondent and blue days
when I wab a child, when things did not go right.
All are too prone to forget that we were once children
ourselves, and are therefore not apt to give children
enough sympathy in their little troubles.
According to authorities which I have looked over,
March gives the highest monthly percentage of cases;
and this corroborates my own observation. The
greatest number of cases in a given locality will arise
at the season in which the greatest mental or nervous
strain is put upon the children, and in our present
system of civilization the spring months, when the
child is anticipating its final examination, is usually
the period when it has the greatest strain.
Concerning the true etiology of this disease there
are many theories. The ancients believed that the
afflicted person had a devil, and efforts were put forth
to exorcise the malignant spirit. They made vows,
did penance, went on pilgrimages, and were doubtless
benefited in so much as may arise from a fashionable
method of treatment, of to-day, known as suggestion.
These pilgrimages also were beneficial in themselves,
from the fact that the people who made them got more
out-door exercise; consequently more fresh air and less
nervous tension.
The definition given of this disease by Sydenham
in 1686 is very interesting: "St. Vitus dance is a
sort of convulsion which takes boys and girls from
the tenth year until they have done growing. At
first it shows itself in a shaking or unsteady move-
ment of one of the legs, which the patient drags.
Then it is seen in the hand of the same side, which
the patient can not keep a moment in its place, when
it lies upon its breast or any part of his body. If
any vessel filled with drink be put in his hand, before
it reaches his mouth he will exhibit a thousand ges-
ticulations like a mountebank, and on this account, if
he is associated with other children, he becomes the
mark of derision, which is always detrimental to his-
condition. He may hold the cup out straight, as if
to move it to his mouth, but has his hand carried else-
where by sudden jerks. Then perhaps he contrives
to bring it to his mouth. If so, he will drink the
liquor off at a gulp, just as if he were trying to
amuse the spectators by his antics, or was afraid he
would not get the water, or fluid, if he did not drink
it hastily. Now this affliction arises from some
humor, falling on the nerves, and such irritation
causes the spasm."
Not an entirely lucid definition, but with all the
wealth of medical knowledge gathered from then
until now, we are forced to confess it is about as good
as the one of to-day. It was said in the history of
the disease that many causes were assigned for chorea.
Age, sex, race, seasons, contagion by imitation, no-
doubt have each some effect on the origin of th&
affliction. Sinkler reports a case in which a trauma
seemed to be the cause. Others attribute the devel-
opment of the disease to some reflex irritation, phy-
mosis, intestinal parasites, pharyngitis, eczema, urti-
1896.]
CUOKEA.
839
caria, eve-strain, menstrual changes, etc. Wliile it
can not be definitely said that any one of these is the
oause of chorea, it is self-evident that any one of them
may place the little patient in a more favorable con-
dition for its development. Many authorities attrib-
ute the eye symptoms to chorea, and not chorea to
the eye-strain. There is, however, a disease with
which chorea goes hand in hand — arthritis. One
might say that the excessive motions which we find
in chorea could be the cause of this condition. One
author says that in five cases of arthritis you will find
one case of chorea. It has either been my fortune or
misfortune not to have this complication to any great
extent. The same author says in five cases of chorea
you will see three of rheumatism. One cause of the
rheumatic disorder is the fact that it is difficult to
keep choreic patients in suitable surroundings, on
aecount of their nervous agitation. Copelnnd. an
English writer, says, too, that the rheumatism when
associated with chorea, has a marked tendency to
leave the joints and extremities and to attack fibro-
serous membranes, as the pericardium and cerebro-
spinal envelopes. Another author (Rogers) goes so
far as to declare that it is his belief that articular
rheumatism, endocarditis and chorea are simply
three phases of one and the same disease, while Osier
states emphatically that there is no known disease in
which endocarditis is found so constantly, postmor-
tem, as chorea.
I do not think it is fair, when we make a postmor-
tem of a patient and find endocarditis, pericarditis,
or any other "itis"' in a patient who has had chorea
to say that death was the result of the latter disease.
Is it not better to say that on account of deficient
vitality or a vitiated constitution, the child became a
victim of chorea, which so debilitated the constitu-
tion that it became an easy prey to the more severe
disease, endocarditis or pericarditis, etc., and that
death, instead of being the result of chorea, was pro-
duced by a disease, or diseases that follow in its train,
as the indirect result of the deficient vitality or vitiated
constitution. On the other hand, it is usually
acknowledged that where both arthritis and chorea
are present the arthritic symptoms appear first. Hirst
says there is a common toxic product, which if it
affects the cortex, produces chorea. How Hirst has
been able to ascertain this I do not know, because it
is seldom, and I believe never, the case where a post-
mortem has been made, that the patient has died
from plain, uncomplicated chorea. Hirst further says
if it turn its attention to the joint surfaces, there is
a rheumatism. This theory presupposes a locus
minoris resistentiae. Sachs believes that in 33 per
cent, of cases either endocarditis or myocarditis pre-
cedes the chorea, and in about the same proportion
of cases is found an organic lesion, usually a mitral
systolic, while in a great proportion of the cases is
heard an anemic murmur, which usually disappears
with the chorea.
Among the causes assigned for chorea is pregnancy
of the early months, and a pregnant woman who has
had a previous attack is especially liable to a recur-
rence at this period. On the other hand, I have seen
women who had attacks of chorea very much bene-
fited by pregnancy and the resultant childbirth.
Among other cases may be mentioned the exanthe-
mata and anemia. Anemia is found in all cases of
chorea, which clearly shows mal-nutrition. But it is
rational to think that the anemia is merely a step in
tin' causal relation, and not an original factor. Ane-
mia may be called a reasonable factor in many cases,
for if a child is well nourished with good, healthy,
rich blood, I believe it is impossible for it to have
chorea. Chorea has also been observed to follow the
toxic use of many medicinal preparations; notably
the poisoning which some times follows the use of
iodoform. This is brought about by the fact that
drugs of this character have to bear on the red cor-
puscular element of the blood.
( thorea has been observed as an intercurrent with
nearly all the more common diseases.
Even more intricate and diappointing than the
etiology of the disease, is the pathology. One unfor-
tunate circumstance in the state of the pathology of
this disease is the fact that it is very doubtful and
improbable that any case of simple, uncomplicated
chorea ever died, and so-called cases of choreic death
have not been produced by the chorea proper, but by
some complication.
Chorea, like hysteria (to which I believe it isclosly
related), in the first stages is assigned to want of ner-
vous equilibrium due to diminished nutrition, which
results in nervous congestion, brought on by over-
work or excitability. And if we could always have
the cases in this first stage, I believe all could be
guarded against complications, and be cured.
The varied pathologic conditions reported as found
in choreic patients, and given as causes for chorea, or
results of chorea, form a public confession of our igno-
rance regarding the subject. Its microbe has been
earnestly sought for, but the search has produced
nothing but disappointment. Pianese and Dana each
declares that he has discovered the bacillus, which
when cultivated gives ptomains, and the injection of
this substances causes chorea. Pianese substantiates
his claim to some extent, but his microbe is not yet
accepted. The staphylococcus pyogenes aureus is
frequently found in the endocarditic vegetations of
the choreic patient, and in one instance has been
found in the blood. That there is a microbe scarcely
admits a doubt, as the endocarditis, pericarditis, arth-
ritis, and sometimes septic thrombi, peritonitis, pleu-
risy, pneumonia and other afflictions, diseases due to
direct microbic infection, or to the absorption of
ptomains, clearly prove, for these diseases are the
comites of chorea. Postmortem pathology in chorea
shows that this chorea microbe, or microbes (for
there may be two or more varieties working in har-
mony, as may be seen in combined scarlet fever and
diphtheria, and in this way account for the frequency
of the intercurrent afflictions) gives its attention to
the structures of the nervous system, and here the
pathologic conditions are so varied and so numerous,
that it is difficult to select the one for which the
chorea is responsible, and find the one due to some
intercurrent disease. Hence there have been found
hemorrhagic infracts in the lenticular nucleus, cere-
bral hyperemia and edema, and the same condition in
the cord; vacuolization of the nerve cells and nerve
trunks as in syringomyelia and hydromyelia; hyalin
degeneration of cells in cortex and basal ganglia, the
motor cells; hyperplasia of neuroglia, the expected
result in chronic chorea, and a condition which remains
after recovery from the disease. Starr thinks that
where mental symptoms predominate, the cortex is the
seat of the degenerative process, and that when the
symptoms are chiefly muscular that the lesion is cere-
bral. There has also been found an evident prolifera-
840
MAN'S BRAIN AND MIND.
[October 17,
tion of cellular elements of the cord into the adventi-
tia of the blood vessels supplying that structure, or
pathologic karyokinesis. It is of interest to note
that the favorite seat of the pathologic lesion is in the
corpora striata.
In comparison with the definition of Sydenham let
me give a modern one; that of Dickenson. "An un-
natural hyperemia of the nerve centers, not due to any
mechanical exertions, but produced by causes, mainly
of two kinds: One, a morbid influence which may
affect the nerve centers, as it affects their organs and
tissues. The other condition is usually mental, but
sometimes what is called reflex, which especially
belongs to, and disturbs the nervous system, and
affects persons differently, according to the inherited
morbidity of their natures."
Having discussed the natural history, etiology and
pathology of chorea in a rather hasty manner, we
now come to the treatment; and in my opinion every
case of pure chorea should be cured; and especially so
if we can have fairly good surroundings, with fairly
sensible people to take care of the patient. It does
not require wealth nor any great ability for the nurs-
ing of this class of patients, but it does require a good
physician, who thoroughly understands the special
constitutional condition of his patient, and under-
stands the results and the action that he may obtain
from the drugs which he will use. First the patient
with chorea ought not to be excited by much com-
pany; and if it is a child it should not be associated
with other children, from the fact that children, see-
ing the constant nervous, and apparently senseless
movements, of their companion are very apt to laugh
and make fun of him, or her, and consequently
destroy what little confidence the patient may have
in its ability to control its movements. The patient
should be kept clean; should be frequently bathed;
well rubbed after each bath, and be placed with cheer-
ful, happy people. His surroundings and companions
should be restful. If it is an exceedingly bad case
the patient should be kept in bed as much as possi-
ble; and if the motions are violent to the extent that
he bruises himself, it is also well to put on a jacket
by which you can fasten his hands. Massage treat-
ment is very beneficial in these cases. If the child is
anemic he should have iron. If he is poorly nour-
ished, and does not eat enough food, he should have
cod-liver oil. If he comes from syphilitic or tuber-
cular parentage, his treatment should be directed to
these peculiar points. All sorts of remedies have
been recommended for the treatment of this disease
(Shoemaker forty-seven, Bartholow seventeen). Ar-
senic, zinc compounds, cimicifuga, antipyrin, chloral,
sulphur, quinin in large doses, opium, digitalis, and I
might mention a host of other remedies, but it is
unnecessary. Then as toward treatment during the
changes in action : If in pain, plasters. In endocar-
ditis, potassium chlorid. Now all these remedies
may be well in their places, but there is one remedy
upon which I place my greatest faith, and that is
strychnin. I have given it so much that I have come
to look upon this drug as a specific in the treatment
of this disease; and no matter what complications I
may find, I treat each complication and hold fast to
my strychnin. I give it about every four hours,
beginning with the one hundred and twentieth of a
grain, and gradually reaching one-sixth, and then
continue it for an indefinite period, or until my
patient gets well. In connection with that I give
digitalis, or iron, or cod-liver oil, or salsoda where
indicated; and if my patient is very restless, and lie
needs rest I give chloral, potassium bromid, morphin
and sulfonal, as I think best for each special patient.
And now as to the prognosis of this disease: I
believe that every case of pure chorea should, and can.
be cured. If you will study the peculiarity of your
patient, and follow the remedies as indicated in this
paper, if you can control the parents, you can abso-
lutely say when a case of chorea is brought to you,
that it will surely be cured.
MAN'S BRAIN AND MIND.
THE FORMER SOMETIMES INSANE,
NEVER.
THE LATTEB
Read in the Section on Neurology and Medical Jurisprudence at the
Forty-seventh Annual Meeting of the American Medical As-..
elation held at Atlanta. Ga., May 5-8, 1896.
BY G. W. DRAKE, M.D.
CHATTANOOGA. TEXN.
Man's brain is the storage battery of energy, the
seat of consciousness and the organ of the mind.
From it are transmitted by nerve fibers, energy for
the functional activity of all Organs and the vital
metabolism of all tissue cells. In it are localized
areas for the reception of energy and the perception of
sensations.
A sane brain is one in which all its cells and cell
derivatives, fibers and other material substances are
in a normal condition chemically, physically and
vitally.
Chemic analysis of the different parts of the brain is
not alone sufficient to enable the neurologist to judge
of its sanity, nor is a microscopic examination ade-
quate. Because neither will reveal the relative posi-
tion of molecules in a cell, or atoms in a molecule, upon
which in my opinion the normal function of the parts
depends, as also the kind, number and shape of the
molecules, together with their atomic structure. When
the cerebral centers are in a ,'normal condition, the
brain is sane, otherwise it is insane. When the dom-
inating brain centers which supply functional energy
to the various organs and tissues of the body are not
perfectly sane there can not be perfect function.
None of these centers are in a condition of perfect
sanity and there is no organ or tissue that is perfectly
healthy in function. The consequence is that the
period of activity of every tissue is limited and it car
not exist perpetually. It must sooner or later cease
to manifest life, dissolve into its original elements am:
return to the dominion of chemic energy, as the dust
of the earth. This is the common lot of all vital
tissues. The source of their vital energy is finite, and
they are consequently doomed to inevitable exhaustion.
Passing from the involuntary centers of the brain
we come to consider the centers of
tion, the habitat of consciousness.
Man is a triune being, consisting of a material,
sensible and an intellectual ego. These parts arc
usually denominated, body, spirit and mind. Con-
trary to the doctrine of the scientific Christian and
that of the christian scientist, I do not believe in the
existence of mental diseases, nor diseases of the sen-
sible ego. Disease, 1 believe to be a disarrangement
of the normal arrangement of matter in the structure
of one or more cells of the body. The gravity of the
symptoms depends on the locality and the number of
the cells affected. So-called "functional diseases,"
all have a material cause, whether the physician can
he
in
Be
id
conscious sensa
•
L896.]
MANS BRAIN AND MIND.
841
Bud it or not. So long as the material structure is
normal the functional activity will be normal. The
Sensible ego, or consciousness, is always ready to exer-
cise its faculties in the various brain centers of sensa-
tion where it is situated, viz.. those of hearing, feeling,
tasting, seeing and smelling. The peripheral and central
organs of the five senses must be in health in order
that the sensations may become conscious of normal
impressions. All the cerebral centers of the special
senses are more or less insane, and there docs not exist
oerfeot vision, perfect hearing or perfection of any of
the sensations. Everybody is color blind to a degree,
and there is a degree of imperfection in all the senses,
owing to material disturbances. There is a material
basis for every pain and every subjective symptom of
disease or discomfort. The sooner physicians recog-
nize this fact and bring to bear their materia medica
on all material disturbances, the better for the patient.
Let not christian science, spiritualism, faith cure and
other kintlred humbugs lead astray the grand old pro-
fession of scientific medicine. The best brains of
our best doctors are to be relied on as bulwarks of
defense against the cunning novelties which are
attempted to be introduced into therapeutics. Sug-
gestion and hypnotism as therapeutic agents can be
affective only as the material structures, the seat of
the diseases, arc responsive to their action. Imaginary
diseases are real material images and should be treated
as such. The intelligent physician should search dili-
gently for the concealed picture before attempting to
efface it. Therapeusis based on mistaken diagnosis
may lead to disastrous results. It is possible thus to
make a diseased image where one did not previously
exist. Insanity of the intellectual centers of the brain
is the form usually denominated mental insanity, and
its subjective symptomatology can be learned by
studying that of the so-called "mental diseases.'-
The function of these centers is to manifest the
faculties of the mind, and it is essential that they be
in perfect order to make a perfect reflex of mental
action. Any derangement of matter or departure from
the normal standard more or less unfits these organs
of the mind for their physiologic work. Every case of
insanity should be carefully studied etiologically, with
the view of cerebral localization of the seat of diseased
tissue. After the discovery of the part affected, a
rational materia medical course of treatment should be
instituted in conjunction with suitable hygienic envi-
ronment. Disarranged brain substance in the intellec-
tual centers can not make a correct manifestation of
the faculties of the mind. Brain culture as a physical
science has not hitherto received the attention which
its importance demands. The cerebral centers for
special senses, together with those for the higher fac-
ulties of the mind should be duly exercised for the
purpose of enhancing their capacity. By systematic
physical culture of these centers the equilibrium of
the brain may be maintained, and in this way insanity
be prevented in many cases. Brain sanitation is con-
ducive to sanity, and I may here interject that water-
ing the brain copiously is a measure of great hygienic
value as well as an essential therapeutic procedure.
Water the sick of all diseases, but especially those
sick of insauity.
I pass to a brief consideration of man's mind.
This is the the terra incognita of the anatomist and
will ever continue so, for it's not of the earth, earthy.
Mind is a general entity, specialized in man and indi-
vidualized in a particular man. Man's mind is the
first person of the human " trinity," and is made in
the likeness of the first person of the divine trinity.
1 1 is the supervisor and supreme director of the material
man. The brain is its organ, but its habitat is unknown.
It may dwell in some localized area or it may be
ubiquitous. The minds of all men I believe to be
equal, bat there is great diversity in the structures of
the brains or mind organs of different individuals.
The mind of the fool or idiot is equal to that of the
most brilliant philosopher. The mind of the newborn
babe is equal to that of the full-grown adult. There
is, however, a marked difference in the manifestations
of mental action in different classes of human beings,
owing to the difference in the material composition of
their brain centers. These brain centers may be cul-
tivated and developed by use. They may be brought
nearer and nearer to perfection and become better
organs of the perfect mind. The mind does not.
develop or deteriorate. The nearer the mental cere-
bral centers approach perfection, the grander their
manifestations of the conceptions of the mind. The
farther they fall below the normal standard the feebler
they portray the mental faculties and the more imbe-
cile their individual possessors. Great thinkers are
all men, young and old, ignorant and educated, sane
and insane or idiots, but great also is the difference of
the brain impression of their thoughts.
The mind is never insane. It belongs to that class
of imponderable agents or energies which was created
perfect in the beginning. It requires a certain adjust-
ment of matter for its manifestation, and the better
tlr's adjustment the better the manifestation.
There can be no change in the mind, but only in its
mode of action through a change in the cerebral ap-
paratus. Defective machinery makes imperfect move-
ment however perfect the motive power. Electricity
is the same, whether it turns a simple wheel or is
applied by suitable adjustment to the most compli-
cated mechanical contrivance. It is no more and no
less electricity whether it runs the street car or the
wheel of the fanning machine. It never gets out of
order and never needs repair. So with the mind, its
brain machine may break down and need adjusting,
but the mind can not be injured by traumatism, auto-
intoxication or bacterial toxins. It can not be pierced
by the bullet or cut in twain by the knife; it fears no
evil from without; its only concern is for its fellow
entity, the body, from which it must sooner or later
be separated. The body will crumble away and return
to the dust as it was and the spirit to "God who gave it,"
but the mind will roam about in the unseen universe
and wait for the resurrection of the body. After the
resurrection, the mind will preside over a perfect body
and spirit, and redeemed man will be a perfect triune
being in the image of the Triune God. Ccrrbnint
sanum in cor-jxyre sano is all that is needed to com-
plete the perfect man. The mens sana needs not a
physician. Brain culture should constitute a prom-
inent department of physical culture. Brain devel-
opment should not be neglected in the present craze
for muscle training. A systematic curriculum of
exercises should be arranged for training every sense
organ with reference to its better education. The
courses in music, painting, sculpture, etc., should be
studied with reference to their importance in brain
culture. Every sound, every picture, every form,
every muscular movement makes its image on the
brain and contributes to its development. The brain
is the highest organ of the body in position and
'842
EFFECTS OF DEGENERATIVE HABIT.
[October 17,
importance. In it mind, spirit and matter meet to
form the triune man in the image of the Triune God.
There is no difference in the members of the human
family, Hottentot, Mongolian or European, as to their
minds, the difference is only in the structure of their
brains. After death and the resurrection all the
redeemed of Adam's race will be equal.
Often on the thoroughfares of crowded cities, in the
parlors of the devotees of fashion, in the offices of
money dealers and in the haunts of the busy fortune
hunters, I have tried to imagine the appearance of the
brain structures of the different types of the homo
genus and compare one with another. Shape of head,
contour of face and form of features furnish a slight
index to the hidden form and individual structure of
the brain. The behavior of the individual is the best
criterion of the sanity or insanity of his mind organ.
The conduct of every individual must be compared
with that of the highest type of man and his brain
can be graded thereby with accurate precision.
Faces may deceive, pomp of wealth or foible of
fashion may conceal, but truth will out and show by
character the inwardness of the brain. The brainiest
men are those whose habits of life are nearest perfec-
tion. The world is full of deformed brains.
A NOTE ON THE PATHOMENTAL EFFECTS
OF DEGENERATIVE HABIT.
Read in the Section on Neurology and Medical Jurisprudence at the
Forty-Seventh Annual Meeting of the American Medical Asso-
ciation at Atlanta. Ga.. May 5-8. 1896.
BY H. S. DRAYTON, M.D., LL.B.
NEW YORK.
In his play, " Two Gentlemen of Verona," Shakes-
peare makes Valentine say —
"How use doth breed a habit in a man."
In this remark we have an expression of psycholog-
ical truth, that three centuries of later observation
has not been able to gainsay. The disciples of
heredity have availed themselves of the apparent
effects of habit impression in formulating their creed,
employing them as evidence of a double meaning,
especially if they were of a degenerate nature. "Evi-
dence here," they would say, "of congenital predis-
position, to think and act in lines that enfeeble mind
and pervert body." The pessimistic speculations of a
Schopenhauer or a Nordau may echo the opinions of
medieval prophets of a fate-bound destiny, and find
a hearing in a certain class, but the cheerful, sunlit
view of a better future for him who seeks it earnestly
is finding a larger recognition among the sober and
thoughtful year by year. In the field of anthro-
pology there does not appear that tenacious insistence
upon the preeminent influence of heredity that char-
acterized the discussions of ten years ago. Manou-
vrier, Brouardel, Magnan, and others of authority
refuse to admit the existence of any distinctive type
of nervous organism for the vice-bound and criminal,
and contend that it is not so much the inheritance of
a disposition toward conduct of an irregular, vicious
nature as it is the social relation into which one is
born or in which he lives, le milieu, that should
receive consideration, when we commence to trace
the etiology of moral perversion and crime. In the
Paris Congress of 1889 M. Manouvrier argued with
great force upon the principle that the commission of
acts in violation of law did not demonstrate a morbid
type of constitution but rather a certain caste of tem-
perament and unfortunate surroundings.
Dr. Henry Maudsley, once a pronounced apostle of
heredity of the severer class, said lately in answer to
the question. "Is a man hopelessly chained down by
the weight of his inheritance ?" " By no means, for
there is something else besides inheritance that makes
fate, and that is education. It is a physiologic law
that the brain throughout infancy, childhood and
youth grows to the circumstances with which it is
placed, and therefore the actual development of a
brain may be as much influenced by the kind of
nutriment supplied to it as long as it grows."
The verdict of psychology is substantiallyin keep-
ing with that of physiology. Sully, for example, in
"Handbook of Psychology," writes: "In the pres-
ent state of knowledge heredity only helps to account
for comparatively few among the host of peculiarities
that go to make up the natural phases of individual
character. . . . External influences cause varia-
tions. No two are subject to the same influences.
The school, the circle of friends, the business, etc..
differentiate minds. The body takes on a form of
growth because of the special line of habit in eating,
exercising, etc., of the individual. So the mind grows
on what it is fed in the daily life. Lines of mental
growth will be to some extent predetermined by
innate capabilities and tendencies, but these only
partly limit the process; they do not fix its precise
character. The particular ideas and connections of
ideas that form the intellectual habits fix the peculiar
coloring of the feelings and the special lines of con-
duct will all be determined by the character of the
surroundings." A particular trend of thought now
becoming popular in educational circles is derived
from a philosopher of a century ago, Herbart. and
which accentuates in stronger terms than those of
Sully the effect of education. According to Herbar-
tian pedagogies children have at first no real moral
character but acquire it through the union or associa-
tion of acts of will that have a moral quality. It is
the business of training to bring all classes of will
action under the dominion of moral maxims in order
that "a symmetrical passion for good" may be created.
Thus it is clear that in the Herbartian doctrine it is
the tone and quality of the general habits that deter-
mine the character, and these habits are not fortu-
itous, or predetermined by birth.
As to the effect of habits, however acquired, it is
undeniable that they produce in time conditions of
mind and body that in themselves reflect a healthful
or injurious nature. Are the habits of a vicious
kind? Persisted in they accomplish alterations in
the substance and relations of the cerebro-spinal
organism that are abnormal and degenerate. Thus
the soil of mind becomes more appropriate for the
generation of evil fruit than for good. The benign
elements become feeble and uninfluential or so per-
verted that their response to suggestions of a vicious
sort contributes to moral disorder.
The studies of the cerebralist have shown that the
form and constitution of the brain bear a particular
relation to mind capacity and character. We know
that certain endowments of structure render one more
susceptible to the adoption of manners and habits of
a coarse and perverting nature. Benedikt, Lombroso,
Maudsley, Spitzka, H. Mann, Allen, Buttolph, etc.,
have discussed the characteristics of structure that
may dispose a man in certain relations of suggestion
to respond to impulses of an unlawful kind. Dr.
Maudsley remarks, "All broad-headed people are very
I
law.]
KKFKCTS OK l>K(i KXKKATIYK II A HIT.
S4!{
■elfish; that is, all who have the head broad in pro-
portion fco its length. . . . An undue preponder-
ance of the breadth of the head throughout the region
in which they (the phrenologists) place the propensi-
ties, indicates with certainty an animal self-love which
can scarcely lie trusted at all times to adopt only fair
means for its gratification." The London professor,
arguing from the relation of the anterior brain lobes
to intellect further remarks, "The bad features of a
badly formed head would include a narrowness and
lowness of the forehead, a flatness of the upper part
of the head, a bulging of the sides toward the base
and a great development of the lower and posterior
part; with these grievous characters might be asso-
ciated, a wideness of the zygomatic arch, as in the
carnivorous animal, and massive jaws." Such a devel-
opment of brain intimates the possession by natureof
strong animal instincts, and a comparatively weak
endowment of those sentiments that inspire kindness,
sympathy and deference. Upon such a stock it were
easy to graft habits of a vicious sort through exposure
to surroundings that are degraded and brutal.
Thought habit then has its coordinate factors in the
cerebral substance, where molecular changes are pro-
duced with facility and effect correspondent to the
duration of the habit. Repetition operates not only
to render these molecular changes more rapid and easy,
but is productive of growth of nerve substance of a
special sort, an evolution correlative to the habit
acquired. The motor areas of a trained artisan are
more extensively furnished with appropriate cells than
those of an office clerk. The use of hand and arm
stimulate action and consequent cell proliferation in the
anterior and posterior ascending convolutions. The
artist develops those centers of form and color that are
of daily employment in his profession and they become
noticeably marked in his cranial physiognomy. Pro-
fessor Grates of Chicago experiments on the color
sense of dogs and proves that the enforced exercise of
that sense for a period had a result in decided increase
of brain tissue in the color area.
0< inversely, disease of mind faculty is attended with
declension and disease of the cell elements of the
coordinate center and decline in strength. Any habit,
therefore, that inhibits or suppresses the activity of
an important intellectnal or moral faculty disturbs the
mental balance and impairs the integrity of judgment
in no trifling degree. This impairment if not com-
pensated will go on until pronounced insanity results.
Interference with the normal function of any physio-
logic organ continued or frequently repeated causes
deterioration of that organ and of its cerebral center
of nervous supply. This deterioration implies either
functional decline or positive disease of the reciprocal
parts. Habits that contribute to the maintenance of
health oppose tendencies to disease, of whatever nature
the disease may be. The late Sir James Coxe, in his
enumeration of the six leading causes of physical
deterioration that may eventuate in insanity, places
" dissipation of various forms" first, because habits of
dissipation affect the nervous system more directly
and certainly than other causes. The specially con-
spicuous of these habits are : Alcoholism, the use of
tobacco and opiates. The disturbances of function
wrought by the practice of taking alcoholic beverages
daily belong to our common stock of knowledge and
represent generally or analogously what of nerve injury
is done by toxic narcotics as a class. They depress
the vital tone of every organ of the body. Of alcohol
we know that its high diffusible quolity enables it to
penetrate the animal tissues in every direction, and
by impairing the nutritive properties of the blood to
interfere with those metabolic changes that are essen-
tial to the maintenance of the integrity and vigor of
every organ, muscle, nerve, gland, mucosa, lymphatic,
etc., all suffer deterioration from frequent contact with
it. We know well its ravages on stomach, kidney,
heart and liver, and its inhibitive effects upon the
cerebral and spinal centers are matters of every day
observation. It may be that Hyrtl more than merely
accentuated his impressions from laboratory examina-
tion when he said that he could easily detect the brain
of a drunkard in the dark because of its comparative
hardness, but we certainly should expect a similar
effect upon the nerve mass whether it were placed in
alcohol to soak, or the latter instilled by daily install-
ments. The impairment of the functional energy is
so reflected in the character and conduct of the habitu6
that we are irresistibly led to the conclusion that the
disturbances of the nervous centers are those with
which the higher psychical faculties of mind are
directly concerned. These no longer exert their normal
control in the intellectual and moral expression, and
weakness of will and instability of judgment advance
pari passu with the alcoholic invasion.
It is not claimed that alcohol has a specific effect
upon certain brain parts, and attacks them on oppor-
tunity, but that by perversion of the nutritive supply
it as an early effect lowers the functional tone of the
brain, and these may introduce a train of evil conse-
quences to motor and psychic action. The senses,
which at first may be exalted through inhibition of
vaso-motor control, become later obtunded; the intel-
lectual perception relatively declines, and with this
power to reflect and to appreciate nice distinctions is
lost. The sentiments of courtesy, refinement and
kindness, esteem of virtuous character, independence
and manly resolve become less and less exhibited,
until quite replaced by indifference to the commonest
usages and requirements of propriety and duty. The
character assumes more and more a pathologic form.
We have the exhibition finally of a mental lesion, as
insanity, whose physical concomitants of perverted
function offer material for an easy diagnosis. The
alcoholic invasion especially affects the higher organic
centers of the brain, those that correlate moral apper-
ception, because of their more delicate adjustment to
the economy of nutrition and sympathetic impression.
Then, too, their comparative remoteness from the
arterial centers may be another reason for their dis-
turbance. Grief, disappointment, chagrin, poverty,
may be alleged as cause for a large proportion of
society's inebriates, but the fact remains that eight-
tenths of the intemperate drinking that abounds is
begun in the home or the friendly circle by indulg-
ence of the appetite in ways imprudent or vicious.
As Dr. Bushnell once said: The scale and order of
simplicity once broken, then ensues a distempered or
distemperate life that runs more certainly to that .
which is intemperate.
The cocain, opium and other drug habits of our day
may run a shorter course than that of the alcoholic,
but their perverting effects are not more certain or
disastrous. A similarly associated impairment of the
physical and mental organisms is the outcome, a
similar change of function, from capacity to incapac-
ity, from strength to impotence, from probity to dis-
honesty, from nobility to vileness, from humanity to
844
EFFECTS OF DEGENERATIVE HABIT.
[October 17,
bestiality. These are pathomental artefacts of an
uncontrolled self-indulgence. Now that we have the
dictum of the French pathologists at command to
supplement our own observations, we know that the
habit of smoking operates to produce changes in the
blood and the tissues through cardiac irritation and
gastric derangement, changes that in time necessarily
lower the general vital tone, and affect unhappily the
economy of mind. The pessimism and dyspepsia of
Carlyle were correlative. What of his inveterate
pipe smoking and his almost equally inveterate indulg-
ence in stomach -trying diet? How the fine cells of
that powerful brain must have suffered from the
scanty nutritive supply that a vitiated blood stream
brought to them! We can easily imagine that the
blood of the author of that story of the French Revo-
lution so luridly picturesque in its narration of horror
must have bristled in the microscope with its billions
of crenated corpuscles. The eccentric vision of the
historian and the distempered conduct of the man as
husband and acquaintance furnish a homily for the
moralist, and a fertile study for the neurologist.
The successful treatment of the chronic habitue
involves as a primary object the readjustment of the
factors of his thought life, so that his motives for
right and orderly living shall be renewed and his will
inspired with energy and persistence. But we shall
fail to restore coherence and harmony in his psy-
chic relations if we do not in the outset attend to
the rebuilding of his body, awakening to fresh activ-
ity the organic functions, so that the nervous corre-
lates of mind — cell and fiber — shall be supplied with
the elements essential to their reinvestment, and this
reinvestment should go on in advance of psychic
reformation in order that the intelligence of the man
shall be conscious of a growing strength. The older
the. habit the more difficult its management, yet it is
the age of the habitu6 that has more to do with the
determination of curability. Who, however, will say
that the degenerative changes in a given case have
gone so far that no improvement is possible? Those
whose experience warrants an expression of judg-
ment are inclined to take encouraging views of the
effect of considerate treatment. The President of
this section, after years of critical observation, has
said : " The tendency in nature being toward the main-
tenance of the perfect type, we may look for an
endowment of new normal tissue where all the con-
ditions are favorable, and under such circumstances a
cure, or what is popularly called reformation, takes
place."
Each case must be studied by itself; the type of
constitution being understood, the stage of degenera-
tion may be approximated, and a forecast of the prob-
able outcome of systematic treatment be ventured.
DISCUSSION ON PAPERS OF DRS. DRAKE AND DRAYTON.
Dr. Charles H. Hughes— The first paper seems to take a
rather peculiar position. The term mental disease, as applied
to insanity, and as a synonym for insanity, has been under-
stood by alienists and psychiatrists in all countries to be a con-
ventional term. Science has assumed that mind is the aggre-
gate of the personality and individuality of the person, as
discerned through the several functions of the brain and cere-
bro spinal axis. It has never entered into the metaphysical
question as to what is mind. Nor has it attempted to fathom
the nature of the cell. Psychologic science has relegated the
question of the nature and essence of mind to the unknow-
able. The Cartesian philosophers maintained that the mind
resided in the whole and in every part of the organism ; that
it represented the individuality of the person and was the
psychic portraiture of his personality. Science has to do
with material things ; its instrumentalities of research are
material, and the organs which it examines with the micro-
scope, the test tube or the crucible are material. Science says
that the brain is the organ of mind, adopting that term and
accepting it from the psychologists. The somatic psycholo-
gists study the physiology of the brain in regard to the mani-
festations of what philosophy has called mind. Now, we have
never attempted to maintain that the material entity of the
psychologists could become diseased, because if it become dis-
eased it might also die, and we know the dilemma in which
we might be placed. Science has judiciously evaded this ques-
tion, and left it to the domain of pure psychology. No sound
psychiatrist, no correct alienist, who is careful of what he says,
will go upon the witness stand or the rostrum and maintain
that the mind can become diseased.
We do not think that the brain centers preside exclusively
over the material metabolism of the organism. While science
has reached the point at which it believes that conditions in
the gray cortex have much to do with the normal metabolism
of the organism, it has not reached the point at which it can
say that they all reside there, for we know that acephalous
beings have the power of physiologic metabolism in their
ganglionic processes ; that hearts are formed, livers developed,
kidneys evolved, etc., without the intervention of the higher
psychic centers of the cerebrum. While, in the main, the
object of the paper would meet with the concurrence of most
men who have made this a life-long study, still I think it has
somewhat trespassed beyond the domain of science.
Dr. Burr — It seems unnecessary for us to go into matters in
connection with the soul, the spirit.
The subject of autointoxication I consider of great impor-
tance to those who are treating insane conditions. I find
myself confronted with difficulties in the way of medicating
those cases ordinarily. They have symptoms which I would
like to meet by medicine directed to the condition, but the
objection of the patient is very difficult to counteract.
As I have always undarstood the term hypochondriasis, it
signifies a willful lack of interest in one's self, and I am satis-
fied that in the majority of cases of hypochondriasis there is
at the bottom a pathologic condition, and often this condition
of autointoxication, owing to trouble with the kidneys, the
intestine, malassimilation and faulty metabolism.
Dr. Sanger Brown— The great trouble in neurology has
been that we have been wanting in sufficient distinct and clear
data with which to work, and I think the conception of the
neuron as it has been promulgated by students in various
countries in the last year or two due mainly to the great im-
provements that have been made in the process of staining, and
studying the primary unity of the nerves — has gone a great
way toward giving the remarks which we have before made,
and which have been hypotheses, an actual definite meaning.
I simply wish to refer to the published results of Dr. Berke-
ley's recent investigations in Johns Hopkins University, which
were set forth some months ago in The Brain. This only cov-
ers one department of this subject, but it is a very important
one and one which I think ought to be emphasized, because it
shows that it is possible we may look forward to a time when
the various poisons, the auto-infections, etc., can be definitely
reducible to a distinct anatomic basis ; indeed, that it may
be possible, perhaps, to reduce insanity to this anatomic basis.
Heretofore we had been forced to say that there were gross
changes in alcoholism in the brain. There might be sclerosis
in alcoholism or there might not ; I do not think it is possible
to demonstrate that. If two brains were laid down before us,
one of the worst drunkard in the world, and one of a man who
had never tasted a drop, I do not think it would be possible to
differentiate between them. Dr. Berkeley took a large number
189C.J
SARCOMA OF THE CHOROID.
845
of rabbits and foil them with all the alcohol they would stand
for seven or eight months, until many of them died of con-
vulsions. He found no process of hardening on examining
their brains but he did find changes in the body of the neuron
not changes in the axis cylinder. This was not the result of
the Btaining process, because ho made numerous control experi-
ments. 1 think this indicates the direction in which we should
look, because when we are studying neurology we are only
studying the function of the neurons, and everything indicates
that they may be regarded us so many units, and we can study
the s\ mptoms exhibited from that standpoint.
Dr. I I' Searcy I refer in my paper to changes by toxins
in the neuron, a change in the shape and size of the body, this
becoming shrunken, and the processes of the neuron being
altered at their extremities.
The changes in the axis cylinders of peripheral nerves are
also noted in some conditions like the neuritis of alcohol and
peripheral neuritis. The whole subject is still in the begin-
ning of its growth.
Dr. Dhakk One of the strictures on my paper seems to be
as to my claim that the functional activity of the centers of
metabolism was dependent upon the tissues in the brain. This
I wisli to explain, as I include in the brain everything in the
cranial cavity. The ganglionic centers I consider to be centers
which receive their energy from these higher centers. If they
receive no reinforcement of energy, then the metabolism
ceases, but so long as they are connected by nerve fibers with
the higher centers then the process continues. Cut the con-
nection and the process continues for awhile, but as soon as
the energy which is already contained in those lower centers is
exhausted the metabolism ceases. The heart can pulsate out
of the body for awhile by virtue of the energy which is con-
tained in its own ganglion centers. As soon as that energy is
expended, it ceases to beat.
Dr. Ki-Ki.nsc hmidt, of Washington, D.C. Hodges has shown
very clearly the great influence exerted upon the central nerve
cells by excitation of its axis cylinder process, the changes
being shown in altered conditions of form, etc. Again, it has
been shown, over and over again, by Weigert especially, that
normal excitation, if repeated through the cells of the nerve
centers, have their influence upon the morphology and
undoubtedly also upon the chemistry and molecular structure
of the central nerve cells. So that, considering the central
nerve cell as the center of energy, we may readily suppose that
influence such as cited by the gentleman from New York will
have a very decided impression upon the central nerve cell.
He held that by a proper mode of educating the brain that had
been reduced by disease or intoxication or bad habits, we were
able to reproduce by proliferation new central nerve cells. I
do not believe that that process has as yet been clearly demon-
strated. I do not believe that the central nerve cell, and espe-
cially the higher differentiated nerve cell of the cerebral cortex,
under any conditions can increase and multiply by prolifera-
tion. But there is another way in which we may educate that
central mechanism. Taking the studies of the neuron we
find that the nerve cell itself adds to its connections and the
capacity of the nerve cell is entirely to be measured by the
number of connections it can make with other nerve cells,
bringing it into nearer connection with the center of the sys-
tem in which it may be. In this case proper education may
lead to a new combination, to increase in the protoplasm pro-
cesses by which new combinations are brought about, and in
that way we gain a greater result. We can not suppose that
all nerve cells are equally affected ; and all the nerve cells in a
single cortex are probably not occupied at one time. Now, if
we can increase the metabolism in a nerve cell to such an extent
that these processes shall form into wider connections, we
therefore improve that nerve cell. I do not think that a cere-
bral cell once formed can proliferate.
Dr. Charles H. Hughes I only know of one man who ever
maintained that the cerebral cortex cells could be reproduced,
and that was John P. Gray, of Utica. The peripheral nervous
system can reproduce the central nervous system. I do not
think in regard to the question of degeneration, that toxicity
is the sole cause of mental aberration in those cases in which
insanity appears. I think that we are not yet prepared by any
of the later researches to explode the doctrine that insanity is
the product of more than one generation ; that a morbid apti-
tude of the cell, or the neuron as we shall have to say now,
and we shall have to speak of neurons, neurils, and epi-neurils,
in order to be in accord with the progress of modern histologic
research— is one of the factors. I do not think that insanity,
as a rule, is primarily developed by any form of acute toxicity.
It is excited by it, but it resides originally in the morbid apti-
tude of the psychic center or cell envelope.
I do not believe, however, in the degeneration of the race,
that the psychic sense of the average human being is less capa-
ble of sustaining pressure ; on the contrary, I believe that they
are standing more than the same centers in our ancestors and
that the tendency of nature is to preserve the type :
"So careful of the type she seems ;
So careless of the single germ."
Individuals fall by the wayside, unable to carry the burdens
laid upon them, and failing to learn wisdom early in life.
It is the pathologic condition of the center of the cell soil
that gives rise to the morbid manifestation. Given a certain
influence that acts upon the psychic centers of one individual
and his cerebrum sustains it without morbid result. One
individual takes alchohol in his blood, and displays no delir-
ium ; another takes oprum, and displays no delirium ; while
the third becomes crazy drunk or markedly insane under the
influence of either. It is the pathologic condition of the cell
that displays the aptitude of degeneracy of habit, and it is the
morbid tendency which is the exciting cause.
SARCOMA OF THE CHOROID, A SERIES
OF CASES.
Delivered before the Section on Ophthalmology at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8. 1896.
BY GEORGE F. FISKE, M.D.
CHICAGO.
Case 1. — M. E. B., architect, age 50, presented himself April
3, 1888, complaining of a cloud in the right eye which followed
a severe attack of "catarrhal fever" three weeks before.
O. D. 36 in. Sph., 42 in. Cyl., 90 deg. 5 5 Sz.
O. D. 48 in. Sph., 18 in. Cyl., 90 deg. 5 6 Sz.
In the left eye there were several choroidal plaques in the
upper outer periphery, and floating opacities in the vitreous.
In the right eye separation of the retina on middle nasal side,
extending within 2 mm. of the papilla. Nothing to distinguish
it from ordinary separation of the retina. No suspicion of
tumor.
Patient gave a history of very close application and was in a
highly nervous state. Consultation was had with two other
specialists, with no thought of sarcoma. Patient stopped work
for two weeks, protected the eyes from light, wore a .bandage
and remained in bed quite constantly, with no change. He
then resumed his work to a certain extent, contrary to advice,
and did not return to the writer until June 18, when vision was
reduced to perception of light, anterior chamber shallow, ten-
sion plus, pain and cyclitis. Diagnosis of sarcoma was made
and immediate evisceration of the orbit advised. Patient pre-
ferred to go to Europe, where eye was enucleated in Berlin, the
middle of July and proved to be a melano-sarcoma, patient
dying within six months, result of metastases in the liver ; no
recurrence at seat of operation.
Case 2. — Mr. G. A., plumber, aged 40, consulted me Oct. 9,
1890, having noticed for five weeks that sight in the right eye
was imperfect.
O. D. 0.75 D. Cyl. 90 deg. 5-8 Sz.
O. S. 0.75 D. Cyl. 90 deg. 5 5 Sz.
Examination of the right eye with the ophthalmoscope
revealed a small separation of the retina on nasal side, showing
the retina pushed forward by a small body, apparently 1 mm.
846
DERMOID TUMORS OF THE CORNEA.
[October 17,
in diameter, extending diagonally over the papilla, not quite to
its center. Diagnosis was made of sarcoma of choroid and
immediate enucleation advised.
Patient did nothing for nearly two weeks and then consulted
three eminent colleagues, all of whom pronounced the separa-
tion as probably not due to a tumor, though one proposed a
needle operation for purpose of diagnosis, which was refused.
This means that the separation had extended greatly during
the two weeks, as there was no question as to the diagnosis
October 9. January 19 patient again consulted a colleague,
presenting iridocyclitis and a glaucomatous condition. Enucle-
ation was performed Feb. 1, 1891, and a choroidal tumor of 5
mm. in diameter found, of uniformly black color, composed of
small spindle cells without reticulum and numerous large pig-
ment cells. Later, patient came again under my observation
; nd remained there for six months. There was no recurrence
ii the orbit of the sarcoma, but the patient began gradually to
fail ; six months after the operation, went away for his health
and died within eighteen months of " liver trouble." No post-
mortem.
Case 3.- Mrs. M. presented herself Sept. 16, 1893, with a
history of poor vision in right eye for several months. Vision
equals fingers in the outer field at two feet. Separation of the
retina involving all but the outer upper and inner upper portion
of the retina. Optic nerve not visible. No tension and no
iritis or cyclitis. Media clear and the retina apparently pushed
forward by a large, dark, rounded mass growing from the outer
central portion of the choroid.
Diagnosis : Melano-sarcoma, and I enucleated September 20.
The tumor was round, 7 mm. in diameter, not extending to the
papilla ; composed of spindle cells, round granular and pigment
cells. Optic nerve showed no infiltration nor did specimens
from the connective tissue of the orbit. Jan. 1, 1896, there
had been no recurrence ; patient in normal condition.
Case 4. — Mr. E. C, merchant, aged 56, came Nov. 6, 1893,
with a history of poor vision in right eye since May 1893. Old
corneal scar from blow with a marble at ten years of age.
Counts fingers at five feet. Separation of the retina nearly
complete, except in upper inner quadrant. Ophthalmoscope
reveals a mass reaching nearly to the iris in front growing from
the outer upper portion of the field, covered by the retina still
showing the retinal vessels. Enucleation advised, with diag-
nosis of sarcoma of choroid. 1 operated Nov. 17, 1893, and
found tumor of 4 mm. diameter, having its origin 6 mm. from
the papilla. Tumor had a very small base, was a spindle-
celled sarcoma with some pigment. Patient's condition Jan.
20, 1896, good, health excellent, with no sign of recurrence.
Case 5. — Mr. C. K., business man, age about 48, consulted
me November 28, 1893, with the request that I give him a pair
of glasses.
O. D. — 1 D. Cyl., 160 deg. 5-6 Sz. Partly.
O. S.— 0.50 D. Cyl., 160 deg. 5 5.
The day was rather dark and vision so good that it was only
a fixed habit which led me to examine the fundus, when 1 was
greatly surprised to find a small tumor on nasal side near the
macula, with retina pushed forward and adherent to the tumor ;
no separation of the retina extending away from the base of
the tumor.
Diagnosis : Sarcoma. The patient lost a brother from car-
cinoma of the tongue. Patient went to Brooklyn for operation
at the hands of a friend who is a specialist and the eye was
enucleated Dec. 5, 1893.
The following is the report of the pathologist at the New
York Hospital : " The tumor is almost spherical in shape. It
originated in the loose connective tissue of the suprachoroidal
space and involved the entire choroidal layer and external layer
of retina, pigment layer, rods and cones, mebrana limitans exter-
na and extended a short distance on either side in the external
molecular layer of the retina, the other layers of the retina are
pushed before the tumor and can be recognized as a thin mem-
brane everywhere limiting the tumor in front. Posteriorly it
is limited by the sclerotic, which at the point of contact with
the tumor is only one half the normal thickness. The tumor
is 7 mm. in diameter. It is estimated that the center of the
tumor is 5 mm. from the physiologic excavation. It is com-
posed of spindle cells of medium size, spindle-celled sarcoma,
with a minimum amount of basement substance. The vascular
supply is quite abundant. There are pigment granules through-
out, but it can not be regarded as a melanotic sarcoma. Along
the course of one or two of the vessels in the sclerotic coat are
numerous round and spindle-form cells, but can not be identi-
fied as sarcomatous elements. The optic nerve, dural sheath
and external sheath show no evidence of tumor tissue."
Feb. 29, 1896, patient's health perfect ; no sign of recurrence.
There are in addition to the above five cases, of
which I have been able to give more or less complete
histories, two cases in my record books which I have
not been able to report; one where the diagnosis was
quite certain and whose history I hope to give later,
and another where it is a question as to whether there
is a tumor under the separation of the retina or not.
Of the above five cases two died, one certainly and
the other probably as a result of a recurrence of the
sarcoma in other parts of the body. Both cases where
death ensued were rapid in progress and had reached
the stage of glaucoma and involvement of the ciliary
body.
The report is presented for the purpose of a discus-
sion as to the practical questions which present them-
selves.
1. The question of early diagnosis between the
separation of the retina and the separation of the
retina which is caused by a tumor behind it.
2. The question as to whether enucleation shall be
advised in cases where the diagnosis is not certain.
3. The importance and duty of assisting one an-
other by giving to each patient, in all cases of doubt,
i. e., in almost all cases of ablatio retinae, full notes
and sketches for use when patients consult other
specialists, which is usually the case.
First, as to diagnosis: This is often easy when the
tumor can be seen, or where glaucomatous symptoms
or inflammations of the ciliary body, have presented
themselves, also where the separation follows extreme
myopia, or a blow, or injury, or seasickness. Where
the separation is slight and occurs in the upper half
of the field, the tendency of the sub-retinal fluid to
seek the lowest level will often assist the diagnosis,
and in some cases drawing off the fluid with a hollow-
needle and syringe will clear up the doubt even
though the separation is not cured by that means.
The importance of early diagnosis is greatly in-
creased by the fact that these choroidal sarcomas
almost always occur as primary and not as metastatic
sarcomas. I have not found in the literature a single
case of a sarcoma or melano-sarcoma occurring as a
metastasis following sarcoma in some other portion
of the body. On the other hand, particularly in the
case of melano-sarcoma, metastases in other parts of
the body following the sarcoma in the eye-ball are
very frequent and fatal.
Second, as to indications for an operation in eases
of doubt, I would suggest enucleation be advised
where : a, the vision is irrevocably destroyed and there
is doubt as to the presence of a tumor; b, where, though
there is slight vision present, it is failing rapidly
through extension of the separation, and there are no
previous examinations by colleagues, excluding the
presence of a tumor, with no good reason for excluding
it from the history of the case; c, where glaucomatous
symptoms show themselves or cyclitis or irido-cyclitis.
DERMOID TUMORS OF THE CORNEA.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8. 189«.
BY ALBERT RUFUS BAKER, M.D.
Professor of Diseases of the Eye, Ear and Throat. In the Cleveland Col-
lege of Physicians and Surgeons, Medical Department of the
Ohio Wesleyan University, Cleveland, Ohio.
Although a number of cases of dermoid tumors of
the cornea have been reported from time to time it
has seemed to me that a brief report of the only two
cases that have come under my observation might be
of sufficient interest to claim your attention .
1896.]
DERMOID TUMORS OF THE CORNEA.
•847
Cose /. July 1880, Mr. M. G., aged 24, a peculiar growth
from the cornea of left eye, protrudinp between the lids, pre-
ent since birth, pedunculated, occupying the entire palpebral
opening, measuring about one inch in length by one-half
inch in breath, ana rather thickly studded with stiff black
hair. Being pressed together by the eyelids, the tumor pre-
sented upon superficial inspection the appearance of a small
bair brush instead of an eye. The eyeball was entirely con-
cealed by the growth, but by opening the lids widely and push-
ing it downward some clear cornea could be seen, and fingers
counted. Patient declined operation at that time but returned
in 1884. He thought the tumor was growing larger but it
■earned to me about the same size as when first seen. An
anesthetic was given and the tumor removed without difficulty.
It was found to be attached to a little more than half of the
cornea at its lower ami outer portion, but peeled off smoothly,
leaving a transparent cornea beneath.
1 1 extended close up to the sclera-corneal margin but did not
encroach much, if any, upon the conjunctiva, with which it
seemed to lie intimately connected. The portion of the cornea
occupied by the tumor became somewhat cloudy for a few days
but soon cleared up excepting a small line running in a semi-
circle across the cornea, marking the point of attachment;
vision fairly good ; is able to read ordinary book print.
Com '.'. duly US, 1893, Miss A. P., aged 17, three small Hat
dermoid tumors of cornea of left eye. Two of them were on
the outer sclero corneal margin and each about one third the
diameter of the cornea : the other a small one consisting of a
fine line extending perpendicularly across the pupillary area
almost at the center of the cornea. The three tumors were all
separated by clear cornea. They had the appearance of ordi-
nary integument with a slightly pinkish tinge. Present since
birth and no increase in size. Patient was seen by Dr. C. R.
Agnew in 1877. it seems to me that I have seen a report of
the case by Dr. Agnew, but I have been unable to find it in the
literature at my command. Under a general anesthetic I dis-
sected off the tumors. Was very glad I gave a general anes-
thetic at the urgent solicitation of the patient because of the
free hemorrhage which would have embarrassed me very much
with cocain alone. The case made an uneventful recovery,
but with much more opacity of the cornea than I had hoped,
judging from my experience with the other case. There was a
high degree of hypermetropic astigmatism and with full cor-
rection vision was only brought up to 20-200 S.
Ryba ' in 1853 collected twenty-seven cases that
had been reported up to that time in human eyes;
three in oxen's and four in dogs' eyes. Mr. Dixon2
reported a case of dermoid tumor the size of a hazel
nut upon the lower part of the cornea and sclerotic of
a little girl. The tumor was removed and found to be
white, smooth and hard. The cornea after removal was
transparent but in three or four days became white
and opaque.
Cases have been reported by Graefe;3 Virchow,4
Arlt,"' Taleferro,6 Hulke,' Wells,s Labrum,9 Cooper,"1
Straw bridge." Risley,1- Roberts,1' Fuchs," Brose,15 and
others.
Amnion "' reports a case of coloboma of eyelids in
which a dermoid tumor of the cornea filled the gap.
Mr. Swanzy IT gives detail of a case he observed
under the care of Von Graefe. The tumor was very
large and was removed by Graefe. It occupied the
whole of the depth of the cornea. The anterior cham-
ber was opened and considerable vitreous escaped.
Milvalsky " (Prague) reports two cases of dermoid
tumors of the eyeball. The paper is published in
Oezechesh with a resume in French. The author has
reviewed the literature on the subject very carefully
and has found recorded seventy-five cases of dermoid
tumors of the eye-ball. Seven of these he calls atyp-
ical, being connected with the eyelids. Five of the
cases were entirely corneal, and twelve were situated
on the sclerotic and fifty-one were placed partly on
the sclerotic.
" The relation of these tumors to the conjunctiva
varied. In some the conjunctiva seemed to be
replaced by the tumor tissue: in others it covered the
surface of the latter, while in most instances a portion
of the growth was apparently covered by conjunctiva,
while the remainder exhibited on the surface a pave-
ment epithelium, papilla, hair follicles and fine hair.
The cystic form or closed dermoid is never met with
in the eye."
A review of the preceding cases seem to show that '
they are all congenital; a few may be located on the
cornea alone, a few on the sclerotic but the largest
number involved both structures and are found most
frequently at the outer and lower sclero-corneal
margin.
Van Dusyse's '" ingenious theory as to the origin of
these tumors is not generally accepted, namely, that '
the amnion was at one time united and through con-
striction and separation, there remained at the orig-
inal point of contact amniotic cells from which later
the dermoid cysts developed." A more reasonable
explanation is the one generally accepted as to the
etiology of dermoid growths in other parts of the body,
i.e. an inversion of the epiblast during embryonic
existence, an islet deposit of cells, which makes skin,
sebaceous glands and hair follicle.
Little need be said as to treatment. Removal for
cosmetic purposes is usually desirable. Notwith-
standing Von Graefe's unfortunate experience the
danger of penetrating the eyeball is slight. It does
not seem to me that cauterizing the wound as recom-
mended by most writers is necessary, and may only
add to the amount of opacity present upon recovery.
The same objection is true with regard to the advisa-
bility of covering the surface of cornea exposed with
conjunctiva, recommended by some writers.
B1BI.IOG1IAPHY.
1 Ryba:Prager Viertel Jahrschrift, 185:1, Bd.3p. i.
2 Dixon : Royal Loudon Ophthalmic Hospital Reports, p, 112, July,
1895.
s Graefe : Arehiv f. Ophthalmologic, vu, p. 8, x p. 214.
* Virchow: Arehiv f. Pathologische Anatomic 6 Band, Heft4, p. 555.
s Arlt : KrankheudincheB Binde & Hornbaut, p. 170.
» Taleferro : American Journal of Medical Science, July, 1841, p. 88,
Lawrence on the eye, p. Ml.
J Hulke: Ophthalmic Hospital reports, Vol. in, p. 832.
s Wells : Royal London Ophthalmic Hospital reports, Vol. in, p. 282.
9 Labrum : Annates d' Oculistique, September 1870, p. 135.
io Cooper: London Medical Gazette. November, 1841, p. 278.
ii Strawbridge : American Journal of Medical Science, 1873, p. 106-107.
12 Risley : Philadelphia Medical Times, 1879-80. p. 490.
U Roberts: Philadelphia Medical Times, 1879-80, p. 548.
i* Fuchs: Text Book Ophthalmology, p. 115. Klin. Monats. f. Augenh.
Stuttgart. 1880, xvm, p. 131-184.
15 Brose: Archives of Ophthalmology, October 1895, p. 479.
lOAmmon: Klinische Darstellungen. Pt. 2. Tab. 1. Fgs. 8 &9.
i" Swanzy: Dublin Quarterly Journal of Medicine, May 1871, Royal
London Ophthalmic Hospital Reports.
isMilvalskv: Ophthalmic Review, Vol. vn, p. 217.
ii» Von Dusvse: Ann.Soc. de Med. de Grand, 1882, lx, p. 170-206. Also
Ann. d' Ocul. Brux., 1S82, lxxxviii, p. 101182.
DISCUSSION.
Dr. Adelaide E. Portman, Washington — From the situation
it can be readily'understood why it is so serious in removal as
it involves the whole depth of the cornea and the sclerotic,
removal causing results to visual acuteness. Hirschberg
reports a^case, in a girl of 17, of enormous size in which th'e
result was vision of normal acuteness.
Dr. J. A. White, Richmond — I reported a case of dermoid
growth of the cornea in a man some years ago. The growth was so
large as to prevent closure of the lids, the cornea being entirely
covered and the sight in consequence abolished. It had begun
at the corneal margin some ten years previously and gradually
overspread the cornea in which by pressure it had produced
ulceration, followed by cicatricial adhesions over one-third of
its surface. Its rsmoval was followed by favorable healing,
the cornea cleared and subsequently the eyesight became-
nearly normal. This tumor was not congenital but was shown
by the microscope to be a dermoid growth.
Dr. D. S. Reynolds, Louisville — The technique of the opera-
tion is vastly more important than the study of the comparative-
848
WATER.
[October 17,
rarity of dermoid growths of the cornea. Any growth of this
kind which invades the sclerotica must make any attempt at
complete removal fatal to vision by the inevitable cyclitis
which ensues. A comparatively large growth located entirely
in the cornea may be safely removed. In the case of a man
who lost the fellow eye, I removed a large dermoid tumor of
the cornea, closing the wound by the Lembert suture, with the
result of restoring such useful vision as enabled the man to go
about alone. If the sutures penetrate the whole thickness of
the cornea the openings through which the sutures pass will
continuously drain away the aqueous humor, keeping the
sutures so long in contact with the surface of the iris as to lead
to its fatal inflammation.
WATER.
BY I. N. LOVE, M.D.
ST. LOUIS, HO.
In searching for the striking and unusual we often
overlook that which is trite and commonplace to our
detriment. Nowhere is this more true than in the
practice of medicine. I believe that we are, safe not only
as teachers in medicine but among ourselves, in lay-
ing stress upon the importance of using the simplest
possible means for gaining a given end. The neo-
phyte is not the only one who seeks for the unusual,
for the formidable, as a means to an end and over-
looks that which is near his hand. Indeed, all of us
are prone to err in the same direction. As a profession
we need to call a halt, ever and anon to get down off
of our stepladder in our search for the unattainable,
to come down to terra firma and use the things that
nature has given us. Drugs, drugs, drugs, seem to
be the chief inspiration in the life work of too many
medical men, and in these modern days we must have
a care in our use of animal therapy, for we know not
as yet but what this form of medicine is quite as
dangerous, if not more so, than the articles belonging
to the mineral and vegetable kingdom; the drugs of
which Oliver Wendell Holmes very truly said, " That
the world at large would be better if they were all
thrown into the sea, " but the fishes would more than
likely cease to be, as a result of the dumping.
Water, which is everywhere near at hand, ready
for use, is one of the most important remedial meas-
ures we can bring into play. The hydropaths, who
for long were looked upon as fanatics, have done
humanity and the medical profession a service, in
that they have demonstrated the great value of water.
However, the fanatic in the use of one remedy often-
times is in danger of denying his patient remedies of
value that would work in harmony with his special
hobby. Surely, when we recall the fact that more
than 75 per cent, of the whole make-up of the
human body (including every tissue of the same) is
water, we can appreciate its importance. It has been
demonstrated, time out of mind, that while water ful-
fills many other subsidiary offices, it is essential for
the occurrence of molecular change, or mobility — the
essence of the manifestations of life. In the absence
of water a state of molecular rest (which means the
absence of activity) prevails.
It goes without saying, that water in some shape or
other, is one of the essential conditions of life and
just as essential as solid matter, it not only entering
into a constitution of every part of the body, but is
required for various purposes in the performance of
the operations of life. Without it there could be no
Head at the meeting of the Mississippi Valley Medical Association,
St. Paul, Minn., Sept. 18, 1896.
circulation or mobility of any kind. " It forms the
liquid element of the secretions through the medium
of dissolving and enabling the digested food to pass
into the system and the effete products to pass out; a
constant ingress and egress are occuring, and the
former requires to stand in proper adjustment to the
latter. The demands for water are effected by the
amount of muscular exercise and the degree of tem-
perature to which the individual is exposed^ as in
both conditions the loss through the skin as well as
through the lungs is greatly increased." It has been
a popular impression for long that the drinking of
water with the meals interferes with digestion in
diluting the gastric juice, and as a result of this
notion, the public have largely refrained from drink-
ing water with their meals. Pavey well says that it
is a mistaken notion to think that when we drink
with a meal we are diluting the gastric juice. The
act of secretion is excited by the arrival of the meal
into the stomach, and the gastric juice is not there at
the time of ingestion. It happens indeed that the
absorption of fluid takes place with great activity
and the liquid drunk during the meal (unless the
quantity be very great) becoming absorbed may be
looked upon as proving advantageous by afterward
contributing to yield the gastric juice which is
required.
For an irritable stomach or an attack of so-called
bilious colic, nothing is superior to liberal quantities
of hot water as pure as possible. The first amount
administered may be rejected, but if so, it accom-
plishes the washing out of the stomach. If the drink-
ing be persisted in, a large quantity will be retained
and finally a relaxation of the pyloric orifice of the
stomach will occur, and the water will pass freely
into ,the smaller bowel, relaxing and stimulating
secretion as it goes. The intense pain of these attacks
can often be promptly relieved and if helped by the
addition of hot water applied over the stomach and
bowels, through the medium of cloths saturated with
the same, and occasionally sprinkled with small
quantities of turpentine, which acts as a counter
irritant. In the majority of cases the stereotyped
administration of morphin by injection, is uncalled
for. Indeed we are safe in saying that in the bulk of
the attacks of acute indigestion and intense pain
resulting therefrom, we had better relieve the condi-
tion in the simple manner suggested, rather than
apply remedies which deaden pain, check secretion
and retard convalescence, and frequently mask the
preliminary symptoms of a dangerous disease. Noth-
ing will more promptly relieve a patient's suffering
from the after-effects of a banquet or midnight dinner,
where the victim has possibly tarried with and looked
too long upon the wine which is red (and white wine
too for that matter) resulting in the dark brown taste
and that terribly different feeling in the morning,
than the imbibition of large quantities of hot water.
The instruction to drink one or two pints of extremely
hot pure water, prior to rising and sandwiching in
between the various glasses a cup of black coffee,
without cream or sugar, will give us a good result.
The hot water washes out the stomach from above
downward, stimulates the activity of the excretory
glands, soothes and tranquilizes the nervous system.
which is thoroughly on edge, and the black coffee
administered in the manner suggested, meets the
necessities of the hungering and the exhausted nerve
centers, serves as a disinfectant for the alimentary
1896. |
WATKR.
H4<»
canal and encourages diuresis. The injuction to
abstain from food for several hours, will as a rule
make our patient all right and in good shape for a
a hearty mid-day meal.
While it is true that water does not in itself under-
pi any ohemic alteration and hence is not susceptible
of liberating force, does not in other words, constitute
a force-producing agent, yet it contributes to chemic
ohange by supplying a necessary condition for its
ooourrenoe in other bodies. In other words the
proper metalK>lism of tissues, the entire scheme of
nutrition, depends upon water. Not only do we need
water then tor the proper accomplishment of nutri-
tion and as an element of iood, but we need it for
eliminating purposes. Pavey has stated that it may
be reckoned that we receive from about fifteen to
twenty-five ounces of fluid into the system mixed
with solid food that is consumed and, besides this, it
is advisable that about sixty to seventy ounces and
even in some eases as much more should be taken.
The average amount of urine passed daily may be
said to be titty ounces and there is considerable loss
of fluid through the skin and lungs. To meet this
waste by elimination, compensation must be affected
by a corresponding amount of liquid; as long as the
fluid taken is devoid of noxious properties a free
supply must be regarded as beneficial, forming as it
does, a means of carrying off impurities from the sys-
tem. Pavey further says he believes that the benefit
derivable from a course of water treatment is often in
a threat measure due to this cause. Water then,
taken in free quantities acts as a purifier of the sys-
tem, tlushing as it were the animated system of sew-
erage, dissolving out poisonous materials and waste
products of the body, which otherwise might be
accumulated. For instance it is well known that uric
acid, a very important factor in gouty conditions,
requires a large amount of water to render it suffici-
ently soluble to be carried out of the system. For
fully fifteen years I have been impressed with the
thought that the majority of people, sick and well
drink an insufficiency of water. I would advise the
establishment of the water drinking habit on the part
of children from the beginning, through life. And as
each year passes, I have been more and more convinced
of the correctness of this position. It is the uni-
versal observation that thin people are scant water
drinkers and a change of habit in this regard often
results in an improvement quite manifest. Then
again we will observe that the fat and well-fed looking
ones are uniformly liberal water drinkers. We have
then in this, evidence of the fact that a free supply
of water improves nutrition. Furthermore, the one who
does not drink water, often has a dark, swarthy, so-
called bilious complexion, inactivity of secretion, mani-
fesfed in the appearance of the face; whereas the
water drinker has a clear, healthy eomplexion, sug-
gestive of the fact that secretion is active and that
the poisons due to waste are not retained and stored
up in the system. We can not impress too forcibly
upon the young and particularly the female devotees
of society, that the greatest improver of the com-
plexion which they can have, is the free use of water
internally and externally. Surely if the general con-
ditions of those who are supposedly well are improved,
it follows that those atticked by disease in any form,
will be the better for the free use of water. When
medicine is administered, it should be accompanied
or followed by as large a quantity of water as may be
retained by the patient. Prompt solution, absorp-
tion, action and elimination of the medicine will be
the result.
For years, in the management of my typhoid fever
patients, as well as most other diseases, I have insisted
upon the drinking of a liberal quantity of water,
endorsing by my practice the course of Debove, who
administers almost to the exclusion of all drugs in
typhoid fever from four to eight ounces of cold water,
every two or three hours when awake, to wash out the
poisons from the system. The free secretion which
follows its use, comforts the patient in every way and
undoubtedly serves as a reducer of temperature.
This internal use of water accompanied by its proper
external application almost excludes medicine from
the field, though it has been my custom for years, not
less than ten, to use infinitesimal doses of the mild
chlorid, eucalyptol, menthol and oil of gaultheria, for
a gentle stimulant to excretion and local antisepsis
for the alimentary canal, preferring always to have
the bowels gently open with a view to eliminating all
poisonous matters rather than a constipated or tied-
up condition of the alimentary canal, with a conse-
quent retention of poisons. In this connection
permit me to say, as I have repeatedly said in debate,
that the views and treatment of my friend, Dr. Wood-
bridge of Ohio, are in no way new, nor are they
original. They are simply the application of the
accepted antiseptic and gentle eliminating treatment
of typhoid fever. I will grant that the extravagant
manner of his presentation of the subject has residted
in a more general dissemination of the advantages of
this treatment, but this is more than offset by the
absurd position taken by him in stating that under
this treatment he allows a complete recklessness in
the matter of food and exercise. I know Dr. Wood-
bridge is honest, but I know furthermore as well as I
know anything, that he is mistaken in his conception
ot typhoid fever, and many of his cases reported as
such, have never been made acquainted in the remot-
est way with Eberth's bacillus, the causative factor.
It is well known that there is no solvent which will
remove poisonous materials, such as uric acid (the
exciting cause of gout) and many other poisons from
the system, so readly and completely as absolutely
pure water. Indeed, the temperature-reducing and
gland-stimulating affect of copious water drinking
has been utilized for many years, and more recently
by Meigs, Cantani, Dujardin-Beaumetz, Debove and
Sahli.
Cantani is a great believer in the reduction of tem-
perature slowly but surely by the regular drinking of
large quantities of water. Indeed, he believes in the
liberal introduction of it into the alimentary canal
from both directions.
Dujardin-Beaumetz, no better authority in the
world, promotes diuresis, or elimination or washing
out of the products of organic disintegration (or
waste) in disease by copious drinking of water.
Debove administers, almost to the exclusion of all
drugs, in typhoid fever, six ounces of cold water
every two hours to wash out the poisons from the
system.
Simon Baruch of New York, one of the highest
authorities upon hydrotherapy and value of water
enjoined as a remedial agent, endorses the use of
water by those whose names have just been cited, and
even goes further.
Every authority will sustain the thought that the
"850
THE TREATMENT OF DIPHTHERIA.
[October 17,
purer the water, the more complete the elimination
and more satisfactory the result in every way.
Let it be remembered that to Dr. James Curry of
Liverpool belongs the credit of first using the cold
water treatment in a systematic way in fevers. He
employed as a rule cold effusions frequently and
occasionally cold baths. His method was adopted by
many physicians and soon came into extensive use
both in England and on the Continent in the treat-
ment of many febrile affections and especially in the
management of typhus, typhoid and scarlet fever. It
gradually fell into neglect, like many other excellent
therapeutic medicines, and was for a long time almost
forgotten. Dr. Ernest Brand of Stettin revived the
cold water treatment of fevers in 18(58 and the method
came rapidly into use in Germany, Austria and
Switzerland. This history of the application of cold
water bears out the thought that in these modern
times, that many measures which have their seeming
origin in Germany are more readily accepted and
popularized than if coming from other directions.
There are many objections that can be presented to
the extreme application of cold baths, as was the rule
with Brand, the modification of Ziemssen being much
to be preferred. Ziemssen recommended the intro-
duction of the patient into water having a tempera-
ture of ninety-five degrees, then cold water to be
gradually reduced to seventy-five degrees Fahrenheit,
or even below. This method is much less apt to pro-
duce shock, and the pleasantness of the procedure is
such as to render it much more acceptable to the
patient and attendants. To secure the same reduc-
tion of temperature to the patient a longer time is
necessary for the bath. The placing of a sensitive
or nervous patient into an ice cold bath skirts the
borderline of the brutal and is to be condemned, except
in rare cases. This method is certainly to be con-
demned in the fevers of children. Sponging of the
surfaces with cold or tepid water in which a little
alcohol or aromatic vinegar has been placed is often
very comforting and soothing to the patient. It does
not reduce the temperature to any very remarkable
degree but has a cleansing effect on the skin and stim-
ulates its activity, and is for that reason oftentimes
a great advantage.
I am convinced that experience in the application
of water in the treatment of fevers will endorse many
of the conclusions of Brand, Ziemssen, Hare, Vou-
veret, Winternitz, Dujardin-Beaumetz, Vogl, Peabody,
Austin Flint, Simon Baruch, to the effect that it is
not only valuable as a reducer of temperature but as
a stimulant and a helper in the direction of elimina-
tion and a tranquilizer and securer of rest and an
aider in the digestive and assimilative processes
essential to repair. He who had ever seen a patient
almost unmanageable with the delirium of high fever
or the convulsions of childhood dependent upon
fever, promptly relieved by a cool bath followed by
restful sleep, can not require further argument.
Indeed, I believe that no one in the profession would
deny that the utility of water used judiciously in this
way, has been absolutely proven.
The hot bath as applied to children suddenly taken
with convulsions is often misapplied. When we
recall the fact that convulsions are more frequently
produced by high temperature than any other cause,
we can readily see the objection to extremely hot
water baths. Before being used the temperature
should always be reduced and if it be used, the bath
should be comfortably warm and cold water gradually
added. However, the 'hot water bath in many condi-
tions in childhood is of great service in the treatment
of those who are sick, particularly in its cleansing
effect upon the skin, rendering the excretory append-
ages of the skin more active. It serves admirably as
a tranquilizer, producing restful sleep when applied
immediately before retiring, to victims who are
sufferers from insomnia and restlessness.
We all know the value of hot water when applied
locally to inflammations. Recalling the parboiled,
shriveled, whitened look of the washwoman, whose
hands remain in hot water long, we can readily under-
stand that the hot water drives the blood from the
inflamed tissues and gives great relief to the pain, as
well as removing the trouble permanently. Racking
headaches can often be relieved magically, as any
lover of the luxury of a graceful barber and a com-
fortable barber's chair can . testify, by the application
of towels rung out in boiling water and laid across the
forehead, eyes and part of the head which seems to be
most affected. Apparent suffocation and complete
stenosis accompanying diphtheria and acute laryngitis
is often relieved very satisfactorily by a liberal appli-
cation for a few hours of cloths wrung out of hot
water to the external parts.
Liberal poulticing with soft cloths saturated witli
almost boiling water are cleaner and in every way to
be preferred to flaxseed, bread and milk poultices,
and other filthy abominations.
THE TREATMENT OF DIPHTHERIA.
BY DOWLING BENJAMIN, M.D.
CAMDEN, N. I.
To thread one's way through the enormous and
conflicting mass of statistics that have been published
in regard to the treatment of diphtheria by means of
antitoxin, or serum therapy, is an undertaking to
appall the stoutest heart.
By patience and application we may observe a few
facts, however, standing prominently and seemingly
substantial enough to remain as useful monuments
to guide us through the wilderness of uncertainties
to some safe vantage ground.
THE RESULTS IN PRIVATE PRACTICE.
A study of the results of the antitoxin treatment in
private practice presents much greater difficulties, for
obvious reasons, than does the study of the same sub-
ject in institutional practice.
Exactly what the results have been can not be
ascertained, as it is not possible to obtain the per-
sonal and private statistics of each individual physi-
cian as to its results and his death rate; nor would it
be wise, since such results might do injustice to thor-
oughly competent men. If results are particularly
good, however, occasionally an individual practitioner
will publish such, which seems to be the only way we
can obtain them.
The limits of this paper would not permit the quot-
ing of each of the publications by private practition-
ers, giving the results of their individual practice.
The introduction of a few, however, will be necessary.
In the present enormous amount of literature and
reports on the subject, the results obtained by any
one man in private practice can have but little effect
on the question.
One year ago, Dr Rosenthal of Philadelphia, in a
paper read at the meeting of the Medical Society of
1896. |
THE TREATMENT OF DIPHTHERIA.
851
1
tlu> StaH- of Pennsylvania, arrived at the following
conclusions: "Antitoxin is a specific for diphtheria.
In early cases, those seen one or two dnys after infec-
ion, no death rate should be recorded. In laryngeal
diphtheria, the so-called membraneous croup, anti-
toxin is especially indicated. It should be used in
even stage and at any date of the disease, no matter
how late we see the ease. Its influence can be proven,
far eases of laryngeal diphtheria perish from suffoca-
tion long before any toxic symptoms can be mani-
fested." For that reason he strongly urges the
necessity of prompt intubation when indicated, even
if before the injection of antitoxin.
Regarding the use of antitoxin, he says: "Do not
delay i 'i' hesitate in this disease because the case is
not so bad, or because it might get well without, but
use ii at once : the earlier it is used, the more certain
its success."
This and similar sentiments from other sources,
and the very logical character of the theory of anti-
toxin treatment, based as it was on laboratory experi-
ences, necessarily made an impression upon thinking
physicians, and Or. Rosenthal was not alone in this
radical and Bweeping position. It represented pretty
fairly the sentiments of the writers on antitoxin dur-
ing the winter of 1894-5.
Three days ago I wrote to a leading antitoxin firm
to send me the latest data in favor of antitoxin, as I
wished to use it in a paper.
This recent literature received consisted of a reprint
from the Atlantic Medical Weekly for March 21, 1896.
In this paper Dr. Rosenthal says, in speaking of the
Dumber of cases treated with antitoxin. " I have treated
seventy-eight casesof diphtheria with but twodeaths."
It is important to state, however, that Dr. Rosenthal
has found that mercury is equally as good a specific
far diphtheria as antitoxin, according to the Medical
and Surgical Reporter of June 13, 1896, for at the
Philadelphia County Society's stated meeting May
•27. 1896: "Dr. Rosenthal said that before the advent
of the antitoxin he had always considered mercury a
specific for diphtheria. As early as 1885 he had given
cah miel in diphtheria but in rather larger doses than
had Dr. Flick."
In laryngeal diphtheria he has given as high as
five grains every hour — in fact, he has given as high
as 120 grains to a child five years old, in twenty-four
hours, nor did he notice that the child showed any of
the physiologic action of the calomel. He was led to
believe that to ptyalise a child who suffered from
diphtheria was an impossibility, and he not only
gave such large doses of calomel to these children,
but he has used at the same time corrosive sublimate
in enormous quantities, having introduced 1-500
solutions into the child's nostrils, and swabbing out
the fauces with it, probably introducing into the
body of the child about a grain of corrosive sublimate,
inside of twenty-four hours.
If the doctor had deaths occur under the above
treatment I believe he would have said so, as it was a
vital point at the time, just as important as to state
the death rate under antitoxin, and if he has treated
seventy-two cases since the advent of antitoxin, he
must have treated a great many more before, with as
good or better results, or we will have to leave his
evidence out altogether.
Dr. S. S. Haldeman, of Portsmouth, Ohio, in a
paper read before the Ohio Medical Society, on May
28, 1896. says:
"I have had an experience of eight months in the
treatment of diphtheria with antitoxin, embracing the
administration of the remedy to seventy cases of the
disease, several of them baoteriologioally examined,
and all presenting the usual well marked signs and
symptoms of the disease, and occurring during an
epidemic of a severe type, characterized by a high
rate of mortality where the antitoxin was not employed
in the treatment, without losing a case treated."
He used it for the purpose of immunizing in twenty-
seven cases that had been exposed to the disease,
with the desired result of preventing it in all but three
cases. In these, the disease began before the end of
the third day after immunization.
He also stated: "That in a child five years old he
had used the antitoxin for the prevention of the dis-
ease, the child being perfectly well. The child died
in four minutes. Other children injected at the same
time were not injured by the antitoxin." He says: "As
to the cause of the fatal result, it is not clear to my
mind." He said further: "The wide adoption of
antitoxin as a remedy in diphtheria enables one to
draw some useful conclusions as to its value. Yet I
speak with some caution and reserve, with my limited
experience of the remedy, and the results in my own
practice have led me to wonder if it were really the
treatment with antitoxin, or the non-employment of
remedies, such as chlorate of potassium internally,
and the local irritants to the diseased parts, that had
something to do with the uniform and rapid recovery
of my cases."
" Usually in conjunction with the injection of
antitoxin, I would give calomel freely, and a pre-
scription combining a few drops of tincture of ferric
chlorid in glycerin and syrup, to be given hourly."
"After exfoliation of the membrane and the subsidence
of fever, I would give small doses of quinin and
strychnia every four hours, to a child one year old,
and order this continued for not less than three or
four weeks. Of the various local applications admin-
istered, I think most of that of Professor Loeffler.
For a young child I have diluted the solution with
alcohol and water, and directed that the mouth be
swabbed out with this preparation, but in the case of
older children and adults would advise the use of
the solution in full strength. The preparation con-
sists of menthol, 24 drams dissolved in 9 drams of
toluol, one dram liq. ferri. chlorid, and alcohol, 2
ounces."
He used local disinfectants to prevent or limit the
growth of bacteria in the throat and supporting treat-
ment. He had but one case with laryngo-stenosis.
Query: Which one or two of the above remedies
cured the disease?
It is well to remember that Professor Loeffler cured
seventy-one consecutive cases of genuine diphtheria
in 1894 with the same remedies that Dr. Haldeman
used (except the antitoxin), during an epidemic, the
general mortality of which was 28 per cent. (See
Loeffler's report at the 8th International Congress of
Hygiene and Demogrophy, held at Budapest, Sept.
1894.)
THE USE OF ANTITOXIN IN GENERAL PRACTICE IN
CAMDEN.
Since the introduction of antitoxin, July 5, 1894,
(it is claimed by Dr. Robinson) it has not been very
extensively used in Camden. As far as I can learn the
number of cases in which it has been used would not
852
THE TKEATMENT OF DIPHTHERIA.
[October IT,
exceed one hundred, and by quite a number of phy-
sicians.
Last May Dr. McAllister reported, in private prac-
tice, ten cases with two deaths, or 20 per cent., and at
West Jersey Orphanage, nineteen cases with no
deaths.
Dr. O. W. Bramer has had thirty cases of diphtheria
treated with tincture chlorid of iron internally, and
local antiseptic sprays of creolin without a death.
He tried antitoxin in three cases, no worse than some
of the others, with one death, a mortality of 33
per cent.
One means of ascertaining the results of the new
treatment outside of hospitals, that we can use at
present, is to take the general returns of the disease
from all sources of private practice, ascertain the
mortality and compare with an equal number of cases
returned by private practitioners, not using antitoxin,
and ascertain the death rate. In this method, however,
there are two sources of error. One is the difficulty
in knowing to what extent the antitoxin has been in
general use, and in ascertaining whether the two sets
of cases were in all respects sufficiently similar as to
the prevailing type of the disease and their environ-
ment. All the official returns available, however, are
composed of both private and institutional practice,
no attempt being made by the boards of health to
keep separate lists.
The results of treatment in 10,240 cases of diph-
theria in the German hospitals and in private practice
were recently reported to the Society for Internal
Medicine by Professor Ulenburg. Of this number
5,790 were treated with the antitoxin serum, with 552
deaths, a mortality of 9.5 per cent, for all ages; 4,450
were treated by other methods with 652 deaths, a
mortality of 14.7 per cent.
The German government is interested in the sale
of antitoxin, and most of these statistics are prepared
by government officials. It should be noted that
most all the literature on the subject is being furnished
to the profession by manufacturers and importers of
antitoxin and I am sorry to find they sometimes leave
out unfavorable reports, as I have ample proof.
It is worthy of note that foreign statistics, especially
the institutional, are so different from ours in their re-
sults that there can hardly be any comparison. For
instance, the high mortality averaging from 50 to 75
per cent, claimed by European hospitals to have been
their rate previous to the antitoxin treatment, is
something an American practitioner can not under-
stand. Either Europe must be a very unhealthy
place, or the professional skill is not equal to the
American. Their standard text-books have never
made such statements of mortality.
The most decided and brilliant test of antitoxin,
and the most favorable so far, seems to have been the
one reported by Dr. Otto Katz of results obtained in
the Kaiser und Kaiserin Friedrich Kinder-Kranken-
haus of Berlin with Schering's antitoxin, in a paper
read before the Berlin Medical Society, June 27, 1894.
From January 1, until March 14, 1894, the date when
the new treatment was begun, there were in 86 cases,
38 deaths, a mortality of 41.8 per cent.
From March 14 to June 20, 128 diphtheritic children
were treated with antitoxin, with 17 deaths. In every
case Loffler bacillus was demonstrated by means of
blood serum culture. Now, if we add to this 13 per
cent, the six moribund cases that were received at the
hospital at the same time, it would give us a mortality
of 19.21 per cent., as against 41.8. The above are the
celebrated "brutal figures" which converted Professor
Virchow.
The other treatment has remained the same that it
was before the injection method was introduced.
Local applications, sprays and salves were used as be-
fore. Tracheotomy or intubation was done for the same
indications. When the antitoxin ran out in July in
this institution the mortality rose to its usual high
average and fell again on the renewal of the antitoxin
treatment, but the average of deaths per year in pro-
portion to population is no less than it was before the
advent of antitoxin, though the remedy is said to be
in pretty general use in Berlin.
To return to the United States: In Boston, during
the year 1895, antitoxin period, 588 deaths occurred,
or 11 for every 10,000 inhabitants. For fourteen
years preceding the antitoxin treatment the average
mortality per 10,000 of population was 9. In New
York, antitoxin treatment 1894-95, 3,993, or 10 deaths
for every 10,000 inhabitants. During the fourteen
years preceding the antitoxin treatment the deaths
averaged each year 10 per every 10,000 inhabitants,
which is about the same as it was after the introduc-
tion of antitoxin. The same is true of Brooklyn.
There were 1,139 deaths from diphtheria in Brooklyn
during 1895, or 10 for every 10,000 inhabitants. In
1890, before the antitoxin treatment, there were 902
deaths, which is 10 per every 10,000 inhabitants.
These statistics are from official returns of the health
department.
In Camden, N.
J. (from
official records) :
Year. Cases.
1893 285
Died.
66
Death rate, Rate per 10,000
I'er cent. inhabitants.
23 16.60
1894 314
61
16 10.10
1895 168
1896, to
29
18 4.50 (antitoxin*
June 15 117
20
18 6.40
HOSPITALS.
In the Boston, New York and Philadelphia Munic-
ipal Hospitals, antitoxin has been applied thoroughly
for a year. It would be fair to presume that more
light cases were sent to the hospitals since the advent
of antitoxin than before, as physicians have improved
greatly in the last two years in their habit of sending
to the health officers notice of their cases. They
more fully appreciate the importance of the matter,
and health authorities have more vigorously enforced
the ordinances. The returns have improved in Cam-
den since the board of health proceeded against sev-
eral physicians, and such is the case in all the large
and progressive cities.
In Berlin, after two doctors were arrested and pun-
ished the returns doubled. For a generation the law
has been, that all deaths must be returned before
burial, but for various well known reasons many
cases were not reported, unless likely to die or
malignant.
BOSTON CITY HOSPITAL.
Year.
Cases.
Deaths.
Per cent.
1892
387
185
47.80
1893
419
203
48.44
1894
598
266
44.48
1895
1,566
207
13.21
(antitoxin]
WILLARD PARKER HOSPITAL, NEW YORK.
1888 258 60 23.25
1889 383 79 20.62
1890 292 67 22.94
1891 289 85 29.41
1892 295 79 26.77
1893 343 108 31.41
isw. ]
THE TREATMENT OF DIPHTHERIA.
853
Yi'HT.
Cases.
I'l'Htlls.
Per eeiit.
L8M
(MX)
•20;.
29.3'2 (antitoxin
thoroughly used)
is;>;>
778
190
24.42
1896 to
May 1 251 58 IBM
The death rate at the Willard Parker Hospital was
lower in 1889 and 1890 without antitoxin than it was
under the antitoxin treatment carefully applied for
over a year.
I have visited New York for the purpose of investi-
fating the subject, I find Dr. Winters of the Willard
'arker Hospital has carefully investigated and veri-
ties these statements. His impression is that 38 per
cent, mortality would fairly represent the actual mor-
tality of Willard Parker Hospital at the present time
under serum therapy, if patients who have clinic evi-
dence of diphtheria were subjected to this treatment
to the exclusion and elimination of those cases which
have no clinic data to warrant the diagnosis of diph-
theria. This was the percentage found by Dr. Ewing
in such eases in that hospital. In laryngeal cases the
mortality is 70 per cent, in this hospital, while in
Geneva it is 49 without antitoxin. In the University
College Hospital, London, it was 47 percent, without
antitoxin. In Philadelphia Municipal it is 52 per
cent.
I have anxiously awaited the criticisms by Dr. J.
\V Brannen of the Willard Parker Hospital in regard
to the statements and figures given by Dr. Joseph P.
Winters ( already quoted by me) before the New York
Academy of Medicine May 21, 1896, and I expected
that he would be able to show many important defects
in Dr. Winter's statistics, but I really find that while
he deprecates the unfortunate position in which Dr.
Winter places the hospital and discusses some of the
subordinate issues and even goes so far as Japan for
testimony, that he makes no perceptible impression
whatever upon the elaborate paper of Dr. Winters,
whose figures seem like the Rock of Gibraltar to stand
firm and unscathed after the assault. The plain fact
remains that the antitoxin treatment has not lowered
the death rate, at least in that institution. Nor was
early treatment by antitoxin better than early treat-
ment by other antiseptic practice.
MUNICIPAL HOSPITAL, PHILADELPHIA.
Results for 1895 were as follows: Treated with
antitoxin 302, deaths 85, rate 28.14 per cent.; treated
without antitoxin 404, deaths 105, rate 25.99 per cent. ;
of the 302 antitoxin cases 51 were intubated, with
27 deaths. 52.94 per cent.; of the 404 non-antitoxin
cases 71 were intubated, with 40 deaths, 56.33 per
cent.; in favor of antitoxin 3.39 per cent.; of the anti-
toxin cases 16.88 per cent, were intubated; of the non-
antitoxin cases 17.57 per cent, were intubated; in nearly
all the cases peroxid of hydrogen was used as a spray
locally; in the 404 non-antitoxin cases tinct. ferri chlor.
and hyd. bichlor. were used internally ; in the 302 anti-
toxin cases tinct. ferri chlor. was used. The death
rate was therefore higher with antitoxin.
LONDON HOSPITALS.
In the Northwestern and Southwestern Hospitals:
1892, 1893, 1894, cases 4,672, deaths 1,187, per cent.
25.4; in all the hospitals, 1895 (antitoxin) cases 2,182,
deaths, 615, per cent. 28.1.
What is embodied in the foregoing in regard to
antitoxin as a therapentic agent must arouse in think-
ing minds a number of reflections. No subject since
the earliest dawn of medical science has been so thor-
oughly and extensively investigated in so short a time
as has the use of antitoxin in diphtheria. This is
gratifying, for it shows that the science of medicine
has emerged from its puerile stage and is advancing
to maturity and accuracy. By the enthusiistic and
universal application of this method by the profession
throughout the world we can settle in one year a
question that would have taken 100 years by the slow
progress of a few generations ago. Electric transmis-
sion of intelligence and statistics have shortened
periods of investigation at least 99 per cent.
The results of treatment without antitoxin in the
United States seems to be better than in Europe. The
results with antitoxin in this country have not been
nearly so favorable as have those reported from Europe.
The fact is, is that nearly all the instances where anti-
toxin has been used it has not been relied upon exclu-
sively, but other treatments of the most important and
powerful character have been used at the same time.
It is worthy of remark that in all cases where good
results have been obtained, antiseptics or disinfectants
have been applied to the throat and mucous mem-
brane. With all the mass of accumulated facts.
experiences and figures, we will have to wait another
year before the question of the value of antitoxin can
be fairly and conclusively settled.
To discuss the value of antitoxin as an immunizer
would require an amount of space, statistics and time
which would make this paper too long. Suffice it to
say on this subject, from what I can gather from a
fair and impartial investigation of the subject it
appears that antitoxin does immunize in the majority
of cases, but not longer than about thirty days.
It does not destroy the bacilli of diphtheria at all
They seem to remain in the throat the usual length
of time, a constant source of danger to other persons,
unless local antiseptics be used. Antitoxin is not an
antiseptic, you can cultivate the bacilli in it.
A number of cases are on record where antitoxin
has been injected as an immunizer, or to cure patients,
and has caused their death. These are not sufficiently
numerous, however, to forbid its use, provided its
claims as a curative agent can be established, as the
deaths occasionally occurring from the use of ether are
not a sufficient argument to lay it aside as an anes-
thetic, and there is good reason to believe that car-
bolic acid or some other foreign substance in the anti-
toxin has been the cause of these accidents. Nor is
there a decided difference in sequelae.
The theory of the antitoxin treatment appears to
be perfect and the treatment seems satisfactory in the
laboratory; I have always been a student of the
microbe pathology and I still have high hopes of the
success of antitoxin; but as Professor Virchow has
stated, "Every consideration and theory must give way
to the mere brute force of figures;" and there does not
appear to be quite enough figures, as yet.
We are no doubt so familiar with the early statistics
which came from abroad, inducing the extensive trial
of antitoxin in this country, statistics of a very favor-
able character, during the latter part of 1894 and the
early part of 1895, that I have naturally not encumb-
ered this paper with them ; as after a year's trial, the
latest results are the only figures of «real interest and
importance, and they do not seem so favorable as we
would have wished for. I do not wish to be classed
as a partisan in this matter, I am simply an earnest
seeker after truth, trying to find the real value of a
remedy.
854
THE TREATMENT OF DIPHTHERIA.
[October 17,
I have great confidence in the results obtained at
the Municipal Hospital in Philadelphia, owing tomy
personal knowledge of the carefulness of Dr. "Welch,
the physician in charge. I have been using the strep-
tococcus antitoxin in cases that have been brought
into the Cooper Hospital with puerperal septicemia
but am not yet ready to report on the results.
THE ANTISEPTIC TREATMENT OF DIPHTHERIA.
Nothing could be of more practical value in the
science of medicine than results obtained by a physi-
cian in general practice and ripe experience upon a
common disease, after fifteen or twenty years of care-
ful practice and close observation; I wish to lay
before you a presentation of what I consider the anti-
septic method of treatment as applied to diphtheria.
In 1877 in my graduating thesis at the University
of Pennsvlvania (which received honorable mention
from that institution) I wrote as follows:
" The evidence that disease may be caused by
germs, or at least in some instances, amounts to
demonstration; and it should be recollected that low
organisms split up their nutrient matter, or pabulum,
into new compounds, which in many instances have a
powerful effect upon the human system, and may
disturb their functions as long as they are generated
within it. When we view the practice of medicine
and surgery with reference to this subject, we find
that all those meteorologic, all those hygienic condi-
tions, all those medical and surgical appliances and
means which are most antagonistic to the form, growth
and development of living germs and low forms of
life, have been the most effective in the treatment of
contagia, even before the laws of germ development
and their relation to disease were so well understood
as at present, practically (owing to the accuracy of
clinical observations) contagia were treated in many
instances as if their true nature had been known.
''Quarantines were established and disinfectants
quite intelligently used; but now, guided by a better
knowledge and understanding of the nature of
zymotic disease we are able to lay down a foundation
of broad principles upon which to erect the super-
structure of a more perfect practice. "
Since that time pathogenic germs or bacilli have
been so universally admitted by the profession to be
the cause of the zymotic diseases that it can no longer
be a debatable point in pathology.
You can not have diphtheria without the presence
of this microbe. Like all other vegetables, and
especially the low forms of life, it is necessarily sub-
ject to variations in the character and amount of its
poisoning products; for the bacillus after all is not
the real poison which causes such disastrous conse-
quences in the human system, but the ptomain which
it produces.
Various staphylococci and micrococci found in con-
nection with this germ in diphtheritic cases no doubt
produce some of the lesions found in the neighbor-
hood of the diphtheritic points, especially the secon-
dary affections.
IMMUNITY.
It is claimed* by good authorities that an attack of
diphtheria does immunize a patient. My own experi-
ence is that I have never known two well-marked
attacks of severe diphtheria in the same person. I
have seen two cases followed in a year or two by a
lighter attack.
The literature on the subject would cause me to
think that some must have had a different experience.
THE MEMBRANE.
Formation of the membrane. — The formation of the
membrane is not well understood. It appears to be
an exudation of fibrin from the capillary blood vessels,
under a high state of irritation and congestion, in
the same manner as it is produced by any other irri-
tation or congestion, and may be seen sometimes
thinner and sometimes thicker in stumps that are
left open to "glaze," in peritonitis, croup, etc. Now
the question arises, as to the nature of those peculi-
arly malignant cases of diphtheria that show intense
intoxication, and even die before any visible mem-
brane is formed. It seems quite probable that large
surfaces of the pharynx and nasal cavity have been
covered by the bacillus in very active and virulent
form before the false membranes are seen; so that
sufficient toxin has been absorbed into a susceptible
system to produce fatal symptoms before the exuda-
tion has had time to form.
Pseudo-membranous croup. — I believe this to bean
entirely different and distinct disease, clinically and
etiologically. While the Loftier bacillus is always
found at some stage of true diphtheria, it is not
found in croup, except as a rare and accidental visitor.
The microscopic and clinical pictures of these two
diseases are totally distinct. Croup usually begins
at the larynx, little or no fever, usually progressive and
fatal, simply by a mechanical stenosis of the larynx,
occasionally extending into the bronchi, seldom vis-
ible in the pharynx, and without the Loftier bacillus.
Diphtheria on the other hand, usually begins with
fever, symptoms of intoxication and one of the first
things seen on examination is the exuded patch in
the throat, often tinged a little yellow. No doubt
many cases of true diphtheria were formerly treated
as cases of croup, or have been returned as such after
death. I do not believe that croup is a contagious
disease. Never but once in nineteen years have I
seen two or three children with croup at the same
time in one family.
At present I am inclined to believe that mem-
branous croup is not due to any bacillus, but to severe
local congestion or a disturbed circulation, caused by
exposure of parts of the body to cold and dampness.
Follicular tonsillitis is sometimes mistaken for
diphtheria, it differs clinically and microscopically,
and I think we are rapidly approaching a period
when it will be demanded of the entire profession to
make use of the microscope in differentiating these
closely allied throat diseases, and I believe that the
Board of Health has done a good thing in ordering
all cases of supposed croup to be reported to the
Board in less than twenty-four hours.
LOCAL QUARANTINE IN DIPHTHERIA.
My experience has been that it is easy to quaran-
tine a case of diphtheria in a room where there is a
large family and many children, successfully prevent-
ing extension of the disease to the other inmates, as I
do not think that the germs spread more than a few
feet in the air at a time, but may be rapidly dissem-
inated by contact or fomites. But, in two instances
where I had successfully quarantined a case in the
house from the rest of the family, in about a year
afterward a number of the family were taken with
the disease, not having been exposed elsewhere; so
that we were driven to the conclusion that quilts or
1896. ]
THE TREATMENT OF DIPHTHERIA.
855
something that was in the room timing the previous
sickness had not been properly sterilized, and the
germs had boon animated after this long period.
This leads mo to a very important reflection in
regard to quarantine in a city, namely, if the case of
diphtheria in a house was properly quarantined, why
could not the family he permitted to go to their work.
pursue their usual avocation, and not be submitted
to the objectionable fate of being compelled to remain
in that house during the disease; ami, since the dis-
ease is more likely to be carried, after the general
quarantine has been removed from the house, by the
inmates for months or years, is it not equally safe
with proper room quarantine to allow the inmates
egress and ingress during the existence of the case in
the house ;
Since the authorities do not thoroughly and per-
sistently quarantine a house usually during all epi-
demics, the inmates of the house go out and the
neighbors intermingle, it might be more practicable
and agreeable to a community for a board of health
to quarantine a portion of the house. This proced-
ure lias many things in its favor.
How is the bread winner to pay his rent, when he
family? How can he pay the doctor'?
Under proper conditions he could see his child's
face at evening if he is anxious to do so without carry -
ins the disease.
Intubation vs. tracheotomy. — I have performed
both intubation and tracheotomy in a number of cases
( 1 always prefer intubation) and I have had recover-
ies take place with intubation under conditions which
I believe would have proven fatal had tracheotomy
been performed; however, we have tracheotomy to
fall back on in case intubation fails.
LOCAL TREATMENT.
The symptoms are usually not very pronounced
before the diphtheritic "patches" are visible. I
make the bacteriologic or culture test in all cases
when possible. From the foregoing statements it
may be seen that I hold that this disease is essentially
local and external; for anything on the mucous mem-
brane practically is not in the system, but the prod-
ucts of the bacillus being absorbed into the system
as fast as produced, cause the general and constitu-
tional symptoms.
Basing our treatment upon the views above stated,
I have for over 15 years held, that the rational pro-
cedure, in combating this disease was simply to
destroy the bacilli where they are located on the
mucous membrane of the throat or elsewhere, by the
proper applications of antiseptics or germicides and
secondly, meeting the poison in the blood by such
therapeutic means as physiologically and chemically
were the best antidotes for it.
Now, while many scientific and learned physicians
have followed these lines in treating diphtheria, they
have so frequently been disappointed in their results
and struggled along with a high mortality (in many
oases, 30 to 40 per cent.), yet I have always contended
that this is the correct line of treatment, and will
give the best results if accurately and thoroughly
carried out.
The important consideration, therefore, is what
local and general medication to use, and equally
important, the method of applying and using these
remedies; for I believe that the failure to cure by
this practice will be due either to a want of proper
applications of the treatment, or to the fact that it
has been commenced too late in the disease.
If you will refresh your knowledge of anatomy by
examining the drawings of the interior of the nose,
pharynx and larynx you will conclude that no treat-
ment applied by the ordinary swab or probang, coidd
Figure i.-Vkrtkai. Section of Heai>, slightly Diagrammatic*
1. Superior turbinated hone. 2. Middle turbinated bone. 8. Lower
turbinated bone. 4. Floor of nasal cavity. 6. Vestibule. 6. Section of
byoid hone. 7. Ventricular band. 8. Vocal cord. 9 anil 23. Section of
thyroid cartilage. 10 and 21. Section of cricoid cartilage. 11. Section of
the tracheal ring. 12. Frontal sinus. 18. Sphenoidal cells. 11. Pharyn-
geal opening of Eustachian tube. 15. Rosenmiiller's groove. 10. Velum
palati. 17. Tonsil. 18. Epiglottis. 19. Adipose tissue behind tongue.
20. Arytenoid cartilage. 21. Tubercle of epiglottis. 22. Section of
arytenoid muscle.
I'h.lHK 2.— ItHINOSCOPIC 1MAGK.
1. Vomer or itasal septum. 2. Floor of noBe. 3. Superior meatus.
1. Middle meatus. 5. Superior turbinated bone. 0. Middle turbinated
bone. 7. Inferior turbinated bone. 8, Pharyngeal orifice of Eustachian
tube. 9. Upper portion of Rosenmiiller's groove. 11. Glandular tissue
at the anterior portion of vault of pharynx. 12. Posterior surface of
velum.
856
THE TREATMENT OF DIPHTHERIA.
[October 17,
by any possibility reach the disease at its most dang-
erous points, and consequently must be very ineffi-
cient in nasal and laryngeal cases. Even the physi-
cian could not apply the treatment thoroughly in an
adult, and the idea of applying it in a struggling child
is preposterous. Moreover, since the treatment has
to be applied every hour at least, it must be left to
the family to be carried out. It is therefore utterly
impracticable, and I have found where it has been
tried it did not accomplish the results. There would
be a considerable mortality.
Antiseptics applied by the nasal douche, after
Thudicum's method, do reach the nasal cavity thor-
oughly, but it is so difficult to accomplish that it can
not be employed with children in private practice to
any great extent, even if the physician superintends
its use.
Gargles are of little or no use in the nasal and
laryngeal cases.
The spray or atomizer therefore remains the only
feasible method of applying antiseptics to all parts
of the affected mucous membrane. To the rec-
ognition of this fact, and its early and thorough
adoption together with an efficient and pleasant anti-
septic remedy to be used in the atomizer I must
attribute largely my success in the treatment of this
disease.
I acknowledge that it is with the profoundest diffi-
dence and respect for the criticisms of my medical
brethren that I advance the following statement:
For over ten years, including 100 cases, I have not
had a death from diphtheria, unless a case that died
about twelve years ago be included; connected with
this were three other physicians and I have never
been convinced that it was not a case of membranous
croup. A white membrane was very distinct in the
pharynx, extending downward. I early practiced the
antiseptic treatment and would not be justified in
experimenting with other things, unless my results
change, but I never use the bichlorid of mercury, nor
do I think it should be used in this disease; because
its action though beneficial is almost wholly due to
its local effect upon the bacilli in the throat. Many
cases, especially in young children, have been injured
by the too free use of this substance. Other anti-
septics, such as carbolic acid, salicylic acid, sesqui-
chlorid of iron, are equally efficacious and may be
used in ample quantity without the same amount of
danger to the person.
Since we usually depend on the laity any treatment
that can be properly and thoroughly applied, even to
young children, must have vast advantages over any
other. In severe cases I have all the mucous mem-
brane thoroughly sprayed through the nose and mouth
at intervals of fifteen or twenty minutes, or even
longer, about fifteen seconds at a time, the child
breathing as naturally as possible during the applica-
tion. The spray comes in contact with every part.
The membranes and symptoms rapidly disappear. On
several occasions I have suspended local treatment
after their disappearance; and in twenty-four or forty-
eight hours the membrane would again spread over
the throat, a few bacilli having been left alive, disap-
pearing again promptly on resuming the local treat-
ment, thus demonstrating its efficacy. It is necessary
to see that the atomizer works properly and that the
attendant applies it thoroughly.
Professor Loeffler claims that the disease being
entirely due to germs lying in the throat, conse-
quently in a position where they could be reached by
local antiseptics, could be readily cured by local
application, and instances seventy-one cases of diph-
theria treated exclusively by local antiseptic applica-
tions, without a single death, in his private practice.
This statement was entirely consonant with my expe-
rience and practice, instituted ten years before his
great discovery of the germ.
If it be true (and I do not think that it can be suc-
cessfully disputed now, that diphtheria is due to the
presence of germs in the pharynx), why would not
germicides destroy them ? For we know that we pos-
sess a number of antiseptic or germicidal medicines
that are invariably fatal to germs and can be used in
quantities sufficient for that purpose without any det-
riment to the patient. Holding the view of the dis-
ease that I have advanced, I could never understand
why a local treatment would not be all that was
required.
Proffessor Loeffler, after various experiments, sug-
gested a combination of:
Menthol cryst 10 gm.
Toluol q, s. ad fac 36 c.c.
Alcohol absolute 60 c.c.
Liquor ferri sesquichloridi i e.c.
I have found the the formula of Professor Loeffler
to be disagreeable to the patient, while the one I use
has not that objection and is quite as efficient.
Acid. acet. dilut fl. 5"
Pot. chlorat ,"ss
Acid, carbol gtt.i
Tinct. ferri chloridi gtt.v
Pulv. Alumen gr. v
Acid, salicylic gr.i
Glycerin rl.3ss
Aqua ros fl.^ss
Aqua q. s. ad A. .^iv
Misce. Sig. Use as directed.
It is a clear, permanent liquid of a purple color.
In making application to the throat of diphtheritic
patients the doctor or nurse may use a disc of glass
held between his face and the patient, to prevent
infection from the sudden coughing and spitting of
the patient.
I always give tincture ferri chloridi in large and
frequent doses, and I believe it produces favorable
conditions of the blood, as it does in many other cases
of septicemia, notably erysipelas, which often disap-
pears under this treatment alone.
One of the benefits derived from this remedy is its
local action while being swallowed.
Result under the local antiseptic treatment: Ben-
jamin, 100 cases, 100 recoveries; Loeffler, 71 cases,
71 recoveries.
I will not weary you with a repetition of illustra-
tive cases. I hope the profession will give this treat-
ment a fair trial and report on it.
CASES IN POINT.
I was called to attend a girl, 10 years old, whose
brother, the only son, had died of the disease the day
before. The patient had diphtheria in a very grave
form ; pulse 140, temperature 101, respiration 40, and
the throat covered with a thick membrane. She was
placed under treatment. Marked improvement took
place in twenty-four hours. At the next visit, the
patch of membrane had diminished in size, the pulse
was 120, the respiration 25. She was well in eight
days, running about the house.
In another part of the town I was called where five
children had the disease, as well as mother and her
L896.]
THE VALUE OF VACCINATION.
857
baby, about six months old. Three children across
the "street had just died and were awaiting burial.
Others in the neighborhood had the disease. All
these cases rapidly recovered. I might go on until it
would become monotonous, relating cases of which 1
have records. .My former assistant. Dr. W. I. Kelch-
uer. reports seventy-rive consecutive cases by this
treatment during the past three years, without a
death.
The more malignant the case the more brilliant the
results that I have obtained by this treatment. When
1 seek an explanation of this phenomenon it seemed
quite natural that it should be so, for the abruptness
and urgency of the onset of the disease causes the
patient to send for medical assistance promptly, and
the severe symptoms being due to the large number
of germs spread over the mucous membrane of the
pharynx and throat, the local antiseptic treatment is
effective before sufficient time has elapsed to protect
themselves by a false membrane.
This was illustrated in the case of a woman who
WEB taken with the most malignant symptoms, after
having just buried her three children who died with
the disease on that day. She was practically well in
forty-eight hours after treatment began, and attended
to her household duties on the fifth day.
If it be true that we can save our patients by local
antiseptic treatment, properly applied early, the local
treatment will displace the antitoxin treatment in
general practice. Patients can go about with less
danger of spreading the disease when convalescing,
since their throats are sterilized and no bacilli can be
found by culture tests.
Microscopic and culture tests should be made before
usiiiLT the treatment, as generally the bacilli disap-
pears after using the antiseptic remedy.
21.") Cooper Street.
THE STATISTIC EVIDENCES OF THE VALUE OF
VACCINATION' TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Read before she American Medical Association at the Jenner Centennial
Celebration, held at Atlanta, Ga., May, 189G.
BV EUGENE FOSTER, M.D.
PROFESSOR OF PRINCIPLES AND PRACTICF. OF MEDICINE AND STATE MEDI-
CINE AND I'EAN OF THE FACULTY OF THE MEDICAL DEPARTMENT
UNIVERSITY OF GEORGIA, AUGUSTA, GA.
' i 'tit iii mil from page 811).
Proposition 7.
In some communities and even nations a greater number of
vaccinated and unvaccinated persons are attacked with small-
pox. Anti vaccinationists parade such instances and use such
data to bolster up their ridiculous assertions that such facts
ehow the utter futility of vaccination. Without a single
exception every such effort is based upon the most shameful
perversion of facts.
Let us take Great Britain to illustrate this proposition. It
is true that in the epidemic of smallpox, 1871-72, a greater
number of vaccinated died than those unvaccinated. But
does this fact prove the failure of vaccination ! By no means.
Why? The vaccinated portion of the population number thirty
to forty times that of the unvaccinated. In 1872 there were
300,000 of children under 5 years of age in Great Britain (Sir
Lyon Playfair, lot. cit.). These were divisible into two classes,
vaccinated and unvaccinated. The vaccinated were thirty to
forty times more numerous than the unvaccinated. Now fbr
results of vaccination. In the vastly more numerous class —
the vaccinated — the smallpox deaths numbered 1,780, while
Among the fractional portion of the population — the unvacci-
nated -the deaths number 413. According to Dr. Playfair the
mortality from smallpox was from 120 to 160 greater among the
unvaccinated than the vaccinated. The Registrar General of
Croat Britain showed that taking the whole community of the
kingdom, there was only one death among the vaccinated for
every forty among the unvaccinated.
Let us take the epidemic of smallpox in London in 1882.
During that year 2,317 deaths were registered from smallpox lir'
\ ide Registrar G«neraTs Annual Summary for 1882). Of these,
524 were stated to have been vaccinated and 9(52 unvaccinated,
while regarding the condition of others as to vaccination, no
statement was made. It is tolerably certain that among the
population of London not more than 10 per cent, are unvacci-
nated, and if 10 per cent, be supposed to be doubtfully vacci-
nated there will remain 80 (this estimate is certainly well within
the true proportion) per cent., presenting clear evidence of
vaccination. If, then, the vaccinated and unvaccinated had been
equally liable to fatal smallpox, the former would have died at
the same rate as the latter, and since 962 of the unvaccinated
died there would have died 7,698 among the vaccinated. But
the actual number of deaths among the vaccinated was 524;
hence it is clear that the vaccinated and unvaccinated were not
equally liable to death from smallpox.
Moreover, if the mortality among children be considered,
the difference between vaccinated and the un vaccinated appears
still more striking. The deaths from smallpox during 1881
included 27 of vaccinated children under the age of 5 and 368
of unvaccinated children under that age. If unvaccinated and
vaccinated children would have died at the same rate as the
unvaccinated, i. c. (taking the proportion of vaccinated and un-
vaccinated as previously stated) the deaths among the vacci-
nated children under 5 would have been 2,944. But the actual
number was 27, and it is therefore obvious that unvaccinated
children are liable to fatal smallpox to an enormously greater
extent than vaccinated children ; or, in other words, vaccinated
children are to a larger extent protected from fatal smallpox.
Dr. Seaton, in Annual Report of the Local Government
Board of Great Britain, 1874, says on this subject :
But if the actual number of smallpox deaths in persons
above puberty who had been vaccinated were equal to, or
even exceeded, that which occurred in persons who had not
been vaccinated, it must be borne in mind that the proportion
of our adult population which is protected against smallpox by
vaccination is at least from twenty-five to thirty times as great,
and much more probably from fifty to sixty times or more as
great, as that which is unvaccinated. The relative number of
persons who nowadays attain manhood or womanhood with-
out having been vaccinated is very small. Examination of the
young men who are recruited for the army has shown for many
years past that, putting aside the small percentage who are
marked with smallpox, the proportion of the remainder who do
not present distinct marks of having undergone vaccination aver-
ages for the whole of England 3.9 per cent, of those examined,
and for London separately, 2.8 per cent. As these small pro-
portions include all doubtful cases, it is clear then that some-
what considerably more than 96 per cent, of those in England,
or than 97 per cent, of those in London only must have been
vaccinated. Now recruits, I apprehend, are not generally
drawn from that class of the population which has been the
most cared for ; and there is, therefore, a reasonable proba-
bility that the proportion of the whole adult population of
England which is thus protected against smallpox is much
larger. But even if the full proportion just given, or more
than that proportion, be applied to the adult population gener-
ally— 4 per cent, being taken as unvaccinated and 96 per cent.
as vaccinated— it is clear that with equal actual mortality
among the two classes, the relative mortality of the former
would be twenty-four times that of the latter. The figures,
then, are conclusive that vaccination as it was practiced in
this country fifteen years ago and upward, instead of failing to
protect persons from fatal smallpox after they had grown up
has, in the immense majority of cases, very effectually pro-
tected them.
But proof of Proposition 7 does not rest alone upon statistics
as to the protective influence of vaccination in children.
Let us inquire as to the value of vaccination upon all classes
and ages of population under recent so-called failures to such
extent as to have shaken the confidence of some few former
advocates, and supplied vaccinophobists with what they term
"an arsenal full of facts testifying to the utter futility of the
measure." Let us take the most widespread and fatal epi-
demics of smallpox which have fastened their remorseless fangs
into the bodies of communities since compulsory vaccination,
and see if we can compare the results of vaccination and non-
vaccination. This is the only rational test. Ask vaccinopho-
bists to select their own tiroes and places of occurrence of
smallpox for this demonstration, and they will point to the
epidemic of smallpox in Great Britain from 1870 to 1873, and
W The Influence of Vaccination to the Prevention and Diminution
of Mortality from Smallpox, presented to the Parliamentary Bills Com-
mittee of the British Medical Association. By Dr. Ernest Hart, Chair-
man of Committee.
858
THE VALUE OF VACCINATION.
[October 17,
with pride declare that in this epidemic we have an illustration
of the futility of the prophylactic powers of vaccination. We
accept the issue thus made, and shall demonstrate the wonder-
ful prophylactic power of vaccination in this time (their own
selection), to the satisfaction of any sane or reasonable man.
Of this epidemic, Dr. Seaton, who was specially detailed to
investigate it, says : "The epidemic of smallpox which began
in England toward the close of 1870 and terminated in the
second quarter of 1873, was part of a general outbreak of that
disease, of world wide diffusion, marked wherever it occurred
by an intensity and malignancy unequaled by any previous epi-
demic of the disease within living memory. The outbreak
seems to have begun in France about a year before it mani-
fested itself in the United Kingdom. In the last quarter of
1869 it was already making considerable progress in Paris.
Early in 1870 it prevailed in Orleans, Bordeaux, Lyons and
other large towns, and in the course of the year extended with
great mortality over nearly the whole of France. Except, how-
ever, in so far as it was directly conveyed by the French pris-
oners to various places in Germany, there was very little
extension beyond France till toward the close of 1870. The
epidemic then manifested itself in London, in two or three of
the chief towns of Holland, in Milan, at Geneva and in some
other places, becoming thereafter rapidly diffused over a great
part of Europe. During 1871, England and Scotland, Holland,
Prussia and the whole north of Germany, Italy and Spain felt
the full force of the epidemic, and the first beginnings of its
ravages were experienced in some of the other countries of
Europe, as in Ireland and Denmark. In the course of this
year it spread beyond Europe to various places in Africa
(where it raged along the Gold Coast), to the West Indies and
to North America. During 1872, while still continuing its
course in most of the countries it had attacked in 1871, it made
further extensions over the continent of Europe, invading
Austria, Hungary, Russia and Finland, over Africa and over
North America ; it spread, also, to South America and the
South Sea Islands, and it invaded various places of the East.
In 1873 the greater part of its course in Europe had been run,
but there were yet, during the earlier parts of the year, various
countries and districts and important capitals, as St. Peters-
burg and Vienna, still under its full influence. By the middle of
1873, however, the pandemic extension of the disease in Europe
may be considered to have terminated, and smallpox generally
has since then been quiescent, though there have been some
considerable local outbreaks."
Here, then, is, we hope, an epidemic of smallpox of wide-
spread prevalence and malignancy sufficient to satisfy these
anti-vaccinists. Now for the lessons taught by this truly fright-
ful epidemic, as applied to great Britain. Seaton says : "The
varying intensity of different epidemics of the same disease is,
indeed, a well-known fact, and had been illustrated as regards
smallpox, at various times, at the hospitals set apart for the
treatment of that disease in London : the ordinary mortality
of natural smallpox as therein observed, 35 per cent, of the cases
admitted having in certain epidemics been known to mount as
high as 47 per cent., and that of postvaccinal smallpox to
increase from 7 to 10 per cent. But no experience which had
been acquired in the hospital had led to the expectation that
the ordinary rate of mortality to attacks would by any epidemic
influence be nearly doubled. Yet such was the case in 1871
and 1872, in the former of which years the deaths from the
natural disease were 66.2 per cent, and in the latter 77 per cent,
of the natural cases, or in the two years combined (for the
admissions in 1872 were too few to form by themselves a proper
basis of comparison) 67.5 per cent, of such cases. This result
is stated by Dr. Munk and Mr. Marson in their report for 1871,
to have been due 'to the severity of the disease, and especially
to the number of cases of malignant smallpox, the proportion
of which to the other cases has been very largely in excess of
anything within the experience of either of your medical
officers.' "
"In the hospitals of the Metropolitan Asylum district, in
which the cases admitted would be of a more average character,
the ratio of deaths to admissions was extraordinary, amounting
to 44.80 per cent, among the unvaccinated and 10.15 per cent,
of the vaccinated. The ratio in the hospitals of provincial and
foreign towns generally has ranged from 40 to 50 per cent,
among the unvaccinated and from 8 to 10 or 11 per cent, of the
vaccinated— enormous rates, and attributed everywhere to the
same cause, viz., the unusual proportion of malignant, black
and hemorrhagic cases. In several of these hospitals the rates
were as high or higher than in the smallpox hospital of Lon-
don, as in the ' Barackem Lazareth auf dem Tempelhofer
Felde,' at Berlin, which were used as additional smallpox hos-
pitals during the epidemic in that city, and in which the mor-
tality among the unvaccinated was 81.25 per cent, and among
the vaccinated 14 per cent., and in the hospital at Leipsic, in
which the mortality among the unvaccinated was 71 per cent,
and among the vaccinated (including doubtful cases) between.
9 and 10 per cent.''
Let us now compare the mortality of this epidemic with that
of other recent epidemics of the disease. Here it is : "In the
thirty-three years which at the time this outbreak commenced
had elapsed, from the first establishment in England of a
complete system of registration of the causes of death, there
had been abundant illustrations of the varying fatality of
smallpox epidemics, but it had been supposed by many — quite
erroneously as it now appears— that that period had been suffi-
cient to exhibit the limits of the fluctuations. Only twice since
the close of the great epidemics of 1837 41 had the smallpox
deaths in England exceeded 7,000, viz., 1852, when they were
7,320, and in 1864, when they were 7,684. And though the
epidemic of 1837-41, just referred to, had exhibited a mortality
enormously in excess of these numbers (the deaths in 1838
alone having been 16,268), yet as this was anterior to any vac-
cination laws and at a time when the proportion of the popula-
tion which was unprotected by vaccination was many times as
great as it is now, a recurrence of any such considerable mor-
tality as was then observed had been quite outside ordinary
calculations. The mortality of the 1870-73 epidemic has not
indeed been by any means so great in proportion to population
as was that of 1837-41, but it has approached it more nearly
than had appeared possible. During the 1837-41 epidemic
there were registered from July 1, 1837, the termination
of the epidemic in 1841, 48,012 smallpox deaths in a mean pop-
ulation of fifteen and one-half millions; during the 1870-73
epidemic, 44,433 deaths ina mean population of nearly twenty-
three millions. The proportionate mortality therefore of the
epidemic of 1870-73 has been less than two- thirds that of
1837-41."
What of the mortality of smallpox in this epidemic of 1870-73
compared with the smallpox mortalitvof the last century? Dr.
Seaton says of it : " The mortality of this epidemic was, as I have
said, such as has not been known in England for thirty years,
and has at least proved a complete answer, if, indeed, an answer
had been required to the notion which had of late years been
ventilated by some that smallpox was a disease naturally tend-
ing to extinction. . . . But, before proceeding further, it
seems very important that it should be noted that the mortal-
ity of this epidemic, alarming as it has been, has not approached
what was the usual annual smallpox mortality of the kingdom
at the time when vaccination was unknown. The annual aver-
age smallpox death rate of that period— not, be it observed,
the death rate of a particular year of special prevalence of the
disease, but the annual average death rate— was more than
three fold the death rate of this, in our time, quite exceptional
outbreak. The estimated annual smallpox death rate of Eng-
land in the last century was 3,000 per 1,000,000 of popu-
lation: the mean annual death rate of this epidemic was
928 per 1,00,000, having in 1871 been 1,024 and in 1872
833 per 1,000,000. The average annual smallpox death
rate of the metropolis in the pre-vaccin period was from
400 to 500 per 100,000 of population ; the mean annual death
rate of this epidemic was 148, having in 1871 been 243
and in 1872 54. And if an average be taken of the smallpox
mortality of England for the whole twenty years (1854-73)
during which there has been a compulsory vaccination law. a
period which includes the whole of the recent epidemic, the
annual death rate is found to be 245 per l,000,00Ocx population,
or less than a twelfth of the rate of last century."
And yet in the face of such facts as these Mr. P. A. Taylor,
M.P. of England, seriously asserts :
" That the practice of vaccination affords no national pro-
tection from smallpox, and has had no effect whatever in pre-
venting or diminishing smallpox epidemics. That the mortality
among vaccinated smallpox patients is as great as among-
un vaccinated."
I have no patience with a man who would seriously advance
such ridiculous nonsense into the arena of scientific discussion.
I would as soon enter into debate with my horse as with such
a man.
Proposition 8.
1. Vaccination performed in infancy in the best manner,
confers upon the majority of these individuals absolute protec-
tion against smallpox during life.
2. In not a few instances (the proportion being unknown)
individuals properly vaccinated, at or or about the age of
puberty partially or wholly regain that susceptibility to small-
pox which vaccination had once extinguished in them.
3. In the overwhelming majority of instances of individuals
contracting smallpox after primary vaccination the disease is so
mitigated as to be practically devoid of danger to- health or life..
1896.]
THE VALUE OF VACCINATION.
859
4. The vast majority of cases of severe post- vaccinal smallpox
result from careless or inefficient smallpox.
Inasmuch as in a considerable proportion of cases smallpox
occurs a second time, and in rare instances, a third and even
a fourth time in individuals, it is expecting too much of vacci
nation to demand that postvaccinal smallpox should not be
found in a considerable portion of those who had been pre
riously thoroughly well vaccinated.
It must be confessed that the illustrious Jenner at first
claimed that a successful vaccination afforded the individual
absolute protection against smallpox. In his work, "An
Inquiry in the Causes and Effects of tho Variolas Vaccina',"
. I unc, 1 TV'S, he says: "But what renders the eowpox virus
so extremely singular is that the person who had thus been
affected is proven afterward secure from the infection of the
■mall]
Further experience caused Jenner to modify his views on
this subject, as follows: "Duly and efficiently performed
vaccination will protect the constitution from subsequent
attacks of smallpox as much as the disease itself will. I never
expected it would do more, and it will not, I believe, do less."''16
It has long been demonstrated that the great benefactor of
his race was mistaken even in his later estimate of the prophy-
lactic powers of vaccination. Primary vaccination is not and
ne\er WW as fully protective against smallpox during life as
a previous attack of smallpox. As early as 1S07 numerous
cases of post vaccinal smallpox were reported in England. The
Royal ' Jollege of Physicians investigated the matter and found
that some of the reported cases were well founded, but said :
■The number of alleged failures has been surprisingly small, so
much so as to form certainly no reasonable objection to the
genera] adoption of vaccination." Within the next few years
the proportion of post vaccinal smallpox was found to be
increasing, and in some epidemic seasons they presented a very
alarming total. It was claimed that these cases of postvac-
cinal smallpox were not chargeable to vaccination properly
performed, but were due to spurious vaccination. But this
claim was disproven to such an extent as to perplex and disap-
point many advocates of vaccination. Injudicious friends of
vaccination endeavored to prevent publicity being given to the
facts, and the enemies of the measure decried it with the zeal
which has ever characterized their fight upon this, the most
beneficent gift to man. Simon very properly says: "At no
moment in the progress of Jenner's discovery had impartial
investigation been needed more than now; for, partly by the
facts themselves and partly by hostile overstatements of them,
public confidence began to be disquieted. There seemed a
breach in the contract under which vaccination had been
accepted. In what had promised so much, failures were all
the more conspicuous ; men looked to them, even where most
exceptional, rather than to the successes of vaccination : and
there were ' 1820 85) not a few persons whose minds began to
misgive them whether the old plan of smallpox inoculation had
not perhaps been too easily abandoned."
In 1818, after vaccination had become general in Scotland an
epidemic of smallpox visited the inhabitants — a large propor-
tion of the smallpox patients having been previously vaccinated.
This gave rise to great surprise, and the prophylactic virtues
of vaccination were freely discussed. An examination into all
the facts relative to these cases of post-vaccinal smallpox so
conclusively demonstrated the beneficial results of vaccination
that public confidence in the measure was regained. The cases
of postvaccinal smallpox were so much milder than in the
unmitigable variety that it gave rise to the term varioloid.
In Sweden an epidemic of smallpox appeared in 1824, in
which 103 cases of post- vaccinal smallpox proved fatal, 69 of
these presenting good vaccinal scars and 34 less perfect vaccin
scars. Smallpox assumed epidemic proportions also in Ger-
many, France, Italy and London, and in many cases appeared
among the inhabitants who had been vaccinated in childhood.
In Ceylon the government of Great Britain, at an early
period of vaccination, had the population so generally vacci-
nated, and so successful did the measure seem that smallpox
was wholly banished from the island for a term of years. In
1819, however, Ceylon suffered a widespread epidemic of
smallpox, which was marked by great virulence of the disease.
In this epidemic many inhabitants who had previously been
vaccinated in childhood, contracted smallpox. This island
had a like experience in 1830, again in 1833 and again in 1836.
In the epidemic of 1833 fully 75 per cent, of those contracting
smallpox had been vaccinated in childhood.
Denmark was visited by several epidemics of smallpox
between the years 1824 to 1835. Gregory says: "Yet in no
country in Europe has more attention been paid to the
ion's Hand-book of Vaccination, p. 898.
'■' John Simon: Royal Vac. Commission, 1889, p. 78.
practice of vaccination, both as to the numbers submitted to
the process and the purity of the lymph employed." Notwith-
standing these facts in Copenhagen, between 1824 to 1835, 3,839
cases of smallpox were observed. 8(1 per cent, of this number
had been vaccinated during childhood. Even under these dis-
couraging facts the value of vaccination was conclusively
demonstrated, for the mortality in postvaccinal smallpox was
only 2.13 per cent.
The British army furnishes valuable statistics proving the
proposition under discussion. Prom 1835 to 1838 the average
strength of the army, including men, women and children, was
105,000, This force (including women and children) had been
thoroughly vaccinated, yet 1,025 of them contracted smallpox
and 122 of them died, a mortality of 11.9 per cent.
The records of almost all hospitals prove that the majority
of cases of smallpox from a community generally vaccinated
are among those who have been vaccinated during childhood.
Dr. (iregory's service at the London Smallpox Hospital (1826
to 1850) has been divided into quinquennial periods with the
following results : In the first period the number of cases was
1,262, of which 34 per cent, had been vaccinated ; in the second
period the number of cases was 1,331, of which 36 per cent,
had been vaccinated ; in the third period there were 1,763
cases, of which 41 per cent, had been vaccinated ; in the fourth
period, number of cases 1,643, of which 43 per cent, had been
vaccinated ; in the fifth period, number of cases 1,780, of which
52percent. had been vaccinated. Thus we see a gradual though
decided increase of cases in persons previously vaccinated — the
proportion of cases of postvaccinal smallpox from the first
quinquennial to the last having been 18 per cent.
In the London Smallpox Hospital Marson says the total
number of smallpox patients received during the ten years,
1855 to 1865, amounts to 7,326, of which 78 per cent, had been
vaccinated.
Dr. Welch, physician in charge of the Municipal Hospital,
Philadelphia, Pa., says that during the epidemic of smallpox,
1871 72, the number of cases received amounted to 2,377, of
which 68 per cent, had been vaccinated in childhood. In the
same hospital in the epidemic of 1880 82 the number of cases
admitted into the hospital was 1,659, 54 per cent, having pre-
viously been vaccinated.
Similar data might be presented from numerous sources,
but it is unnecessary. Enough has been given to conclusively
prove that smallpox occurring in persons who had been vacci-
nated in infancy is of much more frequent occurrence than is
witnessed in individuals previously attacked by smallpox.
Let us now examine the question of redevelopment of sus-
ceptibility to smallpox. This redevelopment of susceptibility
progressively increases up to a given period of life, the greatest
increase up to a definite point corresponding with the length
of time intervening primary vaccination.
The following tables, selected from many at hand, demon-
strate this fact :
Ages.
Gregory
London
if
Helm of
Wttrttemberg.
Kohl of
Denmark.
Cssm,
rx
at lis.
Cases^
i laoes.
Under 5 years of age. .
From 5 to 10 years . .
Prom 10 to 15 years. . .
From 15 to 20 years. . .
From 25 to 30 years. . .
From 30 to 35 years . . .
Above 85 years of age. .
: •■«•
26
90
106
55
13
4
16
8
1
40
68
186
275
239
172
75
14
102
178
187
156
19
8
Total
298
31
1,055
663
The following table compiled by Dr. Welch from the Munic-
ipal Smallpox Hospital, Philadelphia, Pa., shows 2,907 cases
of post- vaccinal smallpox admitted into the hospital from 1871
to 1883, including the cases classified according to the quality
of vaccinal scars in individuals below the age of puberty :
Cases .
Deaths.
Percentage
of deaths.
^ Good cicatrix ....
Under 5 years of a^e Fair cicatrix . . .
( Poor cicatrix ....
1
4
5
0
l
l
Total
10
2
( Good cicatrix ....
( Poor cicatrix
11
9
26
8
80.73
46
^
17.89
860
THE VALUE OF VACCINATION.
[October 11
Cases. Deaths.
From 10 to IS years
( Good cicatrix
. Fair cicatrix .
( Poor cicatrix .
45
18
36
4.44
11.11
11.11
Total
99
8 ! 8.02
388
745
580
356
249
154
105
175
47 12.11
From 25 to 30 years of age
From 86 to 40 years of age
From 40 to 45 years of age
From 45 to 50 years of age
96 . 12.88
92 > 15.86
64 17.97
51 ; 20.48
88 1 24.67
22 1 20.95
68 86. •
Grand total 1 2,907
491 : 16.89
Sufficient data have been presented to conclusively demon-
strate that it is and has ever been during the practice of vac-
cination, fallacious to contend that primary vaccination always
confers upon the recipient an immunity equal to that which he
would enjoy had he previously had an attack of smallpox.
Prom numerous data throughout this paper it must be evident
to every student of vaccination that a primary vaccination
made in infancy confers upon the individual so treated a posi-
tive and well nigh unvarying protection against smallpox for
an unknown number of years, generally to puberty, and that
in a considerable, though undetermined, proportion of such
individuals a redevelopment of susceptibility to contract small-
pox ensues in consequence of the deterioration of the protec-
tive power which vaccination had exerted against smallpox.
This fact in no wise militates against the efficiency of vaccina-
tion in the prevention and control of smallpox ; nor does it
detract one iota from the splendor of the discovery of the
immortal Jenner. An appreciation of this fact places vaccina-
tion upon the impregnable rock of truth, and enables Jenner's
successors to intelligently take the one additional step necessary
to stamp out smallpox, i. e., revaccination.
It being an incontrovertible fact that a thorough primary
vaccination protects the majority through life from smallpox,
but that in a considerable proportion of primary vaccinations
a redevelopment of susceptibility to smallpox ensues, and inas-
much as we are utterly unable, from examination of vaccin
cicatrices or otherwise, to decide who are not enjoying the full
protective influence of vaccination, it is our duty torevaccinate
every vaccinated person within ten or fifteen years from the
primary vaccination, and in the face of exposure to smallpox
to revaccinate even though the primary vaccination had been
performed only several months previously.
Proposition 9.
A good primary vaccination may be made in infancy, coupled
with successful revaccination at puberty, as fully protects every
individual so treated from smallpox as if he had previously
had an attack of smallpox.
Revaccination at puberty being admitted to be necessary to
confer upon the recipient the full protective benefit of vaccin-
ation, let us ascertain what this protective power has been
ascertained to be.
Experience in Smallpox Hospitals. Dr. Welch, physician
in charge of the Municipal Smallpox Hospital, Philadelphia,
Pa., says : "My experience in hospital work, which, as regards
time, comprises a period of more than twelve years (Jan. 1,
1871 to May 1, 1883), entirely agrees with that of Marson and
other observers just quoted. Only very few patients during
that time have been admitted into the hospital under my
charge, with varioloid, who presented evidence of having been
successfully revaccinated, and these few had the disease in so
mild a form that death has not occurred in a single instance.
During my service no person entering the hospital in any offi-
cial capacity, as resident physician, steward, matron, nurse,
laundress, or other employe, who had taken the precaution to
be revaccinated before entering upon duty, has suffered from
smallpox in any form whatsoever. But, on the other hand, I
have seen a few employes in whom revaccination was for some
cause omitted, become infected by the disease."
Dr. Seaton (in report of Medical Officer of Privy Council and
Local Government Board for 1874) says: "The observations
which were made during the recent epidemic (1870-1873)
afforded remarkable evidence of the value of revaccination,
not merely in controlling the mortality from smallpox, but
usually preventing altogether the occurrence of the disease.
Its power of preventing smallpox under circumstances the most
favorable for contracting it was tested on a very large scale on
the nurses, servants and attendants of the various hospitals
established for the treatment of the epidemic in the metropolis
and in the provinces, the attendants in the hospitals of the
Metropolitan Asylum Districts alone amounting at one time to
above three hundred. In every hospital report which has
reached me it is specially stated that not a single one of these
officials, who had been revaccinated before coming to take duty
at the hospital, contracted smallpox. On the other hand, a
few cases occurred among some nurses and servants in the hos-
pitals of the Metropolitan Asylum District, whose revaccina-
tion in the pressure of the epidemic had been overlooked ; and
there was one case in a nurse who, having had smallpox pre-
viously, had consequently not been vaccinated on coming into
the hospital. There was also a modified case in a nurse in
whom revaccination had been performed, but not till after her
arrival at the hospital, and when the smallpox infection had
already been received. The cases of smallpox which were
admitted for treatment in the several hospitals in persons who
had been successfully revaccinated were very few and very-
slight. In the hospitals of the Metropolitan Asylum Board,
in which upward of 14,800 cases of smallpox were treated,
there were but four cases in which there was good evidence of
revaccination having been performed with effect, and these
were all light cases. In Liverpool, says Dr. French, revaccina
tion was found a constant and perfect protection against small-
pox. In the Newcastle-on-Tyne smallpox hospital, in which
778 cases were treated, there were two in which revaccination
was alleged to have been successfully performed, one of them
ten years and the other four years before the attack of small
pox; both of them recovered. In the same hospital eight
patients were admitted, stated to have had smallpox, five of
whom were distinctly marked by it; one of the three not
marked died, the remaining seven all recovered. In the
Leeds hospital there were four cases in which previous revac-
cination was alleged, but in none of them was the evidence
of revaccination conclusive. One of them, in which the revac
cination was said to have been done at seven years of age,
was fatal ; the other three cases were mild. There were three
(fatal) cases of smallpox in persons believed to have had small-
pox previously, but the evidence of the former smallpox is not
stated. Similar infrequency and mildness of smallpox after
revaccination was noted in the hospitals abroad. In the
municipal smallpox hospital at Berlin, in which 1,529 cases
were treated who had been vaccinated, only nineteen of these
were in persons (all above 30 years old) who had been success-
fully revaccinated ; they were all of them cases of varioloid, or
of variolous fever without eruption, and none of them died.
In the same hospital there were seven cases (three of them
fatal) in persons who had previously had smallpox. In the
Baracken-Lazarethe, used also as smallpox hospitals in the
same city, in which 1,805 cases were treated in persons who
had been vaccinated, seven only were in persons who had been
successfully revaccinated, of whom six had a mild attack and
one (a woman 60-70 years old; had the hemorrhagic form and
died. In the hospital at Leipsic, out of 1,504 vaccinated
patients there were thirteen who had been successfully revac-
cinated in early life, all of whom recovered ; in the same hos-
pital there were twenty-two cases in persons who had had pre-
vious smallpox, and of these six died. In the hospital at
Hamburg the cases in persons who had been revaccinated
were more numerous, amounting to fifty-nine out of a total of
2,267 vaccinated patients, and there were three deaths."
Dr. Marson, having the greatest experience perhaps of all
writers upon this subject, says of the test of vaccination in
preventing smallpox : "For thirty years we have revaccinated
all the nurses and servants who had not had smallpox, on their
coming to live at the smallpox hospital, and not one of them
has contracted smallpox during their stay here."
Manchester Royal Infirmary. -Dr. Henry Thomkins, med
ical superintendent of the fever hospital belonging to the
Manchester Royal Infirmary at Monsall, in a paper recently
read at Owens College, said: "The most striking of all evi-
dence is, perhaps, that derived from the smallpox hospitals
themselves. Here the protective influence of vaccination is
seen and proved in a manner beyond all cavil. At Highgate, dur-
ing an experience of forty years, no nurse nor servant, having
been revaccinated, has ever contracted smallpox ;and evidence
of the same character I can myself bring forward, for, dur-
ing the whole time that I have had charge of the fever hospital
more than a thousand cases of smallpox have passed under my
care, yet no servant, nurse, porter, or other person engaged
there has, after revaccination, ever taken it, though exposed
daily to infection in its most concentrated form. . . Again,
among all the students who during the past two years have
attended the hospital for clinic instruction, not one has suf-
fered, all having been revaccinated before being permitted to
enter the smallpox wards. . . I defy the most enthusiastic
or conscientious of anti-vaccinators to produce evidence like
36 Annual Report ot the Board of Health of Detroit, Mich., 1882, pages
109 and 110.
L896. 1
THE VALUE OF VACCINATION.
Hfil
this on his side of the question, or to bring forward oven half
a dozen persons, choose them whence he may, who have not
been protected against smallpox, and expose them as tjie stu-
dents are exposed, without more or less of the number taking
the disease."
At Versailles, in 1828, during an epidemic of smallpox of
marked severity, revaccination was first tested as a means of
checking the ravagesof smallpox. A large number were revac-
einatod. and no one of these revaccinated individuals con-
tracted smallpox.
In Copenhagen, there were three severe epidemics of small-
pox between the years 1828 and 1835, during which not a single
revaccinated person was attacked by smallpox.
In the epidemic in Heidelberg, 1843 44, notwithstanding
rigorous and thorough vaccination, a largo number vaccinated
ten or nunc years previously contracted smallpox, yet not one
revaccinated person was attacked.
[n Wiirttemberg with a vaccinated population of 1,263,298,
during Bve years the total number of cases of smallpox was
1,677, 3M of these were cases of confluent smallpox, 1,043
were cases of \ arioloid being about one case of failure of pro-
tection against smallpox to 217 vaccinated persons. In a few
years subsequently, of 44,000 revaccinated subjects, 20,000
'took the vaccin disease perfectly, 9,000 imperfectly, and failed
with 15,000, the successful revaccinations being almost exclu-
sively in those who had been vaccinated many years previously
and only 3 of these in a subsequent epidemic of smallpox con-
tracted the disease.
Of 14.:t:!l revaccinations in the army of Wiirttemberg, 1831-
lSi."). 8,845 had what are described as genuine vaccin marks
or scars, and of this number 31 per cent, were successfully
revaccinated : aborted vaccin vesicles in 29 per cent. ; and
revaccination failed in 40 per cent. With those having imper-
fect marks of previous vaccination, revaccination succeeded in
cent., modified in "26 per cent., failures 46 per cent. Mr.
Simon, in his able digest of the subject, published by the Gen-
eral Hoard of Health, shows that, during the years from 1833
17, notwithstanding the fact that smallpox had been six-
teen times brought into the army of Wiirttemberg, there
had ensued among the 14, .'134 revaccinated soldiers one single
instance of unmodified smallpox.
In the Prussian army, in 1840, revaccination was performed
Upon 13,522 soldiers. Upon these soldiers were found distinct
vaccin cicatrices in 34,573; indistinct vaccin scars in 6,177;
in "J.TTl1 persons no scars of previous vaccination were found,
although they had formerly been vaccinated. The result
showed 20,952 successful revaccinations; 8,820 partially suc-
cessful: and 13,760 unsuccessful revaccinations. Revaccina-
tion was practiced in this army because of the increase of the
number of cases of post vaccinal smallpox among the soldiers.
For ten years prior to 1831 these cases had been observed : and
from 1831 to 1833. 312 deaths had occurred among the troops
formerly vaccinated. For twenty years subsequent to revac-
cination. two deaths annually have occurred from smallpox,
whereas 104 deaths annually occurred before revaccination was
practiced.
In the Bavarian army revaccination has been compulsory
since 1843 : and for twelve years- 1843 to 1855, as shown by the
report of the minister of war not a case of unmodified small-
pox had occurred. A few cases of varioloid had occurred dur-
ing this period of time, but not a single death from smallpox.
Dr. de Kerschensteiner, chief medical officer of Bavaria, as
the result of official statistics of Bavaria for ten years, 1871-80,
says: "Of those once vaccinated, 12 per cent, of those
attacked, of the revaccinated only 71., per cent., but of the un-
vaccinated, 4ti'2 per cent, died of smallpox."
The annual reports of the Medical Departments of the Army
and the Navy of Great Britain, afford most striking proof
the protective power of revaccination in adult popula-
tions. The soldiers and sailors serving in the United King-
dom may be looked on as virtually a wholly protected force,
for now, for several years past, every man serving in the Army
or Navy, whether or not he has marks of smallpox or of previous
vaccination, is required to be vaccinated on entering the ser-
vice. This rule has been in force in the army since 1858, but
until some ten years later, there was no rule in the navy
requiring the vaccination of all who entered, whether previ-
ously protected or not. This has, however, now been rectified,
and the result is seen in the fact that whereas in the days of
the absence of such rule the smallpox death rate was much
higher in the navy than in the army, the rate is now consider-
ably lower, being in fact, for the six years, 1873-78, absolutely
nil. Indeed, in the whole of the British Navy in all parts of
the world, numbering 46,400 men, there were in 1878 but nine
of smallpox, four on the home station, three on the East
India, one on the Mediterranean, one on the China stations.
All these nine cases are noted as mild, and were unquestiona-
bly modified by revaccination. In the very large proportion of
the men employed in both services, the protection against
smallpox is that afforded by vaccination. In the year 1877 only
5.45 per cent., of recruits proved on examination to have marks
of smallpox, while 90.85 had marks of vaccination, and 3. 69 had
neither vaccination nor smallpox marks.
If the records of these protected services be examined to see
what ravages are now made in them by smallpox, the disease
which, according to Sir Gilbert Blane, was, before the discov-
ery of vaccination, "one of the great embarrassments to the
operation of armies," and obliged ships of war occasionally to
quit the seas, we find that during the eighteen years 185! I 76
inclusive, the annual deaths from it were considerably less
than one per 10,000 (.643 only) amongst troops serving in the
United Kingdom. More than a third of the whole of the
deaths during these eighteen years occurred during the small-
pox epidemic of 1871-72, the exceptionally severe character of
which has already been adverted to. Among the sailors em-
ployed on the home force, there were, during the 20 years,
1859 78, as nearly as possible, one per 10,000 (1.0085) attacked
annually with smallpox. During the same period the cases of
smallpox did not exceed annually 9.05 per 10,000 soldiers and
16.16 per 10,000 sailors. If the influence of the ferocious epi-
demic of 1871 72 be duly allowed for, a steady decrease in the
number of cases and of deaths will be observed from the com-
mencement. In fact, omitting these two years, there has not
been a single death from smallpox in the navy 1864 and 1880,
i. e., sixteen years ago. The recent statistics of the army are
hardly quite so favorable, but still they show the year 1865 to
1880, with the exception of the epidemic years 1871-72, only
one single soldier out of the 80,000 troops serving in the Uuited
Kingdom, has on an average died of smallpox in each year.
Table (>.— Tahle ihowtng for eaeh of the years 1870-83 the mortality
from smallpox In Berlin, In London and in Vienna per 100,000 Inhab-
itants.
Yea r.
Berlin.
London.
V'i< IMKI.
Year.
Berlin .
London.
Vienna.
1870.
28.37
30.20
46.71
1877 . .
0.40
70.98
84.01
1871 .
832. 5tS
242.18
74.90
1878 . .
0.78
88 81
78.91
1872 .
118.01
53.80
»an . s*s
1879 . .
0.75
12.18
46.91
1873 .
11.21
8.55
228.50
1880 . .
0.81
12.50
78.52
1874 .
2.47
1.66
135.26
1881 . .
4.74
81.91
123.95
1578 .
5.19
1.82
118.50
1882. .
0.48
11.07
108.39
1876 .
1.81
20.80
167.80
1883. .
0.88
8.00
9.60
Average for nine years from 1875 to 1888: Berlin, 1.7; London, 25. 88
Vienna, 89.29.
The above table furnishes incontestable proof of the efficacy
of revaccination. The vaccination law of Prussia, requiring
vaccination at the age of 1 year of age and revaccination at the
age of 12 years, was enacted April 8, 1874, and has been rigidly
enforced. In England, primary vaccination is compulsory, but
revaccination, while urged upon the people, is not required
except in the face of exposure to smallpox. In Austria neither
vaccination nor revaccination is compulsory. The Austrian
government warmly recommends vaccination and revaccina-
tion, but citizens adopt or reject the recommendation at will.
Now, for the result. For the five years in the table, 1870 to
1874 inclusive, prior to compulsory vaccination, the average
annual smallpox mortality per 100,000 inhabitants of Berlin
was 162.64, while during the nine years of enforcement of com-
pulsory revaccination at 12 years of age, it was 1.7 per 100,000
inhabitants. In London, it was 66.27, while during the nine
years, 1875 to 1883 inclusive, it was 25.83. In Vienna, 1870 to
1874 inclusive, it was 205.41, while in 1875 to 1883 inclusive it
was 89.25.
Again, during the nine years, 1875 to 1883, the average
annual smallpox mortality in each of the three cities was as
follows: Berlin, 1.7; London, 25.83; Vienna, 89.29 per 100,000
inhabitants. What is lacking to convince any sane man when
such figures are presented?
In the smallpox epidemic in Sheffield, England, 1887 88, as
previously shown, a house- to house examination made under
direction of Dr. Barry, inspector of the local government
board, disclosed the fact that 64,431 citizens of Sheffield had
been revaccinated and only 27, or 0.04 per cent, of the total
revaccinated population had contracted smallpox, and one per-
son, rather more than 0.001 per cent., died: 8,198 of these
revaccinations were made prior to 1887, and of this number 25,
or 0.30 per cent., contracted smallpox and 1, or 0.01 per cent.,
died. The remaining 56,233 were stated to have been revacci-
nated during 1887-88, and of these 2 persons, or 0.004 percent,
were said to have contracted smallpox and none of them died.
The facts detailed by Dr. Barry show, however, that neither of
these two cases were smallpox.
The enumerators under Dr. Barry reported that the total
862
SOCIETY PROCEEDINGS.
[October 17,
number of persons living in Sheffield who had suffered attacks
of smallpox prior to 1887 amounted to 18,292 persons. Of
these, 23, or 0.13 per cent, contracted smallpox, of which 5, or
0.3 per cent., died, the percentage of deaths to cases of sec-
ond attacks of smallpox having been 23.5 per cent.
VACCINATION AND SMALLPOX IN UNITED STATES ARMY AND NAVY.
The following tabular statements relative to vaccination and
smallpox in the United States army and in the United States
navy have been kindly furnished me by Surgeon General
Sternberg of the army and Surgeon General Tryon of the navy.
These tables richly illustrate the value of vaccination in pre-
vention of smallpox.
In the army all men are required to be protected from small-
pox by vaccination at time of enlistment. Now, for the result :
For the eight years, 1884 to 1891 inclusive, in an army never
numbering less than 23,226 men, there were 17 cases of small-
pox and only three deaths from this disease.
In the navy for the sixteen years, 1880 to 1895 inclusive,
among 68,944 men there were 95 cases of smallpox and only five
deaths therefrom.
Vaccination and Smallpox, United States Army; Years 1884-91 inclusive.
"S3
T3
Is
0
a
a
.
a
.
3 P a
3
ti 3
3
Years. £
a
e
n b$ i
B
00
2 OD
I
5
a
6
ases
Und
rima
Vacc
6
a
>
3
si
■nee
Si
> 3
S s
a
u
0 cu
as
H
X
OS
H
1884 . . 24,084 . . .
819
«,889
7,658
271
856
1.127
1885 . . , 24,188 . . .
1,870
7,475
8,845 j1 878
1,110
1,488
1886 . . 28,572 1
2
857
6,319
7,176 444
1,465
1,909
1887 . . ; 28,841 - 2
1,898
8,404
5,802 ! 661
2,099
2,760
1888 . . 24,726 a2
1,605
9,598
11,208 891
2,920
3,811
1889 . . 25,008 | 4
1,800 i
10,877
12,177 1 944
2,985
8,929
1890 . . 24,284 . . .
1
1,224
6.230
7,454 1 729
2,052
2,781
1891 . . 23,269 ,]2
aii
2,882
7,974
10,856 ! 1,455
2,948
4.408
"a" ldied.
1880-1885
1885-1890. UM
-1895.
Report of
Vaccinations.
3
—
— .*
~ .£
«
': s
X
I
1
8
--
1
■
I
■
6
0 *^
8 1
S I
B
6
V
3
■
-I
— B
a a
3
a 2
3
BE
O
CO
a S
O
g
No evidence of pivvi
IUS
vaccination ....
1,560
2,014
1,808 l,2a5
1,767
9,547
Presenting good c
<-;i
triees
8^07
13.372
12,912
5,024
18,597
57,155
Evidence of former
at-
tack of smallpox .
218
770 198
570
U«
375
2.242
Total number vaccinated, 118,944— Successful, 21,764; unsuccessful
17,180
Admissions and Deaths from the following diseases, from 1880 to 1895,
in the United States Navy.
Disease.
Vaccina . .
Varicella. .
Variola, . . ,
Varloloides.
1886-1890.
1890-1895.
Total.
Cases. IDied. Cases. Died. Cases. Died. Cases. Died
433
8
18
1 501
. . 11
2 28
1,802 1
21 I . . .
61 i 6
84 . . .
(To be continued.)
SOCIETY PROCEEDINGS.
American Association of Obstetricians ami
Gynecologists.
Ninth Annual Meeting held in Richmond, Va.,
Sept. 22-24, 1896.
(Concluded from page 816.)
Dr. William G. Myers, of Port Wayne, Ind., read a paper
entitled
ATRESIA WITH RETENTION OF THE MENSES ; TREATMENT.
The author reported two cases of atresia, one with absence
of the vagina and uterus and the other with retained menstrual
fluid. The last was operated upon successfully. He believes
:
that in a case of atresia of the vagina with retention of men- 1
strual fluid in the uterus, an operation ought to be completed I
at ons sitting, adopting the direct method. He thinks the
teaching in a recent work that "the best way is to make a
small opening into the mass and allow the contents to flow
away gradually," is not sound. He could not therefore see in
rapid evacuation such great dangers as were referred to in the
books.
PRINCIPLES AND PROGRESS OF GYNECOLOGY.
The president's address was delivered by Dr. Joseph Pric
of Philadelphia. He first thanked the Association for the di
tinguished honor in electing him president, which he said was
the most gratifying expression of personal and professional
kindness. He said the Association was made up of earnest,
enthusiastic and eminent men of the medical profession. W<
had more than a passing interest in the record of the transac
tions of our medical and surgical associations. From the
the history of the progress of medical and surgical scieno
would be made up ; they would reflect the advanced thought
and opinions, the strength of the endeavors, the results of
clinic experience and research of the profession of this period.
We had the inspiration of the reflection that our high service
was that of humanity, and Dr. Price said the members were
there to learn through the interchange of the best counsel how
to make that service the best.
Dr. George H. Rohe, of Catonsville, Md., read a paper on
"Some Causes of insanity in Women," of which the follow
ing is an abstract.
The general causes of insanity are the same in women as in
rr jn, but there are modifying conditions in the life history of
men and women that influence the causation of mental disturb-
ances in the two sexes. General paresis and alcoholic insanity
are more frequent in men because the latter are exposed to
their causes to a greater degree and intensity. Menstrual,
puerperal and climacteric insanity are on the other hand self
evidently limited to women.
Women are especially subject to mental disturbances depend-
ent upon their sexual nature at three different periods of life :
puberty, the child-bearing period, and the menopause. The
functions and activities peculiar to these periods have an inti-
mate etiologic relation to certain insanities. It is probable,
however, that these functions have no influence in the produc-
tion of insanity in their normal condition. It is only when
the functions are disturbed, or when pathologic conditions are
present that they have any unfavorable influence upon the
psychic functions.
At the period of puberty, menstrual derangements are not
infrequently causative of mental disturbances which do not
yield until the menstruation becomes normal. In the puer-
perium, insanity is dependent upon septic absorption, or the
consequences of other morbid conditions of the reproductive
organs. Lactational insanity may be due to physical exhaus-
tion, but in some cases pathologic conditions of the genitals or
of th easts seem to have an etiologic relation. At the meno-
pause bue disturbances of nutrition associated with the arrest
of menstruation often produce insanity, and in many of these
cases there will also be found abnormal alterations of the repro-
ductive organs. The insanities following gynecologic opera-
tions are either due to septic conditions, or are merely due to
the rapidly induced menopause. Their frequency has been
much exaggerated.
Dr. Walter P. Manton, of Detroit, Mich., read a paper on
THE RELATION OF VISCERAL DISORDERS TO THE DELUSION:-
THE INSANE.
He said, that the delusions of the insane are often an express-
ion of somatic peripheral irritation has long been recognized,
but observation leads Dr. Manton to believe that the import-
ance of these mental manifestations as indices of bodily suffer-
ing was frequently ignored as a mere phase of the brain disor
der, especially in the instances of supposed fancied visceral
disturbances.
For convenience of consideration, he placed the so-called vis-
ceral lesions in four classes : 1, Delusions arising de novo from
the diseased activity of the brain : 2, delusions regarding exter-
nal or visible abnormal bodily conditions ; 3, delusions arising
from easily determined visceral disorders, and 4, delusions
dependent upon obscure abdominal and pelvic states. The
last three classes were briefly considered.
One can readily understand how visible bodily defects may
be misinterpreted and the mind of the patient become confused
as to the real nature of the condition which is always more or
less open to inspection. The site of a dermoid tumor slowly-
developing in the abdominal walls led one of his patients to
believe herself pregnant, but the removal of the growth soon
dispelled the illusion. In another instance a uterine fibroid
I
1896. ]
SOCIETY PROCEEDINGS.
86;}
called out the same impression, and the patient requested the
physician to listen to "near the young ones." The appearance
of a complete procidentia uteri in another r;\sc gave rise to the
idea that the protruding mass was the male organ, and under
■neb conditions the patient could no longer retain her feminine
appellation, and immediately rechristened herself "John."
Such examples might be multiplied, for they were of frequent
observation by all who had to do with the insane. In such
Instances the connection between the delusion and the somatic
disorder was obvious, being, as it wore, on the surface. In
the third class, however, the relation of the condition to the
expressed idea was not always so apparent.
the author reported interesting cases. In each of the
patients the delusions referred chiefly to the abdomen, and in
eaeh an abnormal condition of somo of the viscera was found,
but a condition in which the early intervention of surgery
would have afforded great, if not permanent, relief to the suf-
ferings of patients. Laparotomy, in properly selected cases of
the insane in whom visceral delusions are a pronounced and
constant feat ure of the mental disorder, was not only justifi-
able, in his opinion, but urgently demanded in the interest of
the patient.
Or. David T. Gilliam, of Columbus, Ohio, read a paper on :
OOl'IIDiiKl TOMV KOK THK INS \N1TY AMD EPILEPSY OK THE FEMALE ;
A PLEA FOR ITS MORE GENERAL ADOPTION.
The author showed in this paper that oophorectomy was a
logieal and legitimate operation for the epilepsy and insanity
of the female. Insanity is hereditary, as also epilepsy. They
constitute the greatest curse to humanity. An insane father
or an insane mother brings more misery into the world than
any other father or mother. The offspring of such a parent,
when ushered into the world, would be confronted by the
awful specter of impending doom, and though he called on the
rocks or mountains to fall on him, the curse would pursue and
overtake him. Dr. Gilliam then gave a picture from real life.
He would limit the operation to those in whom the malady
appears in sumo way to be connected with, or dependent on
sexual disturbance. He would go further and include all who
were willing to undergo the operation to save themselves aDd
their offspring from the miseries which awaited them.
Dr. J. F. Baldwin, of Columbus, Ohio, followed with a
paper entitled :
TREATMENT OF THK STUMP TO PREVENT ADHESIONS.
He estimated that about 1 per cent, of all cases operated
upon die from intestinal obstruction, the result of adhesions
to the stump. To diminish as much as possible the danger of
adhesions, he recommended the careful closing in of stumps
by a peritoneal flap, and described the method of securing
this Hap. In cases where the pedicle is, after a simple ovari-
otomy, not too large, he recommended that the pedicle be so
ligated that the ends of the ligature were on the anterior face
of the pedicle : that the ends of the ligature be then carried
across the face of the stump, down and through the broad lig-
ament, transfixing the ligament from behind forward. The
ligatures should be passed through about half an inch apart.
As the ends are drawn through and tightened, the raw end of
the stump is rolled down and under the broad ligament, so as
to be entirely protected. He had used this method in a large
number of cases and with entirely satisfactory results.
Thomas E. McArdle of Washington, D. C, read a paper
entitled
ABDOMINAL SECTION FOR TUBERCULAR DISEASE.
The author formulated in a terse manner what had already
been done by surgical means for the relief of women suffering
from tuberculosis of the generative organs. There is no doubt
that tubercular disease of the female genitalia is more frequent
than is generally supposed. Every portion of the genital tract
may be affected, the order of frequency for the various portions
being the tubes, body of the uterus, ovaries, vagina, cervix and
vulva. The tubes are affected in all cases, the body of the
uterus in about three-fourths of the cases and the ovaries in
about one half of all cases. Tuberculosis of the body of the
uterus is not at all a rare affection and has been frequently
discovered in autopsies upon phithisical subjects. It can be
the only focus of disease of the body, but it is generally asso-
ciated with disease of the tubes and is generally secondary to
disease of that organ. Of all the female genitalia, the vulva is
the least liable to tubercular infection. The author then
dwelt upon the etiology of tuberculosis of the female genitalia,
after which he detailed the various ways by which the disease
might be caused or transmitted.
The treatment of tuberculosis of the vulva, vagina and cer-
vix did not come within the scope of the paper. The destruc-
tion of the tuberculous focus by fluid or solid caustics had
Jbeen advocated by some surgeons, and if these means were not
satisfactory, extirpation of the part was recommended. We
had a very efficient means for the removal of the tubercular
ulcers of the vagina and vulva in the application of the tinc-
ture of iodin. They rapidly disappear under its use. In case
of failure, however, excision could be practiced. When the
cervix is involved, and not the body of the uterus, the method
of treatment advised for the vu\va and vagina should be given
a fair trial, but if they prove ineffectual no time should be lost
in amputating the cervix. When the endometrium is involved
there is a diversity of opinion as to the best method of pro-
cedure. It has been recommended to first curette the organ
and remove all evidence of disease. The iodoform supposi-
tories are introduced into the uterus. If there should be a
recurrence of the trouble, removal of the organ is advised. If
we bear in mind that tuberculosis of the body of the uterus is
so frequently associated with the same disease in the tubes
and ovaries, it seems to Dr. McArdle that having once ascer-
tained the existence of tubercular disease in the uterus, it is
our duty to look for a similar condition in the tubes and
ovaries, and, if found, it behooves us to waste no time in
curetting the uterus and treating it with iodoform, but to pro-
ceed at once to the performance of an abdominal section for
the removal of the uterus, tubes and ovaries. This heroic
method of treatment is advocated in primary disease of these
organs. In a case complicated with tubercular peritonitis
there would be no special danger in removing the tubes and
ovaries. We all know how many cases of that disease have
been cured by section and drainage. We could then curette
and treat the body of the uterus.
Dr. Charles A. Reed of Cincinnati, Ohio, read a paper
entitled
MELANO-SARCOMA OK THE FEMALE URETHRA; URETHRECTOMY :
RECOVERY.
This interesting case was as follows : Mary E. Y. , aged 64, sin-
gle, was brought to his private hospital Dec. 3, 1895. The patient
had had no previous serious illness. There was no history of
tuberculosis or syphilis in the family. The vaginal condition
of the genitalia precluded the supposition of venereal infection
of any character. Her general health was good, although
there was some emaciation about the neck and breasts, the
latter of which were flabby- changes no doubt incident to age.
Careful examination revealed no diseased conditions about
either the lungs or heart. Careful palpation and percussion of
the abdomen yielded negative results.
About eight months previously, i. e., in April, 1895, she
began to notice some pain accompanied with blood on micturi-
tion. This was shortly followed by a more or less constant
pinkish discharge from the genital fissure. The self-examina-
tion which followed revealed a tumor at the meatus urethrae.
This tumor continued to increase in both size and hemorrhagic
tendency until she was prompted to consult Dr. Morris, who
curetted the neoplasm thoroughly aud treated it with styptics.
When the patient came under Dr. Reed's care he found a black
lobulated and eroded mass about three centimeters in diam-
eter separating the labia majora. The orifice of the urethra was
in the very center of this mass. A careful vaginal examination
was not made at the time, as the vaginal structures, present in
their integrity, rendered such an operation very painful.
Operation was done the next day, December 4. The small
blade of a Jones' speculum was introduced ; the patient being
in the Simon's posture, the urethra was exposed in its entire
length. A longitudinal incision was made through the mucous
membrane along the dorsum of the urethra from a point where
the presenting part of the mass was eroded to the base of the
bladder. Another incision through the mucous membrane was
made at right angles to the foregoing at point far enough above
the eroded mass to insure healthy tissue. The mucous mem-
brane was then dissected back in two lateral flaps and the
urethra was enucleated. The urethra was found to be dis-
tinctly conical in shape, the base of the cone being at the
meatus, the apex at the bladder. Care was taken to dissect
out the canal to a point manifestly above the zone of malig-
nant involvement. When this point was reached, but a slight
distance from the bladder, the canal with the neoplastic walls,
was excised. The cut margin of the cystic segment of the
canal was seized at various points in its circumference by
Kocher's forceps, brought down by gentle traction and fixed
by interrupted sutures of silk-worm gut to the vaginal mucous
membrane. A self-retaining catheter was inserted and the
patient put to bed. The sutures were removed on the eighth
day. The catheter was dispensed with on the twelfth day.
The patient sat up on the fourteenth day, when she found
that she could retain her urine and void it at will. She was
dismissed December 21, entirely healed. She remained in
good health until "July 1, following— seven months when she
864
SOCIETY PROCEEDINGS.
[October 17,
again summoned Dr. Morris because of some stomach symp-
toms. He found her suffering from persistent vomiting, and
with a large mass in the epigastrium. This mass rapidly
increased in size until it occupied all of the area between the
navel and the breast, its nodular characteristics becoming more
and more pronounced. She died of exhaustion July 14, 1896,
having had no recurrence whatever of the urethral trouble.
No autopsy was permitted.
Dr. J. B. Murphy of Chicago, addressed the Association on
THE SUTURE OF LARGE VESSELS INJURED IN OPERATIONS.
He demonstrated the method employed by him. He said in
1762 Lembert conceived the idea of suturing injuries to vessels.
He made two experiments, in both of which he failed. Dr.
Murphy then referred briefly to the experimental work of other
surgeons along this line, pointing out their successes and fail-
ures. His own researches and operative work lead him to
believe that, where a large vessel is injured in an operation, a
transverse division of it, not exceeding two thirds of its circum-
ference, the surgeon can resort to immediate suture without
resection, and, if the field of operation be aseptic, can feel
more certain that he will have union of the vessel and contin-
uation of the current than he could where he sutures the intes-
tine as for resection of the bowel. He believes from his obser-
vations that the changes are better with the suture. The
importance of this concerned surgeons more in the treatment
of aneurysms.
Coming to the question of stab and bullet wounds of the
extremities, he said there was a great field for improvement in
our past operative work. Formerly, we ligated vessels, and
when this was done the inevitable result was death of the
limb. He believes that now such limbs can be uniformly
saved, particularly in the aseptic cases. With his present
method of suturing large vessels, he is not afraid to suture any
vessel in the body, feeling confident that adhesion or union
will take place.
CONTUSIONS OF THE ABDOMEN.
A paper on the subject with report of cases and conclusions
was read by Dr. W. G. Macdonald, Albany, N. Y.
Contusions of the abdomen are always grave injuries. The
question of surgical intervention, although much discussed,
can not be regarded as satisfactorily settled. Seven cases of
traumatic rupture of the stomach and small intestines are
reported. Two operations were undertaken, one recovery, one
death the eighth day after operation from second rupture.
All the inoperative cases died. Reference is made to the gen-
eral absence of evidence of contusions in the abdominal walls
when serious visceral injury has occurred. Very slight causes,
particulary if the intestinal canal is distended with fluids,
may produce intestinal rupture, as the falling out of bed, a
blow from a barrow handle. The early symptoms of intestinal
laceration are not always distinctive. An analysis of two hun-
dred cases of intestinal laceration as associated with abdom
inal contusion was made with a view to determining the
symptoms. The following topics are considered the important
ones : History of the nature of the injury, shock or collapse,
pain, vomiting, pulse, temperature and physical signs. That
careful investigation of a given case will usually show suffi-
cient symptoms to make an early exploratory abdominal sec-
tion imperative.
The following officers were elected :
President : Dr. James F. W. Ross, Toronto, Ontario.
First vice president : Dr. Geo. Ben. Johnston, Richmond, Va.
Second vice-president: Dr. John C. Sexton, Rushville, Ind.
Secretary : Dr. Wm. Warren Potter, Buffalo, N. Y.
Treasurer : Dr. X. O. Werder, Pittsburg, Pa.
Place of meeting : Niagara Falls, N. Y. Time : August 24,
25 and 26, 1897.
The American Public Health Association.
[Special Correspondence of the Journal.]
The Twenty-fourth Annual Meeting of the American Public
Health Association held at Buffalo. N. Y., Sept. 16-18, 1896.
( Concluded from page 818. )
Friday, Sept. 18, 1896. Mornino Session, 9 a.m.
The Association met an hour earlier than usual and listened
to the final announcements of the local Committee of Arrange-
ments by Dr. Howe, for the excursions to follow the adjourn-
ment in the afternoon and next day.
The Secretary reported that the Executive Committee had
recommended the passage of the following resolutions which
had been referred to it :
1. The resolution of Dr. Whitehall of New Jersey, that the
standing committee on legislation be requested to report meth-
ods for rural sanitary administration which are in itsjudgment
the most useful and promising.
2. The resolution of Dr. Walter Wyman of Washington, D.
C. : Whereas, yellow fever is believed to be the most subtle
and dangerous of all epidemic diseases: and whereas, it is
ordinarily conveyed into a new country from an infected sea-
port of another ; and whereas, the continued and persistent
presence of this disease in any seaport is believed to be unnec-
essary and may be prevented by proper engineering and other
sanitary measures ; therefore be it
Resolved, 1, That it is the duty of every government possess-
ing seaports thus infected to institute such engineering and
other sanitary measures as shall remove this menace to sea
ports of other nations ; 2, that it is the duty of the govern-
ments continuously threatened with the invasion of yellow
fever from a seaport in which this is allowed to persist, to make
such expostulations to the government in possession of the
offending seaport as shall cause the latter to adopt sanitary
measures necessary to remove this obstruction to commercial
intercourse and menace to human life.
3. The resolution of Dr. Durgin of Boston, protesting against
the passage by the Congress of the United States of the pro-
posed act preventing experimentation on animals.
The Executive Committee further recommended the con-
tinuance of all the special committees except that on the cen-
tennial of vaccination, and the consolidation of the committee
on the cause and prevention of diphtheria with that on the
cause and prevention of infant mortality.
Dr. Wrkiht of Connecticut inquired what had become of
his resolution recommending the discontinuance of oyster
planting at the mouths of polluted streams, and when informed
that it had been tabled by the Executive Committee, for the
reason that it considers the effort should be to first prevent the
pollution of the streams, gave notice of an amendment to the
constitution, making the Executive Committee consist of nine
members, three of whom shall be elected annually.
The Secretary reported forty additional names recommended
by the Executive Committee for election to membership, for
which the Secretary was instructed to cast the vote of the Asso
ciation in block.
Dr. Probst, of the Auditing Committee, reported that the
accounts of the Treasurer had been carefully audited and
found correct.
Mr. Crosby Gray, Secretary of the Advisory Council,
reported that the following members had been nominated by
the Council as officers of the Association for the following
year :
For President, Dr. Henry Buckingham Holbeck of Charles-
ton, S. C, Health Officer of the city of Charleston.
For First Vice president, Dr. Peter Henderson Bryce of
Toronto, Canada, Secretary of the Provincial Board of Health
of Ontario.
For Second Vice-president, Dr. Ernest Wende of Buffalo,
N. Y., Health Commissioner of the city of Buffalo.
For Treasurer, Dr. Henry D wight Holton of Brattleboro, Vt.
For Members of the Executive Committee, Dr. Henry
Mitchell of Trenton, N. J., Secretary of the State Board of
Health of New Jersey, Dr. U. O. B. Wingate, Secretary of the
State Board of Health of Wisconsin, and Dr. Jesus E. Mon-
jaros of San Luis Potosi, Mexico, President of the Superior
Council of Health of the State of San Luis Potosi, who were
all thereupon elected to these respective offices by the vote of
the Association.
Ex presidents Gihon and Formento were delegated by the
Chair to conduct the President elect to the platform, who
made a very feeling address in acknowledgment.
Mr. Gray further reported that the Advisory Council had
selected Toronto, Canada, as its place of meeting in 1897. Dr.
Plunkett, President of the State Board of Health of Tennes-
see, moved to substitute Nashville, Tenn., in which he was
ably seconded by Dr. A. N. Bell of Brooklyn, N. Y. Professor
Bracken of the University of Minnesota moved to amend,
being largely seconded, by substituting Minneapolis, Minn.,
and he was followed by Dr. Benjamin Lee, Secretary of the
State Board of Health of Pennsylvania, who presented invita-
tions from the Mayor of Philadelphia, the board of health of
that city and the State Board of Health to meet in Philadel-
phia, which was ably seconded by Dr. Gihon, who as a Phila
delphian argued the propriety of holding the twenty fifth meet-
ing of the Association— its quarter-centennial- in that city,
where it had not assembled since 1874. He said that the pres
ence of the Mayor of Ottawa, the capital city of the Dominion,
backed by a strong delegation bearing an urgent invitation to
go to that city, in a measure obliged us to hold our next meet-
ing in Canada at Ottawa, having already met in Toronto in
1896.]
SOCIETY PROCEEDINGS.
866
L886 and in Montreal in 1894. After a lengthy and lively
debate bj the advocates of the various cities, Philadelphia was
■elected as the place ol meeting In IS'.it.
The appointment of Dr. Dominoo Orv \\ iRos of the City of
Mexico to be Assistant Treasurer for Mexico was then
announced, and members appointed on the special committees
authorized by the Association.
The members of the new committee on transmissibility of
infections and periods of danger from infected persons, consti-
tuted in accordance with the recommendation of the President
In his annual address are Professor Eduardo Liceaga of the
City of Mexico. Dr. John L. heal, of Paterson. N. J., Surgeon
Fernando Lopez of the Mexican Army, Medical Director New-
ton 1.. Bates, U. S. Navy and Surgeon General J. J. Kinyoun,
U. S. M. II. s.
Professor Stephen Smith of the City of New York was
appointed Chairman of the new committee on international
cooperation in preventing the transmission of contagious dis
cases with authority to select his associates.
The President. Dr. Liceaga, then extended an earnest invi-
tation on the part of Dr. Rafael Lavista, Dr. Manuel Carmona
y Valie and himself as the Committee of Management of the
3d Pan American Medical Congress to all the medical members
of the Association and their professional friends to attend that
Congress which opens in the City of Mexico, November 16
and continues until the 19th.
The thanks of the Association were then tendered the retir-
ing President, who eloquently responded, expressing the hope
that the community of interest between the United States and
Mexico shown by his election might be unending; and to the
retiring First Vice President for the able, prompt, and ener-
getic manner in which he had assisted the President during
the protracted sessions, and after a graceful response on his
part, the scientific work was resumed in the following order:
Report of committee on the "Relation of Forestry to Public
Health." by Professor Robert C. Kedzie, of Michigan; Re-
port of committee on " Transportation of Diseased Tissues by
mail." by Dr. Hknrt Mitchell, of New Jersey.
Dr. [dm commended the committee (Drs. Mitchell of New
Jersey, LaChapelle of Montreal and Orvananos of Mexico) for
the admirable work they had already accomplished and in recog-
nition of the fact that the Hon. William L. Wilson, Postmaster
General of the United States, had permitted the transmission
of diseased tissues through the mail making their distribution
possible, offered a resolution expressing the appreciation of the
American Public Health Association of the deep scientific dis-
cernment exhibited by the Postmaster General in so doing.
A paper " On Statistics of Vaccination and Mortality from
Smallpox in the city of Mexico, 1872-1895," was read by Dr.
Joffl Kvmikez, who said that vaccination met with no opposi-
tion in Mexico, where it was compulsory, and consequently
small|Kix had become very rare, the epidemic outbreaks occa-
sionally occurring being due to foreign importation. A paper
•• On Drunkenness a Vice : it should be so treated," by Dr. A.
Nelson Hell of Brooklyn, N. Y. This paper advocated the
punishment of voluntary drunkenness as a misdemeanor, with
increased penalties for repititionof the offense against society.
" Municipal Cattle and Meat Inspection, by Dr. Peter H.
Bryce of Toronto ; " The Prophylaxis of Scurvy in Prisons by
Pulgue," by Dr. Francisco Martinez Baca, of Puebla,
Mexico. Vice-President Woodhull, in confirmation of the
statement of Dr. Baca, said that the use of the maguey juice
had long been known to medical officers of the army serving in
the Mexican frontier as an excellent remedy for scurvy.
The following papers were presented: "The Relation of
Noises to Public Health," by Dr. William C. Kraitss of Buf-
falo, X. V. : " The Degeneration of the Human Animal Through
the Nursery and Schools," by Dr. J. B. Learned of Massachu-
setts: "The Importance of Supplies of Pure Water," by Dr.
J. L. DeHart of Brooklyn, N. Y. ; "Racial Deterioration," by
Lawrence Ikwell, M.A., of Buffalo, N. Y. ; "The Protection
of the Innocent from Gonorrhea," by Dr. Ferdinand C.Val-
entine of the city of New York : "The Necessity of Isolating
Beds in Hospitals by means of Windows between Them," by
Dr. Jesus E. Monjaras of San Luis Potosi, Mexico: "Filth
Deposits with Regard to Public Health," by Drs. Jose D.
Morales and R. E. de Guerrero of Mexico.
The program having been concluded, Medical Director
Gihon, United States Navy, rose to say that he had deferred
to the last to make formal announcement of the recent death
of two of the most distinguished members of the body, Dr.
Joseph M. Toner of Washington, D. C, one of its founders in
1872 and its second President (1875), and Dr. Jerome Cochran
of Mobile, Ala., State Censor of Alabama and senior member
of the Advisory Council, who since 1878 had never failed in his
attendance at the meetings when that was possible and who
until a few weeks ago anticipated with great pleasure being
with us at Buffalo, and offered a resolution of sorrow and
regret, which was adopted by a rising vote. After appropriate
valedictory remarks, the President at 2 p.m. declared the
twenty-fourth meeting adjourned.
An excursion around the harbor and an exhibition drill by
the life-saving service during the afternoon, and an excursion
on the following day to Niagara Falls, by steamer on the Niagara
River to Chippewa, by trolley along the Canadian bank to
Brock's monument and Queenston Heights, by boat across the
river to Lewiston, thence by trolley through the gorge to
Niagara Falls, where dinner was served, and back to Buffalo
by train closed one of the most interesting and successful
meetings in the history of the Association.
Second International Congress of Gynecology
ancl Obstetrics.
(Continued from page 761. 1
The discussion of pelvic suppurations showed that the con-
servative operators were in the majority. Doloris (Paris)
remarked that the fact which established with the most cer-
tainty the evolution of the subject under discussion was the
return backward. "We have been sliding down an incline at
a dizzy rate, and we are now working our way back." This is
indicated by the more general adoption of vaginal incision. The
success of this simple and familiar operation augurs the adop-
tion of still simpler methods and promises to restore early
uterine therapeutics to its true importance. Anterior vaginal
celiotomy is a more recent but valuable conservative process.
Since we find that pregnancy occurs sometimes even after
double lesions, conservative processes have acquired a new
importance. The conservative tendency which has been mani-
fested at the Congress is logical and bound to assert itself
more and more. After mentioning that the severest and most
virulent processes rarely generate pus, and that about 40 per
cent, of pelvic suppurations contain a sterile fluid without
pathogenic action, he described the unreliability of the symp-
toms upon which we have to base our diagnosis, and concluded
with the assertion that the treatment of pelvic suppurations is
akin to the treatment of pelvic inflammations, and should
follow the same general and absolute therapeutic rules, begin-
ning with simple methods and proceeding to others as may be
found necessary. What we most need is better knowledge of
theevolution of pelvic inflammations, especially of salpingo-
ovaritis, as this is the most frequent; the cases tending natur-
ally to recovery with a series of recrudescences, gradually sub-
siding in intensity, and those in which the acute attacks extend
beyond their usual term with complications that involve the
general health, or when the lesion becomes permanent and
some etiologic factor is discovered, tuberculosis, syphilis, arthri-
tism, neuropathy, alcoholism, etc. He asserted that no real
information is to be derived from the statistics of radical oper-
ations performed without any preliminary conservative treat-
ment, and emphasized that the only treatment for pelvic
suppurations was to try the simplest means of cure first and
only proceed to sacrificial measures as a last resort.
Doederlein (Leipsic) considers that if there is pus in the
tubes or ovaries total ablation of the diseased organs is the
only chance of cure. But the uterus and ovaries may be left
in certain cases. He prefers Pean's operation when the entire
genitalia have to be removed, but when the pus has disap-
peared, anterior and posterior colpo-celiotomy may be pre-
ferred, as this in some cases allows a radical operation.
Segond (Paris) spoke in high terms of the American method,
which allows the total ablation of the uterus and its adnexa
with "veritably marvelous security," as he ascertained for him-
self by watching the American surgeons at work. He has also
performed it himself recently, with success each time. He
called attention to the importance of liberating the cervix as a
preliminary to vaginal hysterectomy, whether it is amputated
later or not. The cervix free, the broad ligaments can be sec-
tioned at the base. As these are the only obstacles to the
descent of the uterus, the fundus can be seized at once. Lib-
erating the cervix also lessens the dangers of injuring the
ureters.
Henrotay (Antwerp) stated that gonorrhea is by far the prin
cipal cause of suppurated adnexa, and that the majority of
cases now called puerperal, are really due to gonorrheal infec-
tion. Prophylactic treatment should be based on the extreme
severity of gonorrheal affections in women, and the obligation
of physicians to fully inform every man with acute or chronic
urethritis of this fact. Medical treatment should be tried first
in every case where possible. If an operation is necessary, he
prefers the vaginal method, and adds that the gonorrheal nature
866
SOCIETY PROCEEDINGS.
[October 17,
of the lesion renders total castration imperative. He considers
closing the vaginal vault and the pelvic peritoneum a marked
improvement in technique, and that it should be done in every
case unless there is some special contraindication.
Jacobs (Brussels) prefers posterior and anterior colpotomy in
cases of extraperitoneal cellulitis, and uses the thermocautery
to make the incision, thus avoiding infecting the vagina with
the pus which escapes and may cause post-operative accidents.
In performing hysterectomy he substitutes ligatures for the
forceps, and since he has done this he has had no post operative
intestinal occlusion nor peritonitis. Drainage is not required
after a radical operation, except when pus has escaped into the
peritoneum.
Acconci (Genoa) prefers vaginal hysterectomy when the indi-
cations allow a choice.
Coromilas (Calameta) reported a case of pelvic suppuration
caused by malaria and cured by quinin.
Laroyenne's method of vaginal debridements was described
by him and its advantages confirmed by Adenot. It is more
conservative than laparotomy or hysterectomy, while it reaches
pus sacs inaccessible by any other method, and makes an open-
ing large enough to empty them and keeps it open long enough
to be really effectual. Laroyenne's trocar invented for the
purpose is convenient and sure, but is not absolutely necessary.
Doyen compared his operation with Plan's with an argument
for its superiority. It consists in opening the posterior peri-
toneal cul-de-sac, and freeing the posterior surface of the
uterus from the adherences, if there are any, and then extract-
ing the organ by inverting it to the vulva, after median hemi-
section of its anterior wall ; afterward extracting the adnexa.
Hemostasis is unnecessary during the course of the operation,
and forcipressure of the broad ligaments is only required after-
ward, and above the adnexa. (The Bulletin Medical of Sep-
tember 6, describes the Doyen method in detail.)
Reynier appealed for a more rational and eclectic treatment,
based upon the indications, which should be more definitely
established. His record since 1891 is 200 operations for pelvic
suppurations. In four cases, with four recoveries, he opened
the pus sac by the inguinal and subperitoneal route for phleg-
mons of the broad ligament after childbirth. In 110 cases he
opened the abdomen, with 9 deaths ; 7 from peritonitis, 1 from
shock and 1 from hemorrhage. He has performed vaginal
hysterectomy 52 times, with 6 deaths ; 1 from hemorrhage, 1
from shock, 2 from intestinal occlusion, and 2 from peritonitis.
In 46 cases he opened and drained the pus sac through the
posterior cul-de sac, with no deaths, but in 9 cases consecutive
hysterectomy was required and laparatomy in 4. His experi-
ence has convinced him that almost all pelvic suppuration can
be approached by the abdomen, and that our methods of drain-
ing render the danger of infection much less than the hyster-
ectomist extremists are willing to admit. In case of a young
woman with symptoms of recent infection and evidences of
pelvic suppuration prominent in the vaginal region, he first
makes an incision in the posterior cul de sac with large drain-
age. If in spite of this, the phenomena of infection continue,
he completes the operation with a hysterectomy if the uterus
is diseased, but if not, he prefers a laparotomy. His indica-
tions for primary hysterectomy are uterine abscesses opening
into a neighboring cavity, especially into the rectum. Also
old salpingo-ovaritis, with pelvi-peritonitic complications which
have produced a diffuse mass walling in the uterus, and also
for fibromatous uteri complicated with pus in the pelvis. In
other cases he is inclined to prefer laparotomy, especially in
cases of doubtful diagnosis.
Pichevin (Paris) has found sclerotic lesions in removed
retrodeviated uteri, and has also produced similar lesions in
rabbits in ths same way.
In discussing the question of surgical treatment of retro-
deviations of the uterus, all" seemed to agree that massage and
the pessary should be tried first, and the metritis and all other
complications receive careful preliminary treatment, which
often puts an end to the displacement without an operation.
Polk (New York) disapproves of fixation, and restores the
uterus to position by shortening the round ligaments through
an opening in the anterior vaginal cul-de-sac. He sutures the
ligament a certain distance above its base, with its peritoneal
covering, to the uterus on a level with its base, leaving a couple
of loops. One of these he sutures to the uterus, and the other
to the ligament above the first suture. At the same time he
shortens the sacrouterine ligaments when necessary, through
a transverse opening in the posterior cul-de-sac, at the utero-
vaginal insertion. A strong silk suture is then placed at each
sacrouterine ligament at a median point ; the ends brought
through the vaginal wall at the extreme corners of the inci-
sion, and tied firmly together ; catgut closing ; drain removed
in fifteen days ; patient kept in bed three weeks ; no pessary
but supervision of urinal and intestinal functions and ventral
belts for patients with prominent abdomens.
Pozzi (Paris) proposed to substitute the term "excessive
movability" for movable retrodeviation. He treats it with the
pessary and hypogastric belt, curing the metritis (curettement,
amputation of the cervix, etc.) and restoring rents in the peri-
toneum by an extensive plastic operation. He considers a
retrodeviation with adherences a secondary symptom, and
treats it by finding and removing the diseased tubes or what-
ever the cause may be.
Byford (Chicago) outlined his cysto-hysterorrhaphy as a T-
shaped incision in the anterior wall of the vagina, separation
of the adherences, suture of the fundus to the vesical periton-
eum, shortening the round ligament through the vagina and
closing with transverse sutures that draw the tranverse inci-
sion into the median line.
Schmeltz (Nice) prefers anterior colporrhaphy (simple incision
in the mucosa, enlarging it with the fingers), combined with,
hysterectomy (ligatures) and perineorrhaphy.
Jacobs (Brussels) reports four successful pregnancies in
twenty-one eases treated by fastening the anterior uterine walL
to the upper partof the peritoneum of the anterior vaginal cul-
de-sac. He announced that the later results of other opera-
tions, inoffensive in themselves, may prove very dangerous,
and exhibited some pedicules that had formed between the
abdominal wall and the uterus causing death from ileus, etc.
Engstroem (Helsingfors) reports eighteen ventro -fixations of
movable retro-deviations and thirty-four of fixed. All success
ful. A single suture is passed through the abdominal wall,
the peritoneum and the fundus. This leaves the uterus with
almost normal movability.
Hartmann (Paris) has found that the development of the-
fetus brings the pregnant uterus into place, assisted by vagina)
manipulation, except where there are adherences between the
bladder, omentum and rectum, which require laparotomy, but
such cases are rare.
Mangin (Marseilles) has failed with the Alexander or Nico-
letis operation alone, but has been successful every time when
they were combined with plastic operations. His advice is,
first, pessary for movable retrodeviations. This failing, vagi
nal colpo-hysteropexy with plastic operation on the vagina.
He limits the Alexander and abdominal hysteropexy to patients
with non-resisting tissues. Complications must be cured with
medical treatment, plastic operations, etc., as may be neces-
sary, and if the condition of the appendages requires it, lapar-
otomy when the lesion is single, hysterectomy if double.
The majority of speakers deprecated the use of fixation, as
it rendered after-pregnancy so dangerous, especially vagino-
fixation, although the operation is a good one after the meno-
pause. Doyen's method of treating painful retrodeviations
differs from all the preceding and, as he claims, has none of
their disadvantages. He performs the Alexander operation
and also shortens the anterior uterine wall, thus avoiding the
dangers of suspending the uterus from any one point, and lim
iting the operation practically to the uterus itself. The cervix-
is seized with two clamp forceps, as if for a hysterectomy, and
drawn down to the vulva. The uterus in this position, an incis-
ion is then made in the anterior cul-de-sac of the vagina, the
bladder is detached and an opening made into the anterior cul-
de-sac of the peritoneum. A silk^thread is then passed trans
versally through the superficial coat of the fundus with a
special needle-holder. The other end is fastened in the lower
part of the subvaginal portion of the cervix. This ligature
shortens the anterior uterine wall and draws the organ into an
upright position without interfering in the least with the
direction of the cervical passage. A second ligature is made
above it to strengthen it, and the vaginal wound is closed with
a silkworm gut, the two ends simply held by a rubber tube.
The entire operation requires only five or six minutes. It is
completed by shortening the round ligaments 8 to 10 centime-
ters, through an incision into the anterior wall of the inguinal
canal.
Reynier performs hysteropexy by putting his threads into
the broad ligament, and passing them under the uterine inser-
tion of the round ligament, fastening them on each side to the
abdominal wall. In every case the uterus has retained its
position.
Schwartz (Paris) reports several successful pregnancies after
his hysteropexy. After preparing the patient for laparotomy
and introducing a Hegar bougie (6 or 7) into the uterus, held in
place with a cotton tampon, he incises i to 5 centimeters,
and explores with his finger the condition of the appendages,
while an assistant straightens the uterus by gently pushing up
the bougie into it. After the adherences are detached, a silk
thread (No. 2 or 3) is passed through the uterus below the
emergence of the two tubes. The loop thus formed serves to
18%.]
SELECTIONS.
8(17
draw the uterus up and allows two or three other threads to be
taken below it, avoiding the vesical cul-de-sac, and keeping as
far from it as possible. If the appendages are diseased, they
are ignipuneturod. resected or removed, before the threads are
fastened, after being passed on each side through the entire
thickness of the wall, except the skin and the subcutaneous
cellular tissue. Separate threads close the peritoneum, the
teguments, and the muscular aponeurotic planes. He has
only had two relapses; one of them after confinement; two
still Buffer pain, thirty are definitely cured.
SELECTIONS.
A Case of Compound Protozoan and Bacterial Infection. The
patient, A. J., was a Pole about 20 years of age, from whom a
satisfactory history could not be obtained. He had been liv-
ing in a malarious district since March of the past year (1895),
but he had been quite well until three weeks prior to his
entrance, which was on October 21. His illness began with
diarrhea, which rapidly assumed a severe character, the move-
ments containing much blood and mucus. Durinf these three
weeks he stated that he had several times experienced slight
chilly sensations and also felt feverish. On entrance to the
hospital he was very anemic, extremely sallow ; had a palpable
spleen, slight fever and severe dysentery, the movements show-
ing much blood and mucus. The dejections contained many
motile amebee having the appearances of the ameba coli. The
blood examinations showed hyalin bodies and crescentic and
ovoid pigmented forms of the malarial parasite. Under the
administration of five grain doses of quinin every three hours
the temperature fell. The diarrhea was treated with irrigations
of quinin (1-1")»K) repeated twice daily, but without apparent
effect. The patient continued to lose blood per rectum and died
on November 2.
The autopsy was performed seven hours post mortem. Body
of a moderately strongly built, much emaciated man. The
surface presented a distinctly sallow hue. The mucous mem-
branes of the mouth and conjunctiva? were extremely pale.
The abdomen was moderately distended ; the subcutaneous
fat almost absent ; the muscles dark-brownish red in color.
The peritoneal cavity. The omentum was well spread out,
covering the intestines, but it presented an opaque appearance
and was covered with a sticky exudate. The loops of the mod-
erately distended small intestine were glued together by a sim-
ilar sticky exudate. The serous membrane itself was in places
vivid] x;ted. In the fossa? small accumulations of fluid
containing flakes of fibrin were encountered. The omentum
was adherent along its lower border to the much enlarged and
inflamed appendix vermiformis. The appendix lay anterior
to the cecum and between it and the anterior abdominal wall ;
it was provided with a mesentery which reached within 3 cm.
of its tip, and at the termination of this the appendix was bent
sharply upon itself, giving rise to a right angle. The distal
3cm, of appendix was the least dilated part; the remainder
had the thickness of the index finger and presented in addition
three bulbous enlargements, which on section were found to
correspond to areas of necrotic tissue. The whole was embed-
ded in a sticky, opaque exudate.
Intestine*. — The large intestines were greatly distended.
The sigmoid flexure was of rigid consistence and projected
beyond the pelvic brim. Within this portion for a distance of
2 x 5 cm. the serous coat was infiltrated with blood and pre-
sented a necrotic appearance. On opening tho large intestine
the entire mucous membrane was found in a frayed and
sloughing condition, opaque, everywhere infiltrated with gela
tinous pus and evidently necrotic. The necrosis seemed to
extend far beyond the mucous coat and to involve the deeper
layers. The walls, as a whole, were very much thickened. In
many places coagula of blood were discovered. Amid this
general necrosis and sloughing more circumscribed ulcerations
existed, some of which seemed to reach to the peritoneal coat.
These in particular were surrounded by thickened and puru-
lent margins, and at times they definitely undermined the
adjacent tissues. The ulcerations and sloughing extended
from the rectum to the cecum, involving the whole of the lat-
ter, penetrating into the appendix, but ending abruptly with
the ileocecal valve. The small intestine was entirely free from
ulceration, and it showed throughout nearly its whole extent,
although most prominently upon the crests of the valvules con-
niventes, a slaty pigmentation. The duodenum was more pig-
mented than other parts of the small intestine.
The spleen was enlarged, weighed 380 grams, its capsule was
wrinkled, and on section it presented a bluish black color. In
consistence it was almost diffluent. The Malpighian bodies
appeared enlarged, the pulp increased.
The liver weighed 2100 grams, its color was dark and slaty.
Small grayish white nodules could be seen on section, which
varied in size from a pin point to a hemp seed. The larger
ones could easily be made out to be abscesses, the contents of
which were opaque, gelatinous and pus-like. The wall of the
gall bladder was thickened and infiltrated with a similar exu-
date to that covering the peritoneum. The mucous membrane
was, however, intact. The remainder of the organs exhibited
no remarkable lesions.
Mieroscopic examination of the fresh specimen. — Attention
was first directed to the study of the exudates for amebic, and
for this purpose pus, a, from the peritoneal cavity ; b, from the
intestinal contents : c, from the liver abscesses, was employed.
The most painstaking search failed to reveal ameba? in the pus
from the peritoneal cavity, while on the other hand many typ-
ical living and moving ameba? were discovered in the pus from
the ulcers in the large intestine and the intestinal contents,
and a smaller number in the contents of the liver abscesses.
The exclusion of ameba? from the peritoneal exudate led
next to the staining of cover-slips for bacteria. By the use of
ordinary staining agents (gentian violet, methylene blue)
myriads of capsulated diplococci resembling the micrococcus
lanceolatus were revealed. The contents of the liver abscesses,
stained in the same manner, failed to show any bacteria what-
ever. The microscopic examination of the abscess contents
indicated that fewer pus cells and more necrotic and disinte-
grating liver cells composed these than in ordinary abscesses,
thus recalling the fact pointed out by Councilman and Lafleur
in their monograph on amebic dysentery, that true suppura-
tion is not caused by the ameba dysenteria?.
The source of the bacteria found in the peritoneal exudate,
and which evidently were the cause of the acute peritonitis,
was sought in the intestinal contents, where, as is well known,
they are not infrequently contained, and from which source,
as we have previously pointed out, they may invade the peri-
toneum and set up a fatal peritonitis. The condition of the
appendix vermiformis, which arrested attention from its swol-
len and necrotic appearance, was believed to have led to the
escape of the microorganisms in question. Upon closer exam-
ination it was found that corresponding with the dilatations
previously described, the entire wall was in a necrotic condi-
tion. The ulcerations themselves reached deeply into the
inner coats, but did not penetrate all the coats. The lumen of
the swollen appendix was filled with yellow, gelatinous pus
quite resembling that found in the peritoneal cavity itself.
Cover-slip preparations showed many encapsulated diplococci,
besides several kinds of bacilli. The former much predomin-
ated in numbers.
Malarial bodies were not numerous in smear preparations
from the organs, although pigment was abundant. However,
a few undoubted ovoid bodies were found in the smears from
the spleen and bone marrow.
Cultures.— Petri's plates were made from the blood in the
heart, the exudates and all the organs, upon agar-agar. Those
868
SELECTIONS.
[October 11
from the heart's blood, spleen, lungs and liver abscesses showed
no growth after haviDg been kept at the temperature of the
thermostat for forty-eight hours.
Peritoneum.— The plate was crowded with colonies, appar-
ently of two kinds, which, owing to the large numbers, proba-
bly did not reach full development. The larger colonies con-
sisted of bacilli which were identified and shown to be the
bacillus coli communis. The smaller colonies (predominating)
were made up of oval diplococci which were shown (cultures
and animal experiments) to be the micrococcus lanceolatus.
The plate made from the bile contained 7, from the liver 30
colonies of the bacillus coli communis. The plate from the
kidney was crowded with colonies of the colon bacillus, among
which a few smaller colonies of diplococci were found, these
bein^ the micrococcus lanceolatus.
Histologic examination.— The microscopic examination of
the hardened tissues was confirmatory only of the features of
the case as already described. Nothing new was discovered.
As regards the malarial pigmentation, the dark pigment was
•found especially in the liver and spleen (bone-marrow not
studied), and in these organs in the usual situations. The
parasites themselves were very difficult of demonstration. The
lesions in the large intestine caused by the invasion of the
ameba? were perhaps the most interesting. The necrosis, it
was found, extended into, but for the most part not through
the innermost muscular tunic, but it was surprising to what
extent the mucous membrane might be dissected away from
the submucosa without losing its vitality. Not a small part of
the frayed appearance presented by the large intestine was pro-
duced by this partial dissection of the mucous coat. The bases
of the ulcers proper were formed for the most part by the cir-
cular muscle, which was itself infiltrated with inflammatory
products, cells, serum, fibrin. The inflammatory infiltration
extended into the depths of the tissue, often to the serous coat,
and spread laterally for a great distance. It seems probable
that the ulcers in the appendix originally were caused by
ameba?, and that subsequently the extension of the necrosis
to the serous surface was the work of the micrococcus lanceo-
latus.
Ameb:e apparently were abundant. But just here it is
proper to state that in the hardened tissues it would be easy to
be led into errror in regard to the significance of many of the
amebalike cells present. From a study of the transitions of
connective-tissue cells and their progeny in the chronically
inflamed parts, it is quite certain that many of the bodies
resembling ameba? are swollen and degenerated (fatty or vac-
uolated) tissue cells. These, too, often lay in definite spaces,
and they were found in the submucosa and muscle and within
small veins. Without the proof supplied by the examination of
the intestinal contents during life and at the autopsy, one
must have remained in doubt as to the presence of ameba-
among these elements.
The kidneys showed a moderate degree of parenchymatous
degeneration. In addition to this, emboli of liver cells were
detected in branches of the renal vein. Similar emboli were
discovered in the central veins of the liver lobules not infre-
quently. Lubarsch has reviewed the literature upon the sub-
ject of " parenchymcell emboli." It appears that liver cell
emboli are either of traumatic or of infectious (or due to intox-
ication) origin. There is no definite relation between the
extent of the injury and the occurrence of such emboli. The
transported liver cells, besides being found in the veins of the
liver, occur in the heart, pulmonary arteries and branches of
the renal and hepatic arteries. Among the infectious diseases
liver cell emboli are found very often in eclampsia and chorea.
In eclampsia they are found very often in the arteries of the
lungs and brain and in the renal veins ; in chorea in the hepa-
tic artery and branches of the portal vein (patent foramen
ovale). Where hemorrhage, necrosis and softening exist, liver
cell emboli are encountered. Thus they have been found in
scarlet fever, in softening of hepatic gummata and in liver
abscess. The transported liver cells have been found followed
from the hepatic veins into the coronary, renal and other arte
ries. Their occurrence in veins— renal and cerebral — is attrib
uted to retrograde embolism, for which a high degree of venous
stasis, such as occurs in eclampsia, has been assumed. Kvi
dence of such stagnation is wanting in our case. On theothe
hand the disintegration of liver tissue, such as has been foun
in other cases, is supplied by the abscess formation and circum
scribed necrosis in the liver. Lubarsch states that the con
veyed liver cells may persist from three weeks to two and one-
half months, but evidences of proliferation have never been
observed. — Reported by Dr. Simon Plexnerini?«/. of the Julius
Hopkins Hospital, September and October.
Foreign Bodies in the Esophagus. Dr. Carl Beck of New York
in the Clinical Recorder argues for an earlier employment of
surgical treatment in these cases. His experience shows that
valuable time is generally wasted by the administration of
emetics and covering (einhiillende) substances, such as soft
bread or hashed potatoes, until even successful removal by
surgical procedures is not able to prevent the fatal outcome
any more. It is justifiable to attempt once to remove the for
eign body by administering an emetic. But if this one effort
fails, either extracting or pushing down should be done without
further delay. All bodies which can either be seen or which
can be felt by finger or explorer, within the pharynx, must be
extracted. If the body has passed the isthmus, it has to be
pushed down into the stomach ; sharp-edged bodies, however,
like splinters of bone or wood, needles, pins, etc., to be excepted.
Repeated attempts should be made to extract such bodies also,
because they may perforate into important blood vessels or the
trachea, or may cause fatal abscess formation. The best instru
ment to be employed for such purposes is a so-called "coin-
catcher," which consists of a long flexible sound made of whale-
bone. To one of its ends a piece of sponge is attached for the
purbose of propulsion toward the stomach ; on the other end
is a grooved metal ring. By passing the foreign body first with
this grooved ring and then withdrawing it slowly, at the same
time turning the instrument slightly, the body is caught in
the groove in the great majority of cases. The coin-catcher is
introduced best after having it lubricated with the white of an
egg. The patient's head is thrown back so as to bring the axis
of the mouth and pharynx in line with the esophagus (just like
the juggling sword-swallowers). The location of the body will
then be indicated by the stoppage of the instrument. If such
methods of fishing up or pushing down do not avail, esophag-
otomy must be performed without delay. Herniotomy does
much less harm to a strangulated gut than a prolonged taxis,
and the same principle and view applies here. Esophagotomy
is by no means a difficult operation, if only the principle is
obeyed to operate with blunt instruments. After having intro-
duced a sound into the esophagus from the mouth as a guide
an incision is made alongside the left anterior margin of the
sterno-cleido mastoid muscle. Then the tissues containing the
carotid and jugular and the pn. vagus, together with the
ramus descendens of the hypoglossus nerve can be separated
without any cutting by the use of the Cooper scissors and
then be retracted with blunt hooks. Now it is easy to feel the
sound, previously, and to incise on it. After the foreign body
is extracted with a suitable forceps, a sharp spoon sometimes
also being useful, the wound is but partially closed and the
remainder packed with iodoform gauze. At the New York
German Medical Society (see iVeif York Medicinische Monats
schrift, April, 1892) Dr. Beck presented a case of a girl, 18
months of age, in whose esophagus a quarter of a dollar piece
had remained for four weeks and which he could extract by the
coin catcher, the patient making a good recovery. But such
cases are only the exception. Repeatedly he has seen cases in
which all the various means of extraction and propulsion were
tried, and only after much valuable time was lost esophagotomy
was resorted to. But the extraction then would not avert sep
tic inflammation and its consequences (broncho-pneumonia,
etc.). The Roentgen rays seem to have started a new era in
the location of foreign bodies in the esophagus, so that they
will not remain unnoticed any more, and are no longer con-
founded with phthisis pulmonum, croup, bronchitis, asthma,
etc. J.W.White (University Medical Medicine, June, 1896 1
could get a definite information by the rays in a successful
case of a girl, 21., years old, which had swallowed a jackstone,
the location of which being such that gastrotomy appeared
to be preferable to esophagotomy.
1896.]
EDITORIAL.
869
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SATURDAY, OCTOBER 17, 1896.
THE TREATMENT OP INSANITY EIGHTEEN
CENTURIES AiiU.
Nowhere in science is the truth of Tennyson, that
"The course of time will swerve.
Crook and turn upon itself in many a backward
streaming curve"
better illustrated than in medicine. All great med-
ical discoveries seem upon the point of being made
long ere the culmination of facts places them beyond
destruction by inertia and conservatism. Anesthesia,
the germ origin of disease, antisepsis and multitudin-
ous "late" discoveries were discernible for centuries
in medical works ere the nineteenth century placed
them in the rank of commonplace facts. This is
peculiarly true of psychiatry, whose essential princi-
ples were outlined eighteen centuries ago. Much suf-
fering might have been saved the hapless insane and
much misfortune to the medical profession been avoid-
ed had these principles then outlined been adopted in
the main. According to Soranus (A. D. 95, whose
writings are recognized as those of C^elius AlTRE-
i.iaxl's. his translator), it is useless to examine into
causes, as different causes may produce analogous
effects. It is only necessary to know the results in
order to apply suitable remedies. He was decidedly
averse to violent emetics and purgatives. He every-
where manifests the fear lest inflammation should be
augmented by the strength of the remedy. He
advises frequent exercise, warm fomentations, inunc-
tions, cataplasms, fumigations, frictions, diet, baths,
leeches and cuppings. He recommends great atten-
tion to the character of the air, whether moist or dry,
etc. He rejects all empiric medication and fetiehistie
formuliv. The maniacal should be placed in rooms
moderately light, of a moderate temperature and
whose tranquillity should be uninterrupted by noise.
No painting should ornament the walls. The air
should come in by elevated openings. The patients
should be placed on the ground floor rather than on
the upper story, as most of them are disposed in their
paroxysms to cast themselves down. Their beds
should be solidly fixed and so disposed that the
patient may not see persons entering, nor be irritated
by a variety of figures. If they be so agitated that
it is not possible to give them aught to lie upon
except straw, this should be well selected, prepared
and stripped of everything hard, in order that it may
be mild and not disagreeable to the touch. If some
parts of the body have suffered from the movements
of the patient, use warm applications and fomenta-
tions of oil mixed with decoctions of fenugreek,
mallow or flaxseed. Frequent passing in and out
should be forbidden. Sometimes use an intentional
indulgence and sometimes a slightly severe reprimand,
with an explanation of the advantages occurring from
a better course of conduct. If agitated, difficult to
restrain, or irritated by solitude, it is necessary to
have supervisors who should be ordered to master the
patients without their perceiving it, approaching as
if to make friction in order never to provoke them,
if the sight of men irritates; and only in very rare
cases he employs ligatures, but with the greatest pre-
caution, seeing that the bonds are of a soft, delicate
texture. Means of repression employed without dis-
cretion augment and even create fury instead of lull-
ing it (Galt's Insanity, 1846). If they have fear and
respect for any one person they should not see him
often; frequent visits compromise such an ascendency.
But when they resist the wishes of those around
them it is necessary to recur to his authority. If
light excites them, their eyes must be deprived of it,
though not the rest of the body.
Abstinence is suitable at first and recourse to bleed-
ing if the strength permits. If no contraindication
exist it should be repeated from time to time. One
of the best means of appreciating the degree of the
strength is drawn from the state of the pulse, which
the physician must observe whether it is strong or
feeble. Soranus should commence feeding with
great precautions and not permit any except very
light diet of easy digestion. The patient must be thus
nourished during the decline of the affection. Injec-
tions must not be neglected if the evacution be not
regular; in a great number of cases the belly should
be covered with emollient cataplasms which descend
to the pubis in order that no organ may suffer any
pain, which the head also would reciprocate.
Physicians should observe with great care the form
of the delirium and have recourse to the salutary innu-
870
TREATMENT OF INSANITY.
[October 17,
ence of moral impressions, gay ideas and those things
causing some relaxation of mind. If the disease
remains stationary he shaves the head. Scarifying
cups should be applied in turn to the breast and
between the shoulders as connected with the head.
But these applications ought not to be too near the
head nor too largely made, as calling the blood in this
quarter, etc. Leeches may be placed on the forehead
or the temples, taking care to favor the flow of blood
by cataplasms of emollient substances or sponges
dipped in water. If the symptoms persist, the same
means must be used the second or third day and as
often as necessary. If the parts covered by the cups
and the leech bites be painful they should be mois-
tened either with oil or a decoction of mallow, etc. If
the disease arise from fatiguing overwatching, it is
necessary to have recourse to rides upon a bed sus-
pended or upon a chair carried along or even upon
enlaced hands. The monotonous noise from the con-
tinual fall of a small current of water from a height
has good effects. Application of warm sponges
upon the eyelids is also useful. When the paroxysm
declines it is necessary to give more varied aliments,
moderately strengthening when they have regained
their strength.
Exercise is then especially beneficial. They must,
also exercise the voice. They should be made to read
writings containing faults, which often at the same
time have the advantage of exercising the mind in the
correction of imperfections in style. These writings
should be of easy comprehension. The physician
should converse with them, asking questions without
fatiguing them. Recourse should be had after read-
ing to theatrical performances, the recreation from
which will diminish a sadness ready to awaken, or
frivolous fears ready to reveal themselves. At a more
advanced epoch of treatment, occupy the patients with
weighty meditations and discussions in order to give
their mind its full capacity, but with the precaution
that the commencement of the subject treated should
be without warmth, that the narration, on the con-
trary, and the demonstration should be clear and com-
plete, should solicit an animated utterance and that
the epilogue should be brief and careless. His hear-
ers should give the patient their benevolent approba-
tion. After this exercise they should promenade or
have their bodies rubbed. As to the unlettered the
physician should discuss with them matter only rela-
tive to their conditions. He should speak to the
laborer concerning agriculture, to the mariner as to
navigation. If we have to act with a man ignorant of
everything he should present very general subjects or
a series of numbers. Physicians are able in truth to
find suitable nourishment for all sorts of minds, but
above all should agreeably complement the patient.
Annointing and frictions which have been recom-
mended should be made at first upon the shoulders
and on the neck, commencing lightly, then more
strongly afterward on the head, after which a bath.
The nourishment should become more and more sub-
stantial. After beans, herbs; then fish, the brains of
different animals, an easily digested aliment; then lit-
tle birds. The larger kind later as thrushes and young
pigeons. There should be even more reserve as to
the hare and the roebuck.
Physicians should grant a little weak and light wine,
at first every five days, then four, three, even until
every day. When no new symptoms occur and the
patient has become much less impressible, change of
air will be of great advantage. Voyages by sea or land,
distractions of all sorts, recreation of the mind, agree-
able, affectionate conversations will produce an excel-
lent effect, for if ennui and sad feelings act on the
sane, how much will they influence the scarcely cured?
The convalescent, should he desire it, can hear the
precepts of the philosopher. They often dissipate
sadness, fear and excitement and may contribute
powerfully to the reestablishment of health. If the
malady really persists and not merely some of its
symptoms, a return is counseled to the previously
mentioned means, to exposure of the body to the
heat of the sun, the head only being free from its
action, to sinapisms and to violent exercise of different
kinds.
Soranus combats his predecessor's recommenda-
tion of darkness in all cases, because it may suit one
and not another, and their recommendations of an
immoderate abstinence without exception, because
this may sometimes throw the patient into fatal feeble-
ness and prevent the use of means otherwise suitable.
They seem, he says, to consider their patients as fero-
cious beasts to be lulled by hunger and thirst, and led
by the same error they wish to chain them cruelly,
not considering that it is more convenient and easy
to restrain by the hands of men than by violence and
the lash, a deplorable treatment which can but aggra-
vate their condition and make bloody their limbs and
offer the sad spectacle of their misfortune at the
moment in which they regain their intelligence. By
medicaments, as the poppy, they provoke a morbid
torpor instead of good sleep. They rub the head with
oil of roses, etc., and excite organs needing relaxation.
They make little judicious use of cold, ignorant that
it is often excitant. They employ irritant clysters
and thus produce dysenteries. They counsel drunk-
enness and love, which are causes. They prescribe
music as a routine, whereas it sometimes excites.
The generative act should not be permitted to the
insane. The repression of their desire may some-
times agitate them, but they are oftener found to be
worse after coitus. His treatment of melancholia has
been indicated in what has been said of mania.
This treatment of insanity was far in advance of
that practiced in Europe in the first decades of the
L896. )
THE SMOKE NUISANCE.
871
present century, or thai of Cook County in 1S71, of
Auburn iN'.V.) in ISTti, of Anchorage (Ky.) in 1882
and of 1896 by the Hahnemanniaes at the Norfolk
(Neb.) Insane Hospitals. Whips, violence and
excessive restraint were the therapeutic methods
employed at these institutions, not spasmodically or
furtively, but on a settled principle. Soranus, long
ere PlNBL, KlSll. TUKE, CoNOLLY Or GARDNER HlLL,
seems to have grasped in the main the true principles
of psycho- therapy.
rill'. PROGNOSIS OF MANIA AND MELANCHOLIA.
The common notion taught in all text-books and
held as one of the axioms of practical psychiatry, that
mania is the most hopeful and curable form of mental
disorder, will receive a severe blow from the lately
issued tifth edition of Kb AEPELIN's "Psychiatric." The
author of this volume, one of the best known and
admittedly one of the ablest of German alienists, has
very Largely remodeled his work, and it contains the
latest and fullest results of a very wide experience,
estimated with a thoroughly critical and competent
judgment. His conception of mania is not essen-
tially different from that generally accepted by author-
it it's on mental disease, but he does not recognize it
as an independent entity in his classification. All
eases, according to him, especially those in the earlier
and middle periods of life, before the downward slope
of life has been reached, are properly to be referred to
the periodic insanities; they are not single, isolated
attacks of a disease that may never be again suffered
from, but are indications of a constitutional disorder,
sure in time to recur. He bases this opinion on an
observation of a thousand cases carried over a great
many years, and in all these he has found but one in
whom the disorder did not recur and that is not in
support of the view stated above. A single exception
in such a series only proves the rule, and so far as
known no one has ever followed up as methodically and
carefully the after-histories of his patients as Kraepe-
lin seems to have done. It has been a matter of
general experience that an attack of mania was per-
haps, as we may say, one of the least self-protective
of disorders, that a second attack was very liable to
occur after a variable lapse of time: but few, if any,
had before been led to generalize from these facts that
it is properly to be reckoned a periodic disease.
Kraepelin himself admits that the interval of men-
tal health may be long — ten years or even more in
some cases — but lie claims none the less the validity
of the rule he has laid down that recurrence is inevi-
table, sooner or later.
It may be thought, perhaps, that this is merely a
change in the point of view, that the facts are the
same, but that they arc differently estimated by him
from those who have written before. It is, however,
really much more than this; if we accept Kraepe-
lin's views, our prognosis of mania and of the
so-called simple insanities generally is completely
reversed; instead of being the least, they are to be
counted amongst the most formidable types of insanity
as regards the future of the patient. What is true of
mania is true also in regard to melancholia, which he
classes amongst the mental disorders of the period of
involution; when it occurs in early life it also falls in
his system into the periodic insanities.
How generally Kraepelin's views will be accepted
is an interesting question. His authority is certainly
of the highest, and his method by which he reaches
his conclusions, the careful and thorough research
into the after-history of his patients, gives them the
very greatest weight. The fact that he was able to
follow the careers of a thousand cases of mania after
discharge shows the range of his clinical observation,
far exceeding the possibilities with many of his less
favored co-workers in this department. It will be,
nevertheless, with something of a strain, that alien-
ists will give up their time-honored views to take up
others, new and altogether different from those they
have been accustomed to hold. The publication of
these, however, will undoubtedly excite fuller anam-
nestic research in all quarters, and thus prove a most
valuable stimulus for work in a direction that has
perhaps been hitherto too much neglected. It will
also lead to a more careful diagnosis and scrutiny of
individual cases, and the separation of the exhaustion
and toxic types from those that fall more properly
under the class considered by Kraepelin. There is
no doubt at all that cases of confusional insanity are
very often diagnosed as mania, as pointed out by Dr.
W. L. Worcester, and the same is true of the post-
febrile, toxic and exhaustion deliriums. Excluding
these, it may very possibly be true, as Kraepelin
holds, that mania and melancholia are indications of
constitutional taint and incurable disorder.
THE SMOKE NUISANCE ; A FABLE.
The editor of the Glasgow Sanitary Journal,
August, seeks to show in fable that the abolition of
smoke nuisances is a possibility. He places his chief
reliance upon the developments of science, giving
experience the go-by, saying :
One day Experience, Inexperience and the Scien-
tific Mind met at a congress and shook hands. They
began talking about the weather.
"What a beautiful morning!" exclaimed Inexpe-
rience.
"Wind in the north," said Experience. "It will be
rain by evening."
"Then we shall see the rainbow," said the Scientific
Mind.
"I wonder," said Inexperience, "when we shall con-
trol the weather, like the man in Rasselas."
"Never," said Experience. "The thing is a demon-
strated impossibility."
"And yet," gently, as to himself, said the Scientific
872
WASHINGTON AND HIS PHYSICIAN'S BILL.
[October 17,
Mind, "but yesterday I first spoke to the antipodes;
but to-day I listened to the stored voices of my dead;
but even now, I have seen with these eyes the cast
shadows of the skeletons we are within the flesh.
To-morrow, what shall I not see and hear?"
"Yes, yes," said Experience. "The telephone, the
phonograph, the X rays, and all that. But that sort
of thing can not go much further; there is not much
more to know, else we should know it."
"On the contrary," said Inexperience, "we know
nothing yet, comparatively."
"You speak for yourself," said Experience.
"For us all!" said the Scientific Mind, humbly.
"How?" inquired Experience, surprised.
"As thus," said the Scientific Mind. "Glasgow is
sick with fog, which is a cloud, which is the rain.
Why? Glasgow burns coal, which is smoke, which
makes the fog blanket, which slays the sunlight, which
is health."
"That's old news," said Experience. "But what do
you propose to do?"
"Burn coke," said the Scientific Mind.
"I never thought of that," said Experience.
"Of course not," said Inexperience. "Who said
you did?"
"Think of it now," said the Scientific Mind.
So they shook hands again and went their ways.
We might add that in all human probability coke
was not accepted by any considerable number of the
people, and the smoke and black fog continue to have
it all their own way.
A MEDICAL SATIRIST OF MEDICINE.
Medicine in France in the seventeenth century was
the peculiar theme of satire; probably for the same
reason it is a safe mark for newspaper sarcasm to-day.
The sensation mongers who dare not attack the rup-
ture-curers, advertising quacks, patent medicine men
or abortifacient mongers, openly assail medical men
on the ground that it amuses the public and does not
hurt medical science. Precisely the same regard for
the sacred cash box prevented the French satirists
from attacking the despot Louis XIV. and caused his
brutal aristocracy and plutocracy to concentrate their
venom on the physician. Molisre was an expert in
this. He had a quasi-medical predecessor to whom
he was probably much indebted. Bertrand Hard-
ouin de St. Jacques (1598 — 1648) entered upon the
study of medicine at the University of Montpelier.
For unusually outrageous contempt of the boundaries
of property, he was expelled and became first a trav-
eling quack and then naturally gravitated into a stroll-
ing player. He came to Paris and, under a false
name, entered the Bourgogne theater troupe, where
his satire against medicine was so renowned that
Moliere, then a youth, was brought to the theater
by his grandfather to see St. Jacques play. The
Paris physicians took the satire good humoredly and
were often auditors. After eight years of Paris stage
life, St. Jacques obtained a medical degree through
the influence of Cardinal Mazarin, and thenceforth
practised medicine reputably till his death. St.
Jacques had something of the degenerate in his
make-up, for: "He was a large brunette with dark
sunken eyes and flat frog nose, who resembled a huge
monkey and did not even need a mask on the stage, as
he wore a natural one."
ANOTHER DONATION TO THE NEWBERRY
LIBRARY.
Professor De Laskie Miller of Chicago, has given
his entire collection to the Newberry Library. It was
one of the most complete private collections in the
city, not made up of periodicals and miscellaneous
books, but composed of standard works of all the best
authors from the earliest times to the modern; such a
collection as a teacher desiring to keep abreast of the
times would naturally purchase.
The library contains about 600 volumes of carefully
selected standard works. Those relating to obstetrics
and diseases of women and children, are noticeable.
Such libraries as these, like keen tools in the hands
of the master workman, are valuable as a whole, not
merely on account of the intrinsic merits of the com-
ponent parts. The books when selected in this way
by a skilled hand, have a reference to each other as
close and enduring as the inlaid pieces of a Florentine
mosaic.
But to use books rightly one must know them.
The elder DTsraeli said that one might as well fill
a room with musical instruments and expect to be an
expert musician by mere contact, as to expect a man
to become a literary man by the mere possession of
books. And so we must turn to the great libraries
for the production of our future literary men, and
when the right man, comes in contact with the work-
ing collection of a worker in his profession, we may
expect great results.
WASHINGTON AND HIS PHYSICIAN'S BILL.
Physicians who are drawing pessimistic auguries
from the difficulty with which collections are made
during the present year, may take some comfort from
the fact that, on the eve of the first election for Pres-
ident of the United States, the financial difficulty was
such as to affect George Washington, the Father of
his Country, the unanimous choice of his countrymen
for President, in the payment of his physician, Dr.
Craig. In a letter to the latter dated Aug. 4, 1788,
Washington says:
"With this letter you will receive the horse I promised you,
and which I now beg your acceptance of. He is not in such
good order as I could wish, but as good as my means would
place him. I also send you thirty pounds cash for one year's
allowance for the schooling of your son Q. W. 1 wish it was
in my power to send the like sum for the other year, which is
now about or near due, and that I could discharge your account
for attendance and ministerings to the sick of my family ; but
it really is not, for with much truth I can say I never felt the
want of money so sensibly since I was a boy of fifteen years
old, as I have done for the last twelve months and probably
shall do for twelve months to come.
'•Sincerely and affectionately, I am yours, etc.,
"George Washington."
1896.]
PUBLIC HEALTH.
873
PUBLIC HEALTH.
Typhoid in Columbus. Ohio. All physicians of this city are
required to report the presence of typhoid fever within twelve
hours after having become advised of it. Such is also the rule
in eases of smallpox, scarlet fever and diphtheria.
The Pennsylvania State Quarantine Board. This Hoard met in
Philadelphia October 5. Dr. Boening the State Quarantine
physician reported for the month of September as follows:
Number of vessels permitted up from quarantine during the
past month !U. all of which were in good sanitary condition.
These vessels were classed as follows : Steamships, 57 ; schoon-
ers, 19; barks, US; brigantine, 1; ships, 2. They were laden
M follows : Single cargo vessels, 49; general cargo vessels, 25;
water ballast. 17 ; solid ballast. 3. Of the foregoing vessels 18
carried passengers, with a total of 1771.
Measles and Diphtheria in Sioux City. The city is threatened
with an epidemic of measles. At least that is the opinion ex-
pressed bj Health Officer Dr. J. M. Henry. The Doctor when
t he tirst case was reported a few days ago looked it up thoroughly
as it is something unusual to have measles at this time of the
year and it is regarded as a serious matter. With the cold
weather coming on he says the disease, however slight, may de-
velop into catarrh, bronchitis and lung trouble. The Doctor
found that the child had been attending the Jennings street
School until the day it became so sick that aphysician had to be
called. Several other cases were immediately reported after
the tirst one. and the Doctor attributes them to the exposure
to the tirst case, as the children all attended the same school.
He says that parents should exercise more precaution and not
send their children to school when they know them to be sick
or threatened with some disease. Some people are of the opin-
ion that the quarantine is not so important in a caseof measles
but the Doctor says it is just as rigid as in a case of smallpox
and if the parents do not pay attention to this fact they will
he dealt with according to law. Aside from the measles sev-
eral cases of diphtheria have been reported to the health offi-
cer from different parts of the city. A diphtheric child rode in the
conveyance provided by the school board for carrying children
from the outlying districts northwest of town to the West side
and an epidemic is feared. At the suggestion of Superintend-
ent Kratz the conveyance will not be run for several days until
there are some new developments and the children will thereby
be given a holiday.— Sioux City (Iowa) Tribune, Oct. 3.
An Epidemic of Fevers. — Diphtheria was reported to the Iowa
State Board of Health yesterday at Dubuque, Conway and
Blockton, Taylor county ; Downs, Wright county ; Fertile,
Worth county ; Clear Lake township, Hamilton county ; Early,
Sac county, and scarlet fever at Woodbine, Harrison 2ounty, and
at Dubuque. Speaking of the epidemic at Dubuque, the Globe
Journal, of that city says : " Scarlet fever and diphtheria are
spreading to an alarming extent in Dubuque. Four cases were
reported this morning by Sanitary Officer Starr to the city health
physician and cards tacked upon the infected houses. These
diseases are confined to children between the ages of 5 and 16
years and are becoming so prevalent that the question of dis-
missing the schools is being seriously considered. There is a
great deal of complaint about people who remove cards from
their houses before the time provided by the ordinance. The
latter provides that a card placed on an infected house shall
not be removed for thirty days. A case was reported to the
sanitary officer a day or two since where a lady tore a card
down from her house that ought not to have been removed
until the 18th of this month and another case was reported
where a policeman without any authority whatever removed a
card. Under the ordinance theBe persons are liable to arrest
and prosecution and they have no more right to remove a card
and go unpunished than have the most humble individual in
the city. The board of health should order that the cards be
replaced. When a card is removed people suppose that there
is no further liability to catching the disease placarded, and it
can therefore be readily seen what danger children are exposed
to who happen to visit such houses or play with the children
who have had the disease. It is said that in some cases physi-
cians attending children afflicted with diphtheria and scarlet
fever told their parents that it was not necessary to keep the
cards out after the children were up again. This is a matter
that the public is deeply interested in and the health officer
and the board of health will be held reponsible for the strict
enforcement of the ordinance. The parties who have removed
the cards should be compelled to put them up again and com-
ply with the law. If this is not done, others may contract the
disease. There are now about seventy cases of the two diseases
in this city."
Health Report of New York State for August, 1896. —The Bulletin
of the State Board of Health of New York, publishes the fol-
lowing summary of the deaths, and rates of deaths by princi-
pal causes, for August. During August was exprienced the
disastrous hot wave beginning on the 6th of the month and
continuing ten days, and causing an almost unprecedented
mortality among adult males, the aged and the infirm. The
actual and proportional mortality among children under five
years were decidedly lower than in July.
The marked deviation from the ordinary mortality of the
month, during which there have been reported 12,475 deaths,
which is 1,600 more than in the corresponding month of last
year, is attributable mainly to deaths from the direct effects of
heat (sun stroke), occurring mostly during the early part of
the month, 1,125 deaths from this cause having been reported ;
1,040 were reported from New York city and Brooklyn, the
recorded deaths occurring mostly in the maritime and Hudson
valley districts. These are reported under deaths from acci-
dent and violence. There is also, compared with August, 1895,
an increase in the reported mortality from diseases of the
urinary, nervous and circulatory systems, and also in deaths
from old age and from unclassified causes. There was no
material variation in the mortality from zymotic diseases and
consumption, the number of deaths from diarrheal diseases
being about the same as last year. The death rate was 23.25
against 20.40 in August, 1895. Compared with the preceding
month there was a daily average mortality of 402 against 408 in
July ; the zymotic mortality was less by 750 deaths, the
decrease being in the deaths from diarrheal diseases, from
which there were 2,326 deaths, or nearly 19 per cent, of the
total ; a large number are reported from dysentery, affecting
adults. There was also a decrease in the mortality from diph-
theria, from which there were 257 deaths, a smaller number
than in any month for the past ten years, August being gener-
ally the month of its smallest prevalence. Scarlet fever has
almost disappeared from the reported causes of death, but 15
deaths being reported from the maritime district and 4 from
the rest of the State. Whooping cough increased to 119 deaths ;
uniformly more deaths occur from this cause in August than
in any other month, the average for the past ten years being
125 against an average of 90 for the other months of the year.
There is the customary increase in deaths from typhoid fever,
which caused 171 deaths, the average for the month. Of
deaths from local diseases, the only material variation is in
those of the digestive system, from which there were 200 fewer
than in July. From the cause stated the reported mortality
from accidents and violence is largely increased. The average
mean temperature of the month was 1 degree above the nor-
mal, but during the first half there was a remarkably pro-
longed period of excessive heat ; the mean highest temperature
was 92 degrees, while the mean lowest was 44 degrees, and
there was a mean relative humidity of 72 per cent, and in the
874
BOOK NOTICES.
[October 17,
eastern part of the State of 78 per cent. There was an unusual
number of cloudless days, the mean barometer was 30.02, and
the rain-fall generally deficient.
New French Sanitarium for Tuberculous Children at Saint Trojan.
—The President of the Republic recently inaugurated this new
institution on the southwest seacoast (He d'Oleron), erected at
an expense of about $120,000 to the state, under the superin-
tendence of Dr. Bergeron, perpetual secretary of the Academic
de Me'decine. Its official purpose is to hospitalize scrofulous
children for tuberculosis. The drinking water is sterilized by
the new Desmaroux system, at an expense of five centimes the
cubic meter, and according to experts in bacteriology, "real-
izes the last word" in sterilization. — Prog. Mid., September 28.
An Island Sanitarium.— According to the 'Tiser, one of the
islands in Boston Bay is to be made a summer sanitarium for
sick children, and steps are to be taken immediately to carry
out the plan. Dr. W. G. Macdonald, the city physician, is
credited with the origin of the plan, and it is said that the
City Board of Health and the mayor actively favor it. It is
proposed to take the small island, just beyond the iron pier at
Marine Park, South Boston. It is 160 feet in diameter and
unused at the present time, although it is under the jurisdic-
tion of the park commissioners. It is contemplated to erect
tents and place a milk plant in operation. The doctors and
nurses will probably be furnished from the City Hospital. The
location selected is a most desirable one for many reasons.
The island can be reached from any section of the city by
electric cars to City Point during the day or evening. There
will be an out-door and in-door patients' department, and the
chances of saving a baby's life will be much better on the island
than at the home. About a week ago Dr. Macdonald called
upon Mayor Quincy and unfolded the scheme, which was fav-
orably received by his honor, after learning the facts and
figures. The large number of deaths during the two months
was astonishing to him. Dr. Macdonald wrote to Conrad
Reuter, Secretary of the Boston City Hospital trustees, in rela-
tion to the matter, and they will consider the scheme at their
next meeting. The letter follows :
" For some time past I have been considering the question
of infant mortality in Boston during the summer months,
and I have been more and more impressed with the idea
that our present means of care and treatment of the little
ones are inadequate. During July and August of the current
year, there were reported to the Boston Board of Health 2,438
deaths from all causes, and including all ages. Of these 919
were infants less than 1 year old. Pour hundred and ninety-
two were classed under the head of 'cholera infantum.' If we
add to this 492, those which were classified as 'enteritis,' 'gas-
troenteritis,' 'diarrhea,' etc., we will have a total of nearly
six hundred and fifty deaths directly attributable to the
weather conditions of these months. Thus we see that during
the heated term more than a third of the total deaths occurred
in infants under 1 year, and more than a fourth were due to
preventable causes. These figures have a pathetic eloquence
of their own. We have at the present time two noble char-
ities engaged particularly in the care of the suffering babies.
I mean the floating hospital and the Hospital at Rainsford's
Island. Both were inaugurated as private charities although
one has become a public charge since. No improvements
could be made on the methods of treatment now in vogue in
these two institutions, since one is under most careful and
intelligent management and the other is under the direc-
torship of Dr. T. M. Rotch, a gentleman who has no superior
in the treatment of infantile ailments. Both, however, have
the same disadvantage in caring for acute cases, in that boat
service is an integral part of both systems. Boat service
means a fixed time for reception, and if that time be exceeded
there is a delay of twenty-four to forty-eight hours. Every
physician knows that a delay of even minutes may mean
the life of the infant. Therefore, it seemed to me that if we
could procure a site for an infant's summer hospital, which
would combine the benefits of the salt water breezes with
accessibility at all times, we would be able to reach a large
number of cases which are not now treated. We would then
not supersede but powerfully assist the work now going on,
in the directions which I have specified.
"Such a site does, exist in the artificial island at the end
of the iron pier at the Marine Park, City Point. We have there
a pier extending into the bay for a distance of 2,640 feet, and
leading out from a park which is itself almost surrounded by
salt water. Beyond the end of the pier an artificial island has
been built, which is yet unused, and which will be unused for
some time. This island is about 160 feet in diameter, a space
ample for our, purpose. Having consulted with the secretary
of the park commission on the matter I am satisfied that there
would be no trouble in securing this place. It is ideally situ-
ated, and remains cool during the hottest days in summer. In
using this island for hospital purposes, we encroach on no one's
rights, since it has been hitherto unused. As it is intended
for use only during the summer months, a tent hospital would
be all sufficient and Mr. Matthew Sullivan, chief of the archi-
tect division of the city of Boston, assures me that a few
marquees at this place would not detract from the architectural
beauties of the park, but would really add to the general effect
by giving the whole place a holiday aspect. Such a hospital
would be extremely inexpensive. Its first cost would include
simply a few tents and some carpentering. No solid buildings
and no costly furnishings would be needed. Then would come
the question of supplies, and the assistants, who perhaps could
be transferred from the central hospital. As to the manage-
ment of such an institution I see no way in which it could be
done so thoroughly, so scientifically and so economically as
through your boards. Your physicians, nurses and attendants
have had experience in tent work, and you have already a com
pleteness of organization which could only be effected by any
other body at the expense of much time and labor. Besides,
the poorer people are acquainted with your work and have
confidence in it. Mothers would thus be willing to intrust
their babies to your care. Physicians, too, understand the
routine by which a patient may be admitted to the Boston City
Hospital, and I am satisfied that they would be extremely
pleased to have a station to which they might send their infant
charges with as little trouble as is now necessary to secure
hospital treatment for adults. This communication is sent to
you at the suggestion of his honor, Mayor Quincy, with whom
I have conferred on the matter."
The trustees will hold a meeting in a short time, and it is
expected that th'ey will do all in their power to make the scheme
a success.
BOOK NOTICES.
A Text-book for Training Schools for Nurses, including physiology
and hygiene and the principles and practice of nursing. By
P.M. Wise, M.D. With an introduction by Dr. Edward
Cowles. In two volumes. Vol. I. New York and London :
G. P. Putnam's Sons, 1896.
The purpose of the book as stated by the author is "to
provide a text-book that will suffice for all the recitations in a
two years' course in training schools for nurses." "The
course adopted" in these volumes, says the author, "is based
upon the hypothesis that a nurse must understand the funda-
mental principles of physiology and hygiene before a rational
understanding of the principles of nursing is possible." The
first volume is therefore preparatory, being intended for the
first course, and the second volume for the principles and
practice of nursing. The book is dedicated to that veteran
hygienist and superintendent, Dr. Edward Cowles.
A System of Surgery, by various authors. Edited by Freder-
ick Treves, F.R.C.S. Vol. II, with two colored plates and
487 illustrations. 8vo, cl., pp. 1120. Philadelphia: Lea
Brothers & Co., 1896.
This volume concludes the work, and will add very consider-
ably to the surgical literature of the period. It includes
"Injuries and Diseases of Muscles and Tendons," by W.
Arbuthnot Lane ; "Surgery of Deformities," by H. H. Clut-
ton ; "Injuries and Diseases of the Head," by H. P. Dean:
"Injuries and Diseases of the Spine," by W. H. Bennett;
"Concussion of the Spine," by H. W. Page; "Diseases and
Injuries of the Ear," "Diseases of the Nose," by A. Marma-
duke Sheild ; " Injuries and Diseases of the Neck," by Bernard
Pitts ; "Surgery of the Chest," by Pearce Gould ; "Affections
of the Mouth, Palate, Tongue, Tonsil and Pharynx," by H. F.
Waterhouse ; "Affections of the Esophagus," by W. Bruce
1896.]
BOOK NOTICES.
875
Clarke ; " Injuries and Diseases of the Abdomen," and "Her-
nia." by F. Treves: "Diseases of the Reotuni," by Charles B.
Kail: "Diseases of the Breast." by W. Watson Cheyne ;
•• Injuries and Diseases of the Urinary Organs," "Injuries and
1 >ise;ises of Testes. Scrotum and Penis," by Henry Morris,
and "Injuries and Diseases of the Female (ienital Organs,"
h\ 1. Bland Sutton. The illustrations are copious but not
very well worked out owing to the thin paper. Many of them
are original. This system is an excellent exponent of tin ttc
steels British surgery.
Medical and Dental Colleges of the West. HlSTOBIC AND BIOGRAPHIC,
Illustrated in photogravure and steel. Edited by H. G.
Ci tiki;. Full gilt, quarto, pp. 638. Chicago: Oxford Pub-
lishing Company. IS96.
This is the Chicago volume and only one published of a
series in which the other western cities are to take their turn.
Mo far as we ran judge the work has been committed to trust-
worthy bands. The history of Rush Medical College was
written by Prof. Norman Bridge and Dr. John Edwin Rhodes ;
the Northwestern Medieal College by Prof. S. J. Jones ; the
Woman's Medical School by Prof. Marie J. Mergler ; the
College of Physicians and Surgeons by Profs. D. A. K. Steele
and William K. Quine; the Chicago College of Dental Surgery
by Prof. Truman W. Brophy ; the Northwestern University
Dental School by Prof. Edgar D. Swain ; the Chicago Poli-
clinic by Prof. Truman W. Miller: the Post-Graduate Medical
School by Prof. W. Franklin Coleman ; Harvey Medical Col-
lege by Prof. Frances Dickinson, and other schools secta-
rian in character by those of their own sect. In addition to
the school histories, biographies of those connected with the
several schools are given and in many instances of prominent
alumni. The work is handsomely printed on fine paper and
bound in morocco. As an authoritative work on the subject
it is not likely to be superseded for many years to come.
Anatomy: Descriptive and Surgical. By Henry Gray, F.R.S. A
new edition, thoroughly revised by American authorities,
from the thirteenth English edition. Edited by T. Picker-
im. Pick, P.R.C.S., with 7r2 illustrations, many of which
are new. Pp. 1250. Philadelphia and New York : Lea
Brothers A Co. 1896.
When a book reaches its thirteenth edition and has become
a standard authority in two hemispheres, there is little to say
by way of review.
We can only congratulate the editor on the new edition, the
publisher for the munificent way in which he has supplied the
tine paper, the beautiful illustrations and the superb binding.
The new American edition, however, is something more.
Certain sections have been rewritten, viz., those on the brain,
the teeth and the abdominal viscera. Dr. B. B. Gallaudet,
Dr. Fred. J. Brockaway and Prof. J. Playfair McMurrich have
had charge of the American revision.
The Medical and Surgical Uses of Electricity. By A. D. Rockwell
A.M., M.D. Illustrated with two hundred engravings. New
edition. New York : William Wood & Co.
No praise could be too high to give this standard book, which
is essentially the ninth edition of the well-known " Beard and
Rockwell." The work has been brought down to date, as one
may easily satisfy himself by examining the chapter on electro-
surgery, which has included the Roentgen ray and the direc-
tions for its use. "Rockwell" will be turned to as a book
which has not disappointed its possessor.
A Manual of Pharmacology and Therapeutics. By William Mur-
kell, M.D., F.R.C.P., Physician to and Lecturer on Phar-
macology at the Westminster Hospital; late Examiner in
Materia Medica in the University of Edinburgh, and Exam-
iner in Materia Medica and Pharmacy to the Conjoint Board
of the Royal College of Surgeons of England, and the Royal
College of Physicians of London. New York : William Wood
A ( '< i. .~>16 pages.
The friends of Dr. Murrell in this country, and they are
many, will be extremely glad to welcome this book, which,
although not exhaustive, is yet eminently scientific and prac-
tical. The American edition has been revised by Dr. Freder-
ick Caswell of New York. The book includes a very enter-
taining introduction, in which the general principles are given :
Pharmacology of Organic Substances ; Pharmacology of Syn-
thetic Compounds ; Pharmacology of Drugs of Vegetable
Origin ; Pharmacology of Drugs of Animal Origin.
Annual Report of the Board of Health and the City and Port of Phila-
delphia for the year 1895.
The volume is included in a city document containing the first
annual message of Mayor Warwick, and the Director of the
Department of Public Safety. The Board reports that the
death rate, while slightly in excess of 1894, was rather better
than the average for the last ten years, being but 20.44 per
1,000. In regard to antitoxin in diphtheria the Board says :
"Antitoxin as an immunizing agent has been used so very
sparingly that its influence in restricting the disease has not
been appreciable. Its use as a curative means has been con-
siderable but far from universal, and while its efficacy may
have been demonstrated in many cases, its use has been too
limited as yet to exercise a marked limiting effect upon the
disease." A laboratory of bacteriology was established at a
a cost of $15,000. The report shows a vast amount of excellent
sanitary work during the period covered by the report.
The Juggernaut of the Moderns ; A novel. By Rosa Hudspeth.
The Arena Publishing Company, Boston, Mass. 1896. Price
50 cents.
This book is one that has no place in the modern household,
nor should it be placed in the hands of the miscellaneous
reader. Those interested in sociology will find the book enter-
taining. The story is of the ruin of a young woman who goes
to a Western town as a typewriter. She is is pictured by the
authoress as of surpassing beauty, of course, but owing to the
fact that she must wear a corset, and displace the abdominal
organs, is subject to attacks of hysteria. Such a condition
naturally makes the subject a fit victim for the wiles of the
hypnotist, and her struggles against the dominant influence,
and final overthrow, form the materials for the book. Cui
bonof
Kemp & Co.'s Prescribes' Pharmacopeia. A synopsis of the more
recent remedies, official and unofficial, with a therapeutic
index. Third edition. Bombay: Kemp & Co., Ld. 1896.
We have tested this book for its account of several of the
newer remedies and find it quite accurate, so far as our test
goes. There is no doubt but it will be found useful in many
countries beside India, for which it was originally prepared.
The additions to the last revisions of the British and U. S.
Pharmacopeias are included in this work. It appears there
has been no revision of the Indian Pharmacopeia since the
edition of 1868.
The compilation has been well done ; the arrangement is
systematic and convenient.
Transactions of the Forty-sixth Annual Meeting of the Illinois State
Medical Society, held in Ottawa, 111., May 19, 20 and 21. Chi-
cago, 1896.
This volume is characterized by its directness throughout.
The transactions are singularly free from superfluous verbiage,
and the authors, as a rule, plunge in medias res without any
circumlocution. The tendency of the time is shown by the
appearance of a Committee on Society History, which, a foot-
note informs us, is composed of those members who have held
continuous membership for forty years. Although several of
the papers have been printed in this Journal many of them
have not been elsewhere printed. The Society will next year
meet at East St. Louis and the Missouri State Medical Society
will meet at St. Louis at the same time. We notice that a
joint committee has been appointed to act with a similar com- '
mittee from the Missouri State Society to make arrangements
for one day's joint meeting.
876
ASSOCIATION NEWS.
[October 17,
An American Text-book of Applied Therapeutics for the Use of
Practitioners and Students. Edited by J. C. Wilson, M.D.,
Philadelphia, assisted by Augustus A. Eshner, M.D., Phil-
adelphia. The authors are I. E. Atkinson, Baltimore ; San-
ger Brown, Chicago ; John B. Chapin, Philadelphia ; Wm.
C. Dabney, Charlottesville, Va. (deceased) ; John C. Da
Costa, Philadelphia; I. N. Danforth, Chicago; John L.
Dawson, Charleston, S. C. ; P. X. Dercum, Philadelphia ;
George Dock, Ann Arbor ; Robert T. Edes, Boston ; Augus-
tus A. Eshner, Philadelphia ; J. T. Eskridge, Denver ; F.
Forchheimer, Cincinnati ; Carl Frese, Philadelphia ; Edwin
E. Graham, Philadelphia ; John Guite'ras, Philadelphia ;
Frederick P. Henry, Philadelphia; Guy Hinsdale, Philadel-
phia ; Orville Horwitz, Philadelphia ; W. W. Johnston, Wash-
ington, D. C. ; Ernest Laplace, Philadelphia ; A. Laveran,
Paris, France ; James Hendrie Lloyd, Philadelphia ; John
Noland Mackenzie, Baltimore ; A. Lawrence Mason, Boston :
Charles K. Mills, Philadelphia ; John K. Mitchell, Philadel-
phia; W. P. Northrup, New York City; William Osier,
Baltimore ; Frederick A. Packard, Philadelphia ; Theophilus
Parvin, Philadelphia ; Beaven Rake, London, England ; E.
O. Shakespeare, Philadelphia ; Wharton Sinkler, Philadel-
phia; Louis Starr, Philadelphia; Henry W. Stelwagon,
Philadelphia ; James Stewart, Montreal ; Charles G. Stock
ton, Buffalo ; James Tyson, Philadelphia ; Victor C. Vaughan,
Ann Arbor ; James T. Whittaker, Cincinnati ; J. C. Wilson,
Philadelphia. Price, cloth, 87 ; sheep, $8. Philadelphia :
W. B. Saunders.
This is a book about the same size as the text-book on sur-
gery, and the others of the American text-book series.
We note with pleasure that the metric system of dosage has
been applied throughout, in addition to the old apothecary
doses for those who do not care to employ the modern form.
We regret to see that in the article on actinomycosis, the
author has failed to notice the work of the Agricultural Depart-
ment of our Government in this matter, and we believe that
the use of potassium iodid was first promulgated by this
bureau, and that the foreign authors are not entitled to prior-
ity in the matter. We trust that Dr. Salmon will be a little
more liberal in the distribution of the valuable documents of
the Department of Agriculture, Bureau of Animal Industry ;
they may in time reach the book-writers.
The Tonic Treatment of Syphilis. By E. L. Keyes, A.M., M.D.
Revised, edition; 8vo, cl., pp. 78. New York: D. Appleton
& Co. 1896.
The author holds in this essay that "mercury in small doses
is a tonic, because under it the general vitality is improved and
the number of red blood cells increased."
Twenty years have passed since Professor Keyes gave his
views on this subject, and we think he has a right to claim that
his position has been fully sustained, and to him more than to
to any other one man has been due the disappearance of pro-
fessional prejudice against the use of mercury, in many forms
of the disease.
The Transactions of the State Medical Society of Wisconsin, for the
year 1896, with the Constitution and By-laws and list of mem-
bers. Cloth, 8vo, pp. 593. Madison, Wis. : Tracy, Gibbs &
Co. 1896.
This meeting of the Society being the semi-centennial anni-
versary of its foundation it was decided to make it of a popular
character and of direct benefit to the people. All papers
therefore were upon hygienic topics. The volume thus pro-
duced is a very creditable one and shows a high state of learn-
ing in the principles of sanitary science by the Wisconsin
faculty. We doubt if there are many States in our Union
where current topics in hygiene would have received as intelli-
gent treatment. The volume concludes with the obituaries of
deceased members and the statistics of local societies. Secre-
tary Sheldon has edited the volume with his usual skill and
precision. The next annual meeting will be held at Racine on
the first Wednesday in May, 1897.
Transactions of the Medical Society of the State of Pennsylvania at
its forty-sixth annual session, held at Harrisburg, 1896.
Vol. XXVII. Published by the Society, Philadelphia, 1896.
Beside the usual number of valuable medical and surgical
i
papers in this volume there is a very interesting summary of
the proceedings of the Society from its original meeting by
Permanent Secretary William B. Atkinson. The volume is
well arranged and has an excellent index. Pittsburg was
selected as the next place of meeting. The minutes are very
full and show the active interest taken in various matters othi
than pure medical science by the Pennsylvania brethrei
This society sets a good example to sister societies by devol
ing a page in its Transactions to the American Medicai, Asso-
ciation, explaining the method of obtaining membership and.
giving a favorable notice to the Journal.
Feeding in Early Infancy. By Arthur V. Meigs, M.D. Octavo,
flexible cloth, pp. 15. Price 25 cents. Philadelphia : W.
B. Saunders. 1896.
This essay was one read at the meeting of the Philadelphia
County Medical Society, April, 1896. The article discusses
the composition of milk, and gives methods of imitating human
milk by proper treatment of cow's milk.
Practical Points in Nursing for Nurses in Private Practice, with an
appendix, etc., by Emily A. M. Stoney, etc. ; pp. 456.
Philadelphia : W. B. Saunders. 1896. Price 81.75 net.
In this book the author has rather successfully covered the
topics of the entire range of private nursing, and how to meet
the various emergencies when distant from medical aid, con-
venient tables, a dose list in old apothecaries' weights, and a
glossary conclude this excellent volume.
A Manual of Obstetrics. By W. A. Newman Dorland, A.M.,
M.D., with 168 illustrations in the text and 6 full-page
plates. Philadelphia: W.B.Saunders. 1896. Price $2.50-
net.
This is a well-written text book, containing the essential
knowledge of the art. The illustrations are numerous and
clear, and the work will be found sufficiently comprehensive to-
meet ordinary wants.
Peroxid of Hydrogen (Medicinal) Glycozone, Hydrozone and Eye Bal-
sam. By Charles Marchand. Treatment of diseases caused
by germs, bacteria and microbes. Eleventh Edition, pp. 216 ;
Paper. New York, 1896. Sent free on application.
This book contains direction for using the above preparations,
and a number of articles by medical writers based upon their
experiences with these drugs, which have appeared in the vari-
ous medical journals.
ASSOCIATION NEWS.
The Rush Monument.— The Rush Monument Committee has
sent the following circular to the Regular profession, which we
hope will be heeded :
My Dear Doctor: — The remarkable success of the relatively
small body of homeopaths in the United States, in collecting
875,000 for their monument to Hahnemann to be erected in.
the city of Washington, ought to make every reputable regu-
lar physician in the country keenly alive to the necessity for
promptly subscribing to the fund for the long-delayed monu-
ment to Benjamin Rush.
The model for the monument to Hahnemann, which has
been on exhibition in New York city, has attracted general
admiration on account of its great beauty and artistic excel-
lence, which will make it unrivaled as a work of this kind.
The regular medical profession, numbering over one hundred
thousand more than the entire body of homeopaths, has thus-
far subscribed less than 84,000 toward the projected monu-
ment to Dr. Rush, for which the Navy Department has already
generously designated a commanding site in the park fronting
the U. S. Naval Museum of Hygiene, where it will be one of
the most conspicuous features of the National capital.
Are the regular physicians of the United States willing that
this illustrious signer of the Declaration of Independence and
the distinguished medical hero of the Revolution, shall be
1896. !
PRACTICAL NOTES.
877
■commemorated by an insignificant bust or a mediocre statue,
in pitiable contrast with the splendid testimonial at their cap-
ital city to a foreign theorist by a comparatively small body of
his misguided followers? The crowds of visitors to Washing-
ton can Dot fail to attach a disparaging significance to the
Spectacle of these two monuments ; and we appeal to you to aid
the Committee in its endeavor to do justice to the memory of
this great father of American medicine pure and undefiled, by
sending by return mail to either of the undersigned as large a
contribution as you may be able to make.
Ai.hkktL. Gihon, M.D.,
Chairman, K. M, C, 8 W. 127th Street, New York City.
Qbobqj II Kohk. M.D., Sec. and Treas., R. M. C, Sykes-
ville, Md.
\V. Mikkiy WiniMvN, M.D., Chairman of R. M. C. for
Pennsylvania, Reading, Pa.
Hi \ki I). Holton, M.D., Treas. Am. Public Health Asso-
ciation. Brattleboro, \'ermont.
Ca mm M MiIm'iuk. M.D., Sec. and Treas., Am. Academy of
Medicine, Easton, Pa.
PRAGTI6AL NOTES.
Artificial Respiration for Infants. -Laborde's method of artificial
respiration by rhythmic traction of the tongue is recommended
in the Cbl. f. Oiueh: No. 28, as especially adapted for newborn
infante. There is none of the painful impression produced on
the witnesses by balancing the infant, and it can even be
treated while in a warm bath. In one case traction repeated
forty times recalled the babe to life after 600 oscillations had
failed to produce any effect. The infant died eight hours later,
and numerous cutaneous and subcutaneous lesions were found,
evidently caused by the balancing. The traction had only-
caused ecchymosis at the tip of the tongue, in the palatine
arch, in the cellular tissue back of the esophagus and in its
mucosa. These lesions should be known as they might have
a medicolegal bearing in cases of suspected suffocation — Bul-
letin MM., September 9.
Transverse Resection of Tuberculous Kidney. Bardenheuer, some
years ago, proved experimentally the possibility of this opera-
tion, and Czerny, Kummell, D'Antona also have affirmed that it
<xmld be performed on man. Bardenheuer has recently
applied it to a couple of patients found on investigation to
have the lower part of the kidney affected with tuberculosis.
He made a transverse section and cut off section after section
until absolutely healthy tissue was reached. The first case
was much enfeebled from traumatic suppuration in the region
four months previously, with intermittent fever, and the
patient succumbed five hours after resection of the kidney,
although the operation had been completed in twenty-five min-
utes, and had teen attended with scarcely any loss of blood.
The other case recovered with no complications. For a month
urine oozed into the dressing, which was changed every day.
After this period the wound healed and the patient recovered
rapidly. The indications for resection in such a case are strict
limitation of the lesion to a part of one kidney and no traces
of infection in the ureters or small pelvis. — Deutsch. Zeit-
schrift /. Our. No. 6.
The Surgical Treatment of Focal Epilepsy. — From a critical
-analysis of the results in nineteen cases Drs. B. Sachs and A.
G. Gerster draw the following conclusions :
1. Surgical interference is advisable in those cases of partial
epilepsy in which not more than one, or at the utmost two
years, have elapsed since the traumatic injury or the begin-
ning of the disease which has given rise to the convulsive
seizures.
2, In cases of depression or other injury of the skull surgical
interference is warranted even though a number of years have
elapsed ; but the prospect of recovery is brighter the shorter
the period of time since the injury.
3. Simple trephining may prove sufficient in a number of
cases, and particularly in those in which there is an injury to
the skull, or in which a cystic condition is the main cause of
the epilepsy.
4. Excision of cortical tissue is advisable if the epilepsy has
lasted but a short time, and if the symptoms point to a strictly
circumscribed focus of disease.
5. Since such cortical lesions are often of a microscopic
character, excision should bo practiced even if the tissue
appears to be perfectly normal at the time of operation ; but
the greatest caution should be exercised in order to make sure
that the proper area is removed.
6. Surgical interference for the cure of epilepsy associated
with infantile cerebral palsies may be attempted, particularly
if too long an interval has not elapsed since the beginning of
the palsy.
7. In cases of epilepsy of long standing, in which there is in
all probability a widespread degeneration of the association
fibers, every surgical procedure is useless. — Am. Jour. Med.
Sciences, October.
Albuminuria In Pregnancy and Parturition and Its Relations to
Eclampsia.— The British Medical Journal quotes Saft, in the
Airhir fiir Gyndcolot/ie, as saying that albuminuria occurs
during the latter half of gestation in 5.41 percent, of all cases,
more frequently toward the end of pregnancy and oftener in
primipane (5.9 per cent.) than in in multipara; (4.1 per cent.) ;
it is more common also in the former (32.08 per cent.) than in
the latter (22.6 per cent.) during labor. As a rule it disappears
within a few days after delivery, but is more likely to persist
in primiparas, in whom the effects of gestation upon the kid-
neys are altogether much more serious than in multipara?.
White and red corpuscles in non-albuminous urine of pregnant
women come from the bladder, but neither during pregnancy
nor labor are cylinders found without albumin, though their
presence does not seem to depend on the degree of albuminuria,
nor to influence its duration. Twins and hydramnion are pre-
disposing factors, contraction of the pelvis also, but in multi-
para" only during labor. Premature labor is a frequent result.
There is an affection of the kidney due solely to the condition
of pregnancy, the pathologic changes in which are merely
degenerative ; this affection is quite different from nephritis :
when not complicated it is of favorable prognosis and not likely
to terminate in chronic inflammation ; but when accompanied
by actual nephritis, or disease of the heart, is of very doubtful
issue. The cause of this affection is probably the auto-intoxi-
cation of the system by some product of tissue change, such
as is the origin of the molimina graviditatis and of the nerv-
ous disturbances of the pregnant state. The muscular exer-
tion during labor throws extra work on the kidneys, and it is
the overloading of the system by this poisonous product that
causes eclampsia and the secondary changes in the kidneys,
liver and other organs. There is thus an intimate, if not a
causal connection between albuminuria and eclampsia, and
the only proper way to solve the mystery surroundiug the lat-
ter is to try to determine the nature of the active poison by
observations made during gestation. In the same journal,
Schreiber analyzes a large number of cases that have come
under treatment since Schauta's report, June, 1880. Of 42,607
confinement cases 137, equal 0.321 per cent., suffered from
eclampsia, 19 being already unconscious and many others
having had many fits before being admitted to the clinic. Of
the mothers 109,. 79.5 per cent., were primipara? ; 113(971-parae)
were not more than 30 years old. One only had had eclamp-
sia in a previous (first) confinement (4 para sect. Caes.) Twins
are noted 12 times, hydrocephalus, hydramnion and low lateral
placenta one each, abnormal rotation twice, abnormal pelvis 9
878
MISCELLANY.
[October 17,
times, 3 breech cases. The attacks commenced before labor in
16.78 per cent., during it in 62.04 per cent., and after delivery
in 21.16 per cent of the cases, and while 53.17 per cent, had
less than 5 fits, the average number of fits in 126 was 8.
Omitting the 34 children of 29 postpartum cases, of the
remaining 115, 37, equal 32.1 per cent., were stillborn, and 56,
equal 48.6 per cent., were premature. The fetus in 4 ante-
partum cases was macerated, but the mothers recovered ; nor
did prolonged duration of the eclamptic state imply a fatal ter-
mination. The central nervous system was affected in 7 women,
6 had puerperal mania. After delivery 62 had no more fits, 5
had only 1, 37 had more than 1, 3 died from Cesarean section,
29 were puerperal cases. In 50.7 per cent, of the whole, or
64.7 per cent, of the cases before delivery, emptying the uterus
had a good effect. In 78 cases operated on (5 induction only)
the proportion was 62.7 per cent. ; in 27 delivered sponta-
neously 70.3 per cent. Of 27 deaths (19.7 per cent.) 17 only
were due to eclampsia alone (12.4 per cent.). Four fatal cases
only were more than 30 years old, but the mortality of multi-
parse (6, equal 21.4 per cent.) was greater than that of primi-
parae (21, equal 19.2 per cent.). The relative mortality of cases
commencing before, during, or after childbirth was 30. 43 per
cent., 18.82 per cent, and 13.79 per cent. The proportion of
deaths is comparatively low, and with the fact shown that
delivery without too active interference tends to stop the fits
is sufficient to warrant the adoption of conservative treat-
ment for eclampsia, the rather as the woman is spared the
dangers inseparable from forced labor. The practice of the
Vienna clinic for many years has been a prophylactic milk
diet for all albuminuric pregnant women : if this fail, the
induction of labor by bougie or colpeurynter. On the out-
break of eclampsia, hot baths, linden tea, wet packing, chloro-
form and delivery as soon as may be without incisions.
NECROLOGY.
Elisha Griswold, M.D. (Jefferson Medical College) at Pitts-
burgh, October 7, aged 68. He was born in Chester, Pa., March
14, 1828. He was appointed in 1861 by Governor Curtin surgeon
of the One Hundred and Twelfth Pennsylvania Volunteers, but
afterward became acting division surgeon. July 30, 1864, he
resigned to accept an appointment by President Lincoln in the
corps of United States surgeons. Dec. 14, 1864, he was trans-
ferred to the charge of Judiciary Square Hospital, afterward
being sent to New Orleans as chief medical examiner of the
Freedmen's bureau for the State of Louisiana. In 1867 he
was commissioned as lieutenant-colonel. He was a member of
the Mercer County Medical Society, the Trumbull Medical
Society of Ohio, and other societies. He leaves a wife and two
sons.
J. v. Kerchensteiner, M.D., Bavaria, aged 65 years. The
distinguished hygienist and promoter of medical, pharmaceutic
and sanitary progress. His death is a great loss to his country.
JohnSeibert, M.D. (University of Pennsylvania, 1857) Chi-
cago, October9, aged 78. George Bonbright Anderson, M.D.
(Jefferson Medical College, Philadelphia, 1877) at Latrobe, Pa.,
October 5. William Eaton, M.D., Lloydsville, Ohio. Octo-
ber 6.
MISCELLANY.
Foundation of Medico-surgical Lrological Society. This new asso-
ciation recently formed in France, welcomes foreign correspond-
ents, who are requested to apply to Dr. Desnos, 31 Rue de
Rome, Paris.
Inefficient Telephone Service In Columbus.- At a recent meeting
of the Academy of Medicine of Columbus, Ohio, resolutions
were passed reflecting on the telephone service of that town,
and a committee was appointed to take proper action in the-
matter.
Pawtucket (R. I.) Medical Association. The Pawtucket (R. I.)
Medical Association petitioned the city council for the estab-
lishment of a modern board of health, without which that city
at present languishes.
Dr. B. Mead Bolton, bacteriologist of the Board of Health at
Baltimore, Md., has been appointed professor in bacteriology
and pathology by the board of curators of the Missouri State
University.
Chicago Day was observed thoughout the city October 9. The
vast processions required medical attention and the Health
Department established stations and furnished ambulance
service. It is under existing ordinances clearly the duty of
the city physician to attend to the service of this character,
but no appropritions have been given the city physician for
these purposes.
Dean of the Profession. Since the death of Dr. Salomon of
England, at the age of 106, Dr. Bossy of Havre, France, is
now, we believe, the dean of the profession. Dr. Salomon
retired at an early age after his marriage to an heiress, but Dr.
Bossy has practiced all his life.
Robbed Doctors' Houses. — Two female sneak thieves were
arrested in Chicago, October 5, charged with stealing articles
from doctors' offices, which they had visited under various pre-
tences. About fourteen physicians have sustained losses at the
hands of this precious pair. Umbrellas, vases, clocks and the
like were classes of articles taken.
American Methods of Treating Pelvic Suppurations. As a supple
ment to the discussion of this subject at the International
Gynecological Congress, the Built tin Midieal summarizes the
views of several of our American surgeons : Noble, Kelly,
McMurtry, Sutton, Stone, Cordier, Marcy, F. H. Martin,
Treves, Wiggin, Kelsey and Carpenter, Ashby and Penrose,
quoting extensively from the addresses and discussions at the
Atlanta Meeting, published in The Journal, Nob. 4 to 6. As
has been seen in the report, Byford, Henrotin, Edebohls, Polk
and Kelly took an active and important part in the proceedings.
Form of "Charcot's Crystals." New light has been thrown on
this subject by Cohn's recent investigations. He has found
that they are not quadratic octahedrons as supposed, but hex-
agonal double pyramids. The cleavage of the figures found in
dried asthma sputum distinctly revealed that they belonged to
the hexagonal system. Crystallographic tests also proved
essential differences between these crystals and Bottcher's,
whose plane of polarization is not parallel to the long axis of
the crystal. — Deutseh. Med. Wocli. 19, from Deutsch. Arehiv
f. /,-. Medioin, 4 and .">.
Can Not Interfere with Proceedings in Higher Tribunals. The
supreme court of Georgia holds, in the case of Baughn v.
Wiley, decided April 27, 1896, that proceedings to obtain a
commission de lunatico inquirendo, under Section 1,855 of the
Code of that State, for the purpose of having a person impris-
oned in the jail of a given county sent to the asylum as a luna-
tic, can not be maintained when it appears that such person
has been convicted of murder in another county, is subject to
the sentence of death, and was confined in the jail in question
under an order of the superior court in which the conviction
was had : and that in such case the writ of mandamus will not
lie to compel the ordinary of the county in the jail of which
the alleged lunatic is confined to entertain jurisdiction of such
proceedings.
Methylene Green for Staining Nerve Terminals in the Muscles.
Corominos in the Revista de Cieneias Medicas de Barcelona,
3, states that this substance stains the terminal ramifications
of tb.e axis cylinders much better than the blue or chlorid of
gold. He uses it in a solution of 100 parts of concentrated
1896.]
MISCELLANY.
879
aqueous solution of methylene green in 50 parts of absolute
alcohol and 1 part acetic acid. He leaves the sections twenty-
four hours in this solution, and then makes his preparation
with glycerin and salt solution. The nerve fibers take a fine
green while the muscle fibers remain a very light color. If
left too long the preparation can be decolorized by soaking
a while in salt free glycerin.
Philadelphia Municipal Home for Consumptives Proposed. —Dr.
Lawrence F. Flick. President of the Society for the Prevention
of Tuberculosis of Philadelphia, has proposed to the city that
Kme suitable spot for a consumptives' home be selected,
whereby those cases to be cared for by themselves in a sanitary
way and those already cared for by the municipality, shall be
gathered in one institution to be managed under municipal
regulation. The plan is said to meet with favor by the muni-
cipal authorities. It is evident that additional means must be
taken to prevent the spread of the disease. This seems prac-
tical and. managed under proper conditions, would be an enor-
mous factor in suppressing the disease in a large city.
Essential of Indictment for Attempting to Procure Abortion.— A
Vermont statute renders all acts done and performed upon a
woman pregnant, or supposed to be pregnant, with intent to
procure her miscarriage, criminal, unless the same be neces-
sary to preserve her life. R. L., see. 4247. Construing it, the
supreme court of the State holds, in the case of State v.
Stevenson, decided Aug. 21, 1896, that "the same" here
refers to the miscarriage, and not to the means to produce a
miscarriage, as it can not be said that the thrusting of an
instrument into a pregnant woman, who is otherwise in perfect
health, is necessary to preserve her life, or that the employ-
ment of any of the means commonly used to procure a mis-
carriage is necessary to preserve her life. Under the statute,
if a miscarriage is necessary to preserve the life of a pregnant
woman, all acts done with the intent to procure it are declared
lawful, but. if unnecessary, criminal. In order to charge an
offense under the statute, it is necessary to negative the excep-
tion. And the court further holds that an averment that the
means employed to procure the miscarriage were not necessary
to preserve the life of the woman is not an equivalent to an
averment that the miscarriage was not necessary to preserve
her life, and that it does not negative the exception.
False Testimony and Suggestion. —Berillon found by recent
experiments that he was able to secure the testimony in regard
to imaginary past occurrences, of over twenty out of every
hundred persons tested (all over 15), by verbal suggestion
alone, and without any preliminary hypnotic maneuvers. The
readiness with which he was able to accomplish this was in
direct relation to the intelligence of the subject; by no means
confined to the lesser developed, but the reverse. He also
found that a personal interest assisted the realization of the
occurrence ; for instance, the subject remained indifferent to
a suggested criminal occurrence until he was made to believe
that the person in question had spoken injuriously of him,
when his attention was at once aroused and the whole imagi-
nary occurrence impressed upon his memory as if he had actu-
ally witnessed it. Berillon states therefore that large numbers
of persons possess such suggestibility in the normal condition
that it would be easy by verbal suggestion alone, without any
hypnotic maneuvers, to cause them to commit unconscious
perjury, and that they should not be considered legally respon-
sible if psychologic examination by a medico-legal expert
establishes the fact of the suggestion. Magistrates are there-
fore warned against the possibility of suggesting false testi-
mony to impressionable witnesses by the questions asked and
methods of procedure, which may produce the same effects by
psychic constraint as the torture chambers of old. See Jour-
nal de Mid. de Paris for further particulars, September 27.
Inebriety, Insanity and Suicide. Inebriety, though long con-
tinued and resulting occasionally in temporary insanity, the
prerogative court of New Jersey holds, in Koegel v. Egner,
decided Aug. 17, 1896, does not require proof of lucid intervals
to give validity to the acts of the drunkard, as is required
where general insanity is proved. Consequently where habitual
intoxication is shown there will be no presumption that inca-
pacitating drunkenness existed, for example, at the time of
making a will. And if it be conceded that bona fide attempts
to commit suicide and accomplishment of suicide, this court
further holds it will not follow that such derangement is
inconsistent with the ability to make a will. It may exist
with testamentary capacity. The court says that we gener-
ally attribute the act of self-destruction to a morbid condition
of the mind, which may be either fixed insanity or a temporary
surrender of reason. It is regarded as being in the latter con-
dition where the object of the intended suicide is to secure
relief from present pains, either in realization of affliction
(mental or physical), disgrace or disaster, or the impelling
cause is the apprehension of such evils ; for we can not believe
that a mind can be in normal health, even though it be
cowardly and skeptic as to the future, if it accepts the uncer-
tainty of the state after death as a relief from present mental
or physical suffering. Proof of mere attempt at suicide and
suicide, without more, exhibit at best but a temporary mental
affliction, having no reference to antecedent or subsequent
periods of time.
The Monument of Paracelsus. In a chapel in Salzburg, Bavaria,
stands Paracelsus's monument. It is a broken pyramid, and
a niche contains his picture with a Latin inscription commem-
orating his skill as universal. It also sets forth that he has
cured diseases before considered as past help, and the he had
left his property to the poor. His coat-of-arms is engraved on
the monument, with the motto : Pax vivis requies (sterna
sepultia, peace to the living, the repose of eternity to those
who slumber. Perhaps one of the most brilliant minds of the
later centuries was Philipp Theophrastus von Hohenheim, or,
as he afterward named himself, Paracelsus. His parents were
persons of note ; the father was a physician of acknowledged
ability and the mother the superintendent of the hospital at
the Abbey of Maria-Einsiedeln. At this place their child was
born in 1493. He grew up in the mountain region and his early
instruction received diligent attention. He learned the medi-
cal art from his father ; then at 16 he became a student at the
university of Basel, but soon left to be a pupil of the dis-
tinguished alchemist and philosopher, Trittheim, bishop of
Wiirzbrug. He afterward spent a season at the laboratory of
Sigismund Pugger, in the Tyrol ; then, after the example of
the sages of ancient times, he made a tour of the various coun-
tries. It is affirmed that he went to Tartary, India and Con-
stantinople. He was a persistent seeker after knowledge,
accepting it with equal readiness from the learned and from
persons in the humbler walks of life. He held the learning of
the universities in low esteem and despised those scholastic
discussions which turn more on theories and definitions than
on actual knowledge. The skill of Paracelsus as a physician
was highly esteemed. He was for some time a surgeon in the
imperial army, and when he had taken up his residence at
Basel he was consulted by Erasmus. At the recommendation
of CEkolampadius, the Protestant reformer, he was made city
physician and appointed professor of medicine at the university.
It was no easy task that he set himself, the reformation of the
art of healing. Luther in Germany, and Zwingli in Switzer-
land, had no harder task. He delivered his lectures in German
instead of Latin, and taught new doctrines in medicine and
philosophy. This created implacable hostility on the part of
his professional rivals, who accused him of being without a
medical degree. He would not prescribe and administer the
880
MISCELLANY.
[October 17, 1896.]
drugs sold by the apothecaries and they joined in the attack.
He was compelled to leave Basel and led a roving life for several
years. At length Duke Ernst of Bavaria, who was a lover of
occult knowledge, gave him a home at Salzburg. But the
unrelenting hatred of his enemies pursued him to this retreat,
and he was treacherously murdered in September, 1541. — Dr.
Alexander Wilder, in Metaphysical Magazine, September.
Equity Will Protect Incapacitated Persons.— It seems to be the
general consensus of judicial opinion, says the court of civil
appeals of Texas, in the case of Edwards v. Edwards, where a
rehearing was denied September 18, 1896, that equity jurisdic-
tion is maintainable on the petition of a "next friend," in
cases where a person of weak mind has not been, or can not be,
adjudged a lunatic by the special tribunal provided by law for
that purpose, and yet is so far incapacitated by disease, decrep-
itude, or other infirmity, as to require the protection of a court
of equity against the undue influence and fraud of others.
Medical Department Syracuse University. The formal opening
of the new medical college building took place at Syracuse
October 5. About four hundred guests were present, and
they were received in the lobby on the first floor by Chan-
cellor and Mrs. Day, Dr. and Mrs. H. D. Didama, Dr. and Mrs.
Nathan Jacobson, Dr. and Mrs. Alfred Mercer, Dr. and Mrs.
John Van Duyn, Dr. and Mrs. H. B. Allen, Dr. and Mrs. A.
B. Miller, and Dr. and Mrs. H. B. Eisner. In part Chancellor
Day said :
I feel that we have great reason for congratulation to-night,
reason to congratulate the city of Syracuse. Some of our
citizens may consider us a burden, but were they to under-
stand the merits of the university they would be with us in
congratulating Syracuse that she has the university. The
university is expending $1,000 per day in Syracuse every day
in the week and of a year of 400 days. Have you any other
institution in Syra6use that pays as good a dividend as that?
Not even the street railway. I measure the influence more
that comes from cultured brains. The city has been elevated
in character by this institution. The university is contrib-
uting many sciences to the city and outlying country. To-
night we open a new era. Now we have the best appointed
medical college on this continent. We have made it solid and
substantial. We have combined things which they have in
the metropolis and some things which they had not thought
of, and now we have a fine college with a peerless faculty.
The college ranks with the best to be found. We are deter-
mined to make doctors. We want quality and not quantity.
There are doctors everywhere, but the doctors you and I
want are not so much in evidence. I ask that the faculty
make as good doctors as they are themselves. I introduce to
you Dean Didama with profound pleasure.
Dean Didama came forward amid applause and made a
brief response to the Chancellor's remarks. In part he said :
Years ago the Geneva College moved to this city and reor-
ganized as the Syracuse Medical College. The system at first
in yogue sent out scores of doctors who were not capable to
practice. A new system was soon adopted and this drove
away many who desired to get a diploma rather than to
deserve one. The new plan was a financial failure. Success
followed later, however, and now we have facilities for doing
work in six departments with the best methods and can furnish
a four years' course.
The Dean gave a brief review of the faculty and spoke of
the high standard of instruction which has been attained. Dr.
D. M. Totman read the following telegram received by Chan-
cellor Day' from Andrew V. V. Raymond, president of Union
University: "The medical department of Union University
sends greeting and congratulation to the College of Medicine
of Syracuse on this happy occasion." Another was read by
the Doctor from Anson J. Upson, chancellor of the Univer
sity of New York. Letters of greeting were sent by a number
of prominent New York physicians.
Dr. Gaylord P. Clark of the faculty gave an interesting his-
tory of the new building. Dr. Clark reviewed the building
from its start up to the time of completion. The structure
cost $65,000 and two-thirds of that amount has been raised
and was acknowledged in Dr. Clark's report. The building
committee was composed of Hendrick Holden, J. B. Brooks
i
and J. B. Clark. The old building was torn down early in the
summer of 1895, and the present structure was started in July
and finished about a fortnight ago. The building is four
stories high and has a floor space of 24,000 square feet. It is
spacious, well lighted and well equipped. It is heated by
steam and the "direct-indirect" method is used for the heat-
ing and ventilating. It is lighted by both gas and electric
lights. There are several large lecture halls on the first and
second floors. On the third floor are the departments of phys-
iology and histology, and on the fourth, anatomy and path-
ology. The floors are all of hard wood and the ceilings steel.
The side walls are of brick and there is little chance for germs
to accumulate. It is a modern building and was inspected
with pleasure by the large number present last evening.
The address of the evening was made by Dr. Stephen Smith
of New York, a former resident of the county. Dr. Smith was
introduced by Dean Didama, and during his address he gave a
review of the various systems of treating the sick, and con-
trasted the methods of years ago with those of the present
time. "Natural talent is necessary in order to study medi-
cine," said Dr. Smith. "The growth of medical schools in
this country has not been entirely healthy. There is now some
advance in sciences, and it is gratifying to note this fact. This
college was the first to adopt a graded course, and now places
itself in the front rank of medical colleges. The new building
is well equipped, and the school enters now upon a new
era. The school will of course suffer some competition. The
best equipped physicians I find are educated in the smaller
schools and simply complete their studies in a metropolitan
institution. The college is to be congratulated upon having
secured everything necessary to insure its future success.
This school furnishes pupils ample opportunity to secure
a thorough medical education." Dr. Smith's remarks were
cordially received. Dr. Smith has enriched the library by the
gift of his large private collection.
Hospitals.
St. Luke's Hospital, New York. — When the authorities of
St. Luke's Hospital sold the hospital lands at Fifth Avenue
and Fifty-fourth Street, they evidently were not aware that
their title only conveyed the property for the use and purpose
of a hospital and chapel. The matter has now come up in the
shape of an unpleasant litigation.
Baptist Hospital ok Chicago. — By the will of the late Mrs.
Maria M. Foster the sum of $35,000 is bequeathed to this insti-
tution, which we believe has been, up to this time, wholly if
not exclusively under the management of the medical sect
known as " homeopaths."
I'bHiiice of Address.
Bourus, F. S., from 65 Capitol Av. to 404 Grand Opera House, Atlanta,
Ga.
Carroll. C. C, from Poughkeepsie to 509 5th A v., New ^ ork.
Helse, E. H.. from Bay View, Mich., to 2815 Washington Av.. Chicago.
Lundgren. C. E., from Jamestown to 4.55 Pacific St. Brook yn, X. Y.
Malone, I,. A., from 427 Senate Av. to 119 N. New Jersey St., Indian
apolis, Ind.
Moody. H. A., from Bailey Springs to Sll Congress St., Mobile, Ala.
Peck, George, from Cooperstown. N. Y., toittG.N. Broad St., Elizabeth.
N.J.
Rosser, J. C, from Grand Rapids to Rosser Hospital, Duluth, Minn.
Yeaman, H. W., from Philadelphia, Pa., to Pier 14 Red Star Line, New
York.
LETTERS RECEIVEU.
Avres.S. C, Cincinnati, Ohio; Anderson, Willis S.. Detroit, Mich.
Bradner, Henry. Benkelman, Neb. ; Berry, J. T., Brando n, Miss.
Demaree. Owen B., Benson, Ky.
Castor, H. C, Indianapolis, Ind,; Cullen, C. R., Gaines Mill, P. O., Va.
Erwin, C. R., Chicago.
Gray, Wm. B.. Richmond, Va.
Haag, D. E. Toledo, Ohio; Hummel A. L. Adv. Agency, New Y'ork.
Johnson, H. L. E.. Washington, D. C.
Kress & Owen Company, New York.
Little, C. H., Detroit, Mich. ; Latta, Samuel W., Philadelphia, Pa.
Miles Jacob F., Philadelphia, Pa.
Newton. R. C, Montclair. N. J.
Oliver, Chas. A., Philadelphia, Pa.; Open Court Publishing Co., Chi-
cago, 111.
Parkinson, James H„ Sacramento, Cal.; Payne, Geo. F., Atlanta, Ga. ;
Parke, Davis & Co., Detroit, Mich.; Pope Mfg. Co., Hartford, Conn.
Riley, W. H., Boulder, Colo. ; Rohe, Geo. H., Sykesville, Md.
Staples, Franklin, Winona, Minn.
Thayer, Chas. P., Boston, Mass.
F
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., OCTOBER 24, 1896.
No. 17.
ADDRESS.
THE EVOLUTION OF MEDICINE AND
NKW METHODS OF M KDICAL
TEACHING.
An kddiw* delWcnd M the ninth mutual opening ol the Department
< edlotne, 1'nJh
BY K. O. BEARD, M.D.
ft:- mi [TelOLOGT. PSPABTMBNT OF mkduisk. DNIVS&BITT
OK MINNESOTA. MINNKAPiil IS.
Tin- time was. and but recently, when the history
of medicine wan regarded as the classic introduction
in a text hook upon medical practice. It was the
subject of a regular course of lectures in many insti-
tutions of medical learning and. in some, it was even
assigned to the guardianship of a distinct chair.
With the rapid growth of the medical sciences
and with the multiplication of essential branches of
instruction, it has been crowded out of the curricu-
lum. Whether wisely or unwisely, in but a very few
schools is its study still maintained.
This is a loss certainly, and one to be deplored, if
the student of medicine does not acquire that loving
reverence for his calling which will lead him to
investigate its past : if he has not sufficient taste for
the literature of his profession to win him to make its
history a voluntary part of his education.
For this history of medicine — a curious and enter-
taining story, centering itself in three great facts of
character — the passion for self-knowledge, the immi-
nence of human need dependent upon self-ignorance,
and the sentiment of human devotion in the sight of
suffering, this history of medicine is as complete and
chromographic a picture of the evolution of intellect
as the records of the race afford.
Deeply into its attractive pages I can not venture
this evening, but I commend their study to your
leisure hours as a recreation from the more arduous
duties of your college course. From this history I
desire only to draw sufficient evidence of the fact that
the medicine of to-day is the still evolving product of
an evolutional process through which it has passed
and still is passing to the position not merely of an
art. but of a true science. And, as the first item of
this evidence, observe that medicine, in its develop-
ment, has always been most quickly responsive to
the favorable environment of physical integrity. It
I ways languished in the atmosphere of physical
degradation. The worship of the body has been an
inspiration to the study of its conditions. The stal-
wart races have been the leaders in medical lore. The
Arabs, the Greeks, the Moors, the Magyars, the Anglo-
Saxons and the Teutons have given the world, at once,
its best types of physical perfection and its pioneers
in the science of medicine.
Again, observe, that the medicine of each period
has been in closest harmony with its intellectual sur-
roundings. It has possessed the general qualities of
each phase in the evolution of the human mind. And
itself a creature of human necessity, it has, in turn,
created for itself in the public mind an atmosphere
luminous in direct proportion to the measure of its
own light. In an age of barbarism we see medicine
as a species of savage sorcery and the popular attitude
toward it is one of fear. In an age of superstition
medicine is the mystery of the alchemist and the
popular attitude toward it is that of wonder. In an
age of ecclesiastic authority medicine becomes oracu-
lar and the popular attitude toward it is one of abso-
lute credulty. In an age of metaphysics medioine is
speculative and the popular attitude toward it is that
of dogmatism. In an age of experience and super-
ficial observation medicine is empiric and the popular
attitude toward it is that which seeks after a sign and
demands a specific. In an age of science medicine
slowly becomes scientific and the popular attitude
toward it is that of scepticism of its traditional form-
ulas and inquiry into the reasons for its faith.
Only in the perspective of history can we see these
periods outlined sufficiently for the recognition of
their essential and separate qualities. Since no lines
of demarcation lie between them, since insensibly
they shade into one another, since the phases of this
evolution have not been of coincident development in
all communities and through all levels of society, it is
not surprising to find the peculiar characteristics of
one period invading the next and often exhibiting a
remarkable viability. It is one of the difficulties
with which the philosophy of evolution has to deal,
that while the fittest ultimately survives, the unfit
makes a desperate struggle for existence. Thus we
find relics of savagery in the torture of the sick, long
outliving the advancement of society into semi-civili-
zation. We find the grave cloths of superstition in
long-continued use as the swaddling clothes of author-
itative medicine. We are not so far removed our-
selves from the speculative era but that "isms" and
"pathies" still persist, and that "systems" of human
cures or "divine healings" still are born and " have
their day and cease to be," proving themselves, in
their premature decline, to be but the "broken lights"
of scientific truth. We are not yet so far beyond the
age of empiricism in medicine, but that we feel the
force of the dangerous argument from experience
alone and that the multitude of us still prescribe
remedies which have a mere reputation of cure;
which, in the vulgar tongue, are good for the ills
which ail our patients. We are not yet so far
advanced into the period of scientific medicine that
we trace a cause for every pathologic effect, that we
demand to know the physiologic action of every
therapeutic agent we employ, that we question our
daily practice till it gives a satisfactory reason for
every custom that we traditionally follow. So great
and so widely distributed has been the mass of the
882
THE EVOLUTION OF MEDICINE.
[October 24,
medical profession necessary to meet the growing
needs of society that it has sometimes visibly suffered
the consequences of its own inertia, rendering it now
conservatively slow in response to a moving impulse
and again subject to the excesses of its own momen-
tal force.
Nevertheless, scientific medicine is, I repeat, the
still evolving product of an evolutional process which
has kept proportional pace with the intellectual
development of the race.
The evolution of medicine, in common with other
subjects of natural development, has not always been
a continuous process. Occasionally it has suffered a
seeming temporary paralysis, and for almost a gene-
ration perhaps no important fact of discovery, no new
achievement of practice breaks the dead level along
which it drags its indifferent way. But this apparent
arrest of progress proves ultimately to be due merely
to some obstacle of error which has barred its upward
course, before which it pauses until it gathers suffi-
cient energy to roll the barrier from its path or which
now and then, perchance, seems to force it back upon
itself and start a retrograde movement which leads
about in the end to some broader and better way.
And not infrequently does the history of medi-
cine show us that in this, as along other lines of evo-
lutionary force, development has sometimes pro-
ceeded by sudden and surprising movements, by the
unexpected discovery of some new and widely illum-
nating truth, by the appearance, as it were, of some
massive points of projection in human events or in
human life which have given to the few, like Moses,
among the mass of men, a glimpse from Pisgah into
the land of promise. Some of those events and some
of those individuals who form these projection-points
in the history of the evolution of medicine have only
been justly measured or even tardily recognized by
the search light of latei development. Born out of
time, they were the abortive products of a false gene-
ration in the eyes of their contemporaries, but they
were the archetypes of a new era in the judgment of
the future. Some of them are still unknown, and yet
their deeds, which passed unrecognized and are even
yet untoll, were prophetic of many a modem "new
departure." We do not know the names, even, of
those obscure professors who conducted a single
annual dissection of the human body at Ingolstadt
and Heidelberg in the early years of the sixteenth
century and who considered it necessary to conduct
religious ceremonies after each demonstration before
their classes, bat it was their spirit which inspired
Vesalius, the traveling anatomist of Brussels, and
Fallopio of Modena and Eustacchi of Rome, whose
discoveries have been christened with and have
immortalized their names.
The simple sow-gelder of a German province, who,
in 1517, successfully removed the ovaries of his
daughter, had little surgical or even veterinary skill
to bring to his task, but he deserves recognition,
nevertheless, as the nameless author of an operation
which has become fashionable, to the weal of many
and the woe of some, in these latter days of the nine-
teenth century.
Small honor in his day was accorded to Felix
Platter, who, in 1557, insisted upon the psychic
treatment instead of the incarceration of the insane,
but he it was who led Pinel, in 1801, to remove the
fetters from the demented and to teach that mental
disease should be looked upon as a brain lesion.
Prophet he was of a deliverance of the defective
classes of society which he anticipated by two cen-
turies and a half of time! Bright projection rising out
of the gloom of the professional ignorance of his own
times into the clear atmosphere of scientific medicine,
his name is deserving of the unconscious worship of
the thousands of the hopeless and the helpless who
have profited by the evangel he proclaimed!
And among the men whose discoveries have made
them famous, many there were " of whom the world
was not worthy " and who were compelled to wait
upon posterity for the recognition they merited. As
we look back upon their history it seems to us that
"there were giants in those days," but they were
giants only by comparison with the mass of their fel-
lows among whom they stood. They would stand
shoulder to shoulder among the scientists of to-day.
They were simply great projection points upon the
medical progress of their time; men who laid down
the new lines along which progress was made, or from
which new departures could come. They were not
only opportune discoverers, but pioneers, who opened
the door to future and sometimes very much post-
poned research.
When Harvey announced the circulation of the
blood in 1628, and Malpighi in 1661, discovered
the capillary circulation, the facts were viewed as won-
der tales by their associates, and not even the dis-
coverers themselves knew what a wonder- world they
had opened up to future investigation. When Hal-
ler, in the eighteenth century, laid down the doctrine
of the functional irritability of the nerve-tissues,
his colleagues received the new theory with mingled
curiosity and suspicion, but they did not know that
by virtue of that demonstration, Haller was destined
to be called, a century later, "the Harvey of the
nervous mechanism."
When Bichat conducted his brilliant anatomic
dissections a hundred years ago, his contemporaries
rightly honored him as being the founder of the
study of general anatomy, but they did not recognize
in him, also, the founder of realism in his profes-
sion; they did not see that his scalpel was uncover-
ing facts that were to be used for the overthrow of
speculative medicine; they did not read the prophecy
of the coming of clinical and laboratory methods in
the teaching of the students of to-day in his preg-
nant words: "Books are merely the memoranda of
facts. We have living books before us in the living
and the dead."
When Jenner discovered the principle of vaccina-
tion he was like a miner who has stumbled upon an
unexpected gem, whose practical value he puts to a
sufficient test, but neither he nor the men who long
debated the value of the "find," nor the thousands
who have since adopted the practice of vaccination
and have minimized the terrors of smallpox thereby,
could foresee that his virus might prove, in genera-
tions to come, to he the type of many antitoxins, the
suggestion of a possibly large field of serotherapy,
the forerunner of the gospel of preventive medicine,
the faint promise of the proof of the doctrine of
immunity from disease.
Like all other products of mental evolution, medi-
cine has always been responsive to the influence of
two forces, the force of attraction from above, inci-
dent to the progress of the related sciences, and the
force of propulsion from below, incident to the rise of
popular intelligence. With the beginning of the
[896.]
THE EVOLUTION OF MEDICINE.
883
present century these two forces became active to an
extraordinary degree. The energy of general scien-
tific development was strongly nascent in the early
years of this period. It burst finally into a tlame which
has been burning with increasing and unparalleled
brilliancy as the century advanced. At the same time
were maturing those social and political forces which
gave impulse to the magic ideas of Pestalozzi, the
fat her of general education. The intelligence which,
in earlier aces, had been the heritage of the high-born,
began to penetrate downward and leaven the lower
strata of society, until it broke forth again, at all
levels, in the energy of a popular demand for knowl-
edge. The influence of this general rise of intelligence
upon the education of the so-called learned profes-
sions learned, hitherto, only by comparision with
the masses who can measure'"
These twin forces found the profession of medi-
cine steeped in the atmosphere of speculation and
apparently unstirred by the touch of that spirit of
practical realism which had its birth in the labors of
Biehat. But. buried as it was in the schools and sys-
tems of speculative thought, it had in it the living
germs of scientific development which could not but
respond to the quickening influences of the times.
Not to attempt a general survey of these influences of
nineteenth century science, we may just pause to
note, by way of illustration, the wide range and varied
character of the attractive forces by the aid of which
medicine has been lifted to a scientific plane. It
needs but to mention the labors of Schwann and
Lamarck and Schleiden in microscopic botany; of
Berthollet and Pasteur in chemistry; of Darwin,
Haeekel and Wallace in the philosophy of develop-
ment: of Faraday. Ohm. Ampere, Seebeck, Edison
and Bell in electricity: of Malus in polarization: of
Kirchhoff in spectrum analysis; of Fox Talbot and
others in photography: of Dutrochet in physiologic
chemistry it needs but to note the names and works
of these to see whence sprung the irresistible influ-
ences which are helping to make of medicine a science
and which have given birth and opportunity to a gen-
eration of medical scientists whose names and num-
ber ami achievements bid fair to rival in brilliancy
those of their fathers in general scientific research.
With the history of these masters in scientific med-
icine you will become familiar as you profit by the
conquests and discoveries they have made. Into this
history even of the moderns in medicine it is not a
part of my purpose to enter. Suffice it that medi-
cine, through their labors, is a science. It has been
difficult for the profession to get away from the spec-
ulative tendencies of an earlier day; those hereditary
habits still crop out with the persistency of tares among
the wheat. It has been difficult to outgrow the love
for our traditional position of authority in the com-
munity, but the day of the oracular in medicine has
yone by; the oracle has been found out and it is
works, not words, which can win allegiance from the
people of to-day. It has been difficult to abandon the
practice of empiricism, to learn that the argument
from experience is a most dangerous one in medicine
when all its conclusions rest upon a "variable'1 quan-
tity in the person of the patient. It has been difficult
to substitute for these, through the great body of the
profession, the exercise of a scientific spirit. Even
to-day that spirit moves but feebly in the minds of
many. It has not been easy to learn the unaccus-
tomed lesson of putting "the why" before "the there-
fore," of distrusting the effect until the cause is clear,
of doubting "symptoms" and seeking "signs," of mak-
ing conclusion wait upon investigation; of applying
to the human body the instruments of demonstration,
rather than the intuitions of the doctor; of accepting
the verdict of the thermometer, the stethoscope, the
battery, the microscope, the chemic reagent, the bac-
teriologic test, aye, even the knife of the autopsy —
the testimony in a word, of eye and ear and touch,
rather than the feelings of the patient or the suppo-
sitious effects of an empiric formula. The transition
period through which medicine has had to pass has
been a slow and tedious phase in its evolution; so
large a body, of necessity, moves slowly, but never-
theless it moves. No longer the physician is com-
pelled to walk in the half-light of variable experience
or in the gloom of metaphysic theories; no longer he
treads softly upon the velvet of popular reverence,
woven out of his fancied possession of occult truths;
he stands out in the light of a new day; his hypothe-
ses are useful but they must be proven; his theories
may outrun his practice but they must be supported
by facts; he must be able to give to every man the
reasons for his faith. For the medicine of to-day is
a science.
But, at first, and for a comparatively long period,
considering the rapid movement of its later evolution,
medicine was, as I have intimated, the science of the
masters. Indeed, this perhaps is to be accounted for
by the very rapidity of its progress. Only the master-
mind, the mind of exceptional opportunities could keep
pace with its league-long steps. Slowly the scientific
spirit permeated the profession; but old and young
were compelled, at first, if they received it at all, to
receive it at the feet of some medical Gamaliel. The
masters have slowly multiplied, but, until very
recently, facts have been acquired of necessity, at
second hand; we have learned the scientific methods
of medicine by proxy. We of the generation you fol-
low, grew up in a period of pupilage, during which
the few were trained in the seats of scientific
learning and went out to preach the gospel to the
many. Students heard with the ear, but did not see
with the eye, the structural secrets of the human body :
if they saw, they did not do the experiments which
proved the problems they studied or the operations
upon which, in practice, they must soon put untrained
hands. Their practical work was confined to the use
of the scalpel in a single dissection of " an upper " and
" a lower," and to the trial of a few chemic reactions
in the test-tube for a few short weeks. Occasionally
they listened to a clinic talk at the bedside of a typ-
ical case, or viewed from the distant benches the
white aprons of the surgeons and the instruments in
the hands of assistants at the operating table; or, far
less often they gathered, with hungry eyes, about the
postmortem table in search of a few living facts to be
discovered from the dead. Some of these imperfect
methods, for want of better, we still pursue. But the
age of the masters in medicine, as in other fields, is
passing by. A period of individualism in medicine,
as in everything else, is upon us. There are not
fewer intellectual giants than of old, but the medicine
of to-day demands that all its members shall be of
larger mold. The many are growing to the stature of
the few. Science is becoming more available. Its
instruments are more accessible. Its methods are
easier of attainment. Its results are more easily
measured by improved means. Its adaptations to
884
THE EVOLUTION OF MEDICINE.
[October 24,
daily practice are more numerous and indispensable.
Personal practical training is more necessary than of
old. Each must do in the medical science of the
future, to a very great degree, what any other has
done. It is not enough, students in medicine of
to-day, that you shall see through others' eyes, you
must also see with your own ; it is not enough that dem-
onstrations shall be made and tests done for you, you
must do them for yourselves; it is not enough that
shall know the names of drugs, you must be able to
recognize them; you must not only learn their action,
but you should see it; you must not only be able to
tell the constituents of the body fluids and tissues, but
you must be able to analyze them; you must not only
learn by ear the structural peculiarities of the tissues,
you must be able to differentiate lung and liver and
nerve tissue, under the microscope; you must not
only be able to count a pulse, you must be able to
study its qualities ; you must not only know the
meaning of heart sounds, you must be able to dis-
cover them and read them aright; you must not only
be able to take temperature, but you must understand
its production, its regulation and its means of loss;
you must not only understand the principles of diet-
etics and food-preparation, you should be able to put
them into personal practice; you must not only learn
the principles of obstetrics, but you must practice
them individually under the guidance of your teach-
ers; you must not only witness operations, you must
do them on the patient or on the cadaver: you must
not not only know the peculiarities of pathologic pro-
ducts, you must be able to make their differential
diagnosis under the glass; you must not only know
the names of disease-germs, you must be able to rec-
ognize their forms: you must see them not only in
the persons of their victims, you must rear them in
the culture-tube; you must not only master the details
of physical diagnosis, you must be able to apply them
to disease at the bedside or in the clinic. The oppor-
tunity to accomplish these things is enlarging with
every passing year. It is the heritage which the mas-
ters of the past have bequeathed to the students of
the present.
Ladies and Gentlemen: I have heard these things
called the adornments of medical teaching. A student
informed me but a few days ago that her preceptor
had advised her that these accessories were "nice but
not necessary.'* They are embellishments, it is true,
of the medical practice of fifteen or twenty years ago,
but they constitute the warp and woof of the scientific
medicine of to-day. For the attainment of this ideal
education, it is necessary for the teacher to come as
closely as possible into contact with the individual
student. The didactic instruction of large classes is
a means of time-saving, but for recitations and
reviews, for laboratory exercises, for demonstrations,
for purposes of bedside and clinic diagnosis, for
obstetric attendance, for the witness or the perform-
ance of operations, in short, for all forms of practical
work, these classes should be divided into small sec-
tions. Upon the adoption of such a recitation system
and upon the initiation of such section work in sev-
eral clinic branches this college is to be congratulated.
Its fuller extension to the entire laboratory and clinic
system and even to the surgical operating room is to
be desired. It is possible for a class of ten or fifteen
students to witness an operation with profit, but the
hours spent by large crowds of students in a surgical
amphitheater are largely wasted and could be spent
by the majority of students more profitably over a
text-book descriptive of the operation they are seek-
ing to witness. A multiplication of laboratory assist-
ants and clinic instructors is involved in this plea for
a more elaborate system of sectional work; it means
a larger equipment and a larger expenditure of mate-
rial, but its adoption is in the path of progress in our
professional schools. As a step in the same satisfac-
tory direction we welcome the partial abandonment
of the final examination system and the substitution
for it of oral recitations throughout the term and at
the close of the college year.
In a word, medical education is to be conducted,
so far as possible, in the individual rather than in the
mass. It is to be less didactic and more practical.
It is to be less in the lecture room and more in the
laboratory, in the hospital, in the dispensary and in
the clinic. Leaders in medical science, teachers in
medical thought there must always be, but each man
and woman who essays to study medicine must be a
master of his or her profession. A new relationship
exists between the leader and his followers, between
the teacher and the taught, a relationship of compan-
ionship. History is repeating itself in a return to
the more conversational methods of the Socratic sys-
tem. The spirit of mastery which put into the mouth
of the teacher that voice of dogmatic authority which
became the old prophets of tradition, "Thus said the
Lord," is passing away and in its place we hear the
voice of more philosophic, more reasonable invitation
"Come now and let us reason together." To such a
companionship of science, to such an intimate asso-
ciation of research, to such a leadership upon the part
of the teacher and to such a following upon the part
of the pupil, to the immediate possession of a place,
at the very outset of your college career, in the pro-
fession of scientific medicine, on behalf of my col-
leagues, I welcome you. Personally. I do not care to
what school of medicine you belong. You may attach
yourselves to any or to all schools; you will be safe.
and your future patients will be safe, under any ban-
ner, if only you are scientists in medicine. If you
are not, it matters nothing to what school you claim
allegiance, you will be an eventual failure. If you
have come here prepared to work with us and for us,
as well as for yourselves, determined to make your-
selves, not merely practitioners of medicine but med-
ical scientists, I extend to you, in the name of this
University, the right hand of scientific fellowship. If
one of you has come here to purchase a diploma and
to gain it by the shortest and easiest route to its
attainment, I want to bid you, in the name of medical
science, to find a less exacting and more lucrative
calling; or, if you must seek it upon this commercial
basis, to go where diplomas are for sale.
But, believing as I do, in the sincerity with which
you seek admission to this honorable and scientific
profession, let me ask you to begin your career with
a clear recognition, not only of the demands which it
will put upon you at the end of your college course,
but also of the demands which it puts upon you. as
men and women, as physicians in the making, now.
If you are to be a medical scientist you must be
equipped to become one. If you are to be a master
among men you must have a due preparation for the
mastery of your science. A pyramid can not be reared
upon the dimensions of its apex. A new education
in medicine is before you. A new standard of require-
ments measures you. If you are to survive in the
L896.]
EXTRACTION OF HARD CATARACT.
885
fierce struggle whioh awaits the competitors of to-day
in this falling of ours, yon must be fit to survive. If
you are not, that struggle will surely crowd the unfit
eventually to the wall. The success of our sowing
will depend upon the quality of the soil you offer to
the seed. The character of the harvest you yield, will
reflect upon the prior preparation of the brain soil you
bring to the seeder You will join with me, I know, in
congratulating this college and the university to
which it belongs, that it has already planned to safe-
guard, still further than it now does, these portals to
the profession by demanding of its matriculants a
higher measure of preliminary culture than they have
been required to possess in the past. The higher
evolution of the science of medicine must depend
upon the quality of the men and women who gather
in its institutions of learning and graduate from their
halls. The medical science of the future will be the
product of the labors of the profession, not merely
among its masters, but in its mass.
ORIGINAL ARTICLES.
REPORT OF ONE HUNDRED CASES OF
EXTRACTION OF HARD CATARACT.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association, held at
Atlanta, Ga., Mav 5-8. 1896.
1SY LYMAN WARE, M.D.
CHICAGO, ILL.
It is not unusual for a surgeon, whether East or
West, at home or abroad, to consider his special
method of extraction of cataract superior to that of
any other. Certainly, when one's cases are somewhat
limited, it is infinitely better to become perfectly
familiar with a special method and adhere to it as
closely as possible, and whenever changes are made
in order to accomplish some definite object, they
should be gradual. The operation to be chosen should
he the simplest and easiest of execution.
The loss of an eye means much to a patient, whether
he be rich or poor. Relatively speaking, it is as unfor-
tunate for an oculist to lose an eye as for a surgeon to
a life. From Daniel's time to the present it has
ever been sought to simplify the operation. I may
be considered too conservative, but the results I have
obtained will. I am sure, compare favorably with those
of any other method, and I think that in the future
they will be better than in the past, for the simple
reason that " practice and care make perfect."
When there is no complication, that is, no disease
of the eye aside from the cataract, and when the
patient is reasonably tractable, every operation ought
to be a success. A number of years ago I reported
(in the Chicago Medical Ex.) Von Jager's method
of operating, which impressed me most favorably.
Many of you can recall the grace and ease with which
he operated; seated, after the manner of Daniel, on a
stool directly in front of, and somewhat higher than
the patient, who faced a large window, he considered
it play to remove cataracts. His methods seemed to
me ideal. The first twenty-five cases operated upon,
I attempted to follow them in most respects. I used
his concavo-convex knives, and cystitome, but instead
of facing. I found it easier to stand behind the patient,
who either lay upon a table near or sat in a chair
facing a window. A single and simple obstacle caused
me to substitute Von Graefe's for Von Jager's knives.
However simple it may seem, it was almost impossible
to get Jager's knives sharpened in this country. After
trying a number of instrument makers in Chicago
and New York, I finally became discouraged and
wholly discontinued their use. No knife, in my expe-
rience, makes so clean and even an incision as Von
Jager's when in perfect condition, and no wound heals
so quickly.
The cases here reported were charity patients. Pre-
liminary iridectomy was done in most of the cases;
in those where the cataract was fully ripe and the
patients came from a distance, the extraction was done
within a week or ten days after the preliminary oper-
ation. When the cataract was not fully ripe, or the
patient lived near, a longer interval was allowed
between the two operations. Usually only a small
portion -of the iris was excised, and as it was always
under the upper lid, there was no deformity, nor was
there, after the lapse of a few weeks, any complaint
of dazzling or glaring light. The subsequent appear-
ance of the eye was that of a very moderate coloboma.
But should some deformity exist, what is that com-
pared to useful vision? Truly, more time is required
of both operator and patient, but what is time to the
doctor when an eye is at stake, or to the patient who
may have groped in darkness for years? Then, too,
by a preliminary iridectomy at least two important
questions may be solved— how the patient, and how
the eye is going to behave. One is warranted in
stating that the first operation will be the more severe,
and consequently if the patient is tractable and quiet
during the first, there is little doubt that he will
be equally so during the second. If there is any pre-
disposition to conjunctivitis or inflammation of any
form, the preliminary iridectomy and subsequent
treatment will most probably develop it, in which
case the extraction would be deferred until the disease
was completely cured. Patients were not operated
upon until they became somewhat familiar with the
surroundings, that is, one or two days after their
admission. The preparatory treatment consisted in
giving a slight mercurial laxative and bath the day
before the operation, and thoroughly washing the
head. The immediate treatment consisted in irritat-
ing the cul-de-sac with a solution of mercury bichlo-
rid, 1 to 5,000, and then with a saturated solution of
boric acid, followed by the instillation of a few drops
of a 4 per cent, solution of cocain every three or four
minutes until the anesthesia of the cornea was com-
plete. As a rule, but three instruments were used —
fixation forceps, knife and cystitome. An assistant
lightly raised the upper lid while the corneal section
was being made, which usually included the upper
two-fifths, and was made in the cornea at the sclero-
corneal junction. In cases where the lens was very
large and hard the section was made even larger,
including nearly one-half of the cornea, as was origi-
nally advised. I am sure that a small section is a
most serious mistake, and probably causes more com-
plications and the loss of more eyes than all others
combined. The capsule was uniformly opened in the
periphery after Knapp's method, except in those cases
of hypermature cataract, and where the capsule
appeared tough or showed calcareous deposits, when
the lens was removed with the capsule by means of
Fosters capsule forceps. It is to be regretted that it
is not always possible to determine in advance when
a lens can be removed in its capsule, as the result is
so much better than when the capsule is incised and
886
EXTRACTION OF HARD CATARACT.
[October 24,
CATARACT.
CONDITION.
OPERATION.
REMARKS.
2-3
4—5
G
7—8
8
10—11
1-2—18
14—15 Peterson. C.
16
17
18—19
20—21
22
23
■24
25
20
27—28
29
Grabb. J . . .
Ferindall.A.S.
Goldburg, N .
Brook, H.. . .
Goodaker, L .
Keenan, J. . .
Key, 8
Benson, A. . .
Bergeron, E.
Hurley, B. .
Wymn, M. . .
Hanson, C . .
O'Malley, K. .
Shodd, C. . .
Cameron, E.C
Welch, C . . .
Hoeveh, F . .
Walker, M . .
Johnson, C. .
30 .Tlndall, M . .
31— 32 Johnson. B. A
33
M
Price. S. . .
Modalna, J.
—38 Beigen, Eliz.
MeNamara, H.
Brown. Eltz. .
87
88
3»— 40Linkin. L.
Henbrogen, E
43-44
45
40
47
48
49
50-51
52—53
54
55-56
57—58
69
60
61
62
Jones, 8. . . .
Carmody, M .
Travis, C. G. .
Welch, Cath .
Islander, J.. .
Leutfer, A. . .
Remney, Eliz
Herverton.T.
Higby. M. B.
Bell, M . . . .
Malin, A. E. .
Call, M
Mederlone, U.
Kemphe, M. .
Maxwell, K. .
r.s
OS
«:.
43
46
Senile, bilateral
20 years.
Senile, bilateral .
Senile, right eye.
Senile
Senile, 6 years . .
Senile, double . .
Senile, double,
years.
Senile, double,
years.
Senile
10
Mature, perception
and projection good
Mature, P. & P. good.
Mature, P. & P. good.
Mature, P. & P. good,
Mature, P. & P. good
Right mature, P. & P.
poor.
P. & P. good ....
P. & P. good . . . ,
Left ext. 1 mo. after irid.
Ext. 2 weeks after irid. . . .
Ext. 12 days after irid. . . .
Left ext. 10 days after irid. .
Right ext. 7 weeks after irid.,
left ext. 2 weeks after irid..
Ext. 2 weeks after irid. . . .
20-70.
L. 20-50, R. 20-20 .
L. 20-50, R. 20-80 .
20-20
20-30, 20-40 . . .
65
M
65
59
78
65
58
Senile, double .
Senile, left eye, 2
years.
Senile, double, 7
years.
Senile, double, 2
years.
Anterior pyrami
dal cataract.
Senile, double, 2
years.
Senile, left eye, 5
years.
Senile, right eye,
3 years.
Senile, left eye, 1
year.
Senile, double.
years.
Senile, double,
years.
Right, calcareous cor-
neal opacities, left
mature 3 years, elir.
conj. dacryocystitis
left.
Mature, P. & P. poor .
Mature, P. & P. poor .
Mature, P. & P. good
Mature, P. & P. good
Right P. & P. poor . .
Mature, P. & P. good.
Left ext. 10 days after irid.
right ext. 1 mo. after irid. .
Left ext. 11 days after irid.,
right ext. 1 mo. after Irid .
Right ext. 1 week after irid.
left ext. 2 weeks after irid.
P. & P. fair
Calcar.
only,
ature, P. & P. good
Mature, P. & P. good
Mature, P. & P. good
Mature, P. & P. good
Senile, right . .
Senile, double .
right,
Senile,
years.
Senile, left eye, 10
years.
Senile, double . .
Senile, right eye
1 year.
Senile, double,
Beret*] years.
Perception cap. .
Senile, double .
Senile, double .
Senile, right eye
1 year.
Senile, right eye, P. & P. good
I years.
Senile, right eye . P. & P. good
Mature, P. & p. only
fair.
Mature, P. & P. good.
Mature, P. & P. good.
Mature, P. & P. good.
Mature, P. & P. good.
Mature, P. & P. good
Mature, P. & P. good.
Left P. & P. had, right
". & P. fair.
Left ext. 10 days after irid. .
Ext. 10 days after irid . . . .
Left ext. 9 days after irid.,
right 1 mo. after irid. . . .
Left ext. 2 weeks after irid.,
right ext. 4 weeks after irid.
Right ext. 2 weeks after irid.
Hyperm. P. & P. poor.
Right mature, P. & P.
good; left 1mm., P.
& P. good.
Mature, P. & P. good.
Left ext. 3 weeks after irid
Fifth day after extraction
patient hit her eye; irido
cyclitis followed and eye
enucleated.
Ext. 18 days after irid . . . .
Ext. 2 weeks after irid. . .
Ext. 2 weeks after irid. . . .
Left ext. 2 weeks after irid.,
right ext. 3 weeks after irid.
Left ext. 1 mo. after irid
Small incision, hard un-
yielding lens which requir-
ed some force to press out,
and some vitreous was lost.
Ext. 2 weeks after irid. Shim 11
incision.8ome vitreous lost
Left ext 2 weeks after irid.
right ext. 3 weeks after irid
Ext. 2 weeks after irid. . . .
Ext. 2 weeks after irid. Dis
cission 4 weeks after ex-
l ruction.
Left ext. 10 days after irid.,
right ext.:; weeks after irid.
Ext. 5 days after irid. .
20-200, 20-100 . . .
20-40, 20-40. . . .
R. no improve
ment, L. 20-200 .
Slight improvm't.
No improvement
20-40, 20-00 ....
20-100, 20-200 . . .
No improvement
Iritis followed irid., which
necessitated postponement
of extraction 1 month.
Floating bodies, vitreous.
Six weeks later returned for
discission left eye. Pan-
ophthal. & phthisis bulbi.
Chr. chorioiditis, floating
bodies in the vitreous.
Chorioidal disease.
No record .
No record .
No record .
20-40, 20-80 .
an
is
se
IS
Senile, left eye, 3
years.
Senile, bilateral
Senile, bilateral,
right 10 years
left 8 years.
Cong. post, polar,
bilateral.
Senile, bilateral, 1
year.
Senile, bilateral, 5
years.
Senile, double, 7
years.
Senile, right eye,
left, aphakia!.
Senile, double . .
Senile, bilateral, 1
year.
Senile, right eye .
Mature, P. & P. good
Left mature, right
1mm., i'. & P. good
Mature, P. & P. good
P. & P. bad
Mature, P. & P. good
Mature, P. & P. good
Left eale., right ma
ture.
Mature, P. & P. good
Right mature, left
imm, P. & P. good
Mature, P. & P. good
Mature, P. & P. good.
Left ext. Q days after irid .
Irid. both eyes and capsule
slightly. Scratched with
cystltome. Left ext.2wks.
after irid., right ext. 1 mo.
after irid.
Right ext. 2 weeks after irid.,
left extraction attempted 8
weeks a fter irid. on account
of liquid vitreous was not
successful.
Right ext. 14 days after irid.
left ext. 6 weeks after irid
Right ext. 14 days after irid.
Ext. 21 days after irid ....
Ext. 12 days after irid., fol
lowed by much pain and
rrrhymo'sis; good recovery.
Ext. 18 days after irid . . . .
Ext. 21 days after irid. Cap
Bale needled 1 mo. later.
Left ext. 14 days after irid.,
right ext. 18 daysafterirld
Right ext. 10 days after irid.,
left ext. 3 weeks after irid.
Ext. 1 mo. after irid . ....
20-30, 20-40.
20-100 . . . .
30-60 ,
Good recovery,
(iood recovery.
Five days after operation was
hurt when dressings were
lwing changed. Chronic
irido-cyclitis. Eve remov-
ed 1 years later.
Occlusion of pupil.
L. 20-40, R. 20-50
No record. . . .
No record
Slight improvm't.
No improvement
Left ext. 10 days after irid.
ri gilt ext. 3 weeks after irid
Right ext. 7 days after irid.
left cap. cal.and adhered to
lens. Removal with cap,
forceps.
Ext. : week after irid ....
Right ext. 2 weeks after irid.
Pterygium removed from
right, left ext. 2 weeks after
irFd.
Ext. 13 days after irid . . .
Xn record .
No record .
Good recovery.
Good recovery.
Retinitis pigmentosa.
Chorioidal atrophy.
20-80 .
20-80, 20-100.
20-80, 20-40 .
20-40, 20-10 .
20-40.
20-100.
20-60.
needled. Nt>
needled. No-
Subsequently
record.
Subsequently
record.
Small incision. Wk. ne
tated pressure to force out
lens. Some vitreous lest.
Slightly Improved only.
Some reaction. Too small
incision. Good recovery.
One week after ext. patient
removed dressingat night ;
reopened wound and caus-
ed some prolapse of iris.
which was excised. (. I
recovery.
Cap. adh. removed with lens.
1896.]
EXTRACTION OP HARD CATARACT.
887
\,>
N \MK.
AGE.
CATAEACT.
CONDITION.
OI'KRATION.
VISION.
REMARKS.
OS— 04
I'onty. J. . . .
58
Senile, bilateral .
Mature, P. A P. good.
Left ext. 1 week after irld..
right ext. 9 weeks after irld.
20-10, 20-40. . . .
(',.",
karsteen, M.
68
Senile, bilateral,
left, lOyears.
Left mature, P. A P.
fair only, right 1mm,
Left ext. 7 weeks after irid .
No record
Considerable reaction fol-
lowed irid. Cap. adh. lens
removed with hook, some
vitreous lost. Good ree'ry.
u
Bandera, B. .
78
Senile, double . .
Right mature, left
Right ext. 8 weeks after Irld.
20-60
07
Welnburg, Y..
60
Senile, right eve .
Senile left, right
Mature, P. A- P. good.
n
Doolittle, B. .
77
Mature, P. & P. good .
Kxt. 1(1 davs after irid . . . .
20-80
aphakial.
n
Baum, M.. .
n
Senile, left e\o. 1
Mature, P. & P. good.
Ext. 14 days after Irld ....
20-80
70—71
Danforth. I.. ,
7a
Senile, bilateral. ■
years.
Mature, p. & P. good.
Left ext. 1 mo. after irid.,
right ext.Sweeksafterirld.
20-80, 20-100. . . .
Can. needled 2|mos. after ext.
No record. -^ ~~*-
68
Senile, right eye.
8 years.
Mature, P. & P. fair
liood recovery .^^"7",^ ,jjg
only .
S3
Trauma tie, s years
Senile, left eye, 16
feus.
P. A P. fair only .
Good recovery."? MSi ^
Slow recovery, counts Angers
5 feet.
84
Uypermature, p. & P.
fair only.
...
Amslrr, M... .
47
Senile, bilateral .
Right mature, p. & p.
good; left ineip.
Right ext. 11 days after irid.
20-40
70
Underwood, 11
61
Senile, double . .
Left mature, right
ineip.
Mature, V. & P. good.
Ext. 12 days after irid ....
20-40
77
Ooonan, a.. .
65
s.inle, left eye, 10
Ext. 2 weeks after irld. . . .
20-80
fewell, R. . .
78
Senile, bilateral .
Left mature, P. & P.
Right ineip.
Left ext. 7 days after irld.,
right ext. 6 raos. after irid.
20-40, 20-60 ....
w— si Ryeraon, E.
:,s
Senile, bilateral, 1
Mature, P. A P. good.
Lett ext. 1 week after irid., '20-40, 20-60. . . .
year.
right e\t. 2 weeks after irid.
■ H MoFarland.
BO
Senile, bilateral .
Ineip.. P. & P. good .
Left ext. 1 mo. after irid.,
right ext.6weeksafterlrld.
20-40, 20-80. . . .
M Orallsh. K . .
40
Senile, left e\ e. ,
Mature, P. & P. good.
Ext. 10 days after irid ....
20-80
M
Senile, right eye .
Mature, P. & P. good.
Ext. 10 days after irid. Needl-
ed 1 mo. later.
20-40
T. M.A
46
Hani, '.' years. . .
P. & P. fair only . . .
Left ext. 1 week after irid.,
20-80, 20-60 ....
right ext. 3 weeks after Irid.
Cap. needled 1 mo. after
extraction.
1 ppel, L. . . .
66
Senile, double . .
Left mature, right
ineip., P. it P.good.
Left ext. 1 week after irid.
Cap. needled 1 mo. after
extraction.
20-80
90 Jager, J. . . .
iv
Senile, left eye.. .
Mature, P. & P. good,
right aphakial 3 yrs.
Left ext. 1 week after irid. .
20-40.'
itl— if.' Hans, Jos. . .
80
Senile, bilateral .
Bilateral mature. P.
&P.
Left ext. 1 week after irid.,
right ext. 3 weeks after irid.
20-200, 20-100 . . .
«3— in Karsteu. C . .
M
Senile, bilateral . Bilateral mature. P.
Left ext. 2 weeks after irid.,
20-80, 20-80 ....
| & P. good.
right ext. 4 weeks after irid.
Conners. . .
M
Senile, right eve . Mature, P. & P. good.
Ext. 1 week after irid ....
20-60
!»<i Sw e.-mv. B.
04
Senile, bilateral . Mature. P. A P. good.
Right ext. 1 week after irid.
20-40
in Melnen, B. . .
M
Senile, right eye . Mature, P. & P. good.
Ext. 1 mo. after irid
20-80
88 Steele, a.
70
Seuile. right eye .
Mature, P. & P. good.
Ext. 12 davs after irid ....
20-60
*
89 McMaher. M.
H
Senile, bilateral .
Mature, P. & P. good.
Right ext. 10 days after irid.
20-100
Slight amount vitreous lost.
Slow recovery.
100 Buckley. J.. .
65
senile, right eye .
Mature, P. & P. good.
Ext. 14 days after irid ....
20-60
the lens only extracted. After the completion of the
corneal incision, the fixation forceps are removed and
the further aid of an assistant is hardly necessary.
Slight pressure is made upon the peripheral lips of
the wound, then, in many cases, the natural contrac-
tion of the lower lid will expel the lens; but should it
not, gentle counter-pressure by means of the thumb
applied upon the lid will be amply sufficient. The
eye is then thoroughly washed with a warm saturated
solution of boric acid, and should there be any lens
matter remaining, it is generally coaxed out in the
same manner. A small pledget of lint or cotton is
saturated with the boric solution and laid upon the
eye, over which absorbent cotton is placed, just suffi-
cient to keep the lids well closed, and feel comfortable
to the patient. After the gauze or woolen bandage is
applied, the patient is allowed to walk to his room,
and is put immediately to bed, where under ordinary
circumstances he remains for twenty-four, or prefer-
ably forty-eight hours. The room is not darkened,
but bright or glaring light excluded. Should the
dressing of the eye be uncomfortable, it is changed
and applied more lightly. Eighteen or twenty hours
after the operation the bandage is removed, the dress-
ing carefully inspected, and should there be no unfa-
vorable indications the eye, unopened, is well bathed
with the saturated boric or bichlorid solution, and a
few drops of a 1 per cent, solution of atropia is
dropped into the inner canthus of the eye. Should
there be no complications the eye is similarly dressed
every twenty-four hours until the third or fourth day,
when the bandage is removed and a single muslin
strip tied over the eye for a day or two, when a shade
is substituted and worn as long as the light is unpleas-
ant. The average length of time in the hospital was
one month, which may seem rather long, but as many
lived at a distance, it was deemed expedient to keep
them as long as possible, in order to perform discission
should it be necessary, this was done in about 25 per
cent, of the cases. Patients were not confined to bed
longer than twenty-four hours if they wished to sit
up, nor to their rooms more than three or four days.
It was, however, generally found that patients recov-
ered more rapidly if kept reasonably quiet the first
few days or week. Patients living in the city were
frequently discharged ten days or two weeks after the
operation.
Discission, which was usually done with Knapp's
needle knife, was performed usually from three to six
weeks after the extraction, and uniformly improved
vision.
I would especially desire to call attention to the
unfavorable cases, as the consideration of such is
sometimes more profitable than that of the successful
ones.
Case 15. — Mrs. C. Peterson, age 65, senile cataract, blind ten
years, chronic conjunctivitis of both eyes for several years and
dacryocystitis of the left for three or four years ; general con-
dition feeble. She was placed at once upon tonics and a gen-
erous diet. The conjunctivitis was treated with astringents
mild sulphates and weak solution of nitrate of silver — the
dacryocystitis by Bowman's method and injections of solution
of bichlorid of mercury, 1 to 4,000, and bougies of iodoform
and zinc. After a month of such treatment the general and
local conditions fully warranted the cataract operation, which
was performed on each eye, one week intervening between the
operations. She made a good recovery without an untoward
symptom — V.=20-100 in left ; right, in which there were corneal
B88
EXTKACTION OF HARD CATARACT.
[October 24,
opacities and calcareous lens, no improvement. Two weeks
after the last extraction she was allowed to go to her home,
with the understanding that she would return in a month or
■six weeks. On her return there was a slight discharge as a
result of the chronic dacryocystitis, but so slight I did not
think it possible, after a thorough irrigation of the sac and
"duct with the bichlorid solution, to cause any trouble ; conse-
quently I did the operation of discission on left eye, hoping to
improve her vision. The operation was performed in the usual
manner and gave every promise of success, yet within twenty-
four hours distinct symptoms of panophthalmitis appeared,
and the patient lost her eye and almost her life. Subsequently
the operator was confronted with a suit for damages. Previ-
ously I had considered the operation of discission so simple
and free from accidents as hardly to give it a thought.
Case 29.— Mrs. M. Johnson, age 64, senile cataract both eyes,
left fully, right partially mature. After preliminary iridectomy
of the left, the lens was easily extracted without any complica-
tion, and until the fifth day there was not an unfavorable indi-
cation. On that day she complained of considerable pain in
the eye and temple. On examination the eye was found to be
much injected, the anterior chamber very shallow and the
wound reopened. In explanation of the greatly changed con-
dition she stated that the resident physician, in changing the
dressing the evening before, had in some manner hit the eye,
which had immediately caused excruciating pain. Chronic
irido cyclitis developed, and as the opposite eye was endan-
gered by sympathetic inflammation, the diseased eye was
advised removed.
Case 23. — Shodd C, aged 47, extracted left eye three weeks
after iridectomy. Operation normal except incision somewhat
small for the hard, unyielding lens, requiring more than the
usual pressure to force it out. Five days after the operation
the patient struck her own eye. Iridocyclitis followed and
the eye was enucleated one month later. Although the patient
distinctly stated that she hit her eye, it is possible that the
pressure and consequent injury to the iris at the time of the
operation may have been the principal or sole cause or the
trouble.
Case 30.— Tindall M., aged 62, senile right eye; motion, per-
ception and projection fair. Extracted two weeks after iridec-
tomy. Lens adherent ; removed with hook, some vitreous was
lost. Plastic iritis and occlusion of the pupil followed.
Case 60.— M., aged 58. Senile bilateral R. M. One week
after operation dressings were removed by patient during the
night. The wound reopened and caused some prolapsus, which
was excised. Good recovery resulted with fair vision.
I much regret that in my notes of cases more details
are not given. When I began to operate I was guided
and much influenced by V. Arlt's teaching, that vision
was the one object, and he said (Knapp's Archives,
Vol. x), "Were I to be operated on for cataract I
would rely on that method which, on the whole,
assures the greatest chances for recovering vision —
more or less good vision, and all that sort of thing, is
secondary so far as concerns the choice of method."
Certainly with the majority of those operated upon
and here reported, vision of any kind was the great
object. Yet I am confident, if care and time be taken
to avoid complications, and the patient is kept under
observation for a few weeks to determine whether dis-
cission may be necessary or not, good vision can be
secured just as easily as moderate. In reviewing the
cases, two weeks was the average time intervening
between the preliminary iridectomy and the extrac-
tion. I have omitted in this calculation those cases
where iridectomy was done to hasten the ripening of
the cataract. The average time of each patient in
hospital was about one month. Many were kept
longer than absolutely necessary, as they came from
a distance and it was considered best to keep them
long enough to fit them with glasses, and also to per-
form discission, should it be advisable. A few living
in the city were discharged from the hospital from
two to three weeks after the extraction. The average
age was 60, varying from 14, pyramidal cataract, to
85, of which latter there were several. The cases 14,
23, 29 and 30, four in all, were failures, and failures
much to be regretted, as they were all preventable.
Cases 9, 15, 16, 17, 22, 24, 40, 39, 41, 42, 52 and 53,
total 12, were complicated with choroidal trouble or
corneal opacities, and little hope was given that vision
would be improved, so that in estimating the number
of those who were benefited by operation, these should
be excluded. In brief, we have in the hundred cases
four complete failures. One only counts fingers at
five feet, partial failure, which would be five failures,
5 per cent. Twelve, complicated cases, abnormal con-
dition, 12 per cent. Twelve cases in which there was
no record as to vision, but noted that they made a
good recovery, which would mean 20-200 or better, si >
that we have:
12 cases, 1-10 or better 13 per cent.
4 " • 1-10 4 " "
9 " 1-5 11 " "
16 " 1-4 or better 19 " "
12 " 13 or better 14 " "
21 " 1-2 24 " "
7 " 2-3 8 " "
2 " 1-1 2 " "
I desire to express thanks to Dr. L. Weber, resident
physician, who kindly aided me in arranging the
above cases.
DISCUSSION.
Dr. W. T. Montgomery, Chicago. — It is only in very excep-
tional cases that I make a preliminary iridectomy. I do not
perform extraction under two weeks from the time of the first
operation. If the conjunctiva is healthy I do not use the
bichlorid solution, 1-5000, because it so frequently produces
decided irritation. Instead I irrigate freely with boric acid
solution before and after operation. I prefer the speculum to
any assistant to keep the lids separated during an operation. 1
do not make the corneal section so large as recommended by
Dr. Ware, but it is better to make it too large than too small.
If the patient has useful vision in one eye I only bandage the
eye operated upon and allow the patient to sit or recline in a
darkened room. If the eye is comfortable the first dressing is
not disturbed until the second or third day and as a rule I rob
stitute a shade for the bandage on the sixth day.
Dr. A. C. Corr, Carlinville, 111. — I am of opinion that in all
operations in which an iridectomy is to be made that it should
be preliminary from the fact that it is not complicated with
the dangers of the manipulation of the extraction, and on the
other hand when the extraction is made it is not complicated
with the dangers of an iridectomy. I regard the preliminary
iridectomy as very important and necessary to an ideal oper-
ation. The teachings by professors and the books is almost all
against the preliminary iridectomy, and it should not be so.
Dr. J. A. White, Richmond If you are working only to
secure to the patient every possible chance of vision, it is
advisable to do a preliminary iridectomy in every case. It is
not always practicable for the reason that the longer you
extend the time of treatment the more trouble you will have
from the patient, who wants to get through the case as soon
as possible. You should have as large a section as possible so
as to have an easy extraction of the lens. It should be as large
as can be, even to the extent of one half of the cornea. I always
make mine two-fifths of the cornea, keeping entirely within the
corneal tissues. As to antiseptics, my method is to prepare the
patient the day before I intend to operate. I first have the
face thoroughly washed with soap and water, then sterilize the
skin about the eye with solution of bichlorid 1-2000. It is im-
possible to thoroughly sterilize the conjunctiva, but we are not
afraid of producing irritation with bichlorid. After the wash-
ing we introduce into the conjunctival sac a 1-3000 salve of
bichlorid, and then sealing up the eye leave it until the next
day. If there is any secretion present when the eye is opened
we do not operate. During the operation we use the instru-
1896.]
ACUTE NON-SYPHILITIC CHOROIDITIS.
889
incuts sterilized with bi-chlorid. It has been my experience
OOCMJonally to remove the whole lens with the forceps on catch-
ing the capsule. If I find any difficulty in delivering the lens
I give the patient the benefit of an iridectomy so as to make
the delivery free and easy. I have found the cortex remaining
was not so dangerous as supposed. It is nearly always
absorbed and I would rather take the chances of a secondary
operation than to prolong the time and subject the patient to
.\tri danger. Since using the forceps I have had better results
and have done fower secondary operations. I do not approve
of permitting the patient to walk about.
Dr. H. li. Yoowa, Burlington, Iowa — As a result of iridec-
tomy, either preliminary or at the extraction, is it not possible
that the stump of the iris is more often incarcerated in the
wound than we commonly suppose? As one of the complica-
tions of cataract extraction I would ask for information as to
the occurrence of acute glaucoma. In one of my cases where
atropia was used as suggested by Noyes, acute pain appeared
twelve boors later with the usual symptoms of acute glaucoma.
Instillations of eserin were used and a good recovery made.
Dr. A. W. SfBU mo, Atlanta— 1 have had under my care one
ease of glaucoma secondary to cataract extraction. One dozen
or more of these cases recorded have been investigated by Nor-
denson. and he found the causes to be chiefly prolapse of the
capsule or the vitreous. When they appear suddenly they are
usually due to the healing in the wound of a bit of capsule
which blocks the How of the fluid. The case I had was due to
secondary needling after extraction. When the needles are
pulled out too rapidly a little vitreous may escape with the
fluid and, becoming fixed, pulls forward the contents of the
eye anil blocks the angle.
Dr. (i. C Savaoe The ideal operation has not yet been per-
fected, that is. the extraction of the lens in its capsule without
iridectomy. If some man will devise means of separating the
lens in its capsule from the suspensory ligament, the operation
will be complete. I always commence with the intention of
doing a simple extraction, and regret to have to perform the
combined operation. I have the things ready, and often have
to do the combined operation. I want a large incision to
include as much as one-half of the circumference.
Dr. A. W. Caxhocm, Atlanta— I do not know that we have
cataract in this country more than in other portions of the
world, but we certainly operate more. I have operated upon
1,900 cases within the last twenty years. I formerly com-
menced with the intention of doing a simple extraction, but I
now prefer an iridectomy. I very rarely have occasion to do a
secondary operation. I take a great deal of trouble to get out
all the cortical substance and usually have a very clear pupil.
Previous to the use of bichlorid I thought 1 was doing very
well if I had 95 per cent, of successes, but with its use I rarely
have any trouble whatever. I use it in the strength of 1 to
10,000, washing out the sac before, during and after the opera-
tion : in fact, keeping the field perfectly flooded with the solu-
tion. I see my patients twice a day for the first week. I keep
them in their rooms longer than is the custom. I have lost
probably not more than one case in the last two or three
hundred. I do not always get 20 20 vision, but 20-200 is very
good vision and enables the individual to do ordinary work. I
used to think that a little loss of vitreous was a serious thing,
but I have found that a slight loss amounts to nothing. The
only danger is that when once started, you can not pre-
dict where it will end. In some cases I have imagined that it
proved of service, for it broke up the posterior capsule and
left a window there. I always endeavor to avoid such a thing.
I use a very weak solution of cocain, i., per cent., and it is just
as satisfactory as the 4 per cent, solution.
Dr. R. L. Randolph, Baltimore— It has been shown that
the weak solutions of bichlorid have no effect upon the organ-
isms. The action of these solutions is not killing but getting
rid of them mechanically, and we will have just as good results,
if we boil the solution, whether it is bichlorid, salt solution
or plain water. I boil my instruments, except the knife,
which is kept in absolute alcohol until ready for use, then
washed in boiling water. A solution strong enough to kill
germs will produce irritation. I have operated on 160 or more
cases, and my best results as regards vision have been those in
which preliminary iridectomy was performed.
A NEW KNIFE FOR SECONDARY
CATARACT.
Read in the Section on Ophthalmology, at the Forty-seventh
Animal Meeting of the American Medical Association,
at Atlanta, Ga., May 6-8, INK..
BY A. J. ERWIN, M.D.
MANSFIELD, OHIO.
In presenting a new instrument to the
American Medical Association it becomes
necessary to show that such an invention is
needed to fill a want. It seems to me that
heretofore we have not had an implement for
the convenient removal of the opaque capsule,
or so-called secondary cataract. Ofte^ on
account of its flaccidity or toughness, the ordi-
nary needling of the capsule will not clear the
pupil. We are frequently obliged to open the
eye and remove the capsule with the forceps.
The knife that I herewith present is about the
size of the smallest discission needle. It is
curved about 50 degrees on both the edge and
the flat, with both edges and point sharp. Its
action is somewhat corkscrew-like. By a rotary
motion of this knife one can tear the capsule
into fragments if necessary, or draw it to the
corneal margin and extract it. I have found
it a very useful instrument. It was made for me
by George Tiemann & Co., New York.
ACUTE NON-SYPHILITIC CHOROIDITIS IN
YOUNG ADULTS.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8. 1896.
BY HIRAM WOODS, Jr., M.D.
ASSOCIATE PROFESSOR OF EYE AND EAR DISEASES, UNIVERSITY OF MARY-
LAND. BALTIMORE, MD.
It has frequently been noted that of all eye struc-
tures the uvea is most apt to show systematic disease.
The iritis, cyclitis and choroiditis of syphilis and
rheumatism are matters of daily observation. The
liability of the iris to become inflamed, in gouty sub-
jects, after such slight trauma as simple cataract
extraction, makes one chary in pressing operation
upon such persons. The choroid is the favorite place
for ocular tuberculosis. Metastatic infection from
sepsis, typhus, typhoid and, more rarely, remittent
fevers, from cerebro-spinal meningitis, most com-
monly appear in the choroid. Now and then one
reads of functional disturbances in the iris or ciliary
structures, attributed to digestive or sexual disorders.
Again, it is from primary choroidal growths that
metastasis is most apt to result. When one examines
treatises upon diseases of the eye for the etiology of
choroiditis, he finds comparatively little. As a rule,,
after a more or less thorough description of the ap-
pearance of the exudate, clouding of the vitreous,
floating opacities, absorption of inflammatory mate-
rial with restoration of function, or gradual develop-
890
ACUTE NON-SYPHILITIC CHOROIDITIS.
\
[October 24,
merit of atrophic areas with heaped-up pigment, pro-
ducing scotomata, one reads: "The most common
cause is syphilis, inherited or acquired. Sometimes
no definite cause can be assigned. Exceptionally,
choroiditis is associated with malnutrition, scrofula,
chlorosis and anemia." This is copied from the
recent edition of Juler's book and is a fair index of
others. That routine office examinations reveal old
choroiditis not due, so far as can be discovered, to
any of the commonly accepted causes, can not, I think,
be denied. Exclusion of syphilis, inherited or
acquired, is not always easy. Lesions, characteristic
of the disease, excite doubt concerning the history
rather than stimulate search for less common or
doubtful causes. All of the cases narrated below are
open to this objection. Careful inquiry was made;
and the presence of an eye disease, thought to be usu-
ally due to syphilis, but not essentially characteristic
of it, was the only reason for suspecting its presence.
During the past eighteen months I have seen in
private practice five cases in the acute stage of the
first attack, and two undergoing relapses of old chor-
oiditis. Five were in females, two in males. Their
clinical history is appended:
RELAPSINO CASES.
Case 1. — Miss D., 27 years of age, seamstress, was referred
to me in February, 1896. For six weeks the right eye had
been defective with constant floating clouds. Vision was 10-
200. Ophthalmoscopic examination revealed muddy vitreous
with floating specks, an area of choroido-retinal exudate, to
the temporal side of the fovea, while more externally was a
mass of pigment suggestive of a former attack. She had fair
health save in one respect, menstruation. Since its com-
mencement at the age of 15, this function had been irregular.
Sometimes six or eight weeks would elapse between periods.
About Christmas after several days hard work and on the third
or fourth of menstruation, she noted the eye symptoms. Im-
provement has been steady and distant vision on April 24 was
20-40. There is still some vitreous clouding.
Case 2. — Miss E. D., 21. In 1888, when this young lady was
in her 13th year, I attended her for left purulent ophthalmia.
How the child contracted this disease was difficult to explain,
though later her family physician attributed it to infection
from a servant, who, he had reason to believe, had gonorrhea
at the time. The eye recovered with a small peripheral corneal
scar. If there was any choroidal disease, acute or chronic,
my ophthalmoscopic examination did not reveal it. In 1892
she consulted me again for asthenopia. Correcting H. As
she obtained 20-15 vision in each eye. At this time when she
was 16 years old, I found in the upper and inner quadrant of
the left eye a patch of choroidal atrophy. The family history
was good, the girl's health perfect, and had been since 1888.
Menstruation had, in the meantime, been established. Later,
in 1892, Miss D. consulted me for "floating specks" and dim
vision in the left eye. The vitreous was found slightly cloudy
and vision 20-40. This attack had come on suddenly during a
menstrual period. She soon recovered. This past winter she
has had a similar experience. At neither time was there a
fresh exudate ; but vitreous clouding and floating opacities
were unmistakable.
PRIMARY CASES.
Case 3. — Miss G., 21 years old, a robust, athletic young lady,
called April 14. On March 14, she suddenly lost the sight of
the left eye. Vision was 20-200 on April 14. The vitreous was
cloudy, and examination difficult. I was able, however, to see
the retinal vessels, hidden in part of their course, with a gray
ish yellow choroido-retinal exudate at the temporal side of the
fovea. There was no hemorrhage. I learned that on the
morning of March 14 menstruation had appeared. Miss G.
had never remained indoors at such times and took an unusual
amount of exercise that day. During that evening she had a
severe headache, and found that Her sickness had ceased.
Shortly afterward the dimness of vision was noticed. Men-
struation reappeared the following day, and she had expected
the eye would soon get better. To-day (April 29) vision is
20-100.
Case 4. — I am somewhat doubtful about the diagnosis of
this case, but its history, and the ophthalmoscopic picture jus-
tify its narration.
A lady, 22 years of age, apparently in perfect health, was
brought to me in March, for an explanation of blurred vision
in the right eye. Visual acuity was 20-50 right, 20-15 left, the
former unimproved by glasses. A week previous, toward the
close of menstruation, this had been noticed. Slight haziness
of the vitreous with a blurred appearance of the fovea, a small
deep red, sub retinal spot; apparently a hemorrhage. It
slowly disappeared, and in three weeks vision was 20-20.
Case 5.— Mr. E., 25 years of age, lost sight in right eye
suddenly in September, 1894. Vision was barely perception of
the moving hand. Densely clouded vitreous, blurred retinal
vessels and an area of foveal choroido-retinal exudation were
easily seen. The case has resulted in a central atrophy with
scotoma. Eccentric vision now is 20-70. Mr. E. is an active
man. He is entirely free from any of the recognized causes of
choroiditis. The only associated condition I could discover
was a tapeworm. He said that several ineffectual attempts
had been made to dislodge this tenant. Except at these
repeated therapeutic onslaughts, his intestinal possession had
not worried him. He has, I believe, recently gotten rid of it.
Case 6. — Mr. R, 33 years of age, was sent me February, 1896.
For two weeks right vision was blurred. It was 20-50. A
choroido-retinal exudate in the upper and inner quadrant with
hazy vitreous explain his symptoms. This is slowly under-
going absorption. On April 30, distant vision was 20-30. Mr.
R is in active business involving large responsibilities. He
enjoys good health, but has recently suffered from what he
terms "nervous dyspepsia," occasionally washing out the
stomach. I could find no other disturbance. Tuberculosis
and syphilis seemed positively excluded.
Case 7. — J. J., 27 years of age, was sent to me in September,
1895. Vision in the right eye had become suddenly blurred
ten days previously. Mr. J. was an engraver by profession
and in robust health. In the lower nasal quadrant there was
a yellowish white exudate, associated with muddy vitreous
and floating opacities. Vision was 20-60. A scotoma was easily
located in upper temporal field. This has remained, corre-
sponding with the atrophy in lower nasal fundus. Central
vision now is 20-20.
Treatment in all of these cases followed the usual
lines. Purgation and diaphoresis in the early stage,
with leeches in one: Case 5. Later tonic, alterative
remedies were administered, as iron, corrosive chloric!.
There is a more or less general recognition of func-
tional relation between the eye and the female pelvic
organs. That affections of one can influence the
functions of the other is seen in the eye symptoms,
sometimes occurring at the menopause, and less fre-
quently at menstruation. Some gynecologists recog-
nize the need of correcting "eyestrain" when refrac-
tion error exists, if certain forms of uterine disease
are to be cured. Dr. Moseley has recently called my
attention to a paper by Dr. Matthew D. Mann of Buf-
falo, read at the Baltimore meeting of the American
Gynecological Society in 1895, setting forth this
necessity. These reflex disturbances, interesting as
they are, do not, however, belong to my subject.
Less generally an inflammatory condition of the
eye caused by pelvic disease is recognized. The fol-
lowing from Soelberg Wells (p. 329), presents it bet-
ter than I have found elsewhere.
"An important exciting cause of idiopathic cyclitis,
especially of the serous form, is found in disease of
the uterus accompanied by disturbance of the men-
strual function. DeWecker thinks this is the reason
why spontaneous irido-cyclitis occurs with so much
greater frequency among women than men. The res-
toration of the menstrual flow in these cases exerts a
beneficial influence upon the ciliary inflammation.
Pregnancy often causes relapses in cases of old chronic
cyclitis. In girls from 16 to 20 years of age. a mixed
form of serous and plastic irido-cyclitis or choroiditis
is frequently encountered, almost constantly associated
with either amenorrhea or irregular menstruation and
chlorosis. This form of inflammation is also not an
uncommon complication of the menopause, especially
1896.]
IDIOPATHIC CHOROIDITIS.
891
in those women in whom the climacteric period comes
mi unusually early."
Trophic changes through reflex nerve influence,
metastasis, or a third trouble acting as common cause
suggest themselves as possible explanations. Dr.
Mann (loo. cit.) speaks of insufficient urinary secre-
tion and lithemia as possible causes of pelvic disease.
Be i races this not infrequently to intestinal troubles.
In all of my cases urinary examination was negative;
but considering the liability of the uveal tract to
inflammation in gouty or rheumatic subjects, one
thinks of the possibility of the same cause producing
both eye and pelvic disorder. The frequency with
which we find evidences of old choroidal inflamma-
tion, of which the patient can often recall nothing, and
the identity of the ophthalmoscopic picture resulting
in eases we treat, with that found in untreated cases,
suggests the question of the value of therapeusis.
Vitreous clouding causes visual defect. When this
clears, the patient has recovered or been cured just
in proportion to the absorption of the exudate, or the
distance of the resulting atrophy from the fovea.
Syphilitic cases, it is recognized, promise best from a
therapeutic standpoint; but even here it is from
relapses that we aim to save our patient, rather than
from the natural result of the lesion present. In so-
called idiopathic cases, if associated troubles of any
kind can be found in a considerable number, etiologic
relation is suggested To find and remove this factor,
if possible, should be the aim of treatment.
816 Park Avenue.
IDIOPATHIC CHOROIDITIS.
Read in the Section on Ophthalmology at the Forty-seventh Annual
NU-eting of the American Medical Association held at
Atlanta. Ga.. May 5-8. 1896.
BY ADELINE E. PORTMAN, M.D.
Phy-ii'ian of Eye and Eur In Woman's Clinic; Assistant in Eye and
Eur Department of Central Dispensary and Emergency Hospital.
WASHINGTON, D. C.
Idiopathic choroiditis is a subject on which we find,
in text-books, almost nothing to aid in diagnosis of
the disease which has had so little investigation by
the busy oculists of the present time.
As you know, the choroid consists of the vascular
parenchyma, an exterior coat of endothelium upon
its scleral surface, and the lamina vitrea. Upon the
latter lies the pigmented epithelium which is assigned
to the retina, though it always suffers when the
choroid is affected. The blood supply of the choroid
is from two groups. The capillary vessels, which lie
nearer the inner surface, and the venous to the outer.
The chief blood supply is from the short, posterior
ciliary arteries. After entering near the optic nerve
and piercing the sclerotic they pass into the choroid,
then branch, forming the capillary network of the
choroid, ending in the indented margin of the ora
serrata. Long posterior and anterior ciliary arteries
send small branches to meet these vessels. The venous
blood, collected from the capillaries into the vena>
vorteooscR, leaves the eye through the sclerotic. The
parenchyma has an abundant nerve supply from the
long and short ciliary nerves and a network of pale
nerve fibers in the choroid which accompany the
blood vessels and have many ganglionic cells. They
end in the capillary layer. From the abundant nerve
and blood supply we understand how rapidly an
inflammation can extend, and why it must always be
considered a grave condition.
It is doubtful if hyperemia of the choroid can be
demonstrated or diagnosed by the ophthalmoscope,
for in long neglected ametropia uncorrected, and in
prolonged eye strain we observe a flannel-red appear-
ance. Idiopathic choroiditis has no subjective symp-
toms, there being pain oidy in the purulent forms, or
where there is iritic complications. The disturbance
of vision is in direct relation to the situation of the
lesion and amount of atrophy. In the period of pro-
gression all stages, from the first yellowish spot of
exudation to complete atrophy, may be seen.
The ophthalmoscopic signs which distinguish
choroidal opacities from those of the retina, are that
the retinal exudation spots have a more brilliant color,
their opacity denser and their contour is defined by
very fine radiating striae, which correspond with the
direction of the nerve fibers, the vessels are tortuous
and partially disappear under the opacities. The
vessels pass freely above choroidal opacities, without
change of appearance, the exudations show a dull
yellowish reflection, the atrophic spots are brilliant,
marbled, bluish, due to the denuded sclerotic. Instead
of a dull red ground, large vessels may be manifest
as reddish and yellowish-red stripes, forming a lace-
work, between which are dark, intervascular spaces,
lozenge-shaped, caused by absorption of the pigment
and capillary layers. In certain instances this condi-
tion is physiologic and is commonly seen in the
space downward and inward from the disk. The large
vessels of the choroid stroma pass in a sinuous
manner across the eye ground, bringing into distinct
relief the pigment connective tissue cells of the
choroid proper, which lies beneath them. We also
find this condition in myopia and in the so-called
stretching eye, where hyperopia is becoming myopia
in glaucoma, and is at times associated with pig-
mentary degeneration in retinal diseases. This atrophy
of idiopathic choroiditis does not disturb the vision
necessarily, at first, to any appreciable extent, though
complete loss of visual acuteness is the ultimate
result. Usually the gradual diminution of visual
power creeps on so insiduously, that the patient only
becomes aware of it after it begins to interfere with
their usual vocation, and by an attempt to have glasses
fitted to improve failing vision. Nettleship gives
accounts of what he calls "generalized choroidal dis-
ease," in persons who have not had or inherited syph-
ilis, but believes it due to scattered hemorrhages into
the choroid, occurring repeatedly at different dates,
leading to patches of atrophy with pigmentation,
which he has found mostly in young males. Hutch-
inson claims that a disseminated choroiditis affecting
both eyes is found occasionally, as a family disease,
independent of syphilis, and connected with diseases
of the nervous system. To this class of cases, of ner-
vous origin perhaps, belong the cases found among
the overworked, the physically enervated man, the
slaves of the everlasting day-book and ledger in large
business houses, where long years of close, hard appli-
cation added to the ever growing demands of a family
that brings an ever increasing worry, where little
exercise and less fresh air combine to sap the failing
strength and low vitality; also that class of over-
burdened women who have spent their lives in the
hardest work, the mothers of large families, who from
rapidly repeated pregnancies and overstrained system,
in vainly trying to bear the endless burdens their
lives impose, have exhausted all reserve of physical
and nervous force they may have had and find them-
selves at the menopause with constitution ruined and
892
OPTIC NERVE ATROPHY.
[October 24,
a mental balance trembling on the verge of insanity.
Again, among the old, who have been exception-
ally healthy and strong during a long life, find the
vision growing strangely dim, in whom there is no
cataract, who go from one oculist to another in a
vain attempt to get glasses to improve their sight, we
find the large patch of choroidal atrophy, usually near
or partially including the disk, a condition of old age
apparently. But not only in the old and middle-aged
do we find this sad enemy, for Magnus in 1886 made
a report giving the results of his investigation of
sixty-four institutions for total blindness. The num-
ber of those affected with idiopathic choroidal disease
under 20 years of age in the 1,060 .examined was 75,
while in the 551 cases of congenital amaurosis were 48
due to the same cause. It also appears frequently in
the 2,528 cases reported by Schinidt-Rimpler, Hirsh-
berg, Magnus, Landesberg, Seidelman and Katz, 276
were of idiopathic choroidal disease, showing it to be
an enemy of all ages. May it not be possible by a
careful investigation into the cases that are met with
before much destruction has taken place, to arrest its
progress and thus save the few who can be benefited?
Let us remember that all choroidal diseases are not
specific and should not be treated as such. May
not continued attention and watchfulness save the
most valuable faculty we have, to some few at least?
And though this form of choroiditis may be the
result of a dyscrasia, so is trachoma, but that does not
make trachoma any less a disease.
DISCUSSION.
Dr. Herbert Harlan, Baltimore — I have seen quite a num-
ber of cases, and have now one under treatment in a very
healthy young woman, who, while there is no suspicion of
syphilis, has taken one-sixth of a grain of bichlorid of mercury
three times a day for several months, and her vision has
improved from light perception to 15-100. A great deal of good
can be gained from treatment, but the prognosis must be
guarded until the fundus can be made out.
Dr. H. B. Young, Burlington — I have recently seen two
cases. One was benefited by potassium iodid, the other was
not. My impression was that the origin of the disease was
ancestral.
Dr. D. S. Reynolds, Louisville— If there is any cause for
disseminated choroiditis other than syphilis, I am entirely
unacquainted with it.
Dr. B. A. Randall, Philadelphia, Pa. — We are generally
correct in contrasting clinically the minor conditions of chor-
oidal irritation with those of unmistakable choroiditis that
leaves permanent scars, but no absolute pathologic line can be
drawn between them.
Dr. A. E. Portman — Many cases have been reported by Drs.
Argyle-Robertson, Hutchinson and others, believed by them
to have no specific connection. Research, however, in this
line can do no harm.
THE OCCURRENCE OF OPTIC NERVE
ATROPHY IN GENERAL DISEASE.
BY H. V. WURDEMANN, M.D.
Director Wisconsin General Hospital and Secretary of the Association ;
Oculist and Aurist to the Milwaukee Children's Hospital and to the
Milwaukee County Hospital for the Chronic Insane.
MILWAUKEK, WIS.
Bring Report of the Chairman of the Special Committee
appointed to report upon "Optic Nerve Atrophy of
Obscure Origin" for the Section on Ophthalmol-
ogy of the American Medical Association,
Forty-seventh Annual Meeting, held at
Atlanta, 6a., May 5-8, 1896.
The origin of most cases of optic nerve atrophy is
certainly obscure. There can be no doubt, when the
amblyopia and characteristic disk changes follow trau-
matism, peripheral disease, or there is positive diag-
nosis of cerebral disease, or following the continued
action of some virus or poison in the system, that is
known to affect the optic nerve. The occurrence of
optic nerve atrophy in general disease always brings
with it doubt as to the causative relation. The
statements of patients are unreliable especially as
regards nature, duration and severity of preexisting
diseases and an element of doubt is always attached
to the relation of such a chronic process as nerve
atrophy which may have begun months or years after
an apparently well authenticated cause.
The atrophy may involve the whole structure of the
optic nerve for its whole length, or may be complete
in only a portion; it may effect a part of the nerve
fibers, in their whole length or only such a portion as
the maculo-papillar bundle. Signs of degeneration
may come on so quickly that the disease may be
deemed acute; the majority of cases, however, are
characterized by slow changes and do not tend to
recovery and hence are truly chronic. The latter
class shows few signs of inflammation, although I be-
lieve, in the beginning, that it may be generally pos-
sible to demonstrate inflammatory changes at the disk.
in the shape of slight haziness and blurring of the
nerve head, especially its edges, and of increase in the
size, tortuosity and number of its small blood vessels.
A large number of cases follow high grades of inflam-
matory conditions of the nerve and retina, such as
occur in neuro-retinitis and choked disk.
It is difficult to decide whether some cases are due
to or simply coincidental with the preceding trauma,
local, cerebral, spinal, toxemic or general affection,
which may be followed by atrophy of any part of the
nerve from the visual centers to the disk, but the
result in any case is eventually seen as a wasting away
of the nerve elements. The disk loses its normal rosy
tinge, the circulation is reduced in amount, in advanced
cases is marked by a cupping of the nerve end, espe-
cially on the temporal side. In all cases the first
symptom is loss of visual acuity followed by more or
less concentric contraction of the visual field, with per-
haps defects and disturbances of color perception.
Where blanching of the macular fibers only appeals.
as in axial or partial atrophy, central or ring scoto-
mata are seen. The color of the disk may vary from
a pure white, as in primary or simple progressive
atrophy, to grayish as is seen after neuritis. Bluish
or greenish shades commonly appear after spinal
lesions and sometimes pigment deposits occur in the
nerve. Glaucomatous disease results in atrophy of
the fibers and here the discoloration is frequently
marked.
In addition to considering optic nerve atrophy with
constitutional and infectious diseases I shall discuss
affections of the digestive, respiratory, circulatory,
urinary and sexual organs with diseases of the skin
and those cases which are supposed to be congenital
and those which for want of a sufficient apparent
cause will be termed idiopathic.
1. Diseases of the Digestive Organs. — Disordered
digestion and assimilation with attendant defective
nutrition are factors in many general and local dis-
eases. Infectious diseases may leave in their train
such conditions of the digestive tract, which act apart
from their toxins in jjroducing effects on the trophic
centers and nerves. I have observed simple white
atrophy for which I could give no other cause than
chronic catarrhal gastritis and the uric acid diathesis.
Blindness and subsequent atrophy has been noticed
after profuse diarrhea. Intestinal hemorrhage has
1890. J
OPTIC NERVE ATROPHY.
893
been loll.. wed by white atrophy. In retinitis pigmen-
ktosa and hemeralopia secondary atrophy of the optic
nerve follows. This condition has been ascribed to
co-incident liver disease, but in no case has there been
a sufficient warrant for ascription of a definite con-
nection between the two. It is certainly more proba-
ble that hereditary syphilis is the cause of these con-
ditions.
2. Diseases of the Sexual Organs. — Excessive sex-
ual indulgence and masturbation have been reported
as causes of this change in the optic nerve. Amenor-
rhea and sudden suppression of the menses with
\ieavious hemorrhage into the nerve sheath is a
probable cause of several personally observed and
other reported cases. The disturbances attending the
menopause in a subject inclined to arterio-sclerosis,
have developed the condition. Pregnancy may develop
a preexisting tendency to eye or general disease.
Although uremic blindness is usually temporary,
repeated attacks occurring in the same or successive
pregnancies have been known to result in permanent
atrophy. Nephritis of pregnancy with accompanying,
so called albuminuric retinitis has been followed by the
same result. Parturition ami childbed offer peripheral
causes, such as hemorrhage into the nerve sheaths or
centers. The mother is exposed to local and general
infection and the child to direct injuries which, in the
case of the latte>r. may be the cause of some of the
congenital cases. Auto-intoxication from lactation
has been reported as a cause of optic neuritis followed
by partial atrophy.
3. Diseases of the Respiratory Organs. — The adja-
cent nerve, chiasm or tracts may be implicated in
diseases of the sphenoidal sinuses following disease
of the nose, causing blindness or diminished vision !
with defective fields. Optic atrophy has followed
pneumonia and repeated operations for empyema.
4. Diseases of the Circulatory System. — In anemia
and plethora the eye is seldom directly affected, for the
amount of blood in the eye may often be the reverse of
that in other parts. The quality of the blood, however,
is certainly a factor in nutrition of the eye and nerve.
Thus, vascular affections may become harmful through
the chronicity of their course and produce optic
atrophy long after the cure of the original disease.
\\ e sometimes see cases of anemia and chlorosis with
heart lesions, which may be a sufficient cause for the
nerve disease, either through the results of embolism
or hemorrhage or through malnutrition. Hemophilia,
epistaxis. hematemesis and general hemorrhage have
been followed by atrophy.
Arterio-sclerosis, atheroma and fatty degeneration of
the blood vessels occur in certain general and specific
diseases and are directly responsible for defective
nutrition or hemorrhage into the nerve or sheaths,
which results in atrophy. Vascular diseases which
cause embolism or thrombosis may give rise to atrophic
patches in the choroid or the retina with secondary
partial degeneration of the optic nerve.
5. Diseases of the Urinary Organs. - Twenty per
cent, of all cases of Bright's disease suffer from albu-
minuric retinitis, which, af ter resolution, will be marked
by more or less atrophic changes. Double optic neu-
ritis followed by partial atrophy has resulted from
retention of the urine in a case of acute nephritis.
6. Infectious Diseases. — Both the acute and chronic
infections act mainly upon the blood vessels, which,
in many cases, are indirectly changed a long time
after the first infection has passed away. Such
lesions are of a simple atrophic and not of an inflam-
matory character and may occur in the brain, spinal
cord or peripheral nerves. When the course is acute
and the eye is soon affected, inflammatory changes or
hemorrhages occur in other parts of the eye as well as
in the nerve. Some of these are purely mechanical,
as in the case of violent coughing or vomiting. When
the course is less acute the virus is expended, apart
from the vessels, upon the interstitial connective tis-
sue, while the parenchyma remains healthy or is in-
volved only in the stage of reaction of the interstitial
process.
In rheumatism the deficient action of the kidneys
and defective elimination of uric acid produce
changes in the blood vessels which affect the nutri-
tion of the optic nerve. So also in arthritis deformans,
podagra and muscular rheumatism, atrophy may result.
These conditions cause glaucomatous disease which
eventuates in optic atrophy. Measles and scarlet
fever aside from nephritis, typhoid fever, cholera,
pertussis, parotitis, dipththeria, beri-beri and pellagra
are occasionally responsible for optic nerve atrophy,
while influenza is a fruitful source of blindness.
Malaria is a cause of atrophy, though some of the
cases reported may have been due to quinin. Syph-
ilis is one of the commonest causes of optic nerve dis-
ease. It either affects the nerve directly by the lesions
it produces in the nerve or its sheaths, in the chiasm
or the tracts, in the brain or spinal cord; or by dis-
turbances of nutrition; these conditions give rise to
neuritis, retrobulbar neuritis, thrombosis or degener-
ative changes in the nerve; or indirectly through the
changes which occur in tabes and allied diseases
resulting from syphilis.
The tertiary stage of syphilis causes interstitial
changes in the peripheral nerves including those of
sight. Gummata of the brain may produce peculiar
defects of the visual fields with atrophy. I have
noticed monocular hemorrhage and retinitis followed
by optic atrophy in congenital syphilis.
Epidemic and other cerebro-spinal meningitis has
been followed by atrophy of the nerves of sight.
7. Constitutional Affections. — Although we may
find atrophy of the optic nerve in some cases of tuber-
culosis* and scrofula and despite the fact that these
conditions are extremely common, no proof has yet
been adduced that they are capable of causing atrophy
in other ways than by affecting the general condition.
Diabetes may set up retinitis, neuro-retinitis or retro-
bulbar neuritis with secondary atrophy of the optic
nerve. Exophthalmic goiter, myxedema and leu-
kemia have been accompanied or followed by atrophy
of the optic nerves. One of the most constant symp-
toms of acromegaly and megalocephalia is optic
atrophy.
8. Congenital Optic Nerve Atrophy. — Many cases
of hereditary atrophy have been reported. The blind-
ness usually commences at puberty or during early
adult life. The actual exciting causes of the amauro-
sis may lie in some of the foregoing diseases or
in alcohol or other toxins. They are certainly of
doubtful origin, although we are inclined to believe
that the original cause of some of them is due to
anatomic changes in the sphenoid bone which pro-
duce pressure on the optic nerve or to the mechanical
influence of dilated and calcified vessels which ensue
later in life and are associated with certain forms of
atrophy in old people.
9. Diseases of the Skin. — We may readily under-
894
TREATMENT OF THE INSANE.
[October 24,
stand how diseases of the skin give rise to conjuncti-
val and corneal disease from extension by continuity
and similarity of structure. A case of neuritis with
resultant atrophy has been seen after extensive erup-
tions on the scalp. Erysipelas may affect the optic
nerve when attended by orbital cellulitis, with atrophy
following. Enormous thickening of the chiasm and
nerve has been found at the autopsy in a case of
elephantiasis.
10. Miscellaneous. — Exposure to cold is a common
cause given by patients to almost every affection. It
is possible that this may be the exciting cause of an
acute exacerbation of previously existing disease,
which may determine optic atrophy. Sunstroke,
exposure to continuous heat, light and high alti-
tude or climatic conditions are certainly very rare
causes. We sometimes see cases of well pronounced
atrophy in which in neither the history nor in the
examination are we able to find a sufficient, apparent
original or exciting cause.
Conclusions. — Optic nerve atrophy occurs in gen-
eral diseases usually as a result of direct irritation from
their toxins, causing inflammation with resultant
interstitial changes or through necro-biotic changes
in the blood vessels affecting the nutrition of the
nerve and retina. A certain proportion of cases are
due to trauma and to actual lesions which cause press-
ure on the nerve or interfere with its nutrition through
ambolic processes. Although many cases are of
apparently obscure origin, in the majority it is possi-
ble to demonstrate a sufficient exciting cause.
Note.— This paper Is but preliminary to another in which about
one hundred case histories will be reported.
The thanks of the author are due to Drs. Risley, Hotz. Hobby,
Foucher, Wilder. Zimmermann, Wheelock, Gould. White, 8palding and
others who so kindly sent examples from their own observation. Ip the
foregoing no authorities are credited; for literature see complete paper.
H. V. WURDEMANN.
TREATMENT OF THE INSANE.
Read by title in the Section on State Medicine at the Forty-seventh
Annual Meeting of the American Medical Associatiou,
at Atlanta. Ga.. May 6-8. 18%.
BY S. V. CLEVENGER, M.D.
Alienist and Neurologist Alexian and Michael Reese Hospitals, Chicago;
formerly Medical Superintendent of the Eastern Illinois Hospital
for the Insane and Pathologist of the Cook County Insane
Asylum; author of "Spinal Concussion," "Comparative
Physiology and Psychology," etc.
CHICAGO. ILL.
Treatment of the insane by our prehistoric ancestry
can be inferred from fragmentary early literature and
from conditions among existing races that have pre-
served the ideas and customs of remote periods. No
precise chronologic statement could be made that
would be true for all countries at any particular time,
for civilization is a relative matter.
In India, a thousand to three hundred years before
Christ, the causes of insanity were recorded as due to
improper food, overwork, poisons, powerful emotions,
etc., deranging the " wind, bile and phlegm," and six
kinds of insanity were described, and in attempts at
cure chastisement alternated with persuasion and
gentleness. Elsewhere, at the same time, possession
by evil spirits was the generally accepted explanation
of insanity, and the afflicted were beaten to rid them
of their devils, while priests were presumed to have
some power of exorcism.
The custom of destroying the weak and defective
was very prevalent. The early Romans threw their
monstrosities from the Tarpeian rock, American
savages often abandoned their aged and crippled to
the wolves, and promptly destroyed idiots and the
otherwise congenitally deformed.
Lunatics have been considered by the Mussulmans
and some other barbarians and semi-civilized as
entitled to special privileges, through a superstitious
regard for them, and epilepsy was inconsistently
looked upon as both a diabolical and a divine afflic-
tion, morbus sacer, or sacred sickness, being the
term often applied to it. The epilepsy of Mohammed
added to his religious influence.
Egyptian papyri indicate that drunkenness was
recognized as a cause of insanity five thousand years
ago; senile decay was also described and evil spirits
were blamed as causing insanity. The Coptic descend-
ant of the Egyptian language has words to express
insanity, stupor and mental loss.
The Bible refers to the feigned dementia of David,
Saul's madness and Nebuchadnezzar's mental afflic-
tion. Herodotus mentions the madness of the Per-
sian king, Cambyses; Sophocles tells of the insane
fury of Ajax, and Euripides describes mania and epi-
leptic insanity. Plato suggests fines for those who do
not properly provide for insane relatives, indicating
that such patients were allowed to run at large and
were neglected, as was the case in England down to a
recent period.
Babylonian inscriptions invoked the gods for aid to
sufferers from "sickness of the head." Plautus
describes senile dementia in a comedy and narrates an
instance of madness caused by "black bile." Hippo-
crates, 500 B. C, combated the popular idea of eyii-
lepsy being a divine disorder and recognized it, as
well as mania, melancholia and dementia as due to
bodily ailments. He prescribed hellebore for insanity.
Asclepiades sought to induce sleep in the insane by
gentle friction. At the beginning of the Christian
era Celsus advocated "hunger, chains and stripes" for
madmen, though there were occasional attempts al cure
by music and reading aloud to them. Caelius Aureli-
anus opposed violence to patients, and Galen gave
rules for treating insanity as sickness. Plutarch
describes melancholia of the religious kind, and
Horace gave rules for determining the sort of insane
who needed interdiction and restraint.
It was the custom among Roman ladies to have
idiots and imbeciles among their servants, though
occasional protests were made against so doing.
Court jesters were frequently selected from among
the deformed or mentally unsound in medieval periods.
Early in the world's history organization for other
than defensive and offensive purposes was compara-
tively crude and cruelty abounded on every side. Not
only were the insane the victims of brutalities to a
greater extent than at present, but degeneracy often
ran riot among rulers, affording the "insanity of power"
mentioned by Italian writers, which raged in connec-
tion with epilepsy, imbecility, paranoia and even
chronic mania in the imperial families of Rome,
Russia, India and other countries, afflicting Julian,
Tiberius, Caligula, Claudius, Nero, Heliogabalus,
Peter the Great, Ivan the Terrible and Mohammed
Toglak, the sultan of India, as well as the founders of
the Mohammedan and other sects in Asia and Europe.
Through the restraints of his environments and
fellows, man is more accustomed to be controlled than
he is fitted for the exercise of unlimited power, which
favors the development of latent mental and moral
imperfections. The abominable cruelties perpetrated
by some of these insane rulers are equaled only by
1896. j
TREATMENT OF THE INSANE.
895
the sufferings which the insane in all countries and ages
have boon forced to endure. Probably when merely
oegleoted and permitted to run at huge these defec-
tives endured less from the peltings and derision of
villagers, with occasional burnings at the stake as
witches, than after the commonwealth began to make
law.- oonoerning them.
The earliest provision made for the custody of luna-
tics in England was under the vagrant act of 1744,
and the constable of Great Staughlon, Huntingdon-
shire, records an official charge of 8 shillings 6 pence
"for watching and whipping a distracted woman."
Shakespeare mentions in "Rosalind" the "dark house
and the whip" with which madmen were punished.
The sequestration of lunatics as a public necessity
had as little reference to the possible cure of such
persons as. until recently, the idea that drunkenness
was due to a diseased state obtained credence. And
the superstitions of the ages found in the gathering
together of the insane better opportunities for prac-
ticing theories of casting out devils by reducing the
patient to extremities through starvation and beatings.
Willis, who had charge of the insane George III,
advocated fear in the treatment of patients. This
royal sufferer's legs were duly blistered and he was
dosed with Peruvian bark after the fashion of the day,
and the king complained of the severity of his attend-
ant, who is reported at times to have "knocked hi*
majesty as flat as a flounder." Public discussion of
this case led to some general amelioration of the
insane in England, which was built upon later by Dr.
Conolly and the compassionate Earl of Shaftesbury,
but not without encountering ignorant opposition, for
Conolly and Gardner Hill were denounced by the
English clergy for imperiling the community by
unchaining lunatics.
Kiel, among others, described the horrors of Ger-
man asylums in 1803. Before a parliamentary com-
mittee in 1808 it was testified that the insane in
Ireland were tied by the arm to a cart and were thus
dragged to the asylum, walking the entire distance,
however far. and that mortification from tightness of
the ligatures caused one in five to lose an arm. The
communal and ecclesiastic control of the insane at
Gheel, in Belgium, was hideous enough until the
State took charge.
Some of the appliances used in restraining and
"treating" the insane were the "Belgian" and other
cages, wicker baskets, rotary machines, suspended
boxes and seats or hanging mats, swings, hollow
wheels, the crib, gags and head frames. The douche
was used as a means of punishment and sudden
plunging into "surprise baths" were in favor at one
time to arouse depressed and discourage refractory
patients. Most of them, however, were penned up in
filthy, close rooms, sometimes of stone with wet floors,
freezing in winter and stifling with heat and offensive
odors in summer, fed on scanty and coarse food, often
sleeping naked on straw and several in one bed. Fre-
quently the poor creatures were devoured by rats if
they survived the thirst, hunger and pestilential dis-
eases that carried off many of them. Added to this
there was usually brutal supervision. Sometimes
convicts were employed to treat them as they pleased,
and Esquirol relates how the madmen, goaded by ill-
treatment, would watch an opportunity to kill their
attendants with their chains.
By very slow degrees the care of the mentally
afflicted has been improved. The inertia of govern-
ments and the merely temporary influence of expos-
ures with want of general concerted action accounts
for much of this slowness. There was fierce opposi-
tion roused in 1855 against the investigations in
Scotland that were instigated by Miss Dix, and it was
by effort out of proportion to results that finally
secured a royal commission which occupied two years
in examining into and finally reporting upon the
cruelties to which the insane were subjected in that
country.
In 1788 a Florentine named Vincenzio Chiarugi
instituted the renowned asylum of Bonifazio in Italy,
as a distinct departure from the inhumanities of the
time. Cleanliness, gentle treatment, medical care and
the fullest liberty supplanted the universal brutalities
in managing the insane. It was ten years later when
the chains were struck off the patients at the French
Bicetre through the long pleading of Pinel. He out-
lined a reform which was improved upon by his suc-
cessors. Esquirol, in 1818, wrote to the Minister of
the Interior: " Nude were the lunatics I saw, covered
with rags, stretched on the pavement, a little straw to
defend them from the damp cold. I saw them grossly
fed, deprived of air to breathe, of water to slake their
thirst and of things necessary to life. I saw them
committed into the hands of whippers, a prey to their
brutality. I saw them in narrow, dirty, fetid recep-
tacles, without light or air, chained in certain dens
and as wild beasts are penned in and kept secure."
Pinel was suspected by the revolutionists of having a
sinister design in asking permission to unchain his
lunatics, and a deputy of Robespierre wrote: "Citizen
Pinel, to-morrow I come to pay you a visit at the
Bicetre, woe to you if you lodge among your lunatics
any enemy of the people."
Passing to our own times we find that an advance
has been made toward a pretense of care. Formerly
it was not necessary to even pretend that humanity
was practicable in the management of the insane.
Home treatment of patients is usually difficult or
impossible, and as the laws concerning supervision
of the insane became more stringent most astounding
instances of cruelty and neglect of insane by their
relatives were discovered. Imbeciles, idiots and
dements were found here and there through the
country confined in dismal, small cells, scantily fed
and clothed, and their bodily needs otherwise disre-
garded. On the other hand there are families who
are making daily sacrifices in many ways to such
unfortunates in their affectionate care.
Small places are not fit for troublesome cases. The
long corridors of the State hospitals and the expanse
of gardens furnish room for exercise and air, where
the privations of a dwelling act prejudicially and
compels resort to confinement and mechanical
restraint, when all possible and reasonable liberty is
everything in the treatment of insanity.
Attendants of the insane as a class are misunder-
stood and often unjustly blamed for what is most fre-
quently due to the system of management of the
institution. Even in the most degraded political
asylum several really worthy persons have by some
accident managed to be present, but too frequently
their lives are made wretched by the perverse element,
and through their inability to prevent the abuse of'
patients by others.
In caring for the insane great forbearance has to-
be constantly used, for patients are often insulting
and abusive to an exasperating degree, and there is
896
TREATMENT OF THE INSANE.
[October 24,
an all too universal disposition to hold them to
account for what they do or say. "They are not
responsible," is daily mentioned by one kind-hearted
attendant to another, and in positions calling for so
much self-restraint and forgiveness under extreme
provocation it is really surprising how well attendants
acquit themselves. But helplessness and opportunity
are sufficient to tempt the brutes that low-grade poli-
ticians appoint to asylums.
If political control can be minimized and attend-
ants be secured on their merits and promoted as they
deserve for efficient service, salaries should be large
enough to induce those possessing more than average
ability to enter the service, but where the salary is the
only inducement to the ruffians who demand reward
for political work it is far better to make the salary
low; for a better class of attendants in those politically
dominated places is thus secured, from among medi-
cal students or other persons of good character who
seek temporary means of study.
The great strain to which attendants are subjected
when on duty makes it but just that they should have
reasonable opportunities for relaxation and recreation.
If the political teaching prevails that it is not wrong
to steal public property, employes can not be expected
to be diferent from those over them, and while trus-
tees or a business management may felicitate them-
selves upon their methods of "addition, division and
silence," as conducted in safety and secrecy, their
workmen claim also political spoils and extend the
system to a practical looting of the place, carrying off
everything portable at times. At Dunning there were
"fence houses" and all-night saloons surrounding
the county asylum where blankets, clothing of
patients, tableware, food, etc., were taken from attend-
ants in payment for drink and gambling losses.
Great differences exist, due to personal excellence of
attendants, as to the treatment patients receive. In
every institution there are instances of life-long friend-
ships springing up between the recovered patients and
those who cared for him or her, and the mere presence
of a well-intentioned, considerate attendant has often
been sufficient to calm the fury that had been caused
by the harshness of others.
On the other hand, the greatest cruelties were prac-
ticed upon the insane at the county asylum by the
criminals who were selected to fill the place of
attendants, as appears from the Report of the Board
of Public Charities, State of Illinois, 1886, page 119,
and years later the asylum was worse than ever, and
several murders of patients were brought to light
judicially.
If the medical superintendent were not hampered
by demands of politicians for positions to be filled
by unworthy persons the decent care of the insane
would be greatly simplified. As an example of the
selections politicians often make it suffices to state
that Peter Kelly, a Chicago policeman, was shot by a
burglar and became insane from the neck wound
inflicted; the assailant served out his time in the
Joliet Penitentiary and was appointed as an attend-
ant at the county asylum and was actually put in
charge of the ward within which was Peter Kelly, his
victim.
Dr. Joseph Lalor of the Dublin, Ireland, asylum,
founded schools for the insane, and he was also an
enthusiast on the subject of keeping the patients
employed. Farm labor is beneficial to both curable
and incurable cases, beside being an economic source
of supply to the asylum. Almost every conceivable
occupation is represented in the best managed insti-
tutions, and the daily labor of the patients contributes
greatly to their welfare and happiness. But there
are opportunities for abuse of employment in over-
working or unsuitable occupations. A contractor at
the county asylum was allowed to appropriate the
patients' labor, and the warden (who later served a
term in the penitentiary for robbery) compelled the
insane to hard labor against their inclination. A
patient died of typhoid fever while digging a trench
for the warden and contractor mentioned, both of
whom resented any medical interference with their
control of the insane. .
Visitors to insane patients often do much harm
unintentionally. Friends and relatives exert an irri-
tating effect upon the insane in unexpected ways,
and calmness has frequently been succeeded by weeks
of disturbance after the visit of a well-meaning rela-
tive. There are times, which the physicians are prompt
to recognize, when the patient is made better by see-
ing his friends, and they are usually notified to come
at once upon such occasions. Several thousand vis-
itors and pleasure seekers have been known to throng
and race through public asylum grounds, especially
on Sundays, and the attendants on such days had their
hardest work in controlling the patients who were
thus improperly disturbed.
Several hundred members of the legislature with
ladies, children and friends, "visited for inspection"
some of the State institutions, taking j)ossession of
the place, converting attendants into nurses for
infants, holding a banquet in the dining room of the
hospital, drinking the dispensary liquors, rioting
through the grounds and actually taunting some of
the patients into fury. The effects of such a visit
were observable for months afterward in many injuri-
ous ways. A small committee of inspection could
accomplish all the legitimate work necessary where a
rabble did nothing but harm.
Attempts to regulate Sunday visiting at a State
institution brought a storm of opposition, as the
diversion of travel threatened to break up some
saloons in the vicinity in which one of the trustees
was interested.
No institution of the kind should contain more than
300 insane is the universal declaration of alienists
and others experienced in the treatment of these
patients, but large and still larger asylums are built,
as they afford better and still better opportunities for
the management of great amounts of money after the
political fashion. The impossibility of a medical
superintendent overseeing so large a place as the
average asylum, with one or two thousand patients,
affords a pretext to politicians for putting in a "busi-
ness agent," but invariably the double-headed arrange-
ment proves to be a monstrosity, for no layman, even
under honest cooperative endeavor, can possibly be
aware of the needs of the patients and the place so
well as the medical director. The insane are sick,
and every moment demand the consideration due to
sickness that only a physician can give.
Every ounce of supplies purchased, every turn of a
wheel has reference to the care of patients, not mere
boarders or cattle who require nothing but housing,
feeding and grooming. When a layman has free con-
trol of a hospital he is more than liable to ignore
medical requirements, as he knows nothing of them,
and the medical head is humiliated and common
1896.]
TREATMENT OF THE INSANE.
897
decency is outraged by the necessity of constant
appeals to ignorance. Bran when a steward is under
the medical management, the latter is often defeated
by intrigues ol the former. What then is to be
azpeoted of divided authority, or, worse than all, the
medical under lay supremacy? Imagine a judge
being dictated to, by anyone, as to what legal books
of reference he should purchase, particularly by a
politician who. while preaching "economy," pocketed
the public appropriations for legal book purchases.
Most of the lay superintendents of county asylums are
purely business agents of politicians in the. worst,
sense of the term. Neglect, abuse and even murder
of patients How from such administration as naturally
as foul water from a sewer.
It is often the case that the purely professional man
is a poor business manager, but that is merely because
of his devotion to his work: let the same professional
man fully realize that in assuming charge of an insti-
tution for the siek that he must become a business
man and his professional knowledge is be merely a
part of intelligent training as to requirements, and the
same ability that made him a good physician will also
convert him into the efficient business medical admin-
istrator, for special ability is nothing more than gen-
eral ability. There will occur differences among
individuals as to whether relinquishment of lifelong
habits are possible, and with this in view superintend-
ents should always have had previous hospital experi-
ence, but there can never be any excuse on the ground
of pretended "lack of executive ability" by medical
men for the foisting of brutal, rapacious, uneducated
politicians into control, however disguised as gentle-
men they may be.
The "business manager" in some institutions has
claimed the right to make purchases of medicines and
very inferior stocks of drugs at high prices are pretty
sure to result, against which physicians dare not com-
plain at the cost of falling under politicians' disfavor.
Inert qninin pills containing a little quassia to impart
a bitter taste have been found in such stocks, fluid
extracts as valuable as so much cold tea, but billed as
Squibb's at his 20 per cent, advance over usual prices.
Calomel which required a teaspoonful to equal ten
grains, and other evidences of business enterprise in
purchasing abound when the "executive ability" of a
layman is placed over professional desire to have pure
medicines.
At the county asylum the warden refused to buy a
few dollars' worth of needed medicines on account of
their expense, but the next drug account itemized
1^ eases of beer, 10 barrels of whisky, 20,000 cigars,
and much wine, brandy and fancy liquors were also
covered by the item "sundry drugs." The periodical
celebrations of the county commissioners and their
friends in the dance-hall and dining-room of the
asylum necessitated rapid and constant replenishing
of that portion of the dispensary stock. Five dollars
per capita would have covered the amount of meat
eaten by 600 insane at the county asylum, yet in 1884
the bills were $15,763.04, and in 1885 amounted to
$18 .U34.ll, averaging $26 and $31 per patient, while
U cents per pound was charged for hogs' heads in a
filthy condition, some of which held iron rings in the
noses. Mike Wasserman, one of the convicted boodle
commissioners of unsavory memory, when once shown
the iron ring in a pig's snout found in the soup of a
patient, remarked: "Well, what would you have; gold
watches?"
The bookkeeping of a large asylum can be made so
elaborate as to be meaningless: Voluminous ledgers
and auxiliary books and records have been known to
be pure shams. Requisitions supposed to be sent to
the storekeeper by attendants were not approved by
supervisors or anyone else, and the storekeeper had
every chance of misappropriating goods, and under the
loose System of issue no proof could be secured of his
guilt. Small quantities of butterine issued have been
charged up as butter in large quantities; the actual
ration of some of the dements consisting in forty
grains of butterine, one five- hundredth of a pound of
inferior tea and a small plate of corn-meal mush, and
patients have fought over their scanty fare, the most
helpless being often wholly deprived of food.
Sixty per cent, of the English asylums are main-
tained at 8 shillings 7| pence for county and 9 shillings
7.'> pence for borough asylums, which cost includes
provisions, medicines, clothing, salaries, wages, fur-
niture, and in some borough asylums, repairs. At
Leavesdon, in 1887, the weekly cost was 7 shillings 5
pence. In Scotland the cost ranged from 5 shillings
10 pence to 10 shillings § pence, the extremes per
annum through England and Scotland being $72.80
and $125.58, with an average of 8 shillings 71 pence
per week or $107.64 per year.
In 1894 the lowest per capita in the United States
was $104 at the Tuscaloosa, Ala., asylum, the South-
ern per capita average of all institutions being $129.23,
the Western $166.58, the Northern $173.60 and East-
ern $173.42. The average of fifty-two asylums in the
United States being $169.15, which is considerably
above the cost of maintenance of the English asylums.
While the average cost of American asylum main-
tenance was about three-fourths greater than in Eng-
land, at the Chicago asylum the per capita in 1885
reached the sum of $270.39 under county commis-
sioners who were subsequently indicted for conspiracy
and fraud. The Illinois per capita of that year was
$174.21. The succeeding year $243,262.33 was expended
for about 700 patients, raising the per capita to
$347.51. The total county charity expenditures for
1886 was $906,478.34, at least two-thirds of which
must have been misdirected on the safe assumption
that the asylum per capita was about thrice what it
should have been.
During the years of the boodle gang control some
" 000,000 of public funds were disbursed; one saloon-
keeper was awarded a contract of $150,000 for covering
the court-house with a mixture of clay and paint, the cost
of which was about $500. The robbery of the insane
asylum fund was a small portion of the political divi-
sion of spoils. In 1886 the poorhouse per capita was
$200 and the county hospital $373.57, while in all
the public charity departments the greatest privations
were experienced by the inmates in spite of the vast
sums appropriated. "Economy" was the excuse of
the politicians for the miserable provision made for
the sick and paupers.
It is with the greatest difficulty that the expense
account of county institutions can be approximated.
Concealment is the rule and in the words of a county
commissioner, "the county expenditures is nobody's
business." Collusion among all asylum officers is not
to be presumed, for many of them are kept in ignor-
ance of financial matters and can only see results in a
general way against which they can not protest.
Estimating possibilities in the State institutions, it
is practicable for $150,000 to be abstracted from
898
TREATMENT OP THE INSANE.
[October 24,
$500,000 biennially appropriated for a single institu-
tion, through perquisites of $30,000 to the one who
heads the division of offices, sometimes a member of
the legislature who has controlled a large number of
votes for the State election; one trustee, who acts
"without salary and merely for the honor of the appoint-
ment, by diligently attending to the hospital business
can secure $50,000; a less influential trustee can save
$20,000 by cooperating with his companion in the
matter of auditing accounts, while the one whose vote
is not needed can be placated with $5,000. The store-
keeper has opportunities to earn $10,000 on his $75
per month salary. An industrious business manager
can net $25,000; the bookkeeper, through occasional
opportunities can add $1,500 to his savings, and $8,500
can be secured by others in various ways from the
wastage and shrinkage fields of the place. The treas-
urer is openly known to receive the interest on the
asylum funds, though there is no legal provision for
so doing. Probably $3,000 per annum is thus earned,
and if in the meanwhile the State is in need of funds
it can readily borrow by paying interest.
From $2,000,000 annually appropriated by a State
for maintenance of its charitable institutions, one-
fourth can be abstracted without the knowledge of
the State board of charities or the medical superin-
tendents, and without causing much privation among
patients, the different funds affording dissimilar
chances for discounts.
The " stuffing " of pay rolls is not so likely in the
State hospitals, particularly when the pay list is pub-
lished, but in county and city offices of all kinds great
sums have been made by placing fictitious or false
names or rates of pay on pay rolls of employes. An
18% instance was unearthed by a civil service com-
mission investigation, conducted by attorney Luther
Laflin Mills. The clothing account can be profitably
manipulated, in county asylums especially. At Dun-
ning 100 suits would be issued to a ward full of
patients, and the next day the same suits were reis-
sued to another ward. The friends of patients inces-
santly complained that the patients were not wearing
the clothing brought to them, and the destructiveness
of a few patients was made to do duty as an excuse
for the disappearance of hundreds of suits.
Fuel purchase in some places enables incredible
sums to be charged. A very superficial examination
would result in astonishing disclosures in this field,
unless baffled by the opposition usually raised against
exposure of any kind.
Trustees are ostensibly selected for their business
aptitude, public spirit and philanthropy ; they receive
no pay, and are presumed to regard the honor of the
appointment as sufficient recompense. Occasionally
it happens, after a political overturn, that prominent
political workers, for services in securing votes, are
rewarded by such trusteeship appointments, and while
it is not invariably the case, it too often happens that
a four years' term as trustee enables a poverty stricken
politician to blossom out as a banker, real estate
owner or man of wealth generally.
Combinations are sometimes formed among them in
such a way as to control matters, and the resentment
of the minority rises to threats at times, with the
compromise that ensures silence. When an indignant
trustee resigns and calls his former comrades hard
names, you may rest assured he is not satisfied with
his share of the profits. A $60 a month clerk has been
known to spend his entire time at an asylum while
acting as trustee without salary, and the loss of his
clerkship was taken quite philosophically. One of
the sixteen county commissioners who were subse-
quently indicted under what was known as the "omni-
bus boodle " finding, neglected his small saloon in
Chicago to reside at the county asylum altogether.
He escaped to Canada too soon in his career to have
saved much money. An Indiana asylum trustee dis-
played more " executive ability " than the rest by
placing $100,000 of asylum funds in his carpet sack
and traveling northward, without the preliminary
bother of obtaining percentages for asylum supplies
from bribing merchants.
All asylum trustees are not dishonest, but the sys-
tem is sufficient to develop whatever dishonesty may
be latent in some, through the opportunities afforded.
Under the New York State Care Act of 1890, separate
institutions for the chronic insane were abolished as
pernicious, and Illinois in 189(5 erects just such an
institution.
The death rate in New York asylums has of late
years been remarkably decreased by regulations that
restricted the chances of political stealing.
Dr. Carlos F. MacDonald, the president of the New-
York State Commission in Lunacy (Alienist ami
Neurologist, July, 1896) relates that the changed
system in that State enabled a saving to the tax pay-
ers of $300,000 over the previous year. The cost of
maintenance for the fiscal year 1892-3 was $216.12,
and in 1891 the per capita cost dropped to $184.84, a
reduction of $31.28. The supervision of all expenses
by a thorough system of scrutinizing public asylum
expenditures in a business-like manner cut off nearly
$500,000 a year from what formerly went to politi-
cians, and the patients now have some of the
remainder.
All per capites in the United States are too high in
the aggregate, and the insane could live as well cm
one-half of what is appropriated for them, were the
politicians' hands taken out of the treasury.
A State board of public charities without pay,
except for its secretary, has ostensible supervision of
accounts in Illinois, but the members have not the
time to spare for anything like careful supervision,
and are thwarted in every way possible in attempts to
thoroughly understand the expenditures. In no one
of the biennial reports of this board is there evidence
that proper access to Cook County public charity
expenditures was afforded the board. Immediately
before the celebrated " boodle trial," which showed
the most reckless plundering of the public funds by
the county commissioners, the State board reported
that the county accounts were correct.
The intriguery, waste, extravagance, plotting, riot-
ing, neglect of duty, insolence of employes, disregard
of the needs of patients and of medical care, the
"doping" of patients by attendants, and frequent
instances of personal abuse, the insufficient cooking
of insufficient food, with the thorough " cooking " of
statistics and accounts, the high death rate and low
recovery rate, the crowding of several violent patients
in one room, and multitudes of other discreditable
affairs, must be witnessed to understand how deep-
rooted and arrogant a hold the political spoils system
has upon the country.
And there would be no bribed were there no bribers.
The merchants who divide public plunder with politi-
cians, and the citizens who look complacently on, are
equally guilty.
1896.]
TREATMENT OF THE INSANE.
899
A physician seeking an appointment to insane asy-
lum service asked a veteran alienist what steps were
necessary, and was advised in all seriousness to make
the acquaintance of the nearest saloon-keeper.
The number of gamblers and liquor sellers who
hold offices of all kinds in connection with public
charity disbursements indicates the influences at work
in American politics. When surprise is expressed
that such selections should be made, it is claimed that
such persons are as honest, capable and deserving as
merchants and board of trade dealers, many of whom
evade tax i>aying and seek nefariously profitable com-
binations with politicians to furnish supplies to asy-
lums, hospitals and poorhouses.
The fact remains, however, that there iB nothing in
the occupations of the liquor dealer and gambler that
specially tits them for caring for the public insane
and their funds, beyond the mere superior ability to
control such appointments afforded by the faulty pri-
mary election laws, which legislators would speedily
remedy, were it not that their own places would be
jeopardized by such changes.
Hut asylum management by such classes is merely
a legitimate outcome of the general spoils system
operation: the helplessness of the sick and insane
affording the best opportunities for brutality and
rapacity. The privations, sufferings and frequent
murders of insane patients are strictly logical out-
comes of the pernicious system which fills our legis-
latures. State, county and city offices with gamblers
and saloon-keepers, who swagger about in vulgar jew-
elry and attire, openly congratulating one another
upon some recent success in prostituting public and
private interests. All such matters are familiar to
citizens who have the power to make reformations,
but do not intelligently combine to make them.
Reports of the State Board of Public Charities
for Illinois are rilled with accounts of the insane
in various counties being treated more as animals
than as men and women, neglected, abused, chained,
locked up in nakedness and filth, no medical or per-
sonal attendance, packed in rooms too small for their
numbers, with poor ventilation and foul odors, no
separation of the sexes, insufficient food, and myriad
other such matters are officially mentioned in these
reports to the governor and legislature, without influ-
encing the least improvement.
The charges sustained in the 1886 investigation of
the Cook County asylum were:
1. Cruelly insufficient provision for the insane in
the county asylum in all respects, when more than
ample funds are alleged to have been used by the
management of said asylum for the care of the insane.
2. Abuse of said insane by said management, said
abuse being direct and indirect, by personal violence
and neglect.
Subsequent to this report to the governor, a county
court investigation on the petition of Julia Willard.
May 13, 1889, was made in which witnesses detailed
murders and abuse of patients, their starvation and
the brutal nature of the management. Patients were
made to work for the profit of attendants, their cloth-
ing was stolen and sold to saloon-keepers; fighting,
rioting,, feasting and drunkenness of politicians were
narrated, with no apparent difference in the conditions
since the State board report of 1878, except in
enlarged opportunities for brutality. In that docu-
ment the county farm was characterized as full of in-
stances of neglect and ill treatment and that " party
politics, trading votes and speculating" contributed
the chief employment of employes.
After the 1889 investigation it was considered safer
to give no physician an opportunity to bring matters
to light, so a lay warden hires the doctors and keeps
them under sufficient control to prevent complaints
getting to the public.
In 1895, as a sample of many instances, two attend-
ants were on trial in Chicago for kicking a patient to
death; an "investigation" was made by the commis-
sioners, who duly whitewashed themselves, and by
publishing hundreds of columns of newspaper inter-
views, and vaporings generally, managed to confuse
everyone and tire out the public. A New York legis-
lative inquiry into the killing of a patient came to
nothing through the report of the committee being
stolen.
Physicians alone are competent to understand the
real wrongs of asylums and even they must reside the
greater part of a year in such places before they can
fathom the real condition of things, which every
ingenuity of political intriguery is invoked to conceal.
A favorite resource of politicians when attacked for
malfeasance or inhuman violation of trust is in divert-
ing public attention from themselves by personal
onslaughts made upon their accuser.
Nothing seemingly could be further apart than dis-
cussions of gambling and the care of the insane, but
the most amazing incongruities are seen in the results
of political control of offices. The successful mana-
ger of politics, "the boss of the machine" in a great
city, is often the head of a large gambling resort with
a saioon and other immoral accompaniments attached,
affording rendezvous for his lieutenants in plunder-
ing schemes. These " bosses" are great organizers,
and exert as complete control over primaries, nomina-
tions, elections and office conferring, as though they
actually owned the State and its revenues. Adepts in
manipulating election machinery and playing upon
the passions, ignorances, and prejudices of the popu-
lace, they have defied attempts at their overthrow and
continue to divide municipal and other governmental
funds and places among themselves. Opposition is
crushed in every way by corruption, or discomfiture
of whoever is rash enough to attempt reform in a prac-
tical way, even to the destruction of individuals.
Windy addresses on reform measures do not disturb
them in the least; they can even make such demon-
strations themselves, and in the name of reform
increase their power for evil. It is when actual inter-
ference with their robberies are made whether through
interposition in behalf of the sick, insane and paupers
whose funds they control, or otherwise, that the hand
of the " gang" falls heaviest, and the motives and
character of the reformer are assailed. Nor is there
hesitation over a mere matter of assassinating too
troublesome an opponent. Political murders have
been numerous and successfully concealed, the party
who makes exposures is adroitly made to appear in
the wrong so as to alienate public sympathy from him
if his murder comes to light.
In the Chicago Inter Ocean, Nov. 4, 1884, appeared
an appeal from a physician at the county asylum stat-
ing the atrocities there and asking " all respectable
men to be sure that the county commissioners for
whom they voted owed no allegiance to gamblers and
thieves."
The doctor was promptly shot at and several other
attempts were made upon his life and as he kept up
900
TREATMENT OF THE INSANE.
[October 24,
the fight ten years he was finally pronounced to be
insane by politicians in general, and certainly from
the standpoint of a community which condones rob-
bery of the helpless, the one who refuses opportuni-
ties to steal from them must be out of his environment
and practically a crank.
The mental construction of most of these politicians
is such that they can not conceive of mere profess-
ional devotion and enthusiasm. A physician who
would lay claim to being actuated by a desire to sci-
entifically advance humane measures is looked upon
as a brother hypocrite and demagogue. Honesty is
inconceivable except as defective intelligence. The
refraining from stealing public funds is considered as
mere want of smartness enough to know how to do so.
It often befalls that an ousted administration busies
itself in inventing occasions for spitework with a view
to possible restoration to power, so it is not all accu-
sations against the ins by the outs that can be
believed.
Deaths of patients by violence afford chances, about
election periods, for exposures. In such investiga-
tions the mode of appointment of all officers and em-
ployes should be inquired into as affording ideas of
the animus and discipline of the place. The incen-
tives of charges and the inevitable counter charges
need deep probing, as well as does the construction
of the investigating body, its interest in the investi-
gation and liability to bring out the truth or cover it
up. Deposed administrations have been active in
arraigning their successors for real or imaginary mis-
deeds, and upon rare occasions some one has insti-
tuted charges from genuine reform motives, but even
these reformers are apt to be jealous of one another
and instead of supporting, detract from and disparage
each other's efforts.
Brutal natures are common enough and it is not
remarkable that many of their possessors find their
way into asylums as attendants in reward for services
performed at the polls for those who appointed them.
When a murder occurs at an asylum the first question
should be: Who appointed the murderer to his posi-
tion? and full light should be thrown upon the char-
acter of the office giver, to disclose the entire respon-
sibility for the commission of the crime.
These weakest and most helpless of humanity are
not only liable to be neglected through their filthiness,
repulsiveness and burdensomeness, but their irrespon-
sible aggressiveness has often aroused the brutal retal-
iation of the none too patient or considerate savage,
who. all too often, happened to be in charge.
The influence of the saloon-keeper and gambler in
placing these characters where they can safely exercise
their low instincts, is easily seen. Many liquor deal-
ers and gamblers are, as they claim to be, as good as
many in other occupations that are regarded more
respectable, but from their numbers in official life it
would seem that they are considered to be even better.
When the liquor business is responsible for so vast
an amount of crime, insanity and pauperism, does it
not seem cruel that liquor dealers should thus be per-
mitted to chase their victims to the grave?
A phase of the wrongs endured by the insane occurs
in the blunted conscience of the people in accepting
the misappropriation of public funds as a matter of
course and even furthering by their votes a deter-
mination of which particular band of plunderers shall
have charge of the spoils.
The merchant who connives with political spoilsmen
to sell inferior materials at extravagant prices to public
institutions may carouse with the business agent of
an asylum and both find happiness in their divided
gains, and the thought that life, health, sanity, has
been taken from patients through depriving them of
what was intended for their care, apparently does not
disturb their commercial minds, but the physician
who sees patients dying from drinking sour milk and
eating rotten meat and vegetables, and from the want
of a few simple remedies, or from insufficient warmth
because the clothing and fuel accounts had been
manipulated with political " executive ability;'" the
physician who witnesses such things sees clearly who
is to blame for the privations, deaths and horrors all
about him, while observing the flashy dress and jewelry
of the vulgar feasting politicians who have divided
almost openly the money lavishly appropriated by the
people for maintenance of the unfortunates.
The cohesion of the spoils system in its immense
ramifications is almost incredible. Its beneficiaries
surround public hospitals and branch out into com-
mercial and social life in all directions. The dema-
gogue relies upon the true condition of things not
being understood by the people at large.
All the asylums of America are not badly managed,
but the present political system does not encourage
humane care of the unfortunates. An occasional hos-
pital for the insane is well managed in spite of the
prevalent bad system, but there is constant danger of
a political change driving out the honest and capable
from such places.
With civil service reform there should be the great-
est publicity demanded for all asylum affairs. A
visiting staff of specialists should be appointed in
spite of the fears of some trustees that the world
would thus be too readily informed of asylum short-
comings. There should be strict scrutiny of the
accounts and a check system adopted that would dis-
courage dishonesty. Banks overhaul the books of
their clerks and railways multiply checks upon their
agents, but with all such precautions the ordinary
mercantile and manufacturing organization is occa-
sionally robbed. Were the defective accounting sys-
tem in use in State and county affairs to be allowed
by all business men and private corporations failures
and industrial wreckage would be universal.
Civil service laws properly enforced would be
directly instrumental in restoring thousands of the
insane to sanity, who, under the present faulty system.
are doomed, and further murders of patients by politi-
cally appointed brutes would cease. When the politi-
cians' profits were reduced by $30 per capita in New
York State the death rate in asylums fell greatly and
the recovery rate rose.
Reforms, as well as institutions, evolve and a more
scientific treatment of the insane will come with other
advances in the world's affairs. But, for the present,
we can look for no radical improvements in asylum
matters until civil service rules are firmly established
therein, which can scarcely be hoped for until the
primary election methods admit of honest candidates
being secured for all public offices, an achievement
which means no more or less than the destruction of
the power for evil now defiantly exercised by the gam-
bler and dram-seller.
Herbert Spencer says: "Any system that confers
the rewards for merit upon the undeserving is demor-
alizing and destructive of social advance," and, "though
all efforts for reform are out of proportion to the
1896. 1
PERTUSSIS AS A NEUROSIS.
901
results. the reformer may take comfort in the knowl-
edge that the little thai is accomplished will endure."
TO State Street.
PERTUSSIS AS A NEUROSIS-
Kuud iu tin- Bectionon Diseases ol Children, at the Forty-seventh
Aniiiinl Masting of the American Medlenl Association.
lu'ia at Atlanta, Ga., tfaj i g, tsae.
i;y s. j. radclippe, a.m., m.d.
MKMliFK IMEB1CAN MEDICAL ASSOCIATION, MEDICAL ASSOCIATION, D. C,
BK1T1SI1 MKl'H'W. ASSOCIATION, KTC.
t vslll\i;TON, D. C.
The pathology of pertussis has long been in doubt;
this is well shown by its varied and uncertain thera-
peutics. The definition of the malady is usuallj
based upon its most prominent symptoms —the char-
acteristic paroxysmal cough and consecutive whoop.
The cause of this characteristic cough and whoop has
never been positively located. It is said by some to
be a local irritation involving the pharyngo-laryngeal
space, set up by some external influence, possibly bac-
terial; some, that in addition the morbid irritant is
absorbed through the lymphatics and blood vessels
and produce a systemic febrile state, and some that it
is a vague oommingling of various elements, local and
general, physical and nervous, and still others that its
phenomena are entirely reflex. There is no doubt
regarding its infectious nature, but the peculiar mode
of this infection is still veiled in uncertainty. It may
be from exhalations from the vomited matter or
expectorations, the breath, the cutaneous surface, or
from all.
Whooping cough may be, or may not be of bacte-
rial origin. It is not yet proven that it is. Certainly
no bacillus of pertussis has yet been isolated, and
therefore no diagnosis can be based upon a bacillus as
ti factor in the etiology of the disease.
Negatively, and practically, no treatment of a purely
bacterial nature has been of any avail. Whatever
benefit that has been derived from germicides has
been by abtunding the terminal branches of the
nerves supplying the parts involved, or the parts
treated, and have only a local effect, without reaching
the source of the nerve energy, its prominent feature.
On the other hand, the only remedies beneficially
affecting the disease are those that have been consid-
ered of a constitutional nature, those that have been
directed to the nervous element upon which it is
believed to be grounded.
The subjects of whooping cough are notably those
coming from neurotic families. They have descended
on one side or the other, or sometimes from both of
the parental lines, from generation to generation, from
neurotic ancestry, through children and children's
children, the concentration varying in individual
cases.
By careful inquiry it will be found that full 75 per
cent, of the subjects of this trouble are neurotics in
the more or less strict sense of the term, by heredity
especially, or it may be by occasionally from acquired
habit; and when we consider that as many or more
escape the disease than contract it, more are naturally
immune than susceptible to it, this view of the sub-
ject comes out in strong relief and merits our closest
attention. No stronger proof is necessary to nega-
tive its local origin, or illustrate the resisting power
inherent in those exposed to its attacks. Those who
escape are made of different stuff, but those attacked
exhibit the nervous characteristics and conditions of
typical neurotics in every phase of life — are easily
alarmed, are easily depressed, or impressed for good
or ill, are easily moved to tears or excited to anger;
their sleep is most always disturbed; they suffer from
enuresis, impaired or arrested digestion from shock or
fright, are easily agitated and prone to convulsions,
which are often produced by very slight causes.
If pulmonary symptoms are associated with the
disorder, death is apt to occur from interference with
the respiratory act, through the dominating nervous
element. It may cause, during a paroxysm, inhibitory
spasm, and, compressing the chest walls, induce
asphyxial convulsions and death, or by violent action
of the heart muscles increase the hyperemia, over-
fullness, congestion, or cause the complete arrest of
the pulmonary circulation, and by sequence the res-
piration, and death by apnea.
Another very important feature of the disease is
the possibility that it is sometimes associated with or
may lead to glycosuria. It is contended at present
that this reference is merely one of suspicion rather
than one of fact; yet if we survey the whole field of
investigation, and the peculiar symptoms of some of
the cases we have had under treatment, where the
issues were not plainly developed, our suspicions may
be more than verified, by a close comparison of the
results of such cases with those symptoms referable
to glycosuria. It certainly does not conflict with the
theory of Pavy, that it (glycosuria) is due to want of
assimilation, for want of assimilation is due to ner-
vous influences.
This feature of the malady has been very largely
neglected, overlooked, or possibly ignored as of little
utility in the examination of cases presented for treat-
ment. But you will be surprised to find, if careful
and proper examination or inquiry is made, how fre-
quently glycosuria is present in given cases, especially
in the severer types of the disease. It is not claimed
that this condition is constant or permanent. It
may be transient, and frequently a very delicate test
is required to detect it. Though the literature of the
subject is at present meager, indeed there is none to
be relied on, the indications are so apparent that it
may be confidently suggested that investigation
on this line would lead to profitable and important
results.
I doubt if one physician in a hundred has had his
attention called to this particular aspect of the matter,
or if he thinks it worth while to examine the urine of
a child under his care, suffering from pertussis. He
usually takes it for granted that it is a child's dis-
ease, has its period of incubation, onset, acme and
decline, and watches to see it pass from one condi-
tion to the other, rather as an interesting pathologic
process, than as a disease to be combatted at every
step, from center to periphery. He is therefore apt or
inclined to ignore or disregard all symptoms except
those in sight, and limit his therapeutics to the local
manifestations, as if they were all of the affection.
We do wrong if, in framing our diagnosis, we leave
out of view other organs which may be involved,
either primarily, or in the course of the disease, espe-
cially such vital organs as the kidneys and their func-
tion and products, if we fail to discover or decide as
to the appearance of sugar in the urine, and its pos-
sible occasion of diabetic conditions, as coma, dyspnea,
or pulmonary edema, which are generally looked upon
as the result of the inflammatory process.
Glycosuric phenomena in whooping cough are
usually slight, and as a general thing play a very
902
SPINAL INJURIES IN INFANTS.
[October 24,
unimportant part in the complications, or, I might
say, in the development of the affection, and on that
account may be easily overlooked. It is usually tem-
porary, as desquamative nephritis is in scarlatina.
Yet that it may and does occur to a greater or less
extent, this is quite sufficient, as said, to emphasize
the suggestion and point attention to it, that we may
in the future properly consider its probable immedi-
ate or remote tendencies and results.
Glycosuria is not properly a complication any more
than endo- or peri-carditis are complications in inflam-
matory or articular rheumatism, or, as now taught,
rheumatic fever. It is a part of the disease, as neph-
ritis in scarlet fever, and pulmonary extension in per-
tussis and measles, and originates from the same
cause, so that in treating a case of whooping cough,
it is well to have in mind all the symptomatic mani-
festations which may be developed in its course — those
that are so far well known and appreciated, as well
as the possibilities of some others, not perhaps in the
category of direct symptoms, but which may be
elicited by careful inquiry pursued in the right
direction.
It may be, therefore, worthy of renewed emphasis
that, if glycosuria is eminently and correctly of ner-
vous origin, affecting primarily the nerve cell and its
proliferations, no discussion of pertussis with this
accompanying symptom of glycosuria can be com-
plete without including the nervous element, at least,
as one of its factors.
Another consideration worthy of notice is in regard
to its therapeutics, that is, that all the best remedies
or treatments heretofore instituted for the relief of
pertussis, have been those known to have beneficial
influence in all diseases of a nervous type, as neuras-
thenia, hysteria and the like. The remedies, therefore,
that do the most good are those that are directed to this
end, and the nearer we come to correcting the condition
at the seat of action, the nervous centers, whether
it be from impaired nutrition, imperfect cell pro-
liferation, antagonism of nerve elements or forces, or
retrograde metamorphosis, the nearer we will come to
perfecting our therapeutics of pertussis.
Those therapeutic agents recognized as anti-spas-
modics are the ones mostly relied on in treatment and
management of pertussis — all those medicinal agents
which act primarily on the nervous system, either
immediately or remotely, that deaden the sensibilities,
have an inhibitory and quieting effect either locally
or generally. Local applications relieve, not by
destroying germs, but by lessening the irritation and
distress of the sensitive parts. They have no con-
tinued or permanent effect upon the course of the
affection, they only temporarily obtund the sensible
terminal nervous filamants distributed to the immedi-
ate seat of the mucosa to which they are applied.
They constringe the capillaries, lessen the blood sup-
ply, quiet the irritation, diminish the tendency to
paroxysmal cough, to closure of the glottis, and the
characteristic whoop. So soon as the local effects
wear off the symptoms and paroxysms are the same as
before. Local treatment can only have a tentative
result, unless persisted in without interruption dur-
ing quickly repeated intervals. Only permanent ben-
efit can proceed, and cure result from constitutional
treatment.
It would be useless and profit but little to enumer-
ate all the remedies prescribed in the treatment of
pertussis: there are legions of them. It will suffice to
mention a few of the most recent and popular, or
those which seem to have given the best results,
namely, bromoform by inhalation; antispasmin, nar-
cein sodium, and sodium salicylate one-sixth to one-
fourth grain three or four times daily; phenyl-gly col-
late of antipyrin, formaldehyd, quinin in large doses;
cocain in doses of one-sixth to one-third grain three
times daily, and vaccination, which is said to have no
effect on those who have been vaccinated. Some
others are still employed, as antipyrin in laurel water,
belladonna, atropia, potassium and sodium bromid in
decided doses, assefetida, valerianate of ammonium,
valerian, infusion of red clover blossom, and chestnut
leaves and extract. Most of these are administered
internally and have a general effect. Some are
applied locally for immediate results. It is agreed
they are all of about the same nature, and we have
the same object in view in their employment. Those
that have a constitutional bearing reach the nervous
centers, and indirectly medicate locally through the
blood current and the nerve supply, and by this
means set up an equilibrium or healthy action through-
out the system.
Spraying the throat and fauces with cocain, anti-
pyrin, potassium, bromid, carbolic acid and the like,
aid materially in the treatment, but as said, have only
a temporary action, and are not relied on as would be
the case if the disease was simply and only of local or
bacillary origin. Spraying with peroxid of hydrogen,
as recommended, could hardly be placed on the list of
successful remedies, unless there were pus germs
present. Spending time in a gas house, at one time
in vogue, has been abandoned as not favorably affect-
ing the disorder.
The main point to have before us in the treatment
of pertussis is the general health of the patient.
This will be most undoubtedly aided, and the cure
facilitated, by the patient living as much as possible
in pure, open air, by diversions of any kind, and by
all means that have a tendency to elevate the stand-
ard of health.
The object of this paper is more suggestive than
argumentative, with no pretense to completeness, and
with no effort at detail. Its symptomatology, and
course and deviation from a typical standard, are too
well known to be rehearsed, and statistic information
is too uncertain a quantity to be of any relative
value.
SPINAL INJURIES IN INFANTS.
Read iu the Section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association
at Atlanta. Georgia, May 5-8, 1896.
BY JAMES PORTER FISKE, M.D.
Instructor in Orthopedic Surgery, New York Post-Graduate College and
Hospital; Assistant Surgeon Roosevelt Hospital, O. P. D.;
Attending Physician Children's Department
Northwestern Dispensary, New York.
The subject of spinal injuries in infants is pre-
sented to you in order that a discussion by this body
of these injuries will determine their relation to the
faulty development of the spine in the young, and to
determine the relation between trauma and spinal
caries.
The "traumatic spine" may be defined as any
injury to the spinal column. Injuries to the spine in
the very young are not infrequent, though the great
majority of such injuries are slight, A simple sprain,
muscular or bony contusion, sometimes combined
with slight shock, is the usual condition following a
1896.]
SPINAL IN.URlKs IN INFANTS.
903
slight fall as from a cot or sofa. Again a very slight
fall or sudden contact with a sharp corner of an object,
may produce a true fracture of the spine, usually a
fracture of a spinous process. If a child falls and
strikes sideways we may have a green-stick fracture
of one or more ribs with twisting of the bodies of the
vertebrae, presenting a clinic picture of "acute rotato-
lateral curvature" or scoliosis.
While many of these injuries are more or less
quickly recovered from, a certain proportion will con-
tinue to give symptoms of pain, irritability and
malaise. A slight jar or wrench may so injure liga-
mentous structures that symptoms persist for a long
period of time, both in adults and children, and such
injuries in children may be an etiologic factor as
regards the faulty development frequently seen in
this region, as in curvature of the spine. To the sur-
geon who persists in making an exact diagnosis, these
cases are trying and unsatisfactory, as every injury to
the spine, whether severe or slight, must of necessity
be somewhat obscure. The name "traumatic spine"
is particularly applicable, as it is frequently impossi-
ble to classify spinal injuries as sprains, muscular con-
tusions, rupture of ligaments or even fracture, unless
the ease readies the operating table or the autopsy
room.
The results of an injury, mild or severe, to the
spinal column can never be foretold, but to the rapidly
growing infant such an injury may be most disas-
trous. We obtain a history of traumatism in about
50 per cent, of Pott's disease, and when we remember
that many children apparently in perfect health are
the offspring of tuberculous parents, and that such a
child has an innate susceptibility for tuberculosis, or
more probably has a latent tuberculosis waiting sim-
ply for a traumatism at a suitable site before firing
up these considerations should lead us to treat such
cases not by observation, as is so frequently done, but
by fixation and protection. A previous injury is often,
1 believe, the predisposing factor in the production
of spinal caries.
Though it is not generally recognized, I believe
that traumatism is an important etiologic factor in
certain cases of rotato-lateral curvature, and if we
could obtain a clear early history, many so-called idio-
pathic scolioses in children could be shown to follow
the traumatic spine. Unilateral muscular rigidity,
an attempt by the patient to assume the position of
greatest ease, a slight bending of one or more ribs,
are in themselves sufficient to stimulate a faulty devel-
opment of the spine in the rapidly growing infant.
The examination of an infant suffering from a sup-
posed traumatism of the spine should be as though
we were trying to detect early Pott's disease. The
■child is undressed and the posture noted, placed on
the table face downward, and spine examined to detect
any point of tenderness, ribs each side examined to
detect any contusion or bending, feet and pelvis care-
fully raised to note any rigidity or diminished flexion.
Pain on pressure, rigidity of the spine and increased
irritability of the patient, point to the diagnosis of
"traumatic spine," and as such demands treatment by
fixation and protection.
The necessary fixation and protection in infants is
most readily, efficiently and cheaply obtained by
a starch-jacket. It gives absolutely no discomfort, is
not heavy, and it can be applied by any one in a few
minutes. The material used is wide-meshed, well-
starched bandage about four inches wide. The body
of the infant is enveloped in seamless shirting from
the axilla to well below the pelvis. The starched
bandages, after being soaked in water, should be
squeezed as dry as possible and then applied. The
starch-jacket may be applied by the hammock method
and should be in the more serious injuries, but as a
rule I have extension and counter-extension made by
having the child held in the horizontal position, face
downward, one assistant making traction at the axilla,
a second pulling the thighs at the great trochanters.
Every jacket should extend from the axilla down to
the great trochanters. After a sufficient thickness of
the starch bandage has been applied, the ends of the
seamless shirting are turned toward and over the
jacket, thus insuring a smooth and soft border to the
jacket. The child is now lowered on a soft pillow and
the jacket allowed to set. It will take some time for
the starch bandages to harden, but as a rule the child
will rest quietly for a few hours. The starch -jacket
is quite elastic, firm and considerably tighter than
plaster of paris, and is admirably adapted to the trau-
matic spine in infants. As a matter of cleanliness,
and for the proper care of the skin, the starch-jacket
should be removed at the end of a week, and if indi-
cated another applied, though I have kept one con-
tinuously applied for three weeks. This jacket is not
to be cut down the front, but is intended to stay on
as applied.
The following case is reported as it represents some
of the points brought out in these notes:
W., age 26 months, traumatic spine, green-stick fracture of
fifth and sixth ribs, near the angle, acute scoliosis, fine
healthy boy, fell from nurse's arms. First saw case on third
day of injury. Pain and swelling over and to the left of spine
over fifth to seventh ribs. Careful examination revealed a
green-stick fracture of two ribs in this region, as well as a con-
tusion to the spine. The child in assuming the position of
greatest ease, showed a lateral curvature. The child was held
in horizontal position, considerable extension made, and a
starch jacket applied. Before application of the jacket the
child was in constant pain and distress ; after application the
child was very quiet. The treatment was continued for six
weeks. At the end of this period all symptoms had disap-
peared, but at the site of fracture of the ribs some thickening
remained. The mother wrote me some months later, stating
that the child was well in every respect. Sufficient extension
was made in this case, so that the spine was absolutely straight
before application of the jacket.
I shall refrain from reporting any other cases as I
expect later to exhibit some statistic tables and these
notes are presented to you in this form simply as a
preliminary to your discussion.
In speaking of the prognosis of any injury, several
factors are of importance in determining the probable
outcome. The condition of the child before the
injury, the existence of a cachexia, a possible latent
strumous diathesis, the hygienic surroundings, are in
themselves sufficient to turn the chances in one direc-
tion or another, whether we shall have an early recov-
ery or a tedious and prolonged convalescence.
The relation between injuries and tubercular pro-
cesses in joints is of great interest. Modern path-
ology, coupled with careful clinic observation, seems
to have established pretty thoroughly that many
tubercular processes have their birth in a previous
traumatism, it being assumed that a tubercular taint
was a concomitant condition. The relation between
prolonged muscular spasm or irritability following a
traumatism and faulty development of the spine
in the rapidly growing infant has already been
referred to.
My observations have led me to adopt the follow-
904
ANGIO-NEUROTIC EDEMA.
[October 24,
ing rule: Any injury to the spine in an infant
which requires treatment, requires the starch-jacket.
Lotions should never be countenanced until the
symptoms have subsided by the proper use of fixation
and protection.
ANGIO-NEUROTIC EDEMA.
Read in the Secrion on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meetlug of the American Medical
Association, held at Atlauta, Ga., May 5-8, 1806.
L. HARRISON METTLER, A.M., M.D.
CHICAGO, ILL.
Though the pathology of angio-neurotic edema is
still a mere theory and its treatment a source of con-
tinual disappointment, the affection itself is of suffi-
cient importance and its occurrence of sufficient fre-
quency to warrant further study. In the American
Journal of Medical Sciences for December 1892, is
an account of the disease, by Collins of New York,
which is the most complete of the more recent
descriptions. Dr. Collins' paper is based upon some
seventy-five cases gathered from literature and per-
sonal observation ; to which I can add two more, one
having been under my care for about two years. The
history of this case is as follows:
A married woman, 64 years of age, white, the mother
of one child living. I was consulted by her in July,
1893. Her family history revealed nothing of special
note. Her own general health had always been fairly
good except for a certain nervousness and mental
depression brought on by financial losses and worry.
The climacteric had come and gone without producing
unusual distress. She was not naturally a neurotic,
though her nervous organization was an active one.
There were no cardiac or pulmonary manifestations.
The special senses were all unaffected. There was no
pelvic trouble; no signs of disease of any of the
abdominal organs. Urinary analysis revealed noth-
ing abnormal. And yet in spite of all this negative
testimony, for a year or more before I saw her, she
had had frequent peculiar attacks of dyspnea, " dis-
tress" in the stomach, followed by violent eructations
of gas, cyanosis of the extremities, chilliness, great
mental anxiety and a horrible fear of sudden dissolu-
tion. These attacks would appear without the slight-
est premonition. Day and night were alike favorable
to them, though the majority of them came on
toward early morning. So often did they awaken her
out of sleep toward daybreak that she dreaded going
to bed, and tried the expedient of having her hus-
band arouse her if he were awake at about the time
they usually came on. Conjointly with these spells
appeared sometimes, large, circumscribed, edematous
spots in various parts of the body, mostly on the arms
and legs, occasionally on the face and epigastrium.
They resembled giant hives, itched slightly, caused
no pain or other sensation than that of slight tension,
were raised above the surrounding skin and were of
the same color, pitted feebly upon pressure, and were
devoid of all signs of an inflammatory nature. Some-
times they would disappear from one part of the body
to reappear a few hours later at another. They have
lasted at times from several hours to several days.
Their disappearance was generally as abrupt as their
appearance. Singularly enough when these edema-
tous swellings would appear, the abdominal distress
and depression of spirits seemed to be somewhat
relieved; and later on the patient would walk vio-
lently up and down the floor or pass into another
room with a different temperature, in the hope of pro-
voking the swellings and thus ameliorating the nervous-
distress of the attack. I have seen her try this sev-
eral times and though I am at a loss for an explana-
tion, I have been an eye-witness of the relief striven
for. When the edematous spots had finally vanished
and the attack had come to an end, the patient would
seem to be almost overcome with extreme exhaustion-
She would sigh heavily and lie for a long time per-
fectly motionless. Even conversation seemed to be
an effort and if left alone she would soon fall into a
sound slumber. During this period of exhaustion I
could not detect any actual difference in the number
or strength of respirations or heart beats. The patient
constantly denied all aura? such as globus hysteri-
cus, etc.
For her trouble the woman had consulted a number
of physicians in the United States and in Canada ;
had received many opinions, but had never been
afforded any permanent benefit. Her appetite was
good; her tongue clean ; her bowels regular. There
were no indications oi gastric catarrh. She was a
sound sleeper and not much of a dreamer; when she
did dream, however, her dreams were decidedly of the
distressing, morbid sort. Latterly she became very
melancholy and much depressed in spirit, especially
about the apparent incurability of her disease. She
suffered no paresthesia save the slight itching of the
edematous enlargements. There was no spinal tend-
erness; no abnormality of any of the reflexes. After
one of her attacks there would be an abundant dis-
charge of urine. Under my direction she patiently
and faithfully tried a long list of nervins, antispas-
modics, general tonics, and methods of general treat-
ment such as electricity, hydrotherapy, etc. There
was no permanent benefit from anything. A change
of environment and a short trip into the country
seemed several times to keep off the attacks for awhile.
Of all the drugs and chemicals tried, salol and the
salicylates, especially the salicylate of soda, appeared
to lessen the number and shorten the duration of the
attacks. While taking these remedies the spells only
came on in the morning and lasted but a few hours.
Though the most effective of all the remedies used,
even these ultimately lost their power.
Recognizing the hysteric semblance of the trouble,
I informed the husband of the same and we tried
every possible means to divert the patient's mind
from herself, such as forcing her into a regular occu-
pation and congenial companionship. For a time this
promised a happy result, the patient being for awhile
less melancholy and depressed: but ere long we were
discouraged to see a return of the old attacks, espe-
cially the shortness of breath, the gastric distress and
the occasional swelling about the feet, hands and chest.
I warned the family of the possibility of a fatal suffo-
cation from sudden edema of the glottis. By and by
the attacks became so frequent that the woman
refused to lie down at all at night but insisted upon
sleeping in a chair. At the same time the most care-
ful examination showed no disease of the heart or of
the kidneys. The patella reflexes seemed to be slightly
diminished. She complained of much weakness,
coughed a trifle without expectoration, said her throat
was very dry and exhibited a flushed countenance and
red tongue. She revived and for several weeks seemed
almost well again. On Oct. 12, 1894, she became
much excited from some unknown cause. The pulse
rose to 100, the temperature remained at normal.
1896.]
ANGIO-NEUROTIC EDEMA.
905
Respirations wore rapid ami shallow. There was loud
complaining of distress ox fullness in the stomach.
She paced the Boor vigorously to bring on, as she
said. " one of her old spells.'* as they at least gave her
relief from the nervous distress. At odd moments
.she would try to remove a ring whieh she supposed
was on her finger or to brush invisible objects out of
her lap. thus revealing slight visual hallucinations.
On Nov. 29, 1894, 1 learned that the woman had been
seized one night with one of her old attacks and had
died of suffocation before the physician who was
summoned in the neighborhood was able to do any-
thing. There was no autopsy. I think the diagnosis
of angio-neurotic edema was perfectly justifiable in
this ease.
Angio-neurotic edema, first definitely described by
Quincke and his pupil, Dinkelaeker, is chiefly
remarkable for the circumscribed swellings that
appear on the face, neck and extremities, without
apparent cause or previous warning. For this reason it
has sometimes been called periodic Swelling, url 'it-arid
tuberosa, giant swelling. There is almost always
present gastrointestinal disturbance, which is proba-
bly of an edematous nature like that of the exterior
of the body. The mucous membrane of the larynx
may be the seat of the sudden edema and so cause an
alarming dyspnea or even death by suffocation.
The etiology of the disease takes cognizance of the
early adult aire of the patient, its more common occur-
rence in the male sex. the occupations which tend to
excessive fatigue of mind and body, and a certain nat-
ural or acquired neurotic state of the constitution.
Heredity seems to play a not unimportant role as
shown by the surprising series of cases, all in one fam-
ily reported by Osier. In five generations of this
family twenty individuals were the victims. Krieg-
er*s' case was a young man 25 years of age, whose
mother was similarly affected. Cold and traumatism
«re frequent exciting causes of the attacks. The
former in conjunction with lowered vitality, may
explain to a certain extent why, as in my own case,
the trouble is so prone to appear toward the early
morning before the patient awakens. Unusual mus-
cular exercise will sometimes precipitate an attack. I
have seen a hard day's shopping, the patient passing
from one store to another through the cold wintry air
and climbing flights of stairs, do it.
Jamieson's case, reported by Collins, affords a good
picture of the symptom-group presented by my own.
The patient would be perfectly well apparently, and
perhaps remain indoors all day. Then going out into
the open air toward evening, or taking a longer walk
than usual, she would experience, without any pre-
monition, a sudden attack of dyspnea, which would
frighten and completely unnerve her. Her extremi-
ties would become cold, the perspiration cease, a
slight cough arise and a feeling come on as though
the stomach were suddenly distended. Generally
these symptoms would be quickly followed by the
characteristic edematous enlargements upon the arms
and face. In a few hours the attack would pass off
as abruptly as it came, leaving the patient completely
exhausted. The disease is often associated with hys-
teria, if indeed it is not itself a hysteric manifestation.
For a long time I regarded my case as one of pure
hysteria, for many of the usual stigmata were present.
In some cases, as in the first one reported by Collins,
J Mcditzinskvle Obozrente, 1889. Sajous' Annual.
hysteric attacks preceded for some years the out-
breaks of the edematous trouble. Irregularities of
the menstrual function seem to perform as much a
part in the disease under, consideration as they do in
true hysteria. Collins, Lewin and Quincke cite
instances in which the onset and disappearance of the
migratory edematous swellings bore a certain relation-
ship to menstruation. Amenorrhea was sometimes
accompanied by a monthly swelling of the ankles,
lips or eyelids.
The diagnosis of angio-neurotic edema is not diffi-
cult if the characteristic symptoms are present. These
symptoms are especially the local swelling of the skin,
the gastro-intestinal disturbance and the nervous
depression. The circumscribed edema of the skin is
to be differentiated in this disease by the abruptness
of its onset, its brief duration and its rapid disappear-
ance. Any part of the body may become its site, espe-
cially the face and extremities; and in a migratory
sort of a way, it may vanish from one part to quickly
reappear at another. There may or may not be itch-
ing. It is strictly non-inflammatory, is always more
or iess sharply circumscribed and sometimes is of a
slightly reddish hue. It does not pit upon pressure
like ordinary dropsical effusion, but if firmly pressed
with the tip of the finger it quickly rises to its former
level. As a rule, it gives rise to no annoyance, though
some patients complain of a local sense of burning or
scalding when it begins to appear.
It is probably true that the alarming dyspnea and
associated gastro-intestinal trouble are the result of
the same edematous process going on within the
mucous membrane. Krieger's case, a typical one, was
found dead in bed one morning and an autopsy
showed that death was caused by sudden edema of the
glottis. Collins finds that out of seventy-two cases
three showed their initial symptoms to be located in
the stomach and in 34 per cent, of them all, gastro-
intestinal manifestations were of sufficient importance
to attract notice. The throat was involved in about
21 per cent, of all cases, a fact which should be care-
fully remarked as death has more than once resulted
from edema of the larynx. The stomach symptoms
are generally a sense of uneasiness and extreme ten-
sion, loss of appetite, enlargement of the epigastrium,
colic, and sometimes profuse vomiting and intolerable
thirst. Osier says the pains may become so severe at
times as to require the administration of morphia.
In my case there was at no time any marked pain, but
an intolerable sense of fullness and of retained undi-
gested matter, and a bloated appearance of the epigas-
trium. The patient was generally constipated. A
colliquative diarrhea sometimes follows the disappear-
ance of an attack. The urine is often voided in large
amount, but frequent examination of it reveals noth-
ing out of the ordinary. Complete exhaustion and
nervous anxiety often terminate an attack. It was
with great difficulty that my patient could be per-
suaded that her heart action was normal, so weak and
prostrated did she feel when recovering. Between
the attacks the general health is good.
Angio-neurotic edema is probably related to hys-
teria but the suddenness with which it comes and
goes, the absence of the usual, well-known stigmata
of the latter and other symptoms, all tend to prove
that it is not hysteria itself. It is a functional trouble
of the sympathetic and central nervous systems; but
the cause and character of this trouble are, up to the
present time, entirely unknown. Plausible theories
906
FIBROMYOMA COMPLICATING PREGNANCY.
[October 24,
and shrewd guesses have been made but nothing of
a positive nature has yet been actually discovered.
The disease is rarely fatal and autopsies have been
exceedingly rare. It is most decidedly a chronic
affection, lasting now and then a whole lifetime. It
is happily only fatal in those rare cases where the
edematous process attacks the mucous membrane of
the larynx.
No -remedy has yet been suggested for its relief.
Neither the disease itself nor the attacks are amenable
to any known treatment. The salicylates, especially
the salicylate of soda, have given the best results in
the hands of others as well as in my own. By them
the intervals between the attacks appeared to be
lengthened, but as for lessening the severity of the
attacks or in any way actually producing anything
like a permanent cure I could not see that this or
any other of the long list of remedies which I exper-
imented with, was of the least avail. Angio-neurotic
edema is a unique affection which needs a great deal
more study for its complete elucidation.
4544 Lake Avenue.
INTRALIGAMENTOUS FIBROMYOMA COM-
PLICATING PREGNANCY AT FULL
TERM; HYSTEROMYOMECTOMY;
RECOVERY.
BY RICHARD DOUGLAS, M.D.
NASHVILLE, TKNN.
As the records do not abound with cases of com-
plete hysterectomy for fibroid complicating pregnancy,
I presume a detailed report of the following case will
bear some interest:
Mrs. N., 83 years of age, a multipara; her youngest
child was born five years ago. All labors normal
with uncomplicated convalescence. During the year
1894 there had been some menstrual disorder, irregu-
larity and at times profuse flow. In May, 1895, she
consulted Dr. J. W. McCall for her uterine trouble;
the result of the examination I report in his words.
"I made a digital and specular examination, was
unable to find the os uteri. The right vaginal vault
and iliac region were filled with a hard tumor.'' The
case passed from under Dr. McCall's observation and
was not seen by him again until March 8, 1896, when
he was called in consultation with Dr. Howard. The
patient had then been in labor sixty hours, supposed
to be at full term. Her physicians recognized that
the pelvis was encroached upon by a hard tumor.
This tumor seemed to lie entirely in front of the os
uteri, completely blocking the natural channel. Recog-
nizing the impossibility of delivering the child per
trias naturales, I was telegraphed for, and with my
assistant, Dr. Barr, and nurse reached the patient
about two o'clock on the morning of March 9, seventy-
two hours after the onset of labor.
That my readers may have some appreciation of
the difficulties encountered in a country practice, I
will say that my patient lived in a little box cabin
about 12 x 20 feet, divided by a rude partition into
two small rooms provided with none of the comforts
and scarcely the necessities of life. Amid these sur-
roundings her noble self-sacrificing physicians had
been in constant attendance, doing all in their power
for the relief of the suffering woman, with no thought
of pecuniary reward and with little hope of being
able to save the patient.
Labor had been most violent and exhausting, but
for the last twelve hours uterine contractions had
almost ceased.
Notwithstanding the protracted labor the patient
appeared in very good general condition. Her pulse
was regular and about 120, temperature 101 degrees;
patient remarkably quiet and composed. Physical
examination of the abdomen revealed rather an un-
usual morphology. The abdomen was asymmetrically
distended, unusually broad in its transverse diameter,
widely bulging in the flanks, somewhat flat or
depressed in the middle line. The greatest enlarge-
ment appeared on the left side and above the umbili-
cus. On palpation a round and very hard swelling
about the size of an adult head could be detected in
the right side. The center portion of the abdomen
was soft, elastic and compressible. In the left side
we could easily determine by manipulation a vertex
presentation, the head resting in the left iliac fossa,
occiput to the left, dorsum of child to mother's left,
side, a first position if in axis of pelvis. There was
no uterine contraction in response to our manipula-
tion. Fetal heart sounds could not be detected upon
auscultation; the patient had not felt fetal movements
for twelve hours.
Vaginal examination revealed a capacious vagina;
the entire pelvis was filled by a smooth, hard, inelastic
tumor which was firmly fixed in the pelvis. Every
effort .to raise it upward was ineffectual. The os uteri
was reached with the greatest difficulty; it lay very
high up out of the true pelvis and to the extreme left
side; could not reach the os sufficiently well to pass
the finger beyond the margin of the right border of
the cervix.
Diagnosis. — Uterine fibromyoma springing from
the supravaginal cervix and the right side of the
body of the womb firmly wedged in the pelvis, filling
that cavity, displacing the uterus and occupying the
hypogastric right inguinal and lumbar regions of the
abdomen; pregnancy at full term, amniotic fluid
escaped and the child in all probability dead. Com-
plete uterine inertia from exhaustion and inefficient
contraction due to presence of the growth.
After consultation with my associates it was deter-
mined that an operation was immediately demanded
and that that operation should be in all probability a
complete hysterectomy. We discussed the propriety
of Cresarean section, but the idea of leaving so large
a tumor with the dangers incident to the operation
and puerperal state, were against such an incomplete
procedure. Furthermore, knowing the uterus to be
in a state of inertia, hemorrhage after Cesarean sec-
tion appeared to our minds a danger of great moment.
Therefore determining upon hysterectomy as the only
means of saving our patient's life, and gaining her
consent to anything that we might deem best, we
prepared with such poor accommodations as the place
afforded for the undertaking.
Preparation. — An ordinary kitchen bench with the
filth of ages upon it, covered however by a clean sheet,
was the improvised operating table. The bed served
as a table for my instrument trays, one bowl and
pitcher for sponge basins, and two dimly burning
lamps gave us all the light we had. Fortunately, my
instruments, ligatures, sponges and towels had all
been thoroughly sterilized and we managed to protect
them from contamination. Boiled water in abund-
ance was supplied. Notwithstanding the urgency of
the case, much time was spent in careful aseptic pre-
m
wjm
FlBKo-MYOMA COMPLICATING PREGNANCY AT FULL TERM. Dr. RlCHARD DOUGLAS' OASI.
A, Cervical canal, 4 inches long. B, Os uteri. Reduced one- third.
1896. 1
CATARRHAL DISKASES OF THE NOSE AND THROAT.
'.ii)7
paiation of the patient, and after aseptioising ourselves
as thoroughly as oonditiona would admit, the patient
was anesthetized with ether by Dr. J. H. MeCall.
Operation. The abdomen was opened by free
incision from well above the umbilicus to the pubes.
The distended uterus was raised up and as well as its
tumor would permit, out of the abdomen. A hot
towel was placed over the intestines and four provi-
sional sutures were placed in the upper portion of the
wound, crossed and given a half turn so as to draw
the wound together and still further protect the
intestines. The uterus was observed to be somewhat
rotated upon its axis, that is. the right border presented
to the center. A large rubber dam was now placed
around the uterus and made to hug it very closely and
fixed with a safety pin toprotect the cavity from blood
or escaping fluid. From the location of the tumor it
was impossible for us to encircle the uterus with a
tourniquet. Therefore my first assistant, Dr. Barr,
grasped the oerni as low down as he could with both
hands making firm pressure so as to control hemor-
rhage. The uterus was opened as in ( Cesarean section,
the child was seized by its breech and removed. It
was observed to gasp once. Waiting a few moments
the cord was severed between catch forceps and the
child intrusted to a physician who made unsuccessful
efforts to resuscitate it. The uterus remained per-
fectly flabby, no contraction whatsoever, and yet the
hemorrhage was not very profuse, a few hot sponges
placed in the line of the wound controlled it. As we
oomtemplated removing the uterus, the placenta was
not disturbed. The assistant still holding the uterus
to control bleeding, I now proceeded with the hyster-
ectomy. The tumor was found to be an intra-liga-
mentous fibroid and it lifted the peritoneum entirely
from the floor of the pelvis. Ligating the right in-
fundibulo-pelvic ligament, catching the tube and
ovary with pressure forceps, I cut between. With
separate ligature the right round ligament was secured.
The Fallopian tube and round ligament were at least
four inches apart, that is, the broad ligament was
expanded to this extent by the tumor. I next split
open the broad ligament on the top of the tumor by
an incision parallel to the tube and without difficulty
peeled down the peritoneum before and behind and
enucleated the tumor, which involved the right side
of the body of the cervix of the uterus. Lifting the
tumor up I felt distinctly pulsating the uterine artery
just as it ascended to the cervix. Isolating it fairly
well its deligation was securely effected. Up to this
point in the operation I had not come in contact with
the bladder. With the tumor now enucleated, attached
only to the uterus and all vessels upon that side
secured, I proceeded in the usual way with the left
side. Here I encountered the greatest difficulty.
After ligating the ovarian vessels the tissues were so
hypertrophied, the veins so enormously distended and
everything distorted, I was not quite sure of my
anatomy, but dissecting the bladder from the anterior
surface of the uterus and carefully avoiding the
ureter I finally succeeded in ligating en masse a lump
of parametric tissue in which was concealed the uterine
artery. I now separated the uterus from its vaginal
attachments and quickly removed the entire organ
with its attached tumor and contained placenta. The
bleeding was very profuse from numerous points,
particularly from the anterior vaginal artery, and all
of these were grasped with forceps and then securely
ligated. All these ligatures and those upon the
uterine artery were left long and pushed into the
vagina; the others were cut, short. The open broad
ligaments were closed with silk sutures, the pelvis
thoroughly cleansed and packed with gauze, the free
end of which was carried into the vagina. The ab-
dominal wound was closed in the usual way. The
shock from the operation was comparatively slight,
considering the time, one hour and fifteen minutes,
and the many difficulties we had to contend with.
The patient had reacted thoroughly in two hours after
the operation and expressed herself as comfortable and
determined to get well. There is little to relate of
the after-treatment of the case. Thanks to the assid-
uous attention of her physicians, Drs. Howard, Mc-
Call and Cox, and her excellent constitution, she
made a quick recovery and is now a perfectly well
woman.
CATARRHAL DISEASES OF THE NOSE
AND THROAT.
BY J. D. ALBRIGHT, M.D.
AKRON, PA.
To any careful observer, and all physicians should
be such, it must have become apparent that catarrhal
diseases of the nose and throat are becoming more and
more frequent and play a most important part in the
practice of every physician who gives more than passing
attention to their treatment.
There seems to be a prevailing opinion in the minds
of many of our profession that the correct treatment
of these diseases involve the use of special and expen-
sive instruments and require a more than ordinary
degree of skill to use them properly, so that these
cases are allowed to drift to the specialist, who, by the
way, is often no more than a physician who keeps
posted and has the courage to apply his knowledge.
By a moderate amount of study and diligent prac-
tice, by perseverance in the use of the methods at
hand the general practitioner may overcome imaginary
difficulties that seem to stand between him and success
and he will be richly rewarded for his time and labor
so spent. The instruments that may be called neces-
sary are: A good light, a head mirror, a nasal speculum,
a tongue depressor and a laryngeal mirror. With these
as aids in diagnosis, if the examination is conducted
carefully, we are certainly in a position to diagnosti-
cate the existing conditions and therefore treat them
intelligently. Among the laity there is much termed
"catarrh" that bears no relation whatever to it, and in
this disease more than in any other these people glory
in making their own diagnosis, so that the physician
is often taken off his guard and is led to treat catarrh
on the strength of his patient's words instead of a
careful examination. We have different forms of this
trouble: 1, simple chronic rhinitis; 2, hypertrophic
rhinitis, and 3, atrophic rhinitis.
Simple chronic rhinitis. — This is a simple inflam-
mation of the tnucous membrane of the nasal cavity,
without any structural changes. Its only symptom is
a discharge of mucus or sometimes, when of long
standing, muco-pus. On examination you will find a
congested membrane, with here and there yellowish
or whitish spots of mucus. In the vault of the pharynx
where there is much glandular tissue there will be a
swelling, giving them a turgid appearance, and the
secretion which covers them will be found to be more
tenacious. When these cases seek a physician, he
can with a certainty predict a perfect cure, as it is
908
THE VALUE OF VACCINATION.
[October 24,
only in the first stage, simple rhinitis, although of
perhaps quite a long standing, getting no worse nor
yet any better. The treatment for this condition is
as follows: Cleanse the mucous membrane thoroughly
with warm water, applied by means of a douche, such
as the Bermingham, after which by means of the same
douche or an atomizer, make an application of the
following: Glyco-thymolin (Kress) one part, water
distilled, three to six parts. This mixture should be
used twice daily. It will be found best to use six
parts of water for a beginning and gradually strengthen
until only three parts are used. As before stated,
there will very seldom be more than this treatment
required in this form of nasal catarrh, as they at once
proceed to recovery.
Hypertrophic rhinitis. — A certain number of cases
suffering with simple rhinitis will neglect taking treat-
ment until they have developed our second class,
chronic hypertrophic rhinitis, and will then consult
the physician. Here, on examination, a different
aspect presents itself, as we have first, marked struc-
tural changes, a proliferation of all the normal mucous
membrane, making it of increased size, therefore
called hypertrophic, enlarged. The glands in the
vault of the pharynx are also enlarged, subject to the
same influence as the membrane of the nose. The
secretions are now thick and tenacious, which with
the enlarged membrane occludes the air passages,
causing difficult breathing, causing the voice to be
nasal in character and causing the patient to become
concerned about himself, perhaps for the first time.
In the treatment of this condition, all that I have said
on the previous stage applies to this one, with more
added. Do not forget to cleanse the passages ; this is
the fundamental principle of successful treatment,
and as such a saline solution, such as glyco-thymolin
(Kress), is practically the best remedy for the pur-
pose. It cleanses and it heals, it causes a proper
degree of healthy stimulation, it acts as an antiseptic
and is a most efficient deodorizer. As the comfort of
the patient is a desideratum, the use of a 5 per cent,
solution of cocain applied to the turgescent mem-
brane is often advisable, covering the membrane which
covers the inferior turbinated bones, in order to allow
more freedom in breathing. This may be done once
or twice daily by the patient, at different times as
occasion demands. The action of cocain on these
tissues is well known. The cleansing solution and the
cocain applications the patient can well himself apply,
but the following application should be made in the
office of the physician, as it can be more thoroughly
accomplished, and I am of the opinion that the mind
influence over the patient is better when he must daily
visit the physician; it reminds him that he is under
treatment and thus prevents his neglecting the home
treatment. For the following remedy a good atomizer
should be used, with a nasal tube, and a long tube for
the pharynx, and an application should be made once
daily, while necessary. This will cure. Iodin 8 grs.,
potass, iodic! 10 grs., zinc sulpho-carb. 15 grs., glyco-
thymolin (Kress) 1 oz., aqua q. s., ad 4 ozs. Mix.
Sig. : Use as above stated. This treatment kept up
for a month, or perhaps longer if a serious case, will
do its work well.
Atrophic rhinitis. — This form is caused at times by
neglecting the disease when in the hypertrophic stage,
and is essentially a death of the tissues. The tissues
were crowded to death by the enlargement. Here
there is plenty of room in the nasal cavity, there is no
interference with the voice or breathing, the secretions
are hard and in the form of crusts, the posterior wall
of the pharynx will be seen to be dry and shiny, the
sense of smell is interfered with, sometimes destroyed,
there is at times pain in the frontal sinuses, or in
other parts of the head, the patient is irritable and
very sensitive to atmospheric changes.
These cases are very often afflicted with a fearful
odor, very often on this account do they consult you.
Our words of encouragement to the patients suffering
with the two varieties preceding must now cease, for
unfortunately the cure of atrophic rhinitis is in most
cases beyond us; be careful then what you promise
your patient. Promise nothing but relief, and if
occasionally one case or another leaves you satisfied
that you have cured him, restored his sense of smell or
hearing do not become elated, for if you thus set up
your standard you will very often meet with bitter
disappointment.
The indications we wish to meet in these cases to
afford our patients relief are two-fold, cleansing and
disinfecting, and I may add keeping them thus and
attempting to regenerate the atrophied membrane,
which as before said can be but very seldom hoped
for. The first indication of cleansing and disinfecting
is met by daily washings with the solution before
given of water and glyco-thymolin, three of the former
to one of the latter, so as to remove all offending
secretions. Occasionally these crusts must be removed
by means of a forceps, which if necessary must not
be neglected. A spray of liquid vaselin to which a
little camphor has been added, after these washings,
will be agreeable to the patient, as it will prevent the
annoying dryness of the air passages, and I doubt not
but that it is of some remedial value.
For the purpose of stimulating and regenerating
the atrophied mucous membrane there are recom-
mended, salicylic acid, galangal root, nitrate of silver,
etc., blown into the nose by an insufflator, but I can
not but repeat myself and say that this will very
seldom be accomplished, and he who is careful will
never promise nor yet expect it. Regarding the
internal treatment of catarrh, I have never seen any
good result from its use and I think the consensus of
opinion of the entire profession, the regular, hold that
it is a local disease and as such requires only local
treatment. Constitutional defects must be recognized
and treated, but the remedies employed have no effect
on the catarrh, per se.
THE STATISTIC EVIDENCES OF THE VALUE OF
VACCINATION TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Read before the American Medical Association at the Jenner Centennial
Celebration, held at Atlanta, Ga., May, 1896.
BY EUGENE FOSTER, M.D.
PEOFKSSOE OF I'RINCIPLER AND PRACTICE OF MEDICINE AND STATE MEDI-
CINE AND DEAN OF THE FACULTY OF THE MEDICAL DEPARTMENT
UNIVERSITY OF GEORGIA, AUGUSTA, GA.
(Continued from, page 862.)
Proposition 10.
If the operation of vaccination be done with due regard to
the rules of modern aseptic surgery, with due regard to the
health of the individual vaccinated, and proper precautions be
observed in obtaining and using vaccine lymph, there need be
no apprehension that vaccination will injure health or commu-
nicate any disease other than vaccinia.
Antivaccinists seriously contend that : "Vaccination propa
gates syphilis, consumption and hereditary diseases, which
appear years afterward at their appointed time. It produces
immediately erysipelas, and aggravates the disorders of child-
hood, destroying the germs of the teeth during teething. It
1896.]
THE VALUE OF VACCINATION.
90J»
is especially productive of mesenteric and glandular diseases,
and lies at the foundation of the shameful mortality of whoop-
ing cough."
Mr. 1'. A. Silje8trom (who the Vaccination Enquirer, the
journal of the antivacciuists, says is "one who has mastered
the vaccination question" I states, "It has lieen proved that dis
ease (especially erysipelas and syphilis) and death have not
infrequently been observed to result from vaccination."
Mr. P. A. Taylor, M. P., of England (another leader of the
antivacciuists) says, "Not tens but hundreds of thousands of
persons in this country (England) have mourned the death or
ruined health of their children through the results of vaccin-
ation."
The above are fair samples of objections raised against vac
cination by antivacciuists, and if it can be shown that either or
all of the above assertions be true, then the medical profession
of the civilised world has for the past century been most
grossly careless and ignorant in accepting and recommending
vaccination as a prophylactic against smallpox.
Let us, then, once again carefully examine these objections,
and decide if or not they be well founded.
As preliminary to a full consideration of these points T sub-
mit, and endorse, the following from John Simon of England,
one of the ablest, most renowned and conscientious sanitar-
ians ami medical philosophers of this century — a man who has
more exhaustively, ably and impartially investigated the vac
cination question than any other physician living or dead.
Simon says :
•• Is properly performed vaccination, then, an absolutely in-
offensive proceeding? Not at all, nor does it pretend to be so.
The very meaning of the thing is, that it shall artificially and
designedly produce a transient and trifling indisposition ; that
for some days the infant shall be uncomfortable with a sore
arm and a slight irritation of the adjacent axillary glands, and
I perceptible amount of general feverishness. Within the
limits of this description, one child may be a little more,
another a little less, inconvenienced : but those limits are rarely
exceeded. And if it can not strictly be said that the imme-
diate effects of well- performed vaccination never exceed the
intentions of the vaccinator, at least it may be affirmed that
any permanent injury resulting from it is an accident barely
known in the practice of surgery.
" Persons hostile to vaccination allege against it, that it pro
duces eruptions on the skin and glandular swellings; and
others, not unfavorable to the practice, doubt whether this to
some extent may not (and especially as regards unhealthy pre-
disposed scrofulous children) be a true allegation.
■■ Vaccination might afford to bear these imputations. For,
to what do they amount? Were they ever so true, the alleged
evil, even to the sufferer, would be little in comparison with
his gain ; and the total amount of such evils, compared to the
social advantages of vaccination, would, literally speaking, be
too small to appreciate.
"But in fact, the imputation is — at least generally — erron-
eous. There is in it again that common fallacy of calling what-
ever happens after an event its effect. Propter, quia post.
The infant is commonly vaccinated at three or four months of
age. Thus whatever physical or moral evils belong to human
life are very likely to have been preceded by vaccination ; and
it is not extraordinary that, especially by ignorant persons,
this operation should often be charged with producing incred-
ible results. When you consider, too, that the few months
after vaccination include events which are very critical to in-
fant life, you will see what frequent room there must be for
misconception. Even to the healthiest and best cared for of
children, weaning and teething are not perfectly safe and com-
fortable processes ; to delicate and ill-nurtured children they
are often fatal : to vast numbers they occasion, sometimes dur-
ing many months, distressing or alarming symptoms. Such
symptoms, I need hardly tell you, affect both vaccinated and
unvaccinated. They have been known as incidental to infansy
from periods long anterior to Jenner's existence. Now, an
extremely frequent one of such symptoms is an inflammation
of skin (known by the technical name of eczema infantile) pro
ducing on the child's face and head, or on other, perhaps many
or most parts of the body a dense eruption of little pimples,
which presenty convert into an itching and discharging surface
so much of the skin as they occupy ; and since irritations of
the skin are peculiarly apt to propagate themselves in the
direction of the return current of the circulation of the blood
to certian organs, the so-called lymphatic or absorbent glands
which are subsidiary to this circulation, so it very commonly
happens that more or less irritation and swelling of these
glands will accompany that eczematouB eruption ; and that,
for instance, the child who has the eruption about its head and
face (which are among the most usual seats of the unsightly
disease) will often be still further disfigured by glandular
swellings in the neck. Though I have spoken of this infantile
complaint as incident to the time of teething and weaning, yet
in lad it may arise at earlier periods of life, even within a few
weeks of birth, and, of course, before vaccination as well as
after it. Indeed, frequently it is a reason for which vaccina-
t ion is postponed ; and perhaps I give you no readier means of
estimating how little vaccination has to do with its occurrence,
than by telling you, first, that before the discovery of vaccin-
ation smallpox inoculation was charged with producing it: and,
secondly, that in 1711, when smallpox inoculation was yet
unknown in England, Dr. Daniel Turner expressed himself in
the following terms : 'Among diseases of infants and young
children scarce any attends more frequently that pustulary
or scabby eruptions in several parts of their bodies, as in the
breech, but more especially their foreheads, brows and other
parts of the face, which we find oftentimes overrun with dry
and crusty scabs.'
"Tho circumstances under which both infantile eczema and
glandular swellings arise are familiarly known to the medical
Erofession. To say that properly performed vaccination can
ave directly to do with them, that it can directly cause gen-
eral eczema, or directly affect any glands but those which it is
intended and expected to affect, would be an assertion not
warranted either by practical experience or by any pathologic
probability. To say that indirectly it may do so, that in the
very few instances where it produces excessive results, the
disturbance that, under such very exceptional circumstances,
it may for the time of its operation predispose the child to this
complaint and to that, may excite the scrofulous child to show
its scrofula, and the eczematous child to show eczema, these
are assertions which may or may not be true ; which are more
easily made than either established or refuted ; but which, if
admitted in their utmost scope, really allege against a cold in
the head, a cut finger, an undigested meal, or any other one of
the thousand minor accidents of everyday life.
" So much for what has been alleged against properly per-
formed vaccination, against such vaccination as alone ought to
prevail in any country where the State requires its perform-
ance. So much for the drawbacks which have falsely been
said to detract from its inestimable advantages, and the dan-
gers which, with almost equal fasehood, have been said to
attend its performance.
" It is less easy and less necessary to dispose of what may be
said against ill-performed vaccination ; understanding in this
phrase not merely such vaccination as is done with an unskil-
ful hand, for commonly the worst effects of clumsiness is only
that the operation fails ; but especially referring to such vac-
cinnation as is done without due inquiry into the health of the
child to be vaccinated, or without due care for the quality of
the lymph to be employed.
" If local scandals have arisen against vaccination, and if
some prejudices against it seem to have in them a show of rea-
son, those are the sources from which such serious evils have
come. All that belongs to the mere manual trick of vaccina-
tion is learnt from a minute's teaching and an hour's practice ;
but not so easily the philosophy of the procedure, or the pre-
cautions which are requisite to make it harmless and useful.
Prom Jenner onward, all great masters of vaccination have
urged that its merits will always appear proportionate to the
merits of the performers ; that if sickly children are vaccinated
without due regard to their actual condition of health, children
teething, and the like ; or if children, healthy or unhealthy,
are vaccinated with improper material, the results must be at
least unsatisfactory, and possibly dangerous. And all compe-
tent persons accordingly recognize that one who would vaccin-
ate must thoroughly study these things.
"Especially as regards the quality of vaccine lymph, the
careless or uneducated vaccinator is using a dangerous weapon.
It is only during part of the course of a vaccine vesicle that its
lymph is suitable for further vaccinations ; for after a given
moment, at which the contents of the vesicle possess their
maximum of simple contagiousness they tend more and more
toward the quality of common inflammatory products ; and
matter now taken from the vesicle is no longer the simple agent
of a specific infection, but both has less efficiency for its real
purpose, and is specially able to produce other undesired
results. A danger of somewhat similar kind is that of taking
lymph from vesicles which already have been accidentally
ruptured, or where from any other cause, local or constitu-
tional, their specific fluid is likely to have been modified by
common irritative processes. Still more critical changes occur
in lymph when removed from the body, unless appropriate
means be taken to preserve it ; for under the influence of air
and moisture it tends, like other dead organic matter to putrid
decomposition ; and inoculation with it, when thus changing,
910
THE VALUE OF VACCINATION.
[October 24,
can hardly be more useful or less dangerous than a casual
scratch inflicted in the dissecting room. According to the usual
practice of vaccination, error is less likely to be committed in
this particular than in the one first mentioned ; for, when the
operation is not performed from arm to arm, use is very gen-
erally made of lancets or ivory points on which lymph has been
allowed to dry. Under this system (at least in our climate) the
matter is almost secure from change ; and there is little room
for such accidents as might arise from failure in those delicate
procedures by which lymph is sometimes kept moist for use.
But the danger of taking matter from irritated vesicles, and
and from vesicles at too advanced a period in their course, is
one which circumstances render frequent ; and there is reason
to believe that, in at least a very large proportion of those cases
where abnormal effects have resulted from so-called vaccina-
tion, it has been the employment of this ambiguous irritative
matter which has occasioned the mischief and scandal.
" Suspicions are sometimes expressed that a slovenly vacci-
nator, careless in his choice of lymph, may thus cammunicate
to one child the constitutional or local disease of another. If
this be true it were nothing against vaccination. It is no
argument against bread that alum constipates the bowels ;
still less is it an argument against quinin that some drunken
shop-boy may give one strychnin instead of it. And, without
intending disrespect to gentlemen whose opinions on this point
may be less decided than my own, I must say that I believe it
to be utterly impossible, except under circumstances of gross
and punishable misconduct, for any other infection than that
of cowpox to be communicated in what pretends to be the per-
formance of vaccination. A vaccinator must forget his duty
in more than one particular ; he must be indifferent both to
the feelings of others and to the social progress of the great
good which he claims to administer, if he affronts the natural
antipathies of those who bring their children to be vaccinated
by drawing the lymph for vaccination from the vesicles of
diseased subjects. And, practically speaking, I can conceive
of no circumstances in this country which justify a departure
from the rule (recognized by the medical profession as unre-
servedly as it is desired by the public) that lymph be taken
only from healthy subjects.
"But, supposing that, in breach of this rule, lymph be taken
from Jennerian vesicles on the arm of a subject suffering con-
stitutional disease, what then? On the assumption only that
it be a true Jennerian vesicle at the proper period of its devel-
opment, there are cogent reasons for believing that such vacci-
nation can produce none but normal results.
' ' There is one simple mass of experience, which, to my mind,
seems conclusive. It has been proved on a large scale that
vaccin lymph, taken from persons actually suffering from
smallpox, conveys to those who are vaccinated with it no other
than the vaccin infection. This most remarkable truth has
been established, I say, on a large scale ; for, not once or
twice, but at least hundreds of times, something to the follow-
ing effect has occurred. A patient has been vaccinated a little
too late for protection. Warned of his danger he has had
recourse to vaccination when already smallpox was in his sys-
tem ; and (under a law which expresses the intimate affinity
of these two agents) the operation of the inhaled variolous con-
tagion, and the opperation of the inoculated vaccin contagion,
have proceeded simultaneously on his person ; the former pro-
ducing the general eruption of smallpox, the latter producing
at the vaccination spots characteristic Jennerian vesicles.
And with the lymph of these vesicles, again and again, succes-
ful vaccination has been performed. Again and again it has
been shown that such lymph is capable only of communicat-
ing, the Jennerian infection.
"Since then it is a quite unquestionable certainty that, even
the system is drenched with that subtlest infection of small-
pox, the Jennerian vesicle preserves its own contagion pure
and isolated, the argument may reasonably be extended. And,
even if there were no evidence in relation to other diseases,
this analogy would have rendered it eminently improbable
that any, the most infectious, of their number could admix its
contagion with the specific products of cowpox. Indeed, so
definitely and so constantly characterized are those local
changes which different morbid poisons severally and specific-
ally produce, that to say of a given phenomenon 'this is a
typical Jennerian vesicle' is, I believe, tantamount to saying
this is a vesicle, which only one modified influence can pro-
duce, which no second influence can concur in producing, and
in the contagion of which no second principle of infection can
possibly reside.
' ' Turning, however, from these general considerations, I may
inform you that the diseases which it has been suspected that
vaccination might communicate have chiefly been scrofulous
and syphilitic complaints, and various eruptions of the skin.
In all but a very limited number of these cases it may be
conclusively answered that the suspected mischief is physi-
cally impossible. Scrofula, for instance, and most skin dis-
eases, even when for experiment their specific discharges and
other products are deliberately inoculated on the healthy, are
absolutely incommunicable by contagion ; and it is inconceiva-
ble that the vaccin lymph, even if it could include these pro-
ducts, would alter the essentia) condition of their nature. Of
some others among the diseases referred to, it may no doubt be
admitted that certain of their products are infectious ; but
then again comes the question (which is already by anticipa-
tion almost disposed of) whether the constitutional existence
of such diseases can qualify the contents without modifying
the characteristic development of a true Jennerian vesicle.
" Experiment, where it has been deliberately addressed to
the solution of this question, has invariably answered, no ; and
such experiment is worth many arguments."
After quoting from M. Taupin, Simon says :
"I am not aware of any counter experiments suggesting dif-
ferent conclusions to those which are expressed and justified in
the preceding passage. They assert for vaccin lymph the
principle which Dr. Mead a century ago asserted for the virus
of smallpox inoculation : It is more material into what kind
of body it be infused, than out of what it be taken. Indeed,
in the whole list of diseases syphilis is the only one to which
serious suspicion will attach ; and, in regard to its communi-
cability by the lymph of a true Jennerian vesicle, various
other observers confirm the accuracy of M. Taupin's result.
"Moreover, Professor Sigmund of Vienna (whose researches
on everything relating to the inoculation of syphilis have been
on a very large scale) has added to M. Taupin's results, one
which quite in a different manner, is equally against the possi-
ble invaccination of syphilis. In an official report on the divi-
sion of the hospital over which he presides (Aertzlicher Bericht
des Allgem. Krankenhauses ; Wien, 1855) he relates experi-
ments to show that syphilis in its inoculable form prevents,
within the sphere of its infection the simultaneous formation
of a vaccin vesicle. The discharge of chancre (in which form
alone syphilis is universally recognized to be inocuable) has
been designedly mixed, as by nature it never could be mixed,
with ordinary vaccin lymph ; and insertion of this compound
poison in the skin has been followed only by the ordinary local
results of syphilitic infection. No Jennerian vesicle had been
formed. No signs have existed of any possible combination of
the two infections. Dr. Friedinger, who conducted these
important experiments in Professor Sigmund's wards and
under his observation, has also communicated their result to
the society of surgeons at Vienna.
"It is unquestionable, however, that cases are recorded in
which the lookers on (sometimes including a medical practi-
tioner) have believed syphilis to have been communicated by
vaccination. A moment's reflection suggests that in such
cases there must generally be sources of fallacy, which render
them, in contrast with experimental results, almost valueless
for instruction. When a child is born with a heritage of syph-
ilis (a very frequent incident, if the parents have been suffer-
ing from that disease) the characteristic symptoms commonly
do not appear till some weeks after birth. And then the scan-
dal discloses itself. Now, among persons with any sense of
shame, the knowledge that one had transmitted syphilis to
one's child would always be a sore subject. There would be
strong temptations to employ false pretense. Not only would
parents often conjointly wish to disguise from their medical
attendant or from members of their household, the real expla-
nation of the child's ailment, but also, not unfrequently, one
parent would wish to conceal from the other that the origin of
the disease had been a conjugal infidelity. In respect even of
unmarried people, every surgeon knows what utterly false, far-
fetched and absurd explanations are given of syphilitic symp-
toms primary and secondary ; and it requires little experience
to imagine how much more pertinacious will be the demand for
excuses, and how much more active the supply of falsehood,
under the complicated circumstances of connubial syphilis.
Accordingly it is a matter of surprise that vaccination has not
almost generally been pitched upon by persons in search of an
apology for their syphilitic children. But in truth even such
allegations against it have been few ; and their paucity (assum-
ing them all to have been made in good faith) would be a
strong reason for regarding them with mistrust ; for surely if
syphilis could be diffused by the vaccin lymph of children
with an hereditary taint of that disease, this possibility must
long ago have been made evident on a scale far too considera-
ble for question.
"Among the scanty number of recorded cases in which such
allegations have been made, there are, however, some in which,
so far as I can judge, it seems almost certain that a person
1896.]
REPORT OF SURGEON-GENERAL OF THE ARMY.
911
pretending to vaccinate did really effect a syphilitic inocula-
tion. Properly to estimate these grevious instances of mal-
practice, two considerations must be adverted to: 1. To the
already quoted negative results obtained by Taupin and many
Other observers in their experimental inoculation* of lymph
from the true .lennerian vesicle of syphilitic children. 2. To
the fact that secondary syphilis itself is very possibly not com-
municable even by ilireet inoculation of matter from the ulcer
and eruptions which it occasions; for many of the ablest
experimenters in Europe declare that in hundreds of trials they
have never once succeeded in thus conveying from person to
person the slightest infection of syphilis. And, regard being
hail to these considerations, it becomes almost certain that in
tin- eases referred to the matter of chancres, the matter of
primary syphilis was used instead of vaccin lymph by the
vaccinator, a mistake [however it may have occurred) of so
gross and criminal a nature that the medical profession would
feel no sympathy for the person through whose neglect or
Incompetence it happened.
"But in coming to eases of this description there is no
longer question of the merit of vaccination. If recorded
instances of the kind, instead of being so few that you count
them on your lingers, were of innumerable frequency, they
would make no argument against vaccination. Only they
would, if possible, render more obvious than it is the expe-
diency and duty of providing that this great self defense of
nations against pestilence be not ignorantly and recklessly
administered.
•Here, indeed, is the whole gist of the matter. Earlier
parts of this letter have shown that by vaccination, properly
administered, the once enormous fatality of smallpox may be
reduced to nothing. The present section justifies a conclusion
that against this vast gain there is no loss account. Of the
various alleged drawbacks to such great advantages the pres-
ent state of medical Knowledge recognizes no single trace,
•tenner's discovery, properly utilized, has been a pure blessing
to mankind, an unmixed addition to the strength and happi-
ness of nations.
"To say of vaccination that it has sometimes been ill-
administered : to say that under the pretext of its administra-
tion harm has sometimes been given instead of good, poison
instead of antidote, is to speak, not against it, but, whether
rightly or wrongly, against its administrators. The vaccina-
tions of Europe are now counted annually by millions. It
may be vain to hope that every lancet shall be used with equal
skill and equal carefulness, or that all populations shall be
equally anxious to render the operations successful ; but
Medicine at least has contributed her share in showing that,
subject to these conditions, smallpox need cause no further fear
nor its antidote be accepted with mistrust."
So much for the general principles controling the question of
objections to vaccination presented by John Simon.
(To be continued.)
Report of the Surgeon-General of the Army for
the Year Ending June 30, 18i><>.
The following is an abstract of Surgeon-General Sternberg's
report, omitting financial statements, special reports of medi-
cal officers, statistic tables and other matters of detail :
War Department, Surgeon-General's Office, /
Washington, D. C. Sept. 8, 1896. \
Sir: I have the honor to submit the following report of my
administration of the duties of this office during the past year.
Beside the health of the troops and the sanitary condition of
the various military posts, this report relates to certain duties
imposed upon the Surgeon-General of the Army by the Revised
Statutes of the United States and by Acts of Congress making
appropriations to be disbursed under his direction.
Among the expenditures authorized by Congress for the year
ended June 30, 1896, were those for artificial limbs and their
commutation, for appliances for disabled soldiers, for trusses,
for the support and treatment of destitute patients in the city
of Washington, D. C, for the Army and Navy General Hospi-
tal, Hot Springs, Ark., for the Army Medical Museum and
Library of the Surgeon- General's Office, for the construction
and repair of hospitals, and for medical and hospital supplies
for the use of the Army.
Artificial limbs and their commutation. — During the fiscal
year ended June 30, 1896, 21 artificial legs were furnished and
commutation was paid in 101 cases of amputated leg, in 69 of
amputated arm, and 13 of amputated foot. Commutation was
jpaid also in 2,402 cases in which the use of a limb was lost.
It is believed that the appropriation of $575,000 for the year
ending June 30, 1897, will suffice to cover the benefits accruing
to the pensioners during the current year.
The amount required for the year ending June 30, 1898, will
amount to about $183,000. This estimate is based on the fact
that of the appropriation of $194,000 for the fiscal year 1895,
£184,192.55 was disbursed during that year, and $7,610.74 dur-
ing the year 1896, making a total of $191,803.29 disbursed from
the appropriation. As these benefits recur every three years,
an appropriation will be roquired for the year ending June 30,
1898, approaching in amount to the sum expended from the
appropriation for the year ended June 30, 1895. The actual
amount that will be required will depend on the number of
| those paid in 1895 who are found to have survived the interval
of three years. As well as can be learned from the statistics,
the death rate is about 1.6 per cent, annually, or 4.8 per cent,
for the three years. The estimate for the fiscal year would,
therefore, bo the amount paid in 1895 lessened by 4.8 per cent.,
or»l88,00a
Appliances.— The number of appliances issued to disabled
soldiers during the year was 162, for which was disbursed a
total of $1,245.22
I'riisses. — There was expended in furnishing and fitting
trusses to disabled soldiers under Sections 1,176 to 1,178,
Revised Statutes of the United States, and the Act of March
3, 1879, the sum of $7,699.70. The number of trusses issued
and fitted during the year was 1,106.
Proindence Hospital. — The Act of Congress approved March
2, 1895, appropriated $19,000 for the support and medical
treatment of destitute patients in the city of Washington, D. C.
The amount of relief afforded under this appropriation was
equivalent to the treatment of 114 patients throughout the
year.
Army and Navy General Hospital, Hot Springs, Ark. —
Twenty-five officers and eighty-five enlisted men were treated
during the year. The special advantages afforded by the
Government in this General Hospital in the treatment of the
diseases mentioned in Circular No. 16, A. G. O., Dec. 8, 1892,
do not seem to be appreciated properly by medical officers of
the Army. It is equipped with all the latest and best appli-
ances for the treatment of patients by hydrotherapy, elec-
tricity, massage and Swedish movements. No sanitarium or
private establishment at Hot Springs offers any such advant-
ages. It is believed that if cases suitable for treatment at the
Springs were sent earlier in the progress of the disease many
serious complications might be prevented and recovery effected
in a larger percentage.
Army Medical Museum. — The total number of specimens
received during the year was 890 ; number on hand June 30,
1896, 33,746.
Library. — The total number of books in the Library is now
120,344 ; of pamphlets and theses 199,600. Volume i, new
series, of the Index Catalogue includes the letter "A" and
forms a volume of 828 pages. It is now in the hands of the
binder and will shortly be ready for distribution. The manu
script of Volume ii, new series, is in the course of preparation
for the printer, the usual appropriation having been made for
this volume.
Medical and hospital supplies. — The approximate value of
the medical supplies actually issued during the fiscal year
ended June 30, 1896, is $97,697.38.
Advantage was taken of the preparation of the new Manual
for the Medical Department of the Army to revise the Supply
Table included therein. Many new remedies were added and
the allowance of others was increased where experience had
shown this to be advisable. Several recent medical works
have been distributed for the use of medical officers. Appli-
ances for operating in accordance with the requirements of
aseptic surgery have been issued to sixty-five post hospitals.
The facilities for prompt and successful surgical relief are now
much more satisfactory than they have been. Portable bath
tubs on wheels, adopted to giving a patient a bath at his bed-
side in cases of fever, have been issued to most of the posts.
The hospital corps. — There were in the service June 30, 1895,
116 hospital stewards, 82 acting hospital stewards and 530 pri-
vates, making a total of 728 men. The loss during the year
by discharge, transfer, retirement, death and desertion
amounted to 270 men and the gain to only 249 men, a net loss of
21 men. There were, therefore, in service at the close of the
last fiscal year 707 men, of whom 106 were hospital stewards, 94
acting hospital stewards and 507 privates, the quota under
existing regulations being 741.
The appropriation bill provides that no appointment to the
grade of hospital steward shall be made until the number of
such non-commissioned officers in service is reduced below 100.
As there are now 106 in the corps it is not likely that an exam-
ination for appointment to this grade will be held for some
912
REPORT OF SURGEON-GENERAL OF THE ARMY.
[October 24,
time to come. Examinations for the position of acting hos-
pital steward were held in November, 1895, and May, 1896.
The successful candidates numbering 31 out of 43 recom-
mended for examination have been detailed to duty in their
new positions.
The issue of hospital corps knives and side arms has been
discontinued. Members of the corps may, however, by Circu-
lar No. 2, Headquarters of the Army, A. G. O., Feb. 6, 1896,
be furnished with firearms during Indian wars or when left
with sick or wounded under circumstances which justify the
expectation that their rights as non-combatants will not be
recognized.
The new litter, model of 1895, is now being issued to mili-
tary posts. A new edition of the Drill Regulations of the Hos-
pital Corps was necessitated by the adoption of this hand litter.
The litter slings of the hand litter previously in use were
attached to the handles of the litter, and in the drill provision
was made for the disposition of the sling in all movements. By
detaching the sling and making it a part of the equipment of
the bearer to be worn over the shoulders with the ends tucked
under the belt in front when not in use the drill has been much
simplified. When the litter is to be raised or lowered the bear-
ers have merely toslip the loops at the free ends of their slings
on or off the handles. Special instruction in the duties of
litter bearers and in the method of rendering first aid to the
sick and wounded is now given to all enlisted men of the army
by their company officers in accordance with G. O. No. 9,
Headquarters of the Army, March 13, 1896.
A change has recently been made in Che method by which
certain of the recruits for the Corps are to be instructed in
their special duties. It consists in the disbandment of the
company of instruction at Fort Riley, Kans., and the distribu-
tion of the men constituting the company in small detachments
at selected posts. Hitherto the expense involved in transport-
ing men to a distance has prevented the posts on the Pacific
Coast and on the Northwestern frontier from being supplied
with men educated in the company of instruction. By distrib-
uting the men and educating them hereafter in small detach-
ments, each department will have its quota of men under
instruction from which assignments may be made with less
expense for transportation than if Fort Riley continued to be
the center of distribution. Emergencies in the East will be
met as heretofore, by drawing on the company of instruction
at Washington Barracks, D. C.
Since the close of the fiscal year favorable action has been
taken on my recommendation that the issue and use of a full
dress uniform for the men of the Hospital Corps be discon-
tinued. These men even on parades and occasions of ceremony
have always to be in readiness to render service in case of acci-
dent and sudden sickness. Fatigue uniform is more suitable
for such work than the full dress suit. The change will be of
benefit to the men otherwise than by relieving them of an un-
necessary uniform, for by drawing the value of the discontin-
ued articles in white cotton duck clothing they will have a suf-
ficient allowance for ward service, which has not hitherto been
the case.
Army Medicul School.— The report of Colonel Charles H.
Alden, President of the Faculty of the Army Medical School
shows the course of study pursued and the excellent results
attained during the session 1895-96. I heartily concur in his
recommendation that the final rank of the student officers in the
army should be made to depend on a combination of their marks
at the examinations at entrance into the service and at the close
of their school work. At present their relative rank is settled by
the results of the examination at entrance and their work during
the session does not alter it. A very desirable incentive to
secure every advantage from the practical courses of the school
would be obtained if the class standing of the students were
made to influence their future rank.
Recruiting. — The total number of men examined for enlist-
ment was 17,645, of whom 8,643 were accepted, or 489.83 of
every thousand examined. The ratio of accepted men was
higher among the colored men, 540.57, than among the whites,
486.46.
Of every thousand accepted recruits 727.18 were natives of
the United States, 659.38 whites and 67.80 negro. In 1894 the
ratio of native born recruits was 679.99, and in 1893 665.95. Of
foreign nationalities Germany and Iceland furnished the largest
proportionate numbers, 88.97 and 75.44 per thousand recruits.
The average height of these recruits was 67.51 inches, the
native born white recruit 67.68 inches, being somewhat taller
than the negro 67.37, and fully half an inch taller than the for-
eign born recruit, whose average was 67.14 inches. The for-
eign born recruit had the advantage over the native born white
in weight, the former averaging 147. 18 pounds, the latter 145.68.
The negro exceeded both, his average being 149.85 pounds. In
chest measurement and expansibility also the advantage
appears to have been with the foreign born recruit, his meas-
urement at expiration and inspiration being 34.80 and 37.73
inches, as compared with the native born white who averaged
34.26 and 37.17. The corresponding measurements of tEe negro
were 34.27 and 36.89 inches.
Identification of deserters. — From July 19, 1890 to Aug. 31,
1896, the whole number of identifications made by means of
outline figure cards was 759. Of this number 18 were made in
the calendar year 1890 ; 111 in 1891 ; 215 in 1892 ; 104 in 1893 ;
110 in 1894 ; 121 in 1895 ; and 80 during the first eight months
of 1896.
The 121 identifications made in 1895 represent the " repeat-
ing" element of 4,929 recruits whose outline cards were exam-
ined ; i.e., of every thousand recruits from civil life 24.55 were
identified, through the outline cards, as deserters, military con-
victs or otherwise bad characters. Fraudulent concealment of
former service is still practiced extensively ; and but for the
almost certain detection indicated by them it is reasonable to
suppose that the practice would attain its former dimensions.
Uniformity in medico-military statistics.— I have embodied
in this report the data concerning the recruiting, sickness and
mortality of our army during the calendar year 1895, tabulated
in the form suggested by the International Commission of Mil-
itary Medical Officers which met at Budapest in September,
1894. The Commission recommended that the various army
medical departments begin publication with the statistics of
the calendar year 1895. but as at this time last year 1 had at
command all the data for 1894 needful to the construction of
International tables for that year, I submitted the first set of
these tables in my last annual report. Copies of the report
were sent to the members of the Committee and to the Chiefs
of the Army Medical Departments represented at the Buda
pest meeting. Reports in exchange are not expected from any
of the foreign offices until the publication of their statistic
data for 1895.
Medical Department of the National Guard.— The interest
taken by medical officers of the Army in the progress and meth-
ods of the Medical Department of the National Guard, is well
shown by an examination of the program of the sixth annual
meeting of the Association of Military Surgeons of the United
States, held at Philadelphia, May 12 and 14, 1896. Out of twenty-
seven papers announced by the program as to be presented for
the consideration of the Association, sixteen were by officers of
the medical department of the Army, five by medical officers
of the U. S. Navy, and six by officers of the National Guard.
HEALTH OF THE ARMY.
It is with much gratification that I report the health of the
Army during the year 1895 as having been excellent. All the
rates that are usually considered by statisticians as throwing
light on the physical condition of a community have been
lower than in any previous year of the recorded history of our
army. In 1894 we were fortunate in having all the rates except
the death rate lower than ever before. In 1895 all the rates
except the admission rate for injuries fell below those of the
previous years and the death rate below that of 1889, which
was the lowest on record. It is customary to compare the
rates of an army with those of the other troops, or the rates of a
military department, garrison, city or other civil or military
community with those of other similar communities. Such
comparisons are of value as indicating insanitary influences at
work in one place and not in the other. They lead to inquiry
into the causation of excessive rates and to the institution
thereafter of remedial measures. But to determine the abso-
lute condition of a community as to health it must be com-
pared, not with other people under other conditions, but with
itself under its most favorable conditions. Its proper standard
of comparison is, therefore, its own best annual record. The
nearer it approaches its best record the higher its standard of
health under conditions which usually affect the individuals.
That progress is being made in eliminating insanitary condi-
tions or other causes which tend to affect injuriously the health
of our troops is shown by the fact that during the past year
the sick rates have been lowered so much that they henceforth
become the standard of comparison for future years.
The admission rate to sick report numbered 1,110.22 per 1,000
of strength, as compared with 1,089.73 in 1894, the lowest pre-
vious rate, and with 1,329.94, the average annual rate for the
preceding decade. The average number of days each case was
treated was 11.1, as compared with 11.6 and 11.7 respectively
for the previous year and the average of the previous decade.
The admission rate for disease was only 837.53, as compared
with 845.52 in 1894, while the rate for injury was 272.69, as
compared with 244.21.
The number constantly sick was 33.89 per 1,000 of strength,
L896. ]
REPORT OF SJJRGEON-dENERAL OF THE ARMY.
913
;vs compared with. 84.48 during 1894 and 41.87 as the average
manual rate of the preceding ten years. The number of days
lost on account of sickness by each man of the army was
12.4. M compared with 12.0 in 1894 and 15.3 during the pre
ceding ten years.
The rate of discharge for disability per 1,000 of strength was
0.15, as compared with 13.30 in 1894 and 23.77 annually in the
preceding ten years. The discharge rate on account of dis-
ease was 6.81 : on account of injury 2.34. The absolute num-
ber of dischargee was 250, of which 186 were for disease and
(VI for injury.
The mortality rate from all causes was 5.16 per 1,000 of
strength, as compared with 6.69 in 1894, 7.85 for the preceding
decade, and 6..'!.'! in 1889, the year of lowest record. Deduct-
ing the rate for injury. 1.61, the death rate for disease was only
■r l.OtX), and compared with 3.95 in 1889 and with 4.76 in
which until now held second place on our records. The
absolute number of deaths was 141. of which 44 were occasioned
by injury.
The mean strength of the command, officers and men, white
and negro, from which medical reports were received during
the year amounted to 25,204 : white 23,195, negro 2,000. The
admission rate for the white troops was 1,127.05, for the colored
troops 915.88. The admission rate of the latter was smaller
than thai of the white troops in 1881), in 1892 and in the years
following to ttie present time. In speaking in my last annual
report of their record of sickness. 1 characterized it as the
most favorable yet shown by the statistics. The same remark
might be made concerning their record in 1895. Their admis-
sion rate for disease was 659.03, as compared with 852.96
among the whites ; their rate for injury 256.84, as compared
with 247.07. and the duration of each case was 10.5 days, as
compared with 11.2. The number of men constantly sick per
1,000 of strength was 26.40 among the colored men, 34.54
anions the white, while each colored soldier of the command
lost 9.6 days on account of sickness during the year and each
white soldier 12.6 days. The rate of discharge for disability-
was 5.03 among the colored men, 9.51 among the whites, and
the deaths 1.12 and 5.25, the deaths from disease being respec-
tivelv 2.71 and.'!. 62. The susceptibility of the negro troopstodis-
ease was noted as greater than that of the whites only in the
instances of rheumatism and neuralgia ; although it was equal
to or slightly in excess in several other diseases, as tonsillitis,
colic and constipation and conjunctivitis.
Health of the military departments.— The admission rate
varied 798 32 in the Department of the Columbia to 1.355.63 in
Texas. It was above the army average only in the Depart-
ments of Texas, the East and the Platte. The rate of constant
sickness was highest in Texas. The Departments of the Colum-
bia, Dakota, California and Colorado had low rates ; the other
departments did not differ much from the army average. The
Department of Texas had the worst record; the Department
of the Columbia had probably the best, closely followed by the
Departments of Dakota and of California.
Four posts during the past year had admissions to sick
report in excess of two entries per man. These were Fort
Myer, Va.. with a rate of 2,800.00 per 1,000 of strength ; Wash-
ington Barracks, D. C, 2,137.74; Fort Slocum, Davis Island,
X. V., 2,103.45, and Fort Ringgold, Texas, 2,078.21. Malarial
infection was the principal cause of these high rates at the first
two posts, but not at the other. Five posts had the rate of
non efficiency or constant sickness over 6 per cent, of the
strength : Forts Brown, Mcintosh and Ringgold, Texas, with
rates per 1,000 of strength respectively of 70.69, 64.05 and 63.92 ;
Fort Myer, Va., 63.78, and Columbus Barracks, Ohio, 60.65.
Washington Barracks, D. C, although second in sequence of
high admission rates, had a constant sickness of only 46.18,
standing eleven in point of non-efficiency, while Fort Brown,
Texas, although heading the list of non-efficiency stands four-
teenth in sequence of admissions.
Six posts gave admission rates of less than 600 per 1,000 of
strength: Fort Yellowstone, Wvo.. 422.02; Alcatraz Island.
CaL, 461.54; Fort Wayne, Mich.", 484.62; Fort Porter, N. Y.,
515.62; Fort McPherson, Ga., 566.14, and Fort Missoula, Mont,
578.75. Twelve posts reported a constant non-efficiency of less
than 2 per cent, of the strength and among them were the posts
of Plattsburg Barracks, Xr. Y. ; Fort Wayne, Mich. ; Fort
Huachuca, Arizona, and Benicia Barracks, Cal. Fort Stanton,
X. M., had less than 1 per cent, constantly sick, only 8.26 per
1,000 of strength.
PREVALENCE OK SPECIAL DISEASES.
Influenza prevailed to a somewhat greater extent than in
1894, 1,156 cases as compared with 875. The disease has con-
tinued since the close of the calendar year, and it may be ex-
pected to form a notable part of the record of 1896.
Diphtheria.— Only a few cases occurred among the troops.
Several interesting reports on the use of antitoxin have been
received. The opinion of Army medical officers is decidedly
favorable to its use as a prophylactic.
Typhoid fcrcr. -One hundred and nine cases, 13 of which
were fatal, were reported during the calendar year. This is an
improvement on the average annual prevalence and fatality of
the preceding ten years, 138.5 cases, of which 19.2 per cent, were
fatal. Of the cases during the past year, 12 per cent, were fatal
and the mortality per thousand of strength was .48. This lat-
ter rate can not be considered high, as it is exceeded by the
typhoid mortality rate of most of our cities, notwithstanding
the great susceptibility of soldiers on account of the predomi-
nance of young men in the ranks.
On account of the uncertainty concerning the nature of the
fevers reported from some of our western posts as Texas fever,
continued fever, etc., a call was made from this office, Aug.
30, 1895, on the medical officers of certain posts for a special
study of the fevers during the season of prevalence. Very
excellent reports were rendered ; but, as a rule, the assistance
afforded by a careful microscopic study of the blood was not
fully utilized in the differentiation of the cases.
Malarial diseases. The admission rate for malarial diseases
in 1895 was 82.56 per 1,000 of strength, and the rate of
non-efficiency 1.70, the former higher, the latter lower, than
the corresponding rates for the previous year, 74.72 and 1.88
respectively, but both considerably lower than the average
annual rates of the preceding decade, 103.32 and 2.57. The
lowest admission rate on our records was reported in the cal-
endar year 1891, 62.23, with a non efficiency of 1.58. Although
some of the posts in Xew York, such as Fort Hamilton, Fort
Wadsworth, Willets Point and West Point, contributed to the
increased rates, the two posts on the Potomac River, Fort Myer,
Va., and Washington Barracks, D. C, were the main source of
the increased rates, the former having 1,092.59 admissions
and a non-efficiency of 14.07 per 1,000 of strength, and the
latter 1,079.89 and 13.71. Major Walter Reed, Surgeon U. S.
Army, investigated the character, prevalence and probable
causation of the malarial fevers at these posts. From a close
study of the conditions, he came to the conclusion that in
both instances the prevalence of the disease was due to the
marsh lands of the Potomac valley.
Diarrheal diseases. — These diseases have been diminishing
gradually in prevalence. The admission rate was only 85.14
per 1,000 of strength, as compared with 94.77 during the
preceding year, and with 129.26 as the average annual rate of
the preceding decade. As a rule, the cases were trivial, the
rate of non-efficiency for the year having been only .78 per
1,000 of strength.
Venereal diseases. — The admission rate for venereal diseases,
i3.72 during the calendar year 1895, was less than that of the
preceding year, 80.43, and less than the average annual rate,
76.32, of the preceding decade. The non efficiency associated
with all these rates did not vary much, being a little over 5 per
1,000 of the strength. The relative prevalence was greater
among the whites than among the negroes, the admission rate
of the latter having been only 52.26. In 1893 the admission
rate of the colored troops fell below that of the white, and it
has so continued since then.
Alcoholism. — The admission rate for alcoholism, 30.11 per
1,000 of strength, is a slight improvement on that of the
previous year, 30.94, but a great improvement in the average
annual rate, 44.20, of the preceding decade. The rate of the
colored troops was, as usual, low, 6.47.
Rheumatic affections. — The admission rate was somewhat
larger in 1895 than in the previous year, 64.08 per 1,000 of
strength, as compared with 63.33, but the discharges for disa-
bility numbered only 12 as compared with 24. The improve-
ment in the health of the troops of late years may be seen by
comparing these figures with the average annual admission
rate of the decade 1884-93, 83.34 with 55.2 discharges for
disability.
Tuberculosis of the lungs. The rates for tuberculosis of
the lungs were smaller this year than last. Admission 2.42,
discharge 1.06, death .37, as compared with 2.96, 1.59 and .61.
They are considerably smaller than those of previous years,
for the prevalence of consumption among the members of the
Indian companies gave high rates as the average of the previ-
ous decade. It is to be noted also that during the past two
years the rates for consumption among the colored troops have
fallen so as to be much lower than those for the whites, whereas
formerly they were much higher.
injuries. — The rate of admission for injuries, 272.69, is larger
than in 1894, when this rate was 244.2; it is larger also than
the average annual rate of the previous ten years, 257.37, but
although the relative number of cases was increased, there was
914
SELECTIONS.
[October 24,
no corresponding increase in their severity, for the non-effi-
ciency, 8.46, was somewhat less than that of the decade cited.
Nineteen cases of suicide were reported, as compared with
18 during the previous year.
Radical cure of hernia. — In September, 1895, after con-
sidering fully the results attained by surgical treatment in the
radical cure of hernia, together with the small amount of risk
involved in the operation as now conducted under careful asep-
tic supervision, I came to the conclusion that the operation
might be made available to preserve good soldiers, although
ruptured, in the service and to lessen the number of men dis-
charged for disability and subsequently pensioned for hernia.
The annual loss of men by rupture has always been consider-
able. During the six calendar years ending Dec. 31, 1894, 153
men were discharged. I did not consider that the progress of
surgery warranted a resort to operative proceedings in all
cases, but felt confident that surgical interference would
enable many to continue in the military service, or earn their
livelihood with comfort in civil life, who are now discharged
and pensioned for hernia.
Since September, 1895, twenty-nine cases of hernia have
been treated by operation with the most satisfactory results so
far as can be determined at this early date. This gives an excel-
lent promise of future benefit in cases that have been hitherto
regarded as disqualified permantly for military service.
THE SANITARY CONDITION OF THE ARMY.
Quarters. — In four instances during the course of the year
attention was specially invited by medical officers to the insan-
itary and generally worthless condition of the barrack build-
ings at their posts. The barracks at Port Preble, Maine, were
characterized as very old and not worth repairing. At Port
Custer, Montana, the barracks with one exception are old and
dilapidated, all the floors uneven, worn through in places, and
so near the ground that the subfloor space can not be cleaned
nor inspected except by taking up the floor. The dilapidated
condition of the buildings at Whipple Barracks, Arizona, has
been reported on various occasions. They are overcrowded,
draughty and poorly ventilated. Estimates for additions to
relieve the overcrowding have been disapproved. In July and
August, 1895, the improvement of this post was again discussed
and urged strongly by the Chief Surgeon, in the hope
that early and favorable action would be taken by the War
Department.
The marked improvement that has been made during the past
few years in the sanitary condition of our military posts, is
especially manifest in the fact that during the past year no
report was received concerning the crowded condition of prison
rooms or guard houses, nor concerning the want of ventilation
or repair of the buildings occupied for prison purposes.
Formerly unfavorable criticism on the quarters provided for
men under guard was as common as it is now infrequent.
Drainage and sewerage. — At the large and important post
of Port Meade, S. D., privy pits are still in use; a suitable
sewerage system will no doubt be considered with the recon-
struction of this post. The privy pits at Port Keogh, Mon-
tana, also should be filled up, and replaced by the dry earth
system until sewers are built.
Concerning the efficiency of the dry earth system there is
ample testimony from the experience of many military posts.
Where complaint is made there is found on investigation to be
some want of the necessary care in carrying out the details of
the method. As an instance in point, it was reported of one
post during the year that "in only one closet was any dry earth
found, and in that no evidence of its systematic use." The
action taken by the post commander on this report was
to call the attention of company commanders to this negligence
and on his next inspection the surgeon found the dry earth
closets in satisfactory condition.
Water. — A temporary scarcity of water was reported from
several posts, as Fort Canby, Columbus Barracks, Port Grant
and Port Monroe. The bad quality of the river waters used at
certain posts, as Jefferson Barracks, Port Leavenworth and
Fort Custer, was specially noted by medical officers, who recom-
mended filtration for their purification. The Las Moras Spring
at Fort Clark appears now to be protected from inflow of sur-
face water. The discovery of a spriDg at Fort Reno furnishing
a water similar to that of Caddo Springs, will greatly benefit
that post. There has been much activity during the year in
improving the water supplies of military posts. Medical offi-
cers take special interest in the subject, and the Quartermas-
ter's Department has carried into effect many suggestions for
extension and improvement.
Food. — The food of the men has been reported almost uni-
formly as ample in quantity, of excellent quality, and well
cooked.
Clothing. — In my last annual report I had occasion to invite-
attention to adverse criticism by certain medical officers on Ine-
quality of the leather in the shoes issued to the troops. No-
such criticism is found in the reports of the present year ; yet-
in one instance a number of men were disabled on a practice
march by abrasions and inflammations of the feet, attributed
to ill-fitting shoes. The shoe now furnished by the Quarter-
master's Department appears to be of excellent quality, make
and shape, and there seems to be no reason why men should
be disabled on a practice march if proper care is taken in hav-
ing their shoes adapted to the feet before the march is under-
taken. Men who begin a practice march simultaneously with
the process of breaking in a pair of new shoes, are likely to suf-
fer from chafings or undue pressure, which may disable them,
temporarily and unnecessarily.
The various articles of clothing have been of good quality,
and suitable to the climate and service.
Habits of the men. — The remarks on sanitary reports con-
cerning the habits of the men are generally satisfactory, and
are corroborated by the lessened rates of the past year for ven-
ereal diseases and alcoholism.
Facilities for personal cleanliness have been greatly improved?
at our military posts during the past few years. At present
they are rarely referred to as inadequate.
Gymnastic training and athletic sports are held responsible
by many medical officers for the increase in the number of
injuries during the past year. Their view is no doubt correct,
but since the increase was not manifested in the rate of non-
efficiency it is evident that the extra cases which raised the
admission rate above the average of the preceding decade, were
not of a severe character. The accidents of the gymnasium
and the athletic field are offset by the benefits derived from the
training. Men are drawn away from vicious habits which tend
to increase the sick list, and the ability of the system to with-
stand harmful influences is greatly increased. Hence, although
the list of injuries is enlarged by the practice of athletics, the
rates of disability from injury and disease are less than in pre-
vious year in the history of our Army.
Respectfully submitted, George M. Sternberg.
Hon. D. S. Lamont, Surgeon-General, U. S. Army.
Secretary of War.
SELECTIONS.
Serum therapy. A fermentation has been going on in medi
cine for the last century, as a sign of which the systems in
rotation appear on the surface and after a longer or shorter
length of time disappear to, who knows at what future date,
start the game anew. The present is the age of serum-therapy.
About a hundred years ago the "humores" also reigned,
although in a different way. Humoral pathology, which sup-
posed the seat of disease to be in the fluid constituents of the
body, was suddenly replaced by cellular pathology. The micro-
scope taught us that the tissues consisted of cells which to a
certain degree were independent organisms and upon whose
functions depended the fate of the entire organic structure.
But as no footing could be found in the cellular pathology, the
research was continued in other directions.
On the one hand there developed by the aid of botany and
chemistry a modern scientific pharmacology, while on the other
side pharmacologic remedies were entirely discredited. This
led to the formation of the nihilistic school, which at least had
the advantage of making unprejudiced observations.
The development of the physiology of to-day has led us, at
the instance of the discovered normal and diseased functions,
to judge the therapy of the latter quite different. It was the
development of a new physiologic school. But now again the
microscope discovered new things, bacteria, bacilli, microbes,
and instantly all diseases were ascribed to these microorganisms.
The next step was for chemistry to appear on the scene with
microbe killing remedies, and as it at the same time furnished
a few new analgesics and febrifuges a temporary armistice was
secured. The observation, however, that it was not the microbes
as much as their poisonous products that were in question,
soon again aroused those who would rest on their laurels.
Chemistry was combined with bacteriology to solve the enigma
1896. 1
SELECTIONS.
915
by laolating the poisonous products and experimenting with
these. This led to their inoculation, as it appeared that these
products were poisons for the microbes themselves, as for
instance alcohol and yeast enzyme. According to this scheme
tuberculin was inoculated a few years ago. The danger of this
inoculation, however, soon showed the fallacy of the theory,
and investigators sought after a perfection of the idea. As the
latest result of their efforts we have the serum treatment.
Serum-therapy can only be understood when we follow the
train of thought which lies at the base of inoculation.
As an original form of vaccinating there was prevalent in
China and India direct transmission by injecting pock-virus.
In place of this, clothing used by smallpox patients was some-
times worn so that at an opportune time they might also pass
through the disease, probably during a light epidemic, as in
those days smallpox was considered as measles and scarlet
fever are to-day. which according to our mothers and grand-
mothers every child must have had.
Vaccination also came into practice by reason of its serving
as a quietus for those mothers who had to send their sons to
India, being thereby enabled to nurse them at home, instead
of having them plague stricken in a foreign clime. But as
inoculation of pock virus demanded too many victims, surgeon
.Tenner conceived the idea of inoculating cowpox, which he
considered transmitted smallpox. As this vaccination in com-
parison to the former inoculation was comparatively harmless,
it soon gained favor and still continues so, although no explana-
tory theory was then advanced or ever since given, and in spite
of being contrary to all modern laws of antisepsis.
One could imagine, and this many an adherent of the vacci-
nation theory does to his own satisfaction, that as a rule a per-
son fata measles and scarlet fever but once, this would be appli-
cable to all infectious diseases and especially to smallpox. In
reality this is neither the case in smallpox, diphtheria nor any
other disease. However, following this supposition it has been
said that, having had smallpox, protects from smallpox, and
further that passing through a mild form of pox, that is vac-
cination, also gives the desired protection. After the word
"protects' was unobservedly smuggled in, nothing remained
to be proven, and up to the present day the votaries of vac-
cination have owed us a satisfactory explanation.
In every falsehood there is, however, contained a kernel of
truth. If we will, namely, observe more frequently that dur-
ing the existence of a febrile disease, the afflicted one is not
susceptible of other infectious diseases, as owing to the in-
creased vital activity, increased oxidation, etc., a second attack
is more easily warded off, we can also admit that an artificially
produced febrile reactionary condition as is produced by vaccin-
ation will give a certain protection for a short time. This pro-
tection can, however, not last longer than a few weeks, it will
therefore be seen why sober observers recommend the unusual
repetition of vaccination. The principle of vaccination, how-
ever, was established and has held its own alongside of all
change of theories. In the course of time, all possible kinds
of vaccinations patterned after both "inoculation" and the
" moderated vaccination" have been tried. But syphilis inoc
ulation as well as cholera, hydrophobia and other vaccinations
were soon abandoned. The same fate was shared by the tuber-
culin inoculation, as they all did notoriously more harm than
good.
Research was continued, but this time from the only correct
standpoint why certain persons were immune, i.e., proof against
contagion. These individuals, whether man or beast, must
contain within themselves a protection. This protection could
be found only in the fluid tissues, the all permeating blood, as
the different tissues are too dissimilar to con tain protective mat
ter. The theory was advanced that serum, the blood fluid of
an animal which had overcome an infection, as for instance
diphtheria inoculation, should be injected into other animals
in the supposition that the serum contained a contra poison,
an antitoxin. This is Behring's serum-therapy. According to
my notion we again have one foot in the too readily dis-
carded humoral pathology, and I can only express my rejoicing
at this, as there is more contained in a humoral pathology
modified according to our latest physiologic and chemic knowl-
edge than many a one would dream. We will accept as
undoubtedly correctly observed the fact that the injected
serum of an animal having survived an infection gives a certain
protection to another animal or in other words puts it in a better
condition to withstand infection. We, however, lack conclu-
sive evidence, whether so large a quantity of serum (about 1
gram to 1 kilo, body weight) of a healthy, unprepared animal
is also capable of producing this so-called immunity in an
infected one. It can be admitted that the addition of so large
a quantity of serum, an excellent nutrient fluid, awakens, that
is, strengthens the vital energy to such a degree that the weaker
organism acquires the ability of the naturally immunized one
to conquer the intoxication. The blood has so many chemic
and physical properties, the body so many protective contriv-
ances, such as fever, etc., that one can not make an apodictic
assertion as regards antitoxins or counter-poisons. Professor
Buchner (Munich) has proven by experiments on animals that
antitoxins are altogether out of question, as the chemic quality
of the animals experimented on has an important bearing on
the case. The originally immune animal can not possess any
antitoxin, beside during the course of an infectious disease a
number of reactions take place which tend to make the intro-
duced injurioussness harmless. In this regard Buchner's
principles may eventually play an important part. But even
admitted that Behring's theory is correct, what good is it?
They claim the mortality to have dropped from 50 per cent, to
25 per cent, in diphtheria. Admitting the correctness of the
statistic observations I still find the rate of mortality so high
that I would hardly venture to use it as an argument. Beside
it is openly admitted that where, as there usually are in severe
cases, streptococci are present these cases are not affected by
the serum. Well, in the milder cases I use no other remedies
but those I have explained in my treatise ' years ago and which
we more or less all use. In severe cases I really need no assist-
ance either, besides such an assistance is made directly impos-
sible by the antitoxin treatment. We can, therefore, not use
this kind of serum-therapy. The contagionists have repeatedly
stated : "Live as you please, only be sure to get vaccinated in
the opportune moment." This is surely not according to the
laws of hygiene. Consequently serum-therapy is no hygienic
triumph. Undoubtedly, and we should not be misled by this,
the serum-therapy will be longer lived than any previous inocu-
lation method, as it is relatively harmless. But the lack of
success will ultimately kill it off.
Those who know what weapons have been employed to con-
quer diphtheria, will also lend a willing ear to the objections
of those skeptics who attribute the lower rate of mortality in
diphtheria under the serum treatment, to the absence of the
old drug poisons. Add to this, better nursing and the possi-
bility of the serum being a blood nutrient, and why should
there not be good results?
We likewise obtained good results during the first period of
tuberculin inoculation, because the patient's appetite was no
longer impaired by giving creosote, and the "interesting cases"
were better nursed. If we start with the principle that the
healthy organism contains a protection, probably protection
matter and possibly antitoxins, then the only sensible thing to
do is to investigate the protective power and by correcting the
mode of living and the like and to impart it to those individuals
who on account of want of natural protection are in need of it.
This is the opinion of the individualists who find within the
I Die wicbtigsteii Kajiitelder natiirlichen Heihvelse. Stuttgart, Zlm-
mer's Verlag.
916
SELECTIONS.
[October 24,
quality of the individual the riddle which is being tried to be
solved without.
I think there are animals and human beings who are rela-
tively immune against all infections. Against certain poisons
they are positively proof ; others by means of chemic and
physiologic protection contrivances, they conquer. We can
impossibly vaccinate against all infectious diseases from the
beginning : that means to vaccinate the sucklings. Further-
more, we can at the decisive moment, that means in case of
sickness, only vaccinate in the culture centers against all possi-
ble attack, presupposed we had "antitoxins" for every disease,
but so far we only have the diphtheria and tetanus antitoxins,
of which the latter has proved itself useless. (Relatively
speaking, in the meantime barring other therapeutics, people
would have to keep on dying for years, as it would take that
long before all the antitoxins would be discovered.) It is
moreover uncertain whether great damage is not done the
body by inoculating various antitoxins, ivhich according to
Buchner are toxin derivatives and related to the toxalbumins.
On one hand we do not care to wait so long, on the other we
must go to work with more logic, expecting nothing from
uncertain remedies, but aspire to acquaint ourselves with the
relatively universal immunity and its conditions. That the
universal immunity is not sparingly distributed among human
kind is proven by the mere existence and constant increase of
humanity, which in spite of thousands of years of aggression
by all possible plagues, has held its own and, as it appears, has
acquired a natural immunity against pestilence, typhoid and
smallpox.
In this field of natural immunity by leading a hygienic life
have I and others, in theory and practice, rendered such ser-
vice that we have therapeutically gained such an ascendancy
over the votaries of serum-therapy, who not until now — and
that in the wrong light— have taken the individual into con-
sideration, so that a better hygiene and therapy than we have
against infectious diseases can not be found anywhere to day.
I do not wish to cite statistics, but on request any physician
of our school will stand ready to treat diphtheria cases under
control with a smaller resulting mortality rate than can be
obtained by means of the so-called serum-therapy. It is our
object to make our own serum of the best possible kind and
quality.
Presupposing that my doctrine of dietetic blood-diathesis-
is well known, we have in it a lesson which if applied to our
diet and mode of living, will bring the protective power of our
serum to its normal height, i. c, will make us relatively
immune. The quintessence of our doctrine is the proof that
the reduced alkalinity of the blood of civilized men can by
dietetic means be brought back to its normal strength. Accord-
ing to Von Fodor and others the degree of alkalescence of the
blood is proportionate to its immunizing power, which experi-
mentally proves the correctness of my views on serum-therapy.
While in a case of mixed diphtheria with streptococci the phy-
sician applying diphtheria antitoxin is helpless, the organism
made relatively immune by means of dietetics is able by way
of its innate protective power assisted by appropriate external
remedies to successfully combat such cases.
For the forgoing reasons I have no fear in my own behalf in
acute diseases such as diphtheria for instance, as I know the
quality of my body and its serum. Not so with others whom
we know to be filled with autotoxins, as the cause of the dis-
ease, be it organized ferment, a microbe or a chemic ferment,
an enzyme liberates them. For the body of the majority of the
population, who are governed by false dietetics, is overloaded
with insufficiently assimilated albumin and insufficiently oxy-
dized substances which by contact are doubtlessly changed
into toxalbumins. (Compare Ernest Krauss in Zeitschrift filr
2 Die diiitetische Biutenmisehung als (irundursache aller Krankhei-
ten. Leipzig, Otto Spamer.
physicalische Chemie, Band xviii, Heft 2 "Uber die Ausnutz-
ung der Eiweissstoffe in der Nahrung in ihrer Abhangigkeit
von der Zusammensetzung der Nahrungsmittel.") Krauss
proves that where albumin is freely taken as nourishment, only
part of the albumin is changed into peptone, the other part
decaying in the bowels, "by which on account of the presence
of a large quantity of decayed matter the body is only
injured."
Upon the chemic condition of the body, not upon the
amount of infection depends the severity of the case. The
microbes do not easily gain access to the inner body, but the
toxins do, which doubtless, being relatives of the enzymes, are
also capable of developing results like these. They furnish us
with new dissecting matter, that is, loosen the vital process
(fever and oxydizing), the deposited decayed matter, auto-
toxins in the real sense of the word. With the autotoxins lies
the danger. They injure the heart and the kidneys and do
harm, when that little diphtheritic toxin has long been made
harmless.
It is interesting to note that Professor Escherich (Graz) in
No. 22 of the Wiener klinische Wochenschrift presents the
following theses covering my views :
1. For the appearance of diphtheritic disease there is neces-
sary, beside the bacillus and the possibility of its invasion, a
specific receptiveness of the organism about to be infected.
2. The condition of the local and general disposition, the
greater or less degree of virulence of the bacillus, the latter
only secondarily considered, are a criterion for the termination
of the case.
3. Also other and even saprophytic bacteria, besides their
products, may have an effect on the spreading and the clinia
termination of the process.
I consider the third thesis a circumlocution of what I under-
stand by autotoxin. My therapy in diphtheria is therefore
primarily aimed to put out of the way the autotoxins. The
evacuation of the lower gut by means of injections furnishes
to us in ninety cases out of one hundred such a terribly smell-
ing stool which differs distinctively from other fever stools,
which are usually dry and not so fusty, this being my reason
for thinking that diphtheria is a general instead of a local dis-
ease, as now supposed.
By these means, at least, dangerous products of decay are
prevented from being absorbed. The next thing for us to do
is to remove the autotoxins by means of increased perspiration
and eventual transpiration, by reason of which long lasting
partial or entire packing, eventually sweat packing, are brought
into question. By increasing perspiration and transpiration,
the almost constant relative hydremia is done away with.
Finally, for nutrition we will not choose albumins, as these,
under the conditions, would be the same as poison. Moreover,
we will introduce into the serum the mineral substances, nour-
ishing salts in the shape of readily assimilable fruit juices and
lemonades, and keep the body with the sugar and water of
them in a sufficiently nourishing condition, without especially
burdening the gut.
That is my position toward serum-therapy. Behring's serum-
therapy is a very interesting scientific problem. Therapeutically
considered it represents a byway which, on having recognized
the truth that our own serum should and will solve the problem,
as a rule comes too late to be of any service to the patients -
Read before the Congress of Physicians at Nurnberg (Ger-
many), by H. Lahmann, M.D. Translated by Carl Strdeh,
M.D., Chicago.
Morphin Antidote to Cyanic! of Potassium. Heim discovered
recently in the course of some experiments that animals which
had received a fatal dose of potassium cyanid were saved by
the injection of a non-fatal dose of hydrochlorate of mor-
phin. This effect seems paradoxical, as the two substances
combined in the laboratory produce only a precipitate of pure
morphin and the elimination of free hydrocyanic acid. —
Semaine Mid., September 23.
1896.]
EDITORIAL.
•117
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SATURDAY, OCTOBER 24, 1896.
COLOR VISION.
The perfeotly satisfactory physiologic explanation
of color sensation has not yet been made, as is demon-
strated by the fact that in nearly all the text-books it
is found necessary to state the two leading hypotheses,
of Hel.mholtz and Hering, side by side, though
widely differing in their methods of accounting for
the phenomena. One may be more favored than the
other, but each has its defects. The latest critic of
the Helmholtz theory, Tschiriew, in the Archives
de Physiologic, Xoriuale ci Patholoyique for October,
asserts that it is defective in that it does not respond
satisfactorily to Johannes Mueller's laws of specific
energies, in that it assumes each spectral ray of a
determined wave length can at once excite all three
elements of the retina in different degrees and thus
to give rise to these different sensations. It also fails
to account for that type of true color-blindness, con-
sisting in a loss of the sensations of violet, red and
purple and their complementary greens; and it does
not explain the effect of large doses of santonin in
producing a greenish-yellow tint in all white or shin-
ing objects. The Hering theory accounts better for
the phenomena of color-blindness and the effects of
santonin, but its assumption of different chemic pro-
's produced by the rays of different length in
the same visual substance of the retina is hard to
prove, and its claim that the sensation of black or of
darkness is due not to a cutting off of the light, but
to what may be called dark rays acting assimilatively
or re-integratively upon the visual substance, is
against all known chemic or physical laws. It is hard
to understand how the diminution of all rays can
cause an increase of the " black " rays. There is
also difficulty in conceiving the existence in the same
space of three different chemic substances that change,
not only singly but two or three together, under the
influence of the light rays received, and do this in
t wo different ways, assimilatively and disassimilatively.
Finally, neither of the two theories is satisfactory
in explaining the union of the different primary color
substances into the complex ones, red and yellow or
red and blue, for example.
In order to meet these difficulties he points out,
Tst HiKiEW otters a theory of his own. In the first,
place he accepts Mueller's law of specific energies
in a rather wider sense than has been hitherto admit-
ted, allowing variations in quality in the homoge-
neous sensations derived from a single excitation of
the peripheral termination of sensory nerve fibers.
In the second place he assumes in the layer of rods
and cones the existence of a special photo-cheinic or>
optic (visual) substance of two kinds, one in the rods,
capable only of change according to the quantity of
the light rays impinging upon it, and giving rise to
the sensations of the different degrees of white or
uncolored light; the other in the cones, changing not
only to excitations of quantity, but also with those of
quality, and producing the conscious sensations of
quality or color as well as of quantity, according to
the length of the luminous wave. He considers these
theoretic assumptions reasonable and in support of
the second one he adduces the facts of the lack of the
cones in the retinae of nocturnal animals (owls, bats),
and the demonstrations that the retinal purple is
decomposed by light so that even optograms have
been made with a rabbit's retina exposed before a
strong light and fixed with alum. The yellow spot,
where only cones exist, changes on the other hand
neither in light or darkness.
Admitting these assumptions, which are supported
by still further evidences than those suggested above,
Tsi hiriew finds it possible to meet the difficulties
where the former hypotheses have failed. In his
explanation of the various types of color sense defect
he does not limit himself to the peripheral retinal
apparatus but supposes a certain "rigidity" of the
nerve cells of the visual centers, by which they lose
their faculty of receiving impressions of qualitative
changes impressed on the retinal cones. In complete
achromatopsy, as occasionally observed in hysteria,
there may have been, for example, a vaso-motor spasm
affecting the nutrition of these cells and rendering
them responsive only to quantitative light impres-
sions. This intervention of the cerebral centers is in
its way an advance ; the optic mechanism has in the
past been a stumbling block from its very perfection;
918
LAY DISTRUST AND ENMITY OF THE PROFESSION. [October 24,
it did not sufficiently suggest the possibility of fail-
ures of color perception not dependent directly on
its defects. Men have written on the color sense as
if consciousness extended down to the peripheral
termination of the optic nerve, or perhaps it should
be better stated, as if color perception there took place.
Helmholtz, Hering, Tschiriew, Fick, or any other
theorizers on this subject have really only the task of
producing a hypothesis that will account for the
phenomena under normal conditions of the higher
visual centers; the derangements of these latter afford
an unknown, but certainly extensive, range of possi-
bilities of morbid alterations or defects of the color
sense.
The theories of the author here quoted may not be
altogether new; indeed, it appears possible some of
them may have been emitted before, but they are in
their way suggestive and noteworthy. His paper con-
tains some other points worthy of mention, such as his
statement that white as a sensation is not the result
of the blending of all the spectral colors but is simply
the effect of the reflection of uncolored light by min-
ute particles under certain special conditions. It is
one of the suggestive contributions to the literature
of the subject, whatever may be the ultimate estimate
of the views it presents.
LAV DISTRUST AND ENMITY OF THE MEDICAL
PROFESSION.
For two thousand years or more the medical pro-
fession has waged a ceaseless war to obtain the funda-
mental condition of medical knowledge and progress,
I. c, dissection material, and to-day many medical col-
leges are compelled to import from long distances and
at a crippling expense an insufficiency of cadavers.
Ever since the rise of the scientific spirit in modern
times the use of animals for experimentation, quite as
necessary a prerequisite of medical progress, has been
bitterly and violently opposed by the non-medical
world, and to-day that opposition is more dogmatic
and furious than ever.
The lay world, as regards both private individuals
and governments, is so indifferent to or suspicious of
us that while endowments, scholarships, etc., running
into millions exist for the encouragement of the study
of languages, astronomy, theology, etc., yet medical
education and medical students are left solely to self-
interest, with almost no endowments to help what is
the first necessity of human life — health and the erad-
ication of disease.
The one benefit of most proved and patent service
to humanity, which medicine has given the world —
vaccination — finds everywhere, but especially in Eng-
land and America, thousands of bitter opponents.
One of these in a speech in England as regards the
recent Gloucester epidemic, where hundreds sacrificed
their lives to the craze, has the audacity to utter the
following words: "Gloucester presented circum-
stances and cases which proved undeniably that vac-
cination was nothing but a delusion and a snare and
that insanitation was the real tap-root of the whole of
the sufferings of that poor, miserable, devoted city.
During the panic the doctors had been piling on the
agony and pocketing the plunder and scattering peo-
ple through the length and breadth of the country
with their arms in slings as if they had just returned
from a great European war."
Lastly, the opinion of the lay world is made still
more plain by the facts of the oceans of "patent" or
secret nostrums eagerly bought and devoured by it; by
the long struggle, still going on, to obtain medical
practice legislation to root out quackery, and by the
avidity with which it supports medical sectarianism
and quackery in the regular profession.
Such facts as these might be multiplied indefinitely.
Upon the other hand, every intelligent physician
has the sincerest and most well-grounded conviction
and consciousness that the profession taken as a
whole is more unselfishly and more successfully
devoted to the alleviation of suffering —of the very
people (and their children) who hate that profession
than any single body of men of so large numbers the
world has ever seen.
All this being true, one is almost disheartened at
the ingratitude, the stupidity and the brutality of our
enemies. Why labor for a united world that scorns
the help and hates the helper, blind and ignorant of
its own true need and inobservant of its best friend?
Beyond a doubt it is the recognition of this very fact
of the combination of ignorance and need of the
world that sustains the devotion to duty of many
physicians and keeps them from joining the ranks of
the shrewd self-seekers. The poor victims of their
own hate and egotism and ignorance are of course too
pitiable to be either duped or detested. They are in
truth pathologic specimens of society and history, and
a man with any largeness of character can not upbraid
or punish or despise a bit of morbid tissue, whether
sealed in alcohol or washed up in the world's sewage.
The cold-blooded will study it and philosophize about
it, the warm-blooded will commiserate, and both will
regret the disease and malignity that produced it and
smile lukewarmly at the passion which fires the hearts
of the monomaniacs.
Two things remain to prevent despair. The first is
that we are gaining, slowly perhaps but still surely,
in our warfare against disease and ignorance as the
lessening death rate certainly shows, and secondly, a
progressively increasing number are recognizing that
the acceptance of the selfish and personal end would
bring no added happiness. We are winning more
and better allies in the lay world, and the insatisfac-
tion of a wholly greedy life is becoming always more
evident to a larger number of physicians. When
18%.]
EMPIRICISM VS. WORKING HYPOTHESES IN THERAPEUTICS.
919
stnu'k by BOme particularly ugly fact BOme triumph
of quackery, some victory of a blatant or sly self-
ad\ertiser over honesty and modesty— we may be
tempted to cry. "It's no use! We might as well give
up! " But a large and healthy outlook and overlook
will at last convince that there is a decided and clear
measure of progress being secured with every gener-
ation's passing.
The puzzling fact remains to challenge our inge-
nuity. Why this persistent opposition? Viewed sim-
ply as a psychologic riddle we can not help being struck
by the incongruous and egregrious blundering of the
lay world in so hating the profession which is seeking
only the good of the hater. Why this century-long
bitterness and malignity of spirit, reaching even to
ludierousness in the diatribe of the poor fellow who
charges the doctors with "pocketing the plunder,"
the fees for vaccination from the be-pested Glouces-
ter folk. To take another instance, doubtless many
anti-viviseetionists are in reality tender-hearted peo-
ple, but doubtless also many are spurred to their vio-
lence not by pity of the "victim."' but by hatred of
the "viviseetionist." Macaulay said that the Puritans
opposed bear-dancing, not out of pity for the animal,
but because it gave pleasure to the spectator. In
every one of Life's cartoons or silly lunges on the
subject of vivisection one sees that the bitterness of
spirit against physicians is many times stronger than
any sentiment aroused by the sufferingsof the animal.
After all deductions are made on account of inher-
ited love of magic and miraele-mongering, one is
fiually driven to believe that the fundamental cause
of the hatred of Lord Omnes for us is due to his utter
inability to realize that men can have any abiding
motive of conduct that is not in its last analysis self-
ish. He knows in his own heart that if he were a
physician he would practice vaccination, not for the
good it would do, but because of the fee he should
derive from performing the operation. According to
his philosophy the preacher makes better wages and
with less labor by preaching than he could by business
or farming or shoveling; and so with the rest of the
"parasites." Feeling that such are his own ethical
standards, he must believe they are also those of all
others, and the half-hidden consciousness that it is
not so with these others arouses in his own heart a
tempest of passion to keep the voice of conscience
from being heard. Then, too, we have in every city
and town self-advertisers, quacks within the profes-
sion, whose trickeries are so manifest as to strike the
attention of all, and seeing these the profession-hater
sticks his tongue in his cheek and gloats over the
supposed fact that this particular charlatan, as he
thinks, only exposes what the others are more shrewd
in hiding, and that at last, if it were known, we are
"all alike."
And thus it comes to the moral, that there is no
enemy so harmful to the profession as the one within
our own ranks who hypocritically pretending accept-
ance of the higher standards of conduct of the guild,
in reality practices the greeds, charlatanism, and self-
seeking.
EMPIRICISM VS. WORKING HYPOTHESES
IN THERAPEUTICS.
The excuse most strongly advanced by the charlatan
for his existence is the specious one that therapeutic
discoveries are all the results of chance empiricism.
This plea is reiterated by physicians whose mental
indolence limits them to what are most absurdly called
the "practical" (but more properly the "receipt
book") side of medicine,' just now exploited at the
expense of the profession, by certain advertising
Hahnemanniac "free doctors." The shallowness of the
scientific foundation of the "receipt book doctrine"
contrasts markedly with its wide acceptance. Many
physicians fail to recognize the great truth pointed
out by Claude Bernard that, "All natural philosophy
is summed up in this: To know the law which gov-
erns phenomena. The experimental problem reduces
itself to this: To foresee and direct phenomena. It
will not satisfy the experimental physician, though it
may the merely empirical one, to know that quinin
cures ague. The essential thing is to know what ague
is and to understand the mechanism by which quinin
cures. All this is of the greatest importance to the
experimental physician, for as soon as he knows it
positively, the fact that quinin cures ague will no
longer be an isolated and empirical fact. This fact
will be connected then with the conditions which bind
it to other phenomena and we shall be thus led to the
knowledge of the laws of the organism and to the
possibility of regulating their manifestations. A
striking example can be quoted in the case of scabies.
To-day the cause of this disease is known and deter-
mined experimentally; the whole subject has become
scientific and empiricism has disappeared. A cure is
surely and without exception effected when the patient
is placed in the condition known to produce this end.
This is the purpose of physiology and medicine, to
make oneself master of life, in order to be able to direct
it." Even the briefest examination demonstrates that
therapeutic discoveries were never made by chance em-
piricism, but that all result from working hypotheses
which though often fetichistic in origin had excellent
results. One excellent illustration is the famous
doctrine of signatures, which though badly abused
from forced interpretation, strongly stimulated re-
search. One most significant evidence of the superi-
ority of even fetichistic working hypotheses to chance
empiricism is the pediatric laxative, manna {Jraxinua
ftrnus). The Aryan races employed birth ceremonies
to propitiate evil spirits. In these ceremonies the sacred
ash played an important part. The infant Zeus, accord-
920
COKRESPONDENCE.
[October 24,
ing to Greek myth, was fed on honey from the sacred
ash and from bees. Among the ancient Germans that
sacred food was the first put to the lips of the new-
born babe. So it was among the Hindus as appears
from a passage in one of their sacred books. The
father puts his mouth to the right ear of the newborn
babe and murmurs three times, "Speech, speech." Then
he gives it a name. Then he mixes clotted milk, ash
and bee honey and butter, and feeds the babe with it
out of pure gold. In the Highlands of Scotland at
the birth of an infant the nurse takes a green stick
of ash, one end of which she puts into the fire and
while it is burning, receives in a spoon the sap that
oozes from the other, which she administrates to the
child as its first food. Some thousands of years ago
the ancestors of this Highland nurse had known the
fraxinua ortms in Arya (Kelly, Indo-European
Folk-lore) and now their descendant, imitating their
practice in the cold North but totally ignorant of its
true meaning, puts the nauseous sap of her native ash
into the mouth of her hapless charge. The old crones
who haunt the obstetric chamber often practice these
antique methods of warding off evil spirits, or, as the
crones would phrase it, preventing bad luck. The
laxative quality of ash honey evinced the beneficent
fetich istic effect of the drug, since, according to a folk-
lore principle (still accepted by certain races), consti-
pation is one of the means "whereby the devil work-
eth," to quote Baxter, the seventeenth century Puri-
tan. Because of the tendency of fetichistic explanation
to vanish with advance in culture, the original work-
ing hypothesis (on which manna was given) disap-
peared to give place to the purely laxative principle.
This slow development of a humble laxative from
the awe-inspiring sacred ash (the Ygdrasil of Scan-
dinavian mythology) significantly demonstrates that
even the slightest scientific discovery is not suddenly
made, but is the product of a long evolution whereby,
as Shelley sings:
"Thought by thought is piled till some great truth
Is loosened and the nations echo round."
The physician who fails to recognize the great
truth here enunciated aids the quack who pretends to
discover stolen and distorted ancient therapeusis.
SOCIAL STATUS OF THE BRITISH MEDICAL
PROFESSION.
The completion of the sixtieth year of Queen
Victoria's reign will doubtless be marked by the usual
anniversary creation of peers, baronets, knights, etc.
At present it seems probable that, as usual, the Brit-
ish medical profession will compete with fertilizer
and sausage manufacturers for baronetcies and knight-
hood but will not dare to rival the lordly distillers
and brewers in the race for peerages. The British
medical profession, during the present century, far
from occupying a high social status, has always been
viewed askance by the present Queen and her ancles.
It disproved the foul calumny, unworthy even a vil-
lage gossip, which the court clique launched against
the Queen's unfortunate maid of honor, Lady Flora
Hastings, whose sarcomatous uterus was proclaimed
by highest authority evidence of unchastity. The
bitterness with which most of the Wettins regard
the medical profession was voiced by that master of
billingsgate, the Duke of Cambridge, when the Brit-
ish army medical service was given a definite status.
a reform struggled for by almost all that is illustrious
in nineteenth century British literature and science.
The Duke thus addressed the surgeon-general of the
army whom he met at a dinner soon after it had been
decided by the government to give official rank to
members of the medical department:
" Good evening, Surgeon-General, or Field Marshal,
or what the they call you now, I don't know how
to address you, you with your new titles, I don't know
what the I am myself: I suppose you expect me
to take my hat off to you; what - do you
fellows want."
This view of the British profession is so accepted
by the snobocracy that the Duke of Westminster will
not let residences on certain London streets to "med-
ical men or other minor tradesmen." The sixtieth
anniversary of Victoria's reign seems a good time to
raise the social status of British medical men by the
creation of medical peers. It should be remembered
in this connection that one of the greatest families of
the present period traces its recent ancestry to a sur-
geon-apothecary, Hugh Smithson. He, a century
ago, on marrying the peeress of the Pei« vs. was cre-
ated Duke of Northumberland in 1766. It was sug-
gested that his ducal coronet bear senna leaves in
lieu of the usual strawberry foliage. The English
peerage marks social status in Great Britain. There
is no reason why, in view of the regard shown physics
in the peerage of Lord Kelvin, medical science
should not be equally recognized. The House of
Lords of the "crowned republic"' could with advant-
age bulwark itself by medical members against the
rising tide of democracy.
CORRESPONDENCE.
Paracelsus.
Chicago, Oct. 19. 1896.
To the Editor: — On page 879 of The Jodbnal is a clipping
which presents the life and character of Paracelsus in some-
what too roseate a hue. When I was at Salzburg in 1889,
admiring the quaint picturesqueness of the town, reviving
memories of Mozart and wondering at the modern troglodytes
residing in furnished apartments cut cave-like out of the solid
rock in the hillside, I naturally, as a physician, hunted up the
relics of Paracelsus. The monument and chapel described in
the clipping are easily discovered. Of much more interest to
me, however, was the home of this curious character. Atone
end of the Salzach bridge and within hailing distance of the
18%.]
CORRESPONDENCE.
921
home of Mozart, stands upon a projecting corner, facing a
kind of little square, a plain, Hat, unornamental four-storied
house, with a luge portrait and explanatory plate in regard to
Paracelsus on the front of it. This was the last residence of
the erratic, wandering, doubtful quack and genius. Even his
name is in doubt. Some say it was Aureolus Philip Theo-
pbnatOB Bombast de Hohenheim ; others declare that it was
only Philip Aureolus Theophrastus, while the Bombast part of
it belonged to his father. Paracelsus, which is an atrocious
lireco Latin rendition of his patronymic, is good enough, I
trust, for us. Amidee Latour was fond of giving some such
advice as this : Remember always to appear to be doingsome-
thing - especially when you are doing nothing. Paracelsus
understood this principle most effectively, and coming upon a
lima for which his peculiar talent was most fitted, he enjoyed
a tremendous success. He seems, in fact, to have been an
intellectual giant, apparently doing everything, when in reality
he was doing nothing. Irascible, eccentric, fond of trickery,
a liar, a charlatan and a quack, a man of undoubted genius
with a few really valuable and practical ideas, a glutton, drunk-
ard and common scold, a visionary, an absurd theorizer and a
shiftless wanderer, he nevertheless impressed so forcibly the
age in which he lived that, to the present day his renown is
considerable. Bombast was not a bad name for him. He was
born near Zurich some time time about 1493. He never attended
any regular school, but was taught some Latin by his father,
who w as a physician. Then he began to travel, or rather roam
about, probably like Goldsmith, supporting himself doing odd
jobs and amusing the people with his necromancy. From the
back of a cart he may already have begun doling out his sure
cures to a gullible and voracious public. He was somewhat of
a chemist and, like many other learned fools of that foolish
time, toiled night and day in search of the mythic philoso-
pher's stone. Think of the man at 33, boasting of having cured
some thirteen princes, all given up, of course, as incurable by
the doctors. The world flocked to him and he waxed rich.
When a man lies why shouldn't he do it thoroughly? says the
quack. Thoroughness is always commendable. The public,
" Dear old Grandam " De Quincey calls it, fairly dotes upon a
liar. Well, the boasting of Paracelsus paid him munificently.
He was appointed professor of something in the University of
Basel, and at once began creating a disturbance. He said
" reading never made a physician," and so he publicly burned
the books of (ialen. "Countries are the leaves of nature's
code of laws — patients his only books." About this time med-
icine was overrun and worm-eaten with theorists, spiritualists,
humoralists, materialists and all the rest of that ilk, and the
turning of the world's gaze back upon nature was really one
notable thing done by this grand charlatan — a thing almost
good enough to atone for his outrageous falsehoods and cheats.
Even to-day a Paracelsus might do some good work in certain
quarters. Finally a climax was reached in Basel. Some grand
dignitary whom, as usual, he proclaimed to have cured, refused
to settle the little matter of the bill. The dignitary controlled
too many wires for the irascible professor, notwithstanding his
mythic thirteen princes, and so one cheerless day the latter
packed up his alembics, retorts, manuscripts, bones, tobacco
pouch and whisky flask and resumed his peregrinations. Like an
unwelcome fowl in an old well-regulated farmyard, he created
an uproar wherever he went. The "profession" of that day
was synonymous with blind conservatism and obstinate unpro-
gressiveness, and naturally it could not have been expected to
fondle this noisy upstart who laughed at all its pet notions and
burned its ponderous tomes. At last he arrived at Salzburg
and was given a most comfortable domicile by one of his
admiring dupes. He began quarreling as usual with the local
profession, and ended by being " pitched out of the window of
an inn by the doctor's servants and had his neck broken by
the fall." Thus ended the strange career of this meddler in
old established customs. Both his life and his teachings were
an incoherent medley. He started medicine upon a new tack
when he turned its eyes upon the doings of nature and away
from the moth-eaten volumes of useless libraries ; but in so
doing he intermingled much bosh, nonsense, fraud, miserable
deception and falsehood. He is dead, however, and may
heaven rest his bones more peacefully there beside the blue
Salzach river, than he did those of his poor patients whom
he cajoled into swallowing his nauseous decoctions. Like the
worthy doctor to whom the immortal Gil Bias once served as
assistant, he had one system for all his patients, and was a
diligent bookkeeper, so to speak, for the next world.
L. Harrison Mettler, M.D.
Medical Expert Testimony.
Dannemora, N. Y., Oct. 15, 1896.
To the Editor: — I have been very much interested in the
papers and discussions published in our Journal relative to
medical expert testimony. As chairman of the committee
appointed in February, 1895, by the Medical Society of the State
of New York, to report upon the most feasible plan for improve-
ment in methods of obtaining medical expert testimony, I pre-
sented to the committee two reports in January, 1896, the one
which was adopted both by the committee and the society
being that practically incorporated in the Bill presented by
Dr. Suiter, and already published in our Journal. The one
which the committee, while favoring the method, thought inad-
visable to present to the Society fearing that it would meet
with opposition, was as follows :
Resolved, That the Medical Society of the State of New
York would recommend the enactment of a law by the legisla-
ture providing for the appointment of experts by the courts,
and that only physicians of repute and holding a certificate
of qualification as hereinafter defined in the particular branch
of medical science to which the question calling for expert
opinion relates shall be appointed.
The above named certificate of qualification to be issued by
the Board of Regents, and duly filed in the County Clerk's
office of the County in which the holder of such certificate is a
resident ; such certificate to be obtained in the following
named manner :
The applicant for a certificate of expert qualification shall
furnish reliable evidence to the State Board of Medical Exam-
iners that he is legally qualified to practice in this State (New
York), is of good standing in the medical profession, and has
not had less than five years experience in the practice of the
special branch in which he desires to stand as an expert, and
shall also pass a satisfactory examination in the branch or
branches in which he is to become an expert.
On the passing of such examination to the satisfaction of
said Board, there shall be issued to him, in the same manner
as a license to practice is now issued, a certificate of qualifica-
tion to give expert testimony in the particular branch therein
specified, and when properly filed all physicians holding such
certificates shall be eligible for appointment by the courts, or
may be called by defence as expert witnesses.
The testimony of any medical witness called by either plain-
tiff or defendant, not holding such certificate shall be restricted
to evidence of fact.
My own opinion is that could such a qualification test be set
up, it would practically settle the question of obtaining relia-
ble expert testimony, and eliminate most of the objectionable
features of the present system. It would seem that such a
qualification could be demanded by the State without the
infringement of any constitutional feature of the law, or an
abridgement in any sense of the rights of the citizen or
practitioner.
There could be no question, it seems to me, as to the right
of the State insisting upon such a qualification, no more than
in its insistance upon a certificate of qualification to practice
general medicine. One of the objections raised by some of the
committee to this feature was that physicians would not qual-
ify ; this, I think is erroneous, for any duly qualified practi-
tioner who cared to become an expert could not object to this
922
PUBLIC HEALTH.
[October 24,
method of examination. It is to be hoped, however, that many
who, under our present system, might pose as experts, would
not qualify as such. I believe that qualification is the first
step in the right direction, and that other remedial legislation
would quickly and naturally follow.
Very respectfully, J. B. Ransom, M.D.
Congress of Leprologists.
New York, Oct. 14, 1896.
To the Editor:— 1 have sent the following to the American
Public Health Association. Will you kindly publish in your
next number?
A Congress of Leprologists and delegates of all civilized gov-
ernments will in all probability, be convened next year for the
suppression and prevention of leprosy. It was at first proposed
to hold this congress at Bergen, Norway, out of compliment to
Hansen. As the latter has renounced his claim, and left that
question to be decided by those who will work for the scheme,
and as there is among the present workers a division of opinion
as to the comparative merits of London and Moscow, nothing
can be said for the present, as to the place where the congress
will meet. Invitations will be issued, we hope, by one govern-
ment to the other governments, to send each an official dele-
gate. These delegates will form a permanent international
committee, whose business it will be to formulate laws suita-
ble for each country. The question of the suppression and
prevention of leprosy, is of paramount importance to Canada,
Mexico and the United States. Lord Aberdeen, President
Diaz and President Cleveland have already been appealed to :
the first through Dr. Smith, Medical Superintendent of the
Leper Asylum of Tracadie, and Inspector of Leprosy for Can-
ada ; the second through Dr. Carmona Y. Valle, the President
of the Second Pan American Medical Congress to meet in the
City of Mexico, next November; and President Cleveland,
through the Secretary of State.
There are in Canada three centers of leprosy; a Scotch,
Irish and French one in Nova Scotia and New Brunswick ; a
Chinese center in British Columbia and a possible Norwegian
one about Winnepeg, from communication with our States, the
Dakotas and Minnesota.
In the United States there is danger from the Chinese inva-
sion on the Pacific coast, and from the Norwegian center above
mentioned, but the greatest peril consists in the possible con-
tamination of our southern negro race from the Louisiana and
West Indian lepers, and possible contamination from the
Hawaiian islands.
Mexico is exposed to Chinese and Japanese invasion and,
moreover, the harbors of Mazatlan and Acapulco may receive
inoculation from the 27,000 lepers of Colombia, South Amer-
ica, through mercantile intercourse.
Queen Victoria, by her private secretary, Sir Arthur Bigge,
has expressed sympathy when informed of this project and the
matter has been referred to her responsible advisers.
As this memorial did not reach the Advisory Council of the
American Public Health Association in time to be brought
before the recent meeting at Buffalo, I take the liberty to
bring the matter under the eyes of the Association in an open
letter, urging that the influence of the Association, which is
known to be great, be brought to bear upon the governments
of Canada, Mexico and the United States, so that we may
obtain from each of them a delegate to the proposed Congress.
Very Respectfully, Albert S. Ashmead, M.D.
PUBLIC HEALTH.
Consumption Among the Colored Population.— A writer in the
Medical and Surgical Reporter for October presents the sta-
tistics of eight of the principal cities of the South which prove
that the proportion of deaths from consumption among the
colored races as compared with the total mortality, is more
than 50 per cent, greater than that of the white population,
while the death rate per thousand from this disease is nearly
three times as great.
The Bubonic Plague.— The Lancet states that an outbreak of
fever, attended by some of the features of what is alleged to
be bubonic plague, has taken place at Bombay and has been
attended by many deaths. The occurrence has naturally
excited a good deal of alarm among the native population,
many of whom have left the city. The troops of the British
and native armies have been temporarily prohibited from
entering the affected locality, and the government has
appointed a committee to inquire into and report upon the
subject. Mr. Dutt has arrived at Calcutta with the special
object of aiding the committee in their investigation. The
outbreak is probably of the same nature as that which occurred
lately in China and Hong Kong. The British Medical Journal
adds : We hope no time will be lost in inviting Dr. Yersin to
practice his serum injections for the cure of the plague. His
success with it has been reported in this Journal.
Tetanus Antitoxin in Brooklyn.— The Department of Health of
Brooklyn, N. Y., has issued under date of October 8, a circu-
lar regarding tetanus antitoxin, as follows :
"The health department is now prepared to furnish to phy
sicians and hospitals antitoxic serum for the treatment of
tetanus. Each vial will contain 20 c. c. of the serum, but the
dose will vary with the age of the patient, the severity of the
attack and the time in the disease when the treatment is begun.
The remedy is administered in the same way as diphtheria
antitoxin, by hypodermic injection, using a large syringe and
carefully sterilizing the syringe and the skin before making
the injection. Some point on the anterior surface of the body
is preferable for the injection. Too much emphasis can not be
placed on the vital importance of injecting the serum at the
earliest possible moment, as every hour's delay decreases the
chances of success and requires larger doses to overcome the
amount of toxin produced and absorbed. When the treatment
is begun at the first appearance of tetanic symptoms, 20 c. c.
should be injected at once, and 10 c. c. at intervals of six
hours for the four following days. If the treatment is not
begun »ntil three or four days after the onset of tetanic symp-
toms, 20 c. c. should be used at once, and repeated at short
intervals according to the results. The use of the serum does
not preclude the employment of other methods of treatment by
the use of antispasmodics. The wound should be treated with
some strong preparation of iodin, such as strong tincture, to
destroy the toxin in it. Carbolic acid and bichlorid of mer-
cury are of little use for this purpose. The exact value of this
method of treatment has not been fully determined, and it is
very desirable that full reports be sent to the department of
each case and the result of the treatment."
Baths for Miners.— On the European continent mining com-
panies have, of late years, devoted much attention to provid-
ing facilities for the miners to perform their ablutions and to
change their wet and dirty clothes, so as to enable them to
return home refreshed in dry and warm clothes. A very elab
orate lavatory has been erected at the Hibernia mine, Gelsen-
kirchen. The plant comprises shower baths for 1,600 miners
and private bathrooms for the managers and overseer. The
success that has attended the use of lavatories in Westphalia
led to the erection of two admirable establishments at the
Dudweiler and Kreuzgraeben collieries, in the Saar coal field.
At Dudweiler the massively built house, which is in direct
communication with the mouth of the adit, has an internal
area of 108 by 61 feet. The height of the roof is 16 feet. Two
high double walls divide the building into three sections, two
of which serve for the married miners and the other for the
young unmarried ones. Light is furnished by forty-five win-
dows and three skylights, and, at night, by three arc lamps.
The floor is of cement, with a slope of 1 in 40. There are fifty-
five shower baths, each in a cell, five of these being supplied
with cold water and the others with water heated in summer
to 86 degrees F., and in winter to 95 degrees F. Each cell
18%.]
NECROLOGY.
923
measures i feet 6 inches by 3 feet 3 inches, and is used by two
miners at the same time. The cold-water cells are somewhat
smaller and are arranged for one person only. In the dress-
ing rooms there are a number of forms, and for each man's
clothes there is a hook and line running over pulleys at the
ceiling. The clothes hung up at the ceiling dry very rapidly.
Fach hook is marked with the man's lamp number. The
building is heated by steam pipes. For a bath, seven gallons
of water are required. Of the 1,900 miners employed in the
mine 1,800 bathe regularly. Seven hundred miners, however,
live in barracks where ample washing accommodation is pro-
vided. The lavatories have been in existence at Dudweiler
and Kreuzgraeben colleries since 1891, and have answered
their purpose admirably.— Health, October 3.
Detention Hospital for Lepers at Honolulu.— Assistant-Surgeon
Ammen Farenholt, U. S. X., writes to the Boston Medical and
JSuraical Journal. September 3, the following account of the
above institution : " In December last, while at the Hawaiian
Islands, on the U. S. S. Baltimore, I visited Kalihi, the hos-
pital of detention for lepers, three miles north of Honolulu.
The primary object of this institution is to afford shelter for
the patients condemned as lepers and awaiting transportation
to the Island of Molokai, the government leper settlement, and
also to serve as a home for the suspects, those in whom the
symptoms of the disease are not sufficiently well marked to
admit of a positive diagnosis. There are also 30 little patients
here, the children of the lepers at Molokai ; 23 are graduated
from the institution, that is, having passed six or seven years
under observation, and showing no signs of disease, they
were allowed to go into the common walks of life. Only
one of these has become a leper, and he lived subsequently
with an infected family in Honolulu. In about one-third of
the eases both the father and mother were lepers. All inmates
are earefully watched and made to remain in the quarters
assigned to patients in the same condition as themselves. The
hospital consists of five or six one-storied whitewashed houses,
arranged around a square tilled with palm-trees and beautiful
beds of flowers. Sisters of Charity from Syracuse, N. Y. , have
charge of the hospital. Every month the suspects brought in
by government spies are examined by a board of five physicians,
also appointed by the government. The patients appear in the
examining room, and are inspected by each medical officer in
turn, who writes his verdict opposite the number of each case
on the list before him. The examination being over, the
recorder reads off the numbers, and the members in turn give
their opinion, the words leper, non-leper or suspect being used.
Three votes out of the five are necessary for a decision. The
first are held until a sufficient number are waiting, and then
they are transferred to Molokai ; the second are allowed to
return to their homes ; and the third are retained for further
observation. An examination of suspects was being held at
the time of my visit, to which I was kindly invited by the
senior physician. Facial paralysis, however slight, absorption
of joints and later of the bones themselves and a reddish or a
whitish macular eruption, are the most common primary
lesions, as the disease is seen in Hawaii. The population of
the islands is about 38,000 (native Hawaiian). At Molokai
there are 1,100 lepers ; and it is said that only one in every four
is detected. Thus out of a population of 38,000, 4,000 are
lepers, almost 12 per cent.
The Daily Medical Inpsection of Schools in a Great City.— We
think it is not generally known, even among those who are con-
sidered to be sanitary adepts, that Boston has, after years of
effort, the benefit of a genuinely systematic school inspection.
The August number of the Archives of Pediatrics shows how
this innovation was secured by the Board of Health as a con-
sequence of a very severe epidemic of diphtheria. The general
plan of operations, that has now been in force for a year, and
that was, as we believe, devised or matured by Dr. S. H. Dur-
gin, is the following : The city was divided into fifty districts,
giving an average of about four school-houses and fourteen
hundred pupils to each district. No difficulty was experienced
in finding well-qualified and discreet physicians who would
undertake the duties prescribed. The Board appointed one
physician for each district, with a salary of $200 a year, plus
the honor and satisfaction of serving in a good cause. His duty
is to make a visit to each master's school daily soon after the
beginning of the morning session. The master receives from
each of the teachers in his district, early reports as to the ap-
pearance of symptoms of illness in any pupil in their charge.
These reports are given to the visiting physician, who at once
examines the reported children and makes a record of his diag-
nosis and action in books furnished for this purpose, and kept
in the custody of the master. If the visiting physician finds
the child too ill to remain in school, he advises the teacher to
send the child home for the observation and care of its parents
and family physician. If the illness is from a contagious dis-
ease, the child is ordered home and the case reported to the
Board of Health. The medical inspectors never undertake to
give professional treatment in any case. They merely point
out the need of professional treatment where the need exists.
The treatment itself must be received from the family physi-
cian or in the hospitals or in the dispensaries. Incidental to
this school inspection the same corps of medical men is also
serving as agents of the Board of Health in the control of con-
tagious diseases which are treated at home. The Board of
Health sends to each of the school inspectors, every morning,
a full list of the cases of diphtheria and scarlet fever which
have been reported during the previous twenty-four hours.
Each medical officer selects the cases reported in his district,
visits them to see if they are properly isolated at home, leaves
a card for the attending physician, politely informing him of
the official visit and reports his approval or disapproval of the
isolation at once to the Board of Health for its action. If the
patient is properly isolated, the officer places a card on the
door of the room to indicate the official designation of such
room for the isolation of the patient. If the case is not prop-
erly isolated and such isolation can not be commanded at home,
he reports such facts to the Board of Health, and such patient
is at once ordered to the hospital. He makes another visit to
the patient. This school inspector and agent of the Board of
Health is indirectly held responsible for the proper isolation of
the patient at home, for causing -the patient's removal to the
hospital when necessary, and for the patient's release from iso-
lation ; in other words, the Board of Health is thus provided
with trustworthy information upon which it can act for the
best protection of the schools and the public against the spread
of contagious diseases.
NECROLOGY.
A. B. Shaw, M.D., St. Louis, aged 49 years. Dr. Shaw died
a martyr to duty. Infected in the performance of duty years
ago, his knowledge of the clinical course of that infection and
its dreadful possibilities placed him often in a frame of mind
to which the physical suffering which it entailed bore no pro-
portion, and only those who were made the confidents of his
mental agony can faintly realize what suffering there was for
years hidden under the pleasant exterior of an apparently
healthy body.
Sir George Murray Humphry, aged 76. "Humphrey of
Cambridge," one of the greatest medical figures of our time,
revered and loved by generations of medical men and honored
by individuals and scientific associations at home and abroad.
The new School of Medicine at Cambridge is his most lasting
monument. The Lancet mentions that he treated cases of
tetanus by giving nourishment in all possible ways and tobacco
924
PRACTICAL NOTES.
[October 24,
smoking to excess. Good port wine was hie favorite internal
remedy. This treatment always soothed the patient, and the
writer has seen three cases recover under it. He commonly
took his holidays abroad, and visited continental hospitals and
museums, seldom failing ts bring back safely packed in a port-
manteau some fragments of humanity which would enrich the
Cambridge collection. Indeed, he looked upon the museum
as only second to the hospital in importance. He often said
that he turned every moment of his life to some account.
Even his severe illnesses were not without their utility, for
his dangerous attacks of phlebitis furnished medical literature
with one of the best monographs on the subject of venous
thrombosis which has ever been written. One of his aphor-
isms to his pupils was : "Eyes first, fingers next, ears last."
SOCIETY NEWS.
Second International Congress of Charities and the Protection of
Children. — Nine governments were officially represented at the
Congress: United States, Switzerland, Prance, Hungary,
Portugal, Sweden, Spain, Luxemburg, and the Argentine
Republic. The resolutions adopted evidence the modern ten-
dency to a more rational conception of the preponderant
importance to the State of the correct physical and moral devel-
opment of the child, and the responsibility of the community
to the children of the poor and degraded. They endorsed the
formation of societies to supply medical care and assistance to
mothers before and during confinement, with rest for four
weeks afterward, and advice and assistance for mother and
infant during the entire nursing period, in charge of local com-
mittees in every district with over twenty-five infants to be
thus protected ; creches near industrial establishments, under
strict daily medical supervision, with guarding classes for
children after school hours until the parents return from work :
more judicious education of the young especially in morality,
in view of the increasing juvenile criminality evidenced by
statistics produced ; complete separation of the young from
adult criminals, and closer organization of all charities accord-
ing to English and American methods. The Congress also
voted that the expense of assistance to foreigners should be
reimbursed to the community by the State, and that the indi-
gent should in every case be returned to their home by birth
or naturalization.
PRAGTI6AL NOTES.
Pernicious Anemia Cured with Bone Marrow.— A young soldier
was brought to the hospital in pernicious anemia consecu-
tive to an attack of dysentery. He was so feeble that he
could not rise ; there was malleolar edema, ascites and dila-
tation of the right heart with systolic murmur at the apex.
Iron and arsenic produced no effect. Blumenau cured him
in two months and a half with the entire disappearance of
the complications by giving him 90 grams a day of raw bone
marrow, spread on bread or taken in soup, with no other med-
ication.— Semaine MM., September 23.
Sulphur Baths In Whooping Cough. Among the many treat-
ments recommended for this disease, the Journal de MM. de
Paris, September 20, describes Josset's prolonged baths, with
0.75 gr. sulphureted potassa to the liter, the temperature at
97 degrees, and the duration of the bath from twenty five to
forty-five minutes, according to age, once a day, the head alone
exposed above the water. With this treatment all complica-
tions were avoided, the sulphur evidently acting on the special
whooping cough bacillus, with a beneficial antiphlogistic
effect on the bronchial mucosa and a revulsive action on the
skin. It is rarely necessary to administer more than fifteen
baths as the cure is usually obtained long before this.
Cause of Inefficacy of Sublimate Spray as a Disinfectant.- Cha-
vigny has found that the sublimate simply affects the outer
surface of the microbes, producing a superficial layer of coag-
ulated protoplasm, which temporarily destroys their virulence
but readily washes off, when they recover all their former
virulence. Hydrosulphate of ammonia is one of the substances
that promptly restores them to their previous activity. Among
other experiments, thin layers of tuberculous sputa exposed
for a long while to direct sublimate spray, produced fatal tuber-
culosis every time when rabbits were inoculated with them. —
Annates de VInstitut Pasteur, June.
Painless Treatment of Ophthalmia Neonatorum.— Hjort of Chris-
tiana states that the same results obtained with the classic
treatment of this affection can be secured with much less
trouble and inconvenience, by first dropping in oxygenated
water at 1 or 1.5 per cent., which causes the pus to effervesce.
The eye is then washed out with 2 per cent, boricated water,
working the lids slightly until the pus has all been cleaned out,
when the solution of nitrate of silver at 1 per cent is gradually
instilled. This method does not require the reverting of the
eyelids, but it should be repeated four times a day at first. It
can be safely intrusted to a well-trained uurse. — Semaine
MMicale, September 23.
On the Misuse of the Pessaries. — Dr. A. J. C. Skene, Brooklyn
Medical Journal, September, participated in a discussion of
Dr. John Byrne's paper on the needs of minor gynecology,
before the Gynecological Society of the city above named. He
generally confirmed the opinion of Dr. Byrne that the misuse
of pessaries, in the treatment of uterine retroversion, was every
day tending to produce conditions, remediable in themselves,
that are absolutely incurable ; that too many of these imple-
ments as sold in the instrument-makers' stores were viciously
devised to produce an atrophy of the tissues impinged upon
and thereby converting simple retro-displacements into incur-
able flexions. Dr. Skene's remarks were in part as follows:
"With reference to the use of the pessaries, and that is only
one thing in which we are apt to go astray in minor gyne-
cology, I have certainly had some experience, though limited
no doubt, compared to that of Dr. Byrne. There was a time
when I introduced very many pessaries, but now I think 1 divide
my time about evenly between removing those that have been
introduced and using others that give relief. It is an unfortu-
nate thing that very few have had practice and patience enough
to master the mechanisms of displacements and the mechanic
appliances for their relief. I have no doubt there are hundreds
of men who do laparotomy and all surgical operations in the
domain of gynecology who could not fit a pessary to correct
a displacement any more than they could make boots to fit
themselves."
Tubercular Meningitis Ending In Recovery. Dr. Jenssen in the
Deutsche medicinische Wochenschrift reports a case of the
above description. The writer adverts to the rarity of recovery
in this disease. In a few cases the diagnosis has been estab-
lished by finding evidence of a past tuberculous meningitis,
the patient having died of some other cause. In Preyhan's
case of recovery, tubercle bacilli were found in the fluid drawn
off by spinal puncture. The author then records the follow-
ing case : A man, aged 19, was admitted in May, 1892, with
headache, stupor, vomiting and constipation. The tempera-
ture was raised and at one time the pulse only numbered forty-
two per minute. Later there was ocular paralysis and retraction
of the head. Some fourteen days after admission the patient
began to improve and he was discharged well a month after-
ward. Three years later he was again admitted into the hos-
pital with early phthisis. The disease ran a rapid course and
he died four months later. At the necropsy a yellow mass,
composed of minute tubercles, and measuring four centime-
ters long and two centimeters wide, was found running along
1896.]
MISCELLANY.
925
•BCD side of the longitudinal fissure. The pia muter was of a
milk white color in soveral places over the convexity of the
brain ; there minute tubercles were also seen. The first-
named tubercles consisted of detritus, fat and a few cells, but
no fibrous tissue; and the last-named of fibrous tissue and a
lis. In no instance were tubercle bacilli found. At the
of the brain the same white spots containing tubercles
wore soon about the chiasma and Sylvanian Assures. In these
white areas the pia mater and arachnoid were adherent to the
underlying brain tissue. As regard the treatment of this
attack of tuberculous meningitis, the head was shaved and
iodid ol potassium was given in large doses; 8 g. were at first
administered in the day, but this quantity was rapidly in-
Oreased. The patient tojk as much as 950g. during the illness.
There was a slight coryza, but no other unpleasant symptom.
All the secretions and excretions gave a marked iodin reaction.
The author thinks that the iodid had undoubtedly a favorable
effort on the disease. This treatment is not new, but these
lar^e doses of iodid have not within the author's knowledge
been used before.
New Operation for Luxation of the Tendons. — Luxation of the
tendons does not occur frequently, but is a source of great
•linOTBBOG when it does happen. An article in the Rente ile
Chiriiryie for September reviews the cases on record and the
various methods of treatment, concluding with a new opera-
tion performed by Kousmine of Kazan. The patient had dis-
located the tendons in an accidental fall two years previously,
when his foot had slipped out to one side. Bandaging had
proved ineffectual, and in spite of every precaution in stepping,
the peroneal tendons sprung out of their normal position, espe-
cially in supination and flexion, producing great pain and caus-
ing the foot to slip, until walking was practically impossible.
A half moon incision was made to the bone behind and below
the external malleolus, and a trapeze-shaped space on the peri-
osteum cut around, the base of the trapeze corresponding to
the lower edge of the malleolus, after which the enclosed small,
flat piece of bone was cut out with the scissors and raised per-
pendicularly to the malleolus. A couple of nickel nails were
inserted to hold this little piece of bone up like a trap door,
and keep the tendons in place. A plaster cast was then applied.
The pain was trifling and soon passed away. There was no
fever. In seventeen days the cast was changed, the nails with-
drawn, and the tendons found in their normal position, with a
considerable elevation thrown up on the outside of the malle-
olus. Another plaster cast was applied and the patient left
the hospital with advice as to slight massage and exercise
after removing the cast in twenty-eight days. The results of
the operation have proved curative and brilliant. The patient
is entirely relieved of his functional troubles. The neoforma-
tion of the bone answers its purpose perfectly, while the trau-
matism was insignificant in the simple operation, as neither
the tendons nor the aponeuroses were wounded.
MISCELLANY.
Ammonia in Alcoholism. — Dr. Baratier recommends, in El Siglo
Medico, the addition of ammonia to wine or liquor in order
to produce a distaste for alcoholic beverages. After a few
doses the disgust to the mixture becomes so intense that even
the sight or smell of wine is unpleasant. — St. Louis Med.
Journal, October.
The Significance of the Diazo Reaction in Phthisis. — Beck, from
investigations carried out in the Institute for Infectious Dis-
eases at Berlin, has come to the conclusion that the appear-
ance of the diazo reaction in the urine of patients suffering
from phthisis makes the prognosis unfavorable, while its long
continuance forebodes an early death. — Boston Med. and Surg.
Journal.
Bahla's Participation In the Pan-American Medical Congress not
Possible. — The OazetUi Medicada Bahia, Brazil, states that the
profession at Bahia does not expect to take any part in the
Pan-American Congress, either personally or by scientific con-
tributions. The circulars in regard to the Congress have only
just been received at Bahia, but this delay is not the cause of
the abstention, but the fact that the same date has been
appointed for the first medico-surgical congress to meet in that
city.
Trained Nurses in Calfornla. — The Medical Record states that
many trained nurses from Philadelphia and Baltimore have
recently been induced to go out to San Diego and other places
in Southern California on the representation that they could
find employment there that would pay them $20 to 125 a week.
On arriving there, however, they have found that there was no
work for them, and that, even if there were, they could not
obtain any such remuneration for their services, and they have
in many cases had to send to their friends in the East for money
to enable them to return home.
Provision for Baltimore Indigent Lying-in Women. — Recognizing
as is stated, that the Maryland Lying-in-Hospital, of Baltimore,
a body corporate, is well and firmly established in said city,
and particularly well equipped for the treatment of lying-in
women, and that it is desirable that the benefits and advan-
tages of such hospital should be extended to the indigent
lying-in women of the State of Maryland, so that skilled and
humane treatment be afforded them, the General Assembly of
the State enacted, in chapter 148 of the Laws of 1896, that the
sum of three thousand per annum be appropriated for each of
the years 1896 and 1897 for the maintenance of free treatment
for indigent lying-in women in said hospital.
Chairs for Maryland Salesladies. — A Maryland statute of 1896
provides that all proprietors or owners of any retail, jobbing
or wholesale dry goods store, notions, millinery or any other
business where any female help are employed for the pur-
pose of serving the public in the capacity of clerks or sales-
ladies, shall provide a chair or stool for each one of such
female help or clerks, in order that during such period as
they are not actively engaged in making sales or taking stock
they may have an opportunity to rest. The penalty for the
first offense is a fine of from $10 to $100 ; and in the event the
owner or proprietor shall continue to disobey, he shall be sub-
jected to a fine at the rate of one dollar a day, daily, for every
chair he fails to furnish his said employes.
Alvarenga Prize of the College of Physicians of Philadelphia. — The
College of Physicians of Philadelphia announces that the next
award of the Alvarenga Prize, being the income for one year of
the bequest of the late Senor Alvarenga, and amounting to
about $180, will be made on July 14, 1897, provided that an
essay deemed by the committee of award to be worthy of the
prize shall have been offered. Essays intended for competition
may be upon any subject in medicine, but can not have been
published, and must be received by the secretary of the college
on or before May 1, 1897. Each essay must be sent without
signature, but must be plainly marked with a motto and be
accompanied by a sealed envelope having on its outside the
motto of the paper and within the name and address of the
author. It is a condition of competition that the successful
essay or a copy of it shall remain in possession of the College
other essays will be returned upon application within three
months after the award. The Alvarenga Prize for 1896 was not
awarded. Thomas R. Neilson, Secretary.
Illinois State Conference of Charities and Corrections. — It has
been found necessary to change the date of the proposed State
Conference of Charities and Corrections. The conference will
take place on Thursday and Friday, Nov. 12 and 13, 1896, at
the Capitol in Springfield, and not November 18 and 19, as pre-
926
MISCELLANY.
[October 24,
viously announced. Among those who it is hoped will take
part in the program are H. H. Hart, secretary Minnesota State
Board of Charities : Ernest Bicknell, secretary Indiana State
Board of Charities ; Bishop Spalding, Dr. Julia Holmes Smith,
Miss Jane Addams, Judge Carter of Chicago and others. Com-
plete program will be published later. Classes for the State
Schools for Blind and for the Deaf and Dumb will give exhibi-
tions. Governor and Mrs. Altgeld will receive the Conference
at the Executive Mansion. Excursion rates of a fare and a
third will be made by the railroads, and special rates will be
obtained at the hotels and boarding houses in Springfield.
For any information or services desired, please address Geo.
F. Miner, Secretary State Board of Charities, Springfield.
Cause and Prevention of Glaucoma. — The etiology of glaucoma
is still disputed, but Schoen of Leipsic, the new professor of
ophthalmology, asserts in an article in the Wien. klin. Rundsch.,
Nos. 26 to 31, that no one need lose his sight from this cause,
unless he chooses. It can always be prevented if the eyes are
seen in time by an expert and his warnings heeded, as the
invariable cause is excessive strain in the effort of accommoda-
tion. As the number of the efforts increase with age, the strain
increases and glaucoma is the result. The particulars of the
last 140 cases he has treated are : 48 per cent, hypermetropic ;
not one had possessed a distance lens. Astigmatism was
present in 33 per cent ; in none had the astigmatism been cor-
rected. In 20 per cent, there were no glasses, or they had been
utterly inadequate. Nearly twice as many cases of glaucoma
occur among women as in men, the former shrinking from wear-
ing glasses until too late. What may be a trifling effort for the
eyes at first, becomes in the course of years an exhausting
strain, and while this strain of over exertion in the efforts of
accommodation produces anatomic changes which lead directly
to glaucoma in time, yet any constitutional morbid tendency,
any weakening or depressing cause, violent couching, night
watching, etc., may hasten its appearance.
New Dental Law for Maryland.— Chapter 378 of the Maryland
laws of 1896, which was approved April 4, 1896, repeals Article
32 of the Code of Public General Laws, entitled "Dentistry,"
and reenacts the article with many changes in it. The new
law makes it unlawful for any person to practice dentistry in
the State unless he shall have obtained a certificate therefor.
It then provides that there shall be a State board of dental
examiners, which shall consist of six practicing dentists of
recognized ability and honor, who have held regular dental
diplomas for five years. They are to be appointed by the gov-
ernor out of a list proposed by the Maryland State Dental
Association. Six years is the regular term of office. Any
member who shall be absent from two successive regular board
meetings shall cease to be a member of it. The regular meetings
are to be held in May and November of every year, with special
meetings as required. Any person 21 years of age, who has
graduated at and holds a diploma from a university or college
authorized to grant diplomas in dental surgery by the laws of
any one of the United States, may be examined by said board
with reference to qualifications, and upon passing an examina-
tion satisfactory to said board, his or her name, residence or
place of business shall be registered and a certificate shall be
issued to such person. Any graduate of a regular college
of dentistry may, at the discretion of the examining board,
be registered without being subjected to an examination.
A temporary certificate for a specified time may be issued
by the officers of the board to any applicant holding a
Tegular dental diploma duly registered by a board of dental
examiners created by the laws of any one of the United States,
but no such certificate shall be issued for any longer time than
until the next regular meeting of the board. The fee for this
temporary certificate shall be $5. Transcripts from the book
of registration, certified by the officer who has the same in
keeping, with the seal of the board, shall be evidence in any
court of the State. Every person shall be said to be practic-
ing dentistry, within the meaning of this act, who shall for a
fee, salary or other compensation, paid either to himself or to
some one else for services rendered, perform operations or
parts of operations of any kind pertaining to the mouth, treat
diseases or lesions of the human teeth or jaws, or correct mal-
positions thereof. The penalty for a violation of these provi-
sions is a fine of not less than $50 nor more than $300, or
confinement in jail not more than six months. But nothing in
this article shall be so construed as to interfere with the rights
and privileges of resident physicians and surgeons or with per-
sons holding certificates duly issued to them prior to the
passage of this act ; and dental students operating under the
immediate supervisions of their instructors in dental infirm-
aries or dental schools chartered by the general assembly of
Maryland. Money received for examination and registration,
the fee therefor being 810, shall be used toward paying the
expenses of the board. All fines received are to be paid into
the common school fund of the city or county in which convic-
tion takes place.
Recent Additions to the Array Medical Museum. —One of our mili-
tary papers, the Army and Navy Journal, in its issue of Octo-
ber 17, has an article entitled "New Surgical Appliances,"
which gives the results of an investigation into the additions
made to the Army Medical Museum during the past year and
particularly with regard to those that relate to the transporta-
tion of wounded. The article displays an excellent knowledge
of the subject. It is as follows :
The last Congress appropriated $5,000 for use of the Army
Medical Museum, at Washington. A portion of this sum has
been expended in the purchase of field appliances used by for-
eign countries for exhibition in the museum side by side with
the improved equipments of the hospital corps of the United
States Army. Many of the new foreign acquisitions have been
received and a place has been found for their permanent dis-
play. The countries thus far represented are Prussia, Switzer-
land, England, France, Austria-Hungary, Norway, Spain and
Japan, and the collection includes litters on wheels and for
hand bearers, knapsacks, surgical pouches, chests and instru
ments, and articles for the use of the sanitary and culinary
departments of the hospital corps. The litters and general
appliances of the European armies, excepting possibly England,
are characterized by exceeding bulkiness and weight, though
admirable in many other resxiects. The Prussian and Spanish
mattresses, in particular, are remarkable for comfort and
hygienic qualities. The Norwegian litter is an unwieldy affair,
and is very uncomfortable. The Japanese have a light and!
easy bamboo bed on wheels, with carriage top, resembling the
jinriksha, which has only one undesirable quality — its fragility,
the bamboo offering little resistance to great weight and shocks.
The Japanese leather-bound medical chests and French pouches-
and panniers are admirable for completeness of outfit and econ-
omy of space. Some tiny surgical pouches of the Austrian
army are marvels in this respect. Other notable articles are a
Spanish seat for carrying wounded men, and the English and
French litter carriages and beds.
The recent additions to the collection of articles used in the
United States service are important and compare favorably
with the best similar appliances in use abroad. Our new litter
is much lighter than any other, except the Japanese, is much
more durable than that, and in every respect is considered
admirably adapted to the use of our arms. The new regulation
adjustable sling, which remains on the bearers, is a great,
improvement over the old method of bearing the litter, both
as regards the comfort of the wounded person and of the
bearers. The Quartermaster's Department has adopted this-
litter, and each company is to receive two litters. The new
drill regulations for the Hospital Corps, recently issued, incor-
porates a revision of the manual of the litter adapted to the-
new improvements. Some other changes have been made in
the regulations, such as the abolition of side arms for Hospital
Corps men, and changes in the manner of packing and trans-
porting clothing. The new operating table for field hospital
work, which finds a place in the collection, seems as nearly-
perfect as science and skill can make it. The latest improve-
ment is an arrangement of cranks by which a patient may be
lifted or lowered, or his position changed without the inter-
position of the attendant's hands.
18%.]
MISCELLANY.
927
Of late acquisitions the telephonic bullet probe and forceps,
made by Tiemann & Co., New York, is a curious mechanism
and would be of greater value if the practice of probing were
more generally pursued. The instrument consists of a band of
metal to be placed around the head of the surgeon, a bell being
affixed near the ear. Prom the bell extends a wire connecting
with the probe, l>oth being in communication with an electric
battery. The principle is that the bell shall ring when the
probe strikes the bullet. It is customary now, however, and
has been for some years, to allow gunshot wounds to heal with-
out suppuration, and the probe is not employed unless the ball
is pressing upon some vital center, or there appear symptoms
of poisoning. If a wound be made by new and clean ammu-
nition there is little or no danger of poisoning. If a cartridge
has been carried alx>ut a long time in the pocket or other
exposed place, it is apt to accumulate foreign matter of a dele-
terious nature.
Other recent additions to the museum are some English
water filters and sterilizers, a litter with disjointing parts and
detachable slings, adopted by the Massachusetts Volunteer
Militia, and cabinet Held desks of the United States Army,
which may bo folded in the form of chests for transportation.
Souvenir Volume of the Centennial of the Faculte de Medeclne.
This large quarto and the accompanying atlas of 130 portraits
is a historical sketch of the institution and what it has accom-
plished, compiled by a special committee and published at the
expense of several of the medical publishers of Paris. It is a
"publication de grand luxe," as evidenced by the price, 100
francs, or about $20.
Hospitals.
Typographical Union Hospital. At the sixth day of the
convention of the International Typographical Union the sub-
ject of providing for the erection of a hospital in connection
with the Childs-Drexel Home for Old Printers, which is located
in Colorada Springs, came up for discussion. Fifteen thou-
sand dollars was provided by the International Union for the
building of the hospital, which amount is to be contributed by
the printers all over the land as a popular subscription. The
amount is expected to be raised by Christmas. The solicit-
ing committee of the Augusta, Me., city hospital has reported
subscriptions to the amount of 65,500. This amount assures
the purchase of a hospital site this fall. The annual meeting
of the Board of Directors of the Kensington Hospital, Philadel-
phia, for Women was held October 12. During the last year
287 patients have been treated in the wards, and 274 in the
dispensary, making an increase of 127 over the previous year.
Pour hundred and sixty-two operations have been performed
and the cost of maintenance for the year was §10,723. An
appeal is made for additional funds to erect a new building
and also to provide for the care of an additional number of free
patients. The new building erected as an annex to the
Flower Hospital of New York was opened for the reception of
patients October 2. The corner stone of the St. John's new
hospital at Long Island City, L. I., will be laid November 1.
The executors of the estate of the late Very Rev. Pr.
McCabe, who was pastor of St. Charles church, and vicar gen-
eral of the Providence diocese, who died several years ago,
have intimated that $500 will be shortly forthcoming from this
estate with which to establish a free bed in the Woonsocket,
R. I., hospital. This is in fulfillment of the intention of the
deceased rector.
Washington.
Located by the X Rays. — Dr. John Van Renssalaer of the
surgical staff of the Garfield Hospital successfully located a
bullet by the X rays and removed it on the 8th inst. The bul-
let was located deep and posterior to the hip joint and had
made the woman practically an invalid.
First Medical Examination for Practice in the Dis-
trict.— The first examination of physicians for license under
the new medical law, was held on the 8th to 11th inst., in
the rooms of the Civil Service Commission. The first three
days were devoted to written, and the last day to oral
examination.
Changes at the Garfield Hospital. — Dr. A. L. Stavely,
who has been the surgeon-in-chief and superintendent of Gar-
Held Hospital for three years past, severed his official connection
with that institution on the 1st inst., in order to resume private
practice. Dr. Stavely tendered his resignation several weeks
ago, and it was accepted in a very complimentary letter from
the board of directors. Dr. Stavely for three years was assist-
ant to Dr. Howard Kelly of Johns Hopkins Hospital, Balti-
more. Dr. M. D'Arcy Magee will act temporarily at Garfield
Hospital in place of Dr. Stavely, while Dr. J. Milton Heller is
to serve as senior resident physician.
Changes at the Central Dispensary and Emergency
Hospital. — The following is the medical staff of the hospital
and the medical assignments for the ensuing year : Health Offi-
cer, Dr. W. C. Woodward ; Sanitary Officer, John A. Frank.
Consulting staff: Drs. N. S. Lincoln, J. Ford Thompson,
W. W. Johnston, J. Taber Johnson and G. L. Magruder.
Diseases and injuries of the eye and ear : Dr. Swan M. Bur-
nett. Diseases and injuries of the throat and chest : Dr. T.
Morris Murray. Diseases and injuries of children and ortho-
pedics : Dr. William H. Hawkes. Diseases peculiar to women
and acute venereal of women : Dr. H. L. E. Johnson. Surgi-
cal diseases : Dr. James Kerr. General diseases, skin diseases,
and venereal of men : Dr. G. B. Harrison. Mental and nerv-
ous diseases : Dr. E. L. Tompkins. The emergency depart-
ment has been placed back in its original position under the
executive officer, with assistants in Drs. W. P. Carr, A. A.
Snyder and John Van Rensselaer. A total of $15,000 is asked
for by the hospital authorities to run the hospital next year,
and the suggestion made last year as a means of liquidating
their present indebtedness is repeated. The indebtedness of
the hospital is $20,000, on which an annual interest is paid.
A total of 10,433 new cases were treated in the dispensary dur-
ing the year, and in the same period 2,828 new cases were cared
for in the emergency department, with 1,925 redressings. The
number received into the wards of the hospital for treatment
and care was 189 ; deaths 49 ; autopsies 28 ; ambulance calls,
421 ; surgical operations 1,443.
Applicants for Police Surgeon. — Twenty-five young med-
ical men recently took the examination for the position of
Police Surgeon. President Kleinschmidt, of the Board of
Medical Supervisors, conducted the examination.
Entitled to Licenses.— Physicians who were registered at
the health office at the time of the passage of the recently
enacted medical practice act are entitled to licenses upon appli-
cation to the board of medical supervisors. Blank forms for
application can be obtained at the health office upon request
in person or by letter.
Medical Association Elects New Members. — At the stated
meeting of the Medical Association, recently held, the follow-
ing new members were elected to active membership : Drs.
Chas. L. Allen, Hugh C. Duffey, Robt. H. Graham, E. M.
Hasbrouck, H. Warfield Howell, G. T. Howland, Francis Lei-
ben, R. F. Mason, Jr., W. L. Masterson, E. D. Perkins, C. V.
Petteys, F. M. Phillips, M. S. Patten, A. M. Ray, E. M.
Schaeffer and Elmer Satheron.
Medical Society Elects New Members. — At the recent
meeting of the society the following new members were elec-
ted : Drs. Walter A. Wells, Edwin Gladmon, John H. Metze-
rott, Abbie C. Tyler, Phoebe R. Norris, Thomas B. Crittenden,
W. R. Maddox, Susan J. Squire, A. L. Stavely, Walter D.
Cannon, Adeline E. Portman, W. A. Caldwell. At the regular
weekly meeting of the society, held on the 14th inst., Dr. J.
C. McGuire read a paper entitled "Electrolysis in the Treat-
ment of Diseases of the Skin," and Dr. L. Eliot read a paper
on the subject of "Suture-Clamp Operation for Hemorrhoids."
Washington Obstetrical and Gynecological Society.—
The 281st meeting of the society was held on the 16th inst. and
was followed by the annual banquet. This meeting was the
business meeting of the society for the election of officers and
928
MISCELLANY.
[October 24, 1896.]
committees for the ensuing year, and resulted in the re-elec-
tion of all the former officers. President, Dr. G. B. Harrison ;
Vice-presidents, Drs. S. S. Adams and G. N. Acker ; Treas-
urer, Dr. John Van Renssalaer ; Recording Secretary, Dr. G.
W. Cook ; Corresponding Secretary, W. S. Bowen.
Auxiliary Committee on Transportation for the Sec-
ond Pan American Medical Congress. — The International
Executive Committee has appointed the following physicians
as an auxiliary committee on transportation for the Congress :
Drs. J. B. Murphy, Chicago ; Robt. Sattler, Cincinnati ; A.
Walter Smith, Herkimer, N. Y. ; J. B. Roberts and W. B.
Atkinson, Philadelphia ; A. W. Calhoun, Atlanta, Ga. ; H. C.
Eccles, Charlotte, N. C. ; I. N. Love, St. Louis, Mo. ; Her-
man Mynter, Buffalo, N. Y. ; Robt. T. Morris, New York City ;
R. Matas, New Orleans, La. ; S. Eliot, Washington, D. C. ;
Hugh Taylor and G. Ben Johnston, Richmond, Va. ; A. Morse,
Elsora, Iowa ; Walter H. White, Boston ; Hugh Hamilton, Har-
risburg and Bedford Brown, Alexandria, Va.
Pan-American Medical Congress Transportation Ar-
rangements.— Dr. H. L. E. Johnson, to whom the arrange-
ments for transportation were assigned by the International
Executive Committee, has made his report which is now print-
ing and will be circulated among the profession during the
week. He has arranged for one-fare rate throughout Mexico
and the United States except in the New England States and
portions of Eastern territory. By single trip from New York
city to Mexico and return direct the entire cost will be : Fare,
$78.50 ; Pullman births round trip, $46 ; meals round trip, $32 ;
total cost, $156.50. Living in Mexico $2.50 per day extra;
intermediate points at proportional rates. A special train has
been arranged for through the American Tourist Association
with Wm. Campbell, manager, to leave Cincinnati on Tuesday,
November 10, 9 a.m., via St. Louis and Eagle Pass, and make a
twenty-one day tour from there through Mexico and return for
$189 ; from Chicago and return, $190 ; from St. Louis and
return, $183.55. This will include railroad fares, double
births, meals in cars and hotels in Mexico and carriage hire
and streetcar ride, steamer on Panuco River from Tampico
and all necessary expenses of the trip. The Baltimore and
Ohio scenic route has been selected to carry the delegates from
the North and East to meet the special train at Cincinnati ;
300 persons have already signified their intention to make the
trip. An ocean route from New York by Ward lines has been
arranged for, the total cost of which will be, including meals
and stateroom, $78. Ten days required each way to make this
trip. The individual trip by rail will take six days each way.
Tribute to Dr. Toner. — The annual report of the Govern-
ment Hospital for the Insane, makes the following allusion to
the late Dr. Toner, President of the Board of Visitors, and
includes the resolutions adopted at the timeof his death : "It
is gratifying to us to know of such good work done in the
Toner building. How he who gave his name to that building
would have rejoiced in it all, and yet the name comes to us
now only to remind us of our loss. Dr. Joseph M. Toner has
been taken from us. He had been so long an active member
of the board, for so many years its president, that something
seems wanting from this annual report without his genial pres-
ence and wise counsel in its preparation. There was nothing
about St. Elizabeth or its inmates in which he did not feel a
lively interest, and as the years went on, with his name on our
hospital buildings and his pleasant face looking in so often
upon us, to name Dr. Toner was to suggest St. Elizabeth. It
leaves a void that will not soon be filled. He died suddenly
at Cresson, where he had gone for a brief summer rest. He
had gone in the full expectation of returning long before our
annual meeting, and looking forward to it as to a coming home.
He has found the home that his life had so well deserved, and
contemplating the nobility of that life we find an inspiration
to go on with the work here which lay so near to his heart."
Dental Inspectors for Schools. — We notice in the Medical Mirror
that the Ontario Board of Health recently adopted the follow-
ing resolution : "That dental inspectors be appointed by local
boards of school trustees to periodically visit schools and ex-
amine children's teeth, and that a dental hospital be started in
Toronto for the benefit of poor children ; and these recom-
mendations be urged upon the attention of the Minister of
Education."
THE PUBLIC SERVICES.
Army Changes. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Oct. 2 to Oct. 16. 1896.
Major Henry McElderry, Surgeon, is relieved from duty at Ft. Robinson,
Neb., on expiration of his present leave of absence, aDd is ordered
to Ft. Leavenworth, Kan., for duty at that station, to relieve . Major
Calvin DeWitt. Surgeon U. S. A.
Capt. William P. Kendall, Asst. Surgeon U. S. A., is relieved from duty
at Ft. Sam Houston, Texas, and ordered to Ft. Brown, Texas, for
duty at that post. to relieve Major Peter J. A. Cleary, Surgeon U.S.A.
Major Calvin DeWitt. Surgeon, upon being relieved from duty at Ft.
Leavenworth, Kan., is ordered to Ft. Monroe. Va., for duty at that
station, to relieve Major Edward B. Moseley, surgeon U. S. A.
Capt. Benjamin Munday, Asst. Surgeon, will, in addition to his present
duties at Ft. Wayne, Mich., examine recruits enlisted at Detroit,
Mich., and will furnish medical attendance at the recruiting station
in that city.
Capt. William B. Davis, Asst. Surgeon, now Major and Surgeon, will be
relieved from duty as attending surgeon and examiner of recruits
in New York city, upon the expiration of the leave of absence granted
him in S. O. 23, A. G. O., Sept. 80, 1886, instead of the conclusion of
his examination for promotion, as heretofore ordered by Par. 4, S. O.
44, A. G. O , Sept. 4, 1896. By direction of the Secretary of War.
First Lieut. George D. DeShon,°Asst. Surgeon, is granted leave of absence
for four months, to take effect after he shall have reported for dutv
at Washington Bks., D. C.
Col. Charles H. Alden, Asst. Surgeon-General, and Major Calvin De
Witt, Surgeon, are detailed as delegates to represent the Medical
Department of the Army at the Second Pan-American Medical Con-
gress, to be held in the City of Mexico, Nov. 16 to 19.1896. By direc-
tion of the Secretary of War.
Capt. N. S. Jarvis, Asst. Surgeon U. 8. A., granted six months' leave of
absence with permission to go beyond sea.
Capt. Jefferson D. Poiudexter, Asst. Surgeon, will be relieved from duty
at Ft. Riley, Kan., and will report in person to the commanding
officer, Willets Point, N. Y., for duty at that post.
Major Peter J. A. Cleary, Surgeon, upon being relieved from duty at Ft.
Brown, Texas, by Capt. Kendall, Asst. Surgeon, will report in person
to the commanding General, Dept. of Texas, for duty as chief sur-
geon of that Department.
promotions.
Lieut. -Col. C. R. Greenleaf, Deputy Surgeon General, to be Asst. Sur-
geon-General, with rank of Colonel, Oct. 10, 1896, vice Town, retired.
Major William H. Gardner, Surgeon, to be Deputy Surgeon-General,
with rank of Lieut. -Colonel, vice Greenleaf, promoted, to date Oct.
10, 1896.
Capt. William W.Gray, Asst. Surgeon, to be Surgeon, with rank of Major,
Oct. 10, 1896, vice Gardner, promoted.
Capt. William B. Davis, Asst. Surgeon, to be Surgeon, with the rank of
Major, Aug. 11, 1896, vice Worthington, deceased.
RETIREMENT.
Col. Francis L. Town, Asst. Surgeon-General, is at his own request
having served over thirty years, retired from active service this
date, Oct. 10, 1896.
Change of AddreN*.
Blech, Gustav, from Detroit, Mich., to 728 17th St. N. W., Washington.
D. C.
Davis. Geo. E.. from Salviso to Lawrenceburg, Ky.
Hamilton, John B„ from Rand McNally Building to 100 State St., Chi-
cago, 111.
De Hart, J. N., from Round Lake to 137 Keap St., Brooklvn. N. Y.
Goelet, A. H., from 350 W. 57th St. to 108 W. 73d St., New York. N. Y.
Gottschalk, F. B., from cor. Clark St. and Chicago Av. to 2050 N. Hal-
sted St., Chicago, 111.
Hall. Lemuel T., from 910 Vandeventer Av. to 4240 West Belle Place,
St. Louis, Mo.
Isbester. R. T., from Chicago, III., to Salem, Iowa.
King, Chas. Lee, from Lamanda Park to Pasadena, Cal.
LETTERS RECEIVED.
Adamson, F. W., Milwaukee, Wis. ; American Journal Publishing Co.,
St. Louis. Mo.
Battle & Co., 8t. Louis, Mo. ; Beard, R. O., Minneapolis, Minn. ; Bonney,
S. G., Denver, Colo. : Bracken. II, M., Minneapolis, Minn,
Dewey, Rithard. Wauwatosa, Wis.
Holland, J. M., Philadelphia. Pa. ; Hummel, A. L. Adv. Agency, New
York, N. Y.
Johnson, J. W., Boston, Mass.
Lincoln, M. H., Philadelphia, Pa.
Macey, Fred Co., Grand Rapids, Mich. ; Marks, A. A., New York, N. Y. ;
Merrick, M. B., Passaic, N. J.: Moore. W. S., Detroit, Mich.; Murphy, T.
C. Maniton, 111.; McNew, H. L., Honey Grove, Texas.
Open Court Pub. Co.. Chicago, 111.
Pasteur Vaccine Co., Chicago, 111.; Peek, J. H., Hampton, Va.
Ransom, J. B.. Dannemora, N. Y. : Robinson, R. E., Frederika, Iowa.
Scherlng & Glatz, New York, N. Y. ; Steams, F. & Co., Boston, Mass.;
Sternberg. Geo. M., Washington, D. C.
Taylor, B. D., Ft. McPherson, Ga.; Tuley, Henry E., Louisville, Kv.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., OCTOBER 31, 1896.
No. 18.
ORIGINAL ARTICLES.
<>X THE TREATMENT OF FRACTURED
SHAFTS OF BONE IN CHILDREN;
SIMPLE, COMPLICATED AND
COMPOUND.
Keait In the Section ou Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association,
held at Atlanta. Get., May 5-8. 1896.
BY THOMAS H. MANLEY, M.D.
IMIOI -KSSOK OF Sl'KGKRY, NEW YORK CLINICAL SCHOOL OF MEDICINK.
NEW YORK.
Fracture is, perhaps, the most common type of
.severe trauma incident to childhood, especially in the
male sex.
When the shafts of bones are involved, although
union is nu>re rapid than in the adult and repair is
more complete, there are several special features of
treatment of them, to be observed in the youth, if we
would avoid possible dangers to the integrity of the
damaged limb and secure the fullest degree of
strength and function in it after recovery.
Anatomic Considerations. — It should be always
remembered, that the bones of a child are immature
structures, neither the epiphyses nor the apophyses
have yet fused with the shaft by osseous union;
through the absence of full calcification, the bone
possesses unusual resiliency and elasticity. Vascular
and cartilaginous elements predominate in the osseous
structures in infancy; both progressively diminish-
ing as age advances. The cancellous heads are the
centers of great vascularity; the periosteum thick and
is everywhere ramified by vessels which course through
it and penetrate the cortex through Howship's lacu-
nar The medullary elements share in the activity of
the nutritive forces, as is demonstrated by the bright
crimson color of the bone marrow and its great prone-
ness to bleed freely, when lacerated. Nutrition and
growth of the bone shafts at this epoch of life are
maintained, by periosteal and endosteal sources; i. e.,
from the circumference and ends. Layer after layer
of the myeloplaxes bud from the true bone roots, the
cancellous heads, and are deposited in consecutive
layers, on either end, preliminary to fusion and the
formation of Haversian systems; while simultaneously
from the circumference, the osteo-blastic layer of
periosteum is steadily superadding concentric lamel-
lae, of neoblastic bone corpuscles.
The overlying soft parts are in a high state of nutri-
tive activity; neither the effect of time, nor occupa-
tion, nor the degenerative consequences of various
local or constitutional disease have made their impress
on the structures of the limbs; arterial sclerosis,
venous varix, or territorial obliteration of the capil-
laries have not yet appeared.
Although, in the young, growing limb the sanguin-
eus supply is abundant, it is important to note that
the volume of force of the blood-current in the great
blood- trunks is not as great as in the adult, and
accordingly in a corresponding degree, it is unable to
resist the effects of pressure or tension.
Etiology of Fracture in Childhood and Youth. —
Traumatic disorganization of bone in children more
often results from direct, than indirect force; from
the latter, we will more often find, epiphyseal separa-
tion or dislocation resulting; Colles' or Pott's fracture
in them, is rarely, if ever, witnessed.
It has seemed that the shock attending the average
simple fracture of a limb, was less in children than in
adults. Muscular action as a conservative factor, plays
an unimportant role in these fractures. As a rule
force must be directly applied; or at all events in
close proximity to where the bone sunders. This will
explain why we so rarely see the shafts or apophyses
shattered, after sudden tortion or twists contiguous to
a joint.
I am not familiar with any constitutional disease
in a child which predisposes to fracture. There is no
doubt, but in the cachectic, rickety, syphilitic, or
badly fed the bones are more vulnerable and prone to
give way to violence; but then, the effects of malnu-
trition are widespread, involving equally the soft
parts and organs, as well as the osseous structures.
It can not be said, therefore, that as a rule, there
are any predisposing causes of fracture during the
stage of growth and development; in this respect
these fractures being widely at variance with the eti-
ology of the same lesion, in the adult. That there is
a strongly marked predisposition to fracture in some
adult individuals no one can deny who has treated a
large number of fractured shafts; but in my own
experience with this traumatism in the child, I have
never been able to find evidence to support the proba-
bility of predisposition.
It seems, however, that with those who have had a
large experience in the treatment of broken bones in
modern children's hospitals, a belief prevails, that
there are dyscrasia tending to fracture in the young.
Thus, Power speaks of osteopsathyrosis, or fragilitas
ossium, rickets and even an inherited tendency, lead-
ing to fracture in young children. (Surgical Dis-
eases of Children, D. Power, p. 160.) It is well to
remember in this connection, that most hospitals for
children are filled with unhappy waifs, illegitimate
offspring and poor poverty-stricken orphans, with fee-
ble constitutions, forming a class quite distinct from
those more fortunately situated in the outside world,
and not to be readily contrasted, in their morbid tend-
encies, with average fairly fed children, at home.
Morbid Anatomy. — In the child the nature and
extent of tissue disorganization in fracture are not
identical with the adult. As the degree of force
necessary to break or crack the bone shaft is less, we
will not so frequently find simultaneous laceration of
contiguous parts, as the vascular or neural; the osse-
ous elements being more elastic and containing more
930
THE TREATMENT OF FRACTURES.
[October 31,
organic material there is rarely shattering unless,
great crushing force acts over a limited area; the
bone being less brittle, the double bladed spurs seen
in the oblique fracture of an adult, are not encoun-
tered, as the rent through the shaft is generally in a
transverse direction. The periosteum being thick,
and the muscular power comparatively feeble, marked
displacement, over-riding of the fragments or surface
deformity are not such prominent characteristics as
in the matured man.
Joint implication constitutes one of their most seri-
ous features. Fracture through any part invested by
the perichondrium on opening through the synovial
membrane, or involving the " growing line," the
epiphyseal bridge, in spite of what particular line of
treatment is followed, may result in marked limita-
tion of joint action, articular deformity, or permanent
arrest of growth of the limb. It is probable that in
all severe fractures, growth in the limb is in the abey-
ance, until after repair is complete.
In many cases of femoral fracture, shortening has
been noticed by me, when perfect apposition of the
fragments was effected, with ultimate solid union,
without any deflection or bulging at the point of frac-
ture; thus temporary arrest of growth was the only pos-
sible explanation for it. The shortening in some cases
was slight, yet clearly apparent on measurement. Sim-
ilar shortening occurs, after arthritic or osseous dis-
ease in children, and reasoning from analogy, we may
expect to find it after fracture when there is long
sonfinement in bed.
Fractures, or diastasis, contiguous to the arthritic
structure give rise to difficulty in diagnosis and treat-
ment, because of the copious, sanguinous extravasate
into the peri-arthritic structures or the capsule and
prompt diffusive inflammation, which so generally
follows. At the complicated articulation of the elbow,
the T. fracture through the head of the humerus is
almost certain to leave some impairment in motion.
In the process of repair, there is sometimes a hyper-
ostosis, with a pushing forward and outward of the
trochlear hollow of the olecranon; resulting in a dis-
turbance of the mechanical relations between the
articular surfaces.
Diastasis through the epiphysis, when the extent of
displacement is slight, in my experience, unites more
quickly than osseous fracture. But, when this occurs
under fleshy parts like the shoulder or hip in the
delicate or strumous, its recognition is not only dif-
ficult, but it may lead to arrest of growth or impair-
ment of joint action. Such results, however, are
exceedingly uncommon. None have ever come under
my observation.
In connection with this subject of diastases or
fracture through joints, in order that judicious treat-
ment may be instituted, an accurate knowledge of the
condition existing is necessary; and here is where the
difficulty comes, for oftentimes this is practically im-
possible, as every umbiased, experienced surgeon must
admit.
In epiphyseal separation of the humeral head at
the shoulder joint, although some writers of fertile
imagination and remarkable descriptive power of what
does not exist, have laid down seriatim the differen-
tial features between this and bone luxation. Jona-
than Hutchinson states that all, or nearly all so-called
shoulder- jomt dislocations are but epiphyseal diasta-
ses. This is no doubt an exaggeration, though not
far from the truth.
In either epiphyseal loosening at the shoulder-
joint intra-articular fracture or dislocation in the child,
although the anatomic elements involved are dissim-
ular, the reactionary efforts are quite the same in all;
hemorrhage, laceration of adjacent soft parts, inflam-
mation, exudation with consecutive fibrosis and exten-
sive adhesions in all or many of the overlying parts,
occurs in each equally frequent.
Compound Fracture in Children. — In the present
state of our knowledge and the great advances made
in the surgery of the extremities, the time has come,
when compound, comminuted or complicated fractures
in children, should be separately considered and their
distinctive etiology, pathology and treatment should
be taught in our medical schools. Nevertheless, the
antiquated and vicious system of dealing with all types
of fracture, in the various epochs of life, on the same
principle, is yet adhered to, even in our latest text-
books on surgery. It has been noted, that the limbs,
during the evolution of growth, are organically, totally,
unlike those of middle or advanced age, being less
firmly set, highly vascular and elastic. The lower ex-
tremities of the child carrying a lighter body are
comparatively exempt from those shocks and jars
inseparable from advancing years.
The recuperative energy of the osseous system of
the child possesses marvelous activity, for it can not
only repair, but also reproduce or restore shattered or
destroyed segments of a bone-shaft. Therefore, by
the aid of antiseptics and by utilizing those osteo-
plastic procedures so elaborated and graphically
described by M. Oilier, we are often enabled to pre-
serve limbs, sometimes so mutilated, as to seem to
justify immediate amputation.
Morbid Anatomy and Pathology of Juvenile ( 'ora-
pound Fracture. — Compound fracture is less frequent
in the young, than in the adult for several reasons.
The first is, at this stage of life the occupations of
children are not so dangerous. Serious injuries most
often befall them, however, through their venturesome
tendencies and heedlessness. Proportionally for their
volume, the solid elements of their bone shafts are
better protected by the enveloping parts, which are
highly elastic; as their fractures are mostly transverse,
muscular action is weaker and the periosteal invest-
ment thicker, displacement after fracture is slight.
The younger the living tissues the greater their resist-
ance to the influence of pathogenic germs which may
infect their protoplasmic elements, every thing else
being equal.
Compound fractures only become grave injuries in
a child, when the violence has been so great as to
totally destroy the limb, or when large vessels have
been opened and a considerable quantity of blood has
been lost ; as even moderate exsanguination in child-
hood is often attended with alarming shock.
The loss of a considerable area of integument by
primary violence or secondary gangrene is a serious
complication. The skin can never be reproduced, but
frequently the bone can. The shock succeeding com-
pound fracture in children is usually greater than in
the adult, and the depression of the vaso-motor sys-
tem is so pronounced that a marked pallor and
depression of temperature pervade the entire surface
of the body. Compound fractures which open into
the joints, when sepsis is prevented and the vascular
current is intact beyond, often do suprisingly well.
Several such injuries involving the elbow and
ankle joints of children have been under my care.
I sue. I
THE TREATMENT OF FRACTURES.
931
When there had been no loss of bone, whether the
lissuring of bene extends into epiphyseal line or not,
it is remarkable what a large degree of function is
restored. What frequently imparts a serious aspect
in those eases is when the patient is strumous, and
when inflammatory changes degenerate into wide-
spread, suppurative infiltration, with sloughing.
In all these cases of compound arthritic fracture,
as in the simple variety involving joints, more or less
inevitable displacement of the fragments, hyperosto-
sis in callous formation and organized or semi-organ-
ized tendino-imisoular adhesions, for some time after
osseous consolidation, more or less lock the joint and
induce muscular atrophy. In the youth, all of those
pathologic conditions, as a rule so serious and often
permanent, in the fully developed individual, are
largely minimized in the ultimate effects by appro-
priate treatment and the innate tendency of the econ-
omy to restore adjustment and a large degree of func-
tion in an injured part,
Treatment This brief review of the subject will
not permit anything like an extended notice of the
subject of diagnosis, something which must always
precedes definite specialised treatment, but to omit it
altogether would be to vitiate, largely, whatever value
the present oontributation may possess. It may be
said, as a general rule, that fractures in children are
most difficult of detection. In fact, in fractures con-
tiguous with joints, it is sometimes quite impossible
to recognise them. In this class, the safest course to
pursue is to proceed on the assumption that there is a
fracture, and apply treatment. It has been pointed
out. that immediately after many fractures, tumefac-
tion. sangninoDS extravasate and muscular spasm,
render examination severely painful, difficult, and
sometimes indefinite.' More than once, when a case
of injury, assumed to be fracture, has come under my
care, when by moderate manipulation its detection
could not be determined, I have made a show of
adjustment and set the limb aside, under soothing
dressings until the following day, when the real exam-
ination was made. Almost invariably now, crepitus
could be detected and the quality of the osseous dis-
organization ascertained with the infliction of no
re pain.
Incision as an aid in diagnosis of fracture of a bone
shaft is a procedure of questionable expediency. Not-
withstanding what asepsis may prevent in flesh
wounds, when we deliberately open into a fracture of
a bone shaft, we introduce fresh complications. We
at once make a simple, a compound fracture and
expose the parts to the dangers of suppurative infil-
tration or necrosis. In any other than rare and
exceptional cases as a diagnostic resource, the in-
cision should be condemned. A practical knowl-
edge of the general rules of diagnosis will seldom fail
us without resorting to this extreme measure. It is
■only necessary that the examination be made with
gentleness and thoroughness; and when the suspected
fracture be located contiguously with the shoulder or
hip-joint, the patient should be placed in a position
of complete muscular relaxation on a table or in bed,
on the back. In this connection it may be well to give
a warning against the possibilitity of diagnosing frac-
tures which do not exist.
It certainly is no reflection on one's knowledge or
skill when in doubt about the existence of fracture to
frankly confess it to the patient, his friends or rela-
tives: but it becomes a reprehensive line of conduct to
decide alone, on a case and put up the limb in an
apparatus or adjustment, for the cure of an imaginary
condition. Such mistaken cases have come under my
observation in nearly all the long bono shafts, at the
wrist and the elbow, the clavicle, scapula and neck of
the humerus, the femur, the tibia and fibula.
Pulmonary anesthesia is an invaluable adjuvant in
diagnosis of various fractures. It may be laid down
however, as a law, thai when detection is only possible
by this agent in the case of bone trauma, the extent of
damage is not great, mid the establishment of definite
diagnosis will not materially effect treatment. It is
very seldom necessary in the youth, and is not with-
out its dangers. We usually resort to it, in order to
avoid the imputation of ignorance or neglect in com-
plex cases, perhaps also as an aid in reduction or
setting.
Treatment Sin/pie Fraeiure.— -The limb of an
infant or youth is more intolerant of protracted
restraint or severe pressure than the adult; with him
are commonly incomplete fractures, or non-displace-
ment of the fragments, and hence not a few of them,
are overlooked, or not discovered, until a large callus
or deflexion attracts attention. Although primary
union of bone is prompt, the uniting bone slowly cal-
cifies, and the tendency to bowing remains for some
time after apparent union, at the sight of fracture.
A mistaken impression prevails, that treatment of
fracture should be instituted on the spot, snr le champ,
as though the limb must perish or fall apart, unless it
be at once placed in a rigid adjustment. This view
has often led to most disastrous consequences and
calls loudly for the voice of a Pott, or of a world-
famed luminary, like Senn, to condemn it.
The aim to be sought for immediately after simple
fracture, is to place the limb in a comfortable position.
In none is this more important than in the tender
susceptible child. Sometimes, this end is effectively
accomplished by immediately setting the bones and
splinting the limb, while in others the best splint is
a bed, the limb well bolstered and enveloped in sooth-
ing dressings, until the following clay or such time as
the inflammatory disturbance has disappeared, tume-
faction has diminished and muscular spasm has passed
off. Nothing has been lost by this delay, as the work
of repair is impossible until the subsidence of local
engorgement.
The treatment of uncomplicated fracture limbs in
general embrace but a few broad principles, which
apply to all ages; they must, under certain conditions
of age and environment be modified.
After all severe fractures the system sustains more
or less shock. The body needs rest, no matter whether
it be the upper or lower extremity which is involved.
The patient should first be treated, then his injured
limb. This should be comfortably adjusted, for if
severe pain persist after the limb has been set, some-
thing is wrong.
On Splinting. — As there is seldom much displace-
ment, if any, in several varieties of fractures in chil-
dren, we will do enough in many cases at the first
visit, to simply place the limb at rest without any
other investment than a bandage, until after the prim-
ary callus is formed, when a support is adjusted to
obviate deflexion in the ossifying stage. Osseous
apposition of the fragments with retention is desirable
in those cases of fracture attended with much dis-
placement.
In order to realize this end or to bring the divided
932
THE TREATMENT OF FRACTURES.
[October 31,
ends of the bones into as convenient contact as pos-
sible and so retain them, we depend mainly on two or
three things: the first, the most important and more
valuable than all others combined, is muscular relax-
ation, or postural treatment. This permits unfettered
liberty of the circulation, and the highest possible
activity of the nutritive processes. In the lower ex-
tremity, for the leg, the foot may be used as a counter-
extending force; in the thigh, both the leg and
foot. In the arm, the forearm is the counter-extend-
ing weight. With the child we have little to fear
from bed-sores, and he bears enforced confinement
with less impairment to health than many who after
middle life accumulate additional flesh. Desault was
the father of the method of fracture treatment now so
generally adopted, in which the principles of muscu-
lar relaxation is so generally discarded. Long splints
are applied and artificial extention is generally
employed.
To enter into the comparative value of various
methods would involve a large task, which can not be
undertaken here, but, after fifteen years experience in
a large traumatic surgical service in hospital and a
fair share outside, I am convinced that mechanically
splinting and confining all fractures is an error: that
the results are not as satisfactory as they should be
and that the time is not far distant when Pott's princi-
ples in fracture treatment will again reign supreme.
But even now, in fractures contiguous to or involv-
ing the articulations, our sole reliance is muscular
relaxation and postural treatment.
Overlaying apparatus in joint fractures are little more
than masks, which practically accomplish nothing.
They, however, fulfill a psychical affect, something
often highly necessary with the fault finding and
supercilious.
Early passive motion, in my experience, is highly
desirable in all fractures of children which involve the
articulations. Not a few distinguished surgeons are
opposed to it, in my judgment very much to the dis-
advantage of the injured.
Marked deflection of long shafts, after treatment is
completed, very justly reflects discredit on the attend-
ing surgeon, when the child is constitutionally sound.
It is most frequently seen in the female.
We may find that the patient has a lump of bone
projecting outward where the shaft has the least mus-
cular investment, the limb is very markedly shortened,
and the patient walks with a limp. It is not my
intention to reflect on the surgeon for .this blemish,
for as a sequel of fracture treatment it may occur in
the hands of anyone; only it should not be allowed to
remain if of an aggravated type.
It is surprising how easily it is overcome if taken
in hand early. The bone is then pliant and by the
use of moderate force can be easily pressed into posi-
tion, the bowing overcome and length restored. Some
of these cases of deflexion are dependent on an
organic defect in the osseous elements, a species of
malnutrition not well understood; in all instances,
however, it is well to favor consolidation of the frag-
ments by close attention to the hygienic surround-
ings, proper nourishment, tonic and reconstructive
medicines.
Massage, bathing, kneading the muscles and fre-
quent changing the position of the patient are help-
ful aids; and as Championiere has lately demon-
strated, entirely innocuous as disturbing agents of
the approximate fragments.
On the Treatment of Complicated Fractures or
Open Compound Fractures. — Although every frac-
ture not attended with an open wound is designated
"simple," under very many circumstances it leads to
a wrong inference; hence it would seem both desira-
ble and necessary that in every instance when the
arthritic, neural or vascular structure, to a considera-
ble degree, share in the traumatic disorganization of
bone, the word complicated should be substituted for
"simple" and the word open for "compound."
To the inexperienced the word "compound fracture"
has a most serious significance, while as a matter of
fact not a few of the cases embraced under this
class recover with better limbs than the "simple."
And, of the latter, occasional instances occur, when the
damage to the fractured limb is so great, as to, later,
demand amputation or lead to a wasting or anchylosis
of the limb.
Modern measures, inhibiting germ infection, great
advances in osteoplastic science, combined with per-
fected mechanical adjustment and prothetic devices,
under no circumstances justify the sacrifice of a limb
or a part of a limb after an injury in a child, unless
the parts have suffered total death by violence.
In open, compound fractures of the limbs our first
concern must be to arrest hemorrhage. This should
be done as far as possible by exposure, ligation, tor-
tion or immediate compression of the spouting arte-
ries. When bleeding is venous or parenchymatous,
moderate tamponage and bandage pressure will
answer for its suppression; but under all circum-
stances very hot water as a styptic or protracted elas-
tic compression, with Esmarch's bandage, as a hemo-
static agent must be condemned; the former for its
destructive action on the vital structures and the pro-
toplasm, and the latter, from the danger of gangrene
following.
Our next step is cleanliness and all that it implies
in a strict surgical sense. Now, we will endeavor to
comfortably adjust the fragments and provide them
necessary support, under appropriate dressings until
general and local reaction is established. In the
average case of severe open shattering of bone, with
more or less displacement and extensive mangling of
the tissues, the safest course of practice to pursue is
not to undertake too much at the primary dressing.
From a theoretic standpoint this advice may seem
untenable and injudicious.
The parts, it is true, are now more or less benumbed,
and may be handled with less pain; yet in all cases in
which any tedious manipulation is necessary an anes-
thetic must be employed. But in all these oasis
severe constitutional shock is present, muscular spasm
drags on the fragments and infection is so constant
that primary union seldom follows without suppura-
tion and limited gangrene of the damaged parts.
Better by far, in all very serious cases of this class
to be contented with temporary adjustment of the
mangled limb, secure against fresh infection and
hemorrhage for at least twenty-four or forty-eight
hours or longer, unless special indication call for a
change.
The question as to what we shall do with the dis-
placed fragments to secure their surfaces in perma-
nent contact, by wiring, pegging or riveting; what
fragments we shall return and what detach, how we
shall place the osseous structures in position most
favorable to regeneration, when there has been much
loss of bone substance, belongs to the subject of
L896.]
TREATMENT OF FRACTURES.
933
osteoplasty, a branch of the healing art which every
BUrgeon must familiarize himself with and master
who would perforin his whole duty to his patient.
As this subject is too large to be considered in this
brochure, it is enough to say what my own experi-
ence long ago convinced me of, viz., that under no
circumstances should any fragments of bone be
removed that preserve an intimate attachment with
the soft parts. In the upper extremity our every
effort should be strained to preserve every possible
particle of Ixine tissue that possesses a cutaneous
investment, and no excision or division should
be done through any other than parts hopelessly
devitalized.
Modern prothetic appliances have done much to
substitute a saeriticd limb, at least for appearance,
though as an appendage for the lower extremity they
sometimes support the body and carry it; neverthe-
less, let no one deceive himself into supposing that
any artificial support can ever fulfill the purposes of
a natural one. and needlessly sacrifice any part of the
lower extremity.
There are several reasons why a severe fracture
through any part of the lower extremity is more diffi-
cult to treat than in the upper. It is here where frac-
ture is very common, and in railway or other serious
accidents the greatest extent of mutilation is inflicted.
Yet. when we can provide proper attention to a case
it is surprising what results we may realize in many
of the frightful cases of bone disorganization.
As an example. I might mention one case of open
fracture in a child of 6 years, run over by a street car,
in whom the entire tibial shaft was so shattered that
it was entirely shelled out through the long breach in
the tissues. Only the epiphyseal ends and perios-
teum remained. In one year this entire shaft was
regenerated: there was no shortening and no limping.
In another, a young adult, the bones were so smashed
that a little more than four inches of the shafts of the
tibia and fibula on damaged side had to be removed,
and the widely separated ends pressed together. In six
months union was complete. By a rise on sole of
shoe shortening is compensated for, no crutch or
walkingcane is used, and last autumn he won a wager,
walking from One Hundred and Twenty-fifth Street,
in Harlem, to Coney Island, a distance of about
twenty-one miles, leaving Harlem at (5 in the morning
and returning before 6 in the evening. This he
accomplished with ease.
We can secure surprising results in most any
description of fracture in the leg of a child, below the
knee, provided the circulation be intact; but when
the fleshy parts are torn open in femoral fracture, we
have good grounds for the most serious apprehension.
The extent of shock is always very great, in com-
pound, femoral fracture, and in most cases there is
considerable loss of blood before efficient surgical care
can be rendered. In spite of anything that we can do
to prevent it infection will set in and spread, always
endangering life through infiltration, resorption and
pyemia.
There are several varieties of fracture of common
occurrence in the adult, rarely or never seen in the
child. In them I have never seen a fractured patella
or a Pott's fracture. One instance of intracapsu-
lar fracture at the hip has come under my care, in a
youth of sixteen years. Subsequent to the injury
necroses of the surface of the distal fragment devel-
oped and provoked suppuration. On incision, through
the anterior plane of muscles, the capsule was
opened and the neck was cleared away and the head
left. The operation was performed four years ago.
The patient is now a full-grown man with a very use-
ful limb, except for about three inches shortening.
I never yet met with a case of Colles' fracture in a
child, although some authors speak of it occuring dur-
ing the stages of growth. I doubt their accuracy of
diagnosis. Codes' fracture almost invariably leaves
deformity through rupture of the internal lateral lig-
ment and displacement outward of the head of the
ulna, impaction and diastasis of the radical head.
Deformities, therefore, should be rarer after juve-
nile fracture, functional restoration better and resto-
ration of strength greater after treatment than with
those approaching or after the meridian of life.
In conclusion, as far as treatment is concerned,
it may be said that as applied to so-called " simple "
fractures, or the complicated, involving the joints,
in the child there has been no special progress
made in late years, the mechanical problem is not
settled and our best authorities are not in accord on
the question of attitude or position of the limb, on
immobilization, extension and counter extension.
The fact is, that mechanical aids in fracture have but
a limited application, as we are dealing with a living
machine not subservient to any physical laws in its
vital processes.
Enduring progress only has been made with the
complicated and open fractures, in which, by adop-
tion of antiseptic methods and osteoplasty, safe con-
servatism is possible, and now we are enabled to
preserve limbs formerly condemned to amputation or
a crippled condition, which rendered them little more
than useless.
DISCUSSION.
Dr. Ella E. Barnes, Birmingham I would like to ask Dr.
Manley if in the German boy there had been a growth of the
other limb sufficient to make the shortness appreciable?
Answei — About an inch.
Dr. Barnes— Will time ever overcome that by the extra use
of that limb? Suppose a high sole were put upon the other
limb and this limb allowed to swing, will the shortened limb
ever become longer?
Answer — I am not able to inform the Doctor. As far as my
experience goes, there is no remedy for shortening. We know
that the limb would stop growth during the process of repair.
Dr. Daniel H. Cunningham, Chicago -I would like to ask
Dr. Manley the manner in which he applies his splint, or what
splint he uses to keep the limb quiet and prevent the edges of
the bones causing laceration.
Ansu'ei — I have nothing special. I adapt treatment to each
individual case. Some families can afford splints and others
can not. We should not wed ourselves to any particular splint
in the adjustment of the limb.
Dr. A. C. Cotton, Chicago— I want to ask Dr. Manley
would he make any objection to blanket splints?
Answer — They are excellent.
Dr. Manley We have to consider the matter of expense.
There has been devised a splint made from strawboard which
acts admirably in children. It is very light and can be easily
cut down with the knife, and by submitting to hot water it
softens and you can shape it to the limb. I think it is about
fifty cents a sheet and a sheet is enough to make about a dozen
splints. If I could not get anything else I would use plaster
of Paris, but I do not believe there is anything else has given
us so many cases of distortions and deformities. When you
remove it you have to give the limb more or less jar to get it
off. The chewing with the knife, or whatever it may be, causes
934
OBSERVATIONS IN CASES OF EPILEPSY.
[October 31,
more or less jarring of the limb, and you can not put a plaster
on the limb from which the limb will not fall away and the
dressing will become loose. Particularly in fractures of the
forearm in children it is important to inspect the limb every
day. I have known plaster encasements, in which there was no
rise in temperature and everything seemed to be going on
splendidly, but after ten days when we cut down through the
plaster, both bones were found projecting through the skin,
and black. So I believe the plaster has a very limited use in
children. It is unyielding and you might just as well put the
limb in a vise ; and after considerable disorganization of the
soft parts, in fracture, there is a great deal of tumefaction and
it is important there be room for this. The plaster simply puts
the patient in torture. When a fracture pains there is some-
thing wrong about it, but with the plaster applied, we have to
cut down through the hard, rigid plaster, shaking and jarring
the limb and causing more pain than ever. I have a positive
prejudice against plaster, except in occasional cases.
Dr. J. A. Work, Elkhart, Ind. — I have had some cases where
I did not expect to save the limb, more particularly the fingers
and toes, and I am glad to say the results were so good I am
ready to attempt to save almost everything. As to splints, I
use almost exclusively the binder's board. What do you think
of the binder's board, Doctor?
Dr. Man ley — I like it very well.
Dr. Work— It is soft and pliable while wet and you can
adjust it very well, indeed. You can allow for distention, while
the inflammatory process is going on, and after the inflamma-
tory process you can retract the splints to the limb. If you
have a perfect cast of the limb, you have your limb in perfect
shape. I think the wet splints have a tendency to keep down
the first inflammation.
Dr. C. G. Slagle, Minneapolis Dr. Manley has spoken of
the shortening, which might sometimes help us out in suits.
It appears to me that if the child is confined to bed two or
three months, the sound limb would grow rapidly while the
growth of the affected limb would be largely suspended. I
have been surprised sometimes at the shortening, but this
explains it nicely. As to setting the limb, the Doctor is very
conservative. But I suppose, Doctor, if you were called imme-
diately you would set the limb, but after the swelling began
you would not do so until the swelling subsided.
Dr. Manley— As the first principle we should put the limb
in a comfortable position, and that would imply setting and
leaving the limb in a temporary dressing, not putting the per-
manent dressing on until the swelling is over.
Dr. A. C. Cotton, Chicago— The remarks have brought out
that no absolute rule can be devised or laid down to fit surgi-
cal procedures. We should let the limb alone and put it in a
comfortable position, if only on a pillow. If we want union by
first intention, the ends of the bones must be approximated,
nicely coapted. Although we get relief from pain by putting
the limb in a comfortable position, unless we approximate the
end of the bones we will not get primary union. We might
have a dozen cases without that condition, while in the thir-
teenth it might be found. A whiff of chloroform could be
given, the ends approximated and a splint applied. The Doc-
tor expresses my views of those of plaster of Paris dressings. I
suppose the orthopedic surgeon, with the necessity for rigid
retention apparatuses, could hardly get along without the
plaster, but he does not have swelling we have to deal with.
Rhinopharyngolith. This is the name given by Janatka of
Prague to a body removed by him from the naso- pharyngeal
cavity of a nine year old boy. It was found to consist of a
tailor's thimble, which the child was supposed to have swal-
lowed when he was one year old, and had thus remained
imbedded in the nasal cavity for eight years, considerably dis-
integrated and coated with calcium carbonate and calcium
phosphate. It had caused difficulties in breathing and hear-
ing, and a tumor had been diagnosed,— Wiener Klin. Rund-
schau, September 20.
OBSERVATIONS IN CASES OF EPILEPSY
FOLLOWING INJURIES TO THE HEAD
IN INFANCY, CHILDHOOD AND
EARLY YOUTH.
Read in the Section on Diseases of Children, at the Forty-seventh
Annua] Meeting of the American Medical Association, at
Atlanta, Ga„ May 5-8. 1896.
BY W. A. DIXON, M.D.
RIPLEY, OHIO.
In introducing this subject, the purpose is to
express my convictions arising from observations in
my own practice that great care should be used in
rearing children, that the head may not receive inju-
ries, lest epilepsy follow as a result.
During my first years of practice I had no conclu-
sions of my own as to the liability of epilepsy to fol-
low injuries to the head in early youth, and sought
to discover in each case presented to me a cause in
heredity, reflex irritation and the many other causes
given in the text books.
In after years, however, when the child that had
received injury to the head was brought under my
care on account of epilepsy, the importance of this
subject became apparent to me.
I can cite a number of cases whose history I am
personally familiar with from the date of the injury
received to the development of the epilepsy.
I take no censure to myself in the treatment of the
injuries at the time of their occurrence, because epi-
lepsy developed in after-years, and cite the following
cases, not to speak of treatment or of the character of
the lesion, but of the fact that epilepsy did follow
the injury, and in the absence of any other known or
suspected cause, must be considered the reasonable
source in each case, and therefore that physicians
should be under obligations to teach parents and
others in charge of children the necessity of guarding
against all injuries to the head that epilepsy may not
follow as a result in after-years when the brain
develops, the sutures unite and expansion or growth
of the cranium ceases.
Case 1.— 3. R., a boy aged 5 years, was kicked by a horse,
fracturing the left parietal bone. There was depression and
symptoms of compression. The fragments were removed, the
depressed bone elevated. The boy rapidly regained conscious-
ness and made a good recovery with nothing to indicate that
he had received so serious an injury. At the age of 24, when
he had attained to full growth in body and mind, without any
premonitory symptoms he fell to the pavement in a fit of epi-
lepsy. His condition rapidly grew more and more grave, so
that in two years' time he consented to an operation of tre-
phining in the hope of finding relief. Dr. P. S. Conner tre-
phined, finding beneath the site of injury within the membranes
a cystic tumor large as a medium sized orange.
Case 2. - W. K., aged 6, was kicked by a horse on the frontal
bone over the left eyebrow, causing slight depression with
symptoms of concussion but not compression. He made a
rapid recovery and exhibited no results of the injury, until
arriving at the age of 20, he was seized with epilepsy, which
continued to become more and more aggravated during the
three years following, when he died from exhaustion.
Case 3.—G. M., aged 10, was kicked by a horse in the mid-
dle of the forehead, fracturing and depressing the bone, caus-
ing deep coma. The fragments of bone were promptly removed,
and the depressed portion elevated. The coma was quickly
recovered from. Recovery was rapid, with no evidences of the
injury remaining. At the age of 20 epilepsy developed. He is
still living and the victim of frequent attacks.
Case 4.- L. P., aged 8, was thrown from a horse, striking
the crown of the head upon a small stone in the road. There
was laceration of the scalp over the left parietal bone, and
slight depression but no symptoms of compression, and no line
of fracture could be determined. Recovery was prompt. At
the age of 28 epilepsy developed. The paroxysms have con-
tinued to increase in severity until now the patient is a com-
plete physical wreck.
1896. |
PETIT MAL IN CHILDREN.
9155
( tew 5. YV. B., a l>oy aged 12, stopped on the sidewalk to
tie liis shoestrings. On attempting to set one foot on a step,
the other slipped from under him, causing him to fall back-
ward, striking the occiput violently on the pavement. There
wi'iv symptoms of concussion, lasting several hours. In a
short time epitope] developed and continues to the present in
an aggravated form.
J. P., aged 8, fell from a swing, striking the head
upon a stone, lacerating the scalp and producing symptoms of
slunk which lasted several hours. There were no symptoms of
compression nor fracture. Recovery was apparently perfect.
A t t he age of 18 epilepsy developed and continued for about
three years, becoming more and more violent until death.
( tea ;. J. It., at the age of 5, fell from a fence, receiving a
blow upon the head, producing violent shock, and was in a
state of stupor for several days. At the age of 16 epilepsy
developed and continues to the present.
Without reciting each case similar in most respects
to the foregoing, I can call to memory many other
cases of injury in whom no history of heredity, spe-
cific disease or reflex neuroses of any character what-
ever can he traced as a cause.
Younger children, in my judgment, are in danger
of epilepsy upon meeting with what may be termed
everv-day casualties, as falling down stairs, out of the
high chair, off the hod to the floor, from the porch to
the pavement and other similar accidents where the
head receives the blow.
I can recall quite a number of epileptics in boys
and girls to whom I was called at the time of such
accidents as spoken of above at the crawling age of
childhood. Some of the worst epileptics I have seen
have no history of cause beside the fall and conse-
quent injury to the head of the infant.
Meddlesome midwifery, it is to be feared, must be
held responsible for some cases, the most wretched
and hopeless we are called upon to witness, the for-
ce] >s having inflicted injury to the head.
Prof. Chas. D. Meigs in his day, foreseeing the ten-
dency to wantonly use the forceps, charged his pupils
to remember that the best obstetrician was he who
stood by his patient with his hands folded behind
him.
There are dystocias when the forceps must be used,
when it would be criminal to not use them, though
epilepsy in the child be sure to follow. The point is
this, that the utmost skill and care should be used to
avoid injury to the fetal head lest epilepsy may
develop in the child.
I have seen two cases, not my own, it is reasonably
certain resulted from injury in forceps delivery, and
two more strongly suspected to owe their origin to
the same cause, every other history of cause being
absent.
My experience is largely among rural people where
the forceps are not often required or resorted to, and
where of course epileptic results would be rare from
such a cause, but if two cases come under the obser-
vation of each city and country physician during a
quarter of a century, see what a vast army of epilep-
tics follow in the wake of the forceps. Epilepsy
merits the attention of the physician from every
standpoint. Large numbers of epileptics are in every
locality. They are of all people the most unfortunate.
Too much can not be known concerning it. How
impotent all physicians confess themselves to be when
confronted with it.
In cases from trivial reflex causes treatment may
be successful. In confirmed cases medicines avail so
little that both physician and patient tire of treatment.
The surgeon on account of so small percentage of
favorable results in the most hopeful cases operated
upon is held at bay. So the most rational procedure
is to adopt preventive measures.
If heredity, insanity, inebriety, specific infection
and so on among the ancestors are found to be causes,
the gravity of the affection demands that means be
employed to curtail the transmission of the disease to
posterity. Knowing injuries to the head to be a fruit-
ful source, all should unite every effort to teach and
impress upon parents and others in charge of children
to use all precautions possible to protect the child's
head from every sort of injury, epilepsy having been
known to follow what seemed to be a slight injury to
the head. It is not the purpose to speak of any theory
of pathology or morbid anatomy.
The literature upon the disease is enriched by the
observations of eminent men in every age and coun-
try. The same views are not long held by any
student, for experiments and postmortems are likely
to revolutionize any theory previously announced.
Most writers regard traumatism overestimated as an
exciting cause. Experiments of any kind that disturb
the cardiac or cerebral functions may excite convul-
sions and establish any theory desired.
In relating cases I selected those in whom a record
in the ancestral line, of heredity, insanity, inebriety,
tuberculosis or specific infection did not exist, so that
the fact of injury alone could remain as the factor,
the kind of injury that can be in a great measure
avoided by watchful care in the rearing of children.
PETIT MAL IN CHILDREN.
Read in the Section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association, held
at Atlanta, Ga.. Mav 5-8, 1896.
BY LOUIS FAUGfeRES BISHOP, A.M., M.D.
NEW YORK.
Idiopathic epilepsy is eminently a disease of children,
occuring in more than three-fourths of the cases before
the twentieth year. So much is this true, that in epi-
lepsy in older people, we always institute a special
search for a local cause. Of the causes of epilepsy we
are not to treat in this place, nor indeed of the typical
severe cases, but because we separate petit mal, we must
not fall into the error of supposing we have to deal with
a different disease. Nor is it always easy from the
description of parents, when there is no opportunity
of observing the attacks, to be sure into which group
the particular case should go.
Though not a common form of manifestation of
epilepsy in children still among a large number of
cases there will be a certain number in which the dis-
ease at least in its onset takes this form. On account
of its comparative rarity and because of the proneness
of young children to convulsive attacks of various
kinds whose etiology is clearly to be found in local
irritation, these minor attacks of epilepsy are seldom
recognized by those whose attention has not been par-
ticularly called to the subject.
There are certain physiologic considerations that
must have weight in our diagnosis. Up to about
three years it is difficult to make the diagnosis of
petit mal because the physiologic irritability of the
nervous system is so great that we can not exclude a
sufficient cause of irritation. After about the age of
three years the nervous system has obtained a degree
or stability that makes the frequent recurrence of con-
vulsive seizures an indication of epilepsy. Of course,
if there is a family history of a tendency to such
936
PETIT MAL IN CHILDKEN.
[October 31,
attacks at a later period, which have not proved to be
epileptic, this circumstance must be given due weight.
As in older people we must exclude kidney disease
and injuries to the brain.
In addition to a due appreciation of this period of
irritability we need to have a more symmetric com-
prehension of epilepsy. Petit mal is not one disease
and grand mal another, but they are different mani-
festations of the same disease. It is for the sake of
emphasizing petit mal to the dignity of true epilepsy
that this study of that particular form of epilepsy in
children has been undertaken. The attack of petit
mal is a sudden temporary unconsciousness, often
accompanied by certain other phenomena. In a
large number of cases the eyes become fixed, the face
pale, and in a moment the patient assumes his ordi-
nary conditions; in others, the patient talks in a wild
manner, often upon some subject entirely disconnected
with the surroundings present. The patient may per-
form some curious automatic action, or go through with
some particular act while in the epileptic state.
A very curious case came to the Vanderbilt Clinic,
New York City, a few days ago. The child, 7 years
old, had frequent attacks in which she suddenly seized
her head by the hair on either side, and then there
was a jerky motion of the arms and head, at the same
time one foot was raised as high as possible and the
child would stand for a moment on the other, but if
not supported, would fall. This occurred while under
observation about every fifteen minutes. The child
was unconscious during the early part of the attack,
which lasted probably during the fraction of a minute.
Another child also seen at the Vanderbilt Clinic
recently, suffered a compound fracture of the skull a
years ago. A few weeks ago she developed attacks,
which come on every night about ten o'clock, after she
had been in bed an hour or two. She wakes out of
her sleep in a fright, and almost immediately becomes
rigid and apparently unconscious.
An attack of petit mal may assume a great variety
of forms. A mere momentary blurring and loss of
consciousness at frequent but irregular intervals, or
sudden sensations of fright without apparent cause, or
a feeling of something in the epigastrium and rising
in the throat. Thus in a case coming under observa-
tion while preparing this paper, a child of five years
old had convulsions during the first two or three
months of life, and since that time had been subject to
attacks at intervals, the mother says "a thousand a
day," during which the child's head suddenly drops,
the arms are stiffened, and after an attack of momen-
tary unconsciousness the child goes on as before.
Such a case is of sufficient severity to attract the
attention of a physician, and to make a diagnosis per-
fectly easy, but it can be seen that attacks of the same
nature occurring at infrequent intervals, and of which
we have only the account of parents, would nearly
always be disregarded. When associated with grand
mal, or when it has been followed by grand mal later
on, the diagnosis of true epilepsy is of course very
much more certain; still when studied carefully these
cases assume a certain definiteness, which it is hard
to convey by a written description.
The diagnosis must rest on the recurrence of the
attacks irrespective of gastric irritation, the fact that
they are not cured by the removal of sources of irrita-
tion, the persistence of the type of the attacks and the
occasional recurrence even in quite young children of
the epileptic equivalent, i.e., periods, during which
instead of loss of consciousness, the patient does and
says things entirely disconnected with the time and
place. The attacks must be distinguished in very
young children, first of all from convulsive seizures
due to local irritation. As we said before, under
three years except in very well marked cases this can
hardly be done.
Simple vertigo may resemble petit mal but the
affection of consciousness is usually described as
somewhat different. In vertigo there is a character-
istic feeling as if objects were whirling around. The
child says, "the house is going around." In epilepsy
there is more the sensation of simple blurring or con-
fusion. Vertigo is preceded by a period of weakness,
while the onset of petit mal is always sudden. The
patient is stiff for a moment, stares, and there is a
momentary loss of consciousness, but the attack passes
over as suddenly as it came, and he goes on with the
occupation in hand. In vertigo the body is limp and
the process is more gradual. In petit mal the pupils
are dilated and the eyes immobile. We must distin-
guish hysteria, which occurs frequently enough in
children. This may be done by the tightly closed
eyes, the tremulous lids, the persistent rigidity, but
especially by the existence of hysteric attacks of other
types. Petit mal may occur every few moments for
years without changing its form of attack. Of course,
this rule is not without exception. Thus in a young
person at present under observation attacks of petit
mal are sometimes replaced by short outbreaks of ill
temper, which are entirely foreign to her ordinary
disposition.
While we have begged the question of a certain
diagnosis of petit mal during the first three years of
age, yet cases from time to time have come under
observation in which a study of the particular case
has convinced us that it was one of true epilepsy. Its
frequency during this period of life is shown by the
statistics ot Growers, who found that 12J per cent, of
all epileptics had developed the disease before three
years, and of these one-half had developed during the
first year of life. In our own histories we find fairly
frequent instances of fully developed epilepsy in later
life having originated as petit mal in children. This
history is brought out more often if, as with us during
the last few months, we have inquired particularly for
symptoms of petit mal antedating the onset of con-
vulsions. It would seem especially interesting to
inquire as to the early existence of petit mal, in those
cases in which under treatment, petit mal is substi-
tuted for the typical severe convulsions. Some of
these cases impress one as if the attack of petit mal
was a development of an epileptic aura, which stopped
short of the convulsion. In some very rare cases
there has been a distinct sensory aura preceding the
attack of petit mal.
Petit mal is essentially a chronic disease, and for
that reason it is difficult to formulate the best plan of
treatment. However, special stress should be laid
upon the care of the stomach and all those meas-
ures which are included under the name of hygienic
management. As to drugs there has been a great
variety recognized. Petit mal is more intractable
than the severer convulsions, but the same treatment
which has been found best in these has on the aver-
age given the best results in petit mal. After experi-
menting with a great variety of drugs it has seemed
that bromid in moderate doses has given on the aver-
age the best results. Occasionally a case has shown
1896.]
DISCUSSION.
937
improvement when under nitroglycerin. Belladonna
in our hands has never given any results, and the
nine is true of borax, digitalis, and a number of other
drugs.
If our oonoeption of epilepsy as a stormy and
nngoverned discharge of the motor cells of the brain
be a (rue one. which belief is strengthened by the fact
thai seizures are more likely to take place in those
who have been sleeping, or who habitually sleep too
much, why would it not be possible by systematic
training of these cells to diminish the liability to such
outbreaks? Systematic exercise of such a varied kind
as would exercise all the muscles of the body might
thus have such an etl'eet beyond that due to the mere
improvement of the general physical condition.
'Phe parents of the child should know of the very
possible persistence of the affection into adult life, so
that everything should be done to render the disease
as bearable as possible to the little patient. The
friends and attendant should be instructed to speak as
seldom as possible of the attacks to the child, and
should be thoroughly instructed that attacks of petit
ma] are entirely beyond the control of the patient. An
effort should be made to treat the child as nearly as
ither children, not restricting it of its
liberty, or treating it like an invalid in any way,
except as far as is necessary to carry out the proper
regimen and treatment.
DISCUSSION ON PAPERS OK ORS. DIXON AND BISHOP.
Dr. Tiio.m «- II. M anley. New York —You know how unsatis-
factory and discouraging the teaching of obstetrics to the med-
ical student has been. It has often occurred to me it would
be better for humanity if we had no such science as the art of
midwifery. You will remember it was claimed the mortality
from sepsis had been reduced to practically nothing, through
the adoption of the antiseptic treatment, washing and flushing
the vagina precedent and antecedent to confinement ; and then,
again, we have been taught later the position we are coming
back to. the best thing to do is to do nothing at all in the way
of using solutions about those passages. The tendency is, that
the ideal man is the one who can make a diagnosis without
passing his fiDger in the vagina. Then we will not have to deal
with a sepsis, because pathogenic germs do not normally belong
in the vagina. When the forceps are used damage may be
done in the way of lacerations and tears of the cervix, vagina
and outlet, so far as the woman is concerned, by not allowing
nature to gradually open the way and send the child along by
slow and natural stages. Next, with reference to the child, I
think the effect of the forceps is murderous, perhaps not at
first but ultimately. You can not make me believe the strength
of a man with the forceps locked on the fetal head, and per-
haps a couple of women holding the women in the bed, will not
injure the delicate structures of the fetal brain. In my own
family, the only one who has manifested any nervousness, and
now she is an adult, was the first born, in whom I believe the
physicians prematurely applied the forceps and damaged the
head. I would not allow the forceps to be used on any of the
others and they have no bad symptoms.
Now as to trauma as a cause of epilepsy. That has not been
my experience, and for fifteen years, I was connected with a
hospital in which traumatisms constituted perhaps four-fifths
of the cases. In New York we have thousands of cases of
traumatisms, from children falling from the fire-escapes. We
have, consequently, many cases of skull injuries, but my expe-
rience has not been that trauma in itself is a cause of epilepsy.
I have traced quite a number of cases, where it became neces-
sary to trephine and elevate depressed bone ; the children had
been brought in the ward perhaps unconscious, and I could not
find in enough of cases the history pointing to trauma to con-
vince me it was a positive etiologic factor in epilepsy as a
general rule.
As to the surgical treatment of epilepsy; I have trephined
quite a number, who had come into the hospital for that spe-
cial purpose. After Professor Horstley's paper, which did
great damage from claiming he could do what could not be
done, I hoped something might be done for the epileptics and
I trephined. In perhaps about a quarter of them I found
those gliomatous tumors, the myxomatous substance between
the dura mater and pia mater. Not in a single instance was
there anything but temporary relief. I believe there is a ques-
tion whether the relief was from the loss of blood, the opening
of the scalp, the anesthesia, the psychic effect of the opera-
tion or what. If there is anything we owe to each other it is
to be truthful. We can not get the facts unless wo get the
cases that do badly as well as those that do well, and I have
not hesitated to go before my optimistic brethren in New York
and ask them to show me one case which showed relief from
operation. But if we have evidence of distinct depression of
bone, it is very clear what the line of action should be. But
otherwise I doubt the expediency of operation. We should
not overlook the fact that these operations are not entirely
innoxious. I have known more than one patient to lose his life
from hemorrhage. When you start a hemorrhage in the brain,
which is an extremely vascular organ, you can not stop it read-
ily. You can not apply pressure without pushing a hole
through the brain substance.
Dr. J. A. Work, Elkhart, Ind.— One point came to my mind
during the reading of the first paper. The author did not say
much about etiology in petit mal in children. It seems to me
we ought to determine the primary cause of all this trouble.
He said we should look well to the condition of the child's
stomach, to the development of the child, to its food, its envi-
ronments. It seems to me there is where the trouble origi-
nates in early infancy or childhood, when we consider that
one-half of the deaths that occur are in children under 5 years
of age. I say the same of the second paper read. We do not
go back far enough in etiology. It has been my fortune to see
cases of epilepsy that have orignated traumatically. I would
like, if the Section would permit the time, to report one or two
of these cases. One case was that of a soldier, on his way from
Indianapolis to another point, who fell off a flat car and was
not found for two or three days. When found, he was suffer-
ing from depression, I think in the right parietal region. The
history of the case was that the patient was unconscious for
probably twenty-four hours. The later history of the case I
had from his own lips. After returning from the army, although
a tnolder by trade, he went into the study of law, about fif-
teen years after the injury, and he said from the time he
recovered consciousness until I was in conversation with him
he had not been void of pain in the region where the injury was
received, except when he was asleep. 1 was called one morning
early. He had gone to the cooking room to build a fire and
was later found on the floor. This was the first attack he had
had of epilepsy, some fifteen to twenty years after the injury.
He seemed to recover as if he had awakened from a sleep, and
wanted to know where he was, how he came there, etc. The
attacks became more frequent, and he became more imbecile
and died about two years after the first attack. A postmortem
was held. Under the dura mater, at the base of the brain, we
found a tumor about the size of a turkey's egg, flattened out,
which we supposed was the cause of the epilepsy and death.
Another case was that of a soldier injured at Chickamauga
by a shell. He lay on the field for some hours, and the sur-
geons pronounced his case hopeless. He finally recovered and
served out his term in the army. But he said a stroke upon
his forehead in the injured region, would bring on temporary
insensibility. After his return home, while employed as a
988
OPTIC NERVE ATROPHY.
[October 31,
laborer, he fell down with epilepsy, and found he could not
t>btain employment because of his attacks, which occurred
■every two weeks. I saw him have an attack near my office. I
thought he never would never recover from it. In two weeks,
after preparatory treatment, I trephined and removed a three-
•quarter inch disc. No evidence of fracture of the skull was
found. The skull was very thick. In two weeks from that
time he had a slight attack and that was the last. He died
some ten years afterward of another disease. There was a case
of cure, to all intents and purposes, by trephining.
Dr. Harold N. Moyer, Chicago, 111. — I can not allow the
opportunity to pass without making a remark or two upon the
papers with reference to epilepsy. This disease is one of the
most interesting in our pathology. I think we are apt to for-
get this is the morbus sacer, the sacred disease of history. I
believe epilepsy is the oldest disease existing. I believe it
began when the animals began to have nervous systems. Ani-
mals have the disease : cats are notoriously affected with it ;
horses have it under the name of "blind staggers;" elephants
have it without a doubt, and how far down the scale it extends
it is impossible to say. It probably existed prior to the stone
age, even prior to the time when man made his advent upon
this earth. We understand it now no better than they did
then. We absolutely know nothing about the pathology or the
pathologic anatomy of epilepsy. We know nothing as to its
etiology, more than the exciting causes which have been men-
tioned. Head injuries, the importance of which has been well
brought out, I consider furnish many cases of epilepsy. There
are doubtless many other causes, but it is well to remember
these are merely exciting causes. Many children receive inju-
ries who do not develop epilepsy. Why do those who receive
these injuries not have epilepsy? The difficulty is that the
underlying etiologic factor in epilepsy is absolutely unknown
to us. If we understood that, we would know its pathology.
When we come to the question of treatment, the same thing
applies ; not knowing the pathology and etiology, the treat-
ment must necessarily be vague. But I wish to emphasize the
statements made by Dr. Manley. Operations for epilepsy
undertaken indiscriminately because the patient is epileptic,
should be discouraged. I believe it is almost malpractice to
operate in these cases, for you thereby add a very severe
trauma. I want to be understood in the proper sense, for it
would not be malpractice if the operation is demanded by
some injury, depressed bone, etc. But otherwise I have never
recommended skull operations except in the form known as
Jacksonian epilepsy where the center could be well localized.
I believe the literature of the subject justifies very strong
statements on this question.
The paper by Dr. Bishop is very interesting. The Doctor
was kind enough to give us his diagnostic rules. I confess as
I listened to him I thought I would be able now to make a
diagnosis of epilepsy in childhood with s"ome precision, but I
fear I will not be able to apply the lines he has laid down.
But there is one good rule, which I shall substitute for those
given by the Doctor, and that is if I have brought to me a
young child in which I suspect epilepsy, I shall assume it is
epilepsy and treat it as such. If it is not epilepsy, such treat-
ment will do no harm ; and if it is epilepsy in its incipiency,
then is the time to do good with treatment. If there is any
one rule in this disease, it is to begin treatment early. After
the condition is confirmed, treatment is almost entirely hope-
less. The petit mal is then more hopeless than the grand mal,
because the petit mal is accompanied by changes in the brain
which lead to early dementia and conditions leading to imbe-
cility. Unfortunately, the treatment is not all that could be
wished. I desire to emphasize the Doctor's remark, that the
hygienic treatment is of the greatest importance. As to the
medicinal treatment, I am a firm believer in the bromid of
sodium and use no other salt. I do not mean to say that you
should simply pour in this remedy and you will secure good
results, for one-third will not tolerate it, another third will be
benefited, and another third will be indifferent to the treat-
ment. But I believe this bromid is better than any of the
others, and it is much better borne than the bromid of potas-
sium. If it is given two hours after meals and well diluted,
and the patient is frequently bathed, very considerable doses
can be given without producing bromism. The bromid of
sodium given within the tolerance of the patient and begun
early I believe is the most efficient treatment.
OPTIC NERVE ATROPHY
AGENTS.
FROM TOXIC
Read in DIscuesion on Optic Nerve Atrophy in the Section on Ophthal-
mology, at the Forty-seventh Annual Meeting of the American
Medical Association, held at Atlanta. Ga.. May 5-8, 1896.
BY G. E. DE SCHWEINITZ, A.M., M.D.
PHILADELPHIA.
Toxic optic nerve atrophy naturally includes, 1,
those cases of atrophy which result from a direct
action of the poisonous substance, or its systemic
results, upon the nerve cells, the nerve fibers or their
vascular supply, and, 2, those cases of atrophy which
are secondary to retino-choroidal or constitutional
changes, which in their turn have been called into
existence by toxic agents.
The first class is separable into three subdivisions,
namely, a, partial atrophy of the optic nerve with
special reference to degeneration of its papillo-macular
bundle, b, scotomatous atrophy of the optic nerve,
which is progressive and may become total, and c,
general atrophy of the optic nerve.
1. Toxic atrophy of the papillo-macular bundle of
the optic nerve preceded by inflammation or degener-
ative changes in this tract and associated with
scotoma. — Cases of this class manifest themselves
either in the form of a chronic retro-bulbar neuritis,
or else as an intoxication-amblyopia, because we may
with propriety draw a clinical distinction between these
two manifestions, although anatomico-pathologically
they are in close accord, the intoxication-amblyopia,
as Groenouw puts it, being a special form of retro-
bulbar neuritis.
A. rial neuritis, a term sometimes employed, accord-
ing to the same author, should be reserved for those
cases characterized by a lesion, confined to the papillo-
macular bundle where it is axial in its course.
Following Groenouw1, the papillo-macular bundle
may be described as consisting of those fibers in the
optic nerve which supply the retina between the
macula lutea and the papilla, and which lie in the
temporal portion of the nerve tip, in a wedge-shaped
segment. The apex of this triangular portion is
directed toward the vessels and occupies about one-
third of the surface of the papilla. As it pursues
its way through the orbital portion, it gradually
approaches the axis of the nerve, which it reaches in
the optic canal. At the foot of the chiasm it occu-
pies its upper and inner portion, but in the tractus it
sinks to the central portion and remains there until it
arrives at the brain.
According to Sachs2, the papillo-macular bundle in
the papilla is a triangle with its apex at the vessels,
and the base toward the supero-temporal quadrant.
Going backward, the bundle becomes elongated and
assumes a crescentic form as it nears the optic canal.
It would not be profitable at present to discuss the
1 Graefe's Archiv, 1892. xxxviii, Abth. I. pp. 1 70.
2 Archives of Ophthalmology. 1889, xviii, N"o. 2 pp 1S8-163.
1890. 1
OPTIC NERVE ATROPHY.
93'J
differences of opinion as to the disposition of these
fibers in the optic nerve trunk, in the region of the
vessel-entrance, and their division in the chiasm. For
their full consideration tlu> reader is referred to the
examinations of Samelsohn,' Yossius,' Nettleship
anil Edmunds. I'hthotV." Bunge, Shells' and Stolt-
ring.'
I |>on this papillo-maoular tract the baleful in fluenoe
of certain toxic agents falls, and there result an aug-
mentation of nuclei, a hypertrophy of the connective
tissue and a wasting of the nerve fibers,' the process
being most intense, according to Saohs, in one small
area, which he calls the '"nuclear group." There is,
in faot, an interstitial sclerosing inflammation com-
parable, according to Samelsohn. to the same patho-
logic process visible in interstitial hepatitis.10
Some difference of opinion exists as to the exaol
nature of the nerve changes. By certain observers
the inflammatory nature of the process has been em-
phasized; by others (Saohs) its degenerative charac-
ter. To quote from Saohs, the diseased process starts
in the interstitial eonneetive tissue and the nerve
libers sutler secondarily from pressure, in the same
manner as the hepatic cells are destroyed in cirrhosis
of tin- liver, The vascular changes of the two afi'ee-
tions are also analogous, and, according to Saohs,
there may be found "not only a proliferating endo-
phlebitis. leading to eonneetive tissue obstruction of
the vascular lumen, but a peri-phlebitis, resulting
first in a choking of the peripheral capillaries and
afterward in small extravasations from them."
The pathologic lesions thus briefly described are
! upon the results of about sixteen autopsies.
The most important of these are as follows:
1. Samelsohn:" The patient suffered from double
retro-bulbar neuritis, which began with the clinical
picture of an intoxieation-amblyopia, the central
scotoma being at first relative and later absolute:
death resulted from ehronic heart disease. The abuse
of tobacco and alcohol was not substantiated.
2. Nettleship and Edmunds:" The patient was a
diabetic and an excessive smoker. The fields of vis-
ion were normal and in each there was a nearly cen-
tral scotoma for red. Death resulted from carbuncle.
3. Yossius-." The patient suffered from alcohol-
amblyopia, had at one time a central scotoma, and
died hemiplegic and aphasic.
i. Bunge:" The patient was a tabetic and also
probably under the influence of tobacco and alcohol.
5. Uhthoff:" (Six cases.) The first patient was a
chronic alcoholic, with marked blanching of the tem-
poral halves of the papilla, but without record of
scotoma, who died from the effects of alcoholism.
I i.raefe's Archiv. JSS2. xxviii, Abth. I, pp. 1-110
iQraefe's Archiv, 1882, xxviii. Abth. III. p. 201.
I Trans. .)i (Jphth. Soc. of the D. K. 1881, 1, p. 124.
» Oracle's Arch i v. 1886, xxxii, Abth. IV, 95-108, and Ibid, xxxiii, Abth.
1. pp.*>7-3l8
I Debar die Geelcht&feld unci Faserverlauf im optischen Leistung's
Apparat, Halle, 1884.
s Archives of Ophthalmology, 1889, xviil. No. a, pp. 188-162, and Ibid,
1894. XXiii. Nn. *.pp. 1-' . -111.
•' Klinische uud Anatomisohe Beitragezur Intoxikations Amblyopie.
rt„ Marburg;, 1893
■I (British Medical Journal, Sept. 12, 1896. p. 629) insists
thai ceutral toxic scotoma is not primarily a neuritis of the macular
bundle, but a disease of the macula lutea, causing degeneration of its
cells, and that the optic nerve changes are secondary to the destruction
of tlie nerve cells of t]le macula. Some experimental confirmation of
this vi.w may be found in the research of Csher and Dean (Ophthalmic
Review. July. 1896!. who have observed macular fiber degeneration fol-
low experimentally produced retinal lesions. Clinically, we know that
atrophy of the tissue of the macula lutea. e.g. in atrophic central retmo-
eborolditis. will cause ophthalmoscopic quadrant atrophy of the disc.
As long ago as 1874. Schoeu. and later Baer and Treitel. advocated the
origin of central scotoma, believing that it Indicated a func-
tional weakness of the center of the retina, due to toxic agents.
■1 Loo. Bit.
The second was a patient with atrophic discoloration
of the temporal halves of the papilla1, absolute cen-
tral scotoma, who died in an attack of delirium tre-
mens from intercurrent pneumonia. The third was a
patient with atrophy of the temporal halves of the
papillre, who suffered from delirium tremens suc-
ceeded by dementia paranoica and died a lunatic. It-
was not possible to test the visual fields. The fourth
was a chronic alcoholic who died of meningitis dur-
ing an attack of delirium tremens. No visual fields
were obtained, but the temporal halves of the papilla;
were atrophic The fifth was a confirmed drunkard,
with atrophic papilke but without demonstrable color
scotoma, who died phthisical, and who suffered also
from interstitial hepatitis. The sixth was a drunkard
with atrophic temporal halves of the papilla; without
defect in the color fields, who died of pulmonary
edema supervening on general paralysis of the insane.
<). Wildbrand:12 The patient suffered from poly-
arthritis and central scotoma which developed sud-
denly; death resulted from cardiac failure.
7. Theodore Sachs : l:l The patient was an alcohol-
tobacco amblyopic, who had typical central scotomata
and who died from intercurrent pneumonia during
nephritis.
8. Stoltzing:14 The patient was a tobacco-alcohol
amblyopic, who died from pleurisy, fatty heart and
atheroma of the aorta; scotomata are not mentioned
or described.
9. Theodore Sachs:''1 The patient was believed to
suffer from intoxieation-amblyopia, although the
abuse of alcohol and tobacco was denied. He had
typical scotomata for all colors on both sides; death
from pulmonary tuberculosis.
Eight of these fourteen patients had demonstrable
central amblyopia and central scotomas. Of the
remaining six, in one, although the case is described
as an intoxieation-amblyopia, the scotoma is not
mentioned, and in others either it was not present or
the patient's general condition was such that it was
not possible to demonstrate it. In all of these, how-
ever, the ophthalmoscopic appearances were those
usually found with central scotoma.
Alcohol was probably the cause of the optic nerve
lesion in seven, alcohol and tobacco combined in two,
diabetes and tobacco combined in one, tabes dorsalis
associated with the abuse of tobacco and alcohol in
one; tobacco was the probable cause in one, although
its abuse was denied and the patient died of tubercu-
losis; in another, although the influence of tobacco
and alcohol could not be proved, the clinical symptoms
indicated intoxieation-amblyopia, and in one the cen-
tral scotoma existed without such influence. Even in
those cases in which alcohol seemed to be the most
potent agent, the effect of tobacco could not be
entirely excluded. Finally, it will be noted that all
of the patients suffered from various types of wide-
spread disease. Therefore we are not actually in pos-
session of the results of an autopsy on a perfectly
pure case of intoxieation-amblyopia. My endeavors
to establish toxic amaurosis in monkeys and dogs
were failures, probably because the drug was not con-
tinued for a sufficiently long time.
When, however, a definite set of clinical symptoms
are taken into consideration, with the results of autop-
sies thus far recorded, we have reason to believe that
12 Bericht iiber die Versammlung der Ophthalmolog. Uesellschaft.
xxii, Heidelberg, 1892, p. 84.
13 Loo. clt.
i* Loc. cit.
y40
OPTIC NERVE ATROPHY.
[October 31,
the pathologic process which determines an intoxica-
tion-amblyopia is situated in the optic nerve, and
especially in that portion which is known as the
papillo-macular bundle.
These clinical symptoms are as follows: Diminution
of sight, associated with fogginess in center of field
of vision, unimproved by glasses; reduced acuity of
vision, which varies from counting fingers to 20-30
(according to Groenouw from 5-200 to 20-30); pallor
of the temporal half of the disc, or of a quadrant-
shaped portion of the papilla; normal peripheral
boundaries of the field of vision; symmetrical central
color scotomas, especially for red and green, usually
oval in shape, stretching from the fixing point to the
blind spot, and rarely passing much to the nasal side
of the former; defective light-sense (Berry, Abney),
but according to R. Wallace Henry, normal light-
perceptive power.
Of these symptoms the most important is the cen-
tral scotoma,1'" and did time permit, it would be profit-
able to study in detail its development, enlargement
and retrogression, which, as Groenouw remarks, rep-
resent a characteristic picture — a picture, moreover,
aicording to Wild brand, which is analogous to that
produced by retro-bulbar axial neuritis, except that
in the latter the defect is absolute.
The average size of this scotoma, according to
Sachs's measurements of fifty-three fields is out 18
degrees, in 5 degrees, up 7 degrees, down 6 degrees.
My own average measurements are out 18 degrees, in
3 degrees, up 7 degrees, down 6 degrees. It is thus,
as we see, an oval with its pointed end toward the
blind spot and its blunt end toward the fixing spot, to
the nasal side of which it passes only slightly.
This scotoma represents a red-green-blind area, and
commonly the extent of green blindness is greater
than that of red, which in its turn may be surrounded
by an area of imperfect color-sense. The "culmina-
tion spot," or "nuclear spot," to use the phraseology
of Sachs, of the scotoma "lies horizontally from 1
degree to 8 degrees in a lateral direction from the fix-
ation point, its breadth, vertically, being mostly below
the horizontal line." Sometimes, however, as we
know from Groenouw's observations, the beginning is
a small, easily overlooked scotoma exactly over the
fixing point.
When the typical egg-shaped scotoma is developed
which, according to Groenouw, results from the union
of the scotoma from the fixing spot with a supple-
mental scotoma around the blind spot, the process
may cease, or there may be a stage of progression,
characterized by an increase in the size of the color
defect, usually above, until it meets the limit of the
red field, i. <>., the scotoma has "broken through." If
this goes on the patient may eventually resemble a
congenitally color-blind person. In severe cases
scotomas for blue and yellow form in similar manner
to the red-green scotomas, especially, according to
Baas,16 in the period of "breaking through." Finally,
small absolute defects may be found, particularly at
the "nuclear spot," but also elsewhere, and in neg-
lected cases, or in those not typically toxic, the sco-
toma becomes absolute.
Instead of the typical egg-shaped or oval scotoma,
the visual defect may pass up and out or down and
out. Occasionally a circular scotoma surrounding the
l» Sachs objects to the designation "paracentral," or "central," as
conveying a false impression and contends, with justice, for the term
"papillo macular scotoma."
is Das Uesichtfeld ; Stuttgart, 18%, p 104.
fixing point has been described, for example, by Net-
tleship, Nelson and by myself.
In cases supposed to be more purely alcoholic in
origin, either in addition to the relative scotoma for
red and green, or instead of it there may be, according
to Uhthoff, complete or partial peripheral defects for
these colors. In rare instances a small central sco-
toma for blue appears, and exceptionally there are
absolute scotomata surrounded by a blue- blind zone
and more peripherally by a red-green-blind region,
the periphery for white being normal. According to
R. Wallace Henry," if the visual field is full, nicotin
is the determining cause of the amblyopia; if spirally
contracted (a "retinal exhaustion" field), alcohol is
the determining factor. A differential diagnosis be-
tween alcohol and tobacco cases, based upon the "peri-
central" or "paracentral" position of the scotoma, as
originally suggested by Hirschberg, has been shown
to be inaccurate.
The various drugs and toxic substances which may
be responsible for the clinical symptoms which have
just been detailed are tobacco, alcohol, either singly
or combined, stramonium, cannabis indica, chloro-
form, opium, cocain (?), bisulphid of carbon, nitro-
benzol, arsenic, lead, iodoform, the toxin of diabetes
and probably, according to Baas, ioduret and thiuret,
two modern antiseptic preparations.
Clinically, at least, tobacco is facile princeps of
these deleterious agents, although its effect on the
system is usually combined with that of alcohol, the
relation of alcohol being not only that of an addi-
tional poison, but also that of a substance which pre-
disposes the system to the influence of tobacco by
depressing nutrition and creating chronic gastritis,
because there seems little doubt that the influence of
the tobacco is much more potent if the patient is the
subject of chronic gastric catarrh. Indeed, Horner
at one time believed that this was the sole influence
of tobacco. It did not, according to this author, pro-
duce the amblyopia, but it created the nutritive dis-
turbances which in their turn were responsible for
the visual defects.
Sachs seeks to explain the action of tobacco in rela-
tion to toxic amblyopia in the presence of stomachic
catarrh by assuming "that certain complex chemic
combinations occur chiefly in the stomach and prob-
ably result from the transformation of the normal
gastric juices into acids of the fatty type, whose com-
pounds with nicotin are either more readily absorbed,
or are with greater difficulty eliminated from the sys-
tem than the simple tobacco bases." There is no
doubt that nicotin is neither alone nor chiefly
responsible for the deleterious effects of tobacco upon
the visual apparatus, or, indeed, upon the nervous
centers generally. It is not unlikely that the nico-
tin of tobacco smoke is almost completely, if not
entirely, decomposed during the combustion of the
tobacco, and we must probably look to other com-
pounds, pyridin, collodin, carbonic acid, etc., for
influences which have usually been solely attributed
to nicotin.
The action of alcohol on the optic nerve is no doubt
analogous to its influence on nervous tissue generally
and on individual organs, for example, the liver and
the kidneys: indeed, we have seen that the pathologic
processes are similar.
In the absence of microscopic investigations we
assume by clinical symptoms that the other drugs in
I Ophthalmic Review, xv, No. 172, 1896.
1896.]
OPTIC NERVE ATROPHY.
941
this list produce a papillo-mnculnr scotoma in like
manner. Four of them, lead, arsenic, nitro-benzol
ami bisnlphid of carbon, rind their chief subjects
among workmen who are engaged in handling these
substances. Three of them, cannabis indica, chloro-
form and opium, to which list perhaps stramonium,
arsenic and probably oooain should be added, are
potent among drug-drunkards. Three of them mani-
fest their deleterious influences chiefly after absorp-
tion through the skin, namely, iodoform, ioduret and
thiuivt. although iodoform may enter the system by
stomachic absorption.
With the exception of cannabis indica, stramonium,
opium, oooain (?), iodoform and perhaps some of the
cases of bisulphid of carbon and nitro-benzol poison-
ing, the clinical symptoms of the visual defects of this
list of substances arc more analogous to those of an
axial neuritis than of pure intoxication-amblyopia.
This is notably the case with lead.
The prognosis of toxic amblyopia is favorable when
only a color scotoma exists and recovery is probable
as tiroenouw points out, even when small absolute
defects arc present. In the earlier stages, especially
of the tobacco cases, the indications are rather of
vascular disturbance than of true neuritis, or per-
haps, as Sachs points out. the alterations do not at
first affect the nerve fibers, but merely the areolar
septa. The nervous tissue is temporarily injured,
and cure is therefore possible. When optic nerve
atrophy ensues, we may assume a real retro- bulbar
neuritis. Nevertheless there appears to be a type of
optic nerve atrophy in which, as Lawford's has said,
although tobacco may not be the sole cause, it has
some share in originating or aggravating the changes
in the optic nerve: or again, as Browne '"has sug-
gested, "there are cases of retro-bulbar neuritis which
begin with the ordinary clinical symptoms of intoxica-
tion-amblyopia, but which do not tend to recovery,
the progression of the central defect indicating that
atrophy of the papillo-macular bundle takes place."
What is the role played by tobacco and the other
agents thus far mentioned in these cases has not been
positively determined. No doubt recovery or progres-
sion of the visual defect is largely determined by the
length of time during which the poisonous substance
has maintained its influence, as well as by the type of
the lesion which it produces, as we shall see in the
subsequent sections.
2. Progressive <nul scotomatous atrophy of the
optic no- re the result of toxic agents. — The class of
- included under this heading, and it is not a
large one, comprises those in which the symptoms are
an absolute central scotoma of the type seen in retro-
bulbar neuritis, that is one not typically oval and
lying bet ween the fixing spot and the blind spot; a
scotoma, moreover, which increases and tends to
"break through," joining the outer limits of the form
field, which, at first normal, progressively contracts
pari passu with the enlargement of the central visual
defect.
It will be remembered that cases of this character
have been dominated "scotomatous optic nerve
atrophy," and are said to occur in young men between
the 20th and 25th years, often without discoverable
cause and with some hereditary tendency. They are
similar to the cases which Edgar A. Browne2" thus
describes: "The affection begins in the central tract,
I! Trans. Ophth. Soc. of the XT. K., 1890, x, p. 166.
i» Trans. Ophth. Soc. of the U. K., 1888, vtii, p. 286.
but gradually spreads until the whole nerve is more
or less involved and atrophy results. Here a distinct
personal proclivity is shown in young persons, mem-
bers of the same family. Whether there is any ascer-
tainable difference betweon those cases in which
tobacco is the exciting cause and those which occur
spontaneously requires investigation." They are
probably analogous to the progressive scotomatous
atrophy which Jensen '" has described and which has
been regarded by him and by others as a particular
form of the development of tabetic atrophy. As has
been said before, the relation of toxic substances to
this form of optic nerve atrophy is uncertain, but a
few cases seem to indicate that they, may be at least
exciting causes. Of those agents n^eady mentioned,
tobacco and alcohol are probably preeminent, lead
less certainly. Of the others I am unprepared to
speak.
X. General atrophy of the optic nerve the result of
toxic agents. — General atrophy of the optic nerve as
the result of toxic agents may be divided thus:
1. Those cases in which there is a preceding retro-
bulbar neuritis or neuritis papillo-macularis, with
central scotoma, and in which the diseased process
has spread from the papillo-macular bundle and the
axis of the optic nerve until it has involved the
peripheral and intermediary fibers. To these cases I
have already referred in the two preceding sections,
and have pointed out that they probably may be due
to tobacco and more certainly to alcohol and lead. To
this class I may add bisulphid of carbon and probably
arsenic.
2. Those cases in which there is a preexisting intra-
ocular optic neuritis, usually of moderate degree,
which is succeeded by an ordinary atrophy, that is, a
post-papillitic atrophy. Scotomata are not present in
these cases.
The most prominent drugs responsible for this state
of affairs are bisulphid of carbon (probably), mer-
cury, iodoform (one case only), and especially lead.
Exceptionally subjects of chronic alcoholism exhibit
optic neuritis. The same is true of patients who are
subjects of the chloral habit. Of all the drugs men-
tioned the most potent in this relation is lead. For
example, in sixty-four cases which I have analyzed there
were thirteen with optic neuritis, four with neuro-
retinitis and seventeen with optic nerve atrophy, while
in seventeen cases the patients were stated to be blind
without description of the ophthalmoscopic appear-
ance, and no doubt in many of these atrophy or neu-
ritis was present.'22
3. Those cases in which there is primary atrophy
of the optic nerve, that is, an atrophy due to a primary
effect of the poison on the visual apparatus without
history or signs of preexisting intra-ocular or retro-
ocular neuritis. It is confessedly difficult to main-
tain this class with exactness, because while the
patient may present himself for treatment with com-
plete optic nerve atrophy, there may have been at an
earlier stage of his disease an axial neuritis with
scotoma or even a general neuritis, neither of which
has left signs of its presence.
Of the various drugs which have been named no
doubt it would be proper to include in this list those
already recited in connection with the previous clas-
sification, and we may with reasonable accuracy state
90 Loc. cit.
21 Abstract in Ophthalmic Review, x. No. 3. p. 13.
W De Schweinitz: The Toxic Amblyopias; Their Classification,
Symptoms, Pathology and Treatment. Philadelphia, 1890, p. 157.
942
OPTIC NERVE ATROPHY.
[October 31,
that this visual defect is possible under the influence
of chronic mercury, chronic arsenic and especially
chronic lead poisoning. Referring to the latter I
may say that there is certainly an optic nerve atrophy
due to the primary effect to lead on the visual appa-
ratus, an atrophy which has been believed by some
observers, for example, Parisotti,23 to be due to changes
which lead causes in the nutrient arteries of the optic
nerve, changes which we know it may cause in the
general retinal circulation.
It is probable also that atrophy may occur under
the influence of nitrate of silver, in a manner analo-
gous to lead and bromid of potassium. It certainly
results from the toxic influence of filix mas, although
thus far reports of this condition are largely confined
to Japanese literature. A few cases, however, have
appeared in French and German reports, and recently
filix mas atrophy has been attributed to filicic acid,
Van Aubel 2i believing that this agent acts upon the
central nervous system, the spinal cord and the sym-
pathetic, causing dilatation of the pupil and through
the vaso-motor nerves contraction of the retinal
arteries. It is interesting to observe that the blind-
ness comes on acutely, generally after the ingestion
of the drug for the purpose of driving out intes-
tinal parasites, and that within a few weeks or even
shorter time, the arteries shrink and the discs become
pallid and atrophic.
In this particular the drug may be classed with
two others that are able to produce what I may
call an acute optic-nerve atrophy, namely, quinin
and salicylic acid, or to speak more accurately,
various preparations of the cinchona bark, and the
salicylates. The last named drugs, namely, quinin
and salicylic acid, produce symptoms so exactly alike
that they may be classed together, although the effect
of quinin is much more potent than that of salicylic
acid.
The symptoms are as follows: Blindness, complete
or incomplete, usually developed with great sudden-
ness and more absolute than in any other recoverable
condition (Mellinger and Browne); dilatation of the
pupils, absence of the light reflex, imperfect response
to accommodative effort, nystagmus, proptosis, occa-
sionally divergent strabismus and increased intraocu-
lar tension (Tiffany); anesthesia of the conjunctiva
and cornea (Voorhies); extreme pallor of the optic
discs and diminution of the retinal vessels simulating
the appearances of progressive atrophy; occasionally
retinal haze and the cherry-colored spot in the macula,
resembling embolism of the central artery of the
retina; gradually partial or complete restoration of
the central vision, associated at first with complete or
partial color blindness; later slow renewal of the
color-sense, which may ultimately return; more often
permanent diminution of the light-sense and color-
sense and contraction of the field of vision, the con-
traction usually assuming an elliptical shape; very
exceptionally permanent blindness (Claiborne).
As we know from the experiments of H. Brunner5
and myself,26 as well as from those of a recent Italian
observer, De Bono,2' the exact picture of quinin
blindness may be repeated in animals, so that there is
do doubt as to a selective influence of this drug upon
the visual apparatus — an influence, as I have shown
W Kec. d'Ophth., 1885, 8 a., vii, p. 350.
M Annales d'Ooolletlqne, T.114, 1895. p. 400.
-'5 UeberChmimimaurose. Iuaug. Dissert., Zurich., 1882.
M Trans. Amer. Ophthalmological Soc 1891.
V Archiv. di Ottal., 1894, 11, pp. 171, 227.
in dogs, which extends from the intraocular end of
the optic nerve throughout the visual tract as far as
this can be traced in the brain. But, even now, the
mechanism of the blindness is somewhat uncer-
tain. Probably it depends upon an influence of the
drug on the peripheral circulation of the visual appa-
ratus, which produces at first a pure ischemia, later
an endo- vasculitis, and still later, as I have further
shown, thrombosis in the vessels and extensive secon-
dary degenerative changes in the optic nerve fibers.
Parisottrs idea of the mechanism of primary lead
atrophy, to which I have already referred, is similar,
namely, that it depends upon changes in the nutrient
arteries of the optic nerve. Indeed, the analogy does
not cease here, because referring to Sachs's observa-
tions on intoxication-amblyopia pure and simple,
we remember that he suggests, and in fact demon-
strates, that vascular changes in the diseased tissues
of tobacco-alcohol atrophy, producing proliferating
endo-phlebitis and leading to connective tissue
obstruction of their vascular lumen, are important
factors in the anatomico-pathologic basis of this
affection.
4. Atrophy of the optic nerve secondary to reti-
nal ami other lesions, in their turn the result of
toxic agents. — Thus far we have discussed the visual
defects caused by an action of toxic substances fall-
ing primarily upon the papillo-macular bundle and
ceasing at this point, or spreading and involving
other tracts in the nerve, or by an action on the entire
optic nerve, preceded or not by an intraocular optic
neuritis. In a certain number of instances atrophy
of the optic nerve is secondary to lesions either in the
retina itself, or elsewhere in the body. The cases
may be divided into:
1. Those in which the action of the drug has fallen
upon the retinal circulation.
Preeminent among substances of this character
quinin and salicylic acid should be placed, that is.
they should be thus placed if we accept the theories
of certain observers in regard to their action, namely,
that it is upon the retinal vessels, causing endo-vas-
culitis and secondary changes. My own observations
indicate that they affect the vessels of the optic nerve
apparatus especially — perhaps, however, an extension
of the original retinal lesion.
2. Those. cases in which the toxic agent has pro-
duced tissue change, either in the retina or in the
retinal vessels.
Preeminent among drugs of this class is phosporus,
which early in its toxemia causes retinal hemorrhages
and later a fatty degeneration of the retinal tissue
itself, which, should the patient live long, would no
doubt produce secondary changes in the optic nerve.
Probably other poisons, chiefly irritant in their effects,
have an analogous action, notably the bichlorid and
other soluble preparations of mercury. The influence
of acute poisons upon the retina and the secondary
changes in the optic nerve require further inves-
tigations. If subsequent investigation substantiate
the view that toxic scotoma is caused primarily by
degeneration in the macula, tobacco and alcohol
would find place in this class.
3. Those cases in which the primary action of the
poison falls upon some organ or tissue of the body.
causing a disease which in its turn is responsible for a
retinal and secondary optic nerve change.
The most notable drug of this class is lead, which, as
we know, may produce a nephritis, a neuro-retinitis as
1896.]
OPTIC NERVE ATROPHY.
943
the result of this nephritis, and finally optic nerve
atrophy. Lead, in like manner, may produce an
encephalitis, or a meninao-enoephalitis and secondary
optic nerve changes. The effect of alcohol upon the
meninges of the brain, causing optic neuritis and sec-
ondary atrophy, has already been described. Whether
the optic neuritis of chloral, mercury, arsenic and
nitrate of silver may have a similar origin, I do not
know. It seems probable that iodoform may cause
meningo-encephalitis and optic atrophy.
OPTIC NERVE ATROPHY OF OBSCURE
SPINAL ORIGIN.
Kea.l in tin- Seetlon on Ophthalmology, at the Forty-seventh
Anuual Meeting of the American Medical Association
at Atlanta. i;a„ May 5-8, im«.
in DUNBAR ROY, A.B., M.D.
Of OPHTHALMOLOGY AND OTOLOGY IN SOUTHERN MKDICAL
OCULIST TO SOUTHERN R.R.. HOME KOR THE FRIENDLESS.
ATLANTA, GA.
The important relationship existing between the
optic nerve and other portions of the central ner-
vous system, especially the spinal cord, has long been
recognized by both neurologist and ophthalmologist.
In fact, most' clinical observers will readily agree with
Growers,' in considering the optic nerve in its devel-
opment, nothing more than an extension of the cen-
tral nervous system and anatomically of the same
structure as the brain and spinal cord. The patho-
relationship between the diseases of the optic
nerve and cerebrum are not so difficult of demonstra-
tion, but when we consider this same relationship in
diseases of the spinal cord, pathologists must as yet
acknowledge their inability to discover any direct ana-
tomic connection.
The portion of the subject allotted to me is not the
discussion of diseases in general of the optic nerve,
which are dependent upon, or associated with patho-
logic conditions of the spinal cord, but the considera-
tion of those eases of optic nerve atrophy, only, which
bear this relationship to well recognized lesions of
the spinal cord. I say "associated with" because no
casual dependence has as yet been anatomically dem-
onstrated, but because we observe clinically an atro-
phv of the optic nerve, and at the same time certain
pathologic lesions of the spinal cord we are in the
habit of trying to trace some casual relationship.
Clinical facts can not always be explained by theo-
retical reasoning or absolute anatomic demonstration,
yet we learn to class them as truths, because of their
frequent occurrence under almost identical conditions.
Most writers divide atrophy of the optic nerve into
two classes: a, primary, b, secondary. In primary
atrophy disturbance of vision" is usually present with
the beginning of the atrophic process, both increasing
together, while in the secondary form there may be a
disturbance of vision long before there are any appear-
ances of degeneration or atrophy in the nerve sub-
stance itself; but it is doubtful whether the final
appearance of these disks can differentiate the two
s. Primary atrophy occurs most frequently
without any discernible cause, yet sometimes is dis-
tinctly traceable to heredity. In this form of atrophy
previous inflammatory signs never exist.
By secondary atrophy is meant those cases in which
the morbid condition maybe traced to distinct causes
as for instance those following intrabulbar neuritis or
choroiditis: ultro-bulbar neuritis, traumatism and
direct extension of the process from the cerebrum
itself.
Atrophy of the optic nerve occurring in this con-
nection with simultaneous lesions of the spinal cord
presents the clearest example of the so-called primary
atrophy.
To aid us more clearly in this discussion, I propose
to treat the subject under the following three
captions:
1. Optic atrophy associated with lesions of the
spinal cord and bulb, as:
a. Meningitis. — Optic nerve atrophies resulting
from or following an acute inflammation (meningitis)
of the meninges or nerve substance proper (myelitis)
of the spinal cord and medulla, must be classed as
consecutive, instead of primary. Such could only
occur as the extension of the inflammation from the
spinal cord to like structures in the brain, with a sim-
ultaneous involvement of the optic nerve. Cases of
this kind are exceedingly rare.
Growers2 mentions a case of the optic atrophy fol-
lowing an attack of sporadic cerebro-spinal menin-
gitis. A boy was brought to him, who after a thor-
ough drenching had suffered from severe headache,
delirium, fever and stiff neck. Ten days later he
became blind. After the blindness, the other symp-
toms disappeared, and when examined by Gowers
there was present only a small degree of light percep-
tion in one eye. The papilla? showed the picture of
consecutive atrophy, the centers being filled with new
connective tissue; the vessels were narrowed, and the
choroid in the neighborhood of the papillae showed
marked changes. This author has mentioned two
other cases of the optic atrophy following myelitis of
the cord which were reported by Clifford- Allbut. In
one there was a slight optic neuritis, with indistinct
borders of the papillre, resulting finally in a gray
atrophy, and in the second a partial gray atrophy, the
cause of which being, probably, a chronic myelitis of
the cord of the dorsal region.
A very interesting case has been reported by
Dreschfeld.3 He had under his care a man 24 years
old, who with the simultaneous development of
double optic neuritis, which led to complete atrophy,
developed symptoms of acute myelitis, from which he
died in one month. The autopsy showed acute dis-
seminated inflammation in the dorsal and lumbar
region of the spinal cord. The brain appeared per-
fectly normal.
b. Locomotor ataxia.— The association of optic
nerve atropy with tabes dorsalis has been recognized as
an early symptom of this latter disease for many years.
A new impetus was given to the study of this asso-
ciated pathologic condition by Smeichler,4 who in
1893, published the result of his studieS( in a large
number of cases found in Professor Alt's clinic at
Vienna, and called attention to optic nerve atrophy
as an initial symptom of beginning tabes. Such
cases of optic nerve atrophy occurring in this connec-
tion must be classed as primary, for the ocular symp-
toms, as a rule, always precede any final manifesta-
tion of the disease, and there is never any history or
signs of a previous neuritis. In fact, some observers,
especially Charcot, have held that all cases of primary
optic nerve atrophy are associated with tabes of the
cord, and that, although the spinal symptoms may not
be present at the time, they will appear at some period
during the patient's life.
On the other hand, Uhthoff,'' with whom Gowers
agrees, holds that in only half of such cases is there
ever any affection of the spinal cord. According to
944
OPTIC NERVE ATROPHY.
[October 31,
Galezwoski6 about two-thirds of all optic nerve atro-
phies are tabetic, while Pelteshon7 found still higher
percentage, namely seventy-eight out of ninety-eight
cases.
The converse of this question, namely, in what per
cent, of cases of tabes is optic nerve atrophy present,
is not so easily answered. Gowers8 remarks that we
are very near the truth when we say that out of every
six cases of tabes, one will suffer from optic atrophy.
Among seventy cases which he observed in succes-
sion, of persons suffering from locomotor ataxy, only
nine had optic nerve atrophy. Voights9 among fifty-
two cases found atrophy nine times, while Erb10
among fifty-six cases, found atrophy seven times.
From the study of this subject, it will be seen that
nearly all cases of primary atrophy of the optic nerve
are associated with tabes of the spinal cord, and that
this association with other sclerotic processes in the
cord is very insignificant in comparison. That the
one is dependent upon the other is not probable, but
my own observation leads me to believe, that since
the two processes are degenerative in character, it is
simply fortuitous as to which part of the nervous sys-
tem is first attacked.
Grunn" has very thoroughly studied these points
and very properly raises the question as to the exist-
ence of independent changes in both the spinal cord
and the optic nerve.
As Gower says, "the pathologic relationship
between optic nerve atrophy and individual lesions
of the spinal cord is yet dark. The fact that the
atrophy can be very far advanced in tabes when the
changes in the cord itself are, as yet, in the very first
stages . . . makes it probable that the changes
in the optic nerve are associated with, rather than a
result of the spinal cord lesions."
That there is a close relationship, all must admit,
but no postmortems have shown any direct anatomic
connection.
Knies12 says that the process in the optic nerve
begins as a disseminated one, and that the atrophy
extends in an ascending or descending direction.
The middle fibers of the nerve remain longest intact,
and we may, therefore, infer an action starting from
the periphery. This may take place most readily at
the place where the nerve passes through the unyield-
ing optic foramen.
The gray atrophy is also noticeable in the chiasm,
tractus,-and as far as the primary optic ganglia, but
there is no direct connection with the degeneration
of the spinal cord.
Pathologic anatomy has not demonstrated the truth
of the statement made by Landois and Stirling13 that
"the discovery of the partial origin of the optic nerve
from the spinal cord, explains the occurrence of the
amblyopia (with partial atrophy of the optic nerve)
in disease of the spinal cord and especially in tabes."
The only connection between the eye and spinal cord is
found in the sympathetic nerves, which come from the
cilio-spinal center in the cervical region of the cord,
and whose connection with the iris is such that their
stimulation will produce a dilation of the pupil. But
this connection is anatomically so slight that it would
be a matter of impossibility to imagine a process reach-
ing the optic nerve from the spinal cord by means of
this route. A most excellent summary of the views
at present held were given by Gowers,14 in opening a
discussion upon "Eye Symptoms in Diseases of the
Spinal Cord before the Ophthalmological Society of
the United Kingdom."
This writer holds that optic nerve atrophy and
internal ocular paralysis must be regarded as associa-
tions, not an effect of spinal lesions. Because: 1.
Diseases of any nature may exist in any part of the
spinal cord without occurrence of ocular symptoms,
if we except rare paralysis of the dilators of the pupil
in disease of the sympathetic tract in the cervical
region. 2. The ocular symptoms which may be
absent when the cord disease is advanced, may exist
in an extreme degree, when such disease is in a very
early stage. 3. With the single exception of the
sympathetic symptoms just mentioned we know of no
anatomic mechanism by which the spinal cord can
produce the ocular symptoms.
What is true of tabes is essentially true of other
sclerosing processes in the spinal cord. It matters
not whether the atrophic or sclerotic process com-
mences first in the optic nerve or spinal cord, this one
fact remains clear that the pathologic processes show
some similarity in character. These associated ocular
symptoms are the results always of degenerative pro-
cesses, and their presence shows that the cord disease
is essentially degenerative in its nature. This is
made evident in the slow progressive character of the
spinal symptoms.
The researches of Pierret, confirmed in part by
Dejerine and anticipated partly by Westphal, have
enlarged and altered our conception in regard to tabes
dorsalis, which, in some measure, throws a ray of
light upon the association of this malady with optic
nerve atrophy.
Pierret has shown that degeneration in the optic
nerve is not the only peripheral lesion, and that the
same in the cord is not the only central change in the
disease. Often there is independent degeneration in
the cutaneous nerves, commencing in their extremi-
ties, to which the optic nerve change is analogous.
There may be degeneration at the central termination
of the optic as well as other cranial nerves, analogous
to that in the posterior columns of the cord. He
terms it "wide sensory neurosis."
What has been said applies not only to tabes in
particular, but to all morbid conditions of the spinal
cord presenting degenerative changes in the nerve
structure.
Ocular symptoms, especially optic nerve atrophy,
have long been a diagnostic sign in spinal cord
lesions, especially tabes. So frequently is this asso-
ciation present that clinicians are in the habit of
associating all primary atrophies of the optic nerve
with similar degenerative processes of the cord. From
what has been said it is evidently improper to speak
of optic nerve atrophy of spinal origin, unless we
mean its orgin is from the same source, as is the
associated lesions in the spinal cord.
The symptoms of optic nerv6 atrophy associated
with tabetic changes in the cord are said to be very
characteristic, which is true when they all exist, but
there are many cases of atrophy where only two ox
even one diagnostic sign is present, as, for instance,
in those cases of slow development of the ataxic
symptoms, and in such cases one can not positively
recognize such associated pathologic changes.
The appearance of the disc in the optic atrophy
occurring in connection with tabes, is said always to
be of a characteristic gray color instead of white, and
this discoloration of the disc has been frequently
commented upon by various writers. Especially is
the color gray, or pearly white by the indirect oph-
1SW. I
OPTIC NERVE ATROPHY.
945
thalmosoopic picture, while by the direct it is gray or
mottled, presenting sometimes according to Growers,
"a peculiar gelatinous opacity." Yet he who would
make a diagnosis solely through the color character-
istics of the disc will often err, for I have seen true
cases of tabetic atrophy, where the appearances much
more resembled the whitish than a grayish tint, and
for that reason I fully agree with Dr. Young, who
says that there is always a possibility' of inaccuracy
since expert ophthalmologists may honestly differ in
the question of definite color. Furthermore, Gowers
has called attention to the fact that gray atrophies
occur under other pathologic conditions, as, for
instance, in consequence of the post-orbital pressure
upon nerves already atrophic from other causes than
tabes.
The histo- pathologic changes in this form of tabetic
atrophy have been thoroughly studied by Uhthoff,
Growers and Leber. According to the latter author,
the microscopic appearances in the nerve show an
increase in the interstitial fibers and sometimes a for-
mation of transparent cell bodies around the vessels
and at the same time atrophy of the nerve fibers.
Another point which is noted in this form of atrophy
is the normal caliber of the blood vessels, especially
the arteries, which in other forms of white atrophies
are usually smaller in size. This, according to Knies,
is due to the fact that the original process is located
behind the entrance of the central vessels. But,
according to my experience, this picture is not uni-
ly present; the conscientious ophthalmologist
must be prepared for deviations on this point. The
disturbance of vision which occurs in connection with
tabetic atrophy, for both form and color, is another
important symptom. It has been especially noted
that the ophthalmoscopic picture is no criterion for
estimating this disturbance of sight. Cases are some-
times seen where the disc is atrophic throughout and
yet there is but a slight diminution in the vision,
while even in the majority of cases atrophy appears
before t here is any disturbance of this function what-
ever.
Yet another symptom, perhaps the first, is the con-
traction of the field of vision for both color and form,
this contraction following in this order, green, red and
white, until there is a total achromatopsia. The field
of vision for both form and color is a concentrically
narrowing one, progressing gradually until there is a
very narrowed, central circle remaining, correspond-
ing perhaps to merely the point of fixation and this
gradual narrowing may continue for years before
there is total loss of vision, and before the patient is
aware of the diminution of sight. This loss of vision
is very gradual and slow, and such cases as the one
reported by Hirschberg,'5 where vision was almost
entirely lost in eight weeks, are extremely rare. Knies1B
says that, prognostically, the color disorder is impor-
tant, because those cases in which the color boundaries
are very much narrower than those for white belong
to the rapidly progressive cases.
A central scotoma in this form of spinal atrophy is
extremely rare and when it does occur should, accord-
ing to certain writers," excite a suspicion of other
spinal lesion than tabes. The "Argyll-Robertson
pupil," or one which responds to accommodation but
not to light, has to me proven of more value in sub-
stantiating the correct diagnosis of this disease than
all others, and this symptom will exist even in the
very latest stages.
Many writers say that a contraction of the pupil is
an early symptom of tabetic atrophy, calling it a
"spinal myosis," but my observation leads me to con-
sider this sign as exceedingly transitory, finding, as a
rule, mydriasis rather than the opposite. A much
more constant symptom is the inequality in size
between the two pupils and which is far more pathog-
nomonic than a myotic condition. One question in
connection with this subject is whether a primary
gray atrophy will always be followed later by the
ataxic symptoms of tabes, as is held by some writers.
This is a question most difficult to answer, because of
the time which may elapse between the appearance
of the optic atrophy and the tabetic symptoms. In
the majority of cases it is a matter of great difficulty
to keep patients under close observation for long
periods of time, hence it is that a statistic report is
difficult to obtain.
Kahler has reported a case where atrophy existed
seven years; Charcot, a case where it existed ten
years, and Gowers one of fifteen and twenty years
before there was any marked tabetic symptoms. I
deem it unnecessary to report here the histories of
cases of this affection, because cases of optic nerve
atrophy in association with tabes dorsalis are by no
means infrequent, and none of those which have come
under my observation presented any symptoms which
are not common to all such cases. The prognosis in
such cases of optic nerve atrophy is bad and we have
yet to find the remedy which will benefit them.
o. Multiple sclerosis. — In this affection it is a mat-
ter of impossibility to consider the pathologic process
as confined exclusively to the spinal cord, for it is
well known that the sclerotic process is liable at the
same time to involve any portion of the cerebro-spinal
system, and rarely is there a limitation to one partic-
ular part. Hence, when optic nerve atrophy does
occur simultaneously with insular sclerosis in the
spinal cord the same sclerotic process will be found
also in the brain substance. My colleagues will no
doubt call your attention to this point when discuss-
ing the brain lesions, for with the majority of writers
multiple sclerosis is more frequently spoken of as
brain than as spinal lesion.
The observations of Buzzard '8 do not agree with the
majority of writers, when he says that atrophy of the
optic nerve is most frequently associated with insular
or disseminated sclerosis, next frequently in connec-
tion with fasciculated sclerosis of the posterior col-
umns (in tabes and general paralysis of the insane),
and least often with fasciculated sclerosis of the lateral
columns.
According to Knies, pronounced atrophy of the
optic nerve in this affection is rare, about 3 per cent.,
incomplete or partial atrophy about 19 per cent.
Gowers. says that atrophy occurring in this connec-
tion is very similar to that occurring with tabes, and
until the ataxic symptoms appear the diagnosis is
somewhat difficult. In pure insular sclerosis of the
spinal cord he has never seen optic nerve atrophy
occur but three times.
<l. Lateral sclerosis. — This pathologic condition
constitutes the last of the chronic sclerotic conditions
of the spinal cord with which atrophy of the optic
nerve is sometimes found associated and likewise the
most infrequent.
Gowers has never seen this associated symptom
but twice in all his vast experience. Such would
naturally be expected, since many cases diagnosed as
946
OPTIC NERVE ATROPHY.
[October 31,
lateral sclerosis have been found, postmortem, to be
due to some other lesions, hence the nervous organic
lesion must be accurately diagnosed first before we
can associate it with optic nerve atrophy. The same
writer above referred to has reported a case of com-
bined sclerosis of the posterior and lateral columns,
with gray atrophy of the optic nerve and bilateral oval
central scotoma, especially for red and green. This
latter symptom is held by some, as before mentioned,
to be a differential sign between optic atrophy associ-
ated with tabes and other pathologic lesions of the
cord.
e. Injuries of the spinal cord. — As we progress
still further into the pathologic changes of the cord
with which optic nerve atrophy is associated, we are
confronted at every turn by a yet wider obscurity in
connecting the two lesions.
There was certainly no necessity for the use of the
word "obscure" in connection with this subject under
discussion to-day, for as soon as one begins to study
the literature of the subject and his own personal
experience, he is confronted on all sides by nothing
but obscurity. There have been a few cases of optic
nerve atrophy reported, which occurred at the same
time or some time after an injury to the spinal cord,
hence it was natural to consider the atrophy some-
what in the light of a propter hoc. Ever since Erich-
sen gave to the medical world, and now the special
property of the legal profession, his brochure upon
"Spinal Concussion," this subject of spinal injury or
"railway spine" has been a fruitful field for a large
amount of medico- legal harangue.
Injuries may occur to the spinal cord without any
discoverable injury to the vertebral column (concus-
sion), yet when this latter is involved we can much
more readily discover the relationship between the
seat of injury and the spinal symptoms. In this, as
in all pathologic conditions of the cord, if optic nerve
atrophy should arise it must be looked upon simply
as an accidental association, not in any causal rela-
tion, since, as yet, no anatomic connection has been
found to exist.
Wharton Jones states that affections of the optic
nerve are frequent after injuries of the spinal cord,
but fails to add that atrophy as one of these is
exceedingly rare. What changes do occur, especially
in cases of concussion, are referable to changes pro-
duced in the sympathetic system, which presides over
the vaso-motor functions of the body.
Fowler 19 has reported the case of a man who was
thrown from a caisson during the war and was run
over, the wheel passing over the lower portion of the
dorsal region. The lower extremities were paralyzed
for a few months. His back rendered weak; he per-
spires freely and his face flushes easily; no suspicion
of syphilis. Sight failed gradually from optic atrophy
of both eyes and vision was finally lost altogther.
Caries of the vertebral column is but another form
of injury when it involves the cord. Abadie "" has
published a supposed case of caries of the vertebral
column at the base of the skull, which was accompa-
nied by atrophy of the optic nerve together with a
meningitis. So far, I have been unable to discover
in literature any trustworthy cases of optic atrophy
where such a casual relationship could be found, as
injury to the spinal cord.
/. Trophoneuroses. — Under this head medical liter-
ature does not afford us many cases of associated optic
atrophy, and I have been unable to find but one
authentically published case. This was "A Case of
Acromegaly, with Atrophy of both Optic Nerves."
reported by Dr. George Carvell :2'
Male, aged 52 ; carpenter. Father died of old age and debility,
while mother died of pulmonary disease. None of patient's
relatives had similar conditions to his own.
History : Up to twenty years ago patient had enjoyed good
health, and between the ages of 20 and 30 was able to wear
No. 8 glove. When about 30 years old he began to grow stout
and suffered from general weakness. He still continued to
work until his sight began to fail. Five years ago he was
unable to read a newspaper, and from that time has become
worse. During the last few years has suffered from shooting
pains in the arms and legs, especially in hip, knee and ankle
joints ; complains of coryza. Present condition : Is of medium
height, corpulent, and clumsy in movements ; pallor of face
and lips ; nose is large ; malar bones prominent ; occipital
tuberosity and lower jaws are unusually developed, the latter
protruding in front of upper jaw ; internal organs healthy ;
urine, orange color ; specific gravity 1030 ; urates in great abun-
dance, no sugar or albumin. Eyes : pupils of equal size and
react to light and accommodation ; right eye vision=6-60 ; left
eye vision=fingers at one meter ; no improvement with glasses.
Ophthalmoscope=marked optic atrophy in both eyes ; discs
milky, edges sharp and defined; fields laterally diminished,
especially in right eye. Color : Distinguishes blue and green ;
calls red and yellow buff.
2. Optic nerve atrophy occurring in connection with
diseases of the peripheral nerves. — According to
Knies, diseases of the peripheral nerves rarely affect
the eye unless they belong to that organ, or are adja-
cent to it. In multiple neuritis an optic neuritis
sometimes occurs, but no cases of optic atrophy have
been reported where a causal dependence could be
found. In the medulla, cases have been reported
where there occurred optic atrophy at the same time
or following certain affections of the peripheral nerves,
which have their nuclear origin from this source. In
chronic bulbar paralysis, changes in the optic nerve,
while sometimes occurring, are very rare. Galez-
woski has observed and reported a case of one-sided
optic atrophy which occurred in connection with a
chronic progressive paralysis of the bulbar nerves.
Robin cites a very interesting case from Von Dianaux,
where a rapid atrophy of both optic nerves appeared
in a man 76 years old, who was suffering from a deep
affliction. It was also accompanied by a paralysis of
the sixth nerve. The vision was entirely lost in two
months, yet, when he was again seen some time later,
the vision had increased even to one- tenth.
A full history of double optic atrophy in connec-
tion with bulbar paralysis is reported by Drs. J. W.
Barrett and P. S. Webster of Victoria, Australia :
E. C, aged 30. Symptoms began three years ago with
drooping of the left lid and turning outward of the eyeball.
When first seen six months ago the following conditions were
present : Right eye, pupil 6 millimeters ; does not react to
either light or accommodation ; no external ocular paralysis.
Vision=5-60. Emmetropic ; optic disc very pale from primary
atrophy. Left eye, pupil 7 millimeters ; no action to light or
accommodation ; paralysis of internal and inferior rectus ;
weakness of superior rectus. Vision— fingers at two feet ; con-
traction and loss of color vision ; at present fields are much
smaller. Right eye vision=5-60 : left eye vision=light percep-
tion ; paresis extended to internal rectus and superior rectus
in riecht eye and has increased in the muscles of the left sup
plied by the third nerve.
Patient's general health good and he has no other spinal
symptoms. At one time he suffered from headaches and has
had a little rheumatism. Seventeen years ago had a chancre
and was treated two months. No secondary symptoms.
Diagnosis. — Atrophy of optic nerve and independent specific
nuclear affection of the nerves implicated.
Through the kindness of Dr. H. V. Wurdemann I
am enabled to report another very interesting case:
T. G., aged 38; hack driver. Presented himself on account
of a nervous trouble in both eyes.
1896. |
OPTIC NERVE ATROPHY.
947
Examination, Right eye vision=5-12; left eye vision=5-
12: total paralysis of third nerves, oxi-opt tile branch going
to levator |ial|iehne sup. The perimeter showed Literal
(homonymous) hemianopsia for form and for white, red and
blue. There was total achromatopsia for green. By ophthal-
moscopic examination the optic discs were white and atrophic,
especially the maeuki fibers. Xyptoms of multiple sclerosis
were present also in other organs.
Leaving now those pathologic conditions of the
spinal cord and medulla, where distinct anatomic
changes could he discovered we come to the third
division of our subject and that portion enveloped still
farther in the domain of obscurity.
'.'<. Optic atrophy associated with functional neuro-
psychoses siirh as hysteria, chorea, etc. — It may be
questionable whether the discussion of this last divi-
sion belongs properly to the domain of the spinal
oord, but since the symptoms of those diseases classed
under the head of ■neuropsychoses'' manifest them-
selves most prominently in those portions of the body
whose activity are dependent upon their relationship
to eertain nerve centers in the spinal cord, it seems
but proper that the spinal cord should take a more
prominent position than any other portion of the
oerebro-spinal system.
Most of the functional neuroses are still enveloped
in obscurity, and since the etiology of the diseases
themselves are still a matter of dispute, it is but nat-
ural to suppose that any association of optic nerve
atrophy with the same affections should be still fur-
ther beyond the reach of even theoretic reasoning.
a. Hysteria. — In this disease we all know of its
multiform symptoms and of the appearance occasion-
ally of various ocular manifestations. I have been
unable to rind any authentic case of optic atrophy
whereby a relationship of the two diseases could be
established, and Growers says that in one or two cases
of hysteria optic atrophy has been observed, but that
its presence was probably purely accidental, or there
existed at the same time some organic disease, as dis-
seminated oerebro-spinal sclerosis. In fact, in all
functional nervous troubles any appearance of optic
atrophy can not be regarded as anything but acci-
dental and not causal.
Weir Mitchell. ■' in narrating a case of tabes in a
child, calls attention to the fact that in hysteric ataxy,
in contradistinction to the congenital forms, both
optic discs are gray, the arteries too small, the veins
and pupils normal, the red and blue fields typically
reversed and fields for form contracted.
Buzzard a calls attention to the fact that contracted
normal fields should make us hesitate in diagnosing
"hysteria/' even though there are no appearances of
atrophy of the optic nerve, for often in such cases a
change in the nerve, which ultimately ends in atrophy,
will subsequently show itself.
Oh the other hand, Leber25 has found objective
changes in the optic nerve in amblyopia with con-
centric narrowing of the field, which, according to
Charcot, is characteristic of hysteria. These changes
were found, by postmortem and microscope^to consist
in an occasional atrophic process in some bundles of
the optic nerve fibers in front of the chiasm, indicat-
ing that the process was peripheral, yet, so far, no
case has been reported where a complete atrophy of
the optic nerve was present. In Leber's case the
optic nerve appeared perfectly normal to the naked
eye.
ft. Chorea. — The pathology of this disease is still a
matter of dispute. Various anatomic lesions have
been found associated with this disease, but its nature
is still a matter of dispute. According to Germain
See and many others, it has a rheumatic basis, while
.) oil' roy holds it to be in the cerebro-spinal system
and is unconnected with rheumatism. The connec-
tion between chorea and heart disease has been fre-
quently noted, hence some consider those cases of
optic nerve atrophy which are found associated with
chorea to be dependent upon emboli of the vessels of
the optic nerve.
A few cases of optic nerve atrophy occurring in
persons at the same time or previously suffering with
chorea have been reported. Prom one of the assist-
ants in the neurologic department of the Manhattan
Eye and Ear Hospital I have ascertained that the
percentage of optic atrophies in true cases of chorea
is about 1 in 250.
Such cases as have been reported have all been due
to an embolus in the central artery of the retina, hence
must be traced back to some probable organic disease
of the heart. An interesting case is reported by
William Greorge Sym.26
B. M., boy, aged 17; came to Royal Infirmary complaining
of loss of sight in right eye. History : Had perfect vision up
to ten years ago ; at that age he had an attack of chorea. He
made a good recovery from this until one morning, when he
felt a sudden mist come over the right eye. At that time he
was walking ; never received any blow or injury near the eye ;
nothing unusual in family history ; neither parent is rheumatic,'
but one brother was said to have had articularrheumatism; Ex-
amination : Left eye vision=20 20 ; right eye vision=0 ; no per-
ception of light ; right eye does not converge on fixing a near
object; pupil does not contract to light; tension normal.
Examination by ophthalmoscope : Right eye presented absolute
atrophy of optic nerve, disc being dead white ; blood vessels
extremely small ; no traces of hemorrhage and exudation, and
disc, in which cupping of optic atrophy was well marked,' was
normally regular in outlines ; macula normal ; choroid coat
apparently normal ; no staphlyoma. Left eye normal in appear-
ance ; evidence of stenosis in mitral valve.
Conclusion : Atrophy of right eye due to embolus plugging
arteria centralis retina? of that side and thus cutting off blood
supply to retina, this having occurred during the attack of
chorea at the time he felt the mist over his eye.
Atrophy following neuritis almost invariably affects
both eyes, though one nerve may be more advanced
than the other. Here we have atrophy of one, asso-
ciated with a normal condition of the other. In chil-
dren, bilateral simple atrophy is rare and so is neu-
ritis, unless dependent upon some gross brain lesion.
Dr. Sym mentions the fact of Gowers having said
that there is on record only two cases of embolism of
the arteria centralis retinas occurring in consequence
of chorea. However, Argyll-Robertson has mentioned
a similar case occurring in a young lady, so that I am
confident that there probably exists other cases which
have never been reported. In the study of any sub-
ject one must be content with such published reports
as can be found in the literature, in hopes that by
the publication of these and his own personal expe-
rience, others may be brought to light which have
been resting in obscurity.
In idiopathic epilepsy, where many of the symp-
toms of this disease show some involvement of the
spinal cord, I have been unable to find any reported
cases of associated optic nerve atrophy, although
other changes, such as hyperemia, anemia, narrowing
of the blood vessels, edema, etc., of the optic disc
have been noted by various observers. In general
paralsis of the insane, which involves the whole cere-
bro-spinal system, changes in the optic nerve of
various kinds have been noted, and among them
atrophy. Bullard,18 in 400 cases of this affection,
•948
FUNCTIONAL NERVOUS DISEASE.
[October 31,
found complete blindness only three times. This
was due to a gray atrophy of the optic nerve, similar
in all respects to that found in tabes, and hence the
causative relation bears the marks here as in tabes.
In forty-seven cases Jehn2' found marked atrophy
seven times; in three the atrophy was double, while
in four it was only on one side. Writers also hold
that a slight degree of atrophy with amblyopia is still
less frequently observed than complete atrophy.
Galezwoski,3" in forty-eight cases, has only observed
beginning atrophy once, while Boy has observed it
four times among eighty cases, which were thor-
oughly examined.
In this affection, as in tabes, it has been noted that
the signs of atrophy may appear some time before
the symptoms of general paralysis, and Magnan men-
tions the fact that he has observed these changes two
to four years before the other symptoms appeared.
In conclusion would say that it is entirely unneces-
sary for us, in considering this subject, to qualify the
term "obscure," for with all our advancement in path-
ologic anatomy we are as yet unable to trace the
casual relationship of many cases of optic nerve
atrophy, and especially is this true when we recognize
that this atrophy is in some mysterious way connected
with lesions of the spinal cord.
Experience and the microscope teach us that certain
well defined chronic lesions of the spinal cord are
more usually associated with atrophic changes in the
optic nerve than certain others, but the raison d'etre is
not yet within the confines of our knowledge. Much
original investigation can yet be made in trying to
extend our knowledge of the subject.
The reports of clinic cases, especially those seem-
ingly of spinal origin or relationship, will add much
to a more thorough comprehension of the subject,
and especially with minute postmortem examinations
will be of much substantial value.
KKH'EKKNCKS.
i Gowers: The Ophthalmoscope in Internal Medicine, German edi-
tion, p. 128.
I Bower* : Ibid, p. 195
3 Goners: Ibid. p. 208.
' H. B. Young, M.D: Paper before Iowa State Society, 1895.
5 Arch, of Ophthal., Vol. xxvi, p. 277.
6 Knies: The Eye in General Diseases, p. 187.
7 Ibid.
s Gowers, n. 209.
» Berlin : Klin. Woch.. 1881, No. 89.
io Deutsch : Arch, of Klin. Med.. 1889.
n Gunn :
12 The Eye in General Disease, p. 188.
13 Landois and Stirling Physiology, p. 608.
it Gowers: Trans, of Ophth. Society United Kingdom, Vol. iii, 1S83.
is Gowers, p. 186.
16 Klin. Beobach. 1874.
II Knies, Gowers.
is British Medical Journal, October, 1898.
19 Journal of Ophth., January, 1891.
20 Gowers, p. 216.
21 Trans. Ophth. Society United Kingdom, Vol xi.
-'2 Jahrof, August, 1881, p. 315
23 Australian Medical Journal, 1894, p. 226.
U Medical News, July, 7, 1894.
» Knies. p. 217.
J6 Edinburgh Med. Journal, 1888, p. 811.
'-'V Ann. Med. Psychologiensis. 1865.
W Gowers: The Ophth. in Internal Med.
29 L'Union Med., Vol. xxi, p. 102.
30 These de Paris, 1879.
Loretin versus Iodoform. The comparative results in"" the
treatment of suppurating surfaces are stated by Dr. W. O.
Green as follows : 1. Loretin is without odor. 2. It is slightly
more stimulating, and causes more pain perhaps when first
applied, but is shortly followed by more permanent analgesic
effect. 3. It has greater antiseptic properties, and on this
account, limits and then diminishes more rapidly the local
inflammatory condition. 4. The process of granulation is more
rapid and more perfect. 5. The local alterative effect is greater,
and therefore the part requires less supplementary treatment
in the way of local applications. 6. The discharge diminishes
more rapidly. — Am. Therapist, September.
THE ETIOLOGY AND PROPHYLAXIS OF
FUNCTIONAL NERVOUS DISEASES.
Read in the Section on Neurology and Medical Jurisprudence, at the
Forty seventh Annual Meeting of the American Medical
Association, held at Atlanta, Ga., May 5-8, 1898.
BY JOHN PUNTON, M.D.
Professor of Nervous and Mental Diseases University Medical College
and Woman's Medical College; Neurologist to All Saints,
Kansas City. Fort Scott and Memphis, and Missouri
Pacific R. R. Hospitals, etc.
KANSAS CITY, MO.
In taking a retrospective view of the principal
features which characterize the age in which we live,
it seems to me none are more conspicuous and striking
than the rapid advance of medical science. In the
many hundred years of its existence no such triumphs
are recorded and no such brilliant results achieved as
those which belong to the present generation.
The principal results of such advance afford us the
means of rendering finer discriminations in classifi-
cation and diagnosis of diseased conditions, and conse-
quent enlargement of medical nomenclature, all of
which tend to increase the great mass of specific
knowledge relevant to each department. In no branch
of medicine, perhaps, are the effects of such marvelous
changes more visible and potent than those which
pertain to the science of neurology.
The vast increase of our knowledge of the anatomy
and physiology of the nervous system and the appli-
cation of this to disease has been found to be most
useful in the correction of former erroneous inferences.
Hence a complete revolution has taken place in our
knowledge of its pathology, which has also been the
means of greatly enlarging the range of its organic
diseases, at the same time gradually limiting the power
and significance of the so-called functional affections.
We find that in connection with the study of the
histology of the nervous system many other factors
were necessarily implicated. Among the most im-
portant of these was the study of their etiology and
prevention, two of the mightiest forces connected with
diseases incident to the progress of modern civiliza-
tion. To trace the intricate change of both structure
and function, as well as all the problems connected
with the prevention of such obscure neurotic affec-
tions is a task which so far has baffled the skill of the
brightest intellects of our profession. Nevertheless
much has been done in not only discovering the cause,
but also preventing their occurence by overcoming
many of the agencies which contribute toward their
production.
Nervous diseases are increasing and multiplying at
a marvelous rate, and there are physiologists who
assert that both the European and American races are
deteriorating as their civilization becomes crystallized.
This is accounted for by the increased demands of
modern civilization. Recognizing the extreme im-
portance of the subject it is right that we devote
special attention to its consideration.
It would be impossible for me to refer *to the many
causes, or the theories which have been offered from
time to time, to account for the presence of the varied
phenomena associated with the more obscure neurotic
affections designated as functional. From time imme-
morial these numerous factors have been recognized
to consist of two classes, viz.: Predisposing, and
exciting. In the former are included all the condi-
tions pertaining to hereditary neuropathic taints, while
the latter embraces all agents which tend to unduly
excite the already predisposed, or become the means
of creating certain morbid neurotic phenomena.
1896.]
FUNCTIONAL NERVOUS DISEASE.
949
One of the most important facts, which has been
clearly demonstrated of late, proves that tho entire ner-
vous system in the normal infant and child is con-
stantly undergoing marked changes in both structure
and function, and that the former is much more rapid
in its development than the latter, and that these are
largely influenced by the conditions of heredity and
environment, both in retarding as well as developing
their normal conditions. There is a marked dispro-
portion between motor and sensory cell activity in the
child and this can be easily explained on physiologic
grounds, but it nevertheless renders the child more
vulnerable to certain neuroses, such as convulsions,
epilepsy and headache.
The highest function of nerve cells is the power of
inhibition, and this endowment is the last to be
developed in the process of physiologic evolution.
Cells are capable of generating or storing up nerve
energy, beside the power of distributing it. For this
purpose the cell rails to its aid the various nerve
liliers. both afferent and efferent, and their peripheral
end organs: henee the whole nervous system becomes
subservient to the cell.
It is very plain to see that if the generating or dis-
charging functions are not subject to proper control
by virtue of their feeble inhibition that nervous
instability results, which is highly characteristic of
the neurotic diathesis and hence playsa very important
role in the production of nervous diseases. When
this abnormal lack of proper nervous adjustment or
balance is again augmented by an already existing
neurotic predisposition the individual is rendered even
more vulnerable to trivial influences.
The cell in its normal state has been shown, micro-
scopically, to present certain definite characteristics,
which when subject to its normal daily activity
gradually undergoes definite changes, both in its
ohemio and morphologic constitution. These changes
when the normal stimuli are unduly prolonged are
even more pronounced. The normal results of all cell
activity is marked fatigue, but if the activity is unduly
prolonged the cell becomes exhausted. In the former
case the cell still retains the power of its normal
reaction during a period of rest, viz., twenty-four
hours for every five hours of normal activity (See
Ttachf ord on Neuroses of Childhood, p. 98 ) and becomes
regenerated, while in the latter case the cell often
becomes unable to further respond and is literally in
a state of inanition. Hence it becomes possible to
clinically recognize three classes of cells, viz. : 1, those
which are normal or in a state of rest; 2, those which
are more or less fatigued after their normal activity ;
3, those which are thoroughly exhausted by over
activity.
In diseases of the nervous system none of us will
have much trouble clinically to recognize conditions
representing these changes, for it has been shown by
Hodge that the cells suffering from fatigue have a
close kinship to neurasthenia, and it is only plausible
to conclude that in functional diseases we may at first
have similar cellular changes of greater or less degree,
which may ultimately give rise to degenerate changes.
Excessive mental and physical application would
therefore seem to be potent factors in the causation of
diseases.
In a recent article by L. H. Mettler on " Work and
Worry," (New York Medical Record, Sept. 7, 1895)
the writer says in summing up: "Work and worry, 1
therefore take it, are not baneful in themselves, not
even when carried to excess, but the monotonous
unbroken continuation of the excess is exceedingly
injurious."
Professor Erb of Heidelberg (See Medical Record.
March It), 1895), in a recent address seemed to regard
the feverish activity of the age as a symptom of dis-
ease. " The over-work, over-crowding, over-stimula-
tion, increased use of tobacco and alcohol, together
with excessive railway travel, with all its nerve-jarring
motion," he thinks all tend to produce a loss of nerve
tone, which ultimately results in neurasthenia, which
is a refined expression of hysteria and hypochondriasis.
Commenting on this, the British Medical Journal
says: "While this may be true, there is another side
to the picture, in that there is a greater knowledge of
the subject, a greater tendency to freedom of exercise,
to the freedom from strict conventionality, to the free-
dom from ailments that come from healthful surround-
ings, and that worry, not, overwork, is the danger of
the age, and this danger arises from decreasing and
deferred marriage."
Worry is an exceedingly potent factor in the pro-
duction of nervous diseases and persons suffer far more
from the effects of worry of things that never happen
than those which actually occur. We live in constant
anticipation of danger, and this brings with it a con-
tinued and prolonged mental state of anxiety. The
effects of such monotonous routine on the nerve cells
is self-evident.
The most conspicuous and important cause and that
which underlies all the rest in producing and propa-
gating all forms of nervous disease, is the transmis-
sion through successive generations of that peculiar
bodily condition known as the " neurotic diathesis."
This manifests itself by nervous instability and defec-
tive innervation of the organic functions, materially
influencing the normal development of the nervous
system in the offspring and makes itself felt by a con-
stant tendency to degenerative changes in the nerve
elements, rendering the subjects of it peculiarly liable
to break down under strain that would not affect per-
sons inheriting a different constitution.
Jonathan Hutchinson says (See " The Pedigree of
Disease" ) : "I would define a diathesis to be any bodily
condition, however induced, in virtue of which the
individual is through a long period, or usually through
the whole life, prone to suffer from some peculiar type
of disease." With this definition I fully agree. The
same author also says: " Some diatheses are inherited,
others are acquired. Of some the effects are perma-
nent or constant, of others they are transitory or
recurrent after intervals of health. The term should,
however, never be applied to any condition of health
which is expected to pass away and leave no trace, for
the idea of persistence in some sense is always
implied. On the other hand, we do not confuse
diathesis with dyscrasia, for whilst the latter definitely
implies bad health, the former only denotes proclivity
and may be used when its subject seems perfectly
well." Hence, we learn that the individual diathesis
may present itself in every degree from a slight weak-
ness to a very pronounced morbid tendency.
The term temperament is also liable to be con-
founded with diathesis in its more simple manifesta-
tion, hence the term temperament is used to designate
the " sum total of the physical peculiarities of an
individual exclusive of all definite tendencies to dis-
ease." Thus says Hutchinson: " To distinguish be-
tween temperament and diathesis we may say that
950
FUNCTIONAL NERVOUS DISEASE.
[October 31,
the former is a matter of physiology and the latter of
pathology,"
Inherited diathesis is more often, than not, entirely
latent at the time of birth and is susceptible of aggra-
vation, or in some cases of cure in after-life. " Such
alternations are not possible in the constitutional
peculiarities which we name as temperament."
I have thus dwelt at length on these terms in order
to overcome a very common source of useless argu-
ment on the part of the profession by failure to com-
prehend the full significance of certain technic, terms.
A certain predisposition or tendency to disease is
transmitted from parent to child, and often is the only
responsible agent for the presence in the offspring of
any one of the various neuroses, such as hysteria,
chorea, neuralgia, migraine, epilepsy, together with
more serious organic spinal and cerebral diseases,
including insanity.
We do not presume to explain all the intricate
details concerned in their genesis, or even the patho-
logic changes occurring in the tissues and cells, as the
laws which govern the transmission of hereditary
traits are generally unknown, but the number of inher-
itable deviations of structure and function are endless.
These abnormal conditions of inheritance are often
the result of imperfect growth, defective nutrition,
incorrect habits, injudicious education and modes of
life of the parent, the general effects of which tend to
lower the normal standard or health and are marked
by having a special injurious influence upon the gen-
eral development of the nervous system, impairing its
functions and exhausting its specific energies. The
morbid products resulting from such deterioration are
readily transmissible from parent to child and furnish
the germs which in the offspring establish the neuro-
pathic constitution. They are the seeds which may
or may not remain latent for years, but if subject to
the stimulating processes of the educational period,
or the excesses incident to society life they rapidly
mature and strengthen until they manifest themselves
in some serious form of nervous disease.
The same causes which produced the deterioration
in the parents are often allowed to have full sway in
the child, already predisposed, and then a still greater
deterioration is liable to occur. Then again, Rachford
(See "Neuroses of Childhood") shows conclusively
that bacterial products are also important factors in
the causation of nervous diseases by their direct
poisonous action on the heat centers, thus producing
fevers, more especially in children.
The same author also states that arterial anemia and
venous congestion produce nervous symptoms by their
influence on the vaso-motor system of nerves, thereby
weakening the inhibitory centers and rendering more
excitable the various reflex functions of the medulla
and spinal cord.
This leads to malnutrition of nerve elements, result-
in an impoverished condition of the blood. This mor-
bid blood state presents itself in two forms, viz., innu-
trition and malnutrition ; the former representing a
quantitative change or reduction in all the nutritive
elements of the blood, while the latter implies a qual-
itative change in the essential constituents of the
blood. Clinically these conditions are recognized as
the various forms of anemia. Such conditions are a
very common feature of nervous disease, as by far the
greater majority of all patients presenting themselves
for treatment are found to be below body weight and
anemic.
Another common source of nervous diseases is
reflex irritations of all kinds. Recent experiments
prove that chronic reflex irritation can produce very
marked changes in the nerve cells of the spinal gan-
glia, and this becomes a potent source of nerve insta-
bility, more especially in children and young girls by
virtue of their special vulnerability.
It is plain that children born of neurotic parentage
inherit a weakness, and as growth and development
takes place, are peculiarly liable to become victims of
nervous disease in the formative periods of their life,
especially at the physiologic crises, such as puberty,
pregnancy, lactation or menopause.
This neuropathic diathesis may not only be congen-
ital, but also acquired, and it can be produced in
persons born of unhealthy parents by the excessive
use and abuse of agents such as alcohol, opium,
tobacco, tea, coffee, excessive study and physical
strains of all kinds.
Education. — All education should be governed and
based upon an intelligent recognition of physiolc >gic
laws of growth, and a proper adaptation to them.
There exists in every child certain laws of growth
and corresponding capacities, the proper development
of which depends, to a large extent, upon the general
bodily constitution of the individual. The natural
law of progressive development is as gradual in its
operation as the growth of trees and flowers, and if
during its formative period, it unduly exercises or
stimulates any organic function, the body will never
be brought to the highest state of development of
which it is capable.
By thus interfering with the natural sequence of
the evolution of the body, we disturb the normal
equilibrium of its various parts, and thus seriously
mar the harmonious relation which should exist
between the mental and physical constitutions. In a
well developed organization the normal equilibrium
of its every force perfectly balances, and. to use the
words of an eminent medical physiologist, "There
should be no power in a higher center or ganglia to
compel a lower one to do more than it is fitted or is
capable of doing."
Clouston says: "The fatigue following their normal
use should be absolute, in themselves, to compel periods
of rest, and yet we all know that it is counted a great
power and achievement for any man or woman to pos-
sess the power of being able to work, think, feel or wake.
not according to their innate capacity, but according to
his or her wish, or the imagined necessity of the occa-
sion. The exercise of such a power is really a want
of nervous adjustment, and a physical imperfection
not to be desired or encouraged; indeed, it is a very
dangerous possession to those who inherit a neurotic
diathesis." The functional activity of the brain and
nervous system is established at different epochs, and
perfected at different rates. By cautious stimulation
we bring it to its highest development, but by undue
haste and excessive use we ruin its normal equilibrium.
In the stimulating process of the educational period
the cerebral cortex, which is the seat of all conscious
mental action, undergoes a change of function cor-
responding to its excessive stimulation, and which, if
long continued, culminates in a preponderance of
nerve action, which is highly characteristic of the
neurotic diathesis. The nervous system, with the
brain as its controlling center, rigidly obeys the natu-
ral law of evolutional precedence, and its functional
energies are as gradual in attaining their full force-
L896. ]
FUNCTIONAL NERVOUS DISEASE
951
ami capacity as any other special apparatus of the
hotly. Anything, therefore, which has a tendency to
force those powers and capacities, interferes with its
normal equilibrium.
It has become the custom of the present day for
school and college professors to prescribe for their
pupils the study of the more intricate problems
relating to their special departments, believing this to
he the one thing needful to accomplish any and every
purpose in life. Thus the ancient Roman law of
physical excellence is completely reversed, and with
us intellectual superiority and mental achievement
take precedence of all turns ami 'duties of life. In
the effort to excel, every other part of the organism
becomes unduly subservient to the intellect, and the
natural physiologic law of evolutional precedence is
wholly ignored.
To-day the instruction of children is on purely busi-
ness principles, without regard to their physiologic
strength or capacity. The largest amount of knowl-
edge is to lie acquired in the shortest time possihle.
Rapid progress and intellectual supremacy is the
highest test of a desirable school, and the teachers
that are most in demand are those who are the most
earnest and zealous in their work.
A magnetic power of inspiration is the qualification
par excellence in a teacher, and that teacher is most
in demand who can secure the greatest brain tension
during the allotted hours of study.
Intellectual achievement is the goal which all are
seeking, irrespective of age, sex, mental or physical
strength. The home management of children also
contributes its share to this brain tension. Late
entertainments, reading exciting works of fiction.
social pleasures and strains of all kinds tend to bring
about in them morbid growth.
Nervous excitement is at a premium, and therefore
prevails in the homes, school, church, and indeed
every relation of life.
A recent writer says it is a question whether the
competitive examinations, as now carried on in schools
and colleges, are not doing more to enervate the mind
than to strengthen it. Those who attain the highest
h mors are generally found to be diseased.
Intellectually speaking, every mind has a track of
its own. To place all children on an equal mental
footing, when they reach a certain age, is a violence
to nature which brings its own equivalent in physical
and mental deterioration.
We recognize that certain causes produce certain
effects, and we can see how the future generations are
influenced by the good health and the proper mode of
living of the present, and we must use every means
at our disposal toward influencing those with whom
we come in contact to study the laws of health, to
reform their habits, and instruct in all matters that
pertain to hygiene, and further in every way a more
complete general knowledge of the human organism,
and the laws and forces which govern it. The short
duration of life and the habits and modes of living
of many persons can be attributed solely to their pro-
found ignorance of themselves. The consequence of
their habitual neglect and ignorance entails upon
their progeny untold misery, much of which might
be prevented by a more intelligent understanding of
themselves.
The neurotic diathesis and its baleful influence
upon the rising generation is not as well understood
by the masses as it should be. The reason for this
may be explained to some extent by the prevailing
false system of medical ethics which condemns any
attempt on the part of the members of the profession
to popularize purely medical topics. The relation of
the physician to society is not only that of a thera-
peutist, but also a conservator of the public health.
The full mission of a cultured physician is not com-
plete if his educational attainments are solely bestowed
upon the medical fraternity, and those coming within
his range for treatment. In addition to his strictly
professional duties he owes a duty to the public. In
the past the attention and efforts of the profession
have been too exclusively directed to the solution of
problems connected with the cure of disease, and the
great importance of its prevention has not been suffi-
ciently recognized.
The duty of every man who deals with his profes-
sion as a noble and humane science, is rather to point
out the methods of preventing occurrence and eradi-
cating, if possible, latent constitutional defects, than
to confine his attention to the treatment of its active
manifestations. The vast amount of preventable dis-
ease which is filling thousands of premature graves
and destroying the hopes and happiness of both the
young and the old in every community of our land,
certainly demands the earnest attention of the medi-
cal profession.
So long as we remain indifferent to this great and
growing evil, just so long will nervous disease con-
tinue to increase and swell the rate of premature
mortality. Several of the more progressive members
of our profession both in Europe and America, now
recognize the great need of a more general dissem-
ination of medical knowledge among the masses, and
are advocating its adoption as one of the most pow-
erful agents in the prevention of the spread of ner-
vous diseases.
" Any work," says Dr. Mann, in his recent work on
physiologic medicine, litbat we, as physicians, do
toward influencing the public to study the laws of
health, to reform their habits of living, to promote
the use of baths, to encourage temperance, ventilation
and due exercise, and to further a more complete
knowledge of the human organism and the laws and
forces winch govern and regulate it, and in diffusing
a knowledge of all the means necessary for the preser-
vation of good health, will produce its exact equiva-
lent of results in the prevention of disease. We shall
thus develop in the masses an intelligent, self-helping
character, tending to robustness of body and robust-
ness of mind."
Another favorable field for a more thorough prac-
tical drill in matters pertaining to mental hygiene and
the study of physiology is the public school. I am
not unmindful that some attempt has been made in
this direction; but it is merely an attempt.
Very few pupils (and shall I say principals of
schools) realize the full force of one of the first
principles of physiology, viz., that within certain
limits the growth of an organ is in proportion to its
exercise, and that all excessive exercise is followed by
a corresponding depression. If this law were thor-
oughly understood and obeyed there would be less
headache and disease attributed to the public school.
In cases where the neurotic constitution is inherited,
the morbid inheritance is not a mysterious and neces-
sarily fatal doom, certain at some time to overwhelm
its victim. It is purely a physical defect, which can
be remedied and even cured. We may not be able to
952
FUNCTIONAL NERVOUS DISEASES.
[October 31,
explain fully its intricate pathology, but we know it
manifests itself in a great many distressing forms of
nervous diseases, and the wise physician, after recog-
nizing the morbid taint, anticipates the pathologic
conditions likely to arise, and therefore does not
neglect to advise means necessary for its complete
removal.
The nervous temperament predominates in Ameri-
can women, which is now recognized to be due to
some trophic lesion. This being readily transmissible
from parent to child, if we are to avoid its continuance
in the young we must resort to such methods as will
produce a better type of physical constitution and
mental stamina. Hence the great indication in the
prevention of nervous diseases, is to harmonize the
physical and mental organizations in such a manner
that their correlative forces equally balance.
Marriage. — In every individual two streams of
ancestry mingle, each furnishing its own specific
mental, moral and physical characteristics. As a
general law, the stronger character predominates, but
never so strongly as to completely overcome the
weaker. Pure blood should certainly be the desire
and lofty ambition of every individual. The promul-
gation that " the iniquities of the fathers shall visit
the children, unto the third and fourth generation,"
can not be gainsaid. Our country to-day stands in
need of more healthy men and women, and one way
to secure these is by wisely regulating matrimony.
Every marriage acts upon society in a fourfold rela-
tion, by first affecting the conjugal p^ir, second their
progeny, third their relatives, and fourth the commu-
nity in which they live.
I believe in certain cases, marriage should be gov-
erned by law, for in the light of facts, who can truth-
fully argue that it is nobody's business whom we
marry"? Habitual governmental regulation of mar-
riage comes with higher grades of civilization.
The Spartans regulated marriage with sole refer-
ence to the good of their republic; men were sub-
jected to severe penalties if they married too early or
deferred it too late. Unhealthy children were destroyed
as unfit to live. (And here allow me to say that such
a movement is already projected in this country.)
Every care was used by the Spartans to insure the
health of infants and children. But instead of study-
ing the interests altogether of the state and nation,
we, as a Christian people, should view it from a more
humane and philosophic standpoint.
Generally speaking, no special effort is now being
made on the part of parents and guardians to choose
proper society for their wards. Those easy American
habits which permit, unchecked, the free social
mingling of the young without regard to the laws of
heredity, often result in marriage and intermarriage
of consumptives, epileptics and other diseased and
defective individuals, while the less demonstrative
insane and more demented specimens of humanity
have also free access to all classes of society. Even
the known vicious and morally perverse often form
unions in the more devout families. We know too
well the sad import of such thoughtless and ill-assorted
marriages; especially, therefore, is it our duty to
impress upon the minds of parents the necessity of
wisely informing their children on these matters, lest
ignorance prove a future source of evil. The respon-
sibility of the medical profession in relation to the
coming manhood and womanhood of our race can not
be overestimated.
The American, however, is accustomed to regard his
individual rights'to the exclusion of all others, and
the conviction that a man can be what he wills to be,
is lodged in the most intimate fiber of his being.
Such an idea, however, is erroneous, especially when
subject to the laws of heredity, and the results of its
misapplication are self-evident.
Physicians who have children growing up under
their professional care should endeavor to have them
well developed physically, even if it be at the expense
of their education. We too often sacrifice the consti-
tution for what is deemed educational necessities.
The prime necessity in our children is to have
plenty of bone, blood and muscle, with an accurate
balance between the physical and the nervous system,
and if something has to be sacrificed let it be their
education, and not their physical health.
The children of neurotic constitutions should be
kept fat from birth, and when they arrive at the school
age their brains should not be forced.
As a general rule, these children are precocious,
hypersensitive and possessed of a vivid imagination.
Their parents and friends admire their quickness to
learn, and urge the teacher to push them forward to
the fullest extent, that they may out-distance all com-
petitors. All such precocity should be discouraged
and condemned, as it is said by the best authorities to
be a sure sign of biologic inferiority.
Dr. Porter of St. Louis, in his studies of school
children states " that mental ability is on the average
greater in large children than in small children of the
same age."
In some recent research in the schools of Kansas
City I found, however, that the precocious children
were invariably below body weight and poorly nour-
ished.
Our local city authorities are too prone to ignore
medical aid in their sanitary and educational legisla-
tion. No class of persons are better prepared to give
useful advice in such matters than the scientific phy-
sician. More especially is this true of education, and
a wisely selected medical board should be appointed
in every city to inspect the public schools at regular
intervals and determine which children should and
which should not be allowed to study the more diffi-
cult branches.
It is nonsense to regard the child's age as the crite-
rion of its mental strength and capacity. It seems
far more logical and scientific to allow the child's
height and body weight to govern this. Definite
standards of weight should be fixed for every age and
height, and every school boy and girl having a ner-
vous diathesis, whether it be congenital or acquired,
should be weighed at regular stated intervals, and if
found to be below the fixed standard they should be
compelled to forego some or all of their studies and
be placed under proper treatment until the loss in
body weight, at least, is recovered.
The first evidence of mental deterioration is mani-
fest in a loss of body weight. Children of nervous
constitutions should be taught to lead regular and
systematic lives, and the necessity of developing fat
and muscle, as well as the dangers attending such
neglect.
It is outside the province of the responsible duties
of a principal of a school to determine which child
shall, and which shall not study hard. It needs a
skilled physician or neurologist.
Such a plan would also prevent much undeserved
1896.]
DEGENERACY; ITS CAUSES AND PREVENTION.
953
censure of the principals ami teachers by the parents
complaining that their children had been unnecessa-
rily retarded in their grades.
We must be more active and alert in this direction,
and not until we, BS a body, take a more decided stand,
can we hope to successfully stem the rapidly advanc-
ing tide of both organic and functional nervous
diseases.
If it be true that the physiologic nerve cell is lim-
ited in its capacity, and that its normal activity
results in the expenditure of a certain amount of
Eoroe whioh, when discharged, presents changes cor-.
responding to fatigue, and that a certain amount of
rest is not only capable but necessary to restore or
regenerate its normal function, in the absence of
which, changes corresponding to its inanition occur;
then, clearly, the duty of the physician is to use all
possible means to secure the needed rest for all mor-
bid conditions of the nervous system in which nervous
irritability and instability are the chief clinical crite-
ria, and those which form so great a part or the sub-
jective phenomena of the purely functional neuroses
and psychoses.
DEGENERACY; ITS CAUSES AND PRE-
VENTION.
BY ARTHUR ROWLEY REYNOLDS, M.D.
rUDDUIT OF THE HOARD OF STATE COMMISSION >B1 OF PUBLIC CHARITIES
OF ILLINOIS AND LATE COMMISSIONER OF HEALTH
OF CHICAti".
Practically all recent books and essays upon the
.subjects quote statistics to prove a startling increase
of insanity, of criminals and of pauperism. They
either state or intimate that the race will soon be over-
whelmed by the number of persons of this character,
unless something is done to prevent them from pro-
creating their miserable kind.
Before we accept this gloomy conclusion, we should
study the matter and see if the statistics may not be
faulty. We may also, with profit, study the condi-
tions that are in the way to prevent those who are
normal in their development from continuing so
indefinitely through succeeding generations, as well
as to recognize and study what influences are at work
to counteract degenerating tendencies.
There is ground for hope that some of the apparent
increase shown by statistics is not real, but due to the
greater care in the census enumeration of later years.
Moreover, insanity and other mental defects are now
treated as a disease and misfortune, and more fre-
quently come to light while formerly they were too often
considered a blemish and disgrace and hidden from
view. We may draw some consolation, too, from the
fact that latter day segregation of many of this class
will prevent their reproduction and favorably impress
the figures of the future. Nevertheless, we recognize
that whatever arguments there may be against the
correctness of the statistics of the question, we yet
know that the dependent individual is most numerous
and a great and ever increasing burden to the s tate.
Economic conditions, new to our generation, have
arisen with the vast application of steam and elec-
tricity and have played a part in the enormous growth
of cities. The furious passion for money pervading
all classes, and the sway its possession gives in busi-
ness, in politics, in society, in religion, in courts of
law, in legislative bodies, is leading us into danger.
Great wealth has led to a desire to still further
enhance its power, and giant combinations have been
formed, enormous enterprises undertaken, all of which
gives a demand for men at wages and destroys the
individuality of small concerns, while the fall in the
price of produce has made farming unprofitable.
These conditions make rural people turn a more will-
ing ear to the promise of shorter hours and regular
stipend, and they swell the stream setting toward the
cities. The farmer forgets his freedom and his inde-
pendence and recalls it too late, when he finds him-
self a mere cog in a great machine in the city, and no
hope of relief when his employment is gone. He is
then in poverty and hope dies within him. He is
tempted or driven to do evil and may never be able to
reform. He has not his native trees for company and
inspiration. There are no flowers to cheer; no calm
for reflection ; no quiet for study. Children born and
reared under such circumstances start the race of life
with a serious handicap.
No argument is needed to prove the power of hered-
ity. It is seeji every day in the development of the
trotting horse, whose breeding is regulated with such
nicety that the height, weight, color, speed and even the
cash value of a colt can be told, almost to a certainty,
before it is born. The state undoubtedly should
make use of this knowledge to perpetuate and up-
build the race, as an offset to the increasing tendency
that density of population, through vice and disease,
makes toward degeneracy.
In our own country we suffer from the additional
burden of imported dependents. Indeed, it has been
said that foreigners furnish one-eighth of our popula-
tion, one-third of our paupers, one-third of our crim-
inals and one-third of our insane. It is true, I believe,
that we have a law of Congress to prevent the impor-
tation of dependent persons. So long, however, as
the conditions of life are easier in our own country,
the degenerates of Europe and Asia will find their
way to our shores.
A striet medical supervision of all marriages is
strongly advocated by some writers, as a safeguard
against the increase of this class of persons. It is
unquestionably wrong for degenerates of a pronounced
type, and those who are dependent, to propagate their
kind, and there can be little doubt that the state has
a right to step in and restrain the weak or the willful
of these classes, through the application of medical
knowledge, to the case of every applicant for a mar-
riage license; but whether or not this will cure the
evil is a question that should be carefully studied. It
is not the purpose of the writer to dampen the ardor
of those who would regulate the evil by law, on the
contrary to urge it and freely avow belief that steps
should at once be taken, beginning at the marriage
license windows of our country, to prevent the union
of those who, by the almost unerring law of heredity,
will reproduce a brood which will be a charge upon
the state or a burden to society. Proper laws, intelli-
gently enforced, will directly restrain a great many.
It is our belief, however, that their chief use will be
to form a focusing point, from which knowledge shall
radiate. We believe further that it is only through
the proper education of the masses that those unfit to
reproduce their kind will be restrained. And we
believe, moreover, even though it be true that the race
is degenerating from one generation to another, where
the conditions of life are unfavorable, it is equally
true that there is a constant regeneration going on
where the conditions of life are favorable. Laws
alone can not cope with the question. Rules and
954
DEGENERACY; ITS CAUSES AND PREVENTION.
[October 31,
statutory enactments are of but little value, unless
backed by a healthy public opinion. But there are
agencies constantly at work to counterect the degen-
erate tendencies that should be considered before we
despair of the race.
While it is necessary to look evils squarely in the
face, it seems wrong to enumerate them too often; to
discant too loudly upon the ills that beset us, or to
see only the dark side of the picture. Human nature
is prone to brood over the sorrows and trials of life.
The uncanny things are too apt to be kept prominent
and we are too likely to forget the cheery, bright and
sunny side of affairs. The world contains more sun-
shine than shadow, more joy than sorrow, more smiles
than tears, more righteousness than sin, more good
than evil, more charity than theft. Adam's sin is
repeated still, but there is an ever-progressive spirit
of the Nazarene pervading every day life.
It is well to prevent the degenerates and depend-
ents from procreating, but it is infinitely more import-
ant to correct whatever there be in our civilization
that drifts toward degeneracy. Human beings
crowded together so close that the home loses its indi-
viduality, its sanctity and its seclusion; or that
vitiates the air that is breathed; that makes artificial
feeding of old or young necessary ; that pollutes the
drinking water or in any way hampers physical
growth. Whatever there is that blunts the moral
sense, that whets the appetite for alcohol, that excites
the passions or gives opportunity for licentiousness
must be wrong. All these evils are fostered by too
close living in tenements, whether located on the
boulevard or in the slums, and just as sure as a cloudy
sky portends the coming of the storm, such condi-
tions lead on directly to drunkenness, crime, idiocy
and insanity. Whatever is being done, or whatever
may be done to make country life profitable and pos-
sible is an aid to segregation and must therefore be a
step in the right direction. The trend of population
toward large cities is not a good omen for the race
and calls loudly for legislation that will turn the cur-
rent back again. The great and rapid growth of our
cities, that receives so much admiration and is quoted
as such signs of prosperity and greatness, will ulti-
mately result in a plague upon humanity if some
wisdom does not appear and set the tide the other
way. Can it be that the crowding will go on till the
curfew will be necessary to segregate the young in their
homes, that the evil of street association, as a school
of vice and crime, will be lessened? It is well to
pause and inquire where is the profit, in the end, of
clustering of industries in large cities, if sweater's
dens must be the accompaniment. It may be well to
consider whether or not those having knowledge of
medical sanitation and sociolgy should not have a
larger place in our legislative assemblies. It seems
that their valuable knowledge should be used in
deciding our laws of immigration and other legisla-
tion relating to the welfare of the race, while it would
lessen the too common tendency to decide such grave
questions upon the sordid demands of barter and
exchange.
We have with us now and always have had splen-
did and powerful agencies, operating with vigor, as a
stay to crime and a help to humanity. Chief among
these is the church through all her divisions and
denominations, for whatever the differences as to
church government may be, their teachings are as one
on the question of morality and right living.
I wish, however, to speak more particularly of an
agency that is paramount to all others in its influence
toward the regeneration of the race; an agency that
has already done a vast amount of good and that
promises, if properly backed and intelligently fol-
lowed, to solve the problem; an agency that strikes
almost at the root of the evil ; an agency almost divine
indeed — for it is none other than the new woman. I
do not refer to the new woman of newspaper creation
— not the woman who hopes by copying the follies of
man or his wearing apparel, to emancipate herself.
Not the woman who would wage a war of strife and
contention with men. She is not new — she is as old
as civilization itself.
The real new woman understands that there is
within her an inherent and natural power to command
the actions of man and sway him for good or for evil.
She realizes her power ; and that hers is the enor-
mous responsibility to shape and control the destiny
and perpetuity of the race. She realizes that it is her
high and divine privilege to be the mother of man-
kind. She realizes that it is among her first duties
to equip herself, mentally and physically, to graci-
ously bear the joys and responsibilities of maternity.
She realizes that there is no loftier mission on earth
than to fashion the character and train aright the
intellect of the growing child. She realizes that the
budding boy is the coming man. She realizes that it
is a crime for man to grow so grasping as to enslave
his fellow creatures of either sex. She realizes that
the good things of this earth are God's bounty and
intended for all his children alike. She realizes that
the mad race for wealth, with its rapid concentration
''makes countless thousands mourn." She realizes that
the frenzy for gold is every day enhanced by the
demands of some of those of her own sex, as they strug-
gle to reach the summit of fashion and social power.
She realizes that the mother is largely responsible for
the traits of the child, other than those of heredity;
and that it requires no more time to learn and love the
ways of purity, than to learn the ways of vice and
iniquity. She realizes too that proper training is the
best preventive of perversions of every kind. She has
established and is all over the country conducting
branches of the greatest institution in American his-
tory— I refer to the kindergarten.
The kindergarten has reversed the old order of
things, when the daughters of the poor and unedu.
cated, and perhaps the vicious, were made the com-
panions, the guardians and instructors of children in
the homes of the rich. Now young ladies of good
position in the world graduate from universities to take
positions in the kindergarten, qualified to mold, fash-
ion and discipline the minds of children of the hum-
blest, beginning with the child at the very dawn of
its intellectual development. Devotees of this new
cause deem it a privilege to work all day in the creche,
caring for children of mothers who must toil for daily
bread.
The new woman believes it is a perfectly normal
desire to want to wash and dress, to entertain and
caress a helpless babe, even though it be of lowly
birth, and if the babe should be her own, she counts-
the moments she is forced to be separated from it.
She feels pity toward her married sister who dwarfs
her maternal instincts, or denies herself the boon of
motherhood, or who shuns the society of the children
she has unwillingly borne. The new woman sees in
life upon a farm better discipline for the mind tham
1896.]
THE PSYCHO-NEURAL FACTOR IN SURGERY.
965
van be found in the greatest counting room. She
sees that the same farm can do more for the physical
development of men and women than any manual
training school in the land. She sees that the music
oi the birds inspires deeper thoughts of God and
Nature than all the grand organs in the universe;
thai the sighing of the wind through the trees and
the patter of the rain on the roof inspire the loftiest
emotions.
The new woman is she who founds homes and set-
tlements among the poor, and successfully conducts
them. She consoles the needy in their trouble and
feeds them when they are hungry. She encourages
the idle to work and helps them to secure it and if
necessary she instructs them how to perform it. She
founds and conducts useful societies, classes, schools
anil clubs of every soli among the poor. Her spirit
and her genius build fresh-air sanitariums, floating
hospitals, and in the summer time sends from the
alleys and slums the debilitated weaklings to the green
fields, the sylvan groves and the babbling brooks, to
drink in the inspiring delights and breathe the pure
air of the countryside. I will not attempt to enumer-
ate all the institutions she is working through, for
they are well nigh countless and daily multiplying.
When the new woman's hand is sought in marriage,
she is likely to have inquiry made as to the young
man's health and his morals, rather than inquiry as
to his bank account. What his wealth in the great
distinguishing characteristic that elevates him above
the animal world — his manhood, his judgment, his
intelligence'^ It is through the new woman that
society will eventually come to apply the same rule
and exact the same standard of morality for men that
it does for women and eventually elevate him to her
plane.
The new woman has learned the terrible cost in
pain and suffering to her sex and her offspring that
so frequently comes from a union with dissolute men.
She has learned, through the advance of medical
science, that the harvest reaped from a sowing of
'"wild oats'' in her husband's youth is too often one
of disease and death to herself and a pitiful inherit-
ance to her child.
Higher education through schools, great universi-
ties and libraries is not enough. Kindergartens
should be founded in sufficient numbers to reach all
the young. The new woman will multiply the kin-
dergartens and reach the degenerate or way ward before
habits of thought or action are formed and do for the
infant mind all that training and example can do.
Through the present work of the new woman and
its future development must come the public knowl-
edge and the public sentiment that will lead to the
necessary reform to let daylight through the slums;
to raze the unsanitary tenement to the ground; to
pull down the towering buildings that harbor miasm
in their shadow, that will make it possible for human
beings even in cities to live on the surface and not be
forced either into the air or under the ground.
Through this direction of forces, cottages will be
built for all so that man can return to his primal condi-
tion . Even the very poor will not be denied free access
to God's sunshine, pure air, green grass, the shade of
trees or the beauty and fragrance of the flowers.
A vast number of holy influences are constantly at
work that realize the necessity of proper care and
training of children while they are young. Let us
hope it will go on till our philanthropists and our
State legislatures will see the economy of laboring
more for institutions for the young; for if they be
trained aright, it surely means economy in hospitals,
asylums and prisons.
•'!<> Washington Street.
THE PSYCHO-NEURAL FACTOR IN
SURGERY.
islppl
Mint)
BY C. H. HUGHES, M.D.
lieu. I a! the Meeting of tin- Misslssi
ut St. 1'aul,
>pl Valley Medical
18911.
Association
1'liESIDKNT OF THK FACULTY AND PROFKSSOR OF PSYCHIATRY AND
NF.URl'OH.Y, BA.RNX0 MEDICAL COLLEGE, ST. LOUIS; HONORARY
PILLOW IIK1TI8H MEDICO-PSYCHOLOGICAL ASSOCIATION,
AND OF THE CHICAGO ACADEMY OF .MEDICINE.
ST. LOUIS. MO.
As a thorough knowledge of general and special
pathology is essential to the soundest surgical judg-
ment as to the propriety and necessity of an operative
procedure, so is a knowledge of the nervous system of
the patient and the relation of his nervous system to
the local disease found essential to proper diagnosis
and prognosis. The time is coming and now is when
the surgeon should have wide neurologic and psychi-
atric knowledge in order to avoid fatal mistakes and
to most successfully practice his art. The manner in
which the necessity of a grave operation is announced
may to certain psychologically unstable constitutions
pre-determine a fatal issue, or it may give to a doubt-
ful issue a possibly favorable result. There are some
constitutions so neuropathic and psychopathically
predisposed that the shock of such an announcement
would precipitate a crisis of mental alienation, and it
were better that the proposed operation should be
abandoned than insisted upon under such circum-
stances, or that the patient should be gradually
approached and prepared by cautious speech and
suitable precursory, reconstructive and tranquil-
izing neurologic treatment. Some patients before
being operated on should be made almost entirely
over in the tone of their nervous systems and some
should be let alone, tranquilized and made comforta-
ble and allowed to die in happy euthanasia. What,
for instance, is the use of exsecting a far-advanced
cancerous uterus after the cachexia has long persisted
and the nerve centers have become irreparably neuro-
pathic and the neurasthenia has become profoundly
irreparable from the prolonged pain and insomnia.
The rational process would be to stop the pain and
insomnia, correct as much as possible the neuratrophia
that exhausts and makes the patient's last days
comfortable by neurologic and antiseptic treatment
and the best surgical suggestion without the knife.
In fatal surgical results the reputation of operative
surgery suffers often because overlooked neuropathic
conditions were at fault.
In my judgment the previously applied skill of a
neurologic clinician would postpone many operations
indefinitely which are now fatally performed, and
properly prepare other cases for the surgeon's knife
and a successful surgical issue, which are now doomed
when the operation is decided upon, because condi-
tions of endurance of the operation are not in the
nerve centers of the patient.
The cause and effect of psychic shock in different
patients are not always considered as they should
be by either physician or surgeon. The possible evil
effects of words and acts at the bedside or before an
operation that tend to paralyze or even produce a
paresis of hope are not always duly considered. The
956
THE VALUE OF VACCINATION.
[October 31,
surgeon who bluntly announces to his patient, after
revealing the necessity for the knife and having all
things ready, "now I am going to operate, the pro-
ceeding may kill you, but you would be better off dead
than alive as you are, let us hope for the best," must
have a strong-nerved, brave subject to not be some-
what depressed by such an announcement, and such a
depression before a further depression of vital centers
by chloroform or ether, even in the strongest nerved
is not good clinical practice. It doeth not "good like
a medicine." Such a procedure may have the virtue
of candor to commend it, like the candid announce-
ment by the physician that his patient is likely to die.
If he is saved it will be "by the skin of his teeth."
Recovery is not the rule when such premature prog-
noses are announced, sometimes because the patient
could not have recovered by reason of an incurable
malady and sometimes of the vitally depressing effect
of the speech that destroys hope and removes its buoy-
ant influence from those vital nerve centers that influ-
ence the metabolisms of the organism and the assimi-
lative processes of organic life and reformations of
tissues.
In our intercourse with patients, medical or
surgical, the untoward and often fatal influence of
depressing mental suggestion on the patient should
always be avoided. Hope, that springs eternal in the
human breast if we do not interfere with it, is itself a
buoyant medicine, and faith in the physician or sur-
geon is therapeutic power that should never be rudely
shattered by us. Candor is to be commended, but it
can be too bluntly displayed and often is, for the wel-
fare of our patients. Besides, the physician's or sur-
geon's judgment may be at fault. It often is. There
is more vital resistance and power of repair in the
patient than the medical or surgical attendant thinks
or knows. Vital' power is not always a definitely
measurable quality, depending as it does, upon ances-
tral factors in the upbuilding of the constitution —
the cerebro-spinal axis and the sympathetic system of
the patient — of which we are never fully cognizant.
The patient should always have the benefit of this
doubt in our prognostications before him or to him.
The little surgeon who pompously displays his tray
of instruments before his trembling patient, and to
his woful, wondering mind descants upon the opera-
tion he is about to perform and the chances of recovery
or displays a nonchalant, unfeeling mien, acts in an
unprofessional manner and does not increase his
patient's chance of getting well quickly. And the
great surgeon who takes his patient into the operat-
ing room and places him while conscious on the table,
himself with instrument in hand, while white-aproned
attendants gather around the victim, approaching
with sponge and bottle and instruments and appli-
ances of the impending operative procedure, is not so
wise a surgeon and does not so fully consider the
effect of depressing psychic influences as he who
chloroforms the intended subject of an operation in
another room or in the same room without these
depressingly suggestive influences.
Had I continued the active practice of surgery
(of which I once had, as you know, ample clinic
experience) I should never vaunt the implements of
my art before my patient, at least before he should
recover from the operation, nor anesthetize him in
the presence of any depressing influences. Where
practicable, I would for purely elevating psychic effect,
begin the administering of the anesthetic in the most
cheerful room I could prepare: I would drape its walls
with suggestions of hope and inspirations of courage.
I would have nothing about me at that time sugges-
tive of blood. I would cheer him so far as I might
without falsity; mention similar cases, if I could, that
had undergone his approaching ordeal successfully and
let him take his operating couch and anesthetic as "one
who lies down to pleasant dreams." I would proceed
thus because I am a psychologist and have added
something more than operative skill to previously
acquired medical knowledge. I would be as tender
with him about inflicting the mental pain of dreaded
apprehension as "one who would not needlessly set
foot upon a worm.'" I would do thus, not only because
it would be the dictate of tender feeling, but because
a sound psychology and psychiatry enjoin it.
THE STATISTIC EVIDENCES OF THE VALUE OF
VACCINATION TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Read before the American Medical Association at the Jenner Centennial
Celebration, held at Atlanta, Ga., May, 1896.
BY EUGENE FOSTER, M.D.
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE AND STATI MHH
CINE AND DEAN OF THE FACULTY OF THE MEDICAL DEPARTMENT
UNIVERSITY OF GEORGIA, AUGUSTA, GA.
(Continued from page 911.)
Now to a circumstantial examination of the charge of trans
mission of syphilis by vaccination.
The medical literature of every civilized nation has been
ransacked for the purpose of substantiating this charge. ''The
London Society for the Abolition of Compulsory Vaccination,"
ever active in seeking and disseminating all information detri-
mental to the cause of vaccination, has put together all cases
of alleged vaccinal syphilis which its active investigators could
hear of. Here is a copy of the original paper from that soci-
ety, received by me in 1884."
VACCINO SYPHILIS.
The following is list of authenticated and published cases'"'
of transmission of this one disease alone :
Lancereaux has published the following cases of vaccino-
syphilis :
Bv Lecoq 2
BvGalligo 14
At Rivalta 46
By Trousseau 1 By Monell 1
By Maronni, 34
By Devergie 1
Bv Cerioli 40
By Tassant 46
By Surgeon B 10
BvHiibner 8
ByMarcolini 40
By Vlani 2
By Chassaignac
By Herard .
By Adehisi.j. . .
By Monell. . . .
Total 258.
To these I have added the following :
At Lebus.
By Hutchinson. . . .24
ByT. Smith 1
By Hulke 1
Bv Oldham K
18 By Kuqua r>2
Bv Cullimore. ... 1
In Algiers 68.
By Depaul 19
By Sebastian 1
By Collins 2 I
Total 478
M. Briquet appropriately says : "A competent observer and
a complete observation, reported with such details as render
the statements capable of being checked by the reader, are
ndispensable requisites for establishing the reality of an ordi
nary fact in medicine ; and if for establishing an ordinary fact,
how much more when the facts alleged are confessedly so rare,
and so contrary to all previous experience, as these must b&
admitted to be." To correctly investigate the question of vac-
vinal syphilis, we must first determine the question of inocu-
lation of the lesions of secondary syphilis. Experiments by
competent observers have demonstrated that condylomata,
ulcerated tubercles, psydracious pustules of ecthyma, pustules
of acne, mucous patches and the blood of syphilitic subjects,
may be inoculated into the constitution of the person not
already infected with syphilis. Now, it is an admitted princi-
ple in the teachings of syphilography that the secretions from
pathologic lesions, not themselves syphilitic, although occur-
ring upon the bodies of syphilitic persons, do not contain the
virus of syphilis, unless admixed with blood. Gonorrhea upon
a syphilitic patient reproduces gonorrhea by inoculation, and
not syphilis ; and the same is true of chancroid. All of these
lesions of secondary syphilis, except the blood, may be elimi-
nated from this discussion, for we can not imagine how any
other of them could contaminate vaccin matter in its rational
propagation.
41 From my paper before American Pub. Health Assn.
»"' These cases have been fully examined, and a brief analysis oJ
some of them will be presented later on.
1896.]
THE VALUE OF VACCINATION.
967
[a the effort to inoculate a healthy person with svphilitic
blood invariably successful; and, if not, what proportion of
success will attend these efforts? The following presents the
results of nil such efforts to be found detailed in the most
authoritative works upon syphilis:
meuter
N'nmher of
inoculations.
With
suecess.
Without
success.
Anonymous
tine . . .
surgeon
of the
l'ala-
9
1
1
5
1
4
:
n
a
i
i
l
i
fl
Waller
tiillicrt.
1
Tliir\ . . .
4
8
20
Total.
44
7
87
Thus, gentlemen, we see that where intelligent physicians,
bold enough to test the matter, after deliberately and carefully
endeavoring to produce syphilitic infection by inoculating
healthy subjects with syphilitic blood, failed in 84 per cent, of
all such efforts, only those efforts were successful where, as by
lYllizzai'i. the anonymous surgeon of the Palatine, Waller and
others, large surfaces were denuded and syphilitic blood in
targe quantities kept for many hours to the denuded spots.
It is. of course, impossible in this discussion to enter into an
extended or minute examination of the cases of alleged trans-
mission of syphilis by vaccination. The following embraces
nearly if not the entire list of reporters of vaccinal syphilis, as
given in the best works upon syphilis:
Name of Reporter.
Number Vac-
olnated.
Ceriol
Tassini . . .
>n B. .
r.
Uonell -
Mareolinl . .
Via ui . . . .
q. . . . .
Uallten . . .
At Rtvalta .
rrouss
ne . . .
Herald.
Bio . .
Totals . .
HI
tV4
21
U
1
411
-'
•2
14
1)8
S
84
1
1
1
Number In-
fected,
Number not
Infected.
40
46
19
8
1
40
2
•2
14
M
4
:14
1
1
1
2
fi
18
5
17
1
52
hutchinson's
CASES.
a
Of Cm
Number Vac-
cinated.
NumlHT In-
fected with
Syphilis.
Number not
Infected with
Syphilis.
12
M
18
I' n known
Unknown
Unknown
10
9
1
1
2
1
1
17
Third
12
Fifth . .
Sixth . .
Unknown
Unknown
It is absolutely necessary, in an "investigation of alleged
cases of vaccinnal syphilis, to ascertain, 1, whether we are
really dealing with syphilis : 2, whether, if this be so, the
syphilis is not hereditary and a mere coincidence or evolution
of vaccination ; 3, whether, if it be acquired syphilis, this has
not some other origin unconnected with vaccination, or attempt
to vaccinate; 4, whether, if the acquisition of syphilis be rea-
sonably traceable to vaccination, or attempted vaccination,
there is evidence, direct or presumable, that the so-called vac-
cination had been done from a genuine vaccin vesicle, and that
the products of that vesicle had not been mixed with some of
the inoculable products of syphilis. Not till this was settled
would any question arise about admixture of blood. The inter-
est and importance, after all, of the cases in which vaccination
is alleged to have communicated something beside its own
infection, turn entirely upon whether the vaccination had been
performed with unmixed lymph of genuine vesicles — vesicles
about which no competent person would make a mistake."
Seaton (Handbook of Vaccination) appropriately says: "It
must obviously be impossible to discuss at length, within such
limits as in a general treatise of this kind could be allowed,
all the cases that have been cited as evidences of thecommuni-
cability of syphilis by vaccination. The most satisfactory-
course will be to examine carefully three or four cases, typical
of the kinds of proof which have been advanced of this occur-
rence."
The following is an extract from his review of alleged cases
of vacinal syphilis: "1. An epidemic of syphilis reported by
Cerioli as having occurred in 1821 (inquiry made eight months
after its orgin. The account given of this epidemic is of the
loosest kind ; it was not proved, or even alleged, that the child,
from whom the lymph supposed to have been the origin of the
outbreak, was taken, had ever had syphilis) ; 2, another epide-
mic in 1841, seen also by Cerioli (investigated likewise after a
very long lapse of time), the child from whom the lymph was
taken never had syphilis ; but it was said that the year before
his father had had syphilis."
Surgeon B. : "It appears that in a town in Germany twenty-
four people belonging to different families, were in February,
1849 (some on the 13th, some on the 14th, and some on the
loth), revaccinated, as they supposed, by him. There is no
statement of vaccin vesicles having been produced in one of the
cases ; but at the end of three or four weeksU'. e., the ordinary
period of incubation of syphilis), ulcerations of a sypnilitic
character began at the points of inoculation in nineteen out of
twenty-four persons operated on, and these were followed in
due course by constitutional syphilis. Here was syphilis, but
no vaccination. What could have been the cause of it? The
vaccinator who was inculpated asserted that the operations
were all done with lymph from a child who was fort et sain,
and who, having been vaccinated on the 4th of the month, had
regular vaccinia. We shall see immediately how far this
statement was borne out ; but it must first be noted— and is an
illustration of the want of precision generally attending these
accounts— that we are nowhere distinctly told whether the so-
called vaccinations, or any, or which of them, were done direct
from the child, or whether the stuff taken from it might not
have been collected on glasses, points, or tubes. For all that
appears to the contrary, there was at least the possibility of a
mistake (such as has happened many times with regard to the
matter of inoculable diseases) of taking lancets, or glasses, or
tubes charged with one kind of inoculable matter instead of
another. But, assuming that the matter used came from the
source indicated, what was the state of this source? Though
it was said to be from an infant fort et sain, and that this was
svrabondamment d6montri par plusieurs timoins, a different
account was given by other witnesses ; and a doctor, who saw
the child on the 21st of February, a week after the lymph was
taken off, when of course no suspicion of anything wrong had
yet arisen, testified to the existence of some erythematous
eruption, which was said to be like syphilitic roseola, and it
died on the 24th, three days after his visit, of hydrocephalus.
But, more importantly, what was the state of its arm? It
turned out that, according to an eye-witness, there was on the
eighth day of the child's vaccination not a vestige of vesicles,
aucune trace de boutotis, and yet two days later, the acconnt
tells us, several vaccinations were performed from it and lymph
continued to be extracted from it for two days."
"In Hiibner's case— a case of malpractice — there could be no
doubt of some children having been syphilized, but no investi-
gation of the circumstances was made till eight months after-
ward, and the account of the so-called vaccinations (in most of
which it is quite certain, and admitted, there had been no proper
vaccine effect), was only what could be got from the statements
and recollections at that interval of time, of the mothers."
Trousseau's case : "A young woman was under treatment in
the wards of the liotel-dieu for a uterine affection, apparently
of a non specific character, at a time when there were some
small-pox cases in the hospital, and wished to be revaccinated.
This was done by three punctures on each arm, from a healthy
child at the time, and which, for anything that was ever known,
never exhibited any taint. Four children who were vaccinated
with its lymph at the same time with this young woman, wont
through vaccinia in its regular way and never had any subse-
quent syphilitic affection. On the young woman's arm slight
papules only arose, and the revaccination was looked upon as
having failed. She remained in the hospital a month after
vaccination, fully the time necessary for the syphilis, if there
had been any imparted by the vaccination to have incubated,
and she went out without anything the matter with her arms.
At the end of another month she attended at the hospital for
treatment of her uterine complaint, and showed them two sores
on one of her arms, the character of which was not at first
recognized, but which turned out to be undoubtedly syphilitic.
It was not known at the time, but was afterward ascertained,
that she was a young woman of very loose character. Now,
assured by no one who knows in what extraordinary situations
chancres have been met with, such as the cheek, the corner of
the eye, in every sort of situation in which there could not be
any, and never was any, suspicion of vaccination, can say this
was a case entirely free from fallacy as to the source of the
syphilis."
958
SOCIETY PROCEEDINGS.
[October 31,
"The occurrences at Rivalta, to which so much interest has
attached, were of a different kind. In 1861 there occurred in
this village a very remarkable syphilitic epidemic. Three sim-
ilar epidemics are said to have been noticed in different places
before in 1814, 1821, and 1841— and if we include an account
given (though not till some years after the occurrence took
place) by a Dr. Marone, a fourth in 1856. It is certainly very
singular that all these epidemics should have occurred in Italy,
and none resembling them met with elsewhere. Whatever
their origin, the facts are of the deepest interest ; a number of
children affected at one time with syphilis ; these infecting
their nurses and mothers ; the mothers infecting their hus-
bands ; the children infecting one another by the act of kissing,
or by the spoons used in feeding ; and whole families infecting
one another by merely being huddled together in confined and
crowded dwellings. For it must not be supposed that only
persons who were at the time the subjects of vaccination were
the sufferers. Various epidemics of this kind, quite as singu-
lar and quite as inexplicable, have occurred under circum-
stances entirely unconnected with vaccination, and indeed
before vaccination was heard of. * * * In the five epide
mics specified in the beginning of this paragraph, a vaccinal
origin was alleged ; and this was made in the Rivalta case the
subject of careful inquiry by a scientific commission. . Unfor-
fortunately, however, the inquiry did not take place till four
months after the outbreak ; and as in no single case of the
children said to have been syphilized by vaccination had any
application been made to a medical man on account of the con-
dition of the arm. facts and dates on the exactitude of which
everything depends had to be got as they could at such dis-
tance of time from the testimony of the villagers, for the most
part ignorant and prejudiced. Under these circumstances, it
is not surprising that differentconclusions were arrived at ; and
though Dr. Pacchiotti and the other commissioners, after a
most careful and painstaking inquiry, reported themselves
satisfied of the vaccinal origin of the disease, Sperino, who
also went to Rivalta and there investigated the circumstances,
and treated some of the cases afterward at Turin, was equally
satisfied that their origin was independent of the vaccination.
The story, as regards the vaccinal origin, is this : A child
(Chiabrera) apparently in good health, but really incubating
syphilis, was vaccinated with some lymph obtained in a tube ;
this child's arm was used on the tenth day for the vaccination
of forty-six children, and one of these forty-six children, named
Manzone, again on the tenth day furnished lymph for vaccinat-
ing seventeen children. Of these sixty-three children, forty-
six had within two months a disease considered by the com-
mission to have been syphilis — the syphilitic symptoms having
manifested themselves in some cases within ten days, and as a
mean at twenty days from the vaccination. Now, in explana-
tion of these events, can we admit that the matter taken from,
Chiabrera's arm contained the contagion of the constitutional
syphilis, which at these intervals of time the children mani-
fested? Not, assuredly, unless we are prepared to give up all
we have been taught as to the incubative period of constitu-
tional syphilis. For it would have required from three to five
weeks for that disease to manifest its primary symptoms. [Lee
gives the period of incubation at from three to seven weeks.
Rollett gives a mean of twenty-six days, and out of a large
number of cases there was only one case in which it was under
fifteen days. In four cases, in which the inoculation was by
blood, the minimum was twenty-five days and the maximum
thirty- five. As recent testimony on this point, it is proper to
state that Hutchinson says, "The period of incubation, prior
to the first specific induration, will usually be five weeks." a]
But if this teaching has been erroneous and true constitutional
syphilis can produce its primary symptoms within ten days,
then, indeed, we can understand how, if syphilitic matter was
mixed with the lymph, either in the original tube or through
the lancet employed in Chiabrera's vaccination, an irregular
vesicle might result, such as that stated in Sperino's experi-
ment with soft chancre, which Baumes and Viennirs held to
contain the two viruses mixed. It must be remembered that
we have no reliable account whatever of what was the sort of
vesicle or result on Chiabrera's arm, from which the so-called
vaccinations were done. From such a result as Sperino's ex-
periment affords, a careless man might, a careful man would
not, take what he called lymph ; and I have very little faith in
the proceedings of anyone who evidently habitually used tenth-
day cases. We might not really, then (that is, supposing the
incubation difficulty got over, which it must be, or else the
Rivalta cases as connected with vaccination fall of themselves)
have any difficulty in accounting for the propagation of syphilis,
for hard and soft chancres would fall in the same category.
*< Rollett's Traili des Maladies Vfniriennc.
But we should have more hesitation as to whether vaccinia
also might be communicated at the same time ; and, in fact,
in what degree the Rivalta children who were syphilized were
also vaccinated, it is impossible to say. I can quite conceive
that if the vesicle on Chiabrera's or Manzone' s arm was all
like that produced in Sperino's experiment, some spurious
vaccin result might follow in some of those vaccinated from
them. There is certainly no satisfactory evidence of any of
the children ever having had regular vaccinia."
{To be continued.)
SOCIETY PROCEEDINGS.
Chicago Academy of Medicine.
The regulur meeting of the Academy was held Oct. 15, 1896.
Dr. W. Xavier Sudduth acted as Chairman.
The subject of "Infantile Paralyses" was discussed from
various specialistic standpoints. Dr. Rosa Engelmann opened
the debate by first exhibiting a a porencephalic brain, obtained
from a babe seven months old upon whom a craniectomy was
performed by Dr. Alexander Hugh Ferguson. She showed
photographs of the asymmetric head, site of the operation and
pathologic intracranial cysts, as well as specimens of the brain,
spinal cord and vertebral canal, from which the nerve exits
and plexuses are demonstrated, for it was at first believed that
these were absent, impossible as such a condition seemed. The
cord itself presented no cauda equinus and was undeveloped.
Dr. Engelmann then discussed the
CONTAGIOUS AND INFECTIOUS DISEASE ETIOLOGY OF INFANTILE
PARALYSIS.
That a relation between the infectious and contagious diseases
to cerebral, spinal and terminal palsies does exist is undisputed,
but what that relation is, is only explained in general terms. No
answer is given as to the reason of such comparatively uniform
action upon nervous structures by such widely differing bacterial
or noxious agents as syphilis, tuberculosis, smallpox, typhoid
fever, scarlatina, purulent affections, pneumonia, measles, diph-
theria, etc. Why a poliomyelitis or neuritis should be a sequela
to these diseases on the one hand, and, on the other, be an
independent entity of a presumably specific origin, is inexpli-
cable. Of course, we recognize the immaturity and conse-
quent instability of infantile nervous structures as a predis-
posing factor, but a wider and more accurate knowledge is
dependent upon future neurologic research and accomplish-
ment. A discussion by the members of this Academy upon a
history and specimen of a case of porencephalia in a babe
seven months old may throw some light upon this evident con-
genital condition so often associated with cerebral palsies and
acquired infantile cerebral palsies.
The brain was obtained after a craniectomy done for me by
Dr. Ferguson. There was a microcephalic state, as shown by
the photographs, but I should have recognized other patho-
logic conditions and known of the uselessness of surgical inter
ference. O However, had no operation been done, no postmor-
tem could have been obtained, and a valuable specimen and
knowledge of great service to me would have been lost. The
history is as follows : Parents Russian ; father healthy ; no
history of nervous diseases, alcoholism or syphilis. Maternal
grandparent consumptive ; mother undersized, with a pro-
nounced dorso-lumbar kyphoscoliosis and rachitic pelvis.
Measurements made by Dr. Rachel Yarros, as follows : bi iliac,
21 c.c. ; anterior superior spine, 20 c.c. ; external conjugate,
11 c.c. ; anterior conjugate, 9 c.c. The very prominent syn-
chondrosis was found about two inches to the left. Married
at 20. Three children born at term and without difficulty,
with the assistance of a midwife. No miscarriages. Two
children died at the ages of four and eleven months respec-
tively of pneumonia and summer complaint. One living healthy
child of 3Jj years; subject to fright and hardships while car-
rying the youngest child : was sick in bed three months ; com-
plained of pain in the side ; could not walk. She also gives a
description of sudden and copious white discharge, in the
nature of a flooding, possibly the breaking of an abscess during
this state. Labor was prolonged, and the physician told the
husband it was a cross presentation. Instrumental delivery.
Child asphyxiated for twenty minutes and to all appearances
dead. The father said the baby's left arm was broken, because
the physician put it in a splint. At the seventh month the
child was brought to me, showing marked asymmetry of head
with a deep left parietal depression, occipital depressions and
elevations — in fact, great irregularities and absolute cranial
synostosis. Some facial asymmetry, but no observable facial
or general paralysis. History of convulsions since its second
L896.]
SOCIETY PROCEEDINGS.
959
week, increasing in frequency and severity until almost con-
stant, beginning Wltfa the ocular and facial muscles and beoom
Ing general. Strabismus: blind and seemingly deaf; idiotic.
Perfect body development without other anomalies. The child
came to me with a history of cranial deformity from forceps
injury, but upon noticing the synostosis, I said that the condi-
tion was congenital, and there was a conformation of the skull
cap due to intrauterine pathologic cerebral conditions. The
operation and postmortem proved the correctness of this view.
On chiseling, the bone was found much hardened and thick-
ened, especially at the sutures. A cyst was noticed and thought
to be hemorrhagic by the operator, but the child was so col
lapsed that the opening of it was left for a second operation.
The child died two hours after the operation. The brain was
removed, and I now present it to you for inspection. The cord
pulled up from the canal was at first thought to be without
spinal nerves. A postmortem was made later which demon-
strated their presence. The organs were found normal. The
only demonstrable pathologic condition was enlarged mesen-
teric glands, which looked tubercular. There were adhesions
of the coverings to the brain, and these and the cerebral tissue
when fresh showed decided inflammatory changes, and pointed
markedly to a fresh meningo encephalitis. The sclerosis and
atrophy were doubtless due to previous intrauterine lesions.
As to the cause, the question of pressure during pregnancy
can be excluded bj reason of the transverse position. It does
not seem plausible that labor or forceps pressure produced this
condition of sclerosis and atrophy that must have been pre-
ceded bv intra uterine acute inflammatory conditions of long
standing, and due possibly to a pus infection in the mother
previously mentioned, instead of developmental reversion. The
future may show that teratologic conditions have their origin
in active fetal disease.
Were there prenatal circulatory disturbances, hemorrhages
or inflammatory disease of the middle cerebral artery, or oblit-
eration early in fetal life, or an intrauterine polio-encephalitis
producing this terminal condition of sclerosis and atrophy?
Was the synostosis due to the agenesis or vice versa? Ziegler
inclines to the former view. He says : " In partial defects the
skull cap is most often closed, giving rise to free spaces filled
by fluid." Was this agenesis due to active intrauterine dis-
ease or to developmental arrest or perversions, or both?
SM'lllLlTU ASPECT O J INFANTILE PARALYSIS.
Dr. Wm. L. Baum— The syphilographer is not frequently
called upon to see cases of infantile paralysis. When it is con-
sidered that between 75 and 80 per cent, of the children suffer-
ing from hereditary syphilis are born dead, or die before the
end of the third month, we can readily see how few cases of
hereditary syphilis there are in comparison with the supposed
number. The lesions of the nervous system in these cases dif-
fer but slightly from those in the acquired type, and many of
the so-called pathognomonic signs of syphilis are not, strictly
speaking, syphilitic manifestations, but symptoms of a dyscra-
si:v which may differ widely from syphilis. The specific lesions
most frequently met with in infantile paralysis are most often
confined to the cortical substance and meninges of the brain.
However, occasionally there are lesions occurring in the bony
capsule which indirectly affect the nervous manifestations, and
then the lesions also found in the medulla and cord. The spe-
cific disease itself gives rise to congested conditions which are
subsequently followed by atheromatous conditions of the cere-
bral arteries. These are frequently followed by the develop-
ment of smaller thrombi or miliary aneurysms. The formation
of these thrombi or aneurysms, especially the rupture of the
latter, gives rise to various paralyses which are met with in
children. In those cases which are due to the formation of a
thrombus the paralysis is gradual in its onset. Where it is due
to a rupture of a small miliary aneurysm, the paralysis is more
sudden. In both classes we have excellent results from treat-
ment—rapid resorption and retrogressive changes to the nor-
mal. In the cases, however, where there is a true sclerosis,
also accompanied at times with the formation of a thrombus
or rupture of a miliary aneurysm, there is softening and a true
destruction of nerve tissue. These cases show no improvement
from treatment.
The general practitioners and syphilographers are frequently
misled into an erroneous diagnosis of the syphilitic origin of
infantile paralysis upon the strength of the results obtained by
therapeutic measures. It is too frequently forgotten that
iodids and mercurials are of great benefit in a great many dis-
eases of non-specific character, and when these individuals
recover as a result of the administration of these anti-syphilitic
remedies a diagnosis of syphilitic disease is made. This is cer-
tainly a mistake, for if there are no other corroborative evi-
dences of a syphilttic disease present, we are not justified in
calling the symptoms, which may have a widely divergent ori-
gin, syphilitic.
Founder has reported a number of cases of syphilitic paraly-
sis, in one of which there was enlargement of the lumbar ver-
tebra, followed by paralysis of both legs. This condition sub-
sided rapidly upon the internal administration of anti-syphi-
litic remedies. While syphilis as an etiologic factor in infantile
paralysis occupies an important place, care should be taken
not to put too much reliance upon such a diagnosis without
more apparent corroborative evidences of the disease being
present.
OBSTETlilC ASPECTS OF INFANTILE PARALYSIS.
Dr. C. E. Paddock— There are only two forms of paralytic
affections occurring in childhood which are common : one of
these is known as spastic infantile paralysis and the other as
infantile paralysis or essential paralysis of children, or scien-
tifically as antero-poliomyelitis. One lesion is in the brain,
the other is in the cord. Of the cerebral palsy we have prob-
ably more to do in so-called birth palsies. Injury to the new-
born during parturition with subsequent paralysis is more fre-
quent than one is led to believe without referring to the liter-
ature upon the subject. Rupture of a blood vessel in the
brain or the meninges in a child results from different causes,
but in the obstetric sense by the application of some extraneous
force. A contracted pelvis, protracted labor, or instrumental
delivery is equivalent to a traumatic injury to the skull and
brain, that is, the result is the same, leading to a hemorrhage,
usually into the meninges. Protracted labor and not the for-
ceps is the cause of greatest danger to the child's brain. First-
born children are most apt to ernffer, owing to the fact that first
labors are, as a rule, harder and longer. Gowers found that
in twenty four cases of meningeal hemorrhage seventeen were
first-born.
The apoplexy of the newborn is, according to Osier, McNutt
and others, one of the chief causes of the bilateral hemiplegia
or paraplegia occurring at birth. The fact that protracted
labor is often the cause of paresis in the newborn is now gener-
ally acknowledged. Whatever may be the cause of the delay
the head is being compressed upon in all its circumference,
the vessels become engorged and a rupture of some of the
smaller vessels of the meninges necessarily follows with their
consequent result. What percentage of cases of paralysis in
the newborn is the result of injury at birth I am unable to say,
but I honestly believe that many cases which are referred to
other causes are really birth palsies. We have been taught in
former days to delay the use of the forceps until such a time
as danger is imminent to either mother or child, and here is
where a great mistake has been made when the labor has been
so protracted that the heart indicates impending asphyxia ;
then, as rule, we are too late, for the child will either be born
dead or born asphyxiated, resuscitated only to live a few days
or a few weeks. One should not wait until such a time has
arrived, but be able to know just the proper time to apply the
forceps, and this can only be accomplished, unfortunately,
through a great amount of clinic experience. The forceps is
in the most skilled hand a dangerous instrument, but its
dangers decrease with the skill which is acquired in its use. A
student goes out into the world to practice never having applied
the instrument, and in his ignorance he does an incalculable
amount of mischief. The principal danger in the use of the
forceps is in the high operations. Thanks to Tarnier, we have
the axis- traction forceps, which has reduced the terrors of a
forceps operation to one of extreme simplicity. The neglect in
the treatment of breech presentation affords us many examples
of infantile paralysis. The traction which is often resorted to
to terminate a breech results in an injury to the cord with
the subsequent poliomyelitis. Too much traction upon the
over-congested cord and compression upon the after-coming
head with hemorrhage at the base of the brain into the cavity
of the arachnoid causes an effusion into the same cavity lower
down, resulting in a spinal paralysis.
What is the treatment of these conditions? A more thorough
knowledge of obstetrics is necessary. No branch of medicine
requires such a thorough knowledge of medicine as obstetrics.
Emergencies are continually arising which call for prompt
action. Most any physician considers himself capable of con-
ducting an obstetric case, and why? Because he has been
taught that 96 per cent, of the cases terminate favorably. In
this 96 per cent, however, cases of infantile paresis are not con-
sidered that can often be traced to his negligence. I have a
fair idea of the operation for inguinal hernia, still I do not con-
sider that I am justified in operating upon such a case ; neither
do I consider that every man simply because he has an M.D.,
to his name is justified in conducting an obstetric case. So
soon as physicians realize that obstetrics is a science ; that pro-
9(50
PRACTICAL NOTES.
[October 31,
traded labors are dangerous ; that the forceps is an instru-
ment of traction, not compression, so soon will the cases of in-
fantile paresis due to mismanagement of obstetric cases be
diminished.
CLINICAL ASPECTS OF INFANTILE PARALYSIS.
Dr. Daniel R. Brower— The clinic-aspects of the several
forms of infantile paralysis are so familiar to every Fellow of
this Academy, that I will not reiterate them on this occasion.
I have here a series of photographs which I think will supple-
ment very well the admirable paper and specimens presented
by Dr. Engelmann. These photographs are those of a family
of infantile cerebral palsies. The mother of these children is
a very robust woman, who does her own work and takes care
of these helpless children. She is 31 years old and never had a
miscarriage. The parturitions of these several children were
all normal. The father is 49 years of age, thin, and very ane-
mic. He has been a painter since the age of 14 : has had no
attacks of lead colic or other evidence of lead poisoning : has
no history of syphilis, but has had numerous attacks of malar-
ial fever, and has some stigmata of degeneration. There are
four children, all boys, three of them are diplegics, the other
one is well with at least the ordinary intellectual and physical
capacity of a boy of three and a half years. The three chil-
dren show the classical symptoms of mental defect— rigidity,
contracture, exaggeration of reflexes and clonus, choreic and
athetoid movements, and a slight amount of atrophy. The old-
est child is 10 years old. The two photographs, one front and
the other back view, show the characteristic attitude of the
disease. ThiB child became diplegic at about two years. The
next child is 51.; years old and became diplegic about the same
time. The next child is 3% years old and is well. The young-
est child was 15 months old when this picture was taken about
one year ago, and has since become diplegic. There has been
no convulsion in any of the cases and the development of the
/ paralytic symptoms has been gradual. I am watching the
cases with great interest, hoping after a while to be able to
unravel the mystery that thus rendered helpless three out of
four children, the offspring of parentage fully equal to the
average of their station.
eye symptoms in infantile paralysis.
Dr. Wm. H. Wilder — There are so many conditions of the
brain in children that may give rise to paralysis of the muscles
of the eye or to paralysis of the optic nerve, if I may so term
it, that one can only touch upon them briefly. I shall first
speak of congenital defects of the muscles of the eye. We are
all familiar with cases of ptosis in children, but we are not so
familiar with congenital paralysis of one of the extrinsic mus-
cles of the eye. A short time ago I presented such a case to the
Chicago Medical Society,in which there was congenital paralysis
of the external rectus. The girl was 22 years of age. There was
no abductive power of the right eye, and this, according to the
statements of the mother, had been the condition since birth.
Such cases are rather infrequent. It can not be positively said
however, that the paralysis is always due to some central
lesion, such as defective growth of the nucleus. We have just
as much right to assume that it is due to defective develop-
ment of the muscle. Two cases are on record, reported by
Seiler in which, on examination, he found absence of the supe-
rior rectus and the inferior oblique muscle of the right eye,
and of the inferior oblique of the left eye. In the second case
there was absence of both oblique muscles in the right eye,
and in the left eye absence of both oblique muscles and the
superior rectus. It is possible that the difficulty is due either
to total absence or to defective development of the muscle.
However, in most cases of congenital ptosis that we see there
is probably some defective growth of the nuclei in the fourth
ventricle that innervate these muscles. In other words, they
should be considered nuclear palsies of congenital origin.
When we come to acquired infantile paralyses we reach a
large field. Almost any disease that will bring about paralysis
of the extrinsic or intrinsic muscles of the eye in adults may
. occasion it also in infants. Trauma may be the cause of paral-
ysis of any of the muscles of the eyeball either directly or
because of a blood clot pressing upon some of the nerves. A
tumor in the orbit or immediately back of it would give a sim-
ilar result.
One of the most common causes of paralysis of the ocular
muscles in children is either pachymeningitis or leptomenin-
gitis ; and naturally we should expect such paralyses to be
more frequent with inflammations affecting the meninges of
the base of the brain than with those confined to the convexity.
Consequently ocular paralysis is a common occurrence in
tubercular meningitis, and may be one of the early signs of the
same. The child may show a pronounced squint, and if old
enough may complain of diplopia. This is not necessarily due
to loss of power of any one muscle, but may be caused by a
spastic contraction of one or more of them, a condition that
may subsequently disappear. Pressure upon the nerves either by
tubercle masses or exudate may be accountable for this,although
in some cases the cause must lie in a neuritis set up by the
irritation. The same cause may bring about partial or total
loss of sight if the optic nerve become involved as it frequently
does. But the physician should be cautious about attaching
too much importance to amblyopia in a case of suspected
meningeal or brain disease, for such amblyopia may be con-
genital or caused by a high refractive error, and only to be
detected by a careful ophthalmoscopic examination or some
other objective test. In children the chronic form of nuclear
palsy of the ocular muscles is not so frequently seen as in
adults, in whom syphilis so often acts to bring about the con-
dition. Dr. Baum has correctly stated that congenital syphi-
lis plays an insignificant role or no role af all in this disease.
Hutchinson in his famous memoir does not cite a case of con-
genital syphilis having caused paralysis of the eye muscles in
children and his opinion is also held by Mauthner and other
observers. But closely allied to the nuclear palsy of adults is
the condition described by Gowers by the name infantile oculo-
facial palsy. To this class probably belong many of the cases
of ptosis and paralysis of individual ocular muscles that are
congenital or that appear in early life. In this condition there
will be associated with palsy of one or more muscles of the eye
a paralysis of one of the facial muscles or jaw muscles. There
seems to be a peculiar connection in some persons between the
center that innervates the levator palpebrarum and the center
that innervates some of the muscles of the jaw. Cases are not
altogether infrequent in which patients having a ptosis are
unable to raise the lid unless they make a corresponding effort
to open the mouth. It seems as if the impulse that is sent to
the levator palpebrarum is, at the same time, sent to the
depressors of the lower jaw. This would seem to explain why
in some cases of oculo-facial paralysis we have a simultaneous
or coincident paralysis of one of the maxillary muscles together
with the muscles of the eyeball.
It is singular that in conditions of intracranial hemorrhage
or spastic paraplegia of infants that we should not have more
trouble on the part of the eye, because we have a blood clot in
some cases pressing upon the convexity of the brain, some-
times reaching back and pressing upon the occipital lobe.
Gowers mentions having seen but one case of complete blind-
ness in such condition. Little mentions no eye symptoms in
connection with it. Unless a clot should be on the occipital
lobes and press upon the sight center, we should hardly expect
any manifestation on part of the eye. We have in some febrile
diseases serious disturbance of the ocular muscles. In diph-
theria we are all familiar with the paralysis of accommodation
that occurs, usually following the paralysis of the muscles of
the palate. This may occur in connection with paralysis of
some of the extrinsic ocular muscles. For instance, a case was
reported in 1885 by Uhthoff in Neurologischen Centralblatt, in
which there was complete external as well as internal ophthal-
moplegia, and a short time after Mendel reported one very
similar. In these cases we must suppose that some poison
acts directly upon the centers in the fourth ventricle. In
Mendel's case, which went to autopsy, there was found con-
siderable congestion around the nuclei of the nerves, the capil-
laries were much ingested, and there was a tendency to
softening of some of the nerve centers.
(To be continued.)
PRACTICAL NOTES.
Infection from Circumcision. — The Semaine Midicale describes
a case of tuberculous infection of the testes in an otherwise
healthy child of healthy Jewish parents. The infection was
traced by a physician to the priest, who was found to be a
confirmed consumptive, and who performed the rite of
circumcision.
The Use of Dry Heat of High Temperature in tbe Treatment of
Chronic Joint Affections. — Dr. Wirt's apparatus consists of a
copper drum twelve inches long and nine inches in diameter,
fitted at each end with a wooden ring and a hood of thick rubber.
Having protected the back of the knee with cotton, it is
enclosed in the apparatus and heat applied to the outside by
means of a Bunsen burner. Most patients will tolerate a
temperature between 250 degrees and 300 degrees F., provided
1896.]
PRACTICAL NOTES.
961
three holes were made in the drum to secure proper ventila-
tion and keep the air dry. This treatment gives an immediate
relief to pain and increases temporarily the mobility of the
joint, st. Louis Mill. Journal, October.
Improved Method of Fastening Plaster Corsets. Gendron recom-
mends the use of strips of zinc, one mm. thick, three wide
and as long as the corset. Two are cut at intervals of two cm.
in oblong Bpaces across the strip, and the oblong piece cut out
on three sides, but left connected by one of the small ends, and
raised up like a trapdoor. An unperforated strip is placed on
the median line of the thorax and the layers of the plaster
bandage applied. On each side of this strip and at a distance
of several centimeters the perforated strips are sunk in the
plaster in the center of its thickness, the projecting raised
pieces standing up out of the plaster. After the corset is thus
applied, the projecting pieces are bent down to form hooks,
which enable the corset to be laced up firm and tight. —
Sfimiiit, .J/c</.. September 30.
Injection of Iodoform camphorated Salol In Chancrous Bubo.
The'.Kii//. Mill, ili' Liige, October 1, describes the prompt
cicatrization of eighteen cases of chancrous bubo treated by a
French army surgeon with an injection into its depths of '., to
% Pravaz syringe of 1-5 per cent, iodoform-camphorated salol.
After the needle is withdrawn the hole should be stopped with
the linger to prevent the escape of the fluid, and afterward
painted with collodion. The incision is postponed until the
following day. when all the gelatinous pus is forced out by
pressure. A little mercurialized water at 1 to 1,000 helps to
empty the pocket, which is then plugged with gauze dipped in
the salol. The pus is removed again the next day and a sec-
ond plug inserted. After this the bubo heals rapidly; the
pain, swellings, etc., gradually disappear and the cicatrization
proceeds regularly. The fifth day collodion is applied and the
cure is complete by the eighth day, leaving a scarcely visible
scar with the skin loose.
Diagnosis of the Possibility of Resuming Qrowth in Cases of
Arrested Development.- Dr. Hertoghe of Antwerp, announces
that growth can be resumed in all cases where the skeleton is
not completely ossified, or as long as the bones retain their
original cartilaginous character. He has been studying three
classes of arrested or delayed development : Myxedema, hyper-
■azoturia and rachitis, simultaneously with the administration
■of thyroidin. The most interesting part of his tests is that he
diagnoses the cases first by means of radiography, which accu-
rately determines the progress of ossification, and his diag-
noses have been confirmed in every instance by the results of
the treatment. In myxedema the ossification is tardy, and
patients with this disease resume therefore their growth upon
the administration of thyroidin. One of his cases was a young
man of 27, who measured 1.37 meters in April, 1895, and
has gained ll:i inches (33 mm.) since then, and is still growing.
The radiograph clearly showed in this case the distinct
light zones in the phalanges, revealing thus their incomplete
ossification and the possibility of a resumption of growth in
epite of his advanced age. Cases of hyperazoturia also pre-
sent a marked lack of ossification, and therefore are able to
resume growing ; but in rachitis, on the contrary, the bones
ossify very early and no further growth is to be expected.—
8emaine MM., September 30.
Treatment of Yellow Fever. The editor of the Tribuna MMica
of Rio de Janeiro, No. -10, announces that he has found that
the tincture of eucalyptus, administered promptly and in large
quantities, has a marked effect in attenuating the severer symp-
toms of yellow fever. He reports thirty-one cases treated with
it, and only three deaths, which were each probably due to the
ignorant and careless attendance the cases received. Very large
doses can be borne, as much as 30 to 40 grams in twenty-four
hours, with frequent enemas of 30 grams in a liter of water.
It seems to have an especially powerful effect |on the kidneys,
and prevents the usual anuria. 0 Brazil MMieo of August 1,
also states that it has been the experience of Da Costa, who
has been at the head of a hospital in Brazil for twenty-four
years, that few if any cases of yellow fever were fatal that
were accompanied by suppurated parotitis. The suggestion is
made that this might be produced artificially, and Fochier pro-
duces abscesses with turpentine, to prevent or modify purulent
transformation of pneumonic exudates.
The Dangers of the Operative Treatment of Enlarged Prostate.
Dumstrey, in Ceiitrulblatt /fir Chirurgie, records a case of
enlarged prostate treated by ligature and resection of the vas
deferens, which shows that this operation can not be regarded
as a simple one and free from risk. A man, aged 65, in all
other respects strong and healthy, came under the author's
care with complete urinary retention and severe cystitis due to
considerable prostatic enlargement. Partial resection of the
vas deferens on both sides was followed in the course of a few
days by decided relief of the local symptoms, the man being
able to pass urine spontaneously and the urine becoming much
less turbid and containing day by day less pus and blood.
The prostate, which just before the operation had been as large
as a fist, was reduced in size by about one-half. These good
results, however, were associated with serious impairment of
both the physical strength and the mental condition of the
patient. He speedily presented the appearance of a very old
and feeble person. His movements became slow and clumsy,
and he was unable to comprehend what was said to him and
also to express his own thoughts. After an interval of about
a fortnight his condition commenced to improve, but the
change for the better was very slow and gradual.
Location of Foreign Bodies In the Eye with Roentgen Rays.— Dr.
Clark, Columbus, reported at the recent meeting of the Amer-
ican Ophthalmological Society at New London, a case in
which the presence of a small fragment of metal in the
extreme angle of the anterior chamber and the iris, where it
could not be seen, had been determined by radiography. The
sensitive plate had been introduced into the adjoining nostril,
the patient being put under ether, and the rays directed upon
it through the eye from the temporal side. He also suggested
that the plate could be placed in the cocainized conjunctival
sac, or an opening could be made in the conjunctiva and the
small plate slipped behind it. He believed that this method of
locating a foreigp body in the eyeball was perfectly practicable,
especially if the particle were lodged anteriorly, as in the cil-
iary region, where it could not be seen with the ophthalmo-
scope. Dr. Williams, Boston, reported a case in which a frag-
ment of the copper case of a cartridge had passed through the
cornea and lens. Nothing could be seen of it and it was not
certain that it was in the eye. The use of the X rays showed
the presence of the fragment, and it was removed. The radio-
graph was obtained with ten minutes' exposure by laying the
patient's head with the side of the injured eye upon the plate,
and placing the Crookes' tube above and rather in front of the
patient's head. — Ophthalmic Review, August.
Chronic Membranous Bronchitis.— Claisse says that the nature
of chronic membranous bronchitis has been but little studied,
and gives the results of a bacteriologic examination of the
membrane from a patient who had expectorated bronchial
casts for several years. Cultures showed an inconstant and
small number of staphylococci and various forms of bacilli,
but the only microorganisms found in abundance and in all
tubes which did not prove sterile, were streptococci. Cut sec-
tions showed the presence of various microbes on the surface
of the false membrane, probably through contamination by
the saliva, but in its center only streptococci were met with.
Fragments of the membrane introduced into the bronchi of
9(52
PRACTICAL NOTES.
[October 31,
animals or beneath their skin, produced practically no reaction,
while inoculation experiments made with cultures of the germs
were equally negative, yet, in spite of their lack of virulence,
their constant presence shows that they were not a mere acci-
dental coincidence, but that the disease was due to a chronic
infection by them. Antistreptococcic serum was tried with
apparent success, the patient leaving the hospital in better
condition than she had been for years. — Boston Med. Journal,
October 8 : from Comp. Rend. Soc. de Biologie, April 3.
Intra cervical Injection of Glycerin ; a Modification of Pelzer's
Method of Inducing Premature Labor. — Helme improves on Pelzer's
intrauterine injections by introducing the nozzle of the syringe
into the cervix alone, and describes with enthusiasm in the
Lancet of October 3, the success of this treatment in two cases.
The important points are : 1, that the intra cervical injection
of glycerin produces a rapid and progressive dilatation of the
cervical canal ; 2, that at the same time the lower pole of the
ovum becomes detached from the lower uterine segment ; 3,
that the intrauterine injection of glycerin between the detached
portion of the membranes and the uterine wall may be carried
out without fear of puncturing the membranes or of interfering
with the placental attachment : and 4, that labor is effectually
induced. As to the manner in which glycerin acts Pelzer
offers the three following suggestions : 1, it acts as a direct
irritant of the uterine surface, setting up muscular contrac-
tions ; 2, it acts through a mechanical separation of the mem-
branes ; and 3, its hygroscopic action causes a transudation of
the liquor amnii ; the ovum becomes smaller and is detached
from the uterine wall ; there is at the same time a contraction
of the uterus upon its diminished contents. But in addition
to this power of setting up uterine contraction careful obser-
vation shows that glycerin possesses the power of causing dila-
tation of the cervical canal before contractions of the uterus,
which* are appreciable to the patient or the physician, are set
up. The injection of pure glycerin into the cervical canal is
followed by immediate softening and relaxation of the cervical
tissues with dilatation of the cervical canal, and this result
seems to be too rapid to be the result of muscular action. In
one caseof rachitic pelvis, four injections of 1 *3 ounces glycerin
were made in eight hours with a fifth of three ounces the next
morning. Labor was shorter and recovery more rapid than
ever before.
Surgical Treatment of Tuberculosis of the Bladder. Greiffen-
hagen describes in the D. Zts. f. Chir. 3, a case of tumefaction
of the bladder in a man of 47, whose urine contained blood
and numerous Koch bacilli. There was great pain and emaci-
ation, with incontinence of the urine. Clinical examination
showed a tumor the size of a nut, a Jittle above the symphysis
pubis, which ascended or descended according to the quantity
of urine in the bladder. A similar tumor was situated also on
the anterior surface of the bladder, and the external orifice of
the urethra was also the seat of another, the size of a cherry.
There was also a hard swelling in the membranous part of the
urethra. The prostate was large but not painful, while the
lower part of the bladder was intensely painful to pressure.
After several weeks of creosote medication- local treatment
being impossible on account of the sensitiveness of the patient
and the smallness of the urethra— a vast tumefaction formed
in the perineal region, combined with complete retention of
urine, which demanded surgical intervention. After opening
the abdomen on the median line, a multitude of small cavities
were encountered, filled with a cheesy pus, and communicating
with the urethra. An opening was made into the fundus of
the bladder and a large drainage tube inserted, after which the
peri-urethral abscesses were curetted out and iodoform gauze
applied. Five weeks after the operation the Koch bacilli had
entirely disappeared from the urine. A permanent catheter
was introduced into the urethra after dilation. The perineal'
wound healed ; the tumors in the vesical wall and at the orifice
of the urethra retroceded, and the general health continued to
improve. A year has passed since of perfect health for the
patient, a farmer, who has pursued his usual occupations.
Greiffenhagen adds that such cases should more frequently be
handed over to the surgeon, whenever instillations of subli-
mate and injections of iodoform fail to relieve.— Sew. M6d.,
September 30.
Serum Diagnosis of Typhoid Fever. ^It has been shown by Pfeif-
fer of Berlin, and Widal of Paris, that the serum obtained
from the blood of a patient suffering from typhoid fever is
capable of so acting upon pure bouillon cultures of the typhoid
bacillus mixed with it as to abolish the active motion charac-
teristic of that organism in fluid culture media and cause an
agglutination of the individual bacilli into large groups or
clumps. This change is easily recognizable under the micro-
scope, or in culture tubes, and usually occurs within a few
minutes. It has since been shown by Dr. Wyatt Johnston,
bacteriologist of the Provincial Board of Health of Ontario, that
the fluid ohtained by moistening with water a dried blood drop
gives the reaction in a prompt and satisfactory manner, even
after it has been dried for several days. This modification of
the process makes it suitable for a system of free public labor
atory diagnosis, similar to that in the case of diphtheria, as a
drop of dried blood can be readily sent to a laboratory for
examination. Dr. Johnston was able to diagnose the presence
or absence of the disease correctly by means of dried blood
drops sent by mail from Montreal, Canada, to Buffalo, N. Y.,
during the recent meeting of the American Public Health
Association. To test the practical utility of the method the
Board of Health of Ontario has issued a circular in which it
offers to examine and report upon any samples of blood sent by
physicians of the province. The blood is to be taken from the
finger tip or lobe of the ear, after thorough cleansing of the
skin, by pricking with a needle previously sterilized by heating
over a lamp or gas flame. The drop is to be absorbed by a
piece of sterilized paper which is furnished in an envelope by
the board, with directions for its return. A report is prom-
ised by 2 p.m. of the day following that on which the sample
is received and will be communicated by telephone when the
number is given. By this systematic investigation the board
wishes and expects to obtain dataon, 1, the proportion of cases
in which a correct diagnosis can be made by the serum test,
and the relative efficiency of the method of employing dried
samples ; 2, the earliest period in typhoid fever at which this
method can be expected to give indications ; 3, the length of
time for which it persists after convalescence ; i, the existence-
of any relation between the intensity of the reaction with th&
test and the course of the disease ; 5, the study of the nature
of the obscure febrile conditions, clinically termed gastric fever,
continued fever, abortive typhoid, bilious fever, typho-malarial
fever, etc., about which our present knowledge is very meager
and unsatisfactory. The board is especially desirious of hear-
ing promptly of and re-examining any genuine typhoid eases in
which the method is not successful. In case of negative
results, it is desired that after a few days an additional sam-
ple should also be sent consisting of a few drops of blood
collected in a glass tube which will be furnished on applica-
tion. With reference to the effect of drying the samples it is
observed that while this may lessen slightly the delicacy of the
reaction it has the practical advantage of obviating a serious
source of error, namely the contamination of the sample and
the subsequent growth of putrefactive bacteria. This is of
special importance in the care of samples having to be sent
long distances. No doubt other boards of health will take up
this subject and aid in the advance of our knowledge of typhoid
fever and other febrile conditions.
1896.]
EDITORIAL.
963
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to await call.
SATURDAY, OCTOBER 31, 1896.
PHYSIOLOGIC TREATMENT OF NEURASTHENIA.
Dr. David Riesman, of Philadelphia, closes up a
well considered article on neurasthenia in the Uni-
versity Medical Magazine, September, by a scheme
of treatment that embraces medicinal, hygienic and
dietetic recommendations.
1. Medicinal treatment can not be a matter of
routine, but there are few remedies that are of benefit
in a large number of cases.
At the head stand the bromids, of which he gener-
ally employs the sodium or potassium salt in doses of
fifteen grains two or three times a day; strontium
bromid. in thirty grain doses, has also given good
results, particularly in lithemic cases.
The coal tar products, either alone or combined
with the bromids, are often of value. A remedy, for
which much has been claimed but which he has not
used, is spermin. The animal extracts have been
employed, but it is questionable whether the results
achieved are not due to suggestion.
Special conditions will naturally demand a modifi-
cation of our treatment. Insomnia needs often to be
combated; frequently a hot sponge-bath before retir-
ing, or the application of hot towels to the fnce, is
sufficient to encourage sleep. When drugs must be
employed, we resort to bromids, sulphonal, trional or
hyoscin; never, if possible, to morphin. Marked
lithemic conditions are corrected by the use of alkal-
ine mineral waters, the lithia salts, or by piperazin
and its congeners.
In nervous dyspepsia, in addition to regulation of
diet, suitable remedies may be administered. The
mineral acids are of value in some cases; antiseptics
and sedatives, such as bismuth subgallate, in others.
The constipation is treated by the customary methods.
2. Dietetics. — The diet in neurasthenia should be
nutritious; it has no special limitations except when
the rest-cure is employed or when distinct indications
are present. The patient's idiosyncrasies must be
considered. If anemia exists, beef, eggs and milk are
given in abundance; in lithemic cases the meats are
restricted, and alcoholic beverages as well as rich
articles of food are excluded from the dietary.
For nearly all cases coffee and tea seem to be harm-
ful, and he has been in the habit, perhaps with too
strict an adherence to routine, of always forbidding
their use.
If symptoms of nervous dyspepsia are present, the
sugars and starches should be as much as possible
eliminated from the diet; the patients often do well
when placed on rare meat, stale bread or gluten bread
and milk. Milk is especially valuable in cases suffer-
ing from gastralgic attacks.
3. Among hygienic measures the most important is
rest; prolonged rest is to the neurasthenic patient
what the nightly sleep is to the healthy man. In
severe cases it is necessary to adopt the so-called
rest cure, or Weir Mitchell treatment, consisting of
rest in bed, massage, electricity and liberal feeding.
This may bring about a cure in an apparently hope-
less case. During the rest cure the patient is uot
permitted to see his or her friends, is not allowed to
read, and is in constant charge of an intelligent,
strong-minded nurse.
As important as any of the measures adopted,
indeed, deserving to be ranked the foremost factor in
treatment, is the personality of the physician. In no
disease is it so essential to inspire the patient with
confidence, and in none is so much good accomplished
by suggestion alone as in neurasthenia. The physi-
cian should listen patiently to the almost interminable
recital of fanciful ailments, and should always make a
careful physical examination to exclude all possibility
of lurking organic disease.
If the rest-cure is impossible or not indicated, the
patient must take a definite amount of rest by lying
down for an hour or two in the morning and in the
afternoon — this is especially valuable in women.
Bathing is not to be neglected. The bath should
be of short duration and-should be followed by a cold
shower bath or cold douche, with friction. In the
so-called sexual neurasthenia, the application of cold
water to the spine and the perineum acts as a powerful
sedative.
A change of climate, such as a sojourn at the sea-
shore, in a retired spot, or a sea voyage of some length,
is valuable in many instances.
964
TABLET MEDICATION.
[October 31.
In neurasthenia with disturbances of the sexual
functions a combination of bromids and hyoscin is
very useful. The patient should also be instructed to
sleep on his side (this maybe accomplished by having
him bind a cigar box on the back, or by tying a towel
about the waist with the knot behind), and to apply
cold douches to the spine and perineum. For this
class of cases outdoor exercise is very valuable.
WATER SUPPLY OF DENVER AND CHICAGO.
An increase of typhoid fever deaths in the city of
Denver, amounting to nearly 35 per cent, in Septem-
ber last over the average for the previous three months
as compared with the usual seasonal increase of less
than 12 per cent., has been made the occasion of an
exhaustive study of the water supply of that city by
its accomplished commissioner of health, Dr. William
P. Munn. His preliminary report to Mayor McMurray
on "The pollution of certain sources of the water
supply of the city," and his comments thereon, will
be a revelation to other commissioners of health and
to other mayors of cities.
Dr. Munn seriously proposes that the water from
all sources of the Denver water supply shall be pure
.and healthful, even if it be necessary that they be
passed through " properly constructed and efficient
filters, which shall give an effluent having an average
at all times of less than 100 germs per cubic centi-
meter," and that " if any of the patented processes
are adopted for the removal of impurities by mechan-
ical or chemical methods, it shall be a condition that
a month's test shall show an effluent at all times con-
taining less than 100 bacteria per cubic centimeter,
and that the test shall be carried on with the waters
of the proposed supply, and that the proposed filter
shall be approved by the mayor and the health com-
missioner, and the tests supervised and accepted by
them as satisfactory."
There are communities far more pretentious than
Denver — one of them has the honor of being the
home office of the Journal — where the permissible
limit of the bacteria is ten times this number, and
where the records show more than seventy times this
number as an actual average.
In his report Dr. Munn shows, as has been shown
by others, that typhoid fever prevalence follows the
pollution of the water supply, that it subsides with
the improvement of the supply, and that " the great
bulk of cases of typhoid fever in all epidemics is due
to the one common cause — an infected water supply."
He adds: "When the probable sources of that infec-
tion are discovered, it is the plain duty of those upon
whom the responsibility lies to suggest the remedies.
Failure to adopt the remedial measures that are neces-
sary means deliberate acceptance of responsibility for
the resultant loss of human life."
The Journal begs to commend this utterance,
which will be endorsed by every sanitarian in the-
country, to the prajterful consideration of the civic
and educational authorities of the city of Chicago,
where the death rate from typhoid fever is again
becoming the highest in the world.
• TABLET MEDICATION.
The " tablet fad," as some of our pharmaceutic
friends choose to call it, appears to have come to stay.
The convenience, cleanliness and presumably accurate-
dosage of the preparations recommend them readily
to the practitioner, and at the present time there is-
hardly a doctor's office where the familiar glass stop-
pered bottles and labels of the different manufacturers
are not to be encountered. They have undoubtedly
affected the druggists' business to some extent, and
have perhaps also modified medical practice ; how
materially is a question to be settled in the future.
That they are the unmitigated evil that some phar-
maceutic writers hold, is doubtful; but that their
extensive adoption as a mode of drug-dispensing by
physicians has in it possibilities to be deprecated, is
pretty nearly certain. In their present development,
it may easily happen that with some they may induce
an indolent or careless therapeutic method — that ready
made shotgun prescriptions may become popular
and an actual evil. It is easy also to see how, without
any standard authority regulating these preparations,
there may be some among them that are not only
useless but absolutely dangerous combinations intro-
duced to manufacturers and sent out among the pro-
fession. It may be there are none as yet of this kind
that are really of any importance, but we have to.
reckon with their possibility. Certainly there are
some among them that are ineffective or uncertain .
All the objections to these tablets could, it would
seem, be avoided if there were a standard list, made
up mainly of simple drugs, a few well tried or rational
combinations perhaps included, which could be pre-
scribed if so desired and supplied by every druggist,
and which could be combined according to the needs
of any special prescription if the physician desired to
dispense his own medicine. A very large proportion
of the pharmacopeia is made up of substances that
can very readily be made up into these tablets, the
convenience of which is now being daily demonstrated.
Others that are not thus suitable, but which are now
included in the manufacturers' lists, would of course
be omitted from the standard list and it would in
this way save both physician and patient from being
misled into trouble and expense. The addition of a.
class of compressed tablets and tablet triturates to the
regular pharmacopeia would not hurt any business,
more than is being done at present, and would regulate
what is at present a somewhat irregular, but widespread
and popular method of medication and one that has its
real advantages and merits.
1896. !
COOK COUNTY (ILLINOIS) HOSPITAL.
965
111 1 : M.W VORK STATE MEDICAL ASSOCIATION.
Thirteen years ago the Now York State Medical
Society separated on the code question. Those who
believed in the code of the National Society began to
hold their animal meetings in New York City, and
were designated as the New York State Medical Asso-
ciation. The State was divided into five districts,
presided over by vice-presidents, and holding quar-
terly and semi-annual meetings. The regular annual
meeting of the Association, at the Mott Memorial
Hall, New York City, was held October 13, 14 and 15,
and was of more than usual interest. The President's
address on " Medical Expert Testimony,'' was a sug-
gestive, thoughtful study of the subject by Dr. Dar-
win Oolvin of Clyde, N. Y., one of the few living
original members of the American* Medical Associa-
tion. Dr. Austin Flint of New York in a special
report on criminology dwelt on the injustice of the
law forced through the legislature by the labor unions,
taking all contract labor from the prisons, leaving the
prisoners in idleness and increasing the cost to the
State. A symposium on prostatic enlargement and its
surgical and medical treatment brought out a very
interesting discussion. Among the large number of
important papers was one by Dr. E. D. Ferguson, on
'Fatal Cases Presumably Due to Intestinal Ptomains,"
which gave a new meaning to a class of obscure
-symptoms, and suggested a new field of study that
promises brilliant discoveries in the near future. The
address on surgery by Dr. Phelps of New York City,
was an exceptionally clear philosophic critique of the
general progress of surgery and medicine; also a plea
for higher ideals of professional life and living. Dr.
Say he's paper "On the Practical Uses of Roentgen's
Discovery as Applied to Surgery," illustrated, was of
great interest. The program as a whole was very sig-
nificant of a great evolution in the practice of medi-
cine. Of the forty-five papers and addresses offered,
over thirty were devoted to surgery. Many of them
were reports and discussions of very formidable oper-
ations, mostly by physicians living away from the
large cities and centers of learning, and doing a gen-
eral practice.
The post-graduate schools are clearly doing a revo-
lutionary work in preparing the general practitioner
for surgical operations which were formerly only done
by leaders in the profession and at large hospitals.
Evidently a decided evolution is building up surgeons
in inland towns and villages, competent for ordinary
demands of modern surgery. This, however, may go
too far, as that manual dexterity resulting from daily
practice required in certain exceptional operations can
only be acquired in the large hospitals. While undoubt-
edly surgery is one of the fascinating branches of mod-
ern medicine, and at present outranks all others in
prominence, yet the topics of papers seen in programs
of medical meetings, indicate many and probably far
more important fields of study. The New York State
.Medical Association is one of the prominent Eastern
societies, whose membership includes many of the
leading medical men of the country and whose pub-
lished transactions are eagerly sought after as repre-
senting the advanced studies of medicine.
Yet all medical societies' meetings suffer from the
inability of readers of papers to condense and give the
listeners the conclusions of their studies only. In an
annual meeting of several days" duration, outside the
addresses on general and special topics, the readers of
papers should be limited to conclusions and summaries
of their arguments, leaving to the printed page the
facts and observations which can be studied at leisure.
Often readers of good papers fail to rouse up any
interest by faults of tone and address. Many authors
appear at their best in print, and should never read
their productions. Others are best in impromptu
debate and exchange of opinion.
The model medical meeting is yet to come, but
there are signs of its near approach every year.
THE COOK COUNTY (ILLINOIS) HOSPITAL.
The Practitioners' Club of Chicago held a meeting
Monday night, under the presidency of Prof. Christian
Fenger, at which they discussed the perennial Cook
County Hospital question. The speakers were Drs.
Steele, Babcock, T. A. Davis, Senn, W. T. Mont< .< >\i -
ery, Brower, Hamilton, Moyer, Lewis and Wilder.
Some curious facts were brought out in the discussion,
among others that the members of the staff, with
very few exceptions, were the private physicians of
the county commissioners, and that the price of
appointment was free treatment of the special com-
missioner and his family, together with the political
pull of the incumbent. One of the speakers stated
that internes at that institution were in the habit of
performing capital operations in emergency cases
without waiting for an attending member of the staff,
and that they did not hesitate to perform such dan-
gerous operations as amputation of the hip joint.
Statement was made that no provision for bedside
instruction was at present made at the hospital, and
that it was optional with the patients whether or not
they were admitted to the clinic amphitheater. One
of the members of the staff, while speaking in a
manner entirely friendly to the management, asserted
that cases of phthisis pulmonalis, even in an advanced
stage, were frequently placed in beds alongside of
cases of typhoid fever, pneumonia or bronchitis,
and that no separation of these cases was even
attempted; that the temperature of the wards was
very badly managed, and as a rule kept entirely too
high, and remonstrances on the part of the staff were
of no particular avail, as the institution is under the
management of a lay " Warden," responsible alone to
the county commissioners.
966
CORRESPONDENCE.
[October 31,
These defects in the largest hospital of Chicago are
not creditable to the public, and the necessity for
putting the hospital under medical rather than lay
supervision has again been demonstrated.
At the same meeting a motion to recommend the
commissioners to abolish the hospital ticket fee for
students was voted down on the statement of Dr. T.
A. Davis that this money was used for laboratory
purposes. Resolution was finally passed inviting the
cooperation of the Chicago Medical and other regular
societies of the city, to take immediate action this
week, before the election, recommending that here-
after the regular members of the hospital staff be
appointed on the recommendation of the Chicago
Medical Society.
GETTING RICH "BY DEGREES" IN ITALY.
The Rome correspondent of the London Lancet,
September 19, records the fact that three years ago
the sale of bogus degrees had reached proportions in
Bologna which incurred the intervention of the police,
and their manufacturer is still, it is believed, serving
his time in one of the local prisons. But the summary
example made of him has not, it would appear, proved
much of a deterrent. At least, from information
gathered in Italy the industry is still a paying one,
if the number of graduates whose scholastic record
is rather dim may be received as a test. This time
the University which confers the diplomas is not
Bologna, but Berne, whose su/illum magnum was
stolen, or in some way got at, so as to be counter-
feited to perfection. The alleged thief or forger has
been arrested, but the article was not found in his
possession and is still to seek. So the world is not
yet safe against the illicit creation of graduates, med-
ical and other, but chiefly medical, of whom, it seems,
there are already nearly three hundred vaunting
themselves alumni of the leading Swiss University.
Scandinavia and Germany boast the majority of such
graduates, while there are some fifty or so practicing
in or on the English-speaking public in both hemi-
spheres. The rest are chiefly to be found in Italy,
Austria and the East.
CORRESPONDENCE.
Glandular Interdependence.
Chicago, Sept. 25, 1896.
To the Editor: -In an editorial on "The Vital and Psychic
Complications in Castration for Prostatic Hypertrophy"
which appeared in the Journal of Saturday September 19, the
writer in speaking of the testicles, observes "that these organs
are absolutely without function at an advanced age is most cer-
tainly untrue for many individuals. . . . There is proba-
bly a germ of truth in the theory of Brown-Se"quard as to the
invigorating influence of the testicular secretion ; certainly the
experimenters in organo- therapy have not lost faith in it alto-
gether. The organs do not atrophy completely even after their
special sexual function has apparently long been lost, and it is
only reasonable to assume that they still have some utility in
the organism." This is perfectly true. I think we may safely
infer that no organ of the body performs but one function and
that alone. The several tissues, using lymph as a medium
live upon the blood, taking up from the blood the materials
for, and returning to the blood the products of, their metabol-
ism. Therefore, the supply of blood that is not only deficient
in quantity but defective in quality, is one of the causes of
nutritive derangement. And another cause is the failure of
the organism to eliminate the waste products which accumu-
late in the blood. But yet a third cause of defective nutrition
is the alteration of the blood which consists in the interdepend-
ence of each and every tissue of the body upon one another,
and hence no part can either be removed or remain inactive
without producing an ill-effect upon the rest of the body.
Foster expresses himself on this subject in the following words :
"Changes in one organ may affect the condition of other dis-
tant organs by changes induced in the composition or qualities
of the blood." And again : "The products of the metabolism of
one organ are carried to other organs for further elaboration and
possible utilization." Take, for instance, the liver. We know
from Minkowski's experiments on birds, and from the experi-
ments of Hahn, Masson, Pawlow, Nencki and others, on dogs
that the extirpation of the liver in the former is attended with
the replacement of uric acid by ammonia and lactic acid, and
the ligation of the hepatic artery in the latter replaced uric
acid by the carbonate of ammonia. These experiments go to
show that the liver protects the organism from poisoning by
the products of its own cellular activity. And Bouchard has
demonstrated that this function of the liver diminishes in an
enormous degree the toxicity of the waste products.
Take next the pancreas. It has been conclusively proved by
the experiments of Von Mering, Minkowski, Lancereaux, Gley
and others that besides its digestive functions the pancreas
subserves the important purpose of utilizing the glucose that
is normally present in the blood. Extirpate the organ or tie
all its veins and we have glycosuria or pancreatic diabetes as
an immediate result. Forty years ago Schiff demonstrated the
troubles and alterations of nutrition following the extirpation
of the thyroid. He then believed that this body elaborated
something which had an important effect on the nutrition of
the nervous system. This has since been verified classically
in myxedema.
From Gley's experiments on the rabbit we come to find now
that acromegaly, that peculiar hypertrophy, is associated with
disease of the pituitary body. From the studies of Addison
and the experiments of Brown-Sequard, Langlois, and recently
of Schaefer and Oliver, we have arrived at the conclusion that
the medullary portion of the suprarenal capsules secretes
something which increases the tone of all muscular tissue,
especially of the heart and arteries. Indeed, even the kidneys
perform other functions besides that of eliminating waste
products. Bradford's experiments conclusively demonstrate
the fact that the renal organs possess and perform another
function, viz., the metabolism of the tissues.
It is more than probable, therefore, that the testicles also
have functions besides those intended for procreative purposes.
Testicular preparations may, therefore, reasonably be assumed
to possess useful properties. That they actually do influence
the general nutrition will be readily admitted by the results
obtained in the following case :
L. M., age 62, an Englishman by birth, has for thirty-eight
years been a sufferer from psoriasis. When examined in June,
1896, was found to be pretty nearly hide-bound by a thick
layer of silvery scales from his head, forehead and neck, down
his front and back, his arms, nates and legs to the palms of
his hands and soles of his feet. His nails looked "worm-
eaten," and the bends of his elbows and knees were cracked
and bleeding. In his travels in Europe he had consulted every
1896.]
CORRESPONDENCE.
91)7
dermatologist of any name and had tried every known remedy
recommended by Startin, Tilbury Fox, Hebra, Unna, Kaposi
ami others. He had tried hydropathic treatment for two
years : every description of sulphur treatment from simple
sulphur to all kinds of sulphur preparations, including ichthyol
and resorcin, with sulphur and mud baths for another two
years : had been pitched and tarred within and without for
another two years; the thrysophanic acid, chrysarobin, araro-
bin, mercury, iodin, pilocarpin and arsenic treatments for yet
another two years; hot vapor baths, pure and medicated with
salicylates, colchicum, potash soda and lithia, with all manner
<>f diaphoretics, diuretics and purgatives for an indefinite
period. But it was of no use: the disease persisted and lat-
terly he had ceased all treatment and was resigned to the
inevitable.
He was given a bottle of phospho albumin, a very palatable
testicular preparation, made in Chicago, and he was advised
to discontinue all external applications, and to avoid the use of
water. He took a tablespoonful three times a day after each
meal, and he felt encouraged to continue the treatment until
he had taken three bottles of it, when he was again examined.
Now it was approximately estimated that this skin trouble
covered about -'.. square feet of the surface of his body and I
have to report the remarkable fact that after taking his third
bottle of phospho albumin there was not a speck of the psoriasis
to be seen. Over the diseased patches were now visible dark
chocolate-brown stains, but of perfectly velvety smoothness
without the least irritation or pruritus. This is not the first or
only case of psoriasis cured by testicular preparations. Bouffe
reports good results from Brown-Sequard's fluid in this obsti-
nate disease 1'ivss Mul. Beige, 1894, No. 35). I have another
case of seveteen years" standing now under this treatment, but
not enough time has yet elapsed to allow of any opinion being
expressed as to its effects. It is just possible this treatment
may not succeed in the next case, for we do not know what the
something is that produced the results and, hence, we are as
yet ignorant as to the exact indications for its use. In the next
place we are ignorant of the causes which produce psoriasis.
When found in conjunction with syphilis specific treatment is
beneficial : when it flourishes on a rheumatic or gouty soil the
salicylates, colchicum aDd alkalies help to alleviate the
urgency of the symptoms, but when it is "idiopathic" (a term
which expresses our ignorance of etiology) and seems to be
nothing more or less than a surface manifestation of some
general nutritive derangement, then phospho-albumin gives
results that are simply marvelous. The glandular bodies
should be studied in the laboratory as to their physiologic
chemistry and histology, and these studies combined with
experimental physiology and empirical therapeutics might
lead to great revelations. M. H. Lackersteen, M.D.
The Proposed I/eprosy Congress.
New York, Oct. 19, 1896.
To tlie Editor: — I enclose some copies of letters relating to
the proposed leprosy congress. The first idea was to hold it in
Bergen, Norway, out of compliment to Hansen. The latter
has now renounced his personal claims, and the opinions are
now divided between London and Moscow. As you will see,
we were happy enough to secure the interest of Queen Victoria,
and we have a well grounded hope that the British government
will take an active part in the enterprise. Dr. Hutchinson
thinks that the Prince of Wales will almost to a certainty con-
sent to act as president of the Congress if held in London. As
the British empire is more interested than any other country
in the question of leprosy, it seems but natural, especially with
these great advantages, that London should be chosen. Dr.
Morrow, who is the committee appointed by the American
Dermatological Association to represent it in the matter of the
Congress, and who was given full powers to act, votes for
Bergen first, London second, as the seat of the Congress, and
thinks that the most successful meeting could be obtained for
London if our Congress meets shortly before or after the Mos-
cow General Congress. I myself shall vote for London. Will
you kindly favor us with an editorial voicing these sentiments,
and greatly oblige, Very truly yours,
AlbertS. Ashmead, M.D.
London, Sept. 22, 1896.
Dr. Albert Asiimk u>. Dear Stt: At the Ambassador's
request I have much pleasure in enclosing herewith the answer
from Sir Arthur Bigge to your letter addressed to the Queen.
I am, dear sir, your obedient servant,
John Ridoely Carter, Secretary to U.S. Ambassador.
Balmoral Castle, Sept. 21, 1896.
Dr. Albert Ashmead. — Dear Sir: In reply to your letter
addressed to the Queen and forwarded through the embassy of
the United States in London, I have the honor to inform you
that your communication has been duly laid before Her
Majesty, who is interested in hearing of the proposed Inter-
national Congress for the suppression and prevention of
leprosy. Your letter has now been forwarded to the Queen's
ministers, in order that the question may be considered and
dealt with by those who in all such matters must be Her
Majesty's responsible advisers. I have the honor to be, dear
sir, yours very faithfully,
Arthur Bigge, Private Secretary to the Queen.
London, Sept. 16, 1896.
Dr. Albert S. Ashmead. — My Dear Sir: I warmly approvs
your scheme and vote with both hands for Bergen. It would
be a mistake to make it a part of the Moscow congress. If in
Bergen and well ahead of the Moscow meeting, so that those
who wished could attend both, it would, I think, be well
attended. For myself I might hope to get to Bergen, but
scarcely to Moscow.
I do not think that I much approve the idea of collecting
money for leper houses. What we have as medical and scien-
tific men to do is to find out the cause and the means of pre-
vention, and we should need all the money we can obtain for
researches. In the administration of the "Prince of Wales
fund" we felt it to be a mistake to have undertaken aid to
asylums. It wasted our funds and did an infinitesimal amount
of good.
If you thought well to compromise and meet in London, I
do not doubt that the Prince of Wales would consent to be
president. If you appoint patrons he would probably give his
name to the Bergen list.
Why not include "Yaws," or why not make it "For the
Study of widely spread Endemic Diseases, Especially Leprosy
and Yaws." It might still take its colloquial name from
leprosy. Wishing you success, 1 am, yours sincerely,
Jonathan Hutchinson.
Tokyo, Japan, Sept. 2, 1896.
Dr. Ashmead. — My Dear Doctor: I am directed to acknow-
ledge with thanks thie receipt of your favor dated New York,
Aug. 5, 1896, and beg leave to reply that Prof. Kitasato is
highly delighted to hear of your project, and that he will be
glad to do all in his power to further the interests of the Con-
gress. He is making researches on the subject you mention,
and if they are completed at the time the Congress meets it
will afford him much pleasure to report them. He sends his
best regards. Yours very truly,
A. Nakagawa, M.D.
Assistant in Institut fiir Infections-krankheiten.
Booota, Colombia, Sept. 12, 1896.
Dr. Albert S. Ashmead. — Dear Sir: I have had the honor
to receive your favor of August 5 of this year, in which you do
me the honor to inform me that in the coming year there will
be held in Bergen a Congress of Leprologists, to which you do
me the honorable distinction to invite me ; and at the same
time my own interest prompts me to interest myself with the
government of my own country to make it accept ths invita-
tion which you address to that government, to take its place
in the said congress, and to send to it an official delegate. As
for me, I accept with the greatest of pleasure, my dear sir,
such a signal show of appreciation, and I shall take my place
in the Congress unless some unforeseen accident prevents me.
Should such an accident happen, you may be sure of the sero-
therapy exposition you desire, for which I have already in my
hands, and I shall receive more, materials to serve as clinical
observations, photographs of diseased people, statistic and
CORRESPONDENCE.
[October 31,
historic information, and a lot of things which seem to me to
interest the eminent leprologists who will meet at the Congress.
Since I have received your letter I have addressed myself to
the Minister of Foreign Relations, in order to satisfy the
recommendation made by you, and he told me that he had not
yet received the communication which you declare having sent
him through the American Minister. But he thinks that he
may assure you that the government will accept the invitation
and that it will send an official commissioner, as you have
asked him.
And now will you allow me to ask you one question? I
should like to know that Dr. Hansen will experiment on some
case of leprosy of the Hospital Luugaarde with serum-therapy
treatment which a year ago 1 have tried here, with good result,
in order that when the Congress of Bergen shall meet, the
distinguished scholar will be able to pronounce his idea accord-
ing to that treatment. For that effect, I remit to you some
copies of my third communication to the Academy of Bogota
in which there are to be found all the details necessary to the
propagation of the anti-leprous serum, and for the treatment
of the patients by that method. Hoping for the kindness of
yourself, that you will forward this paper to Dr. Hansen. If
he wants to make the experiments, without taking to himself
the trouble of making the serum, you will do me the favor to
let me know, that I could send from here the serum which will
be necessary for him.
With the feeling of the most distinguished considerations, 1
have the honor to declare myself your most attentive and sure
servitor, Juan de Dios Carrasquilla, L.
Copenhagen, Sept. 18, 1896.
Dr. Albert Ashmead. — Dear Sir: I have had great pleas-
ure in receiving to-day your letter, because I am working on
the same subject since last year. At the last congress in Lon-
don in August, 1896, 1 spoke with the most renowned European
leprologists of this matter, and they were all together of the
unanimous opinion that a league against leprosy ought to be
formed like the leagues already existing against tuberculosis
and cancer. I am going to Berlin one of the first days of
October to find several other leprologists of our union. I
shall inform you of our deliberations on my return.
Yours very truly, Db. Ehlers.
Treatment of Diphtheria.
Camden, N. J., Oct. 19, 1896.
To the Editor:- In the formula of my antiseptic solution in
the Journal, Oct. 17, 1896, just to hand, an important mis-
print has occurred. It should be in the formula five drops of
carbolic acid instead of one drop.
Will you kindly and promptly correct the same in your next
issue. Also I send you two letters which are of great interest
in connection with my method of treating diphtheria. Please
give them space. Yours very sincerely,
D. Benjamin, M.D.
Camden, N. J., July 16, 1896.
Dr. D. Benjamin, My Dear Doctor: — In reference to your
Antiseptic Treatment for Diphtheria, will say that I have used
your treatment for the past three years in at least seventy-five
cases of true diphtheria, without a death.
The membrane disappeared so quickly in certain cases that
reporting the case to the board of health seemed unnecessary.
In a case of a little girl on South Fourth Street, Camden,
who was taken with malignant diphtheria, her brother having
died only a few days previous, in the hands of another physi-
cian, it was my privilege of witnessing the efficacy of this
antiseptic treatment.
The membrane disappeared in less than thirty -six hours, the
little patient convalescing on the fourth day. As long as the
above treatment gives me this percentage of cures, I have no
need for antitoxin. I remain, fraternally,
Wm. J. Kelchner, M.D.
Camden, N. J., July 9, 1896.
To the .Editor.-- Learning that Dr. Benjamin is going to
publish an interesting case of diphtheria, and seeing the case
with him I desire to make the following statement :
During the practice of twenty one years I have naturally met
with a large number of cases of diphtheria ; but the most ma-
lignant case that I ever saw to fully recover was Mrs. Samuel
Mills, of 726 Clinton Street, this city, who had two children
die in close succession from diphtheria, who had been attended
by a homeopathic physician. Some time in April last, while
attending the funeral of her last child that died, she was sud-
denly taken with a severe chill, and complained of a painful
sensation in the throat, with intense pain in head and back.
She was quickly driven home and Dr. Benjamin sent for. Her
condition became rapidly worse and her symptoms so alarming
that her husband called at my office and requested me to take
charge of the case until Dr. Benjamin arrived.
Under the circumstances I consented to do so. I just had
time to examine the patient, however, when the doctor drove
up. He confirmed my diagnosis that it was not only a typical
case of diphtheria, but a most malignant form of the disease.
Upon examination he found her temperature to be 105, pulse
130, and respiration 26.
I saw at once that it was a case calling for the antitoxin
treatment. Had she been my patient and had I been alone. I
probably would have resorted to that remedy : and then Dr.
Benjamin declared in the face of such an unfavorable progno-
sis, that he not only would cure the case, but would in a very
few hours check the progress of the disease by employing two
well tried remedies of his, both locally and internally ; I must
acknowledge that when he made that statement I became
somewhat incredulous. But nevertheless the doctor evidently
knew whereof he spoke, as in a remarkably short time, under
the antiseptic treatment employed directly to the throat
(which he claims destroys the germs and microbes at once), the
patient showed marked symptoms of improvement. The tem-
perature soon became normal, the diphtheritic patches soon
cleared off, and in less than a week the patient was down stairs.
Respectfully,
217 South Sixth Street. E. E. DeGrokft, M.D.
Drinking Waters for Travelers.
New York, Oct. 16, 1896.
To the Editor:— We regret to encroach upon your time and
we hope you will pardon us for doing so as a result of our desire
to have you favor us by correcting in the Journal an error
which inadvertently crept into the issue of September 19, page
664, where, speaking of the several drinking waters for travel-
ers, it is made to appear that Apollinaris Water and the vari-
ous Hunyadi Waters are aerated drinking waters of the same
standing.
While it is true that Apollinaris is a dietetic and table water
which the profession have time and again recommended to
travelers in districts where the drinking water is the subject of
suspicion, on the other hand the numerous Hungarian Bitter
Waters coming from Buda Pest, which are called Hunyadi
this or that, are strictly medicinal, being aperients, and, if
reports go for anything, vary much from time to time in their
specific gravity, in consequence of which Professor Liebreich
(University of Berlin) in an article published in the Therapeu-
tische Monatshefte, said :
"It is, therefore, a matter for high satisfaction that the
aperient water 'Apenta,' from the Uj Hunyadi Springs in Ofen,
has been placed under state control. The Royal Hungarian
Chemical State Institute (Ministry of Agriculture) has under-
taken this charge, and, therefore, it is now possible to obtain a
water which is free from injurious extraneous waters infected
with organic substances. The analysis has been published- by
Professor Liebermann, Director of the said Institute. The
proportion of sulphate of soda to sulphate of magnesia is
15.432 to 24.4968 in the liter, so that this water is to be classed
with the best aperient waters, and may be pronounced one of
the strongest. Owing to the constancy of the Apenta Water
ensured by the state guarantee, that confidence in aperient
1896. |
PUBLIC HEALTH.
969
waters, which had boon lost, will be revived in favor of this
Important therapeutic agent."
As an error in the columns of a journal of such high stand-
ing and authority as yours is apt to confuse many readers to
their disadvantage and ours, we trust that you will be good
enough to give the matter attention. Yours very truly,
Charles Grakf & Co.
lit- Likes our -Journal, but Money is scarce.
Millboko Si'kim.s, Va., Sept. 6, 1896.
7o tin' Editor: — I received your letter and the Journal
September 86 ; please accept my thanks for them both. After
awhile I D.V. I, 1 will become a member of the American Medi-
OAJ Assih i m'uin when money gets less ridiculously scarce.
There is no money in rural sections now. Corn 15c. per
bushel, butter Tie. per pound, sweet potatoes $1.00 in July
last, when a few years back they were $7.00 per barrel. Noth-
ing that ■ fanner has will sell.
Send me the Journal semi-occasionally. I enjoy the edi-
torials ; the terse and brilliant dash of the versatile pen tends
to reason like the " needle to the pole," making their conclu-
sions "solid buildings, " no "castles in the air."
I am like you, doctor, about that terminology of "fair cul-
ture." We were all taught in about the first lesson in our
Latin grammar that "os" and "on" were Greek terminations.
As to "stomatomyooaiB" and " coprostasis," " fair culture"
slipped like "(.'asar in Africa;" unlike him, however, I am
sure he will not hold his " tripper," or wish to, when he looks
for the words ni-Kpos and itt&vis ; nor will he find lead poisoning,
whatever other morbific (escaping) elementaries there may be
■float This is strictly between you and me. I am no critic,
neither wish to be. In your position you are compelled to
notice such blunders.
1 will join the Association, nothing happening to prevent it,
some time. 1 am sincerely, etc., W. S. S.
Twelfth International Congress of Medicine.
Moscow, Russia, Oct. 10, 1896.
To the Editor: Will you kindly insert in an early issue of
your esteemed journal the following notice :
From tin Surgical Section of the Twelfth International
M, <tiriil ( 'ongn ss in Moscow. Acting upon the advice of Dr.
K. Browitz (KOnigsbergi, the Surgical Section of the Twelfth
International Medical Congress has decided, in view of the
approaching Congress, to collect international statistics on
narcotizations for the current year (1896). For this purpose
the managers of the said Section apply to all their colleagues
and earnestly request them to give answers to the following
questions :
1. Number of nareoses from Jan. 1, 1896, to Jan. 1, 1897?
2. What narcotics were administered?
:i. Number of fatal cases?
The Secretary of the Surgical Section, P. Rein, Malaja
Dmitrowka, house Scheschkov, Moscow, Russia, will be glad
to receive such information, and, if possible, not later than
July 1, 1897.
F. Rein, M.D., Secretary of the Surgical Section.
Serum-therapy.
Chicago, Oct. 25, 1896.
To the Editor .•— Lahmann's assertion (see "Serum-thera-
py," Journal, No. 17, page 914), upon healing diphtheria by
freeing the body of autotoxins reminds us of the old therapy
of evacuating the toxins by moving the bowels and sweating
an old plan, with right relinquished or left to the quacks. The
renewal of the idea with some physiologic rays makes it no
more valuable ; we should be on our guard, having enough of
the sort in the country. Kl.
Journal Volumes for Sale.
Canadian, Texas, Oct. 15, 1896.
To the Editor:— Can you refer me to any one who can use
eleven volumes of The Journal oh the American Medical
Association, Vols. I to XI complete, bound and in good con-
dition? Yours truly, Claude Wolcott.
PUBLIC HEALTH.
Policemen Trained in Care of the Sick and Wounded. A letter to
the British Medical Journal states that a trained "Samaritan"
is always present at each police station in Berlin, and 1,500
men have been trained in ambulance work. There are also
"Samaritans" in each fire brigade. The latter have cared for
1,533 cases since 1893.
Providence Sewerage System. Residents along the west shore
of Narragansett Bay, in the vicinity of Field's Point, are
greatly disturbed over the sewage from this city. The outlet
of the mains is at Field's Point, and the tide carries the sewage
along the flats to the west of Stave Goat Island and causes a
constant nuisance. The residents of Washington Park are
also among the complainants, and attorneys are being con-
sulted to ascertain their legal rights in the matter. The sew-
erage system has just been completed and cost 82,000,000. It
was thought by the Providence officials to be perfect, but
it was predicted some time ago that an outlet inside of
Warwick Neck would be useless. It will cost several more
millions to continue the system to a safe point down the bay.
The Decadent American Birth Rate. France, to-day, with all her
industry, natural resources and ardent national life, finds her-
self face to face with this specter, and her statesmen are plan-
ning, by the modification of the inheritance tax-law, to inspire
a desire on the part of parents for more children. In brief, by
exemptions to families containing more than three children
and by additional taxes on those with less, they hope to coun-
teract the alarmingly crescent tendency of French married
couples to rest content with very few "olive branches." In
1894 the birth rate in France was 22 to every 1,000 inhabitants,
a decrease of 2.7 in a decade. This is believed to be the lowest
birth rate in the world, and no wonder thoughtful Frenchmen
are aghast ; and to this must be added the facts that illegiti-
mate births and divorces are on the increase. Our condition
is by no means so bad, but it is bad enough to demand prompt
attention and remedial efforts, if Dr. Billings' latest figures be
trustworthy. In 1880 he says, our birth rate was 30.95 to
every 1,000 people and in 1890 had dropped to 26.68. If it has
pursued to now the descending ratio, it must be as we write,
about 24.50; not 3 per 1,000 higher than the rate which fright-
ens France. It appears further from the eminent sociologist's
researches that the class of parents best equipped to bring
forth and educate children are the least inclined to this
patriotic responsibility. Into the causes of this we need not
now enter and must content ourselves with simply entering a
caveat. — The New York Press.
Regular Meeting Michigan State Board of Health, Lansing, Oct. 9,
1896. - The meeting was called to order by the president, Hon.
Frank Wells of Lansing. The members present were Prof.
Delos Fall of Albion, Mason W. Gray, M.D., of Pontiac, Judge
Aaron V. McAlvay of Manistee and Secretary Henry B. Baker.
The regular business of auditing of bills and accounts was
transacted. The secretary presented his report of the condi-
tions of health in Michigan and of work in the office during the
quarter ending Sept. 30, 1896. His report showed that the
work of the office was fast being brought up nearer to date,
and that work in connection with preparing the annual report
of the secretary was progressing rapidly. He thought that
by Dec. 31, 1896, his report for the year 1896 would be nearly
970
PtlBLIC HEALTH.
[October 31,
completed. The subject of the quarter-centennial of the State
Board of Health was suggested, and the board appointed the
secretary a committee to report at the next regular meeting a
plan for an appropriate celebration of the twenty-fifth anni-
versary of the establishment of the board, which should occur
July 30, 1898.
Doctor Baker said that during the past quarter he has occu-
pied his spare time in ascertaining the results of the health
work which has been done in Michigan, more especially for
the restriction of dangerous communicable diseases. The sta-
tistics collected by the Secretary of State and those collected
by the State Board of Health agree in indicating that lives
have been saved and sickness prevented which has resulted in
saving to the people of Michigan over 81,000,000 per year. The
outlay has been very small. The public health work of the
State has, therefore, been exceedingly profitable. In recent
years the work has been greatly hampered for lack of money
to properly distribute about the State the information neces-
sary for the people to have in order to make the restriction of
diseases as effective as it would be if all the people could be
taught to cooperate in the work ; nevertheless the results are
very gratifying.
Clinic Instruction In Infectious Diseases at London. — According to
the London Lancet for September 5, the facilities for clinic
study at the public infectious disease hospitals has been mate-
rially improved during the past few years. It says that while
the importance of such study in the regular curriculum of
undergraduates has long been recognized, but it is only within
recent years that proper facilities have been afforded for taking
advantage of the valuable material to be found in the fever
hospitals of the Metropolitan Asylum Board. "In former
years the student had but few opportunities of becoming
familiar with this branch of medicine, and it was by no means
an unheard-of event for a student to complete his career with-
out having seen half a dozen cases of infectious disease. That
there is still evidence of the state of affairs which formerly
obtained may be gathered from the fact that during 1895 no
fewer than 1,277 patients, or a percentage on the total admis-
sion into the Metropolitan Fever Hospitals of 7.6, were after
admission found not to be suffering from the diseases mentioned
in the medical certificates upon which they were removed to
hospitals, the percentage of mistakes at the Eastern Hospital
at Homerton being 11 of the total admissions. At the present
time five of the admirable hospitals of the Asylums Board, viz.,
the Eastern at Homerton, the Western at Pulham, the South-
eastern at Deptford, the Southwestern at Stockwell and the
Northwestern at Hampstead, are open under certain conditions
to students and medical practitioners, while instruction in
smallpox is also afforded at the smallpox ships in the Long
Reach near Dartford. A student desirous of taking a course
at one of the board's hospitals, must have completed his third
year and have held the office of clinic clerk and dresser ; he
must then obtain the sanction of the medical school to which
he belongs and pay a fee of three guineas for the first three
months, and one guinea for each subsequent month to the
clerk of the board, from whom he receives a card indicating
the hospital to which he has to be attached. At this hospital
he must attend at stated times for at least two days in the week
for a minimum period of two months, and on the completion of
his attendance he receives a certificate from the medical super-
intendent whose lectures and classes he has attended. While
in the hospital the student places himself under the control of
the medical superintendent and is bound to obey the regula-
tions in force for the prevention of spread of infection. These
rules comprise the wearing while within the hospital wards of
brown holland overalls, consisting of coat, trousers and cap,
which are provided by the board, and the use of what may be
termed a discharge block, which consists of an infected room
where the overalls are left, a lavatory and a theoretically unin
fected room. The students are further required to keep their
hair short and to be efficiently protected against smallpox. A
duly qualified medical practitioner has equally to conform to
these regulations and obtain the consent of the medical super-
intendent of the hospital at which he elects to attend. The
student who attends these courses will obtain a fair knowledge
of infectious disease, which will stand him in good stead in
years to come, while he will also get an insight into the man-
agement of fever hospitals and the methods of disinfection
practiced therein. The provisions in regard to instruction in
smallpox differ somewhat from the above, as it is necessary for
the student to reside for from two to four weeks on the small
pox ships, where he is provided with rations, apartments and
washing at the extremely moderate sum of 12 shillings per
week. The student has to travel to and from the hospital
ships on the ambulance steamer and to furnish himself with a
suit to which he does not attach much value, in order that it
may be disinfected or destroyed at the termination of the
period. If the student can take this course during the summer
we can promise him, as the result of a personal experience, a
most enjoyable and instructive little holiday."
Typboid Fever in Chicago.— The diagram on the opposite page
furnishes a most striking illustration of the relation of typhoid
fever incidence to the character of a water supply an illus-
tration which, as the London Lancet has said of the first sec
tion of this diagram, reflects with mathematical accuracy the
increase and decrease of the degree of pollution in the rise and
fall of the death line. Referring to this diagram in his "notes
and comments" on the September report, the Assistant Health
Commissioner, Dr. Frank W. Reilly, says that up to the close
of September the daily analyses of the public water supply
made by the city bacteriologist, Dr. Gehrmann, and the city
chemist, Mr. Kennicott, show the water to have been "bad"
22.5 per cent, "supicious" 55 per cent, "usable" 10 per cent,
and "good" 12.5 per cent, of the time since the first of the year.
During this period the death rate from the acute intestinal dis-
eases and from typhoid fever -diseases directly related to
impure water — has been higher than that of any other large
city in the country and nearly double that of New York City.
The deaths from typhoid fever began to show a marked
increase in August, 1895. During the twelve preceding
months there had been a total of 455 typhoid deaths, or an
average of 38 per month. In August, 1895, there were 50
deaths ; in September, 76 ;. in October, 90, and during the
twelve months ended Sept. 30, 1896, there have been 751, an
increase over the preceding twelve months of 65 per cent.
Comparing the first nine months of 1895 with the nine months
of this year, the figures are : January 1 to Sept. 30, 1895, total
typhoid deaths, 326 : January 1 to Sept. 30, 1896, total typhoid
deaths, 559 ; increase in 1896 over 1895, 11 per cent. This is
very nearly the death rate per 10,000 of population of the year
1889, immediately preceding the great typhoid epidemic of 1890-
92. That year, 1889, the typhoid death rate per 10,000 of popula-
tion was 4.83. The foregoing figures give a typhoid death rate
of 4.63 for the past twelve months. As compared with deaths
from all causes the comparison is even more threatening. The
past twelve months have been much more healthful than 1889
in every respect except typhoid fever. The total deaths (for the
twelve months) amount to 23,676 or 14.62 per thousand of pop-
ulation. In 1889 the death rate from all causes was 17.56 per
thousand. The present proportion of deaths from typhoid is
3.17 per cent, of the total from all causes. In 1889 it was only
2.67 per cent. As set forth in the August report the un whole
some quality of the water has almost entirely offset the
improved quality of the milk supply during the period, as
shown by the deaths among infants and young children. While
there has been a marked reduction in the deaths of infante
18%.]
PUBLIC HEALTH.
971
ftfKW/lM S*oW|>«» JULFTloK Btjr<ec:|<
3(\HIT<\ny CHARpCTCIt Of W/lTtR SofpLlT ano PtflTHO fflOM TYPHOID fcvrl\ ||4 C^ichqo
Tmccmmr leao to October 189©
under 1 year of ace who drink little or no raw hydrant water,
the reduction of deaths among children over 1 year of age
who do drink hydrant water has been less than lper cent.
For a better understanding of the diagram it should be
stated that the quality of the water is determined weekly from
the combined chemic and bacteriologic findings for each day
during the week. Four qualities are designated: "Good,"
"usable." "suspicious" and "bad ;" and three degrees of each.
When the supply is designated as "good" or "usable" the
samples have shown an entire absence of any quality capable of
producing disease. When designated as "suspicious" or "bad"
the samples have shown qualities, at one or more times during
the week, capable of producing disease. The quality of "good"
is determined by an entire absence of nitrates and nitrites; by
traces only of free ammonia ; by .001 :100,000 or less of albu-
minoid ammonia ; by entire absence of .pathogenic bacteria,
and by a count of bacteria of less than 500 per c.c. The quality
of "usable" is determined by an entire absence of nitrates and
nitrites : by free ammonia not in excess of .004 :100,000 at any
time ; by albuminoid ammonia not in excess of .02 :100,000 at
any time ; by an entire absence of pathogenic bacteria ; and by
a count of bacteria not more than 1000 to the c.c. The quality
of "suspicious" is determined by any presence of nitrates or
nitrites ; by any excessof free and albuminoid ammonias beyond
.004 and .02 respectively ; and by any excess beyond 1000 bac-
teria to the c.c. whether it occurs on one or more days. The
quality of "bad" is determined by the presence of free or albu-
minoid ammonia beyond the above figures and of nitrates or
nitrites ; the presence of pathogenic bacteria and by a count
of bacteria of more than 1000 to the c.c. The first, second and
third degrees of the designated quality is determined by the
more or less continual presence or absence of the factors of
that quality and by the closeness to which the next quality is
approached. The presence of anyone of the factors of quality,
even when the others are absent, designates the quality ; and
if they are all present, if only at one time, the highest grade
of the quality is indicated. In addition to this the average
findings and their relation to one another — with respect to the
proportion furnished by each tunnel to the total supply— are
taken into consideration in the statement of the sanitary qual-
ity of the total supply. The characterization is a matter of
expert judgment and the figures in themselves do not always
indicate the quality.
The highest point, 5.4 of the typhoid death line, during the
week ended February 1, is thus accounted for by Dr. Reilly :
"For several weeks before that ended Dec. 14, 1895, the water
supply had averaged "usable" or "good," as indicated on the
diagram, and the deaths from typhoid fever and from the acute
intestinal diseases were below the average. During the first
17 days of December the precipitation was considerably less
than one half the average precipitation for this month during
the previous 25 years— only .60 of an inch instead of 1.35 inches.
The sanitary character of the water supply improved from the
first degree of " suspicious" during the week ended December
7, to the second degree of " usable" during the week ended
December 14. On the 18th 1. 10 inches of rain fell ; on the 19th
2.66 inches, and on the 20th 1.67 inches, making a total of 5.43
inches in 72 hours or 3.09 inches more than the average total
for the whole month. This excessive rainfall flushed the sew-
age contents of the river and its branches into the lake and
contamination was first noted on the 20th, increasing to the
middle degree of "bad" — pathogenic— during the week ended
December 28. The daily average of deaths from acute intesti-
nal diseases during this week was 2.1. During the following
week (ended January 4) this rate shot up to 8.4 per day —
exactly quadrupled. The typhoid mortality was affected more
slowly — the incubation period being longer — but during the
week ended January 18, this began to rise from a previous
average of 1.65 deaths per day until it reached 5.4 per day dur-
ing the week ended February 1."
With the improved quality of the water, beginning during
this week, the deaths began to diminish, so that between the
weeks of February 22 and April 4, when the water was contin-
uously "good" or " usable," the deaths declined from a daily
average of 3.4 (Feb. 15-22) to 0.5 per day in the week of April
18, and an average of less than 1 per day, for the eight weeks
from April 11 to May 30. The pollution line culminated again
in the week of April 18, since which time it has varied from
972
MISCELLANY.
[October 31,
first degree of " suspicious" to middle degree of "bad," and
the death line has reflected this pollution at the usual interval
—at the end of the diagram averaging 3.4 per day.
Diphtheria and Typhoid Fever in Ohio.— The following are the
cities and towns in Ohio reporting an unusual prevalence of
diphtheria and typhoid fever, since Aug. 1, 1896 : Diphtheria :
Minster, 39 cases, 6 deaths; Gervais, 27 cases, deaths not
known ; Brilliant, number of cases not known ; Byer, 33 cases,
19 deaths ; Conesville, 12 cases, number of deaths not known ;
Five Point, 7 cases, 2 deaths ; New Matamoras, number of
cases not known ; Bucyrus, 18 cases, 2 deaths ; Franklin, 10
cases, 6 deaths ; Ironton, 33 cases, 4 deaths ; Portsmouth, 56
cases, 7 deaths ; Cincinnati, 131 cases, 35 deaths ; Cleveland,
170 cases, 47 deaths ; Columbus, 17 cases, 2 deaths ; Grover
Hill, 15 cases, 1 death ; Marysville, 29 cases, 2 deaths ; Niles,
23 cases ; Springfield, 59 cases, 14 deaths ; East Liverpool, 28
cases, 6 deaths : Troy, 11 cases, 1 death ; Findlay, 14 cases, 5
deaths ; total 23 places, 7.33 cases and 159 deaths. Typhoid
fever : Gibsonburg, 105 cases, 9 deaths ; Lancaster, 28 cases ;
Dyesville and neighborhood, 22 cases, 4 deaths ; Conesville, 35
cases, number of deaths not known ; Haydenville, 9 cases ;
Conneaut, 12 cases, 2 deaths ; Cincinnati, 27 deaths ; Cleve-
land, 40 deaths ; Columbus, 11 deaths ; Youngstown, 104 cases,
11 deaths ; Salem, 16 cases, 3 deaths ; Mansfield, 34 cases, 3
deaths ; Hayesville, 11 cases, 1 death ; total 13 places, 374 cases
and 111 deaths.
Medical Practice Act of Illinois.— Resolutions adopted by the
Illinois State Board of Health, Oct. 6, 1896 i
Whereas, the wise and progressive enforcement by our pred-
ecessors of the Act to Regulate the Practice of Medicine in
the State of Illinois passed July 1, 1877, has resulted in a gen-
eral, but not uniform improvement of the methods of medical
education throughout the United States, and a material eleva-
tion of the standard of professional attainments and ability nec-
essary to obtain the legal right to practice medicine in many
States, thereby securing in such States a better equipped,
more competent and more scientific body of medical men to
the great gain and advantage of the people thereof ; and
Whereas, this latter result has been attained to the fullest
extent in those States where the college diploma is not recog-
nized as final, but only as a qualification for examination by a
board whose members are not connected with, or interested in
any college or teaching institution ; be it
Resolved, By the present members of the Illinois State
Board of Health, with the fullest appreciation of the invalu-
able work of their predecessors, that Medical Education and
the status of the Doctor in Medicine have outgrown the limi-
tations of the Medical Practice Act of 1877 ; now, therefore
be it
Resolved, That said Act should be so amended as to require,
first, that all applicants for the right to practice medicine and
surgery or any of their branches in the State of Illinois, shall
demonstrate their fitness for such practice, through an exam-
ination by a board of impartial, competent and practical exam-
iners, skilled in the various branches of medicine and surgery,
and no member of which board shall be connected or affiliated
with or interested in any diploma-granting college or teaching
institution. Second, that no applicant shall be eligible to such
examination unless the legal possessor of a diploma of gradua-
tion from a medical college in good standing ;
Resolved, That this Board earnestly invite the cooperation
and assistance of kindred boards throughout the United States,
to the end that uniformity of practice may ultimately obtain
in the recognition of medical practitioners in all parts of the
country ; of all reputable medical colleges whose dignity and
usefulness will thereby be promoted ; of the medical profes-
sion of the State, as represented in the various medical socie-
ties, with the view of excluding the incompetent and unworthy
from its ranks ; and of the members of the forthcoming gen-
eral assembly in this effort to protect the health and lives of
citizens of the State. — J. W. Scott, Secretary Illinois State
Board of Health.
SOCIETY NEWS.
The National Sanitary Association. The second annual conven-
tion of this society was held in Brooklyn on October 14 and 15,
Dr. Frederic Jewett, president. Important scientific business
and the inspection of numerous public works important to san-
itary officers in cities occupied the attention of the members to
the full. At the closing session, officers for the ensuing year
were chosen as follows : President, Dr. F. O. Young, Lexing-
ton, Ky. ; vice-presidents, Drs. H. C. McLean, Brooklyn, N.
Y., F. A. Wilson, Meriden, Conn., and C. S. Benedict, New
York ; secretary, T. E. Veal, Esq., Atlanta, Ga. ; treasurer, J.
Hoadley, Esq., New Haven, Conn. ; executive committee, A.
R. Moore, Esq., Brooklyn, N. Y., Drs. F. A. Jewett, Brooklyn,
N. Y. ; Wallace Sibley, Rochester, N. Y. ; Archibald St. George,
Fall River, Mass., and J. Hoadley, Esq. The third annual
meeting was named for October, 1897, at Lexington, Ky.
The Sixty-eighth Annual Congress of German Naturalists and Phy.
slclans. The Congress at Frankfurt opened with over 3,000
members inscribed, among them all the names most famous
in science in Germany ; Virchow, Leyden, Gebhardt, etc. The
Empress Frederic was also present as a member. Some of the
addresses are summarized elsewhere in the Journal. The
proceedings were preceded by laying the corner stone of a
monument to Sommering, a famous Frankfurt anatomist and
physiologist, and, as the German papers state, the inventor of
the electric telegraph.
The Twelfth International Medical Congress. — It is officially
announced from Russia that no distinctions will be made
against Jewish physicians coming to Russia to attend the Con-
gress. All that is necessary is to have their passports visid at
home by the Russian consul before they start, which is the
regulation for all foreign members of the Congress. Instruc-
tions to this effect have been forwarded to all the Russian con-
sulates and embassies.
The American Laryngologicai, Rhlnoiogical and Otologlcal Society.
The following circular has been issued :
New Orleans, Oct. 20, 1896.
My Dear Doctor :— The meeting of the Southern Section of
the American Laryngologicai, Rhinological and Otological
Society will be held in New Orleans, March 3 and 4, 1897.
This date has been selected as it will permit visiting members
to see New Orleans during the carnival season and will enable
them to secure half-rate railroad transportation. We shall be
pleased to have you attend the meeting and to receive from
you the title of a paper, on a subject within the object of the
Society, to be read before the meeting of the Southern Section.
The number of physicians who devote their attention to dis-
eases of the ear, nose and throat has increased so much and
the subjects for discussion have become so extensive that it is
difficult in the time devoted to the annual meeting of the
Society to give the necessary time to many important questions.
On this account, the four Sections of the Society have been
formed, the object of which is to promote the interest of the
specialty during the interval of the annual meetings. A meet-
ing of the Laryngologicai, Rhinological and Otological Society
in the South is a distinctly new enterprise and should be
encouraged. With the active cooperation of the physicians
interested in this work, the carnival meeting of the Southern
Section of the American Laryngologicai, Rhinological and
Otological Society will be an assured success.
Candidates for membership should send their names, properly
endorsed, to Dr. Robt. C. Myles, Secretary, 46 West 38th Street,
Nsw York, or to Dr. W. Scheppegrell, so that they may be
acted upon by the Council of the Society. Very truly yours,
W. Scheppegrell, Chairman Southern Section.
MISCELLANY.
Dr. S. C. Stanton, formerly connected with the Chicago Medical
Recorder, is now editor of the Medical Standard. He is able
and well qualified for the duty.
Promotion. — H. W. Sparks, formerly passenger agent for the
Big Four Railroad, has been appointed traveling passenger
agent, vice C. W. Norris, resigned. Those who remember the
kindess and courtesy extended by this gentleman to the pas-
sengers on The Journal special train to Atlanta, will be
pleased to learn of his promotion.
"Osteo-malacia" Cured by Oophorectomy. — TheGaz. degliOs/i. of
September 27, reports a case of severe and very painful osteo-
malacia cured by Piretti of Naples with a double normal ova-
18%.]
MISCELLANY.
973
riotoiny, which it says should go on record as one of the really
miraculous cures of modern surgery. The improvement was
apparent in a few hours, and it was soon complete and perma-
nent, over a year having passed since then, with progressive
restoration to perfect health.
Death of Children from Hyperthermia. A recent discussion of this
subject brought outseveral cases of apparently healthy children
whose temperature rose suddenly from some inexplicable cause
9 degrees P. . most of them fatal. Prompt cooling measures
are the only means to save such cases. Some ascribed the fatal
result to heart failure. Engel has observed a case of fatal
hyperthermia following a warm ''wrapping" in pseudo-croup,
which produced irregular action of the heart. Dentsch. Med.
WoeK, October s.
The South African Republic and theUeneva Convention. — Informa-
tion has reached this country on September 30 that His Excel-
lency. Mr. Bulaert Van Blockland, envoy extraordinary and
minister plenipotentiary of the South African Republic at the
Hague, forwarded to the Swiss Federal Council in the name
of his government the act of adhesion of the South African
Republic to the convention concluded at Geneva, Switzerland,
Aug. 22. 1864, for the amelioration of the condition of the
wounded of armies in the field. Prior to this the latest act of
adhesion to the Red Cross Association was that of Siam in
July, 1886.
Rare Case of Gallstones. A recent number of the Deutsch.
Med. Woeh. describes a bunch of sixteen gallstones evacuated
in the feces without much effort and no previous disturbances
except a violent brief attack of fever and pain in the abdominal
region two years before. The case was that of a woman of 46
years, who had worn a truss for umbilical hernia for sixteen
years. The bunch of unmistakable gallstones weighed 12.83
grama and measured three by four centimeters. This recalls
Morgagni' ■ observation of a similar conglomerate which weighed
To grams and consisted of sixty stones.
The Dumb Thermometer. The improvement in this thermome-
ter consists in the absence of the scale, which is apt to depress
patients who catch a glimpse of it, realizing the importance of
the temperature recorded. A small case fits over the instru
meat and a scale on this enables the physician to read the ther-
mometer as he slips it inside after leaving the bed. Mendels-
sohn thinks it will be found useful. Dr. R. D. Murray several
years ago recommended the physician, in cases of yellow fever,
to always use the centigrade thermometer, as the general
public in America were unfamiliar with it, and therefore could
view a high temperature without fear.
The Indian Sacrifice.— Under British rule the Suttee, the Jug-
gernaut and other ancient sacrifices of human life have been done
away with among the natives of India. There is another huge
sacrifice that remains to be attacked ; namely, the enormous
waste of the lives of Indian women and children that is con-
stantly going on from want of medical aid. The customs of
the country forbid the women from consulting men upon mat-
ters concerning the health either of themselves or their off-
spring. The same reluctance, however, does not prevent them
going to their priests, who administer most disgusting and
abominable methods of treatment. This should be a good field
for medical women. — Med. Press, September 30.
Special Hernias in Women.— Waldeyer (Centalbl. f. Gyndk.,
X<>. 30, 1896) demonstrated at a meeting of the Berlin Obstet-
rical Society some important anatomic researches as to the
position of the ovary and other pelvic viscera. He maintains
that the ovary lies in a shallow pit, which is really a triangle of
peritoneum elevated at its margins, formed by the round liga-
ment, the umbilical artery and the ureter. This pit is some-
times very shallow, but it may be very deep, so that the ovary-
lies in it practically in a state of prolapse, and the peritoneum
may even form a hernial pouch, which has been found project-
ing into the lesser sciatic foramen or into the greater, either
above or below the border of the pyriformis. Waldeyer exhib-
ited an incipient hernial pouch of this kind. He likewise
showed an inguinal hernia containing the Fallopian tube, and
a pelvis with a defect in the symphysis pubis, into which a
diverticulum of the bladder had forced itself.
Mixed Clinical Classes. — The announcement that Mr. Jonathan
Hutchinson has been compelled to exclude ladies from his
popular clinical afternoons on account of the unwillingness of
the male patients to undress before them is full of significance.
It is greatly to be regretted that this course should have been
deemed necessary, for it places yet another obstacle in the way
of the acquisition of clinical knowledge by women. Doubtless,
in the near future, the public will become as accustomed to
women as clinical observers as to women cyclists, and will aban-
don foolish protests against the one as they have ceased to
objurgate the other. — Med. Press, September 30.
Bequests to Medical Charities.— The contest over the will of the
late Thomas T. Wyman of Boston, by which $400,000, beside
the residue of his estate, which is said to amount to $472,319,
is left to various public charities, has been settled out of court.
The will was contested by certain relatives, and it is stated
that the amount given to effect the compromise will only
slightly diminish the residue of the estate. The following
medical charities receive $20,000 each : The Emergency Hos-
pital, the Cambridge Hospital, the New England Hospital for
Women and Children, the Boston Lying-in Hospital, the West
End Nursery and Infant's Hospital, the Children's Hospital,
the Massachusetts Charitable Eye and Ear Infirmary, the
Sharon Sanitarium, the Boston Home for Incurables, the Con-
sumptives' Home, the Carney Hospital and the Perkins Insti-
tution and Massachusetts School for the Blind. The residuary
legatees are the Massachusetts General Hospital, the Boston
City Hospital and the Massachusetts Homeopathic Hospital.
The Agglutinating Substance in Typhoid Serum.— It is announced
as the results of the study of the peculiar agglutinating
properties possessed by typhoid serum (which is now a fully
established fact) that the albuminoid substances, fibrinogen,
globulin or casein, isolated from the fluids of a typhoid
fever patient by certain processes (described in the Bulletin
de V Aeadimie de Midecine, September 29) take away with
them the agglutinating property and retain it at least to
a certain degree. They lose it in solution and recover it in
their precipitate. This fact is interesting not only to the
physician but to the chemist, who may find in this aggluti-
nating property some new reaction for the difficult study of
albuminoid substances. Others have discovered the same
property in the serum in "proteus" infections.
Normal Physiologic Standards in Mexico. , It has been found
that the atlases and charts published abroad and accepted as
the standard of the normal individual do not apply to Mexico.
Vergara de Lope announces that in his investigations the char-
acteristics of the urine, for instance, differ from those in other
countries : it is more concentrated, less in quantity and lighter
colored. He ascribes the two former to the effect of the alti-
tude on the intra- vascular arterial tension, as the tension of the
blood diminishes with increased rarefaction of the atmosphere.
He does not attempt to explain the lighter color, merely
remarking that the hematic pigment, which some consider the
cause of the coloration of the urine, is present in this concen-
trated urine to excess and, therefore, the cause of the lack of
coloration must be sought elsewhere. — Revista Quincenal,
September 1.
When Licensing of Milkmen not Authorized.— Where it is doubt-
ful, after giving full force to all the provisions of a city's char-
ter, whether the charter authorizes the licensing of milkmen
974
MISCELLANY.
[October 31,
the supreme court of errors of Connecticut holds, in the case
of State v. Smith, decided May 14, 1896, that it does not
authorize it. To illustrate : The charter of the city of Bridge-
port authorized the common council to make ordinances, not
inconsistent with law, relative to commerce; to the inspection of
produce brought into the city for sale and the election of inspec-
tors for that purpose ; to the sale or offering for sale of unwhole-
some produce of all kinds; to "licensing cartmen, truckmen,
hackmen, butchers, bakers, petty grocers, or hucksters and com-
mon victualers, under such restrictions and limitations as said
common council may deem necessary and proper" to the health
of the city ; and to "any and all other subjects that shall be
deemed necessary or proper for the protection and preservation
of the health, property and lives of the citizens." Here the
court does not find authority for an ordinance excluding every
one who has not received a license from the local health
officer from participating in the business of a milkman within
the city when the public statutes leave it open to all on equal
terms.
Convicted of Being an Unregistered Druggist. The defendant in
the case of Queen v. Simpson, according to a report in the
Canada Laic Journal, being owner of a large departmental
store, was charged with keeping open shop for retailing, dis-
pensing and compounding poisons contrary to the law of the
Province of Ontario. It appeared that part of his store was set
apart for the drug department and was under the management
and control of one Lusk, a duly qualified and certified chemist,
registered under the pharmacy act, who dispensed the drugs,
giving bills for the same on which defendant's name was
printed, and on some of which his own name was also printed
with the word "druggist" under it. The defendant was never
inside of the drug department nor interfered with the conduct
of the business. Lusk purchased all the drugs on his own
judgment, but with the defendant's money, who received the
proceeds, Lusk receiving a certain portion for his remuneration
under agreement with the defendant. Under these circum-
stances, the high court of justice of the Province of Ontario
held June 16, 1896, that the matter must be remitted to the
magistrate (who had dismissed the information) with instruc-
tions to convict the defendant.
Formation of Urobilin. — The conclusions of an article on this
subject in the Brit. Med. Journal, October 3 are as follows :
1. The bile pigment present in the upper part of the small
intestine during its passage along the alimentary canal is con-
verted into some colorless chromogen, to be again converted
in the lower part of the small intestine into bile pigment. 2.
Urobilin is, as a rule, formed in the large intestine below the
ileo cecal valve, and only rarely in the small intestine ; that is
to say, only in those parts where the intestinal putrefaction
is most active. 3. The staining of the wall of the cecum and
large intestine with urobilin is due to postmortem diffusion,
and is not any indication of the absorption of urobilin in the
living animal. Why it should in some cases be most marked
in the cecum and just below the cecum, and not in the rec-
tum, can only be explained by the fact that those parts are
generally found in the postmortem room more decomposed
than the rectum. 4. The increase of urobilin in the urine, as
well as having pathologic significance— as has been already
recognized in cases of internal hemorrhages, such as cerebral,
peritoneal or hemorrhagic infarctions and extrauterine preg-
nancy, and probably when red blood corpuscles are being
destroyed, as in infectious fevers, scurvy and pernicious
anemia— points also in favor of increased intestinal putrefac-
tion, and may be a useful chemic test for such purpose.
Photograph Evidence. — In an action to recover damages from a
city for injuries sustained through a fall alleged to have been
occasioned by an inequality that had been negligently allowed
to exist in a sidewalk, where the defense of contributory negli-
gence was pleaded, it was contended by counsel for plaintiff
that photographs of the place where the accident occurred
should not have been admitted in evidence. He argued that
they did not tell the story told by the human eye, or in
other words, that the picture they made to the apprehension
was not the picture (of the obstruction in this case) made to
the mind by the eye. One of the illustrations used to show
how little analogy there is between a photographic plate and the
retina of the human eye, and that the imaging capacity and the
character of the imaging performance of the former afford no
just criteria of the imaging capacity and performance of the lat-
ter, was that the skin of the human face, which under the micro-
scopic inspection of a physician is smooth and absolutely free
from eruption, under the pitiless revelation of a photographic
plate may be found to be dense with the pustules of smallpox.
But the United States circuit court of appeals does not feel
that it can concur fully in this view of the question, holding,
instead, that the trial court did not err in overruling the objec-
tion, and in considering the objection as going to the effect of
the testimony, and not to its admissibility. Scott v. City of
New Orleans, decided June 9, 1896. At the same time, it
acknowledges there is much force in the suggestions of the
counsel, and says that touching the effect of this testimony the
jury should be fully and carefully instructed, and warned
against its liability to mislead.
" Douglasitis." — This is the name given by Condamin to the
chronic inttammation of the recto uterine cul-de-sac, which
differs from Schultze's posterior parametritis, as there is none
of the tendency of the latter to cause retraction and afterward
extension of the sacro- uterine ligaments, and thus favor retro-
version of the uterus. Douglasitis is usually consecutive to
salpingian lesions, but it also occurs as a primary affection, as
Condamin has found in the course of four laparotomies. Repose
in the dorsal decubitus alleviates the pain of douglasitis much
more readily than of salpingitis, and this is one means of diag-
nosis. It is characterized by the multiplicity of the lesions,
which can be palpated through the vagina by inserting the
middle and index fingers, when not only the sacro uterine liga-
ments can be distinguished, but a number of small attach-
ments, traversing in every direction the floor of the recto-
vaginal pouch. It is treated with massage, and systematic
distension of the vaginal cul-de sac by means of tampons (col-
umnization), but if it does not yield to simple methods, and if
there are diseased appendages, laparotomy is indicated, and
after detaching all the adherences, etc., an anterior abdominal
hysteropexy, to prevent the uterus from becoming displaced.
— Lyon Mid. , September 27.
Absorption of Medicines by the Vagina. — In 1886, at the annual
meeting of the Mississippi Valley Medical Association, Dr. I.
N. Love read a paper with the title " Artificial Alimentation
and Medication," wherein he gave clinical evidence in favor of
the vagina being made available (where the conditions would
permit) as a medium for the administration of medicines and
predigested food. Ten years' additional experience has
strengthened him in his views, and they are confirmed by a
recent article in the Collegione Italiano di Litture sulla Med.,
No. 2. It states that in one hour after the insertion of a tam-
pon saturated with a 20 per cent, solution of potassium iodid
the urine contained iodin, the maximum of elimination being
twenty-four hours after application, and in forty-eight hours
no trace of iodin is found. In the fever patients the absorp-
tion was very rapid, while in the hysterectomies it was not
altered. Iodoform is absorbed in small quantities, commenc-
ing seven hours after application and lasting twenty-four hours.
To secure rapid absorption the vagina should be insufflated
with fresh iodoform, which should be allowed to remain several
days. Salicylic acid is rapidly absorbed in large quantities,
appearing in the urine in one hour and disappearing in twenty-
1896.]
MISCELLANY.
975
four hours. Salol is also rapidly absorbed, and remains for a
long t lino traceable in the urine. Antipyrin is also rapidly
absorbed, appearing in the urine one and a half hours later,
and remain! for fortjr-eight hours: but the antipyretic power
la less than when administered by the mouth. The conclusions
reached here are, in general, that the vagina undoubtedly has
absorptive powers, and that these powers are increased in
pregnancy and in the puerperal state and in the fevers.— Medi-
cal Mirror, September.
Improvements la Antitoxin, Behring stated at the recent Con-
gress of Naturalists and Physicians, that the inconveniences
which sometimes follow the use of antitoxin are due to the
serum it contains, rather than to the antitoxins, as they are
produced as frequent ly by injections of the serum alone. Con-
sequently he is striving to manufacture antitoxin in as concen-
trated form and with as little serum as possible. It will soon,
therefore, be more accurate to designate it antitoxic therapeu-
tics, instead of serum. Knoll's investigations have established
the fact that the blood assimilates the entire amount of anti-
toxin injected, and that it is not taken up by the corpuscles,
but by the Huid elements of the blood/ The antitoxins thus
assimilated gradually vanish out of the blood again, until in
eight days they are reduced to a tenth, and by the end of the
third week they have almost entirely disappeared. Behring
asserts, therefore, that they positively confer immunity for at
least three weeks, and not longer than eight or ten. It is a
curious fact that the length of the period of immunity is fixed,
and does not vary with the quantity of antitoxin injected.
The conclusions of a recent critical and experimental study of
the effects of antitoxin on the organism, by Poix in the Presse
Mi'il. of October 3, confirm Behring' s statement that the acci-
dents following the use of antitoxin are due to the serum and
not to the antitoxins. Poix warns against its use on tubercu-
culous patients, as serious congestions, etc., are liable to follow
in these cases. Behring' s resignation of his professorship at
.Marburg was not accepted, but he was given an extended leave
of absence. Beside the Hochst factory where the antitoxin is
produced for sale, he has his private institution at Marburg,
devoted to strictly scientific research, and the "standardizing "
institute in charge of Professor Ehrlich, which is under gov-
ernment control. — Therap. Woch., October 4.
Louisville.
Annual Mortality Report.— The report of Health Officer
White for the past year contains much that is of interest. He
reports a total of 3,295 deaths, the death rate per 1,000 based
on a population of 211,100 being only 15.5; death rate of
whites, 14, and of colored 22.7. The report shows for the first
time the prevalence of the contagious diseases as it is the first
year that the reporting and placarding of these cases has been
observed. There were 137 cases of diphtheria with 72 deaths,
a mortality of 52.5 per cent. There were 238 cases of scarlet
fever placarded, with four deaths. There were 2,283 vaccina-
tions reported, 724 diseased cattle were killed and 4,514 dis-
eased cattle condemned and sent out of the city. There were
225 stillbirths. Consumption caused 370 deaths, typhoid fever
131 deaths, pneumonia 269; whooping cough 11. Of the total
number of deaths 565 were under 1 year of age and 898 under
5 years of age. Two thousand, four hundred and forty-three
were white. 852 colored ; 67 more male than female.
Cincinnati.
The Cincinnati Hospital has again broken into the editor-
ial colums of the daily press and the present management is
severely criticised for the manner in which the institution is
being run. During the past few days several women have
escaped from the hospital and the last two give as an alleged
reason for their action that they were almost starved. The
much promised reforms have so far failed to materialize. The
Board of Trustees have passed a resolution to ask the next I
legislature to appropriate 850,000 to make necessary improve-
ments, the Board also refused the request of the Board of the
Eclectic Medical Institute to allow their students to witness
the operation (free of charge) on patients sent by the college.
At the first meetino of the Academy of Medicine, Dr. J.
C Oliver read a paper on the " Surgical Treatment of Epi-
lepsy." He considered the operative treatment warranted in
only a very small percentage of cases. This week Dr. R. C.
Hill read a paper on " Intestinal Polypus as a Cause of Death."
The mortality report for the week shows : Zymotic dis-
eases 11 ; constitutional diseases 19 : local diseases 36; devel-
opmental 10 ; violence 3 ; under 5 years 22 ; from all causes 79 :
annual rate per 1,000, 11.73; preceding week, 93; correspond-
ing week 1895, 99 ; 1894, 87 ; 1893, 93.
Dr. Albert Snell has been arrested on a warrant sworn
out by Dr. Frank Winders, secretary of the State Board of
Medical Examiners, charging him with violation of the medical
practice laws. This is the first arrest under the new law.
The State Board of Health of Indiana have ordered all
health officers of the State to provide themselves with a long
glossy linen duster and skull cap to be carried in a separate
bag and to be worn whenever they enter a building when any
contagious disease exists.
A case of hydrophobia recently developed in Columbus,
Ohio. The patient was bitten by a dog last July while attempt-
ing to give the animal, which had been bitten by another dog,
some medicine. For several hours before the man died it be-
came necessary to strap him to his bed.
Suit forfalse Committment. — A woman residing in Colum-
bus has recently entered suit against Dr. W. F. Scatterday for
85,000, alleging damages to this amount as a result of her com-
mitment in an insane asylum by the doctor, who was her phy-
sician. She claims she was sane at the time.
Washington.
Health of the District— The report of the health officer
for the week ended October 17 is as follows : The death rate
during the past week stood at 21.48, as compared with the
average rate of 23.53 and with 26.80 in the same period last
year. The deaths reported to the health department num-
bered 116, of which 60 were white and 56 colored. As com-
pared with the late preceding weeks there was a slight decrease
in the chronic brain, heart and kidney disorders, and in diar-
rheal complaints. In those of the lungs and of children under
5 years old there was an increase. Of diphtheria five deaths
occurred, and none of scarlet fever. The general health of
the city, as indicated by the causes of mortality presented the
same average above the normal as has prevailed throughout
the fall months, the death rate running from 2 to three below
the annual average per 1,000 inhabitants. The new cases of
diphtheria were 12, houses released from quarantine 8 and
those left placarded 31. Of scarlet fever one new case reported,
2 houses released from isolation, leaving 5 placarded.
District Medical Society- Toner Memorial Meeting. —
At the regular meeting of the Medical Society held on Octo-
ber 21 all regular business and papers were suspended and the
meeting made a memorial one in honor of the late Dr. Joseph
Meredith Toner. The meeting was called to order by Dr.
S. C. Busey, the president, who began the exercises by a most
interesting life sketch of Dr. Toner and closed his remarks by
paying high tribute to his memory. Drs. W. W. Godding,
Charles H. A. Kleinschmidt and J. D. Morgan read interesting
addresses in his praise. The papors read at the meeting will
be published and distributed among the profession upon appli-
cation.
Adverse Report on a Dental College. — A special com-
mittee consisting of Drs. W. P. Carr, J. Ryan Devereux, Clif-
ton Mayfield, B. F. Odell and Henry Noble, appointed by the
commissioners to examine the standing of the proposed Wash-
ington College of Dental Surgery, which has applied for a
976
MISCELLANY.
[October 31,
license to do business in the District, has submitted an adverse
report. All the committee except Dr. Odell signed the report,
which says : "The college is just such an institution as the
law proposes to keep out of existence. It has no endowment
or building, and its total plant is valued by the incorporators
at $1,000. The faculty have not demonstrated any ability to
teach, except in the National Homeopathic College, which
was ruled out of existence by Judge Miller. Two members of
this proposed faculty were members of its facultv. Members
of the faculty of the proposed college admit that it is based
upon the Washington Homeopathic Medical College dental
department, whose plant they purchased and a majority of
whose faculty they have absorbed, but proclaim their inten-
tion of raising the institution out of the metaphorical mud
into which they admit it has fallen. Their course and actions,
however, when connected with the Washington Homeopathic
Medical College dental department, and theft* present attempt
to justify that course render it, in the opinion of your commit-
tee, extremely improbable that they will make any serious
effort to do so, while their lack of endowment, lack of sufficient
appliances and lack of eminent reputation preclude such a
possibility, even in the face of earnest effort. None of the
members of the proposed faculty belongs to any reputable
medical or dental society or association, regular or homeo-
pathic, except one, who is now under investigation by the Den-
tal Society of the District of Columbia for unprofessional
conduct. We would, in conclusion, call attention to the fact
that Dr. Odell, who was appointed on this committee, is also
a member of the proposed faculty, and that while he was
present at our most important meeting, he declined on the
ground that he could not pass upon his own character, to sign
any report of this committee."
Philadelphia.
The Mutual Aid Association of the Philadelphia County
Medical Society will hold its annual meeting on November 9,
at the residence of the president, Dr. John C. Da Costa. The
eighteenth annual report will then be presented by the treas-
urer, Dr. Geo. B. Dunmire. The total amount of money now
at interest is $12,889.63, an increase of $1,103.&3 since the last
report. The members of the Association number 122, of whom
87 are life members. The Association has two annuitants, one
widow and one orphan daughter under its care.
The Medical Schools opened their doors on the first of this
month with an increase in the number of matriculants over
last year. Provost Harrison of the University of Pennsylvania
formally opened the several departments. He referred partic-
ularly to the new Dental Hall and the dormitories among the
evidences of progress since last year. Dr. W. M. L. Coplin,
the newly elected professor of pathology and bacteriology at
Jefferson College made the introductory address. At the
Medico-Chirurgical, Dr. Isaac Ott opened the session with a
lecture on Claude Bernard and recent advances in physiology.
Dr. Elizabeth R. Bundy delivered the address before the stu-
dents at the Woman's Medical College, particularly impressing
upon them the importance of hygienic living and the evils of
over study, and spoke on the baneful results of a resort to
bromidsor to narcotic drugs or the caffeinbearing preparations.
She incidentally paid a well deserved tribute to the bicycle as
a means of outdoor exercise for women and as an incentive to
more rational dress.
The College of Physicians held its first fall meeting on the
3d inst, the president, Dr. J. M. Da Costa, in the chair. Dr.
William J. Taylor and Dr. Chas. W. Burr read a paper entitled
"Report of a Case of Tumor of the Medulla Oblongata." It
was remarked that the symptoms during life were insufficient
to establish the diagnosis and the lesions found at the autopsy
did not entirely explain the paralysis. The patient was a
woman, 55 years of age, who after some loss of power in the left
arm and leg, complained of headache and double vision, with a
tendency to fall to the left when walking. Examination of the
eye-ground proved negative. The loss of power gradually
became more marked until paralysis became complete on the
left side. She then had an attack of pneumonia and died in
convulsions. The urine contained neither albumin nor sugar.
On removing the skull cap, the brain appeared at first to be
normal, but on closer examination a growth was discovered
involving the medulla, especially on the right side, projecting
between the lobes of the cerebellum. The tumor was found
to be a sarcoma. It was strange that with so much pressure
on both sides of the medulla, that symptoms should have
been produced only on the left side of the body. The Sec-
tions of the College have all opened their winter sessions with
interesting meetings and active discussions. Dr. B. C. Heist
read a paper before the Section on Gynecology, October 15,
on "Technique in Cresarian Section," Dr. Sprengle read a com-
munication on "Prolonged Pregnancy," and Dr. Chas. B.
Penrose one on "Hysterectomy by Combined Operation through
the Abdomen and Vagina." Before the Surgical Section, Dr.
Randolph Faries described a "Modified Form of Anteroposter-
ior Brace for the treatment of Pott's Disease." A death dur-
ing the administration of ether was reported by Dr. Jos. M.
Spellissy. Dr. John B. Roberts demonstrated a "Successful
Operation for Cleft of Hard and Soft Palate," by the case of
a patient. Dr. J. William White and Dr. Alfred C. Wood
reported on "Some Recent Cases of Renal Surgery."
The Philadelphia County Medical Society has been pros-
pering under the presidency of Dr. James C. Wilson. At the
meeting on the 14th inst. Dr. F. W. Talley read a paper on the
"Proper Position of Celio hysteropexy in Gynecology;" Dr.
A. O. J. Kelly reported four cases of "Essential Paroxysmal
Tachycardia," and Dr. Chas. W. Burr read a paper on "The
Relation of Anemia to Chorea," in which any causative rela-
tion was denied, and the opinion expressed that when con-
currence existed, it might be accidental or the anemia might
be due to the chorea or to the causes which produced the
neurosis.
Mr. William Macewen of Glasgow was recently entertained
by a series of lunches and informal receptions, and received
considerable attention during a recent visit to this city. He
expressed special interest when inspecting the new wards and
recent improvements in the Pennsylvania Hospital, which is
the oldest general hospital in this country.
Detroit.
The Michigan College of Medicine and Surgery opened
with 100 students. A building has been procured in addition
to the college which will be used for extra clinics, general med-
icine and skin diseases. There has also been lobby rooms fitted
up for the students. Dayton Parker has been elected to fill
the chair of gynecology, vice E. W. Jenks, resigned, and W. J.
Brand to lecture on anatomy.
At the Annual Meeting of the Detroit Medical and Library
Association held October 5, the following officers were elected :
President, H. W. Longyear : vice-president, Frank H. Walker ;
secretary, P. C. McEwen ; treasurer, A. P. Biddle ; librarian,
Wm. C. Stevens. After the election of officers, E. T. Tappey
entertained the members of the society with a banquet.
At the Regular Meeting of the Detroit Medical and Library
Association held October 12, H. O. Walker presented some
pathologic specimens, among the number being an ulcerated
appendix with a fistulous opening. The case was one of a his-
tory of several attacks, a suppurating kidney in which he had
done a nephrectomy, also about twenty gallstones, for which
the day before he had made the operation of cholecystotomy.
Each of the patients was doing well at the time of the report.
Theo. A. McGraw read a paper on "The Utility of Omental
Splints in Intestinal Surgery," in which he said that he felt
warranted in bringing the procedure before the profession for
discussion on account of its importance. He also drew atten-
1896.]
MISCELLANY.
977
tion to the fact that the omentum i8 extremely mobile, that it
can be drawn to any part of the intestinal tract that is covered
with peritoneum. He Baid that in certain diseases it becomes
atrophied and in some persons is quite small, and especially
was this so in tubercular subjects, where we find at the autopsy
but a small remnant of the omentum. The Doctor said that
what was characteristic of all peritoneal membranes was also
so of the omentum, the short period it takes to fasten itself to
any irritated surface and so acts as a bearer in preventing intra-
peritoneal suppurations from becoming diffused, and that local-
ized abscesses are frequently found in which the omentum has
been the means of holding the walls intact, that a piece of
Omentum applied over an intestinal fistula will after twenty-
four hours make a strong obstacle to the discharge of feces,
and what is very desirable, this omental splint is very tolerant
to its surroundings, also that the practical value of the omen-
tum splint is its application in wounds and fistula of the large
intestine, and that it made a safe union in operations on this
viseus. The essayist called attention to the fact that inflam-
mations of the appendix are liable to result in suppuration
which invades the connective tissues behind the gut ; that an
abscess also acted in the same way and might affect a large
portion of the intestine. When a bowel under such circum-
stances became torn or ulcerated through, its repair was excep-
tionally difficult. He found that Lembert stitches in that
region were out of the question, as there is no peritoneum in
these desperate cases. There were only two successful proce-
dures, one of which is the resection of the affected portion, and
the other the closure of the fistula by an omental splint. He
reported two cases which he had had at St. Mary's Hospital.
Mr. C., aged 24 years, entered St. Mary's Hospital .Ian. 1, 1895,
with a suppurating appendicitis. The abscess was opened, and
on leaving the hospital after recovery, he was cautioned to
return at once for operation if there should be any recurrence.
On November 26 he returned with renewed inflammation in
that region, the appendix was removed and the adhesions
broken. There was no rise of temperature or sepsis, but on
the third day there appeared some thin feces on the edge of
the wound, and it became necessary to remove the stitches.
The discharge of feces from the wound increased daily in quan-
tity, and soon there was an opening in the gut the size of one's
little finger. Practically no feces passed through the rectum
and anus. Lembert stitches for this false anus were out of the
question on account of the absence, over a large area, of both
muscular band and peritoneum. An incision was made in the
peritoneum over the gut to the extent of 212 inches, through
which cut the omentum was drawn out and fastened with
sutures all around the exposed part of the bowel, tucking well
down behind and under the intestine. On the next day he had
a normal evacuation of feces. That which could not be accom-
plished by purgatives or enemata took place spontaneously, as
soon as the mechanical integrity of the bowel was restored. A
man aged 39 years entered St. Mary's Hospital Dec. 11, 1895,
with chronic appendicitis. On December 13, the appendix was
removed and the wound closed. A month later the wound
reopened, fecal matter began to pass through it, and on his
return to the hospital he was too weak for operation. About
three weeks later, his general condition having improved, the
abdomen was again opened. The omentum was then brought
down and wrapped in a large fold around the diseased bowel,
and fastened with sutures to the neighborhood of the wound,
so that the wound was completely enveloped by it. Three
weeks later he was sent home completely cured of his fecal
fistula. From these two cases it must be conceded that the
value of omental splints under these conditions is obvious, yet
Dr. McGraw said that he should lay it down as a rule that,
whenever a lesion of a large intestine demanded a suture, the
line of union should, if possible, be supported by a thick layer
of omentum, but that in wounds of the small intestine, this
procedure was not necessary, although he would feel more safe
from accident with this additional safeguard.
The Wayne County Medical Society at its annual meeting
October 1, elected the following officers : President, Geo. E.
Frothingham ; vice-president, Lewis E. Maire ; secretary. J.
K. Patton ; treasurer, C. Henri Leonard; board of directors,
E. B. Smith, Frank S. Hough, T. J. Parker, O. P. Eaton and
Kenneth Gunsolus. On the same evening the retiring presi-
dent, E. B. Smith, read his annual address, after which the
retiring secretary, Frank S. Hough, presented his report, which
was approved. At the regular meeting of the Society October
8 (memorial night), E. B. Smith read a biographic paper, tak-
ing up the lives of Wm. Brodie, who had been president of the
Wayne County Medical Society a number of years, Henry F.
Lyster, S. D. Richards, C. J. Lundy and August Kaiser, all of
whom had been prominent members of the above society.
Annual Report of the Surgeon (ieneral of the Navy.— Surgeon -
General Tryon, chief of the Bureau of Medicine and Surgery,
has submitted his annual report to the Secretary of the Navy.
Estimates have been submitted for two ambulances for use at
the naval hospital at Portsmouth, N. H., and Mare Island, Cal.,
where they are urgently needed.
' ' The cemeteries of the several naval hospitals have had very
little done for them since the war, and in no way creditable to
government establishments," says the Surgeon-General.
"Special appropriations will be required for each one to
place them in a condition that they can be cared for in the
future by the hospital force.
"Attention is again called to the necessity of providing im-
proved accommodations for the sick and wounded on board
vessels of war, and to the assignment, when practicable, of
sufficient space on the gun deck for hospital purposes."
The Surgeon General says that the passage of the bill organ-
izing the army hospital corps has already proved of great bene-
fit to the militia of the different States, and the passage of a
similar bill for the navy would also be advantageous to the
naval militia, now being rapidly organized.
AMBULANCE OB HOSPITAL 8HIP8.
A strong argument is made for ambulance or hospital ships
specially fitted up. Considerable attention is now being paid
to the construction of such vessels abroad, and it is universally
conceded that they should be designed and built for this par-
ticular duty, and considered an essential part of the fleet of
war.
The health of the navy is reported as good. The care and
comfort of the sick and wounded of the navy have been much
improved by the adoption of irqn swinging cots for sick bays of
all vessels, and the establishment of an ambulance service at
the naval hospitals at Chelsea, New York, Philadelphia and
Norfolk.
FOOT BALL AT ANNAPOLIS.
In a short chapter about the Naval Academy, the Surgeon-
General says :
"The good health of the station has been maintained
throughout the past year. There were nineteen admissions,
involving sixty-one sick days, for injuries received at the game
of foot ball, and ninety excuses from drills from the same cause.
The injuries consisted of one luxation, two fractures of bones,
one inguinal hernia, two cases of concussion of the brain, and
a number of minor sprains and contusions.
" Attention is called to the unsuitable character of the acad-
emy buildings, many of them being badly ventilated, unsatis-
factorily lighted and heated, and some of them in a condition
almost beyond repair.
"The sewerage system of the academy is defective and unsat-
isfactory, and proper means should be adopted for carrying the
sewage into deep water at some distance from the academy
grounds.
IDENTIFICATION OF RECEUITS.
In regard to the identification of recruits, the Surgeon- Gen-
eral says :
" In consideration of the effect upon the discipline and gen-
eral tone of the enlisted force of the navy, the importance of
preventing deserters and dishonorably discharged men from
re entering the service has caused the question of the identifi-
cation of such undesirable persons to be carefully investigated.
" The anthropometric system of M. Bertillon presents the
advantages over other methods of conformity to scientific
requirements and capability of indefinite expansion.
978
MISCELLANY.
[October 31, 1896.]
"The system employed by the United States army is a mod-
ification of the above, in which personal marks or characteris-
tics take the place of anatomic measurements, and since its
adoption in 1889 has been attended with excellent results, as
shown by the detection of a large number of deserters and the
progressive diminution in the number of undesirable candi-
dates presenting themselves for enlistment."
The bureau is at present considering some plan of combining,
modifying and selecting from these two systems a method
especially adapted to the requirements of the naval service.
VACANCIES IN THE MEDICAL CORPS.
The continued impossibility of filling vacancies in the medi-
cal corps is reverted to by Surgeon-General Tryon in the fol-
lowing words :
The record during the last fiscal year is nearly a repetition
of the figures presented in the last annual report. There were
341 applications made to the department for appointment as
assistant surgeons in the navy. Out of the number only
thirty-six applied for permission to appear before the naval
medical examining boards.
Of the 36, 22 availed themselves of the opportunity to appear
before the boards, and of this number there were 1 rejected
physically and 12 rejected professionally leaving only 6 out of
the 311 original applicants, representing every section of the
country, who were found qualified for appointment as assistant
surgeon.
This state of affairs has existed for years, and will undoubt-
edly continue until there is some favorable legislation for junior
medical officers of the navy.
At this date there are 10 vacancies in the grade of assistant
surgeon, and the bureau is embarrassed by not having a suffi-
cient number of medical officers to fill important stations
ashore and afloat.
Many ships and hospitals are kept without their legitimate
quota of officers, and, unless this is in some way speedily rem-
edied, by reason of increase of men in the navy and number of
new ships placed in commission annually, serious conse-
quences must follow. On account of the great number of
vacancies existing and the probability of the number increasing
instead of diminishing, it is strongly urged that the recom-
mendation contained in the bureau's letter addressed to the
department on the subject, dated Feb. 8, 1896, be approved,
that "a special law be enacted authorizing the Secretary of the
Navy, during the present exigency, to appoint acting assistant
surgeons for temporary duty in the navy until the number of
vacancies in the regular medical corps of the navy are filled."
When this is accomplished, their services can be dispensed
with and no further appointments made, except in time of war
or until additional vacancies occur in the assistant surgeons'
grade.
In regard to local institutions, Surgeon-General Tryon says :
WASHINGTON NAVY YARD.
The sanitary condition of the yard during the past year has
not been satisfactory. During the summer and autumn
months malarial fever of a severe type prevailed extensively, a
large proportion of the cases being of a remittent character.
During the year there were 250 admissions and 48 readmissions
to the sick list. Of this number 216 returned to duty and 79
were transferred to hospital.
There was a loss of 1,021 days from sickness, due principally
to the large number of cases of malarial fever.
Reports have been received that apprentices transferred
from this yard to other stations all suffered from attacks of
malarial fever, undoubtedly due to climatic exposure while
undergoing instruction at the yard.
MARINE HEADQUARTERS.
The health of the post has been satisfactory during the past
year except that in the months of September, October and
November an unusually large number of cases of malarial
fever prevailed, which undoubtedly was caused by the insani-
tary condition existing at the navy yard, which was made the
subject of a report by a sanitary board to the department in
May, 1895.
Beyond some minor improvements in the introduction of
modern water closets and bath tubs, there has been no change
in the general sanitary condition of the post.
NAVAL HOSPITAL.
No material changes have been made during the past year in
the hospital grounds. The paving of 10th street east which
has been commenced, will add much to the comfort of the hos-
pital patients. The hospital is now being furnished with a
modern operating room, properly equipped for the perform-
ance of operations, and it is hoped that it will be completed at
an early date.
The necessity for increased accommodations for the sick at
this establishment is apparent.
The records of the hospital for the five years 1891 to 1895,
inclusive, show 36 admissions of officers, with a total of 1,265
sick days ; other admissions, sailors and marines, number 528.
Patients are supplied to this hospital chiefly by the navy yard
and marine headquarters, but from time to time they are
transferred here fr,om other hospitals, from coast-survey ves-
sels and from other vessels, foreign or belonging to our own
navy, which may be in port ; also old sailors and marines on
the retired list who have no suitable home and when taken ill
find a refuge here.
The officers attached to the navy yard and marine head-
quarters number about 50, while the number of sailors and
marines is about 240. Beside the above, there are in and
about Washington 250 or more officers, active and retired,
liable to need hospital accommodations and treatment.
The situation of the hospital is excellent, occupying an entire
square of land on four streets, having thus abundant sunlight
and fresh air. The elevation above the navy yard is inconsid-
erable, but sufficient to make a very great change perceptible
in the condition of malarial patients transferred. The mere
change from the one place to the other has sometimes sufficed
to put a stop to an attack of malarial fever.
There is but one separate room in which a sick officer can be
isolated. Additional accommodations should be provided, so
that the whole of the two principal floors could be allotted
to patients, the lower or main floor and the second floor to the
enlisted men. The medical officers on duty should be lodged
in an annex, which could be easily built within the present
grounds and in connection with the hospital proper, and an
appropriation with this object in view should be submitted at
an early date.
THE PUBLIC SERVICES.
Army Changes. Official List of changes In the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Oct. 17 to Oct. 23, 18%.
First Lieut. Benjamin Brooke, Asst. Surgeon, leave of absence granted
on surgeon's certificate of disability is extended one month on sur-
geon's certificate of disability.
Major Clarence Ewen, Surgeon, leave of absence granted on surgeon's
certificate of disability is still further extended one month on
account of (Usability.
First Lieut. Charles F. Kieffer, Asst. Surgeon (Ft. Crook, Neb.), is
granted leave of absence for two months, to take effect upon the
completion of his duties with the Third Artillery.
Navy Cnanfres. Changes in the Medical Corps of the U. S. Navy for
the week ending Oct. 24, 1896.
Asst. Surgeon M. S. Elliott, ordered to naval laboratory and department
of instruction, New York.
LETTERS RECEIVED
Anderson, Winslow, San Francisco, Cal.; Alta Pharmacol Co.. St.
Louis, Mo.
Bauseh iv. Lomb Optical Co., Rochester, N.Y.; Burr, C. B., Flint. Midi.:
Bishop. 8. S„ Chicago; Burdett-Browntree Mfg. Co., Chicago: Beard, K.
O.. Minneapolis, Minn.; Bailey, William Curtiss, Las Vegas, N. M.:
Boehringer, C. K. & Soehne, New York, N. Y.
Cleary. \V. P.. Now York, N. Y.; Colvin, !>., Clyde, N. Y.; Clouae, Geo.
If ., Columbus, Ohio; Carter, Howard, St. Louis. Mo.; Cutler, II. G., ( 'hi
cago; Cooper, J. M., Johnstown, Pa.
Dunlap, A. J., Chattanooga, Tenn.; Dewees, William B. (2), Sallna, Kan.:
DegchambOttlt, T. A., Manitoba, Canada; Dunshie, J. P., Puerto Barrels,
Guatemala.
Erwin, A. J., Mansfield, Ohio.
Gould. George M.. Philadelphia, Pa.; Gihon, A. L., New York. N. Y.:
Gracf. < baa. &Co., New York. N. Y.
Haralson, H. II.. Biloxi, Miss.; Holton. Henry E., Brattieboxo, Vt.:
Holland. John W.. Philadelphia. Pa.; Hayes, R. II., Union Springs, Ala.;
Harrison. K. II., Columbus. Texas; Hummt-1. A. 1... A<1\\ Agency (8),
New York, N. Y.
Keller, J. M. (S), Hot Springs, Ark.; Kiernan, Jas. G. .Chicago; Klebs,
Edwin. Chicago; Kendall, H.W.,Quincy, 111.; Kellogg, A. C, Po
Wis.; Kingsbury, G. C. Hi, Carmel, 111.
Ludwig, Henry c. New York. N. Y.; Library Bureau, Chicago; Lea
Brothers & Co.. Philadelphia. Pa.; Millard. M. R„ Detroit. .Mich.; Mc-
Ulster, Alex, Camden, N J.; MeCurdy: s. I... Pittsburg, Pa.; Merrick.
M. B., Passaic, N. J.; Maltine Mfg. Co., New York, N. Y.; Morton, John
P. & Co.. Louisville. Kv.: Madden, John, Milwaukee, Wis.; Mauley.
Thos. H., New York. N. Y.
Porter, Joseph Y.. Jacksonville. Fla.; Probst, C. 0„ Columbus. Ohio;
Parker. James W.. Warsaw, 111.: Patterson, C. E., Grand Rapi<!s. Mich.
Reynolds, Arthur B., Chicago; Reynolds, Dudley 8., Louisville. Ky.;
Riley. \v. H.. Boulder, Colo.; Radeliffe. s. J., Washington, D. C;
Romelke, Henry, New York, N. Y.
Smith. Louise Eleanor. Chattanooga. Tenn.; Stoakley, Wm. S., Mill-
boro Springs, Va.: Surgeon-General U.S.A., Washington, I>. C: Bcho-
field, A. E., Tilden, Neb.; Strueh, Carl, Chicago; Steele. G. A.. Havana.
N. D.; Streeher, J. E., Chattanooga, Tenn.; Sheets, John. Philadel-
phia, Pa.
Tuley, Henry E., Louisville. Ky.
Van 'Nostrand. D.. Company. New York. N. Y.
Woodbury, Frank, Philadelphia. Pa.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., NOVEMBER 7, 1896.
No. 19.
ORIGINAL ARTICLES.
OPERATION FOR THE CURE OF HERNIA
VIEWED FROM A MEDICO-LEGAL
STANDPOINT.
Read hi the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical
Association at Atlanta, Georgia, May 5-8, 189(>.
BY HENRY O. MARCY, M.D.
BOSTON, MASS.
The revision of the duties and obligations which
the medical profession owe to their constituency must
he made in every advancement of science. From this
standpoint it is pertinent to inquire, if the demon-
stration of the easy and safe cure of hernia is not suf-
ficiently ample to demand from our profession a revi-
sion of opinion, which only a brief period since would
have been accepted as unquestionable? Few will
deny that every sufferer from hernia, even in its less
pronounced forms, is not alone incapacitated in a con-
siderable degree for the discharge of certain duties
incumbent upon a great variety of occupations, but
also that there is a recognized life risk, incident to
the individual. This has long been accepted in life
insurance, examinations for the public service, etc. It
is also conceded that, at the best, instrumental sup-
ports are disagreeable make-shifts, and that the usual
history of the subject of hernia is an increased physi-
cal disability.
From the medico-legal standpoint, may it not be
considered as an open question, whether this entire
class of sufferers have not rights which should be
respected, when such life interests are entrusted to
the watchful supervision of their medical and surgical
advisers. If this be true, does the surgeon discharge
his full duty to the one seeking his advice, disabled in
large degree from an irreducible or uncontrollable her-
nia, who offers simply the palliation of rest, condemn-
ing the patient to the wearisome watching for relief
which only death can give? If such queries throw a
new light upon the ever increasing burden of responsi-
bility, which the advancement of science places upon
him who would be its exponent, what becomes the
plain duty of the physician, the rank and file of the
profession, who are ever in close touch with this great
army of invalids, and, as a consequence, must decide
promptly the course to be taken in the constantly
recurring cases of intestinal obstruction caused by
strangulation?
I need not cite even recent experiences to show the
still high death rate in all hospital practice, occurring
from delayed operations for the relief of intestinal
constriction, delays made fatal not by the gravity of
the operation itself, but by the conditions which ren-
der operation necessary.
The early operation for the relief of these condi-
tions is attended by a very minimum of danger, which,
however, increases in geometric ratio with every
passing hour, and yet the average sufferer from acute
intestinal obstruction from hernia, is liable to neglect
at the hands of his medical adviser, and it is the
object of this paper to emphasize this neglect as crim-
inal before the law. There is but one duty for the
physician. Immediately upon the recognition of the
condition, relief must be afforded. Taxis is no longer
warrantable as advised at an earlier period, since this
alone often inflicts irretrievable damage upon the
constricted intestine. An anesthetic should be at
once administered and, if in the relaxed condition of
the parts, gentle manipulation does not restore the
displaced organ, the operation must be immediately
performed.
It is not necessary to give examples of almost daily
flagrant violation of this simple, surgical axiom. In
my experience the series is long and includes many
instances which have come under my observation as a
consultant, where from a medico-legal standpoint, I
unhesitatingly declare that the neglect of prompt
surgical procedures was criminal.
Appealing to the fear of the individual is one of the
most reprehensible ways of quickening his conscience,
especially in our profession, the members of which
are supposed to be actuated in the discharge of their
duties to suffering humanity only by motives of the
highest and most praiseworthy character. Courts of
law are constantly dealing with questions of damage,
arising from alleged incompetence, because of the
improper restoration of fractures and dislocations,
injuries from which a life risk may never be involved
and on account of this surgeons are constantly thought-
ful to guard against medico-legal complications, seek-
ing consultation for self-protection much more than
for the benefit to be derived by the patient. If this
was recognized as a possible sequel to every case of
the severer forms of hernia under supervision, it would
be of great advantage to the patient, to the physician,
and the profession at large.
The causes of hernia should be much more care-
fully studied and understood. A thorough anatomic
knowledge of the parts involved, their functions, and
pathologic changes must be acquired. Such knowl-
edge is of the first importance in many medico-legal
cases. Indeed, the general opinion is that hernia is
produced by some violent strain, or accident, for
which in the general mind the term rupture is a syn-
onym, that is, a sudden giving away of the parts
involved. A superficial study of the case might lead
one often to arrive at this conclusion. This is so
exceptional that it represents a very minute fraction
of the total.
I was called as an expert in court where a town had
been sued for large damages, the injury claimed to
have been received by a man in middle life, who, as
the consequence of a fall into a hole in the street, be-
came ruptured. The hernia was of the indirect
inguinal type, and doubtless was the result of a long
980
OPERATION FOR THE CURE OF HERNIA.
[November 7,
series of antecedent causes, probably commencing in
a congenital non-closure of the canal. Yet the jury
awarded the claim and damages, more from the general
belief that such injuries must be the result of sudden
violence, rather than from the testimony offered.
On the other hand instances are not wanting where
injuries have been inflicted upon large scrotal hernias,
even resulting in death, and here may arise a nice
point at law, to determine if the individual is
liable to recover under such circumstances, when
modern surgical opinion teaches that such a man is
in daily possible risk to his life from a condition
which is amenable to cure by surgical interference of
moderate danger.
In this phase of the subject there is also a very con-
stant factor of a material type represented by a money
equivalent. This has its exponent in the large num-
ber of soldiers of the late war borne upon the pension
rolls, disabled because of hernia. Some time ago at a
meeting of a large number of surgeons, it was desired
that I should give a demonstration of my method of
operating for the cure of hernia before the members
in attendance. A proper case was selected by a local
surgeon, the man having been for years under his
observation partially disabled on account of a large
scrotal hernia. The suffering was freely acknowl-
edged, the desire for relief so great that preparations
for the operation had been partially arranged. It was
finally refused, the sufferer admitting that the hernia
was worth to him as a pensioner of the United States
government $150 per year, and that he would rather
endure the disability, than deprive himself of his
assured income.
I have no hesitancy in declaring that it is the duty
of the government to afford this large class of sufferers,
free of expense, an opportunity to be cured of this
troublesome and dangerous affliction, and in the
event of their refusal to accept the same, order that
the pensioner's name be stricken from the roll.
The statements made in this brief paper may seem
radical to many, indeed to a degree revolutionary, but
I offer them in the full conviction that they are the
expression of a just surgical conservatism, and I
believe the time is not distant when they will be
accepted and amplified.
I look upon the verdict of this Section of the Asso-
ciation to which this contribution is offered as most
important in establishing a new status of opinion upon
a surgical subject which must be far reaching in
results, involving not only large monetary interests
but also pregnant with the salvation of many lives.
DISCUSSION.
Dr. Hughes— I think the suggestions are practical, new and
destined to prove of great value to mankind. I think the sur-
gical section ought to join in their recommendation, that the
pensioners should be offered the opportunity to secuie the
advantage suggested in the paper. I would not say that they
should be compelled to do that or throw up their pensions. I
doubt if this can be done under the law. The Constitution of
the United States provides that no man can be mutilated in
any way. We used to have a law in the State of Missouri pro-
viding for the castration of men who committed rape. It stood
on the statute books until some astute lawyer carried it to the
supreme court, and it was declared unconstitutional.
Dr. Moyer — I was glad to hear Dr. Marcy refer to the rela-
tion of accidents to hernia. More than ten cases have been
sent to me for examination by attorneys, claiming that the
rupture was caused by a fall or sudden injury. In nine of
those cases I gave the opinion that I did not believe that
injury and accident caused hernia.
Regarding the doubtful case, the rupture was not at the
usual site, but was at the linea alba, midway between the
umbilicus and the pubes.
Dr. Hughes — I would like to ask Dr. Marcy whether he
maintains in that paper that accidents are not frequent excit-
ing causes.
Dr. Marcy — I do not.
Dr. Moyer — I think, however, that is the later and more
general view of the matter.
Dr. Hughes — I have always been under the impression that it
is a frequent cause. Anyone who is intimately familiar with
the personnel of soldiers, and has had large numbers of them
to treat — I had an average of 10,000 men under my care dur-
ing the war in what was called a " straggler's camp" — has
doubtless had considerable experience with hernia. Men were
constantly coming to me to be examined whom I had in my own
command, and whom I had examined personally as to whether
they had abdominal or inguinal hernia, finding them appar-
ently sound in that regard — these very men, would develop
hernia from the time they were forced suddenly to jump out of
cars, owing to a surprise or an attack. I never supposed that
the sudden jar was the cause of the hernia, but was the excit-
ing condition.
Dr. Bishop, of Pennsylvania — If Dr. Marcy's paper would
convince people that the operation is comparatively a safe one,
and that the danger by not having the operation is greater it
would certainly be well. Trusses are as dangerous as patent
medicines.
Constant tension— railroad men getting on and off trains :
plasterers or painters working overhead, etc., has a tendency
to precipitate this trouble. I have advised the use of suspen-
sory bandages in such cases.
Dr. Marcy — A careful anatomic study of the inguinal canal
in the male exhibits one of the most beautiful of nature's pro-
visions for protection and safety. The cord traverses the
abdominal wall in an oblique direction, so pronounced that the
intra-abdominal pressure causes a complete approximation
of the walls of the canal, acting always, when in the normal
condition, at or near a right angle to its axis. The transver-
salis fascia is extraordinarily strengthened and thickened so
as to produce a firm, inelastic support posteriorly, while the
internal ring is reinforced about the cord in a way to prevent
a peritoneal depression about its upper border. The testicle
finds its way out of the abdominal cavity at such a late period
of the intrauterine life that the developmental processes,
which result in the normal closure of the canal just referred
to, are often imperfect. When not complete there results a
depression in the peritoneum above the cord, which affords a
point of yielding to the intra-abdominal pressure, although it
may never result in hernia. Often this condition remains
unnoticed until in a later period of life, when the muscular
tonicity of the abdominal wall is lessened, a yielding occurs,
and by a slow process hernia develops. This I believe to be
the common cause of inguinal hernia in the male. Any one
who will take the trouble to examine postmortem will note
that traction upon the cord in a very considerable percentage
of adults demonstrates this condition more or less marked,
although it has never advanced to a degree which allows the
protrusion of any portion of the abdominal contents into or
through the canal. Cloquet, of Paris, in the earlier part of
this century, made careful dissections of 500 cases of hernia
subjects, recording minutely the conditions found. He des-
cribes and figures a condition of normal anatomy under the
name of the infundibular process of the peritoneum. I can not
doubt but that which he describes as normal is pathologic, and
results from imperfect closure of the canal in the early months
of existence.
1896.]
USE OF THE STOMACH AND RECTAL TUBE.
981
That muscular strain of itself in the normal individual is not
the cause of hernia is evidenced by the extraordinary play of
muscular activities in the gymnast, who in every conceivable
way exercises an enormous strain upon the abdominal wall,
yet so far as I have been enabled to learn the circus athletes
and rough riders of the West are not more liable to hernia than
aro those of less active occupations.
DSE OF THE STOMACH AND RECTAL TUBE
IN CHILDREN.
Kriul lu che Section ou Diseases of Children, at the Forty-Seventh
Annual Meetlug of the American Medical Association at
Atlanta, Ga.. Mav 5-8. 1896.
BY W. JAY BELL, M.D.
A .-isiam to the Chair of Obstetrics and Clinical Gynecology, Southern
Medii'ul Collate; ex Assistant Resident Physician of
the New York Infant Asylum.
ATLANTA, OA.
I am fully aware that the stomach and rectal tube
is not so generally used in the south as in the north
and northeast. Having followed their use so closely
daring my service on the staff of the New York Infant
Asylum and since my location in Atlanta, and having
such pronounced beneficial results following thei,r
use. I am constrained to present a short paper on
the subject before this body.
We may well deem our age the most practical in the
world's history and we find theory quickly receding
to give place to the tangible and practical.
The approaching warm season causes one who
handles the little ones to stop and reflect for a time
upon the too often fatal ileo-colitis and gastro-enteritis.
There is nothing to be found infallible in medicine
nor in means; yet we must accept all available means
and apply them judiciously yet assiduously.
Often one will be called in to a little patient with
a history that the child takes food well, even hungrily,
but in a short time suddenly vomits the sour con-
tents of the stomach, this result following each feed-
ing. Now, all are familiar with ferments. A fermen-
tative state often accrues in the stomach causing
fermentation of the stomach's contents with irritation
and consequent vomiting, yet the vomiting does not
entirely free the stomach of ferment, there being a
nucleus of fungus remaining which infects tha next
food taken and persistent vomiting is the expected
consequence. Then what steps must we take to
relieve this class of cases? The cause of persistent
vomiting is retained ferment. Then the most prac-
tical step will be to remove this factor of irritation.
It is in this class of cases that the most happy results
are obtained from a thorough irrigation of the
stomach.
Imperfect digestion is frequently found in the little
patient, this may be due to want of digestive power or
fermentative interference with digestion. An irriga-
tion of the stomach two or two and one -half hours after
feeding and giving a subsequent rest of at least one
hour will be met with gratifying results. Athreptic
or poorly nourished conditions are found due to a
failure of the child to take nourishment; in these
cases gavage is often necessary and will often be fol-
lowed with happy results. In this the same tube may
be used, being careful to cleanse.
It was our custom in the New York Infant Asylum
to use a tube, which consists of a funnel of glass or
hard rubber, with a piece of tubing two or three feet
long, to the end of this is attached a small stomach
tube or large catheter having a small piece of glass
tube intervening for observation. This is a complete
tube for either feeding or irrigation. With tube, a
pitcher of warm water and a slop jar or pan you are
fully equipped. With the patient in the lap of an
attendant or mother, having the face to the physician,
the tube is moistened and with the left index finger
as guide pass the tube steadily into the stomach; with
funnel raised above the patient's head fill the stomach
to full capacity and, lowering the funnel, syphon off
the stomach contents, repeating this until all return
is clear. After irrigation a rest of about one hour
should be given the stomach before giving nour-
ishment. Flax seed water for a few feedings is best.
Gavage is accomplished by passing the tube and
pouring into the stomach the amount of nourishment
desired, being careful to compress the tube and hold
the mouth well open for a moment after the removal
of the tube until irritation of throat passes off, which
will prevent regurgitation. The stomach tube is use-
ful in many other forms of gastric irritation, but I
will not go further. It is, indeed, a most practical
instrument to have on hand at all times and especially
in cases of poisoning.
The rectal tube is far more generally used than the
stomach tube. Dr. Seibert of New York, says that
the first thing that he does when called in to a case
of convulsions in a child is to draw out his fountain
bag, call for a pitcher of hot water and proceeds to
irrigate the colon at once. While the contents of the
rectum and colon are not the sole cause of convul-
sions, yet such a vast majority of these cases are due
to, or irritated by bowel contents that the step is a
most wise one. The apparatus which I use and which
is used in the New York Infant Asylum, consists of a
fountain bag with a small stomach tube attached, and
no better apparatus could be devised except that a
return attachment may be used. The indications for
the use of the rectal tube are so manifold that it
would require too much time to do more than briefly
refer to some of them. It is fully established that
the rectal and colon contents are often most potent
factors in hyperpyrexia. I have observed in a num-
ber of cases a marked fall of temperature from irriga-
tion of the colon.
In ileo-colitis, gastro-enteritis, fermentative and
catarrhal colitis, cholera infantum and other forms of
fermentation and infected bowel contents, most gratify-
ing results will often follow the use of the tube in high
rectal and colon irrigation. Now, it is important that
not only the rectum but also the colon should be irri-
gated. The tube should be passed as high up as the
transverse colon which can be easily accomplished,
with the child in dorsal position on slightly inclined
board, table or bed, the tube is vaselined and passed
with a slight" rotary movement, bearing in mind the
course of the rectum through the curve of the sacrum
and upward over promontory to the left, and the tube
will pass readily into the colon and up with ease to
the transverse colon when the stream is turned on and
continued until bowels are thoroughly irrigated.
Efforts to influence the fluid to pass up the colon
by placing the child on left side and lowering the
head and the trunk, is to me quite unsatisfactory and
but slight cleansing effect can be obtained in this
way, but with the tube well up into the colon, a far
more satisfactory irrigation can be accomplished.
In persistent dysentery I have obtained good
results from irrigation, after which inject flaxseed
water with a small amount of tincture opium. In
cases of gastro-enteritis I have seen splendid results
982
INFANTILE SCORBUTUS.
[November 7,
follow irrigation of both stomach and rectum and am
convinced that this step would be wise in a beginning
cholera infantum, using rectal irrigation quite hot
for stimulating effect and to this may be added a
small amount of salt and alcohol. In habitual con-
stipation the use of the rectal tube is preferable to a
too frequent use of laxatives. In this, however, a
high irrigation is unnecessary. Irrigation is a step
that should always be taken in cases of convulsions in
children.
INFANTILE SCORBUTUS.
Read in the Section ou Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association
held at Atlanta. Ga.. May 5-8, 1896.
BY ALBERT H. BURR, Ph.B., M.D.
CHICAGO.
Dr. William P. Northrup, editor of the chapter on
Scorbutus in the "American Text-book of the Dis-
eases of Children" (1895), says: "The reader will
find in this book for the first time scurvy put down
as a disease occurring in the United States." It is
barely two years since he tabulated some twenty-six
American cases, and directed attention to a disease of
infancy hitherto overlooked in this country because
of its rarity or because of failure in differentiating it
from the somewhat kindred disease of rickets ; since
that time the interest awakened by the discussion of
Northrup's papers has brought out reports of a num-
ber of cases from observers in different parts of the
country. From this it would seem that the disease is
assuming greater importance by reason of its increas-
ing frequency in these days of degenerate mammae,
supplemented by the growing indisposition of Ameri-
can mothers to suckle their young, on the one hand,
and on the other by the commercial enterprise and
ingenuity of man in devising sterilizers and proprie-
tary foods to meet a long-felt want in the failing
maternal fluid and motherly instincts. Between these
physical and mental degenerates and the chromo-
advertised infant foods, represented as perfect( ?) sub-
stitutes for mother's milk, the coming baby must run
fearful odds in its unequal struggle for existence.
Authorities tell us that 25 out of every 100 babies die
before the end of the first year, and of these 25 only 4
die at the breast while 21 perish at the bottle. What
sadder comment is to be found on modern civilization ?
To W. B. Cheadle of London is due the credit of
first recognizing infantile scorbutus on clinical
grounds. In 1878 he published three cases on
account of spongy gums, and obscure symptoms
referred to the lower limbs, which he maintained were
cases of true scurvy. Soon after this, Thomas Barlow
commenced his postmortem investigations and immor-
talized his name by establishing a pathologic basis
for the disorder, which German writers had described
as acute rickets. The results of these valuable and
conclusive labors he published in 1883 and confirmed
the views of Cheadle. Barlow's classic review of the
disease in his Bradshaw lecture of November, 1894,
leaves but little to be added to our knowledge of this,
now inexcusable and easily prevented, disease.
Etiology. — Briefly stated, he says: "The prolonged
use of a defective diet induces the symptoms."
Pathology. — "The essential lesions are subperios-
teal blood extravasation and its secondary sequences;"
hemorrhages into the center of the.shafts of the bones,
producing absorption of the trabecular and leaving
them brittle and easily fractured; effusions of blood
into surrounding muscles and cutaneous tissues, with
progressive anemia resulting from these multiple
hemorrhages.
Diagnosis. — The diagnostic differentials between
scorbutus and rickets are of chief interest and con-
sist in the hemorrhagic phenomena and their sequelae;
the pseudo-paralysis; spongy gums where teeth are
present and the rapid, almost magical improvement
under antiscorbutic diet.
The following case came under my care Dec. 12,
1895:
Dorothy R., thirteen and a half months old, had been
brought to Chicago from a distant State by the advice of the
family physician to be treated for a supposed spinal trouble.
She was placed under the care of one of our best orthopedists.
The diagnosis was rachitis, with slight spinal curvature. As
the child was too weak for any corrective appliances the spe-
cialist addressed himself to general tonics and restoratives with
the view of improving the anemia and malnutrition. At the
end of six weeks the child, which at first seemed to be materi-
ally improved, was found to be decidedly worse, and for two
weeks had not been able to lift its head from the pillow.
Emaciation was progressive and the specialist expressed the
opinion that the case was hopeless and the child must soon die
from marasmus.
The history as given by the mother was this : Up to eight
months of age the child appeared well nourished and in the
the best of health. About this time it became fretful, grew
pale and began to lose flesh. Purple spots appeared over its
shoulders, back and thighs, which suppurated and many of
them were lanced, leaving marks similar to the pitting of
smallpox. The lower extremities were painful on being
handled and the child ceased to move them voluntarily. Ite
diet from birth had been Mellin's food exclusively. The
mother had lost her ability to nurse on account of multiple
abscesses of her breasts at a previous birth.
At this time the child was very anemic and much emaciated,
weighing but thirteen and a half pounds. It could not lift its
head nor move its body or thighs, and was handled on a pillow.
The right femur and left scapula were perceptibly swollen.
Dentition was delayed. The upper and lower middle incisors
only were erupted and these were almost hidden by spongy
ecchymotic gums. In the roof of the mouth was a purplish
tumor with an eroded apex. The fetor of its breath was
marked. The body was bathed in sweat. The stools were
hard and variegated in light drab and dark slate colors, with an
offensive odor like those of a carniverous animal. The child
cried with pain on being handled and was fretful and wakeful
during the nights. This array of symptoms completed a pic-
ture of pitiful distress.
Treatment. — The food was changed at once to fresh
cow's milk and barley flour as a basis. Orange juice and
raw scraped beef were given daily, which the child took
with the greatest avidity. Scraped apple and tender
sprigs of fresh lettuce and cabbage were also allowed
by way of variety. A cool sponge bath at 75 degrees
with gentle friction was given every morning for its
tonic effect. To change the character of the stools
and disinfect as far as possible the intestinal tract,
calomel tablets, one-tenth grain, every two hours, and
a powder composed of guaiacol carbonate, one-sixth
grain, and protonuclein, one grain every four hours,
were ordered given. Hydrolein was administered
three times daily, for its alterative and reconstructive
properties. The improvement even in so short a time
as twenty-four hours was gratifying and astonishing.
At the end of forty-eight hours the character of the
stools were changed and the fetor of the breath had
disappeared and the child was inclined to amuse
itself. After the fourth day it could lift its head and
its nights were restful. At the end of the first week
all traces of spongy gums and sore mouth had disap-
peared and it began to laugh and crow and exercise
its legs and thighs and no longer dreaded handling.
At the end of the second week it had gained one
pound, could lift its feet above its head for the first
18W.]
INFANTILE SCORBUTUS.
983
time in several months. All remedies, except hydro-
lein ami oooaiBOnal closes of inild chlorid, were now
discontinued. A soft-boiled egg with rolled cracker
was allowed every other day alternating the scraped
beef. Third week, anemia has disappeared. Can sit
alone. Has erupted upper lateral incisors. Three
weeks ago there was no sign of these teeth. Is taken
out daily for exercise. Fourth week, has gained in
weight, rolls about on the rug and tries to creep.
Discharged cured and returned home at end of six
weeks. A change like this after six months of help-
lessness and untold suffering seems little less than
magical.
The points of interest in this case are: The sup-
puration of the hemorrhagic cutaneous lesions, which
the family physician diagnosed and treated as eczema;
the swelling of the femur and scapula and slight
curvature of lumbar region, diagnosed and treated for
six weeks by a noted orthopedist as rickets, and lastly
the rapid recovery under antiscorbutic treatment.
The foremost problem in the consideration of every
disease is how to prevent it. Scorbutus is a prevent-
able disease. How shall we guard against and limit
this recently diagnosed and apparently increasing dis-
order':' We will not find it in the homes of the poor,
or among the laboring classes, so often as among the
well to do and in the houses of affluence, for the
mothers in the commoner walks of life more uni-
formly suckle their babes, and this is prophylaxis.
Barlow says : "In no single case at the time of the
malady has the child been breast fed."'
1. Woman herself should be physically prepared
for better motherhood so that she may be capable of
yielding her offspring the only food nature intended
for it.
l!. Mothers should be impressed with the fact that
there is no perfect substitute for breast milk, and that
next to the right of being well born, the babe has an
inalienable right to nature's food, and no trivial
excuse or surmountable difficulty should hazard its
life or health.
3. Where for any reason the breast milk is inade-
quate, or has entirely failed, the nearest approach to
it is to be found in the modified cow's milk of our
modem laboratories, or the home modification of
cow's milk after the plans given by Rotch in his most
valuable recent work on pediatrics.
4. Above all, no continuous administration of any
sterilized, Pasteurized, peptonized or condensed milk,
or any dry commercial foods should be given to the
exclusion of fresh or ran- elements of diet. In what
this antiscorbutic property consists, which is found
in fresh foods, and lacking in the artificially prepared
and manipulated foods, is not yet determined, but it
is more than likely that the important offices per-
formed by the normal germs of the gastro-intestinal
tract in the complicated processes of digestion are
incapable of being completed with artificial food, and
thus putrefactive changes in imperfectly digested
pabulum, lead to auto-infection and malnutrition.
There is a "borderland condition," as Barlow terms
it, without detected lesions, a sort of scorbutic mal-
nutrition, which the physician should be on the
look-out for in every artificially fed infant. I believe
scorbutus exists in incipient forms of malnutrition to
a greater degree than is commonly apprehended. The
causes must be in operation for a more or less pro-
longed period to produce apparent lesions. In its
typical form it is rarely seen before the latter third of
the first year. Happily for most bottle fed infants
they are saved from the active stages of the disease
by the timely admission of certain elements of anti-
scorbutic diet. It is to this class I would call espe-
oial attention. The physical condition of the child
during the first eighteen months of its existence is of
the utmost importance to its future. It is the period
of most active and rapid development, and malnutri-
tion now will weaken its vital powers of resistance for
its whole life.
Some of the premonitory symptoms are fretfulness,
aversion to being handled, crying out as if in pain
when lifted, tenderness of the lower limbs and indis-
position to move them, and progressive anemia. The
diet should be investigated and appropriately regu-
lated and the parents or others having the care of the
child should be instructed as to the necessities of the
case for intelligent cooperation.
If every artificially nourished babe could be care-
fully inspected and its diet harmonized with the car-
dinal principle pointed out by Barlow, Northrup,
Rotch and others, a great army could be saved from
premonitory malnutrition, of which the fully devel-
oped scorbutic forms but a small contingent.
2036 Indiana Avenue.
DI8CUSSION ON PAPERS OF DR8. BELL AND BURR.
Dr. W. A. Dixon, Ripley, Ohio — The use of the stomach
and rectal tube can not be too much impressed upon the pro-
fession. Children are badly fed, and after the stomach is once
loaded and the bowel is disturbed by food that is doing injury
or damage, you must or ought to use the stomach and rectal
tubes. I use them a great deal and to a very great advantage.
Dr. Burr's timely paper had reference to artificial feeding. I
believe if the profession is cursed by anything at all, it is by
the impression abroad that children must be fed by the bottle
and by these artificial foods. I believe we are running in the
wrong direction as a profession when we permit and submit to
the weaning of the child, the taking away from the breast
simply because we have inflammation of the breast. We
ought to interfere if we are the attendant at the time of con-
finement ; or, if we are the family physician, we ought to
anticipate these troubles, we ought to step in beforehand and
announce to the mother that she must be prepared to nurse
her child, and portray to her all the troubles that follow if it
is nursed artificially. Nothing has brought more sorrow to me
in my practice than to treat children fed artificially, and hence
I lay great stress upon impressing upon the mother the import-
ance of being prepared to nurse the child at the breast, and I
take great censure upon myself if I allow mammitis to follow.
Dr. Foster, Deering, Me. — I would like to ask Dr. Bell,
before he goes, how often he irrigates the stomach?
Answer : In the case of imperfect digestion, the process of
irrigation should be continued until you have obtained a
degree of digestive power. The stomach should be tested to
see that it digests the material, and the irrigation should be
continued until the stomach can digest the food given. Of
course, using the predigested food assists this process.
Dr. J. A. Work, Elkhart, Ind. — In this process of irrigation, I
would like to ask the Doctor, does he propose to empty the
stomach of everything or only undigested food?
Answer : It should be cleaned thoroughly at the time of
the irrigation.
Dr. J. A. Work — How is he to do that when the child is fed
upon milk and has a high temperature and the milk is coag-
ulated in the stomach? How is he going to get the food away
without emesis?
Answer : The contraction of the stomach will throw it out
beside the tube as well as through the tube. If you have
984
DISCUSSION.
[November 7,
reason to believe you have large clots there it is well to over-
distend the stomach first. The tube then is used as an irri-
tant and as a means to get other fluid in.
Dr. Burr — Why does the Doctor choose very warm water
in preference to cold water, especially in pyrexia?
Answer : I referred to warm water in cases of depression
from the cholera infantum. The hot water gives a better
cleansing effect. You may have, of course, elevation of the
temperature, but in cholera infantum you have no especial
elevation of temperature and sometimes you have an abnorm-
ally low temperature: And certainly in those cases you would
use the hot water. But outside of that there is no special
reason for using hot water.
Question : What temperature?
Answer : I should use water about 110 degrees. If I
wanted an effect in the reduction of temperature, I should use
it cooler than that.
Dr. Burr — I believe with Dr. Bell that the irrigation of
the stomach and colon is of the utmost importance in all these
cases of malnutrition and indigestion, which are almost synon-
ymous terms. But I have found the application of cold water
externally and internally to be far more stimulating than hot
water. I would use the cold water in colonic flushings
because you can get up peristalsis better with it. The per-
istalsis better empties the bowel, perhaps, than the flushing
itself. The peristaltic action brings matter away from far up
the colon. It is a question whether you often get these tubes
above one of the flexures of the colon or rectum. Now, if
you have infantile convulsions, which are in a large major-
ity of cases induced by indigestion and autoinfection and its
explosive effects on the nerve centers, which are so unstable
in infancy, then the cold water is doubly important. 1 know
nothing more irrational than what I find day after day of
the method of plunging the child into a hot mustard bath and
putting something on the abdomen, but neglecting the import-
tant feature of first emptying the colon. The first step in my
mind is a full cool bath if there is pyrexia, and pyrexia you
will often find is the cause of the convulsions. The over-heated
blood, of course, is another effect of the poison. We have the
poison first, pyrexia next and convulsions third, following the
effects upon the nerve centers. We should use the cold bath
to reduce the temperature first, then the colonic flushing and
then the stomach irrigation, and if we think there is something
irritating left we should give a good old-fashioned dose of castor
oil. With the other process we may have convulsion after
convulsion. I have found sometimes the attending physician
present, who has assured me the child has had bath after bath,
and I would find the hot water there colored with mustard in
evidence, and still the convulsions continued. Fifteen minutes
after rational measures were used the child would be asleep.
Dr. J. A. Work — I asked Dr. Bell the question about
the emptying of the stomach because I believe the first
thing we have to do as physicians in any of these acute cases
is to remove the cause as soon as possible. A physician,
unless he studies to do that, is not worthy the name. My
friend has just given us a key-note. I have practiced that for
twenty-seven years and am more confirmed every day in the
belief that we are not to simply administer medicine, but we
are to study the cause and remove it. That is the reason I
asked the question. In these neurotic cases let us get back to
the first cause, or as near as possible to the primary cause, of
all the trouble. When I am called to a case of acute irritation
of the intestines or stomach with rise of temperature, I first
ascertain how the child has been fed. I then want to know
about the elimination, because we know there are only four
emunctories, or "sewers" as I explain to the friends of the
patient, the bowels, skin, kidneys and lungs, and I inquire
about all these "sewers," whether they are in proper condi-
tion or not. If I find the,bowels have not moved sufficiently
recently, I first secure an evacuation of the bowels and then
depend largely, as to what to do next, on what is the condition
of the contents of bowels passed. After the bowel is thor-
oughly cleansed I give the bath, not so much to reduce the
temperature, but I have the patient given a washing with soap
and water, for nine children out of ten need it at that junc-
ture. After they are washed thoroughly I have them put in a
well-ventilated room, and in almost every case the excitement
is gone and the patient is calm, easy and on the road to recov-
ery immediately.
Now as to the use of the rectal tube. I believe if we come
to consider ourselves as an animal machine, that every thought
and motion wears us out and that by reason of this we have to
take food and drink, and in our younger days we are active and
the activity causes increased circulation and activity of all the
body, but as we grow older we are not as active and we need
prompting of the elimination. We notice the little boys and
girls, say 10 years old, wear out about ten pairs of shoes to our
one, which shows they are more active, and they do not have
the same need of prompting of the elimination. Some ask, if
they begin the use of the enema or purgative, won't they have
to use it all their life. But, I ask them, hadn't they better
use it all their lives than to be invalids all their lives. I
believe there are cases in which nothing else will do but to
have elimination, either by the rectal tube or enema, every
day, twice a day. Here is a proposition I want to lay down,
upon which I have practiced and which I have demonstrated :
The four emunctories I have mentioned must each do its work
and we must not depend upon one to do the work of the other,
but each must be allowed or caused to do its own work within
the proper physiologic time.
Dr. H. E. Garrison, Dixon, 111. — There is one point brought
out which I would like to notice, and that is the use of castor
oil in cases of infantile convulsions. I have experimented
with it for a long time. I had one boy whose diet I could not
control and he would have convulsions now and then. Some-
times he would go two months before a convulsion would occur.
I finally decided to give him Rochelle salts for I could not get
him to take castor oil. I gave the salts in lemonade whenever
he became a little constipated. Eight months have now passed
without the child having a convulsion.
Dr. C. W. Foster, Deering, Me. — I have been somewhat
interested in these papers, but it seems to me the ideas
expressed have been along lines of practice in which I am not
specially interested. It has been my experience usually, when
I have been called, the child has had its fit or convulsion, and
very rarely do I see a second or third one. They usually
remain quiet until I can get a movement of the bowels by
a big dose of calomel or castor oil, and certainly I have seen
or thought I have seen children that have been quieted and
have gone along very nicely with that method. It seems to
quiet the nervous system very well. In regard to the nursing
of children, spoken of in Dr. Burr's paper, in my region it is
not so difficult to get healthy mothers to nurse their children,
but the great, difficulty arises often, I think, in urging the
mother to nurse her child. We have a great many women
who are mothers who are not physically qualified and I do not
believe such mothers are fit to nurse their children. I believe
it is often better to have the children fed with artificial food,
cow's milk, than to have them nursed by these sickly, tuber-
culous women. I am, myself, a sample of a cow-fed baby, for
I came from a tuberculous family. One thing about cow's
milk, overlooked by a good many, is the difference in the milk
supply of large cities and small cities and villages. I live in a
small city and I believe the milk there is better when it is
delivered than that milked last night or early this morning,
twenty miles from the city, left at the depot, collected by milk-
men, mixed together in an ice chest and delivered to-morrow
morning. I do not believe such milk is good when it is deliv-
18%.]
DISCUSSION.
965
ered. That is one difficulty in feeding babies on cow's milk
in the city. I do not believe milk churned a mile is as bad as
milk that has been churned five or ten miles. In my early
life I was on a railroad fifteen months. I had one of these
delightful gravel trains, where we had to have our meals on
the train. I found the milk at the first meal had become well
buttered. The stomach irrigation is delightful where it can
be carried out. In small cities or country, where the patient
may be several miles away and we have to put up with the
ordinary mother, nurse or help, it is very difficult to wash out
tin' stomach every time the child is fed, or even to give it good
rectal injections. It seems to me the sytematic bathing, the
use of warm and cold baths, can be carried on in hospitals and
cities, where competent help is plentiful, but such treatment
is hardly applicable where we can not get competent nurses.
Dr. E. D. Chbbbbo, Providence, R. I. — One point in regard
to infantile scorbutus is the shrinking, anxious expression,
which was particularly interesting to me. This particular
symptom to which I have referred, was very striking. This
child developed no subperiosteal hemorrhage so far as I could
see. but she had repeated attacks of epistaxis. The Doctor
referred to treatment effecting speedy cure, but perhaps the
case he reported would have recovered just as quickly with a
change of diet. It is a question in my mind whether drugs
exert very much influence in these cases.
Dr. A. C. Cotton, Chicago — We have had some talk on
scurvy lately. Last year Dr. Love had something to say, and
the year before something was said upon scurvy. In illustra-
ting a statement that he made, a medical friend of mine, in
speaking of fads and the tendency to follow when anybody
starts anything, said when anybody reads a paper everybody
begins for the first time in his life to find he has a few cases of
the same kind, rather intimating we are not all honest, and he
used scurvy as an illustration. I think it has struck everyone
here we hear a good deal more of scurvy than we used to and
we see a good deal more of it than formerly. There is a good
reason for this. The country is overrun with artificial foods,
persistently advertised by the manufacturers and also by phy-
sicians, who ought to know better. In some whole communi-
ties exclusive artificial baby feeding is adopted and the effect
is seen in the development of scorbutic symptoms. Formerly
they used exclusive milk diet, and then they died of acute
milk poisoning, but they did not have scurvy. I think it is Kerr,
writing upon milk, in his description says it contains living cells,
aside from the proteid substances we have been in the habit of
recognizing and dividing into lact-albuminandcaseinogenand
these living cells are directly absorbed and used in the animal
economy of the infant, but are destroyed by heat, even
heat sufficient to Pasteurize it. He also says, as we have
heard before frequently, that the heat coagulates the albumin.
We all know that even when heated to 160 degrees, some of the
lact albumin is coagulated and the emulsion is thicker than
before. Knowing these two facts, I do not think we should say
we do not see why infants should not develop scorbutus or mal-
nutrition on cooked food and not on raw food. I do not know
anything more interesting to me than the discussion Dr. Burr
brought out so well in his very concise paper.
Now as to the point mentioned by Dr. Burr and Dr. Dixon.
I f a woman were to come into your office and ask you to abort
her, because it is a good deal of trouble and expense to have
a baby and she does not want to undergo the responsibilities
of maternity, I suppose about the first question you would ask
her would be : Who recommended you to come to me on this
errand? That is my first question, because my curiosity is
excited. But it does not take long to disabuse her mind of her
error in coming to you. It is possible you may show her to the
door a little frigidly. Now why not show an attitude similar to
that toward the woman who does not want to nurse her child?
She may sayshehad trouble nursing her previous child, but why
should we not take just as high ground concerning maternal
feeding as we do in regard to this other crime? It is a crime
to allow the mother to wean her baby, unless there is some
thoroughly scientific reason for it. Of course we do not want
a tuberculous mother to nurse her child. We have not paid
enough attention to inducing the mother to produce a proper
food for her baby. We should make the mother a good milker
by feeding her properly and taking care of her. Rotch has
said some good things in his book in regard to the manage-
ment of lactation.
It may be 1 lack the delicacy of touch in passing the tube,
but I find in the majority of cases the sigmoid flexure is
an insuperable obstacle. It has been said, instead of doing as
Dr. Bell suggested, to pass the tube so easily right up to the
transverse colon and then turn on the water, if you turn on
the water while introducing the tube the introduction of the
tube will be facilitated.
Dr. Daniel H. Cunningham, Chicago As to passing rectal
tubes, I have always used about a No. 8 or 9 hard rubber
catheter, turning on the water immediately upon entering the
rectum and directing the catheter with the finger, and have
been sometimes, not always, able to pass the sigmoid flexure.
Dr. Burr— The paper I presented on " Infantile Scorbutus,"
was intended to emphasize the fact that we have a great deal
of incipient scorbutus which does not arrive at the point of
characteristic appearances, so that it can not be recognized as
scorbutus but only as a tendency toward it : the child will event-
ually, perhaps, become scorbutic unless attention is paid to
change in its diet. The question of feeding children in the city
and in the country are two different questions. Our city born,
city fed and bred children labor under many disadvantages the
country children know nothing about. The majority of country
mothers are far beyond the city mothers in the point of health.
When I say a child must be breast fed, I pre-suppose a healthy
mother. I would not advise breast feeding from a mother suffer
ing from tuberculosis, syphilis, or other constitutional disease.
But I believe we should make the healthy mother feel she is a
criminal if she denies the child nature's food, unless there are, as
I stated in the paper, unsurmountable difficulties. The ques-
tion of getting pure milk in cities is one of the most difficult
problems. In our city we have found necessary a well-enforced
ordinance, fining milk men for furnishing bad milk, and every
month some of them are brought up and fined. As to the
remarks of Dr. Chesbro, about the expression of fear and
timidity on the part of the child, I mentioned that in the
paper. What is the cause of the fear? The child dreads to be
touched. Why? Because its little joints are sore ; perhaps there
is hemorrhage already under the periosteum. When you find
that expression, you should look out for scorbutus. Let that
be one of your early symptoms or warnings with reference to
the condition of the child's nourishment. Malnutrition is an
omnibus word ; in one child it may lead to rickets, one form
of malnutrition ; in another scorbutus, another form of mal-
nutrition : in another to petit mal or epilepsy, in which the
malnutrition gives expression in another way ; in another it
may predispose to tuberculosis. Anything which lowers the
power of vital resistance will lead into one of these numerous
roads from health to invalidism. I do not wish to emphasize
the medical treatment of scorbutus. Undoubtedly the orange
juice, raw milk and meat would have worked a wonderful
change in the child. I did believe the calomel and guaiacol of
value in the first few days. With reference to what Dr. Cotton
said about fads, the diagnosis of the condition in this child was
not a fad. The child was under the care of a physician from
eight until twelve months of age, before it was brought to
Chicago. A number of scars were found over the body, from
the breaking down and formation of little abscesses in numer-
ous places. But while the commercial men are distributing
more and more their chromo advertisements of artificial foods,
986
A CASF, OF CHLOKOMA.
[November 7,
and the mothers get recommendations from their family,
friends and neighbors, as well as from the press and even
some physicians, scorbutus will continue to increase. The
tendency is a wrong one and we ought to call a halt with all
the emphasis possible.
As to colonic flushing, I have repeatedly found my rectal tube
or one of these large catheters, which serves the purpose admir-
ably, doubled up and extruded forcibly from the bowel. It is
often utterly impossible to pass it beyond the sigmoid flexure.
A little postural change may assist matters very much. For
instance, by having the hips elevated you may facilitate the
accumulation of water in the colon and assist the peristalsis.
I prefer cool water, at 80 or 75 degrees.
A CASE OF CHLOROMA.
Read in the Section on Ophthalmology, at tho Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 6-8. 1896.
BY S. C. AYRES, M.D.
CINCINNATI. OHIO.
It is possible that the subject of chloroma is as new
and rare to many of you as it was to me when the case
I have to report came into my hands. It qnly came
into my service at the Ophthalmic Hospital because
the neoplasm had invaded the orbits and produced a
marked exophthalmus. In the American Journal of
Medical Sciences for August, 1893, appears a paper
entitled " Chloroma and its Relation to Leukemia,"
by Dr. George Dock, of Michigan, in which he reports
a case. He has examined the literature of all langu-
ages and collected, including his own, seventeen cases
of chloroma.
Edward Ludwig, aged 7, was admitted to the Ophthalmic
Hospital May 18, 1893. His parents are living and in good
health. There are five other children in the family, all of whom
are healthy.
Previous history, — He has always been a bright, intelligent
boy and has never suffered from any serious illness. He has
had repeated attacks of parotitis (?) and the present trouble
seems to have followed one of these attacks. He at first com-
plained of pain in both orbital regions and at the same time
both eyes seemed to be more than usually prominent. After a
week or more, his mother noticed some impairment of his hear-
ing, which slowly increased. The exophthalmus increased
more rapidly. He became very weak and somewhat emaciated,
and complained of a severe pain in the left foot, on account of
which he was unable to walk.
Upon his admission into the hospital both globes were very
prominent, but the right more so than the left. It was with
difficulty that he could close the lids of the right eye over the
ball. The cornea; are clear and there is no impairment of vision.
The conjunctiva; of both eyes are red and chemotic. The
motility of the eyes is unimpaired. In the upper and outer
portion of the right orbit can be felt a dense, inelastic growth
which protrudes beyond the edge of the bone. A similar growth
can also be felt in the left orbit, but not so pronounced. The
optic papilla; are somewhat pale, but there are no other alter-
ations in the fundus of either eye. His hearing is so much
impaired that he has to be spoken to in a loud tone. Pulse 120
per minute ; temperature normal. There is no lesion of any of
the cranial nerves. Muscular power and sensation of both
upper and lower extremities normal. Pressure on the sole of
left foot produces pain, but there is no redness or swelling in
this locality.
May 21. The proptosis of the right eye has increased, but
that of the left is apparently slightly less. There has devel-
oped a swelling in both temporal regions. They are rounded
and elastic, without any sensation of fluctuation.
May 23. Protrusion of both eyes increased : corneae hazy
and covered with inspissated mucus.
May 27. Temperature normal ; pulse 120. Patient complains
of some difficulty of micturition ; later on, retention of urine.
Both corneae are quite opaque. The swellings in the temporal
regions more pronounced. There has developed a hard, firm
swelling in the region of each parotid gland. Intelligence good ;
hearing somewhat improved. Pain in foot still present. No
appetite. The exophthalmus of both eyes increases day by
day. Both globes are now forced beyond the palpebral fissure.
June 2. Condition worse in all respects. He has had a
severe hemorrhage from the conjunctiva of the right eye.
June 5. Died this morning as result of hemorrhage from the
conjunctiva of the right eye.
Three days before death, blood pale and watery.
Staining according to the Ehrlich method showed a
marked increase in the number of white blood corpus-
cles, the increase being due principally to the number
of multinuclear cells, while the small lymphocytes
and those white cells characteristic of splenic and
myelogenic leukemia are not increased. Eosinophile
cells are sparingly present, not above 2 per cent. The
examination of the blood at this time justifies the
diagnosis of leucocytosis only, and not leukemia.
Furthermore, an examination of the patient revealed
no enlargement of the lymphatic glands except those
of the neck.
The postmortem examination was made about
twenty-four hours after death : Body fairly well devel-
oped and nourished; postmortem rigidity well marked,
the upper and lower extremities normal. No evidence
of subcutaneous hemorrhages. Marked swelling of
the lymphatic glands about the neck. Both eyeballs
protrude to such an extent that they are only partly
covered by the eyelids; sloughing of both cornere.
Traces of blood about the eyes, mouth and nose.
Mucous membrane of mouth swollen; teeth covered
with blood. To the touch the lpmphatic glands are
firm and resisting, with no sign of fluctuation. A
small nodular infiltration over the right parietal bone
near the median line. On cutting through this swell-
ing it was found to be situated beneath the periosteum,
and although there was no evidence of its having
arisen from the bone, the latter was at this point
remarkably thin. No trace of inflammation or infil-
tration of the pia mater or the brain. The brain was
found to be intensely anemic. On removing the brain
the orbital plates were seen to bulge upward owing to
the pressure from within. After removing the very
thin orbital plates, both cavities were found filled with
a firm, solid, and somewhat elastic mass of a light
greenish color, which pushed the eyeball forward.
This mass was removed with some difficulty, although
18%.]
A CASE OF CHLOROMA.
987
only at one point did it seem to be firmly adherent to
the periosteum lining the orbital cavity. Here the
bone was somewhat eroded. Behind, the new growth
extended to the sphenoidal fissure, surrounding but
not involving the optic nerve. In front and above,
the newly formed tissue extended to and a little
beyond the orbital arch. On superficial examination
the new growth seemed to be confined to the orbital
cavities: a further examination showed this not to be
the ease, for the cancellous tissue of the sphenoid and
the petrous portion of the temporal bones were soft-
ened and infiltrated with a dirty greenish-yellow fluid,
looking very much like pus. On the left side in the
petrous portion of the temporal bone was an area in
which the bone tissue was completely destroyed and
filled up with a material such as was found in the
orbits, differing from it only by being of a more dirty
greenish-yellow color, and not quite so firm. The
lymphatic glands presented the same appearance in
section as did the tumors of the orbits.
Equally as interesting proved the further examina-
tion of the new growth. On having placed the tumor
in alcohol, the color disappeared entirely within
twelve hours. On the other hand, the specimen kept
within a tightly corked bottle, still retains the green-
ish color: in fact, the color has become even more
marked. Some of the fresh fluid taken from the
interior of the sphenoid bone was examined, . but
revealed only the presence of large numbers of small
corpuscles, fat globules and granular detritus.
The section of the tumor after being hardened in
alcohol and ether seemed to justify the diagnosis of
sarcoma, the cells being almost entirely of the small
round variety, none or very few spindle cells, and
remarkably little intercellular substance; no large
blood vessels, but numerous lymph spaces. Further-
more, the small round celled infiltration extended into
the upper eyelid down to the yellow elastic cartilage.
The seat of the tumor, the peculiar color, the hist-
ory of the growth, the remarkable involvement of the
lymphatic glands, the results of the microscopic
examination, make this case one of a few that have
been put on record under the head of chloroma cancer
vert, the green cancer of the French.
Whether the form of tumor should be called a sar-
coma, whether it is of the so-called connective tissue
variety, or on the other hand, as Dock would seem to
believe, a peculiar condition arising in the course of
true leukemia, the tumors being regarded in this case
as lymphomata — these are questions which the future
must decide. Dock and a number of others have
found by an examination of the blood that they were
contending with true leukemia. My examination of
the blood, as already described, showed a remarkable
increase of white blood corpuscles, but they were
indicative only of a marked leucocytosis, and not a
true leukemia. This examination was made three
days before death. However, there is still a great
deal of obscurity about leukemia as to its true nature,
and when we consider that some writers have sug-
gested the name of sarcoma of the blood for this
disease, we can not wonder that in the case of chlor-
oma the pathologic conditions found were suggestive
of leukemia.
I am greatly indebted to Dr. Greiwe for the above
report of the postmortem and of his microscopic
examination of the growths. His views, while they
may differ from other investigators', are founded on
examinations made of the neoplasm removed from
different localities. It is very unfortunate that the
portmortem did not include the thoracic and abdom-
inal cavities. A more complete examination might
have thrown some light on the tissues invaded by
this strange disease.
In all the prominent diagnostic points my case
seems to correspond with the one reported by Dr.
Dock, as well as most of those he has so carefully
collected.
Color. — In color it was a yellowish-green, or per-
haps a pea green. It did not vary much in the differ-
ent localities, but was more pronounced in the larger
masses.
Consistency. — This differed in different localities.
It was homogeneous and without fibrous septa. I
have described the cut masses as presenting a smooth,
shining, jelly-like appearance.
Involvement of periosteum and bone. — Most of the
cases show involvement of the periosteum, and in this
case it was marked, but more than this an actual
softening of the bone. Dr. Greiwe in his report says
that " the cancellous tissue of the sphenoid and the
petrous portion of the temporal bones were softened
and infiltrated with a dirty greenish-yellow fluid,
looking very much like pus." On the left side in the
petrous portion of the temporal bone was ah area in
which bone tissue was completely destroyed and filled
up with a material such as was found in the orbits,
differing from it only by being of a more dirty green-
ish-yellow color, and not quite so firm.
Duration. — From the report of the mother it seems
that she noticed the exophthalmus only four weeks
before she brought him to the hospital. He died in
two weeks after he was first seen. Allowing two
weeks to elapse in which the changes were not
detected by the parents, the disease ran its course in
the short period of two months. After he was first,
seen the growth was exceedingly rapid and could be
noticed day by day.
Hemorrhage, — Epistaxis is mentioned as occurring
in some of the cases of chloroma reported. In Lud-
wig's case there was severe hemorrhage from the
conjunctiva of the right eye. This occurred in my
patient the day before he died, and then on the follow-
ing day recurred with such violence as to destroy
his life.
Retina. — The eyes were carefully examined and no
swelling of the optic discs and no retinitis was found.
The discs were pale and anemic, but not atrophied.
His vision was good. In a short time the cornea
became so involved that further inspection of the
fundus was impossible.
Exophthalmus. — This was pronounced and was the
first symptom that attracted the attention of his par-
ents. The engraving shows his appearance a day or
two after he was first seen. It was made from a
photograph taken by Dr. Arch. Carson, to whom I
am indebted for his interest in the case. The exoph-
thalmus increased slowly in both eyes, but more in
the right, and in a week from the time he was first
seen the proptosis was so great that he could not close
the eyelids, and in consequence the cornea ulcerated.
Exciting causes. — There is no known exciting
cause in this case, but his illness followed an attack
of parotitis. His mother 'said he had had several
attacks of so-called parotitis. It is not probable that
these attacks were true mumps, but precursors of the
development of the disease.
Deafness. — Deafness was a marked feature. It
988
OPTIC NERVE ATROPHY.
[November 7,
varied slightly in severity from day to day, and it was
always necessary to speak to him in a loud tone. He
had no catarrh and there was no otorrhea. The drum
membranes were not examined.
Dr. Dock says: "From what we do know of the
natural history of leukemia and of chloroma we can
see the analogies of the diseases. We can say that
chloroma is a lymphomatous process similar in its
clinical features to leukemia and pseudo-leukemia.
Our ignorance of its precise relations depend partly
on the fact that our knowledge of chloroma is very
incomplete, partly on the indefinite nature of leu-
kemia and pseudo-leukemia."
OBSCURE CASES OF OPTIC NERVE ATRO-
PHY OF CEREBRAL ORIGIN.
Read before the Section on Ophthalmology at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta, Ga., May fr-8, 1896.
BY CHARLES W. KOLLOCK, M.D.
CHARLESTON, S. C.
Affections of the brain proper that might cause
atrophy of the optic nerve are very numerous, but in
a majority of cases the disease which produces the
optic neuritis causes the death of the patient before
atrophy takes place, or can be recognized by the aid
of the ophthalmoscope. The cases who can survive
the disease sufficiently long for the nerve to become
atrophied are usually too obscure in many instances
for human ingenuity to explain, and though the
neurologists of to-day are wonderfully accurate in
their knowledge of this complex organ — the brain
— still in very many cases their conclusions must be
purely problematical. When we remember that a
tumor growing in the brain tissue may produce optic
neuritis in one case, and in another death may occur
without an eye symptom having been seen, we may
readily understand the difficulties of accurate diag-
nosis.
Lesions at the base of the brain will be followed
by characteristic symptoms according to the parts
involved and compressed, but it does not follow that
atrophy will occur merely because there happens to
be a growth, an aneurysm, or even a thickening of
the meninges at this locality. Meningitis, when not
fatal, often involves the optic nerve and its sheaths
and atrophy gradually supervenes, but such cases are
not obscure. The history will often give a thorough
insight as to the cause of the consequent atrophy.
Lesions of the copora quadrigemina are rare, and
cause blindness, loss of pupil reflex, strabismus and
nystagmus when the anterior pair, and loss of coor-
dination when the posterior pair are effected. But
both pairs usually become involved and when a
defective action of the same branches of the oculo-
motor nerves on both sides is seen it is more charac-
teristic of quadrigeminal disease than is neuritis,
choked disk, or atrophy.
Atrophy from anemia is more common after severe
hemorrhage rather than from inanition. Von Graefe
usually found atrophy coming on some time after
hemorrhage took place and Schweigger says, that the
loss of blood and disease of the optic nerve are wholly
unexplained and can not be due to simple anemia.
Jaeger has described atrophy of the optic nerve that
follows hemorrhage. Soon after the hemorrhage
occurs the vision becomes indistinct, it may improve
or become worse according to the nutrition of the
patient, but after repeated hemorrhages amblyopia
increases and vision is lost. The disk is pale and
bluish in appearance, the sclerotic band is broad, and
the remainder of the eye ground is very pale and the
vessels smaller than normal. Fries says that 35 per
cent, are due to hemorrhage of the stomach and
intestines, 25 per cent, uterine, 25 per cent, from
abstraction of blood, 7.3 per cent, due to epistaxis, 5.2
per cent, to bleeding wounds and 1 per cent, to
hemoptysis and urethral hemorrhage. Tumors pres-
sing upon the cerebral blood vessels and anything
that interferes with the circulation in the brain may
cause atrophy of the optic nerve, but it is more than
propable that death would occur before the atrophy
became apparent.
Embolism occurs generally in young persons and is
caused usually by a diseased condition of the heart
valves; rarely from thrombosis of the veins of the
lower limbs, and still more rarely from myocarditis,
that causes a rupture of the endocardium. It may
also be caused by an atheromatous degeneration of the
inner coats of the aorta, and form gangrenous or other
processes in the lungs; by tumors that press upon and
produce inflammation, and finally form wounds. The
middle cerebral artery is most often plugged, which
does not immediately produce atrophy but more likely
a softening of the brain that may eventually involve
the optic nerve and cause atrophy.
Thrombosis comes from atheromatous degeneration
of vessels and is more frequent after middle life.
There are generally prodromal symptoms and it is at
times very difficult to distinguish between this lesion
and cerebral hemorrhage, but recovery rarely takes
place after the former. The mental powers gradually
fail and the patient finally becomes demented. Atro-
phy is rare from this lesion.
Cerebral aneurysm. — Optic neuritis is uncommon
after this lesion and therefore atrophy is also rare,
except perhaps in some cases where there may be
direct pressure upon the optic nerves or chiasma.
Optic neuritis has been occasionally seen when there
was an aneurysm of the internal carotid and was then
double. Loss of sight in one eye, sometimes extend-
ing to the other, with, or especially without, optic
neuritis, with or without loss of smell on the side
affected, occurs in aneurysm of the internal carotid or
anterior cerebral artery; and the distinction between
the two depends on the presence or absence of paraly-
sis of the other nerves of the eye ball first affected,
which occurs especially when the aneurysm is of the
internal carotid. Cerebral aneurysms occur usually
between the ages of 10 and 60, rarely before or after,
and as often before 40 as after, and more frequently
in males than females.
Cerebral abscess occasionally causes optic nerve
atrophy by extension of the inflammation to the nerve
or its involvment by the consequent softening of the
tissues. Abscess of the brain is generally due to
injury or suppurative inflammation and is more com-
mon among males than females; 42.5 per cent, are
caused by ear disease ; 24 per cent by injury and the
remainder are due to diseases of the nose, orbit, non-
traumatic causes and tumors. It occurs in males and
females in the proportion of 3 to 1 : 1 to 9 years, 24
cases; 10 to W years. 48 cases; 20 to 29 years, 72
cases; 30 to 39 years, 29 cases; 40 to 49 years, 26 cases;
50 to 59 years, 16 cases; 60 to 69 years, 7 cases; 70
and over, 1 case.
Optic neuritis is less common than in tumor. Loon-
L896.J
GLAUCOMA AND OPTIC NERVE ATROPHY.
989
turn does not affect the neuritis and loss of sight is
probably due to neuritis as vision is rarely affected
by the abscess itself.
Multiple sclerosis occurs at all ages but more fre-
quently in the tirst half of adult life, between the
•see oi 20 and 30 years. It may affect any portion of
the brain, henoe the symptoms vary. The cranial
nerves me often affected, especially the first, second,
third, fifth and seventh. Loss of muscular control is
a common and early symptom, movements are peculiar
ami jerky but cease when the parts are at rest.
Nystagmus is very common. The "eye symptoms
are frequent ami important. The optic nerve may
sutler in various ways. There may be impairment of
sight in one eye or both, often with an irregular con-
traction in the field of vision, and without at first any
visible changes in the optic nerve to account for it.
This condition depends upon the development of an
islet of sclerosis in one or both optic nerves, or in the
ohiasma. It may progress almost to complete blind-
ness of one eye. After a time secondary atrophy
supervenes, and can be seen with the ophthalmoscope;
occasionally the atrophy is preceded by slight neu-
ritis, when sclerosis is near the eye ball. In some
cases again there is a primary atrophy of the optic
nerves, exactly like that which occurs in tabes, with a
similar failure of sight, proportioned to the visible
alteration in the nerve. Both eyes usually suffer, but
one is often affected earlier than the other. This
complication is. according to my own experience,
rather more frequent than the form first described,
and is of much pathologic interest." There is at times
loss of accommodation, less frequently light reflex
and the pupils may be unequally dilated.
Bulbar paralysis or labio-glosso-pharyngeal paral-
ysis occurs generally in the second half of life and in
males oftener than females. The causes are obscure;
sometimes mental depression and anxiety, exposure
to cold, debilitating influences and injuries, as blows
upon the back of the neck. Optic nerve atrophy is
of rare occurrence in this disease and of course when
it occurs the symptoms of the disease would be a
guide in diagnosis.
Paralysis of the insane, general paralysis. — Vision
is frequently affected by this disease, the ophthalmo-
scope showing choked disk or consecutive atrophy
according to the stage of the affection. General
paralysis is a disease of the well-to-do, the rich rather
than the poor, and occurs generally among those who
live a busy, hurrying life rather than among those
who reside in rural districts and lead quiet lives. It is
often seen in the highly educated, in males oftener
than females and about the prime of life. Hot climates,
certain pursuits and excessive sexual indulgence are
known to be exciting causes. Child-bearing and over
indulgence'in alcoholic liquors may also be a cause.
It frequently follows or is associated with locomotor
ataxia. The symptoms of this disease are so well
known that it should not be difficult to diagnose the
cause of the optic nerve atrophy. In addition to the
general symptoms there may be at times dilatation of
the pupils, myosis usually occurring at an early stage,
but a difference in the size of the pupils is still more
definite. The " Argyll- Robertson pupil" is often
seen ; these symptoms usually occur in other diseases
of the brain and are chiefly valuable as indicating
central disease. The cause of this disease is " a pro-
gressive degeneration of the encephalo-spinal norvous
system attended by subacute inflammatory changes
in the membranes of the brain and cord." Atrophy
of the optic nerve in this disease may be distinguished
from that caused by tumor of the brain, syphilis of
the brain, etc., by the absence of the symptoms that
indicate those lesions and especially from the latter
by the failure to get improvement by the use of mer-
cury and iodid of potassium. Treatment is of no
avail in this form of atrophy.
Brain tumort cause diffused symptoms, headache,
vertigo, vomiting, general epileptiform convulsions,
apoplectiform attacks, psychic disturbances and
choked disk. Choked disk is found more frequently
(54 per cent.) in cases when the tumor involves the
corpora quadrigemina. Direct pressure on the optic
tract causes atrophy, at times, without choked disk.
Tremors and localized spasms are valuable diagnostic
signs, because, first, they are more frequent with
tumors than other lesions ; and second, they are more
frequent in the cortex; third, more frequent in the
motor zones. In more than one-third of all cases
localized spasms and contractions exist at some time
during the disease and when present they indicate
localization in the cortex oftener than elsewhere, next
the corpus striatum and optic thalamus. Paralysis is
gradual and distinguishes it from hemorrhage.
Tumors of the corpora striata, corpora quadrigemina
and lenticular nuclei cause hemiplegias more slowly
than hemorrhage. Disturbances of vision are very
frequent as symptoms of brain tumor: 1, atrophy
of optic nerve following choked disk; 2, deviation
of the eye ball or eye lids from isolated or com-
bined paralysis of the nerves supplying the ocular
muscles, the third, sixth and seventh; 3, amblyopia,
or amaurosis, resulting from direct affection of the
optic nerve in its course through the cranium, or
at its cerebral centers, the mode of development
being, therefore, almost precisely analogous to that of
paralysis of any of the nervous tracts by direct com-
pression. The optic chiasma or nerve is liable to
pressure from tumors arising from the base of the
cranium or from the hypophysis, and also from the
peduncles. Hemiopia is produced when one tract or
one side of the chiasma is compressed. Tumors of
the thalamus do not often cause blindness. Tumors
of the corpora quadrigemina have a much larger per-
centage of blindness than those of any other part and
those of the cerebellum come next.
THE DIFFERENTIAL DIAGNOSIS BETWEEN
SIMPLE GLAUCOMA AND OPTIC
NERVE ATROPHY.
Read in the Section on Ophthalmology at the Forty-seventh Annual
Meeting of the American Medical Association at
Atlanta. Georgia, May 5-8. 1896.
BY B. ALEXANDER RANDALL, M.D.
Ophthalmic and Aural Surgeon to the Methodist and the Children's
Hospitals, etc.
PHILADELPHIA, PA.
At first thought little difficulty would seem to pre-
sent itself in differentiating simple glaucoma from
optic atrophy, and in the majority of cases any care-
ful student ought to succeed. A table can easily be
constructed, giving the typical like and unlike symp-
toms with such clearness of " deadly parallel col-
umns" as to make the tyro sure that only a blockhead
could err. Yet some or all of our differentiating
signs are at times lacking or doubtful, anomalous or
casual complications are encountered, and experience
teaches that the best-posted observers are tried at
990
GLAUCOMA AND OPTIC NERVE ATROPHY.
[November 7,
times to the uttermost by the uncertainties of some
cases. And when a case passes from one to another
with varying diagnosis, the later student will do well to
temper his self-gratulations by remembering that the
cardinal symptoms may have been wholly masked
before, and better fortune rather than superior skill
has given him the advantage.
It behooves us, therefore, to study out, with all care,
every detail, even in cases that appear perfectly clear;
for most of us have had patients in whom at one time
no trace of glaucoma has been detected, while shortly
afterward they have presented themselves with so
marked a stage of the affection as to convince us that
exhaustive study ought earlier to have recognized it.
I shall not soon forget two ladies sent me, about the
same time, by one physician, each of whom had full
development of glaucoma in the left eye when they
returned two years later. One had rainbow vision,
that made my study exhaustive, though vain for other
symptoms; the other had no suggestions of it. Both
were irretrievably neglected, when seen again. Such
cases passing into other hands must arouse doubts of
the competency of the earlier adviser, unless there is
full and frank communication with him. On the
other hand, optic atrophy may strongly suggest glau-
coma and lead to a tentative or positive suggestion of
iridectomy which the subsequent history shows to
have been groundless.
In simple glaucoma and optic atrophy we may usu-
ally find the contrasted symptoms of the following
table; but it must never be forgotten that they may
be wholly absent, or obscured if present.
TABULATION OF SYMPTOMS.
Simple Glaucoma.
Tension increased.
Cornea hazy and anesthetic.
Anterior chamber shallow or obliter-
ated.
Iris atrophic and discolored.
Pupil dilated and sluggish or fixed.
Reflex yellowish-green, "glaucous."
Perforating vessels dilated and tortu-
ous.
History of pain' and obscurations.
Unilateral character usual at first.
Limitation of field usually to nasal
side.
Color-fields commensurate to form-
fields.
Rainbow- vision about lights.
Knee-jerks unaffected.
Optic disc cupped, margins overhang-
ing.
Halo of choroidal atrophy usual.
Nerve-tissue greenish in shadow.
Arteries and veins pulsating.
The cardinal symptom of increased tension is vari-
able and often uncertain. Hardly any two observers
will exactly agree as to the tension of an eye, and a
rigid sclera, a tense eyelid or a rude touch may easily
cause error. Palpation had better be done with the
index fingers of both hands applied to one eye at a
time and then transferred to the other for comparison.
In doubtful cases it may be done upon the uncovered
sclera, but it is usually better to have the patient look
very far down and palpate above the tarsal cartilage.
If there are intermissions in the symptoms, we may
expect to find corresponding falls of the tension to
the normal. With a shrinking patient the surgeon
must be gentle and not over-endowed with thumbs.
The superficial corneal haze, which gives it a slight
" pin-stuck " appearance like ground-glass or a mirror
Optic Nerve Atrophy.
Normal.
Normal.
Normal.
Normal.
Small or dilated (Rob-
ertson).
Normal.
Normal.
Painless loss.
Bilateral generally.
Concentric limitation.
Disproportionate loss.
No halos.
Often lowered or lost.
Dished, margins shelv-
ing.
Halo rarer.
Nerve bluish-gray.
A rterial pulsation rare.
that has been breathed upon, may be a very delicate
change and, like the anesthesia, demand close obser-
vation to detect it. It is doubtless due to edema of
the epithelium and pressure upon the nerves. Though
most marked near the pole, it is nearly uniform, in
contrast to more localized keratitic changes. Indi-
vidual differences in the depth of the anterior cham-
ber, with a tendency to shallow with advance of life,
must be taken into account; and the pressing forward
of the lens is not usually very marked, but the appear-
ance of the iris is usually quite characteristic. Altered
color, vague detail of the surface or irregularities of
structure and a general suggestion of atrophy are
rarely lacking, and can easily raise a question as to
iritis present or past, by the peculiarity of some of
the changes. So too the pupil, semi-dilated and fixed
as a rule, oval oftener than round, at best slug-
gish and imperfect in action — it is generally more
abnormal in even the beginning of glaucoma than it
becomes in any but the last stages of optic atrophy.
The peculiarities of action to accommodative stimulus
but not to light, which Argyll-Robertson pointed out;
the hemianopic reflex of Wernicke; the consensual
action of an iris otherwise immobile, are rare in any
glaucomatous phase, and may be determinate of the
character of the nerve degeneration which we gener-
ally have to diagnosticate largely on negative data, by
exclusion. The yellowish -green reflex, often seen in
the pupil of the glaucomatous eye, may have some
counterpart in the opalescent haze of the lens in the
patient with atrophic nerves, who is usually well
advanced in life and has more or less arcus senilis
and other diminutions of the transparency of his
media. Yet it joins in the formation of the external
picture of glaucoma which the skilled observer can
often recognize at a glance, although analysis of its
details shows each of them so vague as to bring doubt
as to its real existence. Rarely lacking, however, to
complete the picture and demonstrate the congestion
of the ciliary vessels is the turgid, dark fullness of
the perforating veins as they emerge from the sclera,
several millimeters back from the cornea, and mean-
der beneath the conjunctiva. Many conditions of
ciliary congestion are marked by the undue promi-
nence of these vessels; but in none of the active con-
ditions are they as marked as they usually are in sim-
ple glaucoma. Other injection of the anterior segment,
such as may be great in the acute and subacute glau-
comatous attacks, may be wholly lacking in all phases
of simple glaucoma, and yet the observer will hardly
fail to receive an impression of congestion, out of
proportion to the expanse of these vessels.
The history ought to help the diagnosis greatly, by
the statement of pain in the eye, hemicrania or
"neuralgia," coincident with the periods of obscura-
tion and heralded by rainbows around the light. Both
affections are likely to be bilateral, but in optic atro-
phy the second eye follows but little behind the other
in its decline; whereas years may intervene before the
glaucoma that has blinded one eye manifests itself in
the other.
Mensuration of the visual field should never be
neglected, and although its showings are never to be
accepted as pathognomonic, much can generally be
learned from the charts thus obtained. Color- vision
is generally much lowered in optic atrophy, red and
green even wholly lost or presenting very restricted
areas of perception, with scotoma regions, where the
recognition is weak, if not quite lost. The form-field
L896.]
SPONGE GRAFTING IN THE ORBIT.
991
is more commonly restricted uniformly in the spinal
and sumo of the cerebral cases, although hemianopsia
and quadrant defects are not unusual, and may be
very helpful in localization of the underlying lesions.
In glaucoma the general form-field suffers proportion-
ately more and may be narrowed down, more espe-
cially on the nasal side, until mere central vision
remains, and the patient "sees as through a gun
barrel."
The knee jerks and other tendon and muscle reflexes
are well worthy of careful study in a number of our
eve eases, but especially in any where plantar numb-
ness, lancinating pains in the extremities and imper-
fect station or coordination suggest spinal disease.
None of these defects are to be expectedin glaucoma-
tous conditions, although it is not impossible to have
glaucoma attack an individual giving such evidences
of lesion of the cerebro-spinal axis.
It is to the ophthalmoscope especially that we turn,
however, for our diagnosis in many of these uncertain
cases. Here the picture may be unmistakable, when
much was doubtful in all other directions. Yet we
can be over-confident as to its help, and find a picture
that is almost typical of glaucoma when none is pres-
ent, or that gives no confirmation to a diagnosis that
is unmistakable in spite of such negative findings.
It is easy to make a set of diagrams, as does Fuchs,
to define the difference between physiologic, atrophic
and pressure excavation of the nerve head; but in
fact we may meet combinations or transpositions of
such appearances. Jaeger's admirable atlas gives us
-some of the puzzling findings, while others have
probably never been reported. The total cup, with
overhanging edge and greenish shadow, may seem
typically present in cases with normal fields and per-
fect central vision; and we look again in a vain effort
to see where healthy nerve fibers can find a place at
the margin of such a disc. So, on the contrary, we
may find not only acute, but chronic glaucomas, in
which neither the ophthalmoscope nor even anatomic
study later, under the microscope, can demonstrate
superficial cupping nor underlying depression of the
lamina cribrosa. Most trying is such an inconclusive
or contradictory finding in such cases where one eye
has already been lost by unmistakable glaucoma, and
the other is affected, but with a condition too little
defined to make us positive in deciding either for or
against iridectomy.
Note. — Numerous original illustrations of the typical and
the contradictory appearances of eye grounds, fields and
anatomic sections were thrown upon the screen with the
stereopticon.
SPONGE GRAFTING IN THE ORBIT FOR
SUPPORT OF ARTIFICIAL EYE.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta. Oa., May 5-8, 1896.
BY E. OLIVER BELT, M.D.
WASHINGTON, D. C.
PROKKSSOR OF OPHTHALMOLOGY AND OTOLOGY. HOWARD UNIVERSITY, AND
OCL'LIST AND AURIST TO FREKDMKN'S HOSPITAL.
To a skilled oculist the ordinary enucleation of an
eyeball is one of the simplest operations he is called
upon to perform, and yet there are some cases in
which so much of the conjunctiva is destroyed by
careless or ignorant operators, that it is impossible for
an artificial eye to be worn afterward. This is very
annoying to a patient, and we can not blame him if he
never forgives the doctor who has so afflicted him.
Such cases emphasize the fact that it is the duty of
the surgeon not only to operate skillfully for the
immediate relief desired, but he should do everything
in his power to prevent disfigurement, and when an
organ or limb can not be restored to usefulness, he
should at least obtain the best cosmetic results possi-
ble. After an eyeball has been removed and an arti-
ficial eye inserted, very frequently it is not as promi-
nent as the natural eye. It has a sunken appearance
which attracts attention, at once, to the fact that the
eye is artificial. To remedy this defect has been a
problem for ophthalmologists for years.
One of the most satisfactory operations heretofore
practiced is that known as Mule's operation, which
consists in the evisceration of the contents of the eye,
and the insertion of a hollow glass globe in the scle-
rotic. This is sewed in, and proves fairly satisfactory,
but there is some danger of the globe being broken,
and occasionally the stitches come out and the globe
escapes. There is also the risk of sympathetic oph-
thalmia, where the entire eyeball is not removed. To
obviate these difficulties and at the same time secure
a full orbit, I have devised a method of sponge graft-
ing which seems to meet the requirements without
the disadvantages of other methods.
The operation is a simple one and is performed as
follows: The eyeball is removed by the ordinary
method under strict asepsis. After all hemorrhage is
arrested the socket is washed out with a formalin
solution, 1 to 1,000, followed by sterilized salt solu-
tion. A globe of fine, soft sponge, about three-fourths
the size of the eyeball, previously sterilized in 5 per
cent, formalin solution and rinsed in the salt solution,
is then inserted into the socket, or capsule of Tenon.
The conjunctiva is brought together and sewed with
rat-tail sutures. The eyelids are then closed with
compress and bandage. In a few weeks the sponge is
filled with new tissue, which in time becomes firm,
solid flesh, making a full orbit and a fine support for
the artificial eye. The sponge fibers are apparently
absorbed.
I have performed this operation in five cases with
fairly good results in all, but union of the conjunc-
tiva has not been firm enough to prevent some of the
stitches from breaking or cutting out and the wound
gaping. In future cases, to relieve this strain on the
conjunctiva and to obtain good motion of the eye, I
think of uniting the opposing recti muscles with rat-
tail sutures, and then the conjunctiva over that by the
purse-string or subcutaneous suture. By this method
we should get union by first intention, good motion
of the stump and a full orbit. There seems to be no
danger from infection of the sponge, for in two cases
the eye was removed for panophthalmitis. Not only
has this operation advantages over other methods in
recent cases, but in old cases in which the eye was
removed months or years ago, where there is this
sunken appearance of the artificial eye, the socket
might be reopened and a sponge inserted.
Since making my investigation, I find that Prof. D.
J. Hamilton of Edinburgh practiced sponge grafting
for old ulcers in 1880, since which time a few other
physicians have tried it in fresh wounds and some
other similar conditions that skin grafting has been
used in. However, I can not find in all the medical
literature in the library of the Surgeon-General's
office any mention of sponge being used as I have
suggested and tried.
Case 1. — E. L., colored, aged about 30, came to Preedman's
992
A CASE OF TOTAL BLINDNESS.
[November 7.
Hospital in the spring of 1895, suffering from a ruptured eye-
ball (from a blow). Sight was entirely destroyed, and as the
injury extended entirely across the cornea and through the
ciliary region I advised removal of the eyeball, to which she
consented. As she was willing to stay in the hospital as long
as necessary and I could keep ner under observation, I decided
to try the insertion of a small sponge in the socket, with the
hope that new tissue might form through it, as was reported
to have occurred with a sponge accidentally left in the body
during an operation. Accordingly, after removal of the eye, a
globe of fine sponge was inserted and sewed in the socket.
The sponge had been sterilized by boiling. After a few days
the stitches came away and the sponge was exposed ; however,
there was no tendency for it to come out. There was consid-
erable discharge and the orbit and sponge were cleansed as
frequently as required. In two or three weeks about half of
the sponge separated and came away. I found the remaining
portion filled with new tissue and presenting a healthy granu-
lating surface. The patient left the hospital soon after and
was not seen again until a few days ago, when I found a mod-
erately well filled orbit ; the wound was entirely closed and
appeared to be covered with conjunctiva.
Case 2. — April 7, 1896. A. B., right eye ruptured (eight
days previously by blow) through cornea and ciliary region.
Eye full of pus. Enucleated under anesthesia, socket cleansed
with formalin solution, 1 to 1,000. Sponge (sterilized with
5 per cent, formalin solution) inserted and stitched in with silk
sutures. April 15, sutures out, wound gaping and sponge
showing full length of fissure. May 5 about half of the sponge
separated and came away, the balance filled with new tissue.
June 3, socket full of new tissue and wound closed. Artificial
eye inserted, has good motion and no sunken appearance of
orbit.
Case 3. — April 13. C. T., aged 30, eye lost seven years ago.
Eyeball shrunken. Eye removed under anesthesia. Socket
cleansed with formalin solution, 1 to 1,000. Sponge inserted
and stitched in with rat- tail sutures. April 28, temperature
normal all of the time. No suppuration. Wound healed by
first intention. Smooth stump. April 30, one or two stitches
out, sponge showing for one-fourth inch, but seems to be filled
with new tissue. June 3, wearing artificial eye. Orbit full,
has not a sunken appearance, and motion of eye good.
Case 4. — April 23. A. J., aged 30. Stuck fork in left eye
one week ago. Panophthalmitis. Eye enucleated under anes-
thesia. Socket washed with formalin solution, 1 to 1,000.
Sponge inserted and stitched in with catgut and rat- tail sutures.
April 30, some stitches out and sponge showing. May 5, fissure
closed again with rat-tail sutures. May 7, all stitches out
again. June 3, wound gaping and sponge showing, but adhe-
rent all around and new tissue filling three-fourths of sponge.
Case o. — April 25. M. B., aged 30. Right eye lost by puru-
lent ophthalmia several months ago. Eye enucleated under
anesthesia. Socket cleansed with formalin solution, 1 to 1,000.
Sponge inserted as usual and rat-tail sutures used. May 5,
doing well, but some stitches out. June 3, nearly the entire
sponge is filled with new tissue and the wound closing up.
A CASE OF TOTAL BLINDNESS; POSSIBLE
DUE TO AN OVERDOSE OF QUININ.
Road in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association,
at Atlanta, Ga.. May 5-8. 1896.
BY H. BERT. ELLIS, B.A., M.D.
LOS ANGELES, CAL.
August 8, 1895, I was called to J. W., a man 34
years old. After repeated questioning of the patient
and his sister, the following disconnected, incomplete
and probably somewhat inaccurate history was
elicited :
The young man was an accountant in the employ
of one of the Texas railroads and had been with them
for years, although for some time he had been an
opium, whisky and tobacco habitue. The first habit
he had contracted as a result of the use of opium dur-
ing an attack of dysentery. Four years ago, he had
gone to an institute and had been cured of these
habits, but quickly lapsed into them again, excepting
that he never renewed the use of tobacco.
I was unable to find out definitely the amount of
morphin and whisky that he used daily. His own
statement was to the effect that he had been taking
about 7 grains of morphin daily. This statement was
probably inaccurate, for judging from the amount it
was necessary to give to keep him reasonably quiet,
at the time I was called, he certainly could not have
been taking less than from 10 to 20 grains in the
twenty-four hours, and probably more for some
months ; and of whisky he used from one pint to one
quart daily.
In October, 1894, when suffering from malaria, he
had been given by a physician 120 grains of quinin
in twenty-four hours in four doses. In a very short
time he was totally blind in both eyes, but this con-
dition lasted only about two weeks, after which there
was a gradual return of vision, so that he resumed
work on his books, and was able to continue at inter-
vals by aid of an assistant (for his vision never
became good), till February, 1895, since which time
he had not been able to see anything, except to dis-
tinguish a bright light occasionally. There was no
history of concurrent deafness.
During June and July he had been living with a
woman who was an opium habitu6 and she had kept
him constantly saturated with morphin, till his sister
brought him to Los Angeles.
The patient, five feet, nine or ten inches tall, was
extremely emaciated, weighing about 103 pounds; his
normal weight had been from 145 to 150. He had
the marked opium cachexia and puffiness of lower
lids. There was almost complete loss of the cutane-
ous and deep reflexes, the knee jerk being entirely
absent. The bowels were sluggish, and the urine
very scanty, ten to twelve ounces in twenty-four hours.
He was practically demented, his memory so defective
that he could not sustain a conversation.
The pupils were so small that it was quite impossi-
ble, in his helpless condition, to make a satisfactory
ophthalmoscopic examination, without prodiucing
mydriasis, which I did with a weak solution of sul-
phate of atropin, and found the fundi presenting very
small deviations from the normal. Both nerves were
pallid and the arteries and veins, though relatively
normal, were both slightly reduced in size, no other
changes could be detected.
The morphin was gradually diminished and codein
substituted, the whisky slowly reduced, so that by
November 1, he was taking no morphin or whisky.
At different times, trional in 15 grain doses, chloral-
amid 30 grains, chloral and bromids 20 and 30 grains,
and hyoscyamin 1-30 grain were given to quiet him.
Sulphate of strychnin was administered, in gradually
increased doses, from 1-60 to ^ grain three times daily,
hypodermically, in the temples. The knee jerk and
other reflexes returned. Occasionally he would
describe quite accurately some object in the room, but
these returns of vision were very transient. His intel-
lect improved materially, as did also his physical con-
dition. About November 1, he had two quite marked
convulsions, and we decreased the strychnin. The
patient died late in December, of bronchitis and
edema of the lungs; a condition not unlike senile
bronchitis.
Was this a case of toxic amblyopia? and if so, was
it due to quinin, morphin or whisky?
Now is the time to increase the membership in the
Association. Let every member send in one or more
new names.
18%.]
MEDICAL TREATMENT OF INEBRIETY.
993
THE MEDICAL TREATMENT OF
INEBRIETY.
! before the NViv York State Medloal Society at New Ycrk City,
Oct. IS, IMA.
BY T. D. CROTHERS, M.D.
SUPERINTENDENT WALNUT LODOE. II AliTFORD, CONN.
Inebriety is a more complex disease than insanity.
Its progressive degeneration often dates back to
ancestors, to defects of growth, retarded development
and early physical and psychic injuries. Later, the
poison of alcohol, by its anesthetic and paralyzing
action, develops more complex states of degener-
ation, the form and direction of which is very
largely dependent on conditions of living and sur-
roundings.
The psychic symptoms show progressive disease of
the higher brain centers, both masked and open, with
degrees of palsy and lowered vitality. In insanity
many definite pathologic conditions are traceable.
In inebriety a wider, more complex range of causes
appear, the line of inarch of which is often traceable
in more general laws of dissolution. Its medical
treatment must be based on some clear idea of what
inebriety is. and the conditions present in the case to
be treated. This requires a careful clinical study of
the symptoms, tracing them back to causes, and all
the varied conditions formative in the progress of the
case. In such a study, heredity appears as the most
frequent early predisposing cause. The question then
is: What conditions of life have been most active in
developing these inherited tendencies? How can
these conditions be checked and prevented? What
means and methods are possible in the rational treat-
ment r
The second class of cases most commonly noted are
those due to physical causes. These are the physical
and mental strains and drains, also injuries both
physical and psychic. The remedies here are dis-
tinct, and the means to build up and restore these
defects call for therapeutic skill and judgment. A
third class of inebriates seem to be due to especially
lie causes, of which mental contagion of indi-
viduals, of conditions and surroundings are most
prominent.
Here another class of remedies and therapeutic
measures are required. These classes are often com-
bined, and the various causes are blended, requiring
more accurate study to determine the leading factors
in each case. These are conditions which provoke the
early use of alcohol, and give form and direction to
the progress of the case.
The second part of the clinical study of inebriety
is the effect of alcohol. WThat injury has it caused?
How far has it intensified all previous degenerations,
and formed new pathologic conditions and sources of
dissolution? Also what organs have apparently suf-
fered most seriously from the drink impulse? and,
most important of all, how far is the use of alcohol a
symptom or an active cause? Having ascertained
these facts, the medical treatment is the same as in
other diseases, the removal of the exciting and predis-
posing causes, and building up the body.
The first question is the sudden or rapid removal
of alcohol. If the patient is alarmed, and intensely
in earnest to abstain, he will consent to have the
spirits removed at once. If he is uncertain, and has
delusions of the power of alcohol to sustain life, the
withdrawal should depend upon circumstances. The
removal of all spirits at the beginning of the treat-
ment is always followed by the best results. The
reaction which follows can usually be neutralized by
nitrate of strychnia, one-twentieth of a grain every
four hours, combined with some acid preparation.
Soda bromid, in 50 or 100-grain doses every three or
four hours will break up the insomnia, and cause sleep
the first two nights.
The withdrawal of spirits should always be followed
by a calomel or a saline purge, and a prolonged hot-
air or hot- water bath, followed by vigorous massage.
Hot milk, hot beef tea. and in some cases hot coffee,
are very effectual. If the patient persists in a grad-
ual reduction of the spirits, strychnia 1-20 of a grain
should be given every two hours. The purge and hot
bath should be given every day while the spirits are
used. The form of spirits should be changed from
the stronger liquors to wines and beers. Some of the
medioated wines are useful at this time, or spirits
served up in hot milk. There is no danger of delirium
from the withdrawal of spirits, particularly where
baths and purging are used freely. The two condi-
tions to be treated at this time are poisoning and
starvation. The system is saturated with ptomains
from alcohol, and suffers from defective digestion.
The nutrition is impaired, and organic growth retarded.
Saline or calomel purges with baths meet the first
condition, foods and tonics the second. Not unfre-
quently the withdrawal of spirits reveals degrees of
brain irritation and exhaustion, that are practically
manias and delirium, or dementia and melancholia.
The essential treatment is to regulate the nutrition
and elimination, then arsenic, strychnin, phosphates
and iron will comprise the chief remedies that are
found most useful.
Many of the chronic cases of inebriety reveal de-
mentia when spirits are removed; others show well-
marked paresis, or tuberculosis. Symptoms which
were attributed to the action of alcohol are found to
be due to previous degenerations. In one case the
demented talk and conduct while using spirits burst
into marked dementia when the drug was withdrawn.
In another case, the wild, extravagant conduct of the
inebriate appears in paresis when free from spirits.
The removal of alcohol is often followed by tuber-
culosis, not suspected before, which apparently starts
from some trivial cause and goes on rapidly to a fatal
termination.
Rheumatism and neuritis are forms of disease which
frequently appear after the withdrawal of spirits.
Diseases of digestion are common, also diseases of the
kidneys. The latter is usually masked and bursts
into great activity when alcohol is removed. These
and many other organic diseases suddenly come into
view, and whether they have existed, concealed by the
anesthetic action of alcohol, or have started up from
the favoring conditions of degeneration caused by
spirits, are not known. The therapeutic requirements
must reach out to meet all these unsuspected disease
states which may appear any time.
The removal of spirits in all cases reveals condi-
tions of both physical and psychic degeneration that
call for a great variety of therapeutic measures.
The next question is to ascertain the special exciting
causes and remove or build up against them. In the
periodic cases the early favoring causes of the drink
storm are often reflex irritations from disordered
nutrition, exhaustion and excessive drains or strains.
Later a certain tendency is formed for explosions of
994
MEDICAL TREATMENT OF INEBRIETY.
[November 7,
deranged nerve energy in alcoholic impulses for relief.
This periodicity is often due to causes which can be
studied and prevented by remedial measures. In
certain cases nutrient and sexual excesses are followed
by a drink storm, In another, exposure to malarious
influences, where the disease has existed for a long
time before, brings on the craze for drink. In other
cases, constipation, overwork, neglect of hygienic care
of the body, irregularities of food and sleep, emotional
excitements or depressions are followed by an alco-
holic craze. A vast range of psychic causes have
been noted. Thus, a residence on the seashore or in
high altitudes, on mountains, provokes his thirst for
spirits and removal to higher or lower planes is fol-
lowed by a subsidence of it. Many persons never use
spirits except in large cities, or at special exciting
fatherings, or on holidays and festive occasions,
[ere evidently some defect of the brain exists, either
organic or functional, which should be reached thera-
peutically. Literally, many of these cases have been
cured by change of surroundings as well as medicines.
While the ostensible object of medication is to stop
the drink craze, this is as far from being curative as
the suppression of pain by a dose of opium. Con-
ditions which cause the disordered nerve force to con-
centrate in cravings for the anesthesia of spirits, are
to be neutralized and prevented before a cure can be
expected.
The use of narcotics and drugs to check the desire
for spirits at the beginning is temporary and always
uncertain. Opium, chloral and cocain given freely at
this time often simply changes the drink craze for these
drugs, which are used in the place of spirits ever after.
The return of the drink impulse at regular or irreg-
ular intervals is in most cases preceded by premon-
itory symptoms, which enable the physician to use
preventive remedies. In certain cases calomel and
saline cathartics, with prolonged baths, rest, or exer-
cise, according to the requirements of the case, have
been found curative.
Various cinchona tonics, free from spirits, and iron
preparations are often useful. Large doses of strych-
nin seem more valuable after the full development of
the morbid impulse, given when spirits are discon-
tinued. Some of the various coca compounds on the
market have a strong influence in breaking up the
drink storm.
In a certain number of cases patients are uncon-
scious of the approach of the drink storm and are
difficult to treat. But when they realize its coming
and seek assistance the task is easier. The general
principle of treatment is sharp elimination through
all the excretory organs and the use of mineral tonics,
changes of diet and living; particularly a study of
the exciting and predisposing causes, and their
removal. When the drink paroxysm has passed away,
then radical constitutional remedies are to be used.
The history of syphilis calls for mercury, arsenic and
potassium. Defective nutrition requires a study of
the diet best suited to build up the tissues.
Entailments from other diseases, as malaria, rheu-
matism and various neurotic affections, require appro-
priate remedies.
Tinctures of any form are dangerous. The suscep-
tibility to alcohol is so great that the smallest quantity
is felt, although it may not be recognized. Where
spirits are taken continuously the system is always
depressed; all functional activity lowered and literal
palsy and starvation are present.
The removal of alcohol is only a small part of the
treatment. The demand for alcohol is a symptom of
this progressive degeneration. Given remedies to
produce disgust for the taste of spirits, or to break up
the cravings for it, are not curative. Apomorphia,
mixtures of atropia, hydrastin, and a great variety of
allied remedies, are all dangerous ; while apparently
breaking up a symptom of the disease present they
often literally increase the degeneration by their irri-
tant narcotic properties and further depressing action
on the organism. The indiscriminate use of these,
and allied drugs, in the various specifics for inebriety,
is the most dangerous empiricism. It is the same as
opium or other narcotics for pain in all cases, irre-
spective of all conditions and calling the subsidence
of the pain a cure. Thus in the following cases a
periodic after a gold-cure treatment developed into
acute dementia, which ended fatally. In others epi-
lepsy, acute mania, pneumonia, rheumatism, nephritis,
followed from the chemic suppression of the drink
impulse. In all probability the narcotics used were
active, contributing causes to the particular organic
disease which followed.
The masked character of inebriety makes it dan-
gerous to use narcotics beyond a certain narrow limit.
Cases which have been subjected to active drug treat-
ment to suppress the desire for spirits are feebler and
more debilitated than others. Those who have taken
the so-called specifics are marked examples and whether
they use spirits again or not are always enfeebled and
pronounced neurotics. In all these cases there is so
wide a range of causes and conditions that specific
routine treatment is impossible.
Strychnin has recently come into some prominence
and is a useful, valuable drug. In some cases where
the spirits are withdrawn its action is pronounced as
both a tonic and stimulant. Given in 1-30 grain doses
four times a day, for a few days at a time, then dis-
continued, or given in larger doses for a shorter time,
the results are usually good. In some cases certain
susceptibilities to the action of strychnia are noticeable
and where the drug is taken to prevent the drink
attack it sometimes rouses it, seemingly precipitating
the condition which it is supposed to prevent. This
is often anticipated in the muscular tremors and nerve
twitchings that evidently come from strychnia when
used even in small doses.
Strychnia should never be given alone, except imme-
diately after the withdrawal of spirits. At other
times, combined with cinchona or other vegetable
tonics, is an excellent tonic. Care should be used to
watch its effects on the motor nerves, and be sure that
the patient is not unusually sensitive to it. Belladonna,
atropia, cannabis indica, hyoscyamus and drugs of this
class have a limited value and should be used with
great caution in states of irritation following the
withdrawal of spirits. They are best given in com-
bination with other drugs for a brief time and in par-
ticular cases. The bromids are valuable in the same
way and in the same conditions, only in much larger
doses than mentioned in the text-books. From 50 to
100 grains to a dose are requisite, always accompanied
with baths and never continued more than two or
three days. Coal-tar preparations are of uncertain
value as narcotics, but may be used in certain cases
with good results. The various mineral and vegetable
acids are almost indispensable in selected cases and
often can be given a long time as tonics.
In the treatment of cases, after the paroxysm is
1896. ]
ELECTRIC TRAUMATA.
995
over. Frequent changes of the form of the tonics are
most valuable. Iron, phosphorus, arsenic, potassa
ami bitter vegetable tonics should be alternated, with
free intervals, for periods of months. The various
derangements of the system should be watched and
Heated with appropriate remedies and every case
slum Id be constantly under medical care. The facts
of the ease having been studied, the question of
where the medical treatment can be applied to the
best advantage must be determined from the case aud
its surroundings.
If at home the physician must have full control and
his directions carried out implicitly. When the drink
paroxysm appears the course of treatment must be
prompt and exact. In one ease the patient goes to
bed and is secluded from all sources of excitement;
in another he is sent away to the country and among
strangers; in a third case a few days' residence in a
hospital or asylum under the care of a physician is
sufficient. Hospital treatment, with its exact care
and physical and psychic remedies continued for a
long time give the strongest promise of permanent
restoration. Wisely adapted medical treatment, based
on a careful study of each case, makes it possible for
the family physician to treat these cases, in the early
Stages, with success.
No single remedy is capable of meeting a wider
range of conditions than the Turkish or hot-air baths,
with free massage. Next to this is hot and cold show-
ers, and hot packs with free rubbing. Bitter tonics
and salines with regulated diet are next of importance.
Elimination through the bowels, kidneys and skin
freely are always essential. Beyond this the good
judgment of physicians should determine when to
give narcotics and when to abandon them, always
remembering their danger and very uncertain tem-
porary action. Also that the cessation of the drink
craze is only temporary. If this is accomplished by
drug and chemic restraint the permanency is very
doubtful.
The subsidence of the drink symptom by the
removal of the exciting causes and building up the
in to greater vigor and health is the only rational
treatment. In this the highest medical judgment
possible and the greatest therapeutic skill are essential
for success. The medical judgment, which will deter-
mine the exact condition in each case, and the possi-
ble range of remedies "required ; not any one drug or
combination of drugs; not so-called moral remedies,
or appeals to the will power, but a clear, broad, scien-
tific application of every rational means and measures
are demanded. A large number of these unfortunate
cases are distinctly curable in the early stages, and
later when chronic conditions come on the possibility
of cure continues to a far greater degree than is com-
monly supposed.
It is the common observation of everyone that a
certain number of cases recover from the apparent
application of the crudest empiric and psychic
agencies used in the most unskillful way. This fact
furnishes the strongest possible reasons for believing
that when inebriety shall be studied and treated as a
disease more generally by the profession a degree of
curability will be attained far beyond any present
expectation. The present empiric stage of treatment
should rouse a greater interest and bring the medi-
cal treatment of inebriety into every-day practice.
Then the family physician, and not the clergyman
and quack, should be called in to advise.
A new realm of medical practice is at our doors,
only awaiting medical study above all theory, and
exclusively from the scientific side.
ELECTRIC TRAUMATA, THEIR PECULIAR-
ITIES AND THEIR TREATMENT.
Read at the thirty-ninth aunual session of the Medical Association of
Missouri. May 21. 18M.
BY NORVELLE WALLACE SHARPE, M.D.
ST. LOUIS, MO.
Among the forces of nature that are rapidly being
utilized by man in the arts, sciences and the daily
needs of life, and occupying a prominent rank is elec-
tricity. Its applicability is becoming multifarious,
its capabilities are unknown. We have but to glance
over the columns of the press and note the casualties
to realize the numerous accidents attributable to it
alone. It is needless to observe that the recorded
cases represent but a meager proportion of the actual
number of its victims. Of the varieties used to-day,
two currents stand out prominently over the others in
their applicability to the needs of modern life — the
alternating and direct. The alternating ranging from
1(500 to 2000 voltage, ordinarily, produces our incan-
descent lighting system. The direct current ranging
from 500 to 3000 voltage, supplies the arc lighting
system, and in the lower voltage is the motive power
in street railways, factories, etc. It is obvious that
with the increased usage of these agents, accidents will
occur in direct proportion to the complexity of factors,
and insufficiency of safeguards, unless a superior
attention to safeguarding be practiced. The lethal
force of electricity is almost entirely dependent upon
voltage or electro-motive force, being actually the
result of the current in amperes, which is caused to
flow through the body against its resistance, by the
electro- motive force. In any electric circuit the cur-
rent in amperes flowing, is equal to the electro-motive
force in volts divided by resistance in ohms. This is
known as Ohm's law; and for our purpose is equiva-
lent to stating that with a given resistance the cur-
rent in amperes is proportional to electro-motive force
in volts, and further, the current in amperes is the
actual lethal force. There are cases on record where
a pressure of 500 volts has been fatal, but far the
greater number of casualties have been produced by
pressure exceeding 1000 volts. From 1500 to 2500
volts have been employed in electrocution, the skin
resistance brought to the minimum by contact
sponges of large surface, wet with saline solution.
The usage of these technicalities may be clarified by
the following suggestion: Imagine a pipe conveying
water driven by force, the conventional hose will suf-
fice. Thus we find that: 1, the volt, unit of electro-
motive force equals pressure or head of water; 2, the
ampere, unit of quantity equals quantity of water
passing through the pipe, expressable in gallons; 3,
the ohm, unit of resistance (produced by one ampere
of current, under pressure of one volt in one second of
time) equals the degree of Motional resistance of pipe.
Permitting C to equal current, — quantity, — ampere;
E to equal electro-motive force, — pressure, — volt; R to
equal resistance, — ohm; we deduce C = E -4- R. In
medical application of electricity where the resistance
within the cells is large, R should be subdivided into
R', internal, and R", external resistance; the resultant
equation reading C = E -=- (R'+ R")- But in electric
lighting and power systems where an almost constant
996
ELECTRIC TRAUMATA.
[November 7,
pressure is maintained on the supply mains, the
resistance of the mains is so inconsiderable, as to be
negligible. Demonstration of the practicability of
these formulae is easy. The pressure required for
incandescent lamps (for example) is about 110 volts
(being reduced on alternating current from the high
voltage of mains by means of transformers), the
resistance is 220 ohms. Current to be found: C =
110-4-220 or \ ampere for 16 C. P. lamp.' The 32 C. P.
lamp requires one ampere, pressure 110 volts ; resist-
ance required: R = 110 -f- 1 = 110 ohms.
Of the various human tissues the skin presents the
highest resistance to electric penetration. (Different
thicknesses produce resistance of varying degree).
When it is removed, destruction is markedly intensi-
fied. Skin resistance increases by dryness; moistened,
especially by saline solution, it is notably diminished.
Experience tends to show that a current of one or two
amperes is fatal to the majority of individuals. The
fact that comparatively low voltages in some cases
have proven fatal, and victims of shock from relatively
high voltages have recovered, does not necessarily
show that some systems can withstand more current
than others, but rather that the skin resistance was
greater, or the area of contact smaller in the more
fortunate cases (according to Ohm's law). Any cur-
rent sent through the body being dependent upon the
resistance offered (the skin being the chief factor), it
follows that the larger the area of contact, the less
resistance, and a proportionally greater amount of
current is received. It is known that a 2 or 3 per
cent, saline solution offers a resistance equal to about
one-twentieth of that of pure water, and that sea water
offers about one-fortieth. The resistance offered to
an alternating current by a cubic foot of pure water
at 60 degrees F. is 80 ohms 60 degrees; a cubic foot
of water, plus 15-100 pound of rock salt is 7 ohms.
Elevate these fluids to 212 degrees F., pure water resists
to the extent of 24 ohms, the saline solution 4.2 ohms.
From these data it is clear that the salinity of the
sweat, temperature and humidity of the atmosphere
and season of the year are all important factors in the
determination of the resultant shock to an individual.
Of the two chief currents, direct and alternating, the
former has the greater electrolytic intensity, the latter
produces no permanent chemic change. Death from
either current is without doubt due to sudden and
profound shocking of the sympathetic system.
The injuries resultant from electricity range from
relatively trivial burns to loss of life. Of all such
injuries, an overwhelming percentage consists of
burns. They usually occur upon the hand or forearm
and differ radically from ordinary burns and scalds,
in, 1, appearance; 2, accompanying pain; 3, concom-
itant shock; 4, prognosis; 5, subsequent manifesta-
tions; 6, reaction to treatment, and frequently 7, result.
I may mention en passant that during the four years
these researches have occupied, I have failed in the
search of literature upon this subject.1
Appearance : The majority of electric burns, seen
early, present a dry, crisped aspect, excavated and
bloodless, with surrounding zone characterized by
pallor. This condition changes within thirty-six
hours, serous oozing obtains, the tissues soften, and
hyperemia replaces the pallor.
Pain is as a rule very moderate, in some cases prac-
1 One day before this paper was read I was made cognizant of the
fact that Moyer of Chicago had about a year ago produced an article
on lines somewhat aualagous to those investigated here. I have not
seen the article, nor any other on this subject.
tically absent. Twenty-four to forty-eight hours
after contact it is usually present.
Shock: Electric burns differ from other burns in
that the systemic shock is from the contact, the shock
from the burn per se being nil.
Prognosis, in regard to time: Electric burns average
from one and one-half to three times as long in recovery
as other burns; in some cases, dependent upon locality,
such as proximity to bones and joints, the ratio is as
5 to 1 or more; prognosis, of results, is as uncertain as
time prognosis ; severe cases may progress relatively
rapidly ; mild cases are often persistently rebellious to
recovery ; usually both mild and severe cases are
tedious and prolonged.
Subsequent manifestations : The rule of the electric
burn, from which there are rare exceptions, is that it
changes within thirty-six hours from contact to a
serum saturated area, with disintegrating walls and
floor, progressing to profuse purulent secretion with
continued tissue degeneration. This degeneration
will frequently involve nerve, muscle, tendon, joint
capsule, ligaments, articular surfaces, periosteum and
bone itself. Exuberant granulations springing up,
the entire plain bathed in pus, complete a picture
alike distressing to patient and surgeon.
Reaction to treatment is very unsatisfactory, it
being apparently impossible to check the disorganiz-
ing process, especially in severe cases, with most scru-
pulous antisepsis or asepsis. After a varying period
of from fifteen to fifty or sixty days, and often much
longer, firm granulation will slowly proceed and the
Result will be as good as is ordinarily secured in
other burns. In some cases, however, owing to the
disintegrating process involving bones and joints, pro-
ducing necrotic masses, amputation is necessary. Too
much stress can not be laid upon the above clinical
picture, and errors in prognosis are readily made by
those who have not been brought in contact with such
injuries, in regard to time and result. The sloughing
almost invariably present is noteworthy. Frequently
a burn which in its incipient measurements will not
occupy more than a square inch of surface, will pro-
duce a subsequent area of four or five square inches,
or more, due to degenerative changes. The intensity
and persistence or this process, unabated by usual
surgical methods, can only be accounted for, by a
local trophic death, produced by electrolytic activity
in destruction. This wet gangrene continues as long
as the local trophic inanition lasts; and healthful rejec-
tion of sloughs, and replacement by firm granulation
material, can not and does not obtain, until local
trophic equilibrium is again established.
The treatment of profound shock from an electric
current should be instituted upon lines analagous to
those pursued in shock from other agents. The
patient will be found pulseless or nearly so, respira-
tion of the most feeble character or absent, warm skin
which rapidly cools, with pallor, immobile pupils and
absolute muscular relaxation. Laborde's method of
tongue traction in the horizontal position or with the
head upon a lower plane than the body, is advised.
Frictions, heat to body and extremities, hypodermic
injections of brandy, digitalis, etc., are valuable. In
cases where respiration is not absolutely suspended,
inhalations of nitrite of amyl, until face flushes, fol-
lowed by a massive hypodermic of strychnin, will
bring the vital forces together; this effect should be
followed by nitroglycerin. Electric applications are not
advised. Dissatisfied by the poor results of classic
189(5.]
QUINSY; DIAGNOSIS AND TREATMENT.
997
RETORT OF CASKS ILLUSTRATIVE OP PECULIARITIES OP ELECTRIC TBAUMATA.
Name
Injury.
Cause.
I, 1. . . Burns lust phalanx 8d Klectric wire contact. Alternating.
finger left, dorsum
both hands.
W.H.J. Hums 3d and 4th fingers, •' "
right. 1th finger left.
and right wrist.
N. K. . shook. Hand and foot con- Direct.
tact, dynamo.
P, OK. Burns right hand and fin- KUctrlc wire contact. Alternating
gers and left forearm.
i v Hums right hand and
fingers.
R. H. . Hums left hand, right '•
wrist
Burns left hand, "
Horns thumh 1st and 2d "
lingers, left.
Bums right hand and Electric '
face.
Current.
Duration of Injury.
T I. N
J.J. R.
.1 McK.
Direct.
Hash light.", Alternating
Seventeen days.
Between sixty and
seventy days.
Instantaneous.
Sixty five days.
About ten days.
Forty-seven days.
Eleven days.
Twenty-five days.
Three or four days
Remarks.
Suppuration.
Suppuration and slonghing In-
volved, 1st inter-phalangeal
joint and 1st and '2d phalan-
ges, necrosis. Degeneration
extended rapidly and deeply
on both palmar and dorsal
surfaces of finger, and up-
w urd upon the hand. Ampu-
tation at 4th metacarpophal-
angeal articulation.
Points of contact barely visi-
ble.
Suppuration and sloughing
necrosis of phalanges. Suc-
ceeded, however, in saving
phalanges.
Suppuration.
Suppuration and sloughing.
Sustained while adjusting arc
lamp on a stormy night.
Suppuration and sloughing.
Ran a satisfactory course.
Result.
Good.
Marked cicatrization,
otherwise good.
Death.
Marked cicatrization,
otherwise good.
Good.
Good.
Good.
Good.
Good.
aseptic- treatment of these cases of burns, the author,
in the search for improved methods, utilized, among
other agents, the following: Bichlorid solutions, car-
bolio solutions, pyrozone solutions, chlorid of zinc
solutions, in' varying strengths; peroxid of hydro-
gen, sterilized water, hot and cold; iodoform, dry, in
emulsion and in glycerin; salicylic and boracic acids,
bicarbonate of sodium, loretin, aristol, tartrate of iron
and potassium in solution. And for the digestion of
the sloughs, pepsin, trypsin and pancreatic extract
in appropriate media. Both moist and dry dressings
were employed in various cases. These agents yielded
results practically analagous to the conventional
aseptic and antiseptic measures of wound treatment;
in some cases, the results were not as satisfactory.
They should be employed as adjuvants, fitted to the
demands of the individual case, to aseptic or anti-
septic means, and not as substitutes.
CONCLUSIONS.
1. The skin is the chief factor of resistance in an
individual sustaining an electric shock.
2. That moisture of the skin, and especially,
marked salinity of sweat, favors access of current.
3. Humidity and temperature of atmosphere, and
season of year are important factors in determining
individual resistance.
4. Electric traumata differ from ordinary burns or
scalds in duration.
5. Electric traumata differ from ordinary burns
and scalds in results (noticeable in severe cases).
6. Prognosis in all cases should be guarded.
7. Rigid asepsis should be followed in the manipu-
lation of all cases.
8. Sloughs are best removed by solution of pepsin,
thus: Scale pepsin 2 grms.; hydrochloric acid U.S. P.
1 cubic centimeter, distilled water 120 cubic centi-
meters, washed off in two hours with peroxid of hydro-
gen, pyrozone or hydrozone. Application to be
repeated as may be necessary.
9. Deep disintegration demands especial watchful-
ness for the detection of bone or joint invasion.
10. Necrosis of bone should be combatted by in-
jecting a 3 per cent, solution of hydrocholic acid in
distilled water, repeated not more frequently than
every two hours. Every second day the acid pepsin
solution (see above) should be used until the necrotic
masses are cleared away, when gauze packing should
follow. Tn <->isf>s complicated by tuberculosis n 10
per cent, mixture of iodoform in glycerin or a 7 to
10 per cent, solution of iodoform in ether, should be
subsequently employed.
11. Persistent bone or joint invasion with necrosis,
requires amputation, or in some cases resection.
12. Degenerative division of important nerves
should be subsequently repaired by Levering's
method.
13. Degenerative division of important arteries and
veins should be repaired by Murphy's method, when
possible.
14. Granulating areas, after sterilization, should
when feasible be covered by large skin flaps.
15. When healing process has started, peripheral
skin growth is hastened by the use of a layer of sterile
gauze saturated with an iodoform-glycerin mixture,
and covered by rubber tissue.
QUINSY; THE DIFFERENTIAL DIAGNOSIS
AND TREATMENT.
BY J. HOMER COULTER, A.M., M.D., Ph.D.
CHICAGO, ILL.
The fact that many presumable authorities use
indiscriminately the terms tonsilitis and quinsy, has
led me to attempt, if possible, to emphasize the differ-
entiation so clearly brought out by Bosworth in his
late work. He was, I believe, the first to make
prominent the difference between the two conditions.
Admitting that the symptoms are often analagous,
even more so than are usually seen in other contiguous
structures, yet because the pathology is comparatively
open to inspection, the diagnosis should in the ordi-
nary case be made with approximate certainty. ■
Let us briefly observe the comparative anatomy of
the parts; it may add somewhat to our etiologic
theories. I do not find by dissection nor by any
anatomic authority, that any of the muscular fibers
from the palatoglossus or palatopharyngei muscles
leave the striations of those muscles and branch off
into the body of the tonsil; nor do they anastomose
with each other until they have passed below the tri-
angular space occupied by the tonsil. This olive-
shaped body, which we term the tonsil, is thus
ensconsed within its position much as the eye rocks
in its bony cradle, but with a much less intimate
anatomic relation to surrounding structures.
The lymphatics o? the fon~i! are most important
998
QUINSY; DIAGNOSIS AND TREATMENT.
[November 7.
etiologically. If they anastomose to any great extent
with the lymphatics of the lateral and posterior
pharynx, then we might anticipate an infection in the
tonsil would often be conveyed to the peritonsillar
tissues. Or if the action of the tonsillar lymphatics
was absorptive rather than expulsive the bacteria
would more likely be lodged deep in the plexus with-
in, near the carotid artery, and we would anticipate a
phlegmonous condition as a much more frequent
evidence of the correctness of our etiology. The
comparative absence of these evidences however,
must indicate that, either the lymphatics in the so-
called " lymphoid ring " are not very ready bearers
of bacilli, or else the intimate connection, presumed
by some authorities, between the lymphoid tissues at
the base of the tongue, between the pillars and in the
vault of the pharynx, is an imaginary one.
Some have claimed that the normal secretion of the
tonsil was one of nature's antiseptics, a leucocyte
guard destroying every microbian intruder; but if the
leucocytes be absent from any cause, or the lacuna?
be in a diseased condition, it is then but an open via-
duct into the system, provided this intimate relation-
ship between the lymphatics and the deeper tissues
really existed.
In those cases in which the pillars overlap the
tonsil there may be pseudo-continuity of tissue formed,
but such a condition, I maintain, is distinctly patho-
logic. If a normal anatomic relation exists between
the tonsil and pillar, the former will not appear as an
etiologic factor in the production of peritonsillar
abscess quinsy. If pyogenic germs be pent in by
an overlying pillar and thus forced into the sur-
rounding areolar tissue, we may expect quinsy as a
natural result. Many recurrent attacks of quinsy are
doubtless in some measure due to this cause.
That there does occur non-idiopathic cases of quinsy
can not be doubted; but the post hoc ergo propter
hoc theory of all cases following measles, scarlet
fever, diphtheria or rheumatism is open to discussion.
Indeed such an etiology occasionally receives a severe
"shaking up" by the deductions of clinical experi-
ence. In most cases the origin is in the peritonsillar
areolar tissue. Oftentimes on account of the inten-
sity of the inflammation and edema the tonsil is pro-
truded, but seldom indeed, if ever, is it involved in
the inflammatory process anterior, posterior, or, in
severe cases, surrounding it.
If there existed a more intimate natural continuity
of tissue between the tonsils and the surrounding areo-
lar tissue, we might expect from these bacteria traps a
very frequent infection and consequent quinsy.
Hence it may be argued that the tonsils, even though
pathologic, may be in a measure a preventive rather
than a cause of quinsy. Bosworth says: "An acute
tonsillitis does not, and can not, develop a quinsy
without some particular predisposing cause or
dyscrasia."
Mechanical, chemic or traumatic influence may
each be active in certain cases. Certainly, sudden
changes from heat to cold, with draughts about the
head, produce a fertile field for this disease. A
strumous diathesis, that popular scape-goat of the
"case reporter," and bane of the conscientious etiolo-
gist, should not be forgotten on so appropriate an
occasion. Bosworth and others are inclined to think
a very large percentage of these cases are due to an
uric acid diathesis. If so, why does it not occur more
frequently in rheumatics? My experience does not
confirm such statistics. In my cases, rheumatism has
not occurred more frequently than has a neurotic
temperament, which condition I should hesitate to
offer as an etiologic factor of any considerable
importance.
With the anatomic relations of the tonsils in mind,
and the most probable and only tenable theory of
quinsy being that of a specific bacteria, the exact
nature of which remains to be discovered, we can
posit as our differential definition of quinsy: An
acute inflammatory action in the peritonsillar areolar
tissue, usually resulting in a suppurative process.
The symptoms in general are so well known that I
will not unnecessarily lengthen this paper with a
detail of them; only to such an extent as may be
necessary to elucidate the differential characteristics
of those pathologies most likely to be mistaken for
quinsy. Those occasionally encountered are, follicu-
lar tonsillitis, the early stages of the exanthemata,
acute pharyngitis, fibroid tumor, aneurysm, syphilis
and that severer form of acute infectious phlegmon or
retropharyngeal abscess, which is characterized par-
ticularly by its always serious, and most frequently,
fatal prognosis.
In all tonsil inflammations the tonsillar gland is
more or less hypertrophied, and shows evidence of
recent or present inflammatory action. It is usually
less painful than quinsy. Deglutition is more easily
accomplished, though dysphagia is common in both.
The peritonsillar tissues are not swollen, except as
they may be pulled toward the median line by adhe-
sions to the tonsil. In tonsillitis there is less tender-
ness, though this symptom may depend somewhat on
the temperament of the patient. If the tonsil has
been thoroughly extirpated, tonsillitis is necessarily
excluded. Ear complications can scarcely be caused
by tonsillitis. Respiration is not as a rule embarrassed
by quinsy. The tonsils are not always enlarged in
quinsy; while a peculiar fetid breath and constipa-
tion are almost invariably present. Another, to me,
almost pathognomonic symptom of quinsy is the ina-
bility to expectorate.
In the early stages of the exanthemata, and the first
thirty-six hours of quinsy, there is certainly often
much difficulty in making a positive diagnosis. In
diphtheria the temperature is subnormal or slightly
increased. The possible prevalence of contagion
would be an important factor. In these exanthemata
the throat is rather sore than painful, there is also
more hyperemia. A membrane would indicate, though
not insure diphtheria.
It scarcely seems possible that one could mistake
a fibroid or other benign tumor for quinsy, yet such
mistakes have been made. Its density, duration and
freedom from pain and temperature would positively
differentiate it in any case. Syphilis, in the tertiary
form, might confuse one unaccustomed to seeing
either condition frequently. But the history of the
case should be sufficient. Ulceration, moreover, does
does not occur in quinsy.
Aneurysm, in general appearance, would most
closely resemble quinsy. But its infrequenoy and
history, as well as absence of pain and other symp-
toms, would certainly prevent error.
The acute infectious pharyngeal phlegmon, fortu-
nately, does not occur very frequently. It nevertheless
is an important point in this consideration. I .surmise
that when at some time, a plodding investigator suc-
ceeds in making a specific bacteria culture from both
1896.]
THE VALUE OF VACCINATION.
999
conditions, they will bo found to be identical. The
former differing from quinsy, mainly in the intensity
of its toxemic virulence. Infectious phlegmon also
attacks the deeper tissues and posterior pharyngeal
wall, extending downward, the respiration becoming
embarrassed as the abscess increases in size. Spondy-
litis is not infrequent in infectious phlegmon; but
whether as a cause or as a result, authorities disagree.
Certain it is. however, quinsy is not associated with
spondylitis either as cause or effect. In the infecti-
ous phlegmon, the face is more congested and livid;
the nook stiff, the muscles tense and prominent, and
the usual quinsy symptoms greatly intensified.
Quinsy may occur in children, rarely so the other
disease. In case it is a simple pharyngeal abscess, it
may occur in childhood. Retropharyngeal abscess is
not so acute, painful or serious, and is amenable to
the treatment of abscess in other parts.
Treatment. —In any suggestions as to abortive
measures, 1 recognize the fact that we do not usually
see a quinsy patient until the disease has been pro-
gressing for twenty-four or more hours. To abort it
at this stage is out of the question, in almost any
case. We can not claim for any medicinal remedy or
combination a positive abortive effect in a case of
quinsy.
In every case it is advisable to give a good mer-
curial cathartic, followed by a saline. Unless we are
reasonably positive of the presence of pus, when the
case is first presented, I do not believe the use of the
knife is advisable at that time. We must not pro-
voke the inflammatory action by a too hasty attempt
to relieve our patient by incision. We have all too
often seen a veritable stabbing process performed in
and about the tonsil, in the fruitless endeavor to
locate the abscess. It appears to me this might usually
be avoided by previously assuring ourselves with a
careful differential diagnosis.
For many years the stereotyped line of prescribing
had been quinin, opium, guaiacum, sodium salicylate,
aconite and belladonna, either singly or in compound,
as the opinion of the prescriber was guided by experi-
ence. I have no word of criticism for these. They
were good, and doubtless afforded a vast relief in the
aggregate. But as all things must change, and we
tire, even of friends at times, so wdien improvements
are made we must accept them as such. More recently
salol has come into quite general favor.
From 1892, when I listened to Dr. Newcomb in his
exhaustive paper on the treatment of tonsillitis medi-
cinally, at the meeting of the American Medical
Association in Detroit, until about one year and a
half ago, I have felt that salol was the remedy par
excellence for these cases. At that time three cases,
all clerks in the same department of one of our largest
establishments, presented themselves at the same time.
Two of them roomed together, the other lived with
his parents. Such a coincidence at least suggested
the possibility of contagion. A broken window on a
coal, damp day was the presumable etiologic explana-
tion. They were all suffering intense pain. Two of
them had typical attacks of quinsy, the other tonsil-
litis I used my usual applications, advised hot gar-
gles and poultices, prescribing salol with rather con-
fident promises of speedy relief. I had had two
positive, and two doubtful, failures with salol in the
three years' experience previously, so that to find my
patients growing worse for thirty-six hours did not
entirely surprise me. Free incision was meanwdiile
made without obtaining pus, in either case of quinsy.
The tonsillitis was further advanced, and was much
relieved by the incision. In the other two I prescribed
lactophenin, 10 grains every three hours; after the
second dose Mr. B. was almost entirely relieved of
pain; the temperature the following morning was 99.2.
The other symptoms were likewise very much ameli- '
orated. In the case of Mr. R., the third dose relieved
him quite as completely. At this visit I was able to
thoroughly evacuate the pus and cleanse the cavity,
affording the usual relief in such cases.
Since the above experience I have used the remedy
in twelve cases of quinsy, and in all but one instance
the results have been most gratifying to myself, and
I am sure not less so to the patient. These patients
have been first seen in all stages of the disease, from
the first hour of the attack to the fourth day; and in
one case, in consultation, on the sixth day.
The average time of relief has been about four
hours. In all but three the relief was decided before
the knife was used. In each of these three there were
evidences of pus present, and the bistoury was used
at once; so that the part played by the remedy is
indeterminate.
I have in these cases given the lactophenin to the
exclusion of every other remedy internally, excepting
the cathartic already referred to; not omitting, how-
ever, the usual hot gargles and external applications.
My reasons for preferring it to salol are: Its action
is decidedly more prompt; it has thus far given me
no undesirable after effects; it not only relieves the
pain, but reduces the fever with an equal certainty.
In cases of evident rheumatic diathesis I should cer-
tainly employ, in addition thereto, my customary
remedies.
103 State Street.
THE STATISTIC EVIDENCES OF THE VALUE OP
VACCINATION TO THE HUMAN RACE, PAST,
PRESENT AND FUTURE.
Read before the American Medical Association at the Jenuer Centennial
Celebration, held at Atlanta, Ga., May, 1890.
BY EUGENE FOSTER, M.D.
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE AND STATE MEDI-
CINE AND DEAN OF THE FACULTY OF THE MEDICAL DEPARTMENT
UNIVERSITY OF GEORGIA, AUGUSTA, GA.
(Concluded from page 958.)
Hutchinson's Cases.4'
First Series. — Patients first seen seven weeks after vaccina-
tion. Vaccinifer four months old, healthy looking, vesicle
eighth day lymph. To the vaccinator and the surgeon, she
at the time the lymph was taken, bore the aspect of excellent
health. All of the vesicles from which lymph was taken bled.
Two months afterward Mr. Hutchinson saw vaccinifer. ''My
attention was, however, at once attracted to a slight peculiarity
in the tint of her skin and to the look of her face ; and although
it was strongly denied that she had ever 'snuffled,' yet when
she was made to cry I noticed a tasal twang which was very
suspicious. On having her stripped, not a single spot of rash
could be seen on her skin, but on inspecting the buttocks five
small circular condylomata were discovered close to the anus,
about which there could not be the slightest doubt. Mother
detected condylomata about a week previously, but declared
infant had never been ill. I could not find in the mother her-
self any indications of syphilitic taint, nor obtain any history
of suspicious symptoms. Did not have opportunity to inspect
father. A fortnight later, sought child at its home. The child
then looked more ill than when first seen ; the condylomata
were in the same condition. It had no rash. Its head was
enlarging, and its mother complained that it was wasting away.
About the existence of constitutional syphilis in the infant at
the date of my examination (two months after vaccination)
there could not be any doubt, and scarcely any as to the taint
Hutch
Quoted from Illustrations of Clinical Surgery.
Union, F. R. C. S., 1877.
By Jonathan
1000
THE VALUE OF VACCINATION.
[November 7,
having been an inherited one. There can, I think, be little
doubt that in this instance it was the blood, and not the vaccin
lymph, which was the source of the contamination.
Second Series. — Patients seen about seven weeks after vac-
cination. History of vaccinifer : Child stout, well grown,
seven months old ; selected as vaccinifer from amongst severa-
others, as being most healthy present. Excepting a little
transitory "tooth-rash," probably lichen, on the face he had
no eruption. His head was decidedly large and the fontanelles
widely open. Mother said this had been noticed.for a few weeks.
Mother said "he had snuffled a great deal." No trace of rash
on child's skin, but at anus there was a single small condy-
lomatous patch just healing. Saw infant several times during
six weeks after this first examination, but no symptoms of a
more definite character showed themselves. The condyloma
soon healed and with the exception of a slight tendency to
hydrocephalus, the infant, at time I last saw it, might have
been regarded as a specimen of excellent health. Several per-
sons vaccinated from it mentioned it was very healthy looking
at time lymph was taken. No trustworthy evidence could be
obtained as to whether blood was or was not transferred in the
operation of vaccination. No syphilitic symptoms found in
either parent. Father denied ever having had venereal disease,
and submitted to personal examination at my office, and we
failed to detect anything of a nature to cast suspicion on his
denial.
Third Series. — Patient seen three months after vaccination.
History of vaccinifer : Vaccinator says vaccinifer was a model
of vigor and health. He presented child to me. I found a
very large and very fat baby, eight months old. It had no
rash, nor any trace of condyloma, and the only point about it
suggestive of syphilis was the state of the bridge of the nose,
which was decidedly broad and sunken. Mother'appeared in
good health ; says the first two children died in infancy. This
is only child living.
Fourth Series. — (Onecase.) Patient first seen fifteen months
after vaccination. History of vaccinifer : Patient says vaccini-
fer puny at time of vaccination, and the mother ill. Does not
know if vaccinifer' s arm bled or not. Vaccinator denied that
child looked puny at time of vaccination. Patient was prob-
ably last but one out of a considerable batch vaccinated from
child. Mother of vaccinifer had borne three children previ-
ously. The eldest is a boy 10 years old ; has no symptoms of
syphilis. Second child stillborn. Third child a girl i years of
age, who had no special symptoms in infancy excepting that
for several months during teething she had very troublesome
ulcers at the anus (condylomata) ; also had tendency to water on
the head. Vaccinifer (fourth child) was four months old at
date of vaccination, and appeared, according to the mother's
statements, to be perfectly well. Subsequently, however,
when dentition commenced he, like his elder sister, had very
troublesome sores about the anus and a tendency to water
on the head. For the anus he was three months under
treatment at a dispensary. At twenty-three months of age
patient is living, full grown, and shows no peculiarities except-
ing a large forehead. Surgeon who treated child for trouble of
anus says vaccinifer had syphilitic condylomata, snuffles, a
slight skin-rash, and was very cachectic when he treated him.
He did not ask the parents any direct questions because he
was perfectly certain as to the nature of the ailment.
Fifth Series (two cases). — Patients first seen seven months
after vaccination. Surgeon which did the vaccination could
give no important facts. (History of vaccinifer entirely
unknown to Mr. Hutchinson. )
Sixth Series. — No history of vaccinifer could be given, as lady
had been vaccinated in India.
In contrast to these cases of alleged transmission of syphilis
by vaccination, the following, a few of quite a number of cases,
are cited, in which physicians of the highest professional
standing took as vaccinifers persons known to be syphilitic at
the time, and from them vaccinated a number of persons known
not to be syphilitic, and failed to develop the slightest mani-
festation of syphilis in any one of the persons so vaccinated :
Name of Experi-
menter.
Number Vac-
cinated.
Number In-
fected with
Syphilis.
Number not
Infected with
Syphilis.
6
H
2
67
8
55
55
6
30
57
8
55
55
Total. ..••...
214
214
To these must be added the numerous experiments of Boeck,
Cullerier, Taupin and Heyman. Boeck experimented on a large
number of cases, and he took great care to mix the blood of
the vaccinifer with the vaccin lymph. Here we have a record
of three hundred or more direct efforts to produce vaccinal
syphilis and every such effort was unsuccessful. It must be
admitted that these experiments are a thousand-fold more
valuable than the details of cases of alleged vaccinal syphilis,
for they were conducted under intelligent supervision, and in
accordance with conditions which were carefully observed.
From these experiments the experimenters could and did know
that the vaccinifers were syphilitic ; that the lymph of a gen-
uine vaccin vesicle was used, and if or not it was admixed with
syphilitic blood or other inoculable matter. It should be
remembered, in comparing these data, that the reports of
cases of alleged vaccinal syphilis were wanting in every one of
these essential points of observation ; they were entirely acci-
dental and were not expected to occur. Dr. Viennois of Lyons
made an exhaustive investigation of vaccinal syphilis, and as
result of his labors said : "There is no infectious quality in
the vaccin matter itself, and if we employ the vaccinal fluid only
in inoculating a healthy child, the operation will be safe. If
the vaccin matter taken from a syphilitic subject is without
any admixture of blood the result will be a vaccinal pustule
only, without any syphilitic complications, either immediate
or future." This, gentlemen, is the teaching of the profes-
sion of medicine in all countries at the present day. That
some few persons have been infected with syphilis by persons
attempting to vaccinate them, no one is ready to deny ; but
when such results followed, they were probably inoculations
with syphilitic blood or virus, not vaccin virus. No physician,
except for experiment, should ever vaccinate any person to
serve as a vaccinifer, unless such person be in undoubtedly
good health and known to be free from scrofula, consumption
or syphilis. This proposition is reasonable, for it is wrong to
risk unnecessarily anyone's health.
Call the attention of vaccinophobists to the fact that vaccinal
syphilis has been so rarely pointed out, and they will say the
profession is a body of blind worshippers over the grave of
Jenner, and has never tried to ascertain the truth of the mat-
ter. Let us see if this be true. In 1856, fifty eight years after
vaccination had been generally practiced, the Board of Health
of London issued a circular letter addressed to the various
governments, asking information in relation to vaccination and
its results. This board propounded the following searching
question, among others: "Third. Have you any reason to
believe, or suspect, that lymph from a true Jennerian vesicle
has ever been a vehicle of syphilitic, scrofulous or other consti-
tutional infection to the vaccinated person, or that uninten
tional inoculation with some other disease, instead of the
proposed vaccination, has occurred in the hands of a duly edu-
cated medical practitioner? "
The Imperial Society of Surgeons at Vienna, Austria, replied :
"Although it may be maintained that the blood of individuals
affected with secondary syphilis can 6erve as a vehicle for this
specific contagion, even this theory (if it could be proved)
would not exercise any influence on the practice of vaccina-
tion ; for both experiments made on purpose (Heim) and acci-
dental vaccinations have taught that without considering the
quality of the vaccin lymph, that taken from syphilitic sub-
jects may have been used upon healthy persons and the con-
trary, viz., from healthy individuals and used upon persons
suffering from syphilis, without, on such occasions, the latter
disease having been conveyed with the cowpox. What has
been prpved in reference to syphilis may be applied equally to
all other dyscrasic diseases, since this, even in cases of direct
vaccination with their morbid products, has always shown a
negative result."
The Faculty of Medicine at Prague replied: "The experi-
ence obtained in this country gives no grounds which leads to
the belief or presumption that the consequence to a vaccinated
person can be such as put forth in this question."
The Imperial General Hospital of Vienna replied in like man-
ner with the Faculty of Medicine at Prague.
The Imperial Lying-in and Foundling Hospital replied :
"A true vaccin pustule can not become the vehicle for convey-
ance of syphilitic or any other contagion."
From Bavaria the following reply was given: "In Bavaria
up to the present time, two cases have happened of syphilis
being inoculated with vaccinia. That was, however, in each
of those cases the fault of the vaccinating physicians them-
selves ; and the accident could in either case easily have been
avoided, since syphilis was unmistakably present in the chil-
dren from whom the lymph was taken. The inoculation of
syphilis can at all times be avoided by an observant surgeon
who uses due circumspection in choosing the subject from
whom he will take lymph for vaccination."
L896.]
THE VALUE OF VACCINATION.
1001
The answer from Denmark was as follows : "The experience
which we have acquired in this country does not lead to the
supposition that lymph taken from true vaccin can be the
means of communicating any scrofulous or constitutional con-
tagion."
The Duchies of Hblstein and Lauenburg said : "The expe-
rience which has been gained in the Duchies of Holstein and
Lauenburg requires an answer to this question unconditionally
in the negative."
The same question was propounded to every prominent phy-
sician and surgeon in Great Britain, including physicians and
Burgeons in charge of all the vast hospitals and public charities
ami vaccin stations, and no one of them failed to answer it in
the negative.
Dr. John Simon, Chief Medical Officer of the Privy Council,
examined thoroughly and exhaustively all the alleged cases of
vaccinal syphilis, and, in his report for 1869, says but fourteen
Of all these alleged eases were to be attributed to vaccination,
and every one of these fourteen cases were, he says, the result
of malpractice on the part of the vaccinator. "If," says Si-
mon, -our ordinary current vaccination propogates syphilis,
where is the syphilis it propagates? Who sees it? The expe-
rienee of this department is an entire blank upon the subject.
For the last ten years we have been in incessant intimate com-
munication with the ditferent parts of England on details of
public vaccination, and during these ten years every one
of about 3,600 vaccination districts into which England is
divided has been visited three or four times by an inspector
specially charged with the duty of minutely investigating the
local practice of vaccination: yet, from this systematic and
extremely detailed search for all that has to be said upon the
subject of vaccination in England, no inspector has ever re
ported any local accusation or suspicion that a vaccinator had
communicated syphilis."
Hutchinson's cases have since been reported.
In North Germany, so late as 1873, the testimony has been
given that only two cases of alleged vaccinal syphilis have
occurred during twelve millions of vaccinations made there up
to that date. Syphilographers— those men who are most
highly accomplished in the study of the causes and sources of
syphilis have almost unanimously declared that the alleged
cases of vaccinal syphilis were but inoculations with syphilitic
products, and such results will never follow vaccination, even
from a syphilitic subject, if lymph from a genuine vaccin
vesicle be used Venereal specialists, such as Lancereaux,
Cullerier, Ricord. Langston Parker, Acton, Lee, Bumstead,
Hammond and Keyes, never, in the whole course of their vast
experiences, met with a single instance of vaccinal syphilis.
But let it be admitted (in order that there may be some ground
for the discussion) that every one of these cases of alleged vac-
cinal syphilis reported above was consequent upon vaccination
duly and intelligently performed, even this would not detract
one iota of the value of vaccination — the grandest discovery
which has ever yet blessed man in his checkered career upon
earth. Vaccination is capable of saving at least one million
human lives every year; and if syphilis is actually proven to
have occurred one time in a million vaccinations, is not all this
fuss about vaccinal syphilis as a rational ground for abandon
ing vaccination the old story of the mountain in labor bringing
forth a mouse?
The following extract from a letter (April, 1870) from Dr.
Seaton, throws a flood of light upon this question of vaccinal
syphilis :
"1 am not aware of any fresh case of alleged introduction of
syphilis by vaccination with humanized lymph since I pub
lished my book, but curiously enough there has been discus
sion lately in France on some cases of syphilis in children who
had been vaccinated with animal lymph. Of course, the
svphilis was a latent syphilis, and the vaccination could have
had nothing to do with it, except perhaps to hasten its evolu-
tion : but the cases are instructive, and point, in my opinion,
to the explanation of all the alleged cases of vaccin syphilitic
inoculation with humanized lymph, except those in which
there was downright carelessness and mixture of or substitu-
tion of viruses."
To show the dangersof contracting syphilis which beset man
at every turn in life, the following illustrations are furnished :
But we have recently heard intelligent physicians sny that
if one case of syphilis is proven to have followed vaccination,
then vaccination must be abandoned, (ientlemen, this isseri
ous ground; and if applied with the same rigor to (he other
branches of our profession the practice of surgery, of gynecol-
ogy, of obstetrics, and dentistry must be abandoned. And if
applied to man in all his surroundings wiih the same vigor, he
must live on air, for syphilis has been frequently caused by
the necessary processes of eating food and drinking water.
Further than this : if a few cases of syphilis contracted in any
manner are to doom all things from which they were contracted
to be banished from use by man, then our race roust be con-
tent with the covering of skin placed upon him as he sprang
from the hands of his Maker, for syphilis has been caused
repeatedly by infected clothing. Let us take the simple pro-
cess of cuppiDg, to forcibly illustrate this proposition. It is
a well established fact that an epidemic of syphilis was pro-
duced at Brun, in Moravia, in 1577, by cuppings done by the
bath man of the town. Suizer observed cases of the same
nature at Bamberg in 1602 ; Horst, at Ulm in 1662 ; Wideman,
at Windshelm in 1620 in the latter instance seventy cases of
syphilis were caused by the simple process of cupping. Cath-
eterism of the Eustachian tube is a very delicate yet harmless
operation, and certainly syphilis is not a necessary consequence
of its performance, yet a number of cases of syphilis from this
source have been established— as many as thirteen such cases
have been reported at one meeting of the Medical Society of
Hospitals in France. The operations of circumcision, catheter-
ism of the bladder, uterine examinations, accouchment,
removal and transplanting of teeth, the lancing of a furuncle,
have caused numbers of cases of syphilis, and if the rule
sought to be applied to vaccination be invoked against these
operations, then their performance is criminal. Even the
forks and spoons and drinking-cups and tumblers have
caused large numbers of cases of syphilis ; and yet who
is ready to abandon the use of these articles because some
fellow with a syphilitic mucous patch in his mouth used
them, and a careless and filthy butler placed them back on
the table without cleaning, and syphilitic infection followed?
Again, it has been shown upon as reliable testimony as vac-
cinal syphilis, that wearing apparel and bedding used by a
syphilitic person and afterward used by a careless or filthy son
of Adam have caused syphilis; but we think Ihe day is far
distant ere this clothes-worshipping and bed-loving people will
abandon these comforts because a few cases of syphilis have
followed their use. These cases are all due to the same causes,
i. c, gross and inexcusable carelessness or filthinees.
That these cases have occurred is beyond question, and have
produced ten times as many cases of syphilis as vaccination.
The kiss of a lover has caused, by reason of mucous patches on
the tongue, more syphilis than every one of the alleged cases
of vaccinal syphilis. How often, Mr. President, do we meet
with cases where, in consequence of ill health of the mother,
or of insufficiency or total absence of flow of milk, a wet nurse
is necessary to furnish food for the infant. There is scarcely
a month but what the busy practitioner meets with such cases.
Now, it is well known that syphilis has been caused in a vast
number of infants by infection from syphilitic nurses. And
yet because these unfortunate results are found, are we to
forego the advantages of wet nursing, and thereby consign
such children to the grave by resorting to cows' milk, or other
more indigestible nourishment? Should we not display more
prudence and judgment in selecting wet nurses? Again, how
frequently have wet nurses been infected in nursing syphilitic
children.
It must be admittsd that in submitting to vaccination man
incurs no greater risk of contracting syphilis than he does in
submitting to the minor harmless operations in surgery or den-
tistry, or in the necessary process of eating food and drinking
water in hotels, restaurants, railroad trains, hospitals, etc.
If vaccinal syphilis is thought to be liable to be transmitted
by humanized vaccin virus, then those fearing this result
have in bovine virus a full protection against such an acci-
dent. But this remedy will not satisfy antivaccinists, for
when Dr. Carpenter made this statement Dr. P. A. Taylor
(their leader in England) replied :
" I observe you add that ' tens ' out of every 16,000,000 would
vanish under calf-vaccination. Of course you are perfectly
aware that it is not yet a settled question whether what is
called spontaneous cowpox is (contrary to Jenner's opinion)
protective against smallpox. Professor Simonds, Principal of
the Royal Veterinary College, is (or was in 1879) distinctly of
an opposite opinion. Speaking at the London conference on
Animal Vaccination, he used these remarkable words: 'If
this be so, you must fall back upon one of the old methods,
and must inoculate your calf either with human smallpox, or
horse-pox. In the former case, you come under the statement
of Sir Thomas Watson, that by the use of this lymph 'there
must have been a vast amount of mitigated smallpox spread
about.' If you fall back upon the horse, you will be liable, I
suppose, to such horrible outbreaks as that of glanders, under
which thirty eight children are supposed to have suffered in
Italy.' The following is from the Lyon Midicule of June 22,
1879 : 'On April 20 and 28 the local doctors vaccinated with this
lymph (animal lymph) thirty-eight children, all aged less than
1002
THE VALUE OF VACCINATION.
[November 7,
twenty months. While they were awaiting the incubation of
the vaccin pustules, they soon perceived that they had inocu-
lated one of the most horrible of maladies, and that they were
the involuntary authors of a real massacre of the innocents.
The gentleman who sent these particulars to the Gazetta (T
Italia betook himself to San Quirico. He saw the victims.
He observed vast phlegmons laying bare the muscles and pene-
trating into the joints, accompanied by eclamptic symptoms.
To him it appeared to be very probably an epidemic of glanders.'
But even supposing you are able to inoculate with 'spon-
taneous cow-pox,' what is to secure against the transmission
of bovine disease? I take the following from a letter sent by
the guardians of Ashton-under-Lyne to the president of the
local government board a few months since :
"On December 13, 1879, Mr. Simon wrote :— ' When a given
(animal i body is possessed by one of these constitutional dis-
eases (scrofula, syphilis, etc.), no product of that body can be
warranted safe not to convey the infection ;' and Dr. Creigh-
tou, of Cambridge University, gives the history of twelve cases
of bovine tuberculosis in human beings, the disease being a
more rapid form of consumption than that peculiar to man."48
"As the new lymph will be obtained from bovine animals, in
whom this tuberculosis is hereditary, and occurs in 1.75 per
cent, of any given number of cows, the guardians are anxious
to know if the local government board is prepared to take the
responsibility of introducing another formidable disease (bov-
ine tuberculosis) to man by means of the system of vaccina-
tion. * * *
"Some crazy enthusiasts recommend that lymph be taken
direct from the cow. They can not surely have seen those
frightful pictures of the disease so produced, which were pub-
lished by Mr. Ceely, of Aylesbury, some thirty years ago." ■
After detailing the advantages of animal vaccination, Dr.
Warlomont answers the objections to those who affirm that
bovine tuberculosis and charbon may be transmitted by means
of animal vaccination. It is admitted, in the first place, that
tuberculosis may be inoculated. The experiments of Villeium,
afterward established by Koch, demonstrate the possibility of
transmitting tuberculosis by bacterial infection, the bacteria
being also susceptible of cultivation apart from the body.
After detailing carefully the various experiments of Cohn-
heim and Baumgarten upon monkeys, rabbits and guinea pigs,
including those in which tubercular tissue as well as blood
taken from freshly killed tuberculous animals, was inoculated
into the eyes of rabbits, Dr. Warlomont sums up as follows :
"It is to be inferred from the preceding data that the
bacillus of tubercle can transmit tuberculosis either by means
of tubercle itself, or by tuberculous blood, or by air exhaled
from an infected lung. * * * It would be puerile to over-
look the importance of these data in their relations to vaccina-
tion, either animal or human. The security henceforth
endangered must be no longer established upon theoretic
grounds. It must be supported by experimental facts which,
fortunately, are not wanting. An extremely important fact
is demonstrated by the experience acquired in the inoculation
of tubercle, viz., it is thus far found to be an impossibility to
produce tubercular infection by the superficial insertion of
bacilli. In order to reproduce tubercle in an animal, it is
necessary to convey the bacilli into the depth of the tissues. It
is thus explained why no one is ever infected in making autop-
sies of tubercular subjects, and also a fortiori that no one has
ever been infected with tuberculosis by the process of vaccina-
tion. * * * The absence, therefore, of a single fact
establishing the possibility of producing tuberculosis by the
superficial insertion of tubercle, as in the usual act of vaccina-
tion, assures us of the impossibility of such transmission, when
the operation is performed with products having only remote
relations to it."
The developments of modern pathology clearly prove that
Warlomont was in error when he said : "An extremely impor-
tant fact is demonstrated by the experience acquired in the
inoculation of tubercle, viz., it is thus far found to be an
impossibility to produce tubercular infection by the superficial
insertion of bacilli. In order to reproduce tubercle in an ani-
mal it is necessary to convey the bacilli into the depth of the
tissues." Sternberg, in his magnificent work on bacteriology ;
Ziegler, general pathology, and Green, in his work on pathol-
ogy and morbid anatomy, 1895, all tell us that tubercular
infection in man can and has been known to result from slight
abrasions of the skin. Therefore if matter of any kind con-
taining tubercle bacilli be brought into contact with the skin
abraded for vaccinal purposes it is altogether possible for the
individual so treated to become infected with tuberculosis.
Now, while this is possible, as proven by the most recent
<« October number of Journal of Anatomy and Physiology.
i' current Fallacies about Vaccination, by P. A. Tavlor.M. i'., Lon-
don. 1881.
researches of pathology, this danger is so infinitesimal as to be
practically non-existant. How is this proven. Every modern
authority upon pathology insists that when tuberculosis
results from bacilli entering the system through a lesion of the
body (an abrasion of the skin, for instance) it leaves behind a
permanent change at the portal of entrance. In other words,
that tuberculosis is at first a local disease, the formation of
tubercle at the point of abrasion for vaccination, for instance.
Now for the test : Of the hundreds of millions of vaccinations
performed from 1796 to this day, no single observer has ever
been able to point out so much as one case of tubercular proces
at the point of vaccination from either humanized or bovine
vaccin lymph, crust or scab. The medical literature of the
whole world does not furnish a single example of tuberculosis
proven to have been in traceable connection with vaccination,
humanized or bovine. But suppose tubercular infection did
occasionally result from vaccination would that be a rational
demand for the medical profession or mankind to eschew vac-
cination? Apply this rule of avoiding all danger and what
results? Surgical operations must cease, for a vast legion of
human beings have died from anesthesia. Opium must be
thrown away, for in thousands of instances death has resulted
from opium narcosis even when the drug was given by the most
skillful men of our profession. Not one single instance has
ever been recorded wherein vaccin lymph, even in a tubercu-
lous subject, has ever been found to contain tubercle bacilli.
Tuberculosis is a specific disease and can not result except by
planting the bacilli in the system through a bodily lesion.
There are no tubercle bacilli in vaccin lymph, therefore there
can be no tuberculosis engendered by vaccination. But tubercle
bacilli crowd men down at every turn by infection, ordinarily
through respiration. A disease so universally and constantly
threatening man as does consumption ; it is idle bosh to engage
in an idle warfare upon vaccination to prevent consumption, a
disease more generally prevalent and fatal in pre vaccinal times
than it is at present. I could fill chapter after chapter with
records showing incontrovertibly that consumption was more
prevalent in pre- vaccinal times than at present. I give you
only one instance. In the table already presented showing
the general differential death rate in London per 100,000 living
at seven different periods during the 226 years, 1629 to 1854,
the mortality from consumption was as follows : From 1629 to
1636, 1,021; 1660-79, 1,255; 1728-57, 905; 1771-80, 1,121, 1808
10, 716 ; 1831-36, 567 ; 1840 54, 323.
Here, then, is the proof, and from it there can be no appeal
that the consumption death rate in pre-vaccinal times was
nearly four times as great as that of 1840-54, fifty years after
vaccination was resorted to in London. Furthermore, the
table shows that in the face of an increasing vaccination rate
the consumptive death rate was not one-half as much in the
period, 1840-54, as it was in that of 1801 10. To argue this
question further would be an insult to your intelligence.
Erysipelas. — This is another bugbear of vaccination to anti-
vaccinationists. No truthful man would pretend to deny that
erysipelas is occasionally observed to attack the vaccinal pro-
cess. But erysipelas is in no sense an integral part of vaccina-
tion. It is always and under all circumstances an epiphenom-
enon. Vaccinia and erysipelas are each specific diseases and
differ one from the other as widely as daylight from midnight
darkness. They are as essentially different entities as wheat
and corn. Neither disease can give rise to the other more than
seed corn can produce wheat. Erysipelas in connection with
vaccination results from infection of the vaccinal wound with
the germ of erysipelas. In other words, the erysipelas is due
to the infection of the wound with streptococcus erysipelatis,
the wound happened to be that of vaccination. Only this and
nothing more. But, really, erysipelas does not occur near so
frequently in association with vaccination as it does in associ-
ation with minor surgical wounds. If all the requisites of
modern surgical asepsis were carried out with cases of vaccina
tion erysipelas would rarely, if ever, be encountered. The
vaccin wound, vesicle and scabbing is left unbandaged, which
is not done with other minor surgical operations, and the won-
der is that it is not more frequently encountered. The vacci-
nation wound being left uncovered is constantly an open door
for entrance of the poison from an infected atmosphere,
infected hands, clothing, etc., of the patient and his attend-
ants. In a recent report of the Royal Health Office of Ger-
many it was shown that out of more than 2,225,000 vaccinations
made that year there were eleven deaths from erysipelas.
Every intelligent, truthful student of medical history is forced
to admit that without exception a similar number of wounds
encountered in minor surgery has furnished more deaths from
erysipelas than has vaccination. But let it ever be remembered
that if there had been ten times that number of cases of ery-
sipelas in connection with vaccination the former was in no
1896.]
THE VALUE OF VACCINATION.
1003
wiso an integral part of vaccination. The existence of these
eases of er>sipelas loudly calls for better care of our vaccinal
patients, but is not a tittle of argument against the propriety
of vaccination.
1 "iwcimtl xt/plt H>"- -Not one case of this disease was observed
among these aC226,000 vaccinations.
Inflammation of lymphatic glands and ducts. — Out of 2,225,-
(Xio vaccinations of the year there were four cases of inflamma-
tion of the lymphatic glands and ducts. There was no mention
of death or permanent injury to health from this cause.
Inflammation of shin surrounding the vesicle. — Among the
two and a quarter million of vaccinations made in (iermany
tlic same year a number of cases of severe inflammation of the
skin in the neighborhood of the vaccin vesicles were observed,
but no cases of permanent injury to health, or death resulted.
These inflammatory conditions were by the inspectors generally
attributed to irritation by the clothing, by scratching and by
other mechanic means ; for instance, the vaccineee during
vaccination continued their arduous labors in the fields and
mechanical pursuits.
An examination into all the facts relative to these cases
showed that nearly every one of them was in direct traceable
connection with faulty methods of vaccination or carelessness
on the part of vaeeinees or their parents.
REIH'OTION OF GENERAL MORTALITY.
" Drs. llreenhow and Farr, under the auspices of the Gen-
eral Hoard of Health of London, have shown that, with the
decline of smallpox consequent on vaccination, the general
death rate has greatly diminished from all causes, and that,
too. notwithstanding a severe and fatal epidemic of influenza
and two epidemics of cholera : and under this diminution it is
especially notable that the two classes of disease usually con-
sidered the most fatal— namely, scrofulous and low febrile
affections -have diminished in a remarkable degree. The gen-
eral death rate per 1,000 of living population, during the peri-
ods of 1846 56, was 25 per cent, less than the decennial period
of 174(5 55. and 40 per cent, less than the decennial period of
1681 90, showing a successive decline since the remoter period
from 431 to 355, and since the more recent period from 355
*0 -19- . ■ a it
•According to Dr. Farr's statistics, the average annual death
rates in London, frqm all causes and all ages, per 10,000 living,
were :
From 1771-1780 M0-
•• 1801-1810 292.
" 1831-1835 (smallpox prevailed). . . . 320.
" 1840 1854 248.9.
"The average annual death rates in Sweden, from all causes
and all ages, per 1.000 living, were :
From 1776 to 1795 268.
" 1821 to 1840 233.
" 1841 to 1850 20o.
" In McColloch's Descriptive and Statistical Account of the
British Empire, Dr. Farr has shown that fever has progres-
sively subsided since 1771 (at first under the influence of inoc-
ulation |, 'and that the combined mortality of smallpox, measles
and scarlatina is now only half as great as the mortality formerly
occasioned bv smallpox alone.'
•'According to the researches of Dr. Greenhow, previous to
the introduction of vaccination, the death rate from scrofulous
diseases was five times greater than it is at the present time,
and the present death rate of pulmonary consumption, great
as it is, is 7 per cent, lower than it was previous to Jenner s
discoven , , . . . , . ,
But let us appeal to vaccinophobists for a preventive of
smallpox, and they will say : "We believe in sanitation Let
the people have an abundance of pure air, water and food, and
smallpox will not appear." Now, what does the whole science
of medicine testify as to the etiology of smallpox? Here it is
in a nut-shell : Smallpox spreads at the present time exclu-
sively by means of a specific virus which is begotten in the
body of a smallpox patient, and is conveyed directly by expo-
sure of the person to one sick of smallpox, or coming in con-
tact with infected clothing, bedding, etc. How absurd, then
is the claim for sanitation, for you can take an unvaccinated
person to the purest air of the country, even upon mountain
tops and put him in contact with the virus of smallpox, and
he will contract the disease as readily as if directly exposed to
it in the filthiest slums of the filthiest population on earth.
The same is true of water and food, whatever their purity.
But put your unvaccinated subject into a house where all the
decaving garbage of a city, both animal and vegetable, is piled
high as the second story window, then pour water all through
it, and call upon the heat of the sun to set all this putrefying
mass into the most active putrefactive fermentation, and if
smallpox virus has been kept away from it, your subject may
die of a zymotic fever, but never of smallpox.
Now as to the last part of my subject.
THE FUTURE OF SMALLPOX AND VACCINATION.
i Transactions American Medical Association, 18«5, p. KB.
This depends wholly upon man's action in the future. With
all this incontrovertible testimony before us (and a thousand
pages of a similar kind can be presented if need be) it is proven
beyond the shadow of a doubt that in vaccination and revac-
cination duly and efficiently performed, man is capable of
exerting absolute mastery over smallpox. The existence of an
epidemic of smallpox at the present day, under the known pro-
phylactic powers of vaccination, is a blot upon the civilization
of the age in which we live.
A frightful comment upon man's ingratitude to Jenner, and
disregard of Jenner's teachings, is that of Gloucester, as pub-
lished in London Lancet and copied in the New York Medical
Record, May 3, 1896, p. 634. The Record says :
" It is extraordinary to note how at Gloucester, a town in
which Edward Jenner resided for years, this centenary year of
the discovery of vaccination is bein? kept. First, we find a
board of guardians in fair weather, when there was no small-
pox about, declaring themselves boastingly to be opposed to
vaccination ; then, frightened at their own mischievous default,
first recommending vaccination to the public by means of cir-
culars, and later, when still more frightened, actually turning
right about face on all their former boasts and resolves, and
deciding to enforce the compulsory clauses of the vaccination
acts. Secondly, we find that their experience— just one hundred
years too late— has been most bitterly bought, for, according
to last week's papers, out of ninety deaths from smallpox in
the hospital (there have been 118 in all the city) seventy-four
were of unvaccinated persons. Thirdly, we find that among
this community which has so long been misled by the guar-
dians, there have within a few weeks been some 700 cases of
smallpox, and that in the absence of any controlling vaccina-
tion the disease has seized that part of the town where the
sanitary conditions are by no means worst, but where there
was an undue proportion of unfortunate children who were
unvaccinated. Fourthly, we find some thousands of pounds
being spent in attempts to check smallpox by hospitals, quar-
antining and disinfection, but all in vain, for the disease goes
on multiplying just the same ; indeed, there were no less than
172 fresh cases last week. And, fifthly, we find that even some
of those most responsible for the terrible loss of life among
the unvaccinated are hurrying to get protection by vaccination
for themselves. We leave those who have been so grievously
injured by disease, maiming and death, to apportion the blame.
Here we only note with regret and shame that any British city,
and above all Gloucester, should be in the state in which that
city finds itself in the centenary year of Edward Jenner."
The New York Medical Record, April 25, through its London
correspondent, shows that only one revaccinated person has
been admitted into the hospital. She had undergone smallpox
inoculation fourteen years previously and now contracted small
pox while nursing patients ill of the disease.
Last week's medical journals state that the smallpox epi-
demic in Gloucester continues to reap its fearful harvest of
unnecessary sickness and death from this, when uncontrolled
by vaccination, king of fatal diseases.
What a confirmation of the truth of the old adage, "Whom
thegodB would destroy they first make mad."
I give you two cases in contrast with Gloucester.
Take London, ten or twenty times more populous than
Gloucester. During the year 1895 there were but fifty-five
deaths from smallpox in London.
Take the German army. In a report recently made to the
Reichstag concerning the decline of disease in the German
army, it was shown that from 1873 to 1896 (twenty-three years)
there had been but two deaths from smallpox in the thoroughly
revaccinated army of the empire. These facts carry their own
comment.
In this day when we hear so much of degenerated health
from vaccinaton, and not infrequently death ; when we hear so
much of degenerated lymph, let us remember that the main
trouble lies in degenerated practice relating to vaccination.
Let every physician arouse from the slumber of neglect of
this important "measure, cease to regard it as one of the lost
arte, realize that it is a living, moving reality, which when
rightly practiced and extended shall carry health, long life and
happiness in its train. Let him pledge himself here and now
to enter with renewed zeal upon the high duty of enlightening
the public so grievously ignorant of or indifferent to the pro-
phylactic power of vaccination. Let him who is unacquainted
1004
SOCIETY PKOCEEDINGS.
[November 7,
with the appearance and phenomena of the typical vaccin dis-
ease lose no time in its study ; and then from the unpretentious
husbandman who, in raising wheat and other grain, selects the
finest specimens as seed from which to gather from a fruitful
soil an abundant harvest, learn to select the most typical vac-
cin vesicles from the most healthful subjects and in good
ground sow the seeds of cowpox — a disease which if univer-
sally inoculated, and repeated at necessary intervals, would
banish from the face of the earth one of the most loathsome
and fatal diseases known to man.
On this Centennial celebration of the discovery of vaccina-
tion I close this paper with the following quotation from John
Simon of Great Britain, for many years the honored medical
officer of the local government Board of that nation.
" It can be nocommon certainty which commands so general
an assent. It can have been neither a truthless nor a barren
doctrine, which, within sixty years from its rise, has all but
universally satisfied private judgment, and has converted
nations to its grateful followers.
" No truth can be thought of, against which some one does
not rail, and it would be idle to hope, under existing conditions
of the human mind, that vaccination should be much more
generally credited than it is.
" Perhaps in no age of the world have persons, in proportion
to their instruction, been readier than now to accept physical
marvels, and to modify their conceptions of natural laws, at
the biddings of quacks and conjurers. It goes with this cred-
ulity to be incredulous of proved truth. Alike in respecting
what is known, and believing what is preposterous, the rights
of private foolishness asserts themselves. It is but the same
impotence of judgment, which shrinks from embracing what is
real, and lavishes itself upon clouds of fiction.
"To some extent, therefore, it may be felt a weary and un-
profitable work to have spent time and labor in reasserting
proofs which, fifty years ago, were exhaustive of the subject."
"They have enabled you to estimate the full measure of grat-
titude which is due to the discoverer of vaccination. They
have set before you, as experience, what it must have seemed
mere enthusiasm to foretell. You will read it in the skilled
evidence of individuals, who, solely with the resources of Jen-
ner's antidote, are maintaining day by day against the most
dreadful of infections the victory which he commenced. You
will read it in the colossal statistics of nations, which till sixty
(now ninety-six) years ago were decimated by that one messen-
ger of death.
" If utility to human life be any test of what is noble in labor,
if our teachers of inductive philosophy have rightly advised us,
non tantum et ordini, verum etiam usui et commodis homi-
nuiii consulere— then assuredly the discovery, of which those
things are told, may rank with any achievement of man.
" ' Let men rejoice that there has shone so great a splendor
from amid their race,' is the bidding which at Newton's tomb
reminds us of immortal debts to the greatest interpreter of na-
ture, and claims kindred for us with the power of his intellect,
passionless and 'almost divine.' If corresponding honor be due
to the most beneficent application of science, if our mortal state
owes love to those who lessen its weakness and misery, surely
here has been a second student of nature, who, also matchless
in his career, might have claimed to lie beside that monarch of
the intellect in his last repose, and to share the inadequate
homage of that grateful epitaph.
"For, though a different, it is an equal praise, which the
members of Jenner's profession vindicate for his honored
name. He, too, could interpret nature, but above all, he could
render her teaching fruitful. To arm mankind against the
worst of pestilences, to widen by one discovery the horizon of
human life, to banish a cruel terror from every mother's heart
— such was Jenner's aspiration in his study of nature, such has
been the fruit of his philosophy."
SOCIETY PROCEEDINGS.
Chicago Academy of Medicine.
The regulur meeting of the Academy was held Oct. 15, 1896.
(Concluded from page 960.)
MENTAL ASPECT8 OF INFANTILE PARALYSIS.
Dr. H. B. C. Alexander — The mental symptoms arising in
connection with infantile paralysis vary in type with the con-
stitutional disturbance accompanying the paralysis. The
most frequent permanent disorders occur in the cerebral paral-
yses where conditions of more or less grave imbecility are found
accompanied very often with epilepsy. German and American
statistics show that th:s occurs in at least 35 per pent, of
diplegiacs, and CO per cent, of paraplegiacs, while but 13 per
cent, of hemiplegiacs are mentally affected. In many instances
this mental disorder coexists with a gibbous sclerosis which
seems to be the underlying lesion of the mental defect. In
cases where epilepsy exists the usual epileptic psychoses occur.
The mental state may vary in these chronic cases from slight
stupor to grave mental deterioration. In many instances the
mental defect appears only in moral expression. Not a few of
these children are incapable of learning the ordinary relations,
of meurn and tuum. The epileptic mental disorders are notor-
iously aggravated by bromids. Under these, motor phenomena
disappear to give way to disagreeable mental and moral mani-
festations. The influence of the gradual progressing mental
disorder is excellently illustrated by a case which came under
my observation. The patientcame from a neurotic family and
suffered from suppurative otitis media secondary to scarlatina ;.
this resulted in complete facial paralysis of the right side.
During infancy and childhood there were frequent attacks of
melancholia with decided suicidal tendencies. At 17 she cut
her throat in an attempt at suicide and was admitted to the
Insane Hospital. She was much depressed, very suicidal, in
constant terror and trying to escape from the ward every time
a door was opened. When she first came under my care in
1885, some years after her admission to the hospital, she
seemed partially demented, with little intelligence or memory,
very untidy in habits. Physically she was well nourished and
healthy. There were at that time no marked suicidal tendencies,
but the habit of struggling to escape from the ward each time
the door was opened still remained and made her a most trouble-
some patient. There were never signs of disappointment at a
failure. The effort seemed an uncontrollable impulse, the result
of an old mental habit. September, 1884, she pulled down from
the top a dining-room window, climbed over the lower sash,
before she could be stopped, and fell from the third story.
The shock was considerable, but she did not lose consciousness.
A comminuted fracture of the shaft of the left femur was dis
covered, and the limb was soon placed in a fracture box and a
Buck's extension applied. Very little stimulant was given.
After the first twelve hours the temperature gradually rose to
101. She was very quiet, seemed dazed and frightened for
several days. The temperature gradually fell to normal and
six days after the accident marked mental improvement was
noticed. She was bright and cheerful, talked of her past life,
inquired for her friends, showed a good memory for past events,
and was quite tidy in her habits. The bone united quickly,
and in two months the patient was able to walk about and
apparently quite restored mentally ; was allowed to go home,
but was very soon returned to the hospital in a condition sim-
ilar to that before the accident and has remained so since. In
this case the mental depression probably masked the demen-
tia existing from the first and with the subsidence of the emo-
tional state the dementia became more apparent and pro-
gressed with a gradually developing cortical change. The
acute disorders occurring in connection with the infantile par-
alysis may vary from simple melancholia, which is quite fre-
quent but temporary in duration, to acute mania, much more
rarely acute confusional insanity, which is quite frequent but
often called coma. Imperative conceptions often occur in these
cases and are stimulated by injudicious humoring into positive
delusions.
FORENSIC ASPECT OF INFANTILE PARALYSIS.
Dr. Harold N. Moyer— There is comparatively little to be
said on this subject. The forensic aspects are only those that
pertain to obstetrics. It is possible that a suit for malpractice
might have its origin in infantile paralysis which developed
subsequent to birth. There are none such recorded, so far as
I know, and it would seem to be difficult to fix any degree of
responsibility on a physician for a condition, so obviously
dependent upon diseased states, and not upon negligence of
the practitioner.
As regards infantile paralysis which develops prior to, or
afterbirth, the question is different. The necessary manipu-
lations during delivery of the child, instrumental or otherwise,
may be very easily brought forth as a cause of the paralysis
which follows, whether they have a bearing on it or not. As
Dr. Paddock has said, obstetric manipulations may cause par-
alytic phenomena. The question of the law would be as to
whether due care and diligence had been exercised in carrying
out such manipulations. There is, however, a practical and
important point relating to the jurisprudence of such cases.
In all ordinary surgical operations that are performed on adults-
an action must lie within two years from the time the negli-
gence is said to have taken place, otherwise it lapses by th&
statute of limitation, and no action can be had. If the paraly-
sis has occurred in infancy, a suit may be brought in the case
of a rrrle child at a period PC late as 23 years, that is, two vi>ar»
i
iS'.M',.]
SOCIETY PROCEEDINGS.
1005
after majority. and in the case of a female chile, it. would bo 20
years. There are quite a number of cases on record in which
physician! have had such suits brought against them. I recall
one 0M« in which a suit was brought against a physician more
than 22 years after ho had attended a case of confinement
Whether the paralysis was congenital or due to obstetric man-
ipulations. 1 do not know. There was paralysis of the arm
which persisted throughout life. The man who brought, the
suit against the physician recovered judgment for not less than
live thousand dollars: but on an appeal to a higher court the
ease was reversed, and whether it was subsequently settled out
of court I do not know. These cases are important from the
fact that actions may be brought long after the witnesses are
dead or the facts forgotten by the physician. In the forensic
aspect of infantile paralyses these cases are not wholly devoid
*>f interest.
THKKAl'Kl'TlC RELATIONS OK THK PALSIES OF INFANCY.
lh- Sanger Brown— In a general consideration of this sub-
ject. 1 will first speak of those palsies due to a lesion of the
peripheral neuron ; then of those due to a lesion of the central
neuron, and lastly of those due to a lesion of both neurons. It
may not be out of place to state that by the central neuron I
mean the nerve cell or unit whose body is in the cerebrum and
whose axis cylinder process passes downward to end in an
arborization or brush surmounting the body of a peripheral
neuron, either in the medulla oblongata or in the anterior horn
of the spinal cord. By the peripheral neuron I mean the nerve
cell or unit, the body of which lies in any of the nuclei in the
medulla oblongata or the anterior horn of the spinal cord and
passes thence by the several nerve trunks to the various mus-
cles. So far I have only spoken of the motor neuron, both for
the sake of clearness and because the relations of the sensory
neurons are not so well understood, nor are they so intimately
concerned with our subject. The advantage of discussing the
question according to this natural division appears when it is
stated that the symptoms due to lesion of the central neuron
are very different from those due to lesion of the peripheral
neuron ; that is to say, generally in the former case there is
exaltation of the reflexes or a spastic condition without atro-
phy, and in the latter diminution or loss of the reflexes with
atrophy. And further, no matter upon what part of the
respective neurons the lesion may act, the relation of the sev-
eral symptoms to each other holds as above stated.
Therapeutic measures should be directed, in the first place,
as far as possible, to the lesion producing the paralysis, and,
secondly, to the restoration of the injured neuron upon which
the paralysis depends. Incidentally the nutrition of the par-
alyzed parts should receive prompt and careful attention in
anticipation of the partial or complete ultimate recovery of the
neurons concerned, and, finally, any tendency to deformity
should be met without delay by suitable surgical and ortho-
pedic devices.
I will now proceed to mention some of the peripheral palsies
commonly met with in early infancy and childhood, commenc-
ing with the
Obstetric palsies. — During the process of delivery the fin
gers of the accoucheur may be so firmly pressed into the axilla
of the infant as to injure one or more of the nerve trunks of
the brachial plexus, thus causing a corresponding paralysis of
the arm. In a similar manner the trunk of the facial may be
injured by the blade of delivery forceps. In a case of this
kind no active treatment could be employed for two or three
weeks at least, and in the meantime the paralyzed parts may
be bathed as the other parts are, care being exercised in han-
dling the ailing arm, which may be kept wrapped in absorbent
cotton. After two or three weeks, light massage and gentle
movements are indicated. Prior to the fifth week, young child-
ren's muscles do not respond to any but very strong electric
currents and so this agent can not be used here. No medica-
tion is required and the prognosis is good.
Facial palsy. — In the child, as in the adult, the seventh
nerve may suffer from extension of disease from the middle ear
or brain, but I need here only mention that from which, in
children at least, almost always results from exposure to a
draft and develops very rapidly the so-called rheumatic neu-
ritis. Such cases usually recover in from two to twelve
months, whether treated or not. It is difficult to demonstrate
the utility of blisters, cups or leeches, applied over the mas
toid process, though the practice is pretty firmly established
and usually does no harm. Many patients demand electricity
in some form, and both practical and theoretic considerations
warrant its use, though in my opinion its direct value is not
great. About ten days after the onset the patient may sit
upon a flat electrode, four to six inches square, while a small
square,
electrode is moved slowly from the mastoid process along over
the main divisions of the nerve, using a current of from four applications alternately made to the spine : an ice bag over the
to seven milliamperes. The applications should be made three
times a week and last ten minutes. Either pole may be used,
but slow interruptions should be made.
Multiple neuritis.- A distinction ought to be made between
an inflammatory process acting upon the nervous elements of
the trunk of a mixed nerve and a toxic or toxemic process act-
ing upon the bodies or nuclei of these elements. In the former
case there is always tenderness of the nerve trunk at the seat
of inflammation, and motor and sensory disturbance limited to
the distribution of the respective nerve or nerves. In the lat-
ter case there will be no increased tenderness of nerve trunks :
t here will often be observed considerable motor paralysis with
little or no disturbance of sensation, and when sensory symp-
toms are present they are not limited to the distribution of
particular nerves. Though actual multiple neuritis some-
times occurs in children, if the peripheral palsies are classified
in accordance with the foregoing considerations it will be
found to be quite rare, while the non-inflammatory degenera-
tive forms due to the influence of a poison acting upon the
body or nucleus of the peripheral neuron are very frequent.
The symptoms of multiple neuritis are usually active and
more or less progressive for from four to eight weeks, after
which they slowly decline. During the advance of the disease
pain is a very prominent symptom, and to relieve this, maintain
the strength of the patient, neutralize or eliminate any causa-
tive influence, and if possible diminish the inflammatory pro-
cess, are the main objects of therapy. Where such causes as
lead, malaria or alcohol are suspected, the appropriate treat
ment is obvious. For the relief of pain heat is often of service
and if hot water is employed caution is necessary to prevent
the formation of blisters, for it often happens that the sensa-
tion is so much reduced that the patient can not be depended
upon to make the usual protest. On account of the impaired
nervous force ulcers form easily and heal badly. In many
cases it answers well to swathe the limbs liberally in absorbent
cotton, confined with a loose bandage. Opiates should be
used sparingly, that is, not regularly, for otherwise the pain
remaining urgent so many weeks, too free use of this drug may
have the effect of intensifying the symptoms ; when, however,
Eain prevents sleep, morphia sulphate or codeia phosphate,
ypodermically, will be found the best hypnotic. After the
first few weeks, when the pain has somewhat subsided and
paralysis and atrophy are easily seen, daily applications of gal-
vanism, from 5 to 15 milliamperes, should be made, and as
soon as it can be borne, light massage and passive movements
may be commenced. It may happen that orthopedic appara-
tus or even tenotomy may have to be employed to prevent or
overcome contractures.
Parenchymatous degenerations. — Of the parenchymatous
degenerations of the peripheral neuron, due probably to the
action of a toxic or toxemic influence on the nucleus, lead palsy
and diphtheritic palsy may be taken as types. After proper
measures have been directed against the cause, paralysis and
atrophy may be treated as a multiple neuritis, but a more
speedy recovery and satisfactory recovery may be expected. If
it is a fact, as many authorities assert, that in diphtheria the
knee jerks are always lost, and that this loss is due to the action
of the specific toxin on the nucleus of the peripheral motor
neuron, then in every case of diphtheria, strictly speaking,
there is diphtheritic paralysis ; that is to say, the nutrition and
function of the peripheral motor neuron is impaired, and it is
only a question of degree between the cases in which muscular
weakness is or is not very apparent. According to what I have
just said, if the claims made for the influence of antitoxin are
correct, this substance must act specifically against the devel
opment of diphtheritic paralysis. I do not recall any published
clinic observations on this point.
Acute anterior poliomyelitis. — This disease is essentially an
acute exudative inflammation, affecting chiefly the anterior
horns of the spinal cord in the lumbar and cervical enlarge-
ments, hence the paralysis is due to injury or destruction of
the peripheral motor neurons whose nutritive centers are there
situated. The therapeutic indications are, in the first place,
to limit as far as possible the inflammatory process, and thus
spare the neuron, and, secondly, as in all the other palsies due
to a lesion affecting the peripheral neuron, to restore such of
these elements as have not been destroyed and maintain by
artificial means the nutrition of the muscles over which the
diseased neuron is in the meantime unable properly to preside.
Though the symptoms usually develop rapidly often in a few
hours— it is fair to assume that just in proportion as the
inflammatory process is checked will the number of neurons
which will ultimately recover escape. During this stage the
patient, in order to promote the circulation in the cord, should
rest either on the side or abdomen, and have hot and cold
1006
SOCIETY PROCEEDINGS.
[November 7,
seat of inflammation for half an hour, then a hot water bag for
half an hour, and then neither for an hour, and so on ; and,
indeed, I consider it rational to continue this kind of treatment
for from a week to ten days after the inflammatory process has
probably reached ite height. At the outset it is well to give
one-tenth gr. of calomel every hour till the bowels and kidneys
respond, and this may be repeated after three or four days if
there are no contraindications. During this stage the diet
should be light, and fever if possible should be treated by pallia-
tive remedies. For convulsions full doses of chloral per rectum
are recommended. After the inflammation has subsided,
potassium iodid in doses that will not disturb the digestion
may be given for two or three months in the hope that it may
promote absorption of the exudate. The second indication of
treatment is met by the application of electricity, bathing,
massage and orthopedics, as already indicated ; but here per-
manent paralysis and atrophy are more likely to remain than
in any of the palsies heretofore spoken of. Under judicious
treatment, however, improvement may continue two or three
years after the symptoms have reached their climax, and this
fact warrants a corresponding persistence in the treatment.
The explanation commonly advanced for this prolonged period
of improvement is that each muscle is supplied by neurons
which are distributed in the anterior horn transversely for an
inch or more, and some of them therefore escape complete
destruction and require from two to three years to reach their
limit of recovery and development.
Paralysis due to lesion of the central neuron; infantile
cerebral palsy ; spastic hemiplegia, diplegia and paraplegia.
— These palsies are associated with spasm without actual
atrophy. The causative brain lesion may occur in utero, or as
a result of prolonged difficult labor, or from various causes after
birth. The causes which operate after birth are often obscure,
and authorities differ much in regard to them. There is a gen-
eral agreement, however, that the lesion is nearly always corti-
cal, while in the adult it is in the majority of cases in the inte-
rior part of the brain. In the child convulsions and coma are
usually prominent symptoms of the onset and though treat-
ment during this period is of great importance, time does not
permit me to discuss it, nor will I attempt to discuss the epi-
leptic convulsions and mental defects which commonly accom-
pany the infantile cerebral palsies ; excepting that these chil-
dren often have a deficient circulation, which is assisted by
frictions and passive movements of the limbs. After the brain
lesion has become stationary.such measures as have been recom-
mended in the palsies due to lesion of the peripheral neuron
are of little or no avail in effecting an improvement, and, indeed,
often aggravate the symptoms by eliminating the pathologic-
ally excited peripheral neuron to increased activity. Surgery
has of late shown brilliant results in relieving the spasm and
contractures which are often such a distressing accompaniment
of these palsies. I have already taken up too much time and
can not consider many important palsies of childhood which yet
remain, particularly, for example, those due to a lesion of both
the peripheral and central neuron, as transverse myelitis ; but
I shall feel very well satisfied if I have succeeded in drawing
attention to the essential physiologic difference between the
functions of the peripheral and central neuron and the corres-
ponding variations in the symptoms due to a lesion of each with
the general principles of rational and appropriate treatment.
SURGICAL AND ORTHOPEDIC ASPECT OP INFANTILE PARALYSIS.
Dr. F. S. Coolidge— In discussing this subject, I shall
speak from the standpoint of personal experience. The cases
of this nature coming to the orthopedist are divided into two
groups : 1, the cerebral paralyses, of which hemiplegia and
spastic paraplegia form the major part ; 2, the spinal paralyses,
which, if we throw out the paralyses of Pott's disease, consist
mainly of anterior poliomyelitis. I shall only have time to
speak of the main forms of infantile paralyses. There is a
great difference between the two groups. In the paralyses of
cerebral origin the affected muscles become the seat of spastic
contractions. Any slight irritation causes an involuntary con-
traction. Any effort to use even one of these muscles causes
a contraction of them all. These incessant contractions result
in shortening the bellies of the muscles and stretching the
tendons. On the whole, the muscles are shortened and con-
traction-deformities finally occur. In the cases of anterior
poliomyelitis the affected muscles are paralyzed, become limp
and loose, the "sleeping paralysis" of the Germans. Flexions
and deformities occur because the healthy muscles, pulling the
member over to their side by their normal tenacity, meet with
no opposition and become structurally shortened.
In the cerebral spastic paralyses, contraction of the affected
muscles causes deformity. In anterior poliomyelitis contrac-
tion of the healthy muscles causes deformity.
The mechanical treatment of the spastic cases is rather unsat-
isfactory. There is always present some mental impairment,
varying from a slight amount to complete idiocy. Further-
more, the difficulty is generally not the lack of power, for it is
usually a paresis rather than a paralysis, but in the involun-
tary spasm of all the affected muscles. This in the severer
cases renders a single act, as of placing one foot in front of the
other, impossible, and causes a stiffening and extension of the
entire legs with every muscular effort. To add the weight of
a brace to legs already uncontrollable is, of course, absurd.
Until recently little of advantage was accomplished by sur-
gery. A few years ago, however, it was found that cutting the
tendo Achillis caused a wide separation of the cut ends, and
that when the gap was closed the spastic condition of the calf
muscles entirely disappeared. The strength of the muscles
was possibly diminished somewhat, but they were placed under
the control of the brain. I have never seen any plausible
explanation of this remarkable fact, but have proved it in many
cases. In none has the spastic condition returned. That the
same is true of all the other muscles I have no doubt, except
that the spastic condition does return in them occasionally. If
we could cut all the tendons of the legs in a spastic paraplegia
the spastic condition would disappear and the limbs would
become controllable. Many of the tendons can be cut, and
following the lead of Dr. Bradford, I have repeatedly cut the
tendons of the adductors at the pubis, the internal and exter-
nal hamstring groups and the tendo Achillis in both legs. This,
together with massage and passive motion and teaching the
child its newly found power of coordinate movement, has done
a great deal, and has placed upon their feet children who had
hitherto been helpless. Unquestionably the spastic condition
in some cases returns in the course of years, but this may be
partly due to the fact that not all the muscles can be reached.
Noticing also that the spasm exists in the anterior thigh mus-
cles, from the fact that frequently the patelke are drawn up
quite an inch, and that the belly of the quadriceps extensor is
markedly high up, making what might be called a "ligamen-
tum patella? superius." I recently elongated this tendon an
inch by cutting down, lengthening and suturing it, in addition
to cutting all the other tendons above named. As this is, as
far as I know, an original operation, I am watching the result
with great interest. There is certainly decidedly less spasm
in that leg than in its fellow, which I treated similarly, except
for the elongation of the large extensor tendon. The child,
who is 7 years old and never even stood alone, can now place
one foot in front of the other quite definitely and walks with
a hand supporting him.
The orthopedic treatment of the second group, anterior polio-
myelitis, is of great importance. Early in the disease the
limbs should be massaged and given passive motion, and if the
paralysis remains complete for some time light suitable dress-
ings should be used, holding the limbs in the normal position
to prevent the formation of contraction-deformities. This
simple rule is sadly neglected. In those groups of muscles in
which there is slight power remaining, exercise and training
can yield considerable strength. Those groups of muscles in
which the paralysis remains complete after a few months never
regain any power.
As soon as the line of demarkation is drawn between the
totally paralyzed muscles and those which can be improved, it
becomes necessary to apply some form of apparatus which will
give the best possible use to the limb. But it is a hard task
to perform, for in such limbs the circulation is extremely poor,
the skin bruises easily and sores form easily. To fulfill all the
indications, and yet guard against sores and discomfort, calls
for long, patient, skillful effort.
With reference to the surgical treatment of this group, exist-
ing deformities should be corrected by tenotomies or forcible
stretching before any brace can be applied. I had intended
speaking of transplantation of tendons, suturing tendons of
healthy muscles to the tendons of paralyzed muscles, thus
making the healthy ones do the work of both ; and also of
stiffening the joints by partial resection, so as to yield a stiff
bony support rather than a useless flail-jointed leg ; but will
leave this for Dr. Beck to discuss.
CEREBRO-SURGICAL RELATIONS IN INFANTILE PARALYSIS.
Dr. A. E. Halstead — In the consideration of the treatment
of infantile cerebral paralysis, by operative measures on the
brain, it is essential, first, to briefly review the etiology and
pathologic anatomy of these conditions.
Etiologically we have three groups: First, those in which
the conception of this condition precedes birth. In this group
we have as the most frequent causes :
a. An arrest of development of a part or a whole of the
brain. This arrest may be due to heredity, congenital syphilis
1898.]
SOCIETY PROCEEDINGS.
1007
or to any other condition that interferes with the circulation of
the blood of the brain during early fetal life. An examination
Of the brain of these cases shows an absence or a partial
development of one or more convolutions or at times of a
whole hemisphere. In such cases we have idiocy associated
with paralysis of one or moro of the extremities, depending
upon the location and extent of the brain lesion.
6. Intrauterine infect ions give rise to circumscribed or dif-
fuse meningoencephalitis, this in turn being followed by the
formation of new connective tissues and later by atrophy and
defeneration of the brain tissue. Frequently we have throm-
bosis of the cerebral vessels as a result of this infection, which
later gives rise to circumscribed softenings and to the forma-
tion of cysts.
c. Trauma to the mother during pregnancy is infrequently
the cause of congenital cerebral paralysis. Two of such cases
are on record ; First that of Gibbs, in which the mother
received a blow on the abdomen at the sixth month of preg-
nancy. The child was born at full term with a right hemi-
plegia and died at the end of a month. Autopsy showed a
subdural clot covering the motor area on the left side. The
second was Cotard's case, which was similar to the preceding,
excepting that the child was stillborn and had contractures
end atrophy of the extremities on the left side. Autopsy
showed clot over the right hemisphere.
In the second group we have those paralyses which result
from injuries received during birth. The most frequent
result of this injury is a meningeal hemorrhage. Occasionally
the hemorrhage is into the substance of the brain. In a few
cases a depressed skull fracture is followed by brain symptoms.
Chronic meningeo-encephalitis with sclerosis, atrophy and the
formation of cysts are the constant results of these meningeal
hemorrhages.
In group th (re, those in which the paralyses develop after
birth, we have as the cause, first, intracranial infections occur-
ring during the course of the acute infectious diseases of child-
hood, such as measles, scarlet fever, whoopingcough, etc.
The pathologic conditions found in the brain in these cases
are the same as those found in the cases where the infection
has occurred during intrauterine life, viz., sclerosis, atrophy
and adhesions between meninges and brain, and skull and
meninges.
We also have in this group as the cause of paralysis, trauma
received during the early years of life. This may be either a
depressed fracture or a hemorrhage. The pathologic condi-
tions following are the same as those that follow similar lesions
that occur in adult life, excepting an arrest of development of
the brain commonly follows in children. In the treatment of
cerebral paralysis we must consider not only the palsy, but also
those conditions which so frequently follow or accompany it,
namely, epilepsy, chorea and mental defects.
In the first group, cases of cerebral agenesis are not amena-
ble to surgical treatment. In those cases in which we have
hemorrhage as a result of intrauterine trauma, if the child
lives and the symptoms are such that the lesion can be local-
ized, trephining and removal of the clot are indicated. These
conditions are rarely present.
Where we have intrauterine infection as the primary cause
of paralysis, the brain symptoms are more frequently the
result of arrest of development than of the primary lesion.
In those cases in which sclerosis and adhesions follow the
infection, removal of the sclerosed tissue, if not too ex-
tensive, at times is followed by improvement of the epilepsy or
chorea, but has no effect on the paralysis other than to make
it more complete.
When the paralysis is due to injuries received during birth,
it should be treated immediately by operative measures.
If the brain symptoms (paralysis, paresis or spasms) be
the result of a depressed fracture, the fragment should be
elevated at once. If no fracture be apparent the lesion is
probably a meningeal hemorrhage, and should be treated by
trephining and removal of the clot. If these conditions are
not treated immediately after birth atrophy and sclerosis with
secondary degeneration quickly follow and render operative
treatment useless. If the operation is performed early these
secondary changes do not take place.
In the third group, where the paralysis is due to meningeo-
encephalitis, secondary changes take place rapidly and are such
that operative measures on the brain can benefit the patient
but little. In those cases that are followed by the formation
of cysts, either from thrombosis, embolism or softening of
circumscribed areas, opening the skull and evacuating and
draining the cysts frequently produce favorable changes in the
epileptiform, athetoid or choreiform movements that so often
accompany cerebral palsies, but does not benefit paralysis or
mental defects. ■
In any one of these groups, the paralysis may assume the
form of a diplegia or a paraplegia, in which case the lesion is
too diffuse to be treated by operations on the brain.
ARTHRODESIS IN INFANTILE PARALYSIS.
Dr. Carl Beck — All that was accomplished in the treatment
of infantile paralysis was to enable the patient to hobble about
supported by braces or heavy apparatus. During the last few
years, particularly on the recommendation of Karewski,
attempts have been made to treat these cases surgically. This
departure has proven so successful that many unfortunate
patients prefer operation to wearing heavy support braces.
The operation, which is called arthrodesis, consists essentially
in the destruction of a joint, producing anchylosis, or at least
very restricted movement. The following case affords so good
an illustration of the usefulness of the operation that I will
describe it in detail, concluding with an enumeration of the
indications and contraindications :
D. D., 15 years of age, was admitted to the Cook County
Hospital for the purpose of securing a supporting brace for
her paralyzed limb. Up to the age of 4 years she was a per-
fectly healthy child ; she then became sick with the symptoms
of acute poliomyelitis, which resulted in paralysis of both
limbs. After about one year's treatment with electricity,
massage and other methods, she improved so much as to be
able to use her left lower extremity, while the right leg
remained paralyzed, except that the adductors and the psoas
muscle could be used to a certain degree, enough to allow her
to throw the leg forward and inward, but she was never able
to make any firm, premeditated movement. Extensive passive
movements could be made ; the leg could be placed around
the neck or extended backward to bring the sole in contact
with the head. While the patient was walking on crutches
the leg would swing like a flail. During the following years it
did not improve in the slightest degree, but became atrophic
and slightly flexed. She was obliged to use a crutch all the
time. The changes in the pelvis and vertebral column that are
usual to cases of infantile paralysis, i. e. , scoliosis and incon-
gruity of the pelvis, developed in this case also. It was in
this condition that the young girl, who was very bright and
otherwise well developed, came under observation. The case
seemed to be a suitable one for treatment by operation, inas-
much as the slight but persistent action of the adductors and
flexors allowed of the patient's throwing the limb forward. In
order to convince myself that she would be able to walk on a
stiff leg the limb was put in a plaster of paris cast. The slight
contracture caused a good deal of pain when the limb was
straightened, but she could, nevertheless, walk with the aid of
a crutch. This being satisfactory I decided to make the limb
permanently stiff. On Nov. 16, 1895, the operation of arthrec-
tomy of the knee-joint was performed. In consequence of the
long-standing contracture the bones had become deformed,
and in order to have the limb perfectly straight it was neces-
sary to remove quite a portion of the condyles anteriorly.
Otherwise the operation was a typical resection. The result
was excellent. Four weeks after the operation the leg was
put in a water-glass bandage, so that the patient might walk
in this very light dressing, and six weeks after the operation
she was discharged with a high shoe. The operation which I
first thought of performing on her ankle-joint was unnecessary,
as she could walk firmly with her anchylosed knee. This
patient was exhibited at a meeting of the Chicago Medical
Society January 20. She was then able to walk without sup-
port for the first time in eleven years.
Since that time I have had occasion to observe several other
cases, but the time which has elapsed since treatment is too
short to permit me to make a report. From this one case, how-
ever, I have gained the conviction that arthrodesis is a justifi-
able and very useful operation, by which patients are enabled
to use their limbs without the aid of crutches or braces. The
indications, however, are very restricted, since experience
teaches that by careful and untiring care many cases of infan-
tile paralysis improve so greatly in the course of time that the
muscles acquire some activity. In a case like this, however,
where no change for the better had taken place in eleven years,
it could not be expected that treatment would enable the child
to recover the use of the limb. Furthermore, the small
groups of muscles, adductors and psoas, unless trained become
atrophic and it would not have been possible for the limb to
be thrown forward had not her intelligence led her to practice
the movement and preserve the muscles. As a first indication
I would say that the operation should be done only after all
hope is abandoned that the limb will become useful by the
return of muscular action. Another condition is that power
must be preserved in some muscles at least, otherwise the
stiffness of the knee and ankle will be of no advantage. For-
100S
SOCIETY PROCEEDINGS.
[November 7,
tunately in most cases such a degree of muscular power is
retained.
This method can be used in cases where the feet alone are
paralyzed. In such cases Karewski and others have had good
results in both limbs by producing anchylosis, which, however,
gradually yielded to restricted motion ; motion ata small angle,
so that patients were able to walk firmly on their feet without
braces. The operation would be contraindicated shortly after
an acute attack of poliomyelitis.
The literature on this subject is already quite extensive, a
number of cases having been operated upon in France, Ger-
many, and this country. The results are uniformly good.
Thus, Karasiewicz reports among eighty-seven cases eighty-
four satisfactory results. When we think that many of these
wretched children are not able to buy good braces, or to keep
them in order, but are obliged to hobble about on crutches all
their lives, developing contractures, decubitus, and deformities
of the pelvis and spine, we must admit that this operation has
proven a godsend in the treatment of infantile paralysis and
that it deserves to be placed on the same level with other plas-
tic operations. The object is not to restore form, but to restore
the function (la chose laplusprincipale pourlaclasse ouvriere
-Verneuil) and make the unfortunates useful members of
society.
While I was on the Continent this summer I asked different
surgeons how many craniectomies they had done, and what
kind of results they obtained. In France, where craniectomy
was first done quite extensively, it has been entirely abandoned.
Lannelongue, who was the first to do the operation in France,
has given it up. His results were not good enough to justify the
operation. In Germany the operation has never been done to
any great extent, and, as far as I could learn, only one or two
operations have been performed. In Italy very few craniect-
omies are done. For the last three years I have not resorted
to the operation myself.
After looking at Dr. Engelmann's specimen, I should say that
a craniectomy would have been useless in such a case, because
there is not simply a pathologic condition of the brain, but the
entire nervous system shows lack of development. The nerves
and spinal cord are very small, and the case was undoubtedly
one of micromyelia and microcephalia. There is defective
development of the finest elements of the brain. But there
are cases where craniectomy may be of some use. The post-
mortem of a case which I saw not long since showed me plainly
that I ought to have performed a craniectomy, which might
have been a great benefit to the patient.
As to the surgical treatment of anterior poliomyelitis, as Dr.
Coolidge has said, orthopedic treatment in some of these cases
does not yield good results. This is particularly true where
we have to deal with poor and badly treated children, whose
parents can not afford to buy an apparatus, and who can not
keep the apparatus in good condition if they had it. Such
children are neglected.
CRANIECTOMY AND MENTAL SYMPTOMS.
Dr. James G. Kiebnan — From an alienistic standpoint it has
long been decided that in the majority of cases the results fol-
lowing craniectomy were negative. It had at one time some
support from the standpoint of the alienist, owing to the fact that
cases would occur of this character ; for example, one of the
popes sprang from a family of which the majority were rather
below the average mental standard than above it ; in point of
fact, idiots preponderated, and he himself was not intellectu-
ally of high order until he fell downstairs one day and sus-
tained a fracture of the skull. From that time on he began to
improve mentally and became somewhat renowned for shrewd-
ness as a church politician. Such cases as this appeared from
time to time in the literature. It was also noted in a few in-
stances in autopsies made at insane hospitals, that there were
some cases in which there had previously been skull pressure
interfering with brain growth.
In another set of cases, and these were the vast majority, the
influence of the premature closure of sutures could be entirely
excluded in idiocy. This would appear to me to be the fact in
the case reported by Dr. Rosa Engelmann. The atrophy in
this case is more than pathologic. I should be of the opinion
that the condition was teratologic as well as pathologic, and
that the pathologic condition was secondary to the teratologic
changes. From this standpoint, it would seem that craniect-
omy would be at best useless. A factor which must be con-
sidered in dealing with any apparent improvement, is the con-
stitutional effect of an operation per M irrespective of its
character, or location. This has long been recognized by
alienists and is now being considered by surgeons. The influ-
ence of this factor is strikingly illustrated in the case reported
by Dr. Harriet C. B. Alexander. Alienists have noticed from
time to time that traumatism or even pathologic states will
produce temporary improvement in old cases of insanity.
With reference to some of the etiologic factors, it should be
remembered, as Dr. Baum remarks, that there are a good
many conditions reported as scleroses, so called miliary sclero-
ses, which can be produced on the brain of any healthy dog by
the operation of alcohol. In 1882 Dr. Bottcher of Saxony,
made investigations on the children of women who worked in
the potteries as to the influence of lead poisoning on the
mother, because most of these women potters were then sub-
ject to lead poisoning. His results, which were very valuable,
were published in several neurologic journals. In a large
number of cases the women bore large-headed children, so-
called macrocephalic idiots, in which the normal cerebral tis-
sue was replaced by barren ependyma tissue. He found a
large number of children, apparently healthy at birth, who
later presented conditions similar to those cited by Dr. Brower
as occurring in family paralyses. The autopsies in some cases
showed the condition present, which was found in 1887 by
Spitzka, and subsequently by others, to be a family tendency
to miliary aneurysms. There was a tendency in a number of
generations(in the family that Spitzka studied) to this. It seems
to me, miliary aneurysms would throw some light on the phe-
nomena observed by Dr. Brower. The child would have first the
arterial condition predisposing to miliary aneurysm and subse-
quently aneurysm would develop which, either by rupture or
by pressure, gave rise to the various conditions found in this
class of cases. This condition would also to a certain extent
explain the phenomena of diffuseness, of certain cerebral
lesions in diplegias and paraplegics, to which Dr. Brown has
called attention. This diffuseness of lesions bears directly on
one point brought out in the discussion of the mental symp-
toms. The hemiplegic condition is generally due to localized
lesions, while the other conditions are generally due to diffuse.
With regard to etiology, it is well known that most conta
gious diseases produce a secondary pathologic state closely
allied to the luetic state. As Dr. Baum has said, physicians
are apt to err, on the one hand by considering certain conditions
occurring in luetics as the result of lues ; while on the other
hand, they are liable to regard the reaction to alteratives as an
evidence of lues. Certain diathetic states, such as gout, will
react favorably to potassium of iodid. Furthermore, it should
be remembered in the same connection that when Hutchinson
made the claim that the so called Hutchinson teeth were due
to lues, it was not as positive as many of his co laborers have
made it. He admitted that in 10 or 20 per cent, of the cases
where notched teeth were found, no positive evidence of either
lues in the ancestors or in the patient himself could be detected.
That is one important factor we have to consider in connection
with the etiology of infantile paralyses. It would seem that
almost all contagious diseases have a tendency to produce a
sclerotic state. Researches have shown that scarlatina and
typhoid fever will do it, and herein is an explanation of the
characteristic results of those conditions in producing these
paralyses.
Dr. Halstead has alluded to the question of exsecting scler-
otic masses. Exsection in the brain is going to be followed
sooner or later by scar tissue. I have followed one case
reported by a neurologist and surgeon in which one patch was
removed from the brain, followed by disappearance of the
man's symptoms for two years, after which they returned. A
second patch was then removed, which resulted again in dis-
appearance of the symptoms, since which the case has disap-
peared from the literature, whether from the results of a third
operation or not, remains unknown.
craniectomy in infantile paralysis.
Dr. Alexander Hugh Ferguson — Of all the craniecto-
mies I have done this is the only one that died. I assure you
that craniectomy has its place in surgery. Here was an infant,
7 months old, with constant fits, a history of long tedious
labor and of delivery by forceps. The craniectomy in this
case was undertaken for the purpose of ameliorating the child's
condition and of lessening the fits, doing something better for
it than can be done either physiologically or medically. I do
not intend to report all of my cases to night. Some of them
will illustrate very well the benefits of craniectomy. I think
no operation should be condemned until it has been thoroughly
tried, particularly in those cases where every other form of
treatment has been tried and found useless. It is in this class
of cases that craniectomy has its exact place in surgery. We
often get most benefit when least expected. In one case, a boy
7 years of age, there was paresis of the right arm with some
mental impairment. He could only count up to seven. Con-
vulsions were frequent. We recommended and did a craniec-
tomy on the opposite side. He is now able with this arm to
1 896. J
SOCIETY PROCEEDINGS.
1009
throw stones and break windows. It is a little over two years
since the operation was done. The convulsions have been
materially increased in number. Instead of having ;v fit once
I week, twice a week, etc., he now has a convulsion once in
three months or so, depending upon the excitement to which
tho child has been subjected. However, the boy is very much
improved, is more easily controlled, which is saying a great
deal.
Another case was for the effects of meningitis. There was a
dragging of both the arm and leg. This patient was a marvel
in titrures. After a craniectomy there was an amelioration of
the violent symptoms which he exhibited toward other mem-
bara (children) of the same family. The boy can also walk
much better as the arm and leg improved. In another case in
which craniectomy was performed the result was unsatisfac-
tory. In still another operated upon we got no result. We
declined to operate on another patient, believing that we could
not benefit him.
A craniectomy was done on a child, 5 years of age, who was
unable to stand, walk on talk. She was filthy in her habits.
After the operation she began to improve in temperament and
in habits and can now walk. On account of the improvement
she was brought back for a second craniectomy, which I did
four weeks ago, making a horseshoe-shaped incision backward
and raising the whole roof to see if anything could develop
underneath. We know that in cases of insanity it is remarka-
ble how they improve with very little brain tissue and then
relapse again. But if you improve the brain tissue for the
time being it is better than can be done with medicine. In
those children, feeble-minded, imbecilicand even idiotic, there
is no telling what development and regeneration may take
place after craniectomy".
Another case of craniectomy was that of a little girl of 3
years of age who had hemiparesis of both the right arm and leg.
The child was unable to walk, had frequent fits and was also
a masturbator. We did a broad craniectomy in this case ; there
was a depression of the left side of the head ; there was a his
tory of tabor and of forceps delivery, but I attributed her con-
dition more to the long and tedious labor than to the applica-
tion of the forceps. Following the operation the fits were
under control ; she commenced to use the limbs better. The
improvement was so marked that we did a second operation.
After the second craniectomy she commenced to talk a little,
and I am satisfied that the improvement in this case at the
present time is more than could be brought about by resorting
to medical treatment, training, etc. I claim that the mortality
in those cases where the nerve centers are fairly strong is very
low. The case reported by Dr. Engelmann to-night is the
only one I have lost in twelve operations.
RHINO LARYNGOLOC.IC ASPECT OF INFANTILE PARALYSIS.
Dr. Edward T. Dickerman— What role the nose, throat and
ear play as an etiologic factor in infantile paralysis is difficult
to say. No part of the body is more prone to violent infections
and to the constant presence of pathogenic factors of infection
than the above organs. Id the acute exanthemata of child-
hood we have in the nose, throat and ear the most violent mixed
infections of the mucous membrane and deeper parts. These
inflammatory changes may extend into the accessory sinuses
and involve the bone itself. What is easier than from these
various sources of infection to have the process extend along
the course of the blood vessels or by the minute lymph chan-
nels to the meninges, setting up a local meningoencephalitis
with secondary sclerotic changes and accompanying focal symp-
toms? Another factor to be taken into consideration is the
fact that certain toxic elements may first cause a definite dis-
ease and secondarily be followed by a paralysis, such as diph-
theria. Here we may have first the local action determining
the position of the paralysis, while later the toxic elements in
the blood cause the perineuritis and neuritis with paralysis.
It is also undoubtedly a fact that we may have this paralysis
and neurotic changes without the local affection. This being
true, is it asking too much to think that such changes could
not occur in the brain itself? In looking over the literature of
the subject, which is very meager, I find that as an etiologic
factor, which might be traced to the nose and throat, -tonsil-
litis, diphtheria, measles and scarlet fever,- the reports were
not of such a character that one could draw any definite con-
clusion, and the future will only reveal the exact etiologic r&le
that these parts play.
ORTHOPEDICS IN INFANTILE SPINAL PARALYSIS.
Dr. John Ridlon— ^ A little more than two years ago, in
a paper read before the Chicago Academy of Medicine, I
expressed the belief that early orthopedic treatment of infan-
tile paralysis was of the greatest importance. The results of
my observation and treatment during the past four years have
confirmed the belief expressed two years ago. I am satisfied
now, beyond a question or doubt, that the early orthopedic
treatment of these cases will result in a complete recovery in a
considerable number of cases that otherwise would become
hopeless cripples.
The orthopedic treatment of infantile paralysis consists in
correcting the deformity, if any deformity exists, by mechani-
cal or operative measures, and in constantly maintaining the
limb in the corrected position for a very long period, supple-
mented by more or less local stimulation to the paralyzed
muscles.
The choice between the mechanical and the operative meth-
ods for the correction of the deformity depends upon the
severity and duration of the deformity. Speaking broadly,
slight and moderately severe deformities should be corrected
by mechanical measures : severe deformities by operative
measures. The functional results are undoubtedly better if
the deformity is corrected by mechanical measures. In recent
cases no deformity exists that can not be readily overcome by
gentle manipulation. The deformity having been overcome,
retentive appliances must be carefully adjusted and constantly
worn. The almost universal failure to cure or materially restore
the usefulness of these paralyzed limbs depends more than
any other factor upon the fact that the limbs are not constantly
maintained in the corrected position. Not once during the
period of the retentive treatment must the paralyzed limbs be
put on the stretch. Few physicians and fewer patients and
parents have the perseverance to continue the retention
without relaxation for eighteen months or more, despite the
fact that it is the key note of success in these cases. During
this long period of retention as full a restoration of the control
of the paralyzed muscles takes place as can possibly be had,
and structural shortening takes place in the hopelessly paral-
yzed parte. This structural shortening of itself alone is often
sufficient to prevent a relapse of the deformity in limbs where
whole muscular groups are completely paralyzed.
The local stimulation consists in lashing the paralyzed mus-
cles with the looped end of a double strap, in massage, in local
roasting either at ordinary atmospheric pressure or in a par-
tial vacuum, and possibly also in the application of electric
currents.
Chicago Ophthalmologlcal and Otological
Society.
Regular meeting held April 14, 1896, Dr. Qradle in the Chair.
There were sixteen members in attendance.
Dr. Fisher reported two cases of iron in the eye.
Case 1.— Mr. G. aged 37, struck by a piece of iron in the
right eye fourteen years ago, which caused immediate blind-
ness. He did not work for three months, since which time he
has been troubled once a year, the attacks lasting at first about
a week but becoming more and more severe every year since.
The Doctor saw him February 13, 1896. On examination the
right eye was found to be atrophic and tender : the left eye V.
20—30; the right eye was enucleated, and on section apiece of
iron was found completely encapsulated, the lens being calcar-
eous. The piece weighed 2>8 grains. The remarkable part of
the case was the large size of the metal, remaining so many
years without creating much disturbance.
Case y.— Child, 4 years old. Right eye was injured while
playing with two hammers on November 9. On November 11
the Doctor first saw the child. Vitreous was cloudy ; no reflex
from the fundus. There was a scar in the cornea with a corre-
sponding scar in the iris where the foreign body had pene-
trated. The child was anesthetized and under strict antisep-
tic precautions a piece of iron was removed with the magnet.
A small amount of vitreous was lost, but no reaction followed.
In two weeks the globe was filled with pus and the eye evis-
cerated.
Dr. Hotz reported a case of a piece of steel in the eye of a boy
12 years of age, who on March 1, 1896, was struck in the left
eye by a fine chip from a hatchet. The chip pierced the center
of the cornea and was seen by the family physician lying on
the iris. Atropin was at once used twice a day. On March 1
the boy was brought to Dr. Hotz on account of the inflamma
tion which had started up. A linear scar 2 millimeters long
was seen in the center or the cornea. The nasal side of the
pupil was fully dilated, the temporal side only slightly. On
the temporal half of the iris above the horizontal meridian
near the papillary margin was a white, pearl-like mass of exu-
date, from which the foreign body could be seen protruding.
The lens and vitreous were clear and the tension slightly
minus. There was some tenderness. Extraction was tried
with the magnet through an incision made at the upper tern-
1010
SELECTIONS.
[November 1,
poral junction of the corneal margin, so that an iridectomy
could be done upward if necessary. A magnet could not pull
out the metal and a pair of curved forceps was used. The eye
recovered quickly, the boy leaving the hospital at the end of
four days. The lens, however, became cloudy afterward.
Dr. Geadle spoke of the secondary results in the lens fol-
lowing injury to the eye, and quoted the case of a girl 4 years
of age struck by the blade of a penknife, which cut through
the outer quadrant of the left cornea. On the third day the
iris became slightly entangled in the wound with some exuda-
tion at the margin of the wound. Atropin and a bandage were
used, and recovery occurred after six weeks with the iris adhe-
rent to the wound. There were some deposits on the capsules
of the lens, lace-like in character, but the lens substance itself
was clear. Later the lens substance became opaque.
Dr. Coleman reported the case of a woman, aged 25, com-
plaining of asthenopic symptoms for close work, no trouble at
a distance. He found the abduction at 20 feet 10 degrees ; the
adduction 15 degrees; the right eye refraction — .50, the left
eye— .50 ~ — 4, ax. 180. With the rod test there was esophoria ;
with the double prism test there was exophoria of 3 degrees.
For near the adduction was 12 degrees, abduction 18 degrees.
She has been wearing the correction for some time, but is
unable to read longer than three or four minutes. Exercise
with prisms for four or five weeks without any increase of the
adduction at 20 feet. A tenotomy of the left external rectus
gave the test on the following day of 3 degrees esophoria with
the rod and binocular single vision with the red glass. This
operation was done only a few days ago, so that it is too soon
to judge of results. Dr. Hotz suggested that relief might have
been given to the patient if the spheres had been left out.
C. P. Pinckard, Secretary.
SELECTIONS.
Illinois State Board of Health and Medical Education.— Under the
proceedings of the Nebraska State Board of Health will be
found a report of the investigation made by that board of a
case where the applicant for a certificate to practice made an
affidavit that he was a graduate of the National Medical Col-
lege and Hospital of Chicago. He had no diploma, claiming
that it was granted but held for fees. The board never having
passed on the standing of this college, made inquiries as to its
standing, and facts were brought out that the applicant had
attended another school, had failed to pass, had gone to the
National Medical College, and in two weeks was graduated.
The board therefore refused to recognize the school, and the
application for a certificate was rejected.
The first thing the board did was to ascertain whether the
school was recognized by the State Board of Health of Illinois,
it naturally being supposed that that board ought to know the
standing of schools in its own State. Inquiry showed that the
Illinois board did recognize the school, and had the Nebraska
board not found out the facts referred to it would naturally
have supposed the school was straight and would have recog-
nized it as being in good standing. It showed on its face that
it was ; its catalogue and announcements made it appear that
it had the full time required and everything that is supposed
to be necessary to put a school " in good standing."
That the Illinois board is not what it was in the days of Dr.
John H. Rauch is becoming more and more evident. This is
not the only school in Chicago that the board recognizes as
being in good standing, when evidently they are far from
coming up to even a low standard. In the New York Medical
Journal of August 25, Dr. Julius Grinker exposes one of these,
the "Harvey." After commenting on a paper published in
the Journal by Dr. Morton, of St. Joseph, on medical educa-
tion, he showed up the sorry state of affairs which existed in
Chicago and Illinois as follows :
"Allow me to state that upon careful investigation he will
find in the city of Chicago, besides the three regular medical
schools that maintain a high standard, a number of inferior
evening colleges of medicine, the purpose of their existence
being to defeat the spirit of the medical practice act, though
they profess to comply with the letter of the law.
"These evening colleges of medicine grant diplomas after an I
attendance varying from six months to four years, which the
State Board of Health recognize. Upon the payment of 85
and the presentation of such a diploma, the State Board of
Health of Illinois grants applicants a license to practice medi-
cine and surgery in the State of Illinois."
After eulogizing the Illinois State Board of Health as it used
to be, he says :
" It is this very same State board of health — but now with
another secretary — that enables colleges like the Harvey and
Harvard night schools of medicine to do a thriving business
of inducing young and middle-aged men and women to leave
the workshop and the stock yards, where they slaughter cattle,
for the more remunerative occupation of slaughtering man-
kind."
Speaking of the Harvey Medical College, Dr. Grinker says :
"This school, as well as others of the same character in the
city of Chicago, allows its students to work all day at their
respective operations, and exacts of them an attendance upon
lectures three hours evenings, namely, from 7 to 10 p.m.,
although excuses of three months' absences are accepted.
"As for clinics, they receive mention in the Catalogue, and
students graduate without ever having seen a single capital
operation at the college, their being no hospital connected with
it, and but few dispensary clinics.
"The facilities of the school are of the most limited kind.
It is located on a floor and a half of an office building, where
there are a dentist, a private dispensary of an advertising doc-
tor, and a good-luck store. One can form an idea of what kind
of material they can get up there for the benefit of evening
students."
Dr. J. W. Scott, the secretary of the State Board of Health
of Illinois, answers Dr. Grinker in the Journal of August 15,
and accuses him of having been connected with the school
himself, and in reply to this Dr. Grinker says (see Journal,
August 29) :
"The history of my connection with Harvey is as follows:
After having read in the papers that the Illinois State Board
of Health has decided to recognize the Harvey School of
Medicine, I allowed my name to be used in connection with a
professorship. I was invited to the college, and the secretary
offered me the chair of pathology, which I accepted. Previous
to my acceptance I had several conversations with the secretary
in regard to the scope of the institution, its work and its ulti-
mate future, from all of which I gathered the remarkable
admission that this school was only intended to be a prepara-
tory school, a so-called " feeder" for the day schools of medi-
cine, and that it was expected that some day one of the regular
day schools would buy up the night school and amalgamate
with it. She assured me on a later occasion that her senior
class was virtually useless, that none of the members of the
class had a right to graduate, and it was not intended that
they should. I then reasoned : Are there not reputable phy-
sicians teaching popular physiology and chemistry in the New
York evening high schools, and why should I not connect
myself with a preparatory school of medicine?
"And here comes the most interesting part : As long .as I
was only teaching pathology to juniors I had no idea of the
mental caliber of the seniors, who never were juniors in this
institution, and some not in any ; but when my colleague, the
regular professor of practice of medicine, temporarily discon-
tinued his course of lectures, I had ample opportunities in my
quizzes and lectures before seniors to form a correct estimate
of the composition of the class.
" Imagine my surprise when at the end of the term I received
a note to come down to the office and sign diplomas ! About
the same time I was informed that students would graduate as
full fledged doctors, and eight diplomas were presented to me
for my signature as the professor of pathology. I asked for
credentials which would show that those eight seniors had
passed in my branch with some reputable teacher, but was
told that the directory was well satisfied that the students had
passed in pathology somewhere. I then stated that I should
not attach my signature to any of those diplomas until I had
satisfied myself that the holders of them had passed in my
branch. The secretary then told me that students might pro-
duce cradentials if they saw fit to do so, but that they would
graduate anyhow ; furthermore, that such a request on my
part was unheard of, and I was the only one of the faculty
asking for credentials.
" It was at this time that I discovered a diploma mill, and I
hastened to resign my professorship immediately, and who
would not?
I
f««.]
SELECTIONS.
1011
■• On tlu' tnoning of the same day I met Dr. Scott, and asked
for an investigation of Harvey Medical College.
" Never was 1 more surprised than when Dr. Scott, whom I
saw for the first time, answered all my objections in almost the
■me wonis that the secretary of the college had made ubo of
the previous day. He knew by heart the name of every gradu-
ate of Harvey College, and was armed with an array of argu-
ments that were simply astounding."
And Dr. Drinker goes on and shows that Dr. Scott knew too
much about the Harvey Medical School not to be intimately
connected with it. Proceeding, he tells of the fight he and
others made before the board to have the school declared not
in good standing; how Dr. Scott, the secretary of the board,
fought them at every step, and how he finally gave up in
disgust.
It is interesting but not pleasant reading when one remem-
bers what the State Board of Illinois used to be. What has
become of the spirit that used to animate it? What has become
of the spirit and courage of Dr. Rauch? There was a time
when the Illinois board was a beacon light for those who were
striving to elevate the standard of the medical profession of the
country. It gave courage and hope to those who were anxious
to raise the standard of medical education in the United States
so that the title of " American doctor" should cease to be a
reproach, but rather an honor, before the people of the world.
There was a time when if the Illinois board recognized a school
it was recognized over the country. There are eighteen medi-
cal colleges in Chicago, exclusive of the post-graduate schools,
and of these seven ought to be recognized, and no more. There
is not one of the others that comes up to even a fair standard.
And yet what can the Nebraska and other boards of health do
if these schools show up the required three years' course and
clinical instruction? Nothing. With our present law they
must recognize them, unless evidence outside can be procured
that will give a good reason for refusal. — Western Medical
Review.
Intercurrence of Infectious Diseases. — In the Archives of Pedia-
trics. Dr. Alfred Hand, Jr., of Philadelphia, reports two cases,
brothers, in which there was the coexistence of two and three
(respectively) zymotic affections.
1. W. B., aged 6 years, suffered from diphtheria with a
second attack of measles. On February 10, he came under
notice, complaining that his throat had been sore for several
days. Inspection then showed swollen tonsils with distended
follicles and a slight grayish deposit on the right wall of the
pharynx, the gland at the angle of the jaw was scarcely palpable,
the temperature was 98.6 degrees and the pulse was 85. A
culture was taken from the throat, and the child was isolated
and put on tincture of the chlorid of iron internally, and the
above mentioned spray locally. On February 11, at 10 a. m.,
the clinic diagnosis of diphtheria was clear, the pseudo mem-
brane having spread from the pharynx over the posterior pillar
on to the tonsil, causing glandular enlargement and an inter-
mittent weak pulse. The clinic diagnosis was confirmed bac-
teriologically, and as soon as possible 600 antitoxin units were
given. On the following day the membrane was much less in
extent, and by the next day it had entirely disappeared, strych-
nin and digitalis seemed indicated, the latter and the iron
being given for six days, the strychnin being continued for two
weeks and a half. The case ran without fever at any time
until February 24, when the temperature rose to 102 degrees.
Measles was suspected, but the mother asserted that he had
had them four yeas ago, and from her description of the disease
as it affected her five children there seems to be no reason to
doubt that it was true measles and not roetheln. However,
three days later, W. B. was covered with a typical rash of
measles, the temperature curve showing the preeruptive remis-
sion and the eruptive rise. Convalescence was without inci-
dent, the diphtheria bacilli persisting until 5 per cent, nitrate
of silver solution had been used locally. The immunity which
one attack of measles usually furnishes toward a subsequent
one is, it is well known, sometimes overcome. That it would
occur more frequently is probable if the infection should be sc
concentrated and the exposure to it so long as in W. B.'s case.
It was not possible to isolate the brothers on the appearance
of the measles, and the two occupied the same bed.
2. C. B. who had an intercurrence of diphtheria, measles
and chicken-pox, was 4 years of age. He was first seen Feb-
ruary 7, having numerous varicellar blebs on face and hands.
The source of contagion was readily traced. On February 11,
having been exposed to diphtheria, as shown in the first case,
lie was carefully examined at 10 a. m. for signs of pseudo
membrane, none being visible in the nose or throat, although
the throat was reddened. At 1 :30 p. m., as he was about to
receive an immunizing injection of antitoxin, his skin felt
warmer than normal, and the thermometer showed a tempera-
ture of 101.6. The pulse was 140, the glands at the angle of
the jaw were swollen and the left nostril was occluded by the
swollen mucous membrane and a thin gray pseudo-membrane.
Six hundred antitoxin units were injected and cultures were
taken separately from the nose and fauces, the report from the
bureau of health being affirmative as to the presence of the
diphtheria bacilli in the pseudo-membrane, but negative as to
their presence in the throat. On February 12, his temperature
was 100, and the left nostril was apparently in a perfectly
healthy condition, all the swelling and the pseudo-membrane
having disappeared. The temperature stayed slightly above
normal for several days, the explanation for this not appearing
until February 14, when the child was covered with a profuse
measles rash. An irritating cough was a prominent symptom,
and a slight exudate was detected on the left tonsil, but a
culture from this failed to show the diphtheria bacilli. Con-
valescence was uninterrupted, being rather protracted, as the
diphtheria bacilli were obtained by cultures from the nose
(and ultimately from the fauces) for three weeks longer, in
spite of, or possibly because, local treatment by means of a
spray consisting of equal parts of peroxid of hydrogen, listerin
and water. The rest of the medication consisted in a few doses
of strychnin, tincture of the chlorid of iron, and of a cough
mixture composed of ipecac and citrate of potash.
It is also interesting to note the presence of the diphtheria
bacillus in the respiratory passage during the marked catarrhal
lesions of measles, and yet with no formation of membrane.
Whether this can be ascribed to the antitoxin injections or not,
can not be established, but under former modes of treatment
a relapse of diphtheria might, with reason, have been expected.
The "Livery" Phase of Gout ; The Case of Sir Walter Scott.— Dr.
George Harley writes upon gout for the London Lancet of July
4. referring in an interesting way to the tortures that were
undergone, through the malady, by that friend of our boy-
hood's reading hours, Sir Walter Scott. He says, "Murray
Forbes said that gout, diabetes, renal calculi, gallstones and
jaundice may all occur in the same patient. In order that the
reader may not suspect me of manufacturing a case to confirm
the statement, I shall furnish him with one whose authority
is beyond dispute, seeing that it is none other than that of the
renowned Scottish novelist, Sir Walter Scott, extracted from
his own diary, and thereby rendered all the more valuable from
the fact that the account he gives of his clinic history is alike
unbiased by medical dogma and personal theory, for he was a
lawyer and not a medical practitioner. Sir Walter tells how
he had to diminish the use of alcohol 'for fear of a weakness in
the direction of diabetes, a disease which broke up my father's
health.' He also says he 'was seized with a most violent pain
in the right kidney, which Dr. Clarkson diagnosed as renal
gravel augumented by bile.' In Lockhart's life of Scott it
says he occasionally suffered agonizing pain from the passing
of gallstones accompanied with jaundice. Sir Walter himself
1012
PRACTICAL NOTES.
[November 7,
describes more than one of 'these excruciating attacks.' More-
over in various parts of his journal Scott refers to the violent
attacks of gout he had at different times in his feet, knees,
gums and back, comparing the pain to a 'scorpion's bite,' and
its intensity as being sufficient to make him 'howl.' As is the
case with most 'livery' subjects Sir Walter Scott was subject
to fits of great mental depression. Alluding to one of these in
1826 he says it was accompanied. by 'a fluttering of the heart'
and a feeling as if he 'knew not what was going to befall' him.
Like many other gouty and 'livery' people Sir Walter Scott
ultimately died from apoplexy, so that his is a most instructive
case of hereditary liver derangement, associated with gout,
diabetes, renal calculi, and gallstones, and ending in apoplexy.
When all the foregoing hepatic pathologic data are considered
it is evident that gout in different people must require entirely
different forms of treatment. And in order to treat a case
philosophically each individual constitutional peculiarity must
be prescribed for quite as carefully as the special condition
denominated gout, for while one patient may be benefited by
colchicum it may on another act as a poison. Carbonated
alkali does good to one, and iodid of potassium acts like magic
on another ; whereas, as Scudamore discovered, many require
their livers to be set to rights before any gout remedy what-
ever is of the slightest use. This is one of the reasons why
several of the vegetable purgatives, in combination with quinin
and digitalis, have been vaunted by some of our continental
confreres, and mineral waters by others as podagra specifics.
But the curative effects of both the one and the other of them
spring mainly, I believe, from their hepatic action. Piperazin,
salicylate of soda, diuretin, and guaiacum are all useful in
certain cases. Exactly in the same way different gouty con-
stitutions tolerate different wines. It may, however, be laid
down as a general rule that the less acid and the less alcoholic
a wine is the less likely is it to disagree with a gouty patient.
Hence it is that the sour forms of champagne at present sold
in England should in all cases be shunned, no matter what one
is told by the uninitiated to the contrary. Champagnes such
as the French themselves drink are the safest, for that sugar
gives gout is alike contrary to scientific observation and every-
day practical experience. Again while hot applications with
anodyne liniments and hot alkalin fomentations are of marked
benefit to some, I know from personal experience that ice
applied to the painful part until the skin over it is frozen will
occasionally give immediate relief. Massage again, either
moist or dry, when it can be tolerated often greatly expedites
the cure. Gout is such a protean form of disease that no
special line of treatment can be formulated for it as a whole,
each constitution and each individual paroxysm requires to be
treated according to its own special conditions."
PRACTICAL NOTES.
Treatment of Children's Burns.— For superficial burns, lotions
of warm or hot boiled water, followed by the application of a
tarletan compress folded five or six times and dipped in a
solution of boric acid, 10 grams ; antipyrin, 6 grams ; sterilized
water, 250 grams. Bandage with the following salve : Boric
acid, 3 grams; antipyrin, 1 to 2 grams; vaselin, 30 grams.
Preserve the epidermis as much as possible and merely prick
the blisters at the lowest point. If the burn is on the hand or
arm, it must first be plunged into a basin of warm boiled water,
reducing the temperature gradually, and washed with soapy
water, then with a 2 per cent, phenic water, and the blisters
pricked without removing the skin. If there is pain, moisten
with a tarletan compress wet with a solution of saturated boric
water, 500 grams ; laud. Sydenham, 4 to 10 grams. After this
Reclus' salve can be applied : Iodoform, 1 gram ; antipyrin, 5
grams ; boric acid, 5 grams ; vaselin, 50 grams. If the burn
extends over a large surface of the body, the garments must
be removed with the greatest care not to tear off any of the
epidermis, which must always be carefully preserved. Then
place the child in a large warm bath, and perform the anti-
septic toilet of the parts involved, with chloroform anesthesia
if necessary, and dress the same as a hand or arm. For deep
burns, after the antiseptic toilet of the parts involved, apply a
dry bandage of iodoform gauze with plenty of cotton. If the
burn is on a member it can be dressed with the following dry
powder to attenuate the suppuration : Iodoform, 2 grams ;
charcoal and quinin, each 50 grams. Wait, if necessary to
amputate, until after the shock period has passed. — Perier in
the Journal de Mid. de Paris, September 6.
Placenta Previa. — A writer in the Medical Sentinel, October,
remarks that Dr. Senn in his address at Atlanta came in closer
touch with the great mass of laborers in our profession, than
any other writer has in anything presented to us during the
present year. He proceeds to describe a couple of cases of
placenta previa, emphasizing : 1. The beneficial effect derived
from ergot, and its application to these cases, producing such
strong contractions, the tonicity of which was permanent for
hours. 2. While it is fatiguing, still the hand makes an excel-
lent tampon for applying pressure, and at the same time
can be utilized as a dilating agent of the os, when time is such
a valuable factor. Again the dilation consequent upon its use
prepares the vulva and perineum for the passage of the head
when we resort to the use of forceps.
Artificial Serum for Washing out the Serous Cavities. Mengus
(Independence midicule, July 22), relates two cases. The first
a hydrocele of the tunica vaginalis testis that had relapsed
after the employment of an injection of tincture of iodin. It
was cured by injecting a boiled and filtered 0.70 per cent, solu-
tion of sodium chlorid at the temperature of 104 degrees P.
The second case was one of ascites in a patient with heart dis-
ease. Paracentesis had had to be performed six times in the
course of five months, and the man was becoming cachectic.
The seventh puncture was followed by the injection of about a
quart of the same solution at the same temperature. After
massage, about three quarters of the amount was withdrawn.
The patient regained his general health, and at the time of
the report, three months afterward, no further effusion had
taken place. — N. Y. Medical Journal.
Cocainlzatloo.— Reclus has a record of 3,500 successful cocain
izations, and always administers it to the patient in a reclining
position, retained until after he has eaten something. He also
uses a hundredth solution in all cases, and never allows it to
be injected into a vein, nor in larger quantities than 12 to 15-
centigrams. He states that cocain allows important and deli-
cate operations to be performed almost without assistance,
and without the loss of time, the annoyance and the dangers
of chloroform. He considers its use indicated in the removal
of subcutaneous tumors, in incising an abscess, in ingrown
nails, amputations and disarticulations of the phalanges and
metatarsus, in herniotomy, in the radical cure of hernia and
hydrocele, in anal dilatation, circumcision and castration, in
opening abscesses and hydatic cysts of the liver and in making
an artificial anus. The long duration of the anesthesia is a
point in its favor ; the skin can be sutured without pain even*
after an operation that has lasted twenty to twenty-five
minutes. If the above simple rules are followed, there need
be no fear of syncope, which is the fault of the administrator
and not of the cocain. The reclining position is imperative. —
He rue Int. de Mid. et de Chir., September 10.
Chronic Pericarditis Simulating Cirrhosis of the Liver. — Pick
reports three cases in which the clinic picture was that of
cirrhosis of the liver, but in which the autopsy showed, in
spite of the fact that there were no symptoms of heart disease,
I that a chronic adhesive pericarditis was the primary affection
1896.]
PRACTICAL NOTES.
1018
to which the condition of the liver was secondary. He sums
up his paper as follows : There is a complex of symptoms
which simulates mixed forms of cirrhosis of the liver, with
hepatic enlargement and great ascites, but without icterus,
which is due to an increased growth of the connective tissueof
the liver from the disturbance of circulation produced by a
latent pericarditis. This may lead, through stasis in the portal
circulation, to the most enormous ascites. This is more com-
mon in early life, but nevertheless is also observed in later
] ears. In the differential diagnosis stress must be laid on the
lack of any etiologic factor for cirrhosis of the liver, a history
of the previous pericarditis and edema of the feet, and a thor-
ough examination of the hearts-Boston Medical Journal,
October 8, from Ztxchr. f. Klin. Med., Nos. 5 and 6.
Congenital Luxation of the Hip Joint. —Lorenz claims to avoid
the disadvantages of the methods of Mikulicz, Paci and
Nchede, by what he calls his functional method. He proceeds
first by reduction, then reposition, formation of the acetabu-
lum and restitution. Reduction is accomplished by extension,
with the use of the screw in narcosis ; reposition by flexing,
opening the acetabular cavity, and maximal abduction. The
amount of outward rotation varies in different cases, and the
smallest amount of abduction that will accomplish the reposi-
tion and maintain it, is the limit. Then follows three months'
fixation of this position with an immovable bandage. The soft
parts that formerly prevented, now press the head of the femur
into place in the acetabular region, thereby modeling it in a
measure. In the severest cases the limb can not be walked on
for two or three months, as the amount of original abduction
does not allow the use of a raised sole at first. This can be
resorted to later as abduction grows less, and it is made lower
by degrees from four to two centimeters, etc. The treatment
lasts from six months to a year. It is adapted for children up
to 6 years. Surgical intervention is necessary, of course, in
cases of irreducible luxation. Double-sided luxations are
treated together at the same time. Lorenz has treated thirty
cases successfully in this way. Four double luxations pro-
duced unsatisfactory results. The advantages of this treat-
ment over the surgical are that the number of passive move-
ments is less, the treatment requires less time, and the leg is
not shortened so much. Lorenz also emphasizes the importance
of ambulatory after-treatment. — Wien. Klin. Rundschau.
September 20.
Causes of Death after Laparotomy. Fritsch of Bonn suggested
at the recent congress of German Naturalists and Physicians,
that whichever method a surgeon has made his own, and can
perform with ease and rapidity, that is the best for him ; but
it does not follow that it would be the best for others. He
considers that the results of the various methods in vogue are
due not so much to the special method nor to antisepsis, as to
the skill, rapidity and subsequent care of the operators. The
normal blood destroys or eliminates the cocci, but if the heart
is weak, the circulation sluggish, it is unable to effect this,
and the cocci are not destroyed, but thrive and locate wher-
ever they find a lowered vitality, as in the peritoneum after an
operation. Persons do not die after a laparotomy because they
become septic ; they become septic because they are dying or
while they are dying. He advises, therefore, that in cases of
weak or debilitated heart, in thrombosis after pneumonia or
influenza, it is best not to operate at all, but to wait. Debili-
tating measures, too cool baths, hunger, strong purgatives are
to be avoided before the operation. The technique must be
good ; the after-treatment very careful. Lavage of the stom-
ach, warm enemas, tonics, quinin, etc., combat the weakness.
A long and tedious operation lowers the vitality, especially
when the abdomen is opened, and hence perfected and rapid
technique, whatever the method, increases the chances of suc-
cess. He concludes by warning operators not to trust too
much to antisepsis, but to improve their skill and help to
establish the indications for the various typical operations,
instead of trying to invent new ones.
Malacln in Rheumatism. Malacin is a phenacetin with salicylic
aldehyde in the place of the acetic acid. It has been tried in
Russia as a substitute for salicylate of soda in a few cases of
acute and chronic rheumatism, and its success warrants
further investigation. The cure followed in four to six days ;
the pains rapidly disappeared and there were no stomach dis-
turbances nor depression. It was administered in 1 gram
powders three to five times a day ; a total of 17 to 26 grams.
It has also proved beneficial in neuralgia.— Journal de M. de
Paris, October 4.
Qoltre from Administration of Thyroid Extract A recent paper
by Dr. Robert Hessler, of the Northern Indiana Hospital for
Insane, gives an account of what corresponds to an attack of
exophthalmic goitre, brought on by large doses of desiccated
thyroid gland. The case was that of a cataleptic who had lain
immovable in bed for over three years ; there was an absence
of motor and sensory activities ; the feeding was by means of
the nose-tube. Under increasing doses of gland constantly
increasing activities resulted, until finally the patient "returned
to life" and was able to speak and walk. At a time when 75
grains were given daily, symptoms of exophthalmic goitre
appeared and the remedy had to be discontinued temporarily ;
the pulse going up to 160. In the course of a few days the
patient relapsed to his usual condition but "revived" on again
receiving the remedy, with a return of the symptoms men-
tioned. The case was reported in the Indiana Medical Jour-
nal. A similar case recovered promptly in a few weeks on
small doses. The thus artificially produced exophthalmic
goitre had all the characteristics of the natural disease, minus
the glandular enlargement, and all symptoms disappeared on
withholding the remedy or under a small dosage. From a
study of this case, and several others receiving similar treat-
ment, the author concludes that Graves' disease is due to an
over-stimulation of the nervous system by products of the thy-
roid gland, and that the administration of this gland as a
remedy is injurious ; the proper treatment is one tending to
reduce the functional activity of the thyroid gland.
Treatment of Pneumonia with Inhalations of Amyl Nitrite Hayem
has used this treatment in seventy-five cases of pneumonia,
and recommends it in high terms as successful in diminishing
the dyspnea, rendering expectoration easier and improving the
physical phenomena in general. One inhalation a day was
usually sufficient, but occasionally one was given morning and
night. Fifteen drops were inhaled on a compress at a time,
repeated if necessary until 100 drops had been used, although
the desired results were usually secured with less. The treat-
ment was continued through the whole course of the disease,
and for a couple of days afterward. He ascribes its efficacy
to its influence on the circulation of the blood in the lungs.—
Memorabilien, October.
Treatment of Post-Scarlatina Nephritis.— Schmey recommends
his method of treating this dangerous complication as he has
practiced it for ten years with unfailing success. It is espe-
cially effective in cases with a tendency to dropsical swellings.
The child is wrapped in a wet sheet from head to feet, with a
woolen blanket outside. He is then given every hour a tea-
spoon of syrup jaborandi until he is in a profound perspiration,
and not until then is he released from his wrappings. This
process is repeated every day until all the swelling has sub
sided, which is usually in the course of two or three days. He
prepares the syrup by the following formula : 0.3 folia jabor-
andi concis., heated in a vapor bath for ten minutes, in 20
grams water. It is then strained and 10 grams sugar added.
He administers subcutaneous injections of pilocarpin instead
1014
PRACTICAL NOTES.
[November 7,
of the syrup to children over 15, and has the pack preceded by
a hot bath. — Memorabilien, October.
Tertiary Syphilis in a Child of Five Feulard describes a case
brought to him for a sore in the nostrils, which examination
disclosed to be a pronounced case of tertiary syphilis, with
destruction of the nasal septum, the palate and the posterior
part of the pharynx, the teeth bhaped like the teeth of a saw
with other unmistakable lesions. The father accompanying
the child was a strong healthy man, who had two healthy
grown daughters, all free from any syphilitic taint. The
mother had died a year after the birth of this child, and the
father had before this, grave reasons for doubting his pater-
nity, although the child might have been infected while it was
at nurse in the country. The case is remarkable for the rapid-
ity with which the disease had developed unrecognized to the
tertiary stage, and the fact that it had progressed without
attracting attention or causing much annoyance to the child. —
Annates de Derm, et de Syph. , September.
Hospital Contagion of Syphilis. Fournier records the second
case in his hospital experience of a patient being treated for
eczema and being discharged cured, returning soon after with
syphilis contracted in the hospital. He is inclined to ascribe
the contagion to the patient having perhaps exchanged caps
with some syphilitic, as such extreme precautions are taken at
the Saint Louis to prevent infection. Leredde suggests that
syphilitics with lesions in the mouth ought not to be allowed
to expectorate promiscuously any more than tuberculous
patients. — Ann. de la Soc. de Derm, et de Syph., September.
Tuberculosis of the Spinal Cord.— Schlesinger describes a case of-
pronounced motor and sensory disturbances in a man of 42,
commencing with sudden vertigo and vomiting of fluid through
the nose, violent pain the right half of the face, and terminat-
ing fatally with complete ataxia, etc. The necropsy revealed
an isolated tubercle in the spinal cord, its maximum of devel-
opment corresponding to the third cervical. Transverse sec-
tion showed that it filled almost the entire space of the spinal
cord, only a thin layer of white matter partially surrounding
it. The gray matter had entirely disappeared. The tubercle
diminished in size as it approached the first cervical, where
the lesion was confined to the gray matter. A few scattered
follicles were found at the decussating point of the pyramids.
The medulla was unusually large. — Presse M6d., October 3.
Non-Surgical Treatment of Peri-uterine Phlegmon or Pelvic Cellu-
litis.— Lutaud treats non suppurating uterine phlegmon of the
broad ligament behind or in front of the uterus by absolute
repose at first, with narcotics, rectal opiates, etc., to arrest the
pain which is always severe in acute cases, and is the best guide
to the location of the tumor. He then controls the vomiting,
fever and hyperthermia. He prescribes for this purpose : Anti-
pyrin 2 grams, syrup of papaver somnif. 30 grams, spirit of
menthol 10 grams, tilia- water 60 grams. A tablespoonf ul every
hour. He sometimes applies leeches to the hypogastric region
over the tumor when the phlegmasia extends to the abdominal
wall, with mercurial salve and cataplasms. He also inserts
medicated glycerin suppositories into the vagina, or tampons
dipped in : Glycerin 30 grams, cocain hydrochlorate 1 gram.
He keeps the vagina aseptic by warm irrigations three or four
times a day, of the solution : Naphthol and chloral, each 10
grams, thymic acid 1 gram, alcohol 240 grams. Two table-
spoons of this to the liter. Any other antiseptic can be used,
except sublimate, which is too irritating for prolonged use.
After the pain is under control, the tumor can be investigated,
and even if there is suppuration, surgical intervention is not
always necessary, as numerous examples are known of the
tumor discharging spontaneously into the rectum, the bladder
or vagina, followed by complete cure. The spontaneous dis-
charge may of course produce fistulas or multiple pelvic ab-
scesses, which render laparotomy or hysterectomy inevitable.
But if, as often happens, there is no suppuration, the tumor
hardens and is not painful, but dangerous on account of the
adherences produced. The treatment in these cases is princi-
pally by massage to destroy the adherences and restore mova-
bility to the uterus, while assisting the complete resolution of
the neoplasm. He sometimes also uses blisters or conical cau-
teries, tincture of iodin or croton oil, with always oversight of
the general health and especially of the functions of the blad-
der. He usually administers the following in cases of indura-
tions and adenopathies : Sodium iodid 20 grams, syrup of bit-
ter orange 500 grams. One or two tablespoons a day. He
emphasizes the value of massage as one of the most effective
therapeutic means of treating chronic affections of the uterus
and the adnexa. By introducing two fingers into the vagina to
the cervix or the seat of the tumor, and pressing with the other
hand on the abdomen, the indurated mass or the adherent
uterus can be seized between the two hands and by gentle and
gradual manipulation reduced and rendered movable.— Jour-
nal de M. de Paris, October 4.
Dermatitis Roentgen!.— Dr. Conard, in Codex Medicus, August,
reports a case of skin affection that was, in his opinion,
indirectly referable to the X ray. "R. B., photographer, con-
sulted me August 24 on account of what he considered rheu-
matism in the first and second fingers of his left hand. He
complained of pain and swelling and stiffness of the joints. He
had first noticed some discomfort in them about five or six
days previously and had used some home remedies, but the
pain and swelling increased. Upon examination, I found the
first and second fingers swollen and extremely sensitive to the
least touch and of a peculiar, livid brown color on their dorsal
surfaces from the tips down to and including the carpo- meta-
carpal joints, involving the tissues toward the thumb and then
fading away. The palmar surface was normal. The line of
demarkation was very conspicuous and decided by objective
and subjective tests. There was entire absence of constitu-
tional symptoms. The pain was described as of a burning or
scalding character, as if burned with a hot iron ; upon further
questioning him I learned that in connection with his regular
photographic work he had photographed with Roentgen rays,
and had given public exhibitions of the same, in doing which
the very part of his hand affected as described was for a con-
siderable time and on numerous occasions exposed to the rays,
at a distance of two or three inches from the Crookes' tube.
During the time he was exhibiting X rays he would occasion-
ally have his fingers in chemic solutions, especially potassium
cyanid, but he was always careful to wash them thoroughly:
yet the index finger, which was the most in the solutions, was
the most affected and was first attacked around the nail, the
process extending up that finger and down the other. Evidently
some of the chemicals had been absorbed by the skin and the
X rays had driven them into the tissues, thus helping to set up
this peculiar form of dermatitis. Another peculiar result of
his work was the changing of the color of his mustache from
black to a dull brown and its falling out in places, leaving the
lip perfectly smooth. Treating the condition on general prin-
ciples, for the induration, pain and stiffness, I ordered ichthyol
and lanolin (1 to 7), to be applied on soft linen or lint. In two
days both fingers down to the second joint were blistered.
This was apparently caused by the ichthyol, although the con-
tinued application of it to the other part of the fingers failed
to produce blisters there. Relief from pain and burning was
complete after the blisters formed. Following and up to the
present time, two weeks after the trouble was manifest, the
skin was a dark brown or livid color, much thickened, hard
and stiff, with the sense of touch or feeling greatly diminished.
All inflammatory symptoms, pain and swelling having sub-
sided, the applications were discontinued. The indications
now are that the cuticle will disquamate, and the skin grad-
ually assume it* normal condition and appearance."
I
1896.]
EDITORIAL.
1015
THK
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SATURDAY, NOVEMBER 7, 1896.
THK AMERICAN PUBLIC HEALTH ASSOCIATION
AND AMERICAN BACTERIOLOGISTS.
The sanitarians and publio health men on this side
of the Atlantic have recently given a decided impetus
to bacteriologic work. At the meeting of the American
Public Health Association in Montreal, Canada, two
years ago, a proposition from its committee on the
pollution of water supplies for a cooperative investi-
gation into the bacteriology of water was approved
by the Association, and Major Charles Smart, U. S.
Army, was appointed chairman of a committee to
carry the suggestion into practice. It was the inten-
tion that the committee when fully .formed should
consist of all those bacteriologists who were willing
to cooperate in the investigation. Letters came
promptly from the notable laboratories of the country
manifesting interest in the proposition and expressing
a desire to participate in the undertaking. Some men
of large experience and more than national reputation,
whose administrative duties prevented them from par-
ticipating in laboratory work, heartily agreed to act
as an advisory council to the committee in developing
its work. This council consisted of Surgeon-General
Sternberg of the Army, Professor Welch of Johns
Hopkins University, Vaughan of Michigan, Prudden
of New York, and Smith of the Agricultural Depart-
ment. An effort was made to settle by correspondence
the important subject of the laboratory methods to
be adopted in the investigation, but this developed
so much variance in the practice of different labora-
tories that it became needful to call a convention for
a thorough discussion of the points at issue. The
convention met, but although the members were
informed beforehand of the subjects that were to be
brought up for settlement, many of these presented
so much difficulty that the whole subject was referred
to a committee consisting of Adami of McGill Uni-
versity, Welch of Johns Hopkins, Abbott of the
University of Pennsylvania, Sedgwick of the Massa-
chusetts Institute of Technology, Smith of the
Agricultural Department, Cheesman of New York,
FuUJBBof the Louisville Water Company, and Smart
of the Army. This committee met in New York in
February last to digest its materials and outline its
work. Its report was presented at the meeting of the
Public Health Association in Buffalo in September
last. It insists upon the importance of uniformity of
methods if species are to be grouped correctly. It
recommends for future work certain definite tests to be
adopted in every case, failing which a description shall
be held to be incomplete. It divides the tests applicable
for descriptive work into two categories, the necessary
and the optional; but these terms are used with some
little hesitation, for many of the tests included among
the optional are of value for purposes of species dif-
ferentiation in special cases and might with propriety
be included in the first category. The necessary tests
are described under the headings: 1, source and hab-
itat; 2, morphology; 3, biology, the last including
cultural, biochemic and pathogenic characters. The
optional are aggregated under two heads, morphologic
and physiologic. The report is not a manual of labor-
atory methods. It dwells only on those points on
which it is felt that there is need for greater uniformity
in procedure or a more precise and correct technique.
When presented at Buffalo it was incomplete, in so
far as it had to be submitted to certain of the mem-
bers of the committee for final revision. It will no
doubt appear in an early issue of the Journal of the
American Public Health Association. Whether the
Water Committee of the Association will be able to
carry out its original proposition of a cooperative
investigation into the bacteriology of water is doubt-
ful; but if nothing more is done the Association may
rest satisfied with its work, in that it has led the
bacteriologists to better methods for the identifica-
tion and differentiation of species.
THE CONTAGIOUSNESS OF TUBERCULOSIS.
The inhumanity of certain tendencies of modern
sanitation has been already noticed in the Journal,
in connection with a striking instance of attempted
legislation against tuberculosis in New Zealand, which
it is believed is still pending. One does not, however,
have to look as far as to the antipodes to find some
evidences of a cowardly zeal for self-protection
against disease without regard to the rights or feel-
1016
DEGENERACY THEORIES.
[November
ings of the unfortunates. It is natural enough for
the laity to dread the introduction amongst tbem of
contagious diseases, and precautions are certainly
justifiable, but it is another thing for physicians to
encourage or even tolerate an increasing fear of dis-
orders the contagion of which is manageable or avoid-
able by simple and readily available hygienic precau-
tions. When the disorder is one like tuberculosis,
that may exist anywhere in a latent form, and to
which in times past, and even yet, some exposure has
been and is almost inevitable, any excessive and sel-
fish fear is altogether unreasonable.
In a paper read before the American Climatolog-
ical Association at its late meeting Dr. Vincent Y.
Bowditch of Boston made an earnest plea for moder-
ation in our statements regarding the contagiousness
of pulmonary consumption, which was especially
inspired by reckless and extravagant utterances by
medical men as well as laymen in a recent discus-
sion in the daily press. It was stated by a physician,
possibly by more than one, that consumption "is as
contagious as smallpox," and that "hospitals for con-
sumptives are a source of danger to the whole surround-
ing community." Dr. Bowditch shows that in well reg-
ulated hospitals or sanitaria for consumptives conta-
gion is almost unknown, or, at least, that with ordinary
cleanliness and care as to the destruction of the sputa,
the danger is reduced to a minimum. While the
vitality of the bacillus tuberculosis is very great under
favoring circumstances, the experiments of Ransome
and Delepine have shown that, when dried, an expo-
sure of only a few hours to direct sunlight is fatal to
it, a fact that goes far to account for the advantages
of climates like that of Colorado and New Mexico in
the treatment of this disease. They also find that
even a 1 to 10 per cent, solution of chlorinated lime
is an efficient disinfectant of clothing and apartments
that have been soiled by the sputa, which alone are
the sources of the infection. These results have not
so far been contradicted, and accepting them as true,
some ardent sanitarians will have, in common pru-
dence, to moderate their statements, if not their con-
victions, on this subject.
The fact is that physicians, like other men, are
fallible and subject to go to extremes over any new
and striking discoveries in pathology and therapeu-
tics. While there are many who are unduly conser-
vative or backward in taking up and utilizing new
facts, there are others who in their enthusiasm go
altogether too far, and it is a question sometimes
which of these two classes does the most harm. When
this human weakness of intemperance in conduct of
statement affects matters of sanitary methods and
precautions it is likely to add very effectually to the
sum of human misery, a result in the production of
which certainly no medical man should be desirous of
having any part. This question of the sanitary ,
defense against tuberculosis appears, at the present
time, the one most open to objectionable possibilities
of this nature, and Dr. Bowditch's paper seems,
therefore, a very timely communication.
DEGENERACY THEORIES OP THE SEVENTEENTH
CENTURY.
Physicians who are accustomed to trace the devel-
opment of the degeneracy hypothesis to Noedau or
Lombroso will doubtless be astonished to learn that
its essential principles were recognized by the Bohe-
mians who formed the literary class of the time of
Shakespeare. Thistleton Dyer ("Folklore of
Shakespeare") with a quaint unconsciousness of
the coeval teachings of Morel remarks that " it was
an old prejudice, which is not quite extinct, that
those who are defective or deformed are marked by
nature as prone to mischief." Thus in "King Richard
III." Margaret says of Richard, Duke of Gloucester:
Thou elfish-mark'd, abortive, rooting hog,
Thou that was sealed in thy nativity,
The slave of nature and the son of hell.
She called him hog in allusion to his cognizance,
which was a boar. A popular expression in Shakes-
peare's day for a deformed person was a stigmatic. It-
denoted anyone who had been stigmatized or burnt
with iron as an ignominious punishment; and hence
was employed to represent a person on whom nature
had set a mark of deformity. Thus in " 3 Henry VI."
Queen Margaret says:
But thou are neither like thy sire nor dam,
But like a foul misshapen stigmatic
Mark'd by the destinies to be avoided,
As venom toads, or lizards' dreadful stings.
Again in " 2 Henry VI." young Clifford says to
Richard: "Foul stigmatic, that's more than thou
canst tell." In "A Midsummer Night's Dream"
mothers' marks and congenital forms are deprecated
by Oberon from the issue of happy lovers:
And the blots of Nature's hand
Shall not in their issue stand ;
Never mole, hare-lip, nor scar,
Nor mark prodigious, such as are
Despised in nativity,
Shall upon their children be.
Constant allusions are met with in old English
writers relating to this subject showing how strong
were the feelings of our forefathers on the point.
One further instance given by Shakespeare is
afforded by the words of King John (iv, 2) with
reference to Hubert and his supposed murder of
Prince Arthur:
A fellow by the hand of Nature mark'd,
Quoted and sign'd to do a deed of shame,
This murder had not come into my mind.
The significance of stigmata as evidence of defect
was recognized even by lawyers of the 17th century.
Bacon (who as Harvey says: "Wrote on science like
a Lord Chancellor") dogmatically accepts the coexist-
ence of moral and physical defect, but in place of
1896.]
MEDICAL DEPARTMENTS OF THE ARMY AND NAVY.
1017
tracing both to the same cause, hereditary taint,
remarks that: " Deformed persons are commonly even
with nature, for as nature hath done ill by them, so
do they by nature, being void of natural affection,
and so they have their revenge on nature." The
notion of degeneracy as affecting physical structures
was as old as Empedocles. One quaint use of it was
made by Sylvius (of Fissure of Sylvius fame) in a
oritioism of Vesalius ( "From the Greeks to Darwin").
Vksai.u s ( 1614-1564) had brought the charge against
(i a i. en (A.D. 131-200) that his work could not have
been founded upon the human body, because he had
described an intermaxillary bone. This bone, Vesalius
observed, is found in the lower animals but not in
S\ i.vns (1614 1672) defended Galen warmly
man.
and argued thai the fact that man had no intermaxillary
hone at present was no proof that he did not have it
in Galen's time. " It is luxury,*' he said, " it is sen-
suality whieli has gradually deprived us of this bone."
This passage proves that the idea of degeneration
of structure through disuse as well as the idea
of the inheritance of the effects of habit, or the
transmission of acquired characters, is a very ancient
one. The erroneous conception, that loss of struc-
ture was evidence not of advance, but of degeneracy,
still mars many of the current researches on degen-
eracy and has led both Lombroso and Nor'dau into
many blunders.
THE MEDICAL DEPARTMENTS OF THE ARMY AND
NAVY.
The Federal Government employs medical men in
connection with three of its departments — the War,
the Navy and the Treasury. The officers of each are
appointed by the President, confirmed by the Senate
and hold life positions during good behavior. Pay
and status increase with length of service, as promo-
tion is determined by seniority except in the case of
the chief of each service, who is selected for office by
the President. The scale of pay and the grades of
seniority are arranged on the same general plan so
that at first sight one might expect competition for
appointment to be equally active in all three of the
services. An Army Medical Examining Board has
just closed a four weeks' session in Washington, D. O,
after filling the vacancies in the corps by selecting
eight men out of forty-five candidates, who presented
themselves for examination out of forty-nine invited
to appear. During the past fiscal year three vacan-
cies in the Treasury Department were filled by a
competitive examination for which there were sixty-
one applicants, thirty-six of whom underwent the
ordeal of examination. In the Navy 341 medical
graduates made application for appointment, but only
thirty-six of these requested permission to appear
before the examining board and only twenty-two
availed themselves of the permission. Six vacancies
were filled from this number leaving ten unfilled at
the end of the year. This has been the experience
of the Navy for several years past and the Bureau
has been so embarrassed by not having a sufficient
number of medical officers to fill important positions
afloat and ashore that Surgeon General Tryon has
recommended the appointment of acting assistant
surgeons for temporary duty until the vacancies in the
corps have been filled in the regular way. These
results show that the services of the Federal Govern-
ment do not offer equal inducements to young medical
men although they are organized apparently on the
same general plan.
The passed candidate of the Army Medical Board
is commissioned an assistant surgeon with the rank
and pay of a first lieutenant of cavalry, $1,600 a year.
At the end of five years service he becomes the equal
of a captain of cavalry, and then by seniority the
higher grades are reached, there being ten lieutenant-
colonels, six colonels and one brigadier general to
fifty surgeons with the rank of major and 110 assist-
ant surgeons with the rank of lieutenant or captain
according as they have served less or more than five
years. The proportion of officers of the higher grades
is not so large as in some of the other staff corps of
the Army, nor indeed as in the Navy Medical Depart-
ment, but our Army brethern appear satisfied with
present conditions as all those who now occupy these
higher grades entered the corps at a time when a
mayorship was the highest rank that could be reached
outside of the surgeon generalcy. Ten per cent, is
added to the pay proper of the Army officer for every
five years of service up to twenty years, so that should
there be a delay in his promotion to a higher grade,
its financial effects are considerably neutralized; but
compulsory retirement of the older officers at 64 years
of age makes progressive promotion for the younger
men. Quarters are provided for the medical officer
and forage for his horses as in the case of other
officers of like rank; and the conditions in time of
peace are such that his home life may be as unbroken
as that of a practitioner in civil life.
In the Navy the personnel consists of a surgeon
general or a chief of the bureau with the rank of com-
modore, the naval equivalent of a brigadier general,
fifteen medical directors with the rank of captain or
army colonel, fifteen medical inspectors with the rank
of commander or lieutenant colonel, fifty surgeons
and ninety assistant surgeons. The older officers
have no general ground of complaint. They have
a high rank, corresponding pay and as most of
them have already completed their sea service, their
home life is comparatively unbroken; and good
quarters are provided for them, when on duty at
naval hospitals or navy yards. They are absorbed
into the retired list at 62 years of age. But
the conditions are not so pleasant for the passed can-
1018
LEGISLATIVE PREVENTION OF SUICIDE.
[November 7,
didate of the Naval Medical Board. He is commis-
sioned an assistant surgeon with $1,700 a year, if at
sea, and $1,400, if on shore duty, but with the rela-
tive rank of an ensign, the naval equivalent of a sec-
ond lieutenant in the army, and during the three
years which he is required to hold this rank, he is
thrown into more intimate relations with the warrant
officers of his ship than with his superiors in the
medical department. When he becomes a passed
assistant surgeon, he ceases to draw the 10 per cent,
longevity increase of pay, although the correspond-
ing grade of the engineers of the Navy are allowed
this increase; and he does not receive the relative
rank of lieutenant (equivalent to captain in the army)
until all the line officers who antedated his entry into
service have reached this rank, nor, when he has been
promoted in his own corps to the grade of surgeon
does his relative rank become that of lieutenant-com-
mander, the equivalent of the army major, until the
line officers aforesaid have been promoted. Of the
fifty surgeons now on the Navy list only five have this,
their proper rank, while forty-five are held down and
have been held down for years waiting for the promo-
tion of officers of the line.
Evidently legislation is needful to remove the
obnoxious features of the Naval Medical Service or
the high standard of professional qualifications will
have to be lowered to permit the vacant positions to
be filled. A bill to reorganize the corps should be
supported in the next Congress by the whole strength
of the medical profession.
DANGERS OP COCAIN.
The recent death of a patient in a physician's oper-
ating room from the effects of cocain again calls atten-
tion to the dangers attending the use of this drug.
Regarding the case in question we have no criticisms
to offer, as the circumstances were such that a general
anesthetic would apparently have been more danger-
ous than cocain. While in this instance no blame
can be attached to the medical attendant for the
untoward result, it at the same time recalls the deadly
power of this drug. The number of fatal cases so
far reported is happily not many, but those of severe
poisoning are quite numerous. The employment of
cocain is largely on the increase, it being frequently
prescribed by druggists for the relief of toothache
and other forms of local pain. It is also used by
dentists, and oftentimes in a most reckless manner.
The poisonous properties of cocain seem to be
especially pronounced when used in the urethra, nose
and mouth. It is less so when employed in operations
on the trunk and extremities. This raises the ques-
tion as to whether the additional danger is due to the
facility of absorption from these parts or to the semi-
erect position in which most operations on the nose
and mouth are most frequently conducted. Solutions
of too great strength are often employed; some of
them being made extemporaneously by adding a few
grains of the drug to an unknown quantity of water.
The studies of Schleich have shown that when
efficiently used, very weak solutions may suffice for
lengthy anesthesia of extensive areas.
We feel at this time that a note of warning is
needed regarding the use of cocain. It should never
be prescribed or used by any but qualified medical
practitioners. When used by them it should be in
solutions of known strength, and if for operations,
preferably by the intra-cutaneous method of Schleich.
The patient at the beginning of an operation in which
cocain is used should be placed in a horizontal posi-
tion, which should be maintained until the effect of
the drug wears off.
LEGISLATIVE PREVENTION OP SUICIDE.
The uninterrupted increase of suicides in Great
Britain as officially verified for more than forty years,
so says the recent three years' report, is again attract-
ing attention. This, the jury verdict of insanity
is far from explaining, as in ninety-nine cases out of a
hundred the act of self-destruction is the only evidence
of unsound mind on the part of the deceased. But this
plea in most instances is a fiction of coroners' juries,
originally designed to subvert the almost savage treat-
ment of the corpse by the law itself. The disgrace of
a cross-road burial with the impaling stake has never
attained its object of a warning to the living, and the
penalty of imprisonment in case of failure has like-
wise succeed not a whit better. In the State of New
York there are already signs of a reaction in the shape
of modifications of the latter law, or for the matter of
that, an absolute repeal. The courts themselves
affirm that the inevitable second attempt is certain to
be effectual. Thus the concession to the feelings of
relatives and friends counts for naught.
The strain of an advance civilization with its pessi-
mism and the decrease of the religious sentiment only
in part furnish reason for the present tendency toward
the old Roman idea that this self-murder was an act
of courage rather than a mawkish bid for an often
undeserved sympathy. May we not say that psychol-
ogy rather than pathology can better solve the prob-
lem, since there is always present that indefinite
something known as a moral twist? It is not enough
for us to always beg the question by the dictum that
it is a disease; why not rather call it an impulse
taking instant form through fear of a certain repen-
tance? Often, too, the means for self-destruction at
hand suggest the act, just as much as other surround-
ings will divert into a contrary direction. ' We are all
aware of the ingenuity of suicides and their patience
in the study of expedients for glossing over their
crime against posterity under the name of acci-
dental death. Their act is born of egoism, which, by
1896.]
PUBLIC HEALTH.
1019
some is classed as a mental disease and the final doom
is at the very least the disgrace of their survivors,
which they often seek to mitigate by a homicide or
two. At all events no remedy is effectual after death.
THE QUADRENNIAL ELECTION.
Tlie election of Major Wm. McKinley to be the
President of the United States will set the money
machinery of the country in motion, and now that
capital need no longer fear to come out of its hiding
places we trust that prosperity may come to and abide
with every reader of the Journal. We trust that the
good work of organization may go on apace and that
the members may make renewed efforts to increase
the membership. Our Journal has prospered even
in the face of the great financial depression which has
affected all classes of business. With the business
revival sure to oome, let us all have confidence, and
show it by taking hold of the Association affairs
with renewed vigor.
CORRESPONDENCE.
(Jive Full Names of Authors.
Philadelphia, Oct. 30, 1896.
To the Editor: — Having been engaged lately in a literary
work involving considerable consultation of papers and veri-
fying of references I have realized, as any one must under the
circumstances, the extra labor necessitated by a practice which
has always been more or less general with authors, of mention-
ing only the surname of writers and investigators referred to.
Any one who has had experience can not fail to have been
struck with the large number of persons of the same surname
who are contributors to medical literature, so that a reference
to Dr. Sydenham's or Dr. Jones's views and Dr. Ranklin's
papers gives a very imperfect idea of the individuality of the
author. Take for example the name Hoffmann. The student
will find in the Surgeon-General's Catalogue this surname
more than one hundred times, and of these Hoffmanns quite a
number are authors of voluminous and important papers. So
that to be told that Hoffmann believes thus and so, is of little
assistance to the reader who desires to look up his views and
papers. Again, to take a name to which modern medical liter-
ature often refers— Laveran. At least two Laverans, both
French army surgeons, have written papers of importance.
The Laveran whose name is so identified with the malaria?
Plasmodium is A. Laveran,1 while Louis Laveran is a very dif-
ferent person. Yet writers only quote Laveran. It is needless
to multiply instances. They will occur to anyone. My object
in asking publicity to this letter is to beg writers to adopt the
practice of giving the full name of the authority quoted. This
of course involves a little trouble at first to hunt up the Chris-
tian name, but as years roll on and we are all thus explicit in
indicating the authorities quoted, it will become easier and
easier, while the amount of labor saved to those looking up
references will be immeasurable. Especially important is it
that the editors of the various handbooks and annuals which
are now filling such a useful niche in medical literature should
adopt the practice of using the full name, for it is from sug-
gestions in such books that writers often want to look up
references. Respectfully yours,
James Tyson, M.D.
l Unfortunately, even the Surgeon-General's Catalogue has not the
lull Christian name.
Serum-therapy.
Chicago, Oct. 31, 1896.
To the Editor: — In the last issue of the Journal I find a
short letter referring to and criticising Dr. H. Lahmann's arti-
cle on serum-therapy. As Dr. Lahmann will hardly become
acquainted with the contents of this letter, I think it my duty
to reply to it in his stead, because it was I who translated his
article for the Journal.
In consideration of the fact that every serum-treatment so
far employed has proven to be a failure, and considering also
that the efficiency of the antitoxin treatment of diphtheria is
still either doubted or denied by a great many competent phy-
sicians, it seems to be quite a bold undertaking by any advo-
cate of the serum-therapy to call a physician whose therapeutic
views differ from his, a quack.
In concluding his letter Dr. K. says: "We should be on
our guard, having enough of the sort in the country." 1 would
like to call his attention to the fact that there is another thing
in this country and in the world, which we ought to guard
against still more, and that is the abuse done with the drug
treatment. If we step behind the prescription counter of a
drug- store and look over the prescriptions, we will hav'e a most
elegant opportunity of studying a legitimate quackery which
has done and is doing more harm to the sick than any "old-
fashioned" treatment ever did or ever will do.
Very truly yours, Carl Strueh, M.D.
PUBLIC HEALTH.
Diphtheria in Illinois.— Six cases had occurred at Newman, up
to the 24th ult., with four deaths. In addition to the reports
from West Hammond and Newman, diphtheria has been
reported as existing within the week ending October 24 at the
following places in the State : Flora, Sidell, Clinton, Sparta,
Jacksonville, Springfield, Auburn, Virden, Chrisman, Gales-
burg, Orange Township (Knox Co.), and Melrose, near Astoria.
The reports do not indicate that the disease prevailed exten-
sively at any points, but an unusually large fatality is reported
in proportion to the number of cases.
Water-Supply at East London. The vestry of Hackney, Lon-
don, has been endeavoring to supplement the scant water-sup-
ply of its poorer dependent population by a house-to-house dis-
tribution of water amounting to 100,000 gallons weekly since
the first of August. It has also supplied a number of storage
jars, not less than 1,500 of them, to families having no other
means of storing water. A subcommittee of the vestry has
been in session every day, Sundays inclusive, all through the
vacation period.
Diphtheria in Indiana.- Diphtheria is reported as epidemic in
several counties in Indiana. The southern part of the State
has sent in the greater number of complaints. The story is
generally the same from all points. The first case is pronounced
tonsillitis by the attending physician, consequently no quaran-
tine is established, and so the disease becomes epidemic. In
more than one place the people discovered that physicians had
carried the disease, and demanded protection from the State
Board of Health. Although the State Board has miserable
financial support still it manages to furnish culture outfits for
diphtheria diagnosis and make microscopic examination with-
out charge. Recently at Columbus, a practitioner furnished a
householder a written certificate to the effect that, " no conta-
gious or infectious disease existed at house of — — ,"
despite the fact that cultures proved the reported tonsillitis to
be true diphtheria. To prevent the carrying of contagion by
doctors the State Board of Health has passed rules directing
specifically how they shall protect themselves when knowingly
visiting contagious and infectious diseases.
1020
NECROLOGY.
[November 7,
Payment of Kentucky State Board of Health Bills.— Although it
is provided by section 2053 of the Kentucky Statutes that the
necessary printing of the State board of health shall be done
in the same way and upon the same conditions, as other pub-
lic printing is done, the court of appeals of the State says that
it does not necessarily or properly follow that the cost thereof
was intended by the legislature to be paid to contractors for
State printing out of the general fund. On the contrary, it
thinks it plain that it should be paid out of the fund provided
by section 2054, which appropriates $2,500 per annum, or so
much thereof as may be deemed necessary by the State board
of health, to pay the salary of the secretary, meet contingent
expenses of the office of secretary, and the expenses of the
board, "which shall not exceed the sum hereby appropriated."
The court goes on to say, State Board of Health v. Stone,
Auditor, decided Sept. 24, 1896, that although the State board
of health is an institution invested with considerable responsi-
bility, and undertakes to perform duties deemed essential to
the general health and physical well-being of citizens of the
State, the position of its members is one rather of professional
distinction than pecuniary gain, and hence the only officer
connected with it entitled, under the statute, to compensation
for services rendered, is the secretary, whose salary, though
fixed by the board, can not exceed $1,200. The residue of the
appropriation, as above $1,300, must cover all the expenses
stated, including all legitimate cost of printing.
The Etiology of Hereditary Stigmata.— In the State Hospitals
Bulletin, July-September, Dr. Frederick Peterson of New York
city, contributes a very instructive article on the physical
stigmata of degeneracy. He closes his paper as follows :
A few words should be said concerning the etiology of the
stigmata of degeneration. When we come to investigate the
causes which lead to their formation we meet with much diffi-
culty. Usually we must look to modifications occurring dur-
ing fetal development, during the evolution of the child, modi-
fications brought about by arrest or errors of development, not
so much perhaps in the organs themselves (which show the
effects) as in the central nervous system, in the nervous
mechanism which governs heredity. As the evolution of our
bodies as well as our minds depends upon the brain and spinal
cord and the countless nerve filaments which radiate from
them to every tissue, so the nervous system plays the most
important part in the influences which have to do with heredity.
The nervous coordination must be rearranged by strong stimuli
in order to reproduce the hereditary impulse. This is why
traits acquired by us in our individual lifetime are not apt to
be inherited by our descendants. If a person loses an arm his
children are not deprived of that useful member, for the
nervous mechanism of development which has for ages pro-
duced arms in their proper places and which is fixed in the
powerful hereditary impulse of the race has not been changed.
So in the breed of dogs whose tails have been cut off for count-
less generations, not one is born without a tail, because the
nervous coordinations governing the evolution of the tail bear
down with all the hereditary force of the race since its first
beginning (when the tail existed though the animal was legless)
to keep it in existence. If in some way we could reach the
nervous mechanism which is responsible for the evolution of the
tail, we might modify or even prevent its development. It is
therefore some derangement of the nervous mechanism govern-
ing heredity which brings about deviations from the normal type,
which gives rise to anatomic, physiologic and psychic anomalies
which we designate as the stigmata of degeneration. How is
the nervous mechanism of heredity deranged? It may be readily
and profoundly deranged in a variety of ways, for instance by
poisons. Thus alcohol disarranges the nervous mechanism of
heredity in such a way that the descendants may suffer from
the drink-craving, from idiocy, insanity, epilepsy, hysteria,
neurasthenia, from shattered nervous systems, for at least three
generations, and in these unfortunates we find along with
marked functional stigmata of degeneration, these actual phy-
sical deviations from the normal type which we call anatomic
stigmata. But idiocy, insanity, epilepsy and the like are in
themselves conditions which disarrange the nervous coordina-
tions so profoundly as to effect the hereditary impulse and give
rise to anatomic and functional stigmata in the descendants.
What is bequeathed to the degenerate child is a fragile and
unstable nervous constitution. The evidence of this inherited
fragility of the nerve-mechanism may present itself as insanity,
or it may be epilepsy, or it may be feeblemindedness, or it may
be criminal tendencies, or it may be simple nervousness or hys-
teria or certain kinds of headache or possibly only eccentricity.
All of these disorders are more or less interchangeable and are
merely proofs of an unstable nervous organization. Where
such conditions do not develop they may exist in a latent state
and pass as a legacy to another generation. Whether the neu-
ropathic state be manifest or latent, we are apt to find anato-
mic stigmata of degeneration present on careful examination.
Health Report. — The following reports of mortality from
smallpox, cholera and yellow fever have been received in the
office of the Marine Hospital Bureau of the Treasury
Department :
SMALLPOX — FOREIGN.
Bombay, India, September 22 to 29, 2 deaths.
Gibraltar, October 4 to 11, 1 case.
Hiogo, Japan, September 19 to October 3, 170 cases, 63
deaths.
Licata, Italy, October 3 to 10, 3 deaths.
Madras, India, October 7 to 14, 70 deaths.
Manzanillo, Cuba, October 1 to 15, 2 deaths.
Moscow, Russia, September 26 to October 3, 1 case, 1 death ;
October 3 to 10, 1 case, 1 death.
Nogales, Mexico, October 17 to 24, 4 cases.
Odessa, Russia, October 3 to 10, 12 cases, 5 deaths.
Paris, France, September 26 to October 3, 1 case.
Rio Grande do Sul, August 22 to September 19, 74 cases,
7 deaths.
St. Petersburg, Russia, October 3 to 10, 5 cases, 4 deaths.
Tuxpan, Mexico, October 3 to 10, 2 deaths.
Warsaw, Russia, September 26 to October 3, 5 deaths.
Vera Cruz, Mexico, October 15 to 22, 1 death.
CHOLERA.
Bombay, India, September 22 to 29, 3 deaths.
Calcutta, India, September 12 to 19, 4 deaths.
Hiogo, Japan, September 19 to October 3, 9 cases, 1 death.
Hong Kong, China, September 12 to 19, 2 deaths.
Madras, India, September 19 to 26, 7 deaths.
Yokohama, Japan, September 26 to October 2, 1 case, 1 death.
Cairo, Egypt, September 15 to 21, 28 cases, 9 deaths.
Throughout Egypt to date, September 25, there were 21,565
cases and 17,990 cholera deaths.
YELLOW FEVER.
Matanzas, Cuba, October 7 to 21, 27 deaths.
Santiago, Cuba, October 17 to 24, 12 deaths.
Cardenas, Cuba, October 10 to 17, 4 deaths.
Quantanamo, Cuba, September 1 to 30, 6 deaths.
Cienfugos, Cuba, October 11 to 18, 17 cases, 4 deaths.
Havana, Cuba, September 15, to 22, 145 cases, 55 deaths.
Guadeloupe, W. I., October 1 to 4, 3 cases, 2 deaths.
NECROLOGY.
E. W. Wood, M.D., of Northboro, Mass., died suddenly
September 6, aged 56 years. He was born in Middleboro in
April, 1840. He taught school in his earlier life, beside study-
ing medicine. He enlisted for nine months in Co. C, 4th regi-
ment, Massachusetts volunteers, and was appointed assistant
surgeon under Gen. Banks.
Herman Hardrich, M.D., of Brooklyn died October 4, aged
42 years. He was of German parentage, born in New York
city. He graduated in medicine from the New York University
Medical Departent in 1876. His professional life was spent in
Brooklyn, but during the past fifteen years he had been
maimed or disabled by spinal and other complications. His
final illness was ascribed to pulmonary tuberculosis, ending
with a convulsive seizure.
( Jeorge B. O'Sullivan, M.D., of Brooklyn, died October 11,
aged 30 years. He was a native of that city and a graduate of
the Long Island College Hospital about ten years ago. He
served as interne in St. Mary's General Hospital in 1888 and a
term in St. Mary's Maternity Hospital. After completing his
service in the latter institution, he opened an office and in a
short time built up a large and remunerative practice. Dur-
ing the past winter he had an attack of pneumonia. Although
18%.]
BOOK NOTICES.
1021
this was severe, his convalescence did not progress satisfacto-
rily, and pulmonary tuberculosis supervened. At this time he
was strongly advised to leave Brooklyn and settle in the North-
west, but this he was unable, for family reasons, to do. In
Mav last, he reluctantly agreed to take a vacation and decided
to spend it in the Adirondacks. The climate of this section
did not appear to benefit him, and his stay there was brief.
The midsummer was spent at New Suffolk, L. I. There he
seemed to experience some improvement. In the latter part of
August he returned to the city and resumed his practice, but
his strength was, however, not equal to the task and he was
obliged to gradually give up his business, until toward the
last he was conlined to his home. In his death was ended the
career of a man of great promise, a career that had always
been upright, honorable and useful.
A. C. .\K l.Ki i \n. M.D., a native of Prince Edward Island
and graduate of MeGill University, Montreal, and the Royal
College of Surgeons, Edinburgh, died at Gloucester, Mass.,
October IT. lie was 36 years of age. B. H. Whaley, M.D.,
Of Whaleysville, Md., October 9, aged 29. P. S. Carden,
Al.P.. of Richmond, Va., October 11, aged 60. R. C.
Walker, M.D., of Mobile. Ala., October 11, aged 59. John
Spkinos Baxter, M.D., of Macon, Ga., October 12. He was
bom in Macon in 1S.'!2 and was graduated from the Univer-
sity of Georgia in 1853. He received his medical degree
from the .Jefferson Medical College in 1856 and returned to
Macon to begin the practice of medicine. He enlisted in the
war with the Macon Volunteers in 1861 and was made surgeon
of the battalion in 1862. Later he was assistant surgeon at
Richmond to the Third Georgia Hospital, then became sur-
geon of the Forty-sixth Georgia regiment in the field until
the surrender. After the war he resumed practice in Macon
for about a year and then went into the general merchan-
dise business under the firm name of Jones & Baxter. Retir-
ing from business in 1873, in 1876 he became director in the
Southwestern Railroad and in 1891 became its president,
which position he was holding at the time of his death.
RiniAKi) Beebe, M.D., of Alford, Mass., October 20, aged 72.
He was graduated from the Pittsfield Medical College. M.
H. Raymond, M.D., of Grass Lake, Mich., October 21, aged
60. He was graduated from the University of Michigan in
1852. -Walter P. Brown, M.D., of Lexington, Mich., Octo-
ber 18, aged 43.
SOCIETY NEWS.
Second Pan-American Medical Congress. — President Diaz will
receive the Congress on the 19th inst, and the municipality of
the City of Mexico will tender a reception on the 17th inst.
Dr. H. L. E. Johnson, chairman transportation committee,
has authorized the Baltimore & Ohio road to communicate in
his name with persons north and east desiring to attend the
Congress and make arrangements over that road connecting
with the special train of the American Tourist Association
at Cincinnati. Dr. Listen H. Montgomery has arranged a
special over the Laredo, Texas and Mexican National Rail-
road, at a cost of about $150. Stop-over privileges will be
allowed, and the trip will occupy about three weeks. The
price includes hotel accommodations.
List of Honorary Presidents and Secretaries for Canada : —
Drs. James Stewart, Montreal ; H. P. Wright, Ottawa ; John
Caven. Toronto; L. D. Mignault, Montreal; Morehouse, Lon-
don, Ont. ; J. L. Davidson, Toronto; Sir Wm. H. Hingston,
Montreal ; Cassidy, Toronto ; Edward Farrell, Halifax ; J. A. S.
Brunelle, Montreal; T. J. Roddick, Montreal; Surg. Major
Strange, Colin Sewell, Quebec ; W. Gardner, Montreal ; P. W.
Ross, Toronto; Adam Wright, Toronto; Grondin, Quebec ;
A. B. MacCallum, Toronto; Wesley Mills, Montreal ; J. B. A.
Lamarche, Montreal ; Sheard, Toronto ; J. C. Cameron, Mon-
treal ; Blackader, Montreal ; Burnham, Toronto ; Buller, Mon-
treal; Kirkpatrick, Halifax; A. A. Foucher, Montreal; Chrfi-
tien-Zaugg, Montreal ; Stephen Dodge, Halifax ; Birkett,
Montreal ; J. C. Cornil, Toronto ; D. Marcil, St. Eustache,
P. Q. ; J. E. Graham, Toronto ; A. A. Browne, Montreal ;
E. P. Benoit, Montreal ; F. Montizambert, Quebec ; W. Bay-
ard, St. John, N. B. ; P. H. Bryce, Toronto ; James Patterson,
Winnipeg; Davie, Victoria, B. C. ; A. Vallee, Quebec; Work-
man, Toronto; Stephen Lett, Guelph, Ont.; Burgess, Mon-
treal ; McAviuny, St. John, N. B. ; Beers, Montreal ; Wilmot,
Toronto ; Shepherd, Montreal ; C. E. Lemieux, Quebec ;
Geikie, Toronto ; Adami, Montreal ; A. P. Reid, Halifax ;
A. R. L. Marsolais, Montreal ; Arthur Lemieux, Dentist, Mon-
treal ; Luke Lesky, Dentist, Toronto.
The Medical Society of the District of Columbia.— The following
circular has been issued by this Society :
Sir: — I have the honor of transmitting to you the following
preamble and resolutions adopted by the Medical Society, and
to request that the action suggested therein be taken, and that
the Society be duly informed of the appointment of a repre-
sentative as provided for by the resolutions :
Whereas, There is now pending in both Houses of the Con-
gress of the United States, a bill, entitled, "A bill for the
further prevention of cruelty to animals in the District of
Columbia," which avowedly contemplates the supervision and
restriction of vivisection in this District ; and
Whereas, It is believed that such proposed legislation will
so obstruct and limit experimental research as may seriously
interrupt the pursuit and progress of biologic and medical
research in this District, therefore be it
Resolved, That the Medical Society of the District of Colum-
bia hereby invites the bureaus, departments, schools of medi-
cine and scientific societies hereafter named, to unite with it in
the organization of a commission to be constituted of one
representative from each of such bureaus, departments, schools
of medicine and scientific societies, which shall be known as
the "Joint Commission on Vivisection," charged with the
duty of investigation relating to the practice of animal experi-
mentation in this District, and representation of the constitu-
ent organizations before Congress, in such manner as said
commission may determine.
Resolved Secondly, That this invitation be extended to the
Bureaus of Medicine and Surgery of the Army, Navy, Marine
Hospital Service, Animal Industry, the Medical Departments
of the Columbian, Georgetown, Howard and National Univer-
sities and to the Chemical, Biological, Anthropological, Ento-
mological and Philosophical Societies of the District of
Columbia.
Resolved Thirdly, That the expenses of the Joint Commis-
sion shall be defrayed in equal proportion by each bureau,
department, school and society represented in said Joint
Commission.
Resolved Fourthly, That the corresponding secretary be
requested to transmit a copy of the foregoing preamble and
resolutions to each of the bureaus, departments, schools and
societies named, and request their concurrence, and the name
and address of their representatives. Very respectfully,
[Signed] Thomas C. Smith, M.D., Cor. Sec'y-
BOOK NOTICES.
Modern Greek Mastery; A Short Road to Ancient Greek. By
Thomas L. Stedman, A.M., M.D. New York: Harper &
Bros. 1896.
This is an attempt to bring the English speaking medical
man face to face with the new Greek, but he might as well
know once for all that he can not learn any foreign language
without study. Such books as the one under consideration
are valuable, but they can not take the place of the tutor by
the colloquial method. Dr. Stedman says: "In these days
of international congresses a pressing need is felt for some
common medium of expression, for few men are such masters
of the three languages in which discussions are usually held at
these gatherings to enable them to take an intelligent part in
all the deliberations. English, French and German have each
in turn been proposed as the international language, but
national jealousies would appear to offer insuperable obstacles
to the adoption of any one of them to the exclusion of the
other two. The only solution of the difficulty seems to lie in
the selection of some other language which could be univer-
1022
BOOK NOTICES.
[November 7,
sally accepted without wound to the national pride of any
European people. Many men from Voltaire to Blackie, and
others of the present day, have urged the adoption of Greek
for this purpose, and of all living tongues none has stronger
claims in this regard. Its adaptability to the needs of inter-
national communication is shown by the fact that it is now the
language of commerce throughout the Levant, as it was before
and at the beginning of the Christian era, the common tongue
of men of letters and of polite society in the civilized world."
The author makes a good point in advocating the study of
modern Greek by saying that to learn Greek by the study of
the ancient classics, such as Homer and Xenophon, is like it
would be to undertake the study of the English language by
carefully reading Chaucer and Spenser. The one who will
master this book may be said to have accomplished the mas-
tery of the language which it teaches.
A Text-book of Diseases of the Nose and Throat. By Francke
Huntington Bosworth. New York : William Wood & Co.
1896.
The present edition of some eight hundred pages is a con-
densation of his former voluminous treatise.
This excellent work has lost none of its practical value by
covering the same ground with half the reading text of the
former editions. The pruning process has been rather of words
than ideas, and its value as a text-book for students and prac-
titioners has been greatly enhanced. Bosworth's work is
unquestionably the most complete text-book on the subject as
yet given to the profession by an American author, and may
well be considered to rank with Morell Mackenzie's classic on
the same subject.
Manuale di Materia Medica. Del Dottore Gaetano Malacrido.
Ulrico Hoepli, Milano, 1896.
L'lmpiego Ipodcrmico e la Dosatura del Rimedl. Del Dottore
Gaetano Malacrido. Ulrico Hoepli, Milano, 1895.
Manuale Pratico della Medicatura. Del Dottore Adelchi Zambler,
con Prefazione del Prof. E. Tricomi, con 6 incisioni. Uirico
Hoepli, Milano, 1896.
These three publications of the Hoepli series give very fair
and apparently very complete statements of the present state
of our knowledge of their respective subjects, and a very handy
form for those acquainted with the language. The treatise on
materia medica is especially full and complete for a pocket
manual ; so far as known we have nothing in English that
approaches it in this respect ; some even of the less known drugs
are more fully mentioned than in the U. S. Dispensatory. It
would be an excellent work of reference for any physician and
the language being an easy one to acquire, would not be, by
any means, a serious objection.
The volumes make no special pretense at being other than
handy manuals, and for this they seem eminently suited. Our
Italian confreres appear to be well provided for in this regard.
The Medical and Surgical Uses of Electricity. By A. D. Rockwell,
A.M., M.D. Illustrated with 200 engravings: new'edition.
New York: Wo. Wood & Co. 1896.
m-
This work is practically the ninth edition of Baird and Rock-
well's well-known treatise on the medical and surgical uses of
electricity, but Dr. Baird has long since been dead, and has no
connection with any of the revisions since the second. Baird
and Rockwell has so long been the standard work on electro-
therapeutics that any additional commentation of it is a super-
fluity. It is sufficient therefore to say that the present edition
has been brought down to date, even including a chapter on
the Roentgen ray. Among the new features for^the book we
notice an illustration of Girdner's telephone bullet'probe with
the method of using it, and the Cleaves' electrode for vaginal
hydro-electric applications, and various skiagraphs illustrative
of the Roentgen photography in diagnosis. It is evident that
Dr. Rockwell intends that his book shall be a standard on the
subject for a long time as it has been conscientiously revised.
A Practical Treatise on Medical Diagnosis. For the use of students
and practitioners. By John H. Musser, M.D., Assistant
Professor of Clinical Medicine, University of Pennsylvania,
Philadelphia. New (2d) edition, thoroughly revised. In one
octavo volume of 925 pages, with 177 engravings and 11 full-
page colored plates. Cloth, $5 ; leather, $6. Philadelphia
and New York : Lea Brothers & Co. 1896.
The new edition of this work embodies the latest improved
advances, newly established facts and methods in this branch
of practical medicine. There are many new engravings and
colored plates. We can repeat the favorable mention we gave
the first edition of this work, and can only say that the new
one will be found even more valuable. We notice with pleas-
ure that in the directions for bacteriologic diagnosis the
metric system of weights and measures is used throughout the
volume. The colored plates of bacteria are accurate and com-
prehensive. All classes of practitioners, general and special,
are aware of the fact that they can not have too many good
books on diagnosis. In this class Musser' s book fairly belongs.
A full index adds to the value of the book.
A Practical Treatise on Materia Medica and Therapeutics.- By Rob-
erts Bartholow, M.A., M.D., LL.D. Ninth edition, revised
and enlarged. New York : D. Appleton & Co. 1896.
The ninth edition of Bartholow' s therapeutics has been
enlarged, so that it now forms a volume of 866 pages. The
additions and alterations which have been made as a rule
relate to the accounts, more or less full, of the synthetic reme-
dies from organic chemistry, many of which are patented, but
are the property of the manufacturing chemists. The general
character of the work is unchanged, and it continues to be, as
heretofore, a standard work on therapeutics. We regret, how-
ever, that the author has not revised the system of weights
and measures to correspond, to the new Pharmacopeia or
advanced position of chemic and pharmaceutic science. The
old British weights and measures is still employed throughout
the book. This detracts very much from its value. We hope
to see it corrected in future editions. This has been done in
the chapter on Topical Remedies, Part III of the book, which
is free from criticism in that respect. Centigrade thermometer
is also used in this portion of the work. Where the formula
of the U. S. Pharmacopeia is given, however, it is impossible
for the author to avoid using metric terms, and it looks curi-
ous to see a metric term used in the preparation of the drug,
while the dosage is always given in the old fashioned weights.
With this exception, the new revision stands the test of com-
parison with other works on this subject. It will, we trust,
continue to be a favorite for many a year, and the defects
which we have pointed out are so easily corrected that we hope
the tenth edition will be free from them.
Biennial Report of the Board of Health of the General Assembly of the
State of Louisiana for 1894 95. By S. R. Olliphant, M.D.,
President, Baton Rouge, 1896.
This report contains the most important features of the
work of the Board of Health of the State of Louisiana for the
years 1894 and 1895. It is of considerable interest in many
particulars. Among them is the report of a conference of
quarantine authorities of the Gulf with a view to securing uni-
formity of regulations, governing the fruit trade during the
summer, and it was agreed that the representatives should
maintain a medical inspection service in certain foreign ports.
The committee of the conference consisted of Drs. Patton.
Cochran and Hargiss, who recommended a modification of the
quarantine laws and regulations of the United States, promul-
gated by the Secretary of the Treasury, April 4, 1893. On
account of a disagreement between the Board of Health of New
Orleans and the Marine Hospital Service, it is stated by Dr.
Olliphpnt, page 24, as Secretary, that "in January, 1894, the
local representative of the Marine-Hospital Service especially
informed this board of his instructions to make monthly
inspections of our quarantine stations. The feeling engendered
1896.]
MISCELLANY.
1023
on part of this board by this attempted ojjieious supervision
is fullyset forth in a letter authorized by the board." A letter
addressed to the Secretary of the Treasury follows.
Dr. Olliphant adds: "Despite our protest, the formality of
visiting our stations monthly is regularly indulged in by the
Surgeon in charge of the United States Marine- Hospital in this
city. By the absence of complaint from the Supervising Sur-
geon General at Washington, I infer the reports of our prac-
tices and methods have proven satisfactory." Again on page
27, Dr. Olliphant states that a subordinate of the Board of
Health was requested to furnish a certificate of pratique by
the Marine-Hospital Service instead of by the Board. This
statement follows, and the report continues, page 29: "The
President and Attorney of this Board proceeded at once to
Washington and through the courtesy of our Senators and
Represent;ithes were introduced to the Secretary of the Treas-
ury. This official was not aware that any change in the regu-
lations of the proceedings had been inaugurated. We then
repaired to the office of the Supervising Surgeon-General of
the United States Marine-Hospital and discussed with him the
justice of our claims, and while he did us the courtesy to prom-
ise to give the matter serious consideration, he obstinately
refused to recommend to the Secretary of the Treasury to sus-
pend this order till his decision was rendered. On our depart-
ure from Washington we were assured by the Secretary of the
Treasury that our claim appeared to be well founded and
would receive due Consideration."
On August 16, the regulations of the Louisiana Board were
finally acceded to, and the report continues: "It is to be
hoped the United States Marine-Hospital Service will desist
from further interference with the quarantine affairs of the
State of Louisiana. When that service is prepared to dem-
onstrate the superiority of its regulations and methods, I feel
confident that this Board of Health will most gladly adopt
them. Till then let us progress and not retrograde."
Full accounts are given of the smallpox epidemic of 1894,
and the report concludes with the usual statistic tables and a
republication of the laws of the State and ordinances of the
city of New Orleans in relation to health and sanitation. The
report is, therefore, not only valuable from the standpoint of
history but as a book of reference for those interested in the
sanitary legislation of Louisiana.
The Bausch and Lomb Optical Company of Rochester, N.Y., have
issued a catalogue of unusual merit concerning microscopes,
microtomes, photographic and laboratory apparatus. The
descriptions of the instruments are clear and complete.
MISCELLANY.
Prof. Klebs' Article on "Tuberculosis" translated into Italian.
The article by Professor Klebs on Tuberculosis, which was
published in the Journal, No. 4, Vol. 27, has been translated
into Italian and appears in full in the Gazctta Degli Oapedali e
Delle Cliniehe, September 15.
"Omnibus Physicians."— The Nouvelles dv Jour announces
that at Olloy, near Mariembourg, a physician has been
appointed by the authorities to take charge of all the sick in
the community and attend them gratuitously, for which he
receives a certain salary and all expenses paid. Gaz. M. de
Li&ge, September 10.
Operation for Atresia Vagina.— Mackenrodt (Centralbl. f. Gyn.,
No. 21, 1896) points out that attempts to keep the artificial
vagina open by tampons after operations for this condition are
seldom permanently, if even temporarily, successful, and
states that he has recently in two cases successfully substituted
a vaginal wall by transplantation of flaps obtained in opera-
tions for prolapse on otherwise healthy women. The new
canal is prepared and plugged with iodoform gauze till its
inner surface is covered with healthy granulations, and is then
lined either by several single flaps which are kept in position
by a tampon, or a lining is formed by sewing a number of flaps
together around a Cusco speculum and introduced with its
wounded surface external into the granulating canal, and fixed
by a tampon, which in either case is not removed for eight or
ten days. — St. Louis Med. Journal, October.
To Remove a Foreign Body from the Nose, Urethra, etc. — Beugnies
describes a simple arrangement with which he removes foreign
bodies from small passages. A hole is bored in the end of a
probe and a thread fastened in it. This is then introduced
into the passage and carefully pushed past the foreign body.
The string then held in one hand and the probe in the other,
the little whip thus forms a loop with which the foreign body
is easily withdrawn. — Gaz. MM. de Liege, September 10.
Newly Appointed Army Medical Officers. The Army Medical
Examining Board, which has been in session during the last four
weeks in Washington, D. C, completed its work on Saturday,
October 24, by recommending the appointment of eight of the
candidates, in order of merit as follows : Basil H. Dutcher of
New York, Leigh A. Fuller of New Jersey, Franklin M.
Kemp of New York, George A. Skinner of Minnesota, Carl R.
Darnall of Texas, Wm. E. Richards of Mississippi, Louis P.
Smith of the District of Columbia, Marshall M. Cloud of
Kansas.
The Disinfection of Books by Vapor of Formalin. — An experiment
has recently been made by a medical authority in the disin-
fecting powers of the vapor of formalin on library books. His
conclusions are as follows : 1. Books can be disinfected in a
closed space, simply by vapor of commercial formalin, by using
1 c.c. of formalin to 300 c.c. or less of air. 2. The vapor of
formalin is rapid in its disinfectant action. The effect pro-
duced in the first fifteen minutes is practically equivalent to
that observed after twenty-four hours. 3. An increase in the
amount of air to each c.c. of formalin is not counterbalanced
by an increase in the length of time of exposure. 4. In case the
disinfection has been incomplete, the vitality of the organisms
has been so weakened that they survive only if transferred in a
few hours to media suitable for their development. 5. The use
of the vapor of formalin is not detrimental, as far as observed, in
any manner to the books, nor is it objectionable to the operator
beyond a temporary irritation of the nose and eyes somewhat
similar to that produced by ammonia. — Health, October 17.
Change of Name. — The editors of Mathews' Medical Quarterly
announce that with the January issue of that publication its
name will be changed to Mathews' Quarterly Journal of Rec-
tal and Gastro-Intestinal Diseases. This is a change which '
has been deemed necessary for some time, as it is essential
that the title of a medical journal should convey to the reader
an idea of its contents, and this has not been the case with its
name from the beginning. There will be no change in the
policy of the journal in the least. As it will continue to be
the only English publication devoted to diseases and surgery
of the rectum and gastrointestinal tract, the articles which
will appear in it will be limited to these subjects. The journal
will continue to be edited by Drs. J. M. Mathews and Henry
E. Tuley, and published in Louisville, Ky.
Operative Treatment of Partial Epilepsy.- In the Deutsche Med-
iriuische Wochenschrift for August 27, Sachs and Gerster of
New York give the results of operation in nineteen cases, and
arrive at the following conclusions : 1. Those cases of partial
epilepsy are suitable for operation in which at most one to three
years have elapsed since the trauma or onset of the disease.
2. In depression of the skull or in other injuries to the skull,
operative interference is indicated even in after years. The
prognosis, however, is less good the longer the elapsed time
since the original injury. 3. Simple trephining may suffice in
1024
MISCELLANY.
[November 7,
many cases ; this is especially true if one is concerned with
skull injury or with cyst formation. 4. Excision of the cortical
lesion is advisable, if the epilepsy is of short duration and
referable to an exactly localizable portion of the brain. 5.
Since such lesions are often only visible microscopically, exci-
sion should be undertaken even if the diseased part macro-
scopically appears normal. Still one should, however, use the
greatest caution, in order that the proper portion be excised.
6. Surgical interference in epilepsy occurring in connection
with infantile cerebral paralysis is permissible, if it occurs
not too long after the onset of the paralysis. 7. In old cases
of partial epilepsy, in which very probably an extended degen-
eration of association fibers has taken place, surgical inter-
ference is entirely useless. — Boston Medical and Surgical
Jour nal.
The Healing Craft Defended.— The New York Sun has had upon
its editorial staff for some years a writer whose sympathetic
and intelligent remarks upon medical affairs have been much
quoted in our journals, as showing that the profession is not
absolutely friendless in the daily press. The following short
paragraph was elicited by a New York city event that occurred
in the heated term of last August: "Mrs. S. B. died of the
heat last night, while her husband was trying to get a doctor.
The medical man whom he succeeded in finding refused to
attend the patient because the husband was unable to pay his
fee. It is seldom that a doctor violates the oath of Hippoc-
rates, by which he binds himself before he takes up the work
of his profession. That famous formula defines the duties of
the physician to his master, his pupils, the sick and himself.
With reference to the third of these the doctor promises to
treat the suffering as a father cares for his children. He calls
down upon himself all evil if he fails in this solemn duty. He
prays that he may be accursed. The conduct of this medical
man was in direct violation of the solemn obligation. But a
case of this sort is only the exception that proves the rule. In
no calling in life is there as much self-sacrifice willingly suf-
fered for the good of humanity as in that of the healing craft.
It is, therefore, all the greater shame that any one man should
forget the traditions of a noble profession."
The Late John Eric Ericbsen. Sir John Eric Erichsen, who
has been called the brightest literary exponent of English sur-
gery in his generation, as heretofore announced departed this
life September 23, after a somewhat sudden illness. He had
been in fair health and in a hopeful mood until about one week
before his death. Mr. Malcolm Morris, editor of the Practi-
tioner, has lately written briefly of Erichsen' s position among
his confreres: "Sir John represents all that is best in the
traditions of English surgery which, as Bilroth says, has since
the days of John Hunter had 'about it something noble.' His
career has a special interest for me, as in his early professional
life he devoted a considerable amount of attention to skin dis-
eases, on which he wrote a book which may even at this day
be read with profit. Thirty years ago Sir John Erichsen' s
operations at University College Hospital were among the sur-
gical sights of London, which students from other schools and
visitors from foreign countries flocked to see. Yet on his first
appointment he had had difficulties to contend with, which
might have dismayed a weaker man. The medical student of
'the forties' was an animal ferw natura', as different from the
decorous and examination-ridden youth of the present genera-
tion as Squire Western from the country gentleman of to day.
I have been told that at Mr. Erichsen's first operation in the
hospital theater one of the students expressed his disapproval
by throwing a ball at his head : the missile reached its mark,
but without disturbing the self-possession of the operator.
This little morning mist of unpopularity, however, speedily
melted away before the splendid qualities of the man. It is an
interesting fact that Sir John Erichsen's first house surgeon
was Sir Joseph Lister ; the same post was afterward held by-
Sir Henry Thompson. His pupils, however, are not to be
counted merely by the number of those who were privileged to
hear the living voice of the master ; his great work has for
more than forty years been turned over with nightly and daily
hand by students, and constantly referred to for counsel by
surgeons wherever the English tongue has currency."
Bacterturla Treated by Internal Drug Administration. — The London
Lancet, September 12, refers to a paper in the recently issued
fourth volume of the Edinburgh Hospital Reports, by Dr.
Lowell Gulland, on this subject. Organisms, he says, may
make their way into the normally aseptic parts of the urinary
apparatus in four different ways : 1, by spontaneous growth
from the urethra into the bladder ; 2, by instrumental intro-
duction ; 3, by the bursting of an abscess into the urinary
tract, e.g., from parametritis or appendicitis ; 4, by transmission
through unbroken tissue from elsewhere, e.g., the rectum, and
5, by passage through the kidney from the blood. Only a few
organisms have been proved to appear in the urine in this way.
Although the urine forms an almost ideal culture medium no
organism will remain in permanent possession of the urinary
tract unless it is pathogenic or unless there is retention of
urine. Any organism will probably cause a certain amount of
damage to the mucous membrane, and its primary develop-
ment will thus be favored : but as the epithelium recovers, the
rate of removal of the organism will exceed the rate of growth
and the organism will at last be eliminated. Cystitis is by far
the most common inflammation of the urinary tract. The
ammoniacal fermentation of the urine, formerly thought to be
invariable in cystitis, is only occasionally present, and, as a
matter of fact, the urine in cystitis is frequently acid. In
reference to treatment, when the acute symptoms of the
attack have subsided and the mucous membrane has recovered
to a certain extent, there is still over the whole or part of its
surface a layer of adhesive muco-pus swarming with organ-
isms. In this condition washing out of the bladder is often
most efficacious, but in certain cases it is inadmissible, and
recourse must then be had to administration of remedies by
the mouth. Drugs to render the urine acid if it is alkaline,
are useful. Various germicidal remedies have also been recom-
mended, but all of them Dr. Gulland shows, are excreted in a
form in which their germicide value is small. He suggests,
however, that although they do not destroy the vitality of the
organisms they may have an effect upon their virulence either
by preventing the secretion of their toxic products or by neu-
tralizing these when formed. Such a view is extremely diffi-
cult to put to the test of experiment.
Mania Following Orchotomy ; Successful Treatment with Testiculin.
—Dr. A. T. Cabot of Boston, in the Annals of Surgery for
September, narrates a rare case of the above description in a
well-preserved patient of 75. In the course of a crushing oper-
ation for stone, the surgeon removed both testes ; upon recov-
ery from anesthetic the patient began to manifest a conf usional
mental disturbance with exacerbations of mild mania. Pre-
vious to the operation he had been mentally clear for the most
part, although not free from occasional confusion of ideas.
The wound healed kindly and the prostate became so much
reduced in size that about one month after the operation the
patient passed some urine voluntarily. Testiculin was then
tried as a remedy for the persistent mental confusion. The
improvement under this treatment was prompt, and the man
left the hospital about ninety days after the operation. The
treatment by injection was kept up about two weeks, when it
was discontinued on account^of the pain. This is probably the
first recorded case in which testicular extracts have been used
in such a case as this, but the immediate improvement which
followed confirms the belief that the loss of the testicles had
something to do with the mania, and suggests the importance
18%.]
MISCELLANY.
1025
■of a further trial of these extracts in similar cases. Care was
taken that neither tln> patient nor the friends should have any
idea of what was being given or what results were expected, so
that the possible effect of suggestion should be reduced to a
minimum. This would seem to be a necessary precaution in
any similar trial : for suggestion is a powerful therapeutic
agent in such functional nervous disorders. Beside these imme-
diate and psychic disturbances, there are other cases in which
the operation has a very derided depressing effect on the gen-
eral strength of the patient, leading to an amount of shock
quite out of proportion to the extent of the mutilation. In other
cases, again, the patients have borne the operation well, the
wounds have healed kindly, and still, at the end of a fortnight,
or perhaps a little longer, they have gradually failed without
any marked change in their symptoms and have died. If a
case of this sort comes to autopsy, it usually reveals a condition
of pyelonephritis, and the death is perhaps sufficiently explained
thereby. It is, nevertheless, a striking and suggestive fact
that these patients, who have been carrying the load of par-
tially disabled kidneys for a long time, after a slight operation,
which heals kindly, gradually succumb by progressive loss of
strength without any evident increase of symptoms pointing to
an aggravation of the renal condition. This seems to indicate
that, by the removal of the testes, the vital force of the patient
has been diminished, and thus, in a measure, the theory of
Brown-Soquard finds support.
Combined Vagina abdominal Hysterectomy. Gaston Hardy
appeals in the Annate* dt I" Soc. M4d, Chir. de LQge, Sep-
tember, for a combination of the vaginal and abdominal
methods of hysterectomy. He advises that in every laparot-
omy it is wise to prepare for a vaginal operation also, and in
every vaginal to prepare to open the abdomen if necessary.
His experience seems to have been in many cases that which-
ever route he followed he wished he had taken the other, and
he thinks that only by combining the two can the average sur-
geon secure the best results under certain circumstances. He
advocates the removal of the uterus when both ovaries have
to be ablated.
Contribution to the Physiology and Therapeutics of the Kidneys.
Several explanations have been offered for the fact that the
xanthin series, catfein i trimethylxanthin), theobromin (dime-
thylxanthiniand monomethylxanthin, produce diuretic effects
-on some animals and not on others. It has been ascribed to
the composition of the blood, to the diet, etc., but an extensive
series of experiments by Corin described in the Annates dela
Soc. MM. < 'li ir. de Liige, for September with a review of the
subject in all its phases, demonstrates that the diuretic effect
of caffein on the rabbit and its absence in the dog, is the result
of a vagus tonus possessed by the dog and absent in the rab-
bit. Hence to place the two animals on a level in this respect,
it is necessary to render the vagus inactive in the dog by sec-
tioning it or paralyzing it with atropin. When this is done the
■caffein produces exactly the same decided diuretic effect on
both animals. Corin has established the fact that excitation
of the vagus itself, excluding the ramifications that extend to
the heart, directly diminishes the urinary secretion. This
excitation is without results if the animal has previously been
intoxicated with atropin, which demonstrates that atropin
paralyzes the vascular or other terminals of the pneumogastric
in the kidneys, just as it paralyzes its terminals in the heart.
It is therefore to be assumed that the rabbit is without this
vagus tonus for the kidneys as, we know it is without it for the
heart. He closes with the remark that if there is a renal vagus
tonus in man, as there is in dogs, which everything tends to
establish, then chloral is not to be considered the best adjuvant
for caffein, but atropin or the belladonna preparations are indi-
cated. He is now experimenting on man to confirm this
assertion.
Teratogenesls. I iallant yne remarks in the course of an article
reviewing the testimony for and against the theory that mater-
nal impressions can cause defects in the fetus resembling the
impression, that it is most extraordinary in its wide extension
in time and space, and its firm hold on the minds of both pro-
fession and laity. To those who wish to see it dead it is most
disappointedly vital, and to those who wish to demonstrate its
truth, most strikingly destitute of scientific proof. He con-
cludes that the cases of resemblances reported are merely
coincidences, but that strongly marked and prolonged mental
states do affect the development of the fetus. Fe>e' states for
instance, that the children conceived during the sieges of the
Franco-Prussian war can be recognized by bodily and mental
stigmata so marked that they are known "enfants du siege."
The results of anxiety, insufficient food, etc., are not always
teratologic, but may be of the nature of sterility, abortion,
congenital debility, etc. To this extent he believes in the old
doctrine of maternal impressions, the one grain of truth in
the immense mass of fiction, which has had a most maleficent
effect on antenatal pathology. The general trend in most
countries is decidedly against it, except in America. He men-
tions references to it in recent fiction, Egerton's "Keynotes,"
Cobban's "Red Sultan," Merriman's " From One Generation,"
Henty's "Rujub," Blackmore's "Lorna Doone," as well as in
the " Merchant of Venice," "Tristram Shandy," "Fortunes
of Nigel," and O. W. Holmes' " Elsie Yenner." —Edinburgh
Med. Jon?:, October.
Porokeratosis. — Mibelli has recently described a new affection
produced by a hyperkeratosis of the orifices of the sweat glands,
which he calls porokeratosis. Dubreuilh has since had occasion
to observe a case which confirms Mibelli's announcement that
it is entirely distinct from lichen planus in any form. The
child, 12 years old, has had lupus and the lesions in question
since his first year. They are on the hand and the forearm,
and have gradually extended without ever becoming inflamed,
or causing pain or special inconvenience. They form an irreg-
ular track two to three centimeters wide, skipping the wrist,
from the last phalanx to the elbow, consisting of hard, horny,
verrucose elevations half a centimeter in height at the elbow.
They drop off occasionally, but grow out again at once. The
smallest are the size of the head of a pin, and are small, pale
conical papules, the summit of which is formed by a small
horny tip which projects from the top of the 'papule, from
which it is quite distinct. These are the original lesions, which
began on the hand. Scattered among them are a few cones
from which a hair issues. The largest lesions are the size of
a lentil or hemp seed, and present a central corrugated surface
and a surrounding crater-like slope. The center is horny,
whitish, opaque, thick and hard, separated from the crater
enclosure by a narrow, deep, circular fissure. It is hard to
enucleate this center, as it is tough and adherent, but when it
is done or falls out spontaneously, the depth of the crater is
found to be of the same horny substance. After removal of
the crusts the skin underneath is found normal and soft. The
general health is good. The Arch. Clin, de Bordeaux for
August contains Dubreuilh's report with a few more details.
Acute Infectious Diseases and General Paralysis. In an interest-
ing article in the Archives Cliniques de Bordeaux for August,
Deltnas describes the experiments that have been made by sci-
entists in producing general paralysis, and the conclusions as
to its etiology. It is almost universally admitted now that
general paralysis is consecutive to syphilis in a large number
of cases, which produces this effect by its toxins, as an
infective disease. It has also become an established fact that
acute infective diseases may be followed, after a certain inter-
val, by a confirmed general paralysis, and still more often by
forms of psychopathies such as acute delirium, mental confu-
sion, general pseudo-paralysis, etc., presenting with more or
1026
MISCELLANY.
[November 7,
less completeness the clinical character and the anatomo-
pathology of general paralysis. Infection appears thus to play
an important, even the principal, rdle, in the evolution of gen-
eral paralysis and similar conditions, and the query arises now
whether general paralysis and the psychopathies resembling it
are not essentially of infective origin. He describes one case
of the kind following an attack of influenza in the epidemic of
1889, and agrees with Bannister that it is doubtful whether
grief or venereal or alcoholic excesses alone could produce gen-
eral paralysis, while it is unquestionable that they favor the
evolution of an infective disease, and thus, indirectly, the
paralysis. He mentions among others Charrin's experiment
with a rabbit which he kept for four hours continuously on a
rotating wheel. Examination of the blood of the fatigued and
alarmed animal showed it so full of microbes that one drop
alone produced 800 cultures. Widal also relates the case of a
rabbit inoculated two months before with streptococci, which
apparently retained his usual health until he was placed with a
female, when he promptly succumbed to paralysis. Many author-
ities quoted consider that the acute disease merely arouses a
latent paralysis, but Delmas believes that the lesions discovered
in the brain after certain acute infective diseases, such as
typhoid fever, measles, diphtheria, etc., by Raymond, Barlow,
Popoff, Voisin, etc., produce the paralysis in the same way as
the lesions consecutive to syphilis.
Free Sanatoria for Tuberculosis.— The Red Cross hospitals in
Germany erected in readiness for war, are to be used as sana-
toria for indigent consumptives, if the experiment now being
tried with one of them proves a success. There are already
seven or eight free sanatoria for this purpose in the country,
but their accommodations are limited, and they are "merely a
drop on hot iron" in comparison with the number of persons
affected with the disease (1,200,000). In 1892 Gebhard, the
superintendent of the Hanseatic Anstalt fur Invalidities u.
Altersversicherung (Sickness and Old Age Assurance), found
that as a matter of business economy it was better to take
charge of persons affected with tuberculosis and cure them,
than to pay their indemnity in case of illness. The wisdom of
this measure became more and more apparent with the increas-
ing numbers of tuberculous persons who took advantage of
the offer of the association. At first their expenses were paid
at private institutions, but the association is now erecting a
sanatorium of its own. The persons thus treated prevent the
infection of others at their homes ; they also learn the princi-
ples of hygienic living and teach them to others on their return.
They are also advised in regard to change of occupation if
necessary, etc. The report of 26 persons sent to Gorbersdorf
by an assurance association states that after an average stay
of eighty-three days, 73 per cent, were able to resume their
occupations ; 4 per cent, conditionally, and 16 per cent, derived
no benefit from their stay. The treatment was therefore suc-
cessful in three-fourths of the cases. The Hanseatic associa-
tion reports 226 cases treated, with success in two-thirds ; 155
resumed their former occupation ; 81 are known to have con-
tinued it; 17 gave up in one to nine months and 57 could not
be traced. The association is more than satisfied with this
showing, as if only 29.2 per cent, resume their occupations for
even one year, the amount of payments thus saved covers all
expenses. It is expected that as the public becomes more
accustomed to the idea, more persons will apply in the incipient
stages when the disease is more easily cured, and the finances
of the association benefit accordingly. Dettweiler's combined
report of his private and his free sanatorium shows the results
of his experience with this treatment, which he considers
" very satisfactory ;" in 1895, 120 patients were treated, and in
10 per cent, the bacilli entirely disappeared ; 24 of the rest
were cured part absolutely and part relatively ; 73 of the
remaining 89 were improved ; 9 grew worse ; 2 died and 5 did
not remain. The average gain in weight was ten pounds-
Ascher concludes his review of what has been accomplished
in various countries with the statement that nearly every
canton in Switzerland is erecting a sanatorium for pulmonary
affections.— Deutsch. Med. Woch., September 3.
The Life of the Hospital Interne.— Dr. Charles McBurney, in a
recent address, magnified the influences of hospital life in the
early career of the good young surgeon. Without stopping at
this time to criticize or analyze the glowing periods of the New
York professor, we must say that the natural gifts of energy
and industry of some of our young surgeons, without hospi-
tal privileges, will land them in a higher surgical niche than
can possibly be reached by others, their more highly favored
classmates, who are lacking in dash and push and wisdom.
But Dr. McBurney has a right to be heard whenever he is
pleased to speak upon the bringing up of good surgeons. In
this connection he is reported in the Boston Medical and Sur-
gical Journal, September 24, to have said : "In my opinion
the most important thing in the production of a good doctor
or a good surgeon, I should say, was his hospital life ; that na
other single part of his life compared in value to that.
Whether he has his four years' course or three years' course, I
look upon as comparatively unimportant. The student who-
has had two years' full course, and two years of good course,
and then has a hospital life of two years, is, in my opinion,
worth infinitely more than a student who has his four years'
medical student life and no hospital experience. I would not
be understood as raising a word against the increase in the
number of courses, except a word of warning ; but the hospi-
tal life I look upon as absolutely essential, if we would develop
the fine students that we have given M.D.s to. I see that
constantly year after year. They come into the hospitals as
internes well provided with the fund of knowledge that is
acquired by a student in a good medical college, but totally
unable to apply it, totally at sea as to what they like and what
they do not like, totally ignorant as to whether they are fitted!
for this specialty or that specialty ; and I see them go out of
the hospital fully developed, men that I did not expect it of in
the least, fine characters, able, self-poised, ready to attack
serious problems and fully prepared to become valuable mem-
bers of the profession. And I look upon this as so important
that I would make very large sacrifices in other directions to
encourage students to have this portion of time, a year and a
half or two years, allotted to them for life in a hospital. There
is something about the constant contact with the patients, the
constant feeling of responsibility, which is not too heavy to
crush, though heavy enough to strengthen, that develops the
man month after month with the greatest rapidity."
Report of the Red Cross. —According to the Lancet, October 3,
in the thirty-three years ending July, 1896, there have been
every twelve months on an average sixteen nations engaged in
hostilities ! On the other hand, the organization of the Red
Cross has multiplied its ramifications till even such powers as
Japan have fallen into line and become affiliated to the parent
society, showing an example which Spain, among other coun-
tries, would have done well to follow. Having allowed the-
Red Cross organization to lapse shortly after the Carlist war,
the Spanish government showed signs of a desire to resusci-
tate it, but as far as we can gather her suppression of the
Cuban revolt, with all its sanguinary, not to say ferocious,
incidents, has not yet been mitigated by Red Cross interven-
tion. The most interesting feature in the present report is the
anxiety Japan evinced to place her relief to the wounded on
the best footing known to civilization and to make the pro-
visions of the Red Cross available, not only for her own troops,
but for those of her antagonist. Not content with the meas-
ure of success with which its Red Cross organization was
worked, the Japanese government delegated M. Ariga to con-
1896.]
MISCELLANY.
1027
fer at Goneva with the central authorities of the society so as
still further to perfect the system which in the late war had
given so satisfactory an account of itself. In marked contrast
to the enlightened procedure of Japan, the Ottoman Red
Cross remained inactive during all those Armenian and Cre-
tan butcheries which have scandalized civilization, and when
remonstrated with for its inhumane supineness, urged that
the collisions between the Turks and their subject population
being matters of domestic, not international, import, were out-
side the competence of the Geneva Convention. When the
American Red Cross, having collected large funds for the
relief of the Armenian sufferers, sought to apply them to their
humanitarian purpose, it was met by the same objection as a
liar to its intervention, and Miss Barton, the highly efficient
and skilled president of the society's branch at Washington,
visited Geneva, on her way to Armenia, so as to learn from the
central authority how she could turn to the' best account the
relief funds placed at her disposal. She found she could
apply them only by way of "private benevolence," not as an
agent of the Red Cross ; and the account she gives of her work,
in a letter from Constantinople, is one of the most intensely
interesting features of the present report. Another important
section relates to the coming reunion of the powers which
signed the Geneva Convention, a reunion which will take place
at Vienna next year. Its predecessors have been five in num-
ber meeting first at Paris, then at Berlin, next at Geneva in
1884, then at Carlsruhe, and finally at Rome. One feature of
the Vienna meeting was to have been the extension of the Red
Cross organization to the calamities of civil life— earthquakes,
Hoods, mining explosions, conflagrations, and such like. It is
understood that this proposal has encountered opposition at
headquarters: but it would be interesting to know, in the
probable event of its being revived, on what grounds so mani-
festly humanitarian a development of an essentially humani-
tarian society is to be postponed to the Greek Kalends.
Army Medical School. The session of 1896 97 of the Army
Medical School, Washington, D. C, begins November 4, 1896
and ends March 12, 1897. The order of duties, as announced
in the program issued by Major Walter Reed, Secretary of the
Faculty, calls for instruction in the pathologic laboratory, daily
except Sundays, from 9 a.m. to 12 m. ; in the chemic laboratory
from 1 p. m. to 2 :50 p. m. ; and attendance at lecture 3 to 4 p.m.
On Saturdays instruction in Hospital Corps drill and first aid
is given at Washington Barracks, D. C, 9 a.m. to 10 :15 a.m. fol-
lowed by instruction in equitation at Fort Myer, Virginia, 11
a.m. to 12 M. Lectures are to be delivered as follows : On Mon-
days, military medicine, by Colonel D. L. Huntington ; on
Tuesdays, military hygiene, by Major Charles Smart ; on Wed-
nesdays, duties of medical officers, by Colonel Charles D.
Alden and on Thursdays, military surgery, by Colonel W. H.
Forwood. The hours for operative surgery and optometry will
be anounced hereafter. Toward the close of the session Lieu-
tenant-Colonel Geo. B. Davis, Deputy Judge Advocate Gen-
eral, U. S. Army, Professor of Military Law at the U. S. Mili-
tary Academy, West Point, N. Y., will give a course on military
law. Dr. Robert Fletcher will lecture Monday, February 8,
1897, on the Army Medical Library and the methods of utiliz-
ing it. Clinical instruction will be given on Fridays November
13 and 27 and December 11, 1896 and January 15, 1897 at the
Government Hospital for the Insane, Washington, D. C. Pro-
fessor C. W. Stiles of the Department of Agriculture' will lec-
ture on Fridays, beginning January 30, 1897, on Parasites in
Man. There will be no exercises at the school on Sundays,
Thanksgiving day, December 25 to January 1 inclusive and
Washington's birthday.
Hypnotic Anesthesia. — Milne Bramwell concludes an article on
this subject in the Anesthesia Jubilee number of the Practi-
tioner with the remark : "The chief objection to hypnotism
in surgery is the difficulty and uncertainty in the induction of
the primary hypnosis. Susceptibility varies widely. Recent
statistics show that about 94 per cent, of mankind can be
hypnotized. With a considerable proportion, however, many
preliminary attempts are necessary, and sometimes hypnosis
never becomes deep enough for operative purposes. As an
almost invariable rule the nervous and hysteric are the most
difficult, the healthy and the well balanced the easiest to influ-
ence. Some years ago when in general practice, I could usually
rapidly induce hypnotic anesthesia among my own patients.
Now when my practice is confined almost entirely to those suf-
fering from chronic nervous affections, I find it more difficult
to obtain deep hypnosis with insensibility to pain. Under
these circumstances, unless grave reasons existed for the non-
employment of other anesthetics, I should consider it a waste
of time to attempt to hypnotize a patient for operative pur-
poses alone. Apart from this, hypnosis possesses many advan-
tages : 1. Once deep hypnosis with anesthesia has been
obtained, it can be immediately reinduced at any time. 2. No
repetition of any hypnotic process is necessary, the verbal
order to go to sleep being sufficient. 3, The hypnotizer's
presence is not essential. The patient can be put in touch
with the operator by written order, or by other means pre-
viously suggested during hypnosis. 4. No abstinence from
food or other preparation is requisite. 5. Nervous apprehen-
sion can be removed by suggestion. 6. Hypnosis is pleasant
and absolutely devoid of danger. 7. It can be maintained
indefinitely and terminated at will. 8. The patient can be
placed in any position without risk, a not unimportant point
in operations on the throat and mouth, and will alter that posi-
tion at the command of the operator. Gags and other reten-
tive apparatus are unnecessary. 9. Analgesia alone can be
suggested and the patient left sensitive to other impressions—
an advantage in throat operations. 10. In labor cases, the
influence of the voluntary muscles can be increased or dimin-
ished by suggestion. 11. There is no tendency to sickness
during or after the operation, a distinct gain in abdominal
cases. 12. Pain after operation, or during subsequent dress-
ings, can be entirely prevented. 13. The rapidity of the heal-
ing process, possibly as the result of the absence of pain, is fre-
quently very marked. He adds that numerous operations
during hypnotic anesthesia have recently been reported. The
following are a few examples. France : Dr. Schmeltz, carci-
noma of breast ; Dr. Bourdon, uterine fibroid ; Dr. Taillaux,
colporrhaphy. Germany : Dr. Grossmann, fractures and dis-
locations. Sweden : Mr. Sandberg, dental operations. Switz-
erland : Professor Forel, cataract. Cuba : Dr. Diaz, dental
operations. America : Dr. Wood, necrosis of humerus. Hol-
land : Drs. Van Eeden and Van Renterghem, dental opera-
tions. Many painless confinements, mostly primiparous, have
been recorded in France by Drs. Mesnet, Dumontpallier and
Fanton ; in Germany by Dr. Von Schrenk-Notzing ; in Austria
by Dr. Prtizl ; in Belgium by Professor Fraipont ; in Switzer-
land by Dr. Dobrovolsky ; in Sweden by Dr. Wetterstrand :
in England by Dr. Kingsbury, etc.
Hospitals.
Plans for the New St. Alexis Hospital at Cleveland, Ohio,
are now completed and the ground has been broken. The
monthly report of the Rochester (N. Y.) city hospital shows the
number of patients admitted during the month of September,
72 ; discharged 60 ; deaths 9 ; remaining in hospital 70. In
the will of Maria G. Carr, the testatrix provides that $20,000
of her estate shall go to the Presbyterian Hospital of Chicago,
for the purpose of erecting an annex to be known as the "Dr.
Wilson Carr Memorial." $2,000 is to go to the Home for the
Friendless, $100 to the Humane Society, and $1,000 to the
Chicago Historical Society. The board of governors of St.
Mary's Hospital at Passaic, N. J., haVe decided to modify the
1028
MISCELLANY.
[November 7, 1896.]
plans for the proposed new hospital on account of the exceed-
ingly high bids received from various contractors.
Washington.
Weekly Report of the Health Officer.— The weekly
report of the health officer for the week ended October 24 is as
follows : The health of the city underwent an improvement of
5 per cent, during the past week as compared with the week
previous. The deaths as reported at the health department
were 110, with a death rate of 20.37. In the week before they
numbered 116, with a rate of 21.48, and in the same period
last year 119, with a rate of 22.46. The mortality from typhoid
fever fell from 10 to 3, and that among children under 5 years
old from 35, with a rate of 0.12, to 25, with a rate of 0.09, while
that from diphtheria increased from 5 to 8. Except these no
disease was prevalent in noticeable form. Acute lung diseases
remained stationary; heart and kidney affections showed a
moderate increase and brain disordersa corresponding increase.
New cases of diphtheria 12, cards removed 14, remaining 28 ;
scarlet fever 4 new cases, no cards removed and 8 remaining.
Public Health Committee.— At the meeting of the Com-
mittee on Public health of the Washington Board of Trade
held recently, the committee agreed to adopt and recommend
the report of last year. The chairman of the committee, Dr.
S. C. Busey, called attention to the fact that the board of
trade as a board did not secure the adoption of any of the
recommendations of last year, but that the medical practice
act, the milk act and the act requiring the connection of all
houses with sewer and water, had been passed through the exer-
tions of the Public Health Committee of the Medical Society.
Dr. Busey. is chairman of that committee also.
Decision in the Case of Alleged Violation of the Milk
Regulations.— Judge Kimball on the 31st ultimo rendered his
decision in the ease of a dairyman charged with violating the
milk regulations which were made by the District Commis-
sioners. It was charged that he failed to keep his cows
clean and that he also failed to provide the feeding boxes
required by the regulations. The point had been raised that
the commissioners had not the power to make the regulation.
The proof was heard several days ago, and the court held
that the commissioners had exceeded their authority in requir-
ing that certain troughs and feeding boxes should be used.
The court held, however, that the commissioners had the right
to require dairymen to keep their cows clean and suspended
execution of sentence in the case.
The Episcopal Eye, Ear and Throat Hospital.— A meet-
ing was called on the 26th ultimo to organize an ear and
throat hospital under Episcopal auspices. Dr. E. O. Belt
read an appeal for such an institution signed by Drs. Samuel
C. Busey, J. Ford Thompson, Thomas C. Smith, G. Wythe
Cook, William W. Johnston, Frank Hyatt, George N. Acker,
N. S. Lincoln, William H. Hawkes, Robert Reyburn, H. C.
Yarrow, T. Morris Murray, R. W. Baker, C. D. Hagner,
Henry D. Fry, John H. Mundell, T. B. Hood, J. H. Bryan,
J. Taber Johnson, William Mercer Sprigg, William H. Fox,
S. S. Adams, W. Lindin Bowen, T. V. Hammond, I. C.
Rosse, J. S. McLain, W. H. Wilmer, John Van Rensselaer
and E. Oliver Belt. The members present adopted the project
and the board of governors and managers will consist of several
members from each Episcopal church in the District of Colum-
bia ; the first medical board to comprise Drs. T. Morris Mur-
ray, J. H. Bryan, William H. Fox, William H. Wilmer, Frank
Hyatt and E. Oliver Belt. There are also to be three con-
sulting physicians, Drs. S. C. Busey, W. W. Johnston and J.
Taber Johnson, and three consulting surgeons, Drs. N. S.
Lincoln, J. Ford Thompson and J. W. Bayne. There will be
an indoor and outdoor department, the latter a free dispen-
sary, open daily except Sunday. The indoor department will
tions and special nursing. The institution is to be supported
by annual subscribers, and memorial beds may be endowed by
persons who are anxious to perpetuate a good charity in
commemoration of a departed relative.
Estimate for the Health Department for the Ensuing
Year. — For the health department for the ensuing year the
commissioners recommend an increase of six clerks, two of
whom shall act as sanitary inspectors and food inspectors at
$1,200 each per annum. Six additional sanitary and food
inspectors, who shall also supervise the collection of garbage and
dead animals, are estimated for at 8900 each. A new engineer
for the smallpox hospital at 8900 is asked, as well as a clerk,
who shall be a physician and act as chief of inspectors and
deputy health officer at $1,800 per annum. A sanitary and
food inspector to assist the chemist at $600 is urged, and 8500
is asked for the support of the chemic laboratory. For the
enforcement of the provisions of the act to prevent the spread
of scarlet fever and diphtheria $6,000 additional is asked,
making a total appropriation of $11,000. For the establish-
ment and maintenance of a bacteriologic laboratory the com-
missioners estimate $5,000. The commissioners renew their
estimate of last year of 815.000 for the disposal of the general
refuse of the city. An estimate of $50,000 for the purchase
of a site for a hospital for minor contagious diseases is
urgently recommended, and $25,000 is asked for the erection
of a hospital for the treatment of scarlet fever and diphtheria.
Support for tbe Poor of Paris.— The annual budget for the
Assistance Publique amounts in round numbers to the large
sum of $8,000,000. Of this amount the surgical and medical
personnel receives $200,000.
THE PUBLIC SERVICE.
Army « hangex. Official List of changes in the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Oct. 24 to Oct. 30, 18%.
The following named recently appointed Asst. Surgeons will repair to
Washington, D. C. and report In person Nov. 4, 1886, to the president
of the Army Medical School, for the course of instruction pres.
in general orders No. 78, Sept. 22, 1898, from A. G. O. : First Lieut.
Basil Hicks Dutcher, First Lieut. Leigh Austin Fuller, First Lieut.
Franklin Middleton Kemp. First Lieut. George Alfred Skinner, First
Lieut. Carl Roger Darnall, First Lieut. William Kvans Richards.
Change of Addrem.
Battell, J. G., from Haymarket Thea. Bldg., to cor. Grand and Western
Aves., Chicago.
Carson. J. R„ from Henderson to Waverly Place, Nashville, Tenn.;
Cody, E T..from Chicago, 111., to Tucson, Ariz.
Earll, R. W., from Columbus to 11115 Cedar Street, Milwaukee, Wis.
Hayes, H. L., from 1410 Rhode Island Avenue, to 113 First Street, N. E.
Washington, D. C.
Lyen, J. B., from Kirkwood to Salvisa, Kv.; Lebensohn, M. H., from
Chicago, 111., to Sunbright, Tenn.
Moses, T. F., from Urbana, Ohio, to Worcester Lane, Waltham, Mass.;
McBride, M. A., from Leesville. Texas, to New Orleans, La.
Winterberg, \V., from 1132 to 1208 Sutter Street, San Francisco, Cul ;
Wunderlich, F. W., from 145 State Street to 168 Remsen Street, Brooklyn,
New York.
LETTEKN RECEIVED.
Abbott Alkaloid Co., Chicago, 111.; Ashmead, A. S., New York, N. Y.
Bailey, William Curtiss, Las Vegas, N. M. ; Brown. F. F., Advertising
Agency, New Y'ork ; Bishop. \V. T.. Harrisburg. Pa.; Baker, Philip s
Greencastle,Ind.; Beegle, H. B., Blue Island, HI.
Columbus Phaeton Co . Columbus, Ohio; Cook, S. E., Lincoln, Neb •
Craig, G. G_ Rock Island, III.
Dvorak, W. J., Chicago, 111.
Fenn, C. M., San Diego, Cal.: Fehr. Julius, Hoboken, N. J.
Haralson, H. H., Biloxi, Miss.; Hummel. A. L., Adv. Agency, New
York, N. Y. ; Hannam, A., London, England; Heidner, G A., West
Bend. Wis.
Kreider, George N., Springfield, 111,
La Semaine Medicale, Paris, France.
Merrick, M. B.. Passaic. N. J.; Moyer, Harold N., Chicago, 111. ; Manley,
Thos. H., New York. N. Y.; Mulford, H. K.. Co., Philadelphia, Pa.; Mc-
Allister, E. B., Terre Haute, Ind.; Meehem Investment Co., Colorado
Springs, Colo. ; Mather, A.. Paterson, N. J.
Oakland Chemical Co., New Y'ork, N. Y. ; Open Court Publishing Co
Chicago, 111.
Risley, S IX, Philadelphia, Pa. ; Rothgeb, H. D.. East Lynn, 111.
Savage, G. C, (2) Nashville, Tenn. : Steiger, E. & Co., New Nork, N. Yr. ;
Spencer. John C. San Francisco, Cal.
Thomas, John D„ Washington, D. C; Tyson, James, Philadelphia, Pa.;
Team, J. W.. Ridgeway.S. C.
be the hospital proper, with beds for those requiring opera- cI^5n,elrB»^rS: tt'^flfS^fttttSffSk.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., NOVEMBER 14, 1896.
No. 20.
ORIGINAL ARTICLES.
A FEW PARAGRAPHS ON AFFECTIONS OF
THE LACHRYMAL APPARATUS.
liV WILLIAM B. MEANY, M.D.
MEMBKR OK TBI AMERICAN MEDICAL ASSOCIATION, ETC.
ST. LOUIS, MO.
It will be apparent to any one who is at all familiar
with the anatomic conformation of the lachrymal pas-
sages, that certain shaped appliances fashioned from a
practically unyielding metal, under the name of lach-
rymal probes, do not meet the requirement for the
purpose they were designed.
We have evidence at every hand of the great injury
following the passage of the probe, and the difficulty
of effecting a cure for obstinate cases of epiphora, due
to obstruction of the lachrymal canal.
The "slitting up" or destruction of the puncta?
anil canaliculi, for frequent probings, the indiscrimi-
nate " plunging " and " twisting " of a bistoury or a
sharp double-edged Graefe cataract knife into the tis-
sues of the nasal duct, the application of caustic,
tissue-destroying agents, have not only signally failed
to effect a cure but, in the majority of cases, have
entailed future discomfort and irreparable damage,
with little or no permanent benefit to the patient.
Disease at the worst can only destroy tissue.
What is needed in an inflamed mucous membrane,
with a hypersecretion of mucus and pus, is something
that will coagulate albumin; coagulation of the dis-
charges, taking care to keep the processes in operation
for a short time, carefully and frequently removing the
coagulated matter, will not fail to arrest the progress
of the disease.
The patency of the lachrymal passages is as essen-
tial as that desired in the urethral canal, and in some
particulars the environment of the lachrymal appara-
tus requires a perfect condition for the performance
of its normal functions.
Simple obstructions from catarrhal inflammation
require only a little care in the toilet of the lachrymal
apparatus.
When the tears begin to flow through their natural
conduits, and are poured out in the right place, in
quantity suitable to the need, their useful and multi-
ple office is performed in a way so simple and perfect
that no art, however skillful, could equal it; no anti-
septic lotion is as free from extraneous particles, or
holds in combination better remedial agents than this
secretion; why. then, practice meddlesome and need-
less interference? We will find by careful inspection
that preexisting catarrhal inflammation in the nasal
fossa? is responsible, in a majority of instances, as the
original cause of the trouble in the lachrymal canal;
its extension is easily facilitated owing to the continu-
ity of structure.
An ordinary Schneiderianitis has been known to
produce more or less discomfort of the patient, by the
further involvement of the mucous membrane lining
the lachrymal canal, not only affecting the inferior
end of the nasal duct and sac, but extending to the
canaliculi, through the puncta?, producing irritation in
the ocular and palpebral conjunctiva?. In obstruction
of the lachrymal passages due to inflammatory dis-
turbances, the palliative or antiphlogistic plan of
treatment should- obtain. Filling the nasal angle of
the orbit with warm saline, or saturated solutions of
boric acid, the gentle massage with the fingers of that
part of the face over the nasal duct and sac. so as to
afford sufficient aid to effect irrigation and drainage
into the nose will, in the majority of cases, bring
about a cure; and sometimes, if this simple plan of
treatment be adopted in chronic inflammation of the
sac, in conjunction with proper attention to the naso-
pharynx, no other treatment will be required, save in
debilitated subjects.
Chronic inflammation of the lachrymal sac, or
chronic catarrh, is of frequent occurrence. The symp-
toms are well known and need not be detailed here.
In the normal condition, the lining membrane of the
sac secretes only a little thin mucus, but when irri-
tated, the quantity of the fluid becomes increased,
and its quality changed ; the sac becomes distended,
and on pressure a clear and thick viscid fluid exudes
in many instances through the canaliculus. Accord-
ing to some, pus is rarely seen unless there is some
untoward irritation (such as may be produced by the
laceration of the membrane by injudicious probing),
causing ulcerations of the membrane.
As a rule, there has been some chronic inflamma-
tion preexisting in the lower part of the duct and
nasal fossa?, in most cases of chronic inflammation of
the sac; this having led to the contraction or closure
of the inferior orifice of the canal, and to this region
must the treatment be directed.
We have now to select a plan of treatment for the
removal of the cause of the trouble. By directing
our efforts toward the original catarrhal condition
involving the nasal fossa? and lower orifice of the duct,
and the introduction of solutions of boric acid, euthy-
mol, hydrastia, hydrozoUe, papain (and, should occa-
sion require it, the 1 to 5,000 bichlorid solution care-
fully instilled), using an Anel's lachrymal syringe for
the purpose, by gently inserting the nozzle through
the patent canaliculus into the sac.
Care should be taken to avoid over-distension of the
sac; this can be readily accomplished by emptying the
sac at frequent intervals of the fluid injected.
Another method of treatment, and one which can
claim prestige for a quarter of a century or more, and
has never been known to vary in any particular (save
recently the addition of cocain, that the patient may
be rendered insensitive to pain), and is employed by
many surgeons up to the present time, may be cor-
rectly described as follows :
1030
AFFECTIONS OF THE LACHRYMAL APPARATUS.
[November 14,
The inferior canaliculus is "slit up," a metal probe
is then passed down into the duct until it reaches the
inner wall of the sac, often with great difficulty and
the employment of much force; the patient complains
of severe pain, a little blood appears, as the mucous
membrane has been torn, and perforation of the mem-
brane follows and false passages are made.
A week elapses and the same performance is
repeated, and goes on from week to week, with some
form of a style, it may be of gold, silver or other
metal, yet they fail to prevent the formation of dense
cicatricial strictures in or below the sac; obliteration
or destruction of the lachrymal sac with caustics
accompanies this method of treatment.
An opening made externally through the skin down
to the sac, affords better facilities in the treatment,
and possesses many advantages over the passage of a
probe; a clean incised wound in this location heals
quickly and kindly, and the inflammation rapidly
subsides.
In cases of obstruction of the nasal duct where
there has been abscess of the lachrymal sac, occurring,
as it frequently happens, by inappropriate, or absence
of treatment, it is not uncommon to find external fis-
tulous openings just below the inner canthus. The
openings may be small or almost invisible, or at least
surrounded by an ulcerated area.
In such cases it is sometimes sufficient to cure the
obstruction of the nasal duct — the fistula healing
without treatment; more frequently, however, further
operative procedure is essential to the cure.
Formerly, it was considered good practice to pare
the edges of the fistula with a fine scalpel, but this
procedure often results in a visible and unpleasing
cicatrix in a conspicuous part of the face.
It has been my custom, for some years past, to use
the Volkmann's scoop to scrape away all unhealthy
and thickened tissue that may be in propinquity to
the fistulous openings and apply a pad of dry (sub-
limated) lint, or distilled water dressings.
When the surface to be scraped is small, this is
usually followed by rapid healing without a visible
scar; when the surface is large, it is customary to wait
a few days until the surface presents a red, granular
appearance, and then proceed to graft certain minute
portions of the skin taken from the patient's arm or
elsewhere.
These grafts spread out, and become a center of
new skin growths, to meet the in-growing circumfer-
ence of the patch, and usually in one week's time
from the grafting, the surface will be found to have
kindly healed, with only the slight redness which is
natural to new tissue.
These grafts grow rapidly, and thus materially assist
in preventing the contraction which otherwise follows
the healing of a wound ; by covering the wound with
gold-beater's skin the new growth formation may
readily be observed, and the scraped surface protected
from noxious atmospheric influences.
The canaliculi are occasionally obstructed with con^
crements of micrococcus masses that appear to have
found their way into the lachrymal canal from their
" home " in the buccal, naso-pharyngeal and laryngeal
cavities. The leptothrix buccalis, the chain and spiral
cocci, the streptothrix and pneumococci, have been
found in the lachrymal canal; this canal has ever been
a source of danger to the ocular and corneal conjunc-
tivae, as the starting-point for morbid growths — of
which we may include pterygium rather than the
acceptance of the internal deep-seated vibrio the-
ory— dangerous perforating ulcers of the cornea and
suppurative processes that have, in a number of
recorded cases, caused destruction of the eyeball.
The lachrymal canal is a fruitful source of infection,
and frequently transforms the best of operative pro-
cedures into disastrous failures.
No surgeon should neglect to carefully inspect the
naso-pharyngeal and lachrymal passages, and see that
morbid secretions in these passages are removed and
the passages rendered aseptic, before operating upon
the eye. When therapeutic measures, after a fair trial,
have failed to remove the obstruction, so as to admit
of proper drainage of the lachrymal canal, the intro-
duction of flexible rubber filiform bougies, the Eusta-
chian bougie, catgut and silkworm -gut ligatures, or
electrolysis may be resorted to.
There can be little doubt that a certain proportion
of cases of obstruction indicate a specific origin ; the
local treatment can be readily merged into the consti-
tutional. Should tumors, dacryoliths, deformed tur-
binates and morbid growths appear, the therapeutic
local treatment will in no way interfere with the adop-
tion of any surgical measures that may be required.
Electrolysis is more expeditious and free from
danger, and complications are almost nil, when com-
pared to the passage of probes, the wearing of vari-
ous forms of tubes or styles, nitrate of silver and
other caustics and powerful astringents.
By electrolysis, the site of its influence can be lim-
ited to the smallest point. The duration and extent
of its decomposing action is entirely under the direc-
tion and control of the operator.
The material to be decomposed by electrolysis in
stenosis of the lachrymal canal is not dense, and does
not offer great resistance, and therefore a battery com-
posed of a small number of cells is sufficient. A gal-
vanometer, however, is required for the purpose of
measuring the current, for different batteries have a
different electro-motor force; a difference also exists
in cells which have been recently charged, or which
have been in use for a long time.
Two to four milliamperes will be found a suffi-
ciently strong current to enlarge any narrow lachry-
mal canal. For stenosis of the lachrymal canals, a
probe made of platinum, small enough to be inserted
into the punctum, is introduced and passed along the
canal to the nasal duct; the probe is fitted into a
handle, which is attached to the negative pole of the
battery. A flat electrode, covered with some sub-
stance that will retain moisture, is connected with the
positive pole, which generally is placed on the back
of the neck, having been first moistened with salt
water. The handle of the negative electrode has a
mechanism for completing the circuit.
With four milliamperes the enlargement of the
canaliculus takes place in thirty seconds; no local
anesthetic is required.
In a few seconds after the circuit is closed the
probe, which was at first gripped tightly in the canal,
can be made to move backward and forward along the
canal with ease.
During the operation, a little froth collects by the
side of the probe and oozes out of the punctum ; this,
with a sharp stinging sensation, which lasts thirty
seconds, is the only discomfort the patient has to
endure.
The advantages attending this procedure are chiefly
due to the fact so little alteration or displacement of
1896.]
MATERNAL IMPRESSIONS.
1031
the normal channels is effected. By it we have the
means of increasing the lumen of the punctre and
eanaliculi without excessive stretching, which must
necessarily alter the conditions of the surrounding
muscular and other structures.
2602 Locuet Street.
MATERNAL IMPRESSIONS
I.V WM. P. BATMAN, M.D.
I'RKSIDENT 1NIMANA STATK MBMCAL SOCIETY.
LEBANON, IM>.
The definition of maternal impressions is that a
profound and sudden impression made on the
mother's mind may pervert or stop the growth, or
cause defect in the child with which she is pregnant.
Maternal influences over the young have been recog-
nized from the earliest history of man. The thirtieth
chapter of Genesis gives Jacob's policy whereby he
ue rich. He pilled the rods of green poplar,
hazel and chestnut and set them before Laban's herd
and by maternal impressions he colored enough of
the herd in ten or a dozen years to become rich.
And the next chapter tells us of Rachel's influence
over Joseph and Benjamin to impress the race of
mankind.
While this force has been recognized among all
nations of people, it is only in the last few years that
an attempt has been made to separate the truisms
from the superstitions on this subject. In fact if you
wanted the greatest superstition for ages, the one on
maternal impressions would linger to haunt the mem-
bers of each new generation.
There are two classes of defects which have been
attributed to these impressions: The perceptible or
bodily deformities, and the imperceptible or mental
defects. First, the perceptible or bodily defects, we
will verify by a few well authenticated cases:
I attended a multipara mother a few years ago, who
gave birth to an akephalous fetus. The head of the
child had no bones at the side and top part of the
cranium. The top of the head was even with the
superciliary ridges and auditory meatus, showing total
absence of a cerebrum. The scalp was complete and
well covered with hair. The child was well formed
and above the average in size. It was stillborn.
The mother believed the cause of this to be the caring
for a sick dog while she was in the third month of
pregnancy. But Prof. Rudolph Virchow of Berlin,
thinks that these cases are the result of hydrocephalus.
Dr. Joseph Haven reported the following case to the
Chicago Medical Society, Dec. 9, 1895: "Twelve or
fourteen years ago I was in attendance upon a family
in this city, one of whose members was a little girl
8 or 10 years old, extremely nervous and high strung,
who possessed an uncontrolable fear of dogs. Any-
thing in the canine race, even the picture of a dog
would distress her. Her mother, explaining the mat-
ter to me, said that while carrying the child in utero
she had been frightened by a dog, and that the girl
had inherited that fear. As the child grew older she
did not outgrow that tendency. During an attack of
typhoid fever, in her delirium she had frequent
visions of dogs, so that it was often necessary to em-
ploy narcotics to quiet her. The child grew up and
was married, shortly after which she became pregnant.
About the sixth week of pregnancy I was sent for in
a hurry. I found Mrs. D. hysterically excited. I was
told that in going out of the yard a neighbor's dog
jumped upon her and terribly frightened her. She
was put to bed, began to flow, and a miscarriage
seemed imminent. But she was tided over. I saw
her daily after that for some time. She assured me
that her child would be marked like a dog. I tried
to disabuse her mind of this idea. Time went on and
about the third month the same dog jumped on her
again and bit her in the foot, inflicting a slight lacer-
ated wound. It was some time before I could go to
the case and when I reached the house a miscarriage
had just taken place. I took possession of the fetus,
being careful that the mother should not see it. On
account of the peculiarity of the specimen I secured
the dog that, had been the occasion of so much
trouble, and to-night I show you the skull of the dog
which I would like to have you compare with the
little monster. Those who believe in the transmis-
sion of maternal impressions will get some consolation
from examining these specimens, and those who
believe such results happen as mere coincidences will
have to account for this freak as best they can."
Here is a case that occurred in the practice of my
colleague, Dr. J. C. S'utherlin of Ladoga. This case
differs from any that I have known or read of, the
impression being caused by an act of anger on the
mother's part. At about the fourth month of preg-
nancy she was insulted by a minister. She was get-
ting a meal at the time and was in a perfectly good
humor, but happened to have a large knife in her
hand. The minister had his right hand, palm down,
resting on a table. The insult was unexpected and
made her so intensely angry that she struck at his
fingers with the knife, fully intending to cut them off,
which fortunately missed the culprit and left him
unharmed. A female child was born with the ends
of the fingers amputated on the right hand, the same
hand the mother used in striking.
One of the most striking cases reported is that of
Dr. Addenbroke, British Medical Journal, May 13,
1871. "Two women, sisters, both at about the third
or fourth month of pregnancy, were assisting their
mother, who was an invalid, to night stool, when she
was suddenly paralyzed on one side. The daughters
were greatly shocked, and at full term each gave birth
to a child with facial paralysis on one side."
We could go on and multiply cases well authenti-
cated showing how these impressions have marked the
skin, pierced holes in the ears, maimed and deformed
the extremities, injured the arterial and nervous sys-
tems, indeed, caused malformations in every organ and
part of the body.
Professor Rokitansy, the great pathologist, says
that mental emotions do influence the development of
the embryo. He also refers to the frequent anomalies
of vascular system caused by them.
The period of pregnancy is most liable to impres-
sions for bodily defects in the third and fourth
months. There may be an excess as well as an arrest
of development. Some of the imperceptible or men-
tal impressions are very hard to discriminate from
certain hereditary traits. Now, there is no doubt that
sudden or prolonged impressions on the mother's
mind will cause bodily defects. How easy it would
be to derange the soft pulpy brain structures with its
thousands of delicate cells and pervert their action
for future use, thus giving us more evidence for char-
ity to our weaker members of society. How well I
remember this statement from an intelligent, proud
society woman of Crawfordsville. She raised two
boys and they were both affected with alcoholic dip-
1032
EVOLUTION OF GIRLS.
[November 14,
somania. One studied law with Lew Wallace, who
said he possessed a bright mind and was gifted with
oratory. The other was a most efficient clerk and
salesman. They spent a fortune and both died a pre-
mature death, slaves to their appetite. This mother
told me, with tears in her eyes, that she could never
blame the boys like others, for she craved whisky
while carrying both of them, till she would weep with
agony. The father was an excellent man morally,
and accumulated a fortune by his own work.
James I. would pale at the sight of a drawn sword,
alleged to have been caused by his mother, while
pregnant, seeing Rizzio cut down.
One of France's bravest generals, whose courage
Napoleon said was the best, became pale and tremu-
lous when he saw a sword, caused by his father in a
fit of jealousy trying to kill his mother.
The following is what the Commercial Tribune B&y§
about the child murderer, Carl McElhinney of Dalton,
Ohio: "The question, is the boy morally responsible,
remains unanswered. Half a dozen physicians of
this and the surrounding towns have labored in vain
to solve the mystery of Carl McElhinney's peculiar
brain. At a consultation of two physicians, it was
decided that the child murderer was not, and is not,
mentally deranged. Further facts, however, were not
established. Dr. H. R. Bittern, one of the examiners,
propounded a theory based on anterior conditions.
Said he: 'This is only a theory, and is presented
merely to help a solution of the mystery of the men-
tal condition of seven-year-old McElhinney, and is
not to be taken as my final conclusion. I have some
belief in the inheritance of mental idiosyncrasies.
Both Mr. and Mrs. McElhinney were of sound and
healthy mind. However, at and before the birth of
Carl, I believe, Mrs. McElhinney's mind was not in
an easy, natural and normal condition. This might
account for Carl's singular mental formation. Before
Carl's birth Mrs. McElhinney was an assiduous
reader of novels. Morning, noon and night her mind
was preoccupied with imaginative crimes of the most
bloody sort. Being a woman of fine and delicate per-
ception, she appreciated to an extent almost equaling
reality the extravagant miseries, motives, villainies
set down in novels, so that her mind was miserably
contorted weeks before the birth of her child Carl.
The boy was an abnormal development of criminality.
He has a delight in the inhuman. It takes intense
horror to please this peculiar appetite. Murderer
Holmes was such a being, but even he did not show
his tendencies before maturity. I believe criminal
record does not show a case so remarkable as this.
As the boy matures these mental conditions will
mature. He is dangerous to the community, and I
doubt that even a severe schooling in one of our
severest reformatories would better his condition.
However, by all means, he should be sent to one."
Wars or any tumult in society that may excite fear,
anxiety or grief in pregnant women are dangerous.
The instance of idiotic and stillborn children to the
number of one hundred being born near the great siege
of Landou in 1793. proves this.
We, as scientific physicians, who Dr. Victor C.
Vaughan says are one hundred years in advance of
the politician, should teach our patrons how to care
for our pregnant women, and the danger from mater-
nal influences. The Spartans bred warriors, and I
believe this generation can breed a better people.
One of the future advances to help the generations to
come, will be to teach them the power of maternal
influences, with better care of our pregnant women.
This, with a proper knowledge of the dangerous
hereditary diseases in marriage, will strengthen the
human race.
EVOLUTION OF GIRLS.
Read in the Section on Diseases of Children, at the forty-seventh
Annual Meeting of the American Medical Association.
held at Atlanta, Ga., May 5-8. 1896.
BY HARRIET E. GARRISON, M.D.
DIXON, ILL.
The question whether man has ascended from the
monkey or descended from "a little lower than the
angels" does not matter in the present discussion;
also whether women have passed to a higher or lower
plane in the evolution of our higher woman; whether
it is a higher sphere to wield the keen, logical brain
of a Maria Mitchell or to be the mother of a host of
well trained sons as Cornelia, is not pertinent to the
present subject. For the reason that popular opin-
ion, before which we all fall prostrate, says woman's
brain, whatever its capacity, must be made to hold a
certain amount of book lore which we call an educa-
tion. Sometimes when we have this erudition applied
we think with the poet, "Knowledge comes, but wis-
dom lingers."
"Go on to perfection" is the motto written above
every scientific laboratory door ; and one of the most
weighty problems for the scientists now to solve is,
how can the little tiny mite of brain force, which has
just given its first feeble wail of protest against the
tremendous activity of the nineteenth century, be
evolved into the vast intellect which she must have
when she becomes a higher women, with the least loss
of nerve force?
The majority of our women are the victims of nerve
exhaustion, flow can it be prevented? If child
nurses can only be taught to watch the promptings of
nature and assist her in her work the task of develop-
ing infancy into perfect womanhood would be a com-
paratively easy one. But the mother usually wastes
all her nerve energy in useless repining from the time
that she believes a new spark of life has been kindled
until the anguish she dreads has been endured, or she
is spending it in a vain effort to have a perfect child.
One of our very highest women, a university grad-
uate, said to me when I was called to prescribe for
her three- weeks-old baby, "I was so anxious to have
my child well born that I studied and practiced every
detail of diet and mental gymnastics laid down in
tokology and several kindred works, but I almost died
when baby was born, and here he is, as you see, con-
tinually unhappy. He has been fed at the breast
under the guidance of a trained nurse recommended
by my physician, and her regimen has been very
exacting. The only time the child seems comfortable
is when he is disrobed for his bath, although the
clothes have been made and are worn according to the
directions sent out by one of the largest sanitariums
in the country." "Well, my dear madam," I replied,
"you were so anxious to have your child well born
that he has gone clear back to the state of primeval
innocence of the Garden of Eden. If you had rested
your brain by pleasant reading, eaten what was whole-
some and nourishing, in reasonable quantities at
accustomed times, and then allowed nature to care
for it without spoiling her work by torturing yourself
with imagining that the food would injure you or
1896.]
EVOLUTION OF GIRLS.
id:;;;
your child, and had kept your physique in good con-
dition by light, agreeable exercise, most of it taken
in the open air, or, as a resume, taken life easy and
trusted in Providence, you might have stored up
sufficient nerve force to have made your labor more
easy and your child would certainly have been in as
good condition as he is now; and my experience
says lie would have been in a better condition than
he now is."
The purpose of this article is not to call attention
to the clothing and diet necessary to develop healthy
girls, but to point out some of the things which
have been overlooked in their evolution.
Wo will now glance at some of nature's indications
for development. The cells which control the higher
attributes are located in the anterior lobes of the
brain, while those which control the animal functions
of the digestion and motion are in the posterior or cen-
tral part. The natural mechanism of labor compresses
t he anterior lobes into the smallest possible space, while
the other lobes undergo less pressure. This is made
possible by the largeness of the anterior fontanelle
as compared with the posterior. In this way nature
takes care of what is necessary for the child, and in
other ways provides for future development of the
higher attributes. Modern scientific investigation
teaches that for the first few years of life the brain
can be changed and the different attributes helped or
hindered in their development. Brain material, like
everything else, must have room to grow and there
can be no growth in a part that is compressed. It is
eisy to tell in almost every child, when a few months
old. by the shape of its head if it has been kept a
very long time in one position. The side or part
dpi in which it has been lying will be flattened. Nature
teaches that a girl is first a pronate, then a four-footed,
after which she becomes an erect animal. If the girl
is allowed to follow the dictates of nature the higher
brain will develop as she slowly evolves from one
type to another. But here our civilization steps in
and instead of allowing the embryo woman to develop
along nature's line and be allowed to squirm, kick
and roll through early infancy, she is forced into all
manner of unnatural positions by pillows and props.
As our girl is not allowed to develop the front brain
naturally, we must instruct our nurses to assist the
development by frequently placing her pronate with
the head lower than the chest. This can be done by
placing the child across the knees of the nurse with
the head projecting beyond and hanging slightly
down. This is the position which colicky babies so
much enjoy. Perhaps colic is due to the blood
being in the abdominal viscera when it should be
developing the higher attributes of the brain; hence
the relief when it is sent where it belongs.
The more cultured the family into which our girl
is born the less she is allowed to take the exercise
intended by nature for her proper development.
From birth she is held in as nearly an erect posi-
tion as possible and propped into a sitting posture
by pillows and that instrument of torture, the high
chair, in which so many weary hours of childhood
are passed. I frequently find little girls who have
never resumed the recumbent attitude, except when
asleep, since infancy and the mother says with pride,
"my little daughter never crept like common girls."
We hope in the future we will have more "common"
girls. When the child is sleeping she must be
crowded around with pillows for fear she might
attempt to use her muscles and roll over and give an
ungraceful kick when the nurse is not by to curtail
the movement. As soon as possible baby is placed
upon her feet and encouraged to walk to show how
smart she is. This craze for smartness is the curse
of this age.
In girls the evolution from one type of animal to
another should be made slowly, not alone to give the
higher brain a chance to develop by the pronate pos-
ture and the position required in creeping, which makes
the anterior lobes the most dependent part, but also
that the uterus and its ligaments may be properly
developed so that they may stand the strain brought
upon them when the girl assumes an erect posture.
From my study of the development of the uterus I
expect and have demonstrated by examination, that a
girl who has never learned to creep has a flexed or
infantile uterus. In creeping, the pelvis being higher
than the chest, the force of gravity carries the intes-
tines toward the diaphragm, and in this way pressure
is removed from the undeveloped uterus and it unrolls
and assumes the normal position. A girl naturally
creeps a little space, rises to her feet by some object of
support and then drops to her hands and begins creep-
ing again, in this way alternately relaxing and stretch-
ing the uterine ligaments. Could there be a more
perfect way to strengthen ligaments of any kind.
But our evolution has carried our girl through the
necessary kicking, rolling and crawling of infancy, on
the floor in winter and out of doors in the sand pile
or on the seashore in summer, to girlhood. She has
not been kept in one position long enough to allow
compression of any organ, and if for any reason there
seems to be a lack of development anywhere we have
used all means, by posture or otherwise, to send a good
supply of blood to more fully nourish the weak part.
We do not now seek to unduly develop the brain
to make her brilliant, as force-plants are short-lived,
but we urge her to rival her brothers in all out-door
sport which will develop vigor of limb and strength
of muscle, then she is as nearly fitted as possible to
enter the high school, to go through the cramming,
jamming process to reach what we call an education.
This process crushes out the lives of many of our
sweetest and best girls; but no matter, our school
system must be preserved at any cost.
Our evolution has developed our girl into such a
little perfect animal that she may endure (although I
wish it were otherwise) the strain of sitting on a
bench at a desk for long hours to have crowded into
her brain material which must be jammed out again,
because, forsooth, the brain is not large enough to
contain it all; and in the haste there is not time for
each cell to grasp the part which it should store,
before more is given it to do. Occasionally we find
a child whose brain will store all given it, but in most
cases it is a dismal failure.
Can not some social economist evolve a plan by
which the brain can be fed and developed to think
and reason without this great waste of nerve force?
Counting this loss alone the cost of our school system
to the State is something enormous, and not in any
way commensurable by the results attained. But if
our girl must go through this grind she must be pre-
pared for it in the best way possible.
To supply the higher brain so that it may not suffer
unduly we must suppress other nerve activity. A
great deal of nerve energy can be economized by
delaying the evolution from girlhood to womanhood.
1034
HIGH PRESSURE PROCESS OF TEACHING.
[NOVEMBEK 14,
This can be done by proper hygiene and medication.
All sensational literature should be excluded from a
girl's library.
Girls should become accustomed very young to
cold plunge baths. A few minutes' rest after returning
from school, lying down with the pelvis on a higher
plane than the shoulders, or in the knee-chest posi-
tion, minimizes the effects of the prolonged sitting in
the school room. Plenty of vigorous exercise in the
open air is needed to expel the school room dust and
carbonic acid and invigorate the blood by the deep
draughts of oxygen, which spirited exercise carries
into the remotest recesses of the lungs. We see no
reason why race running, rowing contests or ball
playing should be given over to the boys. In these
the element of contest adds more vigor to the game,
but in school contests which bring the girls at an
early age before the footlights there is no compensa-
tion for the undue excitement, and therefore is to be
deplored. If military drill is beneficial to the boy,
then it is doubly so to the girl, as her organs sustain
more injury if she does not walk right and carry her-
self properly, and the girl is in more need of the dis-
cipline, as one of the evils of the present method of
girl-raising is the absence of control. Bicycle riding
is yet too new an experiment for us to fully deter-
mine whether it would be beneficial to growing girls
or not. We think it might be if taken in modera-
tion and proper position, but it must be injurious
if carried to excess or taken in the stooping position
with an improperly arranged saddle. We can see
how it may be beneficial in developing self-control.
Girls are allowed to think it womanly to scream and
become hysteric at every trivial incident. If learning
to ride a bicycle will correct this it will have done
a grand good work.
Medication: If the lassitude and indisposition to
work, with the wearing pains which sometimes accom-
pany the evolution from girlhood to womanhood,
begins to appear, then use calmatives such as viburnum
prunifolium, cimicifuga racemosa, and above all I
have found helenin, the alkaloid of inula helenium,
especially valuable in controlling erotic excitement.
Above all teach the mother that it is not necessary for
her little immature girl to be subject to this nervous
strain every month, but that it is necessary that she
be kept strong and well.
DISCUSSION.
Dr. C. G. Slagle, Minneapolis— If the advice of that paper
were heeded we would have fewer delicate girls. Too much
novel-reading, too much "culture and refinement," as they
call it, causes too great strain on the nervous system. There
should be very little difference between the sports or pastimes
of girls and boys up to the age of 10 or 12. Until then the girls
should be allowed more freedom, within proper limits, than they
usually enjoy. Their nervous system should be better pro-
tected. This thing of forcing babies to be smart, forcing
development, intellectual development especially, is certainly
very dangerous. I think there can be no question that if most
of our nervous, weakly girls could be induced to use the bicycle
in moderation it would be very beneficial. The best article
upon this subject was written recently by a celebrated doctor
of London. He contends, bicycling in moderation, with the
proper saddle, in the erect position, is beneficial to most and
particularly to delicate women. In Minnesota, the climate
of which is generally considered very healthy, we have consid-
erable chloro-anemia. I find from the history they are too
passive, have been pampered and petted too much, allowed to
have their own way and not given exercise. Their energy is
gone, if they ever had any, so you can not induce most of them
to ride the bicycle. They want to lie in swings and read light
literature. Their is something about higher civilization par-
ticularly enervating to girls.
Dr. Edward H. Small, Pittsburg, Pa. — If any of your
patients, particularly girls, speak to you about bicycling, tell
them to always have the handles at least two inches higher
than the seat, then the rider can not lean over. Tell the girls to
keep their arms well back and then their chest can not be hin-
dered in development. In Pittsburg most of the girls ride
bicycles, skate, etc., and chloro-anemia is not frequent.
Dr. A. C. Cotton, Chicago — I have not thought before of
the children developing the anterior lobe by creeping on the
hands and feet. Often the baby is undoubtedly relieved of
some discomfort by being laid over the knees with the head
dependent. Yet you know you can hold the baby to the
shoulder and by applying pressure over the abdomen the pain
will be relieved.
Dr. Harriet E. Garrison, Dixon, 111. — I hoped to be able
to present some photographs of children I have been develop-
ing along this line. They have very well developed heads. This
should not be overdone, but there is certainly a great deal in
the position of the child in early life.
HIGH PRESSURE PROCESS OF TEACHING
IN OUR PUBLIC SCHOOLS CONSID-
ERED FROM A MEDICAL
STANDPOINT.
Kead in the Section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association, held
at Atlanta. Ga., May 5-8, 1896.
BY W. H. SHORT, M.D.
LA UEJMiK, INI).
There are different temperaments and organizations
in our school children, and of necessity it would be
impossible to adopt any method of teaching that
would reach all in a satisfactory manner; no one
course or routine would be perfectly satisfactory to
the highly nervous child and apply equally to the
lymphatic and sanguine temperament. But we ought
to be able to so conduct our schools that we may do
the greatest good to the whole number.
Our present school system is a high pressure pro-
cess with a constant tendency to add more branches,
so that little children have five or six studies and with
department method, as many teachers. Children of
eight or nine years of age are urged to high intellec-
tual effort and are expected to master studies which
a few years ago were only attempted by children four-
teen or fifteen years old. Are we thus doing the best
for the coming men and women?
We have certain unmistaken effects among our
school children, and there must be a cause. Who
originated such an elaborate course and what was
the object?
It evidently was not by those who were competent
to judge of a growing child's endurance. Writers
and publishers of our text books are influencing our
legislatures to inflict such herculean tasks upon the
youth of our land. We readily see why this course is
being adopted so generally. Shall we stand idly by
and allow the children to be thus wrecked mentally
and physically ?
Can a little child study five or six branches mid
comprehend them ? And if he can not and is over-
sensitive, will it not affect his nervous system and
secondarily his whole organization?
Can the scholar develop into a well organized being
by thus overpowering the child with so much brain
work? We have often observed this trying ordeal
among the nervous class, during monthly examinations;
the scholar becomes restless at night, fails to take suffi-
cient nourishment, becomes constipated, complains of
1896.]
A CASE OF DOUBLE EXOPHTHALMUS.
1085
being tired with a constant headache which in its
incipiency, is generally relieved by rest and out-door
life. There are many causes in and out of the school
rpom which have a tendency to increase certain dis-
eases, but our present sohool system increases nervous
diseases with all their horrors, often worse than death,
ami often close in the wake of disordered nervous
systems follow tuberculosis which ends the school
work of many who promise so much iu early life.
The highly sensitive are in great danger from over-
work, while those less susceptible do not worry and
thus retain their balance, recuperate and throw off
influence of school and studies, as soon as at play.
How different with the nervous child, who when over-
taxed can not throw off anxieties and is constantly
expending his nervous energy. We first have slight
ailments to treat, but soon the child does not recover
front his trouble so easily. The headache becomes
more persistent until we finally have congestion of
brain, epistaxis. increased digestive trouble with more
or less anemia. With the child thus affected his
work becomes more irksome and he now requires urg-
ing to keep up with the classes. Repeated attacks
soon produce a weakness of blood vessels and nerve
centers so that slight causes precipitates one of these
attacks.
Such children soon become restless and emotional
and easily excited or depressed. The girl is now in a
condition to be easily afflicted with hysteric trouble
which we have so often seen as a climax of school
pressure; and the boy thus goaded on does not fare
better, for he is in danger of resorting to habits that
endangers soul and body.
There can be no doubt that when the sensitive are
thus over-worked, we frequently have the epileptic
trouble developed. Even if we do not have such
serious trouble follow, many are so affected that they
are unhappy and unable to compete in life's great
battle. Many of our school children are obliged to
wear glasses and this is largely due to this same high
—are process.
The eye must have rest, and the child who is com-
pelled to work hard during school hours and until
late at night can not thus accommodate it. Thus, not
only one organ or function becomes involved by this
great strain upon the developing child but every part
of the organization is not only endangered but many
valuable lives sacrificed in order to satisfy a false
delusion called education. With the present tendency
to keep adding more branches each year to our course
of study we will have more irritable brains to treat
with all its sequelae.
Have any of our really great and strong men or
those who have achieved greatness been thus edu-
cated? Some of our greatest men only had a knowl-
edge of the common branches, until well matured, and
with some practical knowledge of life, a good physical
organization and an abundance of good common
sense were enabled to honor the highest positions
that fame and fortune could willingly and justly
bestow.
The present over-pressure process of teaching is
having a deleterious effect on our school children in
many ways. Not only is disease thus produced
directly but we are injuring their reasoning powers
in not allowing them to develop into strong physical
beings. A child thus overtaxed may arrive at man-
hood, or womanhood but will never be able to com-
pete with those who are allowed to develop mentally
and physically co-equal. The child who is carefully
taught only such branches as his mind can compre-
hend, and new studies undertaken only when he is
competent to understand them will, other things being
equal, accomplish more in the literary world or
achieve greater success in other spheres of life. He
will be saved untold suffering and not become a bur-
den to our commonwealth. If we continue to crowd
our children through the public schools without ref-
erence to their physical or mental ability we must
increase our burdens, for many are drifting into our
public institutions for treatment.
If we do not call a halt some will have to seek
knowledge in schools for the blind, others find refuge
in our asylums for the insane, while we will be
obliged to establish an institution for a class of ner-
vous individuals who will become so vacillating and
unbalanced, that society will not tolerate them.
We are having more cases of acute tuberculosis
among those who are lowered in vitality by this over-
pressure. They can not resist or throw off ordinary
diseases as they ought. As we observe so many fall-
ing by the wayside, unable to complete a satisfactory
common school course, owing to our present mode of
teaching, we are assured our system is too complicated
and obscure, and should be so remedied that all may
be enabled to take a course that will fit them for the
ordinary vocations of life.
Our teachers should be men and women who under-
stand human nature and be able to develop the schol-
ars' faculties without promise of reward or menace.
The child who is always on a high tension from
such influences can not do good work mentally and
is injured physically. If this high pressure process
continued through the growing child's education, it
must cause a great sacrifice to our coming men and
women. While if our school children are developed
by a judicious course they will attain the greatest
success in the various vocations of life.
As physicians and philanthropists we should inter-
est ourselves in this method of teaching and ascertain
if a better way is not feasible; and while trying to
remedy this great evil, not lose sight of the many
other causes that are working deleterious effects
among our school children. We assert that if the
children are allowed to develop co-equal physically
and mentally, and only as their delicate organizations
will permit, they will become stronger men and
women and thus help solve one of the great problems
of the coming century.
A CASE OF DOUBLE EXOPHTHALMUS.
Read in the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8. 1896.
BY H. BERT ELLIS, M.D.
LOS ANGELES, CAL.
At 1:45 p.m., Feb. 11, 1895, I was summoned to see
a man. The demand was urgent, as the patient was
"bleeding behind his eyes." Before 2 o'clock I
arrived at the place and found the patient on his back
on the floor, with blood trickling from both eyes and
ears. The right eye protruded from the socket,
beyond the lids; the left also protruded from the
socket, but the lids covered most of the ball, the pal-
pebral slit being open only about a quarter of an
inch. The intraocular tension of both globes was of
stony hardness and the pressure from behind on the
balls was so great they could not be made to recede at
1036
A CASE OF DOUBLE EXOPHTHALMUS.
[November 14,
all, and this pressure was so uniform that voluntary
movement of the eye in any direction was impossible.
The displacement was directed forward, the eyes look-
ing straight in front. Both anterior chambers were
filled with blood, completely obscuring the irides and
pupils. Blood was oozing from all portions of the
conjunctivae, but there seemed to be more hemorrhage
beneath that portion which lay in the horizontal
diameters of the balls, the most profuse being between
the external canthi and the corneae. It was my first
impression that there was a double aural hemorrhage,
as blood seemed to be flowing from both external audi-
tory canals. But neither the man's position nor con-
dition was favorable to a careful examination at the
time.
No evidence of traumatism had been found, except-
ing a slight bruise on the forehead where the man
had evidently struck the floor, when falling from the
lounge. I could find no signs of violence.
The history of the case prior to my arrival was
briefly as follows: Mr. M., aged 35 years, who had
been in the block some nine to twelve months, was
temperate and spent most of his evenings in his
rooms reading. For the past three weeks he had been
drinking to excess, and for ten days had been intoxi-
cated. On the 8th he commenced to sober off (taking
as he afterward told me 12 ounces of Fellow's hypo-
phosphites in two days). Becoming very nervous
and restless on the evening of the 10th, he called in
Dr. Clark, who administered \ grain of codein, which
produced a good night's rest. Monday morning, with-
out the knowledge of anyone, he sought the nearest
saloon, where he obtained whisky, the exact quantity
is not known, but it probably was not very much, for
at 12:45, when Dr. Clark called, he was apparently
sober.
At 1:10 p.m. he seemed quite well, but nervous; at
1:15 p.m. the people in the vicinity were startled by
loud and agonizing screeches. The proprietor of the
block at once summoned Dr. Clark, who was in the
building. They found Mr. M. on the floor, on his
knees and elbows, with a finger in each ear, shrieking
with pain. Blood was flowing, apparently, from both
eyes and ears, and the eyeballs were protruding. Dr.
Clark put him on his back and gave him a hypodermic
of morphin, \ grain. This quieted him in a few min-
utes. When I arrived his pulse was 150, regular, but
rather weak; respirations 16. At 2:30 he was given
another \ grain of morphin, his pulse dropped to 120.
He was quiet and his brain, at all times, was suffi-
ciently active to answer all questions intelligently, and
he retained perfect use of all his voluntary muscles.
The diagnosis was uncertain.
Fearing some exacerbation of pain or further hem-
orrhage, he was put to bed without being undressed,
and given 1 dram doses of fluid extract of ergot every
two hours, \ grain doses of morphin, to keep the pain
under control, and 1-100 grain doses of digitalin, hypo-
dermically, to slow and strengthen the heart's action.
Locally, hot cloths wrung out of boric acid solution
were applied.
At 4 p.m. I again visited the patient. At this time
both eyeballs were outside the lids, no motion of balls,
but on attempting to move them, there was the faint-
est movement of the left upper lid. Tension -j- 3,
hemorrhage the same as at first visit, an oozing from
the conjunctivae. An unsatisfactory examination of
the ears showed a perfect right tympanum and in the
left a mere point in the anterior inferior quadrant,
which looked as though it might be a perforation.
On the 12th the eyeballs were beginning to recede
and to soften a little. Another examination of the
ears was made, which decided that the point was not
a perforation but simply a spot between calcareous
deposits in the tympanum.
Until this point was decided I had not been able
to hazard a diagnosis, but with the decision that the
blood which apparently came from the ears was only
that which had flowed into them as it trickled down
the face from the eyes, I felt that the diagnosis was
simplified. At first I thought that there had been
an aneurysm of each of the orbital arteries which
had ruptured almost simultaneously, due to stimu-
lating effect of the whisky and strychnin.
In the second place, it was possible for an aneu-
rysm of the right orbital artery to exist just after it
branches from the internal carotid, within the cranial
cavity but extra-dural. This would cause pressure in
the right orbital cavity first and later in the left, as
the flow of the escaping blood would be in the direc-
tion of the least resistance. This theory as to the
origin of the trouble at once raised the question: If
the hemorrhage was intracranial why did we not have
brain symptoms, a slow pulse, impairment of motion
to some extent or in some part of the body, disturbed
sensation or a clouded intellect? Instead, we found a
rapid pulse, 150 at the time of the accident, 120 later
in the afternoon, 100 the next day. Motion was per-
fect and no disturbed sensation. His intellect, while
not at its best, was very far from showing indications
of a brain lesion. He would answer questions briefly
but clearly ; his memory, in so far as the accident was
concerned up to the 14th, was practically a blank.
From an anatomic standpoint, however, I believe it
would be possible to have an extra-dural hemorrhage
at this point, if the dura mater were sound, which
would cause pressure only within the orbital cavities.
On the morning of the 14th the eyes, although caus-
ing a hideous expression, had receded considerably,
had lost their great tension, and the conjunctivae and
corneae were breaking down, in fact, pus was present
in the anterior chamber of the left eye, but the man's
physical condition was growing worse. Fever in the
afternoon, pulse rapid and irregular, considerable dis-
tress about the orbits but not amounting to actual
pain; he was suffering most from his excessively ner-
vous condition.
I advocated the removal of both eyes at once and
performed a double enucleation on the 15th. After
the operation he began to improve in general vigor,
and March 9, about a month from the the date of the
accident, he started for his home in Ontario, wearing
a pair of "enamels" and feeling as well as he had in
years. A couple of days after the operation be gave
me the following history: He was a Canadian, single,
35 years old. His vision had always been good, but
he had suffered periodically from nervous headaches
and occasionally had severe pain in left side of head.
For six or eight years he had had an external and
internal pterygium of left eye. Occasionally he
became intoxicated and on such occasions both eyes
would become very much congested and the mucous
membrane seemed to extend out over the cheek, but
when he would abstain from stimulants his eyes would
become normal. One year previous to the accident,
while at Seattle, Wash., he had been on a protracted
spree, which ended in a condition similar to that for
which he sought Dr. Clark's services. He was then
18%.]
CAUSES OF GLAUCOMA.
1037
treated for acute mania and was restored to his normal
condition in a couple of weeks. After his attack in
Seattle he drank no spirituous liquors for a year, and
had on previous occasions abstained four or five years
at a time, for he had found by experience that he
could not use liquor at all without using too much.
Daring the past year he had been using Warner's
Sate Cure, thinking that his kidneys were out of
order. For the past throe months his health had
been poor; everything that he did required an effort
and ten days before the accident in order that he
might keep up with his work he took some wine. In a
few hours he was drunk from the amount of port wine
and whisky that he had imbibed, and for seven days
remained intoxicated, eating nothing: at the end of
that time he drank four bottles of ginger. He was
cold to his kneos, his jaws were set and lie could not
move his arms. After the first drink he seemed to be
irresponsible and had no idea of how time passed.
After the seven days* spree he stopped drinking abso-
lutely, but was troubled with hallucinations and illu-
sions, against which he struggled for twenty-four
hours. Sunday morning he was feeling so weak and
A. hemorrhage: B, choroid and retina; C, lens. Retina was also
found in hemorrhage.
miserable, with no passage of the bowels in five or six
days, he commenced on a bottle of Fellows' hypo-
phosphites and in twenty-four hours had used 12
ounces of it, which represented 1 3-5 grains of strych-
nin. Sunday night he was still feeling so distressed
that he called in Dr. Clark, who gave him sufficient
codein (I believe) to assure him a good night's rest.
Monday he was very excited, and when they brought
soup to him at 1 o'clock he would not eat because he
thought it was poison. While lying on the lounge
he had a spasm of the stomach and with the spasm a
blackness came over his eyes; he fell from the lounge,
but saw the carpet as he fell. He thought that he
had gone to hell and that his brain was full of little
devils. With the great pain of the spasm he lost
control of himself and he tried to get his fingers into
his brain through his eyes, but that caused so much
pain that he tried to reach his brain through his ears,
then he recollected nothing more till an hour and a
half later.
After the eyeballs were removed they were hard-
ened in Wickersham's solution and later in formalin.
They were carefully cut, stained and examined micro-
scopically by Dr. Alex. Bruce of Edinburgh. Both
the eyes were practically the same, and the accompany-
ing diagram is a drawing from one of the sections.
This shows the parts very much displaced, the aque-
ous and vitreous spaces filled with blood, subcon-
junctival hemorrhage and blood separating choroid
and retina from the sclera, with parts of the retina in
the hemorrhage. But this gives us no definite infor-
mation as to the cause of the accident. The patho-
logist after hearing the imperfect history writes that
"the condition was a result of a sudden thrombosis of
the sinuses, and of this condition I understand there
are some cases on record."
Personally, I am unable to explain the cause of the
conditions satisfactorily, although I incline to the
theory of his having gouged them out with his
thumbs or fingers, but if he did I do not understand
why the intra-ocular tension should have been so great.
If due to double aneurysm, why was there no aneu-
rysmal bruit and no pulsation, and if due to double
thrombosis of the sinuses why should there not be
more general disturbance?
REMARKS ON THE CAUSES OF
GLAUCOMA.
Read in the Section on Ophthalmology, at tno Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta. Ga.. May 6-8, 1896.
BY LEARTUS CONNOR, A.M., M.D.
DETROIT, MICH.
Judged by its literature, the causation of glaucoma
is unsettled. No effort to harmonize undoubted facts
has met with general support. Whether glaucoma is
a deformity or a disease, remains an open question.
Thus Priestly Smith and his followers- claim that
glaucoma is a deformity of the eyeball, that an engorge-
ment of the blood vessels in the posterior chamber
pushes forward the lens and crowds the ciliary body
and iris into the anterior angle, effectually blocking
the outlet from the eye for the intraocular secretion.
From the resultant intraocular tension he deduces the
phenomena of primary glaucoma. The failure of this
view to account for glaucomatous attacks in the young,
in persons having no iris, in cases of intraocular tumor
or dislocated lens, etc., has prevented, its universal
acceptance.
Of those holding that glaucoma is a disease, part
affirm that it is purely local; and part that it is the
local expression of a constitutional affection.
Von Graefe called simple glaucoma " amaurosis with
excavation," regarding it as quite distinct in origin
and course from glaucoma. Iridectomy failed to ex-
ert any appreciable influence upon its progress, in
contrast with its wonderful power in checking the
destructive force of acute inflammatory glaucoma.
Previous to his time glaucoma was regarded as a
local inflammation, and treated with antiphlogistics,
or as an arthritic disease ; the result was the same in
either case, viz. : total loss of vision. Not content
with the empirical fact that iridectomy would cure a
glaucomatous outburst, ophthalmologists have sought,
out its mechanism and the processes leading to it.
The questions raised by this study are most intricate,
far-reaching and difficult of solution. Thousands of
workers have each contributed something of a posi-
tive or negative nature, but much still remains undone.
The object of this paper is to briefly discuss a few
points bearing upon the causation of glaucoma.
1. An obstruction to the outward flow of the fluids
1038
CAUSES OF GLAUCOMA.
[November 14,
in the posterior chamber is the most uniform character-
istic of an acute glaucoma. Hence the importance of
a clear idea of the normal flow of these fluids, and the
changes made by the glaucomatous disease. The
course of the blood is readily determined, in health,
by the course of its vessels. Elaborate experiments
have seemed to show that the oblique course of the
efferent veins, through the sclerotic, combined with
such disease of the veins as partially occluded their
caliber, obstructed the outflow and so increased the
intraocular tension, but this view has not obtained
large recognition. That a variation in the caliber of
the blood vessels does occur in glaucoma is evident,
but all the facts seem to place these secondary to ob-
struction to the outflow of the secretions.
Knies, Webber and others have experimentally
shown that the aqueous is secreted in the posterior
segment of the eye and passes anteriorly through the
connective tissue of the circumlental space, Fontana's
spaces, Schlemm's canal, and the sclerotic into the cap-
sule of Tenon. In this course the outflow is through
connective tissue, and tissue matrix, not reaching
spaces lined with epithelium until it enters the cap-
sule of Tenon and the efferent lymph spaces of the
subconjunctival tissue. Knies has shown that dis-
solved substances may in addition pass through the
lens capsule and Descemet's membrane, but not formed
or solid matters. Posteriorly, he has shown that the
secretion of the posterior chamber escapes through
the connective tissue spaces of the optic disc. The
obstruction to the outflow of this fluid by a change in
its nature has been the subject of elaborate experi-
ments by Knies as detailed in Arch. Oph., Vol. xxiv.
Aseptic irritants were injected into the posterior
chamber, that formed coagula in the secretion
which obstructed the outflow spaces, producing an
increase of ocular tension, dilatation of the pupil, and
cloudiness of the center of the cornea. On removing
the eyes he found both anterior and posterior outlets
obstructed by the changed secretion. Hence he thinks
that glaucoma is an irido-cyclitis, that secretes a
noxious fluid, which clogs the meshes of the outflow
connective tissue spaces. Experimentally this change
of the secretion in the vitreous was temporary, but in
the irido-cycljtis of glaucoma, he thinks that the secre-
tion of noxious fluid is of longer duration and so the
symptoms of glaucoma longer continued.
The study of glaucomatous eyes which have been
removed, before total destruction, has shown an act-
ual change in the connective tissue spaces of the out-
flow channels. The fibers have been found thicker
and shorter, encroaching upon the spaces, and often
entirely obliterating them. It is not possible to
remove an eye in the early stage of glaucoma, or to
find one in a person dying of acute disease, but in
those studied nearest such a time, the changes in the
outflow spaces have been found. Other changes
have accompanied these, but we pass them for the
present as we desire to state the fundamental idea in
its simplest form. When we examine carefully the
persons having glaucomatous attacks, we find that in
many there is evidence of gout, either acquired or in-
herited; of rheumatic gout, rheumatism, syphilis, of
those whose entire bodies have been surcharged dur-
ing many years with badly assimilated products. In
many of these we find evidences of interstitial diseases
in other organs than in the eye. It is quite fair to
infer that the impure blood produced by these consti-
tutional diseases, may affect the Connective tissue out-
lets. Given then an obstruction of the connective tis-
sue outlets of the posterior chamber by an ophthal-
mitis affecting the connective tissue, due to impure
blood, and any one of the so-called exciting causes of
glaucoma may so change the secretion of the posterior
chamber as to clog the outflow spaces, and so induce
a glaucomatous attack. Our knowledge of general,
so-called, blood diseases, added to Knies' experiments,
and well-known studies of glaucomatous eyes, makes
a rational chain of events leading up to an attack of
glaucoma.
2. The following considerations place this causa-
tion of glaucoma in a clearer light. Thus outbursts
of glaucoma are most frequent during and following
middle life. This fact admits of two interpretations.
First, Priestly Smith argues, that the lens becomes
hardened and enlarged by age, so that it more entirely
fills the circumlental space. Farther, he thinks that
glaucoma occurs mostly in the hyperopic, in eyes in
which this space is already abnormally small. In such
an eye a relatively slight disturbance of the circula-
tion of the posterior chamber suffices to push the lens
forward, to crowd the iris against the anterior angle
of the eye and to prevent the outflow through Fon-
tana's spaces. The so-called causes of glaucoma,
according to this view, produce an engorgement of the
blood vessels of the posterior chamber, and so push
the lens forward, when owing to a deformity of the
parts the anterior angle is closed, and a glaucomatous
attack induced. Second, a broader view of the rela-
tions of glaucoma to age, adds to the changes in the
lens, changes found in other portions of the body.
One has but to make a very superficial study of indi-
viduals during and after middle life to find that all
the conditions are present for the promotion of con-
nective tissue degenerations, as well as vascular, secre-
tive and nervous. Individuals continue to eat as
when they needed food for growth and development,
as well as for the actual work of each day and the
maintenance of existence. This excess of food fails
to be perfectly digested, and so never becomes a part
of the living tissues, but is driven about the blood,
lymph and secretory spaces, in its course disturbing
the wholesome activity of each part. Secretion and
excretion are more or less disturbed, so that effete
materials are retained within the body, thus increas-
ing the disturbing and dangerous elements of the cir-
culating fluids. When the connective tissues have
been subjected for years to this constant irritation,
and auto-infection it is not surprising that there
results a group of interstitial or glandular diseases.
Certainly we ought not to be surprised, if a few among
the whole mass suffered from a degeneration of the
outflow connective tissue spaces of the posterior
chamber, and so became liable to an outburst of glau-
coma, when some especial cause rendered the secre-
tion of the posterior chamber, so noxious as to occlude
the contracted spaces.
Another factor of age, intensifying that already
mentioned, is the diminished muscular activity of
advancing years, by which the utilizing of excess of
food is diminished, secretions and excretions made
less active, and so the accumulation of impure blood
accelerated. Many other elements might be added, all
proving that impure blood is the vice of middle life,
a vice dependent upon numerous physical, mental and
moral factors, but all laying the. foundation for some
organic disease. Why in one, interstitial nephritis
occurs, in another interstitial hepatitis, in another
18%. J
CAUSES OF GLAUCOMA.
1039
spinal sclerosis, and in another that disease of the
connective tissue outflow spaces of the posterior
chamber, is unknown. Possibly the same individual
might have the entire list if he could live long enough.
Sine* diminished spaces in the connective tissues
of the outflow channels is the factor which makes
operative the so-called causes of glaucoma, then a
child may inherit from gouty or rheumatic parents
such diminished spaces, and so be attacked with
glaucoma.
3. But aside from age, certain diseases are certainly
closely allied to the causation of glaucoma. In sev-
eral reoeat papers Dr. Richey has admirably discussed
this point, showing the relation between the manifes-
tations of gout, gouty rheumatism, etc., and glaucoma.
He regards simple glaucoma as the basis of all forms
of primary glaucoma. In each an interstitial oph-
thalmitis exists, originating as other interstitial dis-
eases. The varied forms of the disease he ascribes to
the part of the eye attacked, the rapidity of its prog-
res- and the order in which different portions are
disabled by the disease.
In simple glaucoma the connective tissue in and
about the optic disc is first affected by the noxious
elements; contraction of the tissues follows, leav-
ing more or less extensive excavation of the optic
disc, and destroying in varying degrees the optic
nerve fibers. The central retinal vessels drop to the
sides of the excavation, and by their peculiar appear-
ance, when seen by the ophthalmoscope easily prove
the presence of the excavation. If in such a case the
anterior connective tissue spaces become constricted,
a slight disturbance of the secretion of the posterior
chamber may suffice to clog the outflow, and produce
a ease of acute, sub-acute or chronic inflammatory
glaucoma, according as the obstruction be sudden
and complete or slow and incomplete. The fluid pent
up in the posterior chamber pushes forward the lens
against the posterior wall of the cornea, the ciliary
hotly against the anterior angle; dilates the iris, ren-
ders it immovable and crowds it into the anterior
angle-, increases the tension of the eye ball; renders
the cornea steamy and insensitive; dilates the anter-
ior ciliary vessels, and induces a group of subjective
symptoms, varying with the stage and degree of the
blockage. In hemorrhagic glaucoma the events
already noted are complicated by the rupture of weak-
ened blood vessels within the posterior chamber.
In many cases of acute glaucoma there is no cup-
ping of the optic disc because its connective tissues
have not been attacked, the ophthalmitis being lim-
ited to the anterior outflow spaces. It would seem
that the relationship of chronic humeral diseases to
glaucoma is very important.
Dr. Jonathan Hutchinson (Oph, Rep., Vol. ii)
says that there are many different forms of inflamma-
tion of the eye, or parts of it, which are in connection
with gout and gouty rheumatism. He divides them
into two groups: 1. Those which go with acquired
humoral or renal gout. 2. Those which depend
upon inheritance of structures, damaged or special-
ized by gout in predecessors. The differences
between these two classes is very marked. In one
the attacks are of a transitory nature, acute and
attended with much pain. In the second group there
is great tendency to chronicity and persistence,
though there is a tendency to temporary recovery
and recurrence. The invasion is often insidious, but
the disease is usually in the end destructive. These
two groups admirably describe the characteristics of
acute and chronic glaucoma.
If we seek the mechanism by which these diseases
induce glaucoma we have but to remember that in
them the connective tissue outlets of the eye are con-
stantly bathed in the secretion formed from impure
blood, just as we found in the case of the over- fed, badly
fed, over- worked, under-exercised person of middle life
or beyond. In both the connective tissues of the
outflow spaces undergo organic changes that admit of
their readily clogging, as the secreting fluid of the
posterior chamber is altered by any one of the many
existing causes of the glaucomatous outburst. Dr.
David Webster (Trans. Amer. Oph. Society, 1885)
reports a case in which a glaucomatous outburst fol-
lowed a very hearty meal, and another from the eat-
ing of a peach. Dr. S. D. Risley reports a case in
which certain acid fruits would surely excite such an
attack, the special fruits were the peach and grape.
The one condition present in all cases of primary
glaucoma is a contraction of the outflow channels;
the one cause of this contraction is a hyperplasia due
to the long continued irritation of the secretions from
impure blood; the disorders inducing such blood are
many, to some of which we have called attention, as
the pollution incident to over-eating in middle life,
gout, gouty rheumatism, syphilis, etc.
The one factor which is essential to the precipita-
tion of an outburst of glaucoma is such a change in
the secretion of the posterior chamber that it will
clog the meshes of the outflow spaces. This changed
secretion may be due to many causes, as imprudence
in diet, to mental worry, violent emotion or shock; to
overstrain of the eye, as in uncorrected astigmatism
or presbyopia; to circulatory disturbances, as cardiac
weakness; chronic cough, vomiting, stooping or strain-
ing; to mydriatics, etc. No one of these events has
been known to induce, in a sound eye, an outburst of
glaucoma; otherwise they would be of common occur-
rence, because these events are incident to the course
of nearly every person's daily experience.
CONCLUSIONS.
1. Glaucoma is a disease rather than a deformity,
like hernia or astigmatism.
2. The disease glaucoma has two distinct factors :
one inducing changes in the connective tissues of the
body, including the outflow spaces of the posterior
chamber of the eye; the other so altering the secre-
tion of the posterior chamber that it clogs the crippled
outflow connective tissue spaces.
3. The first factor results from the long continued
action of impure blood upon the connective tissue
elements of the outflow spaces, the second from a
variety of conditions acting through the nervous
vascular, digestive and muscular systems, or through
local strain of the eye, as in presbyopia, uncorrected
astigmatism, or intraocular tumors, dislocated lens, or
from the use of mydriatics.
4. Impure blood may result from many distinct
diseases, as gout, rheumatic gout, syphilis, or from
chronic overloading of the body with food in excess
of its assimilative powers.
5. In simple glaucoma the connective tissue at the
optic papilla is so attacked as to induce an excavation
of the optic disc. If the anterior outflow space
remains patent, there may be no symptoms except
diminishing field of vision and the excavation, but if
the anterior outflow becomes obstructed, increase of
1040
QUESTIONS RELATING TO GLAUCOMA.
[November 14,
tension and other glaucomatous symptoms appear.
6. In acute inflammatory glaucoma the anterior
outflow spaces are suddenly closed, inducing all the
typical symptoms of a glaucomatous outburst.
7. In sub-acute glaucoma the obstruction to the
anterior outflow is less sudden and complete, and
hence the symptoms are less severe and startling.
8. In chronic inflammatory glaucoma the obstruc-
tion is more complete and permanent, and so the
effects are more hopelessly destructive — glaucoma
absolute marking the final stage when vision is totally
lost.
9. In hemorrhagic glaucoma the outburst is com-
plicated by rupture of weakened intraocular blood
vessels, so that hope of relief is slight.
10. In secondary glaucoma the same obstruction to
the outflow channels occur. This may be due to an
intraocular tumor, a dislocated lens, a lens swollen
after decission, or to occlusion of the pupil, etc.
103 Cass Street.
SOME QUESTIONS RELATING TO
GLAUCOMA.
Read in the Section on Ophthalmology at the Forty-seventh Annual
Meeting of the American Medical Association held at
Atlanta. Ga., May 5-8, 1896.
BY ALEX. W. STIRLING, M.D., CM. (Edin.),
D.P.H. (Lond.).
ATLANTA, GA.
I propose to bring forward for discussion certain
parts of the subject of glaucoma, which though far
from novel, yet appear to merit, from their import-
ance and the still divergent views concerning them, a
constantly recurring investigation. These questions
are:
1. Is glaucoma always preceded by papillitis?
2. Are certain doubtful cases of chronic glaucoma
with an apparently normal condition of the anterior
segment of the eye, unaccompanied by any sign of
spinal and cerebral disease, but showing what is
known as the true glaucoma cup; are these really glau-
coma, or are they optic atrophy ?
3. Should all cases of primary glaucoma be oper-
ated upon?
4. What is the cause of the cataract which occa-
sionally appears in eyes which have just undergone
operation for glaucoma?
Question 1. — Those who hold that papillitis is a con-
stant accompaniment of the early symptoms of glau-
coma should be divided into two classes, viz., those
who assert that it actually precedes the glaucoma,
and those who refer to it merely as invariably present
in the initial stages of the disease.
An abnormal condition of the blood vessels on the
disc, with edema, is described by many well-known
authors, and is no doubt familiar to most as a symp-
tom of confirmed glaucoma, and may be dismissed as
a possibly perfectly natural result of the glaucoma
pressure.
But it is otherwise with the assertion that papillitis
is a constant precedent of glaucoma. Klein sup-
ported Jaeger in this contention ; Mauthner1 thought
the optic nerve was so softened by a morbid process
secondary to choroiditis as to cup later under normal
tension ; Brailey and Edmunds2 had reason to believe
that in primary glaucoma "neuritis" precedes the
increased tension, and that an inflammation is also
i Manthner: Archiv. Ophth., N. Y., vii, 1878, p. 178.
- Brailey and Edmunds : London Ophth. Hosp. Reports,
x, 1880, p. 86.
present in the ciliary body and iris; Gruening" recog-
nized a congested disc as visible along with the first
premonitory symptoms in certain cases; Knies4 has
observed: "Among the earliest and most characteris-
tic appearances ... I found marked hyperemia
and edema of the optic nerve. This appears to be
the regular beginning which passes in weeks into
cupping"; Bitzos6 asserted that "one can accept as an
absolutely certain fact" that glaucoma begins "by a
papillitis constituting a lesion which is primary and
at the same time fundamental," and that during this
stage, before the advent of plus tension or of any out-
ward sign, the cases being frequently discovered by
accident, there is diminution of visual acuity and in
the dimensions of the field.
If we admit that glaucoma is always necessarily
preceded by optic neuritis (which has certainly not
been universally observed), it practically follows
either that the condition of the optic nerve blocks
a path of exit for fluids from the eye in such a
manner as to cause forward displacement of lens and
iris, with secondary obliteration of the normal filtra-
tion area in the corneo-iritic angle, or that glaucoma
is an inflammatory disease with iritis secondary to, or
accompanying, the papillitis. Now, experiments have
shown that only a very small proportion of the ocular
fluid leaves the eye in the region of the optic nerve;
and we also know that in ordinary undoubted optic
neuritis glaucoma may be said never to follow either
in the inflammatory or atrophic stage; and even if we
were, for the sake of argument, to admit that, norm-
ally, a large amount of fluid has its exit in this region,
it would yet be hard to see why its blockade should
cause that adhesion between cornea and iris so nearly
universal in glaucoma. We should rather expect
merely a more rapid drainage at the angle.
Against the theory that glaucoma is an inflamma-
tory disease and that the corneo-iritic adhesion is due
to an iritis, a theory upheld especially by Knies, one
might quote the opposite opinion of Bowman,
expressed thirty years ago, and of De Wecker and
many others since then, as well as that of the elder
Critchett, Priestley Smith and Fuchs, that it much
more nearly resembles a strangulaled hernia. The
following facts might also be arrayed against the
inflammatory theory: Glaucoma with glaucomatous
cupping, found in cases of mechanical obstruction to
outflow through the corneo-iritic angle from affections
limited to the anterior part of the eye, as from dislo-
cated lens, in which case the tension may rapidly rise
and fall according to the position of the lens, or, from
hereditary ophthalmia, the result of malformation in
or near the angle of the anterior chamber; the sud-
denness of the early attacks and their disappearance:
the fact that an operation, and that on the anterior
part of the eye, can quickly and permanently remove
the symptoms; as well as the fact that a drop of some
mydriatic may cause an acute attack in an eye prev-
iously absolutely free from inflammation.
Question 2. — The cases referred to are those desig-
nated "amaurosis with optic nerve cupping," by von
Graefe; "glaucomatous optic nerve disease," by Ed-
ward Jaeger; and "excavation atrophy," by Stellwag,
and which have been by some ophthalmologists, sepa-
rated from other forms of glaucoma, but by others of
equally high repute held to be merely one extremity
3 Gruening : Trans. Am. Ophth. Soc, 1889.
* Knies. Centralbla't f. All. Path., April, 1890.
'•> Bitzos : Annal. d'Ocul., vol. 112., 1894, p. 92.
1896.]
QUESTIONS RELATING TO GLAUCOMA.
1041
of a continuous chain of connecting cases which ter-
minate in the other direction in glaucoma fulminans.
I desire to take the position that these cases should
be looked upon as glaucoma, and I presume that there
would be no difference of opinion concerning such of
them as might show even temporary increase of ten-
sion, or any symptoms in the iris which might point
to peripheral corneo-iritic apposition. It will also be
agreed that there is no known reason why glaucoma
and primary optic atrophy should not coexist in the
same eye But leaving out of the question all such
eases, the following appear to be reasons why "simple"
glaucoma may be looked upon as real glaucoma and
not as optic nerve atrophy.
It lias been asserted by Schweigger that unless
increase of tension is distinct this symptom is of no
value for diagnosis, as one can easily discover plus
tension if one have faith enough. But it is well known
that the normal ooolar tension varies with the indi-
vidual. We may. therefore, consider it as certain
that a tension which is normal for some eyes ia plus
for others, that it is just as easy to omit to find a real
plus tension as to imagine one which does not exist,
and conclude that in certain cases, which appear to
palpation normal, there is in reality a heightened
tension. This argument is supported by the fact that
it is not a very infrequent thing to find cases recorded
by ophthalmologists of the first rank, in which at the
the same moment and in the same eye there coexist
the apparently incongruous conditions of glaucoma-
tous halos or rainbows and normal tension, the former
having been proved to result from a very slight edema
of the anterior layers of the cornea due to a rise of
intraocular pressure.
The statement was made by Zentmayer and Posey,
in connection with their examination of 167 cases of
simple glaucoma, noted in the clinics of Norris and
Oliver, in Philadelphia, that shallowing of the anter-
ior chamber was found in glaucomatous eyes where
there was not yet excavation, while the converse was
not true, for every eye which had an excavation had
also a shallow anterior chamber. By a shallow anter-
ior chamber they evidently meant pathologically
shallow, and their statement appears to indicate that
plus tension, relative to the eye involved, as witnessed
by the shallow anterior chamber, was or had been
present in all these cases in which the disc was cupped.
One should also bear in mind that it is easy to fall
into error concerning the condition of the anterior
chamber. It is generally inferred that whenever it
appears to be of normal depth there can be no periph-
eral apposition between cornea and iris. But the
periphery of the iris and of the posterior surface of
the cornea are quite hidden from view by the anterior
margin of the sclerotic, and a deep anterior chamber
has been proved to be quite compatible with corneo-
iritic adhesion. It has also been shown (and such
sections I have in my possession) that the iris some-
times makes an abrupt backward bend at the point
at which it separates from such a corneal adhesion,
which hides more effectually the true condition of
affairs. On the other hand it would be hard to prove
a normal state of the filtration angle, because such
doubtful eyes as those under discussion are not
excised, and even in the rare cases in which the angle
is found open, in primary glaucoma, signs are fre-
quently present that this patency has resulted from
the excision of the globe.
It has been abundantly shown that high tension
occurs at one time or another in the vast majority of
cases, that it may be present only very temporarily
and at long intervals, and also that such cases, or
others in which it happened that apparent plus ten-
sion had never been found, have not infrequently
ended in acute glaucoma. There is also the possi-
bility that, like other bodily functions, the circula-
tion through the eye may vary very considerably in
the twenty-four hours, and that tension may be high
when the patient is beyond observation, in the even-
ing when lie is tired, or even that the recumbent posi-
tion may affect it in one way or another.
We know that there is, in all probability, an auto-
matic action, within the eye, whereby a rise in intra-
ocular pressure has the tendency to again bring the
tension down to normal, through pressure on the
uveal vessels preventing farther secretion from them.
It would appear as if in the quietest forms of simple
glaucoma the blood pressure was so low that a com-
paratively slight rise of intraocular tension would
attain this result, little fresh fluid being poured into
the eye so long as the pressure outside the vessels
remained of sufficient force, and the hypothesis of an
intermittent rise arid fall in pressure appears to me
reasonable. Nettleship has already stated that the
condition, as regards tension and organic changes in
chronic cases, may perhaps be sometimes due to feeble
circulation or loss of arterial elasticity.
The acuity of the onset of symptoms would there-
fore appear to bear a direct relationship to the vascu-
lar tension in the uvea, or else the cause of their
appearance to be of a rapidly fluctuating character.
It might not be unreasonable to suppose that when
the corneo-iritic filtration area is blocked and the
tension in the vitreous is higher than that in the
uveal vessels the capillaries in the ciliary region,
which are wont to carry fluid to the vitreous, may then
assist in removing fluid from it.
A further argument in favor of the glaucomatous
nature of these cases is the growing feeling that iri-
dectomy is beneficial and should be employed for
their relief.
I have purposely avoided reference to certain sup-
posed points of difference between simple glaucoma
and some forms of optic atrophy, the form of the vis-
ual fields, variations in peripheral color vision, and in
the "light difference" and "light minimum," in color
of the disc, in size of retinal veins, in pulsation of the
retinal artery, in the pupil, etc., for I have looked at
the subject from another point of view.
Question 3. — The question will naturally be looked
at from two standpoints — that of practical experience
and that of pathology. Experience at the present
day appears to favor operation, but much depends on
the operation chosen and upon the method of its
performance.
In certain cases operation is by some considered to be
contraindicated; such as glaucoma due to mydriatics,
which is frequently permanently cured by myotics;
chronic glaucoma in patients whose health is poor from
age or disease, but this is doubtful policy, and such
cases of simple glaucoma as appear to benefit from
myotics, and can be kept carefully in view.
From the pathologic standpoint the wisdom of the
earliest possible operation is apparent to those who look
upon glaucoma as an interference with the functions of
ocular excretion, and the objects of treatment, whether
by drugs or operation, to be the opening up of closed
exits.
1042
A CLINICAL NOTE ON THE USE OF PYOKTANIN. [November 14,
When forward displacement of lens and iris are found
denoting that the obstruction lies at the lento-zonular
level, a preliminary posterior sclerotomy to permit of
their retraction, as advised by Priestley Smith, sug-
gests itself as a suitable procedure, to be immediately
followed by iridectomy, sclerotomy, or one of their
modifications. The object of these operations is to
produce a permanent path of exit for the intraocular
fluids, either by opening up the normal filtration
angle, and so removing the iris as to prevent the pos-
sibility of the recurrence of the closure, or, where
this is impracticable, to provide a sufficient substitute.
We know that in the earlier periods of glau-
coma the iris is in contact with, but not adherent to,
the corneal periphery, and cure may be effected, as
has been pointed out by Treacher Collins, by the
mere escape of aqueous or by the dragging on the iris
during its removal ; but iridectomy should have in
view much more than this. As frequently or gener-
ally performed, the iris is seized by forceps and then
cut off, with the result that sufficient remains to
again block up the exit. The better way is to tear
the iris from its junction with the ciliary body, where
it is flimsiest, from one end of the wound up to the
other, and failure to do this has been the most pro-
lific cause of non-success. Indeed, in forming an
opinion as to the benefits of iridectomy one should be
careful to distinguish such operations from those in
which the iris is merely snipped away.
When iris and cornea are so adherent that they can
not be separated, i. e., in chronic, long-continued
cases, our hope lies in the formation of subconjuncti-
val fistula?. When these are permanent and success-
ful they are lined by atrophic iris which keeps the
wound from healing. Where this adhesion is known
to exist an opening into the posterior chamber through
the iritic root as advocated by Treacher Collins,
Nicati and Knies, has the best prospect of success,
and the V-shaped incision of Nicati, which also freely
divides the base of the iris, but upon which I can not
speak from personal experience, appears to be
attended by excellent results. In those cases in Which
the actual position of the angle may at first be doubt-
ful, and in which an iridectomy proves useless,
Nicati's incision downward might well replace the
secondary sclerotomy so frequently employed.
Vincentiis of Naples claims for his operation of
tearing or cutting away the iris from the cornea with
a sickle-shaped needle that, when these tissues are
adherent it acts in a manner superior to either iridec-
tomy or sclerotomy.
In concluding this question I would advocate the
earliest possible operation in practically all cases of
primary glaucoma (at the same time that attention is
given to the general health) independent of contrac-
tion of the field, and so long as there is any vision to be
saved or pain to be relieved ; and that the better eye
should first be treated, because in it there is more to lose
by delay, and because in the event of only moderate
success, or worse, with the first eye, the patient may be
disinclined to return on account of the second.
Question 4. — It has been stated by ophthalmic sur-
geons of the highest order, among whom is one who
has done some of the best work in recent ocular path-
ology, that the cataracts rapidly following upon iri-
dectomy are always due to a wound of the capsule of
the lens received in the course of operation. That
the possibility of this is one of the serious objec-
tions to operation for glaucoma, that it may readily
happen in the hands of the most skillful, especially
when the cornea is small and the anterior chamber
shallow, and that the wound may arise not only from
the edge of the knife, but also from the back of a
"Graefe," from the iridectomy forceps, or during repo-
sition of the edges of the coloboma, will, I think, be
readily admitted.
But it is more pleasant to the feelings of the sur-
geon, who, after the greatest care to avoid the lens,
and in the belief that he had done so, yet shortly dis-
covers a rapidly growing cataract, to know that other
explanations of its occurrence may be forthcoming;
and these, I think, are not difficult to find.
To begin with, any one who will carefully examine
the lenses in a series of apparently healthy senile eyes
under a mydriatic will observe that in no small pro-
portion of them he can discover peripheral stride, not
the normal strise of the section of the lens visible by
transmitted light in the eyes of many old people, but
due to true cataractous change. In glaucomatous
eyes these have been noticed in a still higher proportion.
In such eyes, or even in eyes without such lenticu-
lar change, it can scarcely be considered unreasonable
to hold that the sudden alterations of conditions
resulting from the emptying of the anterior chamber
may have just as much effect in producing or in
ripening cataract as has the well-known method of
friction on it, directly or through the cornea. For
those changes are very considerable: The zonular
attachments are strained by the forward movement of
the lens, and the lens may even come in contact with
the cornea, while one must expect its nourishment to
be seriously interfered with by the rapid passage
from the eye of the fluid upon which its welfare
depends, a fluid which also, as Nicati, Greef and others
have shown, undergoes a change in composition upon
the first opening of the anterior chamber.
A CLINICAL NOTE ON THE USE OF
PYOKTANIN.
Read before the Section on Ophthalmology at the Forty-seventh
Annual Meeting of the American Medical Association
held at Atlanta, Ga., May 5-8, 1896.
BY H. B. YOUNG, M.D.
BORLINGTON, IOWA.
My experience with pyoktanin probably differs lit tie
from that of your own in those suppurative troubles
of the eye and ear for which it has been considerably
lauded, i.e., occasionally very satisfactory, but more
often disappointing, if not indeed aggravating. In
fact after many disappointments I practically dis-
carded it from my list of remedies as I have no doubt
many have done,
About two years ago, however, after an unsuccess-
ful attempt to treat a case that I had diagnosed as
phlyctenular conjunctivitis, by the classical method,
viz. : Pagenstecher's ointment, calomel dust and mydri-
atics locally, plus alterative and tonic medication
internally, pyoktanin in 1-1000 aqueous solution
locally was accidentally suggested. To my surprise
the case improved rapidly under it and was soon well.
A month later the patient, an anemic girl of 15 years,
returned with a fresh efflorescence. Again was the
Pagenstecher's ointment and calomel dust distinctly
irritating and the pyoktanin promptly effective. Fol-
lowing this at irregular intervals the efflorescence
recurred and was promptly subdued by the pyoktanin.
In the meantime a younger sister of this patient
L898.]
FRANKLINIZATION IN NEURASTHENIA.
loi:;
showed the same conditions, had the same treatment
with the same result.
From this time all cases of conjunctivitis lymphat-
ioa were treated in this way and it was noticed that
those were soonest benefited in which the efflorescence
was marked by lachrymation and congestion of the
palpebral conjunctiva, while the elevations at the
limlnis showed irregular outlines and little disposi-
tion to surface softening.
Why there should be this difference or why the
pyoktanin should, in any case of this character, be as
effective as the time honored mercurials I do not know.
Phannaeeutically the mercurials were as perfect as
possible. The Pagenstecher's ointment I prepared by
a method whieh could hardly be improved, as the pro-
duet stands the test of inspection through a powerful
lens. And the calomel was of the best quality, thor-
oughly dried and lightly dusted.
The pyoktanin was Merck's, dissolved in water
whieh had been boiled thoroughly. A fresh solution
was prepared when any change was noted in the color.
DISCUSSION.
Dr. G. C. Savage, Nashville Just before leaving home I
prescribed pyoktanin for three cases of phlyctenular conjunc-
tivitis and as Dr. Price has just entered the room I should like
to know from him what the result has been.
Dr. Price The only one of the patients that has returned is
doing well. It was a bad case and had shown no improvement
under a week's use of the vellow oxid.
I KANKLINIZATION AS A THERAPEUTIC
MEASURE IX NEURASTHENIA.
Read in the Section on Neurology and Medical Jurisprudence at the
Forty -seventh Annual Meeting of the American Medical Asso-
ciation, held at Atlanta, Ga., May 5-8, 1896.
BY MARGARET A. CLEAVES, M.D.
Director Of the New York Electro-Therapeutic Clinic, Laboratory and
Dispensary; late Instructor in Electro-Therapeutics, New York Post
Graduate Medical School; Fellow of the American Electro-
Tlnrapeutic Association, Member Soolete Franeaise D'Elec-
trotherapie. Fellow of the NewY'ork Academy of Medicine,
Fellow of the Medical Society of the County of New-
York. Fellow the American Medical Association,
Member the New York Electrical Society.
NEW YORK.
Looking at it from a purely scientific point of view
the recognition under the head of neurasthenia of the
many and varied expressions of nerve weakness is
most unfortunate, and must have a tendency to hinder
that investigation into the true nature of the under-
lying conditions which is absolutely essential to the
advancement of the science of medicine. On the
other hand this recognition has led to the estab-
lishment of excellent therapeutic methods, which,
however, are so familiar as not to need enumeration
here.
Among them Franklinization takes an important
place, and although it is the oldest form of electric
treatment, its value is not yet fully appreciated by
the profession.
It is not within the scope of this paper to dis-
cuss the' nature of neurasthenia, interesting as the
subject is, suffice it to say that neurasthenia in an
acquired form, may be regarded as primary or sec-
ondary; primary when due to the immediate effects
of nervous overstrain or to a primary toxic disorder
of nutritional processes, and secondary when conse-
quent upon other diseases having a general patho-
logic diathesis with its peculiar and exhausting toxic
influence.
The nutrition of nerve cells is primarily at fault,
and they break down even under slight overstrain,
whether of work or mental anxiety. They lack in
stability, and are incapable of ridding themselves of
the results of physiologic activity. The toxicity
thus induced plays an important role in the pro-
duction of the varied manifestations of physical
and mental discomfort to which the neurasthenic is
subject.
The problem before us in the treatment of neuras-
thenia is to prevent undue waste of nervous substance
from excessive fatigue as well as to eliminate the
toxic influence of self-produced waste products. To
this end whatever can be done to establish and main-
tain the highest nutritive activity is absolutely
imperative.
Whether we regard the neurasthenic condition as
due to exhaustion, starvation or poisoning of nerve
centers its treatment by means of Franklinization is
absolutely rational.
There is nothing of the occult about it, nor can
the action of general Franklinization either by means
of the convective or disruptive discharge be, in any
sense, attributed to suggestion, hypnosis or to some
subtle influence upon the nervous system. The same
effects can not be reproduced by such methods.
The grand function of all electric treatment is to
promote nutritive processes, and in general Franklin-
ization there is no exception to the rule. On the con-
trary, by reason of its physical characteristics it is the
most efficient of the varied manifestations of electric
energy. The ease with which it can be used, requir-
ing no preparation nor tedious detail in its adminis-
tration as do other currents, renders its application
very acceptable to patients.
The influence of high frequency and high potential
currents upon nutrition has been established by
observations in physiologic laboratories and in clinical
work.
In all neuroses there are abnormal chemic condi-
tions of the tissues and aside from the influence of
heredity, deficient constructive and deficient destruc-
tive metabolism are the two prominent factors therein.
The need therefore in our therapeutics of a means
which will influence a more nearly normal metabolism
is imperative. The rationale of general Frankliniza-
tion lies in its ability to set up processes resulting in
the production of physiologic effects.
The increased activity of an organ is indicated by
the increased amount of blood circulation. When an
organ is completely inactive, as in the case of a para-
lyzed muscle or the peripheral end of a divided nerve,
the amount of blood and the nutritive exchange of
fluids diminish within these parts. Thus thrown out
of activity they become pale and relaxed, and ulti-
mately undergo fatty degeneration. If cells are
imperfectly deprived of their detritus they do not
appear to take up oxygen readily, consequently are
not adequately nourished and undergo degenerative
changes.
The average neurasthenic patient is not in a condi-
tion to take the active exercise necessary to bring
muscular tissues into activity so as to profoundly
influence circulatory changes. It is impossible to
change the nutritional state of cells without a pro-
found stimulating action. The general circulation in
these conditions is impaired, while vascular changes
in the nervous system exist. These are of the nature
of a cerebral hyperemia and probably hyperemia of
the spinal gray matter as well. The vaso-motor
1044
FRANKLINIZATION IN NEURASTHENIA.
[November 14,
neuro-mechanism is believed to be at fault. The
extremities are cold and the heart's action feeble. If
the blood stream does not circulate with normal
activity new material is not supplied to the tissues,
nor is effete material removed from them. As a gen-
eral rule the stimulation is more energetic, the more
rapid the variations of the electric current applied to
the nerve (Du Bois Reymond).
In the groat variations of potential which the
patient subjected to general Franklinization experi-
ences, may be found a reason for its profound stimu-
lating effect. A constant and inconceivably rapid
variation of potential characterizes every Frankliniza-
tion, whether by means of the convective or disrup-
tive discharge. And this variation must result in
profound stimulating action upon nerve cells, enabl-
ing them to alter their nutritional state.
In employing currents of great frequency the
organism is traversed without manifesting any reac-
tion. If the frequency of these currents were lowered
their energy would be destroyed in so far as the pro-
duction of characteristic physiologic effects are
concerned.
It is believed by D'Arsonval that these currents
exercise upon nerve centers and upon muscles the
action studied by Brown-S6quard under the name of
inhibition. The tissues traversed by them are those
less susceptible to the ordinary excitements. The
physiologic effects demonstrated by D'Arsonval and
others would indicate that currents of high fre-
quency have a profound influence upon the organism
affecting nerve centers, however deeply placed, even
though the application electrically alters or disturbs
the superficies of the body alone.
The vaso-motor nervous system is also strongly
influenced. After an experiment upon the human
organism with these currents has been long enough
continued there can be seen upon the cutaneous
surface dilated capillary vessels and the skin is found
to be covered with perspiration. There is also an
increased intensity of the respiratory combustion.
The excretion of urea is increased and uric acid, if
present, diminished, or on the other hand a normal
or more nearly normal relation is established between
them. The ultimate effects are upon all the nutri-
tive processes. Oxidation is furthered and meta-
bolic changes hastened.
By means of the disruptive discharge or spark a
profound perturbatory effect is produced. Whenever
a spark impinges there is produced an effect upon the
vaso-motor nerve followed at first by a vaso-constric-
tion as evidenced by the pearly white or goose-flesh
appearance of the skin. This in turn is followed by
a yaso-motor dilatation evidenced by redness of the
skin. If for any reason there is a Realization of the
disruptive discharge there may be produced a distinct
dermatitis as the result of the application. Also as a
result of the disruptive discharge more or less pro-
found muscular contraction is produced according to
the character of the spark, larger and more extensive
with the long spark gap; shorter, sharper and quicker
with the lesser spark gap.
The role of muscular activity is one that is well
established, and the effect is to produce an increased
activity of the blood stream within the muscles of an
intact body. The blood vessels dilate so that the
amount of blood flowing through them is increased.
At the same time the motor fibers are excited, the
vaso-motor fibers are also. Muscular contraction is
attended by the production of heat. This is greater
or less according to whether these contractions are
many but small, or fewer and larger. In the latter case
more heat is generated. This shows that larger
contractions are accompanied by a relatively greater
metabolism than small contractions, which is in
accord with clinical experience.
Then again, we have to deal with the two-fold influ-
ence of the nervous system upon metabolism. On
the one hand it acts indirectly through its effects
upon the blood vessels, by causing them to contract
or dilate through the agency of the vaso-motor nerves,
whereby the amount of blood supplied, as well as the
blood pressure, are influenced. But metabolism is
still further influenced, independently of blood ves-
sels, through the trophic nerves.
The afferent supply of blood current carries to the
tissues the proteids, fats, carbohydrates and salts from
which the tissues are formed, and any interruption of
the arterial supply diminishes the supply of nutri-
ment. On the other hand, the efferent stream carries
away decomposition products from the various tissues,
more especially urea, CO2, H2O and salts, and trans-
fers them as quickly as possible to the organs through
which they are excreted. With the supply of nutri-
ent material thus provided and the removal of the
products of organic life, the vagaries, morbid fears,
melancholias even, the aching and weariness as well
as the hyperemias, are relieved.
The convective discharge is the treatment par
excellence for neurasthenic patients. By it is meant
what is commonly known as the static spray or breeze.
It is in reality a succession of infinitesimal sparks as
obtained from the powerful Holtz machines, which
passes into a continuous stream between the two dis-
charging rods or the insulated patient and the admin-
istering electrode. This discharge is non-oscillatory
in type and, so far as can be seen from its physical
nature, produces but superficial effects. The effect,
therefore, upon the interior of the body is by a sec-
ondary influence, produced primarily upon the super-
ficies, by which it becomes electrically altered or
disturbed. If the charge is mild, this convective dis-
charge will only be felt as a cool wind, but when these
machines are working to their full capacity, and par-
ticularly if the patient holds the chain in the hands,
establishing connection with one prime conductor of
the machine, there is a marked tingling, stinging and
pricking as of many needles. By localizing this dis-
charge to any point desired, the seat of an obstinate
pain, there can be produced an extensive redness and
blistering (dilated capillary vessels) of the skin, and
in sensitive conditions of the spine where there is
pain on pressure, I am in the habit of continuing the
localization long enough to produce this effect.
When a piece of woolen cloth or a patient with
woolen clothing is placed upon the platform in con-
tact with the distributing chain and subjected to a
localized convective discharge, the clothing or the
fabric is microscopically' burned as though by many
minute coals of fire.
Ordinarily, the passage of one coulomb of electricity
through a circuit in one second of time means a rate
of flow or current strength of one ampere, on the
average during that time. If2 this coulomb passes
through the circuit in one-thousandth of a second,
1 With my large 8 plate, 80 Inches in diameter, Holtz machines, this
burning is not only microscopic, but macroscopic as well.
2 Houston and Kenuelly : Electricity in Electro-therapeutics.
1896.]
FRANKLINIZATION IN NEURASTHENIA.
1045
the mean current strength would be 1,000 amperes,
and if in the millionth part of one second the
mean current strength would be 1,000,000 amperes.
For this reason the total quantity of electricity, in a
pair of leyden jars for instance, or in the case of a
working conducting circuit where the patient repre-
sents the one leyden jar and the grounded area the
other, even when charged at a pressure of thousands
of volts, is very small; yet owing to the great fre-
quency or rapidity with which this charge is passed
through the circuit, the current strength during that
time may be considerable. The action upon the
woolen fabric would indicate that such is the case.
The patient in this conducting circuit is doubtless
traversed by an alternating current of greater strength
than would be borne without pain under ordinary
conditions.
In the eonveetive discharge there is produced an
effect upon the nervous system, affecting the vaso-
motor nerves, causing first a vaso-constriction, as evi-
denced by the sense of chill and shivering when first
subjected to its action, followed by a vaso-dilatation,
with an ultimate equalization of the blood stream.
Under the influence of the eonveetive discharge the
activity of the skin is increased with perspiration,
most noticeable in palms of the hands; the tempera-
ture, if subnormal, is raised, if abnormal reduced,
while the heart's action is regulated. Corresponding
circulatory changes are established, as shown by the
number of pulse-beats before and after the discharge,
the change in volume and the sphygmographic trace.
Such physiologic effect can not be produced without
causing a change in the patient's condition and induc-
ing a feeling of well-being.
The pains and weariness, the morbid fears and fixed
ideas disappear under these more nearly normal condi-
tions, but the disappearance at first is only temporary.
The changes set up are not sufficient to endure perhaps
for more than a few minutes, a half hour; in rare
instances, twenty-four or forty-eight hours. More
work must be done before nutritive changes are estab-
lished to such a degree as to prevent a recurrence of
former conditions. The flagging energies are aroused
by the stimulating influence of the application, which,
however, if not persisted in, is as valueless as the
whip and spur to the exhausted horse without rest
and food.
In the desultory and unscientific way in which
Franklinization has been used are to be found the
reasons for its failure. Only with a large clinical
experience is it possible to reach definite conclusions
as to the manner of its application, the length and
number of seances, and to formulate a law governing
its administration. Personal idiosyncrasies, as well
as the duration of the disease and the manner of its
manifestation, must be considered.
Moral means must never be lost sight of; in addi-
tion to the general Franklinization, the rest or exer-
cise, according to the character of the case, is of
paramount utility.
In the treatment of neurasthenic conditions by
means of the Franklinic current, I find that I can
secure without enforced rest and seclusion the return
of health to a considerable class of neurasthenic
patients, with greater independence of character
and increased volition, than is possible by means
of the rest cure and massage. These last named
measures have their value, but to a large num-
ber the seclusion, the dependence upon others for
every thought almost, certainly for every volitional
act, is pernicious in the extreme. Habits of invalidism
are fostered, with fixed ideas as to the suffering and
disability endured, which means a changed nutri-
tional power on the part of nerve cells.
In a paper upon the " Psychical Treatment of
Neurasthenia," by Dr. J. J. Putnam of Boston,3 the
influence of general Franklinization upon tempera-
ture and pulse in neurasthenic patients is considered.
He shows a similar influence with the patient placed
upon the platform and no connection made, but the
machine still in motion as in the ordinary application
of the eonveetive discharge. The conclusion that he
seems to draw therefrom is that the changes in tem-
perature and pulse are due to some subtle influence
upon the nervous system, rather than from the Frank-
linization. He does not state whether in the latter
instance the machine was in a state of charge or not;
the inference must be that it was. Such being the
case, the patient still remained in the electro-static
field even though the insulating platform was not
connected with the source of energy.
From the physical laws governing electricity at
these potentials it is absolutely impossible to keep it
within bounds. There is a constant leakage from the
metal finishings of the machine, and a disturbance is
created in the entire atmosphere of the room. Henry
has shown that a spark from an electric machine
extends its influence to a distance of many feet.
Physiologic effects may be obtained by standing in
the vicinity of powerful dynamos in operation, and
physicians from various sections of the country have
told me of sending their sleepless neurasthenic
patients to electric power houses that they might
have the benefit of the electric disturbance thus
created.
But there is also another influence at work. It
is absolutely impossible to have an electro-static
machine in operation without the production of ozone.
Chemic tests demonstrate the existence of ozone in
the atmosphere, and it is shown that it exists in
greater quantities in the country than in the city, at
the sea shore and in the mountains in still greater
abundance, notably in the best climatic resorts of
high altitude. It is, no doubt, one great source of
the healthful influence of such places. Near the
backbone of the mountain range of the Blue Ridge in
North Carolina, it is so abundant as to be constantly
apparent by its peculiar odor. Its increased chemic
activity renders it more effective than oxygen. It is
not necessary here to speak of its intense oxidizing
action, antiseptic properties and power of destroying
offensive odors. Recently its physiologic effect has
been very carefully studied by M. M. D. Labbe and P.
Oudin and published in the Bulletin Officiel <le la
SociSte Francaise a"Electroth£rapie for November,
1894.
These observations showed, even after ten minutes
inhalation of ozone, an increase in the amount of
hemoglobin of from 1£ to 2 per cent. Subsequent
examinations, made several days later, demonstrated
that the increase persisted. The examinations were
made by means of the spectroscope. There was also
a proportionate increase in the number of red blood
corpuscles and a progressive diminution in the num-
ber of ifrhite, and the conclusion arrived at both from
physiologic experiments and clinic results was that
ozone most powerfully modified the blood and nutri-
3 Boston Med. and Surg. Journal. May 28, 1895.
1046
FRANKLINIZATION IN NEURASTHENIA.
[November 14,
tion, resulting in the establishment of health. One
of the sources for its production are the large Holtz
or influence machines used in medical work.
When the influence machines in my office are in
motion, the electro-static field extends not only over
the entire floor occupied by the machine, but to the
basement below, sparks being drawn from the gas
pipes, etc. The electro-static field is enormous in its
extent, and while we secure our best results from the
use of an insulating platform, it is not necessary to
obtain physiologic effect.
By the action of the electric spark upon the air a
synthesis is produced whereby we have ozone formed.
At least a part of the benefit derived from general
Franklinization by means of the convective dis-
charge is due without doubt to the production of
ozone, and in Dr. Putnam's cases this influence could
not have been eliminated, as the ozone pervades not
only the atmosphere of the room where the machine
is placed but adjoining rooms as well.
During three years' work at the Electro-Therapeu-
tic Clinic at the Post-Graduate Medical School the
nurses who were sent to the clinic for two or three
hours three times a week to assist in the work, spoke
to me of a general physical improvement of which
they were conscious, with relief from menstrual pain
and improved sleep. Their appearance indicated a
nutritional gain. Different nurses made these state-
ments from time to time during their term of service,
and after my attention was called to it I was in the
habit of watching them closely, taking their weight,
etc., and inquiring as to physiologic functions, in
order to establish the correctness of their reports.
In dealing with this form of electric energy we must
remember that on account of its high frequency and
high potential it pervades all space around the con-
ductor. The metallic prime conductors, the conduct-
ing rod connecting the same to the platform, merely
provide a surface from which the charge can enter
and influence the air around it. The charge really
resides in the air, or more strictly in the air and ether
surrounding the body. The energy is distributed
through all the ether in the room, although not
equally. The greatest current density exists upon
the insulating platform and about the body of the
patient; after that in the space near the machine, and
consequently the greatest difference of potential
would be maintained in the former instance, with a
greater and more effective convective discharge.
I can sit upon an insulating platform entirely dis-
connected from the machine and still demonstrate
that I am in the electro-static field by the movement
of a silk thread toward and to one prime conductor.
With the platform disconnected, and the machine
grounded as in ordinary use, there is not only a con-
vective discharge that is apparent by the usual phys-
ical phenomena, but a disruptive discharge can be
produced by approaching any part of the body to the
electrode connected with the ground or the prime con-
ductor. This discharge is of the non-oscillatory type.
Therefore the observations to which I referred are not
convincing.
THE TECHNIQUE OF ADMINISTRATION.
In connecting a machine for use it should always
be grounded. The insulating platform is connected to
one prime conductor by means of the conducting rod,
while the other is connected by means of a chain to
some suitable ground in the room or near by, as for
instance a gas or water pipe.
The disruptive discharge when the machine is not
grounded, is of the non-oscillatory type, as is indi-
cated by its thin, blue straggly appearance. It has a
biting and irritating character, which renders it ex-
tremely objectionable to the average patient, espe-
cially the neurasthenic.
Grounding the machine enlarges the area over
which a charge may be distributed before it is dis-
charged by its spark, and practically amounts to the
use of large condensers, i.e., Leyden jars. It increases,
the electrical capacity; there is not only a greater
charge, but a greater discharge, whether convective
or disruptive. The character of the discharge is
changed in some instances from an non-oscillatory
to an oscillatory one, while in others there is pro-
duced a more typical oscillatory discharge. The dis-
ruptive discharge thus obtained is vivid, clean and
thick and not inclined to break up nor irritate as the
spark obtained from the direct method. This is due
to the change in the character of the discharge, from
an non-oscillatory to an oscillatory one, and in this
physical fact is found the reason for grounding our
machines for medical work.
Until recently the question of insulation was
regarded as an important one, as the physiologic action
of the different insulations, i. c, positive and negative,
had not been accurately determined.
Some six years since Damian of Paris made a series
of observations upon temperature and pulse and the
urine to determine what, if any, difference there was
in the different insulations. The published state-
ment showed that with the positive insulation there
was a regulation of the temperature and heart's action,
an increase of urea and diminution in uric acid:
while with the negative insulation these changes were
less marked in so far as temperature and pulse were
concerned, and that the volume of the urine was
increased, but no change in its organic constituents.
Within the past five years I have made a great
many observations upon the physiologic effect of pos-
itive and negative iifsulations in order to determine
if possible the therapeutic indication. Those with
the positive insulation upon temperature and pulse
were made at the Electro-Therapeutic Clinic of the
Post-Graduate Medical School and upon urine in my
private practice; while those with the negative insu-
lation were made in the New York Electro-Therapeu-
tic Clinic, Laboratory and Dispensary. In both
instances the physiologic effect has been the same,
viz., a regulation of temperature, raising a subnormal,
lowering an abnormal; a regulation of the heart's
action with corresponding circulatory changes, and an
increase of urea and diminution of uric acid.
This is in accord with the physical laws governing
the Franklinic current. It does not matter, there-
fore, which prime conductor, whether positive or i ill-
ative, is connected with the insulating platform, aor
which is grounded. As a matter of fact, the spark
with the negative insulation is much less biting, sharp
and stinging in character, therefore it is preferable
for sensitive patients.
The patient is placed upon the platform and the
machine set in motion. Patients are often timid at
first and need reassuring. Everything that would jar,
shock or disturb is to be avoided. It is therefore best
to allow the patient to sit quietly upon the insulating
platform, without placing the stand holding the elec-
trode near the platform, or using an electrode in the
hand connected with the grounded area. Profoundly
1896.]
FRANKLINIZATION IN NEURASTHENIA.
1047
neurasthenic patients are easily alarmed and their
confidence destroyed at the outset by so doing. As a
patient sits upon the platform, he is in a condition of
ohaige and may be likened to a leyden jar. The
grounded area of the other prime conductor may be
likened to another leyden jar. The patient's poten-
tial is raised and any movement, no matter how alight,
results in some discharge or equalisation of the ditfer-
enee of potential as he comes in contact with the
stress existing in the air about him. Therefore it is
impossible to regard the eondition as simply one of
charge, for in reality a mild convective discharge is
taking plaee all the time. The completeness of this
discharge is greatly increased by approaching the
stand, holding the electrode and connected to the
ground, to the patient, or by swaying the pointed
electrode back and forth over the entire general sur-
face of the body. At first the automatic application
is Inst, for with the electrode in hand, even if great
eare is observed, the difference of potential is often
unintentionally overcome by reduction of distance,
resulting in a disruptive discharge in the form of a
spark which greatly disturbs the patient.
Nervous patients will sit quietly on the platform in
a eondition of "charge," or even with an electrode at
it a tixed distance, when if it be moved gently to
and fro by the operator they will become exceedingly
nervous and apprehensive, shrinking in a blind terror
from the application. Tact and patience will later
enable the operator to use the electrode for a general
application or any desired localization. As confi-
dence i> established the strength and consequently
the effectiveness of this convective discharge may be
increased by having the patient hold in the hands the
distributing chain, thereby placing him in direct con-
nection with one prime conductor of the machine:
then by approaching the electrode fixedly placed in
the stand, or in the hand toward the patient, he is
placed under the influence of a strong convective dis-
charge which is known as the needle spray. From
this we proceed to a friction spark, produced by rub-
bing the patient lightly with the ball electrode. This
must be swiftly done or else it will be intolerable.
The sensation is as of thousands of hot needles, but
if well done is followed by such distinct relief in the
average case as to be uncomplainingly submitted to.
The effect is a revulsive one and there is sent through
the peripheral nerves an influence1 to the nerve cen-
ters most beneficial in its effect. It is a well known
fact that by peripheral excitation the nutrition of
ganglionic cells is altered. Applications by means of
long percussive sparks should follow upon the
"charge," "spray," "needle spray" and friction spark,
and often in neurasthenic patients should not be
used at all. When the need for strong far-reaching
muscular contractions exists, the disruptive discharge
should be resorted to.
As a rule neurasthenics do not tolerate the disrup-
tive discharge. It has too powerful a perturbatory
effect, producing as it. does profound contraction of
muscular tissue. After its use patients are exhausted,
trembling, and later on sore and bruised, unable to
sleep and so profoundly shaken up as to be unwilling
to submit to another treatment. This is especially
true of the neurasthenics of the exhausted type. But
where the condition of nerve exhaustion is really one of
infection from self-poisoning, or where the nutrition
state has been improved by rest, forced feeding, mas-
sage and seclusion even, without corresponding im-
provement in the mental manifestations, the disrup-
tive discharge is indicated after toleration has been
established. In Franklinization it is necessary to
remember that exercise should always be kept within
the limits of fatigue.
In all cases the treatment should be begun by
means of the convective discharge. It is character-
istic of living tissues to respond to stimulation, but
that stimulation must not necessarily be applied in
the form of profound shocks. Leave the severe
measures until later in the treatment of these cases.
In sexual neurasthenia, with impotence or irrita-
tion, the localization should be to the lumbar and
sacral plexuses and by means of the director electrode
to the perineum carrying the electrode as far forward
as the anatomic structures permit. When we bear in
mind the number of nerves which center in the peri-
neum, the beneficial reflex effects from so powerful a
stimulation can readily be appreciated.
In the beginning of the treatment with the Frank-
linic current, in neurasthenia, the earlier seances
should preferably not last more than ten minutes, as
there is danger of inducing an over-stimulation. This
should always be avoided. If it is found that a ten
minutes' sitting is well borne, the next sitting may be
slightly lengthened, and when a patient's toleration is
fully established it may be extended to as much as
thirty minutes. The crown electrode, fixedly attached
to the electrode stand, should be placed over the hand
during the first of the sitting, while the latter part of
the application should be made by means of the point
to the entire general surface of the body, localizing it
to the spine, especially the nape. In those condi-
tions where there is a tendency to a passive conges-
tion of the brain, the application should be made by
means of the point adjusted so as to localize the dis-
charge to the spine, preferably the nape, in order to
obtain an influence over the vaso-motor center.
Sometimes in cases where such congestion exists the
use of the crown electrode intensifies the discomfort
and patients will complain of a full, bulging feeling
in the head, which is most undesirable. When it is
found that the convective discharge is well borne,
which will be indicated by an improvement in the
temperature, in rate and volume of pulse, in the
moisture of the skin, naturally much less marked
than with the disruptive discharge, also by a sense of
well being and often times a sensation of quiet with
a desire to sleep, then if the indication exists for a
profounder revulsive effect, the friction sparks may be
used to the entire general surface of the body, the
localization being as before to the spine and especially
to the nape for the influence upon the vaso-motor
center.
As to the frequency of the application. In most
neurasthenic patients and particularly the exhausted
type, daily seances at first are preferable. The gain
is surer and the time of treatment shortened by daily
applications for the first week, two weeks, or possibly
a month or six weeks. Rarely should the maximum
time be exceeded however. The period of time for
daily seances is to be determined by the persistence
of the relief established from a single treatment; as
soon as it is found that the relief established continues
over twenty-four hours, then the treatment should be
given every other day and subsequently as the improve-
ment maintains itself for a longer time every third
day to once a week, and finally to a discontinuance of
the application. It is not possible to lay down a fixed
1048
FKANKLINIZATION IN NEURASTHENIA.
[NOVEMBEE 14,
rule for the length of time that a patient should
remain under treatment, because the recuperating
power of some of these cases is very much greater
than others; while their environments differ to such
an extent as to modify the effect. The indications,
however, for the discontinuance of the treatment, the
nutritional gain and relief from symptoms are very
clear.
The work can only be done slowly and as soon as
the organism ceases to respond to the stimulation
which has been used, and which has for the moment
set up more nearly normal chemic action, then it
should be repeated. Nothing is gained by waiting
after that time comes, and much is lost. In the
exhausted type of neurasthenics daily seances are
necessary. Patients judge very clearly as to when
less frequent applications are desirable. During the
period of great exhaustion, physical and mental, the
craving for the electro-static bath is very great. As
nutritive changes are set up, followed by increased
strength and energy, these patients are able to go on
with comfort for a period of two or possibly three
days without treatment.
Nerve cells undergo certain changes in the course
of their functional activity which can only be inter-
preted as those of fatigue and we must remember that
in neurasthenia we have to deal with nerve cells
unable to get rid of fatigue or toxic products. They
may be said to have undergone the "molecular or
chemic variation," and as a result have an "exhausted
or changed nutritional power." The whip and spur
must be applied as soon as they lag. But we must
understand clearly that while there is a stimulation,
it is not an evanescent effect, but one that results in
chemic changes tending to the establishment of
nutrition and healthful function.
It must be constantly born in mind that it is work
which is being done in the tissues of the body, and
that the indications 'for the repetition of that work
lies in the permanency of its results.
When we connect a sphere' to a terminal of an
electro-static machine having an electro-motive force
of say 200,000 volts, it will receive a comparatively
large quantity of electricity, which will be a certain
fraction of a coulomb. Suppose the charge communi-
cated to the sphere be 1-1,000,000 of a coulomb,
delivered at a pressure of 100,000 volts. In that case
the work delivered to the sphere would be equal to
0.1 of a joule or 0.0738 foot pound.
This energy is received by the air and ether sur-
rounding the sphere and held there during the main-
tenance of the charge. It is distributed throughout
the room, although not equally. A certain fraction
of a joule is charged in each cubic inch of space, the
greater amount being in the immediate neighborhood
of the sphere and lessening with distance from the
same. Just the same thing happens with the patient
on the insulating platform connected either directly
or indirectly to the prime conductor. The air and
ether about him receive the energy and the work in
this instance is delivered to the patient, representing
work of so many foot pounds or fraction thereof
according to the electro- motive force and coulombs
furnished. The charge is passed into the ether by
electric displacement. This takes place along defined
lines or curves which are called lines or curves of
electro-static flux.
After ten minutes' application the patient is very
i Houston and Kennelly : Electricity in Electro-Therapeutics.
apt to volunteer the statement: "' I feel so quiet and
sleepy." When this condition exists it is an indi-
cation for ending the seance. In my office I am in
the habit of having such patients lie down or rest
before leaving for their homes, and if they feel
inclined to sleep encourage them to do so. Upon
examination such a patient's skin will be found warm,
moist in the palms of the hands, the temperature
which before treatment was subnormal raised more
nearly to normal, the pulse either raised or lowered,
as it was slow or rapid before, but invariably with
improved volume while a sense of general well-being
is experienced. This beneficent influence may per-
sist for an hour, even less, or it may last until the
next day, seldom longer after a first treatment.
Rarely do I allow such patients to talk during the
time of administration, and for that reason I prefer to
use an electrode connected permanently with the
stand, rather than one in the hands of the operator.
One need only bear in mind the pathologic condition,
the nature of the agent being used and what it does
within the tissues, to appreciate the necessity of per-
fect quiet and relaxation in order to secure the best
results. Work, as we have seen, is being done.
Nerve cells must participate in the activity, whatever
its ultimate nature, and by reason of this activity,
energy is given them with corresponding ability
to perform healthful functions. This should be
expended in that direction and not in an effort at
cerebration or muscular movement. Such effort can
be made judiciously later on.
There should always follow the treatment a 6ense of
"glow" or warmth, and a feeling of well-being. The
vaso-motor nerves are stimulated, the cutaneous ves-
sels dilated and activity of the skin established. No
treatment should be persisted in when this reaction
takes place. The perspiration appears first upon the
palms of the hands, then upon the forehead, upper
lip and finally, with the use of the disruptive dis-
charge, all over the entire body.
In rare instances it happens that instead of the
desired reaction of cutaneous vaso-motor dilatation a
vaso-constriction is established with contraction of
the peripheral vessels, goose-flesh and coldness of
skin; the surface is pale, the patient chilly and men-
tally irritable, uneasy and apprehensive, indicating
that the blood vessels of the brain are also in a state
of contraction. Continuous treatments may abate
this condition, but I have known it to persist to the
extent that it seemed best to terminate the sitting,
leaving the patient apparently unbenefited. This
state of affairs is most commonly observable in neu-
rasthenics. The best way to avoid it is to begin
treatment very gently by aid of a mild convective
discharge or "spray," and later on in the same sitting
to use a stronger convective discharge or the "needle
spray." This class of patients do not do so well under
the disruptive discharge until the nutritional change
has been established. If good reaction follows the
use of the "needle spray," they may be gradually
accustomed to Franklinization by means of the disrup-
tive discharge or "spark" applied preferably to the
spine at the first sittings.
It is common for neurasthenics, after the first treat-
ment by the disruptive discharge, to experience an
overpowering sense of lassitude and sometimes
extreme muscular soreness. This is no doubt due to
the release of degenerated and toxic substances.
Two classes of cases are appended. The first from 1
1896.]
FRANKLINIZATION IN NEURASTHENIA.
1049
to 1(5 are dispensary patients for whom change in envi-
ronments, food, habits, etc., was not made, and for
whom no medication was used. The second, 1 to 8,
arc private or office patients for whom such medica-
tion was used as was indicated, as arsenic and iron,
cascara sagrada in constipation and sodium bromid in
the restless, sleepless and excitable cases. The
action of Franklinism is to increase the activity of
drugs and very small doses are used.
The nutritional improvement established is pro-
gressive and enduring. In my experience if over-
strain of any sort induces a relapse, it is but a modifi-
cation of the primary condition and disappears
quickly under treatment.
One of the tirst results obtained from tho judicious
use of the Franklinie current is relief from insomnia.
In five years I have not prescribed a hypnotic save on
one occasion for a business man who could not take
time to come for treatment. I am in the habit of
giving 10 to 15 grains of sodium bromid three times
daily for the first few weeks of treatment in order to
prevent undue expenditure of the energy until such a
time as the nutritional changes are established. In
cases of obstinate insomnia among dispensary patients
nothing is given or permitted save the general Frank-
linization with careful localization to the spine, espe-
cially the nape, and preferably with the frictional
spark. The results in the latter class of cases have
been good. It must be borne in mind, however, that
the extremely nervous, restless and irritable type of
neurasthenic patients, are more frequently met with
in private than in dispensary practice.
The constipation from which neurasthenic patients
in common with many others suffer is almost invaria-
blv relieved by the Franklinie treatment; the relief
resulting in consequence of improved nutrition. The
nutrition of the whole can not be established without
the nutrition of a part. Disease is arrested, modified
or cured by curing the patient.
In conclusion permit me to repeat that the grand
function of Franklinization is to improve and restore
nutrition not only of a part but of the whole, a func-
tion which indicates a usefulness as wide as the
domain of medicine. By reason of this function
Franklinization is a means of inestimable value in
the treatment of neurasthenia.
DISPENSARY CASES.
Case ?.— O. F. B.. male; age 56, physician, March 23, 1892.
Cerebrasthenia with insomnia. Duration two years. Insom-
nia most marked symptom ; resorted to 10 grains of sulfonal
from one to four times weekly. Sleep obtained much broken,
waking every hour or two. Nutrition poor.
Treatment : Franklinie current, positive insulation, fric-
tional sparks to spine, localized to nape (insomnia), needle
spray to head. Ten treatments given, extending over three
weeks. The night after first treatment had seven hours of
uninterrupted sleep. Improvement continued, characterized
by marked nutritional gain, improved appetite and sound,
refreshing sleep.
Case 2.—T. C, male; age 42; single; clergyman; June 8,
1892. Neurasthenia, cerebro spinal. Four years' duration.
Insomnia ; occasional frontal headache ; languid and dis-
tressed, easily moved to tears ; appetite fair, distress and acid
eructations after eating ; flatulence ; bowels regular. Exces-
sively thin.
Treatment : Franklinie current, positive insulation, needle
spray to general surface, frictional sparks to spine and epigas-
trium. First treatment badly borne, inducing a fit of weeping.
Three treatments given, extending over two weeks. Interval
between the first two, twelve days. The night after the fbst
treatment patient slept well, also the following night, and felt
better during the interval. Sparks were better borne at third
visit and patient expressed himself as feeling light and buoy-
ant in consequence of the treatment. The patient made a
good convalescence.
Cam >. R. D., male; age 29; designer; Sept. 23, 1892.
Neurasthenia. Duration one year. Unable to sleep until 3
o'clock in the morning; irritable and inclined to be morbid.
Spine-ache, cervical, dorsal and lumbar. Appetite fair ;
tongue coated ; digestion impaired ; bowels regular. Weight
125 pounds.
Treatment : Franklinie current, positive insulation, long
percussive sparks to spine and general surface, to epigastrium,
also long and frictional to nape. Forty-two treatments given,
extending over six months. Immediate results from first
treatment; less nervous and a more buoyant feeling. At sec-
ond visit reported that he was sleeping better. At end of two
weeks less depressed; sleep improved, also appetite. At end
of third week had gained three pounds, at end of fifth week
four pounds, and at end of three and a half months seven
pounds. Continued his work during treatment. Discharged,
recovered.
Ocut 4. — W. A. J., male; age 57; married; hotel keeper;
July 5, 1893. Neurasthenia. Extreme nervous shock follow-
ing an accident twenty-five years prior to admission. Not well
since. Complained of loss of power in left arm and hand.
Pain from occiput down to lumbar enlargement; no spinal
lesion. Sleeplessness.
Treatment : Franklinie current, positive insulation, long
percussive sparks to entire surface of body, localized to spine
and affected arm. Returned for second treatment July 7, 1893,
when he complained that it had made him worse ; said he felt
sore and tired all over, as though beaten, but that he had slept
all the previous night and again during the entire morning.
This case is reported simply to indicate the necessity for a
more gentle tipplication to a neurasthenic patient at first.
Case 5.— N. C. M., female; age 27; single; saleswoman;
Dec. 9, 1891. Neurasthenia with hysteric symptoms. Not well
for eight years. Contracted gonorrhea eight years prior to
admission ; acute attack three weeks' duration ; abscess in
groin, opened externally ; six months later pregnant, abortion
procured at two months ; four years ago pelvic trouble : irri-
table bladder from that time. In August last, gave birth to
a living child ; less well since. On admission headache ; back-
ache, especially lumbar and sacral, pain in right groin and
dragging sensation ; marked irritability of the bladder ; capri-
cious appetite ; distress and heaviness after eating ; consti-
pated bowels ; extremely nervous ; sleepless, depressed and
hysteric. Tenderness on pressure over spine, entire length.
Uterus normal ; ovaries neither enlarged nor sensitive ; sensi-
tiveness on pressure over fundus of bladder ; general nutrition
fairly good.
Treatment : Franklinie current, positive insulation, long per-
cussive sparks to spine, localized to nape, lumbar and sacral
plexuses, hepatic area and abdominal walls and entire general
surface. Sixty-six treatments given, extending over eleven
months. At fourth visit, sleeping better ; slight improvement in
digestion. Improvement slow, marked by many relapses into
former condition. Eventually, however, a marked improvement
in general health was noted, with increased strength, lessened
nervous irritability, better self-control ; regular bowels ; dimin-
ished pelvic discomfort. June 10, 1892, went into the country
for two months. Seven applications were given after her return,
when she discontinued her visits in better health than she had
been for many years.
Case <>. — C. R., male; age 32, married; carpenter; Feb. 8,
1893. Neurasthenia, with hypochondric symptoms. Dura-
tion two years. First noticed sense of pressure across chest ;
unable to breathe freely ; breathless upon exertion. Past year
difficulty of breathing, nervous, pain at back of neck, and
entire length of spine ; appetite fair ; distress after eating ;
bowels regular ; occasional frontal headache ; depressed and
self-centered ; unable to work with any regularity ; circulation
poor ; all organs interrogated, but no lesion discoverable.
Treatment : Franklinie current, positive insulation, long
percussive and frictional sparks to spine and general surface,
localized to nape and to epigastrium. Eight treatments were
given extending over one month. At second visit felt much
better. At fifth visit circulation much improved. At seventh
visit improvement much more marked ; no depression ; "catch"
in back gone, also difficulty in breathing ; no epigastric heavi-
ness. One more treatment given and patient discharged,
recovered.
Case 7. — J. R., male; age 29; married; butcher; March 24,
1893. Sexual neurasthenia. Not well for a year and a half.
Morbid, depressed and self-centered. Twitching movement,
first in left shoulder, then in right, then in back of neck, then
in eyes. No trouble when quiet and not at work. Unable to
"fix his mind" on anything; general health fair; appetite
1050
FRANKLINIZATION IN NEURASTHENIA.
[November 14,
good ; bowels regular ; sense of numbness front of thighs ;
knee-jerk normal. History of gonorrhea before marriage.
Sexual excesses since.
Treatment : Franklinic current, positive insulation, long
percussive sparks to spine and general surface, localized to
lumbar and sacral plexuses, anterior surface of thighs, and
with director electrode to perineum from anus to scrotum. At
third visit reported much better after second treatment, with
diminution of distressing sensations. At fourth visit less
dejected, felt stronger. At fifth visit no muscular twitchings.
Eight treatments given extending over one month and at last
visit, April 24, 1893, could fix his mind on what he read or
was doing ; no muscular twitching, no distressing symptoms,
skin clearer ; expression bright and hopeful.
Case 8.— -S. P., male; age 29; single; brass-polisher; July
10, 1891. Sexual neurasthenia ; masturbation, nocturnal
emissions, pain in back, lumbar and sacral ; headache ; appe-
tite good ; digestion fair; complexion muddy; anemic; heart
irregular ; no murmur, palpitation ; sleepless.
Treatment : Franklinic current, positive insulation, long per-
cussive sparks to spine and general surface, localized to nape,
lumbar and sacral plexus, and with director electrode to perin-
eum from anus to scrotum. Nineteen treatments given extend-
ing over four months. An interval of twelve days between first
and second treatments ; sleeping better ; no emissions. Improve-
ment continued, and on Nov. 16, 1891, visits discontinued, gene-
ral health improved, sleeping well, relieved of pain in back and
head. Second admission Sept. 1, 1893 ; well for one year after
treatment. On admission, pain in back, lumbar and sacral —
also in right sciatic ; tenderness on pressure at sciatic notch,
middle of thigh, popliteal space, in knee, calf of leg and ankle ;
sensation as though asleep ; insomnia ; nervous ; badly nour-
ished ; bowels regular. Eight treatments given extending over
seven weeks. Relief established at once and continued. Dis-
continued visits Oct. 20, 1893, recovered.
Case .9. — S. E., female ; age 38 ; widow ; seamstress ; Sept. 6,
1893. Neurasthenia ; three years duration ; nervous, easily
depressed ; morbid fears ; backache — sacral. Sleep broken,
bad dreams ; buzzing noise in left ear ; afraid of dying ; appe-
tite good, gaseous eructations ; bowels regular ; weight 110%
pounds.
Treatment : Franklinic current, positive insulation, needle
spray to head and general surface for fifteen minutes with a
few long percussive sparks to spine. Spray used at first to
establish confidence. Nine treatments given extending over
six weeks. At second visit looked brighter. At third visit
patient said she was better. At fifth visit less depressed. Able
to come to clinic alone. Weight 113'2 pounds, gain 2%
pounds. Digestion improved ; daily movements ; and on Oct.
20, 1893, patient discontinued visits. Improved.
Case 10. — B. T., female; age 20; single; reader; April 16,
1894. Neurasthenia; "irritable spine for eight years;" ten-
derness on pressure in dorsal spine especially about midway.
Tired aching feeling in muscles of neck and shoulders ; pain
extended down both arms ; legs and arms felt as though
asleep ; worse at night, sleepless and restless ; depressed,
badly nourished ; gaseous eructations ; irregular bowels.
Treatment : Franklinic current, positive insulation, long per-
cussive sparks to spine and general surface localized to sensi-
tive area in spine, muscles of neck, shoulders and arms. Six-
teen treatments given extending over twelve weeks. Relief
from first treatment lasted three and a half hours. Nutri-
tional gain established ; relief from pain, aching and weariness ;
bowels regular ; sleeping well ; no depression. Recovered.
Case 11.— M. K., female; age 26; nurse; April 8, 1895.
Neurasthenia; duration six months; extremely nervous;
weak ; palpitation ; gaseous eructations ; bowels regular ;
amenorrhea for two months ; pain in left ovarian region ; gen-
eral sense of exhaustion : distressing dreams ; backache ; poor
circulation ; irritable cough. Sensitiveness on pressure at
lumbar spine. Mucous membrane anemic; heart and lungs
normal.
Treatment : Franklinic current, positive insulation spray to
entire general surface over a period of three weeks. Immediate
result from first treatment ; slept better ; after fifth treatment
felt very well ; appetite good. To the sixth and seventh treat-
ments were added long percussive sparks to entire general sur-
face, localized to spine, lumbar and sacral plexuses and abdom-
inal walls. Recovered. April 8, 1896, patient has kept well
during the year and able to work.
Case 12. — K. L., female; age 29; married; April 19, 1895.
Neurasthenia. Pain and weariness at back of neck ; insomnia ;
headaches ; nausea and occasional vomiting ; hysteric attacks ;
neuralgic pains ; prolapsed ovary removed two years since ; less
pain since operation ; laceration of the cervix uteri.
Treatment : Franklinic current, positive insulation, spray to
entire general surface for fifteen minutes, localized to spine and
ovarian region. Three treatments given extending over a per-
iod of two weeks ; to the third treatment was added long per-
cussive sparks localized to lumbar and sacral plexuses,
hepatic area and abdominal walls. With the first treatment,
relief from constipation ; head better ; improved.
Case 13.— J. F. L., male; age 31 years; married; Sept. 6,
1895. Sexual neurasthenia with impotence. Twelve years
ago gonorrhea, followed by stricture. Constant irritation of
prostate ; frequent urination ; deficient muscular power ;
anemic ; voracious appetite ; bowels regular ; drinks and smokes
to excess ; depressed ; morbid fears ; easily fatigued. Genito-
urinary organs normal.
Treatment : Franklinic current, negative insulation, long
percussive sparks to entire general surface, localized to spine
and with director electrode to perineum. Three treatments
given extending over a period of six weeks ; improved.
Case 14. — N. female ; age 41 years ; widow ; thirteen chil-
dren ; Sept. 20, 1895. Neurasthenia ; depressed ; introspec-
tive ; tired in the morning : throbbing pain under right scapula
and precordia ; dizziness ; bowels regular ; heavy feeling in epi-
gastrium after eating ; pain and tenderness in knees ; very nerv-
ous ; sharp pain in leftside during last menstruation ; weariness
and aching and a sense of weakness in cervical region extend-
ing into arms ; anemic.
Treatment : Franklinic current, negative insulation, spray
to entire general surface for five minutes, followed by long
percussive sparks to spine, hepatic area, abdominal walls,
epigastrium and extremities. Fifteen treatments were given
extending over a period of two and one-half months with
marked improvement from the first ; pain in shoulder and knee
relieved ; marked nutritional gain ; improved circulation ;
increase in weight and disappearance of symptoms.
Case 15. — M. P., male; age 41 years; married; farmer;
Sept. 15, 1895. Neurasthenia : morbid fears and depressed.
Eight years since had gonorrhea. No symptoms except drag-
ging sensation in perineum and testicles. No lesion other than
a perineal eczema.
Treatment : Franklinic current, negative insulation, long
percussive sparks to entire general surface, localized to spine,
especially to lumbar and sacral plexuses also with director elec-
trode to perineum. Twelve treatments given extending over
nine and one-half weeks ; after second treatment less discom-
fort. Disappearance of depression, morbid fears and tendency
to introspection. Recovered.
Case 16.— J. P., male; 'age 25; single; wire weaver. Oct.
11, 1895. Neurasthenia, sexual with impotence. Duration four
years : weak feeling ; short breath on exertion ; has had gonor-
rhea ; painful micturition, irregular in quantity ; impaired
vision ; falling of hair ; seminal emissions two or three times a
week and no muscular power; varicose veins of scrotum:
morbid fears, depressed ; introspection.
Treatment: Franklinic current, negative insulation, long
percussive sparks to entire general surface localized to spine,
especially lumbar and sacral plexuses and with director elec-
trode to perineum. Nine treatments given extending over a
period of eighteen days. Recovered.
Case 17.— C. W., male; age 29 years; married; laborer;
Oct. 24, 1895. Sexual neurasthenia. Five years ago sexual
indulgence excessive; for last four years mucous discharge
from urethra ; last six months backache ; headache constantly
for last two months. For one year sexual desire diminished :
tired and drowsy on rising ; forgetful and despondent : bowels
constipated.
Urine analysis : Specific gravity 1012 ; granular casts ; urea
1.2 per cent. ; acid reaction.
Treatment: Franklinic current, negative insulation, long
percussive sparks to entire general surface, localized to spine,
especially to lumbar and sacral plexuses, hepatic area and
abdominal walls and with director electrode to perineum. Four
treatments extending over a period of one week ; relief from
pain in back ; stronger. Urine analysis, specific gravity 1024 :
acid ; no casts. Urea 2.4 per cent.
OFFICE CASES.
Case l.—A. H., March 12, 1895; age 51; widow; superin-
tendent of hospital. Neurasthenia ; duration four years ; men-
opause at 49 ; anorexia : nausea and vomiting : flatulence ;
constipation alternating with diarrhea ; headache ; spine ache ;
cervical and dorsal ; insomnia : nervous and depressed.
Treatment : Franklinic current, positive insulation, needle
spray to entire general surface, localized to spine and epigas-
trium for fifteen minutes. Twenty treatments given extending
over a period of one and one-half months. To the sixth and
following treatments were added long percussive sparks to
spine, nerve trunks and distribution. April 22, 1896. This
1896.]
FRANKLINIZATION IN NEURASTHENIA.
1051
patient has been actively at work during the past year and
reports to me under present date that she is well.
Cone *.— Mr. H. ; Feb. 14, 1895; age 40. Neurasthenia;
duration two years ; morbid: depressed; nervous and melan-
choly; insomnia: anorexia : impaired digestion : constipation ;
thin: Impaired strength.
Treatment : Franklinic current, negative insulation, needle
spray with crown electrode for ten minutes and long percussive
sparks to entire general surface; twenty treatments given
extending over a period of two months. After the first treat-
ment in' change ; looked cold, wan and apprehensive ; reaction
>od. The disruptive discharge badly borne and discon-
tinued; second treatment needle spray to entire general sur-
face for fifteen minutes; to third treatment added frictional
sparks localized to spine from nape to lumbar enlargement for
two minutes. At tenth treatment long percussive sparksgiven.
Patient did not sleep so well. No doubt over-stimulated by
the action of the sparks, but as in my judgment the time had
come when the disruptive discharge was indicated I persisted
in the use of long percussive sparks to the entire general sur-
face loeali/ed to spine, especially nape, lumbar and sacral
plexuses, hepatic area and abdominal walls. Markedand con-
tinued improvement; April 9, almost complete disappearance
of 93 mptoms ; sound and refreshing sleep ; good appetite ; good
color: increased strength: less nervous; bowels regular;
slight gain in weight.
CoseS. Mr. ,T. B. H. : March 19, 1895; age 48. Neuras-
thenia. Within the last ten or fifteen years has broken down
several times from over-strain ; two days since felt worse than
usual, took a drink of whisky, went out, fell down, got up and
wandered about, knowing nothing of his whereabouts. Not
an intemperate man. Congestive condition at base of brain;
sense of fullness in left ear and on left side with inabilty to
move head around quickly without pain : vertigo, sometimes
falls : when walking sense of falling ; two years ago marked
weakness of left side amounting to paresis for twenty-four
hours: gradually improved ; marked tremor of right arm and
hand : insomnia ; exaggerated mental activity ; knee-jerk
slightly diminished: general health good; some backache,
lumbar and sacral : is obliged to consider his coordination,
pupils respond to light and to accommodation ; far sighted.
Treatment : Franklinic current, positive insulation, needle
spray for fifteen minutes, followed by long percussive sparks
to entire general surface, localized to spine, from occiput to
lumbar and sacral plexuses, sciatic nerves and distribution :
frictional spark to nape. Treatment induced free perspiration
followed by relief from pressure at base of brain. Twenty-two
treatments given extending over a period of six weeks. Im-
provement with first treatment ; improvement continuous, and
after one month relieved of former symptoms and better than
before the acute attack in March. May 29, recovered.
\pril '22, 1896, patient has been well during the year.
Case I. J. W. P. Oct. 26, 1893. Male; age 41; single;
teacher : neurasthenia with hypochondriac symptoms. Dur-
ation two vears : sense of dizziness at first not localized, now
occipital : "pressure, sub-occipital ; numbness, creeping in left
side, arm, leg and side of body : sometimes on right side but
not to such an extent as on left ; intolerable sleepiness in the
afternoon with slight rise of temperature ; queer feeling in
head relieved by counter pressure ; darting pain in course of
spinal accessory nerves, increased by excitement ; constant
consciousness of a feeling as though force pump sending blood
down heels; excessively nervous ; sensation of "lump" mid-
wav dorsal spine ; feels suddenly now and then a touch here
and there, sometimes hot and cold, then gone ; sees double
disks at times which coalesce ; eyes astigmatic ; sleeps very
well, except when under excitement; dreams; profoundly
depressed : great nervous irritability ; morbid fears, thinks he
will become insane ; appetite good, gaseous eructations ; no
heaviness : bowels regular : knee jerk normal ; stands and
walks well ; no incoordination ; pupils respond to light and
accommodation ; palpitation on effort or with emotion.
Treatment : Franklinic current, positive insulation, needle
spray for fifteen minutes, followed by long percussive sparks
to entire general surface, localized to spine especially nape for
five minutes. Forty treatments given extending over a period
of six months and twelves days. Following first treatment
relief of discomfort in head which lasted nine hours. Novem-
■ ber 21 no longer thinks of becoming insane ; amelioration of
pain in back of neck. Subsequently slight exacerbation due
to an attack of "grippe." After recovery from "grippe" im-
provement continued; floor and ground do not wave under
him : eyes accommodate better. April 29 : Improvement estab-
lished has been maintained during the past two years and a
half ; no return to former conditions.
Case 5. D. I. P. Dec. 12, 1892. Female ; age 36 ; married.
Seven years since acu te nerve exhaustion ; since then backache,
sacral ; irritable bladder ; leucorrhea ; appetite capricious ;
nausea ; distress and heaviness in stomach ; flatulence, intes-
tinal ; constipation ; hemorrhoids ; headache, neurasthenic
helmet and sub-occipital ; sensitiveness to noise ; emotional,
easily moved to tears ; profound depression ; confusion ; weari-
ness in head ; possessed of fear all the time ; afraid to go out
alone ; thin, pale. Examination : immense cluster of hemor-
rhoids, external, largest size of walnut, ulcerated ; half a dozen
smaller ones ; lacerated cervix ; endometritis ; hyperplasia ;
anemia ; heart and lungs normal. Treatment : Franklinic cur-
rent, positive insulation, spray to entire general surface with a
few sparks to spine at first. Subsequently long percussive
sparks to entire general surface, and frictional sparks to spine.
Fifty-one treatments given extending over a period of six
months and fifteen .days ; after nine days no depression ; no
headache ; nervous fears very much less : appetite better :
bowels acting better : from Dec. 12, 1892 to Jan. 5, 1893 gained
three and one-third pounds ; passed first menstrual period
without local pain ; sense of pressure and pain in varicose veins
of right leg, usually exaggerated at menstrual period, mark-
edly less. After one month's treatmeat she came alone to the
office, first time she had gone out without some member of the
family in six years ; continued to improve so far as neuras-
thenic condition concerned notwithstanding the fact that she
was absent from regular treatment from January 18 to Febru-
ary 20, during which time I operated on hemorrhoids. By the
middle of March able to work and assume the care and respon-
sibility of her family ; May 9, normal movements for past ten
days, before no action without medicine. After symptomatic
relief was established in consequence of the nutritive changes
set up by general Franklinization, uterine treatment was given
with the continuous and induced currents according to indica-
tions. Recovered. October 1894, returned with nervous
symptoms due to fright and excitement. After two week's
treatment restored to former condition.
Case (S.—8. V. A., Oct. 5, 1895. Female ; age 48: teacher;
neurasthenia ; duration fourteen years, broken down at that
time ; rested one year ; menopause five years since ; better at
times ; appetite fair ; no indigestion ; bowels regular ; pain back
of neck extends at times over head ; occasional supra-orbital
pain ; insomnia ; extreme nervous irritability ; pricking sensa-
sation all over, especially calves of legs ; morbid and unreason-
able over little things ; feels like crying ; bronchial irritation
with cough ; post-nasal discharge ; slightly deaf ; anemic.
Treatment : Franklinic current, positive insulation, spray to
entire general surface for ten minutes, frictional sparks to
spine, especially nape. Fourteen treatments given extending
over a period of one month and four days ; felt better from first
treatment. Treatment suspended for a month or two : recom-
menced and continued once a week to date. Marked nutri-
tional improvement ; able to keep at work all winter. Relief
from all distressing nervous and mental symptoms.
Case 7.— R. W. May 2, 1895. Female; single; neurasthenia
with hysteric symptoms. Duration nine years; eight years
since both ovaries and tubes removed ; history of abscess since
operation, discharged per rectum, pus, no blood ; occasional
backache ; intestinal flatulence ; constipation ; during winter
acute attack of stomach and intestinal indigestion ; tired head ;
sensitiveness on pressure over cervical and lumbar vertebrae ;
paresis of facial muscles in October ; insomnia ; depressed ;
nervous ; irritable ; self-centered ; excessively thin ; worn and
ill looking ; worse in the morning.
Treatment : Franklinic current, positive insulation, needle
spray to entire general surface, localized to spine and right
sciatic. Thirty-six treatments given extending over a period
of two months. After a week improved sleep ; bowels more
regular. To eighth treatment added long percussive sparks to
spine, lumbar and sacral plexuses, sciatic nerves and distribu-
tion, to epigastrium and abdominal walls. Improvement con-
tinuous : gained eighteen pounds under treatment.
Case S.— A. H. W. March 1G, 1893. Female ; married ; age
34. Neurasthenia. Not well since first confinement eight
years ago ; unable to stand ; conscious of pelvic organs : bear-
ing down ; veins of both legs, anterior surface, enlarged. Feb-
ruary 1891, operation on cervix and perineum. Backache con-
stant, vesical pain ; leucorrhea, increased by exertion or undue
fatigue ; post-menstrual exhaustion ; headache ; fullness of
head ; pressure at nape ; distress in spine, especially dorsal ;
insomnia ; nervous and excitable ; irritable ; despondent : appe-
tite capricious : flatulence, gastric ; constipation : anemia : cir-
culation poor ; appearance of faulty elimination.
Treatment: Franklinic current, positive insulation, spray to
entire general surface for ten minutes, sparks to spine. At
subsequent treatments long percussive to entire general sur-
face localized to spine. Forty-five treatments given extending
1052
HOMICIDE IN THE UNITED STATES.
[November 14,
over a period of four months ; marked improvement from the
outset. After two months walked one and one-half miles and
took a bicycle lesson of twenty minutes without fatigue ; no
backache save when over-fatigued ; appetite good ; bowels reg-
ular. Recovered. June 28, 1894, confined.
April, 1895, operation, curettement and trachelorrhaphy.
May 9, 1895, came under writer's care again. Incomplete union
at site of highest stitch right side of cervix ; perineum ex-
tremely sensitive ; pelvic congestion ; vaginal walls relaxed ;
anterior wall prolapsed ; constant sense of discomfort, bowels
constipated ; liver inactive ; skill sallow and pigmented.
Treatment : Franklinic current, positive insulation, needle
spray to entire general surface, localized to spine for twenty
minutes. Eleven treatments given extending over a period of
one month and three days with disappearance of symptoms, as
well as improved local conditions.
HOMICIDE IN THE UNITED STATES.
Read before the American Academy of Medicine.
BY PAUL BARTHOLOW, B.A., M.D.
PHILADELPHIA.
Murders are of very great frequency in this coun-
try. The number reported last year was 10,500, an
enormous figure! We might, if there were not some
reasons against it, take this number as the annual
average, which in most countries is a fairly constant
quantity. But here, owing to some conditions that I
shall endeavor to particularize, the amount of homi-
cide in any year, taken as a standard, does not give us
the least reason for predicting that the succeeding
year will be marked by a similar number of murders,
neither many more nor less. In 1885, for instance,
the homicides reported numbered 1,808; in 1890,
4,290; in 1894, 9,800, and I have just mentioned
10,500 in 1895. That is to say, there was nearly six
times as much homicidal crime reported last year as
in 1885, an increase almost in arithmetical ratio. In
a word, the population loses every year from murder
as much as from a battle or a plague. Such an amazing
development of murder has never before been observed
in any other country. There must be some especial
cause or causes at work to produce such a result, but,
before entering upon a discussion of these, let us
undertake a comparative view of the above figures.
We shall thus be enabled fully to appreciate their
gravity. Let us take as affording a sufficiently vivid
comparison, the amount of homicide perpetrated in
war. The total killed in battle on the Federal side
during the late war was in round numbers 49,000
(Medical and Surgical History of the Rebellion).
That is an annual average of little more than 10,000
(the time being a period of nearly five years), or
about the same as the total number of homicides
reported last year. During the Franco- Prussian war
of 1870, the Germans lost in battle 17,500 men, a fig-
ure that sinks into insignificance beside our total of
homicidal crime, for the conditions favoring homicide
in war are or ought to be vastly greater than the con-
ditions favoring it in peace. (Oettingen, die Moral-
statistik, p. 729.)
Again, let us compare last year's total of murders
with the annual average of other countries. In order
to make this comparison as absolutely true as possi-
ble, I shall adopt the method of estimating the total
amount of murder during any given period, recom-
mended by Bosco, who has studied this subject with
the greatest care. In his own words, his method is
described as follows: "As the composition of the
population, with respect to age, varies in different
countries, and as it has to be remembered that all the
population under ten years of age has no share, at
least under normal conditions, id the crime of murder,
it has seemed to me a more exact method to calculate
the proportion of murders to the inhabitants who are
over ten years of age than to include the total popu-
lation." (Quoted by Morrison: Crime and its Causes,
p. 30.) I may mention here that with respect to this
country, such a method of calculation is extremely
difficult. The composition of the population varies
greatly; in some States there is undoubtedly a pre-
ponderance of adults: in others, on the other hand,
the proportion of children under 10 years of age is
probably very high, in such regions as Pennsylvania
and New York, for instance, where the birth rate is
respectable and the casualties, inevitable amid such
enormous trade and manufacture, are great and com-
pose very material losses of adult population, we have
powerful causes tending to raise the proportion of
children under 10. It might be supposed that immi-
gration, including chiefly adult males, would neutral-
ize this result. Doubtless it does modify the propor-
tion of children to adults, but not, I think, to any
great extent. In fact, considering the high birth rate
in those sections that receive the most immigration,
and considering, too, that the rate throughout the
country is normal, I think we shall not be far wrong
in supposing that the proportion of children under
10 years of age is as great here as in England or Ger-
many. Supposing then the population of the United
States at the present day to be 65,622,000, which is
reached by calculating the excess of births over
deaths and the amount of immigration since the last
census, when the population was put at about sixty-
two millions, and taking off 20 per cent, of the whole
as representing the population under 10 years, we
ought to get the total population which under normal
conditions, as Dr. Bosco puts it, might be physically
able to commit murder. The total thus calculated is
52,478,000. Taking last year's number of homicides,
and calculating the rate per 100,000 of population we
get the high proportion of 20. Comparing this rate
with the rate in other countries, according to Bosco's
tables, we find that homicide is a fourth higher here
than in Italy, nearly twice that of Spain, nearly five
times that of Austria, nine times that of France,
nearly twenty times that of England, Scotland or
Germany. All this is bad enough. In order, how-
ever, to bring this high rate into greater relief, let us
compare it with the rate in India. We have, as Mr.
Morrison tells us, excellent statistics of Indian
crime. It is, besides, a country that in point of size
and severity of climate, resembles our own. We
might, if it were not for some social prohibitive
causes, expect a high rate of murder. But what is
really the fact? In Mr. Morrison's words, "India
stands to-day in the proud position of being more
free from crimes against the person than the most
civilized countries of Europe." Astonishing as it
seems, India with its 185,000,000 of population over
10 years of age has an annual average of but 1,930
cases of homicide, scarcely one-fifth of the number
last year in our population of 52,000,000! In other
words, in India with its enormous population the rate
of homicide per 100,000 of population is but 1.31, a
percentage unmeasurably inferior to ours. Mr. Mor-
rison ascribes this low rate of homicidal crime to the
prohibitive influence of caste, but before undertaking
a discussion of this subject, let us look at these fig-
ures from another point of view. The annual aver-
age of homicide in India is the whole number of cases
L896.]
HOMICIDE IN THE UNITED STATES.
1051}
of murder reported and presumably the whole num-
ber committed, which is not the case with regard to
this country. There is, therefore, this remarkable
fact established with respect to crime in India, that
wi> really know the amount of murder committed
annually; not approximately (as we do of England
and the United States) but as nearly as possible abso-
lutely, and this amount, considered from this point of
view, is hut one-half that of England and but 1-34
that of the United States. I can not do better here
than put the mat tor in Mr. Morrison's words: "The
number of cases of homicide in India committed by
parsons over 10 years of age and reported to the
polios is smaller per 100,000 inhabitants than the
number of oases of the same nature brought up for
I rial in England (italics mine). In order to appre-
ciate the full importance of this difference it has to
be remembered that in England a great number of
cases of homicide are reported to the police for which
no one is apprehended or brought to trial. In the case
of the notorious Whitechapel murders, which horrified
the country a year or two ago, no one was ever brought
to trial; hardly any one was arrested or seriously sus-
pected. These crimes and many others like them
materially augment the number of homicides reported
to the police, but they never figure among the cases
annually brought for trial before assizes. As a matter
of fact no one is ever tried in more than one-half of
the cases of homicide reported to the police in the
course of the year. In the year 1888, for instance,
403 cases of homicide were reported to the police in
England and Wales; but in connection with all these
1 only 196 persons were committed for trial. In
short, double the number of homicides are committed
as compared with the persons tried; and if a com-
parison is established between India and England on
the basis of homicides reported to the police, the
outcome of such a comparison will be to show that
there are annually more than twice as many murders
committed per 100,000 inhabitants over the age of 10
in England than there are in India."
I have said that in the United States there are
every year thirty-four murders where there is one in
India. The real number is probably much higher.
But it is, unfortunately, very difficult to calculate this
number, except approximately, for statistics of the
number of persons tried as compared with the num-
ber of murders committed are, as far as I know, not
to be had. But, fortunately, we possess statistics of
the number of executions, and we may draw some
inference as to the amount of murder in the country
by ascertaining the proportion of executions to cases
reported, and comparing this proportion as it exists
in various countries. For it is generally known that
the frequency of capital punishment is a tolerably
accurate indication of the amount of murder prevail-
ing; a high rate in the one being accompanied by a
high rate of the other. If, then, we find that the
number of executions, as compared with the number
of cases of homicide, is relatively large, we might
infer that murder in the country under consideration
is really, and not apparently, of correspondingly com-
mon occurrence. And, incidentally, finding the pro-
portion of executions to cases reported we might be
able to estimate the number of cases tried, a better
method it would seem, according to Bosco and Mor-
rison, of calculating with accuracy the absolute amount
•of homicide in the country during a given period.
In such an inquiry we have to remember that the
proportion of executions to trials must be small,
unless we suppose that the cases of homicide reported
are cases of willful murder — a rash supposition that
may be dismissed. And we must also ask ourselves
whether the death penalty, for any reason in law, is
likely to be enforced in some countries in cases where
in others it would not. Doubtless there is a differ-
ence in this respect between countries like England
and the United States and countries like Germany
and Austria. But this difference need not occupy us
particularly if we find that the proportion of execu-
tions to cases reported is so much greater in the for-
mer countries as to outweigh any effect that the supe-
rior mildness of Continental law in this respect may
have. Nor, again, need we be scrupulous in affirming
our comparison if we find that with this higher pro-
portion of executions there is admittedly a greater
laxity in the administration of the criminal law, a
laxity that may, and does, materially decrease the
number tried, if not the very cases that would, under
a better condition of things, augment the total of
executions.
To proceed then with our view, we may take Ger-
many, as furnishing of all other countries the most
striking example of a high rate of cases convicted
and an exceedingly low rate of executions. In that
country, as in India, it is probable that very few cases
are reported that are not tried and very few tried that
are not convicted. In Germany, for instance, of 567
cases of homicide in 1882, there were 476 convictions
and but 9 executions, or .02 per cent, of convictions. In
England in 1891, 19 persons suffered the extreme pen-
alty, about 12 per cent. In 1890, in the United States,
there were 4,290 cases of homicide reported and 102 exe-
cutions by law. Assuming that convictions amounted
to one-fourth the number of murders reported, a gener-
ous estimate, and taking from that 127 cases summarily
executed without trial, we have left 948 convictions, of
which 102 or 10.7 per cent, were condemned to death.
Thus, in other words, in Germany, where convictions
are relatively frequent, we see a correspondingly low
percentage of death sentences, while on the other hand,
in England and the United States, where convictions
are not so common, the amount of capital punishment
is considerable, including, in fact, in England, about
one-seventh of the cases tried. Even if we should
dismiss the cases of murder reported in the United
States on the ground that the report is inaccurate,
and take merely the combined legal and illegal exe-
cutions for a single year, the 303 of last year, for
instance, as furnishing an estimate of the amount of
murders in the country (it being undeniable that an
execution, whether legal or illegal, is as good an indi-
cation as a trial that a murder has been committed),
we should still have to record an enormous excess of
homicide here over other countries. For what are 19
executions or 9, in comparison with 303?
It is impossible in fact not to believe that the high
proportion of death sentences is an intimation not
only of the gravity and prevalence of murder, but of
some defect in the machinery of the criminal law,
influencing judges to extreme severity in punishing
crime when proved, and, not unlikely, as a means of
consciously or unconsciously satisfying public ven-
geance. We might attain a stronger conviction of the
truth of the foregoing estimate by comparing the num-
bers convicted with the numbers tried. There is a
wide difference in countries in this respect. A very
able student, Mr. Morrison, whom I have several times
1054
HOMICIDE IN THE UNITED STATES.
[November 14,
quoted, observes: "In some countries very few con-
victions may take place in proportion to the number
accused, while in other countries the proportion may
be considerable. In other words, in order to arrive
at an approximate estimate of the amount oi murders
committed in a country, we must consider how many
cases of murder have been tried in the course of the
year. It very seldom happens that a person is tried
for this offense when no murder has been committed,
and it may therefore be assumed that the crime has
taken place when a man has to stand his trial for it.
Estimating, then, the prevalence of murder in the
various countries by trials, rather than convictions, it
will be found that Germany, with a much larger per-
centage of convictions than England, has just as few
cases of murder for trial. And the reason the num-
ber of convictions, as between the two nations, differs,
arises from the fact that a prisoner's chance of acquit-
tal in England is 100 per cent, greater than it is in
Germany. It is not, therefore, accurate to assume
that a greater number of murders are committed in
Germany than in England because a greater number
of persons are annually convicted of this crime; all
that these convictions absolutely prove is, that the
machinery of the criminal law is more effective in
the one country than the other. To take another
instance, more persons are annually tried for murder
in Ireland than in France ; but more cases of convic-
tion are recorded in France than in Ireland. These
contrasts show that, while the French are less addicted
to this grave offense than the Irish, they are more
anxious to secure its detection, and that a greater body
of public opinion is on the side of law in France than
in Ireland. . . . While thus showing that the
number of trials for murder is the best test of the
prevalence of this offense, it is not meant that the
test is in all respects indisputable. At most it is
merely approximate. One obstacle in the way of
its entire accuracy consists in the circumstance that
the proportion of persons tried, as compared with
the amount of crime committed, is in no two coun-
tries precisely the same. In France, for instance,
more murders are perpetrated for which no one is
ultimately tried, than in Italy or England; that is
to say, a murderer runs more risk of being placed
in the dock in this country than in France. But the
difference between the two countries is again to a
great extent adjusted by the fact that once a man is
placed in the dock in France, he has far less chance
of being acquitted than if he were tried by English
law. On the whole, therefore, it may be assumed that
the international statistics of trials, corrected when
necessary by the international statistics of convictions,
present a tolerably accurate idea of the extent to
which the crime of murder prevails among the nation-
alities of Europe."
In order to estimate the number of trials for mur-
der in this country, and apply this test in its rigor we
must look, in default of better means, at the statis-
tics of our prisons. We can find these in the Com-
pendium of the last census, namely for 1890. In that
year the number of persons in prison for homicide was
7,500. As there reported in the years 1885-90 an an-
nual average of more than 3,000 cases of homicide, it
is evident at once that the proportion of persons tried
and convicted of that crime as compared with the
number of cases reported, is insignificant. Assuming
that the persons in prison for homicide in 1890 were
all recruited from the cases extending over the years
1885-90, which is hardly true as some ot them must
have been imprisoned at an earlier date, and assum-
ing that as many cases were reported as were tried,
during those years, we still have a large excess of trials
over convictions, and, what is worse, we must con-
clude that a considerable number of undoubted mur-
ders, supposing that some one was tried for them, are
not represented in the numbers of the prison popula-
tion, nor can it be supposed that this deficiency is
made up by the number of persons executed, a num-
ber far too small to make good the discrepancy. There
is, of course, in every country an excess of trials over
convictions. In England in the years 1882-6, 1.6 per
cent, of the population was annually tried for murder
and 0.76 per cent, convicted. In Germany during the
same period 1.61 per cent., were annually tried and
1.35 per cent convicted. In the United States, basing
our estimate on the number in 1890, and taking the
annual average of committals during the years 1885-
90 as 1,250, or in other words taking this as the num-
ber of convictions, although the real number must
obviously be much lower, and assuming that the trials
averaged half the cases reported during that time, we
have an excess of trials over convictions of one-fifth;
an excess of cases reported over convictions of twelve-
fifths. Lastly, to take India, as a country most like
our own in respect to climatic conditions, the most
powerful influences in causing homicidal crime, we
find the annual average of cases reported to be 1.31
per cent, and the annual average of convictions 0.46
per cent., an excess of cases reported over convictions
of 2.8 or fourteen- fifths, an instructive result that
points to a mild administration of the criminal law in
India, a result too that incidentally shows us that a
laxity in this respect is not necessarily in that coun-
try a provocative of crime.
And this brings us to the curious inquiry as to the
causes of the prevalence of murder. We have just
seen that though in India, as in England, the percent-
age of convictions is not high; yet India, as compared
with England and the United States, is singularly
free from crimes of blood. A hot climate, as Professor
Ferri has shown, is one of the most potent causes of the
prevalence of homicide, and we might expect there-
fore that India, as compared with England, would
show a high percentage of murder. Yet this is not
the case. As compared to the United States, where
the climate is marked by harsh extremes and often
unexpectedly severe weather, we might look for a
lower percentage, but this too is far from being true.
To what, then, is the difference due? It is most
plausibly argued by Mr. Morrison and Sir William
Hunter that the immunity of India from crimes of
violence is due to the influence of caste; and, while,
admitting the unfavorable effects of the Indian cli-
mate, they believe that caste is powerful enough to
repress those effects. By looking at their arguments,
we shall get I think, not only the most just and phil-
osophical view of some of the deeper and more per-
sistent causes of the crime of murder, but also an illus-
tration, an analogy that may usefully be applied in
determining the causes of murder in our own country.
Let us take Mr. Morrison's view first. " The peculiar
structure of society," he says, " is unquestionably the
most satisfactory explanation of the high position
occupied by the inhabitants of India with respect to
crime. The social edifice which a people builds for
itself is among all civilized communities a highly
complex product, and consists of a great agglomera-
1896.]
HOMICIDE IN THE UNITED STATES.
1055
tion of diverse materials. These materials are partly
drawn from the primitive characteristics of the race;
they are partly borrowings from other and contiguous
races; they are to a considerable extent derived from
natural surroundings of all kinds: and in all circum-
stances they are supplemented by the genius of indi-
viiluals. In short, all social structures, when looked
at minutely are found to be composed of two main
ingredients -race and environments; but these two
ingredients are so indissolubly interposed that it is
impossible to say how much is to be attributed to the
one, and how much to the other, in the building up
of society. But if it is impossible to estimate the
value of the several elements composing the fabric of
society, it is easy to ascertain the dominating idea on
which all forms of society are based. That dominat-
ing idea, if it may for the moment be called such, is
the instinct of self-preservation, and it exercises just
as great a power in determining the formation and play
of the social organism as it exercises in determining
the attitude of the individual to the world around
him. In working out the idea of self-preservation
into practioal forms, the social system of most people
has hitherto been built up with a view to protection
against external enemies in the shape of hostile tribes
and nations; the internal enemies of the common-
wealth the thieves, the housebreakers, the disturbers
of public order, the shedders of blood, the perpetrators
of violence— have been treated as only worthy of sec-
ondary consideration The structure of
soeiety in India is, however, an exception to the gen-
eral rule. External security, or in other words, the
desire for political freedom has, to a great extent,
Income extinct in wherever the principle of Brahman-
isin has succeeded in taking root. These principles
have been operating upon the Indian mind for thou-
sands of years; their effect in the sphere of politics
excited the wonder of the ancient Greeks, who tell us
that the Indian peasant might be seen tilling his field
in peace between hostile armies preparing for battle.
A similar spectacle has been seen on the plains of
India in modern times. But Brahmanism, while ex-
tinguishing the principle of liberty in all its branches,
and exposing its adherents to the mercy of every con-
queror, has succeeded, through the caste system, in
bringing internal order, security, and peace to a high
pitch of excellence. This end, the caste system like
most other religious institutions, did not and does not
directly have in view; but the human race often takes
circuitous routes to attain its ends, and while appar-
ently arriving at one object, is in reality securing
another. The permanent forces operating in society
often possess a very different character from those on
the surface, and when the complicated net work in
which they are always wrapped is stripped from off
them, we find that they are some fundamental human
instincts at work in disguise."
" These observations are applicable to the caste sys-
tem. This system, when divested of its externals,
besides being an attempt to satisfy the mystic and
emotional elements in the Indian heart, also repre-
sents the genius of the race engaged in the task of
self-preservation. The manner in which caste exer-
cises this function is thus described by Sir William
Hunter. "Caste or guild,' he says, 'exercises a surveil-
lance over each of its members from the close of
childhood until death. If a man behaves well, he will
rise to an honored place in his caste; and the desire
for such local distinctions exercises an important
influence in the life of a Hindoo. But the caste has
its punishments as well as its rewards. These pun-
ishments consist of fine and excommunication . .
. . . Anglo-Indian law does not enforce caste
decrees. But caste punishments exercise an effica-
cious restraint upon unworthy members of the com-
munity, precisely as caste rewards supply a powerful
motive of action to good ones. A member who can
not be controlled by this mixed discipline of punish-
ment and reward is expelled, and, as a rule, an out-
caste is really a bad man. Imprisonment in jail car-
ries with it that penalty, but may be condoned after
released by heavy expiations.' "
"These remarks of Sir William Hunter afford an
insight into the coercive power exercised by the caste
system on the Indian population. Without that sys-
tem it is probable that the criminal statistics of India
would present as high a proportion of crimes of vio-
lence and blood as now exists among the people of
Southern Europe. But with that system in active
operation, the evil influence of climate is completely
neutralized, and India at the present moment enjoys
a remarkable immunity from violent crime."
This admirable passage from Mr. Morrison displays
in a very clear light the peculiar structure of Indian
society. The chief difference from our present point
of view between that society and ours is the fact that
here the instinct of self-preservation has given away,
as it has not in India, to the desire of possessing
extreme political freedom. Here internal security,
as compared with personal liberty, is of little impor-
tance; and although owing to the geographical posi-
tion of the country the danger of its being disturbed by
external foes is, indeed, very remote, yet, it does not seem
so to the people, as the present prominence of the Mon-
roe doctrine shows, who often are disposed to believe
their external security is in jeopardy, not so much, it
is true, from an invasion of armed enemies, as from
the importation of ideas, hostile to the prevailing con-
ceptions of personal liberty. As there is not this
danger, except in the most remote degree, it would
seem expedient to the people to turn their attention
to the consideration of their internal security ; but it
being well understood that the attainment of a great
degree of internal security would mean sacrifices of
individual liberty, it is scarcely to be expected, the
popular mind being really at bottom extremely con-
servative, that any change of an opinion in this respect
will soon take place. In fact the importance of
external security is as much exaggerated here as it is
kept in abeyance in India, and thus we have the curi-
ous contrast of two countries, alike in possessing a
severe climate, alike in variety and greatness of natural
surroundings, yet presenting the widest differences
socially and with respect to crime.
They are also utterly dissimilar with regard to
industrial activity, which here is enormous and in
India comparatively inconsiderable. The difference
is important and, as it will be seen, partly explains
the low proportion of Indian crime. For crime is
found, according to the exact researches of Ferri and
of Tarde, to be growing in steady relation to the
growth of commercial enterprise; and, it is also now
a matter of certainty that not only is there this close
connection between crime and industrial enterprise,
but there is besides, as Fere has shown, a triple rela-
tion established here, between crime, commercial
activity, the surmenage of modern life and nerve dis-
ease. In other words Tarde has demonstrated that
1056
MEDICAL VIENNA AND HEIDELBERG.
[November 14,
the commercial classes in various countries contribute
the largest proportion of crime ; they are also, as Fer6
tells us, the most afflicted with nervous complaints,
with the exhaustion of the nervous system, so insep-
erable in some degree or other, from a busy, modern
existence, and so fatally linked in its graver forms,
with morbid and criminal impulses. The agricultural
and mechanic classes, on the other hand, whose pur-
suits are different, involving less anxiety and fewer
temptations, prevent a smaller percentage of crime.
The coincidence therefore of the unexampled growth
of crime and of industrial activity is justly held to be
something more than fortuitous.
It is the fashion to use the vague world "degener-
acy" in connection with a condition of the nerves,
supposed to be due to modern influences. When the
word is employed as it is by Krafft-Ebing, Kurella
and Lombroso to describe a peculiar instability of the
nervous system, accompanied by definite anatomic
variations from the normal type and also by peculiar
characteristics of mind, it is undoubtedly indicative
of a physical and moral predisposition to crime. A
lesser degree of degeneracy, however, that acquired
in pursuits too absorbing for the health and strength,
may, and does, predispose to crime, especially to hom-
icide, a form of crime committed for the most part by
persons who have reached any of the stages of mental
and moral deterioration. Nothing, indeed, is more
conclusive with respect to the nature of this crime
than the fact that an extremely large proportion of
the persons convicted of this offence are found to be
insane or mentally infirm. Thus of 441 persons con-
victed of murder in the prisons of England, 143 or
32 per cent, were declared unsound in mind. In
short, we are assured beyond any question by these
facts and many others that might be instanced, that
people who suffer in any degree from maladies of the
nervous system, are particularly addicted, as com-
pared with the healthy, to murder; that industrial
activity, if too absorbing and severe, may produce
various gradations of degeneracy of the mind and ner-
vous system, very often acquired, very often too,
inherited, and furnish with its increasing' growth one
of the predisposing causes of the enormous develop-
ment of murder in recent years.
There is another circumstance connected with this
subject, that I am tempted to touch upon before clos-
ing this paper. It is that murder in this country is
very frequently committed by persons who act under
a notion that they are inflicting just and necessary
vengeance. Such crimes, in which category we must
place lynchings, happen for reasons of which the dis-
cussion belongs more to the sphere of law than medi-
cine. But the distinguishing mark of these crimes
for us is that they are national, that is to say, they
are caused by the exigencies of a race, not yet in per-
fect harmony with its environment, that does not
seem to know, in fact, the economy* of crime. I say
race, for it is undoubted that, in the regions in which
illegal executions are most frequent, a definite nation-
ality has been formed, different in many respects from
any type of the Old World.2 In other parts of the
country the differentiation of the European races in
America from any European type is rapidly proceed-
ing, if, indeed, it has not already been consummated
as was long ago observed by M. de Quatrefages.. I
am inclined to think that a large amount of crime is
flroca : Hist, de la Soc. d'Anthropoloele de Paris, 1863, p. 37.
Krafft-Ebing: Psycho-pathologle, p. 2.
the result of the play of forces, social and physical,
that are at work in this process of differentiation; and
until these forces are met on the part of the inhabit-
ants with a better comprehension of how to combat
their evil influences, until it is known that the fever
of business must subside, that the severities of climate
must be mitigated, the excesses of political passions
controlled, we may expect, what we have now in
frightful amount, an increase in crime.
MEDICAL VIENNA AND HEIDELBERG.
NOTES FROM MY SKETCHBOOK.
L. HARRISON METTLER, A.M., M.D.
CHICAGO, ILL.
Several surprises were in store for me at Vienna.
As I approached the city by way of the Danube, a
day's sail upon which is as fascinating and full of his-
toric reminiscences as a trip up the Rhine, I began
to wonder whether a certain "waltz king" were not the
victim of achromatopsia: for the " beautiful blue
Danube" is most emphatically a bilious brown in
tint. Again when I discovered that the capital of
Austria is not on the Danube but a long way back
from it on a very muddy canal and a very much mud-
dier creek, my confidence in the veracity of a certain
old schoolmaster received a rude shock. To this
insignificant creek, the Wien, does the proud city of
the Hapsburgs owe its name. Once more to my utter
astonishment I found that the great city of Vienna,
the real Vienna, is only about a mile long and a half-
mile wide, while its apparent bigness is due to the
incorporation of some thirty-six or more large suburbs
immediately adjoining it. From these suburbs the
streets all converge, like the spokes of a wheel, toward
the picturesque old cathedral of St. Stephen in the
heart of Old Vienna. Unlike most other cities, the
aristocratic portion, where the royalty, the nobility
and the wealthy have their residence, is the most
ancient. The antiquity of this part of the city is
revealed in the narrowness of its streets, the height
of its buildings, its well paved but undulating thor-
oughfares, and its numerous dark alleys and covered
byways. A touch of orientalism is seen everywhere.
Encircling Old Vienna and occupying the site of the
ancient ramparts, is a broad and magnificent boule-
vard, known as the Ringstrasse and adorned with
parks, fountains, monuments, statues, and some of
the city's finest examples of architecture, among
them the splendid University. The circle of suburbs
stretches away beyond the Ringstrasse. There is a
wealth of history and legend in Old Vienna; its very
life teems with music and art; its people are interest-
ing to know and study; its customs are unique.
Excepting Paris, Vienna is probably the most beautiful
city iu Europe. Its architectural elegance equals the
brightest visions of the most florid imagination. The
first sight of its pomp and splendor so overwhelms
the medical visitor with astonishment, enthusiasm and
admiration, that it takes him several days to acquire
sufficient calm and courage to look up the hospitals
and gaze once more upon filthy sores and ugly tumors.
But, alas, it must be! Marble palaces, Gothic cathe-
prals, Greek temples, art galleries and museums, royal
operas, Hofburg theaters, flower gardens and enter-
taining music, brilliant arcades, curious statues, mag-
nificent monuments, fretted fountains, gorgeous shops
and quaint markets, all must be passed by one who
1896 I
MEDICAL VIENNA AND HEIDELBERG.
1057
would know somewhat of medical Vienna and who
has but a few days to learn it in. Medical Vienna,
both educational and eleemosynary, is full of inter-
esting history and practical suggestion. Go not then
to the city of Marcus Aurelius and Maria Theresa,
the carnival city of wine, woman and song, the city
of the mystic meerschaum and the home of beauty
and art, to study its medical life, unless you go as a
student to take up a long residence there. If you go
for a few days only, its wealth and magnificence wili
so enrapture you that your hours will have vanished
ere you have had an opportunity of getting even a
glimpse of the great University and the vast Imperial
Hospital.
As everybody knows, Vienna leads the world at
pWMBJ in general medical education. The mere men-
tion of such names as Billroth, Ludwig, Nothnagel,
Chrobak, Schauta, Exner, Benedikt, Kaposi, Politzer,
Obersteiner and others, is enough to confirm her pre-
eminence. And yet it was not always thus, for she
was long outshone by France and Germany. In neu-
rology and psychic medicine Paris even to-day holds
an exalted position; while in pathology and thera-
peutics Berlin has scarcely a rival. The reasons for
the preeminence of Vienna are many. One is the
cosmopolitan character, size and wealth of her popu-
lation. The generous support and favor of the gov-
ernment in educational matters is another. Above all,
however, is the unusual concentration of learning in
the capital and its matchless University. In Austria
university education is pretty much the same as it is
in Germany. I will hove somewhat more to say about
it in my sketch of Berlin. Even in Germany, where
learning is so intensely cultivated, the twenty-one
universities drain the educational resources of the
empire more than do the seven universities of Austria.
In both countries the university is a government insti-
tution and one of its four or more faculties is always
that of medicine.
Within sound of the famous Strauss concerts in
the Volksgarten and almost under the shadow of the
lace-like Votivkirche rises the superb building of the
University. A stone's throw from it are the Rathhaus,
as fine a specimen of gothic as one can ever see, the
Parliament Building in the style of the pure Greek,
the gem-like New Hof-theater, the Law Courts con-
structed after the most elegant renaissance manner,
and many other great buildings, museums and monu-
ments. The Franzensring is a veritable architectural
paradise. The designer of the University was Ferstel,
one of a brilliant coterie of artists who have added
luster to the fame of the royal city. Its style is almost
pure renaissance. Immense in size, massive in appear-
ance, and compact, it is nevertheless graceful, chaste
and attractive. Its sides are generally plain but its
front is broken with galleries, facades and retrench-
ments. Its cornice is adorned with exquisite mold-
ings, pediments and statuary, while its roof is varied
with a large central dome and several smaller domes
and cupolas. Its interior is quite as rich and ornate
as its exterior, free use having been made of variously
tinted marble. The University of Vienna is one of
the oldest among the Germanic peoples, having been
founded in 1237. Greatly to its advantage, it was
reformed under Maria Theresa by her celebrated med-
ical adviser Van Swieten. This famous old courtier
physician seems to have been a pretty energetic fellow
in his day. He was born at Leyden in 1700. He
studied at the university of his native city and that of
Louvain, ultimately becoming a pupil of the immortal
Boerhaave. After serving for a time as professor in
the University of Leyden, he was forced to resign on
account of being a catholic. At once Maria Theresa
invited him to Vienna. This was in 1745. He was
appointed physician to the Empress, director-general
of medicine in Austria, imperial librarian, professor
and a baron. He wrote much upon surgery, military
medicine, epidemics and other related matters. His
death occurred in 1772. Such was one of the liberally
educated, representative, old-time physicians who in
their immense learning, untiring industry and wide
capability stand as a permanent protest to the narrow,
technical specialized doctor of the present day. As I
stood beside the grave of this famous old doctor in
the small but elegant church of the Augustins and in
the midst of many magnificent monuments and mau-
soleums, notably the world-renowned one executed by
Canova in memory of the Archduchess Maria Christina,
I thought of the honors and dignities conferred upon
medical men abroad and compared them with those
conferred in America. I fear my head drooped a little
and I confess my reflections as a member of the
American profession, were anything but self-congratu-
latory. In every great city of Europe, streets are
named, statues erected and public monuments conse-
crated to the memory of eminent medical men. I
began wondering whether the fault lay entirely with
our peculiar form of government, or we ourselves
were not to blame in a very large measure. I won-
dered if our numerous ill-prepared colleges, our low
standards of medical education, our senseless desire
for cheap notoriety, our tolerance of 'isms and 'pathies,
our ofttimes badly-concealed efforts to maintain a pro-
fessional air with a trade-and-barter method of con-
duct, and especially our too frequent attacks of pro-
fessional jealousy and absence of laudable esprit de
corps, were not after all more in the way of preventing
the American people honoring our profession as they
should. In the midst of these reflections I strolled
sadly out of the church, but took comfort in the
thought that the last few years had raised our stand-
ard of medical education somewhat and promised
better things for the future.
The old university used to be in the vicinity of
St. Stephen's church, in a building now occupied by
the Academy of Sciences founded in 1846. When it
was transferred to its new location it became the cen-
ter of the educational quarter of the city. The Gen-
eral Hospital, long used for medical teaching, was
already there. A short distance beyond were the
extensive gardens and superb buildings of the insane
asylum for 600 patients. In a neighboring street rose
the chemical laboratory, a beautiful renaissance struc-
ture designed by Ferstel ; while farther along in the
same street stood the Josephinum, or Academy of Med-
icine and Surgery. The latter was founded in 1784
by the Emperor Joseph II. for the training of military
surgeons, but afterward he changed his plans. The
building to-day contains a remarkable collection of
wax preparations illustrating anatomy. In an adjoin-
ing edifice, formerly used for the manufacture of
implements of war, are the anatomic and physiologic
departments. Several military barracks are scattered
about the vicinity; while in the midst of them all,
occupying the center of a large open platz, rises the
magnificent, gothic, highly-ornamented Votivkirche.
The study and practice of medicine in Vienna
seems always to have been a matter for the considera-
1058
MEDICAL VIENNA AND HEIDELBERG.
[November 14,
tion of the state. This may be one reason why the
standard of medical education there has always been
relatively high. The religious orders have had more
of a voice in all educational matters in Austria, other-
wise the educational methods have closely simulated
those of Germany. It is curious to note that some
old statutes of Vienna declare that "medicine is a
truly rational science, both as to its theory and its
practice." Some modern lawmakers in America, 'I
suspect, do not hold the same opinion! If the appli-
cant for honors were already a master in arts, he was
expected to have heard lectures in the medical faculty
for at least two years. He would then be entitled to
the baccalaureate degree, provided he had heard lec-
tures upon Joannicius, Avicenna and some general
work of practice, like that of Rasis Almansor. If he
were a candidate for a licentiateship and were the pos-
sessor of a degree he was required to attend lectures
on medicine for five years. If the authorities found
him fit in knowledge and character, devoid of can-
Practical medicine has always had a stronghold in
Vienna. As early as the seventeenth century the city
contained a large number of hospitals. Its progres-
siveness is shown in the fact that the first asylum in
central Europe, for the exclusive care of the insane,
was established here in 1784. To-day it possesses the
largest general hospital in the world and about twenty-
four other hospitals, four of which are public insti-
tutions, while the rest are more or less private con-
cerns. With a population of about 1,100,000, its
hospital beds number four and a fraction to every
1,000 inhabitants. The oldest hospital in the city
was the Borough Hospital of the Holy Spirit,
founded by Frederick the Combative in 1240. In
1532 this was removed to the convent of the Clarissa
nuns and, like most similar institutions of the time,
combined the attributes of a hospital and almshouse.
It continued to be the chief important charitable
organization of the city for the next 300 years. At
one time it sheltered 3,000 souls. It was still an
i f. :. z
■ i t i f
. ■
UNIVERSITY BUILDING, VIENNA.
onical impediments, and not too effeminate of counte-
nance, he might receive his degree at the age of 26
but strictly not until he was 28. If princes applied
for a degree and were found wanting, they were
refused on the ground of the statutes. The promo-
tion of licentiates to the doctor's degree was for many
yeare ordered by law to take place in St. Stephen's
cathedral, where the new doctor was expected to
deliver an address in praise of medicine and after-
ward a lecture upon Avicenna, Hippocrates or Galen.
In spite of the comparative ignorance of that day,
how much more seriously was a medical education
regarded than is too often the case now ! Given the
same governmental control and intelligent support
that it enjoyed then, with its modern superiority in
knowledge, how much more exalted and effective
would be the profession of medicine to-day than it
actually is!
important institution in 1754, and was made the seat
of a medical school in 1756. The reputation of the
medical school had already long vied with that of
Bologna, Paris and Padua. In 1394 St. Mark's Hos-
pital was erected by a private individual, but it was
upon two occasions destroyed by the Turks. The
Emperor Joseph decided in 1780 to abolish the
numerous small hospitals throughout the city and to
incorporate them into one large establishment. This
was a wise move on the part of the government, for
at the time there were the Crusaders' Hospital built
by the Knights of the Order for twelve patients, the
Military Hospital previously used as a lazaretto, the
Contumazhof, the Baeckerhsensel with its 300 beds
for the use of convalescents from the Borough Hos-
pital, the Imperial for the employes of the Court,
the Spanish, the Trinity and the Strudel Hospitals.
In the amalgamation of these various institutions, the
18%.]
MEDICAL VIENNA AND HEIDELBERG.
1059
monarch appropriated the old workhouse which had
been founded nearly a hundred years before by Leo-
pold I., and established beneath its roof the medical
school as well as the new hospital. The building had
at first been used as a Hotel des Invalides for retired
soldiers and their families. Additions and alterations
were made and the whole opened, in 1784, as the
General Hospital, or Alhivwcinea Krankenhaus,
which has since become world-renowned. For a
long time it contained departments for maternity
cases, lunatics, foundlings and the sick in general.
In 1834 extensive additions were made to the hospital
and again in 1862. The maternity cases, the lunatics
anil the foundlings were separated and placed under
a different management in 1860. In 1887 the hos-
pital contained 2. UK) beds and treated some 25,796
3. Surgery has always been an important feature
of its work.
A tew details in regard to the management of this
great and model hospital may be of interest. The
government controls it and the same management
includes the eare of the Royal Rudolph with its 860
beds and the Royal Wieden with its 597 beds. The
( i eneral Hospital has a director, who draws a salary of
3,800 florins (the florin being equivalent to about 49
cents of our money ) , and a superintendent. The med-
ical staff is paid by the directors out of the hospital
funds ami includes five senior physicians and five
senior sturgeons. Each has three assistants. There
are 16 dressers. The senior members of the staff get
a salary of 1,800 florins per annum without residence.
The nursing staff numbers 226, all of them being lay
women except 12 male attendants. The nurses aver-
age about 1 to every 10 patients. Their compensa-
tion is from 12 to 16 florins per month, with board,
washing and uniform. Members of certain religious
sisterhoods attend to the nursing in the Rudolph and
Wieden. The General Hospital is of course a public
charity but it receives three classes of paying patients,
namely, those who desire the best accommodations at
■5 florins per day, those who can give 2 florins, 50
kreutzers per day and finally those who are satisfied
with the accommodations afforded for 1 florin, 7 kreut-
zers per day. Incurable and obstetric cases, as well as
children under 4 years of age, are not admitted. The
expenses of the institution are met by a Royal Hospi-
tals fund and a reserve fund, both of which are
made up from various sources such as interest upon
the original capital invested, legal tolls and duties,
payments from patients, subscriptions and voluntary
donations.
The Allgemeines Krankenhaus covers an area of
nearly 25 acres and consists really of a series or con-
glomeration of hospitals. There is nothing to be said
of it architecturally. It is an old-time structure and
when I first visited it, toward the latter part of a clear
afternoon, I could scarcely believe that I had actually
arrived in front of the world-renowned institution.
Plain, low and unornamental, it produced in me a
feeling of intense disappointment. A photograph of
it would scarcely have been worth the trouble of tak-
ing. It is an immense rectangular structure sur-
rounding a spacious courtyard and having various
irregular, inharmonious wings attached. As I after-
ward strolled through many of its halls and wards,
having been favored with letters of introduction to
several members of its staff, I was impressed with the
cleanliness and precision with which everything was
done in spite of the many inconveniences and ancient
construction. Without doubt, it is, except architect-
urally, a model hospital . Of course were a new building
to be erected many improvements would be required
for the sake of light, air, ventilation and general
cheerfulness. As is the case with many other hospi-
tals in Europe, antiquity must be pleaded as an
excuse for shortcomings. Small windows, low corri-
dors, curious old-fashioned doors, rambling halls,
musty dark corners, irregular floors, cracked walls and
narrow apartments are not entirely uninteresting, for
they speak of the past with its suggestiveness of quaint
story and feudal history. But in a modern hospital
they are not altogether compatible with the modern
ideas of surgical requirements and hygienic perfec-
tion. The wonder is that in these old hospitals such
splendid results are so often attained. It bespeaks
unusual attention to details, a systematic exactness
and an exceptional skill on the part of the attendants.
And after all that may be one of the causes of the
supremacy of some of the foreign schools of medicine.
The continuous bath for the treatment of skin dis-
eases is a feature in the clinical work of the General
Hospital. Besides this hospital mention should be
made of the Inquisiten with its 163 beds, the new and
attractive Favoriten with its 560 bedsand the St. Anne's.
Vienna is supplied also with a most excellent Small-
pox and Epidemic Hospital, the latter having been
erected at the time of the cholera outbreak in 1873
and the first to be constructed in the pavilion style,
at a cost of some £39,000. It contains about 300 beds.
HEIDELBERG.
One marvels how a town of only 22,000 inhabitants,
and a singularly salubrious town at that, can possibly
furnish a sufficient variety of diseases for the main-
tenance of a school in practical medicine. And yet
Heidelberg, known among tourists chiefly for its fine
old German castle, its :great tun and its dueling stu-
dents, is one of the most celebrated seats of medical
education in all the German empire. It contains a
hospital of nearly 400 beds and the medical faculty
of its famous university ably maintains the ancient
renown of the school. Such distinguished names as
Tiedemann, Gegenbaur, Kuhne, Czerny, Erb and
Vierordt would add luster to the name of any univer-
sity. Many a traveler has departed from Heidel-
berg, after viewing its principal sights and hunting
high and low in vain for the university of which he
had heard so much, with possibly a feeling of doubt
and disappointment as to the veracity of Dame
Rumor. To know scholastic Heidelberg one must
reside a short time there. The town itself consists
chiefly of a single long street, lined on both sides
with many an interesting old building, quaint shop,
open plaza and curious church, all crowded together
as in a vise between the swift flowing Neckar on one
side and the wooded Geisberg, with the famous Schloss
halfway up its declivity, on the other. Minor streets
and byways of course branch off from the main thor-
oughfare and here and there revive memories of
Goethe, Schiller, Martin Luther, Jerome of Prague,
Tilly, Gustavus Adolphus and other great names in
history, science and romance. Not only is the situa-
tion of the town one of the most picturesque in
Europe, but its history is one of the most exciting.
Scarcely less fascinating, however, is the story of the
university, which, next to the universities of Prague
and Vienna, is the oldest in Germany.
One day as I was sauntering about the town, having
1060
MEDICAL VIENNA AND HEIDELBERG.
[November 14,
in despair almost relinquished my efforts toward find-
ing the university, I was made aware of the presence
of an unusual number of student-like fellows hurrying
hither and thither in the Ludwigsplatz. I imagined
I must at last have arrived in the neighborhood of the
school. I looked sharply about me and began getting
my letters of introduction ready, but I saw no mag-
nificent edifice anywhere, and so concluded I had
again lost the trail. As I was passing through a nar-
row street, hoping to encounter some one who would
revive my hopes by giving me the desired information,
I happened to pass a small open doorway in a long,
low, insignificant building that did not seem at least
to be a private residence. I entered, and what was
my astonishment to find, after reading some inscrip-
tions in the vestibule, that at last I was within the
walls of the great University of Heidelberg. It came
home to me then and there with tremendous force,
that buildings do not make universities. Could it be
possible, I mentally exclaimed, that the grand old
school of Heidelberg occupied no more pretentious
structure than this! Truly was it said that the uni-
versity building is very much like a huge model lodg-
ing house in a bad state of repair, being merely a
large, plain stucco structure at one side of a bare open
platz, appearing as desolate as Gray's Inn Square
upon a Sunday. In size and beauty (if, indeed, it
may be said to have any) the university is quite
eclipsed by its neighbor across the square, the
museum. There are no grand open doorways, no
Corinthian columns, no majestic peristyle, no tower-
ing domes or cupolas, nothing but four flat walls.
The anatomic and chemic departments are in another
part of the city, and housed in fairly artistic buildings
in comparison with the university itself. I would
that space allowed me to do more than simply outline
the history of this fine old seat of learning, one of
whose most important departments is that of medi-
cine, for as I strolled about it and learned more of its
life, I grew fonder of it. It was founded in 1386 by
Rupert I., purely as an ecclesiastic institution. The
Bishop of Worms was its first chancellor, and its fac-
ulty consisted entirely of priests and members of the
monastic order. Hence it stuck like a leech to the
old scholastic doctrines during the troublous times of
the Reformation, and always opposed itself to the new
learning which later on had its head and source up
in the castle. Only in the last century has this favored
old school awakened to the progress of the world, and
in that short time made itself a reputation for brilliant
scientific discoveries. When we recall its stagnant
conservatism, what a wealth of sarcasm there is in
Pope Urban's bull of 1385, wherein he states that the
" town of Heidelberg, which in view of its healthy
situation and air and its fertile surroundings, is
admirably adapted to form a universal fountain of the
sciences." The first statutes of the university were
drawn up by Marsilius von Inghen, a former instruc-
tor in the University of Paris. The students were
required to attend the lectures daily on pain of losing
their rights of membership and final certificates. The
highest salary paid to any professor was given to Mar-
silius, and consisted of about £20. The tutors usu-
ally received £5 or 50 florins, a pretty handsome sum,
I presume, for that day, but scarcely enough for shoe
polish in this! Great privileges had this old univer-
sity. Note some of them for curiosity's sake. All
attendants, as well as all who were brought in contact
in any way with this "beloved daughter" of Rupert
I., such as booksellers, bookbinders and servants of
the tutors, were amenable to the jurisdiction of the
university only and were exempt from all taxation.
By a commission, the board of the students for one
week was to be about three farthings. Three farth-
ings, think of it! The good folk of the village who
cared to board any of the students were not required
to pay octroi or city toll duties. And again, if any of
those old Heidelbergers laid violent hands for any
purpose whatever upon those precious students, they
were obliged to pay a "fine of 60 florins and damages."
Every year the magistrates were compelled to take
oath that they would not infringe upon the rights of
the fondling of Rupert. A pretty mess all these
favors soon concocted and as a result students' tears
and other "great uproars arose" until old Rupert him-
self had to hasten down the hill and force the town
to behave itself. In all sorts of ways the succeeding
electors petted and nurtured this spoilt child of theirs
and how little did it give in return! Nothing but a
lot of theologic truck and a fierce opposition to the
advancement of knowledge. At last the electors
became tired of all this and one of them, Otho Henry,
he who built the charming Heinrichsbau of the castle,
"resolved to make the university flourish again even
though it should cost him his last farthing." This
Henry had vim in him and no scholastic nonsense
was able to turn him from his purpose of awakening
once more the spirit of intellectual progress. Invit-
ing Melancthon, the companion of Luther, to join
him, a quartette was formed, including Henry himself,
Melancthon, the councillors Ehem and Propus, to
whom was also added the classicist, Micyll, to under-
take the remodeling of the school. Success attended
their efforts and the ancient scholastic methods were
abolished. The library was enlarged and the whole
institution placed on a firmer basis. Many famous
scholars and teachers occupied its chairs. When
Heidelberg was destroyed in 1693 during the war, the
university was also burnt. The faculty fled for their
lives, but continued their lectures at Frankfort and
Weinheim. In 1700 the university was reestablished
but during the eighteenth century it was again under-
the influence of religious conservatism. During the
Napoleonic upheavals it received a terrible blow, but
in 1803 the Elector of Baden revived it again and'
placed it on a new foundation, since which time its
reputation has steadily increased until now it is one of
the noted schools of Europe. The medical depart-
ment has awakened to new life, and such men as-
Czerny and Erb and Kuhne have brought it fame.
The. students of Heidelberg are always proud of their
school. To-day they retain many of their privileges,
and the easy going burghers are judiciously gracious
to them. Dueling is one of the drawbacks, but the
abolition of that is under consideration. The merry
celebrations, the jovial concourses with rollicking
songs and huge tankards of beer, make college life in
Heidelberg an episode in one's existence never to be-
forgotten. Whatever trials he may have passed
through, however far he may have wandered, whether
high or low be his station in life the old alumnus of
Heidelberg recalls with indescribable delight the
democratic days of his youth when shoulder to
shoulder with emperors' sons, princes and future
savants he drank his beer, roved over the neighboring
mountains and imbibed the pleasures of knowledge
in his dear old alma mater beside the swift-flowing;
Neckar.
1866.]
SELECTIONS.
10G1
As many American physicians visit Europe, and as
medicine is the same there as it is on this side of the
water, 1 thought the limited space at my disposal
would probably be more interestingly occupied with
these brief notes upon Vienna and Heidelberg than
with a description of familiar clinics and technical
details.
1644 Lake Avenue.
SELECTIONS.
Obstruction ot the Bile Duct. At the annual meeting of the
New York State Medical Association, Oct. 14, 1896, Dr. Henry
( >. Maivy of Boston contributed an interesting paper upon the
"Surgical Relief of Obstruction of the Common Duct by Bil-
iary Calculi." He gave a review of his special studies upon
biliary obstruction, which commenced in 1876, with detailed
reports of tin in, occuring in 1880 and 1881, where he urgently
advised operative procedures for the relief of biliary obstruc-
tion. Postmortem examination showed that the causes of the
obstruction was a biliary calculus lodged in the common duct.
Operative interference was refused since there was no record
•of surgical procedures having ever been attempted for this
purpose, and the agreement of the consultants that it was prob-
able that the obstruction was in the common duct. Autopsy
showed that operative interference would have been not only
possible, but that the conditions were favorable for surgical
interference. Dr. Marcy performed his first operation in July,
1887, and although unsuccessful in the removal of the gall-
atone, because of intestinal adhesions, the calculus was dis-
lodged and the patient recovered, followed by a short period of
relief. Later the autopsy demonstrated that the calculus was
in the common duct with a limited range of movement. After-
ward Dr. Marcy criticized his operation, believing that the duct
might have been opened and the calculus removed, followed
by immediate suture of the wound in the duct, with a reason-
able decree of safety. Dr. Marcy gives a careful detailed his-
tory of his first case of successful operation for the removal of
a calculus from the common duct which occurred in his private
hospital Oct "26, 1889. Here the calculus was imbedded in the
common duct so firmly that the backward pressure of the bile
through the cystic duct had caused the gall bladder to be so
enormously dilated that its contents measured ten ounces.
Other methods of removal having failed, the gall bladder was
divided with scissors through its cystic portion, until the cal-
culus was reached and removed. This was nearly globular,
about the size of a large filbert, which weighed fifty-nine
grains when dry. The entire wound in the viscus measured
four inches. It was immediately closed with a fine, continu-
ous tendon suture in three layers, the first including the
mucous membrane, the second the entire wall, while the third
was taken from side to side as a parallel suture which, when
drawn upon, evenly intrafolded the peritoneum over the
wound, itself completely buried from sight. The abdominal
wall was also closed in layers with tendon sutures, without
drainage. The patient made an easy, uninterrupted recovery
and continues well at the time of writing. Dr. Marcy's first
publication upon this subject was read at the meeting of the
American Medical Association, held at Nashville in May,
1890. He reports his subsequent experiences as more than
satisfactory and gives his fullest approval to the advisability of
surgical relief in biliary obstruction caused by a calculus in
the common duct. Dr. Marcy's paper is of the greater import
ance, since he was the first to attempt the operation, and the
first to operate successfully for the removal of a biliary calcu-
lus in the common duct. Courvoisier, to whom the credit of
the first operation has been given by one writer, performed his
first operation Jan. 22, 1890.
Malignant Tumors Treated with Toxins of Erysipelas and Bacillus
Prodigiosus; Series of 160 Cases. -In the Bulletin of the Johns
Hopkins Hospital, August, appears a discussion of Dr. W. B.
Coley's toxin treatment of malignant growths. Dr. Coley
showed that his experience had extended over a period of more
than four years, that the tumors sent to him for treatment
were for the most part such as had been pronounced inopera-
ble by leading surgeons, and that the diagnosis of malignancy
had been determined, in practically all the cases, by a compe-
tent microscopic examination.
An analysis of the cases treated showed that 48 were round-
celled sarcoma, 13 spindle-celled, 7 melanotic, 2 chondrosar-
coma, 3 mixed celled, 14 sarcoma, special type not known.
Total number of cases of sarcoma 93, carcinoma and epitheli-
oma 62 cases, sarcoma or carcinoma 10, tubercular 2, fibro-
angioma 1, mycosis f ungoides 1, goitre 2, keloid 1. Of the cases
of sarcoma, nearly one-half showed more or less improvement ;
the variety that showed the greatest improvement was the
spindle-celled, that which showed the least, the melanotic.
Next in order of benefit was the mixed celled— round
and spindle ; then round celled, while osteosarcoma closely
approached the melanotic in showing but little change. In a
series of nine cases of melanotic sarcoma, no improvement was
noticed in six, very slight in three. Most of the cases of osteo-
sarcoma failed to respond to the treatment, many showed slight
improvement and one case, a very large osteochondrosarcoma
of the ilium, apparently disappeared and the patient remained
well for nearly a year, when a recurrence occurred. One case
of round-celled sarcoma of the neck of very rapid growth
showed very marked decrease during the first week's treatment,
after which time it continued to grow in spite of large doses of
toxins. The writer stated that he did not expect the profes-
sion at large to accept without question and criticism such
remarkable results as he had reported, and for that reason he
had related with some detail the successful cases in the hands
of other surgeons who had employed this method. He was of
opinion that a series of upward of twenty successful cases of
inoperable sarcoma (four of which had remained well upward
of two and a half years), the diagnoses of which had been
established beyond question according to accepted methods
of diagnosis, ought to be sufficient to demonstrate the real and
positive advance that had been made in a field which, up to
this time, had been regarded as absolutely hopeless. He did
not doubt that there were those who would still remain skep-
tical about the value of the toxins in spite of the evidence pre-
sented. Such persons must either fail to see any logical
connection between the accidental erysipelas and the toxins, or
they must go even farther and deny that there are any authen-
tic cases of malignant tumors that were cured by accidental
erysipelas. The only explanation they can have to offer for
the results which can not be questioned is, that in all the suc-
cessful cases there must have been an error of diagnosis.
Remarks by Dr. W. H. Welch : " I have been much impressed
by this personal statement from Dr. Coley, and I see no way
of gainsaying the evidence which he has brought forward, that
there is something specifically and genuinely curative in his
method of treatment. A single undoubted cure of a demon-
strated cancer or sarcoma by this treatment would be enough
to establish the fact that the treatment exerts some spe-
cific curative effect, for the spontaneous disappearance of
undoubted malignant growths of this character is almost
unknown. Dr. Coley has, however, presented to us positive
proof of the cure, not of one only, but of several cases of
malignant tumor by his method. Although I suppose in any
given case the chances of cure by this method are at present
not great, still the demonstration that cure is possible gives
every encouragement for perseverance in this line of investiga-
tion and work, and for efforts to perfect the method of treat-
ment. It is interesting to learn that the most strikingly bene-
ficial results have been obtained in the treatment of spindle
celled sarcomata. There are certain kinds of sarcomata which
some pathologists are inclined to rank rather among the infec-
tious tumors than among the genuine tumors, in the sense in
1062
PRACTICAL NOTES.
[November 14,
which these terms are used by Cohnheim ; but it is rather certain
sarcomata of the lymphoid type than the fusiform-celled sar-
comata which are thus believed to be possibly outside of the
claBS of genuine tumors, according to Cohnheim's classifica-
tion. As Dr. Coley suggests that the variations in his results
may depend in part upon variations in the virulence of his
cultures, and as it is well known that streptococci vary notably
in virulence, I would like to ask if he has as yet utilized the
methods of Marmorek in order to obtain cultures of uniformly
high degrees of virulence. Dr. Livingood in my laboratory has
confirmed the results of Marmorek and succeeded repeatedly
by his method in transforming streptococci of low virulence
into those of very exalted virulence. It seems to me that it
would be practicable and most interesting, and possibly
demonstrative of the specific effects of the treatment, if Dr.
Coley, in carrying out his researches, would occasionally cut
out small bits of tissue from the tumor and by their examina-
tion endeavor to determine the details of the process of cure."
In closing the discussion, Dr. Coley stated further :
"About removing specimens during the course of the treat-
ment, as suggested by Dr. Welch, I will say that I have done
that in a considerable number of cases. In many of these
cases a marked fatty degeneration and necrosis of the malig-
nant cells were clearly visible under the microscope. I shall
try to show these changes in micro-photographs of the sections.
In regard to intraorbital sarcomata, I have not had an oppor-
tunity of treating such cases before removal of the eye. 1 have
had four or five cases of recurrent tumors in the orbit after the
eye had been enucleated. The effects were very slight, if any.
They were all melanotic or round-celled sarcomata. As to the
safety of the treatment, I think that if the cases are selected
with some judgment the injections can be used with almost
perfect safety. I have had three cases in which I am sure
death was hastened by the use of toxins. In one case I ought
not to have used the treatment. There was an enormous sar-
coma of the scapula and chest wall. The patient was so much
emaciated that he could not have lived more than a couple of
weeks, but with two very minute doses of the weaker solution
of the toxins he lived only three days."
PRACTICAL NOTES.
Rupture of the Liver. — Vanverts reports two cases of rupture
of the liver, one fatal from hemorrhage in an hour and a half and
the other after twenty-four hours. He considers that possibly
the latter might have been saved by a prompt laparotomy. In
one case the left lobe was almost entirely detached. — Presse
Mid., October 7.
Gersuny's Sign for Differentiating Stercoral Tumors.— Gersuny
states that if it is difficult to distinguish between a tumor and
a hardened mass of fecal matters, certainty can be obtained by
compressing the protuberance of the tumor with the ends of
the fingers, gradually increasing the pressure until it is very
strong, and then gradually diminishing it without removing
the fingers. As the mucosa pressed against the stercoral mass
sticks to it and is then released by the removal of the fingers it
produces a peculiar sensation easy to distinguish, and use as a
means of differentiating such a mass from a real tumor. —
Semaine Mid., October 7.
Fractures of the Trachea and Larynx.— The Cauvin case recently
decided in France calls attention to the fact that the trachea
and larynx are very easily fractured, especially in the old ; a
slight accident or moderate violence is sufficient. A woman of
82 was strangled, and the three first rings of her trachea frac-
tured. A girl of 15 was the other inmate of the house, out she
denounced the heir as the murderer, and as it seemed impossi-
ble that a young girl could have caused the lesion unaided, the
heir was condemned and an appeal to a higher court only con-
firmed the decision. While he was awaiting removal to the
penal colonies, the girl confessed and proved that she had
unaided committed the murder.
Creosote Pills for Phthisis. — Romeyer and Testevin recommend
the formula below as borne well by the stomach and free from
the disagreeable odor of creosote : Creoso-magnesol, 10 centi-
grams, with honey sufficient to make 100 pills. Six or eight
to be taken during the day. The creoso-magnesol contains 80
per cent, of creosote, and is made by dissolving 20 grams of
potassa in 10 grams of distilled water in a porcelain mortar.
Eight hundred grams of (beech) creosote are then added and
worked into an emulsion, and finally 170 grams of freshly cal-
cined magnesia. The mixture hardens in a few hours, thirty-
six at most, into the proper consistency for pills ; if too hard it
can be pulverized in the mortar and mixed into a paste with
honey. — Semaine Mid., October 7.
Addison's Disease Cured by Extirpation of one Suprarenal Cap-
sule.— Hadra removed a tumor "the size of a small apple" from
a woman of 55, situated directly on the spine, on a level with
the stomach. It was causing great pain, dyspnea, night
sweats, emaciation and extreme muscular weakness, with edema
of the feet. Examination after removal disclosed that it was
nothing else than one of the suprarenal capsules affected
with tuberculosis, and the complications a case of Addison's
disease without the pigmentation, which is not always present.
— Semaine Mid., October 7.
Cure of Local Cutaneous Tuberculosis by Bier's Congesting Method.
— The remarkable fact that persons with mitral insufficiency
are so rarely affected with pulmonary tuberculosis, suggested
the idea to Bier that tuberculosis of the joints might be bene-
fited by producing artificially a similar sluggishness in the
parts affected. The principle is that the bactericidal effect of
the blood is more pronounced the longer it is in contact with
the bacteria and the more abundant the supply where they are
located. Jacoby now proposes to apply it to the early stages
of pulmonary tuberculosis by appropriate positions, partial hot
baths and massage of the thorax. Woltersdorf describes his
experience with it in the Deutnch. med. Woch. of October 8. It
resulted in absolute cure in his case. He cut his finger during
the necropsy of a consumptive in 1892, and local cutaneous
tuberculosis developed at the spot, which resisted the usual
treatment. He kept postponing the radical measures his
friends advised until the leisure time that never came, but
two years afterward he became engaged, and according to the
German customs he began to wear a betrothal ring. This
was worn on the affected finger and caused much pain at first
and congestion. He concluded it was a fine opportunity to
test Bier's method, and was able to announce its success in six
months, as the tuberculosis gradually disappeared, until in a
year there were no traces of the lesion. He concludes by sug-
gesting its application to lupus faciei by ligating the vena
facialis.
Papillo-retinitis In Chlorosis. In a recent number of the
Deutsche Med. Wochenschrift appears a paper by Diabella on
this subject. It describes the case of a female patient aged 21
years, who began to menstruate in her fourteenth year. Her
periods came on irregularly, and she developed a certain degree
of chlorosis which did not quite disappear in spite of treatment
by iron. In the autumn of 1894 she began to suffer from left-
sided headaches and was generally out of health, and in the
spring of 1895 she developed great weakness again. Menstrua-
tion, which had been interrupted, was reestablished and imme-
diately after this there was impairment of vision and later
diplopia. On admission to hospital in April there was marked
anemia with reduction in corpuscles and hemoglobin, papillo-
retinitis on both sides and paralysis of the left external rectus.
There was a loud hemic murmur. Under treatment with iron
and rest in bed there was rapid improvement in the general
condition, and by the end of May her color was natural, the
murmur could no longer be heard and there was a marked
improvement in the state of the blood as regards both corpus-
cles and hemoglobin. There was also a distinct subsidence of
the condition of the optic disc and fundi, and when the patient
presented herself again in September these appeared abso-
lutely normal. The author considers that the physical strain
and the reestablishment of menstruation, which preceded the
onset of the ocular symptoms in this case, were the means of
evoking them in a patient predisposed to disturbance by the
long-standing chlorosis, in a manner analogous to that in which
similar changes are said to take place after severe loss of blood.
—London Lancet, September 19.
1896.]
EDITORIAL.
1065}
THK
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to await call.
SATURDAY, NOVEMBER 14, 1896.
THE POISONING OF A PEOPLE.
In our zeal to prevent the infection of the individual
and to protect against epidemic outbreaks in the com-
munity we are blind to a pathologic process going on
around us of the most stupendous proportion and
with the absolute certainty of frightful consequences —
the poisoning of the entire race — the slow, sure infil-
tration of a subtle venom, as discernible by symptoms
as the solitary case of a toxic dose of opium or arsenic,
or the local scourge of a visitation of cholera or yellow-
fever.
When the nation was young, the tiny stream of
foreign immigration, like a little clouded rivulet adding
its scarcely appreciable substance to the broad extent
of crystal waters, was swallowed and however muddy
its source its particles were soon lost in the multitude
of the clean and strong by which it was overwhelmed.
To-day a thousand sewers are pouring turbulent
streams of fetid, pestiferous slime into the once clear
sea and already the ceaseless, discolored and unclean
inflowing is showing its baneful presence. Shall we
patiently abide the complete surcharge and then awake
to the fact that any remedy is too late?
In an article on "Immigration and Crime," in the
Popular Science Monthly for September of this year,
Sydney Gk Fisher declares that: "The criminal
influence of the alien with its steady increase can be
traced back in our history for the last sixty years."
Our system of foreign immigration, he says, first
began to reach serious proportions in 1820, and its
Paupers
Prisoners
effect on manners and morals soon attracted attention.
The native American party arose some time after 1840.
Revelations of pauperism, crime and corruption
became more apparent from 1830 to 1850. In those
days, "when the foreign population was only one-
eighth of the whole, it furnished 2,000 more paupers
and .1,000 more criminals than the other seven-eighths.
Every 32 foreigners produced a pauper and every 154
a criminal, but it required 317 natives to furnish one
pauper and 1,619 a criminal." The following table
from the census of 1880, based on a ratio to 1,000,000
of population, exhibits the proportion of foreign to
native paupers and prisoners at that and the preced-
ing three decades :
1850 1860 1870 1880
S Native . . 1,765 1,849 1,635 994
I Foreign . . 5,986 7,843 4,095 3,438
S Native . . 207 371 733 1,054
j Foreign . . 1,074 2,161 1,568 1,917
According to the census of 1855 of the State of
Massachusetts, which is exceptionally exact in its
vital statistics, the foreign born in that State were 21.1
per centum of the whole population, and yet they furn-
ish 44.03 per centum of all the paupers, 40.06 per
centum of all the prisoners and 30.87 per centum of all
the convicts.
The national census of 1890 shows that the native
white element of the population is 54.87 per centum of
the whole, but it produces only 43.19 per centum of
white prisoners; and the foreign white element is only
32.93 per centum of the whole, and yet provides 56.81
per centum of the white prisoners. It also shows that
no small proportion of the murders committed by the
natives was due to the example and presence of
foreigners.
" The foreign-born population in this country con-
tributes, directly or indirectly, in the persons of the
foreign born or their immediate descendants very
nearly three-fifths of all paupers supported in alms-
houses ; although less than half the whole popula-
tion it furnishes more than half the paupers."
(Census Bulletin No. 90.)
The fathers of the Republic, Mr. Fisher further
shows, were entirely opposed to promiscuous whole-
sale immigration. The importation of paupers,
vagrants and criminals, together with hundreds of
thousands of men and women capable only of cheap
manual labor was foreign to their thoughts, or if they
contemplated it at all, it was only to revolt against it.
Washington wrote : " My opinion with respect to
immigration is that except of useful mechanics and
some particular descriptions of men or professions,
there is no need of encouragement; while the policy or
advantage of its taking place in a body may be much
questioned." Again: "It is not the policy of this
country to employ aliens, where it can well be avoided,
either in the civil or military walks of life." And
Jefferson: " They will bring with them the princi-
ples of the governments they leave, imbibed in their
1064
THE POISONING OP A PEOPLE.
[November 14,
early youth, or if they are able to throw them off, it
will be in exchange for an unbounded licentiousness,
passing as is usual from one extreme to another."
Madison, who Fisher says, favored immigration
more than any others and introduced the first bill to
encourage it, always insisted that he intended to
bring over only the worthy part of mankind, and said
in a letter written in 1813 : " It is not the provision
of our laws or the practice of the government to give
any encouragement to immigrants, unless it be in
cases where they may bring with them some special
addition to our stock of arts or articles of culture."
Let us note a few symptoms of the morbid inocula-
tion that has been permitted, notwithstanding these
patriot words of warning:
The professional beggar is becoming as familiar an
object in our streets as in his Neapolitan or other
European home. Deformed children, decrepit crones,
and ragged graybeards, crouching on the sidewalks,
assail the passer with well-trained wailing voices.
Want and privation we have always had with us, but
the whine of the mendicant trade has only lately been
heard and the heart-rending, up-turned face of appa-
rent agony on some hideous body never before seen.
If tolerated a little longer we may soon expect the
revolting spectacles of European cities to be dupli-
cated, as well as the establishments in which infants
are mutilated and prepared for street or freak museum
display. The staple attractions of the illustrated
weeklies are " Weary Willies" and " Meandering
Mikes," ragged, filthy and loathsome, whose preach-
ings of idleness and thievery are intended to be hum-
orous, but ought to be abhorent. The word "tramp "
has acquired as recognized a significance as some of
' the novelties of the medical dictionary.
Gallantry toward women has always been the char-
acteristic of the native American, but it is now a daily
exhibition on street cars of churlish young men of
unmistakable foreign type, with vulgarity stamped
all over them, who sit while feeble women old enough
to be their mothers cling to over-hanging straps and
are swung violently by the swaying of the cars. The
public conveyances are crowded with coarse, unclean
alien laborers, whose first lesson in liberty has been a
license to be brutish and insolent. The manly
suavity of the American mechanic, however unculti-
vated, marking him as an innate gentleman, is fast
disappearing before vulgarity and indecency. Ignor-
ance, superstition and brutality breed vice, and the
readers of the newspapers can not fail to note the
prevalence of revolting crimes whose perpetrators have
names unpronounceable by Anglo-Saxon tongues.
Within a month the great city dailies have
published accounts of youthful Pagius, whose rude
pictures evidence their race, who were organized to
teach still younger lads to steal ; of Italian girls, who
first sacrifice with little compunction their pretense
of virtue and then stiletto the recreants who had
undone them easily enough, or the rivals who had
supplanted them; of Russian rabbis who marry and
unmarry their ignorant compatriots in defiance of the
law; and of Hungarian brutes who snarl and fight and
tear and rend the woman, made wife as the beasts
mate, and ruled by blows and kicks and deadly weapons.
The bright, inquisitive children of reputable house-
holds pick up the morning papers as their fathers dis-
card them and read the revolting reports of theft, riot,
pillage, murder, rape, incest, adultery and bigamy
committed by men and women with strange names.
To specify instances in detail would exceed our space.
M. M., longshoreman, beat his 7-year-old daughter
and dragged her by her hair fifty feet and when arrested
claimed she was his child with whom he could do
what he pleased; E. G., married in Hungary, was
divorced by a rabbi, who, when she was arraigned for
bigamy, remarried her to her first husband — both
woman and rabbi escaping punishment; F. L., an
Italian blacksmith working in the New York navy-
yard, tells his wife to dress in her best to go to
Brooklyn after breakfast, "going to Brooklyn" mean-
ing among the low caste (American citizens!) to be
taken in a hearse to Calvary Cemetery, for which he
prepared by killing her; L. N., a boy, kills the younger
pupil of his same race for withholding the profits of
a petty theft; G. F., appropriates a 14-year-old Sicil-
ian girl, whom he sold to another brute, who rented
her, at so much an hour, to his friends.
The Immigration Investigation Commission ap-
pointed by Congress June, 13, 1894, of which Hon.
Herman Stump of Maryland is chairman, is seeking
to exclude paupers. How unsuccessfully the revela-
tions of the New York Board of Health show:
" Squalid quarters, where none of the filthy families
speak English" — "a notorious Italian district, fam-
ous for midnight rows in which the stiletto always
plays a prominent part" — "a single tenement running
the entire block, with people enough to populate a
New England village" — "one roof covering a hundred
families, who screech ' no sika baba ' in reply to the
inspector's inquiry, looking upon him as an emissary
of the evil one." In one day the board of health con-
demned fifty-two rookeries, in which "the filthy
conditions shown to exist seemed to preclude the pos-
sibility of existence." In two houses in Cherry Street
472 persons were herded in quarters unspeakably
wretched. There were 702 human beings found in
"dingy rear tenements, never penetrated by the light
of the sun.nor by a puff of fresh air." In a rear tene-
ment on Mulberry Street, for the last five years, there
has been a death rate of 75.05 per 1,000, and in other
places it has risen at times to 135.5 per 1,000, the
average of the city having been 22 per 1,000. As Dr.
Roger S. Tracy, register of statistics of the board of
health declares ■: "Where, these high death rates prevail
18W.]
PARASITE AND HOST.
1065
are centers from which contagion cnn not fail to spread."
Comment on these appalling facts is unnecessary.
Intelligent Americans, both native and naturalized,
must know that these loathsome dives are dangerous to
Iho entire community . A gentleman riding home on a
street oar from the Cotton Exchange sacrificed a new
suit and scoured himself raw to get rid of the lice a
dirty Pole, against whom he had been wedged, literally
showered upon him. What sacrifice of clothes or scour-
ing of skin could have rid him of the syphilis, tubercu-
losis ot skin disease he might just as readily have con-
tracted? It is claimed that the heretofore dominant
physical traits of the Anglo-Saxon are disappearing
under the admixture of alien races. Whether or not
this be so.there is danger that both the mental and bod-
ily characteristics of the masses will be affected by the
overwhelming influence of excessive unassimilable
importations.
PARASITE AND HOST.
Can impudence, stupidity and selfishness go farther
than in the following "case"? Not long ago a com-
mercial firm enjoying the undisturbed honor of being
a parasite upon the medical profession, requested
medical men to give without any sort of compensation,
their contributions of medical literary articles to the
journals published by this lay firm. Sometimes it
even went so far as to make the contributor pay for
reproducing the illustrations to the article. The very
agreeable contributor gave the result of his scientific
work to the non-professional publisher in order that
the whole profession might learn anything that could
aid it in its struggle with disease. The single desire
of the physician in contributing to medical journals
is to secure the greatest possible professional pub-
licity for his article. What then must be the amused
and disgusted contempt of the medical man when he
learns that the proprietors of the journal to whom he
has given (and even paid for publishing) his article,
turn upon him and by virtue of the privilege accorded
claim sole proprietary rights, refusing other journals
the right to quote from the article, to reproduce illus-
trations, and refusing the author and giver any power
over and any further dissemination of his scientific
results by printing! Can contemptibleness be more
contemptible?
The excuse offered by this old parasite, to his host,
is that he " does not like the business methods" of
another and newer parasite. The deliciousness of
this excuse is heightened by the fact that the new
parasite treats the medical contributor with remark-
able liberality and courtesy, and thus threatens the
old monopolist, famous for avarice and discourtesy,
with some business dangers. The old parasite, which
so unmercifully has bled his host in the past, can not
think of allowing a more gentlemanly competitor.
But has the medical profession nothing to say
about a matter so intimately touching its own rights and
duties? Is it not about time that the host awakened to
a sense of shame, and that he should revolt against
the monopolist parasite which has sucked his juices
and strength so long and so uninterruptedly? There
were 33,000 copies of the first edition of Quain's Dic-
tionary of Medicine sold, and yet, it is said, the authors
and contributors never got a penny of the wealth this
book brought the lay publisher. All through the
history of American medicine, physicians have
supinely, humbly, tremblingly begged the lordly lay
publisher to be allowed to present him with their liter-
ary labors, even paying for the privilege (at least for
the illustrations), and while the publisher grew rich
the poor author never got a cent, or at best only a
nickel flung him in pity. And the publisher went on
gathering his millions!
On top of such indignity now come some of these
old monopolists and tell the author of articles pre-
sented him that he, the author and the medical pro-
fession must not dare to abstract, quote from and
reproduce his own article in other periodicals or pub-
lications. An instrument or method of operation has
been devised, let us say, by a physician, of great value
in the saving of human life ; the deviser describes
and illustrates the same in a lay periodical, giving the
periodical the article and paying perhaps for the illus-
tration. This periodical at the highest estimate
can not be seen by one-twentieth or one-fortieth of
the profession. The author and deviser of course
wishes the entire profession to know of his discovery,
but the lay publisher, who has been allowed to publish
the article first, says: "Oh, no! This is my property!
My competitor, whose business methods I do not like,
must not reproduce this article or illustration for
you; you have no rights in it; I must make all the
money I can out of it. People must buy my period-
ical if they want to know about your professional
progress. Especially must I keep down more liberal-
minded rivals!"
Now, with the rivalries and jealousies and business
methods of lay publishers, so far as relates to them-
selves, we as medical men have no care or concern,
but when an avaricious publisher seeks in the interest
of a narrow commercialism and jealousy to limit the
circulation of medical literature, certainly the medical
profession must have a word to say. With books, for
the material of which a price has been paid the
author, the matter is different, but as regards the
weekly journals which pay authors nothing for con-
tributions (not even reprints) we wish to protest that
the parasite must not dictate to the host. The literature
thus given belongs to the author and the medical pro-
fession and any such impudence as refusing to permit
the use of such literature is a silly impertinence that
must be sharply cracked over the knuckles. When-
ever such greed makes itself manifest medical men
1066
KLEPTOMANIA AND "SHOPPING."
[November 14,
generally should know of it, and if they prefer to thus
limit the circulation of their studies it will be indeed
strange.
It is such stupid selfishness as this, that, if persisted
in and by any large proportion of lay publishers, must
and should finally bring about the very desirable encour-
agement of journals and publishing houses by members
of the profession themselves, and the starving out of
the lay publishing houses and journals that have so
long, so cunningly and so successfully fattened upon
the generosity and indifference of medical men. The
present is a time when a policy of greater liberality
and a better justice on the part of publishers to
authors is imperatively demanded. The contributions
to medical journals owned by laymen must henceforth
be paid for, or else they are the property of the author
and for the use of the medical profession. The author
who thoughtlessly limits the dissemination of medical
truth by unconditionally giving it utterly without
compensation to a publishing firm which shows by
every selfish act and brutal word that its policy is to
use that knowledge solely for its pecuniary advantage,
to crush out rivals and to sell its journals — such a
medical man is false to the Hippocratic oath and to
every principle of professional ethics, as well as blind
to his own self-interest.
Indeed, it is high time that the profession should
take up the attitude of greater sympathy for journals
entirely controlled by members of the profession. Its
motto should be: "Literature of the profession, for
the profession and (published) by the profession,"
and all contributions should be kept from journals
devoted to a narrow financial selfishness, rather than
to the progress of medical science. It is only in
journals published as well as edited by professional
men that there can be the hope of an honest review,
a coming certainty of the realization of medical ethics,
a possible exclusion of nostrum advertisements, etc.
It is in this matter of reviews that the most disgrace-
ful condition of affairs exist. The reviews in the
ordinary lay-published medical journal are roaring
farces, downright lies, or Pecksniffian hypocrisies.
Some time ago a medical author that a publishing
house was deeply interested in "booming" (because
they published his books), wrote a book worse than
bad; it was outrageous. No medical man would write
anything but a negative or highly critical review of
it. To one after another the book was given, and one
after another review was not permitted to appear by
the publishers, who owned body, soul and mind (if
the latter two existed) of the poor invertebrate (med-
ical?) editor, who finally had to insert in this inde-
pendent and scientific journal an eulogistic review of
a wretched book. How long will the profession be
content to dance to such piping? Every physician
who contributes gratis to a lay-published journal
should stipulate that there is to be no limit set to the
reproduction of the article or illustration by other
publishers. The attempt to throttle professional
progress by such an insane selfishness should be
incontinently rebuked. Every medical writer should
append a footnote and demand that there be inserted
with it:
" The right of republishing this article or its illus-
trations is unlimited."
The Journal copyrights its articles, but we have
given the freest right to republish, provided only that
our Journal receives its proper credit.
KLEPTOMANIA AND "SHOPPING."
The case of Mrs. Castle (who has recently been
pronounced a victim of kleptomania by the eminent
English alienist, Dr. Savage, and whose light sentence
and speedy release demonstrate the validity of this di-
agnosis) renders of especial interest Lacassagne's1 re-
cent study of the relationship of kleptomania to "shop-
ping." Kleptomania, as a system of mental disor-
der, has long been recognized by alienists. Marc,
who reported many cases half a century ago, recog-
nized that people, in circumstances which should
have placed them beyond temptation, stole from
shops articles to them almost valueless, whose num-
ber and uselessness indicated mental disorder in the
thief. According to many alienists, kleptomania is
always a manifestation of degeneracy, an episodiac
symptom-complex. There are kleptomaniacs of this
type who steal purely for the sake of stealing. At
the same time, as Lacassagne points out, in the vast
majority of kleptomaniacs, kleptomania is a morbid
manifestation of certain neuroses and psychoses
rather than a psychosis by itself. In many cases of
so-called kleptomania, stealing is a manifestation of
viciousness or feeble morality. Kleptomaniacs steal,
but not all thieves are kleptomaniacs. While the
kleptomaniac impulse of stealing for the sake of
stealing does occur, as a rule, determining psycho-
logic and physiologic factors exist. Even the most
seemingly absurd thefts often have secret determin-
ing causes, whose nature the thief fully recognizes.
These "criminals on occasion" merit, as Lacassagne
points out, the benefit of extenuating circumstances,
for often there is no premeditation, but merely the
absence of conflict with strong desire, which however
is not a morbid impulse. The majority of cases of
both kleptomania and these thievings, occur in the
department stores. Women often steal there and
there only. "Bargain" sales are hence determining
factors of theft. The display fascinates the customer,
provokes desire and causes an intellectual conflict
which often in the strongest women leads at best to
prodigal expenditure. Self-contained, economical
housekeepers admit that they often succumb to temp-
tation to waste more money than they dreamed of
1 Jour, de M<!d. de Paris. Oct. 25 1896.
1896. J
KLEPTOMANIA AND " SHOPPING."
1067
spending when starting out. If such be the influence
on sound women what must be the effect on pregnant,
climacteric and menstruating women, hysterics, neu-
rasthenics, morphin-users, alcoholics, invalids, senil-
ities and other persons whose mental stability is not
on a level with their social status. These "bargain"
sale thieves are often no more insane than other
thieves, from the delusional standpoint, but they have
much less power of resisting temptation. Brouardel
reports the case of a judge's wife who, while preg-
nant, stole a roast goose from a store restaurant.
Lbg&IND ih Satlle has observed another judge's
wife who, in a similar state, stole 300 neckties.
I,u tSBAGNB examined a pregnant woman of the
upper middle class who had stolen by dozens, pocket-
books, knives, scissors, etc., which she hid away,
without using, in a garret closet.
Kleptomaniacs are a vivid feature of Zola's "Ladies'
Paradise." Pure thieves use a pregnant woman as a
shield. Three women, one pregnant, enter a crowded
aisle of the " Ladies' Paradise." While the inspector
is watching the pregnant woman, whom he suspects
of the kleptomaniac propensities of her state, her
companions steal and escape with impunity when the
alarm is given, leaving the pregnant one to bear the
burden and plead her state. The popular opinion of
the irresponsibility of pregnant women thus shown,
is of long standing. Dr. Harriet C. B. Alexander,
in a paper read before the American Medical Asso-
ciatiox nearly a decade ago (Journal of the Amer-
u an Medical Association, Vol. IX, p. 777) pointed
out that as Ben Jonson's plays show, Anglo-Saxon
popular opinion early regarded the pregnant woman
as irresponsible for her " longings." A most natural
and just view, since on careful analysis of the mental
condition of pregnancy, it is apparent that this is
always affected by more or less morbid perturbations
of the monarchic cerebral vaso-motor center, secon-
dary to pelvic fluxionary changes, to irritative condi-
tions, to exhaustional conditions and to pressure neu-
roses of cardiac, pulmonary, gastric, visceral, or
peripheral neuric origins. The various " longings "
of pregnancy arise from imperative conceptions either
pure or dependent on perverted sensations, or from
reversions to early habits of the race during reproduc-
tion. Legally, these mental states predisposed to
kleptomania, either pure or resulting from a desire
for possession dominating a weak will.
In many menstruating, most neurasthenic, all alco-
holic, opiophagistic, hysteric, climacteric and senile
women, the will is also so weakened that they are
ready victims of imperative conceptions and morbid
impulses.
Kleptomania appears in all great cities. London
police and "go-betweens" have lists of kleptoma-
niacs. The " go-betweens' " lists contain about eight
hundred women in easy circumstances, but very few
men, a dozen at most. When a shopkeeper loses
merchandise, he ascertains which of his kleptomaniac
customers has visited him. He then asks the relatives
by a cautiously worded circular letter, to pay for the
lost article. Often the kleptomaniac has stolen noth-
ing, but of this she is not certain and can not affirm
her innocence. The relatives pay to prevent scandal.
As a dozen families may pay for the same lost article,
the shopkeeper profits by the theft. Mrs. Castle,
being an American, did not appear in these lists and
was treated as a mere shoplifter.
The procedure adopted in Paris is different. The
offender is not stopped in the shop, since it would be
easy to drop the stolen object or to say that she was
going to pay for it. • An inspector, plainly dressed,
follows her to the street and quietly but firmly invites
her either to go to the police or to return to a special
room of the shop to be searched. French shopkeepers
are of opinion that there are more kleptomaniacs than
true thieves. They content themselves, as a rule, with
compelling a restoration of the stolen articles. When
an individual is detected they enforce a search of her
rooms, which very frequently puts them in possession
of the products of previous thefts. In Paris, out of
millions of francs thus stolen yearly, but a few thous-
ands are lost. The true thieves sell or pawn the
stolen objects; the kleptomaniacs hide them away. In
one case Lacassagne found 140 pocket-books hidden
away. Paris kleptomaniacs are known to come at
fixed hours. Some steal very skillfully and with
incredible affrontery. One who stole bronze figures
was detected only through the absurd crowding of her
mantelpiece with bronze figures.
. Lacassagne divides the "bargain" sale thieves into
four types: Pure thieves, "collectors," mental insta-
bilities and the insane. The "collectors" closely
approximate ordinary thieves. Men occur much more
frequently among them. They are often in easy cir-
cumstances or even rich. They steal without need
and almost the same things for the pleasure of pos-
sessing them. Bibliomaniacs and other faddists can
not leave a bookshop or other collection without buy-
ing. These "collectors" have the same pleasure in
stealing desired objects. These people may be feeble-
minded and insane, but, as a rule, merit the severity
of law as much for their own sake as that of society.
The mentally unstable are those in whom the desire
to take, quickly occurs and who yield without conflict.
They are usually rich or in very easy circumstances.
Their will weakens rapidly in the seductive surround-
ings of the "bargain" sale and yields readily to
a motive more or less bizarre, but determining and
obvious, such as vanity or coquettishness, even good
sentiments. Others are seized by a vertiginous state
caused by the noise and the crowd and become vic-
tims of a morbid impulse. After several yieldings to
temptation they become inveterate thieves, can not
1068
DIPLOMA MILLS.
[November 14,
master their impulse and systematically, weekly even,
they return to steal, in order to experience the same
fright and intense distress in which they have a mor-
bid delight. The desire becomes irresistible. On
analyzing it they, horrified at themselves, experience
the need of confiding their state to a friend. In spite
of the most bizarre precautions against their penchant,
they succumb. In some cases suicide then suggests
itself. In other cases they find their tendency
checked by legal procedures to which they voluntarily
give themselves up. To settle, even from the stand-
point of the patient's welfare itself, the question of
punishability is therefore not easy. One woman,
who bought forty dollars' worth at a department store,
stole a sponge worth twelve cents. Another woman
bought twelve dollars' worth and stole a three cent
pocket-book for her cook. For this, she, a woman in
easy circumstances, gave the following inventively
stupid excuse: "I have stolen," said she, "because
having bought so many things I thought this small
return due me." The delusional insane are certainly
irresponsible. Their thefts always present character-
istic naiveU, puerility or morbidity.
Lacassagne, like Benjamin Franklin, thinks "bar-
gain" stores a serious social danger to the body politic.
Many women who never have stolen and who would
never steal elsewhere find themselves there bewitched
and excited to take. It is truly a diabolic possession.
In the midst of a hurrying crowd, in the odorous,
overheated, wealth-suggestive atmosphere, the woman
finds herself with clothing aptly adapted to hide stolen
objects. At certain hours there are too few employes
to serve the enormous crowd which waits its turn,
touching and taking goods whose splendor and variety
bewilder.
Certainty of detection would undoubtedly serve as a
deterrent in many cases. As Lacassagne remarks,
it would be better, especially for the mentally unstable
women, to catch the thief rather than merely to pre-
vent theft.
The "collector" type is as a rule perfectly responsi-
ble. "Book snatching" is a besetting vice of many
bibliomaniacs, just as coin and stamp purloining
attacks numismatists and philatelists.
While kleptomania in the United States is legally
a defence for crime, it remains to be determined in
each case whether kleptomania exist and whether it
merely extenuate or completely absolve. Where
states predisposing to mental instability exist, the
burden of proof of sanity is on the State. In the
"collectors" the burden would be on the accused.
Stealing of relatively worthless articles, is, by itself,
no evidence of insanity. Parisians think it "smart"
to steal sugar and matches from restaurants. Not a
few sane Americans think it is equally "smart"
to steal rides on railroads. Deterrent influences must
be carefully adjusted to each case, since, as Lacassagne
shows, the chief object of certain women in stealing
is to secure the voluptuous titillation that worry and
fright over detection gives them. On the other hand
certain victims of kleptomania must be held respon-
sible if they persist in going to "bargain" stores when
they have learned the danger of these to their mental
stability. There is no need for new legal principles
in these cases. The common law properly interpreted
is, in English-speaking states, amply sufficient to
protect the rights of the accused and the community.
DIPLOMA MILLS.
The American Medico- Surgical Bulletin in its
latest issue editorially calls attention to a circular of
a Milwaukee medical diploma mill that was received
by a New York physician. The circular was appar-
ently mailed from Chicago, and the Bulletin remarks:
"If the Journal of the American Medical Asso-
ciation, edited and published at Chicago, where the
above mentioned circular takes its origin, would start
a crusade against this mill in the same fierce spirit
that it displays occasionally when it attempts to
besmirch certain of its contemporaries, it would be
elevating itself to the plane where all expect to find
it, and it would then rise to that high position that
should be the chief aim of every scientific medical
journal."
It is not the custom of the promoters of irregular
and fraudulent schemes to carry on their nefarious
practices in their own vicinity, as the editor of the
New York publication is probably aware ; the diploma
mill in Milwaukee uses Chicago for a postal base and
New York and other distant portions of the country
for the field of its operations. Had the editor of the
Bulletin read the Journal more carefully he would
have seen in the issues of April 25 and June 20, of
the present year, not only that it had been noticed,
but that, owing to that notice, legal proceedings had
been instituted in Wisconsin for its suppression.
The Journal has not been remiss in the way so obvi-
ously hinted, and the insinuation is as uncalled for as
is the direct charge that accompanies it. It is satis-
factory, however, to learn that expectation, that
requires an absolute reasonableness as a condition of
its existence, is so high and universal as regards the
Journal.
Downright diploma mills can exist only surrepti-
tiously in any part of the country ; they have about
the same standing as the green-goods manufactories
that send out their temptation to crime throughout
the rural districts of our country. There is another
class of institutions that, while more legal and respect-
able, are only the more dangerous from that fact; they
are the ones that, while ostensibly offering a full
course of study, offer means and inducements for
individuals to obtain credentials for entering the
practice of medicine without proper preparation and
1896.]
CORRESPONDENCE.
10(59
under false pretenses. That such institutions exist,
and that they are recognized as reputable by some
State boards is demonstrated, as an article in the last
issue of the Journal is evidence. It is not always
easy to bring home the charges against these, but it
is not the intention here to neglect them, or to abate
in any degree the efforts for a high standard in our
profession.
Now York has a hotter medical practice act than
many other States and it is reasonable to presume that
it is fairly well enforced, but it is possible that the
looal medloal journals could find abuses there that
would merit their attention. The Journal of the
Ami-kran Medical Association is not intended to
be at all a local publication, but is published for the
whole country and will not knowingly spare existing
evils and abuses in any section. It will gladly receive
any facts that may be known that may aid in its
efforts todo its part in bettering existing conditions.
In acknowledging its indebtedness to the Medico-
Surgical Bulletin for its rather belated suggestions,
it regrets only that it was not offered in a more cour-
teous manner and without the accompaniment of
unjust accusations. That redoubtable publication
will find food for reflection in the petition of the
Attorney General of Wisconsin for the abrogation of
the charter of the Wisconsin Eclectic Medical Col-
We may also take advantage of this occasion
to announce that all circulars of this kind sent to us
by members, and they have been numerous, have
been promptly sent to the State officer named.
CORRESPONDENCE.
Lay Distrust of the Medical Profession.
New York, Oct. 29, 1896.
To the Editor: — Kindly allow me to make a few comments
upon extracts from the editorials in the Journal for Oct. 24,
1896.
"The lay world, as regards both private individuals and
governments is so indifferent to or suspicious of us that while
endowments, scholarships, etc., running into the millions exist
for the encouragement of the study of languages, astronomy,
theology, etc., yet medical education and medical students are
left solely to self-interest, with almost no endowment to help
what is the first necessity of human life — health and the eradi-
cation of disease."
It is not difficult to make an analysis of the situation and to
arrive at a pretty clear logical deduction in explanation for this
attitude of the lay world. The trouble lies within our own cir-
cle and may be divided into two chief factors.
Factor 1. Physicians guard the truth and the right so jeal-
ously that they instinctively attack all of their colleagues who
are engaged in advancing the profession, because they fear
the promulgation of untried doctrines. This is the working
of a natural law, and it is our only means for preventing
the development and spread of false and fanciful theories.
We know that truth will take the resultant of opposing
forces and come to the top. The men who are honestly
and earnestly engaged in investigating and in lifting the mass
of the profession to a higher level are quite willing to submit
to attacks if they are working unselfishly and have put aside
the vanity of personal feeling. The attacking party is usually
composed largely of important men who have not given a sub-
ject so much attention as investigators have given it, and the
lay friends of the attacking party, not comprehending the
character of the contest, simply assume that the man who is
advancing his profession is a pretty bad character or he would
not be attacked. In the larger cities where hard headed bus-
iness men often understand the situation, endowments are com-
ing in regularly for medical educational institutions. We can
point to some grand examples in New York. Millions will be
given to the post graduate medical colleges in this country as soon
as citizens of wealth and public spirit awaken to a realization of
the (act that they can endow great charities and at the same
time give the horde of busy physicians who wish to get abreast
of the times, opportunities to go back to their homes equip-
ped with newest and best methods for saving life and prevent-
ing suffering. Some of the paternal European governments
give strong impulse and efficient aid to their scientific medical
men. It is difficult though for laymen and governments to
know whom they are to encourage, because of the known im-
portance of men who oppose the views of leaders.
Factor 2. Physicians in their ambition to be useful and good
are so jealous of any colleague who is outstripping them in good
works that they fall into the careless habit of criticizing each
other adversely in the presence of laymen without stopping to
think of the consequences. Seven or eight physicians have per-
il ips heard of the old sentiment to the effect that " United we
stand, divided we fall" but as these seven or eight physicians
da not live in the same town they can not profit by this human
experience. It requires a comprehensive type of mind and
much self-culture and training to enjoy a constructive appre-
ciation of the excellent work of one's competitors — of prophets
in one's own country. There are physicians who have won this
victory for their better natures, but the great majority fail in
such endeavors and they attack a successful man in proportion
to his success. When I am visiting a new city and wish to see
good surgical work done I quietly hunt up the man who is
being most abused by his confreres. The laity do not know of
this trick, and if it is difficult for me to find the man in my
own field whom I wish to know, how much more difficult must
it be for a layman to get upon the right track.
"The opinion of the lay world is made still more plain by the
facts of the oceans of patent or secret nostrums eagerly bought
and devoured by it ; by the long struggle still going on to obtain
medical practice legislation to root out quackery, and by the
audacity with which it supports medical sectarianism and
quackery in the regular profession."
This again is our own fault. Elevate the standard of medi-
cal education. Help the people who are suffering and there
will be no need for legislation against quacks and patent med-
icines. It is not quacks and patent medicines that people want.
It is help for their suffering. That is what they are looking for
and if the regular profession in any town can not give it they
will turn anywhere for relief. I would do it myself. In the
smaller towns members of the regular profession do not derog-
ate the homeopathists a bit more than they do their own best
men, carelessly if you please, but nevertheless with the effect
of sending the laity over to the homeopathists freely.
"The British medical profession during the present century
far from occupying a high social status has always been viewed
askance by the present Queen and her uncles." This is the
fault of the British physicians themselves. What a lot of them
are tardigradous toadies. On more than one occasion when I
have been engaged in conversation with some British physician
who outranked most members of the nobility in true worth and
usefulness, a prince or a duke has come into the room, and
instantly my colleague's eyes would assume a distant far away
look, and his knees would give way by catalysis. I have often
felt like killing the poor thing to put him out of his misery. He
1070
PUBLIC HEALTH.
[November 14,
was certain to be taken at his own estimate of his position.
Men whom I had idealized and placed on pedestals came down
within easy reach of me at sight of some prince or duke who
was of no earthly account in the progress of the world and who
could not even make a decent double shot on grouse. I pre-
sume that a nobleman instinctively feels like elevating such a
toady by employing a method which endangers the integrity of
he coccyx of the man who desires elevation.
Robert T. Morris, M.D.
Dermatitis from X Ray.
Cedar Rapids, Iowa, Nov. 7, 1896.
To the Editor:— I have noted in the last two numbers of
our Journal references to the dermatitis produced by the
Roentgen ray. Will you allow me to report a case which I
know was directly referable to the X-ray, as I am the afflicted
one myself.
Some seven or eight weeks ago I used my wrist in obtaining
a successful skiagraph of the wrist joint three or four days in
succession. The exposure was from ten to fifteen minutes
each time and the ray was produced by Tesla's latent coil.
About ten days later I noticed a reddening of the skin which
grew deeper until it became a purple. It was accompanied
by great pain, excessive tenderness to the touch, considerable
swelling and gave a perfect line of demarkation. Finally
there was complete desquamation over the surface marked out
at the commencement of the inflammation.
At this time, some five weeks since, the skin commenced to
desquamate. I have a lesion about three inches long by two
in width. The process of repair is very slow. The original
lesion was about three by four and a half inches.
The best treatment I have found is the use of peroxid of
hydrogen followed by a simple dressing powder such as aristol
or boric acid.
I know this lesion was directly caused by the X-Ray as my
wrist was not subjected to any other substance which could
produce an inflammation.
Wishing our Journal many years of prosperity, I remain
Respectfully yours,
G. C. Skinner, M.D.
PUBLIC HEALTH.
Alcoholism in Children.— In addition to its effects in producing
criminals, idiots and insane, alcohol arrests the growth.
Children of alcoholic parents, trained to the early use of
liquor, are stunted in their growth, and a French physician is
inclined to ascribe to this fact the decrease in the standard of
normal height shown by statistics in that country- -Bulletin
de L'Acadimie de Mid., October 13.
The Decadent Birth Rate. — Maurel considers the chief cause of
the decreasing natality to be the high living of the well to do
classes, which induces the arthritic tendency with its lowered
vitality. This is inherited by the offspring, and if they con-
tinue in the same mode of life as the parents, the natality
diminishes in corresponding ratio, until the family dies out in
the course of five generations of overfeeding. His ideas are
founded on the statistics of his own province and elsewhere,
which show that as the consumption of nitrogenous sub-
stances increases, the birth rate diminishes. —Bulletin Midieal,
October 14.
Continues Restriction of Use of Tuberculin.— Section 14 of chap-
ter 496 of the Massachusetts Acts of 1895 is amended by act of
1896, extending until June 1, 1897, the provision that the use
of tuberculin as a diagnostic agent for the detection of the dis-
ease known as tuberculosis in domestic animals shall be
restricted to cattle brought into the State from points without,
and to cattle held in quarantine at Brighton, Watertown and
Somerville, except when the owner or person in possession con-
sents in writing thereto, or a competent veterinarian, upon
physical examination, condemns the animals as tuberculous.
To Report Accidents from Gas or Electricity. Chapter 338 of the
Massachusets acts of 1896 provides that the chief of police in
any city or town and the medical examiner in any district in
which a person, corporation or municipality is engaged in the
business of manufacturing and selling gas or electricity for
lighting or for fuel, shall make a written report to the board of
gas and electric light commissioners of every accident caused
by the gas or electricity manufactured or supplied by such
person, corporation or municipality, whereby any person shall
suffer bodily injury or loss of life or be rendered insensible,
stating the time, place and circumstances of the accident.
Such report shall be made by the chief of police within twenty-
four hours and by the medical examiner within seven day
after notice of said accident.
Can Require Removal of Dead Animals. — A city may by ordinanc
lawfully prescribe that unless the owner of a dead animal,
even though the carcass be of some value, shall remove it,
cause it to be removed, beyond the city limits, within a speci-
fied reasonable time, and to a specified reasonable distance,
the municipal authorities may deal with such carcass as a nui-
sance, and as such take charge of it, and make such disposi-
tion thereof as will best conserve the public health. So holds
the supreme court of Georgia, in the case of Schoen v. City of
Atlanta, decided Feb. 7, 1896. It is not, however, the court
goes on to state, lawful to require that such owner, upon
removing the carcass, or causing its removal, within the time
allowed him for this purpose, shall deposit it beyond the city
limits at such place only as may be designated by the munici-
pal authorities, or that upon his refusing so to do the city will
have it removed at his expense to that particular place, pro-
vided the removal intended by the owner contemplates the
deposit of the carcass at some other place outside of the city
not itself within a prohibited distance from the city line, and
such disposition of it, when so deposited, as will in any event
prevent its becoming a nuisance to, or otherwise injuring, any
of the inhabitants of the city.
To Protect Health In Ohio.— Among the laws passed at the
recent session of the Ohio legislature having the preservation
of the public health in view, is one which provides that no
dwelling or building, or any room or apartment of itself, in or
connected with any tenement or dwelling or other building,
shall be used, except by the immediate members of the family
living therein, for carrying on any process of making any kind
of wearing apparel or for the manufacture of cigars, cigarettes
or tobacco goods in any form, when to be supplied to others
for sale, unless such place be regarded as a workshop and
made to conform to the requirements of having direct outside
entrance, no opening into any living or sleeping room, suffi
cient light, heat and ventilation, proper water closets for each
sex, and be kept in a cleanly condition. Another act deals
with the manufacture of flour and meal food products. It
restricts the hours of labor of employes in bakery or confec-
tionery, prescribes as to storage of manufactured products,
arrangements as to wash room, water and earth closets, drain-
age, plumbing, ventilation, height of walls, furniture and
utensils, sleeping places, and declares that "no domestic ani-
mals, except cats, shall be allowed to remain in a room used as
a biscuit, bread or cake bakery, or for the storage of floor and
meal products." March 30, 1896, a new and somewhat
lengthy law was passed to prevent the adulteration of vinegar.
Finally, a supplement to section 6928 of the Revised Statutes
of Ohio makes it a penal offense against the public health to
feed to swine or animals of any kind used for human food the
flesh of any old horse, or the flesh of any animal which has
18%.]
BOOK NOTICES.
1071
become old, decrepit, inflrtn or sick, or of one that has
died from such cause, or any offal or flesh that is putrid or
unwholesome.
Boards of Health to Enforce Massachusetts Bakery Law. A law
■ M passed in Massachusetts, approved May 19, 1896, which
provided, under penalty, that all buildings occupied as biscuit,
broad or cake bakeries shall be so drained and shall be provided
witli such a system of plumbing as shall conduce to the proper
and healthful condition thereof. Every room used for the
manufacture of Hour or meal food products shall have, if
deemed necessary by the proper board of health, an impermea-
ble Boor constructed of cement or of tiles laid in cement, with
an additional tlooringof wood properly saturated with linseed
oil. The side walls and ceilings of such rooms shall be plas-
tered or wainscoted, and, if required, by said board, shall be
whitewashed at least once in three months. The furniture and
utensils in such rooms shall be so arranged that the furniture
and floor may at all times be kept clear and in a proper and
healthf ul sanitary condition. The manufactured flour or meal
food products shall be kept in perfectly dry and airy rooms, so
arranged that the floors, shelves and all other facilities for stor-
ing the same can be easily and perfectly cleaned. Every such
bakery shall be provided with a proper washroom and water-
closet or closets, with ventilation apart from the bakeroom or
rooms where the manufacturing of such products is conducted ;
and no water-closet, earth-closet or closets, privy or ash-pit
shall be within or communicate directly with the bakeroom of
any bakery. The sleeping places for the persons employed in
a bakery shall be separate from the room or rooms where flour
or meal food products are manufactured or stored. The board
of health of a city or town in which a bakery is situated, or in
which the business regulated by this act is carried on, shall
enforce the provisions of the act, and shall cause copies of the
same to be printed and posted in all the bakeries and places in
which such business is carried on within their respective juris-
dictions.
BOOK NOTICES.
A Treatise on Obstetrics for Students and Practitioners.— By Ed-
w u:i> P. Davis, A.M.. M.D. Illustrated with 217 engravings
and 30 plates in colors and monochrome ; cloth, pages 553.
Philadelphia and New York : Lea Bros. & Co., 1896.
The practice of obstetrics has changed materially with the
introduction of bacteriology. Aseptic midwifery is now the
rule, and naturally all the treatises on obstetrics have to be
rewritten from that standpoint, and thus the parturient woman
of to day escapes many of the accidents which were so common
twenty-five years ago. The work includes chapters on obstet-
ric diagnosis ; differential diagnosis of pregnancy ; the diagno-
sis of advanced pregnancy ; the complete examination of the
pregnant patient ; the origin and growth of the ovum and the
development of the embryo ; the physiology of pregnancy ; the
pathology of pregnancy ; normal labor and its management ;
labor resulting in the impaction of the fetus (impossible labor) :
multiple pregnancy : induction of labor ; abnormal labor pains ;
hemorrhage before labor— concealed hemorrhage— placenta
previa ; eclampsia ; sudden death during labor ; labor compli-
cated by disproportion between pelvis and fetus; labor in
enlarged pelves: (justo-tnajor); labor and contracted pelves
ljusto-minor) ; rachitic, flat : labor in rare varieties of deformed
pelves; labor complicated by tumors of the pelvis and genital
organs ; septic infection ; episiotomy, multiple incisions of the
cervix ; suture of tears of the perineum and of pelvic floor ;
the forceps; version and extraction; symphysiotomy, celio-
hysterotomy (Cajsarean section); celio-hystereetomy, in-
cluding Porro's operation; embryotomy; obstetric curette-
ment; emptying of the uterus; abortion and premature
labor ; extrauterine pregnancy : the puerperal state and its
complications ; the repair of lacerations of cervix caused by
labor ; the repair of injuries to the pelvic floor and perineum :
insanity and nervous. disorders accompanying the puerperal
state ; lactation ; normal infancy : the pathology of the fetus ;
injuries at birth ; asphyxia; diseases of early infancy ; incuba-
tion and artificial feeding; fetal abnormalities in size and form,
monstrosities ; diseases of infancy including acute dyspepsia
and enteritis, dentition, the respiratory disorders of infancy ;
disorders of development in infancy, and tuberculosis. The
jurisprudence of obstetrics include legitimacy of birth, infan-
ticide, abortion, evidecce of pregnancy in tedious child-birth,
and the legal aspects of obstetric practice.
This is a carefully written book on the science and art of
obstetrics and is thoroughly up to date. It is destined to
become a favorite.
Diseases of the Eye. A Hand-book of Ophthalmic Practice for
Students and Practitioners. By G. E. De Schweinitz, A.M.,
M.D., Professor of Ophthalmology in the Jefferson Medical
College, etc. With 256 illustrations and two chromo-litho-
graphic plates. Second edition, thoroughly revised. Phila-
delphia : W. B. Saunders. 1896.
With his well-known thoroughness the author has added a
great deal of interesting new matter compiled from the recent
literature, in order to keep the text-book abreast with the
rapid progress of ophthalmic science. It will, therefore,
deservedly continue to be a favorite guide-book among stu-
dents and practitioners. But we are unable to understand
how the keen-eyed scrutiny of the author could overlook a
most unfortunate blunder which has crept into the chapter on
the paralysis of the ocular muscles. Three illustrations are
given a wrong signature and place ; the illustration said to
show the position of the double images in paralysis of the
superior rectus, in reality represents the diplopia in paralysis
of the superior oblique ; while the illustration of the double
images in paralysis of the superior oblique is really a repre-
sentation of the diplopia in paralysis of the superior rectus ;
and the illustration of the double images in paralysis of the
inferior rectus gives the position of the double images in
paralysis of the superior rectus. These are very awkward mis-
takes ; for even with the correct illustrations, the students
generally find it pretty difficult to get a clear understanding of
the subject from the w • n which the different forms of diplo-
pia in paralysis of the ocular muscles are usually described in
the text-books ; but surely they will be dazed and thoroughlv
bewildered if the illustrations do not agree with the descrip-
tions.
The publishers should at once try to rectify these blunders
of the press room by inserting into all unsold copies an extra
leaf correcting these errors, which mar an otherwise so excel-
lent text- book.
Since writing the above we have been informed that the
mistakes have been rectified in those books already bound
by inserting an errata slip, and in those not yet bound by
reprinting the pages and putting the cuts in their proper
places. The publishers also have sent the errata slips to every-
body who has purchased one of the books in which the
mistakes occurred, so far as they were able to ascertain this.
Skiascopy and its Practical Application to the Study of Refraction.
By Edward Jackson, A.M., M.D., Professor of Diseases of
the Eye in the Philadelphia Polyclinic and College for Gradu-
ates in Medicine, etc. Second edition, with twenty- seven
illustrations. Philadelphia : The Edwards and Docker Co.
1896.
The quick sale of the first edition is the strongest indorse-
ment of the favorable opinion we expressed on the merits of
this little book one year ago. There are no material changes
in the second edition ; but we are pleased to note in sev-
eral places slight changes in the phraseology, by which the
author's ideas are expressed with greater precision and the
possibility of a misinterpretation is obviated.
1072
BOOK NOTICES.
[November 14,
Cbaraka Sarahita. Translated into English. Published by Ayi-
nash Chandra Kaviratna. Calcutta: Printed by Girish
Chandra Chakravarti (200 Cornwallis Street). Part XV.
We have before mentioned this venerable treatise, interest-
ing not only because of its great antiquity, but to the medical
historian as showing much of the ancient knowledge that is
still current.
This fasciculus begins the division on Virniinam. The object
of the Virniinam is to help the physician to acquire a knowledge
of the tastes. The various tastes are enumerated, and Hindu
dietetics is discussed as then understood. "Lesson III" in
this fasciculus treats of "how the destruction of cities and
towns and villages are brought about."
In the matter of gastronomy The Charaka Samhita says :
" It (food) should also consist of such ingredients as would
not form a combination of hostile potencies."
" One should take one's food in a place that is agreeable."
"The food one takes should, again, consist of dishes every
one of which is agreeable. One should not eat with haste; or
taking up a long time; or talking or laughing the while."
"While eating one should eat with attention concentrated
thereon."
" Lastly, one should eat after a proper survey of oneself"
(that is, attention to one's state of general health).
In regard to plagues the book says :
"In the capital known as Kiimpilya, situated in the region
called Panchiila that teemed with clusters of villages, and that
was inhabited by many foremost of regenerate persons, the
illustrious Punarvasu, the Son of Atri, surrounded by dissi-
ples, toward the close of the month of sweat (gharme mase),
while engaged in a walk in the woods on the banks of the
Ganga addressed his disciple Agniveca, and said: 'Verily,
O amiable one, of the constellations, the planets, the moon, the
sun, the atmosphere and fire, as also of the points of the
compass, as existing in their natural state, conditions are
observable causing perverse symptoms of season. From this,
very soon, the soil also will not duly impart unto the herbs
juice, energy, assimilable virtue and potency. Through
absence of these an epidemic outbreak is certain to follow.' "
Then follows a discussion of the etiology of epidemics, and it
is seen that bad water occupies the first place.
Truly the world has changed little from the days of the Son
of Atri, when the Sanskrit Vedas were the songs of the people
not less than those of the priests.
Over the Hookah. The Tales of a Talkative Doctor. By G.
Frank Lydston, M.D. Illustrated. Chicago : Fred Klein
Company. 1896.
Dr. Lydston' s reputation as a good story-teller will be
increased by the publication of this book, and those who have
had the pleasure of hearing him tell a story will like the book
all the better after having had that pleasure, for after all, a
large part of the pleasure and charm of story-telling lies in
the voice and manner of the narrator. Particularly is this
true of dialect stories, where the skill of the linguist is shown
not only in construction, but in orthoepy and accent. How-
ever, next to hearing Dr. Lydston tell a story, comes the
pleasure of reading one that he has written or adapted, for his
adaptations have a personal flavor about them that gives
originality.
The hookah, be it known, is an Arabic pipe, consisting of a
box in which tobacco burns, a vessel of water through which
the smoke passes, and a long pliant stem or mouth tube. When
the Doctor lit his hookah, the stories began.
As a rule, the author defends the profession throughout, but
there are many sarcastic passages, and one might almost
believe, severe hits at foibles belonging exclusively to certain
well-known members of the profession. When the author's
" Dr. Weymouth " is fairly launched on this subject he is very
candid, sometimes caustic, but he is never dull.
The stories in the book are all character stories, and truth-
fully drawn. One that is absolutely new, is that of Major
Meriwether, a curious compound of fuss and feathers, poverty
and pride, bombast and braggadocio, egotism and simplicity,
good-nature and cowardice. Dr. Lydston has made a very
readable book, and if some of the stories of the frontier are
rugged, it is because they are true to the characters of the
mining camp, and to the rugged environment of the men them-
selves.
A Text book of Special Pathologic Anatomy. By Ernst Ziegler,
Professor of Pathology in the University of Freiburg. Trans-
lated and edited from the eighth German edition by Donald
MacAlister, M. A., M.D., and Henry W. Cattell, A.M., M.D.
Sections 1 to 8. New York and London : The Macmillan
Co. 1896.
This is the third English edition of Ziegler, the first of which
was published in 1884, but the great advances which have been
made in pathology have been embodied in five German editions
that have appeared in the meantime. So in this work the text
has been recast to correspond to the latest German edition.
The second volume, which will contain sections on the alimen-
tary tract, liver and pancreas, respiratory and genitourinary
systems, the eye and ear, is in press and will shortly be pub-
lished, after which it will be followed by a new translation of
the part on general pathologic anatomy. This volume con-
tains eight sections, as follows: 1, blood and lymph; 2,
the vascular mechanism ; 3, the spleen and the lymph glands ;
1, the osseous system ; 5, the muscles and tendons ; 6, the cen-
tral nervous system ; 7, the peripheral nervous system ; and 8,
the skin.
There are 308 illustrations in this volume. The illustrations
are of the style and appearance of those in Hamilton's Path-
ology. This work is very thorough and complete. The bibli-
ography alone at the end of each of the paragraphs is worth to
any student, writer, or other person interested in the subject,
the price of the volume. The book is greatly condensed, there
being no redundancy of matter or in the style of expression. It
deserves wide publicity and doubtless will receive thatgenerous
support which has been accredited to former editions.
An American Text Book of Physiology. By Henry P. Bowditch,
John G. Curtis, Henry H. Donaldson, W. H. Howell,
Frederick S. Lee, Warren P. Lombard, Graham Lusk,
W. T. Porter, Edward T. Reichert and Henry Sewall.
Edited by Wm. H. Howell, Ph.D., M.D. Illustrated, 1052.
pages, royal octavo. Philadelphia : W. B. Saunders, and
Chicago, W. T, Keener, Agt. Price (cloth) $6.
This book is published in the same general style and size as
the text-book on obstetrics. It is on the collaboration method
and has the natural disadvantage of the overlapping, but it
undoubtedly gives a broader view than single authorship.
Such works, however, can not fail to be detrimental in the
long run to the interests of individual authorship, as each
school represented in the book forces the book on the students
of the college; consequently there is a taste of commercialism
about all books written on this basis that is objectionable. We
have heretofore refrained from touching on this topic, but
believe the time has come for doing so, as however great the
merits of the book, it is not in accordance with that freedom
and liberty of action on the part of our teaching faculties that
should exist in this country. This does not apply alone to the
book under consideration, but refers to all works of its kind.
This text-book is one of the most satisfactory of the series. It
is highly scientific and free from padding, and has embodied
in it the latest observations on the subject. The contents are
as follows : Introduction by the editor, Dr. Howell ; general
physiology of muscle and nerve ; secretion ; chemistry of diges-
tion and nutrition ; movements of the alimentary canal, blad-
der and ureter ; blood and lymph ; circulation, respiration ;
animal heat ; central nervous system ; special senses ; physi-
ology of special muscular mechanisms ; reproductions ; chem-
istry of the animal body.
L896 |
NECROLOGY.
1073
A System of Diseases of the Eye. By American, British, Dutch,
German and Spanish authors. Edited by Wm. P. Xouuis,
A.M., M.D., CiiAKi.is A. Oliver, A.M., M.D., Vol. I
Embryology, Anatomy and Physiology of the Eye, with 23
full page plates and :W>'2 U>xt illustrations. Philadelphia:
J. B. Lippincott Co. 1897.
This is the first volume of a system of diseases of the eye
written in the English language, and embraces the most
advanced theoretical and practical views on the subject. The
broad pages and large type make it a pleasure to the eye ;
while the beautiful illustrations are creditable alike to the
author and the publishers. This is intended to be an
encyclopedia on the subject of diseases of the eye and
will be of service not only to ophthalmologists and special
students, but for reference by the general practitioner as well.
We notice with pleasure that the subjects of dioptrics, percep-
tion of light, binocular vision, have been given to Americans.
It is wall-known that in these subjects our countrymen have
taken the lead. We notice the death of Dr. Rider, who wrote
the chapter on the embryology of the eye, and who died before
the issue of the volume. Professor D wight of Harvard College
has contributed an exhaustive chapter on the anatomy of the
orbit and appendages of the eye; while Dr. Prank Baker of
the University of Georgetown has a very scholarly article
on the anatomy of the eyeball. We congratulate the editors
and the publishers on the production of the first volume, and
we believe that it will take its place at the very head of the
extended works on this subject in English.
Water and Water Supplies. By John C. Thresh. London :
Rebman Publishing Co. : W. B. Saunders, Philadelphia, and
W. T. Keener, Chicago, Agents. Price $2.25 net.
In this day, when the question of water supplies is inter-
esting health officers everywhere and the public generally, this
book will be peculiarly timely and interesting. Its scope
includes discussion of water, its composition, properties, rain
and rain water, surface water, subsoil water, natural spring
water, deep well water, river water, quality of drinking water,
waters, impure water and its effect upon the health, the inter-
pretation of water analyses, the pollution of drinking water,
the self purification of rivers, purification of water on, a large
scale, domestic purification, the softening of hard water,
quantity of water required for domestic and other purposes,
selection of sources of water supply, wells and their construc-
tion, pumps and pumping machinery, the storage of water, the
distribution of water, the law relating to water supplies, rural
and village water supplies, with an appendix.
The book will be found interesting and it is adapted to both
popular and scientific reading. It is accurate in its statements
and will be generally accepted by those interested as authorita-
tiTe. For students and those preparing for examinations as
medical officers of health we commend the book.
Text-book of Training Schools for Nurses; Including Physiology
and Hygiene and the Principles and Practice of Nursing.
By P. M. Wise, M.D., with an introduction by Dr. Edward
Cowles, in two volumes, Vol. II. New York and London :
G. P. Putnam & Sons. 1896.
In our notice of the first volume of this book we took occasion
to commend it as being the best and most systematic text-book
that has fallen under our observation, and we can only repeat
the statement in glancing over the second volume, which is di-
vided in thirty chapters, and contains thirty eight illustrations.
The chapters are as follows : 1, local applications, poultices,
fomentations ; 2, counterirritants, cupping, leeches ; 3, enemata,
suppositories ; 4 and 5, bandages and bandaging, splints ; 6,
fractures, dislocations and sprains ; 7, fever, inflammation ; 8,
hemorrhage ; 9, wounds, burns and scalds, emergencies ; 10,
anesthesia and anesthetics ; 11, surgical nursing operation ;
12, poisons, bites, stings, etc. ; 13, asphyxia, artificial respira-
tion ; 14, convulsions, apoplexy, coma, syncope, etc. ; 15,
nervous disorders ; 16, insanity : 17, forms of insanity ; 18, ob-
servations on care of the insane in the household ; 19, duties of
hospital nurses for the insane ; 20, baths and bathing ; 21,
massage ; 22, medicines and their administration ; 23, forcible
feeding, food for the sick ; 24, special medical cases ; 25, chil-
dren's diseases ; 26, convalescence, signs of death, care of the
dead ; 27, Pregnancy, physiologic signs and symptoms of abor-
tion, miscarriage ; 28, preparation for labor, necessity for anti-
septic care, parturition, etc. ; etc. ; 29, care of the infant, and
30, gynecologic nursing.
In the appendix will be found a glossary of technical words
and phrases and general index to the two volumes. The whole,
as we have stated, form at present one of the best text books
( >f training schools for nurses that is on the market, in our
judgment.
Text-book of Histology, Descriptive and Practical for the use of
Students. By Arthur Clarkson, M.D., CM., Edinburgh,
with 174 original colored illustrations. Philadelphia : W.
B. Saunders, 1896. W. T. Keener, Chicago, agt. Price,
$6.00 net.
This is the English imprint of the work as issued in Edin-
burgh, and notwithstanding the author asserts that the book
being of limited size can not aspire to be of the nature of an
exhaustive treatise on histology, yet it will be seen that the
field is thoroughly covered, and that the work has been well
done. Scotch pathologists and histologists seem to predomi-
nate among the English medical books, and it must be con-
fessed that they have taken a high place. For students and
practitioners, desiring to refresh themselves with histologic
work, the book of Clarkson will be found to be a trustworthy
and very satisfactory guide. Mr. Saunders has done well to
introduce it to the American public.
ASSOCIATION NEWS.
Rush Monument Committee.— The following subscriptions to the
Rush Monument Fund have been received:
April 17, Dr. J. W. Hoff, Pomeroy, Ohio. . . $ 5.00
April 17, Dr. T. J. Acker, Croton-on-Hudson,
N. Y 5.00
April 30, Peoria City Medical Society (through
Dr. O. B. Will), Peoria, 111 25.00
April 30, Dr. D. W. Cathell, Baltimore, Md.. 1.00
April 30, Dr. W. T. Cathell, Baltimore, Md... 1.00
May 9, Dr. J. P. Getler and others, Mifflin
County, Pennsylvania 3.00
May 21, Dr. E. H. Bishop, Towson, Md . . . 1.00
June 10, Dr. C. B. Burr, Flint, Mich .... 10,00
June 29, Dr. W. H. Hardin, Anderson C. H.,
S. C 1.00
June 29, Herkimer County Medical Society
(through Dr. G. Graves, Herkimer, N. Y.). 25 00
Sept. 30, Dr. J. W. Grosvenor, Buffalo, N. Y. 1.00
Sept. 30, Interest to date 81.00
$ 159.00
Before reported 3,727.39
Total $3,886.39
George H. Roh&, M.D., Secretary.
NECROLOGY.
James Bissett Murdoch, M.D., of Pittsburg, late dean of
the Western Pennsylvania Medical College, died October 29.
He was a son of the Rev. David Murdoch, D.D., late of
Elmira, N. Y., and was born in Glasgow, Scotland, Oct. 16,
1830. He was graduated from the New York College of Physi-
cians and Surgeons in 1854, and during the ensuing year was
house surgeon to Bellevue Hospital. Subsequently he became
surgeon of the steamer North Star of the Vanderbilt line.
From 1855 to 1872 he practiced at Elmira, N. Y., and since
that time he has been established at Pittsburg. He was
1074
MISCELLANY.
[November 14.
member of the Oswego County Medical Society, its presi-
dent in 1865 ; of the New York State Medical Society ; of the
Allegheny County Medical Society ; of the Pittsburg Academy
of Medicine and School of Anatomy, president of this society
in 1877 ; of the Pennsylvania State Medical Society, its pres-
ident in 1888, and of the American Medical Association.
During the war he served three years in the Twenty-fourth
New York Volunteers and was surgeon-in-chief of his brigade.
He was a member of the Grand Army and Military Order of
the Loyal Legion, a trustee of the Pennsylvania College for
Women and a director of the Monongahela Navigation Com-
pany. He was a frequent contributor to the various medi-
cal journals and many of his writings have appeared from
time to time in this Journal. He leaves three sons and two
daughters.
Moritz Schifp, M.D., one of the leaders in experimental
physiology, which owes many discoveries to him. Professor of
Physiology at the new University of Geneva and previously at
Berne and Florence. He was born at Frankfurt-on-the
Main in 1823. Author of many works on his specialty, the best
known are perhaps his "Physiology of the Nervous System,"
"Investigation of the Spinal Cord," and the "Influence of the
Nervous System in the Production of Diabetes."
MISCELLANY.
Trained Nurses in the Paris Hospitals.— There are about 1,800
graduated nurses and attendants in the public hospitals of
Paris, but the remainder amounting to 3,459, have never
received special professional training.
Two New Buildings for the Feeble-minded By resolution of the
Massachusetts legislature there is to be allowed and paid out
of the State treasury a sum not exceeding $60,000, to be
expended at the Massachusetts School for the Feeble-minded
at Waltham, under the direction of the trustees of said insti-
tution, for the purpose of erecting two new buildings, in
accordance with the recommendations contained in the forty-
eighth annual report of such trustees.
Authorizes Holding More Property. — Any corporation hertofore
chartered by the legislature of Massachusetts for any of the
purposes mentioned in section 2 of chapter 115 of the Public
Statutes, which includes associations formed for any educa-
tional, charitable or benevolent purpose, or for the prosecution
of any scientific or medical purpose, it was enacted at the
recent session of the legislature of that State, may hold real
and personal estate to the amount of not more than 8500,000
for the purposes set forth in its charter.
Massachusetts Pharmacy Law Codified.— Chapter 397 of the
Massachusetts Acts of 1896, entitled "An act to regulate the
practice of pharmacy," approved May 15, 1896, is a codifica-
tion and consolidation of the laws of that State relating to the
regulation of the practice of pharmacy and of all the laws
which it is the duty of the board of registration in pharmacy
to enforce, which were previously scattered through half a
dozen or so different volumes.
Sphacelotoxln, the Active Principle of Ergot.— Jacoby of Strass-
burg announces that he has succeeded in isolating the active
principle of ergot. It forms a yellow crystalizing substance,
chemically pure, which produces abortion in dogs and cats in
twenty-four hours, without severe general symptoms. It also
decreases the laying of eggs by hens. No poisonous effect is
produced on warm blooded animals, even in very large doses. —
Wien. klin. Rundschau, October 18.
Impotence In Law. — Under the Illinois statute which provides
that where a marriage has been contracted, and it shall be
adjudged, in manner prescribed, that either party, at the time
of such marriage, was and continues to be naturally impotent,
the injured party may obtain a divorce, the supreme court of
Illinois holds, in the case of Griffith v. Griffith, where it
denied a re-hearing Oct. 9, 1896, that where the defect in the
husband proceeds from self-abuse, if he will not exercise a
moral restraint over himself, and test the curability of his dis-
order by proper self-control, his wife has a right of action on
the ground of impotence. The words "naturally impotent,"
as used in the statute, the court holds, means "incurably
impotent," and that it is immaterial whether the impotence
existed at birth and by some formation or nonformation of
nature, or was caused by the party's own fault, so long as it
exists at the date of the marriage.
The History of Surgery In Tableaux.— At the twenty-fifth meet-
ing of the German Surgical Society, lately held, after the
reading of many highly meritorious papers by the most emi-
nent surgeons, an entertainment was given, at which the
Emperor and Empress were present. It consisted of a series
of tableaux which represented the history of surgery. The
first represented the battle of Teutobruger Wald, showing how
the place looked when the soldiers' wounds were dressed on
the battlefield. Then came the monk, the quack and the
barbers as healers, and so on, following the course of surgery
down to to-day, and the final picture was in honor of the Red
Cross.
Alleged Wrong 'Flexion. — In an action to recover from a rail-
road company for personal injuries, which it was alleged,
resulted in a retroflexion of the womb, while the proof estab-
lished an anteflexion, the defendant argued that a verdict
should have been directed for it, on account of this variance.
But the court of appeals of Indian Territory holds otherwise,
case of Missouri, K. & T. R'y Co. v. Turley, decided Sept. 9,
1896, saying that the company having offered no proof that it
was misled, the alleged variance, if, indeed, it could be
termed, must be regarded as harmless, and treated as
immaterial.
Non-Expert Evidence of Insanity In New Mexico.— The supreme
court of New Mexico holds, in the homicide case of Territory
v. Padilla, decided Sept. 1, 1896, that it was competent for a
non-expert to testify that the demeanor of a witness, whos
sanity was attacked, was similar, as nearly as he could remem-
ber, at the coroner's inquest and before the jury in the trial i
the district court, and that he was considered by him a ver
stupid witness, and uncertain as to the facts he stated ; that
non-expert witnesses can be asked as to conduct and appea
ance ; but that they can not give an opinion as to the sanit
or insanity of a person ; and can not testify as to what is his
general reputation as to sanity. At the same time, two of the
justices dissent from the doctrine that a non-expert may not
state his opinion or conclusion as to the sanity or insanity of a
person whose mental soundness or capacity is under con-
sideration.
Restrictions upon Evidence of Attending Physicians.— The court of
appeals of New York holds, in the case of Redmond v. Indus-
trial Benefit Association, decided Oct. 6, 1896, where an insur-
ance company's by-laws required the proofs of death to con-
tain, among other things, a statement, under oath, of the
attending physician, made upon a blank furnished by the com-
pany, and such statement showed that he had treated the
insured for renal calculi some months prior to the time appli-
cation was made for the insurance, that it was evidence, but
not conclusive evidence, of disease of the urinary organs when
the application was made, or within five years prior thereto.
It also holds that the testimony of the physician to prove this
fact at the trial of the action against the insurance company
was properly excluded under section 834 of the Civil Code, as
privileged.
Not Hearsay Evidence. — The supreme court of Georgia holds,
in the case of the Western & Atlantic Railroad Co. v. Stafford,
18%.]
MISCELLANY.
1075
decided July 27, 185)6, that there was no error in allowing a
physician to testify that one who had received violent personal
injuries, and who was under treatment in a boarding house on
the day upon which he was hurt, did not know he had previ-
ously, on the same day, after receiving the injuries, been in
the physician's office. The objection to this testimony was
that it was simply the sayings of the plaintiff, who was seek-
ing to recover for his injuries, made some five hours after the
occurrence and too far off to be a part of the occurrence. But
the court takes the above view, it not appearing on cross-
examination or otherwise, that the physician's knowledge on
the subject was not derived from personal observation of the
patient's condition, or that it depended solely upon statements
made by the latter.
Esophageal Sac or 'Antrum Cardlacum." — Fleiner, Boas and
Kwald have observed in a few cases a cavity above the stom-
ach in the alimentary canal. One patient could only swallow
his food by tilling the esophagus to the top, and then by pres-
sure from the outside force the contents down into the stom-
ach. Others have required the permanent use of the sound.
If the stomach is filled with melted wax after dissection, it
often reveals the presence of an ante-stomach, with no evi-
dence of a previous cicatrization. The symptoms in the case
of an 8 year old child were distress in breathing, pain in the
gastric region, vomiting, regurgitation and eructation after or
during meals, with a peculiar cough at night and a gurgling
sound in the chest. The child masticated slowly, ate very
little, and was much emaciated. Alimentation with the sound
caused it to gain five pounds in ten days. Investigation with
the sound disclosed a cavity above the stomach that contained
70 cm. fluid. The trouble in this case is congenital and will
probably require the continual use of the sound for life. —
Wiener klin. Jiundsehau, October 27.
Examination and Evidence in Personal Injury Case. — The supreme
court of Georgia says that it w not reverse the action of a
trial judge in refusing, pending the rial of a suit for personal
injuries, to order a medical examination of the plaintiff, when
it appears that no request for such on examination was made
of the plaintiff before the trial began, and no request to this
effect was made to the court until after the plaintiff's evidence
had been closed and it was then impracticable, without too
long a suspension of the trial, to obtain a satisfactory and com-
petent physician by whom an impartial examination could be
then made. While the power to order such an examination
exists, it goes on to state that it is in each case to be
exercised or not, according to the sound discretion of the pre-
siding judge. And the court also holds, Savannah, F. & W.
Ry. Co. v. Wainwright, decided July 20, 1896, that while
a husband is not competent to testify as to oral complaints
made to him by his wife concerning her "pains and hurts"
resulting from a physical injury, he may testify as to the
physical condition of any of her members of which he had
actual knowledge ; and, if such condition manifestly caused
suffering, he may so state.
Colorado Inebriate Law Constitutional. — The supreme court of
Colorado holds, "In re House," a case decided June 29, 1896,
that chapter 74 of the State session laws of 1895, which pro-
vides for the sending of indigent habitual drunkards to an
institution for treatment at county expense is constitutional,
thus reversing the decision of the county court. Among the
chief objections raised was that it offended against a provision
of the State constitution that: "No appropriation shall be
made for charitable, industrial, educational or benevolent pur-
poses, to any person, corporation or community not under the
absolute control of the State, nor to any denominational or sec-
tarian institution or association," as well as that it offended
against a provision that : "The general assembly shall not del-
egate to any special commission, private corporation or associ-
ation, any power to make, supervise or interfere with any
municipal improvements, money, property or effects, whether
held in trust or otherwise, or to levy taxes, or perform any
municipal function whatever." But after carefully consider-
ing these, and other constitutional objections, which it says
were ably and exhaustively urged, the supreme court declares
that, while the act may in some respects be defective, and
subject to some criticism, it is not objectionable to any of the
constitutional objections urged, and must be upheld as a
legitimate exercise of legislative power.
The Demand and Supply of Eunuchs In China. — A writer in the
London Lancet gives us some information upon the above
subject. In China the Emperor and certain members of the
royal family are alone entitled to keep eunuchs. His majesty
maintains at least 3,000, but no prince of the blood or imperial
princess has a right to more than thirty. Theoretically the
palace eunuchs are furnished by governors of provinces, each of
whom has to supply eight every five years, receiving in return
250 taels per eunuch. It was found, however, that the num-
ber thus obtained was totally insufficient, so a recruiting office
was established at Pekin for the direct enrollment of candi-
dates. In the production of Chinese eunuchs four chief
factors prevail, viz., greed, predilection, poverty and laziness.
Many parents sell ther male children to the mutilators or
themselves castrate them in the hope of eventually sharing
their earnings.
Young men of from 25 to 30 years of age, some of them hav-
ing wives and families, often accept emasculation, being allured
by the prospects of emolument. Poor wretches destitute of
means and threatened with starvation agree to become eunuchs
in order to gain a living. Finally, a certain number of lazy,
good-for-nothing vagabonds sacrifice their manhood to secure
a life of indolence. The operation is performed in a building
situated close to one of the palace gates, but the operator,
although his office is recognized and a hereditary one, having
been for many years in the same family, receives no regular
wages, being entitled to a fee of 6 taels from each individual
operated on. In the case of destitute candidates he exacts a
lien on their prospective earnings. Dr. Matignon's descrip-
tion of the operation is as follows : The subject, with his
abdomen and thighs tightly bandaged, is placed supine on a
low bed, one assistant tightly grasping him around the waist,
while two more keep his legs widely separated. The operator,
as a rule, uses a curved implement resembling a pruning
knife, but occasionally he substitutes for it a long pair of
scissors. With his left hand he seizes the parts, squeezing
and twisting them to diminish the supply of blood ; but before
cutting he inquires for the last time whether or not the patient
is a consenting party. Adults, of course, answer for them-
selves, no anesthetic being used, but in the case of children
the parents' word is accepted. The reply being in the affirma-
tive, a single rapid sweep of the hand serves to remove both
penis and scrotum, the blade of the instrument passing as close
as possible to the pubis. A small piece of wood or of pewter
shaped like a nail is then inserted into the urethra ; the wound
is washed two or three times with pepper and water, and sev-
eral sheets of paper having been applied to the raw surface the
parts are carefully and tightly bandaged. The subsequent
treatment is remarkable. Immediately after the bandaging
the unfortunate patient is seized by the assistants and made to
walk up and down the room at a rapid rate, not being per-
mitted to lie down for three hours. For three days he is not
allowed to drink anything, and not only does he suffer the
pangs of thirst, but also has to endure the agonies of retention
owing to the plug in the urethra. On the fourth day the band-
ages are removed and the wretched creature is suffered to pass
urine if he can. If the urine flows he is looked upon as cured,
but should the overstrained bladder refuse to act he is left to
die, the virtues of catheterization being apparently unknown
to the Chinese. The amputation leaves a large triangular
wound with the apex downward, which takes on an average
about a hundred days to granulate. Notwithstanding the
primitive mode of procedure the operation is usually success-
ful, and fatal cases do not amount to more than 3 or 4 per
cent. The most frequent complication is the incontinence of
urine, but if this unpleasant symptom continues beyond a
reasonable period the patient is condemned to flagellation, a
mode of treatment which is said to yield the most excellent
results.
1076
MISCELLANY.
[November 14, 1896.]
The Gradual Evolution of the Ambulance. — In Boston, a some-
what novel departure has been put forth in the way of furnish-
ing stretchers for the fire department employes. It is expected
that these means of relief will often be used at fires, before the
police patrol wagons or the city ambulances can reach the
scene. The instrumentality of the late Dr. Henry I. Bowditch
in bringing into play the humane idea of the ambulance has
been sketched in an article in the Independent. A portion of
that article is given below. Quite recently, the French Army
Ambulance service has been holding some very interesting
maneuvers, just outside of Paris ; and we may be sure that the
people who had sons and brothers falling ill by the hundreds
in malarious Madagascar, watched these evolutions with keen
interest. A train was prepared for imaginary "sick and
wounded," and was fitted up by the men of the ambulance
corps. It was taken to a suitable site, and a field hospital was
improvised, in which the invalids were distributed according
to the nature and severity of their imaginary injuries. It was
supposed that night would test the drill and discipline better
than the day, and accordingly, it was chosen, and surgeons
went their rounds, while the subordinates prepared suitable
food for invalids. "Then the 'patients' — who enjoyed it all as
a huge and elaborate joke — were conveyed on stretchers and
in ambulances to their barracks, and the 'ambulance drill'
was over. There is in existence, somewhere, a little pamphlet
put forth during the War of the Rebellion, by Dr. Henry I.
Bowditch of Boston, who had hastened to one of the battle-
fields of Virginia, on learning that a beloved son was wounded.
He describes the horrors of a ride in a common springless farm
wagon — the only procurable vehicle— with a number of
severely wounded men, over the rough ways that served for
roads. The sufferings of these men were terrible ; and the
sound of their groans and shrieks was destined to be heard far
beyond the time and place rendered indescribably horrible by
them. The soul of the good doctor was filled with compassion,
and on his return, with his dead son, he at once set to work to
ameliorate the conditions that must follow every battle. He
strove to invoke the aid of Massachusetts, and the history of
that attempt is enough to make one loathe the word 'politics,'
so much did they do to obstruct and thwart a purely humane
purpose ; but untiring zeal, quickened by the memory of that
awful night ride, at last accomplished an improvement in the
means of conveyance and also the selection of a detail of
drivers who were not— like the one he had known— drunken,
profane and brutal. Some of the ideas embodied in the com-
fortable ambulances that now follow in the wake of civilized
warfare (if there can be such a thing as civilized war), and
that one found in all large cities as part of the paraphernalia
of a well-equipped hospital, were embodied in 'sick wagons'
before the close of the war ; and when it was over the matter
was forgotten, and one quick, observant mind after another
added its full quota of 'improvement' till it seemed to have
touched the ideal ; but within a few months the last desidera-
tum has been attained in the addition of rubber tires to the
wheels that must travel over the uneven city pavements.
Wherever an army corps goes into action now, it is sure to be
followed by a train of these life and pain-saving vehicles, with
the red cross of universal care for the wounded sending forth
its message of hope and comfort."
Marching from Malaria.— For several years back, during the
autumn, the troops stationed at Fort Myer, Va., have suffered
severely from intermittent and remittent fevers. In July of
the present year the post surgeon, Capt. W. H. Arthur, recom-
mended that a practice march be made, for military purposes
so far as the military point of view was under consideration,
but for medical purposes as well, so as to remove the troops to
non-malarious localities during the season of active infection
at Fort Myer. The recommendation was approved by the
higher authorities and the command, consisting of four troops
of the Sixth Cavalry and a detachment of the band, with
Capt. Arthur and some men of the hospital corps, left the post
September 8, and returned, after a march of 260 miles through
northeastern Virginia, on October 5. Their route took them
through Warrenton, Sperryville, Strasburg, Winchester and
Harper's Ferry. Good camping grounds were found at all
points selected, with plenty of running water, usually of excel-
lent quality. A few cases of malarial fever occurred during
the first week, none afterward. The total number of cases was
8 in the command of 220 men. The sick report showed 12
cases during the same period among the 80 men left behind in
garrison. In the corresponding period of 1895, 88 cases
occurred in the Fort Myer command, then 268 strong. These
results are regarded as highly satisfactory. The command will
no doubt have fewer cases of recurring malarial fever during
the coming winter. .
THE PUBLIC SERVICES.
Army Changes. Official List of changes In the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Oct. 31 to Nov. 6. 1896.
Major Edward B. Moseley, Surgeon U. S. A., Is granted leave of absence
for four months, to take effect upon being relieved from duty at
Ft. Monroe, Va.
PROMOTIONS.
To be Asst. Surgeons with rank of Captain after five vears' service:
First Lieut. Henry C. Fisher, Asst. Surgeon, Oct. 31, 18%, First Lieut.
Henry A. Shaw, Asst. Surgeon, Oct. 81, 1896; First Lieut. Charles F.
Kieffer, Asst. Surgeon. Oct. 31, 1896.
Wavy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending Nov. 7, 1896.
Medical Inspector J. L. Neilson, detached from the " Maine " Nov. 10,
and placed on waiting orders.
Surgeon L, G. Heneberger, ordered to the " Maine " Nov. 10.
D. N. Carpenter and F. L. Pleadwell, appointed Asst. Surgeons from
Oct. 24.
Surgeon G. P. Lumsden, detached from the "Yorktown" Nov. 2, ordered
home and granted three months' leave.
P. A. Surgeon J E. Page, detached from the "Boston" and ordered to
the " Yorktown."
P. A. Surgeon G. Rothganger, detached from the " Oregon " and ordered
to the " Patterson."
P. A. Surgeon R. M. Kennedy, detached from the " Patterson," ordered
home and granted three months' leave.
Asst. Surgeon R. ». Blakeman, detached from the '■ Vermont " Nov. 12
and ordered to the *' Boston " per steamer of Nov. 21.
Asst. Surgeon W. M. Wheeler, detached from the "Franklin" Nov. 12
and ordered to the naval hospital. Mare Island.
Asst. Surgeon A. Fareuholt, detached from the Mare Island naval hos-
pital and ordered to the "Oregon."
Asst. Surgeon S B. Palmer, detached from the naval laboratory, New
York, and ordered to the " Vermont."
Asst. Surgeons D.N. Carpenter and F. I.. Plead well, ordered to the naval
laboratory and department of instruction, New York.
Change of Address.
Brown, J. R., from 102 N. Alabama St. to 8 Sterling St., Indianapolis,
Ind.
Craig. S. S., from Alamosa, Colo, to Chama, N. M.
Ewing, F. C, from St. Louis to Webster Grove, Mo.
Hammond J. C, from Denulsou, Iowa, to Hanna. Wyo.
Luebbers, A., from Denver, Colo, to 2407 N. Jefferson Av., St. Louis, Mo.
Mass. F., from 25 Miami Av. to 564 Woodward Av . Detroit. Mich. ;
Montizambert. F.. from Quebec to 180 St. George St., Toronto, Canada;
Murreil, T. E., from St. Louis, Mo. to 2224 E. 11th Av., Denver, Colo.;
Marshall. John S.. from Kankakee, 111. to Elyria, Ohio.
Potts, C. N., from Silverton to 605 N. Cascade St., Colorado Springs,
Colo.
LETTERS RECEIVED.
Alta Pharmacal Co., (2) St. Louis, Mo.
Bishop, Louis F., New York N. Y.; Breedlove, J. W., Fort Smith, Ark. ;
Brockway, Geo. M.. Florence, Ariz.; Breiteenbach. M. J., Company, New-
York. N. Y. ; Bnusch & Lomb Optical Co.. Rochester, N. Y.
Columbus Phaeton Co.. Columbus. Ohio; Curtis, John B., Somerville,
Mass.: Cornell, C. W., Knoxville, Iowa.
Davidson Rubber Co.. Boston. Mass.
Farwell & RhiueB, Watertown, N. Y.; Ferguson & Goodnow. Chicago,
111.: Freeman, C A. Chicago, 111.: Floyd, J. C. M., Steubeuville, Ohio.
Gilpin, l.angdo&& Co., Baltimore. Md.
Hendrick, S. O.rHeury, III.; Haldenstein, I., New York, N. Y.; Hum-
mel, A. L.. Advertising Agency, New York, N. Y.
Jay. E. W , St. Anthony, Io\v«.
Knight, T. H.. Nice. France; Kirkpatrick, Paul W., Nashville, Tenn.
Lee. Elmer. Chicago, III.
Mackie, J. M., Portage La Prairie. Manitoba, Canada; Mellier Drug Co.,
St. Louis, Mo.; Murphy, T. C, Mauito, 111.; Montgomery, E. E., Phila-
dnlphia. Pa.
Norbury, Frank P.. St. Louis, Mo.
Oakland Chemical Co., New York, N. Y.; Oswald, B. Frank, Cleve-
land, Ohio.
Physicians' Periodical Bureau, Janesville, Wis.
Reed. R. Harvey. Col umbos. Ohio: Rabuck, S. EL.Lvle, Minn.
Seeds, E. W„ Columbus. Ohio; Schwartz, J., New York, NY.; Stewart,
O., Port Huron, Mich.; Spencer, J. C San Francisco. Cai.: Shuttee,
H C. West Plains. Mo.; Mailman & Fulton, New York, N. Y.; Stock-
well, G.Archie, Detroit, Mich.
Tiemann, George & Co., New York, N. Y. ; Thomas, John D., Washing-
ton, D. C.
Von Ruck, Carl, Asheville, N. C.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., NOVEMBER 21, 1896.
No. 21.
ORIGINAL ARTICLES.
POINTS IX THE DIAGNOSIS AND TREAT-
MKNT OF SOME COMMON NEUROSES.
Keail hi BMettnc of tlu' White Mountains, White Kiver and Connecticut
Valley Medical Societies, Hanover, N. II., Aug. :i, 18W.
in' ROBERT T. EDES, M.D.
JAMAICA PLAIN, MASS.
There are few occasions in medical practice where
it is of more importance for the reputation of the
physician, the satisfaction of friends, the attainment
of the ends of justice, the advancement of therapeu-
tir science, ami the welfare of the patient, to estab-
lish a correct diagnosis than when the practitioner
has to decide between organic, and functional disease.
The line between them, as is being constantly dem-
onstrated, is indeed a shifting one;' as new methods
are invented new lesions are found where before it
WHS thought none existed; organs that to the naked
eye have presented no morbid changes reveal to the
microscope and the test tube alterations minute and
hitherto imperceptible or evanescent, but none the
less fatally standing in the way of normal activity
than than those grosser ones which have until quite
recent times engrossed the attention of the morbid
anatomist.
Conditions hitherto known to us only as variations
in the vigor of action have been shown to be accom-
panied by changes in structure, transitory indeed
and capable of complete restoration, but none the less
obvious to the minute scrutiny of the microscopist.
Many of these are so slight and so evanescent that
they can not be demonstrated upon the human being,
and whether they correspond accurately with what
we may suppose to exist in functional disorders is not
as yet demonstrated, but practically we know that
running more or less parallel to them we may draw a
line which for purposes of diagnosis and treatment is
of great importance.
In neurasthenia and hysteria, using the latter word
in its most comprehensive sense, we have many symp-
toms which may also exist in organic diseases of the
parts especially involved, and it is not always easy in
a case before us to determine whether they are
dependent upon such actual organic disease or exist
merely as a disturbance engrafted upon the constitu-
tional condition. Yet under hardly any circumstances
is the proper treatment more directly determined by
definite and positive diagnosis. Specific instances
will show some of the difficulties better than general
descriptions, but you will perhaps pardon me if I
simplify matters by laying down, a little dogmatically
perhaps, a few points which I do not think we are
likely to go astray upon.
There is nothing in neurasthenia or hysteria which
acts as a prophylactic against inflammation, degenera-
tion or new formations.
It does not follow that because a patient has a few or
many symptoms that are indubitably of hysteric ori-
gin that all are of that nature.
It does not follow that because certain symptoms are
thoroughly fixed and unchanging, or even if they do
not yield to anesthetics, that they are not hysterical.
Double optic neuritis is not found in mere hysteria.
A well-marked, regular ankle clonus is hardly ever
present and the knee jerk seldom absent in mere hys-
teria. So far as my own experience goes I should say
"never" in both these cases.
There are many cases of hysteria which do not
present all the stigmata thereof; the hysteria of Char-
cot is not common with us.
In the cases of doubt and mistake which I shall
report I intend no unkind criticism. Some of them
were my own.
The will of Seth Adams provided for the care of
" debilitated nervous persons, not insane," and this is
the class which it has been the aim of the managers
of the asylum known by his name to select. Like
many other schemes framed on lines a little different
from the usual, it was at one time spoken of as
"Adams' Folly," but it has abundantly demonstrated
the wisdom and kindliness of the founder by the
number of invalids, of exactly the class he intended
and described, which it has sheltered and relieved.
It has never been considered a part of its function to
treat cases of organic disease of the nervous centers
and of late years insane persons have been admitted
only by mistake or by too liberal a view of the cases
on the part of the physician who sent them and whose
opinion was accepted by the authorities. Notwith-
standing this careful weeding, out of 1,000 persons
received 84 were sooner or later affected with nervous
diseases which could not be classified on subsequent
revision as either melancholia, neurasthenia, hysteria
or hypochondriasis. Among these there were 10 of
organic cerebral and 16 of organic spinal disease.
Debility, dyspepsia and uterine disease acccount for
73 of the 99 which were not, strictly speaking, nerv-
ous diseases at all. Curiously enough, when we con-
sider how often organic disease of the kidneys is
accompanied by nervous symptoms, chronic Bright's
disease is mentioned only once among these. But
this is less singular than to find the very vague and
undemonstrable etiology of "suppressed gout" sug-
gested among so many cases only once, at the very
time when the elastic doctrines of "lithemia" were
growing so popular.
Mistakes or faulty estimates or failures of just
appreciation, in diagnosis between organic and func-
tional disease, can only be avoided by familiarity with
and careful attention to both sides of the question.
It is not enough to determine on the one hand the
presence of gastric or intestinal catarrh, a cardiac
murmur, a scanty urine, a uterine displacement, and
to attribute to these all the symptoms present; and,
1078
SOME COMMON NEUROSES.
[November 21,
on the other hand, it is equally unsafe, because a
patient has a multitude of symptoms, undoubtedly
nervous in character, because many of them are dis-
tinctly recognizable as imaginary or exaggerated, to
assume that she has no real foundation for any of
them. The case should be disentangled symptom by
symptom and the important ones investigated so far
as possible by objective methods, being pronounced
neurasthenic only after a careful exclusion of any
organic disease, especially that most nearly counter-
feited, or even of any more well-defined neurosis.
The interests of the physician as well as those of
his patient and of science, are best promoted by such
care, for a mistake on the latter side is more likely to
be severely judged than on the other, for while he
may be exposed to good natured ridicule among his
professional brethren for needless alarm and over
attention to nervous hypochondriasis, he is likely to
be considered guilty of cruelty and neglect if he
ignores sufferings which afterward prove to have a
substantial foundation.
CASES.
A woman of 36 had been troubled for several years
with severe headaches, occasional vomiting and gas-
tralgia. She had possibly a somewhat nervous tem-
perament but not extremely so. A diagnosis of
gastric inflammation, and later, of neurasthenia with
gastric symptoms, was made. Some years after the
first diagnosis and several months after the second
a double optic neuritis was found and a cerebellar
tumor diagnosticated, of which she died some months
later. No one can say just how long the tumor had
been present and that the earliest symptoms may
not have been correctly diagnosticated, but in the
light of the autopsy, when we can always see so
much more clearly, it seems very probable that the
tumor was really of very slow development and had
probably been causing gastric symptoms for years.
Another female patient had a facial neuralgia
which was called by a justly eminent neurologist
"hysterical." She was later found to have a double
optic neuritis and the case progressed steadily to a
fatal result from a tumor of the brain. Had this
neuritis not existed, as it sometimes does not in such
cases, it would have been almost impossible for a
time, to make the true diagnosis conclusive, although
there were other peculiarities that might well have
cast a doubt upon the original one.
A woman between 50 and 60 became depressed and
weak. She walked feebly in a peculiar crouching
posture and her eyesight was defective. She was con-
sidered a neurasthenic and sent to a hospital as such.
There the shape of her head attracted attention and
it was quite clear that she was a case of the rare dis-
ease "hyperostosis of the cranium." It would have
been, however, quite difficult to substantiate this diag-
nosis if we had not been successful in obtaining a
photograph of the patient as a young woman, for it
was not until she was confronted with this, side by
side with a recent one, that her sister would admit
that there had been any change in the shape of the
head. This case was published in the July number
of the American Journal of the Medical Sciences,
which also contains Dr. Putnam's elaborate article on
the same subject.
I find in an article by Byrom Bramwell a case quoted
from Bennett, of a girl of bad habits, bad temper, a
persistent malingerer, who presented an array of symp-
toms which were calculated to and did deceive the very
elect, for she was seen by several most distinguished
physicians, among them Bennett himself, who all
concurred in a diagnosis of hysteria. She died sud-
denly and a large tumor was found in the right cere-
bral hemisphere.
A woman age 35, had for some years attacks of
supposed sciatica succeeding a tender spot in the
back. She went to New York to consult a physician
but the pain disappeared, so that she went shopping
and to the theater instead. Later, when in a hospital,
there appeared a curvature of the spine, which was
thought little of and she was encouraged to get up,
ride and walk. After this she developed excruciating
pains and tenderness in the abdomen and legs, so
that it was almost impossible to move her to allow
the bed sores to be dressed. The lumbo-dorsal
enlargement increased. She died and there were
found two large sarcomatous tumors in the abdomen
attached the vertebrae and almost total destruction of
the second and third lumbar. It will be noticed in
how many points, as for instance the disappearance of
the pain under excitement, the early stages of this
case resemble the ordinary "spine complaint" with
which we are all familiar, and it was apparently, so
far as one can judge from the treatment, so consid-
ered at the hospital; or, at the most, an ordinary
case of sciatica involving no serious organic change.
A young woman, not hysteric in appearance and
manner, had for some years a persistent pain in the
right hip, for which a diagnosis of "pseudo-hip-joint-
disease" was made and acted upon for a long time.
At a later period careful measurements showed an
enlargement of the upper part of the knee joint with
loss of the normal outlines, and on deep palpation it
was quite clear that there was an enlargement of the
lower half of the femur. This was perhaps a peri-
ostitis or possibly an ostitis, for which a specific ori-
gin was suggested by the family history.
But for one case of this kind there are a dozen of
the other, where a purely neurotic condition of the
joint is treated for a synovitis. Many years ago I
treated a supposed case of chronic synovitis with
great care, until my suspicions being aroused I sought
the advice of an eminent surgeon, who confirmed my
views as to its being a hysteric joint, but when I
asked him if I should take off the stiff bandage he
said: "If she were my own daughter, so that in case
of necessity or doubt I could put it on again without
causing remark, I should do so, but as it is not best
in this case to show any indecision I think you had
better let it stay awhile longer." This I did, but
when I did take it off it stayed off, and there has not
in many years been any return of the trouble, as there
might easily have been had the diagnosis been wrong
and we were making light of a real disease of the
joint.
Coccygodynia is, in many if not most cases, a pure
neurosis, and the removal of several of the joints is
correspondingly often a failure, the "end of the spine"
being just as painful as ever, when it is situated a few
small vertebras higher up. Even the oft boasted and
convenient "moral affect" of the operation is of little
value in such cases.
A little girl fell several feet, striking the lower part
of the back upen a stone step. There was severe pain
in the hip joint, but careful and repeated measure-
ments failed to disclose any shortening, and the extreme
difficulty of handling her in her nervous and excited
18%. J
SOME COMMON NEUROSES.
1079
state interfered with the examinations. A diagnosis
of "hysteric joint" was arrived at, but after a time the
defect in the gait became so marked that this was no
longer satisfactory and renewed examinations dis-
closed the fact that it was a case of that extremely
rare accident "separation of the epiphysis of the head
of the femur." Two precautions had been neglected
in the first examination; one placing the patient on a
laird support, and the second, partly in deference to
the wishes of the parents, etherization.
We can hardly call errors in diagnosis the hesita-
tion which may very properly exist in the early stages
and sometimes even in the later, of abdominal tumors.
When some years ago a new service for nervous
disease was being established at the Boston City Hos-
pital by the transfer of patients from the general ser-
vices, one of the first was a case of persistent abdom-
inal pain which was sent over as "hysteria," but in a
short time developed a tumor that was verified at the
autopsy as eancer of the liver.
A woman suffered from intermitting abdominal
pains without swelling or distinctly localized tender-
ness, which were considered, although it is fair to say,
witli some reserve, to be of the ill defined and func-
tional character common in neurasthenia. Later,
however, an appendicitis was diagnosticated and an
operation planned, but when she was relieved, as she
had been several times before, it was deferred and a
few weeks later she died quite suddenly.
A young woman was treated for some time for ane-
mia and general debility until a diagnosis of myxedema
being made, she recovered rapidly on desiccated thy-
roid capsules.
Functional disorders of the heart are so commonly
taken for something more fixed in character that I
presume many of you, like myself, if a patient solemnly
tells you that he has "heart disease," make up your
minds before you begin the examination that what-
ever else you may find it will not be organic disease.
Some of the less defined forms of spinal sclerosis are
liable, in their early stages, to be overlooked in a gen-
eral diagnosis of neurasthenia or hysteria. Errors in
the opposite direction, however, are much more com-
mon and the persistent pains of nervous fatigue are
attributed to "spinal disease."
Organic disease of the cord is hardly ever accom-
panied by pain in its immediate vicinity. Pain, if
present, is almost certain to be situated in the distri-
bution of the nerves having their origin at the affected
part.
The distinction between vomiting of a purely ner-
vous character, that due to organic disease, inflam-
mation or neoplasms of the stomach and also from
that excited by irritation of distant organs, as the
uterus or the brain, or resulting from general poison-
ing as in Bright's disease, is certainly a very important
one, but as even the special authorities admit, not
always easy.
The first case I have mentioned, where a tumor
pressed upon the floor of the fourth ventricle, is an
excellent instance of one form of resemblance. It is
very often assumed that, if it can be clearly made out
that the vomiting is of a purely neurotic or, as it is
usually termed, hysteric character, the case is devoid
of danger. Vomiting, however, differs from the other
hysteric reflexes in this, that while they may be vio-
lent and highly impressive upon the bystanders, they
do not interfere seriously with any vital function,
while on the other hand the constant and complete
removal of food from the stomach, no matter what the
cause, must inevitably destroy the normal nutrition.
Fortunately it is true, as the authorities state, that in
nervous vomiting sufficient food is usually retained to
sustain life or even to maintain a very fair degree of
nutrition, but sometimes the imitation is so very perfect
and vomiting that has nothing to do with any gastric
lesion is so persistent, so uncontrollable, and so thor-
ough, that the supplies are reduced below the mini-
mum compatible with life. Two such cases I have
seen, where in one the diagnosis remained in doubt
until the autopsy, and in another the physician, a
man of sound judgment and long experience, firmly
believed in the existence of a cancer until a stomach,
healthy so far, at least, as any gross lesions were con-
cerned, was removed and opened.
Is it not possible that the supposed special fre-
quency of gastric ulcer among young women, which
as an anatomic fact is denied by Brinton, and Hilton
Fagge, may depend upon some cases of this kind and
also upon those of metastatic vomiting of blood.
The most complicated knot to be disentangled by
the physician who, without the cultivation of a the-
ory, the pushing of a fad, or the searching after a pet
operation, seeks to assign to all the causes present in
the case before him their true share in the causation,
is undoubtedly that which ties together the pelvic
organs with the general nervous condition. Possibly
a few of you can recollect the time when the thor-
ough and intelligent investigation of local pelvic con-
ditions was the rare exception, when dyspepsia, debil-
ity and spinal irritation were sufficient to cover all
the anemia, backache, depression, nervousness, the
general breaking down from which American women
are supposed to especially suffer. More of you can
remember when "ulceration" was responsible for the
same set of symptoms, to be followed by displace-
ments, cervicitis, endometritis, ovarian disease and
pus tubes, each in its turn almost the sole recognized
condition and each with its appropriate and popular
operation. Who that is familiar with these changes,
with the self satisfaction and boasting that accompa-
nied each shift of theory, fondly supposed to be the
final one, but just as evanescent as its predecessor,
can possibly beiieve exclusively in any one of them?
When such a variety of views is possible, it is hardly
fair that any one should be reproached with errors of
diagnosis, but it is none the less important that cor-
rect and well defined views should be at the basis of
treatment.
Symptoms both local and general are often indubit-
ably present, but which are primary and which are
secondary is a question which is unfortunately too
often answered morein accordance with the precon-
ceived views of the practitioner or of the patient, than
with the study of the individual case. What is
required in such cases is rather an accurate balance
than a sharp line.
The gynecologist points to the constitutional results
of constant pain, to the crippling due to the sagging
of unsupported and hypertrophied organs, to infec-
tion from local inflammations, to the sapping of
strength and vitality from too great functional activ-.
ity, to the exhaustion of too frequent childbirth and
lactation; and when he sees these symptoms he is
likely to attribute them to the set of causes with which
his practice has made him most familiar. The neu-
rologist, on the other hand, knowing how often he
has seen local lesions remain without impairment of
1080
SOME COMMON NEUROSES.
[November 21,
the general health, so long as the strength, muscular
and nervous, remains good, and knowing that the
exhausting effect of a burden is to be estimated not
only by its own weight but by the vigor of the shoul-
ders which have to carry it, that local pain may be
merely the expression of general weakness, is liable
to overlook their existence or to underestimate their
importance. But the consequences of erroneous
opinions on one or the other side are by no means of
equal importance to the patient. If we suppose,
what in practice rarely occurs, that the neurologist or
the general practitioner is allowed by anxious bystand-
ers to pursue the even tenor of his way and that he
does overlook real disease in the pelvis, the worst that
can very well happen is a loss of time and a subse-
quent correction, which may be more or less mortify-
ing, as he has more or less strenuously asserted the
entire innocence of the guilty organs. But if, on the
other hand, the practitioner direct his attention solely
to local lesions, real or imaginary, he will probably
accomplish one of two things. His patient is only
too easily lead to believe as he does, and there will be
established that particular form of hypochondriasis
known as "uterus on the brain," or else he will resort
to heroic surgery, of which the most flagrant and per-
nicious form is normal oophorectomy, with a greater
or less accompaniment of other mutilation accord-
ing to fashion or the desire to go beyond the rival
operator.
I hope it is clearly understood that I am not talk-
ing about surgery, that is, surgery for surgical disease ;
that I do not pretend to meddle with and am content
to leave the question of the removal of a tumor or
the opening of an abscess in the pelvis in the hands
of the surgeon just as I would the treatment of the
same lesions situated anywhere else. When constant
wearing pain was located in one spot, and that an
easily accessible organ, and when a vague pathology
with the facile and elastic phrase of "reflex," found it
so easy to explain most various and distant symp-
toms by a local irritation, it was certainly not strange
that the surgeon should have sought to remove the
organ which seemed to be the cause, and that such
operations should have had their run of popularity.
What, however, to be deprecated is, now that expe-
rience has shown in how small a proportion of cases
is the desired relief obtained, that a desire for sur-
gical reputation or experience, the eclat of numerous
laparotomies, should be such an irresistible tempta-
tion as to permit a useless mutilation, which has
sometimes seemed to me to act as a mordant, fixing
more indelibly in the fabric of the patient's whole
being the deep dye of constant and hopeless suffer-
ing. Admitting that there are cases so desperate and
with so little chance of relief that such an operation,
as offering something even slightly better than death,
is fully justifiable, we know well that they are fortu-
nately not so numerous as to afford any reasonable
basis for some statistics which have been published.
The surgeon has no right to seek such cases. They
should be urged upon him long and strenuously by
those who have had opportunity to observe thor-
oughly, and who are free from operative prejudice,
before he undertakes them. "Art for art's sake," is
no proper motto for him.
Some months ago I looked up as thoroughly as
possible the histories of twenty-seven women who
had come under my notice, who had had their ovaries
removed for nervous affections. Since then I have
known of several more whose fate has not made me
change my opinion. Of the twenty-seven, three or
four recovered or nearly so, one or two of these having
been not far from the natural menopause. Three or
four others have improved, after years of invalidism,
so that it may well be doubted how much their recov-
ery was accelerated. One died of causes not con-
nected with the operation,, one from cocain and one
shot herself a few months after a " highly successful
operation." One died of nervous shock a week after
the operation. One at least (not of the twenty-seven)
is hopelessly insane. Many are invalids and several
have sought admission or readmission to the asylum.
Local irritations, either in the form of pain or of
necessary and frequently recurring muscular action
imperfectly performed, and requiring for each repeti-
tion a conscious mental effort, are the most frequent
accompaniments of nervous breakdown and possibly
important factors in its production. On the other
hand, general weakness, acute or chronic, offers much
less than the average and normal resistance to the
local strain. Thus we have other knots to disentangle
in connection with various organs, of which after
those already discussed, the eyes are perhaps the
most important. Eye strain, either of the muscles of
accommodation or of fixation, arising from their
essential weakness or from a constant more or less
unsuccessful attempt to correct errors of refraction,
has long been recognized as a cause of headache and
many other nervous disturbances, but it is pushing a
theory too far when it is made to lie at the base of all
the most important neuroses. A reading headache
may have nothing to do with the ocular muscles, as in
the case of a girl who read with her fingers and had
no perception of light.
I suppose no scientific man would think of asking
"what is the necessity for making a remote diagnosis
in cases where you have obvious dangerous conditions
to be combated. Treat the symptoms which threaten
life, no matter whence they arise." There may be
under some circumstances, and temporarily, a plausi-
ble foundation for such a view, and it is sometimes
suggested by the laity, or by those who like to con-
sider themselves more "practical" than their col-
leagues, but its inadequacy as a support for any defi-
nite therapeutic plan is obvious upon the mere state-
ment of it.
The treatment of neurasthenic conditions and its
congeners, melancholia, hypochondriasis and hysteria,
is sufficiently well understood and depends largely
on attempts at the restoration of the normal nutri-
tion and action of nerve tissue by rest, diet and exer-
cise, with all the details and adjuncts. These are
always useful and sometimes sufficient.
The special point, however, which I wish to empha-
size is practically far from new, but I do not think it
receives from the medical profession, at least in a
theoretical point of view, all the attention it deserves.
We smile at the preternatural sagacity, the unerring
intuition, the more than human sympathy and devo-
tion, the miraculous successes of the interesting hero,
or now quite as frequently heroine, of the modern
medical novel, but notwithstanding our skepticism as
to the power not born of knowledge, we must seri-
ously recognize how important is the personal feeling
and influence of the physician as expressed by him in
definite statements or received by the patient in vague
but not weak impressions of approaching relief. The
old faith is now becoming a modern doctrine and the
L8U6. 1
SO.NLE COMMON NEUROSES.
1081
art based upon it is called "suggestion" or "suggestive
therapeutics," It is a portion of his art which should
be most jealously guarded by every physician and
never allowed to be monopolized by those whose
ignorance ought to deprive them legally and morally
or the right to use it at all. Whether this is best
carried on by means of hypnotism, with which in
modern discussions it is very apt to be associated, my
experience does not justify me in saying positively.
Its practitioners make very positive claims for it. I am
sure, however, that that is not the only useful way and
that suggestion, as covering a great many methods of
bringing psychic influence to bear, various in detail
but one in principle, is often a most effective agent
without hypnotism. I have seen cases that if they
had gone through with forms of hypnotism, or indeed
those of any miracle cure, would have gained a noto-
riety quite as great as many which have figured in
sensational reports of the daily press or make their
rounds through the clubs and the sewing circles.
Now it is for this purpose that diagnosis, instead of
being of the least, is really of the most importance.
Setting aside the great injury which may arise from
the neglect of efficient therapeutic measures of the
ordinary kind by those who prefer to trust them-
selves to any of the acknowledged forms of faith cure,
it is desirable that the physician, as distinguished
from the faith curist, should be able to gain from his
knowledge the firm persuasion and confidence which
the curist gets from his ignorance. Patients are
shrewd observers of their attendants when their
senses are sharpened by anxiety. The curist can give
them, witli the boldness and undoubting sincerity
which arises from knowing nothing at all about the
nature of the disease in hand, assurances of the dis-
appearance of their troubles, which the physician,
unless he be certain of his diagnosis, would find it
very difficult to assume, even if he thought it right to
make promises which he is doubtful of being able to
fulfill. One of the most interesting phenomena of
the last few years, from a medical and psychologic
point of view, is the systematic development of the
various forms of faith cure, with their colleges,
churches, professors and patients. The ready accept-
ance they find among persons of supposed mental
cultivation would perhaps be not the less remarkable
had it not always been so, which makes it less sur-
prising but no less absurd. We can not talk it down.
It is better to study and to profit by it. A little
inquiry is sufficient to show that the successful cases
are those heard of, while the failures make but little
impression; but even with a very liberal discount in
this direction we must admit that people do get well
under the influence of these humbugs, just as they
have been doing for centuries from the king's touch,
or the witch's brew, or Lourdes, or St. Anne de Beau-
pre. the Zouave Jacob, the Vermont Healer, fashion-
able springs, quack medicines made of the costliest
of metals or the cheapest of weeds, or physicians
good or bad, learned and ignorant. Cures, like fish,
do not grow any smaller by being talked about and
many wonderful stories shrink immensely when
traced back to their original sources. The case which
appears for a few days or weeks as almost a miracle
sinks into obscurity, as specialist after specialist
has been consulted and hospital after hospital is vis-
ited, each with the relief born of renewed hope, but
each leaving untouched the psychic substratum of
weakness, congenital or acquired, or the habit of
invalidism.
But the residuum of real cure6 or of great perma-
nent relief deserves our attention. It is the strong
stimulus of faith and hope, the turning of the atten-
tion into other channels than that of symptom watch-
ing, the firm conviction of the possibility of the dis-
appearance of pain and weakness, which is the active
agent in this kind. There is no doubt that in many
minds the active controlling forces are more easily
reached by mystery and transcendental theories than
by logic and observation; that imagination is a more
powerful stimulus than scientific accuracy notwith-
standing the liking which some have for the latter as
a disguise. A preternatural science which can, with
one sweep of vague theory, wipe away all discussions
of petty details, is much easier to manage and to fit to
the individual case, than a science founded on the
observation of facts, and here utter ignorance gives
to the charlatan an advantage which can not be met
by the physician with any half knowledge. Nothing
but confident diagnosis can invest him with the well
founded authority which the other can so easily
assume because he knows not its dangers.
The practice of "suggestive therapeutics" is no new
thing, but physicians have been too apt to consider it
rather an incident, than an important part, of their
office and to attribute to their drugs or their knives
what properly belonged to themselves and to their
knowledge of pathology and diagnosis. I have heard
an eminent surgeon after a vivid description of his
sufferings from the importunities of a patient whom
he had skillfully relieved of her ovaries but not of
her sufferings, say : "I told her at last that she had
better try 'christian science.' " For my part I prefer
that if the fates have ordered that my patient is to
leave me and seek "christian science" or any other
faith cure for the relief which I have failed to give,
that she should do so unmutilated. The least I can
do is to leave her as well as I found her.
But I much prefer to say in effect something like
the following, and in order to do this I want a diag-
nosis. "You caii get well. Now why will you not do
this for me, whom I presume, from the fact of your
having put yourself under my care, you consider a
reasonably skilful and honest physician, and who
have seen and studied enough cases of cancer of the
stomach to assure you that you have not got one, just
as willingly as for some old woman who does not
know anything about cancers and who if you really
had one would tell you, just as confidently as she does
now, that it was all a product of your own low and
earthly prejudices, and that a cancer of the stomach
is just as easily gotten rid of by a mental effort as any
other set of ideas." If she be a sensible woman and
I have succeeded in gaining her confidence, she will
get well, but if she doubts my diagnosis, which is
very apt to mean that she sees by my manner that I
am not quite sure of it myself; if she prefers to believe
that she actually has what I, with my low and earthly
viewTs, might call a cancer, but if she "puts herself on
a higher plane of thought" there are no such realities
as pain, or vomiting, or emaciation or death; that a
fatal carcinoma is an invention of the doctors; that
is, if instead of being willing to admit that her per-
sonal symptoms may be psychic she has been per-
suaded that the whole fabric of pathology rests on an
imaginary basis, then the faith curist may score as a
miracle the result which I, as a mart of common sense
and resting only on a basis of ordinary knowledge could
not attain as a bit of every day practice. The power
1082
ALTERNATING PERSONALITIES.
[November 21,
of reiterated and confident assertion, unsupported by
a particle of proof or argument, simply ignoring
repeated demonstrations of its baselessness is enor-
mous. It is, for instance, at the basis of all advertis-
ing and we constantly see, in religion and politics, the
most absurd doctrines gain a foothold by the simple
process of stating them over and over again. Such a
position is a short lived one perhaps, when based upon
no element of truth, but it seems a pity that so pow-
erful an agency should not be made to do better and
more permanent work by having something real
behind it, and this something is for us a diagnosis.
ALTERNATING PERSONALITIES; THEIR
ORIGIN AND MEDICO-LEGAL ASPECT.
Read in the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical Asso-
ciation, at Atlauta. Ga., May 5-8, 1896.
BY R. OSGOOD MASON,
NEW YORK.
A.M., M.D.
The condition of double personality has, in a way,
always been recognized, but no special importance has
generally been attached to it by the profession. Cases
of protracted somnambulism or an occasional instance
of catalepsy or trance, either with or without remem-
bered visions or voices, were referred to as curiosities,
but without any just analysis of the condition or
attempt at classification ; in fact, they have been looked
upon as belonging to no system of recognized psychic
phenomena, and in general, like many other variations
from the usual personality — the recognized, reasoning,
knowledge acquiring personality — they have been
looked upon simply as abnormal, and been thrown into
the category of either hysteria or insanity. Of late,
however, the subject has received more definite treat-
ment; many cases of the condition have been care-
fully observed, their peculiarities studied, and their
relations to other psychic states have been considered.
Ribot, Janet, Richet, Kraft-Ebing and others have
given attention to the subject, plainly recognizing the
condition, whatever interpretation it may have received
at their hands. Beside the contributions of these
acknowledged authorities in the profession, and
including them, a vast number of well authenticated
cases have been collected by the English Society for
Psychical Research, with its American Branch, and
have been carefully studied by such men as Professor
James of Harvard, lately president of the Society, Pro-
fessor Sidgwick, and especially by Mr. Frederick W.
H. Myers, the English secretary, who has treated the
subject in the Proceedings of the Society with a degree
of knowledge and ability, as well as scientific accu-
racy, which has not been exceeded even by the noted
writers before mentioned.
At the meeting of the American Medical Associ-
ation at Baltimore, I drew the attention of this Sec-
tion to some facts and observations tending further to
establish the reality and distinct character of this
condition. I described several well authenticated
cases, some of which had long been under my own
personal observation, in which most marked and defi-
, nite alternations of personality occurred, and in which
the second personality was present for long periods of
time — days, weeks and even months — taking complete
possession of the physical organization, caring intel-
ligently for it, and in some instances changing it from
a condition of disease, pain and helplessness to one
of health, and ability to perform all the duties of life
in a perfectly normal and efficient manner. I also
pointed out the relation which this condition bears to
somnambulism and the veridical dreams of ordinary
sleep, to the trance condition, and especially to the
trance and somnambulism occurring in the hypnotic
state.
Kraft-Ebing, after an exhaustive study of the case
of lima S. by means of hypnotism, clearly differenti-
ating three distinct states of consciousness, comes to
the following conclusions : " Frequently repeated
experimentation makes it evident that the three differ-
ent states of consciousness which may be observed and
induced in this patient exist, typically congruous and
apparently regular, under identical conditions. It is
further evident that these states of consciousness have
absolutely nothing in common save that they are
observed in one and the same person. Thus this
person represents three psychic existences."
It will be fully admitted, then, that a second, and
in rare instances even a third, condition of conscious-
ness is shown to exist in the same individual; that
they are entirely distinct psychic states, having differ-
ent and often entirely opposite characteristics, opin-
ions, likes and dislikes, distinct chains of memory
and a different personal history; so distinct are they
that they may be, as indeed they are, properly desig-
nated as distinct personalities, and called by different
names. Kraft-Ebing, however, in saying that these
different states of consciousness have "absolutely
nothing in common," promulgates an error; for, while
the primary personality has no knowledge whatever
of the second, nor of any succeeding personality, the
second personality has always a more or less intimate
knowledge of the primary self, but only as another
and entirely distinct person. Again, the second per-
sonality, while having knowledge of the primary self,
has no knowledge of any third, nor of any subsequent
one; so also the third knows number one and number
two, but nothing of number four, should such a per-
sonality appear; and what is still more wonderful,
number two can sometimes distinctly impress number
one after that personality has resumed consciousness.
So important is this fact that I will illustrate it by
reference to the case of Madame B., Professor Janet's
hypnotic patient, with her three personalities — L6onie,
the original Madame B., Leontine, the second person-
ality, and L6onore, the third.
The patient being hypnotized and Leontine being
present, before awakening her Professor Janet said,
" Now, when I awaken you and Leonie comes back,
you, Leontine, will make her untie her apron and take
it off, and then tie it on again." He then awoke her,
and L6onie — the usual Madame B. — was present. She,
supposing Professor Janet had finished his experi-
ment, of the nature of which she never had any
knowledge, was conducting him to the door, chatting
in the meantime in her ordinary simple, almost stupid
manner. At the same time she commenced to fumble
at her apron strings and, without knowing what she
was doing, untied them. At that moment Professor
Janet called her attention to the matter, saying, " Your
apron is falling off," whereupon she looked surprised
and said, " Why, so it is," and at once, with full con-
sciousness of what she was doing, she returned it to
its place and re-tied it. Professor Janet considered
the experiment complete; not so L6ontine; she had
not finished the work that had been laid out for her,
and again Leonie unconsciously commenced to fum-
ble at her apron strings ; again she took off the gar-
ment, and then quietly replaced and tied it, all the
1896]
ALTERNATING PERSONALITIES.
1083
while talking to Professor Janet and perfectly uncon-
scious of what she had now for the second time done.
The next day when Leonie was again hypnotized
Leontine, as usual, appeared, and at once said to Pro-
fessor Janet, " I did what you told me yesterday; why
did you tell her that her apron was falling off? Just
for that I had to do the job all over again;" thus show-
ing the activity of the second personality while the
primary self was present and in full control, and also
the influence whioh number ficow&a able to exert over
number one. Again. Leonorewas able to make Leon-
tine hear a voice reproving her for her incessant
gabble, by which also Leontine was greatly alarmed.
I have also witnessed similar phenomena in cases
under my own observation.
Having, then, established the fact of separate and
distinct states of consciousness, or personalities, it is
possible to classify the cases or, in other words, to
point out the different conditions under which this
second personality or subliminal self has been
observed.
1. There are the cases of distinctly alternating per-
sonalities, in which the change from one to the other
occurs suddenly and spontaneously, and an entirely
new personality comes upon the scene, entirely sane,
with perfect knowledge of and in perfect harmony
with its environments, continuing not only for hours,
but for months and even years, performing the duties
of life in a wholly normal, useful and exemplary man-
ner, and sometimes, as in Dr. Azam's case, FeJida
X. much better than the original self could do.
2. There is the very large class of cases in which
the second personality or subliminal self is brought
to the surface by means of hypnotism. Of this class
Professor Janet's case of Madame B., Kraft-Ebing's
lima S., Dr. Dufay's case of " Jane " and my own
case of "Miss A." are marked and typical examples,
and to this list doubtless every physician who has
had experience in hypnotizing could add examples.
It is this subliminal self which hears the suggestions
made by the hypnotizer, and impresses them upon
the primary self on its return to consciousness, so as
to insure their fulfillment as post-hypnotic sugges-
tions. It is that also which influences the functions
of organic life, causing such marked changes in diges-
tion, circulation, excretion, and especially that won-
derful influence on the vaso-motor system which by
suggestion causes vesication, stigmatization and kin-
dred marvels.
3. There are the startling phenomena which occur
in ordinary sleep, namely, somnambulism and veridi-
cal dreams.
4. There is the large class of changes in personal-
ity as well as intelligence brought about by recognized
pathologic conditions of the organism.
Beside these classes, there is the whole series of
automatic actions — automatic speaking, writing and
drawing, also hallucinations of hearing voices and
seeing visions; all of which belong to the varied
action and influence of the subliminal self.
It is of course impossible to attack the metaphysical
problems which arise with reference to the origin and
nature of consciousness together with the resulting
personality and its varying phases, but some idea
regarding the nature of personality is necessary to the
further consideration of our subject.
Ribot, in his monograph on the " Diseases of Per-
sonality," tells us regarding this matter that " we are
confronted by only two hypotheses," one the old
supernatural theory, that personality is the funda-
mental property of soul or mind; the other, which he
calls the new and scientific view, that it is " only the
expression of organism." In other words, mind is
the product of organism ; but when the question is
asked "Of what is organism the product ?" his last
word is: "To biology belongs the task of explaining,
if it can, the genesis of organism. Psychologic inter-
pretation can only follow in its wake." He points
out the necessity for a reasonable theory for the gene-
sis of organism, but for himself he simply ignores
the whole matter; he takes a ready-made organism
with its germ of consciousness and assumes, without
the slightest proof, that the germ of consciousness is
the result of the organism. This, plainly stated, is
Ribot's " very recent theory," and this is the particu-
larly scientific method by which it is maintained.
Let us follow up our author's statements, for reason-
ing they can scarcely be called.
A little further on he says: '' It will then be time "
(after having studied its constituent elements), "to
compare personality with the lower forms through
which nature has essayed to produce it, and to show
that the psychic individual is the expression of
organism."
Here a new element, nature, is introduced, and it is
quite important to understand what he means by it.
Is nature active or passive? Ribot says, " Nature
essays to produce personality through lower forms" —
and presumably it does so. That is activity. Nature,
then, is active, whatever else it may be; and there must
of necessity be an active principle in nature which
works, which produces effects. Now, it matters not what
we call that power in nature which works for definite
ends, as Ribot particularly explains, and produces defi-
nite results. We may, with the supernaturalists, sepa-
rate it, personify it, call it deity and clothe it with attri-
butes, or with Herbert Spencer call it the unknowable
and leave it naked; we may with Matthew Arnold call
it the " power which makes for righteousness," or
with Schopenhauer consider it the power which makes
for evil; by whatever name we please to call it, it is
still the power which works; and it is with this power
in nature that Ribot and his school must reckon, and
not with the " very old " theory' of supernaturalism.
In 1874 at the meeting of the British Association
at Belfast, John Tyndall, that Titan of science, as the
incoming president of the association, stood up in that
assembly of distinguished savants and pronounced
these memorable words : "Abandoning all disguise
the confession which I feel bound to make before
you is, that I prolong the vision backward across the
boundary of experimental evidence and discern in
matter, which we in our ignorance. . . . have hitherto
covered with opprobrium, the promise and potency
of every form of life.'"
Throughout the lands where science was known there
went up a cry of indignation from the champions of
supernaturalism on the one hand and from the hard
and fast materialists on the other; but the pendulums
which measured the progress of each of these senti-
ments had registered their widest swing, and from
that day to the present each has been moving in a
gradually ever narrowing arc.
It is not with supernaturalism and ready-made souls
that Ribot has to reckon to-day, but it is with that prom-
ise and potency in nature which lie beyond the reach
of scalpel, microscope and laboratory reagents. Away
beyond the boundaries of experimental evidence,
1084
ALTERNATING PERSONALITIES.
[November 21,
back of consciousness and back of organism, in mat-
ter itself we discern the promise and potency of
every form of life. It- dwells in inorganic matter,
urging it onward to higher forms, to crystallization,
to protoplasm, to the organized cell and then to the
higher forms of life with all their wonderful attri-
butes. It is this that expresses itself through organ-
ism; without it organism has nothing to express. It
is this in nature which "essays to produce personality
through lower forms," remains its basis after it is
produced and is its promise of still further develop-
ment.
Throw out of consideration then the first of Ribot's
"only two hypotheses," by which he so confidently
assures us that we are confronted in our search for
the genesis of personality and in its place put this
"promise and potency'* which is in nature, whose
attributes we need not define, and the two hypotheses
from which to choose stand thus:
1. Personality along with its accompanying organ-
ism is the product of a power inherent in nature.
2. Personality is "only an expression of organism."
The first is broad inclusive and presents a reason-
able explanation of processes which lie beyond and
back of experimental evidence. The second is narrow,
exclusive, timorous and explains nothing. To examine
these propositions critically, to trace this power in its
evolutionary action, first as attraction or repulsion or
simple motion in inorganic matter, as life in the organ-
ized cell and lower organic forms, as sensation in the
animal world and as mind, consciousness, personality
in man, is far beyond the limit to this paper; but
it is this power in nature, ever striving for fuller
expansion and expression which has projected a
universe teeming with motion, life, sensation and
mind.
We have then to deal with personality as some-
thing more than the evanescent exhibition of conscious-
ness, a mere function of organism; it has a basis and
quality drawn from the reservoir of power which is
in nature, power that was before organism and was
that by which and for which organism came into
being; to argue otherwise is to reverse cause and
effect, and make the greater subservient to the less.
But it may be asked, how can this view be recon-
ciled with the theories of multiplex or alternating
personalities and the subliminal self? I reply, not
only does it harmonize with, but it materially
strengthens that theory. Ribot says truly: "Our
conscious personality, the consciousness which each
one of us has of his present state as compared with
prior states, can never be more than a feeble portion
of our total personality which remains buried deep
within us." We have seen how this personality is
recognized by all competent writers ; we have also
seen how promptly this deeply buried portion of our
personality comes to the surface and manifests itself
as distinct and capable of independent action, and
under what circumstances this occurs.
How did these various phases of our personality, so
distinct and different, claiming for themselves sepa-
rate existences and names, come to exist and why do
they manifest themselves at all? As Ribot would
describe personality by a single word, habit, so I,
perhaps with more obvious propriety, might describe
the appearance of a second personality with the single
word atavism.
It is a well recognized fact that certain clearly
defined traits or characteristics, either physical or
mental, existing in ancestors, near or remote, may,
after passing by one or more generations, at length
crop out distinctly and unmistakably in a later one.
Physical peculiarities or deformities, tendency to cer-
tain diseases, or peculiar mental characteristics are
frequently in this manner transposed; also a peculiar
insight or genius for certain pursuits, as, for instance,
hunting, fishing and frontier life, a military career,
mathematics, music, acting or scientific pursuits,
existing in a marked degree in some near or remote
ancestor may, indeed, be inherited directly in the
succeeding generation, but, on the other hand, it may
pass over one or more generations to appear in an
unmistakable manner in a later one.
Suppose, for instance, that five generations back
there appeared a man of marked and thoroughly bad
characteristics married to a right-minded, moral, even
religious woman; that he was a vilifier of morality
and religion, profane and vicious in life and unscrupu-
lous in his dealings with others; that the generations
which immediately succeeded him came under influ-
ences which aided by inherited characteristics from the
mother, led to lives of morality, uprightness or even
conspicuous piety. In the fifth generation, however,
appeared a man who in the midst of these moral and
religious environments was conspicuous for his pro-
fanity, vicious life and unscrupulous conduct, so
identical with his remote ancestor as to make the
connection undoubted. Where did this evil tendency
exist during the four intervening generations? Let
us tap the main line between the two extreme points
and see what information may be extracted. In the
fourth generation was a mild, religiously incline
woman, but of unsound health and perhaps of unsta-
ble personality. From some sudden shock, syncope
or loss of consciousness occurs and, as in the case of
Felida X., on recovery an entirely new and different
personality is found to have taken the place of the
original one. It professes to be a man, and to the
horror and consternation of the good people sur-
rounding her she commences to curse, to vilify every-
thing good and upholds sentiments and practices of
the most offensive and criminal character. This per
son has a chain of memories and a personal history
entirely foreign and unknown to the primary self, but
quite consistent with those of the remote ancestor
whom we have considered. In an hour or a day the
primary consciousness has returned, but there is not
the slightest knowledge or recollection of the charac-
ter which she has represented in her second personal-
ity, and very likely the case is diagnosed as temporary
insanity; in a more primitive age it would have been
called possession by an evil spirit. It was in reality
the strongly impressed characteristics of a distinct
personality which had lain dormant in the subcon-
scious self for three generations, now coming to the
surface temporarily under favoring circumstances in
the fourth. In another generation it actually appeared,
an atavism, as the primary and usual personality. In
like manner a personality of conspicuous goodness or
conspicuous talent might pass over many generations
of mediocrity or of evil-doers, and appear, a pleasant
atavism, after one or many generations had inter-
vened. Less extreme personalities might be formed
in like manner, and more than one might be impressed
upon individuals in successive generations, giving
rise to the perplexing and much debated condition of
multiplex personalities. Kraft-Ebing, as we have seen.
found in his patient " three psychical existences"
1896.]
REFORM IN CRIMINAL JURISPRUDENCE.
1085
or personalities. Professor Janet's patient. Madame
B . possessed three widely differing ones; while one of
my own eases presented three andanother two, alter-
nating spontaneously at longer or shorter intervals,
not including the cases in which changes of personal-
ity were brought about by hypnotism.
With this view of the origin and nature of ordi-
nary as well as alternating personalities, it is not dif-
ficult to determine the medico-legal aspect from
which these cases should be viewed. It is evident,
first, that the primary self must not be held responsi-
ble for actions, either good or bad, committed by the
second or any succeeding personality, since it is
absolutely ignorant of the doings orevenof the exist-
ence of these personalities. It would undoubtedly be
just to restrain the individual from violence or wrong-
doing, during the presence of the personality com-
mitting the wrong, but no longer; and it would be
abhorenl to all our ideas of justice to take the life of
or even to severely punish the individual whose iden-
tity we have been accustomed to associate with the
ordinary self, on account of wrong-doing committed by
any succeeding personality, while the ordinary self
was wholly unconscious.
It would have been manifestly unjust to punish
Kraft- Kbing's lima S. for theft committed by her
second personality, and wisely the court so held.
Again, in judging of the sanity of individuals charac-
terized by alternating personalities, we must judge
each state or personality by itself without reference to
other states, but must ad chiefly with reference to
the primary self.
Insanity is the temporary or permanent loss of an
intelligent comprehension of surroundings and rela-
tionships to such a degree as to incapacitate the affected
it for the fulfilment of the duties and relations
of life, and consequently render him a menace to
himself and others. In the application of this or any
other definition o'f insanity to particular cases, the
fact that it is not the individual's primary or ordi-
nary self which is being examined should make no
difference in the conclusion arrived at; if the action
of the second self falls outside our accepted defini-
tion then that self is sane. Felida X., in her second
condition had even a clearer comprehension of her
surroundings and her relations to others than when
in her primary state; and the same may be said of
many other individual cases of the same kind, but
if found insane, in disposing of the case reference
must be had to the fact that it is not the primary
or usual self that is affected, and that self when
present should not be made to suffer.
The same rule is applicable in judging of insanity
or crime appertaining to persons whose actions are
automatic, even though consciousness is retained, as
is frequently the case with those who have the faculty
of automatic writing, speaking and other automatic
actions carried on by the subliminal self; the ability
of the subliminal self to influence the action of the pri-
mary self, as previously shown, must be taken into
account and the degree of responsibility judged of
accordingly.
Professional experts, by opinions given in courts of
justice, often virtually decide questions of liberty and
even of life; but he who gives such opinions without
taking into account the possible influence and power
of automatism and the subliminal self, assumes a
responsibility which better instructed men would
consider grave, indeed.
In conclusion, I would say that the fact of alternat-
ing personalities, or the subliminal self with its mani-
fold manifestations, has a very important and practical
bearing, and demands a much wider and more intelli-
gent study than has hitherto been accorded to it by
our profession.
A PLEA FOR REFORM IN CRIMINAL
JURISPRUDENCE.
Head in the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical Associa-
tion, at Atlanta, Ga., May 5-8, 1886.
BY F. E. DANIEL, M.D.
EDITOR TKXAS MKDICAL JOURNAL I VICE-CHAIRMAN 8ECTION ON PSYCHOL-
OGY, MEDICO-LKGAL SOCIETY OF NEW YORK, ETC.
AUSTIN, TEXAS.
In all ages and amongst all peoples, civilized and
savage, so far as we have any record, the instinct of
race, tribe or national preservation has led them to
regard the welfare and prosperity of the people as the
supreme law. No individual interests were paramount
to that of the people, and personal rights were cur-
tailed, or sacrificed to the public good. For ages this
has been formulated into the familiar maxim, Salus
Populi est Suprema Lex! And as a corollary, it has
been a maxim that " the few shall suffer, or be sacri-
ficed (if need be), for the preservation or safety of the
whole;" hence, the democratic doctrine, "the majority
shall rule." Among primitive peoples, this principle
was carried to the extent of destroying feeble or
decrepit offspring who would become a burden or
hindrance to the state or tribe; and in the interest,
too, we must assume, of race integrity. Among tribes,
the chief decided what was best for his people, and
his word was the law, to which unhesitating obedience
was exacted. Ancient nations assembled their wise
men, who considered all sources of danger to the peo-
ple, and, conscientiously guarded against them. It
remained for a twentieth century civilization, an
enlightened republican government, to ignore this
"' supreme law," — to give it a secondary place, and to
make the protection of property the highest and
dearest consideration; in the enactment of laws to
utterly disregard the danger of race degeneration; to
permit, nay, promote and accelerate the propagation
of untold evils and dangers to society and the race,
through the medium of heredity. That a government
should — possessing the power and means to do so —
prevent an increase in the criminal element, is a
proposition which requires neither argument nor
defense; that it should permit — nay, deliberately pro-
pagate and encourage an increase of criminals out of
all proportion to population, is monstrous.
In light of the rapid and alarming increase of crime
and criminals in this country, it is evident not only
that there is something radically wrong in our system
of criminal jurisprudence, and that our penal meth-
ods are a failure of the ostensible ends sought, but
that reform has become an imperative, and immediate
necessity. It is demanded by every consideration of
safety to society, public morals, public economy, and
especially duty to tax-payers, who bear the burden^
not only of this, but of every other class of defectives:
leaving out of consideration the higher ground of
humanity to the unfortunate victims of heredity and
environment (for such are criminals for the most part)>
and omitting all reference to the claims of posterity
to protection. What that burden is, may be faintly
estimated when we reflect upon the expense inciden-
1086
REFORM IN CRIMINAL JURISPRUDENCE.
[November 21,
tal to the detection, arrest, prosecution and punish-
ment of the vast hordes of criminals, together with
the pay of the army of constabulary, police detectives,
law officers, judiciary and prison officials, and the
maintenance of prisoners; and an idea of the magni-
tude of the danger threatened and constantly aug-
mented, may be gathered from statistics.
According to the last United States census (1890),
there were, in 1850, 6,737 prisoners in the United
States, or one to every 3,442 of the population. In
1890, there were 82,329 prisoners, or one to every 757
of population. While the population of the United
States has, in four decades, increased 170 per cent.,
the prisoners have increased 445 per cent. The num-
ber of criminals at large, evading arrest or unknown,
is to be added to this. At the present ratio of increase,
it will be a matter of very short time when the crim-
inal will outnumber all other elements of population.
Nothing could testify more emphatically to the inad-
equacy of our system to meet the requirements than
these figures, nor appeal more forcibly for reform;
nor could anything illustrate more fully the needs of
prophylaxis against hereditary criminals.
With such facts before us, it behooves a rational
people to inquire into the causes that lead to such
disastrous results; to ascertain wherein lie the defects
in our system of jurisprudence whereby these things
are made possible; to ask what are the factors con-
cerned in this production and great and rapid multi-
plication of this evil, and to seek, by every legitimate
means, to arrest it.
Beyond doubt, heredity and environment are respon-
sible for a large share of it; the laws regulating mar-
riage are sadly deficient, and licensing the sale of
liquor as a source of revenue to the State, is another
evil, next in order of consequence and potency; and
I believe it can be shown also that the execution of
our penal methods operates to contribute to the ever
sivelling hordes of criminals, rather than to checking
or diminishing it, as I will endeavor to show.
The system of criminal jurisprudence in this coun-
try appears to be founded on the sole idea of revenge,
and punishment to be the end and object of all penal
statutes. And this, too, under the claim and pretext
that it is justice. I can not see that there is the
remotest connection between punishment for crime,
and justice; there is not an element of justice in it.
If a man slay you, in what way are the demands of
justice satisfied by his execution? What satisfaction
is it to the widow and children left destitute by your
death? Or, if a man fire my house, wherein is " jus-
tice" satisfied by sending him to prison to labor? In
either case it is not justice — it is revenge ; and who
gave the State the right to take vengeance? Nor is
"justice" the aggrieved party, it is I — or your family
— who should be satisfied. Justice and equity are
synonymous, and contemplate restitution, to make
amends; and the ends of justice would be better
served were the murderer or incendiary stripped of
his possessions for the benefit of those robbed by his
hand. And where the State metes out punishment to
a man for crime committed under the influence of
liquor, it is worse than a farce to call it justice; it is
the rankest kind of injustice. The State licenses the
sale of liquor, deriving revenue thereby. It thus aids
and abets the saloon-keeper to tempt the young, the
weak, the reckless and the unwary to put that into
their stomach which robs them of reason for the time
being, and deprives them of the power to resist an
evil impulse. Murders have been committed uncon-
sciously by young men under the mania of their first
intoxication. The State hangs or imprisons that
man, robs his wife and children — deprives them of
their bread winner and of bread — and overwhelms
them with disgrace — maybe brings them on the hands
of the tax-payer — as inmates of the poor farm, and
calls it justice! What a cruel wrong! What a bur-
lesque on justice! The justice in this case would seem
to demand restitution to the imprisoned man for
blighting his life, and the State is accessory before
the fact; — and the one so put to death — the State
should make restitution to his widow and orphans.
The evil of the day and generation is the saloon.
But, so long as newspapers are run to make money,
or, as is often the case, subsidized by the whisky ring,
it were idle to preach against it; they will never aid
science in any reform in the interest of truth, human-
ity or religion. No paper can be found with the
honesty and independence to advocate any measure of
reform — or to disseminate any truth in the interest of
humanity that conflicts with that interest.
The failure of our system to either protect society
or diminish crime is in a measure due to lack of vig-
orous enforcement of the laws; but principally it is
due to defects inherent in the laws themselves.
Under the existing system, in order that crime may
be appropriately punished, crimes are classified and
a penalty affixed to each. One great difficulty is that
criminals are not classified also. The fact that a mur-
der, for instance, was a first offense is not considered.
There is a penalty for murder (death by hanging)
and all murderers, old and young, male and female,
good family or bad, penitent or indifferent, first
offense or fortieth, must expiate it to satisfy the ends
of justice.
There is a penalty for homicide, and all homicides
must conform to the penalty; there is no qualifying
circumstance, except the degree of the offense. It is
simply left to the judge to determine the crime,
classify it, and looking in the book find the com-
panion piece to it, the penalty — and fit the one to the
other, and to the jailor or sheriff to execute the pen-
alty. The young boy for his first offense committed,
it may be in resentment of an insult and from an
impulse beyond control or from fear of his life, or
what, unfortunately, is most frequently the case,
while under the influence of liquor; or, if a theft,
committed from want, or temptation, or what not, is
thrown first in jail to await trial. There he is sur-
rounded by a vicious, brutalizing environment, hud-
dled, perhaps, with a lot of filthy negroes and
Mexicans, all hardened criminals; in fact, made to
breathe an atmosphere fatal to every instinct of self-
respect and calculated to crush out every atom of
manhood. When brought to trial the fact that it was
his first killing, that he was drunk at the time and for
the first time in his life, and had not even a knowl-
edge of what he had done ; that, realizing the situa-
tion he is deeply penitent and would give worlds to
undo it and make restitution — does not in the least
qualify the offense, except, perhaps, it may secure
for him the lightest punishment that goes with that
kind of crime; it is a definite term and carries with it
eternal disgrace, social and business ostracism and
disfranchisement. Could anything be more unjust?
Why, what would be thought of a doctor, for instance,
who, having all his cases diagnosed for him, should
treat every one of a class exactly alike with the same
18%. 1
REFORM IN CRIMINAL JURISPRUDENCE.
1087
dose; and without regard to age, sex, temperament or
environment? Here is a case of fever; here is a for-
mula for fever for all comers. Here is a case of rheu-
matism; here is the treatment for rheumatism for all
ages, sizes, sex, color or "previous condition" — the book
sai/s no. Failure would be a foregone conclusion.
Ami so with our classification of the criminal; it is a
lamentable failure.
Again, by existing methods the State essays to
purify the morals of society by perpetrating a shock-
ing crime. The law says "thou shalt not kill," and
forthwith gives us an object lesson in killing and in
colli blood!
The pretext for putting a man to death to protect
society can only apply to the habitual or born crim-
inal; and the ends can be accomplished by a means
less revolting. Surely there could be no such pre-
text urged in a case like that of Dr. Jones, a man who
lived a life of usefulness till past 50, a respected citi-
zen, prominent, indeed, in business and society. He
had been president of this society. A circumstance
occurred which so exasperated him that he felt com-
pelled, to vindicate his honor, to take the life of the
man who had injured him, as he thought. Although
justified in his own mind the law held it to be mur-
der, and he was sentenced to death (a subsequent
trial sentenced him to twenty years in the peniten-
tiary i. Because of this one act, would this man
have been held to be a danger to society which must
be eliminated? And even with regard to the natural
criminal, is not the question of responsibility to be
considered? Take Holmes, Guiteau or Prendergast,
acknowledged dangers; they could no more change
their nature than a leopard could change his spots;
it was born in them to kill. Should they, morally
insane, confessedly, be cruelly put to death for
responding to the promptings of a natural predis-
position? Why not lock them up securely, as we do
man-eating wild beasts in captivity? Because they
might or would kill if they had liberty, do we feel
called upon to shoot them ?
But heredity and environment, as potent as they
are. and as prolific, are not the only factors of increase.
I believe that it can be demonstrated that the exist-
ing conditions and methods of our system not only
fail of their ends, but operate to defeat them and
become a tributary to the growth of crime and the
multiplication of criminals. Take an illustration : A
boy of 17. small for his age, was wanted for suspected
complicity in a burglary. He came of respectable
parentage, among whom crime was unknown; but
owing to environment he grew up to be regarded as a
bad boy. The policeman was afraid of him and
attempted take him by stratagem. He employed a
chum of the lad to call him to the door at night,
when the policeman sprang upon him out of the
darkness, and without a word, covered him with a
pistol. The boy, in fear of his life doubtless, and by
instinct of self-preservation shot and killed the police-
man. For this he was sentenced to seventeen years
in the penitentiary at hard labor. At this writing he
has served eight years; has a record of uniform good
behavior, has given every evidence of repentance and
a desire to lead a correct life; the end and object of
his incarceration has been accomplished; he is
'•reformed," he has been punished. But, no; his sen-
tence was for a definite term of years; that's the law,
and he must serve nine years more, when, better or
worse, he will be released, deprived of every right of I
citizenship, sans pride, sans hope, ambition or self-
respect, his father's name dishonored, his widowed
mother's heart broken; the best years of his life,
all of his youth spent in a felon's cell ; what a mockery
his "liberty" will be. What will he have to live for?
Is it likely that he will become a moral, upright and
useful man?. Or will he, feeling that he has been
unjustly punished, that the State is his enemy and
mankind his natural foe, his hand, like Ishmael's
against every man, will he go to swell the ranks of the
hardened and irreclaimable criminals? Who can ask?
This case will show the absurdity and the worse-
than-uselessness of the "definite sentence" system. It
makes criminals rather than cures them.
The inadequacy of existing statutes to meet the
requirements is an exceedingly grave matter. Not
only that they fail to repress crime and protect society
and operate to increase it, but the want of confidence
on the part of the public engenders a feeling of inse-
curity which drives them to the commission of those
acts of lawlessness for which they are so severely but
unjustly censured. Self-defense and the protection
of home are the strongest instincts of human nature.
The people of Texas are as loyal and law-abiding as
are to be found anywhere; but when they realize that
the methods of dealing with the rapist and the mur-
derer and the double crime, rape and murder (and
that, too, most frequently, of tender young children),
are not effectual to put a stop to it, even' when the lawT
is swiftly executed, but, on the contrary, that an exe-
cution, even in the horrid form of the stake, actually
appears to incite others to the crime, it simply drives
them to madness. The horrible execution of Henry
Smith at Paris must have been known to every negro
in Texas, but it did not deter another negro from a
committing a similar outrage a short time after at
Tyler, and he met a similar fate. Nor have the sev-
eral prompt hangings for rape been attended with
more salutary results. Rape is notoriously on the
increase, not only in Texas but in other States, and
lynch law is brought into execution.
In support of the assertion that an execution incites
others to crime instead of having a deterrent effect
upon the evil disposed (such is the theory of our
system — " to strike terror in his soul " and awe him
into good behavior), I refer to statistics to show that
in England, of 167 criminals condemned to death, all
but three had witnessed executions. May this not be
a psychologic problem not yet unraveled by medical
science? Our knowledge of hypnotism is yet crude
and imperfect. May it not be that persons, especially
the ignorant, witnessing so shocking and impressive
a sight receive, unconsciously, the "suggestion" to
murder? What is it that prompts a person to do,
against his will and intent, an act which he knows he
should not do, and for which he will speedily be put
to death? Poe calls it the " Imp of the Perverse."
But the worst feature connected with the subject,
and that which drives the people to desperation is,
almost as many offenders escape as are caught; and
when they are caught, there are so many delays,
appeals, writs of error, feigned insanity, etc., that the
feeling of insecurity is intensified to the last degree,
and the people take the matter in their own hands.
They do not understand the reasons why, but they
recognize the fact that the laws can not be depended
upon for the suppression of crime and the protection
of their families, and their acts are a spontaneous
though very crude and primitive effort at a remedy.
1088
REFORM IN CRIMINAL JURISPRUDENCE.
[November 21,
I am inclined to believe that the fountain head and
source whence flows this great evil, lynching, can be
traced to the unwise policy that obtains of paying
legislators day-laborers' wages. In Texas the per diem
is $5, and after sixty days it is reduced to $2. It is
hardly to be expected that such remuneration would
command a very high order of law-making talent.
Statutes enacted by men who can afford to leave home
and business for $2 per day, who know nothing of the
requirements of sanitary legislation, and do not want
to be told, and could not fairly comprehend the sub-
ject if they were told, are apt to be defective, ambigu-
ous and conflicting, and so afford grounds for endless
" errors," protracted trials and tedious delays. With
the exception of a respectable per cent, of really able
men — lawyers, for the most part, who have political
aspirations or 3ome reason for serving, other than the
mere pittance of pay, and who really make a pecuni-
ary sacrifice i» so doing — the legislatures of many
States are composed of average representative citi-
zens, farmers, merchants, mechanics, or else young
" limbs of the law:" and this class is in the majority.
It is this element that defeats all attempts at reform;
who ridicule the efforts of the medical profession to
secure improvement in the medical practice acts,
and who mocked and insulted the noble Christian
women of whom Mrs. Gardner tells us in the Aram,
in their efforts to amend the " age of consent " stat-
utes. It would be difficult, I apprehend, to make this
sort realize that their ignorance, bigotry or, most of all,
conceit that makes them refuse to listen to any sugges-
tions of reform in accord with science, and intolerant
of advice, is the real and first cause that leads to
lynchings. They are loud to denounce it, and without
a suspicion of the truth, they serenely set about to
enact statutes to punish the lynchers.
Indeed, may it not be that herein lies the one great
cause of the inadequacy of our system? In the
enactment of the criminal and health statutes the
requisite knowledge is not brought to bear. The
making of all our laws is in the hands of men who
make no pretensions to science, and they are notori-
ously averse to being advised.
Science is applied knowledge. The most civilized
races are the most scientific and progressive. We live
in an age of enlightenment and advanced civilization.
Never, at any period of the world's history, have the
facilities for the acquisition of knowledge and the
dissemination of information been so great in every
department of life, and yet in many respects, and
especially in that pointed out above, vital to society
and human happiness and well-being, man fails to
profit by experience and neglects to make use of the
knowledge gained.
Knowledge, acquired in whatever way, is applied in
the various arts, and made subservient to man's wants.
In enlightened governments there are heads of depart-
ments whose function it is to gather and formulate
the knowledge bearing upon their respective interests.
This is true of everything except man's most vital
interests — his health and well-being and the preserva-
tion of a healthy standard of race. In this great
country there is no department of public health, and
State medicineis a nullity. The vast store of knowl-
edge gained by laborers in the field is not utilized in
framing laws for the protection of the public health
and morals and race preservation.
On this head Judge Benjamin Abbott, in apolo-
gizing for the jurists and the want of progress in the
jurisprudence of insanity (Ref. Bk. Med. Sci., p.
122), says: "The rude division into 'idiots' and
' lunatics ' of two centuries ago survives in jurispru-
dence to-day. . . . Jurisprudence has no peculiar
methods of studying the subject, but has been accus-
tomed to follow the course of medical science, and to
accept, sometimes only after long hesitation and
inquiry, the results which skillful and experienced
alienists have united in declaring established."
Jurisprudence has not studied the subject, yet will
not accept the conclusions of those who have; here is
a confession of bigotry and intolerance.
Judge Abbott here uttered a pregnant truth. It is
the key to the problem, why our criminal and insanity
laws are a failure.
To confess that the jurisprudence of insanity has
not been revised in two hundred years, because jurists
will not accept the conclusions of scientific investi-
gators in this field, when in the meantime insanity
has been studied in all its phases, and subdivided and
classified till now there are nine forms of idiocy and
six forms of madness known to alienists, would indi-
cate that one or other of the forms of idiocy or mania
had seized upon our law makers. Our statutes belong
to past ages.
Granting that the system is a failure, what should
be done to remedy it?
The thinking members of the profession are being
rapidly converted to the belief that crime is <i disease;
that habitual criminals aie sick persons, and that
their condition calls for a more enlightened method
of management. They know that many, if not most
of them, are subjects of heriditary transmission of
vicious temperaments, and are victims of vicious
environment. Sooner or later a change must come,
precisely such change as has taken place with insan-
ity and inebriety. It has not been very long ago that
drunkenness was regarded as a criminal offense, car
rather, as a misdemeanor, — and was punished: nor
since the insane were regarded as monsters, — or "pos-
sessed of a devil" that was to be exorcised only by
blows and by straight- jackets; nor since the poor
dement or idiot and the harmless maniac were, by
law, burned as "witches," an act for which civilization
is not yet done blushing. Opinion has changed radi-
cally, as regards these unfortunates; and with it, the
system of dealing with them. The insane, and in
some States, the inebriate now find repose and tender
care and rational treatment in the great eleemosynary
institutions of an enlightened age; and so opinion is
fast changing with reference to crime and criminals.
and the mission of science is to bring about a corre-
sponding change in their status and management:
Professor Flint, in his paper, says (X. Y. Medical
Journal, Feb. 15, 1896):
"Crime is a disease of our social organization. It is true
that it is ineradicable, but it may be restricted within much
narrower limits than at present exist. Crime calls for intelli-
gent and scientific treatment. While crime can not be abol
ished, all criminals are not hopelessly affected with crime. .
. . Crime may be a constitutional disease, as in the born
criminal, or it may be due in individual cases to surroundings,
teaching, or example — a sort of contagion. It has been abun-
dantly shown that criminals may be divided into two great
classes, the curable and the incurable ; but the disease which
we call crime has nearly as many phases and varieties as are
presented by the nosological catalogue. Society needs the aid
of competent men to undertake the task of separating the
curable from the incurable — to restore the former to useful
ness, and to protect our social organization against the latter.
Jurists, so-called law-givers, and those who execute the law,
1896.]
REFORM IN MEDICAL JURISPRUDENCE.
1089
have failed. In my opinion, the only hope is in the medical
profession."
The problem is. how can these views be impressed
upon those tcho are cut rusted with the enactment of
the statutes/ The utter failure of the State Medical
Association in Texas to awaken in the minds of legis-
lators a just appreciation of the dangers attending the
indiscriminate practice, or the unrestricted sale of nos-
trums deleterious to the public health, gives but little
assurance that anything the medical profession of this
State might bring before them upon this great subject,
would receive more respectful consideration.
State medicine is the application in the aggregate,
of the principles of medical and sanitary science to
the prevention, cure, mitigation or relief of evils
which affect the social body, and the prevention of
those evils to posterity. It bears the same relation to
the state or society that the individual physician
bears to his clientele; and embraces measures of
prophylaxis against future ills as against existing
evils. For illustration, any measure calculated to
improve the race, restrictions upon marriage limiting
the privilege to the fit, or castration of natural crim-
inals, or insane criminals, or the criminal insane, to
cut off succession as here advocated, is as much within
the scope of its beneficent functions as is quar-
antine against disease; indeed, the entire treat-
ment of criminals, as hereinafter proposed, comes
most appropriately within its province; and when we
shall have succeeded in getting a department of public
health, the first step will have been accomplished.
The state owes no higher duty to posterity than to
protect it against a multiplication of those evils we
now deplore, and are ineffectually battling against.
Medicine has ever been characterized by humanity
and benevolence. The profession do all in their
power to relieve suffering. Our grand hospitals and
asylums are monuments to the benevolence and unsel-
fishness of medicine. Yet it seems to be, after all, a
false philanthropy, as it enables the afflicted ones to
live on and beget more children for the next generation
to care for. Thus evil comes out of good, and our
intentions react to the ultimate detriment of
society. By practical charity, alms-giving, and the
tender «'are for the defectives and diseased, the opera-
tion of nature's laws is defeated, and the unfit sur-
vive and breed and multiply like flies.
< hi the subject of marriage, Judge C. H. Reeves of
Plymouth, Ind., in a work called "The Prison Ques-
tion." the most logical exposition of the subject I
have ever seen, says:
"In regulating marriage, the law says that none shall marry
within the third degree of consanguity, and in some States the
fourth, because marriage between near blood relations is likely
to produce offspring deformed or diseased, physically and men-
tally. Insane and idiots shall not marry, because they can
not make a contract, and because of hereditary tendency to
produce idiots and insanity. It makes it a crime to marry in
any of these cases. In this it aims to prevent degenerate off-
spring and protect individuals and society against the evils
that would attend such offspring. . . .
"But if the vilest mortal that can live— one not in these
classes— sees proper to marry, the law issues the license for
the asking, taking a fee, makes a record, and leaves the off-
spring and society to shift for themselves in the best way they
can. The confirmed inebriate, the weak-minded and semi-
idiotic, the confirmed criminal, the offspring of the half-witted
and insane, if lucid at the time— the incurably diseased, the
scrof ulitic, the syphilitic, the hereditary pauper, the depraved
and reckless— even paupers while in the poorhouse, and crim-
inals while in jail, are in every way encouraged, given license,
and are protected by the law. No thought is taken for the
unfortunate offspring, nor for the body politic or social, and the
irreparable evils that must fall upon all. The church adds its
sanction, and its ministers aid in making these civil contracts,
by performing the ceremony with benediction and prayer. .
"If it is wise to prohibit polygamy, marriage between near
relations, between the insane and idiotic, because of heredity
and transmissions of evils, it is equally wise to prohibit it in all
cases where like evils may follow. If the law has the power
to prohibit and punish violations in one case, it has equal
right in all others. . . .
"There is an endless procession of children from all these
sources coming into the mass of population to live lives of
crime, immortality, want, suffering, misfortune and degrada-
tion, transmitting the taint in constantly ever widening
streams, generation after generation, with the ultimate cer-
tainty of the deterioration of the race, and final irreparable
degeneracy. . . .
"It seems to me that there is a moral obliquity that affects
the entire mass of political, social and religious leaders and
teachers on the subject here being considered. When we
analyze the views and actions throughout, the glaring incon-
sistency and unreasonableness that seems to fill them has no
parallel in any other matter seriously affecting individual and
the public welfare. Among the first is a false modesty, that
is shocked by any allusions to the most evident and debasing
facts that stare everybody in the face on all sides ; that rub
everybody at every turn. . . .
' 'The church devotes its time and energies to prove that every
human body possesses an immortal spiritual body, that is liable
to future torture unless it be made perfect in morals and truth,
and that must be done while it remains in its mortal shell. It
pleads and raves for prohibition of liquors and tobacco, for
forced observance of Sunday, for forced attendance on schools,
for recognition of God, Christ and the Protestant religion in
the civil constitutions, and for sundry other restraints and
commands, with penalties, in order to save these imperiled
souls. Reformers go about the land devising ways and means
to educate, civilize, provide for and elevate the ignorant, the
degraded, the poverty stricken that pervade every plane of
human action, and wander in and out among the people every-
where. And yet these, with general society added, hold up
their hands before their faces in horror, if some honest soul
who has truth for a guide, calls them to look and points them
to the source of the evils they are battling with, and tells them
they are responsible for it all, for the law is only their united
will in statutory phraseology. That it is the result of their
voluntary blindness and false conception of civil, moral and
religious duties. That they are seeking to deal with evil con-
ditions alone, instead of the causes of them, and while trying
to mitigate the evils in the results, are supporting and enlarg-
ing the causes. That on every other plane, of action they rec-
ognize and deal with the causes ; but with men and women
they ignore the causes and battle with results alone. That
they regard domestic brutes as of more importance than they
do human beings."
Doubtless Macaulay had this condition of society
in mind, when, forty years ago, he predicted the dis-
integration and downfall of the American Republic.
Writing to Henry S. Randall, in 1857, he said: "I
have long been convinced that institutions purely
democratic must, sooner or later, destroy liberty or
civilization, or both. Your constitution is all sail
and no anchor. Either some Caesar or Napoleon will
seize the reins of goverment with a strong hand, or
your republic will be as fearfully plundered and laid
waste by barbarians in the twentieth century as the
Roman Empire was in the fifth, with this difference —
that the Huns and Vandals who ravaged the Roman
Empire came from without, and that your Huns and
Vandals will have been engendered within your own
country, by your own institutions."
It would seem that a rational people, with such
facts before them, for instance, as those furnished by
Dugdale's history of the Jukes family, from whom
1,200 criminals descended, would profit by it and take
steps to close the flood gates of evil. And the Jukes
case is not an exceptional qne by any means; there
are thousands such; they exist everyday, everywhere.
The magnitude of the evil and danger result-
ing from our criminally lax marriage laws is simply
1090
REFORM IN CRIMINAL JURISPRUDENCE.
[November 21,
appalling. Yet few ordinary citizens, those who pay
the taxes, have a conception of it, or realize the extent
of the cruel wrong done them by permitting it.
An intelligent comprehension of the subject would,
therefore, indicate that the first step in needed reform
is State regulation of marriage with a view to the
arrest of descent of crime by hereditary transmission
of the tendency. And dealing directly, then, with
the crop on hand, it is suggested that punishment, as
such, as a penalty, should have no place in a civilized
code. It is permissible only as a feature of discipline
incidental to reform; that as criminals are divisible
into the two great classes, the curable or accidental
criminal, and the habitual or incurable of Lombroso,
the end and object of penal enactments should be the
cure of the curable, the reclamation to usefulness of
those who are amenable to it, and the elimination of
the incurable. To this end, therefore, a classification
of all criminals is necessary.
Classification can only be done by medical men.
The entire subject comes legitimately within the
scope of State medicine; here, indeed, it finds its
most appropriate field.
When the character of the crime has been deter-
mined by the court, it would seem to be in accord
with the requirements of the case and the dictates of
an enlightened humanity, that there should be med-
ical men to diagnose the criminal, and prescribe the
course which, in their judgment, is best calculated
to meet the demands. If it be one of the curable
class, the treatment, consisting of restraint, disci-
pline, hygiene, education, environment and healthy
labor, should be such as to induce a determination to
never offend again. Pride and self-respect should be
fostered, for they are the highest incentives in life to
good behavior. The term of imprisonment should
depend upon the progress made in reformation; on
good behavior— the culprit made to realize that when
he gives evidence of fitness to be trusted with his lib-
erty it will be restored to him. And primarily he
should be lifted above the environment calculated to
debase him in his own mind. The incurable — the
born criminal of Lombroso — should be dealt with as
a permanent enemy to society, and the first aim in his
case, after sequestration, should be precautions
against a progeny; to cut off his race. When a man
has been diagnosed as a natural, /. e., an irreclaimable
criminal, twice convicted of any felony, along with
the forfeiture of liberty for life and all other rights,
he certainly should be deprived of the right (and the
power, should chance permit) to inflict a progeny
upon the next generation. Can anyone give a single
reason why this right should be respected when all
others are taken away? I think not. The strange
veneration people seem to have for those particular
possessions, which induces them to plead that they
be spared even when every other right has been for-
feited and taken away, is the last remnant of the old
Phallus worship; a superstition of the fifth century.
Capital punishment is becoming more and more
abhorrent to thinking people, and is being very gen-
erally condemned by medical writers as barbarous,
useless and unjustifiable; and castration as a substi-
tute therefor is rapidly growing in popular favor.
Much of the prejudice that existed against castration
is disappearing under the light of reason. Indeed, it
seems to me that there is every reason why capital
punishment should be abolished and isolation and
emasculation substituted; and the fundamental prin-
ciples of justice demand that, where possible, resti-
tution should take the place of imprisonment. It is
true, privation of one's liberty might be called pun-
ishment— it is so, incidentally; but let it be done for
the purposes of reformation and for the improvement
of the morals of society and not of revenge — miscalled
justice. Corporeal punishment never made a school
boy good; and the morals of a community can never
be purified by a system of punishment entailing eter-
nal disgrace as penalty for misdeeds. The sense of
injustice arouses resentment and stirs the worst ele-
ment in one's nature.
The time has come and the occasion demands if
we would make an effort to preserve the integrity of
our race and the safety of the republic, when the
medical profession must look at this question from
the higher standpoint of guardians of society and con-
servators of the public well-being, and none the less
as trustees for posterity. It should be insisted that
the voice of science be heard; that the great truths
revealed by study and research, by laborious investi-
gation, experimentation and compilation — truths vital
to the dearest interests of mankind should be utilized
in medical and criminal jurisprudence. Our entire
system needs to be recast along broader lines, and
made more comprehensive; remodeled and adapted to
the changed conditions of a 20th century civilization.
As at present constituted it deals with results alone,
and utterly ignores causes. We concern ourselves
with, and can not solve the problem of what to do
with the criminals of this day and generation — with-
out a thought toward, or an effort to close the avenues
through which pour in ever swelling tides of the evil
we vainly attempt to remedy.
Sisyphus, condemned to eternally roll the stone,
had no more hopeless, endless task than we are now
engaged in; nor the Danaides one more impossible of
accomplishment ; it is as irrational as the attempt to
purify a sewer by throwing disinfectants into the
outlet. The helpless, worthless, vicious and danger-
ous come faster than love, philanthropy, religion.
science and law can care for, reform or dispose of
them.
Doubtless, by an organized effort on the part of the
two learned professions, medicine and law, Congress
can be awakened to the necessity of taking steps to
make available sanitary knowledge in the jurispru-
dence of medicine and crime; to create a department
of public health and hygiene, whereby such knowl-
edge can be disseminated and made to reach and influ-
ence legislators, however unwilling.
While we may never be civilized up to a system of
scientific breeding of peoples (as we do our stock), it
unquestionably lies within the scope and power of
State medicine to eliminate much that is evil, and
bring aboutgreat improvement, even in the next gen-
eration, in the physical, moral and intellectual status
of society. And chief among the agencies effective
to this end will be State regulation of marriage, and
sterilization. This is the mission of rational medi-
cine; to the accomplishment of which the profession
should address itself, with the conviction that duty
requires it, true philanthrophy dictates it, policy
suggests it, and it is demanded by every consideration
of justice, mercy and humanity.
Subscribe now and receive the Journal free until
December.
1886.]
EXPERIMENTS ON RABBITS.
1091
SOME EXPERIMENTS ON RABBITS MADE
WITH A VIEW TO OBTAINING A STUMP
FOR THE ACCURATE FITTING OF
GLASS EYES.
Ki'tul iii the Section on Ophthalmology itt the Forty-seventh Annual
Meeting of the American Medical Association, at
Atlanta. Ua., May 6-8, 1896.
BY J. HERBERT CLAIBORNE, JR., M.D.
Adjunct Professor of Ophthalmology in New York Polyclinic; instructor
in Oplitlnlniologv in the Vamlerbilt Clinic. College of l'hv-
su-ians ami Surgeons, New York: Assistant sur-
geon to the New Amsterdam Kye and
Kar Hosoital. New York.
In Gdillitni'x Medical Journal for May, 1889, I
gave a detailed account of some experiments made
upon rabbits with a view to obtaining a better stump
for the fitting of glass eyes. In those experiments I
planted sponge and cotton in the scleral cavity and
Sponge in the capsule of Tenon. The results of those
experiments were negative. In experiment No. 1,
the planting of sponge in the scleral cavity, the edges
of the scleral wound held firmly together except at the
forward angle, for four weeks. At that point the
Bponge could be easily seen by inspection, lying
snugly packed away, the stump was firm and com-
preamble and the catgut sutures which had been used
to draw the edges of the scleral wound together had
beoome absorbed.
The entire stump was then removed for microscopic
examination. There was a small zone of granula-
tion tissue in the meshes of the sponge; numerous
groups of pus cells, cocci and rod-shaped microorgan-
isms also were found. In no portion of the fundus,
nor anteriorly in the neighborhood of the wound was
there any evidence of an active destructive process.
In experiment No. 2, cotton was planted in the cap-
sule of Tenon and the lips of the conjunctival open-
ing were brought together with catgut sutures. The
healing was kind and the stump was soft and com-
pressible. About the third week after the operation,
the stump commenced to bulge and finally, at the end
of the second month, pushed its way through the con-
junctiva, apparently through the line of sutures, and
inted a white honeycombed appearance. Micro-
scopic examination of the sponge showed that it was
completely surrounded and penetrated at its periphery
by a zone of granulation tissue and lying in the cen-
tral depths were numerous fine granules, silicious
spicula and many isolated leucocytes.
In experiment No. 3, absorbent cotton was planted
in the scleral cavity. The wound healed kindly and a
soft plump stump persisted until the seventh week
after the operation, when it was discovered that the
cotton had broken through the sclera above the line of
the sutures. The stump having been removed with
the cotton, it was attempted to make a microscopic
examination, but it was so torn in being removed that
nothing satisfactory could be obtained. Granular
matter, a few microorganisms and scattered pus cells
were found among the cotton fibers.
These experiments seemed to warrant me in draw-
ing this conclusion amongst others:
The implantation of sponge and cotton into the
scleral cavity is probably not feasible in the human
being.
I dismissed the idea of implanting anything in the
capsule of Tenon, owing to the slight support given
by the united lips of the conjunctival wound.
In my final conclusion I made the following sug-
gestion :
Based, as yet, on no experimental observation or
experience, I suggest glass wool and asbestos as arti-
ficial "vitreous" bodies in modification of Mr. Mules's
operation.
Following the suggestions contained in this, I have
planted asbestos and glass wool in the scleral cavity
of rabbits, and I shall now detail those experiments
and their results.
Experiment No. 1. — June 6. Blond buck. A cata-
ract knife was passed through cornea and lens at the
sclero-corneal margin and brought out opposite in the
long axis of the palpebral fissure. The lens and vit-
reous body were removed and the iris and cornea were
cut away with scissors. Volkman's spoon was used
to better evacuate the contents of the cavity. Some
small shreds of choroid were left. A ball of glass
wool, made up of prepared modeler's wax, was intro-
duced into the scleral cavity and the lips of the wound
were closed with interrupted silk sutures, which were
carried through conjunctiva and sclera.
Experiment No. 2. — Black and white buck. The
contents of the scleral cavity were removed as in the
first experiment, and a ball of asbestos made up with
antiseptic wax was introduced into the cavity. Silk
sutures were used as before. This buck took ether
badly, having just had a full meal, and indeed kicked
so viciously that the line of sutures were not so accu-
rately adjusted as in the first case. It took each one
some time to recover from the effects of the ether, and
the blond at one time seemed moribund. The lids
were not sewed together, as in temporary tarsorraphy,
nor was any attempt made to dress the eyes. A
double line of interrupted silk sutures was made, the
smaller silk being used to close up the spaces between
the larger sutures. The animals were put into a cage
and allowed to run about.
June 7. Blond buck No. 1. Lids stuck together.
There was considerable discharge of a lymph-like
character and so much swelling of the conjunctiva
that the stump could not be seen. Black buck No. 2.
Lids not stuck together, but chemosis which hid the
stump.
June 10. Both bucks in good condition; chemosis
and discharge gone; sweet, white exudate along line
of sutures. The animals remained in excellent con-
dition.
June 19. Stitches were removed from each stump.
Union of wounds perfect, but line of union quite
irregular. The animals were seen at intervals of a
week or two, till Nov. 30, 1895, when the stumps were
carefully inspected. On examination, a black ball
was found lying loose in the scleral cavity of the
blond buck (subject of experiment No. 1). The line
of sutures had parted and the ball had remained the
original size; when broken up it appeared to have
the same character as when first introduced, except
that it was black externally.
In the black buck the lips of the scleral wound had
fallen in and partly united. When they were opened
nothing was found within. It is interesting to
observe that this animal developed an abscess in
the side during the last month of his captivity which,
apparently, in no way interfered with his appetite or
health.
These experiments were performed under strict
aseptic precautions. Instruments, sutures, absorbent
cotton, etc., were sterilized by boiling in a 2 per cent,
solution of sodium carbonate. The asbestos and
glass wool were sterilized by boiling in a normal
1092
EDEMA OF THE OCULAR CONJUNCTIVA.
[November 21,
saline solution for twenty minutes. It was then
shaped into small balls to fit the scleral cavity and
dipped, by means of sterilized forceps, into boiling
modeler's wax, which had been thoroughly sterilized
previously by repeated boilings. After the balls had
cooled the superfluous wax was removed from the balls,
leaving the cores covered with a thin film that was
required to keep the asbestos and glass wool in the
spherical form. The hands of my assistant and my-
self were thoroughly disinfected after the manner at
present in vogue, and a solution of bichlorid of mer-
cury (1-3,000) was used to disinfect the conjunctival
sac of the animals as well as for an irrigant during
the operations.
This work was done in the Physiological Labora-
tory of the College of Physicians and Surgeons, New
York, and I am indebted to Dr. R. H. Cunningham,
of that department, for his assistance, both in the pre-
paration of the materials used and in the perform-
ance of the operations.
Alfred Graefe of Halle first proposed and performed
the operation of evisceration of the eyeball. He did
it chiefly with a view to cosmetic effect in the fitting
of glass eyes. This operation can scarcely be said to
have much advantage over enucleation, since it leaves
behind the crumpled sclera in addition to the mus-
cles, fat and conjunctiva of the orbit. Since the
glass eye is a concave shell fitted into a concavity, the
grasp on the orbital tissues must be chiefly at the
edges of the shell. It was supposed that the crum-
pled sclera would fit into the concavity of the shell,
and thus assist it to move in conformity with the
movements of the orbital tissues. This occurs only
to a limited degree, and when one considers the fact
that the etiology of sympathetic ophthalmia is not
yet definitely determined, it seems a questionable pro-
cedure to leave so much of the globe behind.
It is not to be forgotten that the operation of evis-
ceration is indicated, according to its author and advo-
cates, in those cases in which no malignant neoplasm,
iridocyclitis or sympathetic ophthalmia exist. Never-
theless, I hold that it is not an ideal procedure to leave
in the orbit a crumpled mass of hard, unyielding tis-
sue in which the ciliary nerves are squeezed and bitten
by cicatricial contraction.
This operation has been popular in Halle chiefly,
to some extent on the continent of Europe in general,
and to a very limited extent here. In England it has
been modified by Mr. Mules of Manchester, who pro-
posed the introduction of glass balls into the scleral
cavity after evisceration. From a theoretic standpoint
the advantages of this operation over simple enuclea-
tion are obvious. Good movement of the stump is
achieved, for the extrinsic muscles are still attached
to a firm and resistent globe, and the circulation in
the blood and lymph spaces is encouraged by the per-
sistence, to a certain extent, of the original form of
the sclera. But the introduction of any hard, unyield-
ing body into the scleral cavity can not, likewise, be
considered an ideal operation. If some soft compres-
sible substance, that would not be affected by a sojourn
in the scleral cavity, and that would not burst the
sclera, could be found, a classical procedure might be
instituted.
The experiments which I have just detailed show
conclusively that, although no serious inflammation
results in either eye from the planting of asbestos and
glass wool in the orbital cavity of rabbits, the line of
healing will part after several months. It is probable
that the same result would be obtained in the human
being.
From the study of this subject the following con-
clusions are drawn:
1. The operation of enucleation does not leave in
the socket enough of a prominence to permit of the
accurate and comfortable fitting of glass eyes.
2. The operation of evisceration, while it leaves a
better stump than the operation of enucleation, is open
to obvious objections.
3. The operation of Mr. Mules of England is objec-
tionable because it subjects the ciliary nerves to con-
stant pressure between two hard and unyielding sur-
faces, because the glass balls are subject to fracture,
and because they are difficult of introduction.
4. The implantation into the scleral cavity of some
soft yielding body, which will not degenerate, which
can be rendered aseptic, which will not swell by imbi-
bition and which will not become absorbed, seems to
be a rational procedure.
5. Sponge, cotton, asbestos and glass wool are not
tolerated in the scleral cavity of rabbits, and would
probably not be tolerated in that of man.
6. The operation of enucleation, while it does not
yield satisfactory cosmetic results, is, nevertheless, the
most popular and safest procedure in those cases in
which the removal of the ball or its contents is
indicated.
39 W. 36th Street.
EDEMA OF THE OCULAR CONJUNCTIVA.
Read tn the Section on Ophthalmology, at the Forty-seventh
Annual Meeting of the American Medical AflSoelfttioo
at Atlanta, Ga„ May 5-8, 189«.
BY F. W. HIGGINS, M.D.
CORTLAND, N. Y.
One of the most constant symptoms of Bright's
disease is edema. Puffiness under the eyes is per-
haps the symptom that the physician first looks for in
a suspected case. That to which I wish to call atten-
tion is the much rarer condition of edema of the ocu-
lar conjunctiva. Edema may occur in any locality
where there is cellular tissue, often without our being
able to determine just why it is so especially markec
in the location where we find it.
Some time ago I was called into the country to see
a patient confined to the house by nephritis, exhibit-
ing a peculiarly marked case of ocular edema or che-
mosis. The invalid was a married man, 22 years old,
a telegraph operator. Four years before, he had been
suffocated by coal gas and remained unconscious for
some hours; to this circumstance he ascribed his ill-
ness. He had been treated for albuminuria, in Michi-
gan, for about two years, when he returned to New
York State to place himself under the care of a pro-
fessional relative, for whom I examined the eyes. I
found the young man in bed, pale, with general ana-
sarca, the urine loaded with albumin, and all the symp-
toms of a parenchymatous nephritis. He was totally
blind, not, as you may suppose, from albuminuric
retinitis, but from edema of' the ocular conjunctiva.
This had first formed a chemosis, then had increased
until the raised folds met over the cornea. These
swellings were red, not having the pale, translucent
appearance one might expect. In each they pre-
sented the aspect of a superior and inferior fold — like
distended lids. The mucous membrane was dry and
appeared thickened from constant contact with the
air. The lids could not be closed. One would
18%.]
EXCESSIVE HEMORRHAGE.
1093
estimate that four drams of fluid was included in
each eye.
The treatment was incisions, made, I must confess,
too cautiously the first time, for my attention had
never been called to a cheinosis of any such extent,
and 1 did not know what pathologic condition might
lx^ concealed beneath. The oozing of serum was
slow, but sufficient to enable the cornea of one eye to
be scon at my next visit. The incisions were repeated
with the effect of enabling me at my third visit to
examine the fundus, which I found almost filled with
white patches of choroidal change, which we might call
edema of the choroid.
Now- a peculiar complication occurred. The cor-
nea was no longer completely covered by the folds,
and still the edematous and thickened conjunctiva
prevented the lids from closing, which compelled me
to give directions in regard to the cornea, to prevent
damage from exposure.
1 -aw him no more, but learned that he had uremic
convulsions, after which sight and general symptoms
improved, and he returned to Michigan. Here the
conjunctiva' were treated by cautery, but the patient
died about three months after I last saw him.
I am not able to give any reason why the ocular
conjunctiva should have become so infiltrated in this
case. No iodid of potassium had been administered,
or any other treatment that could induce it. There
was no history of a previous affection of the eye. No
discharge or symptom of gonorrhea.
This condition seems to be analogous to that of
edema of the glottis. This, as we know, often arises
suddenly and alarmingly, and at times without an
apparent adequate cause. Max Knies1 speaks of
edema of the ocular conjunctiva, but says that it
appears to be very rare.
Brecht" describes one case of chemosis in Bright's
disease. The patient was six months pregnant when
she had an attack of eclampsia, with other symptoms
of acute Bright's disease. He saw her five days later,
when she had detachment of the retina and chemosis.
After fourteen days this had disappeared. His only
explanation of the detachment and the chemosis was
that they were both due to some especial tendency for
the edema to manifest itself in the eye.
Professor Schiess, writing in 1870, thinks the sub-
ject of conjunctival edema has been neglected. He
would ascribe all such cases as my own to preceding
choroidal changes interfering with return circulation.
I noticed that the retina could be seen with a plus
glass in my case, but neglected to record the strength
of it. According to Professor Schiess' view the path-
ology of my case would be that excessive infiltration
of the retina and choroid first occurred, which caused
passive congestion of the anterior portion of the eye,
with exudation of serum and leucocytes. That there
was a sub-acute inflammatory condition he would
predicate from the dark red color of the mucous
membrane and the thickening of the tissues. With
this condition of the conjunctiva present, he would
assume the presence of choroidal disease.
Since my patient had no mental symptoms there is
less analogy to those cases in which chemosis has
been noticed as a result of interference of the return
circulation from the eye within the cranial cavity.
Lawson Tait gives three cases in which after surgical
operations chemosis occurred. Death ensued and
section showed thrombosis of the cerebral tissues.
i The E«e in Its Relation to General Diseases.
2 Arch, 'fur Oph. xvili, 2, pp. 103.
Dr. Hunter3 reports a case of chemosis complica-
ting acute meningitis and refers to cases by Leyden
and Bierbaum. Here the same cause is evident, that
is, intra-cranial pressure interfering with return cir-
culation.
Dr. Swan M. Burnett4 records a case of acute che-
mosis which he thinks was due to neuralgia compli-
cated with slight changes in the choroid, sufficient to
hinder return circulation in some degree.
Zehender5 refers to an acute case of marked edema
of the ocular conjunctiva rapidly recovering. He is
doubtful in regard to the causation. The patient had
had sub-acute pneumonia a short time before and the
attack came on with sneezing.
DISCUSSION.
G. E. DeSchweinitz, Philadelphia, Pa.— There are cases of
acute edema of the conjunctiva which may be due to urticaria,
or to an idiosyncrasy to certain food stuffs, especially fruit. I
also believe that some cases are occasionally the result of the
administration of drugs, particularly massive doses of iodid of
potassium, the ocular manifestations replacing the ordinary
symptoms of iodism.
EXCESSIVE HEMORRHAGE AFTER ENU-
CLEATION OF EYE BALL.
Read in the Section on Ophthalmology at the Forty-seventh Annual
Meeting of the American Medical Association held at
Atlanta. Ga., May 5-8, 1896.
BY ROBERT SATTLER, M.D.
CINCINNATI. OHIO.
The danger of excessive hemorrhage after enuclea-
tio bulbi is ordinarily a matter of little concern. In
most cases the application of a compress bandage or
a compress applied and held in position by the sur-
geon or an assistant for a few moments after the oper-
ation is completed controls and averts unnecessary
bleeding. That hemorrhage, so excessive and uncon-
trollable as to endanger the life of the patient from
shock and loss of blood, can occur even after this
operation so simple in technique and by common con-
sent considered almost devoid of dangerous sequences,
is supported by the accompanying reports of two
cases recently observed.
In every case of enucleation of the eyeball, in addi-
tion to rigid aseptic precautions before and during
the operation, irrigation of the empty orbital cavity
with hot sterilized water, 1 to 10,000 bichlorid solu-
tion or biniodid solution, with the least possible
traumatism, is resorted to immediately after the oper-
ation is completed. After this a compress is held
against the closed lids for a short time by an assistant
or a compress bandage is applied.
This is done as a safeguard against hemorrhage and
possible sepsis. In those cases in which the bleeding
is unusually profuse after the severing of the optic
nerve and surrounding blood vessels or straining and
vomiting from the anesthetic occurs during or imme-
diately after the operation, the index finger is intro-
duced into the apex of the orbit and firm compression
against the ophthalmic artery, or its principal branches,
is made until it is arrested. After this a compress
bandage is applied and the patient watched for seve-
ral hours by an assistant or trained nurse.
This simple after treatment, guarding against other
complications and hemorrhage, and so generally
adopted by ophthalmic surgeons, had always been
-i Arch. f. Klin. Med. ill, p. 001.
t Archives of Ophthalmology, Vol. ix, p. 158.
r. Klin. MonatsbliUter f. Augenheilkunde, viii, p. 158.
1094
EXCESSIVE HEMORRHAGE.
[November 21,
found effectual in my surgical practice. I have had
several exceptional experiences of copious hemorrhage
but all were controlled, after four or five hours, with
little difficulty. In two cases bleeding continued for
twenty-four hours and was finally arrested only by
the introduction of hot antiseptic tampons into the
cavity, secured by compress and bandage after all
other measures had been exhausted. A sharp attack
of cellulitis orbitae followed, but recovery was, after its
subsidence, uneventful. In another case the hemor-
rhage was unusually free and persisted for many hours,
regardless of compression with bandage and hand. The
use of hot compresses did not influence it favorably.
After all other means had failed ice was introduced into
the orbital cavity and arrested the bleeding. Owing to
the discomfort and pain, not to mention greater lia-
bility to cellulitis, attending the introduction of ice,
tampons, styptics, etc., to arrest exceptionally profuse
hemorrhage, these measures are only justifiable in
extreme cases. It was resorted to in the cases referred
to only after all other methods had been faithfully
tried and had yielded negative results and the patient
had become exhausted and frightened.
Before tamponade was resorted to, digital compres-
sion had been tried repeatedly and the orbital cavity
emptied of its clots many times and pressure with
hand or bandage had been persistently done. The
sitting posture and absolute quiet was invariably
enforced. Salines and ergot administered. In these
cases the hemorrhage was not arrested until tampons
were introduced and compression made in addition,
but there was not in a single instance any intimation
of a possible serious termination. Syncope occurred
several times from fright in one case, and marked
prostration and cellulitis orbitas resulted in the sec-
ond case, but aside from a longer confinement in
bed than is usual, never persistent ecchymosis and
swelling of lids, no serious sequences could be ascribed
to the operation. In none of the cases could a hem-
orrhagic tendency be established, either individual or
hereditary, nor did the patients belong to families
in which hemophilia had shown itself in remote
branches. I have always believed that even in a
bleeder, the hemorrhage following or attending the
removal of an eye, could, with the methods of direct
and indirect compression at our command, be con-
trolled without much trouble. My experience with
one of the cases I am about to describe, however, has
taught me otherwise.
Case l.—R. C, age 16. Traumatic iridocyclitis R. E., T 2.
Globe painful, sympathetic irritation unmistakable and per-
sistent. Enucleation imperative. Enucleation February 9 of
right eye, at Ophthalmic Hospital. Ether narcosis. Free but
not excessive bleeding during operation. Patient remained in
recumbent position for three hours and was removed to his
home in a carriage. Had persistent nausea after operation but
vomited only once. At 7 p.m. was called to see him and found
that profuse bleeding had occurred. Bandage, pillow and
linen thoroughly saturated and consistent flow of blood in spite
of compression, to which father had resorted. Dressings and
bandage removed and orbit emptied of clots and Arm compress
applied and held for ten or fifteen minutes ; after this a band-
age and compression with the hand and large pad of gauze was
kept up until 9 o'clock. At this hour it was found that hem-
orrhage, in spite of bandage and pressure, had continued. A
hypodermic of morphia was given and for two hours he was
quiet and slept at intervals. At 11 o'clock I was sent for and
found the patient much prostrated, with feeble and rapid
pulse. The bandage was thoroughly saturated with blood and
numerous compresses had been applied over the bandage, evi-
denced that the bleeding had been profuse. The dressings
were removed and attempt made to tampon the cavity, but the
infiltration was so firm that it was not successful. Several
small pledgets of aseptic gauze were introduced and compress
and bandage applied and pressure made from without. He
was placed in a sitting position and compression of common
carotid resorted to and another hypodermic of morphia admin-
istered. The following morning I was again sent for at an
early hour and found that patient had been bleeding all night
and that he had been restless. During the last hour his con-
dition alarmed his parents. He was delirious and the prostra-
tion excessive. After a hypodermic of strychnia and whisky
and hot applications to the extremities, I removed the dress-
ings and found that complete extrusion of the contents of the
orbit had resulted. The picture presented was a startling one.
Complete evulsion of the conjunctival sac with complete invo-
lution or rolling under of the eyelids so that it was impossible
to distinguish the lid border. The swelling was so great that
it resembled an exuberant, eroded, sarcomatous mass and the
hemorrhage unchecked. A small tampon saturated with per-
sulphate of iron was introduced into the gaping opening of the
conjunctiva and a compress, dipped in a styptic solution,
applied and held with firm pressure against the extruded
mass. Compression of carotid was also resorted to but caused
so much pain that it had to be abandoned. Salines were given
freely and also ergot. At noon general condition was about
the same. Patient as if in a stupor and very listless. Com-
plains of photophobia of sound eye and pain in occipital
region. Has taken little nourishment on account of persis-
tent nausea. Only external compress was removed and con
stant pressure kept up by different members of the family.
Stimulants and ergot continued. At 5 p.m. dressing removed.
Hemorrhage during afternoon was unabated : patient dull and
listless : face pale ; feeble, rapid pulse ; shrieking with pain,
which was referred to head and right orbit. Full hypodermic
enabled us, after a little time, to remove the dressings. It
was found that greater protrusion and infiltration had resulted.
Nothing could be discovered of the eyelids. The swelling was
too great for the grasp of the outstretched hand but the oozing
was as persistent as before. Styptic compresses were immedi-
ately applied and pressure against the bleeding, protruding
mass kept up without interruption. Ligation of the common
carotid was suggested, but after consultation was postponed
until the following morning, as pressure seemed to control,
more effectually, the bleeding. Ergot, stimulants and morphia
continued.
Second day : In spite of constantly applied compression the
bleeding was profuse during the night ; prostration great :
pulse feeble and rapid ; pain in right side of head ; no increase
of temperature. During day condition about the same :
drowsy and listless and delirious most of the time. In after-
noon had chill followed by fever and pains in head more severe.
Complains now of throbbing, pulsating pain in right orbit.
Examination shows that bleeding continues and that swelling
is greater. Cellulitis imminent. Compression applied con
stantly.
Third and fourth days after operation : General condition
bad ; circulation feeble and fever fluctuating between 100 and
103 degrees ; can take little nourishment ; impossible to apply
bandage owing to pain ; compression kept up unintermittingly.
Fifth to eighth day : Cellulitis orbita; pronounced : at
several points present evidence of fluctuation ; exploration with
aspirator needle fails to discover pus ; fever and general pros-
tration marked : less suffering and photophobia of fellow eye.
Under an anesthetic the orbit was carefully explored, in the
hope that a deep-seated collection of pus might be found, but
examination was negative ; hemorrhage much less and can now
be controlled by compression.
Ninth day : Is much brighter and delirium has disappeared ;
very drowsy and complains of great pain in head ; ergot dis-
continued.
Tenth to fifteenth day: Swelling remains marked, but no
evidence of suppuration ; central mass of swelling sloughing :
rigid antiseptic dressing.
Fifteenth to twenty-first day : Swelling subsiding : border of
lower lid visible and entire border sloughing : irrigation with
warm 1 to 10,000 bichlorid and iodoform powder resorted to ;
general health improving ; vertigo less pronounced.
Twenty-first to twenty eighth day: Gradual improvement in
general condition ; subsidence of swelling. Two-thirds of bol-
der of lower lid and inner one-third of upper lid have under-
gone sphacelation ; succeeded in replacing conjunctiva and
lids for first time in four weeks ; again close palpebral fissure.
The patient was a bleeder and belongs to a family
other members of which had manifested a similar
tendency. Only five or six months before the opera-
tion the extraction of a tooth caused him to bleed to
syncope and was only arrested by firm tamponade.
1896.!
VALUE OF HOMATROPIN IN AMETROPIA.
109r,
H .'. J. C.| aged BO; confirmed glaucoma, oataracta
complicata, intraocular neoplasm(?); V.=0; pain excessive
and constant. Operation Imperative to prevent possible sar-
comatous infection and to relieve pain. Is a feeble old man
with evidences of general arterio sclerosis and senile heart.
I'.nueleation August '2(1, 2 p.m. : anesthetic (ether) given with
peat caution: no complications and no unusual bleeding,
either during or immediately after the operation. At i p.m.
nurse noticed slight discoloration of bandage and applied
another bandage and compress over the first : no complaint, no
vomiting. At i p.m. : Nurse after attending to wants of
another patient found bandage and pillow saturated with
blood; pressure with hand was applied and shortly afterward
bandage removed and orbit emptied of clots and firm compres-
sion with fingers in apex and subsequent iced compresses
applied with hand; patient very weak: pulse feeble; under
active stimulations, hot water bottles, etc., he revived and
oozing continued in spite of pressure.
M. : Immediately following an attack of syncope, in spite
of compression with bandage and hand, profuse bleeding again
came on. Hypodermics of whisky and strychnia given ; patient
very weak : orbit was thoroughly cleaned out and all clots
removed ; firm compress bandage reapplied over both eyes and
nurse instructed to keep up constant pressure over bandage.
On the following morning patient was much exhausted ; pale
and yawning constantly: complains of severe pain. Hemor-
rhage had continued during night in spite of compresses; on
removing bandage the entire orbit was found infiltrated with
blood, the palpebral fissure widely open and contents of orbit
partially extended; the lids were swollen and edematous;
attempts to arrest hemorrhage by application of artery forceps,
etc., proved ineffectual. The clots were again removed, com-
pression of carotid was also made and the orbit tamponed with
styptic gauze and compress applied : active supporting meas-
ures were resorted to: saline draughts were given and ergot
freely administered.
At :i p.m. : Patient much weaker, face pallid, extremities
cold : bleeding constantly in spite of bandage and pressure
with hand : compression of carotid could not be tolerated, as
it increased vertigo and tendency to fainting.
At 8 p.m. : Very restless and delirious. Examination showed
that tampon had been forced out and infiltration of orbit much
greater. It was impossible to tampon, so compress of styptic
gauze was applied directly and pressure kept up with relays of
nurses during the night.
The following morning, third day after operation, bleeding
less but patient excessively feeble. The most active supportive
measures were resorted to, hypodermically and per rectum;
nausea intense.
Fourth day: Bandage not disturbed: only slight oozing;
patient has no increase of temperature : drowsy and dull.
Fifth day : Aside from great prostration no complaint : from
this time on his recovery was uneventful.
This patient was not a bleeder. The excessive
hemorrhage was probably due to general arterio-
sclerosis.
THE VALUE OF HOMATROPIN IN THE
DIAGNOSIS OF AMETROPIA.
Ri-aii iu the Section on Ophthalmology, at the Forty-seventh Annual
Meeting of the American Medical Association,
at Atlanta. Ga.. May 5-8. 1896.
BY EDWARD JACKSON, A.M., M.D.
Professor of Diseases of the Eye in the Philadelphia Polyclinic; Sur-
geon to Wills Eye Hospital. Philadelphia; Special Lecturer
on Physiologic Optics, University of Colorado.
Its control over the ciliary muscle. — In 1881, soon
after its introduction, I commenced the use of
honmtropin hydrobromate as a cycloplegic for the
determination of refraction. At first it was used
occasionally, then more frequently, and after a year
or two for the majority of cases of ametropia encoun-
tered in private practice.
It was known to be less powerful than the other
drugs employed for the same purpose. On that
account its results were always regarded with some
doubt, and where there seemed to be any especial
uncertainty as to the findings made with it, it was
followed by the instillation of one of the stronger
mydriatics. In 1886 I published {Medical Neva,
July 24) the results obtained in these cases where
the use of homatropin had been followed by one of
the stronger mydriatics.
"In but fifteen out of the fifty-two eyes was there
any difference between the first and second results.
In eight of these it was one-quarter dioptric in favor
of the second mydriatic, in five it was one-quarter
dioptric in favor of homatropin, in one it was (in one
meridian) one-half dioptric in favor of homatropin
and in another the same in favor of duboisin. In no
case was the variation greater than may well be
allowed for unavoidable inaccuracy of observation.
In no case was the apparent axis of the astigmatism
materially changed."
Since that time the practice of following the use of
homatropin by one of the slower mydriatics, in cases
where the results with homatropin have seemed not
entirely satisfactory, has been continued and the
results obtained have not been materially different.
During these fifteen years I have also been employ-
ing other mydriatics; for refraction cases in private
practice to a limited extent, and for the large majority
of refraction cases in dispensary work. Those habitu-
ally employed were atropin, duboisin and hyoscyamin,
while daturin and scopolamin have been carefully
tested in a limited number of cases. Comparison of
homatropin cases with those subjected to other mydri-
atics has shown that the proportion of cases in which
I failed to secure complete paralysis of accommoda-
tion with homatropin was smaller than with either of
the others.
Mode of application. — When the above observation
is compared with the relative strength of the drugs,
as determined by physiologic experiments ( Transac-
tions of the Section on Ophthalmology for 1895, page 8),
there appears the paradox that the weaker drug is the
more efficient cycloplegic. The explanation of this
is, I think, furnished in the different methods of usiny
the drugs. Schell early pointed out {Philadelphia
Medical Times, October, 1880) that homatropin could
not be used in the same way as the other mydriatics,
and I have from almost the first, followed the plan of
repeated instillations at short intervals. A solution
of from 2 to 5 per cent, was used, one drop being
placed on the upper margin of the cornea every five
to ten minutes until four or six instillations had been
made. The determination of the refraction was com-
pleted within two hours of the instillations. On the
other hand, the other mydriatics have usually been
prescribed to be instilled three times daily at the
patient's home, atropin in about 1 per cent, solution
and the others in solutions of one half that strength.
Used in this way the difference in the strength of
solutions, and in the efficiency of their applications
have together more than counterbalanced the differ-
ence in the physiologic action of the drugs.
It is hard to estimate how much a mydriatic solu-
tion loses in efficiency by imperfect instillation at the
hands of the patient's family, but I have often seen
cases in which the effect produced was less than one-
hundredth of the effect properly to be expected. In
my experience, therefore, homatropin applied by the
surgeon is a more reliable cycloplegic than other
drugs of this class as applied at the patient's home.
Notice that it is not asserted that homatropin is as
reliable as other mydriatics when placed in the hands
of the patient for application, and it is not asserted
that homatropin is reliable unless efficiently used.
There is abundant testimony in medical literature to
1096
VALUE OF HOMATROPIN IN AMETROPIA.
[November 21,
establish the fact that it can be so used as to be quite
unreliable.
In this connection it is worth while to call attention
to the difference in effect secured by different methods
of making the instillation. The one commonly
described, and I fear commonly practiced, is to draw
down the lower lid and place the drop of solution
within it. The one that I have followed in the appli-
cation of mydriatics has been to retract the upper lid,
have the patient look down and place the drop on the
upper margin of the cornea. The involuntary rolling
up of the eye that follows contact, usually causes the
solution to be distributed over the cornea without any
dilution. Some experiments as to the comparative
effect of these two methods of instillation, which I
shall report more in detail elsewhere, seems to show
that the latter method is about twice as efficient as
the former; that is, a solution of a certain strength
applied to the upper margin of the cornea in this way,
will produce the same effect as a solution of double
the strength dropped in the lower conjunctival sac.
Another matter to be considered in this connection
is the strength of solution necessary to produce com-
plete paralysis of accommodation when efficiently
employed. Undoubtedly it is very much less than
we have been accustomed to prescribe for home use.
Not that we have been in error in prescribing the
stronger solutions, but that a large proportion of their
strength was only needed to lessen the effects of
imperfect application. As bearing upcfti this point,
attention may be called to recent reports on the use-
fulness of weak solutions of scopolamin. Thus, Mur-
rell {Annals of Ophthalmology and Otology, 1895, p.
478) finds repeated instillations of a one-tenth of one
per cent, solution of this drug efficient in suspending
the accommodation.
Therapeutic influence, — Although not bearing
directly upon the diagnosis of ametropia, a quality
which should powerfully influence our choice of a
mydriatic for this purpose, is the power of allaying
irritation and quieting the disturbance of the ocular
circulation and the reflex or remote effects proceeding
from eye-strain. Certainly in a very large proportion
of cases of eye-strain we are justified in resorting to a
mydriatic, and securing complete temporary rest of
accommodation as a therapeutic measure. The tem-
porary action of homatropin would seem to make it,
for this purpose, markedly inferior to the stronger
and slower mydriatics. I have in former years, on
this account, used the latter in a considerable propor-
tion of private cases, but this proportion has grown
smaller, and such use of the slower mydriatics is now
confined to the very marked cases of choroidal and
retinal disease with considerable organic change. The
interruption of morbid action within the eye, partic-
ularly that of spasm of accommodation, is as com-
plete with homatropin as with the other mydriatics.
If the instillation of the drug be made after the
middle of the day, or when made earlier if one or
two additional instillations be made in the latter part
of the day to sustain its effect, complete abeyance of
accommodation is secured until the following morn-
ing. The effect of this upon such symptoms as head-
ache, nervous tension, spasmodic closure of the lids,
etc., is very marked. Careful avoidance of any attempt
to use the eyes on the day following the employment
of homatropin will secure the benefit of the interrup-
tion of morbid action until the patient has fully
recovered the power of accommodation.
Here is a marked advantage over the slower mydri-
atics, especially atropin. There is no question that
with the slower mydriatics we secure as complete rest
of the eye, and for a considerably longer period. But
this is followed by a longer period of weakened
accommodative power, during which it is often very
difficult, or quite impossible, to prevent the patient
from making some effort; and in the eye-strain result-
ing from such effort much of the advantage gained by
previous absolute rest is lost. Unless, therefore,
there are marked tissue changes whtch require time
for their resolution, it seems to me that the thera-
peutic effect of homatropin is to be chosen rather
than that of the slower mydriatics.
Brevity of action. — One of the great advantages
of homatropin is the brevity of its action. How great
an advantage does it possess in this direction? We
read of ability to use the eyes after the use of duboi-
sin and hyoscyamin within a week; or after the use
of a weak solution of scopolamin, according to Mur-
rell, " you can safely tell your patient that he will be
able to read in seventy-two hours." But this does
not mean that complete recovery has occurred within
that time. It means that after such an interval the
patient can, with undue effort and the risks of strain
that have just been discussed, make some use of the
eyes, while with homatropin, within the shortest
period mentioned, the restoration of accommodation
will usually have been complete.
It is well within the facts, to state that with homat-
ropin the usual time required for recovery is less than
one-half that required after hyoscyamin, duboisin or
scopolamin, and less than one-third or one-fourth of
the time required after the use of atropin. I have
seen a few cases where recovery from homatropin was
quite complete within twenty-four hours: and I do
not doubt that more have occurred among a larger
number of patients not seen at the expiration of that
time, and giving the history of recovery after such an
interval. In quite a large proportion the recovery
is complete within forty-eight hours, and in more
than 90 per cent, the accommodation has entirely
returned within three days. This brevity of action
removes the chief objection against the use of a
mydriatic for the determination of ametropia, and to
discuss the general question of the use of mydriatics
as though atropin were the only drug of the class
worth considering, is to-day very much out of date.
General symptoms. — Another objection to the use
of mydriatics has been the possibility of symptoms
of general poisoning. We have all seen these general
symptoms, and occasionally have found them very
annoying and quite alarming to the patient's friends.
The patient is not usually much worried over the inco-
ordination of thought and movement produced by
one of the mydriatics. There can be no question that
the danger of such symptoms is less with homatropin
than with any other mydriatic, used so as to be equally
effective. Indeed, my notes show that only about
once in four hundred times was any constitutional
effect noticed by the patient, although in nearly
all cases there was a perceptible change in the pulse
rate.
The most marked case of such constitutional effects
from the use of homatropin that I have seen occurred
recently, in a man aged 38, suffering from headache
and neuralgic pain about the eyes from low hyperopic
astigmatism. At the completion of the measurement
of his refraction he staggered quite perceptibly in
18%.]
POINTS PERTAINING TO REFRACTION.
1097
walking, and said he felt as if he had taken several
drinks of whisky. Reaching his place of business,
his partner at once noticed the disturbance in his
condition and took him into his private office, whore
he lay for three or four hours, at the end of which
tune he had recovered. At the height of the intoxi-
cation there was a tingling all over the body, extend-
ing to the ends of the fingers and toes. The patient
was a nervous man; he expressed relief from the use
of + 0.37 convex cylinder before each eye — said his
eyes had not felt so rested in three years — but he gave
i'o history of especial drug susceptibility. The amount
of I he drug applied in this case was about 1-5 grain.
While the constitutional symptoms were decided, they
were still slight in contrast with those more frequently
observed after the use of other mydriatics, and doubt-
less could at any time have been completely removed
by a small dose of morphin.
Other consideration?. — The greater cost of hom-
atropin. and the additional labor entailed, when the
surgeon must make the applications of the drug, are
important objections to its use in dispensary work,
but are hardly worthy of consideration in private
practice. Indeed, we have found it entirely practical
to use the drug in a considerable number of cases in
our dispensary work at the Philadelphia Polyclinic.
A- to the danger of precipitating an attack of glau-
coma, in an eye already upon the brink of such an out-
break, there can be no doubt that this is shared by
homatropin, with the other mydriatics. But its com-
parative feebleness and brevity of action correspond-
ingly diminish the danger of permanent harm from
such an occurrence. In any case the dilatation of the
pupil, which is the dangerous effect of the mydriatic,
in threatened or actual glaucoma, can be promptly
reduced by the use of eserin, which, in solution of
one-sixth strength, neutralizes the effect of homatro-
pin. And even if the increase of tension be unrec-
ognized, the*rapid diminution in the influence of the
homatropin has, in reported cases, prevented perma-
nent damage.
Homatropin has been credited with the frequent
production of conjunctival irritation. This, I think,
is an error. In my experience, in some 2,000 patients
I have never seen it produce the conjunctival inflam-
mation similar to that occasionally witnessed from the
use of other mydriatics. But in almost every case in
which it is used to secure complete paralysis of the
accommodation it does cause a temporary hyperemia,
involving to some extent the vessels of the conjunc-
tiva, but more particularly those of the sclera and the
pericorneal zone. This hyperemia commonly disap-
pears by the time the full effect upon accommodation
has been produced, and I have never seen it last more
than a few hours. It is unattended by smarting or
other evidence of inflammation, and seems to be of
the same nature as the temporary local flushing I
have pointed out as occurring after the hypodermic
use of the drug. (See Med. News, July 24, 1886.)
Briefly, to summarize, the points that I bring before
you for discussion are :
That homatropin, properly applied, is an efficient,
reliable mydriatic, capable of producing complete
paralysis of accommodation, and possessing the ther-
apeutic influences for which a mydriatic is indicated
in cases of eye-strain.
That, as compared with other drugs of the class, it
is least likely to cause general poisoning or local harm
entails upon the patient the shortest period of inabil-
ity for eye work.
SOME INTERESTING POINTS PERTAINING
TO REFRACTION.
Read in the Section on Ophthalraologv at the Fortv-seventh Annua]
Meeting of the Amerlcau Medical Association at
Atlanta. Georgia. May 5-8, 1896.
BY G. C. SAVAGE, M.D.
Professor of Ophthalmology. Medical Department Vanderbilt
University.
NASHVILLE. TENN.
It is a well-known fact that the curved, colored,
protective glass has the effect of a concave lens. The
surfaces are supposed to be parallel. A short while
ago, while teaching one of my private classes, I
decided to have the effect of such surfaces deter-
mined, both by mathematics and by the experiment
of having such a glass ground. Let the convex sur-
face of such a body have a six-inch radius of curva-
ture and the concave surface have radius of five and
seven-eighths inches; the surfaces being concentric
are one-eighth of an inch apart and parallel. "The
mathematical formula would be: (n — 1)[~(1— R)
therefore f=470 inches, and the lens is divergent.
Hence if a plain glass is bent around a cylinder it
results in an astigmatic divergent lens. If bent
around a sphere a symmetrical divergent lens."
Since the part of the human cornea in front of the
pupillary space has its two surfaces practically paral-
lel, it can be readily seen that, if the refractive
medium behind the cornea was the same as that in
front, the cornea would so refract parallel rays of
light as to make them divergent. The index of
refraction of the aqueous being almost that of the
cornea, the refraction, by means of the convex surface
of the cornea, is maintained by the aqueous.
At the same time I concluded to have a concavo-
convex lens ground, the two surfaces having the same
radius of curvature and separated one-eighth of an
inch in the center. You can readily see by moving
the glass in front of the eye, watching objects beyond
that parallel rays of light before refraction are also
parallel after refraction. ( The rays are crowded more
closely together.) That is, such a glass in effect is a
plain glass. The mathematical formula for such a
lens is: (n-l)[(l-=-R)-(l-=-R/)]=l_^f; but R =
6" and R'=6" .-. .6 ( i— i)=l-^-f=6 .\ f= oc .-. par-
allel rays will emerge parallel. Such a glass would
not only serve to protect the eye from light", but would
also be incapable of exciting any ciliary action. The
third lens is one in which the convex surface has a
six-inch radius of curvature, and the concave surface
has also a six-inch radius; these two surfaces are sep-
arated one-fourth of an inch at center. By moving
the lens in front of the eye objects beyond do not
appear to move, therefore its effect is that of a plain
glass. The mathematic formula would show that the
focus of such a lens is infinity. I suppose that even
a wider separation of these two surfaces would still
give us the effect of a plain glass.
MODEL OF AN ASTIGMATIC CORNEA.
This model is intended to illustrate the refraction of
an astigmatic cornea. The circular end represents
that portion of the cornea immediately in front of the
pupillary space. One of the two diameters of the
circle represents the
represents the meridian of least curvature
by glaucoma or conjunctival irritation, and that it while the other represents the meridian of greatest
1098
MEDICAL- EDUCATION IN THE UNITED STATES.
[November 21,
curvature. In my judgment the best way to study an
astigmatic cornea is to consider it as made up of a
spherical and cylindrical surface, each having its own
radii of curvature. There is no point of such a cornea
but that extending from it are two radii, one of spher-
ical and the other of cylindrical curvature. The radii
of spherical curvature in this model will all come to a
common point six inches behind the circle. The radii
of cylindrical curvature will be in planes parallel with
the plane of the meridian of greatest curvature, and the
radii of each plane will converge to points in a line
which is in the same plane with the meridian of least
curvature. The two sets of radii for the meridian of
least curvature are in the same plane; while the two sets
for the meridian of the greatest curvature are also in the
same plane. Each of these two meridians is an arc of
a circle and therefore has a focus. This is not true
of any other corneal meridian, for the reason that all
other meridians are parts of an elliptical curve. If
the astigmatism be vertical, and according to the rule,
parallel rays of light in the horizontal plane will be so
refracted by the meridian of least curvature as to be
brought to a focus. Parallel rays of light in the ver-
tical plane will be so refracted by the meridian of
greatest curvature as to be brought to a focus in front
of the other. The rays of light refracted by each of
these meridians will be in the same plane after refrac-
tion as before. By revolving the model so as to bring
the meridian of greatest curvature to 45 degrees the
horizontal meridian of such a cornea has its radii of
spherical curvature necessarily in the horizontal
plane. If the eye be the right one, the radius of
cylindrical curvature for the outer extremity of the
horizontal meridian will rise above the horizontal
plane, while the radius of cylindrical curvature
for the inner extremity of the horizontal merid-
ian will point below the horizontal plane. Parallel
rays of light in the horizontal plane will not be in the
same plane after refraction as before. The ray cor-
responding to the visual axis will pass through the
cornea and will strike the yellow spot of Soemmering,
not having deviated any from its original course. An
axial ray striking the temporal extremity of the hori-
zontal meridian of the cornea will be bent, in obedience
to the law of refraction, toward both the radius of spher-
ical and the radius of cylindrical curvature. Striking
the radius of cylindrical curvature above, this ray,
after refraction, rises above the horizontal plane.
Passing across to the nasal side of the retina it would
impinge above the horizontal meridian of the retina.
Another axial ray, in the horizontal plane with the
other two rays, striking the cornea at the left extrem-
ity of the horizontal meridian, beneath the radius of
cylindrical curvature would be refracted beneath the
horizontal plane. Passing across to the outer part of
the retina it would strike it beneath the horizontal
retinal meridian. These three rays of light come, one
from the middle of a horizontal line and one from
each extremity. Connect the points of impingement
on the retina by these rays and the image line must
necessarily be oblique, the nasal extremity of the
image being above the horizontal meridian, the center
of the image on the yellow spot of Soemmering and
therefore in the horizontal meridian, the outer extrem-
ity of the line beneath the horizontal meridian. In
jbedience to the law of direction the object would be
made to appear to incline to the same extent that the
image itself inclines, therefore the object would appear
to be leaning down and to the right. The reverse
would be the case if the meridian of greatest curva-
ture should be at 135 degrees; the model also shows
the relationship that exists between the radii of cylin-
drical and radii of spherical curvature for all corneal
meridians. In the two principal meridians they are
always in the same plane. In all other meridians
it is not possible for them to be in the same plane.
It is not absolutely true that every point of an astig-
matic cornea has these two radii of curvature, but it
is true that there is a resulting radius for every such
point, or, more correctly speaking, a resultant vertical.
So far as the refraction is concerned, however, it is
exactly the same as if every corneal point had the
two radii.
DISCUSSION.
A. W. Stirling, Atlanta— Dr. Savage has said that the
anterior and posterior surfaces are parallel and has founded
his argument on that. With due respect, I submit that that
is not correct. The cornea increases in thickness from the
center to the periphery, and when the pupil is dilated the rays
of light pass through a thicker part of the cornea than when it
is contracted. His would be an argument against mydriatics.
C. M. Hobby, Iowa City— The surface of the cornea is the
surface of an ellipsoid of three axes, how then can we speak of
radii of curvature? How can there be two radii to one curve?
B. A. Randall, Philadelphia — The clearness of some parts
of Dr. Savage's demonstration is due, unfortunately, to the
neglect of some of the essential factors of the problem and the
reduction of some others to too simple terms— as when he
makes his so-called "astigmatic curvature" no curvature at
all and its "radii" parallel. Were the Doctor to work out these
problems in the smoke-filled chamber with proper curvatures
to refract actual rays of light and a screen to receive the actual
results, he would be relieved of many of his misapprehensions
and could turn his abilities to more profitable fields.
Dr. Savage, closing — In the model the two principal merid-
ians of the astigmatic cornea are represented by straight lines.
but they could have been as easily represented bv^ curved lines.
What is correctly shown in the model is the radii of curvature.
The radii of spherical curvature all point to one common
center. The radii of cylindrical curvature are in planes paral-
lel with the plane of the meridian of greatest curvature, each
plane coming together in a line which is in the same plane
with the meridian of least curvature and of the same length.
While 1 am sure that astigmatism can be better understood
and studied in this way yet I am free to say that we have not
these two sets of radii, but for every point there is a resultant
radius or rather resultant vertical.
CONCERNING MEDICAL EDUCATION IN
THE UNITED STATES; A BRIEF
HISTORY.
BY FRANKLIN STAPLES, M.D.
WINONA, MINN.
In ancient times a knowledge of the art of medicine
was held by its possessors as secret, membership in
the order of physicians being restricted and obtained
only by initiation under the conditions and in the
manner prescribed. In ancient Greece the right of
the healing art was held by the order of the Ascle-
piadse; and the Hippocratic oath, among its solemn
requirements and inculcations of virtue and morality,
has the following: I will impart a knowedge of this
art to my own sons, to those of my teachers, and to
disciples bound by a stipulation and oath according
to the law of medicine, but to no others." In times
still more remote, among the Hindus the right of the
1896.]
MEDICAL EDUCATION IN THE UNITED STATES.
1099
knowledge of medicine was hereditary, confined to
the higher class, with physical and moral purity as
requisites for initiation.
In the progress of events in modern times changes
have occurred. Family succession and caste have
ceased to be the requirements necessary for admission
to the orders of the profession. This would seem to
l>e an advance; the question as to how much advance-
ment has been in the way of virtue and professional
righteousness may be considered separately.
The matter of the advancement of the standard for
the amount of scientific knowledge and practical
ability requisite to the practice of medicine has been
a troublesome one in this country for many years;
but that real advancement lias been made in the last
decade and further improvement in the future is
ired, is notable.
In 1S77. the year following that of our great Cen-
tennial Industrial Exposition, the general condition
of things in special educational lines in this country
lily set forth in an anniversary address by an
eminent professor in one of our foremost universities.'
After alluding to the evidences then shown of the
country's great progress, the speaker observed:
•'Surely candor compels us to acknowledge that in
regard to many things which are essential to a lasting
and elevated civilization, we are still far behindhand.
. . . One common thought must be entertained,
which is. that among the influences that have led to
the present state of affairs, one of the most powerful
has been the want of thorough special training and
preparation on the part of those to whom important
duties are intrusted.''
This was the view expressed concerning the condi-
tion of affairs in general at the time of the observa-
tion, and the need of improvement and reform in
general service. It was further observed: " Few
persons who are at all familiar with the subject will
be willing to express even the smallest satisfaction
with the present state of the medical profession in
this country."
The status of medical science and education, and in
part the causes of the same were mentioned as follows:
•' The ranks of the medical profession are overstocked;
only a small percentage of those engaged in its practice
are able to earn a living thereby, and worst of all, the
profession has failed to elevate its standing and
repute with the public, or to exert the powerful influ-
ence upon sanitary legislation, upon public and pri-
vate hygiene, upon education and upon similar
subjects, which is at once its duty and highest pre-
rogative." This was said by eminent authority in
the year 1887, and the truthfulness of the represen-
tation will hardly be denied by those who have given
the subject any considerable attention.
The history of medical education in the United
States from colonial times to the present is volumin-
ous; only a few facts concerning conditions and con-
cerning causes and results may be noticed. The
beginning of medical colleges in this country was in
Philadelphia in 1765. Dr. John Morgan and Dr.
William Shippen, natives of Philadelphia, were the
pioneer professors. Both had been students of Cullen
of Edinburgh, and returning to Philadelphia began
the work of teaching. The College of Philadelphia
was formed with two professorships, which comprised
all the branches; the one ''Theory and Practice of
i Prof. William Pepper, Provost I'niversity ol 1'eunsylVimia, In
"Higher Medieal Education." 1S77.
Physic," held by Dr. Morgan; the other, "Anatomy
and Surgery," filled by Dr. Shippen. This College of
Philadelphia afterward became the Medical Depart-
ment of the University of Pennsylvania. This insti-
tution is, therefore, the pioneer medical college of
America.
The College of New York was founded in 1767.
This became King's College, now the College of
Physicians and Surgeons, Medical Department of
Columbia.
A third chair in the Philadelphia school was formed
in 1768, Dr. Adam Kuhn being made the professor of
materia medica and botany. In the same year Dr.
Thomas Bond of Maryland was elected professor of
clinical medicine. Dr. Benjamin Rush in. 1769 was
elected professor of chemistry. These five professors
constituted the faculty of medicine in the college of
medicine until in 1777, when the city was occupied
by the British army.
The Medical Department of Harvard College was
organized and lectures began in 1782; that of Dart-
mouth College, N. H, in 1797. These four were the
schools of America up to the close of the eighteenth
century.
The following appears as a summary of the rules
adopted for admission and for examinations:
1. Such students as have not taken a degree in arts
must give evidence of a competent knowledge of
Latin and of certain branches of natural philosophy.
2. Three years after matriculation an examination
for the Bachelor's degree will be allowed to students
who have taken one complete course of lectures.
3. One year after taking the primary degree the
student will be admitted to the Doctorate, if he shall
be 22 years of age, shall have attended two full
courses of lectures, and have published and publicly
defended a treatise upon some medical subject.
4. The mode of examinations shall follow that of
the most celebrated universities of Europe.
An announcement of the College of Philadelphia
was made in 1789, signed by Benjamin Franklin as
President of the Board of Trustees, and by William
Smith as Provost of the College, in which the require-
ments for the degree of M.D. were somewhat extended,
specifying that the candidate must have been the
pupil of some respectable practitioner for the space
of three years: also specifying the departments in
which he must have received instruction in the col-
lege, and providing for the written or printed thesis,
in Latin or English at the student's option. At this
time a requirement was also made for "attendance
upon one course of clinical lectures, and on the prac-
tice of the Pennsylvania Hospital one year," this
being the first of clinical instruction in the required
curriculum.
The first medical degrees conferred were of Bach-
elor of Medicine. The first of these were granted in
Philadelphia in 1768 and in New York in 1769. The
first degree of Doctor of Medicine was conferred in
New York in 1770 and in Philadelphia in 1771.
Such, in brief, were the means of medical educa-
tion and the requirements for graduation in medicine
from the early colleges and for admission to the pro-
fession in the American colonies before the war of
the Revolution.
At the time of the beginning of the revolutionary
war in 1775, the general situation is given as follows:
There were in the colonies about three million peo-
ple, who were distributed over a vast extent of terri-
1100
MEDICAL EDUCATION IN THE UNITED STATES.
[November 21,
tory. It has been estimated that there were for this
number of people between 3,000 and 3,500 engaged in
the practice of medicine. Of these, it has been esti-
mated that about 400 had received the degree of M.D.,
and that most of these were from European institutions.
The Philadelphia and New York colleges had con-
ferred fifteen medical degrees prior to the year 1776,
when active operations were suspended by the prog-
ress of the war.2
THE FIRST MEDICAL LEGISLATION.
Concerning the first laws enacted by the colonists
to define the qualifications of physicians, Dr. Davis
has the following in his "Contributions to the His-
tory of Medical Education": "The general assembly
of New York in 1760 ordained that 'no person what-
soever should practice as physician or surgeon in the
city of New York before he shall have been examined
in physic and surgery, and approved of and admitted
by one of His Majesty's counsel, the judges of the
supreme court, the king's attorney general, and the
mayor of the city of New York, for the time being, or
by any three or more of them, taking to their assist-
ance for such examination such proper person or per-
sons as they in their discretion shall see fit.' Such
candidates as were approved, received certificates con-
ferring the right to practice physic or surgery or both
throughout the whole province; and a penalty of £5
was prescribed for all violations of this law. A simi-
lar act was passed by the general assembly of New
Jersey in 1772."
The history of medical education in our country
for almost the whole of the first century of our
national existence may be briefly outlined as follows :
As the population of the country increased and
extended over the vast territory of the United States,
medical colleges were rapidly multiplied. In absence
of governmental restriction, control and support, teach-
ing schools were liable to be organized with power to
confer degrees wherever a few physicians were found
who were desirous of forming a "partnership for tht,
business. While a few of the colleges were so located
as to be able to command good talent in the corps of
instructors and good facilities for clinical and labora-
tory work, yet with many it was otherwise. Many
were either located where good facilities were not
available, or were under the management of a faculty
whose members were incompetent as instructors. The
support of the school and the compensation of the
professors were dependent upon the number of pupils.
With the kind of competition incident to this state of
things it was found difficult to elevate the standard
of qualification necessary for admission to the medical
course, or to that of a degree. A few good men
representing the higher grade schools made efforts
from time to time to move forward, but not always
with the desired success. A notable and illustrative
instance is referred to in an address in 1892 by the
eminent provost of the University of Pennsylvania,
who, referring to the record of the anniversary sixteen
years before, and the reflections then made on the
degeneracy of medical education, gave the history in
words as follows: "We thought of that bitter expe-
rience in 1846, when in accordance with the earnest
recommendation of the American Medical Associa-
tion, the University of Pennsylvania bravely extended
her term of study, only to find that in spite of their
specious assurances, not a single one of her rivals
2 Contributions to the History of Medical Education and Medical
Institutions in the U.S., 1776-1876, by N. S. Davis, M.D., LL.D.
emulated her courage; so that after six discouraging
years of steadily diminishing classes, she sorrowfully
abandoned her advanced position. We thought, too,
alas! of the long and painful controversy lasting
almost five years over the proposition to again elevate
our standard of medical education, and of how the
end had been attained only at the cost of old friend-
ships and of the allegiance of valued associates whose
convictions remained as to the injury that would be
worked to the university by the proposed advance."'
This was said by the learned professor with reference
to experience in the past, in full view of a far better
state of things at the then present, and of still better
prospects for the future which is now at hand. Gen-
eral and professional public opinion has been slow in
coming to its present understanding and position.
The more important causes of the slow progress in
medical education, with suggestions for their removal,
the diagnosis, a little of the pathology and indications
for treatment, are contained in the following words of
President ' Eliot of Harvard University, said in an
address, I think, in 1892, and published in the British
Medical Journal. The points made were as follows:
1, that it is a clear disadvantage in medical education
that the degrees given by the faculty, a teaching
faculty, should admit to membership in the profes-
sion and so to the legal right to practice medicine: 2,
that the standard for membership, giving right to
practice, should be made by law outside the teaching
powers.
President Eliot further observes: "The salary of
a full professor in the medical school is lower than in
any other department of the university." This, he
thinks, is not as it should be and speaks of it as
our English inheritance. He says "From England
we have inherited a lower standard of general educa-
tion in the medical profession, a lower standard for
admission to that profession and a lower standard of
training for the entering upon the duty of medicine.
On the continent they do things far better, and it is
to be regretted that we have not substituted the con-
tinental for the English standard."
This was from the eminent president of Harvard in
1892. His conclusions and practical suggestions were
summed up as follows: "We have obtained for the
medical profession a higher standard in the commu-
nity, but we have still to make proper the standard of
preliminary requirement for admission to the medical
schools, so that they may be equal to the schools of
law and theology."
THE SLOW PROGRESS.
During most of the long period since the beginn-
ing in colonial days and until quite recent years, no
enlargement of requirements in studies and time
were made by the schools. This the most of us now
in practice know from our own observation. Com-
paring the curricula of comparatively recent years
with those of the early times, we see but little differ-
ence. Moreover, the competition instituted and
maintained especially by the lower grade of schools,
effectually rendered null some of the requirements
that were effective in the beginning. This was seen,
for instance, in the total disregard for any standard of
qualification for admission to the college. An una-
voidable evil existed in the fact, that a diploma from
the school of the lower grade was just as good, legally,
as that obtained at greater expense and better appli
cation at the higher institution.
1896.]
MEDICAL EDUCATION IN THE UNITED STATES.
1101
^ This condition of things in free America causes the
United States to be the nation with the largest pro-
portion of physicians and of medical colleges to the
Dumber of inhabitants, of any in the world.'
It is not asserted here that continual progress has
not been made in this as in other countries in the
arts and sciences pertaining to medicine. The reverse
is known to be true, and the discoveries and inven-
tions of the period have been an important means in
promoting the more recent advancement in the higher
medical education.
The following language of a late professor in Har-
vard University is expressive of the truth:
• It is not an extravagant assertion to say that in
all this turmoil, change and progress, medicine has
kept abreast of the other natural sciences, of politics,
and of theology, and has made equal conquests over
authority, error and tradition. If this statement seems
extravagant, it is to be recollected that the brilliant
discoveries in natural sciences and the arts, the great
political changes, and the vacillations of long estab-
lished faiths to which we have referred, influence so
obviously the fate of nations and the aspects of civil-
ization, that they force themselves prominently upon
our attention: while the progress of medicine is silent
and unobserved. Yet the progress and changes of
the latter are not less real than those of the former,
and. perhaps, affect more profoundly than they the
development of civilization and the welfare of the
human race. During the past century, medicine has
been enfranchised from superstition, quasi-charlatan-
ism. bald empiricism and speculation, and has devel-
oped into a symmetric science, affiliated with the
other natural sciences, studied by the same methods
and the same appliances as they are, and, like them,
has been planted upon the solid basis of facts and
demonstration; pathologic anatomy, starting from the
"de Sedibus"of Morgagni and the labors of Baillie, and
illustrated by the later researches of Rokitansky and
others, has become a fundamental branch of medical
science : obstetrics, rescued from the hands of igno-
rant midwives, has been raised with its allied branch,
gynecology, to its legitimate position as a science;
preventive medicine and hygiene, cultivated to an
extent previously unknown, have prolonged the aver-
age of human life; organic and physiologic chemistry
have been substantially created, and achieved import-
ant and brilliant results; physiology has grappled with
the abstrusest problems of the structure of life, and
has revealed so much as to make timid people tremble
at the audacity of its efforts."*
This was said in the year 1876. The great discov-
eries and advances in scientific research since that
time, especially in bacteriology, asepsis, antiseptic
means, the modern possibilities in operative surgery,
and in the great field of preventive medicine, are not
unknown to us.
STATE LEGISLATION AND ITS RESULTS.
The State of Illinois has the credit of first estab-
lishing by law a standard of requirements for practice
in the State.
In June, 1880, the Illinois State Board of Health
appointed a committee to formulate a scheme of edu-
cational requirements and characteristics by which to
determine the good standing of medical colleges.
This step was taken in order to enable the Board the
I Statistics in " lliuher Medical Education." by William Pepper.
« A Century of American Medicine, 1770-1876, by Edward II. Clarke,
M.D.. A. A. S.— Harvard.
better to discharge the duty devolved upon it by the
act to regulate the practice of medicine in the State
of Illinois; and by which act the Board is directed to
"issue certificates (entitling to practice) to all who
furnish satisfactory proof of having received diplo-
mas or licenses from legally chartered medical insti-
tutions in good standing." A schedule was prepared
by the committee, and subsequently formally adopted
by the Board, as the standard entitling to recognition
as the basis for legal qualification for practice in
Illinois.
The first act regulating the practice of medicine in
the State of Minnesota became operative in March,
1883. It was the form of legislation in force in Illi-
nois. Five years later this law gave place to the
present law, which requires an examination by the
State Board of all persons commencing the practice
of medicine in the State, and, as now amended, the
minimum requirements demand that all graduates of
later date than 1898, furnish evidence of having
attended at least four courses of lectures in different
years, of not less than six months each. Other States
have enacted laws with similar requirements, and so
large a number of the States of the Union now have
medical practice acts, defining the requirements for
admission to practice in the respective States, that
such medical schools as would otherwise refuse to
advance, must be compelled to come up to the higher
standard or go out of the business. This movement
shown in the passage of state laws to such an extent
throughout the country, is ominous in that it speaks
of advance in public opinion and knowledge in scien-
tific matters. It is this that has made state medicine
what it now is in this country.
With the educational prospects which we now have,
with the present advanced pathology, with our able
teachers thereof in the medical schools, laboratories
and hospitals, in Philadelphia, Baltimore, New York,
Boston and Chicago, with the world's present knowl-
edge of the means and importance of cleanliness in
medicine and surgery, and with our rapidly increasing
knowledge of the means of prevention of disease in
the land, as medical men we are able to rejoice in the
present and hope well for the future.
The literature of medical history and medical edu-
cation is important. The English writer, Dr. Edward
Berdoe, speaks of the works of Sprengel , Hasser,
Baas, Puschmann, and observes, that " many others
of the same class sustain the claim that Germany has
created the history of medicine, while the well-known
but incomplete treatise of LeClerc shows what a great
French writer could do to make this terra incognita
interesting." Of English writers, we have the works
of Drs. Berdoe and Withington, and other English
contributions in special departments. In this country
are published the works of Joh. Hermann Baas, trans-
lated into English by Dr. H. E. Handerson of Cleve-
land, Ohio; and the " History of Medicine from the
Earliest Ages to the Nineteenth Century," by Robley
Dunglison, is still extant.
" Contributions to the Annals of Medical Progress
and Medical Education in the United States, before
and during the War of Independence," by Joseph
M. Toner, M.D., was published in 1874. " History of
American Medical Literature," an address by Samuel
D. Gross, M.D.. appeared in 1875. " Contributions to
the History of Medical Education and Medical Insti-
tutions in the United States of America, 1776-187(5,"
by Nathan S. Davis, M.D., in 1877. " Medical Edu-
1102
SOCIETY PROCEEDINGS.
[November 21,
cation, Extracts from Lectures before the Johns Hop-
kins University, 1877-78," by John S. Billings, M.D.,
in 1878.
Beside, many anniversary addresses at college com-
mencements and before learned societies have from
time to time made additions to the literature of med-
ical education in this country. What is done in the
medical and surgical practice of to-day, is recorded in
our hospital reports, in medical journal correspondence
and in the practical works of American authors.
RACHITIC CHEST DEFORMITY IN TWINS,
WITH EXHIBITION OP CASTS.
Preseuted in the Section on Diseases of Children, at the Forty-seventh
Annual Meeting of the American Medical Association, held
at Atlanta. Ga.. May 5-8. 1896.
BY W. J. BELL, M.D.
EX-ASSISTANT RESIDENT PHYSICIAN OF NKW YORK INFANT ASYLUM.
ATLANTA, GA.
These cases are presented because they are unique.
They were twins, the mother being a hunchback.
The deformity is very nearly alike in the twins. They
died of atelectasis and pneumonia at the age of fifteen
months. In the case of Sarah Coy, we found a small
strip of lung tissue on the left side, the other being
of an atelectic character. The other lung was slightly
encroached upon. This child just previous to death
weighed eight and one-quarter pounds. Its breath-
ing in best physical condition was eighty to ninety
per minute, and the respiration during the last illness
ran up as high as one hundred and twenty per minute,
practically panting. A line drawn through the chest,
directly from the central portion of the sternum,
would have pierced the inner angle of the cartilages
of the ribs as they were bent in, in each case. The
other case is of a boy, weight seven and one-half
pounds at the time of death. The two cases were
almost exactly parallel. They were each subject to
frequent bronchial attacks. The respiration in the boy
was a little more rapid than in the other; the last illness
gave a respiration that could hardly be counted.
Dr. Byers— How about the limbs?
Answer : There were some evidences of rickets about joints.
The head of the girl showed a slight rachitic square shape, and
the sutures were only partially closed.
Question : Was the chest born that way?
Answer : It was slightly deformed. I did not see the chil-
dren until about the third month and there was a slight sink-
ing in at that time, which seemingly increased until their death.
Question : Is there any such thing as congenital rickets?
Have you noticed such a thing?
Answer : I have heard reports of such cases, but never saw
a ease. These cases occurred in the New York Infant Asylum.
I made molds for these casts over the bodies of the children,
so they are exact reproductions of the chest.
SOCIETY PROCEEDINGS.
Southern Surgical and Gynecological Asso-
ciation.
Abstract of the Proceedings of the Ninth Annual Meeting,
held in Nashville, Tenn.,Nov. 10-12, 1896.
First Day — Morning Session.
The association met in the auditorium of the Nicholson
House, and was called to order by the President, Dr. E. S.
Lewis of New Orleans, La.
An Address of Welcome was delivered by the Hon. John
Bell Keeble of Nashville, which was responded to by Presi-
dent Lewis.
There were fifteen new members elected, after which the-
reading of papers was proceeded with.
The first paper was read by Dr. W. D. Haggard, Jr., of
Nashville, Tenn., entitled
VAGINAL VERSUS ABDOMINAL SECTION 1'OR PDS IN THE PELVIS.
He recounted the transitional periods in the treatment of pus
in the pelvis : Vaginal puncture superseded by abdominal sec-
tion and removal of pyosalpinx, total uterine castration per vag-
inam by the French and through the abdomen by the American
school. They have reluctantly given way to modern vaginal
section and evacuation and drainage of all pus pockets. It is
a distinctly American innovation and will revolutionize the
results in pus disease. The abdominal route affords visual
inspection of the field. The attack on morbid masses can be
made with safety to visceral integrity. If pus accumulations
are multiple, rupture and peritoneal soiling are inevitable ; that
is the supreme disadvantage of abdominal incision. He had
often seen the pelvis deluged with pus with impunity. He had
also seen patients die within twelve hours from fulminant sep-
sis, from peritoneal contamination. The cases perishing from
sepsis on the third day are classical. There is no way of dis-
tinguishing these cases clinically. All should be regarded as
virulent. The writer referred to a mortality of 18.5 per cent,
in a series of collected cases of laparotomy for pus, done in five
metropolitan hospitals in the last year, and asked what must
it be in the "unheard from precincts" and in the hands of the
great unwashed? The abdominal method offers the best
approach in tubercular inflammation of the ovaries and tubes
and in small unilateral pus tubes.
The author referred to the advantages of exploring the pelvis
for retrouterine tumors, inflammatory, and adnexa by vaginal
section. The geography of pus in the pelvis in most cases
makes vaginal incision extraperitoneal, a minor procedure
giving major results; no shock, no risk, no disturbance in
convalescence. Patients will submit to it who will refuse more
formidable procedures. We can change the methods, but we
can not change the patient. In prolonged sepsis from huge
abscesses posterior section and drainage are a life-saving pro-
cedure. The special indications are in : 1, early cases of acute
suppurating salpingitis ; 2, incipient post-puerperal peritonitis :
3, large pyosalpinx and true pelvic abscess. The first group
includes early gonorrheal and abortion cases. The essayist had
incised a tense tube and let out serous fluid and curetted a
gonorrheal case of a month's standing with pain, temperature
and tenderness for three days. The opposite tube was normal.
In a week that tube became similarly affected and was simi-
larly treated. He believed those serous effusions in the Fallo-
pian tube were the preceding pathologic condition to pyosalpinx.
If this be true and is the embryonal history of suppurating
salpingitis in early gonorrheal and other inflammatory cases,
the prophylactic value of vaginal section will be the greatest
boon yet given to infected woman. In puerperal cases, incipi-
ent peritonitis and puddles of pus in Douglas' space impera-
tively demand incision. Should simple pus letting in any of
these cases not effect a cure, subsequent operation for removal
of the relics of previous ravages can be done without the dan-
gers incurred in the presence of pus. The field of vaginal sec-
tion is to prevent suppuration in early cases, to anticipate it in
puerperal cases and to save life in desperate cases. It is simple,
surgical and safe. Its application to the pelvic inflammatory
processes and to pus in the pelvis is one of the greatest surgical
triumphs of the age.
Dr. Joseph Tabeh Johnson of Washington, D. C, said that
while the vaginal method had a great many points in its favor
and was being resorted to more and more in cases of large pus
collections in the pelvis, yet those who had been familiar for a
considerable time with the abdominal route could operate more
conveniently and dextrously by this method and with greater
safety to the patient than by the vaginal method. He could
not agree with the speaker that the vaginal operation may be
done without any risk or damage to the patient. Sometimes
in operating through the vagina for the purpose of removing
the uterus and its adnexa, or for large pus collections high up
in the pelvis, where it is necessary to manipulate the parts a
good deal and to do a thorough enucleation, the surgeon was
likely to tear the intestines, the bladder, the ureter, or rupture
a large vessel which is out of sight. In such cases the abdom
inal is much safer than the vaginal route. However, the
vaginal method had much to commend it in cases of pus col-
lections that are low down in the pelvis.
Dr. Charles P. Noble of Philadelphia believes we should
practice a judicious eclecticism. He did not feel that either
the abdominal or the vaginal method possessed all the advant-
ages, but if restricted to one or the other he should choose the
abdominal rather than the vaginal route. An objection form-
L896.]
SOCIETY PROCEEDINGS.
1103
erly urged against the abdominal route was the large per cent,
of hernias which followed this method. Only a week since he
had tabulated the operations he had done for four years, which
amounted to 397 abdominal cases, in which he had used the
buried suture in closing the abdominal wound. Of this num-
ber seven of the wounds suppurated, while 390 healed by pri-
mary union. Of the seven which suppurated, one had a
hernia. Of the 390 cases, one had a large umbilical hernia.
Aside from these two cases he has not had any hernias in his
operative work for the last four years, particularly where the
buried suture was used. If the patient is in a condition to per-
mit the surgeon to do ideal work, the question of hernia was
such an insignificant one that it might be left out of consider-
ation. The matter of hernia following abdominal operations
was one of the stock arguments against the abdominal method.
The next objection raised against the abdominal method was
the great amount of shock as compared with the vaginal. His
experience has been that unless the gynecologist operates on
the desperately bad cases, shock played a small rdle in abdom-
inal work. In short, he had had more shock following vaginal
than abdominal operations.
Dr. Howard A. Kelly of Baltimore said that, whenever
possible, pus in the pelvis should be treated by vaginal punc-
ture or section posterior to the cervix, without sacrificing any
of the uterine appendages. A large percentage of the cases
thus treated would have no future discomforts. Illustrative
cases were cited. One of the principal arguments advanced by
advocates of the vaginal route in removing the uterus, tubes
and ovaries was the excellent drainage that could be secured
by this method. In Dr. Kelly's opinion it is unnecessary to
take out the uterus to get drainage. By making an incision
posterior to the cervix and breaking up adhesions free drainage
could be established.
Dr. L. S. McMuktrv of Louisville said a deep impression
had been made upon the profession in the last few years by
the vaginal method of operating for pus in the pelvis. The
procedure, however, was by no means a new one, but had
simply passed out of the minds of the profession of this coun-
try for a time, it having been superseded by the abdominal
method, but had been recently revived. Battey, in his origi-
nal operations upon the ovaries, attacked the pelvic organs
through the vault of the vagina. The method of attacking
accumulations of pus in the pelvis by vaginal puncture and
drainage, practiced by Kelly as far back as 1889, was the uni-
versal practice of abdominal surgeons for a long time. The
sacrifice of the uterus in the majority of cases of suppurative
pelvic inflammation was unnecessary. While there were
undoubtedly puerperal cases with suppurative pelvic inflam-
mation, where it was necessary to remove the uterus, it was
not so to such an extent as to make it a rule that this organ
should be taken out. Surgery should be confined within the
limits of removing only such diseased tissue or organs as are
Bary for the complete cure and restoration of the patient.
Dr. J. Wesley Bovee of Washington, D. C, objected to
anterior colpotomy in dealing with pus cases, unless the accu-
mulation of pus was on top and in front of the bladder. He
thought these cases could not be drained through the anterior
vaginal route, and the pus could not be reached in many cases.
He believes it is not necessary to remove the uterus at the
same time pus tubes are taken out. He had seen cases where
there was an abscess of the ovary, an abscess of the Fallopian
tube and another alongside of each ovary, with three separate
cavities on one side. By draining one a large quantity of pus
could be evacuated, and perhaps in some cases this would be
all that was required. He did not want to be understood,
however, as being opposed to the vaginal route in very urgent
cases.
Dr. R. B. Maury, of Memphis, had, during the last two years,
made it his duty to thoroughly study the subject of vaginal
hysterectomy, as he had done quite a number of these opera-
tions without any mortality, without any accident, or unpleas-
ant results. But he would not undertake to say that we ought
to substitute it for laparotomy. Both abdominal and vaginal
hysterectomy were operative measures that surgeons must avail
themselves of according to the circumstances of the case. Dr.
Maury then cited the histories of two cases that he had treated
within the last 30 days, which beautifully illustrated the advan-
i of the two methods.
Dr. W. E. B. Davis, of Birmingham, Ala., said the practice
of incising pelvic abscesses was so old that it hardly required
discussion, but the method of attacking pus tubes by vaginal
section was comparatively recent. Unquestionably vaginal
incision for pus confined to the tubes and ovaries would save
these important organs in a good ijroportion of cases. In all
cases of large pus collections in the pelvis, nothing should be
done more than to incise the abscess and drain, and then later
on the surgeon should be prepared to do an abdominal section
if necessary, but he would rarely find occasion to do this. Total
ablation of the uterus and its adnexa was unnecessary in many
instances in which it was practiced by some surgeons.
CHOLELITHIASIS.
A paper on this subject was contributed by Dr. A. M. Cart-
lkdgk, of Louisville, in which the author reported several inter-
esting cases. He dwelt upon cholecystostomy and cholecysten-
terostomy, pointing out the indications for each operation. He
considered cholecystostomy as the only operation applicable to
the cases cited. In his opinion there were no cases that pri-
marily demanded cholecystenterostomy. He was not prepared
to say that cholecystenterostomy with the use of the Murphy
button was good surgery, nor that the button was free from
danger.
Dr. James McPadden Gaston, of Atlanta, agreed with the
essayist that in ordinary cases of gallstones in the gall bladder
with obstruction of the cystic duct, the simplest procedure was
to lay open the abdominal wall, attach the gall bladder to the
incision, and remove the gallstones. But in a large proportion
of cases of complete obstruction he doubted whether there
would be restoration of bile through the cystic duct into the
gall bladder. Relative to the comparative value of cholecystos-
tomy and cholecystenterostomy, the two operations were appli-
cable to entirely different conditions. No one would operate and
expect benefit from a cholecystostomy except to establish drain-
age for the bile in a case of permanent occlusion of the com-
mon duct, and this was the only condition in which the advo-
cates of cholecystenterostomy had ever claimed anything for it.
Dr. John D. S. Davis, of Birmingham, emphasized the point
that patients frequently have gallstones without symptoms,
more particularly jaundice. He does not believe that it is ever
wise to resort to cholecystenterostomy as a primary procedure.
The surgeon should first resort to drainage, and then if relaxa-
tion does not take place and the flow of bile is not affected, a
cholecystenterostomy should be done.
Dr. George Ben Johnston, of Richmond, Va., spoke of the
diagnosis of gallstones. He is convinced that if examinations
of suspected cases of gallstones were as careful and minute as
they should be, surgeons would frequently find them. It has
been his experience that enlargement of the gall bladder does
not always occur where a gallstone exists, but that a condition
which simulates enlargement of the gall bladder frequently
does exist, this condition being due to the presence of numer-
ous dense adhesions found in the neighborhood of the gall
bladder, gluing it to every tissue with which it comes in con-
tact. One thing which struck him as very singular in connec-
tion with the presence of gallstones was that the size of the
stone or stones seems to make no difference in the production
of symptoms. In regard to hemorrhage, it is generally admit-
ted that in cases in which cholemia is profound, they are the
ones in which we are to expect hemorrhage and by no known
method can this hemorrhage be successfully controlled. The
cholemic condition seems to invite a fatal hemorrhage. The
experience of operators in this field of surgery is that when
cholemia is profound, hemorrhage of a fatal character is to be
expected. He considers cholecystostomy a proper procedure
in all cases, except in those where the obstruction is in the
common duct and can not be relieved.
Dr. W. E. B. Davis of Birmingham, said surgery of the gall
bladder for the removal of gallstones had given quite brilliant
results, but there were still questions in regard to operative
procedures on the ducts that were not as yet definitely settled.
He did not believe the essayist referred to cholecystostomy as
being the choice of operation in a case where the obstruction
of the duct could not be removed ; that he must have had in
mind the procedure advocated by Murphy of resorting to this
operation in a case of stone in the gall bladder where there
was no obstruction in the duct. Murphy resorts to cholecys-
tenterostomy instead of cholecystostomy, and he thought the
essayist did not intend to convey the idea that he would not
do a cholecystenterostomy where the obstruction in the duct
could not be removed. Cholemic cases were bad to operate
upon. Perhaps in not more than 5 or 6 per cent, of the cases
is the obstruction found in the common duct. Some years
ago the author made experiments which conclusively showed
that the surgeon could incise the duct and drain with gauze
without peritonitis following this procedure. A paper on this
subject was read by him before the American Medical Asso-
ciation in 1892, since which time he had done further experi-
mental operative work in which sutures were not used after
the stone was removed from the duct, and while several of the
cases were already very nearly dead from cholemia and
eventually died, yet in the cases in which this method was
resorted to the abdominal cavity was walled of and peritonitis
did not result.
1104
SOCIETY PROCEEDINGS.
[November 21,
Dr. George A. Baxter of Chattanooga, directed attention
to the frequency of gallstones unattended with the ordinary
symptoms of pain or colic, and cited an illustrative case in
which there were found, postmortem, three large stones in the
gall bladder.
Dr. F. W. McRAEof Atlanta, cited a case in which there were
repeated attacks of colic with profound cholemia. An opera-
tion was undertaken with the idea that the obstruction was in
the common duct, and that there were stones in the gall
bladder. On opening the abdomen in the presence of several
physicians he found the liver much enlarged and reaching
almost to the umbilicus, but instead of finding the gall blad-
der enlarged, he found a fibrous cord not larger than his index
finger. The common duct from disuse was reduced to a mere
cord. A calculus was found in the hepatic duct, extending up
into the transverse fissure of the liver. He did not know what
to do for a case like this, and after consultation with his col-
leagues closed the abdomen. The patient died five days later
from exhaustion. If anything could be done for such patients
he would like to know it.
First Day Afternoon Session.
Dr. John T. Wilson of Sherman, Texas, read a paper
entitled
MENTAL COMPLICATIONS FOLLOWING SURGICAL OPERATIONS.
The subject of mental disorders produced by or following
surgical operations has not been discussed to any great extent,
and until within the past few years only a passing notice was
given it. It is a strange fact that while surgical operations
will sometimes cause serious mental disturbance, on the other
hand, these same operations will sometimes cure them ; espe-
cially is this the case with some melancholiacs. Many females
laboring under attacks of melancholia caused by some disease
of the genital apparatus, have been cured when relieved of the
physical defect by operation ; others have been much improved,
and yet some have received no benefit. The question may very
properly be asked why a surgical operation should produce an
attack of insanity. This can no more be answered in every
case satisfactorily than can the question why some persons
become insane from the many other causes to which it is
attributed, for in most cases these mental complications are a
surprise and no good reason can be given why they should fol-
low. In others, however, a logical explanation might be had.
If the patient is a high-strung, nervous individual, easily
excited, unable to bear pain, the great and increasing dread of
the anesthetic, the operation, or both, will so affect him that
he will lose control of the will power and the explosion will
come after the operation and reaction from the anesthetic. In
many of these cases, probably a majority, there is an heredi-
tary taint or a strong neurotic tendency.
The author quoted Mairet, who thinks, 1, that it is in those
individuals who are predisposed by heredity or other grave
causes— alcoholism, infectious diseases, etc., that surgical oper-
ations give rise to insanity ; 2, in the constituent elements of
an operation that might act on the brain were two most impor-
tant ones, namely, the anesthetic and the degree of surgical
traumatism with its after-effects, of which disturbed nutrition
plays a very important part: 3, when predisposition also is
considerable the anesthetic alone may produce insanity, or it
may result even after minor operations. It is necessary to
take into consideration the mental state of the patient prior to
the operation, especially in those graver ones where questions
of life or death are frequently involved.
Dr. E. S. Lewis of New Orleans related the case of a woman,
40 years of age, very hysteric, upon whom he had operated
for laceration of the perineum. She had manifested no evi-
dences of insanity prior to operative interference, but during
convalescence the hysteric manifestations increased and were
associated with delusions. Her condition became so serious
that on different occasions she threatened to commit suicide.
She was transferred to an insane asylum, and after a thorough
examination by the physician in charge an unfavorable prog-
nosis was given. Investigation of the family history showed
traces of insanity.
In another case, a woman 60 years of age, he removed a very
large adherent ovarian tumor. The operation was attended
with considerable shock. For a few days subsequently the
patient did very well, had no fever during convalescence, but
she later became perfectly insane. These were the only two
cases he vividly remembered, although he had seen cases of
temporary insanity after operations which had passed off fn the
course of a few months.
Dr. W. E. Parker of New Orleans had seen two or three
cases of insanity in men following surgical operations, but had
never been able to trace any history of insanity in the family.
The insanity occurred in alcoholic cases. Two of the men
either took cocain or morphin. In the management of such
cases the particular drug to which the patient was addicted
should still be continued in very small doses, being cut off
gradually, not suddenly, as great prostration often follows the
interdiction of a habit that has continued for a number of
years.
Dr. R. B. Rhett of Charleston, S. C, had met with three
cases of post-operative mental aberration. The mental aber-
ration occurred in two old women after removal of the breast
for cancer. A third case occurred in a young woman who had
had puerperal insanity prior to operation. In two instances
the insanity lasted for three days, in the other three weeks.
Dr. A. M. CARTLEDGEof Louisville said the question of post-
operative insanity led us to discriminate as to the probable eti-
ology in many of the cases. He thought the author of the
paper had in mind to deal with those cases of post-operative
insanity supposed to be more or less functional in character,
rather than those suffering from the mental impression pro-
duced by the operation in general. He was quite sure most of
the cases, except those characterized by hereditary tendencies
and traits, could be traced to some organic lesions. The his-
tory of the case should always be thoroughly investigated. He
had only encountered what he considers pure post operative
insanity in two cases. One patient had been in an insane asy-
lum four years previous to operation and had developed subse-
quently a pus tube. Just before operation the patient seemed
perfectly rational, but on the third day thereafter a violent
mania developed which terminated fatally. The other case of
insanity occurred in an unmarried woman, 38 years old, from
whom he had removed an ovarian cyst.
Dr. John D. S. Davis considered the matter interesting from
a medico-legal aspect. No surgeon was absolutely free from
such mental complications occurring in his operative work.
He had encountered four cases. In one case, a young man,
there was no history of insanity, but an analysis of the urine
showed a great many casts and a slight trace of albumin before
operation. Operative interference was followed by acute mania
which lasted seven days, then disappeared, and the patient
recovered. He would like the essayist, in closing, to touch
upon the responsibility of the surgeon in this class of cases.
Dr. Joseph Taber Johnson said that in talking with Drs.
Kelly and Noble, he learned that the latter had met with eight
cases of insanity following operations upon the perineum. He
asked the essayist to state whether perineal operations were
more frequently followed by insanity than others.
Dr. Wilson had seen a number of cases of various forms of
insanity following surgical operations, but does not think the
disease occurs more frequently after operations upon the
perineum and genitalia than any other part of the body. In
answer to Dr. Davis' question, he does not think the physician
is any more responsible for the death of a patient from insan-
ity following an operation than he is for death following any
other operation. He had never heard of a suit of malprac-
tice being brought against a practitioner for a case of men-
tal derangement from a surgical operation.
Dr. George Ben Johnston of Richmond, Va., followed with
a paper on
SPLITTING THE CAPSULE FOR THE RELIEF OF NEPHRALGIA.
He drew the following conclusions : 1. Nephralgia is not
always associated with a demonstrable lesion. 2. When other
evidences of kidney disease are wanting the pain is due to a
too tight capsule. 3. Nephralgia may and frequently does
simulate symptoms of gross tissue changes or mechanical irri-
tants. 4. Where severe and persistent pain in the kidney exists
without other evidences of renal disease, exploratory operation
is indicated. 5. When inspection, palpation and needle punc
ture fail to disclose a condition sufficient to account for the
pain, the capsule should be freely opened.
URETERO- URETERAL ANASTOMOSIS.
Dr. J. Wesley Bovee of Washington, D. C, read a paper
on this subject and reported an interesting case. The author
dwelt at length upon the literature of the subject, quoting from
the contributions to the surgery of the ureters by Van Hook,
Fenger, Kelly and Cabot in this country, and the classical work
of Glantenay, Liaudet, Tuffier and others in Europe. He
drew the following conclusions; 1. Uretero-ureteral anasto-
mosis is a perfectly feasible procedure. 2. Uretero-ureteral
anastomosis, whenever possible, is far preferable to any other
form of ureteral grafting, to nephrectomy and to ligation of
the ureter. 3. Itshould be done preferably by lateral implanta-
tion or by oblique end-to-end anastomosis, though the trans
verse end-to-end, or the end-in-end methods may be safely
employed. 4. That constrictions of the caliber of the ureter
do not usually follow attempts at suturing in closure of corn-
's.
ht
S
1896.]
SELECTIONS.
1105
plete transverse section of the duct. 5. That nephrectomy for
transverse injuries of the ureter per ae is an unjustifiable oper-
ation, ti. That simple ligation of the ureter to produce extinc-
tion of the function of the kidney is too uncertain to justify its
practice. 7. That drainage is not necessary if the wound be
perfectly closed and the tissues throughout are aseptic.
Dr. Howard A. Kelly was very much interested in this sub-
ject and said every abdominal surgeon should be familiar with
uretero cystectomy or uretero-ureteral anastomosis, because
in doing abdominal operations the surgeon was liable at any
time to injure the ureter, when he would be confronted with
the necessity of doing something to repair it. Dr. Kelly then
pointed out the various ways in which the ureter might be cut
during operations and described the method he pursues in
repairing such injuries.
Dr. Charles P. Noble cited a case of neglected extra uter-
ine pregnancy complicated with an intraligamentous ovarian
tumor. In operating, the intestines were apparently adherent
over a mass of blood and a large fleshy adhesion ran up on it.
To save time this was clamped, cut through and the pelvis
cleaned out. It was necessary to do a hysterectomy in order
anything to tie as the anatomic landmarks were obliter-
ated on both sides of the pelvis. Furthermore, the broad liga-
ments did not come down in the usual way. When the opera-
tion was completed the patient was in collapse, and it was
found that what was supposed to have been a fleshy adhesion
was really the ureter and thickened peritoneum. The ureter
was cut off almost up to the kidney itself. The lower part of
the ureter was taken out with the mass of blood, there being
only the upper three or four inches of the ureter left. Had
any attempt been made to prolong the operation with the
patient in collapse, death would have resulted. Although the
meter was short, it was dragged up into the upper end of the
abdominal incision. It was impossible to do a uretero-ureteral
•mosis, likewise to switch the ureter into the bladder,
because it did not reach anywhere near the brim of the pelvis,
much less the bladder, and there was nothing else to do but to
remove the kidney, which Dr. Noble did, and the patient
recovered.
( To be continued. )
SELECTIONS.
Maragiiano's Sero-Tberapeutics of Tuberculosis. -The Gazzetta
degli Osp. « defle ( 7m., of October 18 and 20, contains Marag-
iiano's latest report. The number of cases treated is more than
71:!, but he includes only those of which he has personal knowl-
edge. And first he announces that the harmlessness of the
serum treatment is now established beyond question. The
occasional transient cutaneous and thermal disturbances are
trifling, and the rare instances of vasomotor phenomena,
resembling angina pectoris (nine cases in all), are also tran-
sient and without after-consequences, although he partially
suspends the treatment when they occur. He states that the
gravity of the disease is not determined by the length of time
that has elapsed since its first appearance, but by the presence
of fever and emaciation, as these are manifestations of toxemia,
and this is a much more serious condition in tuberculosis than
local lesions. If this is appreciated the benefits of sero-thera-
peutics will be more justly understood. He also adds that the
persistence of the area of dullness is an evidence of cure and
not of the reverse, as many suppose. This dullness is the
result of sclerotic processes which are conservative and heal-
ing. If patients would apply for help in the early stages of
the disease, when the organism is able to cooperate more effec-
tually with the treatment, the cures would be much more
numerous, but such cases are rare indeed.
The therapeutic value of the serum treatment is brilliantly
manifested by the statistics which include all the bad as well
as the favorable cases, as he emphasizes again and again. He
admits that there were cases, and not a few, in which the
results were negative, and the disease continued its course to a
fatal termination in spite of the serum, but they only serve to
enhance the benefits derived from it in the numerous other
cases in which its curative effect on the principal morbid phe-
nomena of the disease was unmistakable and permanent up to
date.
At present the final permanence of the cure has still to be
established, which time alone will tell. The effect of the treat-
ment on the fever is slow and gradual. Where it persists in
spite of the serum, it has been his experience that there was
always some .active microbic complication. He reports that the
fever disappeared in 285 out of the 524 cases with fever. These
include all stages of tuberculosis.
In 62.85 per cent, of the cases, the patients gained in weight ;
two gained 20 kilograms. In this connection he emphasizes
again that the benefits do not depend on the amount of serum
injected at a time, but on the regularity and long continuance
of the treatment.
The broncho-pneumonic foci entirely disappeared in 25
per cent, of the total number of patients, the percentage
diminishing with the increasing severity of the disease, from
85 per cent, in the circumscribed apyretic form downward.
The bacilli disappeared completely from the sputa in 33 per
cent.
He has also personally cured three cases of cutaneous tuber-
losis, and one case of tuberculosis of the kidneys. He refers
briefly to similar cures made by others.but does not include them
in his report, among them a tuberculous anal fistula, reported
cured by topic applications of the serum. The best results are
obtained with small, regular, persistent doses of one c.c. every
other day although some cases required more. (Moggi and
Regnier used 10 c.c. at each injection.)
His usual method is by hypodermic injections, but he has
obtained the same result with rectal injections of 10 to 20 c.c.
He has also tried administering the serum by the mouth, but
has not had sufficient experience with this method to formu-
late an opinion at present. One of his earliest patients appar-
ently cured, has relapsed, but a second course of treatment
has again caused the disappearance of all the symptoms. Out
of the 114 earliest patients in the most advanced stages who
showed marked improvement, 14 have relapsed and died since,
and 6 others are in a serious condition. The rest are all doing
well.
He classifies his 712 cases as follows :
1. Destructive broncho-pulmonitis with cavities, 168 cases.
With fever, 129. Fever disappeared in 55 ; attenuated in 22 ;
stationary in 52. Sputa examined and bacilli found in 59.
Bacilli disappeared in 10 ; diminished in 27 ; stationary in 19 ;
increased in 3. Weight measured in 129 cases ; increased in 75 ;
stationary in 38 ; diminished in 16. The positive results in the
168 patients in this category were : Apparently cured, 14 ;
marked improvement, 75; stationary, 50; disease pro-
gressed, 29.
2. Destructive broncho-pulmonitis without evidences of cav-
ities, but with microbic complications, 127 cases. With fever,
94. Fever disappeared in 54 ; attenuated in 15 ; stationary in
25. Bacilli in sputa in 52. Bacilli disappeared in 13 : dimin-
ished in 27: stationary in 12. Weight measured in 113;
increased 74 ; stationary 35 ; diminished in 4. Positive results
in the 127 patients in this category were : Apparently cured,
12 ; marked improvement, 71 ; stationary, 35 ; disease pro-
gressed, 9.
3. Diffuse febrile broncho-pulmonitis with or without
destruction of tissue, 220 cases. Fever disappeared in 107 ;
diminished in 37 ; stationary in 60 ; increased in 16. Bacilli in
sputa in 81. Bacilli disappeared in 13 ; diminished in 53 ; sta-
tionary in 12 ; increased in 3. Weight measured in 151 cases ;
increased in 90 ; stationary in 49 ; diminished in 12. Positive
results in the 220 cases in this category were : Apparently
cured, 10 : marked improvement, 121 ; stationary, 67 ; disease
progressed, 22.
4. Diffuse apyretic broncho-pulmonitis, with or without
destruction of tissue. Bacilli in sputa in 17. Bacilli disap-
peared in 7 ; diminished in 9 ; stationary in 1. Weight meas-
ured in 58 ; increased in 43 ; stationary in 15. Positive results
1106
SELECTIONS.
[November 21,
in the 68 patients in this category : Apparently cured, 2 :
marked improvement, 54 ; stationary, 12.
5. Circumscribed febrile broncho-pulmonitis, 81 cases. Fever
disappeared in 69; diminished in 7; stationary in 4; increased
1. Bacilli in sputa in 44 cases. Bacilli disappeared in
27 ; diminished in 16 ; stationary in 1. Positive results in
the 81 patients in this category : Apparently cured, .33 ; marked
improvement, 45 : stationary, 3.
6. Apyretic circumscribed broncho-pulmonitis, 48 cases. Ba-
cilli in sputa, 36. Bacilli disappeared in 33 ; diminished in 3.
Weight measured in 45. Weight increased in 44 ; stationary in
1. Positive results in the 48 patients in this category : Appar-
ently cured, 33 : marked improvement, 13 : stationary, 2.
The Influence of the Jews on Medicine.^ Dr. Richard Landau in
his Geschichte der Jiidischen Aerzte has traced the course of
medicine among the Hebrews from the time of Moses, their
great law giver, claiming the latter as a member of the medical
profession, in the highest and best sense, on the ground that
he was a sanitarian, and thence onward through Solomon,
Elisha, Isaiah, Ezekiel and Jesus the son of Sirach, to the
Essenes, whose Aramaic root-name shows that they at first
professed medicine, though the sect soon became lost in mys-
ticism. It was not until the first century of our present era,
however, that the really great school of Jewish physicians
began with Akiba and Ismael, followed by Hanina about the
year 200. Hanina was contemporary with Samuel, the great
oculist and even greater accoucheur, whose collyrium was long
a formula throughout the then known world. Samuel prac-
ticed first in Palestine and afterward in Mesopotamia. His
bosom friend was Raw, a man possessed of the truest scientific
spirit, for the Talmud tells us that he would spend his all to
obtain bodies for dissection to perfect himself in anatomy.
Abba Oumna and Rabbi Gamaiel III. in the fourth century
ably maintained the prestige of the Jewish physicians, who in
the fifth century became preeminent in Western Europe.
When a knowledge of Greek was lost they made themselves
master of Arabic and obtained a key to all that mass of litera-
ture which was locked away for many subsequent years. Soon
after Spain had been conquered by the Caliphs in the eighth
century great schools arose in Africa and in Europe, and in
these the Jews were the leading teachers. The Jewish School
at Cairo first migrated to Cordova, then to Sicily, and, after-
ward moving to the Italian mainland, it established itself at
Salerno, proceeding thence to Aries, Narbonne, and still later
to Montpellier and Paris. Avicenna, a Latinised form of Ebn-
Sina, Ebn Zohar, who is better known to us as Avenzoar, Ibn
Roschd or Averroes, and Moses ben Maimon, called Maimo-
nides, were the most illustrious Jews in the tenth and eleventh
centuries : their names are familiar to us from Chaucer's men-
tion of them in his "Prologue to the Canterbury Tales." The
priests looked with a jealous eye upon the encroachments of
the Jews in medicine, and they obtained a formal excommuni-
cation against all who committed themselves to the care of a
Jewish physician. During the twelfth and thirteenth centu-
ries the Jewish doctors spread from Spain over the whole of
Europe, penetrating even to the far East, for Saad Eddula
was both physician and prime minister to the great Cham,
Argun. The Spanish decree of 1492 compelled 160,000 to
800,000 Jews to leave Spain within four months of its pro-
mulgation. About a tenth of these made their way into
Portugal and established schools there; the rest were dis-
persed, but many thousands died by the way. The persecu-
tion of the Spanish Jews was not an unmixed evil ; it led to
a wider distribution of the Hebrew race throughout Europe
and to a dissemination of the knowledge and of the culture
possessed by its best members. France and Italy received
especial benefit, and the Popes were wise enough to attach a
Jewish physician to their service for several generations after
the edict of banishment had been promulgated in Spain.
On a Form of Low-temperature Pasteurization of Milk In the
Archives of Pediatrics for August Dr. Rowland Freeman con-
tributes a laborious research, with the original processes and
photogravure illustrations, on the above subject. His conclu-
sions are that Pasteurization at between 65 and 70 degrees C.
is recommended for the following reasons :
1. It destroys almost all the ordinary air bacteria which
occur commonly in milk.
2. It destroys the bacillus tuberculosis, the bacillus typhosus,
the bacillus diphtherias and many other pathogenic bacteria.
3. It causes no change in the taste of the milk and avoids
those chemic changes in milk which are produced by higher
temperatures.
4. It is possible to Pasteurize accurately at this temperature
without the use of a thermometer.
A question has been raised as to the advisability of the term
Pasteurize. It seems to me that this name is necessary, as no
other word indicates the same thing— that is a low-tempera-
ture sterilization followed by rapid cooling. The rapid cooling
is a most important part of the process. If we use the expres-
sion low -temperature sterilization, the rapid cooling is apt to
be overlooked. Milk should be used only during the twenty-
four hours following Pasteurization. Although the Pasteur-
ized milk will not sour in several days if kept cold, it should be
used only during the interval I have indicated. Bottles of
milk Pasteurized at about 68 degrees C. and left standing on
my laboratory table during the spring usually showed no sepa-
ration of casein in less than three days. Milk Pasteurized at
75 degrees C. I have found to keep for a week or ten days in a
refrigerator. A very good demonstration of the keeping quali-
ties of Pasteurized milk has been afforded by the Nathan
Straus milk depots of New York. The milk sold at these
depots is Pasteurized at about 75 degrees C. in large appara-
tuses constructed on the same principle as the one I have just
shown. After cooling it is stored in iced water until dispensed.
As many as seven thousand bottles are distributed by these
depots during some days in summer. This milk supplies the
very poor of New York and goes into many homes that are not
supplied with ice. Two years ago, while preparing a paper I
inquired of the superintendent whether they were at all
troubled by any of the milk souring in the tenement houses.
He replied that he had had one complaint, which he had
investigated, and had found that the milk had been kept
under the kitchen stove. When this charity was started in
1893 I advised Pasteurization at 75 degree C, and it was
undertaken, although the gentleman having charge of it was
assured by others that milk Pasteurized at this temperature
would not keep under the conditions existing in tenement
houses, and that a temperature of at least 80 or 90 degrees C.
should be used. They have seen no necessity for using a
higher temperature after three years' experience.
The editor of the Archives, Dr. Crandall, adds some perti-
nent remarks, as follows :
"According to our prevailing terminology, the term Pasteur-
ization is applied to the process of heating milk to a tempera-
ture of 167 degrees F., followed by rapid cooling. This pro-
cess modifies, somewhat, the taste of milk and produces slight
chemic changes. It is certainly desirable, if possible, to
destroy the bacteria in milk without producing any other
change. Milk is a complex and delicate fluid and is very easily
disturbed. It is difficult in the case of large numbers of chil-
dren to adapt cow's milk to the digestive capacity of the
stomach, and it has been felt by practitioners that every added
difficulty should be avoided so far as is compatible with safety.
The apparently simple question of the taste of milk becomes in
some cases an important one. Experience shows that change
in taste does not occur in milk heated to about 70 degrees C,
and very few if any chemic changes. The chief objection to
Pasteurization below this temperature has been the uncer-
tainty as to the thermal death point of the tubercle bacillus.
The more recent but very convincing investigations upon this
point show that the deatfl point for these germs is sufficiently
low to warrant Pasteurization at a lower temperature than 167
18%.]
PRACTICAL NOTES.
1107
•degrees P. Dr. Preeman certainly seems to have proved that
Pasteurization at about 155 degrees P. is a safe and effective
prooeM by which many of the objections incident to the higher
temperature are obviated. His apparatus offers the most
practical means of accomplishing this end which has yet been
devised."
PRACTICAL NOTES.
Unguents for Insect Bites. — Brocq suggests the following pre-
parations for the bites of fleas, gnats and bugs :
1. Camphorated chamomile oil 100 grams ; balsam of storax
pur. 20; essence of peppermint 5 gr.
"J Olive oil 20 gr. : ointment of storax 25 gr. : balsam of
Peru 5 ft.
.'i. Xaphthol ."> to 10 grams ; ether q. s. to dis. ; menthol 0.25 c.
Id 1 |il>m vaselin 100 grams.— Journal de Mid. de Paris,
October 18.
Serum-therapy of Typhoid Fever. — Funck, superintendent of
the Serum Institute of Brussels, announces as the results of
extensive experiments, that the serum of animals immunized
by means of typhoid cultures possesses all the properties
ascribed by Pfeiffer to anti-cholera serum, namely, that small
doses protect against typhoid infection, but do not protect
against infection from the coli bacillus. He therefore believes
in the therapeutic efficacy of the typhoid serum, but does not
venture yet to recommend it for use outside of the laboratory.
Pngria M4d.t October 17.
Intravenous Injections of Saline Solution in Puerperal Eclampsia.-
The patient had already had twenty attacks of convulsions,
with profound coma between, when the first intravenous injec-
tion was made. Five further attacks followed, and a second
injection was made the next day, followed by complete cure
with no more eclampsia. Three thousand grams were injected
in all, at 0.75 per cent. — Coen in the An n. <li Ostet. e Gin. ; Gaz.
MM. de /./'('(/(•, October 15.
Cerium Oxalate in the Crises of Tabes. — Professor Bechterew
has been using cerium oxalate in cases of gastric crises of loco-
motor ataxy and reports marked success from this treatment.
The seizures of vomiting were greatly reduced in number,
while the actual act of vomiting became easier, and at the
same time pain, thirst and nausea were, to a great extent,
diminished. The psychic conditions also improved, restless-
ness subsided and sleep returned. Micturition is said to have
become slightly more difficult, but not enough to require a
catheter. The most important improvement, however, was
that food could be retained owing to the diminished number
of paroxysms of vomiting. — London Lancet, August 22.
Appendicitis a '• Dysentery" of the Appendix.— Oolubow does not
consider appendicitis a specific bacterial disease, but due to
the fact that the usual microbes in the alimentary canal
acquire extraordinary virulence from some cause unknown, and
produce dysentery of the appendix, which may be epidemic.
He is led to these conclusions from observation of several cases
of benign appendicitis appearing as an epidemic in his practice,
among others, three scholars in a certain school who sat
together on the same bench, were all taken with appendicitis
within three days. He describes the symptoms of this benign
form as sudden sensitiveness in the center of the abdomen,
localized by palpation above the right Poupart's ligament, ele-
vated temperature, loss of appetite and constipation. He
thinks this form is often overlooked. It passes away in two
to three days. — St. Pet. Med. Woch., November 10.
New Method of Making a Stomach Fistula. — Heusner has treated
successfully seven cases of impassible cardiac carcinoma, open-
ing a fistula into the stomach by the following process : He
first makes a transverse incision just below the left hypochon-
drium, about 10 centimeters long, parallel with the long axis
of the stomach. He then exposes the cartilage of the seventh
rib at its point of attachment to the costal arch. This point is
not above the pleural cavity, but over the first fibers of the
diaphragm. With the left hand a gauze tampon is introduced
under the cartilage, and a hole is cut through it with a trocar
the size of a thumb, passing obliquely from above downward
and inward through the cartilage and the peritoneum. With
the fingers of the left hand and a pair of forceps, a piece of
the anterior wall of the stomach is then drawn out through this
hole and sutured, first to the cartilage and then to the skin.
The abdominal wound is then closed and painted with iodoform
collodion, after which the protruding bunch of the stomach
wall is opened and food introduced. The operation is simple
and without danger and the fistula thus made never shows an
inclination to grow smaller in diameter, an important advan-
tage— Cbl. f. Chir., October 17.
Salol In Progressive Pernicious Anemia.— The cure of a case of
severe anemia is reported from Budapesth which had resisted
for months the administration of iron, quinin, bone marrow,
arsenic and inhalations of oxygen. The cause was unknown.
No parasites were found in the feces, either adult or embryo.
Suspecting at last some auto-infection salol was administered
in 1-gram doses five times a day, and the condition of the patient
began to improve at once. Each time the medicine was sus-
pended the former symptoms returned, but the dose was
gradually diminished to 3 grams a day, and in three months
it was possible to discontinue it entirely, as the patient had
recovered his former health, with complete disappearance of
all the anemic symptoms, including the paleness, heart mur-
mur, tumefaction of the liver and spleen and the character-
istic alterations in the blood. — Semaine MM., October 7.
Gutta-percha Qauze for Postpartum Hemorrhages. Cases of uter-
ine or other hemorrhage that persist in spite of the tightest
packing with the usual gauze, are relieved by an additional
tampon of gauze impregnated with gutta-percha. The iodo-
form gauze acts as a drain and the blood keeps oozing through,
but it is arrested by the gutta percha gauze, which is also
soft and pliable, but is not absorbent. Schseffer recommends
to tampon first with the usual gauze, leaving a small end pro-
jecting as a drain, and then pack with the gutta-percha gauze,
closing the drain entirely if necessary. — Semaine Mid., Octo-
ber 21.
Macroqulla.— The Revista MMica de Chile describes and
illustrates in its April number a case of this rare congenital
affection of the lips. The young man's lip, hypertrophied
and ulcerated, formed a conical projection, measuring 12
centimeters from the corner of the mouth to the point,
8.5 at its widest and 4.75 at its thickest part. The lip had
always protruded, but not enough to constitute a deformity,
until he was 13, when a violent blow on the chin caused
him to bite the lip lengthwise, producing a deep wound
and severe hemorrhage. It slowly increased in size after
this and a tumor formed, until the lip resembled the end of
a "Vienna loaf" of bread. San Cristobal removed the tumor
and part of the lip, making a new one. A fistula persisted a
couple of months ; when it healed nothing but the scar
remained of the previous deformity.
Estlander's Operation on a Child.— Preetorius describes in the
Antwerp Annals his surprising success with this operation in
a case of purulent pleurisy on the left side of eighteen month's
standing, the patient a girl of 6. He first resected 5 cm. of
the fifth rib on the nipple line and 5 cm. of the seventh on the
scapular line, leaving a double drain in the thorax. Two weeks
afterward he resected 14 cm. of the seventh rib, 13 cm. of the
sixth, 12 cm. of the fifth, 10 cm. of the fourth and 4 cm. of the
third. The cavity still persisting and containing about 70
grams of fluid, he performed a third operation a month later,
removing the ten last centimeters of the sixth rib. The fistula
healed in the course of a month and complete recovery fol-
1108
PKACTICAL NOTES.
[November 21,
lowed. The child would inevitably have succumbed without
this heroic operation, as liver and spleen were very much
enlarged at first, but gradually subsided.— Prense Mid.,
October 3.
Neuritis Cured by Local Compression.— Peripheral neuritis of
traumatic origin is apt to be exceedingly rebellious to either
medical or surgical treatment, but Delorme has invented a new
cure which has proved a perfect success in each of the ten cases
in which he has tried it, and its efficacy has also been confirmed
by others. His first case was a soldier wounded in 1870 by a
bullet in the neck. A keloid scar had formed where it had
emerged close to the posterior border of the sterno mastoid,
three by four centimeters in size, which had been the seat of
continuous pain ever since, that is, for twenty-three years. No
relief had been derived from the use of the thermocautery, bis-
toury, galvano-cautery, Vienna caustic, etc. Delorme con-
ceived the idea of destroying the nerve tissue in the cicatrix
by forcible compression. Seizing it between the thumb and
the forefinger of each hand, he squeezed it with all his might,
for a few seconds. Pour days later he repeated the operation,
and the pains vanished, and have never returned during the
three years since. The other cases were of more recent occur-
rence, but they had resisted all other treatment, and the same
forcible compression produced complete cure. Six were neu-
ritis consecutive to accidents to the feet, finger or wrist, the
others to the face, neck, leg or shoulder. In case of pain in the
finger after a partial amputation, opening of a phlegmon, or a
crushing bruise, he first carefully locates the exact limits of the
hyperesthetic zone, and then, the patient seated or reclining,
held by the assistants, the arm and wrist immovably fastened,
he seizes the finger between his two thumbs and forefingers,
and exerting all his strength, compresses successively every
spot on the entire surface of the hyperesthetic zone, commenc-
ing with the most painful points, and exerting there the maxi-
mum pressure. A few seconds exhausts both operator and
patient, as the process is very painful. After a few minutes
rest it is repeated by the operator or one of the assistants,
sometimes two or three taking it in turn. One operation is
usually sufficient, but sometimes as many as three are required,
at intervals of several days. The trophic troubles, cyanosis,
edema, stiffness in the joints, etc., disappear with the pain.
Delorme has never used an anesthetic for fear of interfering
bulbar reflex, but suggests that chloroform or local anesthetics
might be used. -Bulletin Medical, October 14.
Treatment of Malaria in Children.— Peuchtwanger describes in
the Therap. Mon. for August the results of his experience in
Palestine, where malaria is endemic. He tried various substi-
tutes that have been suggested recently, but found that he
always had to return to quinin. He uses principally the bisul-
phate for children, as it seems more efficient with them, although
it does not contain so much quinin as the sulphate. He gives as
many decigrams as the child has years, or as many milligrams
as it has months. Under 2 months he has it rubbed into the
arm-pits and groins in a salve made of 2 grams of quinin in 40
grams of lard. The effect of these frictions has always been
the same as if the quinin had been administered by the mouth,
notwithstanding that the absorption of quinin through the
skin is denied by all the authorities. At 3 to 4 months of age
he administers the quinin in suppositories three times a day,
each containing twice the dose for that age. Sometimes they
produce rectal tenesmus, when he substitutes enemas for the
suppositories. The quinin produces exactly the same effect
in suppositories or enemas as if taken into the stomach. He
substitutes the valerianite of quinin for the bisulphate in cases
of malarial neuralgia. He has also obtained brilliant success
in cases of pernicious malaria with coma, paresis of the pupils,
vomiting, hemoglobinuria, etc., in children of 10 to 12, by sub-
cutaneous injections of hydrochlorate of quinin. After the
third injection of 50 centigrams the hemoglobinuria ceased as
if by magic ; ice taken internally arrested the vomiting and
baths at 27 degrees C. controlled the hyperthermia. In three
days quinin suppositories were given and the children were
saved. The consecutive malarial cachexia in one case was
cured by tonics, iron, arsenic, calisaya bark. This cachexia is
often difficult to conquer. To prevent the return of the febrile
attacks, he keeps up the use of the quinin for several weeks,
with or without tincture of litmus and small quantities of
diluted hydrochloric acid. If this treatment fails, he returns
to arsenic and administers a mixture containing 2 grams of
solution of potassium arseniate and 8 grams of the tincture of
malate of iron. Of this he gives five drops three times a day
to a child of 3 years, increasing the dose a drop a day until it
is 15 drops, and then diminishing to 5 again. If there are
gastric troubles this arsenic medication is contraindicated.
In this case there is no resource but change of locality. He
has been successful with older children, 8 to 15, with pills
composed of hydrochlorate of quinin, arsenious acid and
reduced iron. Presse Mid., October 3.
tiypodermoclysis in the Treatment of Thermic Fever.— Dr. P. A.
Packard of Philadelphia communicates to the Medical News,
August 22, a case of the above nature as treated in the wards
of the Pennsylvania Hospital. The patient was a contractor,
aged 48 years, received in the hospital at 8 :30 p.m. on August
12. He was rubbed with ice on the way to the hospital in the
ambulance, but on admission he was found to have a tempera-
ture of 109.6 degrees, pulse 154, respirations 33. He was
unconscious, but not convulsed, with moderately contracted
pupils and markedly stertorous respiration. He was at once
put in a tub of iced water and given nitroglycerin (1-100 gr. )
hypodermically. After being in the tub for five minutes he was
removed, placed on a bed and vigorously "ironed" with ice. At
9 :07 his temperature was 103.4, pulse 146, respiration 32 and
irregular. At this time he began to have spasmodic contrac-
tion of the extremities. At 9 :35 he became very cyanotic, the
respirations became slow and labored, requiring, finally, the
use of artificial respiration and the battery. At 10 :05 his tem-
perature had remained below 103 degrees for some time, but
there was marked twitching of the right side of the face added
to the previous spasmodic contractions. The pulse at the
wrist was imperceptible at this time. At 10:18 he was "fear
fully cyanotic," and the jaws became rigidly fixed. He was
bled from the median basilic vein to the extent of sixteen
ounces, immediately after which the respirations became more
deep and quiet and the spasmodic twitching lessened. At
10 :25 half a pint of sterilized normal salt solution was slowly
introduced beneath the skin of the pectoral region on both
sides. The pulse at once improved and at 10:40 he became
conscious and gave his name, while at about the same time
the twitchings ceased. Nothing further of interest has occurred
up to the present time, the patient being thoroughly rational,
perfectly comfortable and showing no symptoms, save tor
slight elevation of temperature that is easily accounted for
by a quite severe glossitis that has resulted from a lacerated
wound of his tongue, produced by his teeth during his period
of pseudo- convulsions. Inasmuch as in a very large number
of cases of thermic fever the symptoms rapidly disappear after
reduction of temperature, there must be some factor other than
the high bodily temperature alone, which continues to be
present in those cases wherein improvement fails to follow the
fall in the bodily temperature. If, in such obstinate eases.
bleeding is performed, it is found that the blood flows very
sluggishly from the vein, that it is thick and tarry, and that it
is evidently lacking in its fluid portion. Such being the case,
it seems not unreasonable to surmise that the persistence of
coma, stertor, muscular rigidity, etc. , may be due to the lack
of water in the blood. Why some cases should suffer from
this condition, while others escape, it is difficult to say, but
careful inquiry might elicit some facts in regard to the amount
of perspiration lost, the amount of fluid ingested just prior to
the attack, and other features of the various cases that might
throw some light upon this difference in course.
1896.]
EDITORIAL.
1109
THE
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SATURDAY, NOVEMBER 21, 1896.
POLIENCEPHALOMYELITIS.
Wo have a good deal yet to learn concerning the
action of various poisons upon the nervous system
and particularly as to the effects induced by the
group of infectious diseases. A growing experience
has taught that nerve-fibers and nerve-cells may suf-
fer in numerous ways through the deleterious influ-
ence of the agencies just named. We may thus have
inflammation, hyperplasia, degeneration and sclerosis
in white or gray matter in varying distribution, with
corresponding diversity of symptoms. There are,
however, many conditions in which, despite the pres-
ence of the most profound and pronounced symptoms,
no lesion is demonstrable. The alterations that exist
under these circumstances must therefore be looked
upon as of the intangible nature which for the pres-
ent we must be satisfied to designate nutritional,
chemic or toxic. When recovery takes place these
changes may disappear and leave no trace of their
previous existence. On the other hand they may lead
to structural alterations, with persistence of symp-
toms. A group of disorders of this kind, especially
characterized by muscular weakness and undue read-
iness of fatigue and exhaustion has received interest-
ing consideration at the hands of Kalischer
( Zeitschriftfilr klinische Medici n, B. xxxi, H. 1, 2, p.
93), who enters at length into a discussion of their
clinical and pathologic aspects. He reports in detail
a carefully studied case of chronic poliencephalomye-
litis in a man, 50 years old. developing in the sequence
of an attack of influenza, and refers to a number of
( ither cases, some of which have been reported under
various other designations, all agreeing, however, in
their essential features, and the symptoms present
being referable to disturbance in the functions of the
motor bulbo-spinal nuclei for the entire muscular sys-
tem, situated in the central gray matter from the floor
of the fourth ventricle to the lumbar portion of the
spinal cord.
The disease is most common in persons between 20
and 60 years of age. It is usually subacute in onset,
rarely acute or insidious, at first progressing subacutely
and later pursuing a chronic, stationary or varying
course. Manifestations of constitutional disturbance,
such as fever, headache, vertigo, vomiting, are gener-
ally wanting throughout. In most cases the ocular
muscles are first involved and in irregular order one
after the other. Ptosis may appear first on one side
and then on the other and may be slight or pro-
nounced. Then the other muscles become involved,
usually in greater degree upon one side than upon the
other. The fourth and sixth nerves are not spared.
Diplopia is not always present; and almost never well
defined strabismus. The internal ocular muscles
usually escape. The disturbance of the ocular mus-
cles generally recedes, to give place to bulbar or spi-
nal symptoms, or they may remain in association with
the latter. Sometimes the disease sets in with bulbar
symptoms and rarely with weakness of the muscles of
the neck, trunk and extremities, advancing upward.
Usually extension occurs in stages, weakness in the
upper or lower extremities being suddenly added to
the paralysis of the ocular muscles; or paralysis of the
muscles of deglutition or of the ocular muscles being
added to weakness of the neck. Not rarely bulbar
symptoms predominate, including weakness, fatigue,
permanent or progressive paralysis of the muscles of
the face, tongue, those of mastication, of deglutition,
those of the esophagus, in unequal degree upon both
sides. In the extremities the parts nearest the trunk
are involved earlier than those at a distance ; the exten-
sors at times more than the flexors.
The tendon-reflexes, and especially the knee-jerks,
are enfeebled or lost. The sensory and the sensorial
functions usually remain uninvolved, as well as psy-
chic activity and the sphincters. Fibrillary twitching
is not observed. Muscular atrophy does not take
place as a rule; if at all, late and in slight degree. Par-
alysis is the primary and the most conspicuous mani-
festation. The electric reactions remain unchanged
or are enfeebled and in grave cases perhaps lost.
Degenerative reactions are rare. The so-called myas-
thenic reaction is observed in some cases — that is, the
muscles respond normally to faradic currents of ordi-
nary intensity, but to tetanizing currents the response
grows gradually more and more feeble until it ceases
altogether. It appears most marked when the fatigue-
1110
THE PASSING OF THE HOLY-STONE.
[November 21,
phenomena on voluntary innervation are quick and
pronounced.
The intensity of the palsy is variable. Fatigue and
recovery take place readily and quickly. The degree
of fatigue does not always correspond to the degree of
permanent weakness and paresis. In severe cases the
patients become completely helpless. In walking,
the knees may give way; or the gait may be stagger-
ing. Active exercise may be attended with an urgent
sense of the need of air, from fatigue of the respira-
tory muscles. Not rarely sudden death occurs from
paralysis of the vagus or of the diaphragm. Other
dangers may arise from sudden weakness of the mus-
cles of the pharynx and esophagus, so that liquid diet
may be necessary and regurgitation through the nares
may take place. If the hands are involved there may
be difficulty in carrying food to the mouth, in writing
and in other manual exercises. When the eyes are
used, the ptosis is aggravated and the muscles of the
neck become weaker from efforts to hold the head
erect. Speech becomes nasal and after a time indis-
tinct, low and whispering. The ability to sing and to
whistle is lost, and smoking becomes difficult.
A characteristic feature of the disease -is the rapid
recovery of strength after rest and the improvement
in the morning after sleep. Remissions in the inten-
sity of the symptoms occur from time to time and may
continue for varying periods — from days even to
years — and simulate perfect recovery. The progress
of the disease may further be very slow and character-
ized by exacerbations; or the morbid process may
finally cease to progress, leaving a condition of per-
manent weakness. Sometimes death occurs unex-
pectedly.
In many cases no lesion has been found after death.
In one case degenerative changes were present in the
medullary sheaths of the nerve-roots of the medulla
oblongata. In another there was vascular dilatation,
with hemorrhage and degenerative-atrophic conditions
of the ganglion-cells of the central gray matter. These
various lesions, however, are inconstant and inade-
quate to explain all of the symptoms; so that it must
be assumed that there occur chemic, nutritive or toxic
changes capable of disappearing and of repair without
leaving evidences of their previous presence.
In an etiologic connection most of the cases
reported have had some direct or indirect relation with
one or another of the infectious diseases; others with
over-exertion or with excessive use of alcohol or
tobacco. No relation to syphilis could be established.
Subacute or chronic poliencephalomyelitis is to be
distinguished from acute encephalitis by the absence
of acute onset, of constitutional manifestations (fever,
delirium, etc.) and other cerebral symptoms (aphasia,
etc. ) ; by its peculiar and more systematic invasion
(bulbo-spinal symptoms) and its chronic, partly remit-
ting, partly progressive course. Poliencephalomye-
litis differs from acute poliencephalitis in the absence
of symptoms of general disturbance (vertigo, vomit-
ing, optic neuritis, delirium, etc.), in the less rapid
course and in the presence of bulbar and spinal
symptoms. From progressive bulbar paralysis it
differs in the less characteristic localization and a less-
universal involvement of the bulbar nuclei, in its
irregular, fluctuating, remitting course, in the absence
of fibrillary twitching and of degenerative reactions,
in the relative absence of muscular atrophy, in the
presence of muscular fatigue, the possibility of im-
provement, in the absence of distinctive lesions, in 1 he
early and frequent involvement of the ocular muscles
and also those of the neck and extremities, and in the
irregular, abrupt involvement of the entire system of
bulbo-spinal nuclei. From amyotrophic lateral scler-
osis it is to be differentiated by the absence of spastic
manifestations and from progressive muscular atrophy
by the varying course, characteristic localization,
atypic distribution, unsteady progression, early par-
ticipation or precedence of paralyses of bulbar nerves
and of the ocular muscles. It is to be distinguished
from pseudo-bulbar palsy by the mode of onset and
by the absence of psychic disturbance and of hemi-
plegia.
In the treatment of poliencephalomyelitis drugs
have proved of no service. The best results will be
secured through rest and the avoidance so far as pos-
sible of muscular activity; every unnecessary fatigue
should be avoided. Solid food should be interdicted
and only small quantities of soft food and of liquid
given at frequent intervals. In aggravated cases the
administration of nutritive enemata may answer a
useful purpose. Especial attention should be directed
to prophylaxis, in so far as the danger of infection is
always to be avoided, and should such effort prove
futile the acquired disease, with its attendant intoxi-
cation, should be gotten rid of with all possible expe-
dition. During convalescence from infectious dis-
eases undue physical effort should be avoided and
roborant treatment should be instituted.
THE PASSING OF THE HOLY-STONE.
'■ Six days shalt thou work ami do all that thou art able;
On the seventh, holy-stone the deck and scrape the iron cable."
— Old Merchantman h'hnmt .
Another time-honored "custom of the service" — but
honored in no other respect than its antiquity — has
fallen before a few pen-strokes over the signature of the
Assistant Secretary of the Navy — the practice of holy-
stoning the decks of men-of-war is to be henceforth
abandoned. As commodores and midshipmen were
once head and tail of the personnel of the naval service,
and sails and spars and tacks and sheets, things with-
out which no man-of-war could be, so was the holy-
stone, the sacred possession of the Kaaba of the
quarter-deck, which every old shell-back had first
detested in his youth and then accepted in his old
1896.]
THE PHYSICIAN'S WIFE.
1111
ago. as the thorn in the tlesh which it was his lot to
wear without repining. This was yesterday ; and
to-day Midshipman Easy might roam the decks with
his little hanger and find no messmate; "commodore"
is soazoelymore than a traditional title; sails and spars
have disappeared, reefing and furling are lost arts; and
now t ho holy-stone is for all future time to be anath-
ema. Maran atha!
For years before the oldest living medical officer of
the Navy received the blue ribboned parchment which
constituted him during the pleasure of the President
of the United States, an officer of the Navy, to whose
orders "all officers, seamen and marines under bis
command-' were "strictly charged and required to be
obedient" (pregnant words, though the pregnancy be
only phantom) this venerable stone has been
denounced for the unholy uses to which it has been
devoted, and now. at last, each old survivor of the
conflict can congratulate himself and reverently say:
"I have fought a good fight; I have run my course."
The scourge of the sea has not been storm and
wreckage, not battle and bloodshed, not typhus and
scurvy, ship fever and dysentery, but more murderous
than all these, irrt decks, not decks wetted by raging
sea or drenching rain, but deluged daily and deliber-
ately by the pumps under pretense of cleanliness,
and this in defiance of the unanimous protest of the
medical officers of every naval service on the globe.
In vain they showed how this artificial saturation of the
ship's atmosphere was inimical to health. They demon-
strated by unerring statistics that a iret ship was
always an unhealthy ship. They pleaded and pro-
tested: they suffered insult and braved court-mar-
tial— but the holy-stone kept on grinding out, in
daily swing, with sand and water, the lives of men
whom wind and sea had failed to mark and mar.
There have been, in recent years, many instances
of commanding officers of exceptional intelligence,
who have listened to the advice of the medical officers
anil instituted the practice of shellacking the decks
below the water line and cleaning them with hot
water cloths and swabs. Captain John McNeill
Boyd of the British Navy candidly admitted that "the
objections to wet decks are supported by the medical
officers with such a weight of evidence that they can
not be gainsaid." But the upper decks have suffered
the infliction of sand and water and holy-stones
until a few weeks ago, when the fulmen of the Depart-
ment consigned them to the scrap-heap, not because
they were insanitary and consequently, damnable, but
because they wore out the decks and were conse-
quently expensive. Finis coronat ojnMS, however it
may be accomplished, and hence no sanitarian will
repine that the credit be not given to him for having
accomplished this crowning achievement of the work
of naval hygiene.
The kindred need of marine hygiene, ventilation,
has come about through necessity following the con-
struction of the great machine vessels, which have
supplanted the white-winged queens of the sea. The
almost hermetically sealed floating iron boxes were
uninhabitable without constant artificial ventilation
established by aspirating tubes and fans, whose motor
engines, added to the hundred and more others that
fill the interiors of modern battleships and cruisers,
encroach upon the air space. With fresh dry air,
tempering somewhat the evils of overcrowding, with
distilled aerated water, good food and proper clothing,
the man of the sea is now far better cared for than his
predecessor, Ben Bolt, except when he gets sick or
breaks a bone, and then he is stowed away in the
same contracted, dark noisy place in the bows, that is,
in American men-of-war, where the din of rattling
chains and capstans, the odors of the paint room, and
the grime and grease of this region, neutralize ano-
dynes and soporifics and keep him keen to suffering.
The sites of the hospitals in other services are chosen
because of their fitness for their purpose, but
with us the suggestion that "she would be nothing
but a damned quarantine hulk and had better hoist
the yellow flag at once," was urged in the case of one
of our finest modern vessels, when the medical depart-
ments ought to equip her with the same hospital estab-
lishment as English, French, German and Russian
vessels of her type.
The hostility to their medical associates by line
officers is incredible to civilians and perhaps can only
be explained by an original underlying jealousy of the
acquirements of a corps, whose humanitarian duties
and obligations impel its members to persevere in the
face of every opposition, until as in the matter of
holy -stoning the decks, their humane objects shall be
accomplished. Ultimately, the claims of the sick, as
of their care-takers, will be recognized and provision
be made for them more in accordance with the enlight-
enment and philanthropy which characterize this age.
Much of the disagreement, as in civil life, doubtless
depends upon the inability of non -professional men,
who are themselves robust and healthy, to recognize
the importance of what seems to them to be only
trivial fault-finding by their medical associates, and
they attribute to cavil recommendations that conflict
with their own. no doubt honestly conceived ideas.
The health officer on shore, and the medical officer on
board ship, who is preeminently a health officer, have
the same up-hill work, but they have at last gained so
sure a foot-hold that ere long their views will be heard
not in entreaty, but as of those having authority.
THE PHYSICIAN'S WIFE.
The social economy of the physician's life, matri-
mony makes or mars. The wife either seriously
handicaps or aids the physician in practice and his
intellectual life. As Jeafferson remarks ("Book
1112
THE PHYSICIAN'S WIFE.
[November 21,
about Doctors"); Considering the opportunities that
medical men have for pressing a suit in love, the
many tempations to gentle emotion that they experi-
ence in the aspect of feminine suffering, and the con-
fiding gratitude of their fair patients, it is perhaps to
be wondered at that only one medical duke is to be
found in the annals of the British peerage.
Prudence would dictate to a physician, endowed
with a heart, to treat it in the same way as Dr. Glynn
thought a cucumber ought to be dressed, to slice very
thin, pepper it plentifully, pour upon it plenty of the
best vinegar, and then throw it away. A sentimental
disposition is a great nuisance to a physician. He
has quite enough work on his hands to keep the affec-
tions of his patients in check, without having to
mount guard over his own emotions. According to
Thackeray, girls make love in the nursery and prac-
tice the art of coquetry on the page-boy who brings
coal upstairs; a hard saying for simple young gentle-
men triumphing in the possession of a first love. An
English fair dame, who enjoys rank among the high-
est and wealth equal to the station assigned her by
the heralds, not only aimed tender glances and sighed
amorously to a young waxen-faced, blue-eyed apoth-
ecary, but even went so far as to write him a letter
proposing an elopement, and other merry arrange-
ments, in which a carriage everlastingly careering
over the country at the heels of four horses, bore a
conspicuous part. The silly maiden had, like Dinah,
a "fortune in silvyer and gold," amounting to $200,000,
and her blue-eyed Adonis was twice her age. Fortu-
nately he was a gentleman of honor. Without divulg-
ing the mad proposition of the young lady he induced
her father to take her for twelve months for change
of air and scene. Many years thereafter when the
heroine of this little episode, had become the wife of
a very great man, and the mother of children who
bid fair to become ornaments to their illustrious race,
she expressed her gratitude cordially to this Joseph
of physicians, for magnanimity in not profiting by
the absurd fancies of a child and the delicacy with
which he had taken prompt measures for her happi-
ness. More recently, she manifested her good will to
the man who had offered her what is generally
regarded as the greatest insult a woman can experi-
ence, by procuring a commission in the army for his
eldest son.
The embarrassment Sir John Eliot suffered
under from emotional overtures of his fair patients
are well known. The quack St. John Long himself
had not more admirers among the elite of high-born
English ladies. The King had a strong personal
dislike to Sir John, heightened by a feeling that it
was sheer impudence in a medical man to capture
without effort the hearts of half the prettiest English
women and then shrug his shoulders with chagrin
at his success. Lord George Germaix had hard
work to wring a baronetcy from his Majesty for the
victim of misplaced affection.
"Well," said the king at last, grudgingly promising
to make Eliot a baronet, "my lord, since you desire
it, let it be; but remember, he shall not be my phy-
sician." "No sir," answered Lord George, "he shall
be your Majesty's baronet and my physician."
Sir John, to scare away his patients and patron-
esses, had a death's head painted on his carriage
panels. The result of this on his practice and his
sufferings, however, was the reverse of what he desired.
One lady, daughter of a prime minister, ignorant that
Sir John was otherwise occupied, made him an offer,
but learning to her astonishment, that he was married
vowed that she would not rest till she had assassin-
ated his wife.
Dr. CADOGAN,of Charles II. s time, was also a favo-
rite with the ladies. He was wont to spend his days
in shooting and his evenings in flirtation. The
former tastes led him to receive the following poetic
dose :
"Doctor, all game you either ought to shun,
Or sport no longer with the unsteady gun ;
But, like physicians of undoubted skill,
Gladly attempt what never fails to kill,
Not lead's uncertain dross, but physic's deadly pill."
That he was a good shot is not known, but he
was adroit as a squire of dames, since he secured
as his wife a wealthy lady over whose property he
had unfettered control. Against the money, how-
ever, there were two important points that had to be
"set off;" the bride was old and querulous. Such a
woman was unfitted to live happily with an eminent
physician on whom bevies of court ladies smiled.
After spending a few months in alternate fits of jeal-
ous hate and jealous fondness, the poor creature con-
ceived that her husband was bent on ridding his life
of her execrable temper by poison. One day, sur-
rounded by her friends, in the presence of her lord
and master, she fell in a hysteric spasm exclaiming:
"Ah, he has killed me at last: I am poisoned!"
"Poisoned," cried the lady friend, turning up the
whites of her eyes, "Oh, gracious goodness, you have
done it, Doctor!" "Of what do you accuse me?" asked
Cadogan, with surprise. "I accuse you of killing
me-ee," responded the wife, doing her best to imitate
a death-struggle. "Ladies," answered the Doctor,
with admirable nonchalance bowing to Mrs. Cado-
gan's bosom associates, "it is perfectly false. You
are quite welcome to open her at once, and then you'll
discover the calumny."
John Hunter administered a scarcely less startling
reproof to his wife, who, though devoted to him, and
in every respect a lady worthy of esteem, caused Hun-
ter at times no little vexation by her fondness for
society. She was in the habit of giving enormous
receptions, at which authors and artists of all shades
lS'.tf,. I
THE PHYSICIAN'S WIFE.
1113
used to assemble to render homage to her far from
commonplace literary powers. Hunter had no sym-
pathy with his wife's poetic aspirations, still less with
the society whioh those aspirations led her to culti-
vato. Grudging even the time which the labors of
piaotioe prevented him from devoting to the pursuits
of his museum and laboratory, he naturally could not
restrain his too irritable temper (due to cardiac dis-
l when Mrs. Hunter's frivolous amusements
deprived him of the quiet requisite for study. Even
a tee that called him from his dissecting instruments
could not reconcile him to interruption. "I mustgo,"
he would say reluctantly, " and earn this d guinea,
or I shall be sure to want it to-morrow." Imagine the
wrath of such a man. finding on return from a long
day's work, his house full of musical professors, con-
noisseurs and fashionable idlers, in all the confusion,
hubbub and heat of a grand party, of which his lady
had forgotten to inform him. Walking straight into
the middle of the reception room, he surveyed his
unwelcome guests, surprised to see him dusty, toil-
worn and grim, so unlike what the man of the house
ought to be on such an occasion. " I knew nothing,"
was his brief address, " I knew nothing of this kick-up
and I ought to have been informed of it beforehand;
but as I have now returned home to study, I hope the
present company will retire." Mrs. Hunter's draw-
ing-rooms were speedily empty.
One of the drollest medical love stories relates to Dr.
Thomas Dawson, a century since alike admired by
the inhabitants of Hackney as a pulpiteer and physi-
cian. Of his acquaintances Miss Corbett of Hack-
ney was at the same time the richest, most devout and
most afflicted in health. Ministering to her body and
soul, Dr. Dawson had frequent occasion for visiting her.
< me day he found her alone sitting with the large family
Bible before her, meditating. Dr. Dawson read the
words to which her right forefinger pointed, the words
of Nathan to David: "Thou art the man." The Doctor
took the hint; May 29, 1758, he found a wife, and the
pious lady won a husband.
The day Abernethy was married he went down to
the lecture room to deliver his customary instructions
to his pupils. His selection of a wife was as judicious
as his marriage was happy. The funny stories long
current about his mode of "popping the question"
are known to be most delusive fabrications and extreme
exaggerations. The brutality of procedure attributed
to him by current rumor was foreign to his nature.
The Abernethy biscuit was not more audaciously
pinned upon his reputation, than was the absurd false-
hood that, when he made his offer to his future wife,
he had only seen her once, and then wrote saying he
should like to marry her, but as he was too busy to
" make love," she must entertain his proposal without
further preliminaries, and let him know her decision
by the end of a week.
One type of wife different from these is drawn by
Dr. Weymouth in "Over the Hookah:"
"Speaking of the selection of wives, I know one doctor, a
type of a hundred others, who evidently had an eye to wind-
ward when he married. The lady in the case is a past mistress
of diplomacy and medico-political intrigue, beside whom Dis-
uaki.i's reputation and MACHiAVELLi'smalodor are weak indeed.
She belongs to several churches and' to card and social clubs
galore, and makes a specialty of drumming up practice for
'my doctor.' The doctor rarely goes out with her — he don't
have to ; she can do business better with him out of the way.
It is embarrassing, you know, just as she is in the midst of a
peroration descriptive of the latest exploit of this modern Hip-
pocrates, to have the dried up, microcephalic, weasened little
animal appear in evidence.
" ' Do you know, ladies, I am afraid my poor doctor is going
to work himself to death. Why, he was out three whole nights
last week, and didn't have a wink of sleep. A prominent lady
on Michigan Avenue (the patient is always prominent and lives
on Michigan Avenue or Astor Street or in some equally fashion-
able locality) had an attack of appendicitis and had been given
up by five doctors before my doctor saw her. She pulled
through, but my doctor says that if the family had delayed
sending for him just thirty minutes more she would have died.'
" Now as a matter of fact, my boy, remarks Dr. Weymouth,
I once overheard this lady in the midst of a similar yarn,
when I happened to know the circumstances. In the first
place, that doctor couldn't lance a 'gum-boil ' without endan-
gering the internal carotid, and in the second place, those three
nights were spent in discussing the relative merits of ' two
pair,' and ' three of a kind.' He did make several calls, of the
other fellow's hand, you know, but the only ladies he saw were
a choice variety of queens, hearts, clubs, spades and diamonds.
They didn't live on Michigan Avenue either, but he found
those particular lady patients in a cosy corner of the M
club."
This type in its best qualities caricatures the nobler,
truer picture of the American physician's wife, drawn
by Dr. Claiborne in an address before the Virginia
Medical Society. The Virginia physician, with
whose wife Dr. Claiborne deals, was always known
as a family man. He usually married early in life
and with the advantages of social position, wealth
and culture, the latter sharpened and improved by
travel, a privilege not so common or easy then as now,
was considered an eligible party and had no difficulty
in securing a desirable partner. But he was often,
indeed, generally away from home, physicians being
few and the distance between the homes of his
patients often great. On the mistress of the mansion
therefore devolved more than her share of domestic
duties. If his home were on a plantation or in a
country town — eyen then a plantation and negroes
were essentially a part of a gentleman's estate — the
management of affairs in general, in conjunction per-
haps with an overseer, devolved upon her to a great
extent. She was known as a business woman and as
the characteristic lavish hospitality called to the doc-
tor's house a retinue of visitors and retainers on
occasion and without occasion, upon her devolved, in
his frequent and protracted absence, their reception
and entertainment. In dispensing these offices she
was to the manner born. As the daughter of an old
Virginia gentleman, and only such a woman could
have filled the heart and fitted the fortunes of the old
Virginia physician, she was in her native sphere
when playing the gracious hostess and the doctor
trusted her with a faith born not only of personal
1114
LIBRARY WANTS AND SUPPLIES.
[November 21,
devotion but of pride in her preeminent fitness for
her place. As the mother of his children he con-
signed to her with perfect trustfulness all the respon-
sibilities of their management, their habits, their
morals and their education. Even in their sickness,
often succumbing to the habit of perfect confidence
in her wise and judicious management, he left her to
do the dosing of the family and she would give a
dozen doses of physic to his one. She was not only
literally but liberally his helpmate.
SERUM DIAGNOSIS OF TYPHOID FEVER.
In an article on the serum diagnosis of typhoid
fever which appeared in our issue of October 31, page
962, we called attention to the action of one of the
provincial boards of health of Canada in testing the
practical utility of Dr. Wyatt Johnston's method of
dealing with a little dried blood from the lobe of the
ear or the tip of the finger of the patient under obser-
vation. We concluded our remarks by saying that
no doubt other boards of health would take up the
subject and aid in the advance of our knowledge of
typhoid fever and other febrile conditions. The
promptness with which Dr. Johnston's experiments
have been verified shows that we did not over-estimate
the energy of the bacteriologists in ever striving after
something new, nor the enterprise of the health
authorities in utilizing their work. Recent experi-
ments in the bacteriologic laboratory of the Army
Medical Museum, Washington, D. C, have given
results which inspire confidence in the method. The test
is based on the action of the blood serum of a typhoid
fever patient, or the liquid obtained by moistening
a dried blood drop from such a patient, on the typhoid
bacilli of a pure bouillon culture. The active move-
ments characteristic of the typhoid bacillus in liquid
cultures are promptly stopped and the bacilli become
aggregated into groups or masses. These results are
not produced by the blood of a person in health. Dr.
Walter Reed, U. S. Army, conducted the experi-
ments at the suggestion of Surgeon-General Stern-
berg. He examined twenty-eight cases of suspected
typhoid fever and obtained twenty-two positive and
six negative results. The patients were in various
stages of the disease, but most of them had passed the
second week and a few were convalescent. In two of
the negative cases the estivo-autumnal malarial para-
site was found; a third case was shown at the post-
mortem examination to have been one of general per-
itonitis, originating in disease of the appendix; a fourth
case was probably one of tubercular disease of the brain
in a child. Concerning the two remaining negative cases
the conclusion was reached that they were probably
not typhoid fever cases. In view of these successful
results the Surgeon-General has called upon medical
officers in charge of post hospitals to forward to
Washington, D. C, samples of blood from febrile
cases of undetermined causation with a full clinical
record of each case submitted to the bacteriologic test.
Glass slides in suitable slide boxes have been issued
for the transmission of the samples. This, it is
believed, will aid in defining the character of the
febrile cases sometimes reported as simple fever, con-
tinued fever, typhomalarial fever, Texas fever, moun-
tain fever, etc., and will enable medical officers to
recognize the existence of typhoid in cases clinically
obscure without having to wait for a postmortem
opportunity of demonstrating the pathognomonic
lesion.
The Health Department of the City of New York
also has moved in this direction. Mr. Hermann M.
Biggs, the bacteriologist in charge of its laboratory,
was authorized Nov. 6, 1896, to place facilities at the
command of local physicians for the diagnosis of thei
obscure cases. The Health Department of Chicagi
has issued an unsigned circular giving the history of
this method of diagnosis, which was distributed at
the last meeting of the Chicago Medical Society
(November 16).
y>
E
LIBRARY WANTS AND SUPPLIES.
In another column we publish the first of a series
of lists of periodicals and books either desired by
public medical libraries or that will be given to such
libraries in furtherance of a work undertaken by Dr.
Gould of Philadelphia.
It should be most earnestly brought home to the
conscience of the profession that we need more and
better public medical libraries, and that there is annu-
ally wasted most valuable literature which, with a
little care and system might be made highly service-
able to medical science and progress. Every year the
private libraries of physicians are being scattered or
sold for old paper, while public reference-libraries; are
in the greatest need of the same material for complet-
ing their files or sets. Wishing to do what is possible
for the purpose Dr. Gould has in view, we call espe-
cial attention to this most commendable enterprise. It
is Dr. Gould's intention to act as the intermediary
between libraries and donors, in order that books or
files of medical journals of physicians may not be
destroyed, and that public libraries may be multiplied
and their shelves filled with works which each year
become more and more valuable.
Upon the death of a physician, friends should use
their influence to have his library utilized in this way.
The better plan is for the owners during life to so
arrange for the proper disposal of the books, etc.
Every medical society, the physicians of every city,
village, or county, should consider it an important
duty they owe their profession to encourage the for-
mation of a public medical library. It does not enter
into Dr. Gould's plan to supply private libraries; but
on the contrary to guide the private library to its
1896.]
CORRESPONDENCE.
1115
proper destination, the public library. Neither is it,
except in peculiar circumstances to buy or sell. The
entire service is gratuitous, aiming to help those who
wish to give, to place their gifts where there is prom-
is*1 of the greatest professional benefit. Already Dr.
QOULD has been able to supply libraries with several
thousand numbers that would otherwise have been
wasted.
We most cordially commend the scheme and ttrust
our readers will bear it in mind, preserve the pub-
lished lists, and whenever any occasion may arise, to
correspond1 with Dr. Gould. Librarians of public
libraries should classify and make lists of the dupli-
■ they will give away to other libraries, or ex-
change for others needed to complete their own files
CORRESPONDENCE.
A Prevalent Error In Refraction Work.
Minneapolis, Minn., Nov. 16, 1896.
To the Editor:— 1 have been strongly impressed for some
years with the fact that many oculists, some of whom are
scientific and careful men, are in the habit of over-correcting
plus refractive errors. For a shorter period I have been con-
vinced that most oculists, myself included, have been giving
low plus cylinders where minus lenses were indicated.
This error has grown out of the teaching of our text books
that at six meters or twenty feet the rays of light are approxi-
mately parallel, and that for the correction of refractive errors
the strongest plus or the weakest minus glass should be given
which give the clearest vision at this distance.
Charles S. Bull, I think, called attention to the fact this rule
would lead to an overcorrection of .25 D. in the case of H., but
the fact has evidently not been sufficiently impressed. With a
less distance than 20' the error is evidently greater, and as a
large number of oculists have not more than 15' at their disposal,
unless some efficient method is at hand for checking and correct-
ing their findings, serious trouble is likely to result. Theretino-
scope is a very efficient check if one has sufficient skill and confi-
dence in his findings, and if as a final test the patient is made
to look across the street while weaker and stronger lenses are
alternately placed before the eye, the surgeon may be abso-
lutely sure of his results.
While the giving of a too strong plus lens is bad enough, the
other error mentioned, the giving of a low plus cylinder where
a minus glass is demanded, is in some cases even more disas-
trous, and is unfortunately a very common error. After I had
become fairly proficient in the use of the plane mirror as a
retinoscope, I found that in cases where reversal of the shadow
was induced by a weaker plus lens than 1 D., in one or more
meridians, my patient would generally accept a + .50 or -(- .25
cylinder, and as my veneration for authority was stronger than
my confidence in my retinoscopic results, he always got a plus
cylinder. Most of my patients were satisfied that they had
got the best correction possible. With the few exceptions I
always found some heterophoria and satisfied most of them
with muscle training. During all this time I was suspicious
of my results in certain of these cases. In hyperopic cases
where the retinoscope indicated a considerable degree the trial
lens findings were consistent with the retinoscopic, while in
the class of cases under consideration I knew they were not
consistent.
In May, 1894, X.,a clergyman, consulted me, complaining of
eye and headache and general nervousness. He had had trouble
for years and was able to do his work only with great difficulty.
He had been under the care of prominent oculists in Milwau-
kee and Chicago. In 1892 Dr. B. of the latter city had given
him -4- .75 ~ + .50 C. vert., which he had been able to use with
some relief in his work. In 1893 Dr. Hotz had ordered con-
stant use of + .50 C. vert. He had also ordered .the use of
prisms for work. I found 2° prisms base in. Whether they
were so ordered is uncertain. Dr. Hotz's prescription had
given decided relief for a time, though the ability to work had
remained limited.
I found R. 20-30, L. 20-20, slightly improved in each eye by
-f- .50 C. vert. Latent R. hyperphoria .5°. Esophoria at 20'
1°. At 13" exophoria 6°. Abduction 3°, adduction 60°. Under
atropia -f-.50C. vert, was still accepted, improved vision some-
what and no change was made. Retinoscopic test under atro-
pia was as follows : With plane mirror at 40" R both meridi-
ans — and both became -f- with — .25. L. both meridians -4-,
vertical reversed by -|- .25 and horizontal by -\- .50, a showing
that ought to have suggested minus lenses to any man who was
less under the power of authority — but Dr. Hotz's R. of 4-. 50
C. vert, was continued, and with muscular exercises the
patient was made comparatively comfortable for another year,
when he collapsed. I had then made up my mind that I had
been doing faulty work in these cases, so I examined him again
and found that he would accept — .50 C. hor., and that vision
was decidedly better than with the plus glass. He was given
the new correction, and has been in better condition since
beginning their use than for many years. Several other patients
have been given weak minus cylinders for whom in former
years I had ordered plus cylinders, and with uniformly good
results.
As I have been writing, a lady came in and reported relief
from the use of — .25 C. hor. She had been ordered by some
optician + .75 S. for work. She could read with comfort, but
the nervousness and sick headaches continued. Under hom-
atropia the retinoscopic findings were as follows : Horizontal
and vertical meridians both eyes +. Reversed in R. by H. -4-
1.25 and V. + 1 ; in L. by H. + .75 and V. + .50. These find-
ings clearly indicate a minus quarter cylinder, and such a glass
with axis 45° temporal was accepted and gives complete relief,
in spite of the presence of a right hyperphoria of 1.5°. A
still later case is Mrs. D., whom Dr. Wiirdemann of Milwau-
kee gave + .25 3 + .25 C. V., which gave relief for six months.
I find retinoscopic test to give in both eyes — , vertical reversed
by + .25, horizontal by + .75. — .25 C. 75° temporal improves
distant vision, makes reading easier than with Dr. Wiirde-
mann's compound plus lenses, and also gives as much relief
from the glare of lamp and sunlight as the tinted -(-.25 S.
given by Dr. Bradford of Boston. The mention of other ocu-
lists by name is in no spirit of criticism, but simply to show
that other men, and competent ones, have been making these
same mistakes. Edward J. Brown, M.D.
■Parasite and Host."
Philadelphia, Nov. 16, 1896.
To the Editor :— Your editorial entitled "Parasite and Host"
in your issue of November 14 should be read, pondered and
inwardly digested by every member of the American profes-
sion. I can heartily subscribe to every word of it so far as
relates to one publishing house. It is, however, gratifying to
know that medical publishers are generally not guilty of the
(medical) sin you so justly stigmatize, and that as a rule they
are either sufficiently courteous or politic to recognize their
duty to the medical profession. In this connection it is espe-
ally noteworthy that I have heard nothing of any disinclina-
tion upon the part of the one publishing firm which pays its
contributors for articles published in its journals. How much
more astonishing therefore is the stand taken by our publisher
who pays contributors nothing ("not even reprints"), that the
1116
BOOK NOTICES.
[November 21,
matter and illustrations of articles given him shall not be re-
produced by another publisher ! As a physician I would not edit
a journal using unpaid contributions that refused physicians
the [right to reproduce their articles when and where they
pleased. As you pertinently observe, the object of a physician
in publishing his article is to tell every medical man the results
of his studies, but no periodical has a circulation more than
one-tenth of the total number of physicians of our country,
therefore any other means that may arise for insuring a still
greater publicity is desirable, and any attempt on the part of a
publisher to limit the reproduction of articles gratuitously
furnished him is clearly against the author's interest and that
of medical science. I cordially endorse your suggestion that
in contributing to medical journals every writer make it a
clearly-defined and accepted stipulation that the right to
reproduce the article and its illustrations shall be free to all.
In editing the American Year-Book of Medicine and Surgery
every publisher but one has recognized the rights of authors
and of the profession as regards abstracts, extracts and the
reproduction of illustrations. Curiously enough the one who
refused this was one who pays its contributors nothing for
their articles. As it happened, also, some of these very arti-
cles first published in the journals of this firm were written by
departmental editors of the Year-Book. Thus an author was
refused the right of using his own article because he had first
given it to a lay medical journal ! The Year-Book reaches
thousands of readers that the journal can not expect to reach,
and it will be remarkable if authors hereafter permit themselves
to be caught in such a trap. You are correct in suggesting to
the profession that it should look more sharply after its own
interests, and should encourage journals of, for and by the
profession. Cordially yours, Geo. M. Gould, M.D.
119 South Seventeenth Street.
BOOK NOTICES.
Important Notice Concerning Library Wants
and Supplies.
Notice to Medical Men, and Librarians of Public Medical Libraries.
[Medical ji>urn:ils :"■<■ requested to publish this notice.]
1. All correspondence in relation to the enterprise should be
addressed to Dr. Geo. M. Gould, 119 S. 17th Street, Phila-
delphia, Pa.
2. Librarians of public medical libraries are requested to
forward : 1. Accurate lists of periodicals, books or pamphlets
needed to complete their files; 2. Lists of duplicates which
they will give other libraries or exchange for numbers desired.
Oive both volume numbers and dates of periodicals.
3. Owing to the additional labor it would involve, queries
concerning the supply of desired items to private libraries can
not be answered.
4. The conditions of all gifts are that the recipients shall be
reputable organizations, composed of the regular medical pro-
fession; that the library shall be a public one, i.e., open for
consultation during stated times to physicians generally ; and
that, if unbound, the periodicals and books received shall be
bound and catalogued.
5. Every physician is invited to give the books and periodicals
for which he has no further use to public iibraries, and having
no particular choice, to correspond with Dr. Gould in reference
to their disposal in order to secure the greatest usefulness by
the profession.
6. Send nothing before corresponding, in order that the gifts
may go direct from the donors to their proper destination.
7. In order to secure the best success, physicians and libra-
rians of other countries are invited to cooperate.
FOE PRESENTATION.
Librarians needing any of the following volumes (all num-
bers inclusive) to complete their files are requested to apply for
them :
American Journal of Medical Sciences, 1879 to 1890, except
1887, which is missing.
American Medical Association, Reports and Transactions,
21 odd volumes, 1847 8 53-55-56 66-68 to 76 and supplement
volumes 1876 to 82.
American Clinical Lectures, Vol. 2 (1876).
American Medical Journal, 1884.
American Medical Times, Vols. 1 and 2 (1860-61).
American Public Health Association Reports, etc., Vols. 1
to 17.
One ( Archives of Scientific Practical Medicine, Vol. 1 (1873).
Vol. ( Chicago Medical Journal, Vol. 28 (1871).
Boston Medical and Surgical Journal, Vols. 94 to 99 (1876-78).
Braithwaite's Retrospect, Vols. 50 to 89.
Canada Lancet, Vol. 8 (1876).
Chicago Medical Journal and Examiner, Vols. 27 (1870) ; 33
(1876) ; 34, 35 (1877).
Cincinnati Lancet and Obstetrics, Vols. 18 and 19 (1875-76).
One \ Canadian Journal Medical Science, 1876.
Vol. I London Medical Record, part of 1873.
Detroit Medical Review, Vol. 10 (1875-76).
Gaillard's Medical Journal, Vols. 46 and 47 (1888).
Journal of Nervous and Mental Diseases, Vol. 3 (1876).
Louisville Medical News (in one volume), Vols. 1, 2 and 3
(1876-77).
Medical News, Vols. 31 to 39 (1873-1881) ; also Vols. 43 to 47
(1883-85) ; Vols. 50 and 51 (1887), and Vols. (1860-72) :
Vol. — (1880) ; Vols. (1883-89) ; Vols. (1891 96).
Medical Gazette, Vol. 4 (1870).
Medical Record, 4, 5, 6, 7 (1869-72), 12 (1877) ; (1890-93).
Medical and Surgical Reporter, Vols. 34, 35, 36 (1876-7).
(1885-89.)
Monthly Abstract Medical Science, Vols. 2, 3, 4 (1875 77).
New York Medical Journal, Vols. 22, 23, 24, 25 (1875-77).
Obstetrical Journal of Great Britain and Ireland, Vols. 3, 4,
5, 6 and 7 (1875-7).
One volume miscellany.
Peninsular Journal Medical, Vol. 1 (1876).
Philadelphia Medical Times, 1870-1879, and 1882 1887.
Proceedings Philadelphia County Medical Society, Vols,
to 15 (1876-94).
Polyclinic, July to June, 1883 89.
Practitioner, The, 1868, July to December ; 1869 73 ; 1877 94.
Quarterly Epitome, 1 to 20.
Reports and Transactions International Medical Congress in
London, 1881. Four volumes.
Richmond Medical Journal, 186fr 69.
Transactions of College of Physicians, 1889, 1890.
Transactions of Medico-Psychologic Association, 1895,
Denver.
Transactions of Medical Society of Pennsylvania, 1865 1894.
Twenty-five volumes.
Transactions of Medical Society of Virginia, 1896.
University Medical Magazine, October 1888 to September
1889.
FOR SALE.
The following volumes may be had at exceptionally low rates.
Prices made upon application. These sets were bought remark-
ably cheap and will be sold at cost, but only to public medical
libraries. Private buyers need not apply.
American Journal of the Medical Sciences, unbound, com-
plete from November 1827 to December 1895.
London Medico-Chirurgical Transactions, complete, in cloth,
from Vol. 1 to 77, with catalogue and index.
British and Foreign Medical Review, Vols. 5 to 24 (1836-47),
and an index volume. In half-calf.
Johnson's Medico-Chirurgical Review, Vols. 1 to 42, includ-
ing the years 1820-1843 in the old series and a continuation of
six volumes in the new series, 1843-47. Cloth.
American Journal of Obstetrics and Diseases of Women and
Children from the commencement in 1868 to 1895. Unbound.
PERIODICALS REQUIRED TO COMPLETE SETS.
The Library Committee of the McGill University, Montreal,
will be grateful for any of the following periodicals, which
should be addressed to the Library, Medical Faculty, McGill
University :
American Journal of Obstetrics, The— Vol. 1, No. 7.
American Practitioner and News— Vol. 17, Nos. Dec. to June ;
Vol. 18, Jan. to July.
Anatomie und Physiologie, Hyman und Schwalte— All
before Bd. 13, 1886.
Annals of Surgery- Vol. 5, Nos. 1, 2, 3, 4, 6 ; Vol. 6, Nos. 4,
5 ; Vol. 7, Nos. 1, 2 ; Vol. 8, Nos. 1, 2, 3, 5, 6 ; Vol. 9, Nos. 1, 2,
4, 5, 6 ; Vol. 10, Nos. 1, 3, 4, 5, 6 ; Vol. 12, Nos. 1, 2, 3, 4, 5 ;
Vol. 13, Nos. 1 to 6 ; Vol. 14, Nos. 1 to 6 ; Vol. 15, Nos. 1 to 6 ;
Vol. 16, Nos. 1 to 6.
Archiv fur experimentelle Pathologie und Pharmakologie —
All before 1881 ; Bd. 13, Heft. 2 ; Bd. 17, Heft. 5 ; Bd. 18,
Heft. 1 to 6 ; Bd. 19, Heft. 1, 6 ; Bd. 20, Heft. 1 to 6.
1896.]
BOOK NOTICES.
1117
Arehiv fur Klinisehe Chirurgie — All before 1876 and after
1877 to 1884 ; Band 33, Heft 3 : Band 45, Heft 2, 3, 4.
Arehiv fiir Mikroskopische Anatotnie All before 1886.
Arehiv fiir Pathologische Anatotuie und Physiologic und fur
Klinisehe Mediein, von R. Virehow - All before 1881: Bd. 87,
Heft 2; Bd. 89, Heft 2, 3; Bd. 102, Heft 3: Bd. 108, Heft 1.
Archives of Surgery— All before 1890.
Berliner Klinisehe Wochenschrift— All before 1880 ; Vol. 88,
Nos. 1 to 40.
Brain Vol. 9 and from Vol. 11.
British Journal of Dermatology— All before 1891; Vol. 6,
No. 5,
Canada Lancet, The— Vol. 1, Vol.2; Vol. 23, Jan. Feb.
July : Vol. 24, Oct ; Vol. 26, Sept, Oct., Nov., Dee. ; Vol. 27,
Oct., Jan., March and June.
Canada Medical Record Vol. 2, No. 4 and index : Vols. 13
to IS, want ind«I ; Vol. 19, Nos. 6, 7; Vol. 20, Nos. 1, 2: Vol.
Jl. No*. 'J to 12; Vol. 22. Nos. 1, 2, 3, 4, 5, 7, 8, 9, 10, 11.
Centralblatt fiir Bakteriologie und Parasitenkunde — Bd. 14,
No. IS; Vol. 10, No. 9; Vol. 11, No. 25.
Centralblatt fiir Chirurgie-All before 1886.
Climatologist, The— Vol. 1, Nos. 1, 5; Vol. 2, No. 5, and all
attar.
College of Physicians, Transactions of the — All before 1879.
Congress of American Physicians and Surgeons, Transac-
tions of the— All before 1891.
Deutachea Arehiv fiir klinisehe Mediein —Vol. 54.
Deutsche medicinisehe Wochenschrift— All before 1886;
Vols. 18! H i>:!.
Dominion Medical Monthly -1893, No. 6; 1894, No. 6.
Edinburgh Medical Journal, The Vol. 16; Dec. 1894;
April. lS!>f>; June, 1895.
Gaaette Medicale de Montreal, La — Vol. 1.
Gynecological Journal- All after 1872.
Gynecological Transactions— Vols. 3, and all after 1881.
Uiiv's Hospital Reports Series 3, Vols. 16, 25.
St. 'Bartholomew's Hospital Reports— Vols. 27, 28.
Royal London Ophthalmic Hospital Reports— Vol. 5, Part 3 ;
Vol. "10, l'art 2: Vol. 11, Part 3; Vol. 12, Part 3; Vol. 13,
Index.
Jahresberieht liber die Fortschritte der Anatomie und
Physiologic Bd. 12.
Jahresberieht liber die Leistungen und Fortschritte in der
Geaamottan Mediein— All before 1882; Band 2, Abth. 3.
Journal de l'Anatomie et de la Physiologie — All before 1886.
.ToTUNAL OF THE AMERICAN MEDICAL ASSOCIATION — Vol. 2,
Feb. 2 It!, May 24 ; Vol. 3, July 26, Sept. 20, Oct. 11-18 25, Nov.
1 : Vol. 4, Jan. 10, 24, April 25 ; Vol. 5, July 18, Sept. 12 19. Oct.
.'!, Nov. 28, Dec. 19 ; Vol. 8, Jan. 1, March 19, April 9 16 23-30,
May 7 21, June entire: Vol. 9, July 9 16-23, Aug. 6-13-20,
Sept. 10, Oct. 8, Nov. entire, Dec. 3 10-17; Vol. 11, July 21,
Sept. 8, Oct. 6. Nov. 24 ; Vol. 12, Jan. 12. Feb. 16-23, April 27,
May 1, June 8; Vol. 13, Aug. 10, 24, 31, Sept. 7, Oct. 26. Nov.
9, Dec. 7-14 : Vol. 14, Jan. entire, Feb. 1-22, March 8-15 22,
April 19-26, May 24-31, June entire.
Journal of Cutaneous and Genito-Urinary Diseases— Vol. 2,
Vol. 3 : Vol. 4, Nos. 1, 4 to 12 : Vol. 6. Nos. 5, 8, 9 ; Vol. 7.
Journal of Cutaneous and Venereal Diseases — Vol. 1, Nos.
3. 4, 8, 10, 11, 12: Vol. 2, Nos. 1, 2; Vol. 4, Nos. 1, 2, 3, 10, 11.
Medical News, The— All before 1882.
Medical Record, The— All before 1875.
Montreal Medical Gazette — Vol. 1.
New York Medical Journal, The— All before 1883 : 1885, Nos.
1, 2 : 1886, Nos. 1, 2 : 1887, Nos. 1, 2 ; 1888, Nos. 1, 2.
Ontario Medical journal, The— Vol. 1 ; Vol. 2, Nos. 1, 6 ;
Vol. 3.
Ophthalmological Society of the United Kingdom, Transac-
tions of the— Vols. 1, 2, 3.
Pathological Society of London, Transactions of the— Vols.
I, 2, 3, 20.
Pharmaceutical Journal and Transactions- Second series,
Nos. 4, 5, and all after 1886.
Practitioner, The (London)— Vol. 29.
Revue de Chirurgie — All before 1886.
Revue de Medecine— Tome 3, No. 2 ; Tome 4, No. 1 ; Tome
5, Nos. 2, 3.
Revue des Sciences M^dicales — Tomes 1, 6, 10, 26.
Royal Academy of Medicine in Ireland, Transactions of the
—Vols. 1, 2, and all after 1888.
Sanitarian, The— Vol. 31, Sept. ; Vol. 32, March, June,
July, Oct., Nov., Dec.
Schmidt's Jahrbiicher— All before 1884.
Societe de Biologie— Tomes 2, 3, 4, and all after Tome 5.
Therapeutic Gazette, The— All before 1881 ; Vol. 14, Nos. 5,
II, 12 ; Vol. 17. Nos. 1, 2, 3, 4, 8, 12 ; Vol. 18.
Union Me"dicale, L'— Vol. 7, Nos. 2, 8 ; Vol. 8, No. 12.
Year-Book of Pharmacy- All before 1870 and after 1880.
Zeitschrift fiir Klinisehe Mediein — Band 4, Nos. 3, 5, 6;
Band 8, No. 4; Band 9, Nos. 10, 11, 12: Band 13, Nos. 1, 6;
Band 14, Nos. 4, 5, 6.
The Practice of Medicine. By Horatio C. Wood, A.M., M.D.,
LL.D., and Reginald H. Fitz, A.M., M.D. Philadelphia:
The J. B. Lippincott Co. 1896.
Anything emanating from the pen of two of the most dis-
tinguished American physicians, as these are, would attract
attention, and this book, which has been prepared by perhaps
our ablest pathologist and our ablest clinician, is one which
will be a credit not only to the English language in which it is
written, but to America, and will undoubtedly be received
abroad as the highest type of an American production. The
style of the work is naturally somewhat dogmatic, but its
careful condensation compensates for this, as there is nothing
superfluous in the book from beginning to end. A clean-cut
statement of the conviction of the authors and the state of
their knowledge on the subjects treated is given.
In the treatment of typhoid fever we notice that the book
gives little space or consideration to the so-called antiseptic
treatment. Indeed, it is not mentioned as such, although tur-
pentine, one of the most robust antiseptics, is still adhered to
by Dr. Wood, as it was by his uncle who introduced it. We
notice with some surprise in the formulary in the appendix
that the old dose system has been used, although Professor
Fitz himself is a Boston man ; it is the home of the American
metric bureau, and the active center of its propaganda. The
book will remain a favorite for many years to come.
A Text-Book of Materia Medlca, Therapeutics and Pharmacology. By
George F. Butler, Ph.G., M.D., Professor of Materia Med-
ica and of Clinical Medicine in the College of Physicians
and Surgeons, Chicago, etc. Price, el., $4; 8vo, pp. 858.
Chicago agent, W. T. Keener. Philadelphia : W. B.
Saunders. 1896.
Dr. Butler has produced a very creditable book, and one
that in our judgment is destined to become popular. The con-
tents of the book include : 1, pharmacology and general thera-
peutics ; 2, pharmaceutic preparations ; 3, disease medicines ;
4, antiseptics : 5, symptom medicines ; 6, topical remedies.
That too little attention to materia medica is given in these
degenerate days we think there is no question, and although
there are already several excellent works on therapeutics on the
market, we are not likely to have too many. We commend
the author for having modernized his book by adopting the
Romanesque pronunciation, and designating the precise
orthoepy for all the names ; for the use of the decimal system
throughout and for having conveniently placed the genitive
form after each official name. These features will be of great
use to students. That the work is quite up to date is seen by
the section on organotherapy and serumtherapy. We are of
impression that the French quotations, such for example, as
the ones from Bernheim on pages 271 and 293 should have
been translated into English, especially as there is a typo-
graphic error in the first. Taken as a whole the book may
fairly be considered as one of the most satisfactory of any
single- volume work on materia medica on the market.
A Treatise on Surgery by American Authors. For Students and
Practitioners of Surgery and Medicine. Edited by Roswell
Park, A.M., M.D. Vol. II. Special or Regional Surgery,
with 451 engravings and 17 full-page plates in colors and
monochrome. 8vo, cloth, pp. 804. Philadelphia and New
York : Lea Bros. & Co. 1896.
The contributors to Vol. II aro Drs. Park, E. H. Bradford,
Duncan Eve, D. Bryson Delavan, Edmond Souchon, Frederick
5. Dennis, A. D. Bevan, M. H. Richardson, Farrar Cobb,
Chas. B. Kelsey, W. T. Belfleld, James H. Etheridge, Chas. B.
Parker, Rudolph Matas, Robert W. Lovett, Arpad G. Gerster,
Chas. S. Bull and Clarence J. Blake.
The work is characterized by thoroughness of detail and
breadth of general knowledge. The many excellent works on
1118
BOOK NOTICES.
[November 21,
surgery now on the market (International, Dennis' System,
Moullin, American Text-book, Treves) preventour quoting this
as the best, but there are few that surpass it in general utility.
The authors have done well in escaping the old rut, by provid-
ing so many original illustrations, and the publisher has given
the text a handsome setting. There is some unevenness between
the articles, perhaps inseparable from joint authorship, but
some of the chapters are of exceptional merit.
The work as a whole compares favorably with other recent
American works, and is a creditable addition to current medi-
cal literature.
Medical Jurisprudence, Forensic Medicine and Toxicology. By II. A.
Witthaus, A.M., M.D., and Tracy C. Becker, A. B., LL.B.,
and a staff of collaborators. In four royal octavo volumes.
Volume IV. , Toxicology. New York: William Wood &
Company. 1896.
The completion of this volume adds another magnificent work
on jurisprudence to the already creditable list of American
works on the subject.
We have recorded our favorable opinion of the first three
volumes of this series. This volume, devoted entirely to toxi-
cology, is not only equal to its predecessors, but in some
respects the most interesting. The chapter on the history of
poisons, by way of introduction, is a credit to American medical
literature.
The practical value of this work has been much increased
by the copious index at the end of each volume.
Anatomical Atlas of Obstetric Diagnosis and Treatment. By Oscar
Schaeffer, M.D. With 145 illustrations: 12mo, cl., pp. 254.
New York : William Wood & Co. 1896.
This volume adds another useful volume to the excellent series
of atlases published by this well-known firm. The book, says
Dr. Schaeffer, "deals with the morphology of the female
pelvic organs as the anatomic basis of the physiologic and
pathologic phenomena of pregnancy and labor." From this
basis the diagnosis is deduced and the pathologic changes
can be estimated. The book is much more than an atlas,
for the accompanying text is very instructive. Gentlemen
preparing for examinations will find the work invaluable, and
practitioners will be able to refresh their obstetric knowledge
with some additions by its perusal.
Fourteenth Biennial Report of the State Board of Health of Cali-
fornia, for the fiscal years from June 30, 1894, to June 30,
1896. Also, the Transactions of the Fourth Annual Sanitary
Convention held at Los Angeles, April 20, 1896. Sacra-
mento : A. J. Johnston, Superintendent of State Printing.
1896.
There are more voluminous reports than the one under con-
sideration, but there are few that show more intelligent super-
vision of public health. In addition to the statistic tables
showing the mortality of various diseases throughout the
State, there are special reports from committees appointed to
investigate various public institutions, and the papers read at
the annual State sanitary convention. Dr. W. F. Wiard of
Sacramento is president and Dr. J. R. Laine of Sacramento is
secretary.
Transactions of the Texas State Medical Association, Twenty-eighth
Annual Session, held at Fort Worth, Texas, 1896. Paper,
pp. 470. Printed for the Association. 1896.
This handsomely printed volume tells a pleasant story of the
great activity of the Texas profession in medical progress
and the advancement of science. The business features of the
meeting were mostly of local interest, although we notice reso-
lutions reaffirming their adhesion to the Code of Ethics of the
American Medical Association and favoring the transfer of
the State quarantines to the National Government. The
papers are of a high order ; among those of home production
we notice articles respectively by Drs. J. M. Cline, A. H.
Schenk, W. R. Blailock, H. L. Tate, David Cerna, C. O. Mat-
thews, Lawrence Ashton, J. J. Williamson, W. M. Yater, J. E.
Gilchrist, W. J. Lane, Z. T. Bundy, Henry P. Cookes, F. E.
Daniel, T. J. Bell, R. R. Walker, A. W. Fly, F. S. White, J.
Aloysius Mullen, J. O. McReynolds, H. L. Hillgartner, E. J.
Mathery, G. W. Grove, R. F. Miller. V. H. Hulen, Geo. H.
Lee and R. W. Knox. Authors from New York, Philadelphia,
New Orleans and elsewhere, contributed to the volume, which
has been carefully edited by the accomplished secretary, Dr.
H. A. West of Galveston.
Twenty-seventh Annual Report of the State Board of Health of Massa-
chusetts. Bds., pp. 808, 8vo. Boston. 1896.
The annual reports of this Board have always taken the
front rank among publications on sanitary subjects. Indeed
it is not too much to claim for this Board that from its begin-
ning in 1870 the reports issued have served as a model. The
routine work as set forth in the current volume shows that the
cities and towns of the Old Bay State appreciate the work of
their Board of Health, and have year by year learned to depend
more and more upon their advice in all matters affecting their
respective municipalities. Nor is this aid to municipalities the
sole good accomplished ; every year some new topic of public
hygiene is made a prominent feature of the report, with the
effect of materially adding to our knowledge of the subject.
Last year it was water filtration and the results of the experi-
ment stations, and this year the accounts are continued. A
favorable judgment of the use of diphtheria antitoxin is
recorded, based on abundant observations. The experiments
upon the purification of sewage at the Lawrence have been
continued. The Massachusetts commonwealth is really
benefiting the other States by the maintenance of this now
famous station almost as much as herself. Those interested
will find careful studies of the question of the permanency of
sewage filters, the best modes of management to secure this
permanency, the preliminary treatment of sewage by different
methods to remove sludge before filtration, and different
methods of aerating sewage filters to secure the greatest effi-
ciency, and as well discussion of the methods of utilization of
sewage for industrial purposes.
Transactions of the Fifty-first Annual Meeting of the Ohio State
Medical Society, held at Columbus, May 27, 28 and 29, 1896.
CL, pp. 492; 8vo. Toledo.
The volume has as a frontispiece an excellent picture of the
president. Dr. Daniel Millikenof Hamilton, whose presidential
address was replete with sound advice. The addresses are
excellent and some of the papers admirable. Obituary notices
of Drs. Wm. S. Battles, T. J. Barton, Henry C. Beard, C. G.
Comegys, T. M. Cook, Joseph Price and W. J. Scott are
included in the volume. A copy of the new act to regulate the
practice of medicine in Ohio, a list of members and a good
index complete the volume.
The volume has been carefully edited by the secretary, Dr.
Thomas Hubbard of Toledo.
Transactions of the New Hampshire Medical Society, at the 105th
anniversary held at Concord, June 1 and 2, 1896. Cl., pp
202, 8vo. Concord, N. H.
One of the entertaining features of the New Hampshire Med-
ical Society is the annual dinner and the excellent postpran-
dial speeches. In this particular few medical societies sur-
pass that of the Old Granite State. Nor are the scientific
needs of the meeting in any way neglected. The president's
address (Dr. McQuesten) is instructive and the address of Dr.
Gore with the discussion thereon by Dr. Conn and Dr. Hiland
constitute an important contribution to climatology.
The next meeting of the society will be held in Concord
the last week in May, 1897, under the presidency of Dr. A.
P. Richardson of Walpole.
Preservation of Human Heads. The Journal D' Hygibne of
October 29, describes a simple process by which the savages
of New Zealand prevent decomposition and keep as trophies
the heads of their enemies in a perfect state of preservation.
It suggests that a most interesting collection of specimens of
the different races of the world might be made by this process
for the practical study of ethnology.
L896.]
NECROLOGY.
1119
NEW INSTRUMENTS.
A MODIFIED DIRECTOR.
MY K. K. I.ARNKD.
CLASS Qf '■>', Mm MKDICAI. COLLEGE.
For the purposes of blunt dissection, no surgical instrument
is so universally used as the grooved "director" devised by
Professor Kocher of Berne, and yet it does not fully meet all
the requirements of the general surgeon.
The writer does not claim perfection for this modified instru-
ment, but believes that the alterations from the original have
added very largely to its usefulness.
These changes consist in having the entire instrument made
from one pieee of metal (the handle portion being concave on
two sides to decrease weight) for it is obvious that a solid instru-
ment will not make as many visits to the repair shop as the one
with ■ soldered hollow handle.
The blade has been made longer, more curved and much
thinner than the ordinary director to facilitate working around
glandular structures, in vascular regions, particularly in opera-
tions for the enucleation of tubercular and carcinomatous
glands, and in the inguinal regions where thin-walled abscesses
are likely to be punctured in the use of the knife.
The principal modification will be seen to be the serrations
in the edges of the blade, which may vary in number and size
to suit individual preferences as well as the length and width
of the blade.
The purpose of these serrations is to enable the operator to
use ■ sawing or tearing motion, increasing his power in sepa-
rating tissues and breaking down adhesions, obviating still
further the use of the knife after the initial incision.
The blade is grooved to guide the knife when it must be used
(as in dividing the sterno-cleido-mastoid muscle in enucleat-
ing deep cervical glands) ; one groove is substituted for the three
in the ordinary instrument, doing away with two unnecessary
grooves and permitting greater thinness of the blade without
diminution of its strength.
A fenestra at the tip of the blade as in Kocher' s latest pattern
permits its use as a ligature carrier — so that when necessary,
vessels may be tied speedily without the aid of an aneurysm
needle or regular ligature carrier. Directors without fenestra}
may be obtained.
The instrument illustrated was made by Messrs. Drake &
Mueller, 266 Ogden Avenue, Chicago, from the writer's model
and was suggested by witnessing the frequent use of Kocher's
director in the multitude of operations seen during three years
attendance upon the surgical clinics of Rush Medical College,
and by the statements of surgeon friends.
A NEW GROOVED ASPIRATOR NEEDLE.
BY J. A. DIBRKLL, Jr., M.I).
PROFKSSOR OF ANATOMY, ARKANSAS INDUSTRIAL UNIVKRSITY, MEDICAL
DEPARTMENT.
LITTLE ROCK, ARK.
In a case of suspected pelvic abscess, I introduced an aspira-
tor needle for diagnostic purposes, and finding pus, I incised
the vaginal mucous membrane at the base of the needle with
the intention of conducting along the round needle a director,
and in the groove of this instrument a narrow scissors with the
view of so dilating the opening that I could insert a drainage
tube, irrigate and secure drainage.
Though the director was rather sharp pointed, the result was
to push it out of the abscess wall.
It occurred to me that an aspirator needle could be made
with a groove like a director for use in similar cases, and when
the presence of pus or other accumulations are found, that the
grooved director needle could be used without removal, to
conduct a knife, scissors or other instruments for dilatation,
and the introduction of drainage tubes.
I submitted a design and description of the needle to be
made, to George Tiemann & Co., of New York City, who made
the needle for me which is represented in the folowing cut.
The needle can be made of any size.
There are many conditions beside pelvic abscesses which
will suggest themselves to the surgeon, in which such an in-
strument may be convenient ; in accumulations in the pleural
cavities for example.
There are also hepatic abscesses in which there are some-
times chunks of necrosed hepatic tissue too large to pass
through any aspirator needle or trocar, and in which drainage
becomes a necessity.
SOCIETY NEWS.
The Western Surgical and Gynecological Association. The fifth
annual meeting of the Western Surgical and Gynecological*
Association will be held at Topeka, Kas., Monday and Tuesday,
Dec. 28 and 29. We desire to extend to all regular physicians
and surgeons a cordial invitation to be present and take a part
in the proceedings. Topeka is a delightful city, noted for its
hospitality and the local profession have arranged for our
entertainment. A strong program is assured. Opening ses-
sion at 1 p.m., December 28. H. E. Pearse, M.D., Secretary.
Association of Assistant Physicians of Hospitals for the Insane.
The fourth meeting of this association will be held at the East-
ern Michigan Asylum, Pontiac, Mich., on Dec. Sand 4, 1896.
Irwin H. Nefk, Pontiac, Secretary.
NECROLOGY.
Chaki.es M. KiTTREDtiE, M.D., of Fishkill-on-the-Hudson.
N. Y., died suddenly at Mount Vernon, N.'H., on August 19.
His death is believed to have been due to apoplexy. He had
been in poor health and his case had been considered as very
serious. He was suffering from Bright's disease, and he
passed through a severe and dangerous attack from that mal-
ady in June. He left for New Hampshire on June 23, accom-
panied by his children, to spend the summer months in his
native town, in hopes of gaining strength among the New
Hampshire hills. Dr. Kittredge had been no worse since he
left Pishkill and it could not be said that he had improved in
health. Dr. Kittredge was born at Mount Vernon, 58 years
ago. He spent his boyhood days there, finally taking up the
study of medicine, after a liberal academic education. He
graduated from Howard Medical College in 1867. He went to
Fishkill twenty-six years ago, but previous to that he had
been in the Hartford Retreat, an institution for the treatment
of nervous diseases. At Fishkill-on-Hudson he established a
home for nervous people, which comprised a beautiful estate.
Dr. Kittredge took a great interest in his home, and he had
one of the most beautiful and complete places in that town. He
was one of the most prominent and best known citizens and
was largely identified with all the movements to promote the
welfare of the town. No one knew him but to like him and
we believe that everybody was his friend. As a physician he
had a prominence and he was a successful practitioner, though
he did not care for an extensive practice, as he had his home
1120
PUBLIC HEALTH.
[November 21,
to look after. Dr. Kittredge was one of our well-known base
singers and his excellent voice was often heard at the church
concerts and at funerals. His wife died three years ago. Dr.
Kittredge took a great interest in military matters. He
served in the late war, enlisting in Company B, 13th Regi-
ment Volunteers, of New Hampshire, Sept. 18, 1862. He
enlisted as first sergeant and was promoted on March 26, 1863,
to second lieutenant.
J. S. Wintermute, M.D., of Tacoma, Wash., was shot by
an insane patient on the morning of November 10, the bullet
passing through the abdomen making six perforations of the
intestines. The abdomen was opened and the bullet wounds
in the intestines stitched up, but he died a few moments after
leaving the operating table. James Stinson Wintermute was
born April 27, 1860, at St. Paul, Minn. His boyhood years
were spent in Canada ; he entered the University of Michigan
in 1879 and graduated at Rush College, Chicago, in 1883. Dr.
Wintermute went to Tacoma, Wash., in 1884 and soon took a
place in the front rank of the physicians in this city. He was
married in 1888 to Miss Florence K. Jones of Olympia, and
one son survives him. Dr. Wintermute has paid special
attention to surgery and his practice in this line during the
good times was a very lucrative one and he also accumulated
quite a sum from fortunate real estate transactions. He was
a member of the Pierce County Medical Society and also of
the Washington State Medical Society.
Dr. George W. Betton died at his home in Tallahassee,
Fla., on All Saints Day, Sunday Nov. 1, 1896, after a short ill-
ness. He was born in Alexandria, Va., on Feb. 22, 1822, and
at the early age of four, before the days of railroads, he came
with his parents to Florida on board a sailing vessel and landed
on the Gulf Coast at the port of St. Marks. In 1842 he was
graduated as Bachelor of Arts from St. Johns College, Annap-
olis, Md. He next attended lectures at the University of
Pennsylvania at Philadelphia, and on the 4th of April 1845
received the degree of Doctor of Medicine from that time-hon-
ored institution. Although in his 74th year at the time of his
death he still continued in active practice of his profession of
medicine which he had followed for more than forty years.
PUBLIC HEALTH.
Etiology of Typhoid Fever. — The epidemic at Rheims among
the dragoons was traced unmistakably to the dust stirred up
by their evolutions, and Uffelmann's experiments demonstrate
that the dried typhoid bacillus as also the cholera microbe can
be disseminated in the air, and thus alight in dust on articles
of food. Similar experiences are reported from Belgium as the
cause of the present slight epidemic at Tirlemont. These facts
tend to show that the water supply is not always to blame in
epidemics of typhoid fever. — From Journal d' Hygiene, Octo-
ber 29.
Epidemic of Scarlet Fever in Brazil. — Dos Reis describes in the
Gazeta Mid. da Bahia a recent epidemic of scarlet fever in
Curityba, lasting almost a year. He had himself over five
hundred cases in his practice. The disease was unusually
severe in its manifestations, with many deaths and cases of
consecutive paralysis and nephritis. More adults were attacked
than children under 10 and it was more serious with them.
He describes his treatment in detail, with which he was very
successful, stating that the only deaths among his patients 4
per cent, were those whom he saw for the first time in an
advanced and most critical stage.
The Garbage Question at Baltimore. -The following comments
by the Baltimore Herald indicate how civic work is sometimes
done, only to be done over again : "The agitation of the prob-
lem how to dispose of garbage in the most economical and sat-
isfactory manner has borne fruit in the appointment of a
special committee from the city council, which will visit various
cities to study the methods in vogue there, and report the
results of the investigations. Whether this is the most prac-
tical way of ascertaining what is the best method may be ques-
tioned. Men without special knowledge of the subject are
hardly in a position to perceive and weigh the relative advan-
tages of the several systems in vogue, special study being
required to arrive at an intelligent comprehension of details.
At the same time, however, the disposal of garbage otherwise
than by dumping it in some more or less remote place has
passed the stage of experiment. Reduction or incineration
plants are being successfully operated in nearly all progressive
cities. Not only do they dispose of the waste material
which would otherwise contaminate the soil or pollute
water courses but they make possible a considerable reduc-
tion in the expense of removal. The products of incineration
or reduction, unlike when offal is merely carted away and
dumped, have a commercial value which, in some instances,
not only covers the cost of the processes, but leaves a margin
of profit. The principal consideration, however, is that such
disposal removes a grave menace to health. In Baltimore gar-
bage is collected, loaded on scows and carried some distance
down the river to be dumped into the water. Aside from the
wastefulness of the proceeding, the decomposing vegetable and
animal matter helps to fill up the ship channel and becomes a
menace from a hygienic standpoint."
A Sanitary Triumph; Swill-feeding Enjoined at Philadelphia.— The
Board of Health of Philadelpia has been waging war since Feb-
ruary last against the use of the city's garbage for the feeding
of pigs at points a short distance beyond the city limits. This
matter culminated on October 17, at a trial in the court of
common pleas. The bearing of this proceeding is stated as
follows in the October issue of Public Health, and is held to be
a victory for sanitation in the State at large: "This was an
application for an injunction to restrain the defendant from
collecting kitchen garbage and offal in any part of the city,
from carrying it through the streets of the city, and then dis-
posing of it to hogs, or by spreading it upon lands in the city
or adjoining it. The allegation was that of collecting garbage
and conveying it to a farm in Delaware County, near the
county line, where he fed it to hogs ; that he had no contract
with the city for the collection of garbage, nor any license or
permit from the Board of Health ; that this course of conduct
was in violation of the ordinances of Councils and the regula-
tions of the Board of Health ; that it was liable to prejudice the
public health by reason of the bad odors which were carried
from the farm to the city, and the probable sale of the
unwholsome flesh of such fed hogs in the city. The defend-
ant's answer consisted of admission of fact and denial of mat-
ters of law, and after arguments the court granted the injunc-
tion asked for by the city. When the case was called it was
found that a cross suit had been brought asking for a manda-
mus to compel the Board of Health of Philadelphia to grant
these parties a permit to conduct the business in any way that
seemed good to them. The court held that the Board of
Health of Philadelphia was established for the express pur-
pose of deciding questions of this kind, and that, should the
court grant the mandamus it would be usurping the functions
of the Board and itself issuing the license, or that, in other
words, the court would be substituting itself for the Board.
The effect of this decision will be very far-reaching and will
strengthen the position of every board of health in the State."
A Low Rate of Mortality.— The monthly statement of the
Board of Health of the State of New York, for September,
shows the low rate of mortality for the whole State of 17.5 per
mille. Of the cities having 100,000 population or over, Roch-
ester had 13.2, Buffalo 13.8, Syracuse 14.0, Brooklyn 18.2,
Albany 18.6, New York City 18.7, respectively. There were
1896.]
PUBLIC HEALTH.
1121
500 fewer deaths reported than in the corresponding month of
last year. Among zymotic diseases the only material differ-
ence from the mortality of September, 1895, is in diarrheal dis-
eases, from whirh the number of deaths is loss by 600 ; the
mortality from all diseases of the digestive organs is dimin<
ished. Acute respiratory diseases caused 150 more deaths,
and from diseases of the circulatory system there were 100
more deaths than a year ago : from other local diseases as also
from consumption and constitutional diseases there was no
material variation. There were 800 fewer deaths under 5
years of age. Compared with the preceding month of August,
the total reported mortality is decreased by 3,000, the deaths
under G years of age being fewer by 1,200. Among zymotic
diseases, the diarrheal mortality was not half as large.
Typhoid fever, malarial diseases and diphtheria show an
increase ; whooping cough a decrease. Acute respiratory dis-
have increased, all other local diseases diminished, and
the deaths from accidents and violence, under which was
placed last month a number from sunstroke, have fallen to the
normal. The death rate from all causes is 17.50 against 23.25
in August and 18.60 in September last. The percentage of
infant and zymotic mortality are respectively 36.0 and 19.75
against 48.0 and 24.65 in August, and 41.5 and 25.0 in Septem-
ber last. The September prevalence of typhoid fever is
excessive in the Hudson and Mohawk Valley districts and in
the Southern Tier and East Central districts; the percentage
of deaths from typhoid fever in urban parts of the State was
2.0; in rural parts of the State 3.66. Diphtheria increased a
little from August, but caused fewer deaths than in Septem-
ber of any year for ten years ; in cities and villages it caused
3. 50 per cent, of the deaths; in rural parts of the State, 1.57
per cent. Scarlet fever continues to cause few deaths, but is
more widely distributed than in August.
Illinois Vaccine Establishment. The following is Dr. Cook's
report :
Mendota, III., Oct. 30, 1896.
To B. M. Griffith, M.D., President Illinois State Board of
Health.
Dt or Doctor: -In compliance with your request, conveyed
to me by letter of the 22nd inst., from Dr. J. W. Scott, Secre-
tary of the State Board of Health, I visited Urbana on the 26th
inst., and, as desired, inspected the State Vaccine Propagation
Station established in connection with the veterinary depart-
ment of the Agricultural College of the State University.
By an Act of the Legislature, approved June 15, 1895, in
force July 1, 1895, it was made the duty of the Trustees of the
University to establish and manage "a laboratory in connec-
tion with the State University for the propagation of pure
vaccine virus." It was provided in said Act, " That the State
Board of Health shall exercise supervision of the methods of
propagation and certify to the purity of all products."
In the interest of public health provision was thus made by
the State to put in operation a vaccine propagation laboratory,
to be equipped with all of the modern appliances, and under
most approved conditions to produce a vaccine virus of such
purity and effectiveness that the medical profession and the
public could be assured of its safety and potency to prevent
one of the remaining scourges of humanity — smallpox. We
need not recite what is so well known, namely, the very great
importance of knowledge, skill and conscientious care in all
the details to be followed in providing an agent so valuable as
a preventive of a loathsome disease. And further fact that its
wider usefulness will be much advanced by increasing confi-
dence on the part of the medical profession and public in the
purity and reliability of the virus thus produced. It is to be
regretted that the commercial spirit — the question of profit
accruing to private parties— has so dominated its production
as to cause want of confidence in the purity and safety of much
of the vaccine virus on the market. Prompted by that knowl-
edge, and actuated by the desire to advance a great public
sanitary interest, the Legislature, at the suggestion of the
State Board of Health, made provision for the establishment
of a propagation station in connection with her great University,
feeling confident that the work would be in hands in every way
competent and reliable, fully informed in all the recognized
methods and free from the trammels of desire for pecuniary
pun.
We have the pleasure of reporting that every facility was
given us to inspect thoroughly the State Vaccine Laboratory.
We were fortunate in meeting and being aided in our examina-
tion by two members of the faculty of the University who have
taken especial interest in and have given much personal atten-
tion to all the details necessary to equip and manage the Labor-
atory. We refer to Dr. Thomas 1. Burrill, Vice-President,
Dean of the General Faculty, and Professor of Botany and
Horticulture; and Dr. Donald Mcintosh, V. S., Professor of
Veterinary Science, who is in charge of the Laboratory. These
gentlemen are eminently competent, by reason of scientific
attainments, to accomplish the work assigned to them and
impress one with the thought that their desire and effort is to
produce a product the purity and reliability of which can be
certified by the State Board of Health.
We indorse the following extract taken from a recent circular
letter sent out from the Laboratory: "The Laboratory, an
isolated building to be used for no other purpose; has been
provided and properly equipped to attain the purposes of the
law. The most careful attention has been given to everything
which can facilitate freedom from contamination. The ceil-
ings, walls and floors of the operating and animal rooms are so
finished that they can be frequently washed with hose and
scrubbing-brush and thoroughly disinfected. A crematory is
provided for burning all litter and other organic matter. None
but animals bred by the university, or of well-known parentage
and selected with great care will be used. Everything is being
done to secure bacterial cleanliness and insure the preservation
of the virus in a state of reliable purity."
Careful examination verified the correctness of the above
statement. The building had been constructed for and used
by the veterinary department. Some necessary changes were
made in its arrangements, adapting it very well to the purpose
of a vaccine laboratory. It is very pleasantly located in a
grove nearly equidistant from University Hall and the build-
ings on the university experimental farm. In its exterior it
has the appearance of a neat cottage, being extended in one of
its dimensions by that part of the structure that is the tem-
porary home of the juvenile bovines, in whose living laboratory
is produced the animal immunizing agent — vaccine virus. The
grounds, like all others about the university, are neatly kept.
The interior of the building is pleasing. It is a model of
neatness ; with office, operating room and room adjoining,
equipped with modern facilities for sterilizing, etc. The rooms
for the heifers — we can not call them stalls— are convenient,
well lighted and ventilated. The degree of cleanliness of all
approaches very nearly that of one of our modern hospitals.
The heifers selected are the best obtainable and their care and
treatment the best possible. Their preparation for inoculation,
the operation, subsequent care and process of securing and
preserving the lymph are as aseptically done as possible. We
only need to add that Sec. 3 of the Act establishing the labor-
atory reads: "That the product of the vaccine laboratory
shall be furnished all physicians and health officers within the
State at the cost of propagation."
Permit us to say that it is a great satisfaction to know that
this, the first effort on the part of the State to produce and
supply the people with an agent of universal value in prevent-
ing a terrible disease promises to be so successful, and that the
money thus appropriated has been wisely expended. We can
but feel that this and other kindred interests relating to the
public health and the prevention and cure of disease appeal to
our legislators for generous appropriations. Other States have
demonstrated the feasibility and good results of establishing
and sustaining laboratories for the production of antitoxin in
the interest of public health. Edgar P. Cook, M.D.
Health Report. — The following reports of mortality from
smallpox, cholera and yellow fever have been received in the
office of the Marine Hospital Bureau of the Treasury
Department :
SMALLPOX — FOREIGN.
Athens, May 1 to 31, 7 cases, 1 death ; June 1 to 30, 5 cases,
1 death : July 1 to 31, 1 case, 1 death ; August 1 to 31, 4 cases.
Alexandria, July 23 to 29, 1 death.
Barcelona, September 1 to 30, 15 deaths.
Birmingham, October 17 to 24, 1 case.
Cairo, July 23 to 29, 3 deaths.
Gibraltar, October 11 to 18, 2 cases.
Havana, October 15 to 29, 470 cases, 69 deaths.
Licata, Italy, October 10 to 17, 5 deaths.
Liverpool, October 10 to 17, 1 case.
London, October 10 to 17, 2 cases.
Montevido, September 19 to October 3, 10 cases, 3 deaths.
Mozambique, August 1 to 31, 1 case.
1122
MISCELLANY.
[November 21,
Odessa, October 10 to 17, 16 cases, 3 deaths.
Rio de Janeiro, September 26 to October 3, 10 cases, 1 death.
St. Petersburg, October 10 to 17, 13 cases.
Tuxpan, Mexico, October 10 to 17, 4 deaths.
Warsaw, October 3 to 17, 13 deaths.
CHOLERA.
Alexandria, July 23 to 29, 24 deaths.
Bombay, September 30 to October 6, 11 deaths.
Cairo, July 23 to 29, 11 deaths.
Calcutta, September 19 to 26, 4 deaths.
Madras, September 26 to October 2, 8 deaths.
Yokohama, October 2 to 9, 2 cases, 2 deaths.
YELLOW FEVER.
Havana, October 15 to 29, 345 cases, 128 deaths.
Matanzas, October 21 to 28, 10 deaths.
Rio de Janeiro, September 26 to October 3, 5 cases, 1 death.
Sagua la Grande, October 10 to 24, 168 cases, 13 deaths.
MISCELLANY.
Deformity-Producing Shoes. — According to a recent article in
the Boston Med. and Surg. Reporter, the ability to walk erect
which distinguishes men from the lower animals, is menaced
by our present fashions in foot gear. The writer evidently
thinks it useless to combat the styles of shoes in vogue among
adults, but he makes a vigorous appeal to have the feet of our
children preserved from deformity, by supplying them with
hygienic foot covering. He hopes that by the time they have
attained maturity the fashions in shoes will become more sen-
sible ; and urges in the meanwhile that their shoes should bo
constructed on scientific principles. The sole of the shoe
should not taper toward the toes, but should be broadest at
the base of the toes, and continue broad or even wider to the
tip, instead of compressing and utterly ignoring the functions
of the fore part of the foot, as is the present custom. He
thinks that the pointed toes worn so much recently by adults
will result finally in serious senile troubles.
Customs of Russian Doctors. The Russian physician, the
Record says, considers it beneath his dignity to send a bill to a
patient, but leaves it to the patient to pay what he thinks
proper. Many think it proper to pay nothing. Are you acting
the Russian in business matters? If so neither free silver, free
gold, nor anything can save you from financial distress. — Kan-
sas City Medical Index.
Illinois State Board of Health. — At the last meeting of the Illi-
nois State Board of Health the " Illinois Medical College" was
given further time in which to complete its equipment of the
school, in order to obtain recognition ; it has not yet been
recognized. The "Dunham" Medical College (homeop.) was
given time in which to complete its equipment. The "Harvard"
Medical College was given authority to change its name to that
of the Jenner Medical College.
Commission to Investigate Charitable Interests. A resolution
was passed by the legislature of Massachusetts at its recent
session providing that the governor, by and with the advice of
the council, appoint a commission, consisting of three persons,
to investigate the public charitable and reformatory interests
and institutions of the State ; to inquire into the expediency of
revising the system of administering the same and of revising all
existing laws in regard to pauperism and insanity, including all
laws relating to pauper settlements ; and furthermore to inquire
into the relation of pauperism and insanity to crime, with a
view to securing economy and efficiency in the care of the poor
and insane in the State. The commission is authorized to em-
ploy a stenographer and is given power to send for persons and
papers, and to incur such expenses and receive such compen-
sation for their services as the governor and council may
determine. It is to submit its report, with a bill or bills, if
practicable, to the governor and council before the first day of
February, 1897.
Early Aid for Injured Employes.— The number of indemnities
paid to injured employes in Berlin has dropped to about one-
third since the practice has been adopted of taking charge of
them with trained attendance from the start, and thus prevent-
ing the development of serious complications. The number of
deaths has also decreased in proportion. The patients are
restored to their work in the shortest possible space of time,
and it is calculated that many thousands of dollars have thus
been saved to the corporations which insure their employes
against accidents. The Journal D' Hygiene of October 22, con-
tains the report presented at the recent Samaritan Congress at
Berlin. The ten "emergency stations" for first aid to the
wounded, that were established by the corporations, are open
also to the general public as the city allows them an annual
appropriation of 1,000 marks. During 1895 they took charge of
13,856 injured persons : 7,508 belonging to the corporations.
Over one-half the rest were too poor to reimburse the corpora-
tions for the expenses incurred on their behalf.
Vallid Warranty Against Suicide.— A warranty in an application
for life insurance that the insured will not die by his own hand,
whether sane or insane, the United States circuit court holds,
in the case of Kelley v. Mutual Life Insurance Company,
decided August 25, 1896, is valid. It had been contended that
the warranty, in so far as it attempted to control the acts
of the insured while insane imposed an impossible condition
upon the contract, which was at the time of its execution
known to be impossible, and was therefore void. But the
court maintains that the clause should be construed in accord-
ance with the announced general principles of construction,
and that, under the situation, the warranty became of the
force and effect of a promissory one, or stipulation to be per-
formed, exempting from liability on the policy upon substan-
tial breach thereof.
Allowable Use of Copyrighted Works. - According to the decision
of the United States circuit court, N. D. California, handed
down, in the case of Simms v. Stanton, June 25, 1896, what the
law seeks to prohibit and to punish is the use of any part of a
previous (copyrighted) book, anitno furandi, with an intent to
take for the purpose of saving oneself labor. It says that a
copyright gives no exclusive property in the ideas of an author.
These are public property, and any one may use them as such.
An author may also resort with full liberty to the common
sources of information, and make use of the common materials
open to all. But his work must be the result of his own inde-
pendent labor. Copying is not confined to literal repetition,
but it includes also the various modes in which the matter of
any publication may be adopted, imitated, or transferred, with
more or less colorable alterations, to disguise the piracy. If
such use is made of a previous work as to substantially dimin-
ish its value, or the labors of the original author are, to a ma-
terial degree, appropriated by another, such use or appropria-
tion is then deemed sufficient in point of law to support a suit
for infringement of copyright. What would be a " fair use" in
one case might not be in another. In determining this ques
tion, courts often look more to the value of the matter pirated
than to the quantity. A controlling factor, which, among
others, influenced the court in determining this particular case,
was that both authors were writing on the same subject. It is
difficult, it says, to conceive how writers on the same art or
science can very well avoid resorting to the same common
source of information and using the same common materials,
and also in employing similar expressions and terms peculiar
to the subject they are treating of. And it expressly holds
that a writer of a work on physiognomy, which it thinks is an
art, or approximates to a science, did not violate the copy-right
law, in consulting and using another's works on that subject,
it having been done without drawing from them to a substan-
tial degree, though there were parallelisms, errors and repeti-
tions, suggesting servile copying from the works of the com-
ISW.J
MISCELLANY.
112;}
plaining author, some of which were explained by evidence that
certain features common to the rival works had been obtained
from other common and permissible sources.
Primary Sarcoma of the Vagina in Early Life Mr. D' Arcy Power,
in the S& liarllioloincir's Hospital Reports, 1896, records a
one of this nature. The patient was somewhat more than 2
years of age when she first came under the care of the surgeon.
.Mr. Power refers to twenty-four other cases collected in a
rather hasty examination of the literature. From a considera-
tion of these eases he concludes that primary sarcoma of the
vagina is only a specialized form of malignant disease which
may effect any or all of those connective tissues which are
involved in the complicated development processes associated
with the formation of the cloaca. The sarcoma grows in the
connective tissue of the pelvic organs and extends into the
bladder, the urethra, the uterus or the vagina. It is either
well circumscribed as in the case described, or is diffuse as in
a case reported by Ahlfeld lAirliiv f. Qyn&kql., Bd. xvi, p.
135), but whether circumscribed or diffuse, whether affecting
the vagina alone or infiltrating all the neighboring organs, this
form of sarcoma shows an almost constant tendency to become
polypoid and multiple. As it occurs in children primary sar-
coma does not, in the majority of cases, run a very rapid
course. It does not ulcerate very readily. It does not usually
effect the lymphatic glands. It does not disseminate, but its
prognosis is very grave. It recurs quickly after removal, and
it kills by interfering with the action of the pelvic organs, by
retention of urine more often than by obstruction of the
bowels. The diagnosis is easy, but the polypi are often looked
upon as innocent growths, and their true nature remains un-
recognized until the presence of a tumor in the pelvis shows
that it is too late for surgical interference. Multiple polypi of
the rectum and of the genito-urinary tract in young people,
however, are so rare, and when they do occur, are so often
associated with malignant disease, that their presence should
always lead to a suspicion of such a condition. The complete
cure has been effected in one or two cases of primary sarcoma
of the vagina in children shows that the early and complete
removal of the growth may be effectual in this as in other
forms of malignant disease.
Construction of Representations to Medical Examiner. In an
action to enforce the collection of a policy of life insurance
payment was resisted on the ground that there had been mis-
representations made by the insured to the medical examiner
which constituted a breach of the warranty contained in the
policy. A mong other things, the insured had stated that he
never had any disease of the bladder ; that he never had any
disease of the skin ; and that he never had any disease of the
urinary organs. Relating thereto, the jury were charged
that a mere temporary ailment of the kind named would
not constitute the diseases named as contemplated in
the questions and answers given. In construing policies
of insurance, it was further said that it must be gener-
ally true that, before any temporary ailment can be called a
disease, it must be such as to indicate a vice in the constitu-
tion, or be so serious as to have some bearing, at least, on the
general health and continuance of life, or such as, according to
common understanding, would be called a disease ; that the
legal meaning of all or nearly all of the questions referred to
had in one way or another been fixed by law ; that in finding
a verdict as to whether or not the answers to them were true
when made they should be considered from and under the
meaning given to them by the court ; that the term "serious
illness" means such illness as is likely to impair permanently
the constitution, and render the risk more hazardous ; and
that 'addicted to the use of chloral" means habitual con-
stant use of it. These instructions, the supreme court of Ten-
nessee holds, in Rand v. Provident Sav. Life Assur. Soc.,
decided Sept. 26, 1896, accord with the authorities and cor-
rectly state the law. When the applicant says that he has
never had any "serious illness," it adds, the courts will con-
strue the meaning to be that he has never been so seriously ill
as to permanently impair his constitution, and render the risk
unusually hazardous.
Connection Between the Cortex and the Labyrinth.— Ewald has
found by experiments on dogs that the auditory nerve performs
more than the mere auditory function, and therefore suggests
that this name is misleading, and that it would be better to
call it nervus octavus instead. He states that if the labyrinth
is destroyed in a dog the animal loses the coordination of its
movements, is unable to stand up, to walk, etc., but in the
course of a few weeks these disturbances pass away, and the
missing functions seem to be fully compensated in some way.
The same phenomena occur if the other labyrinth is also
destroyed ; in time the animal learns to move as usual, even to
run and jump. Similar results are produced by destroying on
one side only the "excitable zone" in the cerebrum for the
movements of the fore and hind legs ; the dog learns in time
to run and jump as nimbly as ever, even in the dark. But if
later the remaining half of the " excitable zone " is also
removed, then intensely severe and permanent disturbances
follow. The animal can neither stand nor walk ; he can not
lie down on his breast or belly, only on his side, and in spite of
the most strenuous efforts, he can not get up on his feet. He
is still able to move his head, and uses it to propel himself. He
gradually learns in time to use his extremities by purely reflex
action, but is unable to make a single voluntary movement,
and even the reflex movements are impossible in the dark. He
loses control of his movements completely if taken into a dark
room, and tumbles helpless to the floor ; but after the room is
lighted he regains control of his movements and is able to
move as before. Ewald considers that this throws a new light
upon the connection between the sight and the locomotor func-
tion. The proof of the extra functions of the nervus acusticus
is therefore the diminished muscle power in the animal after
the nerve is severed ; also the lack of precision in its move-
ments ; also the lack of muscle sense, shown by the vertigo.
The influence of the auditory nerve on the striated muscula-
ture is explained by the presence of the ciliated cells in the
labyrinth, which produce uninterrupted excitation of the cen-
tral nervous system. As the severed auditory nerve does not
grow again, the explanation of the disappearance of the dis-
turbances must be that its functions are substituted by other
organs. The sense of touch substitutes the function of the
labyrinth, as is evidenced by the fact that the coordinating
power is not totally abolished until the entire " excitable zone"
in the cerebral cortex is removed. The " excitable zone " and
the labyrinth are able to substitute each other, and the same
is true of the muscle sense and the sense of touch. This
explains the comparatively slight motor disturbances in per-
sons with injured labyrinths. — Deutsche Med. Wocli., Octo-
ber 22.
Liability of Counties in Emergency Cases. Section 24 of the
Illinois Pauper Act provides that "when any non-resident, or
any person not coming within the definition of a pauper, of
any county or town, shall fall sick, not having money or prop-
erty to pay his board, nursing and medical aid, the overseer of
the poor of the town or precinct in which he may be, shall give,
or cause to be given to him, such assistance as they may deem
necessary and proper, or cause him to be conveyed to his home,
subject to such rules and regulations as the county board may
prescribe ; and if he shall die, cause him to be decently buried."
By this, the appellate court of Illinois, for the third district,
holds, in the case of the County of Madison v. Haskell,
decided Dec. 6, 1895 (63 111. App. 537), that the legislature
made it absolutely obligatory upon the county to make all
necessary and proper provisions for extreme cases, such for
1124
MISCELLANY.
[November 21, 1896.]
example as where persons, who are not paupers, are seriously
burned by an explosion of oil when congregated at the scene
of a railway accident. It can not avoid the liability so
imposed, by its failure to appoint necessary agents or prescribe
regulations as to the manner of doing it. If the defense is
that the provision was not made, or not furnished in accor-
dance with the rules and regulations prescribed by the board
of supervisors, it is incumbent on the county to show that the
county board prescribed reasonable rules and regulations on
the subject, and what they were. Any rule or regulation of
the county board which would have required a moment's delay
on the physician's part, in such a case as that under consider-
ation, if he had been informed of it, and that the overseer of
the poor was within speaking distance, the court goes on to
declare, would have been unreasonable, and he unworthy of a
place in his profession if he had thought of it before acting.
These people were entitled to medical aid if it could be had,
on the instant and at the county's expense. Accordingly, the
court affirms a judgment for services and materials furnished
in favor of a physician who had those injured in this case con-
veyed to a hospital, in a neighboring city, of which he was a
regular physician and surgeon, and where he afterward ren-
dered the services in question, attending them. In the com-
panion case of the County of Madison v. Halliburton, which
has just been reported in 64 111. App. 99, the court further
holds that the fact that the physician seeking to recover for
services rendered under such circumstances is employed as the
county physician, and paid an annual salary, will not prevent
him from maintaining his action, his contract, though only
verbal, covering the cases of the county "poor" only, his
purpose in this case being to recover for the treatment of other
than poor persons.
Hospitals.
The dedicatory exercises attending the opening of the new
Post-Graduate Medical School and Hospital in Chicago were
held November 7. The hospital was formerly on West Harri-
son Street, but was found to be inadequate. The new build-
ing is well equipped and fitted up according to modern designs.
The ceremonies consisted of a surgical clinic held by Dr. L. L.
McArthur, which was followed by a gynecologic clinic by Dr.
Albert Goldspohn. A well-attended evening reception was
given by the faculty, which was followed with an address by
Dr. Theodor Klebs on the future of the institution. The
Bender Hygienic Laboratory of the Albany Medical College
was formally dedicated October 27. The new Provident
Hospital Training School in Chicago was formally presented to
the colored race October 29. Plans have been prepared for
the new University Hospital at Iowa City, Iowa. The struc-
ture will cost 850,000 and will consist for the present of a west
wing and amphitheater. The new buildings of theBethesda
Hospital, St. Paul, were dedicated November 12. At the
session of the United Presbyterian Women's Association, held
in Pittsburg, October 30, property in Allegheny valusd at
$35,000 was presented by Dr. J. B. Herron to be devoted to the
association and its successors to the use and benefit of the
Memorial Hospital, with the proviso that a Campbell B. Herron
memorial bed be established. The corner stone of the St.
John's Hospital at Long Island City was laid November 11
with appropriate exercises. The annual meeting of the
board of directors of the Free Hospital for Women in Brook-
line, Mass., was held October 29. The report showed 261
patients treated in the hospital during the year. The man-
agement of the National Temperance Hospital, an affiliated
interest of the W. C. T. U., has purchased ground for a tem-
perance hospital in Chicago.
Cincinnati.
The moRTALiTY report for the week shows : Diphtheria 4,
typhoid fever 4, other zymotic diseases 7, cancer 3, phthisis
pulmonalis 8, local diseases 57, developmental 17, violence 2 ;
under 5 years 31 ; all causes 102 ; annual rate per 1,000, 15.15 ;
deaths during preceding week 90; corresponding week in 1895,
102 ; 1894, 123 ; 1893, 110.
Dr. Charles A. Hough of Lebanon, Ohio, recently passed
through an attack of diphtheria. He was in a private ward at
the Cincinnati Hospital.
The latest news item from the Cincinnati Hospital is that
they have been receiving less milk than has been paid for, and
something over $1,000 is claimed in rebate. It is alleged that
the cans do not hold as much as they were supposed to.
The Hospital Corps of the First Regiment have recently
been denied admission to the receiving ward of the hospital.
This organization has been doing much good work in the past
and without one cent of expense to the city, and this new move
on the part of the new management will in times of serious dis-
asters deprive the institution of the valuable aid of this well
trained corps ; and the reason for the move has not as yet been
evident.
An unusual case of mental disease was admitted to the city
hospital last week. A middle aged man was found wandering
about the streets and when questioned could give no account of
himself. Upon examination, when recovered, he talked
rationally until asked what his name was and where he lived,
both of which he is unable to say. His general health is good
and this is the second attack he has had within a period of
several years.
A severe epidemic of diphtheria is present at Parkersburg,
W. Va., and several cases of the malignant type have appeared.
THE PUBLIC SERVICES.
Army Chanjres. Official List of changes Id the stations and duties
of officers serving in the Medical Department, U. S. Army, from
Nov. 7 to Nov. 13, 1896.
First Lieut. John H. Stone, Asst. Surgeon, is relieved from duty at Ft.
Leavenworth, Kan., and ordered to Ft. Klley, Kan., for duty at that
station.
Navy Changes. Changes in the Medical Corps of the U. S. Navy for
the week ending Nov. 14, 1896.
Asst. Surgeon H. La Motte, detached from the naval hospital, Norfolk,
Va.. and ordered to treatment at naval hospital, Philadelphia,
November 11.
Surgeon E. H. Marsteller. detached from the " St. Mary's," ordered home
and placed on waiting orders, November 18.
Surgeon B. Whiting, ordered to the " St. Mary's."
Change of Address.
Akins, W. T., from 180 Wilmot St. to 1122 Southport Av.. Chicae*.
Grote, H. W., from Oakland Music Hall to 5127 Lexington Av.. Chicago.
Scates, D. W., from Greenfield, Tenn., to 223 Lexington At., New York.
LETTERS RECEIVED.
Aikman, J. C, New York, N. Y.
Bailey, Wm. Curtis, Las Vegas Hot Springs, N. M,; Boehringer, C. F.
&Soehne (2), New York, N. Y.; Betton, G. W., & Son (Drs.), Tallahas-
see, Fla. ; Battle Creek Sanitarium, Battle Creek, Mich.; Boot, G. W.,
Spencer, Iowa.
Cantwell, A. W., Davenport, Iowa; Cowan, Chas. S., Fort Jones. Cal.;
Cullen, G. W., & Son, Cullen P. 0„ Va.; Cordier, A. H., Kansas City,
Mo.; Cale.G. W., Jr., St. Louis, Mo. ; Chapman, C. J., Chicago, 111.; Car-
ter, J. A., Carthage, Mo.
Dewees, Wm. B.,Salina, Kan.; De Bchweinitz, G. E., Philadelphia, Pa. ;
Daly, B., Lake View. Ore. ; Daland, Judson. Philadelphia, Pa.
Ewing, W. G., Nashville, Tenn. ; Elliott, A. R., New York, N. Y. ; East-
man, C. A., Exeter, N. H
Fassett, Chas. Wood, St. Louis, Mo. ; Fuller's, Chas. H., Advertising
Agency. Chicago, 111.; French, J. M., Milford, Mass.
Garcelon, A.. Lewlston, Me.; Grace, M. B., Iredell, Tex.
Howard, Wm. R., Ft. Worth, Tex.; Hare, H. A., Philadelphia, Pa.;
Haldenstein, I., (2) New York. N. Y. ; Herriek, J. B., Chicago, III.
Kny, Richard, & Co., New York, N. Y.; Korn, A., Chicago, 111.; Ken-
nedy, T. C, Shelbyville, Ind.; Kreider, Geo. N., Springfield, 111.
Long Island Bottling Co., Brooklyn, N. Y.
Mayfield, W. H., St. Louis, Mo.; Meany, Wm. B., St. Louis, Mo.; Mc-
Farland. George C., Jacksonville, 111.
Open Court Publishing Co., Chicago, 111.
Probst, C. O., Columbus, Ohio: Parke, Davis & Co., (2) Detroit, Mich.
Smart, Charles, Washington, D. C; Souchon, Edmond, New Orleans,
La.; Shuey, J. J., Red Oak, Iowa; Short, J. L. La Grange, Ind.
Tinker, N., Athens, Ohio; Taylor, Lewis H., Wilkes Barre, Pa.; Tiffin
Newspaper Agency, Tiffin, Ohio.
Van Nort, John P., Bayshore, L. I., N. Y. ; Von Ruck, Karl, Asheville,
N. C.
Woitishek, F. J., Cedar Rapids, Iowa; Watseu, Walter, Jacksonville,
111.; Winn & Hammond, Detroit, Mich. ; Wyckoff, R. M., Brooklyn, N.Y. ;
Wood, William & Co., New York, N. Y. ; Whitfield, S. T. Uniontown, Ala.
The Journal of the
American Medical Association
Vol. XXVII.
CHICAGO, ILL., NOVEMBER 28, 1896.
No. 22.
ADDRESSES.
NOTES ON SOME OF THE NEWER REME-
DIES USED IN DISEASES OF
THE SKIN.
A.Uliv-sot' the Chairman delivered in the Section on Dermatology and
ihllogranhy. at tee Forty seventh Annual Meeting of the
American Medical Association, held at Atlanta, Ua„
May .VS. iv>,;.
HV 1..
DUNCAN BULKLEY,
SEW YORK.
A.M., M.D.
This is certainly the age of progress, and the cry
is continually for something new. The wonderful
advances which have been made in medicine and sur-
gery daring the past fifty years would seem to warrant
us in looking for newer remedies and measures in all
departments of medicine: and indeed, the number of
these which have of late years been pressed upon us
by writers in medical journals and manufacturers, is
so great that much confusion of thought and purpose
is often induced thereby.
It is well, therefore, now and again, to stop and weigh
and try to estimate the value or worthlessness of the
new. and to see what of it should be added to our
stock of old, and thus to recognize where true advance
has been made.
It would be really amusing, were it not so sad, to
read and record carefully all that is written in jour-
nals and publications relating to therapeutics, mate-
ria medioa and new remedies, and then each year
carefully note the true value of this and that remedy,
as developed by the experience of others than the one
presenting it; and it would be still more interesting
and instructive to sum this up at the end of five, ten,
twenty and more years.
Time and space fail me entirely to even mention
the so-called and supposed " advances " and new
remedies which have been vaunted during the more
than twenty-five years that I have been occupied with
diseases of the skin; indeed, such vast numbers of
them have passed out of sight that it would require
much laborious research to resurrect their ghosts.
However, this would only serve to show the easy
credulity of physicians and patients, and furnish a
monument of disappointed hopes. In addition to the
large number of remedies advocated by members of
the regular profession, from time to time, reference
should also be made to the innumerable remedies or
combinations which have been patented and adver-
tised, many of which have not been without some
merit in individual cases, and some of which have
been only too often employed or indorsed by physi-
cians of good standing.
Therefore, before remarking upon some of the
newer remedies, allow me to enter my strong protest
against the restless seeking after the new to the
exclusion of older and well tried and approved meth-
ods in the treatment of diseases of the skin, which
seems to be so common of late years. It is not so
muoh new remedies we need, as it is a better under-
standing and adaptation of those we already have.
There is no king's road to learning, nor is there any
short cut to the successful treatment of disease. One
is, however, often led toward the contrary view by
the voluminous announcements and advertisements
of new remedies in modern times, whether they are
written by members of the regular profession, or
issued by manufacturers of drugs, or charlatans.
Dermatology is a large field, and much study and
experience are necessary to attain success in practice;
and yet how very little is this recognized. How often
have I been asked by medical friends, " Well, what is
there new that is good for diseases of the skin?" In
few branches of medicine is accuracy of diagnosis
more important for therapeutic success than in this,
and there never can be any remedy, new or old, which
is " good for diseases of the skin ; every remedy must
have its exact adaptations pointed out, not only in
regard to the special disease in which it is of value,
but also as to the phase or stage of such disease — and
that is what often is not clearly stated in connec-
tion with new remedies.
In concluding these introductory remarks, I wish
again to emphasize the fact that our older remedies
and methods of treatment yield fairly satisfactory
results when applied with skill and thought, without
which no remedy can be of avail. I wish also to say
that, in my opinion, new remedies, as they appear
from time to time, are very much less employed by
specialists in this line than by the general profession.
For myself I may say, that it happens not very infre-
quently, that I have never given certain new remedies
a single trial, because, before it seemed best to do so,
further experience by others has demonstrated their
relative worthlessness. I am sorry to seem thus pes-
simistic in my views on this subject, but being some-
what conservative by nature, each year has added to
my distrust of new remedies and measures, which are
often put forth by those of very slender experience.
I shall, therefore, remark only upon some of the
newer remedies, not the newest, of which I can speak
from personal experience, or from their use in the
New York Skin and Cancer Hospital.
Since the time of the elder Hebra, and largely by
his influence, attention has been chiefly directed
toward the local study of diseases of the skin, and
their treatment by external methods, and I have to
record that relatively few striking advances have been
made in their internal treatment; it is, indeed, remark-
able how very few new internal remedies have been
proposed in this class of affections of late years, and
recent additions can be quite briefly dismissed.
I will not attempt to analyze the facts in regard to
the injections of tuberculin in lupus, or the antitox.-
ins in sarcoma and epithelioma, for the subjects are
still so much discussed that no proper judgment can
1126
NEWER REMEDIES IN DISEASES OF THE SKIN.
[November 28,
be passed upon them. Recently Hebra has reported
on the subcutaneous injection of thiosiamin in lupus,
glandular swellings and exudative products, and other
remedies are being tried hypodermically, but the
results are still too uncertain to be recorded. The
thyroid extract is also being tried and reported on in
psoriasis and some other skin affections. Although I
can not say much in its favor from personal experi-
ence, I am inclined to think favorably of it in psoriasis.
A ntipyrjm, while not a very new remedy for general
use, has recently been advocated in urticaria and will
* often prove very effective, provided there is not some
alimentary disorder continuing the trouble. When
cases have resisted ordinary remedies, a moderate dose
of antipyrin given three or four times daily, between
meals, will often serve to stop the tendency to the
eruption. Phenacetin and even antifebrin, will some-
times prove of great service as antipruritics, especially
when given at night.
Many new preparations of mercury have been intro-
duced for the treatment of syphilis in the last few
years, no less than twenty-four new combinations
appearing in a recent publication; but, as far as can
be seen, the advantage from them relates only to their
tolerance by the digestive system, and there is no one
to which I can refer with special recommendation.
In all it is only the mercury which is the active agent,
and I have yet to find any yield better results in early
syphilis than the one grain tablets of mercury and
chalk given every two hours, as recommended by
Jonathan Hutchinson. In the later stages of syphi-
lis, the combinations with iodin still hold their old
and valued position. The many suggestions in regard
to the hypodermic use of mercury, in various forms,
occasionally prove valuable in rare cases where there
is great stomach intolerance of the drug, or where for
some special reason very prompt action is desired; or
where the patient, for social or other reasons, prefers
an occasional injection to the taking of repeated doses
internally. But I have never found it necessary or
desirable to resort to them largely, and I question if
many of those engaged in treating syphilis now use
this method much more frequently than I do.
Some new preparations of iodin have been intro-
duced, notably the iodid of rubidium, which is said to
be very well tolerated by the stomach; but from a
moderate experience with it, I can not see the great
advantage of this expensive drug. Nor can I say
much more for the iodid of strontium or several other
iodic preparations; but the syrup of hydriodic acid is
certainly a most valuable remedy in certain late cases
of syphilis.
Turning now to the local treatment of diseases of
the skin, we find that a host of new remedies have
been presented of late years; among these many have
not fulfilled the expectations which were raised, while
many are of very considerable value, and their worth
has been confirmed by many observers.
Resorcin stands prominent among these, and of its
value, when properly used, there can be no doubt.
To Unna is due the credit of pressing the importance
of this remedy upon the profession, maiidy in connec-
tion with eczema seborrhoicum, with which his name
has become inseparably connected. In this eruption,
which in reality is no eczema, but a parasitic disease
of microbic origin, resorcin is almost a sovereign
remedy. In a strength of about 6 per cent, in zinc
ointment, or irt solution with a little alcohol and gly-
cerin, it will often clear off a well-defined eruption in
a very few days. The solution is particularly appli-
cable in the scalp, and the surface should be thor-
oughly wet with it morning and night by means of a
large medicine dropper; it will thus commonly arrest
at once the itching attending the scaling of the scalp,
which is often one of the earliest signs of seborrheic
eczema, and which often leads to a loss of the hair.
Resorcin used much stronger, even up to 25 per
cent, in zinc ointment, will sometimes give brilliant
results, locally, in the treatment of acne rosacea. The
application is kept on for several days, and causes
some little inflammation, after which the previous
redness and pustular condition will be found to have
largely disappeared. A second or third application
may be necessary, and if the cause of the reflex con-
gestion has been removed by appropriate diet and
medication, there will be very much permanent bene-
fit. Resorcin also proves serviceable in certain ulcer-
ative conditions, notably those of a tuberculous type,
used in a mild ointment, not exceeding 10 per cent.
Ichthyol certainly stands next in importance among
the newer additions to therapeutics in dermatology, as
it is also valuable in other branches of medicine, and
all are undoubtedly familiar with its use. As an
antipruritic it is often of great service. Added to oint-
ments, in a strength of from 6 to 10 per cent., it is
very valuable in eczema, and may be used in even
quite acute conditions. In dermatitis herpetiformis
a watery solution, 5, 10 or even 20 per cent, will often
give more relief than any other local remedy. When
the skin is too dry it can be used in almost the same
strength in oil with much advantage ; the same meas-
ures are of much service in pruritis ani. In burns
an ichthyol ointment, about 6 per cent., will often
prove the most comfortable dressing, and on old
ulcers of the leg the same, though stronger, is very
valuable.
Ichthyol has a power of reducing infiltrations, and
in chronic conditions may be painted pure over the
surface with much advantage. I have a number of
times seen the greatest benefit result from painting
pure ichthyol over joints enlarged by rheumatism and
gout, and then applying one or two thicknesses of
flannel, wrapped firmly on the part, forming an adhe-
rent dressing with the ichthyol. This may be
removed and fresh ichthyol painted on daily, and
wrapped with the same flannel; patients who have
long suffered from these conditions have obtained
more relief from this method of treatment than from
any previously adopted.
In this connection I may mention another non-
dermatologic use of ichthyol, although it has some
connection with the troublesome skin conditions
observed about the anus. This is the internal use of
ichthyol, in piles, which I do not think is generally
known. Taken in doses from five to fifteen drops, in
water or capsule, after each meal, it seldom fails in
giving relief to the congested capillaries of the lower
rectum and anus, if the condition is not too exagger-
ated; when by long duration the blood vessels have
become permanently dilated with intercellular exuda-
tion and some vascular new formation, and especially
if a clot has formed in the mass, this remedy has little
effect. But in the milder and recurrent cases, where
small tumors form, ichthyol, if freely used internally,
and perhaps externally, will give a relief which is
most gratifying, and I have many patients who at
once resort to it on every return of this trouble.
The disagreeable odor and the staining of ichthyol
1896. J
XKWER REMEDIES IN DISEASES OF THE SKIN.
1127
have led to the introduction of several other sub-
stances Intended to take its place. One of those is
thiol ■ sort of artificial ichthyol, less unpleasant in
smell and producing less permanent stains on linen.
From what I have seen of its use in the hospital, I do
not think it fulfils the requirements as well as the
natural drug. 1 may add that it is sometimes dirri-
eult to obtain the true and pure ichthyol, as there
have been several synthetic produote offered in its
place, none of whieh seem as good as the imported
natural product.
Another of these iehthyol-like remedies is tumenol,
upon whieh a number of observers have reported. It
aets much like tar in relieving itching, but it is expen-
si\e. and rather hard to manage, and from some
experience with it 1 do not see its advantage over
ichthyol.
Bra! astringent remedies have been introduced
of late, some of which are of considerable value.
Prominent among these is alumnol, an aluminum salt
containing sulphur. It is in a tine white powder, very
soluble in water, in glycerin, and in warm alcohol,
and insoluble in ether. A 1 to 5 per cent, solution in
water may be applied with advantage even in acute
eczema. It is also of advantage in ointments, 10 to
90 per cent., and also in dusting powders, even up to
;>0 per cent.
Dermatol, a basic gallate of bismuth, in form of a
yellow, insoluble powder, is also a safe astringent,
used in ointment 5 to 10 per cent., or as a dusting
powder.
QaUanol acts much in the same manner, and is
valuable iti the more chronic stages of eczema and in
psoriasis. Being white and not staining or irritating
the skin, it has advantages over chrysophanic and
pyrogallic acid.
Gallaceto-phenonB, a compound from pyrogallic
acid, acts much in the same manner as that drug, and
is oertianlj of considerable value in psoriasis, in an
ointment of about 10 per cent.
Beta naphthol is an old remedy, but still one of the
later additions to our dermatologic armamentarium ;
it has considerable power over psoriasis, in ointments,
in a strength from 6 to 10 per cent., and is also use-
ful in scabies, and of moderate value in the vegetable
parasitic eruptions.
Of the newer preparations of iodin. europhen takes
a prominent place. It is non-toxic, but slightly
odorous, and with many has supplanted iodoform, in
the treatment of venereal ulcers; it serves well also to
promote cicatrization when dusted on all forms of
ulceration.
Aristol still holds its place for much the same con-
ditions, and is also valuable in an ointment, 4 to 10
per cent., in psoriasis.
Iodol is one of the newest claimants of attention,
and acts very well in place of iodoform, it being said
to contain 89 per cent, of iodin; it is practically iodo-
form and therefore a desirable preparation.
Boric add has also come prominently into view as
an antiseptic and astringent, used both as a powder
and in solution in water and in ointments, in a strength
of from 5 to 20 per cent. It is always a safe and often
a very serviceable remedy. As an antiseptic the j>er-
o.rii/ of hydrogen has steadily gained in reputation,
and often serves most admirably in checking suppu-
ration, either on external surfaces or injected into
cavities or sinuses.
Several remedies of value have been brought for-
ward of late for the relief of itohing. Prominent
among them is menthol, used in ointmentor oily solu-
tions, in a strength of from 2 to 10 per cent. Gener-
ally it is best to combine with it about double the
proportion of carbolic acid, partly to aid its action
and partly to overcome some of the chilly sensation
produced by the menthol when used alone.
( 'ocain also sometimes serves an excellent purpose,
added to ointments, in a strength of 1 to 5 per cent.
Care must be exercised in applying it over too large a
surface, for fear of systemic results, and I have some-
times thought that it acted as a local irritant.
The combination of camphor and chloral, rubbed
together in equal parts till a liquid results, and added
to ointments, in a strength of from 5 to 15 per cent.,
is also a valuable antipruritic. Its application is
attended with considerable burning sensation, if there
is any raw surface, but when used in proper strength
this need by no means interfere with its appplication.
Recently a similar compound with the addition of
eucalyptus has been introduced under the name of
eatnpho-lyptus.
Campho-phenique, a patented combination of cam-
phor and carbolic acid, is also of real value in many
conditions, where an antiseptic and antipruritic action
are desired. It may be used in an ointment or in oil,
of a strength from 6 to 20 per cent.
A combination of equal parts of carbolic acid,
tincture of io<lin and chloral has been introduced by
Dr. Cutler of New York, which answers well as a
parasiticide in favus and tinea, and is also valuable as
an antipruritic; it often requires to be diluted.
Various dusting powders have been brought for-
ward. Notably the stearate of zinc with other reme-
dies combined with it; these answer fairly under
favorable circumstances. Emol, a natural silicate,
has been introduced by Jamieson of Edinburgh, and
often acts excellently as a powder or in paste with
water, in chronic eczematous conditions.
Considerable attention has been paid to the bases
in which applications are to be made to the skin, and
it would occupy far too much time if I attempted to
give even a brief description of the advances which
have been made in this direction. Some years ago
ointments were largely used, with lard as a base, to
which later were added the cerates. These are all apt
to become rancid, and a variety of substances have
been brought forward to obviate this difficulty. The
preparations from petroleum, vaselin, cosmolin, albo-
lene, etc., are all valuable, but are not firm enough ti
make a sufficiently protective dressing, in many in-
stances. Later we have had preparations from sheep's
wool, lanolin, agnin, etc., which are more firm and
sticky, and form a good addition to the petroleum
products, or to other bases.
Still later the attempt has been made to provide
dressings which shall be applied in such a manner
that they shall adhere to the skin, and, while hold-
ing a medicament in solution or suspension, shall
thoroughly cover and protect the diseased surface.
Beginning with the idea embodied in collodion, or
the liquid guttapercha of the old pharmacopeia, vari-
ous combinations of gelatin, with dextrin, starch,
glycerin, etc., have been presented, most of which
serve the purpose fairly well, but can not be detailed
here. One of the most recent of these is Bassorin
paste, composed of gum tragacanth 48, dextrin 25,
glycerin 10, water q. s. ad 100. This may be com-
bined with various substances, and forms a varnish-
1128
EULOGY ON JENNER.
[November 28,
like covering, which protects the parts well, while
healing progresses beneath.
Finally, Unna has introduced quite a line of pflaster-
mulls and salbe-mulls, in which various medicaments
are incorporated. These certainly are of very con-
siderable value in certain cases, and afford a means of
keeping the remedy required in close juxtaposition
with the diseased surface.
I have said nothing in regard to the various medi-
cated soaps, and have little to say commendatory; for,
as a rule, little washing is desirable in diseases of the
skin, and they have always seemed to me to be an
irrational method of making other applications to the
skin.
There are many more of the newer remedies and
measures which I might, with advantage, bring before
you. But this paper has already overstepped the limits
within which I had proposed to speak, and I must leave
them for consideration on another occasion.
I have said enough, however, to show that there have
been real advances of late years in the therapeutics of
diseases of the skin ; although I still feel that I must
repeat what I said at the opening, that caution should
be exercised against accepting much of the new which
is brought to our attention. The science of medicine
is a grand and difficult one, and we must not be content
with ordering this or that remedy, on however high
authority, without understanding the diseased condi-
tion we have to meet, and the true nature and uses of
the remedy we are to prescribe. All thoughtful men
must regret the ready and often careless way in which
some of the newer remedies have been pushed, too
often for the gain of manufacturers or proprietors,
and the profession should make a stand against and
repudiate the impudent manner in which many of
them have been vaunted, for commercial purposes.
4 East Thirty-seventh Street.
EULOGY ON JENNER.
Delivered before the Jenner Centennial Memorial, held under the
auspices of the Golden Belt Medical Society of Kansas,
at Salina, Kan.. Oct. 1, 1X96.
BY WILLIAM B. DEWEES, A.M., M.D., LL.D.
8ALINA. KAN.
Mr. President, Ladies and Gentlemen: We have
gathered to-night to commemorate the life, worth and
work of a really good man — a great country doctor.
It is meet that the doctors of a community, and espe-
cially the members of a medical society of country
doctors, pause a brief while and assemble with the
people whom they serve in a public gathering like
this, to pay their tribute to him who laid the founda-
tion of preventive medicine.
By invitation of your committee, Mr. President, on
the celebration of the centennial memorial of the
Jennerian discovery of the protective value of vacci-
nation, I appear before you. Your learned and greatly
beloved secretary, Dr. LaFevre, has most ably and
interestingly made known to you much of " The Life
and Works of Jenner." In my paper I am limited to
an " Eulogy on Jenner." Standing as I do on this
occasion to speak for the memory of the illustrious
dead, I shall earnestly endeavor to judge as I would
be judged, and
" If, unhappily, I dream,
And prove too weak for so divine a theme,
Let charity forgive me a mistake
Which zeal, not vanity, has chanced to make,
And spare the speaker for the subject's sake,"
Dr. Edward Jenner was preeminently one of the
noblest benefactors of the human race. His precepts
and examples are ever a trustworthy guide to the true
physician. He earned and held a proud position in
the medical world and in the public thought. He
stood for independence, for intelligence, for self-dis-
cipline, for courage, for reason, for temperate thought,
speech and deed, and above all for absolute integrity.
He disdained and spurned the temptations of wealth
and fame. His sympathy was wide as want, and like
the sky, bent above a suffering world. He found
happiness in diligently laboring for the prevention
and relief of human suffering, and the elevation of
the race, being content with a competence sufficient
to supply all real wants. His full measure of joy was
realized only in the felicities of his domestic life.
This distinguished Briton was a great man, a good
man, a renowned physician, whose name and work
were honored by millions of his fellow-men thoughout
the civilized world; even so a hundred years after his
great and immortal discovery. The thoughts and
deeds of such a man are truly worthy of commemora-
tion.
The literature of many lands is rich with the trib-
utes that admiration, gratitude and love have paid to
the noble deeds of the great and honored dead. These
tributes disclose the character of nations, the ideals of
the human race. In them we find the estimate of
greatness, the lives, the thoughts, the deeds that chal-
lenged praise and thrilled the hearts of humanity.
They teach us that men are only fragments; that
the greatest walk in shadows; that faults and failures
mingle with the lives of all; that silence is the most
complete refutation for every misinterpretation of
motive, for every unjust charge of wrong; that charity
holds the scales in which are weighed the deeds of
mankind; that peculiar traits, born of locality and
surroundings; prejudices and passions, born of conflict
and envy; superstition and egotism, born of ignorance
and vanity; these are but the dust of the race — tin se
are accidents, customs, clothes, habits, fashions that
have nothing to do with the individual, except to i.ide
character.
These tributes show us how poor this world would
be without its graves, without the recorded memories
of its mighty dead, without their indisputable proof
that only the voiceless speak forever, and that a noble
life enriches all the world.
Again, we learn from these tributes, that each dis-
covery that marked a new epoch in the history, and
started a new era in the advance of medicine, was
rightfully subjected to the crucial test of that wonder-
ful and only scientific crucible — practical experience —
and thus received in due time its merited accordance
of the profession. That, moreover, the authors of
such discoveries have been in the meantime made to
suffer most unjustly the pangs of envy and prejudice,
of designing and deluding intelligence, of fanaticism
and ignorance, but all to no purpose in dissuading
them from their conviction.
Not all men have the courage of their convictions.
So it is with doctors. But, nevertheless, the impera-
tive duty of every doctor remains to support and stand
up bravely for what he believes will benefit mankind.
Did Ambrose Pare cease to tie arteries after amputa-
tion, because all the doctors of Paris denounced him ?
Did William Harvey recant from his immortal dis-
covery of the circulation of blood, because he was
renounced by his colleagues and because his discovery
1896.]
EULOGY ON JENNER.
1129
proved a boomerang which cost him his practice for
many years?
Did Kphraim McDowell cease to follow his convic-
tions, because a raging and howling mob threatened
to lynch him and because the entire medical world
stood still to denounce him. while he dared to step
ard in the advance of science to save the life of a
patient, thus unconsciously inaugurating abdominal
surgery?
Did Chamberlain refrain from advocating the use
of the obstetric forceps, because he was ridiculed and
censured us a fanatic and egoist?
Did Long of Georgia, who was the first man to pro-
duce general anesthesia and do a painless surgical oper-
ation, cease to prevent all surgical pain, because his
colleagues and friends showed their contempt for so
rash a deed:
Did the At lees of Philadelphia cease to operate for
ovarian tumors, because Dr. Charles D. Meiges de-
nounced them as murderers and asked the aid of the
law to stop their operations?
Did Jenner — the subject of our sketch — cease to
struggle in following the light of his brain and the
impulse of his heart, because he was made the victim
of medical hate and scorn for years, before he was
honored and rewarded for his immortal discovery,
which marked a new epoch and started the era of
immunization which remained to be augmented by
the labors of Pasteur?
I answer, Xo! No! These are the examples of the
character of men who had the courage of their con-
victions, the integrity that is guided by reason, and
the sincerity that has the light of truth; men whom
we ever delight to honor, because to the influence of
such men alone is due the real progress in medicine.
Edward .Tenner was a progressive and a loyal physi-
cian. Progress in medicine is simply improvement
of the art in its application and depends upon the
loyalty of the profession. With true physicians loy-
alty does not stand on the side of concealment, but on
the side of exposure. The only dictum of medical
progress is reason. Well may we say then, in the
language of the Prophet Isaiah, "Come now, and let
us reason together and take counsel, since
" A little counsel now and then
Is relished by the wisest men."
A close observer of history will note that the prog-
>f rational medicine in each succeeding age had
to contend with the influences of preceding ages.
Each succeeding generation is based on the preceding
one. We are the children of our parents; we reap
what they sowed. In the same way the future depends
to a great extent upon the present. If this be true in
political, religious and social life, in matters of science
and trade, it is, perhaps, most of all the truth in med-
icine. If we wish to throw a glance on the future of
medicine we must construct it on the basis of the
influences prevailing in the present age. We can
predict future progress only upon the basis of judging
the past and present. However, in doing so we must
always make allowance for the fact that in the natural
course of events forces of peculiar strength may and
do come forward which we can not foresee. Such
forces are, for example, the appearance on the scene,
of men of extraordinary power. If politically, men
like Napoleon, Bismarck and Washington gave a new
turn to the history of France, Germany and America;
if men like Luther in Germany and Wesley in Eng-
land gave a new stamp to the religions life of their
age, we point with much pride to such country doc-
tors as McDowell, Long, Sims, Battey and the immor-
tal Jenner, who have marked some of the most pro-
found epochs in the medical history of the world.
Jenner stood in the front ranks braving truth, prog-
ress, harmony and peace. He was a pioneer, a torch-
bearer of truth and reason, a ceaseless toiler in the
great field we call the world, an honest worker for the
progressive welfare of his fellow-men. He was
endowed with a great mind, blessed with a heart
filled with benevolence and possessed with self-disci-
pline to philosophic study. No wonder that the
remark of the milkmaid proved such a prolific seed in
so fertile a soil, as only the brain of a Jenner afforded.
He abhorred all connection with a progress which can
not discriminate between essence and accident, between
truth and her clothes.
He knew that the practice of medicine is not and
can never progress to become an exact science, because
the individual equation always contains an unknown
quantity — vital resistance.
He worked on common ground; he had common-
sense, because he knew the law of average.
He taught the principles of loyalty as a virtue which
should never go out of fashion.
He ever oiled the troubled waters, knowing that
medicine serves best when it builds, and not when it
fights. With him the law of progress in medicine
was not an inexorable edict, but a command of reason.
He knew that our instincts are the legacy of ages; that
the office of reason (the oldest and yet most acquired
faculty of man ) is not to inaugurate a sort of nihilism
of the senses to strangle and crush out the instincts,
as some suppose, but to train, cultivate and develop
them along the lines made necessary by the ever-
changing conditions of civilization.
Edward Jenner was a man of absolule integrity, of
superb courage and of true sincerity. Integrity is
the oak around which all other virtues cling; courage
is the support and guard of the other virtues; sincer-
ity is the perfect mirror of the mind, it reflects the
honest thought.
Jenner knew that sincerity is the foundation of
character and that without it there is no moral sub-
limity. He knew that without character, without
honesty, without bravery, there is no worth; and that
below indolency, below poverty, there is the rayless
abyss of reputation. His soul thirsting for truth, he
was ever repulsive to a practice sunk into dead for-
malities. He honestly braved the work before him
and showed to the world what living medicine means.
He not only acted without fear, but he had the forti-
tude of soul that bears consequences of the course
pursued without complaint. He demonstrated the
truth, that the heart must be in any life-work that is
to be of permanent benefit to humanity; and that
above all wealth, above all station, above the robed
and the crowned, rises the sincere man. He knew
that the confidence of mankind is not set down in
writing, signed, sealed and delivered to order, but
resides in honor. He followed the light of his brain
and the impulse of his heart.
He was attacked and made a "mark for every pass-
ing blast of scorn to whistle through" by "a class of crit-
ical dicta everywhere current," but he never wavered
and he never swerved. He said nothing harsh ; he
did nothing rash. He answered the insulters with a
smile, and labored on quietly, faithfully and patiently
as eternity, knowing what the end would be. He
1130
FIELD OF MONOCULAR FIXATION.
[November 28,
knew that truth can wait, that the day would come,
and he lived to be rewarded and honored by seeing
the best and greatest minds of the world acknowledge
the rays of light shed by his torch.
We can proclaim truly that, were it not for such
brave, sincere and honest souls like Jenner, " the dust
of antique time would be unswept, and mountainous
errors be too highly heaped for truth to overpower."
Edward Jenner was the ideal country doctor. Born
in a quiet country town, a representative of an hon-
orable family, an orphan at the age of six years (his
father dying), reared amid the influences of his native
groves, meadows and the health-giving country air,
and the cruel superstitions and traditional customs of
his age and time, Jenner developed a passionate love
for nature and a marked manhood and courage to
investigate. He found the height of his ambition
and the zenith of his power to benefit mankind while
walking with nature — a country doctor during his
entire professional life. He had the physicianhood
and fortitude to search nature by following her, and
to honestly reveal the light he saw. He belonged
to the distinguished class of country doctors to the
credit of whom truth records most of the greatest dis-
coveries freighted with the greatest good to human-
ity— who did accept early Dame Nature's invitation
to Agassiz:
"Come, wander with me, she said,
Into regions untrod,
And read what is still unread
In the manuscript of God."
Jenner thus learned to know early that " childhood
is the era of scientific acquisition," and ever after
labored as a child of nature:
" To search through all I felt or saw,
The springs of life, the depths of awe,
And read the law within the law."
He assumed the whole responsibility as is common
to country doctors, with whom responsibility is an
educator. He wholly disapproved any attempt to stifle
doubt as distinct from the effort to confront it fairly
with the deeper facts of life. He taught us well the
lesson of magnanimity and toleration. He was the
ideal country doctor, a boon to medicine and human-
ity, cultivated by true and natural methods, enlisted
in the service of love, daily exercised in deeds of be-
nevolence and unselfishness, and representing a class
who are walking together in the pathway of progress
in honorable and rational medicine, who can justly
proclaim :
" We are the ancients of the earth,
And in the morning of our times."
Unless all signs fail, the medical world will ever
delight to honor the memory of Edward Jenner, for
his love of nature and all that is truthful and good,
for his benevolence and unselfish desire to prevent
and relieve human suffering, and for his patient and
persevering pursuit of whatever promised to result
in material benefit to mankind.
When the great work of a good man has bestowed
its boundless blessings upon nations for an hundred
years; when it has stood the scientific test of practi-
cal experience for a century in spite of jeer and taunt;
when the entire civilized world has bowed in acknowl-
edgment its centennial homage; in honoring the mem-
ory of such a man, in speaking words of praise and
gratitude to the commemoration of his name, we pay
a lasting tribute to ourselves.
ORIGINAL ARTICLES:
THE FIELD OF MONOCULAR FIXATION
AND ITS RELATION TO
HETEROPHORIA.
Read before the Section on Ophthalmology at the Forty-seventh
Annual Meeting of the American Medical Association, at
Atlanta, Ga., May 5-8, 1896.
BY CASEY A. WOOD, M.D.
CHICAGO.
So little is said in English text-books on ophthal-
mology about the field of fixation — monocular or
binocular — and so much space is given to it in that
portion of foreign works devoted to physiologic optics
that it seemed worth while to bring up the subject
for discussion here. We are so concerned in investi-
gating the relations of the extrinsic ocular muscles,
as they are engaged in fixing some point (doubtless
the most important point) immediately in front of
the eyes, i.e., at the center of the field of fixation, that
we are apt to lose sight of the fact that the fixing of
eccentric objects and points at the extreme periphery
of the field is also of great importance. It should be
remembered that while binocular vision may be
obtained and maintained with ease, so long as the
object fixed is directly in front, this result is often
difficult or impossible when looking obliquely to the
extreme left, right, up or down. Not only is this
true in marked paretic conditions of one or other of
the straight or oblique muscles, but it is also true in
the so-called insufficiencies. In other words the usual
tests for heterophoria or heterotropia — the various
kinds of photometric measurements especially — give
us but one phase of the conditions under which the
extrinsic muscles do, or fail to do, their daily work.
I wish to confine my observations to one of the
means by which we may measure the excursions, in
all directions, of each eye separately, as indicative of
the part which eccentric excursions play in the pro-
duction of muscular asthenopia.
It is to Landolt that we are chiefly indebted for
utilizing the field of fixation in practical ophthal-
mology. The monograph written by Eperon in the
Traits complet, taken in connection with Aubert's
chapters in the Graefe-Saemisch Handbuch, tell us in
a few pages about all we know of this subject.
My only apology for referring to these fundamen-
tal laws of optic physiology is that I have made a few
observations which may be of use to those who are
now pursuing this interesting study.
The field of fixation of an eye includes all those
points which the eye can successively fix, the head
being completely at rest. The limits of the field rep-
resent the extreme excursions of the eyes in all
directions. At least three methods (two objective
and one subjective) have been and may be employed
in making these measurements. One of the objective
tests consists of observing, on the center of the cornea,
the image of a small flame carried along the arc of
the perimeter, just as one does in determining the
degree of squint. Another plan of objective observa-
tion is seen in the ingenious and excellent tropometer
devised by Stevens and described by him in the
Annates d'oculistique for July, 1895. By means of
this all the movements of rotation can be exactly
measured.
In the subjective method we utilize the visual
acuity and the perimeter. The object is usually a
18%.]
FIELD OF MONOCULAR FIXATION.
1131
tetter or series of letters, which can be readily changed,
attached to a carrier that is run along the arc of the
perimeter as in measuring the field of vision.
Owing to the different methods employed by vari-
ous observers of the limits of the normal field, authors
differ somewhat iu their measurements. The follow-
ing, by Landolt, are as nearly correct as we can
obtain them:
45° \ 92
. 47° \ *&
Directly out. . . 45° [ oao Out and down.
Directly in . . 45° J In and up. . .
Directly down. . .50° I enp Down and in. .
Directly up. . . 43° \ * Up and out. .
These figures vary slightly in individuals, but the
directly interior angle is always the largest, while the
infero-internal is always the smallest. The eyelids,
margins oJ the orbit and bridge of the nose must
alwavs affeot the result of these measurements just as
they do in determining the extent of the visual field.
Stevens, after Bpeaking <>f the importance of deter-
mining the absolute as well as the comparative rota-
tion of the eyes, not only from side to side but up
and down, says: "We have had, until quite recently,
no sufficient means for determining these rotations.
The judgment which we may form by watching the
rotations is not to be relied upon. The perimeter is
destitute of any considerable value for this purpose.
By it we can not measure the downward rotation in
many easses. for the pupil buries itself behind the
lower lid; nor can it measure the rotation inward, for
the nose interferes, and even the outward, the only
one which can be generally measured, is not well
measured."
While I recognize, in general, the advantage of
objective over subjective tests, it appears to me that
Dr. Stevens' objections to the subjective method of
determining the limits of the ocular excursions are
weakened by the fact that what we wish chiefly to
know is not the extreme limit of rotation of the eye
in various directions so much as its limit of observa-
tion. What we desire to ascertain in practice is whether
the various muscles, alone and in combination, are
capable of making all the excursions required for the
purpose of securing and maintaining single and
binocular vision. Whether an eye would be able to
fix an object further to the right or left if the nose
were removed, or one higher or lower if a projecting
lid or orbital margin were cut away is not of essential
importance.
We are usually advised, also, to make use of the
candle image when the eye is amblyopic or can not
read large type. Now these are just the conditions
under which we are not usually concerned about the
fixation field. It is the eye that sees and not the
blind eye that causes trouble in defective excursions.
If an eye takes no part, or only a feeble part, in the
work of fixation, why trouble ourselves at all about
its rotation?
These considerations caused me to attempt to
remedy what seems to be certain defects in the tech-
nique of determining the field of monocular fixation,
as it is commonly applied. So far as I know, the
most effective plan employed — decidedly superior to
the old Helmholtz-Berthold method — is that exhibited
in the modified Landolt apparatus attached to the
McHardy perimeter. The head of the patient is
placed in the primary position and fixed by biting a
rigid crossbar of hard wood.
Lang thus describes the method of examination:
'• The balanced test object exhibits a single word of
two or three letters printed with the smallest type
that can be distinctly seen by the eye under investi-
gation. The patient is seated at the perimeter, directly
facing the fixation point, with his head erect and his
chin supported on that half of the chin-rest which
brings the eye that is about to be tested into the
middle line, opposite the fixation spot. If the patient
can not maintain this position during the whole exam-
ination, he is asked to grip the bar of the bite-fixa-
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tion-apparatus between his teeth, which effectually
prevents the least movement of the head. The other
eye is covered with a pad and bandage, or its lids are
closed and held down by the lashes with the tip of
the patient's forefinger. The words in the test object,
in the various sized type, are now exhibited, and one,
in the finest print that the eye can read, either with-
out or with glasses, is exposed after the test object
has been moved to the end of the perimeter arc, which
1132
FIELD OF MONOCULAR FIXATION.
[November 2b,
is extended horizontally outward. While the patient,
without moving the head, turns his eye to the
utmost outward toward the extremity of the arc, the
observer slowly moves the test object inward toward
the fixation point, but stops directly the patient can
read the word, and at once records, in degrees, the
position which the test object occupies in the arc.
"The arc is now placed horizontally inward, the test
object is moved back again to the extremity of the
arc, a fresh word is exposed, and the observation is
repeated. When the field of fixation has been tested
in the horizontal meridian, which is all that is gen-
erally necessary, the examination of the remainder of
the field can be ascertained by placing the arc in
each 30 degrees of the circle, and recording the
results on a field of vision chart.
"When the examination of one eye is" completed,
the head is shifted to the opposite side of the chin
rest and the second eye is tested in the same manner."
On making examinations with this apparatus I
long ago noticed that the continuous effort to hold
the eye at its extremest rotation, in so many direc-
tions, was exceedingly fatiguing and often made it
difficult to complete the examination. It was also
remarked that the results varied in the same individ-
ual, and I feel certain that these different measure-
ments are due to the fatigue incident to the attempt of
the eye to fix an object whose exact position at the
extremity of rotation is unknown. The nystagmus-
like movements of the globe, after a number of these
trials, is quite noticeable.
Instead of using an object attached to the carrier
on the perimeter arm I have used an exceedingly
simple device whereby the rotation of the globe in any
direction is rapidly and easily measured. It may be
used by all persons who can read Jaeger xii at fifty
centimeters, and may even be employed for others
whose visual acuity at that distance is considerably
less. Four strips of unglazed parchment paper have
printed on them words of two letters placed between,
as well as below, figures representing the degrees of
latitude on the perimeter arc. These strips are,
together, placed in position on the arm of the peri-
meter, the patient's head being in the primary posi-
tion (I usually do not consider any elaborate fixation
necessary) and he is asked to read to the lower line, as
far away from the center as possible. This accomp-
lished he is requested to give the figure placed above
the word just recognized and to try and read, farther
out, additional letters on the figure line. Each word
beyond represents about one degree on the scale and
the number of words so read added to the previous
figure gives the limit, in degrees, of the field in that
direction. As each quadrant of the circle is passed
over, a slip of paper is removed, revealing the next
paper whose lettering, being different, suggests
nothing to the person under examination. I have
found that instead of making the vertical letters
face up and down one can accomplish the purpose
of distinct vision by printing them with type of
a bolder face, thus providing for those rare cases in
which it is desired to test the muscles of an eye
that can not read Jaeger xii, or thereabouts.
My investigations of the field of fixation have
developed nothing new except that the normal field,
in persons whose view is not cut off by the nose,
lids or orbital margins, seems to have wider limits
than those set down by Landolt, particularly in the
downward direction.
The causes that determine an unusual shape or
abnormal position of the whole field, as pictured on
the perimetric chart are, commonly, actual paresis of
one or more of the external muscles of the eye. Apart
from an abnormal configuration of the face, we also
recognize those influences that underlie the various
forms of heterophoria, i. c, general fatigue, weariness
of one or more of the extrinsic muscles, age, defective
innervation and, possibly, congenital defects in the
muscular fibers. But in cases of heterophoria occur-
ring during the fixation of objects directly in front of
the eye, the state of the refraction exerts a very wide
influence on the size, shape and situation of the whole
field. Its boundaries are enlarged in moderate degrees
of hyperopia, but are diminished in the higher grades,
owing, as Landolt thinks, to the developed muscles
acting on a not too large globe in the former instance
and to the lack of development, in the latter case,
affecting the muscular elements in common with all
other parts of the eye. It is restricted in the elongated
and enlarged globe of the extreme myope, owing
mainly to the greater size of the eye and the weakness
due to the stretching of the muscles.
My former assistant, Dr. T. A. Woodruff, and I
have carefully measured a large number of fields, nor-
mal and abnormal, in persons of all ages and all states
of health and refraction, and I feel justified in think-
ing that when carefully done, using the device I have
just described, the defective excursions and often the
defective muscle or muscles can be readily detected by
a glance at the perimeter chart. Take for example a
case of simple left hyperphoria of 4 pr. diopters.
Here one obtains a perimetric picture whose irregular
outline covers, perhaps, as much ground as the nor-
mal field but whose directly upward and downward
limits in the left eye are higher than normal. Thus
we have not only an indication of the amount and
kind of the heterophoria but we are enabled, by a
comparison with the normal field, to arrive at a con-
clusion not only as to the actual direction of the
muscular defect but, also, in some cases, to venture an
opinion as to particular muscle or muscles involved.
DISCUSSION.
Dr. G. C. Savage, Nashville— In studying binocular fixation
we must have a few things constantly in our minds. One is,
that the yellow spot of Soemmering is the point from which
the visual axis starts. From this point it must pass through
the center of the retinal curvature, in monocular vision, cut-
ting the cornea wherever it may, sometimes in the center,
above, below, to the outer side or within. If the visual axis,
for the left eye, should pierce the cornea beneath the center,
while the visual axis, for the right eye, pierces it above, in
binocular vision there would be a necessity for action of the
superior rectus of the right and inferior rectus of the left, in
order to make the visual axes meet at the point of fixation.
Even if the muscles are well balanced in their inherent power,
a test of these eyes would show a left hyperphoria. It is only
in a case of this kind that the use of a prism, in position of
rest, would be justifiable, as I have shown before now. In the
same way I might be able to show an exophoria, also an eso-
phoria, dependent on the fact that the visual lines do not cut
the cornea at the proper points. The Javel ophthalmometer, if
it did nothing else, would be worth its cost, in that it always
shows quickly and accurately, the decentration of the yellow
spot of Soemmering, or, what is the same thing, the misplaced
cornea.
Dr. D. S. Reynolds, Louisville — In my experience all the
other methods tried have been more or less unsatisfactory and
ISt Hi. J
REMOVAL OF THE LENS IN MYOPIA.
1133
am quite willing to try Dr. Wood's method as soon as 1 shall
have had time to master it.
Dr. C. A. WOOD This instrument does not take the plaeeof
tlio various iihorometere. I thought we ought to know some-
thing more than the relative insufficiency of the muscles. We
want to know what particular muscle is at fault. This is
something of a step in that direction.
A CONTRIBUTION TO THE QUESTION OF
REMOVAL OF THE LENS IN MYOPIA.
Kcait ui tb« Section on Ophthalmology. at the Forty-seventh Annual
Meeting of the American Medleel Association, held at
Atlanta, Ga., May 5-«. 18SH>.
BY HERBERT HARLAN, A.M., M.D.
BALTIMORE, MP.
My contribution is in the form of a report of two
oases, both the result of accident, and in one case
thirty-three yours have passed between the accidental
operation and the observation; much the longest
period of which I am aware.
J no. Harvey, aged 32, a Welshman and laborer, by
occupation, had always been very shortsighted. He
carried in his pocket a pair of — 13 D. glasses which
lie occasionally used for reading. By their help it was
not necessary to hold the print so near his face. For
distance, lie said they were not much good. On Jan-
uary 8, he received a blow in the right eye, which, he
said, had always been the better. Some hours later
lie came to me at the Presbyterian Eye and Ear Hos-
pital. There was a bruise on the right cheek and eye
lid and examination showed the lens still perfectly
clear, dislocated into the anterior chamber. The upper
edge was a little above the center of the pupil and
with the ophthalmoscope the fundus could be easily
seen, either through the lens or above it, and by the
indirect method, in one position, two images of the
optic nerve could readily be seen, at the same time.
There was some redness and pain. The left eye had
high myopia with choroidal atrophies and very little
vision. Removal of the lens was advised and the fol-
lowing tlay the operation was performed, a down-
ward corneal section being made. There was some
loss of vitreous but the healing process was unevent-
ful. The iris was not touched at the time of opera-
tion, but at the present time is tucked down behind,
as it were, though not adherent to the corneal wound.
The appearance is as if there had been a large down-
ward iridectomy done. On February 4, + 3.50 D. S.
-f- 4.50 cyl. 165 gave 15-40 vision and 8 D. S. same
cvl. enabled him to read No. 1 readily. On looking
out of the office window where a mild storm was in
progress he remarked that it was the first time he had
ever seen snow falling when on the inside of the
house. The glasses indeed would indicate a much
less degree of original myopia than — 13 D. the old
glasses. Fukala, Pflueger, Von Hoppel and others
have noted the very high refractive power of the
human lens in these cases.
The second is a case of accidental removal of a lens,
in a child, with high myopia, resulting in good vision
at the age of 45. Fellow eye at that time lost by
choroidal atrophy.
Sister M. a cloistered nun, aged 45, stated that she
had always used her right eye, but of late, she did not
see well with this one and that the left, which had
been injured, was now the better, but she could not
read at all. I found the right had only a vision equal
to the counting of fingers at eighteen inches. With
the left V. 20-50 and was slightly improved by plus
lenses up to 2 D. The ophthalmoscope revealed in
the right high myopia with extensive choroidal atro-
phies while in the left there was seen, behind the iris,
an irregular opening through what was evidently the
remnants of an opaque lens capsule. Further ques-
tioning brought out the fact that the injury was caused
by a blow from the end of a stick and occurred at the
age of 13 years.
It was then plain that there bad been, at that time,
a traumatic cataract, followed by absorption of the
lens substance. There was no fundus trouble in this
eye and 5 D -f- enabled her to read "brilliant" at twelve
inches.
So here was a case of accidental removal of a lens
at 13 followed by good vision, 20-50 without glasses,
at 45, in this eye, while in the fellow, in which no
attempt at correction by glasses, has ever been made,
the myopia had probably increased, the choroid had
atrophied and all useful vision had been lost. Would
removal of this lens in childhood have saved this eye?
The fact of about 2 D. of accommodation in an eye
without a lens is of some interest. It is likely that a
carefully adjusted glass would improve the given vis-
ion in the left eye, but I was obliged to see the patient
at the nunnery and to use a candle for the ophthal-
moscopic examination. The patient was apparently
embarrassed and gave hesitating answers and no
attempt was made to correct possible astigmatism.
DISCUSSION.
C. M. Hobby, Iowa City — In high myopia the necessary con-
cave glasses diminish the size of retinal images and this is the
sole reason why in otherwise normal conditions the operation
should be suggested. This difficulty is scarcely appreciated
by the patient. In cases of retinal disease, or choroiditis the
removal of the lens in high myopia might, by enlarging the
distinct retinal image, be of advantage. In cases where, in
high myopia, degenerative changes appear the early removal
of the lens is indicated. I have seen one case in which the lens
was removed with resulting vision, without glasses, of 20-40.
C. W. Kollock, Charleston, S. C— I have recently seen a
German music teacher with a myopia of about 30 D. who was
going to Europe to have his lenses removed. It is doubtful
whether the operation would improve his condition as he has
posterior staphyloma.
A. W. Stirling, Atlanta— I have seen operations performed,
one by Scholler, having the desired effect. Two operated upon
in London went to suppuration. In the third case the retina
became detached to the full extent so that the eye was worse
than before.
C. A. Wood, Chicago — I think I performed the first opera-
tion of the kind done in this country. The case was as follows :
March 2, 1891, A. M., seamstress, 17 years old, been myopic
for eight years, lately getting much worse. Could not go to
school and now unable to do any sort of work. If she attempts
to sew her eyes ache and feel as if they were bulging out of her
head. Glasses make objects brighter but do not otherwise
help. V. R. fingers at seven feet, with -14 D. 20-100. V. L.,
fingers at eight feet, with — 15 D. 20-70. There are sharp tem-
poral crescents of about % d. d. in both eyes. No choroidi-
tis, although the choroidal vessels can be readily seen over the
whole background. Macular regions show as cherry red spots.
March 3, needled the right lens— a small central opening.
Used atropin and hot water to relieve subsequent pain. In a
week tension with pericorneal injection and pain. Made a cor-
neal opening and removed most of the lens. Did two subse-
quent needlings. August 5, V. R. 20-100. The pupil is irregular
and attached to pupillary membrane. In December needled
left lens without mishap. The lens absorbed nicely V. L. 20-100.
1134
DEGENERATE JAWS AND TEETH.
[November 28,
With L. 90° +.50+ 14 = 20-50 and with 90° +50 + 8 = J 2.
Did not order lenses for right eye although with this correction
on left side patient was able to read and do other near work
and eyes were comfortable. I did not see her again until
March of this year when the following condition was observed :
secondary cataract V. R. fingers at 5' and improvement. V. L.
+ 9° + .50 + 3 12-200 and 90° + 50 + 8. J xvi. Left membrane
needled and with 90° + 75 +2.50 = 20-50 and 90° + .75 +6.50
= J2. Two weeks later did a De Wecker's capsule scissors
operation, after which patient obtained 20-50 vision and could
read J2 and do near work without trouble.
THE DEGENERATE JAWS AND TEETH.
Read in the Section on Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of American Medical Associa-
tion, held at Atlanta, Ga., May 5-8, 18%.
BY EUGENE S. TALBOT, M.D., D.D.S.
FELLOW OP CHICAGO ACADEMY OF MEDICINE.
Next to the ears, the jaws and teeth (as was to be
expected from the variability of these organs in allied
animals), are most affected by degeneracy. This is
particularly true of the vertebrates; especially the
mammals, as might have been anticipated from their
phylogeny or line of descent. At the head of the ver-
tebrates is man ; at the foot is the lancelet ( amph ioxna ) ,
most akin to those semi-vertebrates the ascidians,
who, in their larval phase, are higher than when adult
and whose life history excellently illustrates that
potent phase of evolution, degeneracy.1
The lancelet 2 has a spinal cord inclosed in a soft
semi-cartilaginous canal (the notochord). It is prac-
tically destitute of a brain. The cerebral vesicle which
represents this, is a plain cavity without true subdi-
vision into ventricles. There is no cranium and the
median eye is a mere pigment spot with which it is
able to distinguish light from darkness. Behind this
is a small pit lined with cilia for olfactory purposes.
Into this the cerebral vesicle of the larval lancelet
opens. The -mouth is well guarded against the intru-
sion of noxious substances, which have to pass through
a vestibule richly provided with sensitive epithelial
cells resembling the taste buds of the human mouth.
There is no heart. In this the lancelet is lower than
the ascidians, the insects, crustacea and many mol-
lusks. It approximates the worms, which, despite a
very elaborate vascular system, are destitute of a heart,
the function of which is performed by contractile
blood vessels. From an embryologic and morphologic
standpoint, the proximate ancestor of the vertebrates
seems to have been a free swimming animal interme-
diate between an ascidian tadpole and the lancelet,
while the primordial ancestor was a worm-like animal
organized on a level with the starfish. The vertebrates,
embryologically, develop from this stage to the lam-
preys thence to the cartilaginous fish (shark), to the
amphibia (frog, toad, axolotl), to the reptiles and
thence to the oviparous mammals (duckbill and spiny
ant-eater), to the lemurs and through forms like the
pithecanthropus erectus to man. The present study
will be confined to the mammals, passing from the
simple types of teeth found in that oviparous edentate,
the spiny ant-eater (echidna) of Australia to the in-
deciduous ancestors of the sloths and armadilloes and
their descendants, inclusive of the dolphins and
whales, whose teeth, both in the fetal Greenland and
adult sperm whale, preserve this old type. The whales, 3
i Kay Lankester: Degeneracy, a Phase of Evolution.
^ Willey: The Ampbioxus.
it should be remembered, have degenerated from the
hoofed mammals to suit their environment. While,
as in the edentates, these teeth may be few, they may
also (as in the insectivorous marsupials) approximate
those of the reptilia in number (60 or 70 on a side)
and characteristic location.
The evolution of this primitive, tooth to the bicuspid
and molar type has been explained by two theories:
the concrescence theory and the differentiation. The
first, advanced by Magitot in 1877, was later advocated
by Schwalbe, Carl Rose and Ktirkenthal. The last
was offered by Osborn and Cope. Of these two con-
trasted theories Osborn * has given the following lucid
presentation :
" Now let me illustrate, in a very simple manner,
what is meant by the theory of concrescence and how
we can imagine that the human molars have been
built up by bringing together a number of isolated
teeth. Placing a number of conical teeth in line, as
they lie in the jaw of the whale, they would represent
the primitive dentition. In the course of time a num-
ber of these teeth would become clustered together in
such a manner as to form the four cusps of a human
molar, each one of the whale-tooth points taking the
place of one of the cusps of the mammalian tooth in
other words, by a concrescence, four teeth would be
brought into one so as to constitute the four cusps of
the molar crown. Vertically succeeding teeth might
also be grouped. Now, what evidence is there in favor
of this theory, and what is there against it? First,
there is this, that all primitive types of reptiles from
which the mammalians have descended and many
existing mammals, as we have noted, have a large
number of isolated teeth of a conical form; secondly,
we find that by a shortening of the jaw, the dental
fold or embryonic fold, from which each of the numer-
ous tooth-caps is budded off in the course of develop-
ment, may be supposed to have been brought together
in such a manner that cusps which were originally
stretched out in a line would be brought together so
as to form groups of a variable number of cusps
according to the more or less complex pattern of the
crown. What may be advanced agains this theory'?
This, and it is conclusive to my mind: We find at the
present time that cusps, quite similar in all respects
to each of the cusps which form the angles of the
human molar, are even now being added to the teeth
in certain types of animals, such as the elephant, whose
molar teeth cusps are being complicated now or until
very recent times. Then we find in the mesozoic
period certain animals with tricuspid teeth. Now,
according to the theory of concrescence these teeth
ought not to show any increase of cusps in later geo-
logic periods; but as we come through the ages nearer
to the present time we find that the successors of those
animals show a very much larger number of cusps.
How is this increase of cusps to be accounted for?
Has there been a reserve store of conical teeth to in-
crease the cluster? No. Most obviously, to every
student of the fossil history of cusps there is no
reserve store, but new cusps are constantly rising up
on the original crown itself by cusp addition. How-
ever, do not let me give you the impression that these
researches of Rose and Kiikenthal are not of the
greastest value and interest; we shall see later on how
the very facts of embryology which are advanced by
Dr. Carl Rose in support of his hypothesis can be
3 Haeckel : History of Creation, p. 242, Vol. n.
* International Dental Journal, July, 1895.
1896. |
DEGENERATE JAWS AND TEETH.
1135
tamed against him and used to support the differen-
tiation theory.
"Now lei us tuvntot he differentiation theory and see
what evidence we have of that. Let us go baok to a
very remote period of time, through the geologic ages
of the pliocene and the miocene, through the eocene,
round, reptilian, or dolphin-like teeth. There are
also some aberrant types which possess complex or
multitubercular teeth.
" These teeth begin to show the first traces of cusp
addition, as shown in the plate at the beginning of
this article and in the accompanying key to this plate.
I
\ 0 M
m*» flD30i£>
l'LATE B.
through the cretaceous or chalk period, and even the
Jurassic. Still further back we go to the triassic, and
the interval between this and the present period has
been estimated at over ten million years. Now, in
the triassic we find the mammalia, or the first animals
which we can recognize as mammalia, possess conical, the main cone are two cuspules. These teeth were
Here (Fig. 1, Plate A) we have represented the teeth
of the dromatherium, an animal found in this country
in the coal-beds of North Carolina, and on the sides
of the main cone are cusps or rudimentary cuspules.
In this enlarged model you see that on either side of
1136
DEGENERATE JAWS AND TEETH.
[November 28,
found six hundred feet below the surface in a coal-
mine, and in the same mine we find another animal,
represented by a single tooth here (Fig. 2), in which
these cusps are slightly larger. These cusps have
obviously been added to the side of the tooth, and are
now growing. Then we pass to teeth of the Jurassic
period, found in large numbers both in America and
in England, but still of very minute size; and we ob-
serve the same three cusps, but these cusps have now
taken two different positions; in one case they have
the arrangement represented in Fig. B; the middle
cusp is relatively lower, and the lateral cusps are rela-
tively higher ; in fact, these cones are almost equal in
size; these teeth are termed triconodont, as having
three nearly equal cones. But associated with this of
triconodont is another animal named spalacotherium,
you see in Fig. 5, amphitherium. To sum up : We have
a reptilian cone, two cusps added to it, and a heel —
four cusps altogether and we shall now see what rela-
tion these bear to the human molar. First let us turn
to some transitional forms. Examine a molar of the
living opossum, a marsupial, which still distinctly pre-
serves the ancient triangle. Look at it in profile, in
side, or in top view, and see that the anterior part of
that tooth is unmodified. This triangle we also trace
through a number of intermediate types. In this fig-
ure (Fig. 6) of miacis, a primitive carnivore, we ob-
serve a high triangle and a heel, and when we come to
look at it from above (6 a) we find that the heel has
spread out broader, so that is as broad as the triangle.
Now, the three molars of this animal illustrate a most
important principle — namely, that the anterior triang-
Figure 15.
the teeth type of which are represented in Fig. 4.
This is one of the most significant teeth which we
have among all the fossil series, because this tooth
illustrates the step that was taken in the transforma-
tion of a tooth (triconodont) with three cusps in line
to a tooth with three cusps forming a triangle; for the
primitive cusp is now seen to be the apex of a triangle,
of which the two lateral cusps are the base. Now,
this fact in itself is of great significance, because this
tooth in this single genus is the key of comparison of
the teeth of all mammalia of the great class to which
man belongs. By this we are able, as you shall see,
to determine that part of a human molar which corre-
sponds with a conical reptilian tooth. The stage
shown you is the triangle stage; the next stage is the
development of a heel or spur upon this triangle, as
ular portion of the crown has been simply leveled
down to the posterior portion of the crown. Compare
these three teeth, therefore, and you see illustrated a
series of intermediate steps between a most ancient
molar and the modern molar of the human type. The
second tooth is half-way between the first and third.
Look at the second molar from above and you see it
has exactly the same cusps as the first, so it is not dif-
ficult to recognize that each cusp has been directly
derived from its fellow. Now direct attention to the
third tooth of the series (Fig. 7), for it is of equal
significance with the others. This tooth has lost one
of its cusps; it has lost a cusp of the triangle. It is
now a tooth with only half the triangle left on the
anterior side, and with a very long heel. That tooth
has exactly the same pattern as the lower human molar
1896.]
DKi'KNKKATK JAWS AND TKNTH.
1137
tooth ( Pig. 8); the only difference is that the heel is
Bomewhal more prolonged. These teeth belong toone
of the oldest fossil monkeys, aitdptomorphus. I have
no doubt many of you have observed, in the examina-
tion of human lower molars, that occasionally instead
of having four cusps they have five. The fifth cusp
always appears in the middle of the heel, does it not,
or between the posterior lingua) and the posterior
buccal? You find this in the monkeys and in many
other mammals, but I know of no record of the ancient
anterior lingual reappearing. So we see that the human
lower molar tooth with its low. quadritubercular crown
has evolved by addition of cusps and by gradual mod-
eling from a high-crowned, simple-pointed tooth.*'
Figaro in.
Carl Rose' has contributed considerably to our
knowledge of the evolution of the teeth. He says: "I
rind no mention in literature of the development of
the teeth of the ehanwleonidse, nor of any other
aorodonl reptile. As the chameleon possesses multi-
tubereulate molars in the posterior portion of its jaws,
therefore the development of the teeth in this animal
must be doubly interesting, especially with regard to
the origin of the molars generally. I examined the
heads and jaws of both young and adult animals.
Unfortunately, I was unable to procure embryos of
the chameleon. All the material was seotionized into
series of 20 m thickness, and doubly stained with alum
carmin and bleu de Lyons. The figures have been
drawn with Oberhauser's camera. Figure 13 shows the
teeth of the upper jaw five times magnified. The
Figure 17.
anterior teeth are unituberculate, the posterior ones
bi- or trituberculate. All teeth are fused to the edge
of the maxilla. There is no shedding of the teeth in
tlif chameleon, nor could I prove it to take place in
hatteria; but still there is, especially in the upper
jaw, behind the functional teeth, a well-developed
dental or reserve ridge. On its posterior end there
takes place, throughout life, a continuous new forma-
tion of teeth. Accordingly, older animals have
always a larger number of teeth than young ones.
Although I examined macroscopically, with a lens, a
number of heads of the chameleon, and microscop-
ically six different series of sectionized jaws, I never
succeeded in finding any indications of reserve teeth."
5 October, 1883, Dental Coamos.
To alienists, biologists, criminal anthropologists
and sociologists the human jaw and teeth are of pecu-
liar interest since their study establishes many points
in evolution and environment not clearly determina-
ble in other structures. Their study enables the
observer without much difficulty to determine inher-
ited and acquired stigmata. For this purpose the
teeth should be studied from the first evidence of
their development until they are all in place, which
occurs normally in most cases, by the twenty-second
year.
Teeth enamel is formed from the epiblast; and den-
tine, cementum and pulp (except as to nerve tissue)
Figure 18.
from the mesoblast. The enamel organs of the first
set form during the seventh week of fetal life, the den-
tine bulb during the ninth week. At this period the
tooth obtains its shape and size and calcification
begins at its periphery. This models the enamel cap
which fits over the dentine like a glove. When im-
perfections in hand or fingers exist these deformities
are distinctly observed upon the glove. In precisely
the same manner are observed the different shapes and
sizes of the incisors, cuspids and molars. Calcification
of the teeth begins at the seventeenth week of fetal
life. Illustration (Fig. 14) shows the progress of cal-
cification and development of the temporary set of
Figure 19.
teeth. Examination will show that any defect in
nutrition from conception to birth (due to inherited
states or maternal impressions) has been registered
upon the teeth. The state of the constitution and
the locality registers the date of such defects. Thus,
if the tooth as a whole be larger or smaller than nor-
mal or abnormally irregular, taint is undoubtedly
inherited from one or both parents. If on the other
hand, there be defect at any part, on the crowns of
the teeth and the contour be perfect, the date of mal-
nutrition can be easily determined by consulting this
chart. More or less than the normal number of teeth
abnormally placed demonstrate the existence of inher-
ited defect since the germs must have been deposited
at the periods mentioned. No absolute rule can be
1138
DEGENERATE JAWS AND TEETH.
[November 28,
laid down as to the date of the eruption of the teeth.
The teeth of the temporary set erupt nearly as follows:
After Birth. Time of Eruption.
Lower central incisors ... 7 months 1 to 10 weeks
Upper " " . . . 9 " 4 to 6 "
Upper and lower lateral . . 12 " "
First molars 14 " 1 to 2 months
Cuspids 18 " 2 to 3 months
Second molars 26 " 3 to 5 months
The enamel organs and dentine bulb for the per-
manent teeth form just before birth (Fig. 15) in like
manner with the temporary set. They form just
I / ' jY
More. than twenty teeth in the temporary or than
thirty-two in the permanent is hence an atavistic
abnormality.
From a maxillary and dental standpoint man
reached his highest development when his well devel-
oped jaws held twenty temporary and thirty-two per-
manent teeth. Decrease in the numbers meant, from
the dental standpoint, degeneracy, albeit it might
mark advance in the man's evolution as a complete
being. Marsh6 points out that in the New Mexican
lower eocene occur a few representatives of the lowest
primates such as the lemurarius and limnotheriuin,
each the type of a distinct family. The lemurarius,
most nearly allied to the lemurs, is the most general-
ized primate yet found. It had forty-four teeth in
continuous series above and below. The limnothe-
rium, while related to the lemurs, had some affinit ics
Figure 20.
above the temporary set on the upper and below on
the lower jaw. The permanent molars begin to calcify
at the twenty-fifth week of fetal life. The permanent
incisors do not calcify until a year after birth. Any
deviation in size or contour of the permanent teeth,
from the normal, must hence be due to defect in
nutrition in the dentine bulb between the fifteenth
and twenty -fifth week of fetal life. Any deviation in
calcification (except the cusps of the first permanent
molars) must occur after birth. At the third year
twenty-four teeth are fairly well calcified. At the
fifth year the second permanent molars and at the
eighth year the third molars or wisdom teeth begin
to calcify.
The following table gives the age of eruption of
permanent teeth.
First permanent molars Circa
Upper and lower central incisors .
Upper and lower lateral
First bicuspids
Second bicuspids
Cuspids
Second permanent molars
Third
Figure 22.
with the American marmosets. Dr. A. H. Thompson'
in discussing the "missing teeth" of man remarks
that these researches of Marsh suggested and subse-
quent studies aided the solution of the problem of the
origin of the extra teeth (known as supernumeraries )
that sometimes occur in man. These, usually
regarded as pure freaks like polydactylism, are how-
ever beautiful illustrations of atavism and demon-
strate that man during his evolution from the lowest
primate has lost twelve teeth. These supernumerary
•teeth assume two forms; either they resemble the
adjoining teeth or are cone-shaped. While they
rarely are exactly counterparts, every tooth can be
Figure 21.
Man at his present stage of evolution has twenty
teeth in his temporary, and thirty-two in his perma-
nent set. Any deviation in number is the result of
embryonic change occurring between the sixth and
fifteenth week for the temporary teeth and the fif-
teenth week and birth for the permanent. The germs
of teeth which erupt late in life and are (properly)
called third sets, of necessity appear ere birth and are
completely formed at the beginning of the second
year although they remain protected in the jaw until
late in life.
Figure 23.
and is duplicated as the following illustrations show.
Figure 1(5 illustrates fairly well fromed duplicate cen-
tral incisors; the normal incisors being outside the
dental arch. They are crowded laterally by the large
roots of the supernumerary incisors. Figure 17
shows an extra right lateral in a temporary set in the
upper jaw ; Figure 18, an extra right lateral in the per-
manent set. Figure 19 illustrates normally devel-
oped supernumerary cuspids which are all grouped
6 Vertebrate Life in American Assoc, for Adv. Science, 1877.
t Dental Cosmos, 1894.
L896.]
DEGENERATE JAWS AND TEETH.
1139
together upon the right side; the bicuspids being
also duplicated on each side; indeed, nil but the
molars are duplicated. Figure 20 shows supernumer-
ary third molars easily demarcated from the normal
molars. The teeth, which fail to approximate their
normal neighbors, assume the cone shape of the prim-
itive tooth.
The fact that the cone-shaped tooth, ns a rule, is
perfect in construction, is found everywhere in the
jaw hut especially in the anterior and posterior part
A
Figure 'its.
of the mouth, is of much value in outlining tooth and
jaw evolution especially from degeneracy aspects.
The upper jaw, being an integral part of the skull and
fixed, is of necessity influenced by brain and skull
growth, hence degeneracy is more detectable in it than
in the lower.
The evolution of the jaw is toward shortening in
both directions. This shortening will continue so
long as the jaw must be adjusted to a varying envir-
onment. The jaw of man having originally contained
more teeth than at present, lack of adjustment to en-
vironment produces from the shortening, degeneracy
of the jaw and atavism of the teeth. While this
may coincide with general advances of the individual
it indicates that he is not yet adjusted to his new en-
vironment. The shortening of the upper jaw causes
supernumerary cone-shaped teeth to erupt in mass at
the extreme ends of the jaw as shown in the follow-
ing figures. Figure 21 illustrates a cone-shaped
tooth between the two central incisors, forcing them
Figure 29.
out of position. Figure 22 shows three supernumer-
ary teeth; a cone-shaped tooth between the central,
lateral and cuspids out of position. The left perma-
nent lateral is at the median line, another cone-shaped
tooth remains in the vault, while the supernumerary-
left lateral is in place. As many as eight are at times
to be observed in the anterior vault. Posteriorly these
teeth are most often noticed in connection with the
third molars usually on a line with other teeth, poste-
rior to the last molar. Figure 23 shows two supernu-
1140
ERB'S PRIMARY MUSCULAR ATROPHY.
[November 28,
merary cuspids in the anterior and two in the posterior
part of the left arch; the molars have been extracted.
Supernumerary teeth are not confined to these localities
but may be observed at any point in the dental arch
(Figs. 24 and 25). The primitive cone-shaped tooth
is rarely observed in the lower jaw. In twenty-six
years practice I have not seen a case. The mobil-
ity of the lower jaw prevents that mal-adjustment to
environment present in the upper.
The continual shortening in both directions of the
jaw causes the third molars frequently so to wedge in
between the angle of the jaw and the second molar that
eruption, if possible, is difficult. The third molar is
often absent in the Caucasion races. In 46 per cent,
of 670 patients it was missing. Frequently its devel-
opment is abortive. This tooth in the struggle for
existence seems destined to disappear. It is more
often absent from the upper than the lower jaw.
When absent or badly developed the jaw is smaller
and frequently teeth irregularities, nasal stenosis, nasal
Figure 30.
bone and mucous membrane hypertrophy, adenoids
and eye disorders coexist. Figure 26 shows absence
of the left third molar with irregularities of that side
of the arch. In Figure 27 both third molars are seen
to be missing coincident with irregularities on both
sides of the arch. Anteriorly the lateral incisors are
most often wanting; 14 per cent, of the laterals were
wanting in 670 patients. In the progress of evolution
man has lost one lateral upon each side of the mouth
and the second lateral seems also destined to disappear.
In Figure 28 the left lateral incisor has disappeared
and in Figure 29 both lateral incisors are absent.
Not infrequently does it occur that centrals, cuspids,
bicuspids and even molars are absent, even their
germs are not detectable. Figure 30 illustrates a cast
showing three supernumeraries in the anterior part of
the mouth and but two molars. The absence of teeth
indicates lack of development of germs due either to
heredity or defective maternal nutrition of the line of
conception or during early pregnancy.
(To be continued.)
ERB'S PRIMARY MUSCULAR ATROPHY.
Read in the Section <»n Neurology and Medical Jurisprudence, at the
Forty-seventh Annual Meeting of the American Medical
Association at Atlanta, Georgia, May 5-8. 1896.
BY ELMORE S. PETTYJOHN, M.D.
MEDICAL SUPERINTENDENT AI.MA SANITARIUM. ALMA, MICH.
Since Duchenne first described progressive muscu-
lar atrophy in adults and infants and regraded each
form as of peripheral origin, the study of the clinical
history and pathology of muscular dystrophies has
only partially decided which are of muscular and
which of spinal origin. We now believe that the
hereditary form found during infancy and early life,
especially if it attacks several members of the same
family, is of muscular origin, and certainly so if there
are present postmortem hypertrophied muscular fibers
side by side with atrophied and degenerated fibers,
and with no changes in the anterior horns of gray
matter of the cord nor in the nuclei of the fourth ven-
tricle or aqueductus sylvii.
One chief reason for considering this much talked
about disease is the desire to establish a definite
symptomatology, to accomplish a differential diagno-
sis and arrive at the rational treatment for the bemiit
of the patient, rather than to originate classifications.
Idiopathic muscular atrophy is primarily a disease
of childhood and youth and usually develops before
the age of 20. It is more frequent in males than
FlG.l.— Primary muscular atrophy. Age 22. Left side shows more
atrophythan right. Hands large by comparison. Right shoulder droops.
Pectoral muscles wasted. Forearms unaffected. Dr. K. s. Pettyjohn,
Case 1.
females, probably due to transmission through the
mother, though she herself is exempt, as the son usu-
ally inherits the peculiarities of the mother and the
daughter those of the father. In this way it is hered-
itary in three-fourths of the cases, and often appears
in several members of the same family, but usually of
the same type in the different members of the same
family.
The onset of the disease is gradual and the
atrophy and weakness progress simultaneously with
or without any initial hypertrophy. In the parts
affected the disease slowly increases and thence
spreads. The shoulder girdle is first affected, i. e., the
pectorals, the trapezii, rhomboidii, latissimus dorsi,
the upper arm muscles and the supinators, and later
lS'.Ki.j
ERBS PRIMARY MUSCULAR ATROPHY.
1141
the forearms, glutei, thighs and legs. The patient is
often unaware of the wasting of these muscles on
account of their relative unimportance. The deltoids
are rarely involved and the serratus magnus often
escapes noticeable changes.
On electrical examination the irritability of the
atVected muscles is usually lessened, on the use of
either current anil either pole, out of proportion to
the atrophy present. The typical reaction of degen-
eration is not present; however, the action is not
entirely normal. Were we to divide the reaction <\f
degeneration into three stages they might be desig-
nated: Simple atrophy, atrophy with muscular cell
proliferation and atrophy with muscular cirrhosis. The
or lost, never increased. The sphincters are not
affected. The disease is painless.
Aside from heredity, acute febrile diseases, espe-
cially scarlatina and diphtheria, and over-exertion, lack
of good food and exposure to vicissitudes of the
weather undoubtedly enter into the etiology. The
course and duration (from ten to thirty years) of the
disease are exceedingly variable, but can undoubtedly
be influenced by treatment. Death usually occurs
from some intercurrent disease.
The treatment in its prophylactic form should in-
clude the prohibition of marriage of one so afflicted,
Fig. 2.— Chest expansion, nipple line 37 inches; tip of sternum VflA
Inches. Intercostal* unaffected. Biceps atrophied with deltoid and
peotorales. (Conditions not well shown in the picture.) The scapula?
are drawn up by the trapezius and levator anguli scapula? in absence of
opposition. I>r. K. B. Pettyjohn. Case 1.
reaction found in this disease would be that of the
first mentioned stage. Febrillary twitchings are
absent, though not invariably, and the sensibility to
the faradic current and heat and cold is usually
unimpaired.
The absence of nerve irritation alone would seem
to prove the atrophy to have begun in the end organs
of the nerve, and also in the nerve itself. Implication
of the nerve is shown by the increased action of the
muscles when the electrode is placed over the motor
point, as compared with the reaction obtained when
placed over the muscles. The reflexes are weakened
Fig. 3.— Wing-like projection of scapulse, showing atrophy of tra-
pezii and serrati. Drooping of right shoulder. Triceps complicated as
well as the entire shoulder girdle. Age 22 years. Began at 14 years.
Dr. E. S. Pettyjohn. Case 3.
and of bringing into the world other children by
parents the physical combination of whom produced
such dystrophies. Infants of such mothers should be
reared by a wet nurse or by artificial feeding. All
children of families where disease exists in one mem-
ber, should be reared hijgienically with every effort to
increase and develop the muscles of the body sym-
metrically.
The active treatment should combine every useful
agency to prevent nutritional deterioration of the
skin, the muscles and the nerves supplying them.
The cleansing of the skin and mild elimination there-
1142
GASTROSTOMY.
[November 28,
from has been shown to increase the assimilation and
nutrition of the underlying muscles. Fomentations,
followed by cold sprays, stimulate to greater activity
the circulation of the part. Light friction continued
for a considerable length of time and frequently
repeated, especially with camphor liniment increases
the cutaneous nutrition.
For the muscles, methodical, graduated exercise
with or without apparatus (never tiring the muscle)
will increase their nutrition. In addition to this,
massage, skillfully used by the hand of an operator
who understands the anatomy of the part and can
select the various groups affected for treatment, is a
most excellent aid to increasing the nutrition of the
muscle. The wasted and degenerate tissue of the
muscle is forced into the circulation, the blood vessels
arid lymphatics are emptied of the already accumu-
lated debris and new material is brought to increase
every elemental part. This treatment should be given
twice daily, gradually increasing the force and time
occupied. Electrization of the affected muscles and
those in the immediate region, especially with the
sinusoidal current, should be practiced daily. This
should be done in an especial manner to every affected
muscle. The current ought never to be strong nor
continued until the sensibility is greatly increased.
The current in use should rather be diminished than
increased. One or two minutes should be allowed to
each muscle, when the current should be distributed
over several muscles; the entire stance lasting only
from fifteen to twenty minutes, depending upon the
area of the muscles affected.
The static current and alternating hot fomentations
and ice to the spine, to stimulate the nerve centers
supplying the affected groups of muscles, augments
the innervation and increases the nutrition.
The very best internal remedy is, in my opinion,
wholesome, nourishing food, a generous mixed diet
combined with long hours of rest in bed and pro-
longed undisturbed sleep. Strychnia preparations
combined with quinin are the best tonics. As the
hemoglobin and the number of blood corpuscles are
neither diminished, iron is not especially indicated.
I report a case in point: Two years ago Daniel L.
presented himself at the sanitarium and gave the fol-
lowing history: Age 19, son of a farmer; one of seven
children all in good health at the time. No neurotic
heredity ; father died at the age of 45, of some stom-
ach disease; mother living, in good health. Family
history good. At 9 years of age had scarlatina and
made an uneventful and complete recovery.
At the age of 15 he performed a hard day's work,
carrying bags and pitching bundles. No immediate
effects were noticed, but a month afterward he began
to notice weakness in the muscles of the chest, shoul-
ders and arms. Some time after this these muscles began
to atrophy. For the six months previous to my first
observation the case had grown rapidly worse. Dur-
ing this time he complained of being very weak and
tired after very moderate effort. While swimming
his companions noticed the wing-like projection of
the scapulae. He gradually grew weaker, so he was
hardly able to do milking. The family called him
lazy, much to his discomfort.
On examination the entire shoulder girdle was
found affected. The upper intercostals and pectorals
were so weakened that the breathing was largely
diaphragmatic. The expansion at the nipple line
thirty-seven inches, just below the sternum forty
and one-half inches. When the arms were at the
side the scapulae projected so that the two hands
could be laid between them and not be seen on the
line across. The trapezii, rhomboidii, latissimus
dorsi, biceps and triceps were all affected, the left
side more atrophied than the right. The forearms
and hands were not noticeably changed or weakened,
although the hands seemed large by contrast. He
could not put either hand on the top of the head
without the momentum of a swinging action for
several seconds. On trying to lift him from the
floor by placing the hands in the arm-pits the shoul-
ders were raised nearly to the ears. He walked
similarly to one with a lame back. The patellar
reflexes were entirely absent, but there was no in-
coordination when standing. There were no mus-
cular vibrations, convulsive twitchings nor momen-
tary tremors such as are often found in progres-
sive paralysis. The sensibility to heat, cold and
cutaneous irritation were unimpaired, though the
superficial temperature was slightly lowered, especially
in the arms and hands. On electrical examination the
irritability of the affected muscles was lessened gener-
ally, but the increased action of the muscles on both
cathodal and anodal opening and closing were more
marked when the electrode was placed directly over
the motor point. The pupils responded to light and
accommodation. The patient was not especially intel-
ligent, his mental actions being sluggish though his
judgment was firm and his emotions under control.
After six months' treatment on the plans hereinbefore
mentioned the patient has gained twenty-six pounds
in weight; the superficial temperature of the affected
muscles is normal; there is increased strength in the
muscles and so far as can be discovered no atrophy
in the previously unaffected parts.
A few weeks ago a younger brother, a boy of 11
years, was brought to me and upon examination was
found to be afflicted in the same way, but in a lesser
degree, the commencement unknown. There is true
atrophy and a minimum amount of adipose tissue
along with stunted growth for the child's age.
May 1, 1896, the patient has not grown especially
weaker and the good fibers are increased somewhat in
strength. The electric reactions and other physical
signs remain about the same. His general nutrition
has increased somewhat during the past year and there
has been no further noticeable involvement of muscles.
GASTROSTOMY BY A CIRCULAR VALVE
METHOD.
BY EMANUEL J. SENN, M.D.
INSTRUCTOR IN SURGERY, RUSH MEDICAL COLLEGE, CHICAGO.
Gastrostomy, since it was first suggested by Egeberg
in 1837 and performed by Sedillot in 1849, has under-
gone many transformations in the evolution of tech-
nique. The primitive operations as done by Sedillot,
Fenger, Foster, Durham, Langenbeck, Kronlein and
Verneuil, consisted simply in making the external
incision through the abdominal wall and fastening
the stomach in the wound with sutures or steel needles
as a support, and then incising it. There naturally
was no resistance to the stomach contents, the great
obstacle to gastrostomy. The operation fell into ill
repute and practically lay dormant until the present
decade, when it was revived and received an impetus
in the modern methods of Von Hacker, Hahn, Witzel.
Ssabanajew and Frank, in the hope of rectifying the
L896. 1
(JASTROSTOMY,
1143
disagreeable features that are inevitable in a continual
Leakage of a gastric fistula. It is rather strange when
«re oompare tin- great mortality attendant upon gas-
trostomy with that of colostomy, which is the identical
operation lower down the alimentary canal, and entails
little risk to life under corresponding conditions. The
mortality varies according to different observers. Of
-JOT cases collected by Gross, 1(57 were for cancer and
10 for cicatricial stenosis, with a death rate of 29.47
per cent, from the operation itself. Dr. N. Senn esti-
mates it at "J.") per cent.: while Zesas is more radical
than either of the other observers, and places the nior-
Viu. L— Puckering strings in situ.
S. stomach.
1, skin; 2, muscle; 8, peritoneum ;
tality at 60 per cent, for cicatricial stenosis and 84 per
cent, for malignant cases. This great mortality is
probably due in a great measure to the extreme ema-
ciation which patients undergo before they will sub-
mit to operation. In stenosis of the rectum, both
benign anil malignant, we meet with the same condi-
tions, but without such a frightful mortality. I am
of the opinion that the great shock which so often
follows gastrostomy is in a great degree due to the
tension exerted on the rich plexuses of the sympa-
thetic system which have such an intimate relation
with the stomach. This is especially the case when
Puckering strings tied, forming a constriction.
there is considerable contraction of the stomach.
Before dwelling on the subject of this paper, it will
be in order to review the muscular structures of the
stomach in a concise manner. The muscular coat,
which here is exceedingly well developed, consists of
three layers: 1, longitudinal, the most superficial; 2,
circular or transverse ; 3, oblique, the deepest layer.
The use of the muscular fibers are: 1, adaptation of
the stomach to the quantity of food; 2, to keep the
stomach closed until the food is digested; 3, peristaltic
movements. The contractile power of the walls in
the pyloric region is the most energetic, as here more
force is necessary to overcome the resistance of the
pylorus. Nevertheless the stomach throughout its
continuity is a powerful muscular organ and its walls
tend to contract when stimulated. This phenomenon
was beautifully demonstrated in the case of St. Mar-
tin, where the bulb of the thermometer was tightly
grasped when placed in a gastric fistula. This natu-
ral adaptation of the stomach to its contents in the
old-fashioned gastrostomy is interfered with to a cer-
tain extent by the adhesions which form between the
parietal peritoneum and the stomach. It is in this
area, surrounded by adhesions, that the fistula is
made, being a straight incision into the stomach with
no pretense of making a valve, or of devising an
oblique or circuitous route. The strong adhesions to
Flo. 3.— Omental cuff covering constriction and stomach sutured to
abdominal wall.
the parietal wall prevented the muscular structures
around the fistula to contract or dilate in conformity
with the rest of the stomach, and consequently the
fistula remained patent. It has been my purpose to
plan a logical method of gastrostomy to meet the fol-
lowing indications :
1. To prevent leakage by making a valve of the
stomach wall itself, instead of utilizing extrinsic struc-
tures to that end, and also for the same purpose to
provide a constriction in imitation of a sphincter.
2. To minimize shock by putting the least possible
strain on the stomach.
t'IG. 4— Inversion of stomach above constriction and sutured with
Lembert sutures, forming a circular valve.
3. To have a fistula which remains closed during
digestion and can be opened ad libitum for the inges-
tion of food.
In search of an ideal mechanism, I found a proto-
type in the valves of veins. These valves are, as a
rule, semilunar, and allow the blood to flow in one
direction; but when there is resistance they are set into
action and are infallible to regurgitation. I modified
the principle by making a circular valve. The oper-
ation consists of an abdominal incision of about four
inches in length, and which can be made in any loca-
tion deemed advisable, as no abdominal muscular
structures are required for sphincter action. How-
1144
GASTROSTOMY.
[November 28,
ever, Fengers incision, which is parallel to the left
costal border left of the rectus muscle, is preferable.
The stomach is seized as near the great curvature as
possible and a cone is formed by an assistant, who
holds the apex with his fingers or a tissue forceps.
Two puckering strings of heavy chromicized catgut
are placed parallel to each other about two and one-
half inches below the apex of the cone. These sutures
include the serous and muscular coats of the stomach
(see Fig. 1). These sutures are next drawn taut and
tied, forming a constriction or neck (see Fig. 2). This
end may also be accomplished by folding the stomach
with Lembert sutures, but requires more time. Next,
a portion of the gastro-colic omentum is brought up
and a cuff is sutured with fine silk over the constric-
tion (see Fig. 3). The stomach is now ready to be
fastened into the parietal wound. This is done with
interrupted silk sutures which include the upper por-
tion of the omental cuff, the peritoneal and muscular
coats of the stomach, and all of the abdominal wall
except the skin. The rest of the abdominal wound is
now closed with silkworm sutures, leaving only that
portion of the stomach visible which is to form the
valve. This concludes the first stage of the operation.
The second stage can be done at this time or can be
deferred for forty-eight hours until adhesions have
formed. This consists of an incision about one-half
inch in length in the center of the portion of the
stomach exposed. A rubber tube is inserted through
this opening into the stomach. The stomach wall is
now inverted, forming a circular valve. The inversion
is secured by Lembert sutures of silk (see Fig. 4).
The tube is now withdrawn and the operation is com-
pleted (see Fig. 5). If properly performed, the valve
should be below the level of the external integument.
The retraction is greatly favored by subsequent con-
traction of the wound.
This method of gastrostomy entirely obviates the
possibility of regurgitation of ingesta. There are two
barriers against this mishap, the constriction and the
circular valve. The tendency of the constriction, or
neck, is to remain contracted on account of the
omento-peritoneal adhesions which surround it. It is
also under the inherent control of the muscular walls
of the stomach itself, as the adhesions to the abdom-
inal wall are above this point. This constriction, in
all probability, would be sufficient to control regurgi-
tation; but as an additional safeguard, stress is laid
on the value of the circular valve, which is invincible
to all passage of fluids from the stomach externally.
The importance of the omental cuff is twofold, in that
it aids the maintenance of the neck and acts as a
plastic substance to fill in the spaces between the
folds formed by the puckering strings, making a con-
tinuous surface for suture to the abdominal wall.
Following is the report of a case in which the cir-
cular valve method was used with most excellent
results :
Mr. M. E. consulted me Aug. 26, 1896, for stenosis
of the esophagus. Age 48 years, married; family his-
tory negative. He first became aware of difficult
deglutition some six months before. This gradually
became more marked until he had to subsist entirely
upon liquid diet. Fifteen days before the patient
came into my hands, the stenosis became complete.
The patient was emaciated almost to a skeleton, and
presented that cachexia so pathognomonic of malig-
nant disease. He lost approximately sixty pounds in
weight. Upon examination of the esophagus, I found
the pathologic lesion at the cardiac end of the stom-
ach. With careful manipulation, I was enabled to
pass the smallest-sized olive-pointed bougie into the
stomach. There were apparently two points of ste-
nosis about an inch apart. The bougie would become
engaged in the upper one, then become free, and
finally pass through the lower one into the stomach.
After exploration there was no bleeding whatever; nor
did the patient ever have any hemorrhage. The diag-
nosis was conclusive of carcinoma of the cardiac end
of the stomach, especially with the aid of the clinical
history. I suggested gastrostomy as a palliative
measure, and after consultation with his family and
friends an operation was agreed upon and the patient
sent to St. Joseph's Hospital. The man was so weak,
the pulse being only 46, that an operation at this time
would most certainly have been fatal. He was given
1-30 gr. of strychnin hypodermatically every three
hours and enemata of milk, beaten eggs and whisky,
until August 31, at which time he became somewhat
stronger.
Operation completed.
Operation: Before taken to the operating room,
patient was given an enema of black coffee, also a
hypodermic of 1-30 gr. of strychnin. Pulse 56.
Anesthetic, ether, which was sparingly given and was
administered with great care by Dr. Homer Thomas.
Fenger's incision was made. The abdominal wall was
unusually thin. Immediately after opening the abdo-
men the stomach presented itself, which I found very
much contracted. I passed my hand along the great
curvature up to the cardiac end, where I felt a hard
nodulated mass, which confirmed the diagnosis. The
point selected for the gastrostomy was at the greater
curvature, and as near the cardiac end as possible with-
out putting tension on the organ. The first stage of the
operation was completed in the manner I described
before. During the operation, which took twenty min-
utes, the patient gave evidences of shock and the pulse
became almost imperceptible; but he was revived with
hypodermics of whisky and external heat. I decided to
defer the second stage of the operation, that of mak-
1896.]
LITHOLAPAXY.
1 1 1;>
lag the fistula, for thirty-six hours, until firm adhe-
sions had fanned. After reaching his bed, the patient
rallied. Temperature 99.2: pulse 82. The patient
did well until the evening of September 2, when the
temperature rose to 101.8; pulse 120. He also coughed
considerably. Upon examination of the chest, I found
thai lobular pneumonia was present, a complication
which is very frequent after gastrostomy. I con-
cluded that procrastination in doing the second stage
of the operation would be dangerous. The patient
was so debilitated that no anesthetic could be given,
nor was it deemed advisable to remove the patient to
the operating room; so 1 completed the operation
upon the patient in his bed. Four ounces of pepton-
ized milk was then introduced through the tube. This
was continued, with the addition of one ounce of
whisky every three hours. The pneumonia gradually
left and the patient grew stronger. Ten days after
the operation he was able to sit up and he left the
hospital after three weeks, although the disease was
pursuing its relentless course.
Remarks: After each feeding the tube was removed,
and at no time was there the least leakage from the fis-
tula. The valve was easily opened with slight pressure
of the tube, as was also the constriction. Upon with-
drawal of the tube, the valve would close with the preci-
sion of a trap-door. I put the valve to the crucial test,
by filling the stomach with milk and having the patient
cough violently, and shifted him in every possible posi-
tion to favor leakage; but the valve remained true to its
purpose and there was not a vestige of regurgitation,
a positive clinical demonstration. The wound con-
tracted so that the mouth of the fistula was the only
portion of the stomach exposed.
Note. — Since the preparation of this paper, I find
in the Neu York M edical Journal of Nov. 7, 1896,
that Dr. Willy Meyer describes a modification of Wit-
zel's operation devised by Dr. Bronislaw Kader, assis-
tant in the surgical clinic of Professor Mikulicz of
Breslau. In this operation the stomach is inverted
in the manner I describe, except that the inversion is
carried to a greater degree by making two rows of
Lembert sutures, instead of one; the principle being
to form a canal of serous tissue. The rectus muscle
is bluntly. divided as in the Von Hacker operation, in
order to be utilized for sphincter action.
31 Washington Street.
LITHOLAPAXY; SUCCESSFUL REMOVAL,
FROM THE BLADDER OF A MAN 30
YEARS OLD, OF A WILLOW TWIG 7
INCHES LONG, WITH HEAVY IN-
CRUSTATION OF CALCIUM
PHOSPHATE.
BY W. S. FORBES, M.D.
PROFESSOR OF ANATOMY, JEFFERSON MEDICAL COLLEGE; CLINICAL SUR-
GEON TO JEFFERSON MEDICAL COLLEGE HOSPITAL.
PHILADELPHIA.
In the month of September, 1895, I was called in
consultation in Johnstown by Dr. A. N. Wakefield
and Dr. F. Shill, to see a man about 30 years of age,
who stated that he had gravel. The man showed us
a small piece of willow twig, half an inch long and
about the thickness of an ordinary match, incrusted
for half its length with phosphate of lime making
the mass one-quarter of an inch in diameter.
He had passed this piece of twig from his bladder
within a week, also two smaller pieces during the
month of January last. He said that in November,
1895, he had shoved up in his urethra a long piece of
willow twig and that it had accidently broken off at
the head of his penis. As is usually the case with
foreign bodies in the urethra, this willow twig had
been carried by muscular action back into the blad-
der. The man was in a good deal of pain and could
not lie down without increasing it very much. He
could not retain his water longer than an hour. He
had had three hemorrhages from his bladder within
three weeks, and the last one was so extensive as to
frighten him. On sounding his bladder the charac-
teristic "click" was readily obtained. The "click"
was observed on the right side as well as on the left
side of the bladder. From examination, we concluded
that the twig arched over from the right to the left
side, the top of the arch being at the summit of the
bladder. In consultation it was decided that I should
attempt to remove the mass by crushing the lime
incrustation with a lithotrite, and as far as possible to
reduce the twig so as to remove the entire mass by the
evacuator. If this proved impossible it was agreed
that I should perform suprapubic cystotomy.
On September 4, in the presence of Dr. Wakefield,
Dr. Shill, Dr. Lowman and his son, Dr. John B.
Lowman, and other medical gentlemen in Johnstown,
the patient was placed under ether by Dr. Wagoner,
Dr. John B. Lowman assisting. It was observed that
the foreign body had not moved from its previous
position. I introduced my lithotrite, a No. 18 F/ and
readily crushed the incrustation. By screwing down
the male blade it entirely severed the encased twig,
which was easily cut across. The crushing of the
incrustation imparted a very different sensation to my
hands from that of cutting the body of the twig. After
performing this cutting and crushing for several min-
utes, the lithotrite was removed, and introducing a No.
25 F. canula, the evacuator drew out quite an amount of
broken pieces of incrustations and a number of pieces
of the twig. The operation was continued for forty-
eight minutes, the bladder being washed out with a
warm borated solution. The incrustations and the
pieces of the twig weighed 184 grams. The pieces of
twig placed end to end, by Dr. Wagoner, measured
seven inches in length. The man had no untoward
symptoms, was up and about in five days and went
home well in ten days.
The action of the new lithotrite was everything
that could be desired. Unlike the older lithotrites the
present instrument holds in its grasp and then divides
into pieces instead of only mashing. I described this
lithotrite in a paper read before the American Surgical
Association, at the meeting held in Washington June
1, 1894, and published in their proceedings, and also
in the Medical News, June 23, 1894.
I have now performed twenty-one operations (lith-
olapaxies) with this new instrument. The ages of my
patients ranged from a child of 4 years to an old man
of 82. Of these twenty-one operations, my first lith-
olapaxies, eighteen are now living and well. The
three deaths were occasioned by debility and suppres-
sion. They were aged respectively 58, 66 and 74
years. In the case of the man 74 years of age, per-
haps it would have been well not to have operated at
all, as his debilitated condition (from alcoholism), I
told him, would probably prevent his recovery, but as
' Recently, six Forbes' improved new lithotrites were sent to Can-
ton, China, through the Board of Foreign Missions. They were in size
Not. 88. 30, 27,23. 18 and 15, French. The No. 30 was tested in tiietesting
machine to 680 pounds and remained uninjured.
1146
PISTOL SHOT WOUND OP ABDOMEN.
[November 28,
his sufferings were extreme and as there was some
hope for him in the operation, I concluded to extend
it to him, as he wished.
' In these twenty-one cases of litholapaxy, seven of
them were operated upon without ether, the bladder
having been injected with four ounces of an 8 per
cent, solution of cocain just before each operation.
In every case a warm borated solution was used both
during and after the operation.
The smallest stone weighed 90 grains, the largest
640 grains.
Mr. Gilbert Barling, P.R.C.S., surgeon to the
Birmingham Hospital, England, in the British Med-
ical Journal of May 5, 1894, gives the following tables
as to the comparative mortality of the three opera-
tions, suprapubic lithotomy, perineal lithotomy and
litholapaxy, in male cases under 20 years of age.
This table presents the result of the practice for five
years, 1888 to 1892 inclusive, in six provincial and six
London hospitals, the majority being medical schools.
Suprapubic Lithotomy (males).
Under 10 years.
10 to 20 years.
Cases.
44
Recovered.
Died.
Cases.
34
10
28
II
Recovered.
23
Died.
Total under 20,72 cases with 15 deaths. Deducting 3 deaths, this leaves
CM cases with 12 deaths, a mortality of 17.4 per cent. The reason for this
deduction is given in the text.
Lateral Lithotomy.
Under 10 years.
10 to 20 years.
Cases.
Recovered.
37
Died.
Cases.
20
Recovered.
20
Died.
Total under 20. 69 cases with i deaths. Add one death from supra-
pubic operation after uncompleted lateral, makingfiO cases with 3 deaths,
a mortality of 5 per cent.
Litholapaxy (males).
Under 10 years. 10 to 20 years.
Cases.
Recovered.
Died. Cases.
Recovered.
Died.
43
42
1 16
16
0
Total under 20,59 cases with 1 death. Add 2 deaths from suprapubic
operation after uncompleted litholapaxy, making 61 cases with 3 deaths,
n mortality of 4.'.i2 per cent.
It is manifest from this very carefully prepared
table that the rate of mortality in suprapubic lithot-
omy in young males is much higher than that follow-
ing perineal lithotomy and litholapaxy in this class of
cases. And this opinion has since been confirmed by
the recorded practice of Indian, British and American
surgeons generally.
Surgeon P. J. Freyer of the Bengal Army, India,
states in the last edition, 1896, of his most excellent
essay on the " Modern Treatment of Stone in the
Bladder," that in the government hospitals of Punjab
and Bambay alone there were 7,694 litholapaxies per-
formed on patients of all ages in four years, 1891-94,
with 255 deaths, or a mortality of 3.45 per cent.
In view of this experience, litholapaxy is no longer
on trial. It is now a firmly established practice and
destined to replace all forms of lithotomy, save in
very exceptional cases.
"By litholapaxy," writes Freyer, "the surgery of the
bladder has been truly revolutionized. The surgeon
who would give his patients suffering from stone in
the bladder the best prospect of recovery must prac-
tice litholapaxy and, I confidently anticipate," adds
this experienced and able surgeon, "that with increased
perfection in the instruments employed, larger calculi
than any hitherto attacked will successfully yield to
the operation."
901 Pine Street.
PISTOL SHOT WOUND OF ABDOMEN;
WITH RECOVERY.
BY A. E. SCOF1ELD, M.D.
TII.I'KN, NEB.
July 24, 1896, 1 was called into the country to see a
14 year old German boy, accidentally shot in abdo-
men with a pistol from a distance of 8 feet. He was
quite weak; not much pain unless by pressure, and
some dullness over lower abdomen; had vomited
twice, temperature 97.5 degrees, pulse 85. The ball
had entered 2i inches from umbilicus at a point H
inches below a line from umbilicus to the anterior-
superior spine of ileum. The sanitary conditions were
most unfavorable, the family temporarily living in a
10 by 10 feet granary, with a dirty hen house attached.
I informed the family an operation would be imper-
ative and had an abundance of water boiled and
returned to my office for assistance, instruments and
dressings. Being unable to obtain surgical help I
invoked the aid of two non-professionals and returned,
put the boy on a table out of door and prepared him
for the operation. Chloroform was given. I made a
2f inch incision at site of wound. No vessels required
ligation and no positive evidence that ball had entered
cavity until peritoneum was reached. On opening
the same about 1| pints of blood was found in peri-
toneal cavity, most of which was removed and nine
holes were found in gut: lower jejunum and ileum,
These were repaired by the Czerny-Lembert suture,
with pure silk; the folding in corresponded lengthwise
with the long axis of the gut. No holes were found
through the mesentery. Considerable time was con-
sumed searching for injured viscera and twice the
pulse became imperceptible, but regained nicely by
injecting very warm salines in the rectum. Large
amount of the same was used in flushing the peritoneal
cavity. After the rents in intestines were repaired, two
rows of chromicized ligatures were put in to close
incision, dressings applied and boy placed on a cot in
the house and strychnia given hypodermically. Tem-
perature was three degrees below normal and very
much exhausted. Nothing was seen of the bullet,
which was a 22 caliber, and as an odd number of per-
forations was made the supposition was it had lodged
in lumen of the gut and would pass, but was not dis-
covered in feces, though sufficient vigilance was used
in the search. That night he was quite restless and
vomited twice. Next day he vomited once, but was
quite comfortable for the balance of the time. Recov-
ery was complete in two weeks, when he was up and
out.
Despite the filthy surroundings, his temperature
kept below 100 degrees and there was absolutely no
unfavorable symptoms during his convalescence.
Tinct. opii deod. was given when required to quiet,
but with extreme care not to prevent the absorbent
power of the peritoneum, which does so much for the
abdominal surgeon. Sulph. magnesia was also given
in small doses after twenty-four hours and continued
until motion of bowels, which was secured by the
assistance of an enema of the same in solution.
1896.]
ABOUT FEVER.
1147
VBOIT FEVER: REFERRING TO NATURAL
ECONOMICS.
in WILLIAM S. STOAKLEV, M.D.
MILL1IOKO sl'KlNiis. V k.
The stress which is laid on the hyperthermic condi-
tion which nature shows in her attempt to restore the
•• normal status of affairs" when she is aflame, as the
leading symptom to be speedily suppressed by us, is,
in tnv humble opinion, carried something to the
extreme.
Fever is a signal to us that nature is offended, con-
sequently perturbed, and she takes this course to
relieve herself of the offenders. If it is only a symp-
tom, it should not draw our attention too far from the
cause, which latter, if we can remedy, will lower the
temperature as a matter of course. This hyperpyrexia
mobilization, then, is nature's way to get rid of her
troubles, ami we are induced to believe that the mor-
bific elementaries are either destroyed or rendered
liors tin combat by this, we think, inhibitory action,
when aided in the proper direction by art. How many
gastric fermentative fevers ("upset stomachs") get
well without remedies, through nature's modes. Gen-
eral practitioners can not tell the material character-
istics of the microorganism that produces the fever;
but grn them the case, and they can approximate the
diagnosis as to whether it be of the fermentative or
putrescent type. Along with the temperature there
are certain •'inexplicable pointers" (derivatives of
experience) taught clinicians as to its significancy ;
and the call for remedies as well.
Remedial theory can be spun into dulce and
" catchy " shapes far from the sick-room. We admire
such perhaps no less, only the bedside indications
more. Our imaginations may be persuaded adverse
to legitimate procedure in making us believe that
certain diseases fit such and such drugs. We can not
see it in that light. The converse of this should
obtain. The " foot should not be fitted to the shoe,"
because it is not in accord with natural economics.
If this theory is not " hewed to the lines " of natu-
ral dictation, it is minus the utile, and practical, which
latter is exactly what we are trying to get at when we
don the ''medical harness;" and get at it, too, from
every legitimate source, with the freedom of all the
sciences as integral aids to the accomplishment of a
practical end.
As an illustration of one branch in our aid, note
the close connection with meteorology.
Let us " make haste slowly," and surely as we can.
There are many ways to accomplish our athermic
object; none like the natural way. It may be well
not to go at this fever with preconceived ideas that to
cure the disease it must be hastily controlled, blind
to other equally prominent points. We may obtund
nature, and shut up in the system what should be
eliminated as effete and offensive.
Doubtless you ask right here: " Must we not lower
this high temperature?"
Most assuredly we should, and in an humble way I
am attempting to give my idea about it.
The manner of doing this is a point in successful
practice worthy of study. The compositeness of the
grand harmonic "human machine" must be taken
into consideration in this matter, and the laws of com-
pensation likewise; never forgetting the controlling
power the nerves have over the " driving wheel."
Should we handle them too harshly when perturbed
we bewilder the directors along our pathway; beside,
"the machine" will have no mode of intercommuni-
cation with its several parts. Obtunded nature will
not answer to the "fuel in getting up steam " again;
thus a stasis is apt to occur as the result.
Yes, we should endeavor to get the temperature to
the normal point, but not by too heavy a blow upon
the nerves. We may attempt it indirectly by freeing
the "escape valves" (emunctories), with an eye to
compensation. This relief they will answer with a
refreshing nap, a good warm sweat, and on awaking a
big urination also not infrequently will occur. Just
here "the madam" (Dame Nature) will smile upon us.
To establish a chain of reliefs is what we are " driv-
ing at " and what the nerves call for, and what will
lower the temperature by normal stages, and draw the
smile above noted.
This one symptom of fever may be made up of a
combination of other symptoms, some of them of
more import to us to look after than the high tem-
perature. The most obstinate of all cases are those
with less prominent temperature. Every physician
knows that, as a rule, the gravity in pneumonia is
proportioned to the lack of thermic indications. Wit-
ness those old cold, sweaty fevers, on and in the vicin-
ity of rice plantations. Here, fever is not much of a
symptom, but the want of it is. Indeed, there are
some " ugly " and " scarey " presentments made to
us in adynamic fevers when the nerves have been
overwhelmed, and through them the heart, right in
the start, and the case is " dead all over " because the
" big wheel won't go." We attach fault to this latter
organ (the heart) sometimes wrongly, and "whip
it up" with strophanthus and other drugs, when
really we have failed to clear the life-giving stream by
looking to our "safety valves;" and this because so
much of our attention was centered on " smothering "
the morbific elementaries (noso-germs) in their " hol-
lows." This way is all right and proper so far as it
goes, and all of us believe in this mode of medication;
still, we must look to the dictates of the vis natural
first, especially so when these are made with such
emphasis.
Modern medicine is an illustration of " history
repeating itself " in some ways, notably in the treat-
ment of typhoid fever with alterative doses of mercu-
rous mild chlorid; and successfully, too. The late
adjuvants which we owe to our never-tiring chemists
have given us an impetus in the right direction, and
doubtless with them in the near future we shall over-
turn many of the old plans of procedure, and extract
from them at some time whatever points of value they
may possess.
The power of this organ (the heart), which of late
has been giving us so much trouble, we must remem-
ber is derived from a chain of interacting connectives,
each dependent on another. The cause of this trouble
opens a field for study, inasmuch as the affection is
of such frequent occurrence now, compared with its
rarity in time back.
When we take into consideration the interdepen-
dence of every link in the chain of our existence, it
is patent that we should conserve with no partiality.
There is hope in unison if it be only feebly expressed.
To sum up and conclude: It is not intended to
condemn any other plan of lowering the temperature
in fever, that this is written; only to advocate one
which experience has shown to be a good one, and
well-pleasing to the economy.
1148
DOCTORATE ADDRESS.
[November 28,
THE DOCTORATE ADDRESS DELIVERED
AT THE COMMENCEMENT OF THE
ILLINOIS MEDICAL COLLEGE.
BY SETH SCOTT BISHOP, M.D., LL.D.
Professor of Diseases of the Nose, Throat and Ear; Professor of Otology
in the Post-Graduate Medical School and Hospital ; Surgeon
to the Illinois Charitable Eye and Ear Infirmary, etc.
Members of the Graduating Class : In conferring
the degree of Doctor of Medicine upon you to-day,
the honor and privileges conveyed with the title are
not likely to be underestimated or forgotten. But
you should be reminded that in accepting the privil-
eges of physicians, you assume at the same time duties
of the gravest nature. Your relations to the mem-
bers of the community who will entrust themselves
to your care are changed. Such relations become as
sacred and inviolable as those existing between priest
and parishioner — between lawyer and client. Your
duties will involve an intimate knowledge of their
affairs, their habits and their characters, such as no
other professional relation in life conveys.
Our laws recognize, protect and dignify this high
position which is maintained by every honorable phy-
sician. In the safety vaults of your memories will be
treasured those confidences and secrets that are poured,
confession-like, into every Doctor's willing or unwill-
ing ears. In your power may rest the integrity and
the happiness of families, the destiny of citizens and
the sanitary welfare and safety of communities.
Let your influence protect the home and the family.
Let your force of character encourage and uplift the
fallen victims of disease and despair. Let your supe-
rior knowledge, skill and judgment protect the com-
munity from the devastating contagion of epidemics.
Modern medicine has increased your power for
good many fold over that of your ancestors. It is
truly a great privilege to practice medicine in the
closing years of the nineteenth century. We possess
a mastery of medicine not dreamed of by our plodding
forefathers. The refinements of diagnosis made pos-
sible by the microscope, and the improved processes
of the laboratories of chemistry and bacteriology ; the
prevention of diseases and their spread by vaccination
and the antitoxins: the concentration of drugs and the
extraction of their alkaloid principles, united with the
palatable and elegant products of advanced pharmacy;
the various adaptations of electricity to the service of
medicine, with the Roentgen ray accomplishing the
seemingly impossible; the economic division of labor,
typified in the various specialties of medicine, permit-
ting and enforcing the highest degree of perfection
in every branch of medical achievement, place the
advancing science and art of modern medicine above
all others of vital importance to the well-being and
the life of mankind.
No sphere of human activity excells the achieve-
ments of the coordinate sciences of medicine, and the
brilliant accomplishments of surgery; and we may be
permitted to indulge a pardonable pride in the part
played by members of our own local profession in the
great scientific drama of our day.
Let these truths broaden your views and stimulate
you to put forth your best endeavors to achieve the
highest ideals of attainment. Be not content to drone
your lives away like tow-path mules of medicine.
Rise above mediocrity. Strive to out-strip all run-
ners in the race. With every nerve and muscle tense,
leap forward to the goal.
Above all things, be studious. Be the first to know
each new discovery. An ignorant doctor is an unpar-
donable sin. Doctor means learned. You should be
learned above all your neighbors. You should be
looked to as a leader in your community. You should
diversify your learning beyond the confines of medi-
cine, and to broaden your culture, you should strive-
to excel in some important branch of learning. If you
live in a mining country, let geology occupy your
leisure hours, for they will not be few in the first
years of practice. Geology and mineralogy may lead
you to a mine of wealth.
The profession and the people would profit alike if
the able physicians of America, like the brilliant pro-
fessors of foreign lands, of whom the erudite Virchow
is an illustrious example, would engage in the study
and actual practice of political economy. The phil-
osophy of good government is a subject worthy of the
work of the best minds a great country can produce.
In such lands as Germany, Italy and the South Amer-
ican Republics, physicians of culture honor them-
selves and their profession in the highest councils of
their governments.
When will the people of America awaken to their
own most vital interests, and dedicate a government
bureau, with a medical head, to the cause of disease-
prevention, State medicine and higher education?
We are blessed with a department of agriculture that
predicts the weather; a department of war that relieves
us of our surplus millions; a department of law that
really fights the nation's battles. The time must
come when State medicine shall be represented in
the National government, to protect against invasions
of contagious diseases and to safe-guard the nation's
health in every quarter. Our local profession con-
tains within its ranks the ability and the experience
to organize, equip and properly conduct such a depart-
ment of State.
Not until the government of the United States rec-
ognizes the vast possibilities of State medicine to con-
serve the health and vigor of the nation, and to save
the great waste of human life that modern scientific
research has rendered preventable, can it lay claim to
being abreast of the times and the first of the nations
of the earth.
It has been the custom in the past to say to gradu-
ating classes: " Your school days are ended. You now
enter upon a life of activity, a career of usefulness,"
etc., but in these days of post-graduate schools, in
which a college education can be supplemented by
actual experience in the practice of medicine, your
schooling should not end with a blue ribbon and a
sheepskin. Time was, when no physician was consid-
ered to have been initiated into the highest degrees of
proficiency until he had crossed the Atlantic and
walked the wards of the Old-world hospitals.
The conditions are changed. American teachers of
to-day stand abreast of the world. These are not idle
claims. They are not only verified by Americans
conversant with European teaching and practice, but
are substantiated to the satisfaction of European sci-
entists who visit our schools, laboratories and hospi-
tals. It is evident, then, that you may enjoy the ad-
vantages offered by home institutions of learning to
perfect yourselves in post-graduate work with far less
loss of time and money than it cost your predecessors.
But travel enlarges the views, expands the intellect-
ual horizon and broadens culture. Visits to foreign
countries lend polish to the manners, evoke the spirit
of tolerance and stifle bigotry. The diversified teach-
1896.]
SOCIETY PROCEEDINGS.
1149
nigs of OkUworid medical centers will arm you with
those principles ami methods that contribute to a fin-
ished education and a successful practice.
Therefore, let those who have walked the beaten
path you are to tread exhort you to cap the climax of
a collegiate course with the practical knowledge and
skill obtainable under the direction of eminent spe-
cialists in hospital and dispensary practice, first at
home, and afterward abroad.
It is appropriate at this time to tone down the
roseate hues of your imaginative pictures of the
future, with the neutral tints of reality.
'Tta pleasant, sure, to think you'll own a mint;
A aunt's a mint, although there's nothing in't.
A diploma is not a lien on the public for a living.
That pretty and attractive si^n you have in mind,
with the big M.D., in shining letters of gold, or of
glittering silver, is not an unfailing magnet to draw
the masses of suffering humanity into your health-
giving presence. The fund of knowledge you have
stored within the temple of the mind will not find
quick appreciation and admiration. Then let the
truth be spoken, and faced without flinching.
You now set sail under the smiles of heaven and
the plaudits of teachers and friends. Good wishes
«nd flowers illuminate your pleasant pathway; but no
bouquets of rhetoric can screen you from the harass-
ing storms or the dangerous breakers ahead. Your
schooling, good sense and self-reliance must sustain
you in the time of need.
We speak from experience when we predict that you
will meet with that wise old doctor who will welcome you
with a machine-made cordiality to the precincts of his
practice. He has gone through the same formality many
times before, and recalls the ghosts of practice aban-
doned by the little army of doctors who have pitched
Iheir tents in his door-yard, spent their little all, and
moved on to new fields, a little wiser than before. This
grizzled veteran, who can not boast like you of a real
parchment and ribbon, owns the community in which
he lives. Sooner or later this fact dawns upon your
mind. He magnanimously promises you all his night
work — that does not pay. He will help you out of your
hard cases. He does. He helps you out of your
cases, your fees and your patrons. This great-hearted
individual volunteers to teach you how to make money
while you appear to be sacrificing yourself for the
benefit of the poor public. He tells you how you
should charge less, and make many more visits; how
you should ape the artful dentist who makes holes to
fill, when he can not find them ready-made. He is a
devotee of the black art. Beware of this Mephisto-
pheles of medicine.
Another neighbor, you will meet, grown fat and
sleek, who easts a withering glance as you pass by.
You, poor novice, are an intruder; but you have heard
that it is your duty, being new, to call on him. You
honor tradition. He receives you with a fraction of a
nod, a blighting look and a condescending wave of the
hand toward his most uncomfortable chair. You in-
form him that you have come to "Ah," he has
heard of it — " bad place to locate ; next town would be
better; here, it is every man for himself, and "
and so forth. Are you discomfited, discouraged? No;
you know your preceptors have been through the same
mill, and still they live. You are a little stirred in the
depths of your soul, but every fiber of your being
vows that eternal success shall crown your life.
Undaunted, you make another sally. You visit the
brother of your neighbor, less fat and sleek, but beneath
his more careless exterior he reveals unconsciously a
soul of truth and honor. His sympathetic words of
cheer and sound advice anchor in your heart. He
stands like an oasis in a desert, like a cross of hope,
and you linger in his presence and cling to his per-
sonality. You feel him worthy of your fraternal love;
no trust is violated and no confidence is betrayed.
With a mind well stored with medical lore; with a
wealth of the richest professional experience; with a
broad philanthropy that the world has blessed with
material abundance, this noble son of the healing art
rescues the name of physician from the selfish and
son lid estate to which the unworthy would drag it,
and adorns it with the transcendent glory of a great
manhood.
These three types of medical men, and more, you
will meet. You will have no quarrel with any. You
will cultivate the society and friendship of your equals
and, perhaps of your betters. You will be guided by
the principles of the immortal Hippocrates and the
code of ethics of the American Medical Association.
With homeopaths and eclecties you will have an
honest, but good-natured difference. Life is too short,
and charity is too broad to permit of bickerings. Be
generous enough to credit every competitor with sin-
cerity, as you would be credited. Remember our laws,
to which we all are alike amenable. Your privileges
and theirs are identical, and their respect and friend-
ship are worth many times their hate.
To your patients be true. Their interest and yours
are one, for the greater good you do to them, the more
success it will reflect on you. In the alleviation of
suffering you will derive much satisfaction; in the
conquering of disease you will delight. Commit one
robbery at every opportunity — rob Death of his prey.
While you may not be able to realize for this service
a fee commensurate with the law's estimate of the
value of a human life — $5,000 — you will enjoy the
consciousness of having rendered a fellow-being an
inestimable service, and of having fulfilled the utmost
requirements of a most exacting profession.
Adopt correct business methods. Whether you
practice general medicine, or confine yourselves to a
specialty, especially obstetrics, let your rule be " cash
on delivery."
Finally, your personal influence over the sick and
dying may turn tears into smiles, and darkness into
light. The attributes of the true physician, united
with an inspiring Christian character, present an ideal
type of manhood and useful citizenship. Such a phy-
sician instills the dew of courage into the drooping
soul; refreshes the withering heart with rainbows of
promise, and paves the pathway of the dying with the
peaceful flowers of hope.
SOCIETY PROCEEDINGS.
Medical ami Chirurgical Faculty of Maryland.
Semi-annual Meeting held at Hagerstown, Md., Tuesday
and Wednesday, Nov. 10 and 11. 1896.
First Day — Tuesday, November 10.
Dr. William Osler, President, in the Chair. Dr. John S.
Pulton, Secretary.
After an address of welcome by Dr. J. W. Humrichouse of
Hagerstown, which was responded to by Dr. Wtn. Osier of
Baltimore, the regular order of business began.
CONTINUED FEVERS.
This was the subject of a paper by Dr. C. Birnie of Taney-
1150
SOCIETY PKOCEEDINGS.
[November 28,
town, Md. He related several cases of fever lasting from two
to six weeks, or sometimes longer, lacking the characteristic
symptoms or lesions of typhoid or malarial fever and not due
to any definite lesion. He gave the points of distinction
between the two cases related and typhoid fever. In many
instances he treated the patients symptomatically. He finds
that antipyretics were useless and harmful. Phenacetin is
very successful in his hands.
Dr. John C. Hemmeter asked what were the latest views
concerning gastric fever ; some persist that such fevers do exist
and others that they do not.
Dr. Birnie said that no microscopic examination had been
made in these cases and he was of the opinion that gastric
fever was more of a gastric catarrh.
Dr. Osler said that he had no personal knowledge of gastric
fever.
Dr. Chas. M. Ellis of Elkton, has had similar experience
as that related by Dr. Birnie.
Dr. A. S. Mason of Hagerstown, said that such cases as
those related by Dr. Birnie were known to physicians and he
was inclined to call them continued fevers. In some cases
quinin had no effect at all. He referred to an epidemic that
spread over this country twelve years ago, he had sixty or
seventy cases, and typhoid cases from polluted water, but also
many cases with no local disturbance. He did not know the
classification of these fevers.
Dr. George J. Preston said that the subject of continued
fevers was of great practical importance and spoke of the
physiology of heat and cold production on fevers. We do not
give due weight to the physiologic questions in the study of
this fever. We often have distinct hysteric fever running over
weeks ; these are rare cases, but they do occur. We rarely see
these cases in the hospital, because these mild cases do not
enter the hospital as a rule. We do have certain cases in
typhoid fever, such as walking typhoid fever, which is made
known by the relapse. The enlargement of the spleen and
liver are not diagnosed. The diazo-reaction has not met with
much success in his hands. There are many cases of fever in
which quinin is of no use.
THE NATURE AND TREATMENT OF GASTRIC ACIDITY.
This was the subject of a paper by Dr. John C. Hemmeter.
He asked if there was a distinct lesion in these troubles or not ;
that had been the question often asked. Not arriving at con-
clusions, he examined the gastric contents after double test
meal of Salzer. In these two consecutive meals representing
an ordinary diet one can determine the number of important
pathologic states in gastric digestion almost without further
analyses. These test meals consist, first of a cup of milk and
a plate of rice with a piece of bread, followed four hours later
by a roll and a glass of water. If the stomach contents be
removed one hour after the second meal there should be no
remnants if the stomach is healthy. Proteid remnants, such
as meat and eggs would point to an acidity, while a hyperacidity
would be indicated by a large amount of carbo hydrates in the
remnants. After some few words on the digesting power of
the stomach, he concluded by some important directions on the
dietetic treatment of this trouble.
Dr. George J. Preston read a paper on
CEREBRAL SYPHILIS.
The symptoms of this trouble are very varied and the history
of the primary lesion is often uncertain. Moreover, the inter-
val between the primary lesion and the brain trouble may be
so long as to make the connection between the two uncertain.
Meningitis from syphilis is nearly always chronic, the symp-
toms coming on gradually, the first one being headache, then
there may be paralysis of the third pair of nerves, or the fourth
or sixth, then there may be hemianopsia. The most common
f orm is great mental depression, or rather apathy. He related six
typical cases illustrating some of the most important symptoms
of cerebral syphilis. We should make our diagnosis and then
treat vigorously. This method of treatment is much more
used in this country than in Europe, hence the better results
obtained here. He has given as much as 300 to 500 grains of
lodid of potash a day, and we are justified in doing this. He
thinks that mercury very materially helps the iodid.
Dr. E. N. Brush thinks that the interval between primary
lesion and the brain troubles is much longer than Dr. Preston
intimated in his paper. In one case he has given 900 grains of
iodid of potash a day. He does not believe in the therapeutic
test and does not think that because a patient can take large
doses of the iodid that it should be treated as specific : some
syphihtics can not take large doses while those who have never
had the disease can often stand very large doses.
Dr. John Whitridge Williams read a paper on
MALARIA COMPLICATING GYNECOLOGIC OPERATIONS.
He spoke of the importance of examining the blood in all
febrile conditions, and the necessity for great accuracy and
said that post-partum fever was more frequently attributed to
puerperal fever than to malarial fever and that there were few
references to malarial postpartum in the text-books. He had
had two cases recently. In the first the examination of the
blood had given him great confidence and had allowed him to
exclude sepsis. In the second case neglect of the blood exam-
ination had resulted in a faulty diagnosis, and as a consequence
an operation was performed, although as it turned out, this
operation was entirely justifiable. These two cases convinced
him of the importance of blood examination in all febrile cases
after labor, even though malaria be suspected. He is confi-
dent that malarial fever is often mistaken and treated for other
postpartum fevers.
Dr. J. M. Hundley said that he had several cases of late in
which malaria complicated gynecologic operations, and the
blood examination had made the diagnosis certain. He thought
that this year especially, such malarial complications were
more common.
THE CYSTOSCOPE IN THE DIAGNOSIS AND TREATMENT OK
DISEASES OF THE FEMALE BLADDER.
This was the subject of a paper by Dr. J. M. Hundley.
Heretofore the treatment of these diseases has been unsatis-
factory. Drugs internally and washing out the bladder" were
the two methods of treatment used. Through the skill of Dr.
H. A. Kelly, the modern cystoscope has been so perfected that
the interior of the bladder may be examined and treated and
the openings of the ureters may be seen. The bladder is more
frequently subject to organic disease than was previously
believed before the use of the cystoscope. Not only uterine,
but also rectal diseases cause an irritable bladder. He thought
that the routine examination of the bladder with the cysto-
scope should be made in every gynecologic case, whether the
complaint was referred to that organ or not. He related two
cases attesting the value of the cystoscope in his line of work
and urged the profession not to neglect this modern means of
diagnosis.
Dr. A. C. Wentz of Hanover, Pa., related a case in which
he applied ichthyol ointment on the balloon to the interior of
the bladder, as recommended by Dr. Clarke. He also used
applications of 10 to 15 per cent, nitrate of silver.
TO WHAT EXTENT DOES THE HYPERTROI'HIED PHARYNGEAL
TONSIL ATROPHY AT OR ABOUT PUBERTY?
This was the subject of a paper by Dr. S. K. Merrick.
He had been struck by the frequency with which the family
physicians had told parents that the enlarged pharyngeal ton-
sils of their children would disappear spontaneously at from 12
to 14 years of age. Indeed he had found that several of the
text-books gave this same opinion, or else avoided the question
altogether. He had been able to collect a few statistics from
his own practice and in all cases which he had seen which have
refused operation in childhood, in none of them have the ton
sils disappeared at puberty. There is some information obtained
in observing the ages at which patients applied to him for treat-
ment ; out of fifty cases operated on in 1895 and 1896, sixteen
were under 14 years of age, while thirty-four were above that
age. If the tonsils atrophied after puberty it is strange that
so many cases come to operation after puberty. We may con-
clude that an insignificant number of hypertrophied glands
will disappear at puberty if left to themselves. Not only this,
adenoids make a patient prone to repeated colds as other-
throat affections and may become tuberculous in character.
Dr. John N. Mackenzie said he had never allowed the case
to reach puberty without operation. It is amazing what
troubles these pharyngeal growths may cause and what fearful
inroads these troubles make in the health. He had operated
on infants in arms. -The growth should be operated on as soon
as discovered and should never be allowed to proceed unchecked.
He spoke of the great disfigurements of the countenance from
this trouble and the affections of hearing, etc.
THE EARLY SYMPTOMS OK GENERAL PARESIS.
This was the subject of a paper by Dr. George H. Rohe.
We should look for the early symptoms although the results
of treatment are not encouraging. The diagnosis must be
made from a collection of symptoms of partly physical and
partly psychical. The disease generally begins after the thirty-
fifth year and rarely after the fiftieth. Those in the higher
walks of life are attacked by preference and men more than
women. Clergymen are almost exempt and actors are most
frequently affected. Syphilis may be one of the causes. The
symptoms are various and the treatment is unsatisfactory and
1896.]
SOCIETY PROCEEDINGS.
1151
ratal] docs more than prolong life a few years. The iodids may
in- given.
Dr. Edward N. Boss was much pleased with Dr. RoWs
pai>er. Ho thought that the early symptoms of paresis
occurred in this order : 1, vasomotor ; 2, motor, and 3, psychic.
Sometimes depressing ideas usher in the disease.
K\ imni. Si ssion.
Dr. Wm. Osler presented a case of diffuse scleroderma.
The patient was a white man about 30 years old who has suf-
fered from a hardening, thickening and gradual immobility of
the skin. There had been inflammation, erosion and finally
disability. This trouble was most marked in the hands and
anus and fare, although the skin of the whole body was some
what hide bound ; it is hard to pinch the skin, the patient can
not close his hands tight. There are two forms of this disease,
thi" diffuse form and the local form. This is a case of diffuse
scleroderma. The etiology of the disease is not known and the
pathology is very obscure. Thyroid extract is sometimes efti
carious in this disease and sometimes not. In this case the
man had bean helped very much by it and there were chances
that it would stop the progress of the disease, if not cure it.
lie can not elevate his shoulders. This is a slow progressive
disease and it is very rare ; he himself had been in practice
twenty years before he saw a case and had seen only six cases
altogether.
THE PATHOLOGY VN'D BACTERIOLOGY OF TYPHOID FEVER.
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